Introduce yourself, check the right patient, explain confidentiality.

• I am going to explain to you a little bit about how to use a nebulizer, how to clean it, and how to use it safely. If you have any questions feel free to interrupt at any time.

• Compressor – this is the noisy little box that compresses air and pumps it through the nebulizer.
• Oxygen – an oxygen canister

Keeping it clean

Oxygen safety

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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Introduction to patient

• State your name and role and confirm patient’s identity
• State purpose of interaction and gain informed consent
  • Check patient’s understanding eg ‘Have you ever had this done before?/ Do you know what this will involve?’
  • Explain procedure
  • Mention risks: bleeding, infection, pain

Establish site and assess the wound

Screening questions: there are eight…

1. How did you acquire the wound?
2. Has the wound been x-rayed? What did the x-ray report show?
3. Has the wound been cleaned?
4. Has the wound been anaesthetised?
5. Have you had a tetanus jab?
6. Are you allergic to latex?
7. Do you have any trouble with needles? You can advise the patient to look away when suturing or distract them with conversation
8. Are you on any blood-thinning medication?

Equipment

• Suture material
• 0.9% Sodium Chloride
• Gauze
• Eye protection
• Clean trolley
• Dressing(s)
• Sterile gloves
• Suture instruments – needle holder, scissors, toothed forceps, dressing forceps.
• Sharps bin

The Procedure

1. Wash hands with soap and water, including distal third of forearms
2. Clean the trolley and gather equipment.
3. Open suture pack correctly using sterile technique and unfold the sterile field
4. Check expiry date of appropriate suture material
5. Open suture material and sterile gloves onto unfolded sterile field.
6. Put on sterile gloves. In the event that you have to prepare the wound yourself:
   Administer local anaesthetic (LA)Remove debris with forceps
   Clean wound with normal saline or betadine soaked gauze; starting from the wound edges in an outwards motion away from the wound.
   Dry with clean gauze
   • Check expiry date and dose of LA with another health professional
   • Draw up 5ml using 21 gauge needle
   • Dispose needle in the sharps bin
   • Administer LA with 25 gauge needle
7. Lay sterile field with an appropriate window over the wound
8. With forceps, press gently on either side of the wound to ensure that the anaesthetic has taken effect (this can take 5-10 minutes), although the patient may feel pressure.
9. Grasp needle at 2/3 distance from its tip with needle holder.
10. Insert the first suture in the middle of the wound and then continue dividing into equal sections – approximately 5-10mm apart.
11. Holding the skin with toothed forceps, pierce the skin at a 90° angle not closer than 5mm from the wound edge, following the curvature line of the needle as it passes through the tissue, into the middle of the wound.
12. Remove the needle and remount it in the needle holder before taking a corresponding bite on the other side of the wound. Ensure needle is not touched to avoid needle stick injury, and is handled only by toothed forceps whist repositioning it in the needle holder
13. Pull the suture through until a short length remains.
14. Tie 3 surgeon’s knots (instrument tie) ensuring that all knots end up on the same side of the wound. Ensure the opposing edges meet well in the middle without excess tension.
15. Cut ends of suture to an appropriate length ~5- 10mm
16. Dispose of sharps straight away in the sharps bin
17. Take note of the number of sutures before applying a non-adherent dressing.
18. Explain to patient what you have done
19. Instruct the patient appropriately, including precautions and aftercare.
    1. Keep wound dry- take showers instead of baths and avoid swimming
    2. Educate patient on signs of infection: hot, pain, redness, swelling around wound site ± fever, pus. Tell them to visit A&E if any of these signs appear.
20. Provide clear instructions about the time and place of suture removal
    1. 7- 14 days for sutures  in limbs
    2. 5 days for suture on the face.
21.  Clean hands
22. Document the procedure in the patient notes including anaesthetic effect, suture material, number of sutures and follow up information given.

Global marks

• Attend to patient’s comfort throughout the procedure
• Have good eye contact, express concern, and respond to their expressions and body language.
• Engage with patient throughout the procedure- Maintaining a conversation whilst suturing proficiently is worth practicing, this will impress any examiner!

References

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Theory – PEFR – (peak expiratory flow rate) is a measure of the maximum speed of expiration. It is measured in litres/minute. It is used to asses if bronchoconstriction is reversible – i.e. the test is diagnostic for asthma. Not only is it used to diagnose asthma, but it can also be used to monitor the effectiveness of drugs.
Normal values are related to age, gender and height. You don’t need to learn this, this can be found on tables and charts. The value is increased if you are:

• Male
• Tall
• Age 18-30

Explaining how to use a peak flow meter

• Establish if the patient is using the peak flow meter to make a diagnosis of asthma, or to measure how well the disease is being controlled
• Gain consent

Position – the patient should be sitting upright or standing
Meter – should be set to 0

• Make sure the patient’s finger is not covering the meter, as this can block the slider moving up the scale.
• Also, make the sure patient’s finger does not cover any of the slide scale at all – as sometimes this can create a ‘spring effect; and the slider can zoom off and give a higher reading than the true value.

Tell the patient to take a deep breath in, and then make a tight seal around the mouth piece, then blow out as hard and as fast as they can.

• The patient does not need to do a full expiration

You should do a minimum of three readings. If the reading differ wildly, then you should continue until you have three roughly consistent readings. If the results vary like this it is likely the patient is not following the right procedure.

