No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain.

OBJECTIVE: To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES: Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE: Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES: The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS: The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; G) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

No 164 - Directive clinique de consensus pour la prise en charge de la douleur pelvienne chronique.

OBJECTIF: Améliorer La compréhension de la douleur pelvienne chronique (DPC) et fournir des directives cliniques factuelles qui bénéficieront aux fournisseurs de soins de santé primaires, aux obstétriciens-gynécologues et aux spécialistes de la douleur chronique. FARDEAU DE LA SOUFFRANCE: La DPC est une pathologie débilitante courante qui affecte les femmes. Elle est à l'origine d'importantes souffrances personnelles et de dépenses de santé considérables associées aux interventions, dont de multiples consultations et un grand nombre de traitements médicaux et chirurgicaux. Puisque la pathophysiologie sous-jacente de cet état pathologique complexe est mal comprise, ces traitements n'ont obtenu que des taux de réussite variables. ISSUES: Efficacité des options diagnostiques et thérapeutiques (y compris l'évaluation du dysfonctionnement myofascial); soins multidisciplinaires; un modèle de réadaptation mettant l'accent sur l'obtention d'un fonctionnement supérieur malgré la présence d'une certaine douleur (plutôt que de chercher à obtenir une guérison totale); et utilisation appropriée des opiacés pour le soulagement de la douleur chronique. PREUVES: Des recherches ont été menées dans Medline et la base de données Cochrane en vue d'en tirer les articles de langue anglaise, publiés entre 1982 et 2004, portant sur des sujets liés à la DPC, dont la gestion des soins actifs, le dysfonctionnement myofascial et les options thérapeutiques médicales et chirurgicales. Les membres du comité ont analysé la littérature pertinente, ainsi que les données disponibles tirées d'une évaluation des besoins des personnes présentant une DPC; ils ont fait appel à une approche de consensus pour l'élaboration des recommandations. VALEURS: La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur l'examen médical périodique. Les recommandations visant la pratique ont été classées conformément à la méthode décrite dans ce rapport (Tableau 1). RECOMMANDATIONS: Les recommandations visent ce qui suit : (a) compréhension des besoins des femmes présentant une DPC ; (b) évaluation clinique générale ; (c) évaluation pratique des niveaux de douleur ; (d) douleur myofasciale ; (e) médicaments et interventions chirurgicales ; (f) principes de la gestion des opiacés; (g) utilisation accrue de l'imagerie par résonance magnétique (IRM) ; (h) documentation de l'étendue de La maladie constatée au moyen de la chirurgie ; (i) thérapies non conventionnelles; (j) accès à des modèles de soins multidisciplinaires faisant appel à des composantes de physiothérapie (comme l'exercice et la posture) et de psychologie (comme La thérapie cognitivo- comportementale), conjointement avec d'autres disciplines médicales, telles que La gynécologie et l'anesthésie ; (k) attention accrue portée à La DPC dans La formation des professionnels de La sante ; et (l) attention accrue portée à la DPC dans le domaine des recherches officielles et de haut calibre. Le comité recommande que les ministères provinciaux de La Sante prennent des mesures en faveur de la création d'équipes multidisciplinaires pouvant assurer La prise en charge de cette pathologie. Chapitre 2 : Portee et definition de La douleur pelvienne chronique Chapitre 3 : Anamnese, examen physique et évaluation psychologique Chapitre 4 : Explorations Chapitre 5 : Sources de douleur pelvienne chronique Chapitre 6 : Causes urologiques et gastro-intestinales de La douleur pelvienne chronique Chapitre 7 : Dysfonctionnement myofasclal Chapitre 8 : Therapie medicale - résultats en matiere d'efficacite Chapitre 9 : Chirurgie - résultats en matiere d'efficacite Chapitre 11 : Prise en charge multidisciplinaire de La douleur chronique Chapitre 14 : Orientations futures.

Propagation of an Avirulent Turkey Hemorrhagic Enteritis Virus Isolate in Chickens.

A series of studies were undertaken to optimize the propagation of hemorrhagic enteritis virus (HEV) in specific-pathogen-free (SPF) chickens. A total of 562 SPF chickens were orally inoculated with an Australian avirulent HEV isolate of turkey origin at 9, 14, 21, or 28 days of age with 5, 6, 7, or 8 log 10 genomic copies (GC), while 102 chickens served as uninfected controls. No clinical signs were observed in infected chickens. There was an inoculum-dose-dependent increase in the relative spleen and liver weight ( P < 0.01). Relative spleen weight 7 days post-HEV inoculation was up to 85% higher in chickens that were inoculated with 6 to 7 GC compared with controls, with no further increase at higher doses. Relative liver weight increased up to 14% in chickens inoculated with 6 GC, with no further increase. Birds inoculated with a 7 GC dose had a higher frequency of HEV DNA-positive birds (77% to 86%) than birds inoculated with lower doses (33% to 59%; P < 0.01). The most efficient dose for live passage propagation was 7 GC inoculated in 9-to-14-day-old birds, yielding an infection rate of 81%. Livers and spleens from infected birds at all doses were processed to produce a putative vaccine with a final GC recovery in the vaccine material of 8.6 GC/bird. In summary, HEV of turkey origin can be readily propagated in SPF chickens, and conditions to maximize viral retrieval were established.

