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By B. Ismael. University of Florida.

Recent research into alternative approaches for the secondary preven- 1 purchase kemadrin 5mg with amex. Worldwide particularly ‘screen and treat’ programs that have burden of cervical cancer in 2008 order kemadrin 5 mg on line. Ann Oncol 2011;22: been tested in randomized trials in South Africa and 2675–86 India and shown that HPV-based screening coupled 3 generic 5mg kemadrin mastercard. Geneva: WHO cheapest kemadrin, 2010 with immediate treatment using cryotherapy 4. Burden and trends of significantly reduces both cervical cancer precursors type-specific human papillomavirus infections and re- and cervical cancer. In addition to new approaches lated diseases in the Asia Pacific region. Vaccine 2008;26 to secondary prevention of cervical cancer, the re- (Suppl. Human papillomavirus infection and cervical cancer prevention against HPV infection has major implications for in India, Bangladesh, Sri Lanka and Nepal. Vaccine future prevention: the bivalent vaccine targets HPV 2008;26 (Suppl. A screening programme for gets types 6 and 11 (responsible for genital warts) cervical cancer that worked. Human research is towards molecular detection of cervical papillomavirus is a necessary cause of invasive cervical cancer precursors which should overcome many of cancer worldwide. J Pathol 1999;189:12–19 the deficiencies associated with cervical cytology- 8. Human (NCCPs) is a critical next step for cancer control in papillomavirus types in invasive cervical cancer world- developing countries. Br J Cancer 2003;88:63–73 countries must adopt policies at national level. Human NCCPs have four pillars: prevention, early detec- papillomavirus genotype attribution in invasive cervical tion through diagnosis, treatment and palliation. Lancet Oncol 2010;11:1048–56 Political will is an important element in putting dis- 11. Precancerous eases such as cervical cancer on the health agenda. Blaustein’s WHO has established a cancer control program Pathology of the Female Genital Tract. NY: Springer- which has published some interesting materials on Verlag, 2002 334 Cervical Cancer Prevention and Treatment 12. N Engl J Med 2007;356: absolute risk of cervical intraepithelial neoplasia grade 3 1928–43 or worse following human papillomavirus infec- 29. J Natl Cancer Inst 2010;102: bivalent L1 virus-like particle vaccine in prevention of 1478–88 infection with human papillomavirus types 16 and 18 in 13. Cervical human young women: a randomised controlled trial. Lancet papillomavirus prevalence in 5 continents: meta-analysis 2004;364:1757–65 of 1 million women with normal cytological findings. Sustained J Infect Dis 2010;202:1789–99 efficacy up to 4. Annual Review particle vaccine against human papillomavirus types 16 of Development Effectiveness: Achieving Sustainable and 18: follow-up from a randomised control trial. Washington, DC: World Bank, 2009 Lancet 2006;367:1247–55 15. Sankaranarayanan R, Swaminathan R, Brenner H, et al. Chapter 13: Current findings Cancer survival in Africa, Asia, and Central America: a from prophylactic HPV vaccine trials. Prophylactic quad- countries: using health data and health services research rivalent human papillomavirus (types 6, 11, 16, and 18) to measure and improve access, quality and efficiency. L1 virus-like particle vaccine in young women: a ran- BMC Int Health Hum Rights 2010;10:24 domised double-blind placebo-controlled multicentre 17. Working Together for Health: the World Health phase II efficacy trial. Estimates economic outcomes of HPV 16,18 vaccination in 72 of health care professional shortages in sub-Saharan GAVI-eligible countries. MMWR Recomm Rep 1992; news/press-releases/2011 41:1–19 35. Incidence cal assessment of screening methods for cervical neo- of cervical squamous intraepithelial lesions in HIV- plasia. Incidence of visual inspection with acetic acid for cervical cancer cervical squamous intraepithelial lesions associated with screening. Int J Gynaecol Obstet 2011;113:14–24 HIV serostatus, CD4 cell counts, and human papilloma- 37. JAMA 2005;293:1471–6 virus-based cervical cancer prevention: long-term 22. J Natl Cancer Inst vaginal human papillomavirus infection in human 2010;102:1557–67 immunodeficiency virus-1 (HIV)-positive and high-risk 38. J Natl Cancer Inst 1999;91: screening for cervical cancer in rural India. Comprehensive cervical cancer control: a guide papillomavirus infection and cervical cytology in HIV- to essential practice. Available infected and HIV-uninfected Rwandan women. Revised FIGO stag- papillomavirus infection and cervical disease in human ing for carcinoma of the cervix. Int J Gynaecol Obstet immunodeficiency virus-1-infected women. London: FIGO, 2010 detection of