Inherited pulmonary cylindromas: extending the phenotype of CYLD mutation carriers.

BACKGROUND: Germline mutations in the tumour suppressor gene CYLD are recognized to be associated with the development of multiple cutaneous cylindromas. We encountered such a patient who presented with breathlessness because of multiple pulmonary cylindromas. OBJECTIVES: To search for clinical and radiological features of multiple pulmonary cylindromas in a cohort of 16 patients with CYLD mutations. METHODS: A retrospective case-note review was carried out in a tertiary dermatogenetics clinic where CYLD mutation carriers are reviewed on an annual basis. In-depth investigation was carried out for patients with pulmonary tumours. RESULTS: Four patients had radiological imaging of their lungs, of which two had multiple pulmonary cylindromas that were confirmed histologically. Serial computed tomography monitoring allowed for pre-emptive endobronchial laser ablation, preventing major airway obstruction and pulmonary collapse. CONCLUSIONS: Pulmonary cylindromas are an unrecognized, but infrequently symptomatic, aspect of the phenotype in these patients that can have implications for patient care. They should be considered in patients with a high tumour burden that present with respiratory symptoms, and where appropriate, monitored with serial imaging.

The epidemiology of HIV infection in Zambia.

Population surveys of health and fertility are an important source of information about demographic trends and their likely impact on the HIV/AIDS epidemic. In contrast to groups sampled at health facilities they can provide nationally and regionally representative estimates of a range of variables. Data on HIV-sero-status were collected in the 2001 Zambia Demographic and Health Survey (ZDHS) and made available in a separate data file in which HIV status was linked to a very limited set of demographic variables. We utilized this data set to examine associations between HIV prevalence, gender, age and geographical location. We applied the generalized geo-additive semi-parametric model as an alternative to the common linear model, in the context of analyzing the prevalence of HIV infection. This model enabled us to account for spatial auto-correlation, non-linear, location effects on the prevalence of HIV infection at the disaggregated provincial level (nine provinces) and assess temporal and geographical variation in the prevalence of HIV infection, while simultaneously controlling for important risk factors. Of the overall sample of 3950, 54% was female. The overall HIV-positivity rate was 565 (14.3%). The mean age at HIV diagnosis for male was 30.3 (SD=11.2) and 27.7 (SD=9.3) for female respectively. Lusaka and Copperbelt have the first and second highest prevalence of AIDS/HIV (marginal odds ratios of 3.24 and 2.88, respectively) but when the younger age of the urban population and the spatial auto-correlation was taken into account, Lusaka and Copperbelt were no longer among the areas with the highest prevalence. Non-linear effects of age at HIV diagnosis are also discussed and the importance of spatial residual effects and control of confounders on the prevalence of HIV infection. The study was conducted to assess the spatial pattern and the effect of confounding risk factors on AIDS/HIV prevalence and to develop a means of adjusting estimates of AIDS/HIV prevalence on the important risk factors. Controlling for important risk factors, such as geographical location (spatial auto-correlation), age structure of the population and gender, gave estimates of prevalence that are statistically robust. Researchers should be encouraged to use all available information in the data to account for important risk factors when reporting AIDS/HIV prevalence. Where this is not possible, correction factors should be applied, particularly where estimates of AIDS/HIV prevalence are pooled in systematic reviews. Our maps can be used for policy planning and management of AIDS/HIV in Zambia.

Determinants of post-partum maternal mortality at Queen Elizabeth Central Hospital, Blantyre, Malawi: a case-control study 2001-2002.

The aim of this research is to identify the clinical, demographic and service-based determinants of postpartum maternal mortality within Queen Elizabeth Central Hospital, Blantyre, Malawi, during 2001 and 2002. The study uses a case-control design using all postpartum maternal deaths in 2001 and 2002 as cases, with analysis conducted using conditional logistic regression. The results indicate that the mothers' reason for admission into hospital and the outcome of the birth were significantly related to maternal death when analysing all potential explanatory variables in one model. A group of high-risk mothers can be identified using these factors. If these criteria were applied as a predictive tool in the clinical setting the resulting sensitivity and specificity would be over 85%. Identification within the hospital setting of a group of very high-risk mothers in whom serious complications are aggressively managed in a coordinated way across the medical specialties may reduce maternal mortality.

Doctors and the chronic pelvic pain patient.

