The minimally abnormal Pap smear. A conservative approach.
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Carcinoma in Situ↗
Biomedical subjects
T J Zuber
Publications and source records attributed to T J Zuber.
'See and treat' electrosurgical loop excision of the cervical transformation zone.
BACKGROUND: "See and treat" electrosurgical loop excision of the cervical transformation zone (ELECTZ) is an excisional surgical procedure that enables simultaneous histologic diagnosis and treatment of premalignant cervical disease, thus eliminating the need for a preliminary cervical biopsy and an additional patient visit. Indications for the procedure include an abnormal cervical Papanicolaou (Pap) smear and a colposcopic impression of cervical intraepithelial neoplasia (CIN). The purpose of this study was to assess the "see and treat" ELECTZ procedure performed by family physicians. METHODS: Women who were scheduled for colposcopic evaluation because of an abnormal cervical cytology report were enrolled from the practices of three family physician colposcopists located at three sites. The "see and treat" ELECTZ procedure was performed on patients with both abnormal Pap smear results and abnormal colposcopic findings. Procedural complications were documented. Subjects were evaluated at follow-up examinations during the first postoperative year to determine therapeutic cure. RESULTS: "See and treat" ELECTZ was performed on 48 women. The histologic results from "see and treat" ELECTZ were normal for 36.1% of subjects. When subjects with a low-grade lesion on Pap smear were considered, 40.7% had normal loop histologic findings. Of women with a preoperative colposcopic impression of low-grade lesion, 54.2% had normal histologic results, and 12% of women with a high-grade colposcopic impression had normal histologic results (P<.001). When the colposcopic impression was reported as high-grade disease, 82% of loop specimens were reported as CIN 2 or 3. CONCLUSIONS: Selective use of "see and treat" ELECTZ may be appropriate only when practiced by experienced colposcopists who are able to reliably differentiate low-grade from high-grade disease by means of colposcopy, and if cytologic and colposcopic findings unequivocally indicate high-grade cervical disease.
Adolescent↗
A pilot project in office-based diagnostic esophagogastroduodenoscopy comparing two nonintravenous methods of sedation and anesthesia.
OBJECTIVE: To evaluate the performance and findings of diagnostic esophagogastroduodenoscopy (EGD) procedures in a primary care office setting, comparing two nonintravenous methods of sedation and anesthesia. DESIGN: A consecutive case series of patients with appropriate indications referred over a 13-month period for the EGD procedure was studied. Procedure outcomes and patient acceptance were evaluated following the procedure. SETTING: Patients were referred from community primary care physician offices to another community private office. PATIENTS: Medically stable adult patients with indications for nonemergent EGD were referred for evaluation. INTERVENTION: Esophagogastroduodenoscopy was performed in an office setting using small-caliber (7.9-mm or 9.0-mm) fiberoptic endoscopes. Patients were given either diazepam orally and ketorolac tromethamine intramuscularly or triazolam orally and butorphanol tartrate spray intranasally as sedation prior to the procedure. MAIN OUTCOME MEASURES: Clinical findings observed, histopathologic results, complications, oxygen desaturation, cardiac dysrhythmias, and length of procedures were recorded. Patients reported pain and satisfaction scores on a linear numeric scale following the procedure. RESULTS: No major complications were noted in this study population. Seventy-three percent (52/71) of all patients rated their discomfort during the office-based EGD procedure as mild, with 49% (35/71) giving the lowest possible pain score rating. Ninety-six percent (68/71) of all patients rated their satisfaction with the procedure as high, with 65% (46/71) reporting the highest possible level of satisfaction. The study did not demonstrate a significant difference in patient comfort or satisfaction between the two methods of nonintravenous sedation. CONCLUSIONS: Two alternative methods to intravenous sedation and anesthesia appear to create adequate comfort and satisfaction for patients undergoing EGD and merit future study and consideration.
Administration, Intranasal↗
Electrosurgical loop excision of the cervical transformation zone: the experience of family physicians.
BACKGROUND: Electrosurgical loop excision of the cervical transformation zone (ELECTZ) is an excisional surgical procedure for treatment of premalignant cervical disease and the abnormal transformation zone by wire loop electrodes. The purpose of this study was to describe and assess the clinical experiences and complications of family-physician-performed ELECTZ and ELECTZ conization. METHODS: Women who were scheduled for the ELECTZ or ELECTZ conization procedures were enrolled in the study between March 1992 and March 1993, inclusive. Subjects were recruited from the practices of six family physician colposcopists located at five sites. The ELECTZ and ELECTZ conization procedures were performed on patients with abnormal Papanicolaou (Pap) smears or abnormal histologic results and abnormal colposcopic findings. Procedural complications were documented. Subjects were serially assessed during the first postoperative year by Pap smears, colposcopy, and, when necessary, by biopsy to determine therapeutic cure. RESULTS: Of 198 subjects enrolled in the study, 148 women were assessed at least once in follow-up by Pap smear and colposcopy. Only 7.6% of women were defined as treatment failures by subsequent histologic assessment. Women treated by ELECTZ conization were older (32.2 vs 25.1 years, P = .02), were more likely to develop posttreatment cervical stenosis (25.9% vs 3.8%, P = .001), and were more likely to have the postoperative squamocolumnar junction positioned in the endocervical canal (32.4% vs 8.7%, P = .002) than were women treated by ELECTZ: Loop excision specimen margins demonstrated dysplasia for 27 (13.6%) subjects. Significant operative bleeding (> 25 mL) was noted in 6.8% of subjects. Histologic thermal artifact was reported for 9.6% of specimens. One case of microinvasive cancer and one case of invasive cancer were identified unexpectedly by ELECTZ conization. CONCLUSIONS: Electrosurgical loop excision of the cervical transformation zone and ELECTZ conization may be safely and effectively performed in office settings by family physicians. Complications and treatment failure rates for the ELECTZ and ELECTZ conization procedures were similar to those experienced by other clinicians.