• You should record the highest reading

DEMONSTRATE THE TECHNIQUE, AND THEN ASK THE PATIENT TO SHOW YOU – so you know they are doing it correctly.
Keeping a diary – sometimes the patient may wish to/ be asked to keep a peak flow diary. This mainly assesses diurnal variation. This is usually kept for a period of two weeks. The results may be drawn on a graph to show the variation, e.g.:

 

References

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1. Wash your hands and get your equipment ready – DO NOT FORGET THE SHARPS BIN! There are two types of alcohol wipe found around the hospital. You should try and use the red wipe for equipment and the blue wipe for skin, but if only one type is available, then don’t worry. You should clean out the blue tray with the red wipe. Start on the inside, then do the outside. Then collect together the rest of your equipment – a blue wipe for the skin, cotton wool, tape, needle, syringe and tourniquet. Twist the needle onto your tourniquet so it is ready (but leave the needle sheathed). If you are to take more than one sample, make sure you have enough syringes. There are different coloured syringes that are for taking samples for different purposes: [note – these will vary in different Trusts / regions / countries]
   1. Red top – haem
   2. Brown top – urea/electrolytes
   3. Yellow top – glucose
   4. Green top – coagulation
   5. Blue top – blood transfusion
   6. NOTE – you don’t have to wear gloves for this procedure – is it just a matter of choice. If you do wear them, make sure you change them where indicated.
2. Introduce yourself – go and see your patient – check they are the right person; check their name on their wristband and their date of birth. Tell them what you are going to do and why, ask if this is ok.
   1. Check for allergies, and anti-coagulant medication
   2. if they are on anti-coagulant therapy, tell them it might bleed a little bit more than normal, but that this is nothing to worry about.
3. Find the vein – expose the patient’s arm, and put the tourniquet on about 2-3cm above the cubital fossa. If you can’t see much, then ask the patient to clench and open their fist a few times. You should FEEL for a vein. You want one that feels bouncy, and that you can palpate both edges of. When you are happy,  (take off your gloves), wash your hands, (put new gloves on) and then wash the patient arm. Use either the blue wipe, or one of the swab things that you have to crack open. Wash the area for 30 seconds and let it dry completely. When you are washing, do it firmly both along the direction of the arm, and at 90’ to this. Do a firm hard scrub.
4. Stick the needle in! – anchor the vein just below where you are going to puncture it with your non-needle (left) hand. Do not touch the actual entry site after you have cleaned it. With the needle at 20’ to the arm, push it into the vein, with the hole of the needle pointing upwards. Push it in about 2-3mm. Pull back the syringe just a little to see if it fills with blood (i.e. to check you are actually in the vein). Make sure you keep the needle fixed and secure all the time. You should ideally hold the base of the needle with your left hand, to keep your right hand free to do other things. If you are confident you are in a vein then you can pull the syringe all the way back. You can do this as quickly or as slowly as you want. When it clicks in place, you can’t pull it back anymore. Make sure you fill up the syringe to past the filling line. If you need to take more samples, then you can remove the syringe but keep the needle in place and just attach a new syringe.
   1. Flashback – this is the first bit of blood that comes into the syringe. It shows you that you are actually in the vein. If you see flashback, but are then unable to withdraw anymore blood, you have probably gone all the way through the vein and out the other side! In this case, pull the needle out a bit and try to withdraw a bit more blood.
   2. when you have filled your syringe, make sure you tilt/shake the bottle, to ensure that any preservatives in the syringe will mix properly with the blood.
5. Take the tourniquet off! – as soon as you have finished, and BEOFRE you remove the needle, take the tourniquet off!! Then put cotton wool over the needle entry site, and then withdraw the needle and press on with the cotton wool. Get rid of your needle quickly – straight into a sharps bin! You can ask the patient to hold down the cotton wool if they are able to. If not then you should hold it down until it stops bleeding. Never leave the patient if it is still bleeding.
   1. When you do leave, stick a plaster over (if not allergic), or if they are, just tape down some cotton wool.
6. Label up your blood samples, and then put them in their packets, and label up the packets. Students are not allowed to sign off blood samples – i.e. you are not allowed to send the sample off to the lab; you will have to get someone else to check it over first.
7. Clean up – throw everything away that should be thrown away, and clean your blue tray. Thank the patient, and don’t forget to wash your hands.

General tips

• If you have to take lots of samples, start with the largest sample and work your way down – its easier to get more blood at the beginning.
• Straight after you have taken your sample, turn it upside down, swill it around a bit. The different coloured tubes each have different substances inside them that react with the blood. You should make sure the blood is well mixed with these substances.
• You don’t have to fill the samples to above the line, except those for coagulation.
• If you can’t easily see a vein, then you can leave the tourniquet on for up to 2 minutes to see if one becomes visible/palpable. Watch out for the arm turning blue though! You could also try asking the patient to lower their arm, as this reduces venous return from the arm to the heart. Also ask them to do this fist thing. If all else fails you can try the hand – but this is more difficult and painful for the patient. You are more likely to rupture the vein, and its unlikely you can collect more than 10ml from here do to the reduced perfusion in this regions
• Always be polite, courteous and enthusiastic! If you make a mistake, patients are much less likely to complain if you were nice to them than if you were rude.
• You should not take blood from an arm when:
  • There is an obvious AV fistula. This is where there is an abnormal connection between an artery and a vein. It make be the result of a congenital defect, pathological, or most likely it will be surgical.
  • There has been a mastectomy (removal of breast) on that side of the patient.
  • The arm is damaged from stroke
  • The arm has a drip going into it.
• You should never take blood from a vessel that has a pulse!

Complications

• Haematoma (a collection of blood in the subcutaneous tissues) – this is relatively common, and will most likely be seen as a lump under the needle site after you remove the needle. It is normally the result of going all the way through the vein (and consequently you may also have not collected any blood at all.). They are more likely to occur if you leave the tourniquet on as you remove the needle because this causes increased pressure, thus forcing blood out of the hole you have just made. If you cause a haematoma, then press down on it firmly with a swab for about 2 minutes.
• Bruising – relatively common but can be unsightly and painful for patient.
• Nerve Damage – you always run the risk of getting a nerve when you perform this procedure. Just be aware of where the nerves are and be careful. Never perform Venipuncture near the wrist (particularly the inner aspect) as there are a lot of nerves in this region.

