Diagnosis of Endometriosis

Endometriosis is defined as the presence of endometrial-like endometrial cells, glands, and stroma outside the uterus, causing a wide range of symptoms and signs, including acute and chronic pelvic pain and infertility. Endometriosis affects approximately 10% of women of reproductive age, and up to 50% of infertile women. The etiopathogenesis of endometriosis still remains controversial: immune, hormonal, genetic, and epigenetic factors may be all involved, and several theories have been proposed to explain it.One of the main problems for the management of endometriosis is the significant diagnostic delay: to date, several biomarkers are currently being tested in order to provide a reliable non-invasive diagnosis in case of symptoms and signs suspicious for endometriosis.In addition, ultrasound techniques and magnetic resonance imaging are evolving rapidly, allowing for better accuracy, even with the use of artificial intelligence. Finally, new potential histological makers are helping to correlate the occurrence of endometriosis in different anatomical landmarks, supporting specific pathways to clarify the etiology of the disease

‘Myth or reality?’ Preoperative pain planning and management: A critical ethnographic examination and exploration of day surgery preoperative practices

The assessment and management of surgical pain are paramount to good quality perioperative care. Regrettably, patients still declare inadequate satisfaction levels within this important area of practice. Holistic preoperative pain planning and education is a useful strategy to address this issue which has never been fully studied in day case surgery. This thesis has used a critical ethnographic research approach to explore and examine preoperative cultural practices and provide insight into what influences and shapes pain planning, management strategies and interactions with day surgical patients. This methodology observed healthcare interactions in the day case unit through a critical lens, underpinned by critical social theory and a transformative paradigm. Using Carpspecken’s (1996) analytical enquiry framework, the preoperative practice of one department was investigated over nine months. Both qualitative and quantitative data collection methods were used, including observations, interviews and timings of interactions. One hundred and twenty-four patients and thirty-three healthcare professionals took part in the study, one hundred and thirty hours of practice were observed, and twenty in-depth interviews with healthcare professionals took place. Data were analysed using reconstructive and statistical analysis, and four main themes were identified as having an impact on preoperative interactions. These four themes were: • The prioritisation of patient safety over pain management. • A production line culture which negatively impacted on holistic practice. • The existence of paternalism and power that affected staff and patient autonomy. • Unconscious gender and surgery bias, which had a direct impact on the levels and depth of preoperative pain conversations and management strategies. These were explored further in relation to Bourdieu's (1977) sociological theory of habitus and capital, in an attempt to raise awareness of practice culture and increase transparency, in order to challenge the status quo

Investigation of neonatal mouse kidney and endometrial cell populations in explant culture combined with an in silico approach to the endometrium

