Single-visit Approach Research Articles

Alternative cervical cancer prevention in low‐resource settings: Experiences of visual inspection by acetic acid with single‐visit approach in the first five provinces of Thailand

After the confirmation of its safety, acceptability and feasibility in a cervical cancer prevention demonstration project in 2002, a visual inspection by acetic acid (VIA) followed by an effective treatment using cryotherapy as a single-visit approach (SVA) was recently introduced in five provinces having low Pap smear screening rates, in Thailand. The effectiveness of a screening program is usually associated with a high level of coverage; however, in low-resource settings such a high coverage is still hard to attain by the conventional Pap smear approach. To evaluate whether VIA/SVA can increase women's access to the prevention services in low-resource provinces of Thailand. A cross-sectional study was conducted by analysing electronic screening records of the provinces. A chi2 test was used in the comparisons of screening coverage between the year before and the first year of VIA/SVA implementation during 1998-2005. This comparative study, which included 88 554 screening visits totally, shows a significant increase in the screening coverage of five provinces after the VIA/SVA implementation (P < 0.001). As a result of the large substitution of VIA/SVA for Pap smears, the costs of screening were lowered by as much as $US362,300 (66.8%) in the first year. VIA/SVA has provided good screening coverage and lowered the financial burden in five low-resource provinces of Thailand. Therefore, it is promisingly competitive as a potential alternative means of cervical cancer prevention in low-resource areas.

Pregnancies of unknown location: consensus statement

The rate of PULs in different studies ranges from 8 to 31%1-10. The prevalence of PULs is determined by the quality of ultrasound scanning11. The higher the quality of scanning, the better the detection of ectopic pregnancy using ultrasound as a single diagnostic test, which in turn results in fewer women being classified with a PUL. Up to 90% of clinically relevant ectopic pregnancies can be detected at the initial ultrasound scan12-14. The panel believes that most modern units using TVS should maintain PUL rates below 15%. Most PULs are not aggressive and represent either failing intrauterine or ectopic pregnancies which are never visualized using TVS (failing PULs) or intrauterine pregnancies too early to visualize using TVS. Clinically stable women with a PUL should initially be managed expectantly, as expectant management of women with a PUL is safe1-7, 15. There is no consensus about appropriate intervention rates in women with a PUL. Clinical audit should be regularly performed to determine the rate of emergency surgery because of undetected ectopic pregnancies and the rate of unnecessary intervention (negative laparoscopy). The initial serum human chorionic gonadotropin (hCG) level is not predictive of PUL outcome11, 16. The change in serum hCG over time or the hCG ratio (hCG at 48 h/hCG at 0 h) can be used to define failing PULs16, 17. Initial serum progesterone levels <20 nmol/L or a 48-h hCG ratio <0.87, i.e. a serum hCG fall >13% over 48 h, identify those PULs which resolve spontaneously and do not require intervention4, 16. Further studies are required to compare the hCG ratio to serum progesterone as markers of pregnancy failure. Serum progesterone measurements are not reliable in the diagnosis of ectopic pregnancy18. According to a meta-analysis, serum progesterone measurement can identify women at risk for ectopic pregnancy, but its discriminative capacity is insufficient to diagnose ectopic pregnancy with certainty19. Mathematical models based on the hCG ratio20, 21 have been developed to predict PUL outcome. These need to be tested prospectively in multicenter trials in order to evaluate their diagnostic performance in different populations. In most cases, uterine curettage should not play a role in the classification of PULs. It does not accurately differentiate between intra- and extrauterine pregnancies and may lead to inadvertent termination of a viable pregnancy22. A single-visit approach to the management of PULs is not appropriate, because it may result in an unacceptably large proportion of clinically significant ectopic pregnancies being missed23. The optimal clinical management of women with PULs involves reducing the number of visits without compromising the outcome of these pregnancies. In conclusion, consensus can be achieved in both the diagnostic approach and management of women with PULs. The panel agreed that because most PULs are at low risk of being an ectopic pregnancy, provided that the ultrasound examiner is sufficiently skilled and uses an ultrasound system with acceptable image quality, future efforts should concentrate on minimizing follow-up.

