DENGUE
The deterioration in the quality of air and water results in the occurrences of various forms of diseases in different parts of the country. For example, parts of southern India experience widespread cases of chicken guano, U.P. and Bihar face problems of Encephalitis and Meningitis. Delhi and the surrounding states observe increase in Dengue cases after rainy season and almost in all states Jaundice, Typhoid, Viral fever and gasteroentitis cases are on the rise.
Efforts are always made by the Central and State agencies to provide necessary medical assistance and reduce the causalities. However, it is also important that each one of us should owe the responsibility to provide the desired help as and when required. One such way could be that of making ourselves available to donate blood so that the lives of many are saved. The Jamia Dengue Helpline is primarily aimed at creating a feeling of universal brotherhood and to motivate people across various sections of the society as to how they could involve themselves in this great mission.
The present initiative will be directed towards mobilizing people for blood donation to the needy ones, including dengue patients, and to make available information pertaining to the potential donors so that needy persons may contact them as and when required.
DENGUE FEVER
What is Dengue Fever?
• Dengue [DEN-ghee] is a flu-like viral disease spread by the bite of infected mosquitoes. Dengue hemorrhagic fever is a severe, often fatal, complication of dengue.
• Dengue occurs in most tropical areas of the world. Most U.S. cases occur in travelers returning from abroad, but the dengue risk is increasing for persons living along the Texas-Mexico border and in other parts of the southern United States.
• There is no specific treatment for dengue.
Prevention centers on avoiding mosquito bites in areas where dengue occurs or might occur and eliminating breeding sites.
How can dengue be prevented?
There is no vaccine to prevent dengue. Prevention centers on avoiding mosquito bites when traveling to areas where dengue occurs and when in U.S. areas, especially along the Texas-Mexico border, where dengue might occur. Eliminating mosquito breeding sites in these areas is another key prevention measure.
Avoid mosquito bites when traveling in tropical areas:
• Use mosquito repellents on skin and clothing.
• When outdoors during times that mosquitoes are biting, wear long-sleeved shirts and long pants tucked into socks.
• Avoid heavily populated residential areas.
• When indoors, stay in air-conditioned or screened areas. Use bed nets if sleeping areas are not screened or air-conditioned.
If you have symptoms of dengue, report your travel history to your doctor.
Eliminate mosquito breeding sites in areas where dengue might occur:
• Eliminate mosquito breeding sites around homes. Discard items that can collect rain or run-off water, especially old tires.
Regularly change the water in outdoor bird baths and pet and animal water containers
What are the signs and symptoms of dengue fever and dengue hemorrhagic fever?
Dengue fever usually starts suddenly with a high fever, rash, severe headache, pain behind the eyes, and muscle and joint pain. The severity of the joint pain has given dengue the name "break bone fever." Nausea, vomiting, and loss of appetite are common. A rash usually appears 3 to 4 days after the start of the fever. The illness can last up to 10 days, but complete recovery can take as long as a month. Older children and adults are usually sicker than young children.
Most dengue infections result in relatively mild illness, but some can progress to dengue hemorrhagic fever. With dengue hemorrhagic fever, the blood vessels start to leak and cause bleeding from the nose, mouth, and gums. Bruising can be a sign of bleeding inside the body. Without prompt treatment, the blood vessels can collapse, causing shock (dengue shock syndrome). Dengue hemorrhagic fever is fatal in about 5 percent of cases, mostly among children and young adults.
What is the treatment for dengue and dengue hemorrhagic fever?
There is no specific treatment for dengue. Persons with dengue fever should rest and drink plenty of fluids. They should be kept away from mosquitoes for the protection of others. Dengue hemorrhagic fever is treated by replacing lost fluids. Some patients need transfusions to control bleeding.
What can be done to reduce the risk of acquiring dengue?
There is no vaccine for preventing dengue. The best preventive measure for residents living in areas infested with Aedes aegypti is to eliminate the places where the mosquito lays her eggs, primarily artificial containers that hold water.
Items that collect rainwater or are used to store water (for example, plastic containers, big drums, buckets, or used automobile tires) should be covered or properly discarded. Pet and animal watering containers and vases with fresh flowers should be emptied and scoured at least once a week. This will eliminate the mosquito eggs and larvae and reduce the number of mosquitoes present in these areas
If you live or travel in tropical areas
Living in or traveling to an area where dengue fever viruses are present puts you at risk of the disease. These areas include many tropical and subtropical areas around the world, for example:
Central and South America
Southeast Asia
The Caribbean
Africa
India
The Middle East
The South and Central Pacific
Particularly high-risk areas include tropical Asia, Central and South America and the Caribbean. Dengue virus transmission may occur year-round, although the risk is highest during a recognized dengue fever outbreak.
Dengue fever is a disease transmitted by specific mosquitoes and found in tropical areas around the world including parts of India
Symptoms
Infection with the dengue virus may be sub clinical (no apparent symptoms) or may cause illness ranging from a mild fever to a severe, even fatal condition, ie.dengue hemorrhagic fever or dengue shock syndrome.
The symptoms may last up to a week. Some people may experience a resurgence of fever and other symptoms that may last another 2-3 days.
Dengue fever symptoms
Symptoms are most commonly seen in adults and older children. Young children may show no symptoms. Typical symptoms may include:
sudden onset of fever (lasting three to seven days)
intense headache (especially behind the eyes)
muscle and joint pain (ankles, knees and elbows)
unpleasant metallic taste in mouth, loss of appetite, vomiting, diarrhoea, abdominal pain
flushed skin on face and neck, fine skin rash as fever subsides
rash on arms and legs, severe itching, peeling of skin and hair loss
minor bleeding (nose or gums) and heavy menstrual periods
extreme fatigue
Dengue hemorrhagic fever symptoms
This is a rare complication of dengue in Australia. More commonly seen in children aged under 15 years, but can occur in adults. Symptoms include:
same signs as dengue fever
2-5 days after onset of fever, rapid deterioration and cardiovascular disease
Perhaps shock and sometimes death.
Tests and diagnosis
Diagnosing dengue fever can be difficult. That's because its signs and symptoms can be easily confused with those of other diseases, such as malaria, leptospirosis and typhoid fever. Still, diagnosis of dengue fever is typically done by evaluating your signs and symptoms along with your medical and travel history. To diagnose your condition, your doctor will likely ask about these. In addition, your blood may be tested for evidence of a dengue virus.
Blood test
Laboratory tests, usually using a sample of your blood, are needed to confirm a diagnosis of dengue fever. If you have dengue fever, your blood may reveal the virus itself.
If not, blood tests known as hem agglutination inhibition (HI) assay, enzyme-linked immunosorbent assay (ELISA) and reverse transcriptase-polymerase chain reaction (RT-PCR) also can detect antigens, antibodies or nucleic acids specific to the viruses. These tests may take several days
Treatment
Dengue fever treatment
See a doctor / general practitioner (GP) immediately.
Wear insect repellent. If you have dengue fever, mosquitoes that bite you may pass dengue on to other people.
Drink plenty of liquids and take paracetamol for fever and pain. Do not take aspirin because it can affect blood clotting.
Dengue hemorrhagic fever treatment
All patients with dengue hemorrhagic fever need to be hospitalized for fluid therapy and monitoring.
Doctors and health professionals can refer to Dengue hemorrhagic fever: diagnosis, treatment, prevention and control (2nd edition. Geneva : World Health Organization, 1997) for detailed information on dengue symptoms and treatment.
Types of dengue
There are four types of dengue viruses that cause dengue fever worldwide - Dengue 1, 2, 3 and 4. A person infected with one type of dengue will subsequently only be immune to that type. They will not be immune to other types of dengue and will, in fact, be at risk of developing severe symptoms if they contract another type of dengue.
Dengue fever is a terrible viral disease blighting many of the world's tropical regions. Carried by mosquitoes, such as Aedes aegypti, 40% of the world's population is believed to be at risk from the infection. What is more, previous exposure to other strains of the fever does not confer protection. In fact, subsequent infections are significantly worse, and can result in fatal dengue hemorrhagic fever.
The lack of a functioning vaccine forced Scott O'Neill and Elizabeth McGraw to look for a more creative form of defence. Knowing that a parasite, Wolbachia pipientis, shortens the lifespan of host insects and could restrict dengue fever transmission by killing the insects before they can pass the infection on, O'Neill and his team successfully infected Ae. aegypti with a strain of the Wolbachia bacterium and shortened the mosquitoes' lifespan.
But before insects carrying the bacterium can be released into the environment, the O'Neill and McGraw teams have to convince international governments that mosquitoes carrying the Wolbachia parasite could successfully limit transmission of the virus. McGraw and O'Neill had to find out how the bacterium affects the mosquito's physiology and behavior.
Knowing that Wolbachia slows down some insects' activity and speeds up others, the team decided to test how the parasite affects Ae. aegypti as they age and the infection takes hold. Working with uninfected and infected mosquitoes produced by Conor McMeniman, Oliver Evans and Eric Caragata used a system designed by Craig Williams to film the activities of male and female mosquitoes as they aged to find how the bacteria affected the insects' activity levels. According to McGraw, the experiments generated a huge amount of video data, so Evans teamed up with Megan Woolfit and David Green to pipe the data to a cluster of workstations to track the insects' movements and analyse their activity levels.
After a year of experimental design, data collection and analysis, it was clear that the infected mosquitoes were more active than the uninfected insects. Most surprisingly, as the mosquitoes aged and the infection took hold, it did not increase their activity levels further.
Having found that the insects became more active in response to their bacterial lodgers, Craig Franklin joined the team to help measure the insects' CO2 production to find how their metabolic rates respond to the parasite. Again, the insects' metabolic rates were higher than those of the uninfected mosquitoes.
So why are the infected insects more active than the uninfected insects? McGraw says there are three possible explanations; the insects are living fast and dying young; the insects are hungrier and consume more energy in their constant search for food; or the bacteria somehow affect the insects' tissues to change their behavior and increase their metabolic rate. McGraw suspects that the last explanation is the most likely.
Having shown that the activity levels of Walachia infected mosquitoes respond to the bacterium, McGraw and O'Neill are continuing to test how the infection affects the insects' biting behavior and whether a Walachia infection can become established in Ae. Aegypti populations to limit their life spans. Ultimately, McGraw and O'Neill hope to release infected mosquitoes into afflicted regions of the world to limit dengue fever transmission, but only once they are sure that the insects will do no harm to the environment.
References and Notes
• http://www.fda.gov/bbs/topics/NEWS/2006/NEW01385.html.
• http://www.jci.org/articles/view/JCI28607.
• http://www.cancer.gov/cancertopics/factsheet/risk/HPV-vaccine.
• http://info.cancerresearchuk.org/cancerstats/types/cervix/incidence/. http://www.aafp.org/afp/20000301/1369.html.. National Institutes of Health. http://www.nlm.nih.gov/medlineplus/ency/article/000893.htm.