Background The endometrium is a highly dynamic tissue undergoing up to 400 cycles of proliferation, differentiation and breakdown in an average woman’s reproductive life. The mechanisms of this proliferative potential are the subject of active study and one candidate is Adult Stem Cells (ASCs). Endometriosis is a benign proliferative endometrial disease resulting from ectopic growth of endometrial tissue comprising glands and stroma with unknown pathogenesis. ASCs have also been implicated in the pathogenesis of endometriosis and attempts have been made in recent years to characterise and isolate this cell population within the endometrium. A great deal of investigation into cellular and molecular processes governing this disease has been undertaken with conflicting results. A useful tool to guide future investigation is the emerging discipline of bioinformatics. Objectives: One of the difficulties with investigating endometriosis and endometrial ASCs is the lack of suitable in-vitro models to study the benign yet abnormal growth of endometrial epithelial cells in culture. Ex-vivo culture models using a multicellular culture system are highly desirable for future work and the present study aimed to investigate two of the features associated with ASCs: proliferation and differentiation potential. A crudely fractionated epithelial population of endometrial cells in a neonatal kidney explant model was used to assess this. The kidney is an ideal tissue for use in co-culture with endometrial cells as the endometrium and the kidney both embryologically derive from the intermediate mesoderm. Furthermore, it has been shown previously that human endometrial cells can generate endometrial-like tissue, including glandular structures, when transplanted into the kidneys of immune-compromised adult mice. To investigate whether an in vitro model using neonatal kidney cells could support the growth and differentiation of endometrial cells, endometrial epithelial cells were grown in a chimeric explant model using kidney tissue isolated from CD1 neonatal mice. Chimeras were generated using a recently developed reaggregation protocol. Controls comprised explants of reaggregated kidneys that did not contain any endometrial cells. Explants were cultured at an air-medium interface for 2 hours (0 Days), 3 Days and 7 Days respectively before being fixed, processed and analysed with immunofluorescence and RT-qPCR to detect the presence of endometrial-derived glandular structures, and endometrial differentiation markers. Markers of interest for analysis of the chimeras included: Laminin, Progesterone Receptor and Mucin1. A human-specific cytoplasmic antibody was used to identify human cells in the chimeras. This work was further extended to assess nephrogenesis and endothelial cell survival in the neonatal kidney explants. In the study of the developmental processes governing the mammalian kidney progress has been achieved through the use of embryo explant models. These models are useful for studying early developmental processes such as reciprocal induction but are less suitable for studying later maturation events (e.g. foot process formation in podocytes), due to the fact that the endothelial cell population dies. Podocytes depend upon interactions with the glomerular basement membrane (GBM) to achieve maturity and the GBM is known to be formed, at least in part, from factors secreted by endothelial cells. If an explant model could be established with an intact endothelial population there is potential to study these maturation processes. Markers of interest for neonatal kidney explants included: WT1, Pecam, Synaptopodin, Laminin and Calbindin. Bioinformatics tools were employed to examine existing microarray data sets of normal endometrium during various stages of the menstrual cycle with the aim of identifying molecular pathways of interest and generating suitable hypotheses. The same process was carried out for endometrium from patients with endometriosis with the future goal of comparing these datasets. Results: Analysis of chimeric explants indicated that a large proportion of the endometrial cells died in culture with only a small population present by Day 7 that showed no evidence of forming glandular structures. A degree of nephrogenesis appeared to have occurred in the neonatal kidney explant model with evidence of endothelial cells surviving and forming cord like structures in culture. Initial investigation of the transcriptomic datasets associated with normal endometrium and patients with endometriosis was submitted to Ingenuity Pathways Analysis (IPA) and Cytoscape. A large amount of output was obtained and specific pathways suitable for further investigation were identified including: Super Oxide Radicals Degradation, Tryptophan Degradation to 2-amino-3 Semi Aldehyde and Wnt/β Catenin Pathway. Conclusions: The three main conclusions were as follows. 1 Human endometrial cells were not able to survive in the chimeric model of ex-vivo culture, indicating that this is unlikely to be a suitable model system for studying the formation of endometrial cell-derived glandular structures. 2 Nephrogenesis may be occurring in the reaggreagted neonatal explants, and the endothelial population appeared to have survived and formed capillary like structures in vitro. This is an important observation because in explants of embryonic kidneys, the endothelial cells do not survive. 3. Investigation of the molecular processes at play in the normal endometrium and endometriosis has generated some interesting hypotheses that will be further investigated using ‘wet’ laboratory techniques

Characterization of the epigenetic modifications in human uterine leiomyomas and evaluation of their potential as therapeutic targets in vitro

