Primary adenocarcinoma of the cervix. A clinicopathologic study of prognostic variables in 55 cases.

Fifty-five primary invasive adenocarcinomas of the cervix, presenting over a 20-year period, were retrospectively studied with particular reference to clinical and pathologic prognostic indicators. Mean age at presentation was 54.5 years (range 27-91), with an age distribution showing two incidence peaks of equal size in the 31-35 and 61-65 groups, respectively. Twenty-four patients died of the disease and the remaining patients were followed up for a mean of 4.9 years (range 1-17). The results were analyzed using a Cox's proportional hazards survival model. The independent good prognostic indicators were early tumor stage (P < 0.001). and young patient age (P < 0.001) at presentation. The presence within the tumor of numerous intraepithelial lymphocytes and the concomitant occurrence of background in situ carcinoma were also good prognostic indicators, although these did not operate independently of stage and age. Histologic tumor subtype and grade of tumor differentiation were not significant prognostic factors. Treatment did not have a significant independent effect on survival. No definite conclusions could be drawn about the effect of oral contraceptives on the disease process.

Uterine balloon therapy for menorrhagia: a feasibility study of its use in the community setting.

OBJECTIVES: To determine whether uterine balloon therapy (UBT) for menorrhagia can be performed safely in the community setting, obviating the need for hospital admission or general anaesthesia. DESIGN: Prospective case studies of 20 women undergoing Thermachoice endometrial ablation for menorrhagia. SETTING: Glasgow Centre for Family Planning and Reproductive Health Care, Greater Glasgow Primary Care NHS Trust, Glasgow, UK. PARTICIPANTS: Twenty women with menorrhagia unresponsive to medical therapy. MAIN OUTCOME MEASURES: Pain levels experienced by women during the procedure, measured by visual analogue scores and analgesia requirements postoperatively. RESULTS: Pain scores were in the range 0.1-6.6 (median 1.1) for outpatient hysteroscopy, compared to 0.1-9.8 (median 4.0) for uterine balloon therapy. No procedure was abandoned due to pain. CONCLUSION: UBT performed under local anaesthetic is tolerated well by patients. It is an effective treatment for menorrhagia, which is safe and easy to perform in the community setting.

Public and private collaboration in establishing a young person's sexual health clinic in a commercial setting.

OBJECTIVE: To define the key factors and constraints in public-private sector collaboration in establishing and delivering a young person's sexual health clinic within an existing commercial establishment. CONSULTATION, PLANNING AND IMPLEMENTATION PHASES: Consultations were held between the Health Promotion Department, family planning and commercial outlets, resulting in the establishment of the UK's first sexual health service within commercial premises. Once the clinic had been operational for 6 months, a single researcher carried out semi-structured interviews with 13 staff representing all levels within the partner organisations. POST-IMPLEMENTATION INTERVIEWS: There was agreement by all interviewees on the objectives of the clinic. The problems encountered during the establishment of the service were with the legislation pertaining to pharmacies and the adverse press coverage of a minority public view of the provision of sexual health services to young people. No respondent identified conflict between the aims of the clinic and the strategic objectives of their organisation. RECOMMENDATIONS: Common aims are imperative for successful interagency working. Wider initial consultations may have helped to identify potential problems and confirm common aims at an earlier stage of the development of the project. The involvement of senior management may also have improved the smooth running of the project.

Evaluation of a young person's sexual health service in a commercial setting.

OBJECTIVE: To determine the acceptability and accessibility of a sexual health service for young people in a city centre pharmacy. DESIGN: Prospective qualitative survey of clients attending a new sexual health service, including client characteristics and semi-structured interviews. PARTICIPANTS: Clients attending the service between January and May 1999. MAIN OUTCOME MEASURES: Social demographics, reasons for attendance and consultation outcomes for clients together with their views of the service. RESULTS: A total of 98 clients (average of three clients per session) attended from January to May 1999, ranging from 14 to 39 years of age. Clients came from 41 postcode areas of the city (which has over 80 postcode areas) and neighbouring districts, covering all social strata. Only four clients had never been sexually active; 53 clients attended for emergency contraception, with 26 attending for hormonal contraception. A total of 93% of those asked were either satisfied or very satisfied with the opening times. All clients were satisfied or very satisfied with the clinic location. CONCLUSIONS: The setting of a sexual health service for young people in a city centre pharmacy allows access from a wide area. The timing and location of the service were the most commonly quoted reasons for attendance. All clients were asked to participate in a semi-structured interview, unless the interviewer was already engaged; results were obtained for 66 clients (67% of attendees).

