profile/2360PW.jpg

Lana

Cervical Intraepithelial Neoplasia (CIN)

Between 250,000 and 1 million American women are diagnosed with CIN annually. Women can develop CIN at any age, however women generally develop it between the ages of 25 to 35. One of the most significant advances in the therapy of neoplasia has been the realization that cervical carcinoma arises from precursor lesions. Most cervical cancer is the end stage of continuum of progressively more atypical changes in which one stage merges imperceptibly with the next. The first and apparently earliest change is the appearance of atypical cells in the basal layers of the squamous epithelium, but nonetheless with preexistence of normal differentiation towards the prickle and keratinizing cell layers (Robbins and Cotran, PATHOLOGIC BASIS OF DISEASE, 7th edition, pg 718-721, ISBN 9781416029731).

The earliest microscopic change corresponding to CIN is dysplasia of the epithelial or surface lining of the cervix, which is essentially undetectable by the woman.  Dysplasia, mean  “bad molding’’ or, in more scientifically terms, disordered development.  CIN is dysplastic changes beginning at the squamo-columnar junction in the uterine cervix that may be precursor of squamous cell carcinoma.


NORMAL GROSS ANATOMY OF CERVIX

The cervix of the uterus is cylindrical, relatively narrow inferior third of the uterus, approximately 2.5 cm long in an adult non pregnant woman. For descriptive purposes, two parts are described: a supravaginal part between the isthmus and the vagina, and a vaginal part, which protrudes into the vagina. The rounded vaginal part surrounds the external os of the uterus and is surrounded in turn by a narrow recess, the vaginal fornix. The spravaginal part is separated from the bladder anteriorly by loose connective tissues and from the rectum posteriorly by the rectouterine pouch.

The slit-like uterine cavity, is approximately 6 cm in length from the external os to the wall of the fundus. The uterine horns are the superolateral regions of the uterine cavity, where the uterine tube enter. The uterine cavity continues inferiorly as the cervical canal. The fusiform canal extends from a narrowing inside the isthmus of the uterine body, the anatomical internal os, through the supravaginal and vaginal part of the cervix, communicating with the lumen of the vagina through the external os. The uterine cavity (in particular, the cervical canal) and the lumen of the vagina together constitute the birth canal through with fetus passes at the end of the gestation. (Clinically oriented anatomy by Moore, Dalley & Agur, 6th edition, pg-385, ISBN- 9788184731835).

The blood supply to the cervix is by the descending branch of the uterine artery and drains into uterine vein. The pelvic splanchnic nerves emerges as S2-S3, transmit the sensation of pain from the cervix to the brain. The nerves travel along the uterosacral ligaments which pass from the uterus to the anterior sacrum. The lymphatic drainage is through internal iliac nodes. the embryonic origin of the cervix is from paramesonephric or mullerian ducts which develop around 6 weeks of emryogenesis.


DIAGNOSING AND GRADING OF CIN BY HISTOPATHOLOGY

The major cause of CIN is chronic infection of the cervix with the sexually transmitted human papillomavirus (HPV), especially the high-risk HPV types 16 or 18. Over 100 types of HPV have been identified. About a dozen of these types appear to cause cervical dysplasia and may lead to the development of cervical cancer. Other types cause warts.

Cellular changes associated with HPV infection, such as koilocytes, are also commonly seen in CIN. CIN is usually discovered by a screening test, the Papanicolau or "Pap" smear. The purpose of this test is to detect potentially precancerous changes. Pap smear results may be reported using the Bethesda System. An abnormal Pap smear result may lead to a recommendation for colposcopy of the cervix, during which the cervix is examined under magnification. A biopsy is taken of any abnormal appearing areas. Cervical dysplasia can be diagnosed by biopsy. (Cervical intraepithelial neoplasia, Wikipedia the free encyclopedia.webarchive)

Dysplasia is subdivided into mild, moderate and severe forms to carcinoma in situ, depending on the extend of involvement of epithelium. Grade 1, mild dysplasia involving the lower one third or less of epithelial thickness. Grade2, moderate dysplasia with one-third to two-third involvements. Grade 3, severe dysplasia or carcinoma in situ with two-third to full thickness involvement.

Grade 1 may progress to next higher grade during a ten-year follow-up period. Grade 2 to grade 3 and so on. 3In one study, 50% of women with CIN 1 progressed to grade 3 and 28% either progressed to grade 2 or remained at grade1 for 9 years. The more severe the grade od dysplasia, the shorter is the time span for the development of carcinoma in situ. The rate of progression, however, are by no means uniform, and in general it is difficult, if not impossible for a clinician using any technique to predict the outcome in an individual patient. Careful follow-up is the only recourse. Regression does occur, but only in mild lesions and flat condylomas.