• http://www.cancer.org/docroot/CRI/content/CRI_2_2_2X_What_causes_cancer_of_the_cervix_Can_it_be_prevented_8.asp?sitearea=..
• http://www.ajph.org/cgi/pmidlookup?view=long&pmid=11392939.
• http://www.mdlab.com/html/testing/hpv_typedetect.html.
• http://www.merck.com/mmhe/sec22/ch252/ch252d.html.
• http://www.cancerhelp.org.uk/help/default.asp?page=9260.
• http://www.papscreen.org.au/
Saturday, September 19, 2009
Monday, September 14, 2009
Dyslexia
Dyslexia
Dyslexia is a difficulty in learning to read, speak, or write. It is a difference in brain organization that is present at birth & results in a struggle when trying to learn, remember, or express information. It is a learning disability that alters the way the brain processes written material. The effects of the disorder vary from person to person. In fact, the only common trait among people with dyslexia is that they read at levels significantly lower than typical for people of their age and intelligence.
Experts say it occurs in up to 15% of the general population. Although dyslexia continues through life, it is very possible to learn to deal effectively with dyslexia & accomplish high levels of success.
The most universal problems are:
• weak recognition of numbers, letters & words
• difficulty remembering numbers & letters in sequence
• poor manipulation of numbers & letters
• poor spelling
To suspect a diagnosis of dyslexia, a cluster of symptoms must be evidenced - not just one symptom. Symptoms may appear different in childhood or in adolescence & adulthood.
Dyslexia can result in a severe loss of self-esteem, limited friendships, & failure in school & career.
These effects can be prevented by:
• early diagnosis
• special remediation using multisensory techniques
• teaching of coping skills
Dyslexia Is ...
• not a sign of poor intelligence
• not the result of laziness or of not caring
• not a disease
• cannot be cured with pills or diets
• not an eye problem
• not outgrown
but... dyslexics can learn how to learn
the good news is that with appropriate education, understanding, & time, many dyslexics learn to read & write & to develop their special abilities & talents. Many successful people: scientists, artists, athletes & world leaders have dyslexia.
• Dyslexia is difficulty with language. For people with dyslexia, intelligence is not the problem. The problem is language.
• People with dyslexia may struggle with reading, spelling, understanding language they hear, or expressing themselves clearly in speaking or in writing.
• An unexpected gap exists between their potential for learning and their school achievement.
Typical responses when people find out that they or someone they know is dyslexic include dismay and anxiety – like the feelings people have when they find out they have a serious disease. Dyslexia is not a disease, but it is a lifelong problem that presents challenges that need to be overcome daily. The good news is that with proper diagnosis, appropriate education, hard work and support from family, friends, teachers and others, people who are dyslexic can lead successful and productive lives.
The first step in helping a person with dyslexia is to give emotional support and understanding. That’s one reason why you’re here right now – to find out how you can give that support. And that’s why we have this website – to help you with information and support.
The Left Hemisphere of the Brain - is it the right side?
Simply explained: A dyslectic uses the brain's right side instead of the left to read and spell.
In a human brain, the left-hemisphere is programmed to do the things you need for reading: to match a letter with its sound, or to handle information that comes into your brain in strings, like the sounds in a word - one after the other. It separates a word into individual sounds and so helps understand grammar and syntax.
The right hemisphere is different. It deals in areas and space and patterns. It doesn't understand parts of speech, or keep track of letter order in spelling. It "reads" a word as a drawing that it has been taught has a meaning (as a sketch, not a line up of sounds). So if it sees the shape "HOUSE," it knows that it's a place where somebody lives. But the person is just as apt to speak out home or residence (or igloo or tepee) instead of house. You can see that if the left side is leaves the reading to the right side, the result can be a totally different sound.
Corpus Callosum - A Bridge of Nerve cells in the brain.
It has long been thought that there were two contributing factors in the brain of a dyslectic. One is an underutilized left-hemisphere, and the other is a problem involving a central bridge of tissue in the brain called the Corpus Callosum.
The Corpus Callosum is a bridge of nerve cells over which information signals from one side of the brain reaches the other. Everything you see or hear goes to both sides, but each side has it own specialty. The Corpus Callosum not only transfers information, but also helps decide which is the appropriate side, and sends it there.
Recent research using the latest brain scanning techniques has now proven both suppositions: dyslectics do not use the Angular Gyrus in the left hemisphere when they read - and oddities in the construction of the Corpus Callosum are correlated with poor reading.
Obviously, a weak Corpus Callosum may not correctly deliver language tasks to the left where they belong. Further, it may transmit slowly, so some information arrives out of sync with the rest.
Also, the language areas in the dyslectic brain tend to be smaller than they are in a standard brain. This combination of a slow Corpus Callosum, an over eager right-hemisphere and an undersized left language area, is the recipe for dyslexia.
Suspecting Dyslexia ?
To suspect a diagnosis of dyslexia, a cluster of symptoms must be evidenced - not just one symptom.
• Dyslexia is difficulty with language. For people with dyslexia, intelligence is not the problem. The problem is language.
• People with dyslexia may struggle with reading, spelling, understanding language they hear, or expressing themselves clearly in speaking or in writing.
• An unexpected gap exists between their potential for learning and their school achievement.
Causes of Dyslexia
• results from differences within the organization of the brain. See What causes it?
• tends to run in families - dyslexics are born with the difference
• the exact cause may still be unknown
Diagnostic Tests
Tests for dyslexia look for just the telltale signs: overuse of the right-hemisphere and a poorly operating Corpus Callosum. First, of course, you have to be sure you are looking at a real reading problem, so you want a reading score of some kind and a rough-and-ready IQ score. If there is a big discrepancy between potential and production, that's an important clue.
Second, you want to see whether the right hemisphere of the brain is doing the reading. This is easily accomplished by having a student read a group of words that have been misspelled (but which if pronounced as written, would sound like real words. Example: fut, brade, blone, or peze. (Foot, braid, blown, or peas, in case your own left side needs jogging!). These words are called misspelled homophones.
Third, you want to test the state of the corpus callosum. This test is called Tactile Localization. It is easy to do and is explained under Diagnostic Tests.
Last, you will want a writing sample done from dictation. Check for bizarre spelling, omission of small words and punctuation, misplaced apostrophes, reversed letters and other odd mistakes.
If your student is intelligent, reads at about half the level he should, makes mistakes on the misspelled homophones test, writes as though some of the words originated in Outer Mongolia and makes 15% or more mistakes on the tactile localization test, you've most likely got a dyslectic child
To suspect a diagnosis of dyslexia, a cluster of symptoms must be evidenced - not just one symptom. Dyslexia is difficulty with language. For people with dyslexia, intelligence is not the problem. The problem is language.
An unexpected gap exists between their potential for learning and their school achievement.
Below are listed some of the common Symptoms found in Dyslectics (10-15% of the population)
The following difficulties may be associated with dyslexia. To verify that an individual is dyslexic, he/she should be tested by a qualified doctor.
Common Symptoms in Preschool Children
• May talk later than most children
• Fine motor skills may develop more slowly (like tying shoes)
• May have difficulty expressing self
• May have difficulty pronouncing words
• May be unable to recall the right word
• May have inability to follow directions
• May have left-right confusion
• May have difficulty learning alphabet, words of songs
• May have difficulty learning rhymes
• May have trouble interacting with peers
• May be unable to follow multi-step directions or routines
• Often has difficulty separating sounds in words and blending sounds to make words
• May have difficulty telling and/or retelling a story in the correct sequence
Caution: it is developmentally normal for children to have some of the above symptoms and to reverse letters and words when they first learn to write. This normally disappears by 2nd grade.
Common Symptoms at Kindergarten level
• Has difficulty decoding single words (reading single words in isolation)
• May be slow to learn the connection between letters and sounds
• May confuse small words - at - to, said - and, does - goes
• Makes consistent reading and spelling errors including:
o Inversions - m and w, u and n
o Substitutions - house and home
o Letter reversals - d for b as in, dog for bog
o Word reversals - top for pot
o Transpositions - felt and left
• May transpose number sequences and confuse arithmetic signs (+ - x / =)
• May have trouble remembering facts
• May be slow to learn new skills; relies heavily on memorizing without understanding
• May be impulsive and prone to accidents
• May have difficulty planning
• Often uses an awkward pencil grip (fist, thumb hooked over fingers, etc.)
• May have trouble learning to tell time
• May have poor fine motor coordination
Caution: To verify that an individual is dyslexic, he/she should be tested by a qualified doctor.
Common Symptoms at Junior School level
• Is usually reading below class level
• May reverse letter sequences - soiled for solid, left for felt
• May be slow to discern and to learn prefixes, suffixes, root words, and other reading and spelling strategies
• May have difficulty spelling, spells same word differently on the same page
• May avoid reading aloud
• May have trouble with word problems in math
• May write with difficulty with illegible handwriting; pencil grip is awkward, fist-like or tight
• May avoid writing
• May have slow or poor recall of facts
• May have difficulty with comprehension
• May have difficulty making friends
• May not understand body language and facial expressions of others
• May have trouble with non-literal language (idioms, jokes, proverbs, slang)
• May forget to hand in homework or to bring in homework
• May have difficulty with planning and time management
Caution: To verify that an individual is dyslexic, he/she should be tested by a qualified doctor.
Common Symptoms at Senior School level
• May read very slowly with many inaccuracies
• Continues to spell incorrectly, frequently spells the same word differently in a single piece of writing
• May procrastinate reading and writing tasks
• May avoid writing
• May have trouble summarizing and outlining
• May have trouble answering open-ended questions on tests
• May have poor memory skills
• May not adjust well to new settings or to change
• May work slowly
• May have poor grasp of abstract concepts
• May pay too little attention to details or focus too much on them
• May misread information
• Difficulty remembering names of people and places
• Hesitant speech
• Difficulty finding appropriate words
• Difficulty organizing ideas to write a letter or paper
• Inability to recall numbers in proper sequences (as in phone numbers)
• May not complete assignments; may complete them and not hand them in
• May have an inadequate vocabulary
• May have an inadequate store of knowledge from previous reading
• May have difficulty with planning and time management
Caution: To verify that an individual is dyslexic, he/she should be tested by a qualified doctor.
Common Symptoms in Adults
• May hide their reading problems; many subterfuges
• May spell poorly; relies on others
• Avoids writing; may not be able to write
• Often very competent in oral language
• Relies on memory; may have excellent memories
• Often has good “people” skills
• Often is spatially talented; engineers, architects, designers, artists and craftspeople, mathematicians, physicists, physicians (esp. orthopads, surgeons), dentists
• May be very good at “reading” people (intuitive)
• In jobs is often working well below their intellectual capacity
• May have difficulty with planning and organization
• May have difficulty with time; often too early, late or forgets appointments. Relies on digital watches; cannot tell analog time
• Often entrepreneurs; may have lost one or more businesses they started
• Difficulty remembering names of people and places
• Hesitant speech
• Difficulty finding appropriate words
• Difficulty organizing ideas to write a letter or paper
• Inability to recall numbers in proper sequences (as in phone numbers)
• Lowered self-esteem due to past frustrations and failures
• Poor ability to find way around and trouble finding car in parking lot OR excellent ability to find way around
Caution: To verify that an individual is dyslexic, he/she should be tested by a qualified doctor.
