Given Foundation Professor of Urology and Vice Chair,
Department of Urology,
Columbia University, College of Physicians and Surgeons,
New York, New York
Canada best antibiotics for acne treatment buy cheapest azithromycin, are experiencing a clear decline in incidence and mortality from cancer of the Pathology and genetics uterus virus 41 states order azithromycin with visa, particularly among young women bacterial jock itch buy 500 mg azithromycin. Uterine can this tumour type is characterized by the cer occurs primarily in elderly women virus blocker order azithromycin from india, the disappearance of stroma between abnor median age of onset being around 60 years old; only 5% of cases develop before age 40 antibiotic strep throat discount azithromycin online visa. Etiology Cancer of the endometrium is linked to reproductive life with increased risk among nulliparous women and women undergoing late menopause (Reproductive factors and hormones antibiotics for dogs australia azithromycin 250mg otc, p76) virus cell purchase azithromycin 100 mg. The endometrium is normally a hormonally responsive tissue virus x book discount 250mg azithromycin otc, responding to estrogens with growth and glandular proliferation and Fig. Post ings into the lumens, disordered nuclear endometrial tumorigenesis is becoming operative radiation therapy is currently chromatin distribution, nuclear enlarge characterized (Fig. Patients with given to patients at a high risk of relapse ment, a variable degree of mitosis and is lesions which are positive for cytoplasmic following surgery. In inoperable cases, associated with necrosis and haemorrhage estrogen and progesterone receptors have pelvic radiation therapy, usually external [16]. Adenosquamous carcinoma, which a better rate of disease-free survival than beam and intracavity irradiation, may be comprises 7% or less of cases, has a poor those with no identifiable receptors [16]. An enhanced sus herin are associated with metastasis and cisplatin, doxorubicin and cyclophos ceptibility to endometrial cancer has also depth of myometrial invasion. Estrogen and perimenopausal women and are estro abdominal hysterectomy and bilateral salp replacement therapy is recommended gen-related, with hyperplasia ante cedent ingo-oophorectomy (removal of the fallopi initially only in patients with in situ dis (adenomatous and atypical adenomatous an tubes and ovaries) are the definitive ease or with low risk stage I tumours. More 75-85% and for localized disease up to appear in postmenopausal women tend to than 50% of recurrences occur in the first 90% (Fig. Thus regular and evidence to suggest that black women Cancers of the female reproductive tract 219 Fig. Pelvic ultra slightly increased with nulliparity and a per sonography, tumour markers and clinical Definition sonal history of breast cancer. Decreased examination have proved ineffective in mass the majority of ovarian cancers are carci risk follows the use of oral contraceptives. In screening [7] and are employed only for nomas, which arise from the surface contrast, hormonal treatment for infertility patients having a high familial risk of ovarian epithelium of the ovary. The comparison of molecular profiles at the menopause is only associated with a generated by laser capture microdissection Epidemiology small risk. Early menarche or late is hoped to identify patterns of proteins About 190,000 new cases and 114,000 menopause may also entail a slightly which are uniquely expressed in early dis deaths from ovarian cancer are estimated increased risk [18]. Diet plays a role, with ease in order to generate valuable markers to occur annually. The highest rates are increased risk linked to obesity and height, as for early detection [20]. Low rates A history of pelvic inflammatory disease, Pathology and genetics are found in Africa and Asia (Fig. Detection lial tumours, including germ cell tumours, the great majority of patients with epithelial gonadal-stromal tumours and tumours which Etiology ovarian cancer present with disease that has have metastasized to the ovary, are less com Although most ovarian cancers are sporadic, spread outside of the ovary and even the mon. Three categories of lesions are recog a family history is the single most important pelvis [19]. Symptoms may include abdomi nized: benign, low malignancy potential or 220 Human cancers by organ site invasive malignant. The reasons for such differences undergo screening for breast, cervical and recorded with reference to national or oth are likely to be complex and multifactorial. Such differences involv den is rarely distributed uniformly across Environmental/behavioural factors may dif ing increased incidence provide an oppor such groupings. A number of variables may contribute quantities of red meat, large quantities of affected by ethnic and social differences. One such variable, fruit and vegetables) may be protective in For example, the way that pain is per genetic make-up, is not amenable to inter relation to risk of colorectal cancer, but risk ceived and dealt with is influenced by the vention but nonetheless may have an increases with the adoption of a Western ethnocultural background of the patient impact. Ethical dilemmas can develop in cer risk, with high rates of incidence in multicultural settings due to differing cul African-Americans, which may be partly Timely visits to a medical practitioner and tural beliefs and practices. More research related to genetic differences in hormone participation in screening programmes are into the relationship between ethnicity metabolism (Farkas A et al. Language may be a barrier to support, survival, and quality of life is confer susceptibility to cancer may be car understanding health issues. Recognition of multicultural issues is this may be partly attributable to the novel becoming more widespread. Women of lower Networks for Cancer Awareness Research than that of the general population. In Cancers of the female reproductive tract 221 early disease includes bilateral salpingo ed with vincristine, actinomycin and oophorectomy and total abdominal hys cyclophosphamide; cisplatin, vinblastine terectomy, total omentectomy, appendec and bleomycin; or cisplatin, etoposide and tomy, collecting samples of peritoneal bleomycin. Recurrent ovarian cancer may washings for cytological analysis and pos be treated with