Correlation between squamous cytology results and any squamous histology that was performed within 6 months is shown in Figure 3 gastritis vs heart attack discount protonix 20 mg amex. These data do not include cytology tests not followed by histology gastritis diet book buy 20 mg protonix with amex, for which it is not possible to know the true disease state gastritis symptoms loose stools buy protonix cheap online, or for cytology tests followed by histology more than 6 months after the cytology test gastritis in dogs purchase 40 mg protonix overnight delivery. For clarity gastritis pancreatitis symptoms cheap protonix 20 mg with visa, the text around the results clearly states which calculation has been used jenis diet gastritis discount protonix 40 mg without a prescription. Negative and low-grade abnormalities were not usually followed up with histology gastritis diet евросеть order protonix with american express, so these results should not be considered indicative of all negative and low-grade cytology gastritis diet zucchini protonix 40 mg otc. Of note, very few predictions of possible low-grade or low-grade cytology, for which there was histology performed within 6 months, were found to be cancer. Cervical screening in Australia 2018 15 Possible and definite high-grade squamous abnormalities were usually followed up by colposcopy, and often by histology, so these results can be considered indicative. This is despite abnormalities preceding adenocarcinoma being less well understood than the abnormalities preceding squamous cell carcinoma, and the adequate sampling and subsequent interpretation of endocervical cells being more difficult. These factors all affect the correlation between endocervical cytology and endocervical histology. In the correlation for cases that were followed by histology, these atypical cells were sometimes found to be a serious abnormality, but often found to be not associated with any abnormality. Detection of high-grade abnormalities in this context is by histology, not by cytology. This means that, for every 1,000 women screened, just over 7 had a high-grade abnormality discovered, providing an opportunity for treatment before possible progression to cervical cancer. It is not clear why there was an increase in high-grade abnormality detection for those years. Contributing factors may include the increased use of immunohistochemistry, which can assist in the confirmation of high-grade abnormalities. In contrast with the overall trend of increasing detection over time, there was a steady decline in high-grade abnormality detection in younger women. In addition, this continued decrease in rates for the younger age groups appears to be affecting the overall high-grade abnormality detection rate, despite the other factors that have driven it up, as the latest age-standardised rates of 7. Each cancer has a national screening program, with both Australian Government and state and territory government components. The Australian Government provides funding to the states and territories for public health services through National Health Reform Payments (known as National Specific Purpose Payments prior to 1 July 2012) and National Partnership Payments. The funding for the National Bowel Cancer Screening Program is through a specific National Partnership Payment. In addition, by moving to the nonavalent vaccine, and decreasing the number of recommended doses, the rate of compliance with the vaccination schedule is expected to increase. Data in this section are sourced from the 2014 version of the Australian Cancer Database. In 2018, it is estimated that there will be 930 new cases of cervical cancer, equivalent to 7. Incidence remained steady for this age group at around 9 new cases per 100,000 women until 2010 to 2014, for which incidence was around 10 new cases per 100,000 women (Figure 4. Incidence for women of all ages has been steady at around 7 new cases per 100,000 women from 2002 to 2014. This has decreased substantially over time, due to cervical screening either detecting these cervical cancers earlier or preventing their occurrence altogether. Histology codes for cancers are collected in the Australian Cancer Database, which allows the analysis of trends in cervical cancer incidence for different histological types. The histological types presented are based on the histological groupings for cervical cancer set out in Chapter 4 of Cancer incidence in five continents vol. Thus, cervical cancer has been disaggregated into the broad histological types of carcinoma (cancers of epithelial origin), sarcoma (cancers originating in connective tissue such as bone, muscle and fat), and other specified and unspecified malignant neoplasms (unusual cancers and cancers too poorly differentiated to be classified). Carcinoma has been further split into squamous cell carcinoma (which arises from the squamous cells that cover the outer surface of the cervix), adenocarcinoma (which arises from the glandular (columnar) cells in the endocervical canal), adenosquamous carcinoma (which contains malignant squamous and glandular cells), and other carcinoma. Within the carcinomas, squamous cell carcinoma comprised the greatest proportion at 68. Incidence trends for adenosquamous and other carcinomas are more difficult to ascertain due to small numbers, both having an incidence of less than 1 new case per 100,000 women. In contrast, adenocarcinomas have not been reduced by cervical screening to the same degree. The inability of cervical screening to reduce glandular cancers below the level reached a decade ago is recognised as a reflection of the difficulties in sampling glandular cells (Sasieni et al. Further, the cytological interpretation of abnormal glandular cells that are sampled (which occur much less frequently than squamous abnormalities) is more difficult, and the progression from glandular abnormality to adenocarcinoma is not well characterised (Sasieni et al. Some cervical cancers do not have a precancerous stage, and therefore cannot be detected, so their incidence is not affected by cervical screening. The source of survival data is the 2014 Australian Cancer Database which includes data from the National Death Index on deaths (from any cause) that occurred up to 31 December 2014, which were used to determine which people with cancer had died and when this occurred. In this graph, the lighter blue line shows relative survival for each year after diagnosis (as shown by the numbers in black on the x-axis), whereas the darker blue line shows relative survival for each year once an individual has already survived a certain number of years (as shown by the numbers in grey on the x-axis). The source of prevalence data is the 2014 Australian Cancer Database which includes data from the National Death Index on deaths (from any cause) that occurred up to 31 December 2014, which were used to determine which people with cancer had died and when this occurred. Individuals who have been diagnosed with cancer and are still alive contribute to prevalence data. The latest national data available at the time of publication were for deaths in 2015. In 2018, it is estimated that there will be 258 deaths from cervical cancer, equivalent to 1. The large reduction in mortality occurred after the introduction of organised cervical screening in 1991, with the greatest reduction occurring in older women. Number of deaths Number of deaths per 100,000 women 300 6 Number of deaths Number of deaths per 100,000 women 250 5 200 4 150 3 100 2 50 1 0 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 Year Notes 1. The rankings for cervical cancer according to the 3 measures that comprise burden of disease are shown in Table 4. Cervical screening in Australia 2018 39 5 Cervical screening and cervical cancer outcomes in Indigenous women Aboriginal and Torres Strait Islander women of Australia, hereafter respectfully referred to as Indigenous women, experience a high burden from cervical cancer compared with non-Indigenous women. It is also the fifth most common cancer in Indigenous women (behind breast, lung, colorectal and uterus). This chapter therefore aims to bring together the cervical screening participation, incidence and mortality data, and supplements these with additional analyses on incidence, survival and mortality data, as well as incorporating relevant data and findings from other published sources. To determine to what extent initiatives are achieving their desired aims, it is important that participation in cervical screening be measured by Indigenous status to provide an evidence base, both to benchmark current rates and to monitor ongoing rates. At the time of reporting, participation in cervical screening cannot be measured nationally for Indigenous women because Indigenous status is not included on all pathology forms in all states and territories, the only source of information for cervical screening registers. However, we can draw on some published data, and a growing body of evidence indicates that Indigenous women are under-screened. Coory and others (2002) found that participation in 13 rural and remote Indigenous communities in Queensland was 41. As this data set matures, it will become increasingly useful for understanding the extent of participation by Indigenous women attending these services. Since identification of Indigenous women on cervical screening data is the major impediment to the reporting of participation by Indigenous status, recent research using data linkage to transfer Indigenous status from the Queensland Health Admitted Patient Data Collection to data from the Queensland Health Pap Smear Register has provided new insights into participation of Indigenous women in cervical screening in Queensland. Disparities such as this in participation in cervical screening are likely to have downstream effects on cancer incidence and mortality in Indigenous women. This is because cervical screening is able to detect precancerous abnormalities, thereby preventing cancers from developing, and reducing the incidence of malignant disease. Cancers that are detected are also more likely to be at an earlier stage, which tends to be associated with better survival, if treated. The cervical cancer outcomes of incidence, survival and mortality