Tailor management to the patient with fibroids.

Fibroids are benign, hormone-dependent tumours of uterine smooth muscle and connective tissue. They are commonly asymptomatic, but can cause symptoms such as heavy menstrual bleeding and pelvic pressure symptoms. Between 20 to 30% of women with heavy menstrual bleeding have fibroids. Fibroids are most prevalent in women aged 30-50 years and there may be a genetic predisposition. They are more common in black women than white women. Other risk factors include obesity and nulliparity. Asymptomatic women should only be referred if their uterus is palpable abdominally, if fibroids distort the uterine cavity or the uterus is larger than 12 cm in length. Symptomatic women should be referred when heavy menstrual bleeding has not responded to medical treatment, if large fibroids are causing pressure symptoms or when fibroids are associated with fertility or obstetric problems. Malignant change (leiomyosarcoma) is rare in premenopausal women. Fast track referral is indicated for women with rapid onset and progressive symptoms or rapidly enlarging fibroids, as these symptoms are suspicious of leiomyosarcoma; postmenopausal women presenting with enlarging fibroids or vaginal bleeding; and women with fibroids with any other features of cancer e.g. abnormal bleeding or weight loss.

Managing debilitating menopausal symptoms.

Severity and duration of menopausal symptoms varies markedly. Eight out of ten women experience symptoms and on average these last four years, with one in ten women experiencing symptoms for up to 12 years. A recent study found that women whose vasomotor symptoms started before the menopause suffered longest, median 11.8 years. Women whose hot flushes and night sweats started after the menopause had symptoms for a median of 3.4 years. Menopausal symptoms can begin years before menstruation ceases. Menopausal status needs to be evaluated based on history and symptoms. Testing for FSH levels should only be considered in women aged 40-45 with menopausal symptoms or those under 40 with suspected early menopause. In general, the benefits of short-term HRT outweigh the risks in the majority of symptomatic women, especially in those under 60. There is no evidence that HRT confers any cardiovascular protection (or harm) or protection against the development of dementia. Cardiovascular risk should be assessed. Women with cardiovascular disease are not necessarily unsuitable for HRT but need their cardiovascular health optimised. In those women with a high risk of venous thromboembolism a thrombophilia screen should be considered (although even if this is negative, it does not absolve risk). If there is a history of arterial disease a lipid profile should be considered. If there is a high risk of breast cancer, counsel the woman with regards to her risk and consider referring for mammography.

An audit of the cervical screening programme in the National Drug Treatment Centre (NDTC).

BACKGROUND: Women diagnosed with substance use disorders (SUDs) have higher rates of major medical conditions compared to women without SUDs. Cervical cancer is the second leading cause of cancer death in women aged 20-39 years worldwide and women with SUDs have an increased risk of cervical cancer compared to women without SUD. The National Drug Treatment Centre (NDTC) cervical screening programme, derived from the national CervicalCheck programme, offers free cervical screening to patients attending for treatment of SUDs. AIMS: This study aimed to audit adherence to the NDTC Cervical Screening guidelines before and after the implementation of an awareness-raising educational intervention. METHODS: The electronic clinical records of women aged between 25 and 60 years attending the lead consultant's (M.S.) outpatient clinic were reviewed for documentary evidence indicating that information about the cervical screening programme had been discussed. This was completed before and one month after the implementation of an awareness-raising educational intervention. RESULTS: All women (n = 46, mean age 36.3 (SD = 6.5) years) had an opioid use disorder; 85% had a benzodiazepine use disorder, and 24% had an alcohol use disorder. Of these, 80% had at least one chronic medical condition, 76% had a psychiatric disorder, and 59% were homeless. Adherence to the NDTC cervical screening guideline, as indicated by documentary evidence in clinical records, was 33% (14/43) at baseline, and rose to 88% (36/41) (p < 0.0001) one month after the intervention. CONCLUSIONS: This completed audit cycle shows that an awareness-raising educational intervention can significantly improve adherence to a cervical screening programme in women with SUDs.

Clinical teaching fellows: everyone's a winner.

BACKGROUND: The principle teachers of the undergraduate medical curriculum are junior doctors and consultants, who may not necessarily be trained to teach. In addition, pressurised clinical environments may limit teaching time and decrease teaching quality. Clinical teaching fellows (CTFs) are doctors employed to teach, often undergoing a teaching qualification. This makes them well placed to bridge this gap between clinical practice and medical education. QUESTION: How useful are CTFs as a teaching resource for medical students, from a student perspective? METHODS: This is an evaluation of CTF teaching from student perspectives, with discussion relating to the role of CTFs. Questionnaires were given to 70 final-year medical students during the academic year 2011-2012. Questions related to teaching throughout medical school and involved scoring teaching numerically, with additional free-text sections for qualitative data. RESULTS: A total of 38/70 (54%) students responded. All had received CTF teaching. All of the students said that CTFs were 'extremely useful' for teaching. There were many reasons given for this. Students also highlighted the managerial and pastoral benefits of CTFs. DISCUSSION: We believe that CTFs could be a useful asset in all medical schools by delivering high-quality, reliable, standardised teaching for students, as an adjunct to consultant teaching, with additional managerial roles and trainee benefits. CTFs can benefit non-CTF trainees by facilitating and encouraging them to teach. CTFs can organise sessions and advise on curriculum topics, allowing trainees to deliver more targeted teaching. Teaching students may improve trainees' communication, management and leadership skills, which are useful for clinical practice.

Using simulation for prescribing: an evaluation.

BACKGROUND: Drug errors are a major cause of patient morbidity. The UK General Medical Council has highlighted that prescribing teaching should be prioritised. How should medical teachers best teach the practical aspects of prescribing? METHOD: We piloted a set of eight prescribing simulation tutorials for 35 final-year undergraduate medical students in Great Western Hospital, Swindon, UK. Students completed baseline questionnaires addressing confidence levels in prescribing. They then prescribed independently for simulated cases of common medical emergencies within tutor-led tutorials (n = 17) or self-directed prescribing tutorials (n = 18). Confidence scores and numbers of drug errors were documented at baseline and following four tutorials. Drug errors were categorised according to potential harm. Students then swapped to receive the alternative tutorial type. RESULTS: Both tutorial types resulted in a statistically significant decrease in the number of unsafe drug errors: from 57 to three in the tutor-led group (p = 0.003) and from 60 to 14 in the self-directed learning group (p = 0.001). Both tutorial types led to statistically significant increases in confidence scores for global prescribing, prescribing in medical emergencies and managing medical emergencies (with a median increase of one point on a modified Likert scale). Confidence using the British National Formulary improved, but reached statistical significance for the self-directed group only. DISCUSSION: Simulating cases and using real drug charts is an effective method for improving students' prescribing ability and confidence in common medical emergencies. Tutorials like these, whether tutor-led or self-directed, could be incorporated into medical curricula. This could help prevent drug errors in practice, thereby improving patient care and safety.