human papillomavirus (HPV) infection 42. Revised FIGO staging for carcinoma of the soon after incident HIV infection among South African vulva, cervix, and endometrium. Assessing the relationship between HIV infection clinical/pathologic factors matter in the era of chemo- and cervical cancer in Cote d’Ivoire: a case–control radiation as treatment for locally advanced cervical car- study. A situational analysis of cervical cancer in (GOG) trials. Gynecol Oncol 2007;105:427–33 Latin America and the Caribbean. Carcinoma of PAHO, 2004 the cervix treated with radiation therapy. Cancer 1991;67:2776–85 335 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS 45. Philadephia, national assessment of some operational costs of tele- USA: Wolter Kluwer, 2009;341–95 therapy. Radiotherapy services in coun- in early-stage cervical cancer: indications and applica- tries in transition: gross national income per capita as a tions. J Natl Comp Cancer Netw 2010;8:1435–8 significant factor. Chemoradiotherapy for Cervical Cancer Meta-Analysis chemotherapy followed by surgery for locally advanced Collaboration. Reducing uncertainties about the effects cervical cancer. J Clinical Oncol 2008;26:5802–12 in cancer control in low-income and middle-income 53. Poor nations need more help to slow growing cancer burden: the International Atomic Energy Agency asks donors to provide millions of dollars to buy radio- therapy equipment. When GTD INCIDENCE persists or recurs it is often called gestational tropho- blastic neoplasm (GTN). The spectrum of GTD Molar pregnancies are rare: approximately 1 in includes: every 400–800 pregnancies is a complete or partial • Complete and partial hydatidiform molar preg- molar pregnancy. Choriocarcinoma and persistent nancies: the most common form of GTD inva- trophoblastic neoplasm are even rarer with an sive mole (GTN).

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Subpopulations Fair 2 studies found no difference in adverse effects in subgroups of age buy kemadrin 5mg low cost, gender order 5 mg kemadrin visa, and racial groups A single open-label study of 320 patients with mean age of 77 years with erosive esophagitis found that that pantoprazole 40 mg and rabeprazole 20 mg were superior to omeprazole 20 mg in healing rate at 8 weeks order 5 mg kemadrin mastercard, no difference compared to lansoprazole 30 mg cheap kemadrin 5 mg. Pantoprazole and rabeprazole were superior to both omeprazole and lansoprazole in symptom relief at 8 weeks. These results differ to those found in younger populations and need confirmation. Based on a cohort study of more than 8000 patients, use of a proton pump inhibitor concomitant with clopidogrel following acute coronary syndrome can increase the risk of death or rehospitalization for acute coronary syndrome with adjusted odds ratio of 1. Similarly, use of a proton pump inhibitor concomitant with clopidogrel following acute myocardial infarction can increase the risk of readmission for recurrent myocardial infarction within 90 days with adjusted odds ratio 1. Analysis of the subgroup taking pantoprazole indicated no increased risk, while analysis of the other proton pump inhibitors (as a group) indicated a similar increase in risk. Proton pump inhibitors Page 72 of 121 Final Report Update 5 Drug Effectiveness Review Project REFERENCES 1. Emerging strategies in the treatment of gastroesophageal reflux disease. Esomeprazole (40 mg) compared with lansoprazole (30 mg) in the treatment of erosive esophagitis. Esomeprazole improves healing and symptom resolution as compared with omeprazole in reflux oesophagitis patients: a randomized controlled trial. Medical Review of Nexium (Esomeprazole Magnesium) Delayed-Release Capsules. Once-daily pantoprazole 40 mg and esomeprazole 40 mg have equivalent overall efficacy in relieving GERD-related symptoms. Richter JE, Kahrilas PJ, Sontag SJ, Kovacs TO, Huang B, Pencyla JL. Comparing lansoprazole and omeprazole in onset of heartburn relief: results of a randomized, controlled trial in erosive esophagitis patients. Efficacy and safety of esomeprazole compared with omeprazole in GERD patients with erosive esophagitis: a randomized controlled trial. A double-blind, randomized comparison of omeprazole Multiple Unit Pellet System (MUPS) 20 mg, lansoprazole 30 mg and pantoprazole 40 mg in symptomatic reflux oesophagitis followed by 3 months of omeprazole MUPS maintenance treatment: a Dutch multicentre trial. Lansoprazole 30 mg versus omeprazole 40 mg in the treatment of reflux oesophagitis grade II, III and IVa (a Dutch multicentre trial). Rapid symptom relief in reflux oesophagitis: a comparison of lansoprazole and omeprazole. Proton pump inhibitors Page 73 of 121 Final Report Update 5 Drug Effectiveness Review Project 16. On-demand