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By Y. Miguel. Concord College.

Lancet 2000;355:1404–11 considered in patients with extrauterine extension 5 buy levlen 0.15 mg free shipping. Vaginal brachy- and high-dose progesterone or aromatase inhibitors therapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate (if available; for more information see Chapter 30) risk (PORTEC-2): an open-label generic 0.15mg levlen visa, non-inferiority, may be used depending on the ER and PR of the randomised trial. Surgical pattern and life-long follow-up is indicated. A phase III trial of surgery with or without adjunctive external Undifferentiated sarcomas and adenosarcomas form pelvic radiation therapy in intermediate risk endometrial the remainder of the uterine sarcomas. The histological features include myo- lymphadenectomy be performed in early stage I and II metrial invasion, nuclear pleomorphism, necrosis sarcomas of the corpus uteri. Moshi INTRODUCTION investigate these factors and apply the knowledge to control disease. This chapter will help you to plan preventive Diseases or other health-related events do not measures to control gynecological diseases in your occur at random. The preceding chapters have talked about people, exposed in a particular way (at risk) to a specific preventive measures and risk factors for condition/environment that causes the disease in each disease. Also all diseases the need for such measures in your area and how to have preventive factors that can be identified. The collect data on gynecological diseases in order to set problem is usually how to link the diseases to their priorities and discuss these priorities with policy causes so that prevention can be planned. Furthermore this chapter will help you to searchers try to connect diseases to possible causes better understand scientific literature on gyneco- in order to identify the definite cause. The knowl- logical diseases by explaining statistical terms that edge from research is used to plan (or research) for are most commonly used. Gynecological diseases like other diseases have a BASIC EPIDEMIOLOGY causal relationship with some factors in the popula- Epidemiology is the study of the distribution and tion/environment. These factors may be physical determinants of health-related states or events, in a or/and social. Someone may suffer from gyneco- specified population and the application of this logical diseases either due to her physical condi- study in the control of a health problem1. In this book there was a chapter while dealing with gynecological disease clinically, on environmental influences on health. This chapter mentioned that weather (hot, cold and is important not only for gynecological diseases be- winds), water quality (contamination), drinking cause in many regions of the world large propor- and eating habits (behavior), indolence, exercise tions of women are at more risk for diseases and and labor have influence on disease occurrence. Many women Thus Hippocrates concluded that disease does not are often less educated, have less power in decision- just happen. There were several assumptions but all making, have lower economic status etc. There are several ways to analyse disease epi- Also he assumed that diseases have causal relation- demiologically. Some of the common ways are ships with some risk factors and so preventive mentioned below. The more advanced ones are measures can be identified. Therefore researchers not in the scope of this book. This has resulted in classifying diseases as either communicable or Agent factors non-communicable: These are conditions/characteristics that favor the 1. Communicable diseases are the diseases that can ability of the causative agent to cause the disease. Communicable agent to enter, survive and multiply in the host), diseases are commonly caused by micro- pathogenicity (ability to cause disease) or virulence organisms. For example, sexually transmitted (the ability of the agent to cause death). Non-communicable diseases are the diseases that cannot be transmitted from one person to These are conditions/characteristics existing in the another. Examples of non-communicable dis- environment that favor the ability of an agent to eases include trauma/injuries, tumors (benign cause disease or favor the susceptibility of the host or malignant), congenital malformations etc. Examples are availability of disease vec- tors, population density, cleanliness, air quality, This is one way of classifying diseases.