READING AND IQ
If your pupil is in school and is reading badly, you can probably get a reading level from the school. If he is an adult and reading badly enough to want to go through tutoring, you probably don't have to do a reading test, unless you want a nice before-and-after showing for your efforts.
For an I.Q. test, a child in real trouble in school may already already have had one. If not, you're entitled to ask for it. You don't need an exact score, just an indication that the student is at least average or above in intelligence. If he is somewhat slow, his reading problems may be due to something other than dyslexia.
Here are two basic diagnostic test-
Misspelled Homophones and Tactile Localization.
1. MISSPELLED HOMOPHONES TEST
Tell your pupil that some of the "words" he sees in the following bunch actually sound like real words, although they would be spelled differently. Have him look down a column - without reading them aloud - and have him point to any he thinks would be real words. When he points to one, then have him pronounce what he thinks it would be. You do this because otherwise you may miss some of his mistakes. For instance, if he looks at "sed" and says that would be a real word, you will think he has it right. But if he tells you that it would say "seed" you know it is a mistake. Then go on to the next column until he has done them all. He should be able to do this without more than one mistake.
zam lep crope bete mord
sed rool peze frire blone
baik calp hib masp thoe
vust praid blut kern crasp
He should identify sed and baik (said and bake) in the first column, rool and praid (rule and prayed) in the second, peze (peas) in the third, bete and frire (beat and fryer) in the fourth, and blone and thoe (blown and though) in the last column. This is a killer test for dyslectics.
2. TACTILE LOCALIZATION TEST
This is a test for the Corpus Callosum. If you touch someone lightly on the inside of his fingers with his hand behind his back (where he can't see what you do), and then you ask him to show you on the other hand where he was touched, that information has to goes through the Corpus Callosum.
The Corpus Callosum is fully matured by about ten years old, so no adult should make more than one or two mistakes on this.
Here is how you do the test:
Have a child's paint brush ready for light touching. Imagine the finger broken into three sections called "pads" separated by the joints. The three sections are the fleshy parts of the finger. You will touch either the far pad (fingerprint area) or the near pad next to his palm (never the middle one.)
Have your friend hold out both his hands, palms up, fingers spread out, one in front of him and one behind. Explain that you will be touching the fingers on the hand behind him where he can't see it. He is to point with his thumb on his front hand to where you touched him. Hold out your own hand, touch one of your fingers, and ask him where he would point on his own hand. Do this with several spots on both the inside and the outside joints of your fingers until you know he has the idea and never tries to touch that middle joint. Warn him that when you have touched the hand behind him, he is NOT to wiggle those fingers at all.
Touch him twice on each location on each finger, skipping around, of course, making a total of 16 touches, four to a finger, on each hand. Make sure your touches are light and quick! Make a diagram of the hands, and mark the spots where you touched him. If he identified it right, mark a 0 and mark a X to the wrong spots. If he makes three or more errors, his Corpus Callosum is not transferring information from one hemisphere to the other quickly and accurately.
If you find someone with reading problems who is intelligent, makes mistakes on the Misspelled Homophones and blows the Tactile Localization test, you are as sure as you are going to get in this world that you are looking at dyslexia.\
SUGGESTIONS TO PARENTS
• many students who learn differently struggle with homework
• assist your child in a positive way with homework
• reward your child's progress
• use lots of praise
• display your child's work
• acknowledge your child's difficulties
• help provide your child with other activities that focus on his or her strengths and gifts
• provide structure at home
• help your child become a self-advocate with teachers
HELPING WITH HOMEWORK
• It helps if you (as the parent) are aware of the type and amount of homework your child has. Teachers appreciate hearing from parents who have questions about homework - if you find your child is spending too much time on homework, ask the teacher how much time is expected. Often a teacher will tell parents to limit the homework to a given time, rather than have the child while away hours every evening..
o help your child set up a homework environment
o provide a suitable place for homework - quiet and away from TV
o some children, however, work better with a low radio
o some children work better while chewing gum
o provide good lighting
o develop a homework schedule that is relatively easy to stick to
o talk to your child about the homework assignment
o go over your child's work to see if it is complete - and to answer questions
o make sure your child has the appropriate tools:
pencils
pencil sharpener
desk (or table top)
computer, if appropriate
• Most important: avoid making homework a punishment for your child.
• If your child is struggling with reading, writing, math, and is exceptionally frustrated, consider requesting extra help:
o Contact your child's teacher
o Check into what is available from the school
o Have your child tested for Dyslexia
Dyslexia is a difficulty in learning to read, speak, or write. It is a difference in brain organization that is present at birth & results in a struggle when trying to learn, remember, or express information. It is a learning disability that alters the way the brain processes written material. The effects of the disorder vary from person to person. In fact, the only common trait among people with dyslexia is that they read at levels significantly lower than typical for people of their age and intelligence.
Experts say it occurs in up to 15% of the general population. Although dyslexia continues through life, it is very possible to learn to deal effectively with dyslexia & accomplish high levels of success.
The most universal problems are:
• weak recognition of numbers, letters & words
• difficulty remembering numbers & letters in sequence
• poor manipulation of numbers & letters
• poor spelling
To suspect a diagnosis of dyslexia, a cluster of symptoms must be evidenced - not just one symptom. Symptoms may appear different in childhood or in adolescence & adulthood.
Dyslexia can result in a severe loss of self-esteem, limited friendships, & failure in school & career.
These effects can be prevented by:
• early diagnosis
• special remediation using multisensory techniques
• teaching of coping skills
Dyslexia Is ...
• not a sign of poor intelligence
• not the result of laziness or of not caring
• not a disease
• cannot be cured with pills or diets
• not an eye problem
• not outgrown
but... dyslexics can learn how to learn
the good news is that with appropriate education, understanding, & time, many dyslexics learn to read & write & to develop their special abilities & talents. Many successful people: scientists, artists, athletes & world leaders have dyslexia.
• Dyslexia is difficulty with language. For people with dyslexia, intelligence is not the problem. The problem is language.
• People with dyslexia may struggle with reading, spelling, understanding language they hear, or expressing themselves clearly in speaking or in writing.
• An unexpected gap exists between their potential for learning and their school achievement.
Typical responses when people find out that they or someone they know is dyslexic include dismay and anxiety – like the feelings people have when they find out they have a serious disease. Dyslexia is not a disease, but it is a lifelong problem that presents challenges that need to be overcome daily. The good news is that with proper diagnosis, appropriate education, hard work and support from family, friends, teachers and others, people who are dyslexic can lead successful and productive lives.
The first step in helping a person with dyslexia is to give emotional support and understanding. That’s one reason why you’re here right now – to find out how you can give that support. And that’s why we have this website – to help you with information and support.
The Left Hemisphere of the Brain - is it the right side?
Simply explained: A dyslectic uses the brain's right side instead of the left to read and spell.
In a human brain, the left-hemisphere is programmed to do the things you need for reading: to match a letter with its sound, or to handle information that comes into your brain in strings, like the sounds in a word - one after the other. It separates a word into individual sounds and so helps understand grammar and syntax.
The right hemisphere is different. It deals in areas and space and patterns. It doesn't understand parts of speech, or keep track of letter order in spelling. It "reads" a word as a drawing that it has been taught has a meaning (as a sketch, not a line up of sounds). So if it sees the shape "HOUSE," it knows that it's a place where somebody lives. But the person is just as apt to speak out home or residence (or igloo or tepee) instead of house. You can see that if the left side is leaves the reading to the right side, the result can be a totally different sound.
Corpus Callosum - A Bridge of Nerve cells in the brain.
It has long been thought that there were two contributing factors in the brain of a dyslectic. One is an underutilized left-hemisphere, and the other is a problem involving a central bridge of tissue in the brain called the Corpus Callosum.
The Corpus Callosum is a bridge of nerve cells over which information signals from one side of the brain reaches the other. Everything you see or hear goes to both sides, but each side has it own specialty. The Corpus Callosum not only transfers information, but also helps decide which is the appropriate side, and sends it there.
Recent research using the latest brain scanning techniques has now proven both suppositions: dyslectics do not use the Angular Gyrus in the left hemisphere when they read - and oddities in the construction of the Corpus Callosum are correlated with poor reading.
Obviously, a weak Corpus Callosum may not correctly deliver language tasks to the left where they belong. Further, it may transmit slowly, so some information arrives out of sync with the rest.
Also, the language areas in the dyslectic brain tend to be smaller than they are in a standard brain. This combination of a slow Corpus Callosum, an over eager right-hemisphere and an undersized left language area, is the recipe for dyslexia.
Suspecting Dyslexia ?
To suspect a diagnosis of dyslexia, a cluster of symptoms must be evidenced - not just one symptom.
• Dyslexia is difficulty with language. For people with dyslexia, intelligence is not the problem. The problem is language.
• People with dyslexia may struggle with reading, spelling, understanding language they hear, or expressing themselves clearly in speaking or in writing.
• An unexpected gap exists between their potential for learning and their school achievement.
Causes of Dyslexia
• results from differences within the organization of the brain. See What causes it?
• tends to run in families - dyslexics are born with the difference
• the exact cause may still be unknown
Diagnostic Tests
Tests for dyslexia look for just the telltale signs: overuse of the right-hemisphere and a poorly operating Corpus Callosum. First, of course, you have to be sure you are looking at a real reading problem, so you want a reading score of some kind and a rough-and-ready IQ score. If there is a big discrepancy between potential and production, that's an important clue.
Second, you want to see whether the right hemisphere of the brain is doing the reading. This is easily accomplished by having a student read a group of words that have been misspelled (but which if pronounced as written, would sound like real words. Example: fut, brade, blone, or peze. (Foot, braid, blown, or peas, in case your own left side needs jogging!). These words are called misspelled homophones.
Third, you want to test the state of the corpus callosum. This test is called Tactile Localization. It is easy to do and is explained under Diagnostic Tests.
Last, you will want a writing sample done from dictation. Check for bizarre spelling, omission of small words and punctuation, misplaced apostrophes, reversed letters and other odd mistakes.
If your student is intelligent, reads at about half the level he should, makes mistakes on the misspelled homophones test, writes as though some of the words originated in Outer Mongolia and makes 15% or more mistakes on the tactile localization test, you've most likely got a dyslectic child
To suspect a diagnosis of dyslexia, a cluster of symptoms must be evidenced - not just one symptom. Dyslexia is difficulty with language. For people with dyslexia, intelligence is not the problem. The problem is language.
An unexpected gap exists between their potential for learning and their school achievement.