In CIN 1 there is good maturation with minimal nuclear abnormalities and few mitotic figures . Undifferentiated cells are confined to the deeper layers (lower third) of the epithelium. Mitotic figures are present, but not very numerous. Cytopathic changes due to HPV infection may be observed in the full thickness of the epithelium.

CIN 2 is characterized by dysplastic cellular changes mostly restricted to the lower half or the lower two-thirds of the epithelium, with more marked nuclear abnormalities than in CIN 1. Mitotic figures may be seen throughout the lower half of the epithelium.

In CIN 3, differentiation and stratification may be totally absent or present only in the superficial quarter of the epithelium with numerous mitotic figures. Nuclear abnormalities extend throughout the thickness of the epithelium. Many mitotic figures have abnormal forms.

A close interaction between cytologists, histopathologists and colposcopists improves reporting in all three disciplines. This particularly helps in differentiating milder degrees of CIN from other conditions with which there can be confusion.







Figure 22-20 A, Histology of CIN I (flat condyloma), illustrating the prominent koilocytotic atypia in the upper epithelial cells, as evidenced by the prominent perinuclear halos. B, Nucleic

acid in situ hybridization of the same lesion for HPV nucleic acids. The blue staining denotes HPV DNA, which is typically most abundant in the koilocytes. C, Diffuse immunostaining of

CIN II for Ki-67, illustrating widespread deregulation of cell cycle controls. D, Up-regulation of p161NK4 (seen as intense immunostaining) characterizes high-risk HPV infections

(http://screening.iarc.fr).

RISK FACTORS

Epidemiological studies have identified a number of risk factors that contribute to the development of cervical cancer precursors and cervical cancer. These include infection with certain oncogenic types of human papillomaviruses (HPV), sexual intercourse at an early age, multiple sexual partners, multiparity, long-term oral contraceptive use, tobacco smoking, low socioeconomic status, infection with Chlamydia trachomatis, micronutrient deficiency and a diet deficient in vegetables and fruits.

HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68 are strongly associated with CIN and invasive cancer. Persistent infection with one or more of the above oncogenic types is considered to be a necessary cause for cervical neoplasia . The pooled analysis of results from a multicentre case-control study conducted by the International Agency for Research on Cancer revealed relative risks (RR) ranging from 17 in Colombia to 156 in the Philippines, with a pooled RR of 60 (95% confidence interval: 49-73) for cervical cancer. The association was equally strong for squamous cell carcinoma (RR: 62) and adenocarcinoma of the cervix (RR: 51). HPV DNA was detected in 99.7% of 1000 evaluable cervical cancer biopsy specimens obtained from 22 countries. HPV 16 and 18 are the main viral genotypes found in cervical cancers worldwide. (International Agency for research on cancer, WHO, Chapter 2: An introduction to CIN, 2013).

HPV infection is transmitted through sexual contact and the risk factors therefore are closely related to sexual behaviour (e.g., lifetime number of sexual partners, sexual intercourse at an early age). In most women, HPV infections are transient.


 
TREATMENT

Treatment for CIN 1, which is mild dysplasia, is not recommended if it lasts fewer than 2 years. Usually when a biopsy detects CIN 1 the woman has an HPV infection which may clear on its own within 12 months, and thus it is instead followed for later testing rather than treated.

Treatment for higher grade CIN involves removal or destruction of the neoplastic cervical cells by cryocautery, electrocautery, laser cautery, loop electrical excision procedure (LEEP), or cervical conization. Therapeutic vaccines are currently undergoing clinical trials. The lifetime recurrence rate of CIN is about 20%, but it isn't clear what proportion of these cases are new infections rather than recurrences of the original infection.

Surgical treatment of CIN lesions is associated with an increased risk of infertility or subfertility, with an odds ratio of approximately 2 according to a case-control study. As long as patients can be followed by means of periodic Papanicolaou smears of colposcopy, much can be gained from a conservative and individualized approach. (Robbins and Cotran PATHOLOGIC BASIS OF DISEASE, 7th edition, pg 731-733, ISBN 9781416029731).


SUMMARY

Most cervical cancer is the end stage of continuum of progressively more atypical changes in which one stage merges imperceptibly with the next. The first and apparently earliest change is the appearance of atypical cells in the basal layers of the squamous epithelium, but nonetheless with preexistence of normal differentiation towards the prickle and keratinizing cell layers

CIN is dysplastic changes beginning at the squamo-columnar junction in the uterine cervix that may be precursor of cervical cancer. Dysplasia is subdivided into mild, moderate and severe forms to carcinoma in situ, depending on the extend of involvement of epithelium. Grade 1, mild dysplasia involving the lower one third or less of epithelial thickness. Grade2, moderate dysplasia with one-third to two-third involvements. Grade 3, severe dysplasia or carcinoma in situ with two-third to full thickness involvement.