in Indigenous women are explored in the next section. Like the state and territory cervical screening registers, the cancer registers rely on pathology forms as their primary source of information, which, as discussed previously, do not include Indigenous status in all states and territories. Unlike the cervical screening registers, however, the cancer registers collect information from additional sources, such as hospital records and death records, which allows information on Indigenous status to be collected. The level of identification of Indigenous status is considered sufficient to enable analysis in 5 jurisdictionsfiew South Wales, Victoria, Queensland, Western Australia and the Northern Territory. It is also unclear how many Indigenous Australians are misclassified as non-Indigenous. Number of new cases per 100,000 women 25 20 15 10 5 0 Indigenous Non-Indigenous Total Indigenous status Note: Rates age-standardised to the Australian population as at 30 June 2001. A second consideration is comparability of populations, since, after the 2011 Census, Indigenous populations were rebased and recast back to 2001, resulting in higher population estimates for Indigenous women. This means that, to cover the range of cancer incidence data, two sources of population data need to be usedfiistorical populations available from 1986 to 2001, and current populations available from 2001 to 2011fihich, due to the recasting, no longer form a series. In considering this time trend, note that the first 2 points include data only from Western Australia and the Northern Territory, with Queensland being introduced from 1997, New South Wales from 1999, and Victoria from 2008. Again, there is evidence that there has been a decrease in cervical cancer mortality in Indigenous women. Direct comparisons between the states and territories of Australia are not advised, due to the substantial differences that exist between the jurisdictions, including population, area, geographical structure, policies and other factors. Caution is required when examining differences across remoteness areas (see Appendix D). Caution is required when examining differences across socioeconomic groups (see Appendix D). Direct comparisons between the states and territories of Australia are not advised, due to the substantial differences that exist between the jurisdictions, including population, area, geographical structure, and policies. For national consistency, the histology results of endocervical dysplasia and adenocarcinoma in situ are grouped to form a broad high-grade abnormality category, and microinvasive and invasive adenocarcinoma are grouped to form a broad adenocarcinoma category. The histology results of adenosquamous carcinoma and carcinoma of the cervix (other) are excluded, since these are not solely squamous or endocervical in origin, and thus would not necessarily be expected to correlate with cytology results of either cell type. Remoteness classification is based on area of usual residence (Statistical Local Area Level 2) at the time of diagnosis. Some states and territories use an imputation method for determining Indigenous cancers, which may lead to differences between these data and those shown in jurisdictional cancer incidence reports. Data from these jurisdictions for these years were considered to have adequate levels of Indigenous identification in cancer registration data at the time this report was prepared. Cervical screening in Australia 2018 71 Survival after a diagnosis of cervical cancer Table A6. Cervical screening in Australia 2018 73 A7 Mortality from cervical cancer 74 Cervical screening in Australia 2018 Table A7. Remoteness classification is based on area of usual residence (Statistical Local Area Level 2) at time of death. Data from these jurisdictions for these years were considered to have adequate levels of Indigenous identification in cancer mortality data at the time this report was prepared. Deaths registered in 2013 and earlier are based on the final version of cause of death data. These are used as a guide to interpretation only, since this is Cervical screening in Australia 2018 79 a different purpose from that for which these standards were developed, and differences in definitions and data may exist. For the purposes of this report, actual mortality data are based on the year the death occurred, except for the most recent year (2015), for which the number of people whose death was registered is used. However, in some instances, deaths at the end of each calendar year may not be registered until the following year. Thus, year-of-death information for the latest available year is generally an underestimate of the actual number of deaths that occurred in that year. Hysterectomy fractions Hysterectomy fractions represent the proportion of women with an intact uterus (and cervix) at a particular age, and are the tool used to adjust the population for participation calculations. The results of these combined approaches are robust hysterectomy fractions that reflect both historical and current hysterectomy trends, which can be used in the calculation of participation in cervical screening for the most recent participation data. The fractions themselves are similar to previous estimates taken from population health surveys, with the proportion of women with an intact cervix remaining comparatively higher in most age groups, a reflection of the national trend of decreasing incidence of hysterectomies over time. The incorporation of these new hysterectomy fractions, based on lower prevalence of hysterectomy procedures, into cervical screening participation calculations results in a slight decrease in the participation rate compared with calculations using the previous hysterectomy fractions, as would be expected, since the population at risk (and therefore the population eligible for cervical screening) is larger. This means that it is possible for a woman to be double-counted in the screening data. If she was screened in 1 jurisdiction and then screened again less than 2 years later in another jurisdiction, both screens may be included in participation. The remoteness structure divides each state and territory into several regions on the basis of their relative access to services. This index is based on factors such as average household income, education levels and unemployment rates. For participation, women were allocated to a socioeconomic group using their residential postcode, as supplied at the time of screening. Classification of cervical cancer by histology Histology codes to classify cervical cancer into histological groups are listed in Table D1. For example, a crude cancer incidence rate is similarly defined as the number of new cases of cancer in a specified period of time divided by the population at risk. Crude mortality rates and cancer incidence rates are expressed in this report as number of deaths or new cases per 100,000 population. Age-specific rates Age-specific rates provide information on the incidence of a particular event in an age group, relative to the total number of people at risk of that event in the same age group. Age-standardised rates A crude rate provides information on the number of, for example, new cases of cancer or deaths from cancer in the population at risk in a specified period. Since the risk of cancer is heavily dependent on age, crude rates are not suitable for looking at trends or making comparisons across groups in cancer incidence and mortality. More meaningful comparisons can be made by using age-standardised rates, with such rates adjusted for age in order to facilitate comparisons between populations that have different age structures, for example, between Indigenous people and other Australians. In this report, the direct standardisation approach presented by Jensen and colleagues (1991) is used. To age-standardise using the direct method, the first step is to obtain population numbers and numbers of cases (or deaths) in age ranges, typically 5-year age ranges. The next step is to multiply the age-specific population numbers for the standard population (in this case, the Australian population as at 30 June 2001) by the age-specific incidence rates (or death rates) for the population of interest (such as those in a certain socioeconomic group or those who lived in Major cities). The next step is to sum across the age groups and divide this sum by the total of the standard population, to give an age-standardised rate for the population of interest. These cells can invade and damage the area around them, and can also spread to other parts of the body to cause further damage. People with cancer who die of other causes are not counted in the mortality statistics in this publication. Disability-adjusted life years: A measure (in years) of healthy life lost, either through premature death, defined as dying before the ideal life span or, equivalently, through living with ill health due to illness or injury. One person may have more than one cancer and therefore may be counted twice in incidence statistics if it is decided that the 2 cancers are not of the same origin. This decision is based on a series of principles, set out in more detail in a publication by Jensen et al. During a Pap test, cells are collected from the transformation zone of the cervix, the area of the cervix where the squamous cells from the outer opening of the cervix and glandular cells from the endocervical canal meet. For conventional cytology, these cells are transferred onto a slide, and sent to a pathology laboratory for assessment. The screening test is used to identify people who require further investigation to determine the presence or absence of disease, and is not primarily a diagnostic test. The purpose of screening an asymptomatic individual is to detect early evidence of an abnormality or abnormalities, such as pre-malignant changes (for example, by Pap test) or early invasive malignancy (for example, by mammography), in order to recommend preventive strategies or treatment that will provide a better health outcome than if the disease were diagnosed at a later stage. This may be due to either too few or too many cells, or to the presence of blood or other factors obscuring the cells, or to poor staining or preservation. Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011. National Key Performance Indicators for Aboriginal and Torres Strait Islander primary health care: results from June 2016. National key performance indicators for Aboriginal and Torres Strait Islander primary health care series no. Participation in cervical screening by Indigenous women in the Northern Territory: a longitudinal study. National Cervical Screening Program: guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Cervical cancer in Australia and the United Kingdom: comparison of screening policy and uptake, and cancer incidence and mortality. Report of the Steering Group on Quality Assurance in Screening for the Prevention of Cancer of the Cervix. Trends in cancer incidence and survival for Indigenous and non-Indigenous people in the Northern Territory. Participation in cervical screening by women in rural and remote Aboriginal and Torres Strait Islander communities in Queensland. Cervical cancer screening in Australia: modelled evaluation of the impact of changing the recommended interval from two to three years. Principles of practice, standards and guidelines for providers of cervical screening services for Indigenous women. Benefits and harms of cervical screening from age 20 years compared with screening from age 25 years. Benchmarking epidemiological characteristics of cervical cancer in advance of change in screening practice and commencement of vaccination. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities. Outcomes of screening to prevent cancer: analysis of cumulative incidence of cervical abnormality and modelling of cases and deaths prevented.
Distribution down the ladder is by pull system gastritis diet for children 20 mg protonix visa, done quarterly at provincial and monthly at district levels gastritis and ulcers buy discount protonix 40 mg line. The Government of the Republic of Zambia Public Finance Act and related financial regulations gastritis zimt buy protonix 20 mg on line, as well as generally accepted accounting principles gastritis kronis pdf buy protonix cheap online, will be used to account for the resources which will be received under the grant gastritis unspecified icd 9 code buy protonix with amex. While the Zambia Public Procurement Act will apply to all Procurements under the grant gastritis diet 7-up purchase cheap protonix on-line. Monitoring of performance will be conducted through data review of administrative reports including number of girls vaccinated diet bei gastritis order protonix without a prescription, fully vaccinated and drop out rate gastritis diet treatment medications purchase protonix 40mg overnight delivery. Tally sheets will be used to capture daily vaccinations and reported at the end of each day to the district, province, and national command centres. Note that the necessary time for licensure should be factored into the introduction timeline and reflected in the Vaccine Introduction Plan or Plan of Action. For each of the vaccine(s) requested, please provide the actual licensure status of the preferred presentation and of any alternative presentations, if required. Please describe local customs regulations, requirements for pre-delivery inspection, special documentation requirements that may potentially cause delays in receiving the vaccine. This should include details on sufficient availability of waste management supplies (including safety boxes), the safe handling, storage, transportation and disposal of immunisation waste, as part of a healthcare waste management strategy. An official immunization record from your doctor or another school will be accepted. Due dates for undergraduate students: July 8, 2020 for Fall 2020 semester start and December 13, 2020 for Spring 2021 start. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Moscicki et al (2012) Updating the Natural History of Human Papillomavirus and Anogenital Cancers. Peitzmeier et al (Forthcoming) Pap Test Use Lower among Female-to-Male Patients than Non-Transgender Women. Identify strategies that providers can use to address these systems, interpersonal, and technical barriers, including specific techniques for adjusting the Pap exam 4. Saslow et al (2012) American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer. This article focuses on Malawi, but the issues are relevant to other lowincome settings. Our studies of a most common female cancer, with approximately 528,000 screening population in Nkhoma in rural Malawi suggest a cancers in 2012 (1, 2). Persistence of infection and progression to cancer Expanded vaccination of adult women 3 doses regimen may therefore be linked to a failure of the immune response, Secondary prevention: Papanicolaou. Cervical cancer has become a screening approach used in any particular context (country, rare disease in high-income countries, and there is widespread or healthcare facility) dependent on factors that include the consensus that these very substantial benefts would not balance of benefts and harms, the potential for women to be lost have come about in the absence of substantial investments to follow-up, cost and availability of the necessary equipment in screening (24). Organized screening thermo-ablation) programmes seek to ensure that the steps of call and recall Different approaches are needed in poor regions of the world. In recent years there has been renewed these barriers constitute an enormous challenge if we are interest in use of thermo-coagulation (also known as cold to improve cervical cancer prevention in poor countries such coagulation or increasingly, thermal ablation) to treat cervical as Malawi. Both screening test (Qiagen), concluded further developments were vaccines have been in use in different countries since 2006. Tanzania is now in the second year of a trained healthcare professional, it would be quicker to provide demonstration project, delivered in schools by campaign weeks. There is therefore considerable Malaysia was the frst Muslim country to introduce a national interest in self-collected specimens. She is currently Chair of the Screening Cervical cancer impacts family, community and national life. Recent and ongoing projects span the cancer journey from are beyond the scope of this article. Nonetheless, it is important screening through symptomatic diagnosis and survivorship, but with to recognise that such evidence is available. Non-communicable an emphasis on cancer screening both within the United Kingdom diseases, including cervical cancer, have been shown to adversely and in sub-Saharan Africa. She leads a programme of research in the interface of and international research and government committees on cancer, cancer and primary care. Comparison treat approach for the treatment of cervical precancerous lesions in sub-Saharan Africa. Reproductive health carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies. Barriers to utilisation of cervical cancer screening in Sub Sahara Africa: 368-83. Integrated Review of Barriers to Cervical 27 Cancer Screening in Sub-Saharan Africa. Bruni L, Diaz M, Barrionuevo-Rosas L, Herrero R, Bray F, Bosch X, de Sanjose S, 18. Global estimates of human papillomavirus vaccination coverage by papillomavirus, human immunodefciency virus and immunosuppression. The cervical cancer epidemic that screening of invasive cervical cancer: follow-up of four European randomised controlled trials. Breast and cervical cancer screening programme implementation in 16 testing for the detection of cervical cancer. Effect of visual screening on cervical 20:1355-13 cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. The aim of the programme is to protect girls from their future risk of developing cervical cancer. Girls with at least stage 3 are considered to have completed a course of vaccination. All the denominator data was entered on the immunisation database by the relevant System Administrator. These figures are provisional and subject to change due to ongoing updating of data on the database. The identification of denominator data for the target birth cohorts in these settings was difficult and staff focused on vaccinations rather than defining cohort numbers accurately. Total doses administered A total of 139,646 administered vaccine doses were recorded. This cohort predominantly received vaccine in general practice as 7 many of these individuals were not in full-time education. Some girls aged 13 years were in second year of secondary school during the first year of the programme and were therefore eligible for immunisation as part of the routine programme. These girls are excluded from the catch-up cohort figures, as they were offered immunisation as part of the routine programme. The recommended vaccination ages are diverse ranging from 10 to 18 years as are the ages for the catch-up campaigns, where they range from 12 to 24 years. There was also variation between countries in the vaccination delivery infrastructure and financing. It is particularly encouraging to see the very high retention of girls within the programme once they commence vaccination. Similarily, "at least stage 3" means a person had a stage 3 recorded on the database, they may or may not have had stage 1 or a stage 2 recorded. Similarily, "at least stage 2" means a person had a stage 2 recorded on the database, they may or may not have had stage 1 or a stage 3 recorded. The Role of Human Papillomavirus Vaccines in Reducing the Risk of Cervical Cancer in Ireland A Health Technology Assessment. Background: Cervical cancer is the second commonest cancer amongst Sri Lankan women. Methods: Primigravids attending Colombo North Teaching Hospital antenatal clinics were recruited over 8 months as surrogates for women who have recently become sexually active. Among those aware of Pap screening, generally there were favourable attitudes to having a test. These data have implications for acceptance of the vaccine and any future expansion of cervical screening with newer, more cost-effective technologies. Sri Lanka ranks conservative societal attitudes to sexual relationships outside fourth in the age standardised incidence rates of cervical cancer, marriage. Cytology is conducted in Well Woman Clinics country4 Colombo North Teaching Hospital is a large government wide, but the coverage was less than 40. Currently