Below are listed some of the common Symptoms found in Dyslectics (10-15% of the population)
The following difficulties may be associated with dyslexia. To verify that an individual is dyslexic, he/she should be tested by a qualified doctor.
Common Symptoms in Preschool Children
• May talk later than most children
• Fine motor skills may develop more slowly (like tying shoes)
• May have difficulty expressing self
• May have difficulty pronouncing words
• May be unable to recall the right word
• May have inability to follow directions
• May have left-right confusion
• May have difficulty learning alphabet, words of songs
• May have difficulty learning rhymes
• May have trouble interacting with peers
• May be unable to follow multi-step directions or routines
• Often has difficulty separating sounds in words and blending sounds to make words
• May have difficulty telling and/or retelling a story in the correct sequence
Caution: it is developmentally normal for children to have some of the above symptoms and to reverse letters and words when they first learn to write. This normally disappears by 2nd grade.
Common Symptoms at Kindergarten level
• Has difficulty decoding single words (reading single words in isolation)
• May be slow to learn the connection between letters and sounds
• May confuse small words - at - to, said - and, does - goes
• Makes consistent reading and spelling errors including:
o Inversions - m and w, u and n
o Substitutions - house and home
o Letter reversals - d for b as in, dog for bog
o Word reversals - top for pot
o Transpositions - felt and left
• May transpose number sequences and confuse arithmetic signs (+ - x / =)
• May have trouble remembering facts
• May be slow to learn new skills; relies heavily on memorizing without understanding
• May be impulsive and prone to accidents
• May have difficulty planning
• Often uses an awkward pencil grip (fist, thumb hooked over fingers, etc.)
• May have trouble learning to tell time
• May have poor fine motor coordination
Caution: To verify that an individual is dyslexic, he/she should be tested by a qualified doctor.
Common Symptoms at Junior School level
• Is usually reading below class level
• May reverse letter sequences - soiled for solid, left for felt
• May be slow to discern and to learn prefixes, suffixes, root words, and other reading and spelling strategies
• May have difficulty spelling, spells same word differently on the same page
• May avoid reading aloud
• May have trouble with word problems in math
• May write with difficulty with illegible handwriting; pencil grip is awkward, fist-like or tight
• May avoid writing
• May have slow or poor recall of facts
• May have difficulty with comprehension
• May have difficulty making friends
• May not understand body language and facial expressions of others
• May have trouble with non-literal language (idioms, jokes, proverbs, slang)
• May forget to hand in homework or to bring in homework
• May have difficulty with planning and time management
Caution: To verify that an individual is dyslexic, he/she should be tested by a qualified doctor.
Common Symptoms at Senior School level
• May read very slowly with many inaccuracies
• Continues to spell incorrectly, frequently spells the same word differently in a single piece of writing
• May procrastinate reading and writing tasks
• May avoid writing
• May have trouble summarizing and outlining
• May have trouble answering open-ended questions on tests
• May have poor memory skills
• May not adjust well to new settings or to change
• May work slowly
• May have poor grasp of abstract concepts
• May pay too little attention to details or focus too much on them
• May misread information
• Difficulty remembering names of people and places
• Hesitant speech
• Difficulty finding appropriate words
• Difficulty organizing ideas to write a letter or paper
• Inability to recall numbers in proper sequences (as in phone numbers)
• May not complete assignments; may complete them and not hand them in
• May have an inadequate vocabulary
• May have an inadequate store of knowledge from previous reading
• May have difficulty with planning and time management
Caution: To verify that an individual is dyslexic, he/she should be tested by a qualified doctor.
Common Symptoms in Adults
• May hide their reading problems; many subterfuges
• May spell poorly; relies on others
• Avoids writing; may not be able to write
• Often very competent in oral language
• Relies on memory; may have excellent memories
• Often has good “people” skills
• Often is spatially talented; engineers, architects, designers, artists and craftspeople, mathematicians, physicists, physicians (esp. orthopads, surgeons), dentists
• May be very good at “reading” people (intuitive)
• In jobs is often working well below their intellectual capacity
• May have difficulty with planning and organization
• May have difficulty with time; often too early, late or forgets appointments. Relies on digital watches; cannot tell analog time
• Often entrepreneurs; may have lost one or more businesses they started
• Difficulty remembering names of people and places
• Hesitant speech
• Difficulty finding appropriate words
• Difficulty organizing ideas to write a letter or paper
• Inability to recall numbers in proper sequences (as in phone numbers)
• Lowered self-esteem due to past frustrations and failures
• Poor ability to find way around and trouble finding car in parking lot OR excellent ability to find way around
Caution: To verify that an individual is dyslexic, he/she should be tested by a qualified doctor.
READING AND IQ
If your pupil is in school and is reading badly, you can probably get a reading level from the school. If he is an adult and reading badly enough to want to go through tutoring, you probably don't have to do a reading test, unless you want a nice before-and-after showing for your efforts.
For an I.Q. test, a child in real trouble in school may already already have had one. If not, you're entitled to ask for it. You don't need an exact score, just an indication that the student is at least average or above in intelligence. If he is somewhat slow, his reading problems may be due to something other than dyslexia.
Here are two basic diagnostic test-
Misspelled Homophones and Tactile Localization.
1. MISSPELLED HOMOPHONES TEST
Tell your pupil that some of the "words" he sees in the following bunch actually sound like real words, although they would be spelled differently. Have him look down a column - without reading them aloud - and have him point to any he thinks would be real words. When he points to one, then have him pronounce what he thinks it would be. You do this because otherwise you may miss some of his mistakes. For instance, if he looks at "sed" and says that would be a real word, you will think he has it right. But if he tells you that it would say "seed" you know it is a mistake. Then go on to the next column until he has done them all. He should be able to do this without more than one mistake.
zam lep crope bete mord
sed rool peze frire blone
baik calp hib masp thoe
vust praid blut kern crasp
He should identify sed and baik (said and bake) in the first column, rool and praid (rule and prayed) in the second, peze (peas) in the third, bete and frire (beat and fryer) in the fourth, and blone and thoe (blown and though) in the last column. This is a killer test for dyslectics.
2. TACTILE LOCALIZATION TEST
This is a test for the Corpus Callosum. If you touch someone lightly on the inside of his fingers with his hand behind his back (where he can't see what you do), and then you ask him to show you on the other hand where he was touched, that information has to goes through the Corpus Callosum.
The Corpus Callosum is fully matured by about ten years old, so no adult should make more than one or two mistakes on this.
Here is how you do the test:
Have a child's paint brush ready for light touching. Imagine the finger broken into three sections called "pads" separated by the joints. The three sections are the fleshy parts of the finger. You will touch either the far pad (fingerprint area) or the near pad next to his palm (never the middle one.)
Have your friend hold out both his hands, palms up, fingers spread out, one in front of him and one behind. Explain that you will be touching the fingers on the hand behind him where he can't see it. He is to point with his thumb on his front hand to where you touched him. Hold out your own hand, touch one of your fingers, and ask him where he would point on his own hand. Do this with several spots on both the inside and the outside joints of your fingers until you know he has the idea and never tries to touch that middle joint. Warn him that when you have touched the hand behind him, he is NOT to wiggle those fingers at all.
Touch him twice on each location on each finger, skipping around, of course, making a total of 16 touches, four to a finger, on each hand. Make sure your touches are light and quick! Make a diagram of the hands, and mark the spots where you touched him. If he identified it right, mark a 0 and mark a X to the wrong spots. If he makes three or more errors, his Corpus Callosum is not transferring information from one hemisphere to the other quickly and accurately.
If you find someone with reading problems who is intelligent, makes mistakes on the Misspelled Homophones and blows the Tactile Localization test, you are as sure as you are going to get in this world that you are looking at dyslexia.\
SUGGESTIONS TO PARENTS
• many students who learn differently struggle with homework
• assist your child in a positive way with homework
• reward your child's progress
• use lots of praise
• display your child's work
• acknowledge your child's difficulties
• help provide your child with other activities that focus on his or her strengths and gifts
• provide structure at home
• help your child become a self-advocate with teachers
HELPING WITH HOMEWORK
• It helps if you (as the parent) are aware of the type and amount of homework your child has. Teachers appreciate hearing from parents who have questions about homework - if you find your child is spending too much time on homework, ask the teacher how much time is expected. Often a teacher will tell parents to limit the homework to a given time, rather than have the child while away hours every evening..
o help your child set up a homework environment
o provide a suitable place for homework - quiet and away from TV
o some children, however, work better with a low radio
o some children work better while chewing gum
o provide good lighting
o develop a homework schedule that is relatively easy to stick to
o talk to your child about the homework assignment
o go over your child's work to see if it is complete - and to answer questions
o make sure your child has the appropriate tools:
pencils
pencil sharpener
desk (or table top)
computer, if appropriate
• Most important: avoid making homework a punishment for your child.
• If your child is struggling with reading, writing, math, and is exceptionally frustrated, consider requesting extra help:
o Contact your child's teacher
o Check into what is available from the school
o Have your child tested for Dyslexia
Wednesday, August 26, 2009
Cervical cancer
Cervical cance
Contents
1. 1 Classification
2. 2 Signs and symptoms
3. 3 Causes
3.1 Human papillomavirus infection
3.2 Cofactors
4. 4 Diagnosis
4.1 Biopsy procedures
4.2 Pathologic types
4.3 Staging
5. 5 Treatment
6. 6 Prevention
6.1 Awareness
6.2 Screening
6.3 Preventive Vaccination
6.4 Condoms
6.5 Nutrition
6.5.1 Fruits and vegetables
6.5.2 Vitamin A
6.5.3 Vitamin C
6.5.4 Vitamin E
6.5.5 Folic acid
6.5.6 Carotenoids
6.5.7 CoQ10
6.5.8 Fish oil
7. 7 Prognosis
8. 8 Epidemiology
9. 9 History
10. 10 References and Notes
What Is Cancer?
1. 1 Classification
2. 2 Signs and symptoms
3. 3 Causes
3.1 Human papillomavirus infection
3.2 Cofactors
4. 4 Diagnosis
4.1 Biopsy procedures
4.2 Pathologic types
4.3 Staging
5. 5 Treatment
6. 6 Prevention
6.1 Awareness
6.2 Screening
6.3 Preventive Vaccination
6.4 Condoms
6.5 Nutrition
6.5.1 Fruits and vegetables
6.5.2 Vitamin A
6.5.3 Vitamin C
6.5.4 Vitamin E
6.5.5 Folic acid
6.5.6 Carotenoids
6.5.7 CoQ10
6.5.8 Fish oil
7. 7 Prognosis
8. 8 Epidemiology
9. 9 History
10. 10 References and Notes
What Is Cancer?
Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide faster to allow the person to grow. After the person becomes an adult, most cells divide only to replace worn-out or dying cells or to repair injuries.