cytoreductive surgery plus sibly removal of pelvic retroperitoneal and chemotherapy and palliative radiotherapy. Reproductive function Hormonal therapy may include progesta and fertility may be conserved in patients tional agents and anti-estrogens. Aneuploidy has therapy may play a limited role in selected been linked to poor survival. A standard chemotherapy for advanced five-year survival rates for all stages com stage ovarian cancer using cisplatin and bined (Fig. Most Management paclitaxel achieves response rates of up to women, however, present with late stage Surgery is most often the first recourse in 60-80%. Germ cell tumours are very sen disease which is associated with a five diagnosis and treatment. Treatment of sitive to chemotherapy and may be treat year survival rate of about 20%. Esteller M, Xercavins J, Reventos J (1999) Advances in Kearsley J, Williams C eds, Cancer: a comprehensive clinical the molecular genetics of endometrial cancer. High incidence rates occur in Northern Iran, the survival rates are less than 15%. Central Asian republics, North-Central China, parts of South America and in Southern and Eastern Africa. However, in particular areas, oesophageal cancer in distinct geograph such as Normandy and Brittany in France ical areas are more extreme than and in the north-east of Italy, the inci Definition observed for any other cancer. Regions dence rates are much higher in males (up the great majority of oesophageal can of high incidence of squamous cell carci to 30 per 100,000), while remaining rela cers (over 95%) are either squamous cell noma in Asia [1] stretch from the tively low in females. Other incidence of all oesophageal cancers Cancers of the oesophagus are the sixth high-incidence areas are found in parts vary greatly (Fig. In of South America and in Southern and 2000, the number of deaths due to Eastern Africa. Even within these high Etiology oesophageal cancer amounted to some risk areas, there are striking local varia Consumption of tobacco and alcohol, 337,500 out of a total of 6. Studies of migrant popula associated with low intake of fresh fruit, cer deaths worldwide. About 412,000 tions suggest that when they move to vegetables and meat, is causally associat cases of cancer of the oesophagus occur areas of low-risk, they lose their high ed with squamous cell carcinoma of the each year, of which over 80% are in devel rates, confirming the importance of local oesophagus worldwide. In more developed countries, it is esti Oesophageal cancer 223 being the outcome of chronic mucosal the vast majority of patients initially injury. Other risk factors include con complain of progressive dysphagia, sumption of pickled vegetables, betel which may not become apparent until chewing in South East Asia, and oral con some two-thirds of the lumen has been sumption of opium by-products in the obstructed, especially in the case of Caspian Sea area. Regur have proposed a role for human papillo gitation and pain on swallowing are fre maviruses in squamous cell carcinoma quent, as is weight loss. Other environmental risk factors involvement may be indicated by hoarse include nitrosamines, food contamination ness. Patients with adenocarcinomas of with fungi such as Geotrichum candidum the cardia may also suffer from gastro and Fusarium sp. A barium swallow p43) and deficiency of vitamins A and C, (ingestion of liquid containing barium molybdenum, copper and zinc. Endoscopic ultrasonography Balloon tumour type is directly associated with is currently the most accurate staging Barrett oesophagus, a premalignant method, but is not widely available. In East Asia, mutations at A:T base pairs are less common, but transversions at G:C base pairs occur at a higher rate than in Western Europe [10]. It is often associated often subject to hypermethylation of the with chronic gastro-oesophageal acid Fig. In the Japanese population, a poly more commonly affected than women atypical squamous cells which infiltrate morphism in the gene encoding aldehyde [14]. There are three to squamous cell carcinoma is only par Adenocarcinoma of the oesophagus subtypes: fundic (base of oesophagus), tially understood (Fig. Mutation of mostly occurs within the distal third of cardiac (the region between the oesoph the p53 gene is an early event, detected the oesophagus and is preceded by a agus and the stomach), and intestinal. Oesophageal cancer 225 adenocarcinoma, reduced expression of the cadherin/catenin complex and incre Factor Alteration ased expression of various proteases is detectable [15]. The primary treatment E-cadherin Loss of expression in intraepithelial and invasive carcinoma Catenins Similar loss of expression to E-cadherin for local disease is oesophagectomy. Placement of a prosthetic tube or neoplasia stent across the tumour stenosis (narrow Membrane trafficking ing) may be indicated to restore swallow rab11 High expression in low-grade intraepithelial neoplasia ing in patients not suitable for surgery. The pres native to surgery, particularly if combined ence of a p53 mutation in Barrett mucosa and in dysplasia may precede the development of adenocarcinoma. Almost half of these are C to T Netherlands 12 transitions at dipyrimidine sites (CpG Osaka, Japan 11. In contrast, a number of 8 Slovakia other loci are altered at a relatively late Madras, India 6. Prevalent changes (>50%) include loss of heterozygosity on chromosomes Qidong, China 4. Molecules involved in membrane % survival, both sexes traffic, such as rab11, have been report ed to be specific for the loss of polarity Fig. Taniere P, Martel-Planche G, Puttawibul P, Casson A, eds (1997) Cancer Incidence in Five Continents, Vol. Gignoux M (1997) Alcohol, tobacco and oesophageal can cer: effects of the duration of consumption, mean intake 11. Br J Cancer, 75: steps in the development of squamous cell carcinoma of 1389-1396. Montesano R, Hollstein M, Hainaut P (1996) Genetic Teuchmann S (1990) Mate drinking, alcohol, tobacco, diet, alterations in esophageal cancer and their relevance to eti and esophageal cancer in Uruguay. Int J Maruyama K, Shirakura K, Ishii H (1998) Alcohol-related Cancer, 81: 225-228. Other less impor tant causes include analgesic abuse (phenacetin), some types of cancer chemotherapy and, historically, occupa tional exposure to chemicals such as 2 naphthylamine. In Egypt and some Asian regions, chronic