By: Y. Ateras, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.
Vice Chair, University of Texas Rio Grande Valley School of Medicine
Specimen adequacy and false negative diagnosis rate in fine- needle aspirates of palpable breast masses symptoms 5 weeks into pregnancy purchase flexeril 15 mg visa. What constitutes an adequate smear in fine needle aspiration cytology of the breast? Interobserver reproducibility in the diagnosis of ductal proliferative lesions using standardized criteria treatment jammed finger discount 15 mg flexeril with mastercard. Hyperplastic ductal and lobular lesions and carcinomas in situ of the breast: reproducibility of current diagnostic criteria among community- and academic-based pathologists medications ending in zole buy discount flexeril 15mg online. Pathololgists agreement with experts and reproducibility of breast ductal carcinoma-in-situ classification schemes. Practical considertions in the pathologic diagnosis of needle core biopsies of breast. Stereotaxic large-core needle biopsy of 450 nonpalpable breast lesions with surgical correlation in lesions with cancer or atypical hyperplasia. A comparison of accuracy rates between open biopsy, cutting-needle biopsy, and fine-needle aspiration biopsy of the breast: a 3-year experience. Potential contribution of computer- aided detection to the sensitivity of screening mammography. Troxel, MD, FCAP SUMMARY This chapter reviews The Doctors Company experience with medical liability claims involving the Pap smear. The historical factors leading to the explosive growth in Pap smear litigation are discussed and an expert medical panel’s analysis of the sources of error in the Pap smear are presented in detail. The panel’s recommendations for reducing the Pap smear’s inherent false-negative rate, thereby decreasing patient injury from “missed” cervical cancers and their precursors, are reviewed. Finally, new technologies and strategies that enhance the Pap test’s sensitivity (liquid-based cytology and DNA testing for human papillomavirus) are presented. Key Words: Pap smear liability; Pap smear sensitivity; Pap smear false-negative rate; cervical cancer; human papillomavirus; liq- uid-based cytology. INTRODUCTION During the 1990s, both the frequency and severity (average indem- nity paid per allocated claim) of claims involving cervical cytology (Pap smears) increased dramatically and became the most important source of malpractice liability for pathologists and pathology labora- tories. The severity of pathology claims had become among the highest From: Medical Malpractice: A Physician’s Sourcebook Edited by: R. The Doctors Company (TDC) is a national physician-owned medical malpractice insurance company that covers more than 1200 patholo- gists. Table 1 documents its experience with Pap smear claims from 1992 to 2002. There were many reasons for this increase, including the landmark article published in November 1987 in the Wall Street Jour- nal entitled “Lax Laboratories: The Pap Test Misses Much Cervical Cancer Through Labs Errors,” which alerted the public to the fact that a Pap smear may be falsely negative. The article implied that false- negative Pap tests resulted largely from carelessness. This led to pas- sage of the Clinical Laboratory Improvement Act of 1988 (CLIA 88) that legislated comprehensive regulation of the gynecologic cytology laboratory. Subsequently, there was extensive media coverage of women dying from cervical cancers that had been “missed” on prior Pap smears because of “laboratory error. This was reinforced by CLIA 88 that required review of all prior negative Pap smears in the 5 years preceeding a new diagnosis of a high-grade squamous intraepithelial lesion (HSIL) or carcinoma. Thus, a frequent scenario leading to a Pap smear claim involved a false-negative smear “discovered” upon review of prior “negatives” in a woman diagnosed with cervical carcinoma.