Because cancer cells continue to grow and divide, they are different from normal cells. Instead of dying, cancer cells outlive normal cells and keep forming new abnormal cells. Another difference between cancer cells and normal cells is that cancer cells can invade (grow into) other tissues. Being able to grow out of control and to invade other tissues makes a cell a cancer cell.
Cells become cancer cells because of damage to DNA. DNA is in every cell and directs all its actions. Most of the time, when DNA gets damaged the cell can fix it. If the cell can’t repair the damage, the cell dies. In cancer cells the damaged DNA is not repaired, but the cell doesn’t die like it should. Instead, this cell goes on making new cells even though the body does not need them. These new cells will all have the same DNA damage as the first cell does.
People can inherit damaged DNA, but most of the time DNA damage is caused by something we are exposed to in our environment. Sometimes the cause of the DNA damage is something obvious, like cigarette smoking. But many times no clear cause is found.
A cancer cell has many mistakes in its DNA -- having damage in just one spot does not cause cancer. Even when someone inherits damaged DNA, more mistakes in their DNA are needed before a cancer will develop. Staying away from things that are known to damage DNA (like smoking) as a part of a healthy life style lowers the chance that more DNA damage will take place. This can reduce the risk of cancer -- even in people who have an inherited tendency to get cancer.
How cancers grow and spread
In most cases the cancer cells form a tumor. Some cancers, like leukemia, do not form tumors. Instead, these cancer cells involve the blood and blood-forming organs and circulate through other tissues where they grow. But sometimes the extra cells in these blood cancers may also form a mass of tissue called a tumor.
Cancer cells often travel to other parts of the body, where they begin to grow and replace normal tissue. This process is called metastasis. It happens when the cancer cells get into the bloodstream or lymph vessels of our body.
But no matter where a cancer may spread, it is always named for the place where it started. For example, breast cancer that has spread to the liver is still called breast cancer, not liver cancer. Prostate cancer that has spread to the bone is metastatic prostate cancer, not bone cancer.
Not all tumors are cancerous. Tumors that aren't cancer are called benign. Benign tumors can cause problems -- they can grow very large and press on healthy organs and tissues. But they cannot grow into (invade) other tissues. Because they can't invade, they also can't spread to other parts of the body (metastasize). These tumors are almost never life threatening.
How cancers differ
Different types of cancer can behave very differently. For example, lung cancer and breast cancer are very different diseases. They grow at different rates and respond to different treatments. That is why people with cancer need treatment that is aimed at their particular kind of cancer.
How common is cancer
Today, millions of people are living with cancer or have had cancer. The risk of developing most types of cancer can be reduced by changes in a person's lifestyle, for example, by quitting smoking and eating a better diet. Often, the sooner a cancer is found and treatment begins, the better are the chances for living for many years
Cervical cancer is malignant cancer of the cervix uteri or cervical area. It may present with vaginal bleeding but symptoms may be absent until the cancer is in its advanced stages. Treatment consists of surgery (including local excision) in early stages and chemotherapy and radiotherapy in advanced stages of the disease.
Pap smear screening can identify potentially precancerous changes. Treatment of high grade changes can prevent the development of cancer. In developed countries, the widespread use of cervical screening programs has reduced the incid
ence of invasive cervical cancer by 50% Human papillomavirus (HPV) infection is a necessary factor in the development of nearly all cases of cervical cancer.HPV vaccine effective against the two strains of HPV that cause the most cervical cancer has been licensed in the U.S. and the EU. These two HPV strains together are currently responsible for approximately 70%of all cervical cancers. Since the vaccine only covers some high-risk types, women should seek regular Pap smear screening, even after vaccination
Classification
The naming and classification of cervical carcinoma percursor lesions has changed many times over the 20th century. The World Health Organization classification system was descriptive of the lesions, naming them mild, moderate or severe dysplasia or carcinoma in situ (CIS). The term, Cervical Intraepithelial Neoplasia (CIN) was developed to place emphasis on the spectrum of abnormality in these lesions, and to help standardise treatment.
It classifies mild dysplasia as CIN1, moderate dysplasia as CIN2, and severe dysplasia and CIS as CIN3. The most recent classification is the Bethesda System, which divides all cervical epithelial presursor lesions into 2 groups: Low-grade Squamous Intraepithelial Lesion (LSIL) and High-grade Squamous Intraepithelial Lesion (HSIL). LSIL corresponds to CIN1, and HSIL includes CIN2 and CIN3.More recently, CIN2 and CIN3 have been combined into CIN2/3.
Signs and symptoms
The early stages of cervical cancer may be completely asymptomatic. Vaginal bleeding, contact bleeding or (rarely) a vaginal mass may indicate the presence of malignancy. Also, moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer. In advanced disease, metastases may be present in the abdomen, lungs or elsewhere.
Symptoms of advanced cervical cancer may include: loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, single swollen leg, heavy bleeding from the vagina, leaking of urine or faeces from the vagina,[ and bone fractures.
Causes
Human papillomavirus infection
The most important risk factor in the development of cervical cancer is infection with a high-risk strain of human papillomavirus. The virus cancer link works by triggering alterations in the cells of the cervix, which can lead to the development of cervical intraepithelial neoplasia, which can lead to cancer.
Women who have many sexual partners (or who have sex with men or women who had many other partners) have a greater risk.
More than 150 types of HPV are acknowledged to exist (some sources indicate more than 200 subtypes). Of these, 15 are classified as high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82), 3 as probable high-risk (26, 53, and 66), and 12 as low-risk (6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81, and CP6108), but even those may cause cancer. Types 16 and 18 are generally acknowledged to cause about 70% of cervical cancer cases. Together with type 31, they are the prime risk factors for cervical cancer.
Genital warts are caused by various strains of HPV which are usually not related to cervical cancer.
The medically accepted paradigm, officially endorsed by the American Cancer Society and other organizations, is that a patient must have been infected with HPV to develop cervical cancer, and is hence viewed as a sexually transmitted disease, but most women infected with high risk HPV will not develop cervical cancer. Use of condoms reduces, but does not always prevent transmission. Likewise, HPV can be transmitted by skin-to-skin-contact with infected areas. In males, HPV is thought to grow preferentially in the epithelium of the gleans penis, and cleaning of this area may be preventative.
Cofactors
The American Cancer Society provides the following list of risk factors for cervical cancer: human papillomavirus (HPV) infection, smoking, HIV infection, chlamydia infection, dietary factors, hormonal contraception, multiple pregnancies, exposure to the hormonal drug diethylstilbestrol (DES) and a family history of cervical cancer.[ There is a possible genetic risk associated with HLA-B7
Despite the development of an HPV vaccine, some researchers argue that routine neonatal male circumcision is an acceptable way to lower the risk of cervical cancer in their future female sexual partner. Others maintain that the benefits do not outweigh the risks and/or consider the removal of healthy genital tissue from infants to be unethical as it cannot be reasonably assumed that a male would choose to be circumcised.
There has not been any definitive evidence to support the claim that male circumcision prevents cervical cancer, although some researchers say there is compelling epidemiological evidence that men who have been circumcised are less likely to be infected with HPV.
However, in men with low-risk sexual behaviour and monogamous female partners, circumcision makes no difference to the risk of cervical cancer.
Diagnosis
Biopsy procedures
While the pap smear is an effective screening test, confirmation of the diagnosis of cervical cancer or pre-cancer requires a biopsy of the cervix. This is often done through colposcopy, a magnified visual inspection of the cervix aided by using a dilute acetic acid (e.g. vinegar) solution to highlight abnormal cells on the surface of the cervix.
Further diagnostic procedures are loop electrical excision procedure (LEEP) and conization, in which the inner lining of the cervix is removed to be examined pathologically. These are carried out if the biopsy confirms severe cervical intraepithelial neoplasia.
Pathologic types
Cervical intraepithelial neoplasia, the precursor to cervical cancer, is often diagnosed on examination of cervical biopsies by a pathologist. Histologic subtypes of invasive cervical cancer with the most incidence, the incidence of adenocarcinoma of the cervix has been increasing in recent decades
· squamous cell carcinoma (about 80-85%)
· adenocarcinoma (about 15% of cervical cancers in the UK])
· adenosquamous carcinoma
· small cell carcinoma
· neuroendocrine carcinoma
Non-carcinoma malignancies which can rarely occur in the cervix include
· melanoma
· lymphoma
Note that the FIGO stage does not incorporate lymph node involvement in contrast to the TNM staging for most other cancers.
For cases treated surgically, information obtained from the pathologist can be used in assigning a separate pathologic stage but is not to replace the original clinical stage.
For premalignant dysplastic changes, the CIN (cervical intraepithelial neoplasia) grading is used.
Staging
Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, which is based on clinical examination, rather than surgical findings. It allows only the following diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray examination of the lungs and skeleton and cervical conization.
The TNM staging system for cervical cancer is analogous to the FIGO stage.
· Stage 0 - full-thickness involvement of the epithelium without invasion into the stoma (carcinoma in situ)
o Stage I - limited to the cervix
o IA - diagnosed only by microscopy; no visible lesions
§ IA1 - stromal invasion less than 3 mm in depth and 7 mm or less in horizontal spread
§ IA2 - stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less
o IB - visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm
§ IB1 - visible lesion 4 cm or less in greatest dimension
§ IB2 - visible lesion more than 4 cm
o Stage II - invades beyond cervix
o IIA - without parametrial invasion, but involve upper 2/3 of vagina
o IIB - with parametrial invasion
o Stage III - extends to pelvic wall or lower third of the vagina
o IIIA - involves lower third of vagina
o IIIB - extends to pelvic wall and/or causes hydronephrosis or non-functioning kidney
o IVA - invades mucosa of bladder or rectum and/or extends beyond true pelvis
o IVB - distant metastasis
Treatment
Microinvasive cancer (stage IA) is usually treated by hysterectomy (removal of the whole uterus including part of the vagina). For stage IA2, the lymph nodes are removed as well. An alternative for patients who desire to remain fertile is a local surgical procedure such as a loop electrical excision procedure (LEEP) or cone biopsy.
If a cone biopsy does not produce clear margins, one more possible treatment option for patients who want to preserve their fertility is a trachelectomy. This attempts to surgically remove the cancer while preserving the ovaries and uterus, providing for a more conservative operation than a hysterectomy. It is a viable option for those in stage I cervical cancer which has not spread; however, it is not yet considered a standard of care, as few doctors are skilled in this procedure. Even the most experienced surgeon cannot promise that a trachelectomy can be performed until after surgical microscopic examination, as the extent of the spread of cancer is unknown.
If the surgeon is not able to microscopically confirm clear margins of cervical tissue once the patient is under general anesthesia in the operating room, a hysterectomy may still be needed. This can only be done during the same operation if the patient has given prior consent. Due to the possible risk of cancer spread to the lymph nodes in stage 1b cancers and some stage 1a cancers, the surgeon may also need to remove some lymph nodes from around the uterus for pathologic evaluation.