therapy for Los Angeles grade A and B reflux esophagitis: esomeprazole versus omeprazole. Comparable efficacy of pantoprazole and omeprazole in patients with moderate to severe reflux esophagitis. Evidence for therapeutic equivalence of lansoprazole 30mg and esomeprazole 40mg in the treatment of erosive oesophagitis. A randomized, double-blind, comparative study of standard-dose rabeprazole and high-dose omeprazole in gastro- oesophageal reflux disease. Lansoprazole versus omeprazole in short-term treatment of reflux oesophagitis. Rabeprazole, 20 mg once daily or 10 mg twice daily, is equivalent to omeprazole, 20 mg once daily, in the healing of erosive gastrooesophageal reflux disease. Dupas JL, Houcke P, Samoyeau R, French Collaborative Pantaprazole Study G. Pantoprazole versus lansoprazole in French patients with reflux esophagitis. Double-blind, placebo-controlled comparison of rabeprazole 20 mg vs. Castell DO, Richter JE, Robinson M, Sontag SJ, Haber MM. Efficacy and safety of lansoprazole in the treatment of erosive reflux esophagitis. Corinaldesi R, Valentini M, Belaiche J, Colin R, Geldof H, Maier C. Pantoprazole and omeprazole in the treatment of oesophagitis: a European multicenter study. Comparable clinical efficacy and tolerability of 20 mg pantoprazole and 20 mg omeprazole in patients with grade I reflux oesophagitis. Symptom relief in patients with reflux esophagitis: comparative study of omeprazole, lansoprazole, and rabeprazole. Proton pump inhibitors Page 74 of 121 Final Report Update 5 Drug Effectiveness Review Project 30. A randomized comparative study of esomeprazole 40 mg versus pantoprazole 40 mg for healing erosive oesophagitis: the EXPO study. Chen C-Y, Lu C-L, Luo J-C, Chang F-Y, Lee S-D, Lai Y-L. Esomeprazole tablet vs omeprazole capsule in treating erosive esophagitis. Rabeprazole is equivalent to omeprazole in the treatment of erosive gastro-oesophageal reflux disease. A randomised, double-blind, comparative study of rabeprazole and omeprazole 20 mg in acute treatment of reflux oesophagitis, followed by a maintenance open-label, low-dose therapy with rabeprazole. Bytzer P, Morocutti A, Kennerly P, Ravic M, Miller N, Investigators RT. Effect of rabeprazole and omeprazole on the onset of gastro-oesophageal reflux disease symptom relief during the first seven days of treatment. Pantoprazole 40 mg is as effective as esomeprazole 40 mg to relieve symptoms of gastroesophageal reflux disease after 4 weeks of treatment and superior regarding the prevention of symptomatic relapse. A multicenter, randomized, double-blind, 8-week comparative trial of standard doses of esomeprazole (40 mg) and omeprazole (20 mg) for the treatment of erosive esophagitis. Esomeprazole versus pantoprazole for healing erosive oesophagitis. A Multicenter, Randomized, Double- Blind, 8-Week Comparative Trial of Low-Dose Esomeprazole (20 mg) and Standard- Dose Omeprazole (20 mg) in Patients with Erosive Esophagitis. Early heartburn relief with proton pump inhibitors: a systematic review and meta-analysis of clinical trials. Pace F, Negrini C, Wiklund I, Rossi C, Savarino V, The Italian One Investigators Study G. Quality of life in acute and maintenance treatment of non-erosive and mild erosive gastro-oesophageal reflux disease. Dekkers CP, Beker JA, Thjodleifsson B, Gabryelewicz A, Bell NE, Humphries TJ. Comparison of rabeprazole 20 mg versus omeprazole 20 mg in the treatment of active duodenal ulcer: a European multicentre study. Khan M, Santana J, Donnellan C, Preston C, Moayyedi P. Medical treatments in the short term management of reflux oesophagitis. Proton pump inhibitors Page 75 of 121 Final Report Update 5 Drug Effectiveness Review Project 43. Systematic review: proton pump inhibitors (PPIs) for the healing of reflux oesophagitis - a comparison of esomeprazole with other PPIs. Esomeprazole versus other proton pump inhibitors in erosive esophagitis: a meta-analysis of randomized clinical trials. Healing and relapse rates in gastroesophageal reflux disease treated with the newer proton-pump inhibitors lansoprazole, rabeprazole, and pantoprazole compared with omeprazole, ranitidine, and placebo: Evidence from randomized clinical trials. Direct comparative trials of the efficacy of proton pump inhibitors in the management of gastro-oesophageal reflux disease and peptic ulcer disease. Meta-analysis: comparing the efficacy of proton pump inhibitors in short-term use. A review of the clinical and economic impact of using esomeprazole or lansoprazole for the treatment of erosive esophagitis. Comparison of omeprazole and cimetidine in reflux oesophagitis: symptomatic, endoscopic, and histological evaluations.