Los miomas o fibromas uterinos (UL) son los tumores benignos más frecuentes en las mujeres en edad reproductiva. A pesar de su elevada prevalencia y de las diferentes opciones de tratamiento, no existe terapia eficaz para la reducción del tamaño de los UL que sea mínimamente invasiva y sin efectos secundarios a largo plazo. Su patología tumoral permanece desconocida, lo que dificulta el desarrollo de tratamientos seguros y eficaces. Por lo tanto, la identificación de los mecanismos moleculares implicados en la generación de UL podría permitir el desarrollo de tratamientos más eficaces. Las modificaciones epigenéticas están implicadas en el desarrollo de los tumores y pueden revertirse mediante agentes químicos. Esta posibilidad abre la puerta a nuevas opciones terapéuticas para las pacientes con UL. El objetivo principal de esta tesis es describir los mecanismos epigenéticos, en relación con la metilación del ADN y la modificación de las histonas, implicados en el desarrollo de los UL, los cuales podrían ser nuevas opciones terapéuticas para tratarlos. Nuestros resultados revelaron una mayor metilación del ADN en los UL en comparación con el miometrio (MM) adyacente. Esta metilación aberrante regula la expresión de genes implicados en el desarrollo y mantenimiento de tumores, provocando la hipometilación/sobreexpresión de oncogenes y la hipermetilación/infraexpresión de genes supresores de tumores. En consecuencia, se alteran procesos importantes en la fisiología de los UL, como la proliferación, invasión, vesículas extracelulares, metabolismo, deposición de la matriz extracelular (ECM) y la vía Wnt/β-catenina. Además, la inhibición de las metiltransferasas de ADN mediante el tratamiento con 5-aza-CdR inhibe la proliferación celular, formación de ECM y la vía de señalización Wnt/β-catenina en las células HULP in vitro. Estos resultados sugieren que la inhibición de la metilación del ADN podría ofrecer una nueva opción terapéutica para tratar a las pacientes con UL. También encontramos una alterada acetilación en la lisina 27 de la histona 3, causando la hiperacetilación/sobreexpresión de oncogenes y la hipoacetilación/infraexpresión de genes supresores de tumores en el UL, que están relacionados con el sistema inmunitario, angiogénesis, invasión, alteración del metabolismo, deposición aberrante de ECM, y la desregulación de las vías Wnt/β-catenina y TGFβ. La reversión de la desacetilación de las histonas mediante el tratamiento con SAHA induce la reducción del depósito de ECM, disminuye la progresión del ciclo celular y la proliferación celular en las células de UL in vitro, lo que conllevaría a la inhibición del crecimiento del UL. Estos resultados ponen de manifiesto que la inhibición de las HDACs a través del SAHA puede ser una diana terapéutica viable para tratar el UL. Basándonos en los resultados obtenidos en esta tesis, concluimos que los mecanismos epigenéticos, a través de la metilación del ADN y las modificaciones de las histonas tales como la acetilación, son un desencadenante clave de la patogénesis del UL. Además, dirigirse a las enzimas que catalizan estos cambios epigenéticos es un prometedor enfoque terapéutico para tratar a las pacientes con UL.Uterine leiomyomas or fibroids (UL) are the most common benign tumors in women of reproductive age. Despite the high prevalence, and the large amount of management options, there is no effective treatment for UL size reduction minimally invasive and without long-term side effects. Its tumor pathology remains unclear, which hampers the development of safe and effective treatments. Therefore, the identification of molecular mechanisms involved in UL pathogenesis could allow the development of more efficient treatments. Epigenetic modifications are involved in tumor development, and they can be reversed by chemical agents. This possibility opens insights into new therapeutic options for patients with UL. Considering this, the main objective of our study is to describe the epigenetic mechanisms, regarding DNA methylation and histone modification, involved in UL development, which could be a new therapeutic target to treat UL. Our results revealed a higher DNA methylation in UL compared to adjacent myometrium (MM). This aberrant methylation regulates the expression of genes involved in tumor development and maintenance, causing hypomethylation/upregulation of oncogenes and hypermethylation/downregulation of tumor suppressor genes. Consequently, several important processes in UL physiology are altered such as proliferation, invasion, extracellular vesicles, metabolism, deposition of extracellular matrix (ECM), and Wnt/β-catenin pathway. In addition, DNA methyltransferases inhibition by 5-aza-CdR treatment inhibits cell proliferation, ECM formation, and Wnt/β-catenin signaling pathway in HULP cells in vitro. These results suggest that DNA methylation inhibition could offer a new therapeutic option to treat patients with UL. We also found an altered acetylation in Lysine 27 of Histone 3 (H3K27ac), causing a hyperacetylation/upregulation of oncogenes and hypoacetylation/downregulation of tumor suppressor genes in UL, which are related to the immune system, angiogenesis, invasion, altered metabolism, aberrant deposit of ECM, TGFβ and Wnt/β-catenin pathway dysregulation. The reversal of histone deacetylation through SAHA treatment induces the reduction of ECM deposition, decreases cell cycle progression and cell proliferation in UL cells in vitro, which may induce inhibition of UL growth. These findings highlight that inhibition of HDACs through SAHA may be a viable therapeutic target to treat UL. Based on the results obtained in this thesis, we conclude that epigenetic mechanisms, through DNA methylation and histone modifications as acetylation of histone 3, are key trigger of UL pathogenesis. In addition, targeting enzymes that catalyze these epigenetic changes is a possible therapeutic approach to treat patients with UL

"I really dislike taking painkillers; I would rather weather the storm": using interpretative phenomenological analysis to make sense of patients' use of analgesics following day case surgery.