Many women with chronic pelvic pain (CPP) turn out not to have any identifiable pathology despite having undergone multiple investigations. There is no consensus as to the best management for women in this group. Although a multidisciplinary approach to diagnosis and care has been advocated as best practice, it is costly and not practical in most units in the United Kingdom, and many other countries. Clinicians need to be aware of the importance of attitude and medical consultation as factors influencing patients' outcome from investigation and treatment. While consulting styles reflect the individual personality of the doctor, we need to be aware of our own underlying attitudes and how these might enter into the dynamics of the consultation. Some patients may want to have open, non-directive consultations, some more directive consultation styles. It is, therefore, essential for the physicians to identify patients' expectations or preferences and then try to meet them, in order to attain "concordance" in communication. In this chapter, we will examine some studies that relate to the doctor-patient relationship in women with CPP.

Chronic pelvic pain: aetiology and therapy.

Chronic pelvic pain (CPP) is a common condition in women and rates of consultation for CPP in general practice are similar to those for asthma and migraine. US and UK population-based studies, together with data from UK hospital settings demonstrate a substantial impact of CPP on health-related quality of life. In this review, we will examine the current evidence on the aetiology and management of CPP, focussing on the randomised controlled trials (RCTs) that are available to date. CPP is a heterogeneous condition and causation is often unclear. There are associations with specific pathological processes but a barrier to understanding is that many studies have data that are not comparable. In the community setting, as many as 60% of women with CPP have not received a specific diagnosis and up to 20% have not undergone any investigation. The factor most commonly associated with CPP in the community is irritable bowel syndrome, although in a tertiary setting with laparoscopy, pathology associated with CPP in ascending order of frequency is endometriosis (33%), adhesions (24%) and 'no pathology' (35%). Current RCT evidence provides some support for the use of ultrasound scanning as an aid to counselling and reassurance, progestogen (medroxyprogesterone acetate) or goserelin for pelvic congestion and a multidisciplinary approach to assessment and treatment. Adhesiolysis is not shown to be of benefit other than in women with extensive adhesions. While studied in relation to dysmenorrhoea rather than CPP, the short term results for presacral neurectomy (PSN) and laparoscopic utero-sacral nerve ablation (LUNA) seem to be similar, although PSN has better results in the long term. Selective serotonin reuptake inhibitor (SSRI) antidepressants have not been shown to be of benefit in CPP. Most of these conclusions are based on the outcome of single randomised trials and therefore need replication.

Lasting impressions: influence of the initial hospital consultation for chronic pelvic pain on dimensions of patient satisfaction at follow-up.

OBJECTIVE: Chronic pelvic pain (CPP) is a common condition in women, and care experiences are distressing and unsatisfactory for many. Research suggests that elements of the initial hospital consultation influence clinical outcome. This study aimed to identify the dimensions through which initial consultations were subsequently recalled at follow-up. METHOD: A questionnaire study of 100 women, 6 months following a hospital gynaecology consultation for CPP, was conducted. Measures of pain and ratings of the medical consultation were completed at initial consultation and at follow-up. RESULTS: Follow-up questionnaire items loaded to constructs of "affect", "expectation", and "cognition", forming three subscales. Patients' initial ratings of the consultation and scores on all three subscales measured at follow-up were correlated, remaining significant for both affect and expectation after controlling for current pain status. CONCLUSION: Doctor's affect and the appropriateness of information to meet expectations are important influences on experiences of care and contribute to the long-term therapeutic element of the consultation.

Maternal and social factors associated with abortion in India: a population-based study.

CONTEXT: A cultural preference for sons may be a factor driving recourse to abortion in India, as women carrying female fetuses may decide to terminate their pregnancies. To assess this hypothesis, more information on the incidence of abortion, and on maternal and social correlates of the procedure, is needed. METHODS: Birth order-specific abortion ratios were calculated using the birth histories of 90,303 ever-married women aged 15-49 who participated in India's 1998-1999 National Family Health Survey. For the first four births, the association between abortion and various maternal and social variables, including the sex of the respondent's last child, was assessed using logistic regression. RESULTS: The overall abortion ratio was 17.0 per 1,000 pregnancies. The ratio increased from 5.3 per 1,000 pregnancies for first-order births to 25.8 per 1,000 pregnancies for third-order births and then declined. The strongest predictor of abortion was maternal education: Women with at least a primary education were more likely than those with no education to have had an abortion (odds ratios, 1.9-6.7). Rural residence was associated with a reduced likelihood of abortion (0.6). There was no association between the sex of a woman's previous child and the odds that she subsequently had an abortion. CONCLUSION: At the national level, it is likely that unintended pregnancy, rather than the sex of the previous child, underlies demand for abortion in India. Rising educational attainment among women may lead to an increase in the demand for abortion.

