Freiburg i. Br., Univ., Diss., 2008.

Thesis (Ph. D.)--University of Hawaii at Manoa, 2004. / Includes bibliographical references (leaves 129-137).

Thesis (Ph. D)--UCLA, 2007. / Vita. Includes bibliographical references (leaves 197-214).

Thesis (M.P.H.)--University of Texas at El Paso, 2009. / Title from title screen. Vita. CD-ROM. Includes bibliographical references. Also available online.

The purpose of this study is to investigate specific contributing factors affecting quality assurance in the diagnosis of conventional cervical smears. More than half of South- African women fail to have one cervical smear in their lifetime and +/- 50 percent of those who do have cervical smears taken, are lost to follow-up. Since cervical cancer is the most common malignancy amongst women in developing countries, the medical profession will have to endeavor to screen a higher rate of women and ensure a 100 percent quality assurance with every patient treated in order to reduce the unacceptable high incidence of cervical carcinoma. At this stage it seems like an impossible task to screen all women in South Africa, due to far-off rural areas, shortage of medical professionals and the lack of knowledge of some women of the necessity of cervical smears. Many newly qualified South-African doctors leave the country to go and work elsewhere. South Africa then in turn has to recruit doctors from other countries to staff the State hospitals and clinics. Some areas have one doctor to thousands of patients, insufficient nursing personnel and inadequate equipment. Doctors in some areas cannot cope with the volume of work and the long hours. One has to accept that the quality of the management of some patients is affected negatively. There are a number of medico-legal issues (world wide) in relation to aspects of cervical cancer prevention practices which are controversial and are of particular concern to all of those involved in cervical cancer prevention. Various countries have therefore formed different national organizations to address the medico-legal issues in screening for the prevention of cancer. These organizations monitors procedures, internal quality control as well as external quality control. In South Africa, medico-legal cases are not so prevalent, but may become so shortly. The South-African medical professionals therefore have to ensure that their quality of work conforms to accepted good practice in all circumstances. State hospitals serve thousands of patients per month and it is an every day occurrence to see long queues of patients sitting waiting for doctors and who often have to come back the following day. The situation appears to be much improved in private practice and since patients have medical cover and accessible medical facilities. Since cervical cancer is the most common malignancy amongst women in developing countries, the medical profession will have to endeavor to screen a higher rate of women and ensure a 100 percent quality assurance with every patient treated in order to reduce the unacceptable high incidence of cervical carcinoma. At this stage it seems like an impossible task to screen 100 percent of women in South Africa, due to far-off rural areas, the shortage of medical professionals and ignorance of patients. Quality assurance is therefore of paramount importance to every medical professional for every patient treated. Laboratories all worldwide have been, or are in the process of being accredited by their specific accreditation authorities. The main reason for this is improvement of quality control and therefore quality assurance. The South African National Accreditation Society (SANAS) now accredits various laboratories in South Africa with the view of accreditting all laboratories within a certain time limit. The Ampath laboratory Port Elizabeth was successfully accredited during 2001. Accredited laboratories have to uphold a very high degree of quality to remain accredited. A team of professionals inspects the laboratory every 2 years and other quality assurance staff inspects the laboratories every few months. All aspects of the laboratory are checked, e.g. the qualification of staff, their registration with the Health Professions Council of South Africa (HPCSA), their curriculum vitaes, equipment, safety of the laboratory etc. Since the laboratory chosen for this study, is accredited, the author evaluated every cervical smear that was received in the laboratory since the year 2000, with the following objectives in mind: · Whether the presence or absence of an endocervical component has an effect on the adequacy of cervical smears · To determine the effect of using smaller coverslips on quality assurance in the cytology laboratory · Evaluate the effect that manual re-screening of smears has on quality assurance in the cytology laboratory. As there is a shortage of cytotechnologists and pathologists worldwide, several countries make use of automated screening devices as primary screening or secondary screening for quality assurance. These devices were tested in some laboratories in South Africa but were found to be very expensive and sensitivity and specificity were not up to standard. Sensitivity is a measure of the ability of a test to detect the abnormal - Sensitivity is the ratio of true positives to true positives + false negatives. Specificity is a measure of the ability of a test to correctly identify the negative - Specificity is the ratio of true negative to true negatives + false positives. The automated screening machines failed to identify abnormal cells amongst inflammatory cells, as well as in very blood stained smears. Several other problems also occurred and an increasing number of smears had to be manually rescreened, thus making this exercise costly and not helpful as a quality assurance instrument. The slides used for this thesis, have been retrieved from the archives of the Ampath laboratory in Port Elizabeth. Fourteen specific contributing factors affecting quality assurance in the diagnosis of cervical smears are also discussed and conclusions and recommendations given.