TSH is a glyco- greatly; therefore treatment for strep throat order 15mg flexeril free shipping, the thyrotrophs are continuously ex- protein consisting of two structurally different subunits medicine journals impact factor purchase flexeril australia. The subunit of human TSH is a single peptide chain of TRH binds to receptors on the plasma membranes of thy- 92 amino acid residues with two carbohydrate chains rotrophs medications purchase 15 mg flexeril with amex. These receptors are coupled to PLC by G proteins linked to its structure. The interaction of TRH with its receptor acti- chain of 112 amino acid residues, to which a single carbo- vates PLC, causing the hydrolysis of PIP2 in the membrane. The and subunits are held to- This action releases the intracellular messengers IP3 and 2 gether by noncovalent bonds. IP3 causes the concentration of Ca in the cytosol to give the TSH molecule a molecular weight of about 28,000. CHAPTER 32 The Hypothalamus and the Pituitary Gland 589 Thyrotroph Hypothalamus - + TRH (+) SRIF (-) Ca2+ Nucleus Thyrotroph Ca2+ 2+ Ca Ca2+ TSHα,β mRNA TRH TSH (+) Gq 2+ IP3 Ca TSHα,β Thyroid - follicles PLC PIP2 TSH Thyroid hormones DAG PKC P proteins FIGURE 32. Secretory TRH stimulates and somatostatin (SRIF) in- granules hibits TSH release by acting directly on the thyrotroph. The neg- ative-feedback loops (-), shown in red, inhibit TRH secretion and action on the thyrotroph, causing a decrease in TSH secretion. The feedback loops ( ), shown in gray, stimulate somatostatin TSH secretion, causing a decrease in TRH secretion. TRH binds to membrane receptors, which are cou- pled to phospholipase C (PLC) by G proteins (Gq). PLC hy- drolyzes phosphatidylinositol 4,5-bisphosphate (PIP2) in the lease. The thyroid hormones also increase the release of so- plasma membrane, generating inositol trisphosphate (IP3) and di- matostatin from the hypothalamus. In the pituitary, thyroid hormones reduce the sensi- vate protein kinase C (PKC), which phosphorylates proteins (P tivity of the thyrotroph to TRH and inhibit TSH synthesis. Both T4 and T3 circulate in the blood bound to plasma proteins, with only a small percentage (less than 2 The rise in cytosolic Ca and the increase in DAG activate 1%) unbound or free (see Chapter 33). PKC phosphorylates proteins that are molecules are taken up by thyrotrophs, and T4is converted in some way involved in stimulating TSH secretion. The TRH also stimulates the expression of the genes for the newly formed T3 molecules and those taken up directly and subunits of TSH (see Fig. As a result, the amount from the blood enter the nucleus, where they bind to thy- of mRNA for the and subunits is maintained in the thy- roid hormone receptors in the chromatin. For example, T3 inhibits the The thyroid hormones exert a direct negative-feedback ef- expression of the genes for the and subunits of TSH, fect on TSH secretion. For example, when the blood con- directly decreasing the synthesis of TSH. Also, T3 influ- centration of thyroid hormones is high, the rate of TSH se- ences the expression of other unidentified genes that code cretion falls. In turn, the stimulatory effect of TSH on the for proteins that decrease thyrotroph sensitivity to TRH. However, when the circulat- duction in the number of TRH receptors in thyrotroph ing levels of T4 and T3 are low, their negative-feedback ef- plasma membranes. This control system is part of the hypothalamic- certain animals to a cold environment stimulates TSH se- pituitary-thyroid axis (Fig.
Sexuality encompasses the whole for different people and is not always person and is reflected in all that individ- based on blood or law treatment regimen discount flexeril 15 mg on line. It is an important part of protection symptoms 4dpo buy flexeril with a visa, socialization medications you cant drink alcohol purchase flexeril line, physical care, identity, self-image, and self-concept. Each individual with- Each person is a sexual being with a need in the family structure plays some role for intimacy, physical contact, and love. Family reactions to The expression of sexual urges is one chronic illness and disability may be sim- form of sexuality. Chronic illness or dis- ilar to those experienced by the individ- ability can affect sexual expression be- ual and may include shock, denial, anger, cause of physical limitations, depression, guilt, anxiety, and depression. Families lack of energy, pain, alterations in self- must make adaptations, adjustments, and image, or the reactions of others. In some role changes both as a unit and as individ- conditions, the main barrier to sexual ual family members. The way in which expression may be problems with self-con- families react and adapt to chronic illness cept and body-image; in other condi- and disability affects an individual’s sub- tions, physical changes may present phys- sequent adjustment. Whether families ical barriers that affect sexual function foster independence or dependence, show directly. In When a family member is no longer some instances, it may be necessary to able to perform certain functions, families help individuals overcome their own mis- may react in various ways. There may be perceptions and fears in order to establish a strong desire to be a “normal” family a means for sexual expression. Family members with prior ex- instances, individuals may need assistance pectations for the individual’s future or to overcome barriers or to learn methods “what he or she might have been” may of sexual expression different from those experience anger, resentment, or disap- used previously. In any case, sexual adjust- pointment if they see chronic illness or ment is a significant element in the disability interfering with the achieve- restoration of an individual’s maximal ment of their expectations. They may need to FAMILY ADAPTATION TO CHRONIC become more involved with health profes- ILLNESS AND DISABILITY sionals and service agencies or may need to be increasingly