Birth intervals and injectable contraception in sub-Saharan Africa.

OBJECTIVE: The interval between births is associated with child survival in the developing world. We aimed to investigate associations between use of depot-medroxyprogesterone acetate and other reversible contraception and short birth intervals in sub-Saharan Africa. METHODS: Data from successive Demographic and Health Surveys undertaken in nine African countries were analyzed. Logistic regression was used to explain changes in the proportion of short birth intervals in four countries with relatively high use of reversible contraception. FINDINGS: The overall odds ratio for the trend was 0.90 (95% CI 0.84 to 0.95) and this was unaffected by adjusting for the other variables. The odds of a short birth interval were reduced by exclusive breastfeeding (OR 0.67, 95% CI 0.58 to 0.78) and increased by use of injectable contraception (OR 1.23, 95% CI 1.11 to 1.38). CONCLUSION: The proportion of short birth intervals has changed little over the last decade in a context of very low use of the intrauterine device. Widespread adoption of injectable contraception is associated with greater odds of a short birth interval, thus not contributing favorable conditions for improved child health.

Substance P: endothelial localization and pharmacology in the human ovarian vein.

OBJECTIVE: To investigate the possible role of substance P as an endothelial factor in the local regulation of vascular tone in the human ovarian vein. METHODS: We performed immunolocalization of substance P in human ovarian venous endothelium in situ and in culture, and observed responses to substance P in preconstricted ring preparations of human ovarian vein in the presence of either the prostaglandin synthesis inhibitor indomethacin or the inhibitor of nitric oxide synthesis L-nitro arginine methyl ester (L-NAME), with and without luminal rubbing. RESULTS: Substance P was localized in a subpopulation of ovarian vein endothelial cells. Maximal relaxation induced by substance P was not significantly affected by indomethacin (10 mumol/L), but was reduced from 58.7% (95% confidence interval [CI] 41.3-76.1) in control experiments to 24.7% (95% CI 18.3-31.1) after luminal rubbing and to 32.3% (95% CI 19.8-44.8) after exposure to L-NAME (0.1 mmol/L) (P = .001). CONCLUSION: The localization of substance P in ovarian vein endothelium together with vasodilator effects mediated partially via the endothelium suggests that the peptide has a role in the local control of vascular tone in this vessel.

Antenatal care: provision and inequality in rural north India.

The objectives of this paper are to examine factors associated with use of antenatal care in rural areas of north India, to investigate access to specific critical components of care and to study differences in the pattern of services received via health facilities versus home visits. We used the 1998-1999 Indian National Family Health Survey of ever-married women in the reproductive age group and analysed data from the states of Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh (n = 11,369). Overall, about three-fifths of rural women did not receive any antenatal check-up during their last pregnancy. Services actually received were predominantly provision of tetanus toxoid vaccination and supply of iron and folic acid tablets. Only about 13% of pregnant women had their blood pressure checked and a blood test done at least once. Women visited by health workers received fewer services compared to women who visited a health facility. Home visits were biased towards households with a better standard of living. There was significant under-utilisation of nurse/midwives in the provision of antenatal services and doctors were often the lead providers. The average number of antenatal visits reported in this study was 2.4 and most visits were in the second trimester. Higher social and economic status was associated with increased chances of receiving an antenatal check-up, and of receiving specific components including blood pressure measurement, a blood test and urine testing but not the obstetric physical examination, which was however linked to ever-use of family planning and the education of women and their husbands. Thus, pregnant women from poor and uneducated backgrounds with at least one child were the least likely to receive antenatal check-ups and services in the four large north Indian states. Basic antenatal care components are effective means to prevent a range of pregnancy complications and reduce maternal mortality. The findings indicate substantial limitations of the health services in overcoming socio-economic and cultural barriers to access.

Pelvic congestion in women: evaluation with transvaginal ultrasound and observation of venous pharmacology.