Using quantification of residual disease-directed therapy in acute myeloid leukemia generic levlen 0.15 mg amex. Semin the PML-RARalpha transcript to stratify the risk of relapse in patients Oncol discount 0.15mg levlen. Prospective minimal 2013;2(2):e22943 residual disease monitoring to predict relapse of acute promyelocytic 28. Azacitidine fails to eradicate leukemia and to direct pre-emptive arsenic trioxide therapy. J Clin leukemic stem/progenitor cell populations in patients with acute my- Oncol. Lo-Coco F, Avvisati G, Vignetti M, et al; Gruppo Italiano Malattie 29. Human acute myelogenous Ematologiche dell’Adulto; German-Austrian Acute Myeloid Leukemia leukemia stem cells are rare and heterogeneous when assayed in Study Group; Study Alliance Leukemia. Retinoic acid and arsenic NOD/SCID/IL2R c-deficient mice. Can we say farewell to cells from some acute myeloid leukemia patients with mutated nucleo- monitoring minimal residual disease in acute promyelocytic leukaemia? Coexistence of LMPP-like minimal residual disease in CBFB-MYH11-positive acute myeloid and GMP-like leukemia stem cells in acute myeloid leukemia. Yin JA, O’Brien MA, Hills RK, Daly SB, Wheatley K, Burnett AK. Normal hematopoietic stem Minimal residual disease monitoring by quantitative RT-PCR in core cells within the AML bone marrow have a distinct and higher ALDH binding factor AML allows risk stratification and predicts relapse: activity level than co-existing leukemic stem cells. Jourdan E, Boissel N, Chevret S, et al; French AML Intergroup. MRD-directed risk stratification transplants for acute myeloid leukaemia: predictive role of WT1 treatment may improve outcomes of t(8;21) AML in the first complete expression. Quantitative assessment of tracking of minimal residual disease in JAK2-V617F-associated myelopro- minimal residual disease in acute myeloid leukemia carrying nucleophos- liferative neoplasms: a joint European LeukemiaNet/MPN&MPNr- min (NPM1) gene mutations. Next-generation sequencing for nostic information in AML. Monitoring of minimal residual with FLT3-ITD or NPM1 mutations. Shayegi N, Kramer M, Bornhäuser M, et al; Study Alliance Leukemia identify acute myeloid leukemia patients with resistant disease. The level of residual disease based on mutant NPM1 is an mia. Detection and standardized WT1 assay to enhance risk stratification in acute myeloid quantification of BCR-ABL1 fusion transcripts by droplet digital PCR. Residual disease in AML, a target that can move in more 56. Leukaemia relapse after allogeneic than one direction. Heeney1 1Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA Iron is an ubiquitous metal of vital importance to the normal physiologic processes of many organisms. Over the last 2 decades, the discovery of mutations in genes leading to hereditary disorders of iron overload, iron deficiency, and iron maldistribution have accelerated our understanding of human iron homeostasis. This chapter provides an updated overview of the human iron cycle, regulation of iron homeostasis, and how perturbations in these homeostatic mechanisms lead to iron overload disease and provides strategies for the diagnosis of hereditary iron overload. This excess cellular iron deposition ultimately exceeds the capacity of iron-binding proteins, thereby leading to cellular damage, organ dysfunction, and eventually to clinical symptoms. Introduction Iron is an essential metal for many biological processes due to its Ferritin is the primary intracellular iron storage protein, which ability to transfer electrons in reduction/oxidation reactions. This forms multimeric complexes that facilitate iron sequestration and reactivity also provides the potential for great damage to biological mobilization depending on cellular need. In contrast, hemosiderin is systems if iron is not chaperoned through a tightly regulated an amorphous and poorly bioavailable iron-containing conglomer- network of iron-binding proteins and transporters. If the capacity of ate the presence of which is generally a pathologic sign of cellular these iron-binding proteins is exceeded, “free” iron is capable of iron excess. A soluble form of ferritin is also found in the plasma forming reactive oxygen species that may damage macromolecular and is expelled primarily from reticuloendothelial macrophages and cellular components such as nucleic acids, proteins, and lipids and the liver; however, its biological role remains unclear. Iron homeostasis in humans is maintained ferritin correlates with iron stores in many conditions; however, almost exclusively at the level of intestinal absorption because caution must be taken before interpreting in the setting of inflamma- evolution has not provided a physiologically regulated mechanism tion and cellular injury.