References

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The safe triangle is an anatomical space created by:

• Mid-axillary line / boarder of latissimus dorsi
• Lateral boarder of pec major
• Imaginary horizontal line from the nipple

The Procedure

• Find a location in the safe triangle
• Alternate locations include 2^nd intercostal space mid-clavicular line, and 7^th intercostal space, posteriorly, but these are less comfortable for the patient.
• Using 10-20ml 1% lidocaine inject down at the pleural level, just above the rib (to avoid the neurovascular bundle), usually the 6^th rib
• Then attempt to aspirate air of fluid – if you cant, then don’t insert the drain here! Wait 3 minutes, and try again
• Then blunt dissect down to the level of the pleura (e.g. using scissors, using the opening action of the scissors to dissect, or using forceps)
• Puncture the pleura with scissors or forceps
• If you are using a large bore tube, you may need to insert a finger into your dissect to remove any adherent lung
• Remove the metal part of the drip before inserting – you should already have done your dissection – don’t force it in!
• Advance the drain slowly, using forceps if necessary. Stop if you hit serious resistance
• Attached the other end of the drain to the underwater seal
  • The long tube should be under the water, and should bubble with respiration
• Medium and large bore tubes may require suturing around the entry site
• Fix the chest drain in place with a tie around the tube
• Request CXR to ensure the drain has been placed correctly

Clamping a chest drain

• This is occasionally performed in the case of pleural effusion, to control the rate of drainage, as draining too fast can result in expansion pulmonary oedema.
• You should never clamp a chest drain in the case of pneumothorax

Complications

• Trauma / injury to thoracic / abdominal organs
• Trauma to the long thoracic nerve of bell resulting in wing scapula
• Arrhythmia (rare)

Things to watch out for

• Backwards flow of water seal towards chest cavity
• Prolonged bubbling of the chest drain fluid
• Blockage of the tube due to kinks, blood clot / other. There will be no ‘swinging’ or ‘bubbling’ in the seal fluid
• Wrongly positioned chest drain – check the CXR

Removing the tube

• Check there is re-expansion on CXR
• In pleural effusion you may want to clamp the drain, as you may want to re-insert it
• In pneumothorax, clamping is not necessary as reinsertion is unlikely
• Give the patient a strong analgesic (e.g. morphine)
• Remove the tube during expiration, and suture the insertion site

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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Medical students are unlikely to be asked to perform a lumbar puncture, but as a junior doctor in emergency, intensive care or on medical wards you will be doing the procedure routinely.

In this article we discuss the use of lumbar puncture as a diagnostic procedure.

Indications

• Menningeal
• Encephalitis
• Causes of infection
  • Bacterial (TB, streptococcus)
  • Viral (herpes)

Bleeding into the CSF

• E.g. sub-arachnoid haemorrhage

Inflammation in the brain / spinal cord / CSF

• E.g. Multiple sclerosis

To administer local anaesthetic / or therapeutic agent (e.g. in chemotherapy)

Contraindications

• Raised ICP – lumbar puncture should never be performed when there is a raised ICP. By removing fluid from the spinal canal, you lower the pressure in this area. The relatively higher pressure within the cranium may then cause herniation of the brainstem through the foramen magnum, with disastrous neurological consequences. This brainstem herniation is sometimes referred to as ‘coning’.
  • The one exception is benign raised ICP – which is usually in young women.
  • Symptoms of RICP: headache, impaired consciousness, ↓pulse ↓BP (late stage compensation might make ↓BP), papilloedema
  • If you suspect RICP, then send for CT brain instead of lumbar puncture. Other indications to consider a CT brain before LP include
    • Aged >60
    • Immunocompromised
    • Neurological signs
    • Known intracranial mass / lesion
• Coagulopathy
• Local infection at site of needle insertion
• No consent!

Complications

• Failure of procedure
• Headache – very common, and usually benign. Can be managed with basic analgesia, and tell the patient to take onboard fluids. Patients can be given an infusion if necessary – although the evidence for this uncertain
  • There is no evidence for lying flat and / or bed rest to improve or reduce the incidence of post LP headache
  • Persistent headache – can indicate CSF leak from the puncture site. Is often self-limiting.
  • Headache more likely in – multiple attempts, women, dehydrated patients, large bore needle, excessive removal of CSF
• Parasthesia – may be felt during the procedure as the spinal needle comes into contact with nerve roots or nerves of the cauda equina. May feel uncomfortable during the procedure, but usually causes no lasting damage
• Serious complications are very rare, but can include:
  • Permanent nerve damage (mainly manifested as parasthesia), or even more rare, paraplegia
  • Brain stem herniation (described above)
  • Infection (abscess or meningitis)

Procedure

Gather your equipment

• Toxic dose of lidocaine:
  • 3mg/Kg, OR
  • 7mg/Kg with adrenaline

Spinal needle with which to perform the procedure

• This needle actually is made up on two needles, one inside the other. This arrangement prevents a bore of skin and other subcutaneous structures becoming lodged in the inner needle – thus preventing you from getting a sample of fluid.
• There is also a smaller, wider ‘style’ needle on the outside of the other 2 needles to help guide the more delicate spinal needle through the skin and subcutaneous tissues.

Lumbar Puncture Pack

Many hospitals stock a lumbar puncture kit, that contains the LP fluid bottles, a spinal needle, drops, trays gauze and other useful equipment. If your hospital doesn’t supply one you will have to source this equipment individually.

Don’t forget a gown, mask and sterile gloves!

Patient positioning and Location

There are two accepted way to position the patient:

1. Sitting upright and leaning forwards on the edge of the bed
2. Lateral – patient lying on their side (usually their left) in the ‘foetal position’, with their legs tucked into their torso and head forwards.

Both of these position are design to accentuate the curvature of the spine and allow easier access for the spinal needle. In practice, the position I see most commonly used is the lateral position.

Usually I would position the patient and find the location before ‘scrubbing up’.