A conservative strategy for women with a low-grade abnormal cervical smear is continued cytological surveillance by repeat Papinacolaou testing, but there is surprisingly little information on the management of such follow-up. Our objectives were to investigate such management pathways, their determinants, and psychological implications using data from the cytological surveillance arm of the Trial of Management of Borderline and Other Low-grade Abnormal cervical smears. A substantial proportion of participants had ongoing unresolved cytology at last follow-up (42.7%); a policy of following women solely though cytological surveillance to manage these women may be inefficient. A high-risk human papillomavirus test, smoking and age were significantly associated with the management pathways (p-value <0.05). While there were some limitations, our results were reassuring with respect to this group of women with ongoing unresolved cytology, since there were no differences in anxiety and depression scores across the management pathways after thirty months of follow-up.

Small cell (neuroendocrine) carcinoma of the uterine cervix (SMCC) is a rare, highly aggressive malignant neoplasm. Both conventional and liquid-based cytology (LBC) cervical smears have low sensitivity in diagnosing SMCC, requiring immunocytochemical (ICH) confirmation. We present the first series of SMCC primarily diagnosed in cytology specimens, and ICH studies performed on the residual LBC specimens with subsequent confirmation of the diagnosis on surgical pathology specimens. Immunocytochemical stains for keratin, p16INK4, and neuroendocrine markers (synaptophysin, chromogranin, CD56) were performed on additional ThinPrep slides. HPV test used chromogenic in situ hybridization high risk HPV DNA probe. The Pap smears in all three specimens were highly cellular with a mixture of squamous cells and numerous well-preserved single or small cohesive clusters of malignant epithelial cells. Tumor cells were small, monomorphic with minimal cytoplasm and high nuclear/cytoplasmic ratio. There was significant nuclear overlap, but no nuclear molding, or smudging of nuclear chromatin. The chromatin pattern was stippled. A background tumor diathesis was prominent. Atypical squamous cells of undetermined significance (ASCUS) were noted in one case, and markedly abnormal squamous cells were seen in another case. The main cytology differential diagnoses included high-grade squamous intraepithelial lesion and an endometrial adenocarcinoma. Immunocytochemical positivity for the neuroendocrine markers supported the diagnoses of SMCC in all three cases. The morphologic features of the concurrent surgical pathology specimens were typical of SMCC. The tissue diagnoses were also confirmed by immunohistochemistry. Our study allows us to conclude that SMCC can be primarily diagnosed in LBC specimens using a panel of immunocytochemical stains.

No description available.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Background: Cervical cancer is reportedly the easiest gynecologic cancer to prevent, and measures that have the most impact are regular screening and timely follow-up. Although the Papanicolaou (Pap) test used to screen for cervical cancer has been recognized as one of the most valuable clinical preventive service for women, variation in screening and tracking remain a barrier for some women achieving optimal health. Missed opportunities for care in the form of inadequate follow-up is a patient safety and quality of care issue that can be appropriately addressed through implementation of a tool to be used as a component of a cervical cancer surveillance program. Purpose: The purpose of this quality improvement (QI) project was to develop an evidence-based, tracking tool for cervical cytology screening to facilitate surveillance measures in a community health center. Theoretical Framework: The theoretical framework applied was Donebedian’s quality of care framework that incorporates the Structure-Process-Outcome model. Methods: The study was conducted in five phases over a period of 14 months. After permission was granted to implement the study, the tracking tool was developed with input from the mentor. The final two phases consisted of training, implementation, and evaluation of tool’s effectiveness towards improving practice. A survey questionnaire measuring the staff’s opinion of the tool was administered and verbal feedback regarding perception of the tool’s capability to impact clinical practice was collected. Results: Informal surveys were performed by asking stakeholders to share their attitudes and opinions of the surveillance tool. Conclusion: Consistent evidence-based practice among those charged with providing care is paramount to helping patients achieve their best outcome. Surveillance is an internal process and improving surveillance is pivotal to the goal of optimizing outcomes. The findings of the QI project indicate that through the provision of this evidence-based practice, clinical resource, quality of care will be improved. Additionally, the surveillance tool will be incorporated into clinical practice and used as the official method for tracking abnormal cervical cancer screenings, scheduling follow up care, and tracking patients until resolution of cervical pathology.