Group A Streptococcus in the Gynecologic Patient

Background: Over the past few decades, physicians have been reminded of the potential for serious complications arising from group A streptococcal (GAS) infections. These infections continue to pose a serious threat, primarily because the pathophysiology of these infections is complex. This article reviews some of the features of GAS infections and presents two case reports of GAS pelvic infections in women

Understanding the magnetic polarizability tensor

The aim of this paper is to provide new insights into the properties of the rank 2 polarizability tensor M̆ proposed by Ledger and Lionheart for describing the perturbation in the magnetic field caused by the presence of a conducting object in the eddy-current regime. In particular, we explore its connection with the magnetic polarizability tensor and the Pólya-Szegö tensor and how, by introducing new splittings of M̆, they form a family of rank 2 tensors for describing the response from different categories of conducting (permeable) objects. We include new bounds on the invariants of the Pólya-Szegö tensor and expressions for the low-frequency and high-conductivity limiting coefficients of M̆. We show, for the high-conductivity case (and for frequencies at the limit of the quasi-static approximation), that it is important to consider whether the object is simply or multiply connected but, for the low-frequency case, the coefficients are independent of the connectedness of the object. Furthermore, we explore the frequency response of the coefficients of M̆ for a range of simply and multiply connected objects

Home ovulation tests and stress in women trying to conceive: a randomized controlled trial.

STUDY QUESTION: Does the use of a digital home ovulation test have any effect on the level of stress in women seeking to conceive? SUMMARY ANSWER: No difference was found in levels of stress between women using digital ovulation tests to time intercourse compared with women who were trying to conceive without any additional aids: in addition, their use did not negatively impact time to conception in users but may provide additional benefits, including an increased understanding of the menstrual cycle, reassurance and confidence in focusing conception attempts to the correct time in the cycle. WHAT IS KNOWN ALREADY: It has been suggested that timing of intercourse in such a way that it coincides with ovulation by using ovulation tests can lead to emotional distress; however, no study has been conducted to investigate this hypothesis specifically, until now. STUDY DESIGN, SIZE AND DURATION: The study was performed over two complete menstrual cycles as a prospective, randomized, controlled trial including quantitative and qualitative methods. The intervention (test) group were given digital ovulation tests to time intercourse to the most fertile time of the cycle and the control group were provided with the current National Institute for Health and Clinical Excellence guidelines for increasing the chances of conception (intercourse every 2-3 days) and asked not to use any additional methods to time when ovulation occurs. PARTICIPANTS/MATERIALS, SETTING AND METHODS: A total of 210 women who were seeking to conceive were recruited from the general UK population. A total of 115 women were randomized to the test group and 95 to the control group through block randomization. The positive and negative affect schedule (PANAS) and the Perceived Stress Scale (PSS) were used to measure subjective stress levels, the Short-Form 12 health survey was used as a measure of general health and well-being and urine samples were measured for biochemical markers of stress including urinary cortisol. Qualitative data were collected in the form of a telephone interview upon study completion. MAIN RESULTS AND THE ROLE OF CHANCE: There was no evidence for a difference either in total stress as measured using the PSS or in total positive or negative affect using the PANAS questionnaire between the test and control groups at any time point for the duration of the study. During cycle 1, for example, on Day 6, the difference in total stress score (test-control) was -0.62 [95% confidence interval (CI) -2.47 to 1.24] and on the day of the LH surge, it was 0.53 (95% CI -1.38 to 2.44). In addition, no correlation was observed between time trying to conceive and levels of stress, or between age and levels of stress, and no evidence was found to show that stress affected whether or not a pregnancy was achieved. There is also no evidence that the biochemistry measurements are related to whether a pregnancy was achieved or of a difference in biochemistry between the treatment groups. The use of digital ovulation tests did not negatively affect time to conception and with an adequately sized study, could potentially show improvement. To ensure that the results of this study were not affected by chance, we used a number of different methods for measuring stress, each of which had been independently validated. LIMITATIONS AND REASONS FOR CAUTION: Randomization occurred before the start of the study because of the need to provide the ovulation tests in readiness for Day 6 of the first cycle. As a consequence, a number of women fell pregnant during this period (22 and 13 in the test and control groups, respectively). A further 15 women were either lost to follow-up or withdrew consent prior to study start. Pregnancy rate was higher overall in the test group, so to ensure that there were sufficient data from women who failed to become pregnant in the test group, we implemented an additional biased recruitment. This second cohort may have been different from the first, although no significant differences were observed between the two phases of recruitment for any of the information collected upon admission to the study. WIDER IMPLICATIONS OF THE FINDINGS: Women who seek medical advice while trying to conceive should not be discouraged by health care professionals from using digital ovulation tests in order to time intercourse. The cohort of women recruited to this study initially had no evidence of infertility and were looking to conceive in a non-medical setting. A separate study to assess the impact of home ovulation tests in a subfertile population would be of interest and complementary to the present study. STUDY FUNDING/COMPETING INTERESTS: This study was funded by SPD Swiss Precision Diagnostics, GmbH, manufacturer of Clearblue(®) pregnancy and ovulation tests. SPD Development Company Ltd is a wholly owned subsidiary of SPD Swiss Precision Diagnostics GmbH; together referred to as SPD. TRIAL REGISTRATION NUMBER: NCT01084304 (www.clinicaltrials.gov)