Lateral position set up

• Ask the patient to lay on their left hand side, and bring their knees up to their chest, as much is as comfortable.
• Expose the patient’s back
• Find the posterior superior iliac spine, on both sides
• Imagine a line between the two – this is called Tuffier’s line.
• Find the spinous process that lies on this line. This is roughly usually about L3. Palpate into the space below this spinous process (L3/L4). You may also wish to palpate the other spinous processes to confirm this is indeed the L3/L4 location.
• In patients with larger body habits it can be very difficult to find the right location

Scrub up and Prepare skin

Administer Lidocaine

• Raise a bleb on the skin, then go in slightly deeper, and use the rest of the solution
• Leave to act for 2-3 minutes before performing the rest of the procedure

Anatomy

• Skin
• Fat
• Ligaments
  • Supraspinous ligaments
  • Infraspinous ligaments
  • Flavum (‘yellow’)
• Dura
• CSF

• Put your thumb on the spinous process you found earlier (L3). You know that you are going to insert your needle just below this.
• Gently advance the needle. You may be able to feel the needle pass through the individual layers. When you reach the ligaments, you will feel some resistance, this is normal. Press gently to advance the needle through the ligaments. You will feel the needle suddenly ‘give’ as you pass through the ligaments and dura, and you will now (hopefully!) be in the CSF.
• Don’t go to far, or you can end up scraping on spinal bone
• You can now withdraw the ‘stylet’ from the middle of the needle, and CSF should begin to flow out of the end of the needle
  • Often it takes several attempts of slightly withdrawing and re-etnering the needle to find the correct placement
• Remember that the procedure is often painful for patients
  • They may also comment about parasethesia of the legs. Reassure them this is normal and should subside after the procedure.
• Collection of fluid
  • Don’t forget to measure the pressure before you take a sample, if indicated. This done with the manometer included in the lumbar puncture kit
  • When measuring the pressure it is very easy to get false readings. Allow the reading time to settle, and ask the patient to cough when the reading has come to rest, as this can readjust the reading to the correct level
  • Collect the drops of CSF into the three sample bottles – in the correct order – they are usually numbered 1,2 and 3
  • You should collect about 15 drops for each sample bottle
  • Look at the appearance of the CSF
    • Normal CSF – is clear – congratulate yourself on a successful procedure!
    • Bloodstained – may represent a traumatic tap (especially if staining fades from bottle 1 to bottle 3), or a subarachnoid haemorrhage
    • Purulent – pus – indicates meningitis
• When you have finished, withdraw your needle and stylet together
• Common practice is to place x2 tegaderm (or similar) dressings over the puncture site, to reduce the risk of infection
• Let your patient relax!

Results – Normal values

• Protein – 40g / dl
• White Cell count <4-5
• Red cell count – 0 (ideally)
  • Depends on how traumatic the procedure was!
  • A true red cell count of “0” is referred to as a champagne tap and is rare (perhaps <30%)
  • More often, a result of single digits is seen in a ‘normal’ tap
  • Result of >100,000 is highly suggestive of Sub-arachnoid haemorrhage
  • Comparison of the red cell count in tube 1 and tube 3 can be used to differentiate the true presence of blood in the CSF – if the blood is purely due to a traumatic procedure, then the red cell count will fall significantly. If it is truly blood in the CSF, the red cell count will remain constant between all 3 tubes.
• Opening Pressure – <20cm
• Glucose – 2/3 of serum glucose
• Xanthochromia – a test for the presence of blood. Xanthochromia is a slight yellow discolouration of the CSF. In obvious cases it can be seen with the naked eye, but a more sensitive test can be performed in the lab with spectrophotometry. It is caused by the presence of bilirubin in the CSF – which is a result of breakdown of red cells. It occurs only several hours after a bleed (usually about 6+ hours). The red cells by this point may have all broken down

Table adapted from LITFL – CSF Analysis

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Cervical screening programmes have existed in many counties since the late 1980s. They have dramatically reduced the incidence of cervical cancer. In the mid 2000’s, the advent of vaccines against HPV – the main causes of cervical cancer have further reduced the incidence of the disease. However, screening programmes still remain an important part of cervical cancer prevention. Not all teenagers are vaccinated, and the vaccine is not 100% effective. There are also instance where patients may contract HPV before the HPV vaccine is given.

Traditionally cervical screening involves the use of a smear test. In this test, a brush is used to collect cells from the cervix, and these cells are then examined under the microscope for changes associated with cervical cancer. It is recommended that women undergo a smear test every 2-3 years (depending on country).

In the late 2010’s a new type of cervical screening became available – known as the “Co-test”. In this test, a similar technique is used, however the sample is first checked for evidence of HPV DNA, using a PCR technique. If no HPV DNA is detected the test is considered negative – and patients do not need a repeat test for another 5 years. If HPV DNA is detected, then the sample is also examined for the presence of cancerous cells – using cytology. Depending on the results of this cytology, then the test may be repeated in 1 year, or various other management may be required (such as referral to gynaecology for colonoscopy).

In the article, we will discuss the new “Co-test” from the perspective of the Australian Screening programme (which was the first to implement the new test). For historical context, the original “Pap smear” (or sometimes just “smear”) test is also discussed.

The Co-Test

Australia has one of the lowest incidences of cervical cancer in the world, thanks to the success of the cervical screening programme.

