The management of vaginal discharge: diagnosis in a community setting

Women with abnormal vaginal discharge may seek treatment at a Family Planning (FP) or Genitourinary Medicine (GUM) clinic. This common problem may also be managed in Primary Care or at a gynaecology clinic. There is no accepted standard strategy in the United Kingdom (UK) for management of this condition. Protocols for care have evolved mainly by custom and practice rather than from a firm evidence base. Although in the UK the specialities of GUM and FP have traditionally been organised separately, recently these services have become more integrated in order to provide an efficient, patient-orientated approach. In some centres, such as the Sandyford Initiative in Glasgow, FP and GUM services are now housed under the one roof This has highlighted the difference in approaches to the management of vaginal discharge. The GUM strategy utilises near-patient microscopy of the genital specimens and offers an immediate microscopy-based diagnosis. Specimens from the FP strategy however, are transferred to the local laboratory for analysis. Using this strategy, the clinician will make a presumptive initial diagnosis based on the clinical signs and symptoms. Integration of services at the Sandyford Initiative allowed us the opportunity to perform a study comparing the FP and GUM strategies for the management of vaginal discharge in terms of diagnostic accuracy. 200 women (100 each from FP and GUM) were recruited to, and completed this randomised controlled cross-over study. The FP and GUM strategies were performed on all participants. The sequence in which the strategies were performed was randomised to avoid sampling bias. The initial FP diagnosis based on clinical symptoms and signs and the GUM microscopy diagnosis were compared with the reference standard of both strategies combined, In addition, the final results from both strategies were compared with the reference standard. The researcher administered four clinical case scenarios. Each participant had to make a diagnosis based on the patient history and clinical photographs, which were provided. Following attendance at the STIF course, the participants were re-tested with the initial scenarios. The pre- and post-course scores were compared. Statistical analysis was performed using one and two sample t-tests and confidence intervals for the difference of two means. There was a mean increase of 2.5 points in all participants' scores. Comparison of pre- and post-course scores revealed a statistically significant improvement (p = 0.001). In summary the studies presented in this thesis were performed in response to the changing remit of sexual health services in the UK. The findings of these studies have been used to modify and influence practice at the Sandyford Initiative, and could be used to implement change in departments offering a similar service

Access to and experience of later abortion: accounts from women in Scotland

Context: Except in the presence of significant medical indications, the legal limit for abortion in Great Britain is 24 weeks’ gestation. Nevertheless, abortion for nonmedical reasons is not usually provided in Scotland after 18–20 weeks, meaning women have to travel to England for the procedure. Methods: In-depth interviews were conducted with 23 women presenting for "later" abortions (i.e., at 16 or more weeks’ gestation) in Scotland. Participants were women who sought an abortion at a participating National Health Service clinic between January and July 2013. Interviews addressed reasons for and consequences of later presentation, as well as women's experiences of abortion. Thematic analysis attended to emerging issues and employed the conceptual tool of candidacy. Results: Delayed recognition of pregnancy, changed life circumstances and conflicting candidacies for motherhood and having an abortion were common reasons for women's presentation for later abortion. Women perceived that the resources required to travel to England for a later abortion were potential barriers to access, and felt that such travel was distressing and stigmatizing. Participants who continued their pregnancy did so after learning they were at a later gestational age than expected or after receiving assurances of support from partners, friends or family. Conclusions: Reasons for seeking later abortion are complex and varied among women in Scotland, and suggest that reducing barriers to access and improving local provision of such abortions are a necessity. The candidacy framework allows for a fuller understanding of the difficulties involved in obtaining abortions

Oncogenic Properties of Apoptotic Tumor Cells in Aggressive B Cell Lymphoma

BACKGROUND: Cells undergoing apoptosis are known to modulate their tissue microenvironments. By acting on phagocytes, notably macrophages, apoptotic cells inhibit immunological and inflammatory responses and promote trophic signaling pathways. Paradoxically, because of their potential to cause death of tumor cells and thereby militate against malignant disease progression, both apoptosis and tumor-associated macrophages (TAMs) are often associated with poor prognosis in cancer. We hypothesized that, in progression of malignant disease, constitutive loss of a fraction of the tumor cell population through apoptosis could yield tumor-promoting effects. RESULTS: Here, we demonstrate that apoptotic tumor cells promote coordinated tumor growth, angiogenesis, and accumulation of TAMs in aggressive B cell lymphomas. Through unbiased "in situ transcriptomics" analysis-gene expression profiling of laser-captured TAMs to establish their activation signature in situ-we show that these cells are activated to signal via multiple tumor-promoting reparatory, trophic, angiogenic, tissue remodeling, and anti-inflammatory pathways. Our results also suggest that apoptotic lymphoma cells help drive this signature. Furthermore, we demonstrate that, upon induction of apoptosis, lymphoma cells not only activate expression of the tumor-promoting matrix metalloproteinases MMP2 and MMP12 in macrophages but also express and process these MMPs directly. Finally, using a model of malignant melanoma, we show that the oncogenic potential of apoptotic tumor cells extends beyond lymphoma. CONCLUSIONS: In addition to its profound tumor-suppressive role, apoptosis can potentiate cancer progression. These results have important implications for understanding the fundamental biology of cell death, its roles in malignant disease, and the broader consequences of apoptosis-inducing anti-cancer therapy

At a glance kesehatan reproduksi

Buku ini menyajikan pengantar tentang semua aspek kesehatan reproduksi yang diperkaya dengan tampilan ilustrasi dan foto berwarna. Pembahasan dimulai dari keterampilan pemeriksaan klinis dasar sampai dengan tata laksana Infeksi Menular Seksual akut serta dijelaskan pula tentang kehamilan yang tidak direncanakan

Characteristics of women who present for abortion towards the end of the mid-trimester in Scotland: national audit 2013–2014

Objectives: Women in Scotland who request an abortion (for non-medical reasons) within the legal gestational limit (up to 24 weeks) but beyond the gestational limit of all abortion facilities in Scotland (only up to 20 weeks) must travel to England if they wish to terminate the pregnancy. We wished to determine the number and characteristics of women presenting at ≥16 weeks’ gestation for abortion, and compare the characteristics of those proceeding to abortion with those continuing the pregnancy. Methods: Over a period of 12 months we conducted a prospective audit of women presenting at ≥16 weeks’ gestation to abortion services throughout Scotland. The characteristics of women proceeding to abortion and those continuing the pregnancy were compared. Results: A total of 267 women presented for abortion at ≥16 weeks’ gestation. Their median age was 22 years (range 14 to 47 years); 231 were from deprived areas (86.5%), 128 (47.9%) already had a child and 73 (27.3%) had previously undergone abortion. A total of 175 women (65.5%) proceeded to abortion, locally (n = 125; 46.8%) or in England (50; 18.7%). Those at ≥20 weeks’ gestation were statistically more likely to continue the pregnancy than those at earlier gestations (p < 0.001). Conclusions: Relatively few women present for abortion in Scotland at ≥16 weeks’ gestation. Those who are over 20 weeks’ gestation and would need to travel to England for abortion are more likely to continue the pregnancy, suggesting that travel is a barrier to accessing legal abortion for this group of women. Provision of abortion services up to 24 weeks’ gestation should be considered within Scotland