cystitis caused by Schistosoma haematodium infection is a major risk factor. Although the majority of cases occur in devel countries, where 65% of patients live for oped countries, bladder cancer also occurs at high rates in some developing countries, including parts at least five years after diagnosis. Bladder can common are adenocarcinoma (6%), squa About 132,000 people each year die from cer risk increases approximately linearly mous cell carcinoma (2%) and small cell bladder cancer, men throughout the world with duration of smoking, reaching a five carcinoma (less than 1%). Approximately 336,000 new cases cases and 30% of female cases in popula Work in the rubber and dyestuff industries occurred in 2000, two-thirds of which were tions of developed countries [2]. Incidence and ly that smokers of black (air-cured) tobac aromatic amines, particularly including 2 mortality rise sharply with age and about co are at a greater risk than smokers of naphthylamine and benzidine, are correlat two-thirds of cases occur in people over the blond (flue-cured) tobacco and this may ed with a high risk of bladder cancer [3]. The male:female ratio is approx explain some of the disparity observed in Exposure to polycyclic aromatic hydrocar imately 3:1. High incidence rates (>12 per European incidence rates and also the bons, polychlorinated biphenyls, formalde 100,000 men and >3 per 100,000 women) high incidence observed in Uruguay. Such canals may provide a habitat for the snails which are host to Schistosoma parasites. Chronic infection with Schistosoma haematobium causes cystitis and often bladder cancer. In common with cancer of the renal pelvis, a has been proposed as a screening consistent relationship has been observed approach for bladder cancer, in particular between use of phenacetin-containing anal among industrial workers potentially B gesics and bladder cancer, with relative risks exposed to aromatic amines, but there is varying from 2. T T anticancer drug cyclophosphamide, an alky Other methods are also under investiga lating agent, has been strongly and consis tion [5]. Non-Hodgkin Haematuria, usually painless, is the pre lymphoma patients treated with cyclophos senting symptom for the majority of phamide therapy have a dose-dependent patients with bladder cancer. Diagnosis is made by urine analy der, moderately differentiated, with a papillary with an up to five-fold increased risk. Tissue for and in several West Asian countries, infec histopathological analysis may be tion as a result of ingestion of contaminated obtained through transurethral resection. Spread can squamous cell type, increases as from the Approximately 90% of bladder cancers are occur by growth into the submucosa and third decade of life. The infection is respon classified as transitional cell carcinoma muscularis of the bladder wall (25% of sible for about 10% of bladder cancer cases and are believed to originate in intra cases). About 70% of transitional cell car in the developing world and about 3% of epithelial neoplastic transformation of the cinomas are of the papillary type (Fig. Altered expres Egypt, this type constitutes 90% of bladder sion of the phosphorylated form of the tumours [7]. Nuclear overexpression of p53 bladder carcinogens have been identified protein, essentially attributable to muta and it has been hypothesized that sub tion of the gene, is common and is associ jects carrying specific genotypes could be ated with disease progression (Fig. There for superficial transitional cell carcino is no evidence for high-penetrance gene mas, to prevent recurrence, and possibly of the bladder, prostate and seminal vesi mutations that carry an elevated risk of decrease progression and improve sur cles in males or the bladder, ovaries, bladder cancer. Overexpression of the bovis bacterium which causes tuberculo restoration of bladder function, may be epidermal growth factor receptor is asso sis. Cytotoxic drugs such as thiotepa, dox achieved through a range of reconstruc ciated with invasive disease. Globocan 2000: Cancer Incidence and Mortality Worldwide Morris D, Kearsley J, Williams C eds, Cancer: a compre. Epidemiology and Prevention, Oxford, New York, Oxford University Press, 1156-1179. Oral cancer patients have Age-standardized incidence/100,000 population a five-year survival rate of less than 50%. Oral cancer is common in India, Australia, Hungary, France, Brazil and Southern Africa. In most countries, tors, such as tobacco use and alcohol con oral/pharyngeal cancer incidence and mor sumption. A high incidence of these cancers tality rates have either been stable or increas Definition is observed in the Indian subcontinent, ing in the last four decades. Sharp increases Head and neck cancers as described here Australia, France, South America (Brazil) and in incidence have been reported in Germany, will be restricted to squamous cell carcino Southern Africa (Fig. Worldwide, about 389,000 new New cases of cancer of the larynx occurring ing the oropharynx, hypopharynx and cases occurred in 2000, two-thirds of which worldwide number about 160,000, i. Other tumours which occur in were in developing countries, and these can 2% of the total world cancer cases, making this area, such as those of the brain and thy cers are responsible for some 200,000 laryngeal cancer the 18thmost common can roid and melanoma, are conventionally dealt deaths each year. The disease is markedly more frequent in with separately (Tumours of the nervous sys the male:female ratio of occurrence varies males than in females (male:female ratio of tem, p265; Thyroid cancer, p257; Melanoma, from 2-15:1 depending on the anatomical 12:1 and 6:1 in developing and developed p253). There is a large geo tongue, floor of mouth and pharyngeal can graphic variability in disease frequency, high Epidemiology cers. The highest incidence among males is risk countries being in Southern Europe Cancers of the oral mucosa and oro and reported in Bas-Rhin and Calvados in France, (France, Italy, Spain), Eastern Europe (Russia, hypopharynx can be considered together, as whereas among females the highest occur Ukraine), South America (Uruguay, there are similarities in their epidemiology, rence is observed in India. Cancers of the Argentina), and Western Asia (Turkey, Iraq) treatment and prognosis. Mortality from laryngeal cancer is 232 Human cancers by