In December 2017, the screening programme underwent largescale change with several benefits – including:

• Earlier detection of at risk patients
• Reduced frequency of testing for the majority of the population
• A self-collection option will be available for women over 30

Cervical Cancer

• Most cases causes by oncogenic types of HPV
• HPV infection of the anal and genital regions is common in both men and women and is transmitted by direct skin to skin contact. It does not necessarily require penetrative sex, and can be transmitted by oral or anal sex as well as skin to skin contact of anogenital areas
• Most HPV infections are transient and are cleared within 1-2 years
• Infection persists in up to 10% of women
• In these cases, HPV infection can cause pre-cancerous changes of the cervix – often referred to as squamous intraepithelial lesions (SIL)
• If these early abnormalities are not detected and treated, then cervical cancer can develop – but usually takes about 10-15 years
• HPV
  • Over 100 types
  • 40 are associated with anogenital infection
  • 14 of these 40 types are oncogenic
  • Types 16 and 18 are most strongly associated with cervical cancer
  • Types 16 and 18 are also strongly associated with anal cancer. Anal cancer is particularly common in men who have sex with men
  • Other cancers are also associated with HPV (and in particular with types 16 and 18), including vulval, vaginal, penis and oropharyngeal cancers
  • Types 6 and 11 cause most cases of genital warts
• Other risk factors for HPV:
  • Lack of regular cervical screening – as many as 50% of cases of cervical cancer are associated with women who have never been screened, and a further 30% in women who are under screened
  • Diethlystilbosterol (DES) exposure in utero. DES is a form of synthetic oestrogen that was prescribed to pregnant women between 1940 and 1971 to prevent miscarriage, premature labour and complications of pregnancy
  • Smoking
  • Oral contraceptive use for more than 5 years. The risk declines when use is stopped, and returns to baseline at 10 years after useage ceases
  • Age – most commonly seen in women over 35
  • Early age at first pregnancy
  • A large number of full term pregnancies – risk increases with number of pregnancies
  • Immune deficiency

HPV to cervical cancer

• Not a linear process
• Some HPV infections cleared quickly
  • “Clearing” of HPV infection is controversial. The term “clearing” refers to the lack of ability to detect HPV in testing. It is not clear whether the infection is completely cured, or the HPV virus just enters a latent stage.
  • Latency lasts years or decades
• Some take longer
• Some early pre-cancerous changes can regress
• High-grade squamous intraepithelial lesions (HSIL) regress in 62% of women with oncogenic HPV infection over 12 months, compared to 100% without oncogenic HPV infection

Cancer almost always occurs as the “transformation zone”. This is the area of the cervix, where the epithelium changes from a columnar shaped epithelium (which lines the endocervical canal) to a squamous epithelium, which covers the rest of the visible cervix.

The transofrmation zone moves naturally with age – in older women it tends to be higher up inside the cervical os, and in younger women, lower down and spreading across the cervix.

Therefore there are two type of cervical cancer – Squamous cell carcinoma (majority of cases) and adenocarcinoma.

Squamous cell abnormalities

In increasing order of severity

• Possible low grade squamous intraepithelial lesion
  • No specific cquamous cell changes – not enough to meet diagnostic criteria for LSIL
• Low grade squamous epithelial lesions – LSIL
  • Equivalent to CIN1 or “HPV effect”
  • 78% of these lesions will regress within 1 year and 90% within 2 years
• Possible high grade squamous intraepithelial lesion
  • High grade changes are noted, but the changes are not sufficient to warrant a diagnosis of HSIL
  • High grade changes, but do not meet criteria for CIN2,3 or SCC
• High grade intra-epithelial lesion – HSIL – this includes CIN2 and CIN3
  • These can still regress, but less often than lower grade lesions
• Squamous cell carcinoma

Glandular Tissue Abnormalities

• Atypical endocervical cells of undetermined significance
• Atypical glandular cells
• Possible high grade glandular lesions
• Endocervical adenocarcinoma in situ
• Adenocarcinoma

HPV prevention

• Primary prevention – HPV vaccination programme
• Secondary prevention – Cervical Screening Programme

The HPV vaccination programme

• Started in Australia in 2007
• Gardasil – protection against 4 HOV types – 16,18 (cervical cancer) and 6 and 11 (warts)
• Originally only for girls aged 12-13
• Catch up offered for females up to the age of 26
• By 2015 75% of Australia females aged 15 have received all three doses of the vaccine
• in 2013 programme extended to include boys aged 12-13
  • Designed to protect men from oral, and other anogenital cancer, and warts
  • Also designed to protect unvaccinated females
  • By 2015, 66% of 15 year old males had received all three doses of the vaccine

Impact of the programme

• Reduced prevalence of affected HPV types
  • 92% reduction in vaccinated individuals, 77% in population in general
  • Reduced prevalence of target HPV types even in unvaccinated women – probably due to herd immunity
• Reduced incidence of genital warts in men and women aged under 30
  • 82% reduction
  • Also a 61% reduction in the number of women aged 15-27 presenting for management of genital warts to GP practices
• Reduced incidence of high-grade cervical changes in vaccinated women

The previous screening Programme

From 1991 to 2007 in Australia

• Reduced incidence of cervical cancer
  • 18 per 100 000 per year women in the 1980s
  • 9 per 100 000 per year women in 2012
  • Squamous cell carcinoma overwhelmingly responsible for the reduction
  • Adenocarcinoma rates have only dropped by about 30%
  • Adenocarcinoma responsible for about 25% of cervical cancer now, as opposed to 15% in the 1980s
• Reduction in mortality from cervical cancer
  • 4 deaths per 100 000 women in 1991
  • 9 deaths per 100 000 women in 2013

Underscreened populations

• Aboriginal and Torres Straight Islander Individuals – approx. only 33.5%
  • 2x more likely to get cervical cancer
  • 4x more likely to die from cervical cancer
  • Still – there has been a reduction in incidence (-60%) and mortality (-90%) in ATSI populations since 1991
• Women with disabilities
• LGBTI – up to 10x less likely to have been screened – possibly related to a belief that only sex with men is a risk factor (which is not true). Screening rate approx. 38%
• Culturally and linguistically diverse backgrounds (CALD) – rate around 25-30% depending on population
• Women in rural or remote locations
• Women with history of sexual trauma

The New Screening Programme

• For patients ages 25-74
• Patients will usually be required to attend within 2years of the their last PAP smear as the programme rolls out
  • Women under 25 who HAVE previously been screened, but have had no abnormalities do not need to attend until they are 25
• After that, for low risk results, screening will be every 5 years
• Women who have had the HPV vaccine still need to be screened