A radical trachelectomy can be performed abdominally or vaginally] and there are conflicting opinions as to which is better. A radical abdominal trachelectomy with lymphadenectomy usually only requires a two to three day hospital stay, and most women recover very quickly (approximately six weeks). Complications are uncommon, although women who are able to conceive after surgery are susceptible to preterm labor and possible late miscarriage. It is generally recommended to wait at least one year before attempting to become pregnant after surger Recurrence in the residual cervix is very rare if the cancer has been cleared with the trachelectomyYet, it is recommended for patients to practice vigilant prevention and follow up care including pap screenings/colposcopy, with biopsies of the remaining lower uterine segment as needed (every 3–4 months for at least 5 years) to monitor for any recurrence in addition to minimizing any new exposures to HPV through safe sex practices until one is actively trying to conceive.
Early stages (IB1 and IIA less than 4 cm) can be treated with radical hysterectomy with removal of the lymph nodes or radiation therapy. Radiation therapy is given as external beam radiotherapy to the pelvis and Brach therapy (internal radiation). Patients treated with surgery who have high risk features found on pathologic examination are given radiation therapy with or without chemotherapy in order to reduce the risk of relapse.
Larger early stage tumors (IB2 and IIA more than 4 cm) may be treated with radiation therapy and cisplatin-based chemotherapy, hysterectomy (which then usually requires adjuvant radiation therapy), or cisplatin chemotherapy followed by hysterectomy.
Advanced stage tumors (IIB-IVA) are treated with radiation therapy and cisplatin-based chemotherapy.
On June 15, 2006, the US Food and Drug Administration approved the use of a combination of two chemotherapy drugs, hycamtin and cisplatin for women with late-stage (IVB) cervical cancer treatment. Combination treatment has significant risk of neutropenia, anemia, and thrombocytopenia side effects. Hycamtin is manufactured by GlaxoSmithKline.
Prevention
Awareness
According to the US National Cancer Institute's 2005 Health Information National Trends survey, only 40% of American women surveyed had heard of human papillomavirus (HPV) infection and only 20% had heard of its link to cervical cancer. In 2008 an estimated 3,870 women in the US will die of cervical cancer, and around 11,000 new cases are expected to be diagnosed.
Screening
The widespread introduction of the Papanicolaou test, or Pap smear for cervical cancer screening has been credited with dramatically reducing the incidence and mortality of cervical cancer in developed countries. Abnormal Pap smear results may suggest the presence of cervical intraepithelial neoplasia (potentially premalignant changes in the cervix) before a cancer has developed, allowing examination and possible preventive treatment. Recommendations for how often a Pap smear should be done vary from once a year to once every five years. The ]] (ACS) recommends that cervical cancer screening should begin approximately three years after the onset of vaginal intercourse and/or no later than twenty-one years of age.[ Guidelines vary on how long to continue screening, but well screened women who have not had abnormal smears can stop screening about age 65 (USPSTF) to 70 (ACS). If premalignant disease or cervical cancer is detected early, it can be monitored or treated relatively noninvasively, and without impairing fertility.
Automated technologies have been developed with the aim of improving on the interpretation of smears, normally carried out by cytotechnologists. Unfortunately these on the whole have proven less useful; although the more recent reviews suggest that generally they may be no worse than human interpretation
Until recently the Pap smear has remained the principal technology for preventing cervical cancer. However, following a rapid review of the published literature, originally commissioned by NICE, liquid based cytology has been incorporated within the UK national screening programme
. Although it was probably intended to improve on the accuracy of the Pap test, its main advantage has been to reduce the number of inadequate smears from around 9% to around 1%.[ This reduces the need to recall women for a further smear.
The HPV test is a newer technique for cervical cancer triage which detects the presence of human papillomavirus infection in the cervix. It is more sensitive than the pap smear (less likely to produce false negative results), but less specific (more likely to produce false positive results) and its role in routine screening is still evolving. Since more than 99% of invasive cervical cancers worldwide contain HPV, some researchers recommend that HPV testing be done together with routine cervical screening. But, given the prevalence of HPV (around 80% infection history among the sexually active population) others suggest that routine HPV testing would cause undue alarm to carriers.
HPV testing can reduce the incidence of grade 2 or 3 cervical intraepithelial neoplasia or cervical cancer detected by subsequent screening tests among women 32–38 years old according to a randomized controlled trial.[ The relative risk reduction was 41.3%. For patients at similar risk to those in this study (63.0% had CIN 2-3 or cancer), this leads to an absolute risk reduction of 26%. 3.8 patients must be treated for one to benefit (number needed to treat = 3.8). to adjust these results for patients at higher or lower risk of CIN 2-3.
Preventive Vaccination
Main article: HPV vaccine
Gardasil, licensed and manufactured by Merck & Co. is a vaccine against HPV 16 & 18 which are responsible for approximately 70% of all cervical cancers, it is up to 98% effective.. It is now on the market after receiving approval from the US Food and Drug Administration on June 8, 2006. Gardasil has also been approved in the EU.
GlaxoSmithKline has developed a vaccine called Cervarix which has been shown to be 92% effective in preventing HPV strains 16 and 18 and is effective for more than four years.[ Cervarix has been approved some places and is in approval process elsewhere.
Neither Merck & Co. nor GlaxoSmithKline invented the vaccine. The vaccine's key developmental steps are claimed by the National Cancer Institute in the US, the University of Rochester in New York, Georgetown University in Washington, DC, Dartmouth College in Hanover, NH, and the Queensland University in Brisbane, Australia. Both Merck & Co. and GlaxoSmithKline have licensed patents from all of these parties.[
Together, HPV types 16 and 18 currently cause about 70% of cervical cancer cases. HPV types 6 and 11 cause about 90% of genital wart cases.
HPV vaccines are targeted at girls and women of age 9 to 26 because the vaccine only works if given before infection occurs; therefore, public health workers are targeting girls before they begin having sex. The use of the vaccine in men to prevent genital warts and interrupt transmission to women is initially considered only a secondary market.
The high cost of this vaccine has been a cause for concern. Several countries have or are considering programs to fund HPV vaccination.
Condoms
Condoms may also be useful in treating potentially precancerous changes in the cervix. Exposure to semen appears to increase the risk of precancerous changes (CIN 3), and use of condoms helps to cause these changes to regress and helps clear HPV One study suggests that prostaglandin in semen may fuel the growth of cervical and uterine tumours and that affected women may benefit from the use of condoms.
Nutrition
Fruits and vegetables
Higher levels of vegetable consumption were associated with a 54% decrease risk of HPV persistence. Consumption of papaya at least once a week was inversely associated with persistent HPV infection.
Vitamin A
There is weak evidence to suggest a significant deficiency of retinol can increase chances of cervical dysplasia, independently of HPV infection. A small (n~=500) case-control study of a narrow ethnic group (native Americans in New Mexico) assessed serum micro-nutrients as risk factors for cervical dysplasia. Subjects in the lowest serum retinol quartile were at increased risk of CIN I compared with women in the highest quartile.[
However, the study population had low overall serum retinol, suggesting deficiency. A study of serum retinol in a well-nourished population reveals that the bottom 20% had serum retinol close to that of the highest levels in this New Mexico sub-population.
Vitamin C
Risk of type-specific, persistent HPV infection was lower among women reporting intake values of vitamin C in the upper quartile compared with those reporting intake in the lowest quartile.
Vitamin E
HPV clearance time was significantly shorter among women with the highest compared with the lowest serum levels of tocopherols, but significant trends in these associations were limited to infections lasting 120 days) was not significantly associated with circulating levels of tocopherols. Results from this investigation support an association of micronutrients with the rapid clearance of incident oncogenic HPV infection of the uterine cervix.
A statistically significantly lower level of alpha-tocopherol was observed in the blood serum of HPV-positive patients with cervical intraepithelial neoplasia. The risk of dysplasia was four times higher for an alpha-tocopherol level < name="Folic_acid">Folic acid
Higher folate status was inversely associated with becoming HPV test-positive. Women with higher folate status were significantly less likely to be repeatedly HPV test-positive and more likely to become test-negative. Studies have shown that lower levels of antioxidants coexisting with low levels of folic acid increases the risk of CIN development. Improving folate status in subjects at risk of getting infected or already infected with high-risk HPV may have a beneficial impact in the prevention of cervical cancer.
However, another study showed no relationship between folate status and cervical dysplasia
Carotenoids
Higher circulating levels of carotenoids were associated with a significant decrease in the clearance time of type-specific HPV infection, particularlyduring the early stages of infection (120 days) was not significantly associated with circulating levels of carotenoids.[
The likelihood of clearing an oncogenic HPV infection is significantly higher with increasing levels of lycopenes. A 56% reduction in HPV persistence risk was observed in women with the highest plasma [lycopene] concentrations compared with women with the lowest plasma lycopene concentrations. These data suggests that vegetable consumption and circulating lycopene may be protective against HPV persistence.
CoQ10
Women who had either CIN or cervical cancer had markedly lower levels of CoQ10 in their blood and in their cervical cells than the women who were healthy.
Fish oil
In a 1999 study, Docosahexaenoic acid inhibited growth of HPV16 immortalized cells.[
Prognosis
Prognosis depends on the stage of the cancer. With treatment, the 5-year relative survival rate for the earliest stage of invasive cervical cancer is 92%, and the overall (all stages combined) 5-year survival rate is about 72%. These statistics may be improved when applied to women newly diagnosed, bearing in mind that these outcomes may be partly based on the state of treatment five years ago when the women studied were first diagnosed.
With treatment, 80 to 90% of women with stage I cancer and 50 to 65% of those with stage II cancer are alive 5 years after diagnosis. Only 25 to 35% of women with stage III cancer and 15% or fewer of those with stage IV cancer are alive after 5 years.
According to the International Federation of Gynecology and Obstetrics, survival improves when radiotherapy is combined with cisplatin-based chemotherapy.
As the cancer metastasizes to other parts of the body, prognosis drops dramatically because treatment of local lesions is generally more effective than whole body treatments such as chemotherapy.
Interval evaluation of the patient after therapy is imperative. Recurrent cervical cancer detected at its earliest stages might be successfully treated with surgery, radiation, chemotherapy, or a combination of the three. Thirty-five percent of patients with invasive cervical cancer have persistent or recurrent disease after treatment.
Average years of potential life lost from cervical cancer are 25.3 (SEER Cancer Statistics Review 1975-2000, National Cancer Institute (NCI)). Approximately 4,600 women were projected to die in 2001 in the US of cervical cancer (DSTD), and the annual incidence was 13,000 in 2002 in the US, as calculated by SEER. Thus the ratio of deaths to incidence is approximately 35.4%.
Regular screening has meant that pre cancerous changes and early stage cervical cancers have been detected and treated early. Figures suggest that cervical screening is saving 5,000 lives each year in the UK by preventing cervical cancerAbout 1,000 women per year die of cervical cancer in the UK.