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Primordial prevention is the combination of actions involves the diagnosis and treatment of con- and measures that reduce or eliminate the emer- firmed cases of cancer buy kemadrin 5 mg with amex. Treatment is through gence of risk factors in the population purchase kemadrin without prescription. Here surgery buy generic kemadrin on-line, radiotherapy and sometimes chemo- efforts are directed toward discouraging those therapy purchase kemadrin with a mastercard. For example early Some authors talk about quaternary prevention. This sexual debut and multiple sexual partners are risk consists of actions that identify patients at risk of factors for the development of cancer of the cer- over-diagnosis or over-medication and that protect vix or STI. At primordial level of prevention, them from excessive medical intervention which children will be sensitized to delay their sexual may result in iatrogenesis, (inadvertent adverse debut and to avoid multiple sexual partners. For example over-diagnosis of obstruc- through individual and mass education. This may increase the Disease burden is the effect/impact of a disease in a rate of ruptured uterus in subsequent pregnancies if community measured by financial cost, mortality, emergency services are not very good. It is often quantified the proper management of labor may be considered in terms of quality-adjusted life years (QALYs), as quaternary prevention disability-adjusted life years (DALYs) or years lost Successful prevention depends on knowledge of due to disability (YLD) which combines the bur- causation, dynamics of transmission, identification den due to both death and morbidity into one in- of risk factors and risk groups, availability of dex. This allows for the comparison of the disease prophylactic or early detection and treatment burden for varying risk factors or diseases. It also measures, an organization for applying these meas- makes it possible to predict the possible impact of ures to appropriate persons or groups, and continu- health interventions in a community. Without these, the likelihood of success- the fraction of actual disease burden in the com- fully preventing any disease in the community is munity. It is like the tip of an iceberg: what is seen very low. The difference between what is seen in the health facility and what is actually Outcome of preventive measures present in the community depends on the health- These are usually categorized into control, elimina- seeking behavior of the respective community. If tion, eradication and extinction depending on the most of the sick people in the community seek achievement: medical treatment in health facilities (good health- seeking behavior), the difference is small and vice • Control The reduction of disease incidence, versa. For example, if preva- description can be found in epidemiology lence of STIs in a community is low (0. The aim of this study is of a specified disease in a defined geographical to obtain estimates of the burden of gynecologi- area as a result of deliberate efforts. For example, • Effective planning for health services. The agent of the disease may be avail- • To justify initiation of preventive measures. No dis- quality of life generated by healthcare interventions. It is the measure of the life-expectancy corrected 430 Epidemiology in Gynecological Diseases for loss of quality of that life caused by diseases and probability of an individual developing a change in disabilities. Some health interventions do not pro- health status over a fixed time interval. A year of normal health is given a QALY of 1 while death has a QALY of 0. Size of population at start of period Relative risk Disability-adjusted life years Relative risk (RR, also referred as rate ratio or risk DALYs are a measure of the burden of disease and ratio) compares the risk of developing a disease (any reflect the potential years of life lost due to pre- other health event, e. These disabilities can be physi- the risk in the exposed group by the risk in the cal or mental. One DALY can be thought of as one unexposed group The risk may be in the form lost year of ‘healthy’ life. The two groups are All these measures of disease burden are used to typically differentiated by demographic factors such measure the impact of disease burden in the com- as gender (e. Relative Risk of disease in exposed group MEASURES OF DISEASE ASSOCIATION risk = Risk of disease in comparison group AND IMPACT For the calculation of measures of disease associa- To measure a disease association means to quantify tion, two-by-two tables are very useful. If you are the relationship between exposure and disease interested in using them, please refer to books on among two groups. One probability is race, sex), biologic characteristics (immune status), that the event of interest will occur, the other