The New Test Regimen

• A 5 yearly test – the Cervical Screening Test replaces the 2 yearly Pap Test
• Screening now starts at age 25 and continues until 74
• Women should have their first Cervical Screening Test at the time they are due for their next Pap test – i.e. 2 years since their last Pap test
• Vaccination against HPV does not affect the testing regimen
• Women who have ever been sexually active should undergo testing
• Women who have low risk results can now undergo testing once every 5 years, instead of once every 2 years
• The new testing regimen is more effective and equally as safe as the previous testing regimen
• The new test is accompanied by a national register which will send out reminders to patients from a national database for their next test, and when they have not attended for FU

The Test

• Liquid based cytology for HPV genotyping
• This is more sensitive than Pap testing, and can detect high-grade HPV earlier, before it has progressed to cancer
• The test can detect:
  • Oncogenic HPV types 16 and 18
  • Other oncogenic HPV types (pooled result)
• If any oncogenic HPV types are detected, then liquid based cytology (LBC) will be performed on the same sample to check for any abnormal cells

Pap test vs HPV test

Randomised control trials have shown that HPV testing is superior to Pap testing in the prevention of invasive cervical cancer. Compared to cytology, HPV testing shows 60-70% greater protection from invasive cervical cancers.

• HPV testing follow-up has improved rates of detection of HSIL or worse compared to cytology alone
• Equal specificity for HSIL or greater
• High negative predictive value (>99%)
• LBC testing following HPV testing reduces the need for colposcopy
• LBC vs traditional cytology – fewer unsatisfactory samples, can be performed on same sample as the HPV test
• Pap tests have a significant false negative rate – which is partially minimised by a more frequent testing regimen

Why the age increase to 25?

• HPV infections more common in young women and frequently transient
• HPV vaccination has reduced the rate of cervical abnormalities in young women
• Cervical abnormalities are more likely to spontaneously resolve in young women. Treating these abnormalities increases the risk of pregnancy complications
• Cervical cancer in young women is rare. Screening in this age group does not impact on incidiecne or mortality of cervical cancer

Increasing the upper age limit

• Predicted to decrease incidence of cervical cancer by 4% and deaths from cervical cancer by 7%
• Increasing life expectancies mean it is now more appropriate

Pathway

• Women with no symptoms of or past history of cervical cancer
  • Screening every 5 years
  • Start at age 25
  • Cease at 70 to 74 if HPV has not been detected
• No HPV detected
  • Low risk – repeat in 5 years
• HPV detected (NOT type 16 or 18) but LSIL or less on LBC
  • Intermediate risk – repeat test in 12 months
  • Repeat test in 12 months – any HPV detected – for LBC and refer for consideration for colposcopy regardless of LBC result
  • If initial LBC result is unsatisfactory – repeat LBC only within 6 weeks
• HPV and HSIL or above, OR HPV type 16/18 detected (regardless of LBC result)
  • Refer for consideration for colposcopy
• HPV test result unsatisfactory
  • Repeat in 6 months
• Self collected sampling will be available for women OVER the age of 30 who have previous not attended screening, or who are more than 2 years overdue
  • This is less sensitive than a speculum collected sample, but designed to increase rates of participation in under screened women (something is better than nothing!)
• Women with abnormal vaginal bleeding or unusual discharge – at any age – should be tested regardless of where they are up to in relation to the screening programme

Results

It is recommended that results are interpreted in accordance with the following pathway:

The Smear Test

What is a smear?

• 1 in 10 smears will show dyskaryosis
• The vast majority of these cases will spontaneously resolve

Methods

• Pap smear – older method, in which sample cells are transferred directly to slide for viewing
• Liquid-based cytology – sample cells are placed in liquid solution for transport to the lab, whereby they are extracted for cytologic analysis.

Indications for smear

• Clinical suspicion – E.g. IMB, PMB
• Screening

Indications for swabs

• Suspected infection
• Elective: to test for subclinical infection
• Before insertion of IUD / IUS

The Previous NHS Smear Screening Programme

• NHS screening programme began in 1988
• It is estimated to have reduced cervical cancer incidence by 90%
• Estimated to save 4,500 lives per year
• Now less than 1,00 deaths per year in the UK from cervical cancer
• Offered to all women aged 25 – 65
• Every three years between 25-50
• Every 5 years between 50-65
• Age 65+ – offered to those:
  • Who have not been screened since 50
  • Who have had recent abnormal smears
  • Used to be offered to all women aged 20-65 – but at age 20, the physiological changes seen in puberty may still be apparent, and thus there was a very high percentage of false positives.
• What does it involve?
  • A smear test – usually performed at the GP surgery.
  • If this is abnormal, then the patient will be referred for colposcopy, at which time, treatment can be performed if necessary.
• Attendance
  • Roughly 80% of those eligible attend for smear screening
  • Reminders – usually, if one appointment is missed, a second invitiation is sent, then if this is missed, another reminder probably won’t be sent, but whenever the patient attends to GP, it will be flagged that a smear has been missed.