Flare-ups Incidence and Severity after Using Calcium Hydroxide as an Intra Canal Dressing

INTRODUCTION: Acute pain and swelling following endodontic treatment are challenges for patients and dentists. According to previous studies, the incidence of flare-ups increases after endodontic treatment of teeth with necrotic pulp. Calcium hydroxide is currently used as a multipotential medicament in root canal therapy. The aim of this study was to evaluate the incidence and severity of flare-ups after treatment of pulpless teeth using calcium hydroxide as an intracanal dressing. MATERIALS AND METHODS: Sixty patients with single root necrotic teeth participated in this study. These patients were randomly divided into three groups of twenty. The patients in group A were treated in a single-visit approach, in group B with a two-visit approach without any intracanal dressing and in group C with a two-visit approach using calcium hydroxide as an intracanal dressing for one week. All of the patients were followed for 72 h after each treatment session. The information about the incidence and severity of pain and swelling was recorded in tables, using a modified visual analogue scale for pain severity measurement and a scale with four degree for measuring the severity of swelling. The data were analyzed by chi-square test and GENMODE procedure. RESULTS: The incidence of pain showed to be the highest in group B and the lowest in group C. These differences were statistically significant. There was no significant difference in the severity of pain after the first visit between groups B and C; however, the severity of pain was significantly lower in group C after the second visit. The incidence of pain in group C was significantly lower than that in group A, but there was no significant difference in the severity of pain between these two groups. There was no significant difference in the incidence and severity of swelling among the three groups. CONCLUSION: It is concluded that calcium hydroxide as an intracanal dressing could be effective to decrease the postoperative pain and swelling. Therefore it is recommended to use calcium hydroxide as an interappointment dressing in necrotic teeth.

Pregnancies of unknown location: diagnostic dilemmas and management

This review discusses various aspects of the management of women with pregnancies of unknown location. The prevalence of pregnancies of unknown location is dependent on the quality of scanning for a given early-pregnancy unit. The higher the quality of scanning, the better the detection of ectopic pregnancy using ultrasound as a single diagnostic test, which in turn results in fewer women being classified with a pregnancy of unknown location. Varying the discriminatory zone does not significantly improve the detection of ectopic pregnancies in a pregnancy of unknown location population. A single serum human chorionic gonadotrophin, when used in a specialized transvaginal scanning unit, is not only potentially falsely reassuring but also unhelpful in excluding the presence of an ectopic pregnancy. A single-visit approach has also been shown to be ineffective. The vast majority of women with a pregnancy of unknown location are at low-risk for ectopic pregnancy. Traditional strategies are capable of detecting the failing pregnancies of unknown location and intra-uterine pregnancies within a pregnancy of unknown location population, but they lack sensitivity for detecting ectopic pregnancies. This justifies the recent development and use of mathematical modelling techniques to predict ectopic pregnancies in the pregnancies of unknown location population. New mathematical models have been developed to predict the outcome of pregnancies of unknown location; however, prospective studies are needed to assess the reproducibility of these models in different centres on different populations. Hopefully such models will enable the clinician to correctly classify pregnancies of unknown location earlier, in turn reducing the number of follow-up visits.