organ site poorly known since hypopharyngeal cancer deaths are often mis-certified as deaths from cancer of the larynx. Carcinomas of the salivary glands and nasopharynx are distinguished from head and neck cancers at other sites both by epi demiology and by etiology. Nasopharyngeal cancer is relatively rare on a world scale (65,000 new cases per year, or 0. Age-standardized inci dence rates are high for populations living in or originating from Southern China, whilst populations elsewhere in China, South East Asia, North Africa, and the Inuits (Eskimos) of Canada and Alaska, all have moderately ele vated rates (Fig. In moderate-risk Age-standardized incidence/100,000 population populations, however, most notably in North Fig. High-risk countries are found in Southern Africa, there is a peak in incidence in adoles and Eastern Europe, Latin America and Western Asia. There appears to have been a decrease in incidence over time in some high-risk populations. Additional risk fac countries, in the Caribbean and in South cancer, particularly among young males in tors implicated in cancer of the larynx include American countries [1-3]. Consistently, Infection with Epstein-Barr virus is important these proportions vary amongst different studies also indicate a protective effect of a in the etiology of nasopharyngeal cancer. Tobacco smoking has also been diet rich in vegetables and fruits (20-60% this virus is not found in normal epithelial found to be an important risk factor for reduction in risk). A high intake of salted fish cells of the nasopharynx, but is present in all nasopharyngeal cancer in otherwise low-risk and meat and the release of nitrosamines on nasopharyngeal tumour cells, and even in populations. These risk factors have been cooking such foods have been linked to dysplastic precursor lesions [7] (Chronic shown, for laryngeal and oropharyngeal can nasopharyngeal cancer in endemic regions. Symptoms of oral can with or without other condiments), bidi (a and neck squamous cell carcinoma are very cer include pain, bleeding, difficulty in open locally hand-rolled cigarette of dried tem variable, ranging from 8-100%, but an unusu ing the mouth, chewing, swallowing and burni leaf containing coarse tobacco) smok al laryngeal pathologic subtype, verrucous speech, and a swelling in the neck. Early ing and drinking locally brewed crude alco laryngeal carcinoma, has a 100% prevalence lesions are often painless and present as holic drinks are the major causative factors. In more advanced stages, from Pakistan reported a high risk of oral itive than tumours at other head and neck a large ulceroproliferative mass, with areas of cancer [4]. Women with a history of in situ or inva necrosis, and extension to neighbouring Head and neck cancer 233 structures such as bone, muscles and skin may be evident. Cancers of the oral cavity may be preceded by, and present with, leuko plakias (Fig. Some 5-15% of patients with cancer of the lip mucosa present with lymph node metas tases, compared with more than 50-70% of those with tongue and floor of the mouth cancers.
A personal history of radiation to the abdomen (belly) or pelvic area to treat a prior cancer f antimicrobial fibers order azithromycin online pills. Anyone with these risk factors should speak with their health care provider about when they should begin screening and how often they should be screened bacteria found on mars cheap azithromycin 500mg on-line. In a Americans have a 5% lifetime risk of developing Pennsylvania study antibiotics for uti metronidazole discount azithromycin 250 mg with visa, the cost per patient with a primary colorectal cancer antibiotic resistance exam questions buy azithromycin on line amex. The manual antibiotics for acne pregnancy purchase discount azithromycin online, which provides step-by-step templates human eye antibiotics for dogs azithromycin 250mg cheap, and resources to get you started antibiotic rash proven 500mg azithromycin. Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers 8 may have had two or three visits but have not yet Step #1: Make a Plan designated a clinician as their primary care provider antibiotic wipes buy generic azithromycin 250 mg online. For example, some patients may have enrolled with one visit but have never been seen again in the clinic. Reproduced with permission from Panel Size: How Many Patients Can One Doctor Manage One useful tool to help collect and least one medical visit during the reporting year). The two most commonly used screening strategies for average-risk patients are either colonoscopy every 10 years or annual stool blood testing. Screening for colorectal cancer can reduce mortality rates only if screening is performed with adequate quality. It is important to emphasize that in-office stool testing and digital rectal exams are not appropriate methods of screening for colorectal cancer. In addition, colonoscopy was preferred despite the fact that 51% of providers reported colonoscopy was not readily available for their patients, and 82% felt that many of their patients had financial barriers to screening Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers 12 colonoscopy. One advantage of remember that colonoscopy will still be needed using colonoscopy as a primary screening method for for patients with positive stool blood tests. However, offering of the characteristics of each screening method is in only colonoscopy may be problematic. Choosing the Right Test Choosing the right test Do You Have: Family history of colorectal cancer Colonoscopy or polyps Provider and Or Yes patient determine Personal history of colorectal cancer or if testing should polyps or infammatory bowel disease For others, a stool blood test option will be or false-positive results in the presence of many important to offer to patients who refuse a colonoscopy. Either way, it is very important for programs to select a high-quality stool blood test. This analysis is one because the procedure is no longer categorized as a example of an effort to switch an entire system from screening once polyp removal occurs. This also remains an issue for samples mixed with liquid buffer, number of samples colonoscopies done after a positive stool-based test. Insured be added to the online/digital version of this manual as patients should be aware of this distinction when soon as it becomes available. We