Symptomatic and incidental mammary duct ectasia.

The histology obtained from 1256 female patients undergoing breast surgery was reviewed. Mammary duct ectasia was noted in 51 (4.2%) patients who had associated symptoms and in 103 (8.1%) patients where duct ectasia was recognized as an incidental finding. The syndrome is defined by primary (nipple change or sepsis) and secondary (pain and lump) symptoms. Formal duct excision gives good results for symptomatic duct ectasia. It is postulated that many women have nonsymptomatic mammary duct ectasia. Secondary infection gives rise to nipple change, lump and pain. In the severe form abscess and fistula formation occurs which necessitates repeated surgical treatment, and rarely mastectomy.

Induction of labour in the presence of ruptured membranes with prostaglandin E2 gel.

The study shows the safety and the efficacy of labour induction with prostaglandin E2 gel. By combining an initially conservative approach with later induction by PGE2 a vaginal delivery rate of 96.8% was achieved.

Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening.

OBJECTIVES: To investigate the psychosocial impact for women of a diagnosis of Chlamydia trachomatis and discuss the implications for the proposed UK chlamydia screening programme. DESIGN: Qualitative study with semistructured interviews. Interview transcripts analysed to identify recurrent themes. PARTICIPANTS: Seventeen women with a current or recent diagnosis of chlamydia. SETTING: A family planning clinic and a genitourinary medicine clinic in Glasgow. RESULTS: Three themes were identified: perceptions of stigma associated with sexually transmitted infection, uncertainty about reproductive health after diagnosis, and anxieties regarding partner's reaction to diagnosis. Most women had not previously perceived sexually transmitted infections as personally relevant; this was a function of stereotypical beliefs about who was "at risk" of sexually transmitted infection. These beliefs were pervasive and negatively affected reactions to diagnosis and produced anxiety about disclosure of the condition to others (particularly sexual partners) and future reproductive morbidity. This anxiety, given the uncertain natural history of chlamydia, may prove difficult to dispel. CONCLUSIONS: There are three primary areas of concern for women after a diagnosis of chlamydia which need to be examined in the proposed screening programme. Information provided should normalise and destigmatise chlamydial infection and positively promote genitourinary medicine services. Support services should be available because notification of partner can cause anxiety. Uncertainty about future reproductive morbidity may be inevitable; staff providing screening will require guidance in providing advice under such conditions.

Use of a staff administered structured questionnaire to identify relevant life-style issues and social-health determinants in a sexual and reproductive health service.

OBJECTIVE: To evaluate a staff-administered questionnaire to identify life-style issues and social-health determinants. DESIGN: Structured questionnaire administered by a health professional after dealing with the primary reason for attendance. SETTING: Community-based UK sexual and reproductive health service. POPULATION: First 1329 selected clinic patients comprising 1018 women attending Family Planning and 161 women plus 150 men attending Genitourinary Medicine; 47% were aged under 25. MAIN OUTCOME MEASURES: Identification of relevant health-risk taking, life-style issues, and unaddressed health concerns. Participants were offered appropriate support, information and referrals. RESULTS: Two hundred and sixty-four (23%) of the Family Planning women and 83 (52%) of the Genitourinary Medicine women [plus 103 (69%) of the men] reported two or more sexual partners in the last year. A third of participants denied regular condom use. Six per cent of women and 5% of men questioned had previously been forced to have sex. Eleven per cent of men admitted to having paid for sex and 9% of women disclosed physical assault (one-quarter in the home). Eight per cent of women and 7% of men had unresolved issues relating to previous miscarriage, termination, or stillbirth. CONCLUSIONS: It is possible to identify relevant life-style issues and social determinants of health during routine practice using a staff-administered questionnaire. The resulting information may not otherwise have been disclosed and may impact significantly on health and care delivery. The information collected provides opportunities for both individuals and service planners to address wider health needs.