Optical diagnosis of cervical dysplasia

Cervical cancer is a major burden to women’s health in developing countries. Worldwide cancer of the uterine cervix accounts for approximately 470000 new cases every year and 233000 deaths. Many components of comprehensive screening and treatment programs practiced in industrialized nations are not feasible for most developing countries. Moreover an optimal strategy for a particular low-resource setting may vary from another due to differences in disease prevalence health care infrastructure human and financial resources and local customs. Even a casual look at the quandary cannot help but impress the viewer with the scope and complexity of the problem. In March 2004 the American College of Obstetricians and Gynecologist (ACOG) issued a statement of policy regarding cervical cancer prevention in low-resource setting. In this joint policy statement a “single-visit approach” incorporating visual inspection of the cervix with acetic acid (VIA) followed by immediate treatment was considered an acceptable and costeffective strategy for cervical cancer prevention. In the last decade substantial progress has been made in understanding the origin and pathogenesis of cervical neoplasia. This knowledge in combination with technologies such as self-sampling devices optical detection systems and more recently molecular technologies has allowed physicians and researchers to develop new algorithms to improve the global burden of cervical cancer. (excerpt)

First-trimester ultrasound: is a single-visit strategy in pregnancies of unknown location safe?

Objective: The aim of this study was to evaluate the safety and feasibility of a single-visit approach to pregnancies of unknown location (PUL).Methods: All PUL had serum HCG and PROG measured at presentation and 48 hours (hrs). All women were followed until a diagnosis was established: failing pregnancy, intrauterine pregnancy (IUP), or ectopic pregnancy (EP). We then retrospectively tested the need for a second visit based upon the first blood result only. Two groups could be eliminated from the system (i.e., not necessary to have either a second transvaginal scan [TVS] or a second blood test). Those with resolving pregnancies (PROG ≤ 20 nmol/L and HCG > 25 IU/L) and those with ongoing pregnancies (PROG > 60 nmol/L and HCG ≤ 1000 IU/L). These are defined as the non-ectopic PUL group. Two groups of patients would need a second visit to the hospital. Those with a high risk for EP (PROG 20–60 nmol/L and HCG > 25 IU/L) would need a repeat TVS and a blood test at 48 hrs and those with an EP (PROG > 60 nmol/L and HCG > 1000 IU/L) would undergo laparoscopy. These are defined as the ectopic PUL group.Results: 352 PUL: 192 (54.55%) failing PUL, 128 (36.36%) IUP, and 32 (9.09%) EP. The sensitivity and specificity of a second visit to detect EP were 50% and 68.75%, respectively (see Table 1). The positive predictive and negative predictive values of a second visit were 13.79% and 93.22%, respectively (see Table 1). Of the 68 classified as high risk for ectopic PUL, 53 (77.9%) were not non-ectopic PUL, i.e., failing or intrauterine pregnancies. Of the 20 classified as ectopic PUL, 19 (95%) were non-ectopic PUL.Conclusions: Single-visit management of PUL is unsafe, with 50% of ectopics being discharged with no follow-up. A single-visit strategy should not be used as an alternative to the current two-visit strategy.Tabled 1DiagnosisNeed for 2nd Visit NoNeed for 2nd Visit YesNon-ectopic PUL220100Ectopic PUL1616 Open table in a new tab Objective: The aim of this study was to evaluate the safety and feasibility of a single-visit approach to pregnancies of unknown location (PUL). Methods: All PUL had serum HCG and PROG measured at presentation and 48 hours (hrs). All women were followed until a diagnosis was established: failing pregnancy, intrauterine pregnancy (IUP), or ectopic pregnancy (EP). We then retrospectively tested the need for a second visit based upon the first blood result only. Two groups could be eliminated from the system (i.e., not necessary to have either a second transvaginal scan [TVS] or a second blood test). Those with resolving pregnancies (PROG ≤ 20 nmol/L and HCG > 25 IU/L) and those with ongoing pregnancies (PROG > 60 nmol/L and HCG ≤ 1000 IU/L). These are defined as the non-ectopic PUL group. Two groups of patients would need a second visit to the hospital. Those with a high risk for EP (PROG 20–60 nmol/L and HCG > 25 IU/L) would need a repeat TVS and a blood test at 48 hrs and those with an EP (PROG > 60 nmol/L and HCG > 1000 IU/L) would undergo laparoscopy. These are defined as the ectopic PUL group. Results: 352 PUL: 192 (54.55%) failing PUL, 128 (36.36%) IUP, and 32 (9.09%) EP. The sensitivity and specificity of a second visit to detect EP were 50% and 68.75%, respectively (see Table 1). The positive predictive and negative predictive values of a second visit were 13.79% and 93.22%, respectively (see Table 1). Of the 68 classified as high risk for ectopic PUL, 53 (77.9%) were not non-ectopic PUL, i.e., failing or intrauterine pregnancies. Of the 20 classified as ectopic PUL, 19 (95%) were non-ectopic PUL. Conclusions: Single-visit management of PUL is unsafe, with 50% of ectopics being discharged with no follow-up. A single-visit strategy should not be used as an alternative to the current two-visit strategy. Tabled 1DiagnosisNeed for 2nd Visit NoNeed for 2nd Visit YesNon-ectopic PUL220100Ectopic PUL1616 Open table in a new tab

Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project

To increase screening and treatment coverage, innovative approaches to cervical-cancer prevention are being investigated in rural Thailand. We assessed the value of a single-visit approach combining visual inspection of the cervix with acetic acid wash (VIA) and cryotherapy. 12 trained nurses provided services in mobile (village health centre-based) and static (hospital-based) teams in four districts of Roi-et Province, Thailand. Over 7 months, 5999 women were tested by VIA. If they tested positive, after counselling about the benefits, potential risks, and probable side-effects they were offered cryotherapy. Data measuring safety, acceptability, feasibility, and effort to implement the programme were gathered. The VIA test-positive rate was 13.3% (798/5999), and 98.5% (609/618) of those eligible accepted immediate treatment. Overall, 756 women received cryotherapy, 629 (83.2%) of whom returned for their first follow-up visit. No major complications were recorded, and 33 (4.4%) of those treated returned for a perceived problem. Only 17 (2.2%) of the treated women needed clinical management other than reassurance about side-effects. Both VIA and cryotherapy were highly acceptable to the patients (over 95% expressed satisfaction with their experience). At their 1-year visit, the squamocolumnar junction was visible to the nurses, and the VIA test-negative rate was 94.3%. A single-visit approach with VIA and cryotherapy seems to be safe, acceptable, and feasible in rural Thailand, and is a potentially efficient method of cervical-cancer prevention in such settings.

OC016: Can we safely adopt a single visit approach to the management of pregnancies of unknown location?

OC016: Can we safely adopt a single visit approach to the management of pregnancies of unknown location?

Single-Visit Approach to Cervical Cancer Prevention

Blumenthal, Paul D. MD; Limpaphayom, Kobchitt MD; Lumbiganon, Pisake MD; Ringers, Patricia PhD; Srisupundit, Somkeart MD; Gaffikin, Lynne DrPH Author Information

Single-visit approach to cervical cancer prevention: safety and acceptability in rural Thailand

Single-visit approach to cervical cancer prevention: safety and acceptability in rural Thailand