know that 15% of the population over 40 is likely to require colonoscopy because All programs must have colonoscopies of increased risk status. In some locations, limited capacity for colonoscopy results from a poor supply of colonoscopists, low For planning purposes, screening the rates of insurance coverage, or restricted acceptance entire increased-risk group in the first of Medicaid patients by colonoscopists. Though the We can calculate that for years 1-3 the total need may seem to be difficult to achieve, in fact it is need would be one-third of that or 150/3 = typically finite and measurable. Approaching specialists could be expected to spread out over and local hospitals for help in meeting the need more years. We can use five years for this for a specific number of colonoscopies per year is calculation, which means about 150/5 = 30 more effective than making an open-ended request. The calculation producing an estimate of the finite number needed can be derived in the following way: A (Year 1, 2, 3) = (0. This number (also epidemiologically 750), 5% of those are expected to have derived) is roughly about 15% of the population over 30 positive stool tests. Not all of the 15% at increased risk is likely to get a colonoscopy in the first year of a program. Once these increased-risk patients have had one colonoscopy, Year 1, 2, 3: 50 + 32 = 82 colonoscopies most of them will need repeat screening only once needed/year every 5-10 years. Years 4+: 30 + 32 = 62 total colonoscopies From these two numbers, the total number of needed/year colonoscopies needed per year can be determined. A sample calculation is as follows: 17 Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers Some of these colonoscopies can be purchased easily in the local health system marketplace by the patients who have Medicare or commercial insurance. With rising rates of private insurance through the new health exchanges, the number of colonoscopies requiring special planning may be even further reduced. If there are several gastroenterologists in the area, it may be possible to get more than one donated colonoscopy per week from each office. Despite rising rates of Medicaid coverage, the acceptance of Medicaid patients remains a problem in most medical marketplaces. These patients who are uninsured or inadequately insured may still need to be scheduled based on special agreements between the health center and area gastroenterologists, surgeons, or hospitals. While access to colonoscopy does depend on location, it is important to note that successful colonoscopy-based screening programs have been implemented in such geographically diverse regions of the country as New York City, rural Georgia, New Hampshire, and Colorado. See the following sections on identifying an internal champion and a physician champion who will help build a local culture that promotes cancer screening in the community. Many programs have found they can reduce the need for pre-procedure appointments with colonoscopists by sending patients who are fully prepared for colonoscopy and can receive the procedure on the day of their first contact with the colonoscopist. Primary Care Clinicians Evidence-Based Toolbox and A clear organizational structure is needed early in the Guide nccrt. Navigators can be recruited and this empowerment of the navigator role has been very trained from among patients, social workers, community 38,39 successful. It is important to note that patient navigators health workers, nurses, or case managers. For can be of assistance with other aspects of health, additional information on how to design a patient including chronic disease management, preventive care, navigation intervention for colorectal cancer and other cancer screenings. Additional Successful patient navigation has been implemented resources and manuals for patient navigators are in colorectal cancer screening programs in states and available in Appendix D-3. The effective use of patient navigators by Operation Access in San Francisco screening targeted to specific patient populations has led to a 97% patient compliance rate. Navigators in these programs have assisted with test choice, Empower the patients and educate them about scheduling appointments, patient support and the preparation. Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers 20 o Conduct calls for appointment reminders and to problems. These checklists are included in Appendix reinforce instructions for colonoscopy preparation. An important question for programs will include how to o obtain funding for patient navigators. Several programs Transition diagnosed patients to hospital patient with patient navigation systems currently have grants navigation. Coupling colorectal cancer New Hampshire Colorectal Cancer Screening screening with established annual flu shot Program is available in Appendix C-1. For additional websites describing evidence o based programs that could be useful in your Choose the specific type of stool-based kit and community, see Appendix D-5. The screening and objectives, assess the effect on the target process and office flow should be evaluated on an population, assess efficiency and effectiveness of ongoing basis. No Yes Make direct contact through postcard Follow guidelines, reminders, phone calls, and personal contact depending on *An alternate timeframe is to repeat the by outreach worker colonoscopy results reminder every 2 weeks for up to 2 months 23 Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers Partner with Colonoscopists. It is important to understand the level of need and capacity for colonoscopy in your community (see Step #1). Once this information is available, one of the most helpful strategies for finding colonoscopists is to identify a physician champion. Whether your program is based on offering all patients colonoscopy or emphasizing home stool testing for average-risk patients, access to colonoscopy services is essential for the success of any colorectal cancer screening program. Several pilot programs have implemented colorectal cancer screening programs in community health centers with a physician champion as a key component of their success. These efforts to improve screening often start at the physician level, and grow by recruiting other physicians to the cause. Oncologists and cancer surgeons are often the best hospital-based champions because they see many patients with late-stage disease that could have been prevented by screening. Following is a table outlining programs that have been championed by a physician(s) with a description of their effective strategies. Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers 24 Table 2. One study demonstrated that the in-office stool test missed 90% of cancers found at subsequent colonoscopy. This includes information on appropriate to have complete information about their medical and screening intervals, and how to stratify patients into family histories. All providers should be aware of the most recent guidelines for Conduct a risk assessment. Documentation of prior of either adenomatous polyps or colorectal cancer, screening should include the date, test, result, and no first-degree relatives with a history of either of recommended follow-up. It is always worth adding a reminder to Increased-risk patients have a personal or family all providers and staff that in-office stool history of adenomatous polyps or colorectal cancer. Genetic testing on Screening and Surveillance for the Early is often located in cancer centers that are interested in Detection of Colorectal Adenomas and Cancer in serving the community. However, genetic counseling People at Average Risk, Increased Risk, or at High and testing may not be accessible in rural communities. See the list below for moreinformation/colonandrectumcancerearlydetection/ a list of websites with additional information. If the answer to any one of these is information on how to find a genetic counselor yes, a genogram will help assess for other cancers at abgc. Train staff to communicate with patients and to provide appropriate test instructions. See Tables 3 and 4 on page 33 for eligibility criteria for direct endoscopy referral and for a list of colonoscopy preparatory agents. The main risks are perforation (making a small hole in the intestine), complications from anesthesia, or bleeding from the removal of a polyp. Testing may help prevent cancer or find it early while it can often be treated successfully. This is especially important because there are often no symptoms for colorectal cancer. If you have a polyp, it can be removed right there during the time of the colonoscopy, and taking it out can help prevent cancer. The main risks are perforation (making a small hole in the intestine), complications from anesthesia, or bleeding after polyp removal. If you are found to have blood in your stool, you will need a follow-up colonoscopy. These tests can also find cancers at an early stage while they can often be treated successfully. A colonoscopy is an exam in which the doctor inserts a thin, flexible tube to look at the inside of the intestine. This procedure allows us to find and painlessly remove growths (polyps) in the colon. If you have a polyp, it can be removed right there during the time of the colonoscopy, and taking it out may help prevent cancer. The main risks are perforation (making a small hole), complications from anesthesia, or bleeding following removal of a polyp. If there is any chance that we find a cancer, then treating it early may help save your life. Eligibility Criteria for Direct Endoscopy Referral31 Which patients are eligible for direct endoscopy referral This may be done in the primary care setting if good coordination and information fow exists with the endoscopy unit. At is the most influential factor on patient screening every visit, the provider and members of the provider behavior. They suggested using examples from high value on having only one test less frequently may real life, such as other patients who had a delayed prefer a colonoscopy, so that potential pre-cancerous cancer diagnosis. Communication plays a strong or cancerous polyps can be removed and biopsied at role between provider and patient. Patients who place a high value on reported they would sometimes speak bluntly to convenience, reassurance from more frequent testing, patients (especially those in a high-risk group) and or are uncomfortable with the more invasive test, may provide statistics to motivate them to get screened. It was also considered and a significant number of patients prefer a stool test necessary to hold the patient accountable and revisit over colonoscopy. One provider noted that in his experience patients the provider can help provide the best screening are more likely to accept a stool-based test after first recommendation using shared decision making. Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers 34 Ensure Quality Screening for For patients with a positive stool test who have not yet had diagnostic colonoscopy, patient navigators or other a Stool-based Screening Program. When giving normal (negative) results, it is always good to tell the patient that a repeat test will be needed in one year so that they know what to expect. Once colorectal screening has been completed, it is critical to follow-up on positive results. Track positive test results and refer all patients with positive tests for colonoscopy. This helps ensure that providers caring for the patient will be alerted to the result and need for follow-up if the patient fails to get a colonoscopy immediately. Follow up all patients who have a positive stool test Stool-based screening results in decreased incidence and with colonoscopy. Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers 36 Track Return Rates and Follow-up. A tickler file is created when a flag the chart with abnormal results so staff can notify copy of a lab order, referral, reminder, or tracking sheet patients and refer them for diagnostic colonoscopy. When results or reports are available, Orders with no accompanying results within a specified the copy can be pulled from the tickler file, the patient timeframe. Orders with no accompanying results within To help ensure patients follow through on referrals, 30 days can be followed up with a phone call by a patient navigators can help schedule the colonoscopy, staff member. See Appendix C for to provide prompts to the provider when patients who helpful tools on following up with patients. Seeing the alert, the provider can refer the patient for colonoscopy or office-based support staff can distribute screening 37 Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers Measure and Improve Performance.