Adolescent↗
Management of ingrown toenails.
Patients with an ingrown toenail are frequently encountered in primary care practice. Ingrown toenails are the result of an alteration in the proper fit of the nail plate in the lateral nail groove. The alteration can be caused by such factors as wearing shoes that do not fit properly or an incorrect nail-trimming technique. Conservative approaches, including soaking the foot in warm water, use of topical or oral antibiotics, proper nail-trimming technique and elevation of the corner of the nail, are often used in patients with mild stage 1 disease. Stage 2 disease is characterized by worsening of symptoms, drainage and infection, and can be managed conservatively or surgically. Stage 3 disease is characterized by lateral wall hypertrophy and is best treated with partial nail avulsion, lateral matricectomy and destruction of the lateral wall granulation tissue. Chemical matricectomy with phenol is effective, but electrosurgical matricectomy may offer more controlled tissue destruction and less postoperative drainage. A modern office technique for managing stage 3 ingrown toenails is reviewed.
Humans↗
Disposable sheath endoscopes: a new office technology.
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Disposable Equipment↗
The fusiform excision.
The fusiform excision of a skin lesion is a common procedure in outpatient care. The appearance of the final scar is improved by orienting the excision parallel to resting skin tension lines with at least a 3:1 length-to-width ratio, undermining the lateral wound edges and using absorbable subcuticular sutures. A properly designed fusiform excision can be closed primarily and infrequently results in the formation of excessive mounds of tissue at the wound ends, known as "dog-ears."
Dermatologic Surgical Procedures↗
Nodular fasciitis.
Nodular fasciitis is a benign proliferation of fibroblasts and myofibroblasts in the subcutaneous tissues. The lesions are generally small and solitary, arising commonly in the upper extremities of adults and in the head and neck region of infants and children. A history of trauma may precede these reactive lesions, but their cause is unknown. The rapid growth, abundant cellularity, and mitotic activity frequently cause these lesions to be misdiagnosed as sarcomas. Local excision is the treatment of choice for these generally nonrecurring lesions. A case report, differential diagnosis, and review of the literature are presented. Physicians need to be aware of this clinical entity and to work closely with pathology consultants in confirming this difficult diagnosis.
Adult↗
Coding and reimbursement for gastrointestinal endoscopic procedures in primary care.
Endoscopic diagnostic procedures have become part of the comprehensive care provided by many primary care physicians, and when these physicians interact with third-party payers, they must correctly report the endoscopic services they have provided. Included in this review are commonly used upper and lower gastrointestinal endoscopic procedure codes; corresponding reimbursement values from one state's Medicare and Medicaid program; lists of diagnosis codes used in reporting upper and lower endoscopy services; and instructions for reporting visits and intravenous anesthesia associated with endoscopy procedures.
Anesthesia, Intravenous↗
Earlobe keloids.
Earlobe keloids are a challenging management problem. These benign, fibrous proliferations develop in predisposed persons at sites of cutaneous injury or as the result of ear piercing, burns or surgical procedures. Earlobe keloids usually appear as shiny, smooth, globular growths on one or both sides of the earlobe. Patients frequently complain of cosmetic embarrassment, but also may report pruritus, pain or paresthesias. No single therapeutic modality is best. The location, size, depth and duration of the earlobe keloid influence the choice of therapy. Surgical treatment for earlobe keloids generally includes core excision with low-tension wound closure, and shave excision. Surgical repair with corticosteroid injections and postoperative pressure on the incision site usually provide good cosmetic results. Patients must be counseled about recurrence, palpable postoperative nodules and the need for close monitoring.
Adrenal Cortex Hormones↗
Medicare CPT codes.
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Abstracting and Indexing↗
Interspecialty wars over endoscopy.
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Endoscopy↗
Occupational Safety and Health Administration regulations for the physician's office.
Mandatory reporting and recordkeeping on job safety were established for all employers by the Occupational Safety and Health Administration (OSHA) Act of 1970. Physician interest in OSHA regulations recently increased with the publication of the Bloodborne Pathogens Standard. This review examines general employer communication to employees about new standards as well as reporting requirements for physician offices, including special OSHA forms needed to comply with illness and injury reporting.
Acquired Immunodeficiency Syndrome↗
Primary care physician consultations.
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Centers for Medicare and Medicaid Services, U.S.↗
Physician payment reforms and family physicians.
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Fee Schedules↗
Coding and reimbursement of primary care biopsy and destruction procedures.
Current medical practice requires physicians to accurately report services provided to patients. Billing for destruction of benign and malignant lesions and for surgical, needle, and endoscopic biopsy procedures involves the selection of specific 1992 Current Procedural Terminology (CPT) codes. Payment for these procedures by third-party payers often requires the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding for neoplastic lesions. This review explains the proper codes to use in identifying common biopsy and destruction procedures performed by primary care physicians. The Health Care Financing Administration's relative value units and one state's published Medicaid payment rates are included for each procedure code. Instructions for selecting site-specific biopsy and destruction codes are provided.
Abstracting and Indexing↗