Fourteen women with chronic pelvic pain due to congestion underwent transvaginal ultrasound scanning to observe changes in the diameters of dilated pelvic veins. Spontaneous fluctuations were observed, and intravenous dihydroergotamine resulted in a consistent venoconstrictor response (p = 0.0021) during 20 min observation. Transvaginal ultrasound is useful for imaging dilated pelvic veins and for the study of venous pharmacology.

Interventions for treating chronic pelvic pain in women.

BACKGROUND: Chronic pelvic pain is common in women in the reproductive age group and it causes disability and distress and results in significant costs to health services. The pathogenesis of chronic pelvic pain is poorly understood. Often, investigation by laparoscopy reveals no obvious cause for pain. There are several possible explanations for chronic pelvic pain including undetected irritable bowel syndrome, the vascular hypothesis where pain is thought to arise from dilated pelvic veins in which blood flow is markedly reduced and altered spinal cord and brain processing of stimuli in women with chronic pelvic pain. As the pathophysiology of chronic pelvic pain is not well understood, its treatment is often unsatisfactory and limited to symptom relief. Currently, the main approaches to treatment include counseling or psychotherapy, attempting to provide reassurance using laparoscopy to exclude serious pathology, progestogen therapy such as medroxyprogesterone acetate, and surgery to interrupt nerve pathways. OBJECTIVES: We aimed to identify and review treatments for chronic pelvic pain in women in the reproductive years. The review included studies of patients with a diagnosis of pelvic congestion syndrome or adhesions but excluded those with pain known to be caused by i) endometriosis, ii) primary dysmenorrhoea (period pain), iii) pain due to active chronic pelvic inflammatory disease, or iv) irritable bowel syndrome. SEARCH STRATEGY: The search strategy adopted by the Cochrane Menstrual Disorders and Subfertility Group was used. SELECTION CRITERIA: Randomised controlled trials (RCTs) with women who had chronic pelvic pain, excluding endometriosis, primary dysmenorrhoea, pain due to chronic pelvic inflammatory disease, or irritable bowel syndrome. The reviewers were prepared to consider studies of any intervention including lifestyle, physical, medical, surgical and psychological treatments. Outcome measures were pain rating scales, quality of life measures, economic analyses and adverse events. DATA COLLECTION AND ANALYSIS: For each included trial, information was collected regarding the method of randomisation, allocation concealment, blinding, whether an intention to treat analysis could possibly be performed and relevant interventions and outcomes (see previous sections). Data were extracted independently by the two reviewers, using forms designed according to the Cochrane guidelines. MAIN RESULTS: Nine studies were identified of which five were of good methodological quality. Two studies were reported in a brief abstract only and were excluded. Progestogen (Medroxyprogesterone acetate) was associated with a reduction of pain during treatment. Counselling supported by ultrasound scanning was associated with reduced pain and improvement in mood. A multidisciplinary approach was beneficial for some outcome measures. Adhesiolysis was not associated with an improved outcome apart from where adhesions were severe. Sertraline was not beneficial. REVIEWER'S CONCLUSIONS: Further studies to confirm these observations are needed, together with full reporting of those studies which have been undertaken. Given the prevalence and health care costs associated with chronic pelvic pain in women, randomised controlled trials of other medical, surgical and psychological interventions are urgently required.

Interventions for treating chronic pelvic pain in women.