Notation of defects in orientation antibiotics to treat pneumonia purchase 500 mg azithromycin, language problems (dysarthria headphones bacteria 700 times azithromycin 500 mg mastercard, expressive/recep tive aphasia infection questions buy azithromycin canada, paraphasias) may be reported here topical antibiotics for acne vulgaris buy cheap azithromycin 250mg online. As with mental status virus paralysis azithromycin 100mg on-line, it is not always clear when this is a cursory evaluation versus a summation of a detailed exami nation treatment for uti bactrim discount azithromycin 500 mg mastercard. Neurologists will often group cranial nerves into functional clusters including smell antibiotic guideline malaysia buy cheap azithromycin 500 mg online, taste antibiotic ointment for acne order 500mg azithromycin mastercard, vision and eye movement, hearing, swallowing, and facial and neck strength and sensa tion. Frequently, these are provided along with a stick drawing of a person with reflexes noted (see Fig. A variety of terms may be used to describe when it is present, but the most com mon will be action tremor (including postural, kinetic, physiological, and inten tion tremors) or resting tremor (classically, Parkinsonian tremor). Classically, it affects the upper limbs bilaterally, but may present worse in one limb (typi cally dominant hand). It can progress to be disabling, making writing illegible and preventing a patient from holding a cup of water to drink (see also Chap. When exaggerated, termed Enhanced Physiological tremor, by fright, anxiety, extreme exertion, withdraw from alcohol, toxic effects from some chemicals (caffeine, lithium, etc. Intention tremor refers to a tremor distinguished from other action or postural tremor by its form and associated features. Other abnormal movements, such as chorea, athetosis, dystonias, ballismus (often hemiballismus) or akinesia, are often noted here. Choreiform movements may involve the proximal or distal muscles and are involuntary, excessive, jerky, irregularly timed, and randomly distributed. Ballismus describes an extreme of choreiform movement in which motor movements are rapid and include violent flinging move ments. Hypertonicity refers to excess motor tension, presence of spasticity, lead pipe rigidity (rigidity of a limb maintained during and after passive movement of muscle), cogwheel rigidity (passive movement results in a cogwheel or ratchet like catching and quickly releasing as limb moves), and paratonia (involuntary vari able resistance to efforts at passive movement of a muscle, like a limb) (see Chaps. The presence of apraxia, ataxia and/or disorders associated with cerebellar function, such as dysmetria or dysdiadochokinesia, may be identified here or in the Gait and Balance section below. Apraxia refers to the loss of ability to complete previously learned purposeful motor movements, not due to motor weakness (see Chap. Ataxia refers to inability to coordinate muscle movements that is not due to motor weakness. Ataxic respiration is the poor coordination of muscles in chest and diagram, related to damage of the respiratory centers in the medulla oblongata or associated pathways. Dysmetria is abnormal movements associated with cerebellar damage, and involves dysfunction in the ability to accurately control the range of movement needed for a muscular action. Dysdiadochokinesia is the inability to complete rapid alternating movements associated with cerebellar ataxia, and is often tested by having a patient rap idly alternate slapping the palm of each hand and back of the hand on a stable surface. Gait may be described with various terms, but some of the more common include: normal, spastic, apraxic (wide based), ataxic (also wide-based), parkinsonian, steppage, or scissored gait (see Fig. Basic sensory modalities include light touch, pain sensation, vibratory sensation and joint position testing. Presence of agraphasthesia is asso ciated with contralateral parietal lobe damage. Frequently listed after the physical examination in both the admission note and daily progress notes, laboratory evaluations include many abbreviations and common ways of recording the results. Outpatient Medical Chart the outpatient medical chart is often very similar to the inpatient chart, although follow-up visit notes may note less detail than above for some medical subspecial ties. However, like the inpatient medical chart, the beginning consultation (office visit) report generally will include a detailed written report of the patients present ing history and medical evaluation similar in format (often identical to) that reviewed above for the inpatient medical record. Chapter 3 Neuroanatomy Primer: Structure and Function of the Human Nervous System Mike R. Lerner Abstract this chapter is provided as a general primer for the neuropsychologist and others interested in functional neuroanatomy. This chapter is not meant as a detailed examination of the nervous system, and readers are encouraged to review comprehensive texts in the area for further detail. Oxford University Press, New York, 2007; Kolb B, Whishaw I, Fundamentals of human neuropsychology, 6th edn. While neuropsychologists are generally well versed in aspects and organization of the central nervous system, particularly the cerebral cortex, less attention is given to the spinal cord, brain stem, diencephalon, and peripheral nervous system. This chapter will also provide a brief overview of gross pathology of the skull, meninges, cerebral spinal fluid, and important afferent and efferent pathways of the human nervous system. The parasympathetic nervous system maintains consistent homeostasis while the sympathetic nervous system involves the changes necessary to respond to threats. Lasts about 1 ms and can travel rapidly throughout the length of a neuron at rates up to around 60 m/s. Classically, they travel from the dendritic end of a neuron along its axon to reach presynap tic terminals, and are often coupled to neu rotransmitter release from the presynaptic terminal. For example sensory pathways are afferent, sending sensory infor mation to the brain. Basal ganglia Term used to describe a cluster of nuclei lying in the deep white matter under the cerebral cortex. Commissure White matter pathway connecting analogous structures between the right and left hemi spheres of the brain. The corpus callosum is divided into four sections: rostrum, genu, body, and splenium. Classically motor pathways are frequently thought of as taking motor signals from the brain to muscles, and are termed effer ents or efferent (fibers, pathways, or tracts). Fascicle/fasciculus White matter tract connecting areas within a (see also fiber) hemisphere. Fibers fascicle, lemniscus, or tract) have been classified as association, commis sural, or projection. Gyri Bumps or ridges between sulci giving the cortex its characteristic wrinkled appearance. Longitudinal fissure Midline fissure separating the two (or interhemispheric fissure) hemispheres. Myelin sheath Insulating lipid layer of an axon formed by specialized glial cells speeds the rate of action potential conduction. Schwann cells wrap around the axons of neurons to form the myelin sheath for nerves which increases speed of neuronal transmission via salutatory conduction. Synapse Gap or space