Day case surgery is expanding in the UK and is the favoured approach to elective surgery by the Government and patients alike. However studies have revealed patients' experience unacceptable postoperative pain when they return home after day surgery, leading to a variety of negative consequences, stemming many years, affecting many lives, with emotional and financial cost. It is imperative that pain is adequately controlled following day surgery to reduce these consequences and ensure the potential of day surgery is reached. Previous research has investigated barriers to pain management in this area, one barrier that has received little attention is that posed by the patient, and it has been suggested that patients may not utilising their analgesics appropriately with papers calling for further research in this area. Employing Interpretative Phenomenological Analysis (IPA) this study explored patients' use of analgesics on returning home following day surgery. Using IPA for analysis, interviews with twenty eight patients revealed many to avoid analgesics enduring severe postoperative pain during their recovery, and provided new understanding showing patients' use of analgesics to be as a result of a complex intentional decision making process based on a matrix of beliefs they held surrounding pain, analgesics and day surgery. These beliefs were found to be influenced by past experience, and cultural context, with this research being the first to identify many of these beliefs and make further sense of them by producing an explanatory framework illustrating how they exert their influence upon patients' decisions regarding analgesic use. One implication of these findings is that day surgery is not as straightforward as suggested, and simply providing patients pain management information and effective analgesics underestimates the complexity of the patient's experience when they return home. Further research is now required to identify alternative ways to reduce pain following day case surgery. One recommendation is to overcome erroneous beliefs held by patients. In particular the explanatory framework produced by this research provides a unique insight into the mechanism by which these beliefs may exert their influence upon patients' analgesic use, and may prove a useful tool to achieving this, overcoming pain and its negative consequences, paving the way for day case surgery to reach its full potential

Developing a Diagnosis Aiding Ontology Based on Hysteroscopy Image Processing

In this paper we describe an ontology design process which will introduce the steps and mechanisms required in order to create and develop an ontology which will be able to represent and describe the contents and attributes of hysteroscopy images,as well as their relationships,thus providing a useful ground for the development of tools related with medical diagnosis from physician

Development of recommendations to improve patient experiences of brachytherapy for locally advanced cervical cancer

Brachytherapy is a type of internal radiation treatment where a radioactive source is placed close to a tumour. For locally advanced cervical cancer (LACC), too advanced to be cured by a hysterectomy, radiotherapy with chemotherapy is the standard treatment. Typically, brachytherapy follows five weeks of daily external beam radiotherapy alongside weekly chemotherapy. Brachytherapy requires patients to have applicators/needles positioned inside them in an operating theatre and to remain lying flat and still on a bed for the planning and treatment delivery. Currently, the way the brachytherapy is given is not standardised. It may be given as three or four day case procedures, or one or two inpatient stays for up to three days where the applicators stay in place for this duration. Brachytherapy is a highly invasive procedure and is known to cause pain, anxiety and distress. Currently there is no consensus on how to minimise this in the context of a rapidly developing technique with wide variations in delivery. This research was undertaken to better understand patient experiences of brachytherapy for LACC, to identify areas needing improvement and ways to reduce distress caused by brachytherapy. A total of three studies were carried out. The first study was a survey to ascertain current UK brachytherapy service provision, including pain management and procedures to provide patient care and support. This found that many different treatment regimens were in use, confirming the lack of standardisation of procedures. The second study was a qualitative interview study, to explore patient experiences of brachytherapy across a number of UK centres where brachytherapy is delivered in different ways. This showed that some women had difficult and traumatic experiences with periods of severe pain and a perception of poor nursing care on the wards. Others described more positive experiences, with some having had no pain. Aspects of what had gone well were identified as well as suggestions for how the treatment could be improved. In the final stage of the research, study data were used to develop potential patient care recommendations. These were discussed and ranked by service providers and service users meeting together in nominal group technique workshops. Some recommendations were amended to improve clarity and a few new recommendations were created in the workshops. From the workshops a list of potential recommendations was produced to be taken forwards for future development, with the aim of improving standards and consistency of care in brachytherapy for LACC