Real-time PCR quantification of infectious laryngotracheitis virus in chicken tissues, faeces, isolator-dust and bedding material over 28 days following infection reveals high levels in faeces and dust.

Infectious laryngotracheitis (ILT) is an important disease of chickens caused by ILT virus (ILTV). We used the Australian SA2 and A20 vaccine strains of ILTV to determine tissue distribution and excretion characteristics of ILTV in specific-pathogen-free chickens and to determine whether ILTV is readily detectable in environmental samples such as faeces, bedding material and dust using real-time quantitative PCR. Three groups of 10 freshly hatched chicks were placed in isolators and infected orally with high doses of the two strains of vaccine virus or left unchallenged as controls. Over a 28-day post-infection (p.i.) period, faecal and serum samples were collected at frequent intervals from six individually identified chickens in each group. Dust and litter samples from the isolators were collected less frequently. Tissue samples were collected from three to four sacrificed or dead/euthanized birds at 6, 14 and 28 days p.i. Infection resulted in clinical ILT, a pronounced antibody response and sustained qPCR detection of the viral genome in the trachea, Harderian gland, lung and kidney up to 28 days p.i. A high level of the viral genome was also detected in faeces between 2 and 7 days p.i., declining by about approximately four orders of magnitude to low, but detectable, levels at 21 and 28 days p.i. The finding of high-level shedding of ILTV in faeces warrants further investigation into the epidemiological role of this, and the sustained high levels of ILTV observed in dust suggest that it may be a useful sample material for monitoring ILTV status in flocks.

Development, application, and results of routine monitoring of Marek's disease virus in broiler house dust using real-time quantitative PCR.

Results are presented from four studies between 2002 and 2011 into the feasibility of routinely monitoring Marek's disease virus serotype 1 (MDV-1) in broiler house dust using real-time quantitative PCR (qPCR) measurement. Study 1 on two farms showed that detection of MDV-1 occurred earlier on average in dust samples tested using qPCR than standard PCR and in spleen samples from five birds per shed assayed for MDV-1 by qPCR or standard PCR. DNA quality following extraction from dust had no effect on detection of MDV-1. Study 2 demonstrated that herpesvirus of turkeys (HVT) and MDV serotype 2 (MDV-2) in addition to MDV-1 could be readily amplified from commercial farm dust samples, often in mixtures. MDV-2 was detected in 11 of 20 samples despite the absence of vaccination with this serotype. Study 3 investigated the reproducibility and sensitivity of the qPCR test and the presence of inhibitors in the samples. Samples extracted and amplified in triplicate showed a high level of reproducibility except at very low levels of virus near the limit of detection. Mixing of samples prior to extraction provided results consistent with the proportions in the mixture. Tests for inhibition showed that if the template contained DNA in the range 0.5-20 ng/microl no inhibition of the reaction was detectable. The sensitivity of the tests in terms of viral copy number (VCN) per milligram of dust was calculated to be in the range 24-600 VCN/mg for MDV-1, 48-1200 VCN/mg for MDV-2, and 182-4560 VCN/mg for HVT. In study 4 the results of 1976 commercial tests carried out for one company were analyzed. Overall 23.1% of samples were positive for MDV-1, 26.1% in unvaccinated and 16.4% in vaccinated chickens. There was marked regional and temporal variation in the proportion of positive samples and the MDV-1 load. The tests were useful in formulating Marek's disease vaccination strategies. The number of samples submitted has increased recently, as has the incidence of positive samples. These studies provide strong evidence that detection and quantitation of MDV-1, HVT, and MDV-2 in poultry house dust using qPCR is robust, sensitive, reproducible, and meaningful, both biologically and commercially. Tactical vaccination based on monitoring of MDV-1 rather than routine vaccination may reduce selection pressure for increased virulence in MDV-1.

Preliminary development of a scale to measure stigma relating to sexually transmitted infections among women in a high risk neighbourhood.