Results

Performing the procedure

1. Introduction and explanation – introduce yourself, check the right patient (name, DOB, wrist band). Explain the procedure, state you would like to use a chaperone , and gain consent – this may involve a brief explanation of what a positive result might mean for the patient.  Explain that you will be taking a smear and/or swabs, and what the swabs are for.
   1. Ask the patient to get undressed below the wait, and cover up with a sheet provided, whilst you fetch a chaperone
2. 2)      Collect your equipment. You will need:
   1. Cousco’s speculum
   2. Cervical brush
   3. Transport medium for smear
   4. Cytology Forms
   5. Lubricant
   6. Gloves
   7. Light source
   8. Tissues / gauze
   9.  Endocervical swab
   10. Charcoal swab
   11. CHAPERONE!
   12. Wash your hands. Wash out the tray with soap/water (if visibly dirty) or alcohol wipe (if visible clean). Collect the equipment.
3. Brief inspection / palpation of abdomen – feel for any pain / tenderness in the pelvic region. Ask if any pain soreness in pelvic region or vagina
   1. Wash your hands again and put on gloves
4. Inspect vulva and vagina – ask the patient to lie back on the bed, bend her knee, and gently allow her legs to fall apart. Look for any signs of discharge, blood or lesions, prolapse. Don’t forget to check the peroneal area.
5. Speculum – ask the patient to try to relax, and breathe deeply. Apply some lubricant to the speculum. Ask the patient to take a deep breath in, and insert the speculum, , with the handle at 3 o’clock, as you hold the labia open with your other hand. Once inside the vagina, you can rotate the handle 90’, and slowly open the speculum, to allow viewing of the cervix. Lock the speculum in place.
   1. Look at the cervix and vaginal walls – and comment on their appearance
   2. Take a cervical smear – using the smear brush, insert the middle of the brush into the os, then rotate the brush through 360’, five times. Take the brush out of the vagina, and remove the head, placing it into the transport medium.
   3. Taking swabs – make sure you have explained what the swabs are for. It is not normal practice to perform swabs at the same time as smear. Usually three samples are taken “Triple swabs”
      1. Endocervical – charcoal – “Stuarts medium” – Gonorrhoea 
      2. High vaginal – charcoal – “Stuarts medium”–HVS high vaginal swab – for TB & BV [anaerobes], group B strep, and candida. swab around the posterior fornix. White Physiological discharge in this area is normal, but if excessive and/or offensive, may indicate infection, particularly in the case of TB, BV and candida. Return the swab to the tube containing the sticky transport medium
      3. Endocervical –Chlamyia – uses a different type of swab. These come in two sizes with different diameters. Use the larger one, but in nulliparus women, this may not be possible. Put the swab into the endocervix, and rotate through 360’, 3x. This is a test for chlamydia. The smaller of the two swabs can be used to test for chlamydia in the male urethra. When you have taken the sample, put the swab into the liquid for cytology, and break off the end of the stick, to seal it in the tube.                               
6. Remove the speculum – have a look at the vaginal walls as you do so. Then wipe away any lube, and thank and cover the patient, and allow them to get dressed
7. Filling in the forms – label your samples (gonorrhoea, general and chlamydia), and fill out the forms.

Cervical Smear	Stuarts Medium Used for HVS and Gonorrhoea (endocervical)	Chlamydia Swab
Image Source	Image Source	Image Source

Bi-manual examination and smear/swabs

• Always perform the smear / swabs / speculum examination first – so you can see any lesions that you might want to palpate
• Offer a full abdominal exam with your bi manual

References

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• Urinary retention
• Monitor fluid output (e.g. post-op, renal failure, trauma, sepsis, general illness) – in pretty much all seriously ill patients! – also pre-op to measure urine output during op.
• Investigation – to determine residual volume
• Manage incontinence – e.g. due to disability, e.g. spina bifida
• To instil prescribed medicine (e.g. for treatment of bladder cancer)

Contraindications

• UTI – There is a 5-10% risk of UTI each day the catheter is in!
• Patient refusal
• Known urethral strictures
• Enlarged prostate (seek expert advice)
• Trauma! – be careful e.g. in RTA or straddle injury – if there are any perineal signs of injury then don’t do it!
• History of urethral stricture – e.g. a false passage (common in males)
• Blood on the meatus (tip of penis)
• Scrotal haematoma
• Pyelonephritis (if the catheter is left in for long enough)
• Patient has an erection!

Complications

• Pain
• Infection
• Local trauma
• Strictures (if catheter is left in long term)
• Retention upon removal of catheter
• Bladder spasm
• Bleeding /trauma – although a small amount of blood within the first 24hours is normal.

Catheters

• Single channel catheters (10ch) are often used in neurological disease just to allow fluid out.
• Three channels might be used when you need to put something into the bladder, these can be up to 20ch.

Procedure

• Use a chaperone. Fully explain what you are going to do, and get proper consent.
• Say that you would like to pass a ‘rubber’ tube up the patient’s ‘water pipe’ and explain why you want to do it in their individual case. Say they may feel the need to pass urine (this is normal). Deep breathing can help the passing of the catheter if they feel particularly uncomfortable.
• Explain the complications. ask the patient to tell you if it gets very painful – then you will stop.
• Catheterisation is an ANTT procedure – aseptic non-touch technique – you need to demonstrate you understand this!

• **Extremely important*** –  ALWAYS REPLACE THE FORESKIN IN MALES! – if not you may cause a paraphimosis. *** This can be very painful and may require surgical correction. Also check there is no phimosis in the first place.
• Also, when you expose the patient you may want to clean the region is it is particularly dirty / soiled.