A number of risk factors that contribute to the development of cervical cancer precursors (CIN) and cervical cancer, include infection with certain oncogenic types of human papillomaviruses (HPV), sexual intercourse at an early age, multiple sexual partners, multiparity, long-term oral contraceptive use, tobacco smoking, low socioeconomic status, infection with Chlamydia trachomatis, micronutrient deficiency and a diet deficient in vegetables and fruits.

Treatment of CIN involves removal or destruction of the neoplastic cervical cells by cryocautery, electrocautery, laser cautery, loop electrical excision procedure (LEEP), or cervical conization. Therapeutic vaccines are currently undergoing clinical trials. A close interaction between cytologists, histopathologists and colposcopists improves reporting in all three disciplines. This particularly helps in differentiating milder degrees of CIN from other conditions with which there can be confusion.


REFERENCE

1.    Cervical intraepithelial neoplasia, Wikipedia the free encyclopedia.webarchive

2.    Clinically oriented anatomy by Moore, Dalley & Agur, 6th edition, pg-385, ISBN- 9788184731835.

3.    "Fertility and early pregnancy outcomes after treatment for cervical intraepithelial neoplasia: systematic review and meta-analysis". BMJ (Clinical research ed.) pg-349, (28 October 2014).

4.    International Agency for research on cancer, WHO, Chapter 2: An introduction to CIN, 2013

5.    http://screening.iarc.fr

6.    Robbins and Cotran PATHOLOGIC BASIS OF DISEASE, 7th edition, pg 718-721, ISBN 9781416029731.

7.    Robbins and Cotran PATHOLOGIC BASIS OF DISEASE, 7th edition, pg 731-733, ISBN 9781416029731).

 

 

 

 

profile/2360PW.jpg

Lana

DEPENDENCY SYNDROME AND MENTAL HEALTH IN THE GAMBIA

 INTRODUCTION

WHAT IS DEPENDENCY SYNDROME?
It is a personalized disorder that is characterized by a pervasive psychological dependence on others. This personality disorder is a long term (chronic) condition in which people depend on others to meet their emotional, physical and financial needs, with only a minority achieving normal levels of independence. Long-term provision of aid to people in need of assistance has been associated with fear of creating a dependency syndrome. The primary concerns are that beneficiaries will lose the motivation to work to improve their own livelihoods after receiving benefits, or that they will deliberately reduce their work efforts in order to qualify for the transfer. This paper strives to answer the question of whether long-term recipients of aid develop a dependency syndrome, reducing their own efforts to improve their livelihoods, by analyzing the behavior and livelihoods activities of financial aid beneficiary in the Gambia to whom financial aid is provided to. (Frank Ellis, 2000)

According to the World Health Organization, dependency syndrome is characterized by at least 3 of the following:

1) Encouraging or allowing other to make most of one’s important life decisions;
2) Subordination of one’s own needs to those of others on whom one is dependent, and undue compliance with others’ wishes;
3) Unwillingness to make even reasonable demands on the people one depends on;
4)  Feeling uncomfortable or helpless when alone because of exaggerated fears of inability to care for oneself;
5) Preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself
6) Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others. (Beck, A.T; et al (1990).

In our research work, we have analyzed how dependency syndrome has affected the mental health of both providers and dependants in Africa with the Gambia in view.
                                             
METHODOLOGY
This study is based on ethnographic fieldwork conducted within two (2) areas in the Gambia during a period of about three (3) weeks from 27th May 2015 – 14th of June 2015 in response to the question: Is there dependency syndrome in the Gambia?

The fieldwork was carried out by a team of four (4) qualified researchers who used the empirical approach and made use of the survey method. A questionnaire was made which aimed to get relevant and in-depth data from the interviewees voluntarily.

In order to get the demographic interpretations of the research, the people interviewed comprised of literates and illiterates, high income earners or business owners and minimum wage earners, dependents and independents. All the interviewed people ranged between the ages of 17 and 80 years old. Due to some challenges, the team was only able to interview people within Kanifing municipal council and Banjul, the Gambia. The total number of people interviewed was seventy-two (72).

Although the study had its limitations, we were able to achieve our main aim, though future research is needed to show the effects of dependency syndrome in the African society on a wide scale. The study was effective in its approach because it answered our questions about dependency syndrome.

RESULTS
This research was focused on proving the extent of dependency syndrome and its effect on the mental health of both dependants and providers in The Gambia. For clarity, these results were gotten via the above mentioned methodologies and it is centered on The Gambia.

AGE RANGE             PERCENTAGE OF DEPENDANTS
0-110....................................100%
11-20.....................................87.6%
21-30.....................................54.0%
31-40.....................................37.0%
41-50.....................................35.0%
51-60.....................................48.0%
61-70......................................71.4%
71-80......................................83.1%

The table above shows the age ranges interviewed, directly or indirectly calculated percentage of dependants within each range.