The impact of introducing patient co-payments in Germany on the use of IVF and ICSI:a price-elasticity of demand assessment

BACKGROUND: Authorities concerned by rising healthcare costs have a tendency to target reproductive treatments because of the perception that infertility is a low priority. In 2004 German health authorities introduced a 50% co-payment for patients, in an effort to save cost. We explored the impact of this pricing policy on the utilization of reproductive treatments in Germany. METHODS: Using aggregated annual in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycle data in Germany, we evaluated the relationship between changes in the number of cycles in relation to changes in costs faced by consumers following the introduction of a patient co-payment from 'no fees' to (sic)1500-2000 by estimating the short-run price-elasticity of demand. The impact of introducing patient co-payments for IVF/ICSI on the likelihood of switching to other low-cost fertility treatments was evaluated using the cross-price elasticity methodology. RESULTS: The reduction in demand for IVF and ICSI cycles in the year following the introduction of patient co-payments resulted in elasticities of -0.41 and -0.34, respectively. The price-elasticity for the combined reduction of IVF/ICSI in relation to the co-payment was estimated to be -0.36. The cross-price elasticity for clomifene was close to zero (-0.01) suggesting that demand for these interventions are independent of each other and no substitution occurred. CONCLUSIONS: We report price elasticities for IVF and ICSI of -0.41 and -0.34 after introducing a (sic)1500-2000 co-payment. These findings likely represent short-run elasticities that are likely to vary over time as factors that influence the supply and demand for fertility treatments change

What factors hinder the decision-making process for women with cancer and contemplating fertility preservation treatment?

Background: Although fertility preservation (FP) treatment options have increased, the existing evidence suggests that many women with cancer do not feel well supported in making these decisions, but find them stressful and complex and fail to take up fertility care at this crucial time. Whilst existing reviews have all made important contributions to our understanding of the FP decision-making process, none of them examine solely and specifically these processes for women of reproductive age with a diagnosis of any cancer, leaving a gap in the knowledge base. Given the expectation that care is patient-centred, our review aims to address this gap which may be of help to those managing patients struggling to make difficult decisions in the often brief period before potentially sterilising cancer treatment is started. Objective and rationale: Underpinning this narrative review was the question “What factors hinder the decision-making process for women with any cancer and contemplating FP treatment?” Our objectives were to i) assess and summarise this existing literature, ii) identify the factors that hinder this decision-making process, iii) explore to what extent these factors may differ for women choosing different methods of FP, and iv) make recommendations for service delivery and future research. Search methods: A systematic search of the medical and social science literature from the 1st January 2005 up to the end of January 2016 was carried out using three electronic databases (Web of Science (PubMed), Ovid SP Medline and CINAHL via Ebsco). Included in the review were quantitative, qualitative and mixed-method studies. Reference lists of relevant papers were also hand searched. From the 983 papers identified, 46 papers were included. Quality assessment was undertaken using the Mixed Methods Appraisal Tool and thematic analysis was used to analyse the data. Outcomes: From the analysis, six key themes with 15 sub-themes emerged: 1) fertility information provision (lack of information, timing of the information, patient-provider communication); 2) fear concerning the perceived risks associated with pursuing FP (delaying cancer treatment, aggravating a hormone positive cancer, consequences of a future pregnancy); 3) non-referral from oncology (personal situation, having a hormone positive cancer, not a priority, transition between service issues); 4) the dilemma (in survival mode, whether to prioritise one treatment over another); 5) personal situation (parity, relationship status); and 6) costs (financial concerns). Wider implications: This review has found that a wide range of internal and external factors impact the FP decision-making process. Key external issues related to current service delivery such as the provision and timing of FP information, and lack of referral from oncology to the fertility clinic. However, internal issues such as women’s fears concerning the perceived risks associated with pursuing FP also hindered decision-making but these ‘risks’ were typically overestimated and non-evidence based. These findings suggest that the implementation of a range of decision support interventions may be of benefit within the clinical care pathway of FP and cancer. Women would benefit from the provision of more evidence-based FP information, ideally received at cancer diagnosis, in advance of seeing a fertility specialist, for example through the implementation of patient decision aids. Health care professionals in both oncology and fertility services may also benefit from the implementation of training programs and educational tools targeted at improving the communication skills needed to improve collaborative decision-making and deliver care that is patient-centred. Exploration of the current barriers, both intellectual and practical, that prevent some patients from accepting FP will help care providers to do better for their patients in the future. Finally, the extent to which a poor prognosis and moral, ethical and religious beliefs influence the FP decision-making process also warrant further research