Are computers of any use in a family planning clinic?

PIP: The Family Planning Directorate in Glasgow received trust financing at the end of the financial year 1994-95 to purchase computer hardware and software to update the family planning appointment system at the central clinic and to introduce electronic clinical records for clients attending the clinic. The system was expected to improve the efficiency of clinic administration and raise standards in the clinical areas of management, communication, audit, and information. This paper discusses the use of information technology (IT) within the clinic and considers how far the objectives have been achieved. Over the years, the system has embedded itself in the culture of the central clinic. In the clients¿ viewpoints, taken in 1997, the majority thought that the computers were necessary and were not more time-consuming during the clinical consultation. In addition, most clients thought enough care was taken with confidentiality of their personal records and they were happy with the personal details held on file about them. In the context of meeting initial objectives, the overall observation is that the IT system provides support to many aspects of administration and clinical care, improves the standard of record keeping, and increases the consultation time.^ieng

Outcomes in action: how relevant to clinical practice are health outcome measures such as the rate of unintended pregnancies in young teenagers?

Scientific evidence shows that correct contraceptive use will prevent unintended pregnancy and the provision of contraceptives is recognized as a cost-effective intervention. This could encourage health authorities to keep investing more resources in family planning until the target rate of unintended pregnancies is reached, but if this was the only approach taken, the target rate never would be reached. Clinicians and their public health colleagues need to examine their practice in the light of all available evidence. Once desirable changes of practice are identified, local relevant health outcome measures need to be used to assess the effectiveness of the chosen approaches. Blunt factors, such as the unintended pregnancy rate in a city or region, will not suffice to inform individuals whether they are contributing to the overall picture.

The patient's perspective of commercial clinical trials.

All drugs are tested on a large number of volunteers and patients prior to licensing by the Medical Controls Agency. Patients are often recruited while attending National Health Service (NHS) clinics. This paper reports a survey designed to ascertain patients' views of the desirability of such trials being undertaken in the NHS. Patients have a sophisticated understanding of who benefits from commercial clinical trials. Nonetheless, those taking part in trials did feel the process had some personal benefit. The patients overwhelmingly supported such clinical trials being undertaken in the NHS and felt that they were likely to raise the overall quality of care. The results can be used to influence the design of future patient information leaflets and the trial process.

Pill knowledge amongst oral contraceptive users in family planning clinics in Scotland: facts, myths and fantasies.

OBJECTIVES: To document the extent of understanding about the combined pill amongst oral contraceptive users in Scotland. METHOD: A questionnaire was distributed to 2700 pill users in Scottish family planning clinics prior to their consultation with a clinician for a repeat prescription. RESULTS: Knowledge was patchy and usually incomplete in any given area. CONCLUSION: Counselling and teaching about oral contraceptives are important parts of the clinical consultation; even if the user appears knowledgeable about their contraceptive method, there are likely to be some areas where their knowledge could be improved.

Nationwide audit of pill knowledge amongst family planning users in Scotland.

OBJECTIVES: The primary objective of this study was to estimate knowledge about oral contraceptives amongst oral contraceptive users within family planning clinics in Scotland and to ascertain if this was due to clinicians not attempting to convey certain information or to a lack of understanding of teaching. METHOD: This was a criterion-based audit using three separate questionnaires to estimate the agreement of senior staff with criteria set by a multi-disciplinary expert panel, actual routine clinical practice and user knowledge. RESULTS: Senior clinical staff within family planning clinics in Scotland agreed with 12 out of 15 criteria set by a multidisciplinary panel in over 85% of cases. For six out of 15 criteria, there was a discrepancy of more than 30% in what clinicians did in practice compared to what senior staff thought they ought to do. For a further two criteria, there was a deficiency of over 30% between the number of clients who understood the criteria and the number of clients the clinicians thought they had taught. Most importantly, these latter criteria included the rules for safe and effective pill taking. CONCLUSION: An improvement in user knowledge is required to achieve effective and reliable use of oral contraceptives. Methods of doing this, such as staff and client prompts, should be further explored.