BACKGROUND: As stigma is a socially constructed concept, it would follow that stigma related to sexual behaviours and sexually transmitted infections would carry with it many of the gender-based morals that are entrenched in social constructs of sexuality. In many societies, women tend to be judged more harshly with respect to sexual morals, and would therefore have a different experience of stigma related to sexual behaviours as compared to men. While a variety of stigma scales exist for sexually transmitted infections (STIs) in general; none incorporate these female-specific aspects. The objective of this study was to develop a scale to measure the unique experience of STI-related stigma among women. METHODS: A pool of items was identified from qualitative and quantitative literature on sexual behaviour and STIs among women. Women attending a social evening program at a local community health clinic in a low-income neighbourhood with high prevalence of substance use were passively recruited to take part in a cross-sectional structured interview, including questions on sexual behaviour, sexual health and STI-related stigma. Exploratory factor analysis was used to identify stigma scales, and descriptive statistics were used to assess the associations of demographics, sexual and drug-related risk behaviours with the emerging scales. RESULTS: Three scales emerged from exploratory factor analysis--female-specific moral stigma, social stigma (judgement by others) and internal stigma (self-judgement)--with alpha co-efficients of 0.737, 0.705 and 0.729, respectively. In this population of women, internal stigma and social stigma carried higher scores than female-specific moral stigma. Aboriginal ethnicity was associated with higher internal and female-specific moral stigma scores, while older age (>30 years) was associated with higher female-specific moral stigma scores. CONCLUSION: Descriptive statistics indicated an important influence of culture and age on specific types of stigma. Quantitative researchers examining STI-stigma should consider incorporating these female-specific factors in order to tailor scales for women.

Demographics, sexual risk behaviours and uptake of screening for sexually transmitted infections among attendees of a weekly women-only community clinic program.

OBJECTIVES: Vancouver's DTES represents a high-risk neighbourhood, in which there exist a number of community clinics and outreach programs. The purpose of this study was twofold: 1) to describe the population of women attending a weekly women's program with respect to demographics, risk behaviours and prevalence of STI, and 2) to assess the uptake of STI screening in this setting. METHODS: A cross-sectional survey was undertaken during a weekly community clinic-based women's program from October to December, 2004. Women were recruited at the start of the program each week and were invited to provide urine samples for chlamydia and gonorrhea screening. RESULTS: Among 126 respondents, the median age was 42 (36-49), more than half (52%) self-identified as White and 40% as Aboriginal ethnicity. Forty percent were currently involved in the sex trade. Two thirds reported a Pap smear in the past year, while 14% had not accessed sexual health care (Pap smear, STI or HIV testing). Among the 92/126 (74%) women providing a urine sample, the prevalence of chlamydia and gonorrhea was 2.2% and 0.0%, respectively. CONCLUSION: The majority of women accessing this program were over 35 years of age, and while nearly half were currently involved in the sex trade, cross-sectional screening did not reveal a substantial prevalence of STIs. Women who were not regular program attendees reported less sexual health care, and represented the only two cases of chlamydia found. Innovative programs that better serve the needs of populations that remain unable or unwilling to seek sexual health care in its current formats are needed.

Association of sexually transmitted disease-related stigma with sexual health care among women attending a community clinic program.

OBJECTIVES: The objective of this study was to assess the association of sexually transmitted disease (STD)-related stigma on sexual health care behaviors, including Papanicolaou smears and STD testing/treatment, among women from a high-risk community. METHODS: Descriptive statistics were used to assess the association of demographics, sexual and drug-related risk behaviors, and 3 measures of STD-stigma (internal, social, and tribal stigma, the latter referring to "tribes" of womanhood) with sexual health care in the past year. Pearson's chi-square test and Mann-Whitney test were used to assess significance. Multivariate logistic models were used to determine the association of STD-stigma with sexual health care after controlling for other factors. RESULTS: Lower internal stigma score was marginally associated with reporting an STD test in the past year [median score (interquartile range) for those reporting and not reporting an STD test were 0.79 (0.30-1.59) and 1.35 (0.67-1.93), respectively]. In an adjusted model, internal stigma retained a negative association with reporting of STD testing in the past year (adjusted odds ratio, 0.92; 95% confidence interval, 0.85-0.99). DISCUSSION: Most women had received a Papanicolaou smear in the past year, and none of the STD-stigma scales were associated with reporting this behavior. Internal stigma retained an association with not having any STD test or treatment. Although sexual stigma is a deeply rooted social construct, paying attention to how prevention messages and STD information are delivered may help remove one barrier to sexual health care.

The use of ancestral haplotypes in the molecular diagnosis of familial breast cancer.