Pap screening is recommended 5 of Colombo, and provides free healthcare services. Lack pilot tested for readability and ease of understanding on 10 of awareness may still reduce the vaccine uptake. Two rounds of revision were done to ensure face the vaccine into the target population. The aim of this study was to assess the knowledge using a seven-point Likert scale. Asyoungsexuallyactivewomenarethemostvulnerable clarify any doubts or answer any questions the participants 214 Sexual Health A. For the two questions on Pap test, half of the in focus was strongly associated with level of education participants answered them correctly, while 37. Among the participants aware of the Pap test, considered having a regular Pap smear as an important health 16 (26. Half of married 25to 65-year-old Sri Lankan women attending a them were willing to be vaccinated if the vaccine is offered medical clinic of a tertiary care hospital in 2013, 59. Only eighteen percent who should be vaccinated, when the vaccine should be 15 had undergone a Pap test. In a study in the major strength of this study was targeting a young Mangalore, India, among pre-university and degree college sexually active female population using primigravid women students, 16. Undergraduates of Bhutan had study setting used to recruit subjects was a tertiary care public 11 similar levels of knowledge. Cervical cancer is not included in the and comprehensive education program to the general public, as school curriculum and there is no national level public health well as clinicians, to ensure good uptake of the vaccine. Cervical cancer knowledge and screening Acknowledgements behaviors among female university graduates of year 2012 attending national graduate orientation program, Bhutan. We are grateful to the Knowledge and practices on breast and cervical cancer screening hospital staff at the Colombo North Teaching Hospital for facilitating our methods among female health care workers: a Sri Lankan experience. Knowledge, attitudes and practice toward cervical utmost gratitude to all study participants for their invaluable contribution. Impact and effectiveness of the 21 Department of Census and Statistics, Ministry of Policy Planning quadrivalent human papillomavirus vaccine: a systematic review Economic Affairs, Child Youth and Cultural Affairs Sri Lanka. There are three main sources of human protein in vaccines: (1) fetal cell lines, (2) human albumin derived from human blood and (3) human albumin genetically engineered from yeast. In addition to the substances listed, most vaccines contain Sodium Chloride (table salt). October, 2011 Hep B (Recombivax) yeast protein, soy peptone, dextrose, amino acids, mineral salts, potassium aluminum sulfate, amorphous aluminum hydroxyphosphate sulfate, formaldehyde. Excluded material owned by third parties may include, for example, design and layout, images obtained under licence from third parties and signatures. This report was produced in collaboration with the National Cervical Screening Program, and thanks are extended to the state and territory program and data managers listed below for providing data, expertise and overall assistance in the production of this document. Financial support and professional assistance provided by the Screening Policy Section of the Australian Government Department of Health are also gratefully acknowledged. This is equivalent to 10 new cases of cervical cancer diagnosed and 2 deaths per 100,000 women. High-grade abnormality detection rate continued to decline in young women In 2016, for every 1,000 women screened, 7 women had a high-grade abnormality detected by histology, providing an opportunity for treatment before possible progression to cancer. The rate of detection of high-grade abnormalities for women under 30 has declined. Indigenous women had lower screening rates and poorer outcomes National participation rates for Aboriginal and Torres Strait Islander women are not available, as Indigenous status information is not collected on pathology forms in all jurisdictions, but there is evidence that this population group is under-screened. Incidence of cervical cancer in Aboriginal and Torres Strait Islander women is more than twice that of non-Indigenous women, and mortality nearly 4 times the non-Indigenous rate. Amber light: trend starting to head in an unfavourable directionfieep an eye on this. Cancers are distinguished from each other by the specific type of cell involved and by the place in the body in which the disease began. Cervical cancer develops when abnormal cells in the lining of the cervix begin to multiply out of control and form precancerous lesions. If undetected, these lesions can develop into tumours and spread into the surrounding tissue. Source: Reproduced with permission from M Schiffman, National Cancer Institute (Schiffman and Kjaer 2003). The strength of cervical screening comes from repeating the screening test at agreed rescreening intervals, which allows more accurate detection of precancerous abnormalities over the long preinvasive stage of squamous cervical cancers. The aim of the screening Pap test was to identify those women who may have a cervical abnormality (as indicated by the presence of abnormal cells in the specimen collected) and therefore require further diagnostic testing. These tend to be rare but aggressive cancers, such as neuroendocrine cancer of the cervix. The two most aggressive types are small cell neuroendocrine carcinoma and large cell neuroendocrine carcinoma, neither of which appears to have a preinvasive stage (Necervix. Cervical screening is possible because cervical cancer is one of the few cancers that has a precancerous stage that lasts for many years prior to the development of invasive disease, which provides an opportunity for detection and treatment. Note, however, that some rare (and often aggressive) cervical cancers do not have a precancerous stage, and therefore cannot be detected by cervical screening. Cervical screening in Australia 2018 3 2 Moving towards a new National Cervical Screening Program 2. Soon afterwards, this became known as the National Cervical Screening Program, operating as a joint program of the Australian Government and state and territory governments, and recommending 2-yearly Pap tests. The initial aim of an organised approach to screening was to further reduce the incidence and mortality of cervical cancer beyond the reductions attributable to the opportunistic cervical screening available in Australia since the mid-1960s (Dickinson 2002). Indeed, the relatively low incidence and mortality of cervical cancer in Australia, compared with other countries (Ferlay et al. This commenced in 2011, undertaken by the Standing Committee on Screening and supported by the Department of Health. Cervical screening in Australia 2018 5 3 Key qualities of the National Cervical Screening Program 3. Three-year participation is particularly relevant, as this may provide a more accurate indication than 2-year data of the proportion of women who participated regularly in cervical screening. This reminder to screen took the form of a letter sent by a cervical screening register 27 months after a previous negative Pap test, and there is evidence that it does indeed act as a prompt to screen for many women, with the latest rescreening data indicating that 31. While data show that many women participated in screening less often than recommended, some participated more often than recommended. More recent results are directly comparable, because the same definition of early rescreening has been applied to them. A low proportion of women rescreening early is desirable, since modelling has shown that a decrease in early rescreening reduces the cost of a screening program without changing its effectiveness (Creighton et al. There was also a clear association between participation and socioeconomic group, with participation rising from 50. This coding sheet allowed pathologists to report on both the squamous and endocervical components of the cervical cytology sample, which together gave an overall cervical cytology result. This overall cytology result may indicate no abnormality, a squamous abnormality, an endocervical abnormality or (rarely) concurrent squamous and endocervical abnormalities. The squamous cell and endocervical component reporting categories of the National Cervical Cytology Coding Sheet are shown in Table 3. Screening test results Most screening Pap tests were negative, meaning that no abnormality was present. While most Pap tests were negative, a proportion contained abnormal cells, this being influenced by the underlying prevalence of disease in the population. While overall these rates are similar to those of previous years, the proportion of abnormalities in women aged under 20 fell to 10. The decline is likely to be observed for older age groups over the coming years, further reducing the overall number of abnormalities detected by cytology. The age distribution of negative cytology results, as well as low-grade and high-grade cytology results, is shown in Figure 3. An indication of quality is the proportion of Pap tests that are unsatisfactoryfihose from which the pathologist was unable to determine a clear result. This may be due to too few or too many cells, or to the presence of blood or other factors obscuring the cells, or to poor staining or preservation. An unsatisfactory screening Pap test needed to be repeated, so it was desirable that these be minimised. While low, the proportion of unsatisfactory cytology tests has increased slightly, from 2. The performance measures for unsatisfactory cytology and abnormalities detected by cytology are detailed in Table 3. Cervical screening in Australia 2018 13 In 2016, the number of Pap tests for which no endocervical component was collected continued to increase, disproportionate to the increase in the number of cytology tests. The number of Pap tests with no endocervical component increased from 350,670 to 508,758. This increase is also reflected in the steady increase in the proportion of cytology tests with no endocervical component, from 17. As sampling of the transformation zone is required for endocervical cells to be present in a cervical cytology sample, a transformation zone high up in the endocervical canal is likely to be more difficult to sample than a transformation zone on the ectocervix. This does not explain, however, the increase in the proportion of cytology with no endocervical component across all age groups, including younger women who are likely to have a transformation zone located on the ectocervix.