Analysis of pill knowledge amongst oral contraceptive users in Scotland according to client characteristics.

OBJECTIVES: The primary objective of this study was to investigate the relationship between various client characteristics and knowledge of oral contraceptives amongst pill users. METHOD: This was a subanalysis of the data from the national audit of Scottish family planning clinics. RESULTS: There were significant differences in knowledge about many different criteria according to the characteristics of the client group. Low educational attainment, unemployment and more rural residence produced greater significant differences in contraception knowledge than social deprivation according to postcode (zipcode). Age and duration of use affected different criteria to varying degrees, but teenagers scored relatively poorly compared to the general population and knowledge did not significantly improve overall with duration of use. CONCLUSION: Client characteristics do affect levels of pill knowledge. Clinicians must reflect on how to communicate more effectively with all types of pill users. They should take the opportunity of clinic visits for repeat pill prescriptions to improve knowledge levels.

Is evacuation of the uterus necessary after middle trimester abortion?

PIP: To assess the importance of uterine evacuation after prostaglandin- induced mid-trimester abortion, the results of management with and without this procedure were compared. The gestational age of study participants was 15 weeks (range, 12-18 weeks). The procedure involved insertion of a Foley catheter through the cervical canal and infusion of a solution of prostaglandin E2 into the extra-amniotic space. Complete abortion was considered to have occurred if the placenta and products appeared intact, the uterus was well contracted, and there was no excessive bleeding. If complete abortion has occurred, the patients were randomly assigned to have uterine evacuation under general anesthesia (9 patients) or no uterine evacuation (22 patients). The 37 patients who were diagnosed clinically has having incomplete abortion also underwent uterine evacuation. Women who had evacuation of the uterus performed after clinically complete abortion were more likely to visit their general practitioner (4.9 cases) and to require antibiotics (4 cases) than those who did not undergo evacuation (4/22 and 4 cases, respectively). In 1 of the 9 cases where complete abortion was judged to have occurred, a moderate amount of retained placental tissue was found. However, the possible complications of uterine evacuation after an apparently complete abortion--the need for general anesthesia, and the danger of introducing infection into the uterine cavity--suggest that this procedure is not a advisable component of the management of prostaglandin-induced mid-trimester abortions.^ieng

Oral contraceptives and thrombosis.

PIP: Recent studies have identified an increased risk of venous thromboembolism associated with use of third-generation oral contraceptives (OCs). Use of these newer formulations has been estimated to cause an excess of 10 deaths/year in the UK. The possibility has been raised, however, that prescribing bias and confounding by duration of OC use and other personal risk factors accounts for the difference in the risk of venous thromboembolism between second- and third-generation OCs. Other studies have identified an increased risk of myocardial infarction and stroke in OC users, including users of low-dose formulations, but this risk is almost exclusively limited to older women who smoke or have other cardiovascular risk factors. The interpretation of all such studies on OC side effects should take into account that the absolute risk of an adverse thrombotic event while taking OCs is small. This risk appears to be affected far more by factors such as smoking, age, hypertension, and familial disorders than the type of progestagen contained in the OC.^ieng

A comparison of the efficacy of gemeprost vaginal pessaries and extra-amniotic prostaglandin E2 gel in the induction of middle trimester abortion.

In an open random allocation trial of 50 patients, 25 had abortion induced vaginally with gemeprost (16.16-dimethyl-trans-delta squared- prostaglandin E1 methyl ester; PGE) 1 mg pessaries inserted into the posterior fornix. The remainder received 7.5 mg PGE2 in a gel inserted into the extraamniotic space. Following the administration of 2 doses of PGE2 gel, abortion was achieved in 100% of the cases within 24 hours, whereas the group treated with a maximum of 3 gemeprost pessaries administered at 3-hour intervals only achieved abortion within 24 hours in 76% of the cases. 3 doses of gemeprost pessaries are the cost equivalent of 2 doses of PGE2 gel.