Multi-Media CD-ROM Review One-Visit Endodontic Treatment

The advent of digital radiography, apex locators, NiTi rotary preparation and rapid thermoplastic obturation have made it possible to complete many endodontic cases with a single visit. But such an approach is not without problems. Practitioners must first be philosophically convinced that single-visit treatment is reliable and scientifically based, and must then become fully conversant with the time-saving technology and its use before turning to patients. One-Visit Endodontic Treatment follows closely on the heals of ‘Cleaning and Shaping’ (reviewed IEJ 33 : 79), and aims to provide a rationale and technique guide for the predictable management of endodontic infection at a single clinical visit. The quality of production is again impressive, exploiting well the potential of multimedia, and incorporating photographs and detailed illustrations with video and animation to describe a broad range of contemporary issues and procedures. This package covers a lot of ground, but it is rightly emphasized that no amount of viewing can circumvent the need for practical, hands-on training and caution. During a total of approximately one and a half h, the software guides the viewer through an easily navigated series of five self-contained modules covering: rationale, access opening, cleaning and shaping, obturation and post-treatment care. The illustrative material is of stunning quality, and is readily understood and assimilated. Each section contains core material, supplemented by helpful additional notes, problem-solving tips and a bibliography of key references. It is assumed that future upgrades will allow a dynamic bibliography and technique guide. The scope of the clinical sections is ambitious and promises much, but can be little more than an introductory taste of the many fruits on offer. Some sections are already in need of updating, with little coverage of well-established Profile .06 protocols, little discussion of root canal sealers, and no mention of the Lightspeed Simplifil obturation technique. It would also be helpful to see the important issue of coronal seal covered more carefully, with clear guidance on cutting back root-fillings deep and effective temporization. Most controversial is the section on post-treatment patient care, where the routine prescription of analgesic and antibiotic drugs is commended. Analgesic prescribing is rationally based in Hargreaves’ flexible prescribing protocol, but blanket prescription of ibuprofen and acetaminophen for 72 h does not seem to be in the spirit of a responsive protocol tailored to individual analgesic needs. Greater caution should also be noted in the routine prescription of antimicrobial drugs given the growing worldwide concerns about antibiotic misuse and the emergence of drug resistance. Whilst routine medication may represent expedient, defensive practice, such an approach does seem anomalous in the light of the rationale section, which indicates that few post-operative complications are to be expected following the one-visit approach. The final section of self-assessment tests is disappointingly scant, with few explanatory notes. This section could usefully be expanded to provide a much more effective educational resource, and to reinforce the many messages contained in this substantial work. One-Visit Endodontics is an impressively produced piece of work which has been well received by our students and general dentists as an updating resource, and by established endodontists as a catalyst for debate. In short, this has proved to be an attractive and useful package, and one we will continue to use in all of our teaching areas. But this reviewer is still to be convinced by the single-visit approach to infected cases. One-Visit Endodontic Treatment is designed and presented by Dr Stephen Cohen, coauthor and editor of Pathways of the Pulp. It is available from NewMentor Group, 360 Post Street, Suite 402, San Francisco, CA 94108, USA (Website: http://www.newmentor.com), and in Europe from PJ Le Berre, 12 Ch. de la Dole, CH 1260 Nyon (E-mail: pinicega@bluewin.ch). Minimum system requirements Processor: Pentium 160 Operating System: Windows 95, 98, NT 4.X CD-ROM: 8x CD-ROM Ram: 32MB RAM (20MB free on hard drive) Sound: 16bit sound card Display: 640 × 480 display in thousands of colours Mouse required.

Low cost methods for secondary prevention of cervical cancer in developing countries

Cervical cancer is both a preventable and a curable disease- preventable because the pre-invasive stage can be detected by screening and curable because the very early stage can be cured. It is the commonest genital cancer among females in Nigeria. The incidence and mortality from this disease in developing countries is very high. This is due to the unavailability of organised screening programmes. To address this problem, effective and practical alternatives to cytology are being investigated in many studies. To examine the strengths and limitations of new methods currently undergoing evaluation for secondary prevention of cervical cancer in developing countries. We conducted a computerised literature search for published articles. Mesh phrases used for the search were cervical cancer screening, cervical cancer screening in developing countries, cervical cancer screening- new techniques. Hand searches of journals and the proceedings of major conferences were also done. The visual tests for screening for cervical cancer was found to be highly sensitive and can be performed by not only physician but also other trained health care providers. The "single visit approach" to prevention of cervical cancer also referred to as "see and treat" has been tried in some countries in Asia and Africa and found to be effective and acceptable to women and their partners. Several studies conducted in many developing countries have shown that low cost methods for cervical cancer prevention do have a place in reducing the incidence of this deadly disease.