The impact of surgery for vulval cancer upon health-related quality of life and pelvic floor outcomes during the first year of treatment: A longitudinal, mixed methods study

© 2015 The Authors.Objective: To measure the long-term impact of surgical treatment for vulval cancer upon health-related quality of life and pelvic floor outcomes during the first year of therapy. Methods: Prospective, longitudinal, mixed-methods study. Twenty-three women aged >18 years with a new diagnosis of vulval cancer were recruited. The EORTC QLQ C30, SF-36 and an electronic pelvic floor assessment questionnaire (ePAQ-PF) were administered at baseline (pre-treatment) and 3, 6, 9 and 12 months post-treatment. Mixed effects repeated measures models (all adjusted for age and BMI) were used to investigate changes over time and differences between cancer stage. Qualitative interviews were carried out with 11 of the women and analysed using a thematic approach. Results: Mean age was 59.9 years (SD=15.3; range=23.8-86.6 yrs). Mean BMI was 30.0 (SD=4.5; range=24.4-38.2). Sixteen women had early (Stage 1 to 2B), and seven women had advanced stage disease (Stage 3 to 4B). Questionnaire scores revealed that physical and social functioning, fatigue, pain and general sex life were significantly worse at 12 months than pre-treatment (p=< 0.05). Qualitative analysis revealed multiple treatment side effects which were perceived as severe and enduring. Women with advanced vulval cancer had significantly worse SF-36 mental health scores at 12 months compared to women with early stage disease (p=0.037). Conclusions: Surgery for vulval cancer has long-term implications which can be persistent 12 months post-treatment. High rates of morbidity relating to lymphoedema and sexual function re-enforce the need for specialist clinics to support women who suffer these complications

Health-Related Conditions and Depression in Elderly Mexican American and Non-Hispanic White Residents of a United States-Mexico Border County: Moderating Effects of Educational Attainment

We investigated the prevalence of “high” levels of depressive symptomatology and 13 health-related medical conditions in elderly Mexican American (MA) and non-Hispanic white (NHW) residents of El Paso County, Texas. We analyzed the extent to which depressive symptoms in this population are associated with these conditions. Elderly MA residents possessed a higher prevalence of current depression, a relatively unique health-related condition profile, and were more likely to experience a set of conditions that impede participation in daily life—conditions that we found to be strongly associated with high depressive symptomatology in the elderly. After adjusting for educational attainment, using multiple regression analyses, depression was not associated with ethnicity and only six of the health related conditions showed significant differences between MA and NHW subjects. We believe these results provide an important insight into the mechanism of health-related conditions and depressive symptomatology in a large sample of elderly MAs; and how conditions typically attributed to MA ethnicity may in actuality be an artifact of socioeconomic status variables such as educational-attainment

Characterisation of multiple conducting permeable objects in metal detection by polarizability tensors

Realistic applications in metal detection involve multiple inhomogeneous‐conducting permeable objects, and the aim of this paper is to characterise such objects by polarizability tensors. We show that, for the eddy current model, the leading order terms for the perturbation in the magnetic field, due to the presence of N small conducting permeable homogeneous inclusions, comprises of a sum of N terms with each containing a complex symmetric rank 2 polarizability tensor. Each tensor contains information about the shape and material properties of one of the objects and is independent of its position. The asymptotic expansion we obtain extends a previously known result for a single isolated object and applies in situations where the object sizes are small and the objects are sufficiently well separated. We also obtain a second expansion that describes the perturbed magnetic field for inhomogeneous and closely spaced objects, which again characterises the objects by a complex symmetric rank 2 tensor. The tensor's coefficients can be computed by solving a vector valued transmission problem, and we include numerical examples to illustrate the agreement between the asymptotic formula describing the perturbed fields and the numerical prediction. We also include algorithms for the localisation and identification of multiple inhomogeneous objects