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Epilepsy Although rarely associated with serious violence epilepsy can sometimes be so gastritis diet узбек order cheap protonix on line, and so can be raised in relation to defences at trial (usually automatism and insanity) gastritis diet karbo cheap 20 mg protonix with visa. And only very rarely are sleep disorders associated with violence or sexual behaviour in an individual gastritis symptoms livestrong generic protonix 40 mg amex. Crucial is whether there is an established history of a sleep disorder per se gastritis diet mayo order generic protonix, almost always going back to childhood gastritis diet 30 discount protonix online master card, unless the disorder has apparently arisen secondary to acquired brain damage gastritis diet rice protonix 20 mg generic. Determining the likelihood of ofending having occurred during sleep is complex and controversial gastritis symptoms lower back pain safe protonix 40 mg, and requires assessment by a specialist sleep clinic chronic gastritis raw vegetables 20 mg protonix otc. Comorbidity Aside from the fact that there can be overlap of symptoms of, and criteria for diagnosis of some psychiatric conditions (for example, for more than one type of personality disorder), there can, of course, be comorbidity of mental conditions, plus of mental and physical conditions. And this can potentially 24 Mental disorder and criminal behaviour impact upon patterns of ofending behaviour. So, for example, a defendant might exhibit some type(s) of personality disorder plus psychosis of some sort, or an afective condition, or brain damage, or substance misuse disorder. Indeed, specifcally, comorbidity of personality disorder with some other condition is common in forensic psychiatric practice. Tat is, a psychotic person who also exhibits personality disorder may be more at risk of ofending than might be represented by their psychosis alone. And, although comorbidity particularly involving personality disorder is the most common occurrence in forensic psychiatric practice,19, 20 clearly, any combination of comorbid conditions is possible. Conclusion Even where there is a known association at a population level between a given mental disorder and ofending, in an individual case this can be only of background relevance. However, it is ofered bearing in mind that some readers will be legal and not medical in professional background. Also, we have attempted to place medical process into the particular legal context within which it must occur. Handbook of Forensic Psychiatric Practice in Capital Cases Overview Tere are essential features of any psychiatric assessment. However, aspects of the form and detail of any assessment must depend, in some measure, upon the context of the assessment and upon the purposes for which it is intended. Each psychiatric interview is, therefore, somewhat specifc to its circumstance and, in forensic psychiatry, is driven by either the legal or clinical question that needs to be addressed. Since the relationship between assessor and assessee is diferent, as are the potential implications of the assessment for the assessee. Tere are, however, general principles that apply to all psychiatric assessments, including forensic assessments, since assessing a defendant for court requires application of the same core clinical techniques as does assessment of a patient, even though the context may somewhat alter the process and the result may be applied to legal rather than medical questions. Put more strongly, the essentials of clinical method must not be distorted by virtue of the legal context. The reader should, therefore, consult a general psychiatry text for detailed advice about assessment. What is also added to a forensic assessment is the utilisation of more, and diferent, information. Within the clinical assessment itself, attention must also be paid explicitly to the possibility of feigning, or exaggeration, of symptoms beyond what might routinely be pursued in an ordinary clinical assessment. Tis, again, marks the assessment out clearly from a general adult psychiatric assessment. Additional stages in capital cases Whether in regard to a capital case or other serious criminal case, any forensic assessment can be in respect of pre-trial, trial or sentencing issues. Tat is, the particular situation and role of the assessee determines an entirely diferent relationship with the assessor than applies within a general psychiatric assessment. In terms of the implications of this unusual relationship, typically, when seen by a doctor, the patient can withdraw their consent, if necessary, by leaving the interview room. Also, do not accept instructions without confrming that you are able to prepare the report within the timescale required. This might include providing an independent report on a patient already under your care, where the fact of a therapeutic relationship is likely to give rise to the risk of bias or at least the perception by others, including the court, of bias (see Chapter 15). Finally, once instructions have been accepted in a case, it is crucially important to clarify the instructions, including any relevant legal constructs or terminology. Hence, before leaving your base to conduct an assessment, ensure you have the contact details of the lawyer who is coordinating the assessment. So consider whether you have received all that you need, recognising that what will be required will vary depending upon whether the assessment is for trial or appeal, and the questions to which the assessment will be directed. A bare minimum, for trial, in respect of legal papers is likely to be a case summary and prosecution witness statements, plus police interviews with the defendant. Medical notes will also need to be seen but are sometimes difcult for legal representatives to locate, and often arrive late in the assessment process. It is always good practice, however, to obtain all records, since defendants may not inform you of signifcant medical events. For example, if the medical records describe contact with psychiatric services, or a brain injury, then questioning and examining the subject in relation to this is likely to be important. It is also often relevant to gain school records, particularly if there is a possible diagnosis of personality disorder. If travelling to conduct the assessment, think about how much documentation you should actually take with you, since the total volume may be large. As regards interviewer physical safety, very often the psychiatrist will face the prospect of interviewing a subject not known to him. And, in any event, many doctors would consider placing themselves squarely behind a desk to be overly formal, and as likely to his run the risk of further intimidating the defendant, 33 Handbook of Forensic Psychiatric Practice in Capital Cases who is likely to be anxious. An alternative is to sit at a diagonal, keeping some distance from the subject but allowing a more relaxed interaction. It is also useful to know in advance what to expect if they are pushed (it can be a source of particular embarrassment to press a button hoping that someone will simply open the door, then to fnd that it triggers a full scale response from the prison security team). To facilitate the subject feeling psychologically safe, or as safe as is possible, the interview should be conducted in a quiet room where the defendant cannot be overheard, especially as they are likely to be disclosing information that is highly personal and sensitive. Hence, negotiation in advance is required to ensure privacy, with the provision of a letter agreeing to this from the governor of the prison. However, any expectation of ideal conditions is likely to be disappointed, and some compromises will need to be made, albeit there must be a limit to such compromise. Patients typically meet doctors with the proper expectation of privacy and secrecy. However, in this and others ways, a forensic assessment is diferent from consultations in other forms of medicine, and this must be made clear at the outset. The interview Unless the diagnosis, or the lack of any disorder, is crudely obvious, psychiatric assessment involves lengthy interviewing. So it is unusual to be able to complete an adequate assessment of someone facing a serious criminal charge in less than three or four hours (this excludes time considering past medical records and the legal papers in the case or time gaining data from informants). And this is likely to be advisable also in serious criminal or capital cases, since the presence of someone else can distort or inhibit clinical interaction. However, occasionally, it is worth at least considering whether the presence of a lay advocate or interpreter is advisable, especially in interpreting cultural nuances of communication and behaviour where the doctor originates from a diferent country or culture. Consideration should therefore be given to adopting techniques specifcally designed to determine whether there is feigning or exaggeration of symptoms (see also Chapter 5). And, related to this, any diagnostic, or other opinion expressed in the report subsequently ofered to the court should be accompanied by explicit consideration of likely validity (see Chapter 8). Open questions should always precede closed ones, and direct questions can, for example, include asking about symptoms that one would not expect to be experienced in any of the diagnoses that you have under active consideration. A particular common difculty is the limited amount of time made available to the clinician by prison authorities. So often the interviewer needs to control the assessment more than would usually apply in ordinary clinical practice. The foregoing said, the good interviewer will allow the subject at times to talk freely. At the conclusion of an interview, it should be explained to the defendant what is likely to happen next, with approximate timescales