According to this result, 20% showed the dependency syndrome and this largely included severely handicapped people and 80% were largely without dependency syndrome but sure depend on people from time to time.

                                           DISCUSSION
The purpose of this study which was conducted on 72 volunteers including both men and women ranging from different age groups, educational qualifications, occupations and living in different demographic areas and from different works of lives was to examine and to explore dependency syndrome in Africa with the Gambia in view.

In our research we were able to find out that 68% of interviewed subjects give financial help to their immediate families and relatives as well as external people not related to them. On one hand 100% of the providers interviewed supported feeling gratified helping others. On the other hand, 46% reported to have borrowed money from other to provide for their immediate and extended family. 59% of interviewed subject reported feeling mentally stressed while 36.4% support helping each other as means of social security. Among the dependants interview which included 50 people from age range of 11-80 years acknowledge the importance of help they receive. A dependency trend was being observed from our data. The data reflects that dependency is highest among 0-20 years old, from 30-50 years its lowest where from 51 and onwards, its increasing as people of the group is mostly old and retired people who depend on their families for their needs almost entirely.

Measuring the extent of dependency syndrome is not simple, as it relates to individual behavior. Though this research has tried to address the issue of dependency syndrome in the context of the Gambia, the study is not without limitations. It is focused on two research areas of the Gambia; Kanifing Municipal Council (K.M.C) and Banjul which is not enough of a representative sampling strategy to make generalizations about dependency syndrome in the Gambia overall. This is partly due to the limited period available during which this research was conducted and partly due to lack of access to transportation to the rural areas of the Gambia. One of the challenges faced during the research was language barrier which limited our interviews to English speaking interviewees as there were no interpreter available and the team which conducted the interviews was mainly composed of English speaking non- Gambians.

Helping others theoretically can contribute to dependency syndrome. This is especially true when people receive financial help from others even when they are not chronically in need of external assistance to meet their daily needs. This is what is described as a negative dependency, which occurs when individuals’ or households’ needs are met at the expense of recipients’ capacity to meet their own basic needs in the future. This has a limiting effect in the long run on majority of people who provide for others, in the sense that, after providing for others, they themselves are left with little or no resources to embark on future investment and developmental plans of their own. Also helping others on regular basis is mentally draining. From our research, 46% of people go as far as borrowing money from others to use and help others; also people interviewed tend to prioritize other people’s needs at times before their own.

One interviewee said “it is stressful because too many people depend on too few people”. Accordingly, survey result shows that most people were providing for five people at least on regular basis and many others from time to time. Some of the interviewees were providing for as much as ten or more people on regular basis. Another interviewee expressed “helping others is suffocating because it is mostly one way”. This interviewee’s perception was shared by 63.6% of other interviewees; this makes some people want to travel abroad in other to escape and others to distance themselves from friends and families in other to find their peace. In our study all interviewed people claimed to feel satisfaction helping others yet look for coping mechanisms to deal with the stress of having to not jus cater for their needs, their immediate families’ but also extended family members and external people as well

Generally, results of this research reveal that in the study area there is no evidence a dependency syndrome or a dependency mentality among beneficiary individuals except in the case of physically disabled and children. Research findings indicate that, given individuals’ experience with financial assistance, it is unlikely that financial aid beneficiary individuals have developed a dependency syndrome as a result of the financial help from others, because the amount of help is limited while the reliability and predictability is not guaranteed. However, due to limited livelihood opportunities to improve their lifestyle and financial status, a large number of individuals depend on financial help from friends and families to cover part of their financial shortages. This is a reflection of positive dependency and should not be confused with dependency syndrome, which is characterized by unwillingness to engage in life-changing activities due to anticipation of external help (Aschale, D.S (2012).

However, regardless of the limitations, the results discussed in this paper provide important insights regarding what should be taken into account when dealing with local people’s behavior and dependence on help from others and thus have significant implications for future research on the subject.

                                       SUMMARY
Dependency syndrome is defined as a pervasive dependence on others for ones daily needs. Our research was to find out the extent of dependency syndrome in the Gambia and the mental health implications on both dependents and providers. We used empirical approach and an extensive survey method to undertake this research.

The results showed an average of 20% of the population exhibiting the dependency syndrome; the study was not without limitations.

In conclusion the Gambian society according to our research had a very little percentage of its population with the dependency syndrome including handicapped people and children.


                                                 REFERENCES
1. Aschale, D.S (2012) the journal of humanitarian assistance November 27, 2012
2. Beck, A.T; et al (1990) Cognitive therapy of personality disorders. New York; Guilford press ISBN 978-0-89862-434-2
3. Frank Ellis, Rural Livelihoods and Diversity in Developing Countries (Oxford: Oxford University Press, 2000): 40.