1. Wash hands, put on apron, clean trolley with 70% alcohol wipe. Clean the surfaces of the trolley as well as the legs. (In OSCE probably just explain you would do this otherwise it would take too long). Get:
   1. Catheter pack
   2. Catheter
   3. Urine bag
   4. Instiller gel
   5. Water
   6. sterile gloves
   7. syringes x2 – these will probably come pre-packed – one for instiller gel, one for sterile water to fill catheter balloon with
   8. pot of aqua gel (the same stuff used for rectal examination)
   9.  when gathering your bits and pieces, put them ALL on the bottom tray. When you open them out, you can put them on the top tray.
2. wash your hands again, put on some normal gloves
3. Open the catheter pack being careful which bits you touch. Don’t lean over it (to prevent bits of fluff or whatever falling into it. This means you have to open one half, walk around it, then open the other half.
   1. If you need to move bits of the catheter pack, then you may be able to touch them if there is a bag for rubbish in the pack. If there is you can put your hand in the bag of rubbish, and this allows you to touch the various bits and pieces and move them around.
4. Open the catheter bag, and the instiller gel. If things are pre-packed, you can open them out onto the blue sheet of the catheter pack. For other things with a non-sterile surface (e.g. the packet of water) then you just put these onto the tray, but not on the blue sheet.
5. Clean the outside of the packet of water with an alcohol wipe, then pour water into the tray
6. Wash your hands again!
7. Put on the sterile gloves – don’t put the packet down on the sterile surface! You can use any old surface lying around. You can touch the ‘cuff’ of the gloves but not any other part with your bare hands. Once you have got one glove on, you can touch the outer surface of the other glove with your gloved hand.
8. Ask the patient to lie on their back and expose themselves. Females need to bend their knees and spread the legs, males don’t.
9. Put the kidney dish under the genitalia where you will later use it to catch urine
10. For men, loop a bit of cloth round the penis to hold it up. The hand holding the penis is the NON-STERILE HAND. Using firm rather than gentle pressure help avoid an erection.Do not touch anything that is not sterile with the other hand. Roll back the foreskin and clean the four quadrants of the penis with the sterile water you poured out earlier, using the cleaning ball things. Use only one sweep with each bud, and sweep away from the tip.
    1. For women, use three buds, and wipe from front to back, three time, middle and two sides. Hold the labia apart with the thumb and forefinger of the non-dominant hand
11. For men, make a ‘sterile field’ by tearing a hole in the sheet from the catheter pack. Put this over the penis. For women, just put the sterile sheet down between the woman’s legs.
12. Put 1ml of gel on the end of the penis, and slowly inject another 10ml of gel up the urethra. This takes 3-4 minutes to act.
    1. For women, just inject 5ml of gel into the urethra
13. Open the catheter – whatever you do: do not touch the catheter! Only take 1-2cm of the catheter out of the packet at once.
    1. Dip the end of the catheter into the aqua-gel as lubricant
    2. Start to insert the catheter gently. Never force it. At some point, urine will being to flow out of the catheter into the catheter packet. At the point put the kidney dish beneath the catheter packet.
    3. Having trouble? If the catheter does not seem to be passing very easily up the man’s urethra, the prostate may be to blame. In which case, you can ask the patient to cough, or you can try altering the position of the penis; try lifting it up, so that it ‘points’ more vertically.
14. Fill the balloon up with sterile water – do not use saline stupid! About 10ml of fluid should be enough. Ask the patient if they feel any pain – if they do you probably aren’t in the bladder yet! Once you have filled it up, you can pull it back out, so it now rests in the neck of the bladder.
15. Attach the catheter bag below the level of the bed, and retract the foreskin! Also remove your sterile field. Attach the catheter tube/bag tube to the abdomen or the thigh. Make sure there is no tension in the tube.

• If you get stuck, stop and call for expert advice!
• Always explain what you are doing, get good consent etc.
• Normal urine output is 30ml/hour.

Finishing off

• Measure the volume of urine collected (residual volume)
• Do a urine dipstick
• Note the colour and smell of the urine
• Document in the notes:
  • ANTT used
  • Chaperone present
  • Date / sticker from catheter pack
  • Foreskin replaced
  • How much fluid used to inflate balloon
  • Lubricant was used

References

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1. Find the patient. Check they are the right patient, and then tell them what you are going to do. i.e. ‘we would like to put a needle in you arm so we can give you drugs. The needle will stay in for several days, this is so we don’t have to use lots of needles every time we give you drugs. ‘ or the same for a drip etc etc.
2. Wash your hands with soap and water.
3. Clean tray – inside and out with alcohol swab. Allow 30seconds to dry.
4. Alcohol gel your hands and then put on gloves.
5. Collect your equipment – you will need a tourniquet, cannula, an IV link, syringe x2, saline, liquid wipes, and a clean sticky label. You should always use the smallest cannula possible for your intended purpose. Normally, the smallest are pink or blue and the largest is brown.Open all your packets, and check the date on all the equipment. Usually blue or pink are fine, but brown or green may be used in emergency situations where the pateint may need a lot of fluid.
6. Fill up the syringe with 5ml saline solution, and dispose of the needle in the sharps bin. Then fill the IV connector with the solution, making sure there are no air bubbles.
7. Visit the patient –Put on the tourniquet. Palpate for a good vein. Ideally, you want one on the top of the hand / wrist / forearm. You should go upstream of bends and splits – you want the straightest bit you can find. The requirements of a vein for cannulation are different from those for venipuncture. For Cannulation you want a vein that is far from joints so that the cannula itself will be subject to little movement in relation to the body. preferably, you should chose a vein on the non-dominant hand. Once you are happy you have found one, clean it with the cleany thing.
8. Wash hands again! – after you have found a good site, then wash your hands and put on new gloves. Then swab the area for 3 seconds and leave to dry (usually take about 15 seconds)
9. Insert the cannula – do this at a small angle (about 20’). When you see flashback, you should still push it a bit further in. Push it all the way into the vein, but make sure you don’t puncture the far side of the vein! A little tip would be that when you are in the vein, retract the needle slightly, but then push the cannula tube in a little further. You need to withdraw the needle from the plastic part a little bit to check for flashback.  Take the tourniquet off BEFORE removing the needle from the cannula!

10. Blocking off the cannula – you should take off the tourniquet, then remove the needle slowly. If the cannula begins to fill with blood as you are removing the needle, then you know you have got it in the right place. You can stick the cannula even further in at this stage. You can now remove the tourniquet. Withdraw the rest of the needle and the very quickly, stick on the IV connector and make sure you dispose of the needle quickly in the sharps bin. You will probably spill a little bit of blood. Use your syringe filled with saline to flush out any blood from the cannula. If you are spilling a lot of blood, then it is possible to press on the vein upstream of the cannula site to prevent as much blood spilling everywhere.

11. Stick it down – Clean away the blood, then stick down the wings of the cannula first with tape. Then stick the big sticky thing down over the cannula. Date the date sticker and stick this down. If you don’t get flashback, then withdraw the needle as far as you can without taking it out of the skin. It is less painful to poke around in the subcutaneous tissue (and saves you the time of getting a new cannula!) than sticking it back in the skin again.

Finishing off

• Date
• Location (i.e. which arm etc)
• That ANTT was used

Complications

• Infection
• Haematoma
• Nerve damage

References

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