for the production of a report, if possible. Aside from taking time properly to read all available information and to think, your opinion and its implications will have to be set in the context of all of the evidence in the case, as a whole, and of legal opinion concerning the totality of the evidence, of which yours is only one 36 Forensic psychiatric assessment part. Terefore, information to the defendant about your opinion should come from his lawyer, whether you have been instructed by the defence or by the prosecution. Clinical history taking via an interpreter is not easy, and requires skill on the part of both the interpreter and the doctor. And, clearly, the choice of interpreter is important but practically that might be limited. A professional interpreter who has some experience of psychiatric interviews is preferred. Note-taking Clinicians will have their own ways of taking notes, plus their own idiosyncratic notations and abbreviations. Tat accepted, however pursued, note-taking should not interrupt the fow of what ideally will appear to the subject as a natural conversation. So they need to be understandable, accurate, and full enough for you later to be able to prepare a report by reference to them. A very full account of the interview is then available to the court, particularly of how symptoms of mental disorder emerged during the interview. However, the process can be laborious and can interrupt the fow of the interview, and report of it. Hence, in practice it is probably best to write notes in summary form, and in the third person, but also to ensure that topics that may be legally crucial are recorded verbatim, with answers written in the frst person, as they were spoken by the defendant. In addition, the mental state of the defendant can be observed on two separate occasions, allowing noting of any changes or inconsistencies between the two interviews. This is likely to be especially important in cases of suspected personality disorder. After the clinical interview(s) After the assessment per se has been completed, it will be necessary to review all current and past medical records from whatever source they may arise, including the prison. In some circumstances, it may also be necessary to read educational records in order to gain information about childhood development. This is important diagnostically per se, but is also of importance in determining the extent to which any disorder persists, or did persist over some period of time in the past. Second, assessment by a psychiatrist for trial often occurs after a substantial period of time has elapsed since the date of the alleged ofence. Retrospective reconstruction is the norm for the forensic psychiatrist, and records are important in such reconstruction. Since variation of the person from their own usual functioning is, in general terms, often an important contributor to the conclusion that the person is indeed currently mentally ill, or was at the time of the ofence, the availability of such information is important. Of course, 38 Forensic psychiatric assessment given that such availability is dependent upon circumstance and is not under the control of the doctor, its absence may have to be coped with. However, gathering information from others may be subject to special rules if they are also prosecution witnesses, requiring consent from the prosecution lawyers (there is usually no difculty in questioning defence witnesses, if you are instructed by that side). Notwithstanding its importance, it can be difcult practically to conduct a physical examination, particularly in a prison, where there may be a relative lack of both privacy and equipment (see above). The examiner may also thereby place himself in close contact with the defendant, and in some cases could possibly expose himself to an enhanced risk of violence. The assessing clinician needs to come to a view as to how necessary these investigations are. Arrangements for the investigations to take place should be made with a hospital that is local to the prison, if at all possible. However, in terms of the relevance and use of such testing in conjunction with psychiatric or medical assessment, the following may assist understanding of their value and use from a medical perspective. From the perspective of a psychiatrist assessing a case, psychometric tests that may assist fall essentially into two categories. First, tests that are directed at brain function and which typically assess cognition. Such tests can demonstrate or confrm the presence of brain damage, by showing that the person cannot use their brain in a normal way. Neuropsychometric testing can also be important in order to complement scanning in assessing whether there is brain damage, resultant from head injuries or sustained alcohol abuse for example. As in all medicine, the combination of clinical assessment and the administration of a range of tests of varying sorts of brain, mind and body, contribute together to the conclusion that a person sufers (or does not) from a particular condition. It is also equally important that any conclusion that no abnormality is present is held with maximum confdence. Personality assessment Tere are particular issues and difculties accompanying the assessment of personality, including towards a possible diagnosis of personality disorder. By contrast, mental illness and brain disorder are expressed in terms of change away from some previously normal state in the individual (unless the brain damage is congenital). Tere is complexity in defning personality, with varying weighting attached to individual capacities, afective traits, psychological defences, cognitive abnormalities and social aspects. It is defned in psychiatric manuals in terms of requiring the condition to be enduring, developing or manifesting in early life and reaching such severity as to have a signifcant impact on functioning. The clinical interview is important in the assessment of personality but should always be combined with other information from a wide range of sources. Learning disability Diagnosis of learning disability, like that of personality disorder, is dependent upon comparison with normal, and so is open somewhat to judgement. However, it is less so than is personality disorder because intelligence can be quantifed validly and reliably psychometrically. Tat said, diagnosis rests not solely upon psychometrics, but also on variation from normal performance in aspects of living, so detailed information about this must be collected too. Ultimately, the diagnosis requires judgement across several sources of information. Tat is, diagnosis is dependent upon the presence of sufcient pieces, arising from various sources, to suggest with confdence the presence of the picture, plus the absence of pieces that are inconsistent with the picture, and diagnosis. As regards establishing the presence of symptoms within the clinical interview, this should not be approached with naivety but with recognition that someone engaged in legal proceedings might seek to fabricate or exaggerate symptoms. Tird, the absence of description of symptoms inconsistent with a given diagnosis will ofer further validity support. Fourth, consistency of expression of symptoms over several interviews, or with other reports on the defendant, will suggest validity, so that the reporting of highly unusual or unheard of symptoms, or of symptoms likely to be what defendants would expect to be symptoms of disorder will cast doubt upon validity. Fifth, consistency between reported symptoms 42 Forensic psychiatric assessment and symptoms recorded in past medical records, especially close to the time of the alleged ofence will suggest validity. Beyond the foregoing, if there is signifcant concern about the veracity of symptoms reported, psychological testing can be undertaken to assist in establishing whether malingering or fabrication of symptoms is occurring (see Chapter 5). Ultimately, however, fabrication is both difcult to achieve efectively and relatively unusual. This means that the presence of one or more pieces of a particular type can reinforce the likely validity of others. Medical assessment in capital cases Given how high the stakes are, clinicians who undertake assessments in capital cases need to demonstrate a higher standard of professional practice than those engaged in general forensic psychiatric work. And in jurisdictions retaining the death penalty, the stakes are far higher, given that there is no ability to set errors right at a later stage. Experts undertaking such work also need to be able to work in potentially very difcult environments. Even clinicians who are experienced in other areas of forensic psychiatry are likely to be unfamiliar with the case law relating to capital cases. And advice on relevant law, including legal tests, should be sought and fully understood, if not already known to the doctor. Perhaps the greatest challenge, both technically and ethically, arises from the fact that the future risk of violence is likely to be an important consideration in sentencing in almost all jurisdictions that maintain the death penalty on a discretionary basis. However, even soon after an assessment is concluded, it can often be valuable to discuss the fndings with an experienced colleague, in an anonymised fashion. This will allow an opportunity for refection from a position of some distance, and for tentative conclusions to be challenged and, if necessary, revised. And, if there has been discussion with a colleague, this should be made plain in the report. This chapter provides a practical guide to best practice concerning a range of matters that clinical psychologists are routinely asked to comment on in relation to criminal trials. Tese two appendices may be used as quick reference guides to appropriate practice. Expert psychological evidence can, and often does, stand alone, of course, since clinical psychologists are independent practitioners who express within their own discipline. Use of psychometric tests Psychometric techniques represent science concerned with the knowledge and techniques of measuring psychological attributes, such as cognitive abilities, emotions, attitudes and personality features. This is usually pursued by way of a questionnaire, or questions