Regular two-yearly Pap tests can reduce the incidence of cervical cancer by up to 90% in Australia, and save 1,200 Australian women dying from the disease each year.
Epidemiology
Worldwide, cervical cancer is the fifth most deadly cancer in women.[ It affects about 16 per 100,000 women per year and kills about 9 per 100,000 per year.
In the United States, it is only the 8th most common cancer of women. In 1998, about 12,800 women were diagnosed in the US and about 4,800 died.[ Among gynecological cancers it ranks behind endometrial cancer and ovarian cancer. The incidence and mortality in the US are about half those for the rest of the world, which is due in part to the success of screening with the Pap smear The incidence of new cases of cervical cancer in the United States was 7 per 100,000 women in 2004.
In the United Kingdom, the incidence is 9.1/100,000 per year (2005), similar to the rest of Northern Europe, and mortality is 3.1/100,000 per year (2006) (Cancer Research UK Cervical cancer statistics for the UK). With a 42% reduction from 1988-1997 the NHS implemented screening programme has been highly successful, screening the highest risk age group (25–49 years) every 3 years, and those ages 50–64 every 5 years.
In Canada, an estimated 1,300 women will be diagnosed with cervical cancer in 2008 and 380 will die.
In Australia, there were 734 cases of cervical cancer (2005).The number of women diagnosed with cervical cancer has dropped on average by 4.5% each year since organised screening began in 1991 (1991-2005).
Worldwide it is estimated that there are 473,000 cases of cervical cancer, and 253,500 deaths per year.
History
400 BCE - Hippocrates: cervical cancer incurable
1925 - Hans Hinselmann: invented colposcope
1928 - Papanicolaou: developed Pap technique
1941 - Papanicolaou and Trout: Pap screening
1946 - Ayer: spatula to scrape the cervix
1976 - Zur Hausen and Gisam: found HPV DNA in cervical cancer and warts
1988 - Bethesda System for Pap results developed
Epidemiologists working in the early 20th century noted that:
Cervical cancer was common in female sex workers.
It was rare in nuns, except for those who had been sexually active before entering the convent. (Rigoni in 1841)
It was more common in the second wives of men whose first wives had died from cervical cancer.
It was rare in Jewish women
In 1935, Syverton and Berry discovered a relationship between RPV (Rabbit Papillomavirus) and skin cancer in rabbits. (HPV is species-specific and therefore cannot be transmitted to rabbits)
This led to the deduction that cervical cancer could be caused by a sexually transmitted agent. Initial research in the 1950s and 1960s put the blame on smegma (e.g. Heins et al. 1958) , but it wasn't until the 1970s that human papillomavirus (HPV) was identified. A description by electron microscopy was given earlier in 1949 and HPV-DNA was identified in 1963. It has since been demonstrated that HPV is implicated in virtually all cervical cancers Specific viral subtypes implicated are HPV 16, 18, 31, 45 and others.
References and Notes
http://www.fda.gov/bbs/topics/NEWS/2006/NEW01385.html.
http://www.jci.org/articles/view/JCI28607.
http://www.cancer.gov/cancertopics/factsheet/risk/HPV-vaccine.
http://info.cancerresearchuk.org/cancerstats/types/cervix/incidence/. http://www.aafp.org/afp/20000301/1369.html.. National Institutes of Health. http://www.nlm.nih.gov/medlineplus/ency/article/000893.htm.
http://www.cancer.org/docroot/CRI/content/CRI_2_2_2X_What_causes_cancer_of_the_cervix_Can_it_be_prevented_8.asp?sitearea=..
http://www.ajph.org/cgi/pmidlookup?view=long&pmid=11392939.
http://www.mdlab.com/html/testing/hpv_typedetect.html.
http://www.merck.com/mmhe/sec22/ch252/ch252d.html.
http://www.cancerhelp.org.uk/help/default.asp?page=9260.
http://www.papscreen.org.au/ http://www.who.int/mediace
Pathologic types
Cervical intraepithelial neoplasia, the precursor to cervical cancer, is often diagnosed on examination of cervical biopsies by a pathologist. Histologic subtypes of invasive cervical cancer with the most incidence, the incidence of adenocarcinoma of the cervix has been increasing in recent decades
· squamous cell carcinoma (about 80-85%)
· adenocarcinoma (about 15% of cervical cancers in the UK])
· adenosquamous carcinoma
· small cell carcinoma
· neuroendocrine carcinoma
Non-carcinoma malignancies which can rarely occur in the cervix include
· melanoma
· lymphoma
Note that the FIGO stage does not incorporate lymph node involvement in contrast to the TNM staging for most other cancers.
For cases treated surgically, information obtained from the pathologist can be used in assigning a separate pathologic stage but is not to replace the original clinical stage.
For premalignant dysplastic changes, the CIN (cervical intraepithelial neoplasia) grading is used.
Staging
Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, which is based on clinical examination, rather than surgical findings. It allows only the following diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray examination of the lungs and skeleton and cervical conization.
The TNM staging system for cervical cancer is analogous to the FIGO stage.
· Stage 0 - full-thickness involvement of the epithelium without invasion into the stoma (carcinoma in situ)
o Stage I - limited to the cervix
o IA - diagnosed only by microscopy; no visible lesions
§ IA1 - stromal invasion less than 3 mm in depth and 7 mm or less in horizontal spread
§ IA2 - stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less
o IB - visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm
§ IB1 - visible lesion 4 cm or less in greatest dimension
§ IB2 - visible lesion more than 4 cm
o Stage II - invades beyond cervix
o IIA - without parametrial invasion, but involve upper 2/3 of vagina
o IIB - with parametrial invasion
o Stage III - extends to pelvic wall or lower third of the vagina
o IIIA - involves lower third of vagina
o IIIB - extends to pelvic wall and/or causes hydronephrosis or non-functioning kidney
o IVA - invades mucosa of bladder or rectum and/or extends beyond true pelvis
o IVB - distant metastasis
Treatment
Microinvasive cancer (stage IA) is usually treated by hysterectomy (removal of the whole uterus including part of the vagina). For stage IA2, the lymph nodes are removed as well. An alternative for patients who desire to remain fertile is a local surgical procedure such as a loop electrical excision procedure (LEEP) or cone biopsy.
If a cone biopsy does not produce clear margins, one more possible treatment option for patients who want to preserve their fertility is a trachelectomy. This attempts to surgically remove the cancer while preserving the ovaries and uterus, providing for a more conservative operation than a hysterectomy. It is a viable option for those in stage I cervical cancer which has not spread; however, it is not yet considered a standard of care, as few doctors are skilled in this procedure. Even the most experienced surgeon cannot promise that a trachelectomy can be performed until after surgical microscopic examination, as the extent of the spread of cancer is unknown.
If the surgeon is not able to microscopically confirm clear margins of cervical tissue once the patient is under general anesthesia in the operating room, a hysterectomy may still be needed. This can only be done during the same operation if the patient has given prior consent. Due to the possible risk of cancer spread to the lymph nodes in stage 1b cancers and some stage 1a cancers, the surgeon may also need to remove some lymph nodes from around the uterus for pathologic evaluation.
A radical trachelectomy can be performed abdominally or vaginally] and there are conflicting opinions as to which is better. A radical abdominal trachelectomy with lymphadenectomy usually only requires a two to three day hospital stay, and most women recover very quickly (approximately six weeks). Complications are uncommon, although women who are able to conceive after surgery are susceptible to preterm labor and possible late miscarriage. It is generally recommended to wait at least one year before attempting to become pregnant after surger Recurrence in the residual cervix is very rare if the cancer has been cleared with the trachelectomyYet, it is recommended for patients to practice vigilant prevention and follow up care including pap screenings/colposcopy, with biopsies of the remaining lower uterine segment as needed (every 3–4 months for at least 5 years) to monitor for any recurrence in addition to minimizing any new exposures to HPV through safe sex practices until one is actively trying to conceive.
Early stages (IB1 and IIA less than 4 cm) can be treated with radical hysterectomy with removal of the lymph nodes or radiation therapy. Radiation therapy is given as external beam radiotherapy to the pelvis and Brach therapy (internal radiation). Patients treated with surgery who have high risk features found on pathologic examination are given radiation therapy with or without chemotherapy in order to reduce the risk of relapse.
Larger early stage tumors (IB2 and IIA more than 4 cm) may be treated with radiation therapy and cisplatin-based chemotherapy, hysterectomy (which then usually requires adjuvant radiation therapy), or cisplatin chemotherapy followed by hysterectomy.
Advanced stage tumors (IIB-IVA) are treated with radiation therapy and cisplatin-based chemotherapy.
On June 15, 2006, the US Food and Drug Administration approved the use of a combination of two chemotherapy drugs, hycamtin and cisplatin for women with late-stage (IVB) cervical cancer treatment. Combination treatment has significant risk of neutropenia, anemia, and thrombocytopenia side effects. Hycamtin is manufactured by GlaxoSmithKline.
Prevention
Awareness
According to the US National Cancer Institute's 2005 Health Information National Trends survey, only 40% of American women surveyed had heard of human papillomavirus (HPV) infection and only 20% had heard of its link to cervical cancer. In 2008 an estimated 3,870 women in the US will die of cervical cancer, and around 11,000 new cases are expected to be diagnosed.
Screening
The widespread introduction of the Papanicolaou test, or Pap smear for cervical cancer screening has been credited with dramatically reducing the incidence and mortality of cervical cancer in developed countries. Abnormal Pap smear results may suggest the presence of cervical intraepithelial neoplasia (potentially premalignant changes in the cervix) before a cancer has developed, allowing examination and possible preventive treatment. Recommendations for how often a Pap smear should be done vary from once a year to once every five years. The ]] (ACS) recommends that cervical cancer screening should begin approximately three years after the onset of vaginal intercourse and/or no later than twenty-one years of age.[ Guidelines vary on how long to continue screening, but well screened women who have not had abnormal smears can stop screening about age 65 (USPSTF) to 70 (ACS). If premalignant disease or cervical cancer is detected early, it can be monitored or treated relatively noninvasively, and without impairing fertility.
Automated technologies have been developed with the aim of improving on the interpretation of smears, normally carried out by cytotechnologists. Unfortunately these on the whole have proven less useful; although the more recent reviews suggest that generally they may be no worse than human interpretation
Until recently the Pap smear has remained the principal technology for preventing cervical cancer. However, following a rapid review of the published literature, originally commissioned by NICE, liquid based cytology has been incorporated within the UK national screening programme
. Although it was probably intended to improve on the accuracy of the Pap test, its main advantage has been to reduce the number of inadequate smears from around 9% to around 1%.[ This reduces the need to recall women for a further smear.
The HPV test is a newer technique for cervical cancer triage which detects the presence of human papillomavirus infection in the cervix. It is more sensitive than the pap smear (less likely to produce false negative results), but less specific (more likely to produce false positive results) and its role in routine screening is still evolving. Since more than 99% of invasive cervical cancers worldwide contain HPV, some researchers recommend that HPV testing be done together with routine cervical screening. But, given the prevalence of HPV (around 80% infection history among the sexually active population) others suggest that routine HPV testing would cause undue alarm to carriers.