assertive to obtain nec- The family is the social network from essary services. If individuals with chron- which individuals derive identity and with ic illness or disability require significant 16 CHAPTER 1 PSYCHOSOCIAL AND FUNCTIONAL ASPECTS OF CHRONIC ILLNESS AND DISABILITY care or therapies to be administered at attitudes and reactions of those within the home, family members may become environment all influence the interpreta- fatigued because of the extra responsibil- tion of quality of life. People with similar conditions, members may be called upon to provide symptoms, and limitations may perceive not only emotional support but also their condition in totally different man- physical care, supervision, transporta- ners. Determining factors are the charac- tion, or a variety of other services neces- teristics of the condition and its treat- sitated by the individual’s condition. In ment, the age and developmental stage of addition, changes in roles or financial cir- the individual, the degree of limitation cumstances due to chronic illness or dis- and the extent of disability experienced, ability may alter the goals and plans of and how characteristics of the condition other family members, such as a sibling’s affect the individual’s definition of qual- plans for college or a parent’s retirement ity of life. The amount of care and attention one individual accepts and adapts to may required by individuals with chronic ill- be overwhelming and intolerable to ness or disability may create emotional another. Attempts may make it necessary to redefine family to discover and accurately measure qual- relationships as new and unaccustomed ity of life have caused considerable con- duties and responsibilities arise. In addition, studies of quality helping them achieve and enhance their of life have often identified discrepancies quality of life. Quality of life is subjective between the judgment of service providers in nature and has no universal meaning. Only the individual can deter- treatment, and satisfaction with treatment mine the personal meaning of this term. How some individ- Individual value systems, cultural back- uals assess the impact of their condition grounds, spiritual perspectives, and the on their quality of life is determined by Adherence to Prescribed Treatment and Recommendations 17 the degree to which they feel control over behavior. Different reactions, experiences, and and treatment, together with active par- motives direct behavior and can help or ticipation in decision making about the hinder adherence with treatment recom- management of the condition, can enable mendations.
In netic and environmental factors (probably viral) appear to be particular treatment esophageal cancer purchase cheap flexeril line, some anticonvulsants used in the treatment of important treatment xyy flexeril 15 mg line. Several therapies are available for treating the dis- epilepsy may produce osteomalacia or rickets with pro- ease treatment genital warts cheap flexeril amex, including treatment with CT, but these typically offer longed treatment. REVIEW QUESTIONS DIRECTIONS: Each of the numbered (B) 50% (D) Bile items or incomplete statements in this (C) 60% 4. Which of the following is ONE lettered answer or completion that is of calcium during a 24-hour period. What is the major route of calcium involved in formation of 1,25- excretion from the body? As part of a routine physical exam, a (A) Urine (A) Bone patient’s serum electrolyte levels were (B) Sweat (B) Skin measured. Among the measurements, it (C) Feces (C) Kidney was determined that total plasma (D) Bile (D) Liver calcium concentration was 10. A 42-year-old woman develops an What percentage of total plasma phosphate leaves the body is via the autoimmune disease that damages her calcium is normally present as the free (A) Urine kidneys. Male (C) 25-Hydroxycholecalciferol to Raise plasma calcium and phosphate skeletal health and osteoporosis. A 62-year-old woman stumbles on a (B) Lower plasma calcium and raise Griffin JE, Ojeda SR, eds. Textbook of En- crack in the sidewalk, falls, and breaks plasma phosphate docrine Physiology. She suffers from a form (C) Raise plasma calcium and lower Oxford University Press, 2000. The 25-hydroxyvitamin D 1 - there is an equivalent loss of bone hydroxylase. National Osteoporosis Foundation Web (B) Rickets Parathyroid hormone, calcitonin, and site. CASE STUDIES FOR PART IX • • • CASE STUDY FOR CHAPTER 31 CASE STUDY FOR CHAPTER 32 Diabetes Mellitus Growth Hormone Charlie was diagnosed with type 1 diabetes mellitus A 6-year-old boy was brought to the clinic to be evalu- during the summer of his eighth year. The boy’s height is between 2 suspected he was drinking excessive amounts of fluids and 3 standard deviations below the average height for that summer; however, he was in and out of the house his age. Initial physical examination rules out head and visiting friends, and she couldn’t be certain. The patient’s ing an afternoon at a friend’s birthday party, Charlie family history does not suggest similar short stature in drank nearly 3 quarts of fruit juice; his mother became immediate relatives. Why would the doctor order a blood test for levels of Charlie’s tests are normal, except that he tests positive IGFBP3 and IGF-I? The levels of IGFBP3 and IGF-I are below the normal range blood sugar is elevated (620 mg/dL). What is GH resistance, and what measurements would sup- placed on a regimen of daily insulin injections, along port the presence of this problem? His mother is instructed about changes in Charlie’s prior to the onset of puberty? Why is resistance to insulin action a potential adverse effect for several follow-up visits and to adjust his insulin of giving extremely high pharmacological doses of GH for a dosage. What might be the reason for the decrease in Charlie’s C- secretion the blood concentration may be undetectable in peptide after one year?
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