being presented to the examinee. Notably, many psychological tests, particularly neuropsychological tests, are culturally biased, and such 46 Forensic psychological assessment tests are only valid if norms upon which they have been developed apply to the examinee. Terefore, a test needs to be culturally appropriate, and the normative sample that the test was developed upon needs to match the individual to be tested. However, all self-report measures can be afected by factors such as malingering, lack of insight and literacy problems, as well as inappropriate cultural norms. They include specifc questions related to each diagnostic criterion, and therefore tend to be more thorough and objective than self-report questionnaires. However, the relative disadvantage of semi-structured interviews compared with self-report questionnaires is that the interview process, and scoring procedures, are timeconsuming. It is also used as a risk assessment tool, since high scores are associated with higher levels of risk of reofending. Neuropsychological assessment Neuropsychology is concerned with the relationship between behaviour, cognitive functioning and emotion, and the brain. It employs a range of standardised, scientifcally validated assessment tools designed to measure various aspects of mainly cognitive functioning, and to determine the presence, and severity, of any dysfunction. A comprehensive neuropsychological assessment covers various aspects of cognitive functioning, including intellectual functioning, memory, language abilities, visuospatial skills and executive functioning. Additionally, some decline of memory functioning is a normal aspect of aging, so a formal memory assessment is often required in order to diferentiate between pathological and normal age-related memory loss. Apparent absence of memory for past events (amnesia) is a common focus of assessment for clinical psychologists, both in relation to court cases and in routine clinical work. A number of robust psychometric measures have been developed to assess diferent aspects of executive functioning.
Families sufering complex perinatal mental health issues commonly have associated histories of childhood abuse gastritis hemorrhoids discount protonix 40mg otc, alcohol / substance abuse and / or domestic violence gastritis inflammation diet order protonix with a mastercard. Higher level services Y Case management strategies may include: z Targeted home visiting according to need/risk z Early Intervention Clinician / Parenting Specialist z Targeted parenting groups gastritis espanol discount protonix 20 mg without prescription. Parents may be raise concerns such as their child being: z Overly sensitive gastritis diet шарики purchase protonix online, fearful gastritis binge eating buy protonix with amex, anxious z Intolerant to change z Slow to engage or react z Difcult to control with prolonged tantrums and aggressive outbursts z Poor impulse control and overactivity z Commonly these issues are associated with poor feeding diet bagi gastritis buy protonix with visa, sleeping behaviours gastritis symptoms and diet order cheapest protonix and protonix. This may include: Establishing a family routine around sleep gastritis hypertrophic effective 40 mg protonix, mealtimes, hygiene needs, exercise and playing, using reward charts for positive behaviours. Higher level services Y Case management strategies may include: z Targeted parenting groups. Clinical practice points Y When facing unexpected events, parents generally want: z a clear simple explanation regarding z the diagnosis z what the future may look like for the child z advice on what to do now z advice on what to do next z a warm, sympathetic listener z time to ask questions at the time and as they come to terms with the situation. Child and Youth Health Practice Manual 171 Section 2 Birth to fve years Y Parents of a special needs child may need to work through range of psychological tasks in relation to: z hospitalisation of their child, adaptation to the health care environment, fear of bringing their child into the home environment, and fear of their child dying. Higher level services Y Case management strategies may include: z Targeted home visiting according to need/risk. Department of Health guidelines clearly articulate these responsibilities, including: Y Health Professional Child Safety Capability Requirements Y Reporting and responding to a reasonable suspicion of child abuse and neglect Y Responding to an unborn child health risk alert Y Information sharing in child protection Initial orientation to local child protection processes and key contacts should be part of the onboarding of all 172 Child and Youth Health Practice Manual 2014 Section 2 Birth to fve years child health staf along with annual updates. The following are some factors in the frst year of life that may increase the risk of child abuse or neglect: Child factors Family characteristics Y Intrauterine exposure to toxins Y First time parent Y Prematurity Y Maternal / Paternal depression Y Low Birth Weight Y Maternal / Paternal mental illness Y Feeding difculties Y Maternal / Paternal criminality Y Sleep difculties Y Isolated, single parent Y Developmental delay Y Isolated, disadvantaged parents Y Difcult temperament Y Interparental conflict Y Disruptive behaviour Y Financial stress Y Insecure attachment Y Coercive family practices / domestic violence Y Alcohol consumption particularly in single parent households Y Substance abuse Y Poor parental role modelling including past abuse as a child 24, 171, 189 Y Clinical fndings that may indicate harm may include: z Any injury noted on an infant who is not yet mobile z Bruises on any part of a baby z Pinch marks z Human bite marks z Burns. Child and Youth Health Practice Manual 173 Section 2 Birth to fve years Y Shaken baby syndrome occurs most commonly in infants under 12 months correlating with the normal peaks of infant crying 107. Abusive head trauma (inclusive of shaken baby syndrome) is the most common cause of infant morbidity and mortality in physically abused infants with 20% of these infants dying as a direct result of injuries sustained during such an incident. Does the caregiver have a diagnosis of mental illness (50% of perpetrators have a factitious disorder themself and 75% have a co-existing personality disorder) 2. Within this framework, risk factors are those that have the potential to increase the risk of harm and protective factors are those that have the potential to provide additional safety for the child or lessen the risk189. Sample framework of protective and risk factors 174 Child and Youth Health Practice Manual 2014 Section 2 Birth to fve years 0-12 mths Protective factors Risk factors Infant/child Y Settled infant/child Y Unsettled infant/child factors Y Sleep patterns Y Poor infant/child sleep. This does not preclude reporting of signifcant harm caused by emotional/psychological abuse and neglect. Explore these resources with the Mother / Father and encourage the parent to assume an active role within the plan. Please note: Some children in this stage of the continuum may also experience issues discussed in the Twelve to Eighteen Years section of this manual. Developmental surveillance and health monitoring Developmental surveillance, health monitoring and assessment aims to ensure early and accurate identifcation of children who have health issues and/or developmental delays, and facilitate access to early intervention services. This section includes: Y the context of healthcare, Y child health surveillance and monitoring Y common health concerns including: z speech and communication concerns z daytime and bed wetting z soiling and constipation z Pediculus Capitis (head lice). The healthcare context Y In Queensland during this age stage, universal child and family health services are commonly focused more on parenting support and skill development through group parenting programs; provision of additional services is available to those families at risk or in greater need, such as Aboriginal and Torres Strait Islander families 4,59. A shortage of funding particularly in recent times with global economic constraints has meant many school nursing services have been cutback to align with service redesign193. At a health service level, schools ofer an efcient point to access a large proportion of the younger age group and established links between health and educational departments fosters opportunities around service delivery in the school setting192. Many services in this age group are on an ad-hoc basis, commonly at a targeted service level. Child and Youth Health Practice Manual 179 Section 3 Five to twelve years Y Child health services may also be provided at a targeted level by early intervention parenting specialists/early intervention clinicians/child health psychologists/social workers. For example: z Advise school children, parents and school staf of the services available to school-aged children. A proforma article may be written for insertion into the school newsletter, with details of the screening program/s, role of the child health professional, screening date/s and contact details. These health checks form the early detection component of the chronic disease strategy to identify risk factors and early markers which lead to the development of chronic diseases141. Resources: Healthy Kids Check checklist and fact sheet Chronic Conditions Manual Child health assessment Physical assessment Y A physical assessment is conducted and combined with history taking and interviewing to enable the health professional to develop a holistic view of the individual health status of a child. There are three components of accurate measuring: z technique that is standardised z equipment that is calibrated and accurate z measurers that are trained so they are accurate and reliable. See practice tips, page 45 Y Growth during childhood is an important indicator of nutritional and health status and remains the best method of assessment at the primary care level81. Towards the end of this age range the rapid growth in height and weight, especially for girls signals prepubescence. The development of secondary sexual characteristics ofen creates concerns for children in this age group 24. If the child is uncertain as to