prob- acquired characteristics (marital status), activities ability is that it will not occur. The measures of association des- in case–control studies, incidence of disease among cribed in the following section compare disease the exposed group is not calculated directly, occurrence among one group with disease occur- through the probability of developing disease rence in another group. A case–control study association include risk ratio (relative risk), odds estimates the proportion of cases with exposure and ratio and risk difference. In this chapter only rela- the proportion of controls with exposure in order tive risk and odds ratio will be discussed. Risk EFFECT OF A DISEASE ON AN INDIVIDUAL AND THE SOCIETY This is the probability that an event will occur, e. It is the that an exposure contributes to the frequency of 431 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS disease in the population. A measure of public husband may be needed to take over some health impact is used to place the association be- responsibilities that were initially been done by his tween an exposure and an outcome into a mean- wife. He will be overburdened, unable to concen- ingful public health context. Whereas a measure of trate on his bread-winning activities or to partici- association quantifies the relationship between pate in his usual social activities. He may abandon exposure and disease, the measure of public health the family, creating more problems to the children. Because of smell and increasing Economic impact pain, she will be unable to mix with other people so she will be unable to attend her social activities The economic impact of diseases is very profound. Her A sick person/community is unproductive and death will result into longstanding grief for the consumes more resources to survive. This is double family and produce orphans in the family/commu- impact on the economy (not producing and at the nity. Some of the gynecological diseases do not same time the need for more to survive). It is very import- individuals of their health and productive potential. Mismanagement of one patient savings, and compete with investment activities; may mean mismanagement of a certain group of instead of saving or investing, the money is spent people, e. From a country’s perspective, chronic diseases reduce life-expectancy and ulti- STATISTICS IN GYNECOLOGY mately economic productivity, thus depleting the quality and quantity of a country’s labor force. This While managing gynecological diseases, it is recom- may result in lower national output and national mended to keep a record of the patients. There has been some parameters can be recorded in registers for analysis description in the literature of how diseases reduce at the end of certain periods, preferably a year. School- will help to track the characteristic of diseases in the ing of the children is affected, propagating the spi- surrounding community and nationwide to plan ral of ill health and poverty. The burden in the for management and prioritize financial means. A lot of resources including drugs, manpower, time etc. If a sick person It is very important to keep record of all gyneco- dies, the funeral will also consume some resources. This is the very basic Social impact step in epidemiology (see above). It is very basic The social impact arising from diseases is of signifi- because for the information to be analysed it must cant importance. It is hard to over-emphasize the have been recorded previously. If no information trauma and hardship that family members are forced has been recorded, there will be nothing to count, to bear when one of them is sick. Assume a mother nothing to divide and nothing to interpret. Provision of meals at home important to record all (gynecological) patients and other household activities done by the mother given health services in a health facility. Informa- cease (mother cannot look after her children), so tion to collect may include sex, age, marital status, children have to take care of themselves and their ethnicity, residency, occupation, initial diagnosis, cleanliness, cook food, prepare each other for final diagnosis, investigation results, treatment school etc. Girls (sometimes boys) drop out of given, result of treatments and recurrence. Addi- school to help their mother and take care of their tional information may be collected depending on siblings ruining their prospects for education, a the guideline from the public health authority in well-paid work and thus their future lives. It is important to collect meaningful data 432 Epidemiology in Gynecological Diseases that enable your staff to do their clinical work provider that just started to operate in the area.

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