BACKGROUND: Chronic pelvic pain is common in women in the reproductive age group and it causes disability and distress and results in significant costs to health services. The pathogenesis of chronic pelvic pain is poorly understood. Often, investigation by laparoscopy reveals no obvious cause for pain. There are several possible explanations for chronic pelvic pain including undetected irritable bowel syndrome, the vascular hypothesis where pain is thought to arise from dilated pelvic veins in which blood flow is markedly reduced and altered spinal cord and brain processing of stimuli in women with chronic pelvic pain. As the pathophysiology of chronic pelvic pain is not well understood, its treatment is often unsatisfactory and limited to symptom relief. Currently, the main approaches to treatment include counselling or psychotherapy, attempting to provide reassurance using laparoscopy to exclude serious pathology, progestogen therapy such as medroxyprogesterone acetate, and surgery to interrupt nerve pathways. OBJECTIVES: We aimed to identify and review treatments for chronic pelvic pain in women in the reproductive years. The review included studies of patients with a diagnosis of pelvic congestion syndrome but excluded those with pain known to be caused by i) endometriosis, ii) primary dysmenorrhoea (period pain), iii) pain due to chronic pelvic inflammatory disease, or iv) irritable bowel syndrome. SEARCH STRATEGY: The search strategy adopted by the Cochrane Menstrual Disorders and Subfertility Group was used. SELECTION CRITERIA: Randomised controlled trials (RCTs) with women who had chronic pelvic pain, excluding endometriosis, primary dysmenorrhoea, pain due to chronic pelvic inflammatory disease, or irritable bowel syndrome. The reviewers were prepared to consider studies of any intervention including lifestyle, physical, medical, surgical and psychological treatments. Outcome measures were pain rating scales, quality of life measures, economic analyses and adverse events. DATA COLLECTION AND ANALYSIS: For each included trial, information was collected regarding the method of randomisation, allocation concealment, blinding, whether an intention to treat analysis could possibly be performed and relevant interventions and outcomes (see previous sections). Data were extracted independently by the two reviewers, using forms designed according to the Cochrane guidelines. MAIN RESULTS: Seven studies were identified of which four were of good methodological quality. One study was reported in a brief abstract only and was excluded. Progestagen (Medroxyprogesterone acetate) was associated with a reduction of pain during treatment. Counselling supported by ultrasound scanning was associated with reduced pain and improvement in mood. A multidisciplinary approach was beneficial for some outcome measures. Adhesiolysis was not associated with an improved outcome apart from where adhesions were severe. REVIEWER'S CONCLUSIONS: Further studies to confirm these observations are needed, together with full reporting of those studies which have been undertaken. Given the prevalence and health care costs associated with chronic pelvic pain in women, randomised controlled trials of other medical, surgical and psychological interventions are urgently required.

Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea.

BACKGROUND: Dysmenorrhoea is the occurrence of painful menstrual cramps of the uterus. Medical therapy for dysmenorrhoea commonly consists of nonsteroidal anti-inflammatory drugs or the oral contraceptive pill both of which work by reducing myometrial (uterine muscle) activity. However, these treatments are accompanied by a number of side effects, making an effective non-pharmacological method of treating dysmenorrhoea of potential value. Transcutaneous electrical nerve stimulation (TENS) is a treatment that has been shown to be effective for pain relief in a variety of conditions. Electrodes are placed on the skin and electric current applied at different pulse rates (frequencies) and intensities is used to stimulate these areas so as to provide pain relief. In dysmenorrhoea. TENS is thought to work by alteration of the body's ability to receive or perceive pain signals rather than by having a direct effect on the uterine contractions. Acupuncture may also be indicated as a useful, non-pharmacological method for treating dysmenorrhoea. Acupuncture is thought to excite receptors or nerve fibres which, through a complicated interaction with mediators such as serotonin and endorphins, blocks pain impulses. Acupuncture typically involves penetration of the skin by fine, solid metallic needles, which are manipulated manually or by electrical stimulation. OBJECTIVES: To determine the effectiveness of high and low frequency transcutaneous electrical nerve stimulation and acupuncture when compared to each other, placebo, no treatment, or medical treatment for primary dysmenorrhoea. SEARCH STRATEGY: Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group Register of controlled trials, CCTR (Cochrane Library Issue 3, 2001), MEDLINE, EMBASE, CINAHL, Bio extracts, PsycLIT and SPORTDiscus were performed in August 2001 to identify relevant randomised controlled trials (RCTs). The Cochrane Complementary Medicine Field's Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the UK National Research Register, the Clinical Trial Register and the citation lists of review articles and included trials. In most cases, the first or corresponding author of each included trial was contacted for additional information. SELECTION CRITERIA: The inclusion criteria were randomised controlled trials of transcutaneous electrical nerve stimulation and acupuncture that compared these treatments to each other, placebo, no treatment, or medical treatment for primary dysmenorrhoea. Exclusion criteria were: mild, infrequent or secondary dysmenorrhoea and dysmenorrhoea associated with an IUD. DATA COLLECTION AND ANALYSIS: Nine RCTs were identified that fulfilled the inclusion criteria for this review, seven involving TENS, one acupuncture, and one both treatments. Quality assessment and data extraction were performed independently by two reviewers. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis was reported as descriptive data and was also included for discussion. The outcome measures were pain relief (dichotomous, visual analogue scales, descriptive), adverse effects, use of analgesics additional to treatment and absence from work or school. MAIN RESULTS: Overall high frequency TENS was shown to be more effective for pain relief than placebo TENS. Low frequency TENS was found to be no more effective in reducing pain than placebo TENS. There were conflicting results regarding whether high frequency TENS is more effective than low frequency TENS. One small trial showed acupuncture to be significantly more effective for pain relief than both placebo acupuncture and two no treatment control groups. REVIEWER'S CONCLUSIONS: High frequency TENS was found to be effective for the treatment of dysmenorrhoea by a number of small trials. The minor adverse effects reported in one trial requires further investigation. There is insufficient evidence to determine the effectiveness of low frequency TENS in reducing dysmenorrhoea. There is also insufficient evidence to determine the effectiveness of acupuncture in reducing dysmenorrhoea, however a single small but methodologically sound trial of acupuncture suggests benefit for this modality.