between two neuron structures in which neurotransmitter substances are trans ferred and cellular communication occurs. The brain is a three-pound organ encased in the skull while the spinal cord is located in the spinal canal within the vertebrae. The cranial nerves include somatosensory and motor functions, and a description of the function and assessment of each cranial nerve is provided in Chap. Fourteen of the bones make up the facial structures of the skull and 8 cranial bones house the brain. The cranial bones include: Parietal, Temporal, Occipital, Frontal and right and left Ethmoid and Sphenoid bones (see also Fig. The meninges surround the entire brain and spinal cord, and are composed of three different membranes: Dura mater, Arachnoid mater, and Pia mater. Adherent to the inside of the cranial bones and surrounding the entire brain is the Dura mater. In addition to surrounding the brain, the dura folds to divide the cranium into separate compartments and create the venus sinuses which drain blood from the brain. The falx cerebri divides the cranium vertically into right and left compartments housing the right and left hemispheres of the brain. The tentorium cerebelli supports the occipital lobes hori zontally and separates them from the cerebellum. The falx cerebelli is analogous to the falx cerebri and separates the left and right hemispheres of the cerebellum. The next layer is the arachnoid, which is an elastic and fibrous two-layered membrane lining the inner surface of the Dura mater. Between the dura and the arachnoid mater is a non-communicating space called the subdural space. Subdural veins with very little mechanical support traverse the subdural space and are susceptible to mechanical injury (subdural hemorrhage). Because the subdural space is non communicating (closed space), bleeding from a subdural vein accumulates to create a subdural hematoma. Subdural hematomas can become large and exert pressure on brain structures necessitating external drainage through the skull (see Chap. Inferior to the arachnoid mater is a fine membrane rich in blood supply called the pia mater. The pia mater is intimately associated with the brain surface, following all the sulci, gyri and conformations of Fig. Damage to blood vessels here results in subarachnoid hemorrhages, which may result in blood products entering the spaces of the cerebrospinal fluid. Brain Anatomy Overview the brain is divided into Hindbrain (Rhombencephalon), Midbrain (Mesencephalon) and Forebrain (Prosencephalon) based on anatomic location and embryologic ori gin of the tissues which make up each division (see Fig. The hindbrain and midbrain contain nuclei essential for sustaining life and homeostasis. The forebrain includes the basal ganglia, white matter, and neocortex traditionally associated with complex behaviors and cognition. The Hindbrain (Rhombencephalon) is composed of the Medulla, Oblongata, Pons and Cerebellum. The medulla oblongata (or medulla) is the most rostral portion of the brain and continues to form the spinal cord as it exits the skull. Centers for respiration, vaso motor and cardiac control, as well as many mechanisms for controlling reflex activities such as coughing, gagging, swallowing and vomiting, are located in the medulla. A group of neurons referred to as the pontine respiratory group, which influences the rate of breathing, is located in the upper pons. In addition to respiration, the pons is associated with sensory (crossed afferent pathways) and motor functions (crossed efferent pathways) and arousal and attention due to function of locus cerelus and general projection of norepinephrine throughout brain (see below). The cerebellum is a structure attached to the brain stem via the cerebellar peduncles that appears like a second smaller brain. It is divided into right and left hemispheres with a midline structure referred to as the vermis. Like the cerebrum, the cerebellum has an outer cortex, an inner white matter, and deep nuclei below the white matter. The traditional func tion of the cerebellum has been considered coordination of voluntary motor move ment, balance and equilibrium, and muscle tone. However, more recently, the cerebellum has been shown to be involved in some types of learning (nondeclarative or implicit learning). The cerebellum receives indirect input from the cerebral cortex, including information from: (1) sensory areas of the cerebral cortex, (2) motor areas, (3) cognitive/language/emotional areas of the cortex and thalamic nuclei. The Midbrain (Mesencephalon) is composed of the Tectum, Cerebral peduncles, Tegmentum, Pretectum, and Mesencephalic duct (aka aqueduct of Sylvias) (see Figs. The superior colliculus is involved in preliminary visual processing and control of eye movements (automatic/uncon scious visual orientation). Afferent fibers than project to the thalamus to relay auditory information to the primary auditory cortex. The cerebral peduncles are the part of the midbrain that links the remainder of the brainstem to the thalami. The midbrain tegmentum is the part of the midbrain extending from the substan tia nigra to the cerebral aqueduct in a horizontal section of the midbrain, and forms the floor of the midbrain which surrounds the cerebral aqueduct. Running through the midbrain tegmentum is the reticular formation, which is integrally involved in maintenance of arousal and the conscious state. The ventral tegmental area has a concentration of dopaminergic neurons which project to the nucleus accumbens, limbic structures, and frontal lobes. The pretectum receives input from retinal cells, and is responsible for the pupillary light reflex. The Mesencephalic Duct (aqueduct of Sylvius), connects the third and fourth ventricles. Term to describe a part of the brain that includes the Epithalamus, Thalamus, Hypothalamus, Subthalamus, Pituitary gland, Pineal gland, and the Third ventricle (see Figs. The thalamus is a roughly football-shaped pair of structures at the top of the midbrain. All afferent somatosensory neurons, except olfaction (smell), synapse at thalamic nuclei prior to reaching the cerebral cortex. Efferent motor commands are processed by thalamic nuclei as well, prior to being acted on. In addition to senses, the thalamus receives input from the cerebral cortex, basal ganglia as well as brain stem/cerebellum nuclei (see Fig. The fourth nuclear group is a series of nuclei that lie within the internal medullary lamina termed the intralaminar nuclei. The fifth thalamic nuclear group, a thin wall of neurons covering the lateral aspect of the thalamus, is termed the reticular nucleus. The nuclei of the thalamus are of three types: Relay, Association, and Nonspecific nuclei. Relay nuclei have well-defined afferent projections and relay this to func tionally distinct cerebral cortex areas (see Table 3. These nuclei maintain a somatotropic organization from afferent to efferent projections. Association nuclei receive afferents (input projections) from the cerebral cortex and project back to association cortex [e. All thalamic nuclei have reciprocal projections to and from the reticular nuclei of the thalamus and associated cortical regions. Clinically, lesions to the thalamus are typically associated with marked neurologic impairment.
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