which letter requires a response, circle the letter with the pointer. This may indicate that they are experiencing difculty reading the letters on the chart. If the child actively resists the covering of one eye, the uncovered eye may have a vision defect. Child and Youth Health Practice Manual 183 Section 3 Five to twelve years Practice tips: Ears and hearing screen: 5 to 12 years Y A Registered Nurse or an appropriately trained Health Worker/Practitioner may undertake an ear and hearing health screen 141. It may be appropriate to ask these verbally or incorporate these questions into the written history/consent form. Refer to page 85 for practice tips on otoscopy, tympanometry, audiometry and referral. A child may be considered to have a developmental delay when they have not met a particular milestone by a particular time[110]. When there is delay across many areas of development at a health check they are considered to have global developmental delay 114. Concerns raised by parents, teachers and other school staf, once the child is integrated into the school setting will also impact on developmental surveillance 196. As cognitive development progresses, perceptual thinking (based on what can be seen) and conceptual thinking (unseen factors) combine to enable the child to make judgements based on their own reasoning. The child learns to incorporate their previous experiences, observations and memories into anticipation and how they experience and understand current situations 24. A child learns to act according to these standards and develops feelings relating to their own behaviour. These behaviours can be guided by others by positive reinforcement and children develop feelings such as guilt when behaviours do not meet with expected standards. School aged children begin to consider what is natural and supernatural and are fascinated with learning about spirituality and religious views of their family. Children develop a sense of conscience and are guided by family ideals and beliefs more so than those of their peers at this stage. Children may expect punishment for misbehaviours and fnd comfort in religious rituals depending on their spiritual beliefs 24. Fitting in within a peer group becomes increasingly important as a child develops during the school years. As a child develops individuality and begins to gain independence from their parents/carers, they experience dealing with leadership, dominance, authority, etc. Sex roles between boys and girls seem insignifcant early on, but in the later school years diferences become more apparent. Negative feelings may lead to self-doubt and positive feelings develop self-respect and self-confdence 24. Screening tools There are a number of validated tools available for health care professionals to complete a developmental assessment during this age range. Health care professionals should check which developmental assessment tools are recommended to be used in their particular setting and be trained to administer and interpret the outcomes of the tools correctly. Completed by: Trained health care professionals use as a secondary screening tool when indicated. Common health concerns Child health professionals are frequently asked for information on a broad range of topics. The following common health concerns will be covered in this section: Y speech and communication concerns, Y daytime and bed wetting Y Soiling and constipation Y Pediculus capitis (head lice). Parenting tips / Skills to support child development Y Stuttering, stammering and various speech dysfluencies relating to sensorimotor integration where the child is thinking quicker than the word is formed by the body, are common up to approximately fve years. For example, children who are having difculties: z Expressing themselves to their parent. The remainder of children become dry at night (for a period of > 6 months) and then start bed wetting again. A follow-up appointment between two and three weeks afer an enuresis alarm is commenced, facilitates support with any initial difculties and continued use. If no positive response is evident afer two to three months of use, stop use and re-try again at later date. It has also been reported as a diagnosis in 20% of children attending emergency departments for abdominal pain and the second most common reason for referral to a paediatric gastroenterologist. Over time, overflow incontinence may occur and/or a stretched rectal vault and a decreased urge to defecate. Cautions and things to avoid Y Avoid punishing a child for not getting to the toilet on time. These products are obtainable without a prescription and contain four diferent types of active ingredients: z Pyrethrins, z Synthetic Pyrethroids, z Organophosphates, z Combinations of herbal and essential oils. Early detection can break the cycle of lice reproduction and decrease treatment time. At the completion of the process used tissues should be disposed of into a rubbish bin tied in a plastic bag. Repeat the process every two days for 10 consecutive days with no lice being found. Many Queensland schools adopt the Health Promoting Schools Framework, based on the Ottawa Charter for Health Promotion (1986). This framework incorporates three interconnected domains of: Y curriculum, teaching and learning; Y school, organisation, ethos and environment; and Y partnerships and services 198. By using a comprehensive approach and working in partnership with schools, it is possible to build the capacity of communities through enhanced knowledge, skills, resources and management support for health promotion in the school setting. In this way, communities are better equipped to identify and address issues of concern in the future 198. For further information about the Health Promoting Schools Framework, see page 236. At a health service level, schools offer an efficient point to access a large proportion of the younger age group and established links between health and educational departments fosters opportunities around service delivery in the school setting 192. For child health services not directly providing services within the school setting, working with government and non-government organisations is important to build community capacity. Collaborative planning for community events, activities or health services helps to ensure there is adequate time, funds, and resources to provide a sustainable service or activity 199. These groups may be co-facilitated by a child health nurse and an early intervention parenting specialist. Group information sessions, provided to parents in groups, effectively encourages networking building possible supportive contacts for the longer term and improves parental psychosocial wellbeing 174. For further information about practice tips on facilitating group parenting programs, see page 100. It is recommended that services facilitate the involvement of fathers and signifcant others by considering a range of strategies including: Y Create a physical and attitudinal environment that welcomes the father/ partner/extended family. Providing parenting education in groups enables normalisation of many common developmental issues which supports parents in their role and also can be a more efcient way to deliver information to a greater number of people at the one time 174. Parents are encouraged to reflect about their child, their feelings and needs, and the child-parent relationship within the sessions. There is an endless range of topics that may be discussed with children and families, this section discusses topics recommended specifc to health promotion and illness/injury prevention within the National Framework for Universal Child and Family Health Services 1 as follows: 194 Child and Youth Health Practice Manual 2014 Section 3 Five to twelve years 84,197,200 Nutrition and healthy eating patterns Y 25% of Australian children between 2 and 17 years are overweight or obese and 5% are underweight. Parenting tips / skills to support child development Y Ensure children receive all the nutrients they need to grow and develop normally by including a wide variety of nutritious foods from these core food groups every day: z Plenty of vegetables, legumes and fruits of diferent types and colours. Child and Youth Health Practice Manual 195 Section 3 Five to twelve years 84,197,200 Nutrition and healthy eating patterns Parenting tips / skills to support child development cont. Parenting tips / skills to support child development Y Motivate children to engage in at least 60 minutes every day on moderate to vigorous physical activity (accumulated across the day). Additional physical activity up to several hours per day may have additional health benefts. Cautions and things to avoid Y Discourage computers and televisions in the bedroom. Parenting tips / skills to support child development Y Permanent teeth will begin to erupt from around 6 years age; some permanent teeth will replace baby teeth and others such as the permanent molars will come through behind the last baby molars. Parenting tips / skills to support child development Y Parents are encouraged to: z Spend quality time with their child and provide a safe physical and emotional environment the child health professional may use the Australian Family Strengths Nursing Assessment Guide (See Appendix 1) as a tool to explore family strengths and encourage activities to enhance efective family functioning and build resilience [131]. Child health professionals may use the Australian Family Strengths Nursing Assessment Guide, see appendix 1. Since 2001, the most common cancer types in these cases have been lymphoid leukaemias, neuroblastoma and ganglioneuroblastoma, and acute myeloid leukaemias (4. The rate of new cases of type 1 diabetes in children did not change signifcantly from 2000 to 2011, with between 21 and 26 per 100,000 children each year. Recommendations Y Hand washing is the single best method of reducing the spread of pathogens and nosocomial infections. Model positive hygiene behaviours by washing own hands regularly; teach children how to wash their hands and when to wash their hands ie: before eating, afer toileting. This may include: z Carrying relievers at all times z Learning to recognise and avoid triggers z Avoiding smoking environments Staying Healthy in Child Care |