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Feiger A buy levlen 0.15mg with amex, Kiev A buy generic levlen 0.15 mg, Shrivastava RK, Wisselink PG, Wilcox CX. Nefazodone versus sertraline in outpatients with major depression: focus on efficacy, tolerability, and effects on sexual function and satisfaction. Are SSRIs really more effective for anxious depression? Mirtazapine versus other antidepressants in the acute-phase treatment of adults with major depression: systematic review and meta- analysis. Fluoxetine versus sertraline and paroxetine in major depressive disorder: changes in weight with long-term treatment. Second-generation antidepressants 124 of 190 Final Update 5 Report Drug Effectiveness Review Project 125. Do equivalent doses of escitalopram and citalopram have similar efficacy? A pooled analysis of two positive placebocontrolled studies in major depressive disorder. A randomised study comparing escitalopram with venlafaxine XR in primary care patients with major depressive disorder. Re-evaluation of the efficacy and tolerability of venlafaxine vs SSRI: meta-analysis. Evaluation of sexual functioning in depressed outpatients: a double-blind comparison of sustained-release bupropion and sertraline treatment. A placebo-controlled, randomized clinical trial comparing sertraline and imipramine for the treatment of dysthymia. Double-blind comparison of sertraline, imipramine, and placebo in the treatment of dysthymia: psychosocial outcomes. Hellerstein DJ, Kocsis JH, Chapman D, Stewart JW, Harrison W. Double-blind comparison of sertraline, imipramine, and placebo in the treatment of dysthymia: effects on personality. Treatment of dysthymia with sertraline: a double-blind, placebo-controlled trial in dysthymic patients without major depression. Treatment of dysthymia and minor depression in primary care: a randomized trial in patients aged 18 to 59 years. Treatment of dysthymia and minor depression in primary care: A randomized controlled trial in older adults. Randomized, double-blind, placebo-controlled trial of fluoxetine treatment for elderly patients with dysthymic disorder. Vanelle JM, Attar-Levy D, Poirier MF, Bouhassira M, Blin P, Olie JP. Controlled efficacy study of fluoxetine in dysthymia. Citalopram versus sertraline in late-life nonmajor clinically significant depression: a 1-year follow-up clinical trial. Randomized, placebo-controlled trial of fluoxetine for acute treatment of minor depressive disorder. A placebo-controlled study of sertraline in the treatment of outpatients with seasonal affective disorder. Second-generation antidepressants 125 of 190 Final Update 5 Report Drug Effectiveness Review Project 140. The Can-SAD study: a randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder. Quality of life as an outcome indicator in patients with seasonal affective disorder: results from the Can-SAD study. Effects of fluoxetine versus bright light in the treatment of seasonal affective disorder. Multicenter, placebo-controlled study of fluoxetine in seasonal affective disorder. Wagner KD, Jonas J, Findling RL, Ventura D, Saikali K. A double-blind, randomized, placebo-controlled trial of escitalopram in the treatment of pediatric depression. Escitalopram in the treatment of adolescent depression: a randomized placebo-controlled multisite trial.

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IVF and ICSI were far more effective than IUI (Ohl 2005) safe 0.15mg levlen. In the Barcelona program generic 0.15mg levlen amex, Coll (2006) observed a decreased pregnancy rate after IVF com- pared to age-matched HIV-negative controls and HIV+ women who received donated oocytes. Results indicated a decreased ovarian response to hyperstimulation. A slightly impaired ovarian response to stimulation during 66 ICSI cycles in 29 HIV+ women was also described by Terriou (2005). Martinet (2006) found no difference in ovarian response between HIV+ and HIV-negative women in Brussels. Data concerning a possible association between ART and fertility disorders in women is limited (van Leeuwen 2006). Although assisted reproduction for seropositive women with fertility disorders is offered in centers in various European countries as well as the US, access to assisted reproduction often is still more limited for women than for men. HIV infection of both partners A growing number of HIV-concordant couples are now seeking reproductive coun- seling. In some centers, these couples are also accepted for reproductive treatment in case of fertility disorders. If both partners are on effective ART and there are no fertility disorders present, timed unprotected intercourse can be the method of choice. The discussion pertaining to the transmission of mutated drug-resistant virus between partners is still ongoing. Following a recent review (Redd 2013), the trans- mission rate is higher than previously assumed, showing an incidence rate of up to 7. Couples should be offered the same range of fertility counseling and screening as HIV-discordant couples. The current health of each partner should be carefully eval- uated with a full report from their HIV physician. Psychosocial aspects Experiences from more than a decade of counselling show the importance of offe- ring professional psychosocial support to couples planning to conceive, especially if reproductive assistance is necessary. Accepting the desire to become parents and dealing with the underlying motives as well as the psychosocial situation in an empa- thic way enables couples to see obstacles as well as to develop alternative perspecti- ves if this wish cannot be realized. Frustration, strains and disappointment may accompany unsuccessful treatment cycles or premature termination of pregnancy. Psychiatric co-morbidities in one or both partners (i. Professional diagnosis and support is necessary in these cases. Often, the central importance of the wish for parenthood of many migrant couples is overlooked in the medical and psychosocial counselling system. Language or communication difficulties on both sides, ignorance of different cultural back- grounds and lack of acceptance of other life-styles can lead to feelings of discrimi- nation, isolation, helplessness or despair in couples. Issues concerning the welfare of the child should be openly discussed during repro- ductive counselling. Many couples are concerned about a potential negative effect of antiretroviral drugs on their offspring. Severe impairment of the health of the pro- spective parents might lead to concerns for the future well-being of the child. HIV and Wanting to be a Parent 553 The future Healthcare professionals are encountering a growing number of couples or individ- uals who are contemplating parenthood. Having a child is an expression of a fulfilled partnership and an important perspective in life. In the medical and psychosocial care of patients, it is important to create an environment where reproductive aspects and parenting can be discussed on an open and non-judgemental basis. Worldwide, there is a growing demand to estab- lish reproductive health services, to support sexual rights of people living with HIV/AIDS and to provide reproductive counselling and assistance. Recent data has encouraged a growing number of health care professionals in many countries to discuss natural conception as an option for HIV+ men and women with suppressed viral load.