Mutations in BRCA1 and BRCA2 account for about 40% of families with an inherited susceptibility to breast and/or ovarian cancer. Mutational analysis of these two genes has become the standard of care for families with a strong suggestion of inherited susceptibility. Methodologies for screening vary, but one of the more popular techniques is dHPLC, due to its combination of high sensitivity and low cost. The presence of a large number of polymorphisms in the two BRCA genes complicates dHPLC analysis, often leading to complex elution profiles. There are concerns that a pattern produced by a sample heterozygous for a polymorphism may be very similar to that produced by a sample heterozygous for a unique mutation within the same amplicon. Further molecular analysis is often required to resolve whether any given shift is due to a polymorphism or a disease-causing mutation. The use of ancestral haplotypes was explored as a means to minimize the need for further analysis. Groups of 86 patients were genotyped for 12 BRCA1 polymorphisms or 20 BRCA2 polymorphisms. For BRCA1, eight distinct haplotypes were identified, which are largely derivatives of two main lineages. For BRCA2, 17 distinct haplotypes were identified, leading to a much more complex polymorphic pattern. With this knowledge, we have defined a system to determine which patients, if any, require further investigations. This method could be used to supplement any comprehensive screening methodology for other large genes that lie within strong regions of linkage disequilibrium such as NF1, CFTR, MLH1, or MSH2.

Consensus guidelines for the management of chronic pelvic pain.

OBJECTIVE: To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES: Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE: Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES: The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS: The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; (j) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

Consensus guidelines for the management of chronic pelvic pain.

OBJECTIVE: To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES: Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE: Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES: The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS: The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (f) principles of opiate management; (g) increased use of magnetic resonance imaging (MRI); (h) documentation of the surgically observed extent of disease; (i) alternative therapies; (j) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical isciplines, such as gynaecology and anesthesia; (k) increased attention to CPP in the training of health care professionals; and (l) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition. CHAPTER 7: MYOFASCIAL DYSFUNCTION: 1. Health care providers should become more aware of myofascial dysfunction as a cause of chronic pelvic pain (CPP) and the available treatment options (IB). 2. Patients should participate in the management of CPP due to myofascial dysfunction by actively using a home stretching and exercise program (ll-2B). CHAPTER 8: MEDICAL THERAPY--EVIDENCE ON EFFECTIVENESS: 1. Opioid therapy can be considered for pain control under adequate supervision (II-3B). 2. Hormonal treatment of chronic pelvic pain of gynaecologic origin, including oral contraceptives, progestins, danazol, and gonadotropin-releasing hormone agonists, has been studied extensively and should be considered as the first line for many women, especially those with endometriosis (I and II-1A). 3. Adjuvant medications, such as antidepressants and antibiotics, can be of supporting help in specific situations (II-3B). CHAPTER 9: SURGERY-EVIDENCE ON EFFECTIVENESS: 1. The lack of robust clinical trials of the surgical management of chronic pelvic pain should be addressed. The use of alternative epidemiologic models, including case-controlled and cohort-controlled trials, should be considered (III-A). 2. Further delineation of the role of appendectomy and of presacral neurectomy appears warranted in the management of endometriosis-related pain (III-A). CHAPTER 11: MULTIDISCIPLINARY CHRONIC PAIN MANAGEMENT: 1. Multidisciplinary chronic pain management should be available for women with chronic pelvic pain within the publicly funded health care system in each province and territory of Canada (III-B). CHAPTER 14: FUTURE DIRECTIONS: 1. The curriculum for professional development should be expanded to include theory and techniques in the management of myofascial dysfunction (A). 2. Research into CPP should be encouraged, particularly in the areas of the impact of CPP on the use of health services, the pathophysiology of myofascial dysfunction, and gene therapy. Because randomized trials for qualitative outcomes are exceedingly difficult, alternative robust models, such as case-controlled or cohort-controlled trials, should be pursued (A). 3. Methods of improving interaction with patients should be explored. They might include formal contractual approaches to managing pain with opiates and efforts to better appreciate the patient's perceived needs (A).

Insulin and IGF-I stimulated RNA synthesis in primary cultures of neuronal cells: involvement of cyclic AMP and protein kinase-c

La insulina y el IGF-I promueven el crecimiento de las células neuronales de rata en cultivo primario. Con el objeto de investigar el mecanismo de transducción de señales hormonales en este sistema biológico, estudiamos el efecto de agonistas de AMP cíclico y un estimulador de la proteína kinasa-C sobre la síntesis de ARN basal e inducida por hormonas. Los agentes que aumentan los níveles de AMP cíclico endógenos (foraskolina, dibutiril-AMP cíclico, toxina colérica) bloquearon los efectos estimuladores de la insulina y el factor de crecimiento; el dibutiril AMP cíclico, sin embargo, no alteró la unión de las hormonas a sus receptores. Aunque a diferencia de los agentes antes mencionados, el ester de forbol elevó significativamente la síntesis de ARN basal; este, no obstante, inhibió la estimulación por la insulina. Este último efecto probablemente fue mediado por un incremento en los niveles de AMP cíclico, como se ha encontrado en otros tipos de células. La estaurosporina, un inhibidor de la proteína kinasa-C, también bloqueó los efectos de la insulina sobre la síntesis de RNA