HPV testing can reduce the incidence of grade 2 or 3 cervical intraepithelial neoplasia or cervical cancer detected by subsequent screening tests among women 32–38 years old according to a randomized controlled trial.[ The relative risk reduction was 41.3%. For patients at similar risk to those in this study (63.0% had CIN 2-3 or cancer), this leads to an absolute risk reduction of 26%. 3.8 patients must be treated for one to benefit (number needed to treat = 3.8). to adjust these results for patients at higher or lower risk of CIN 2-3.
Preventive Vaccination
Main article: HPV vaccine
Gardasil, licensed and manufactured by Merck & Co. is a vaccine against HPV 16 & 18 which are responsible for approximately 70% of all cervical cancers, it is up to 98% effective.. It is now on the market after receiving approval from the US Food and Drug Administration on June 8, 2006. Gardasil has also been approved in the EU.
GlaxoSmithKline has developed a vaccine called Cervarix which has been shown to be 92% effective in preventing HPV strains 16 and 18 and is effective for more than four years.[ Cervarix has been approved some places and is in approval process elsewhere.
Neither Merck & Co. nor GlaxoSmithKline invented the vaccine. The vaccine's key developmental steps are claimed by the National Cancer Institute in the US, the University of Rochester in New York, Georgetown University in Washington, DC, Dartmouth College in Hanover, NH, and the Queensland University in Brisbane, Australia. Both Merck & Co. and GlaxoSmithKline have licensed patents from all of these parties.[
Together, HPV types 16 and 18 currently cause about 70% of cervical cancer cases. HPV types 6 and 11 cause about 90% of genital wart cases.
HPV vaccines are targeted at girls and women of age 9 to 26 because the vaccine only works if given before infection occurs; therefore, public health workers are targeting girls before they begin having sex. The use of the vaccine in men to prevent genital warts and interrupt transmission to women is initially considered only a secondary market.
The high cost of this vaccine has been a cause for concern. Several countries have or are considering programs to fund HPV vaccination.
Condoms
Condoms may also be useful in treating potentially precancerous changes in the cervix. Exposure to semen appears to increase the risk of precancerous changes (CIN 3), and use of condoms helps to cause these changes to regress and helps clear HPV One study suggests that prostaglandin in semen may fuel the growth of cervical and uterine tumours and that affected women may benefit from the use of condoms.
Nutrition
Fruits and vegetables
Higher levels of vegetable consumption were associated with a 54% decrease risk of HPV persistence. Consumption of papaya at least once a week was inversely associated with persistent HPV infection.
Vitamin A
There is weak evidence to suggest a significant deficiency of retinol can increase chances of cervical dysplasia, independently of HPV infection. A small (n~=500) case-control study of a narrow ethnic group (native Americans in New Mexico) assessed serum micro-nutrients as risk factors for cervical dysplasia. Subjects in the lowest serum retinol quartile were at increased risk of CIN I compared with women in the highest quartile.[
However, the study population had low overall serum retinol, suggesting deficiency. A study of serum retinol in a well-nourished population reveals that the bottom 20% had serum retinol close to that of the highest levels in this New Mexico sub-population.
Vitamin C
Risk of type-specific, persistent HPV infection was lower among women reporting intake values of vitamin C in the upper quartile compared with those reporting intake in the lowest quartile.
Vitamin E
HPV clearance time was significantly shorter among women with the highest compared with the lowest serum levels of tocopherols, but significant trends in these associations were limited to infections lasting 120 days) was not significantly associated with circulating levels of tocopherols. Results from this investigation support an association of micronutrients with the rapid clearance of incident oncogenic HPV infection of the uterine cervix.
A statistically significantly lower level of alpha-tocopherol was observed in the blood serum of HPV-positive patients with cervical intraepithelial neoplasia. The risk of dysplasia was four times higher for an alpha-tocopherol level < name="Folic_acid">Folic acid
Higher folate status was inversely associated with becoming HPV test-positive. Women with higher folate status were significantly less likely to be repeatedly HPV test-positive and more likely to become test-negative. Studies have shown that lower levels of antioxidants coexisting with low levels of folic acid increases the risk of CIN development. Improving folate status in subjects at risk of getting infected or already infected with high-risk HPV may have a beneficial impact in the prevention of cervical cancer.
However, another study showed no relationship between folate status and cervical dysplasia
Carotenoids
Higher circulating levels of carotenoids were associated with a significant decrease in the clearance time of type-specific HPV infection, particularlyduring the early stages of infection (120 days) was not significantly associated with circulating levels of carotenoids.[
The likelihood of clearing an oncogenic HPV infection is significantly higher with increasing levels of lycopenes. A 56% reduction in HPV persistence risk was observed in women with the highest plasma [lycopene] concentrations compared with women with the lowest plasma lycopene concentrations. These data suggests that vegetable consumption and circulating lycopene may be protective against HPV persistence.
CoQ10
Women who had either CIN or cervical cancer had markedly lower levels of CoQ10 in their blood and in their cervical cells than the women who were healthy.
Fish oil
In a 1999 study, Docosahexaenoic acid inhibited growth of HPV16 immortalized cells.[
Prognosis
Prognosis depends on the stage of the cancer. With treatment, the 5-year relative survival rate for the earliest stage of invasive cervical cancer is 92%, and the overall (all stages combined) 5-year survival rate is about 72%. These statistics may be improved when applied to women newly diagnosed, bearing in mind that these outcomes may be partly based on the state of treatment five years ago when the women studied were first diagnosed.
With treatment, 80 to 90% of women with stage I cancer and 50 to 65% of those with stage II cancer are alive 5 years after diagnosis. Only 25 to 35% of women with stage III cancer and 15% or fewer of those with stage IV cancer are alive after 5 years.
According to the International Federation of Gynecology and Obstetrics, survival improves when radiotherapy is combined with cisplatin-based chemotherapy.
As the cancer metastasizes to other parts of the body, prognosis drops dramatically because treatment of local lesions is generally more effective than whole body treatments such as chemotherapy.
Interval evaluation of the patient after therapy is imperative. Recurrent cervical cancer detected at its earliest stages might be successfully treated with surgery, radiation, chemotherapy, or a combination of the three. Thirty-five percent of patients with invasive cervical cancer have persistent or recurrent disease after treatment.
Average years of potential life lost from cervical cancer are 25.3 (SEER Cancer Statistics Review 1975-2000, National Cancer Institute (NCI)). Approximately 4,600 women were projected to die in 2001 in the US of cervical cancer (DSTD), and the annual incidence was 13,000 in 2002 in the US, as calculated by SEER. Thus the ratio of deaths to incidence is approximately 35.4%.
Regular screening has meant that pre cancerous changes and early stage cervical cancers have been detected and treated early. Figures suggest that cervical screening is saving 5,000 lives each year in the UK by preventing cervical cancerAbout 1,000 women per year die of cervical cancer in the UK.
Regular two-yearly Pap tests can reduce the incidence of cervical cancer by up to 90% in Australia, and save 1,200 Australian women dying from the disease each year.
Epidemiology
Worldwide, cervical cancer is the fifth most deadly cancer in women.[ It affects about 16 per 100,000 women per year and kills about 9 per 100,000 per year.
In the United States, it is only the 8th most common cancer of women. In 1998, about 12,800 women were diagnosed in the US and about 4,800 died.[ Among gynecological cancers it ranks behind endometrial cancer and ovarian cancer. The incidence and mortality in the US are about half those for the rest of the world, which is due in part to the success of screening with the Pap smear The incidence of new cases of cervical cancer in the United States was 7 per 100,000 women in 2004.
In the United Kingdom, the incidence is 9.1/100,000 per year (2005), similar to the rest of Northern Europe, and mortality is 3.1/100,000 per year (2006) (Cancer Research UK Cervical cancer statistics for the UK). With a 42% reduction from 1988-1997 the NHS implemented screening programme has been highly successful, screening the highest risk age group (25–49 years) every 3 years, and those ages 50–64 every 5 years.
In Canada, an estimated 1,300 women will be diagnosed with cervical cancer in 2008 and 380 will die.
In Australia, there were 734 cases of cervical cancer (2005).The number of women diagnosed with cervical cancer has dropped on average by 4.5% each year since organised screening began in 1991 (1991-2005).
Worldwide it is estimated that there are 473,000 cases of cervical cancer, and 253,500 deaths per year.
History
400 BCE - Hippocrates: cervical cancer incurable
1925 - Hans Hinselmann: invented colposcope
1928 - Papanicolaou: developed Pap technique
1941 - Papanicolaou and Trout: Pap screening
1946 - Ayer: spatula to scrape the cervix
1976 - Zur Hausen and Gisam: found HPV DNA in cervical cancer and warts
1988 - Bethesda System for Pap results developed
Epidemiologists working in the early 20th century noted that:
Cervical cancer was common in female sex workers.
It was rare in nuns, except for those who had been sexually active before entering the convent. (Rigoni in 1841)
It was more common in the second wives of men whose first wives had died from cervical cancer.
It was rare in Jewish women
In 1935, Syverton and Berry discovered a relationship between RPV (Rabbit Papillomavirus) and skin cancer in rabbits. (HPV is species-specific and therefore cannot be transmitted to rabbits)
This led to the deduction that cervical cancer could be caused by a sexually transmitted agent. Initial research in the 1950s and 1960s put the blame on smegma (e.g. Heins et al. 1958) , but it wasn't until the 1970s that human papillomavirus (HPV) was identified. A description by electron microscopy was given earlier in 1949 and HPV-DNA was identified in 1963. It has since been demonstrated that HPV is implicated in virtually all cervical cancers Specific viral subtypes implicated are HPV 16, 18, 31, 45 and others.
References and Notes
http://www.fda.gov/bbs/topics/NEWS/2006/NEW01385.html.
http://www.jci.org/articles/view/JCI28607.
http://www.cancer.gov/cancertopics/factsheet/risk/HPV-vaccine.
http://info.cancerresearchuk.org/cancerstats/types/cervix/incidence/. http://www.aafp.org/afp/20000301/1369.html.. National Institutes of Health. http://www.nlm.nih.gov/medlineplus/ency/article/000893.htm.
http://www.cancer.org/docroot/CRI/content/CRI_2_2_2X_What_causes_cancer_of_the_cervix_Can_it_be_prevented_8.asp?sitearea=..
http://www.ajph.org/cgi/pmidlookup?view=long&pmid=11392939.
http://www.mdlab.com/html/testing/hpv_typedetect.html.
http://www.merck.com/mmhe/sec22/ch252/ch252d.html.
http://www.cancerhelp.org.uk/help/default.asp?page=9260.
http://www.papscreen.org.au/ http://www.who.int/mediace
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