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Results of the interventions will be dis- audits on complications and near-miss cases order levlen 0.15 mg without a prescription. When the list of desired interventions is long generic 0.15mg levlen mastercard, it is Implementation will start as soon as approval has necessary to classify into immediate interventions been obtained from the stakeholders. Follow-up of and the list of those which can come later. To make implementation will be done in each quality team this classification, a tool called prioritization matrix meeting that is expected to be at least once a month. First, develop criteria for prioritization (Table 9). These could include the following: The quality circles 1. Effectiveness (the intervention is capable of In the context of gynecology services in a hospital bringing about desired improvements within or a stand-alone clinic, quality circles can be de- reasonable time). The results will be positively appreciated by in the department or clinic who meet regularly to both staff and patients. There are adequate resources to carry out this tween 8 and 10. In the Table 9 Prioritization matrix Intervention Criterion 1 Criterion 2 Criterion 3 Criterion 4 Criterion 5 Total A 2 2 2 2 2 10 B 1 1 0 0 2 4 C 2 2 1 2 2 9 D 2 2 2 2 2 10 E 2 2 1 2 2 9 450 Quality Improvement and Clinical Audits Table 10 The intervention matrix Responsible Activity Indicators Goal Resources person By when The maintenance BP machines BP machines Maintenance Mr Y August 2011 department of Hospital breakdown time in maintenance schedule technician, (maintenance X designs and imple- gynecology ward of displayed in the ward. This practice should be encouraged address the challenge, implement and follow up the throughout the facility. The strength of this quality improvement A re-assessment should be planned after a par- approach is the fact that the team remains the same ticular agreed period, e. It should be follow up changes, as they are the implementers as timed to match expected progress according to the well. Ideally all team members must have initial intervention matrix. Re-assessment has two pur- training from an experienced facilitator. A clear poses: to check progress following interventions link and support from the department management implemented and to identify new problem areas. Documentation of each meet- The information collected during re-assessment ing must be done in order to be able to follow up will be compared with the results of the baseline and refer to the recommendations. Re-assessment should focus on quality improvement and beyond, but they do not the areas identified for improvement during the replace or work on behalf of the quality teams. Such circles should not be used as a forum for addressing staff demands, neither are they a solution Self-assessment to all challenges in the work place. This is a method of identifying one’s strengths and Assessment results and the gaps list can be chan- weaknesses. An individual or a team will conduct nelled to these quality circles for them to discuss assessment of their respective performance using and identify causes and solutions. They should be the same standards and tools which are used in ex- encouraged to make own action plans and follow ternal assessment. During the overall hospital (department) assess- ment, areas of strength and weakness are identified Step 8: Re-assessment by the assessors and communicated. Departmental It is the individual health worker at the facility who and functional unit action plans are developed with can make changes for the better. This is why self- the intention of addressing the performance gaps assessment becomes of crucial importance. Specific activities show the health worker who is doing the assess- are developed in line with responsible people and 451 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS time limits. After a period of implementation, the referred to as organization-wide involvement in individual or team would like to know what has quality improvement. This type allows the facility changed in the direction of filling the performance stakeholders (staff, management, users and the com- gaps. Using the same tools, a self-assessment is con- munity) to take part. Using the example above the performance users and the community to have a better health gap and planned action is reiterated as follows: facility are part of it. It will allow staff across the facility to discuss and give inputs that will make the Performance gap In the gynecology ward of Hospital management take into consideration disruptions of X only 50% of the patient vital information (regis- staff expectations, their fears and their life in the tration, medication and vital signs) is documented. This will positively support staff to Target Documentation of patient vital information manage changes more on an individual basis.

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