Risk factors for major obstetric haemorrhage.

The factors associated with major obstetric haemorrhage were analyzed using data relating to 37,497 women delivered in 1988 in National Health Service maternity units in the North West Thames Region, UK. Four hundred ninety-eight cases (1.33%) were complicated by haemorrhage of 1000 ml or more. Intrinsic factors associated with significant risk ratios (99% confidence intervals) included placental abruption 12.6 (7.61-20.9), placenta praevia 13.1 (7.47-23.0), multiple pregnancy 4.46 (3.01-6.61) and obesity 1.64 (1.24-2.17), but not high parity. Significant risk factors related to obstetric management and delivery included retained placenta 5.15 (3.36-7.87), induced labour 2.22 (1.67-2.96), episiotomy 2.06 (1.36-3.11) and birthweight 4 kg or more 1.90 (1.38 to 2.60). Among the 59 women who lost 1000 ml or more in association with a spontaneous vaginal delivery with an intact perineum, significant risk ratios (99% confidence intervals) were retained placenta 13.7 (5.92-31.8) and induced labour 2.35 (1.11-4.98). These data provide a more comprehensive assessment of risk factors for potentially life threatening haemorrhage in British obstetric practice than is possible using maternal mortality statistics. The hazards of well known factors such as multiple pregnancy, abruption, placenta praevia and caesarean delivery were confirmed but attention is drawn to the potential risk of haemorrhage associated with obesity or a large baby and to that associated with retained placenta in women classified as 'low risk'.

Release of vasoactive agents from the isolated perfused human ovary.

OBJECTIVE: To investigate local vascular control in the isolated perfused premenopausal human ovary by measuring flow-induced release of vasoactive substances. DESIGN: Release of adenosine 5' triphosphate (ATP), substance P (SP), endothelin (ET), and vasopressin (AVP) from the ovarian vascular endothelium was estimated in perfusate under basal conditions and during two periods of increased flow. MAIN OUTCOME MEASURES: Vascular resistance; ATP, SP, ET and AVP release. RESULTS: The mean ratio (pressure/flow during increased flow):(pressure/flow at basal flow) was 1.27 +/- 0.04 for the first, and 1.15 +/- 0.05 for the second period of increased flow (n = 10), indicating significant vasoconstriction (P < 0.01 and 0.05, respectively), present to a greater extent during the first period of increased flow compared to the second (P < 0.05). ATP release was seen in response to increased flow (n = 8, P < 0.05). From 12 ovarian bed preparations, five released ET and SP and three of these released AVP. Four of the five perfused ovaries that released peptides contained either a developing follicle or a corpus luteum while all those that showed no peptide release were inactive. CONCLUSIONS: ATP release may play a role in the local control of the human premenopausal ovarian vasculature independent of ovulatory status. Peptides may also contribute to local vascular control in the ovary and their release from predominantly active ovaries suggests a relationship between ovulation and vascular endothelial function.

Simulators for intimate examination training in the developing world.

CONTEXT: Family planning clinic in urban India. OBJECTIVE: To assess the usefulness of a pelvic simulator for intimate examination and intrauterine device insertion training, and for enhancing reproductive education for women. DESIGN: Observational study using evaluation forms completed by staff, and focus group interviews with women and girls participating in sexual health education. Content analysis of interview material. RESULTS: Staff being trained in intimate examination found the simulator to be useful in increasing their level of skill. Participants in sexual health education reported an improved range and depth of knowledge following demonstrations with the simulator. CONCLUSION: Where working and training conditions are crowded and lacking in privacy, inappropriate examination practices are likely to be propagated. Training for intimate examinations can be enhanced by the use of pelvic simulators.