Disclosing the results of the invasive cervical cancer review to patients: a survey of lead colposcopists across England.

OBJECTIVE: To survey lead colposcopists to explore the extent to which patients are currently being invited to discuss the results of their invasive cervical cancer review, the reasons why this might not be happening and the clinician experience. METHODS: An online survey was sent to lead colposcopists across England. They were asked whether they offered the review to patients, if they did how they did so and what their experience was and if they did not, why not. RESULTS: There was a 68.5% (N = 122) response rate, with 53% of respondents currently offering the review meetings. Patients were predominantly invited to the review meeting face to face and clinicians' experiences were mixed with a variety of positive and negative aspects of the meetings given. For those clinicians not currently offering a review meeting, there were a variety of reasons: 25% cited a lack of awareness of the guidelines, 19% time constraints, 12% a fear of causing additional distress and 2% a fear of litigation. Open-ended responses demonstrated a considerable amount of misunderstanding about the process. CONCLUSION: Despite National Health Service Cervical Screening Programme guidelines, not all clinicians offer review meetings to patients and those who do offer them do not always offer them to all women. Patient research needs to be conducted to explore the value of the meetings further, and there is a need to do more to engage clinicians in the process.

Prediction of nitrogen excretion by beef cattle: a meta-analysis.

Reliable estimates of N excretion in the urine and feces of beef cattle are essential for developing cost-effective and environmentally sound nutrient management plans. A meta-analysis dataset was compiled that included data for starting live BW, DMI, N intake, dietary CP and RDP concentrations, urine N excretion, and feces N excretion. The data were taken from 12 individual feeding trials that included N balance data, and represented a total of 47 different dietary treatments and 255 animals. Correlation analysis was used to determine the animal and dietary parameters that were most closely related to N excretion in urine and feces by beef cattle. A multivariate mixed modeling approach was used to develop empirical equations to predict excretion of urine N, feces N, and the partitioning of total N excretion between urine and feces, as a function of N intake and the concentration of dietary CP. Univariate, regression, and mean difference comparisons indicated 46 to 95% agreement between observed and predicted values for the developed equations. Evaluation of the equations with an independent dataset taken from 6 studies, and 2 random subsets of the meta-analysis dataset showed moderate agreement (P < 0.05, r(2) = 0.34 to 0.86) for urine N excretion as a function of both N intake and %CP, and the partitioning of total N excretion into urine as a function of %CP. There was less agreement between predictions and observations for feces N excretion as a function of %CP (r(2) = 0.003 to 0.14) than N intake (r(2) = 0.52 to 0.75), indicating that %CP is not a good predictor of fecal N excretion. The empirical equations provide a simple tool that, if used with caution, could predict N excretion characteristics for a wide range of dietary and animal characteristics and could improve ammonia emissions estimates by process-based models.

Implementing the national invasive cervical cancer audit: a local perspective.

OBJECTIVE: To monitor the effectiveness of the cervical screening programme and identify suboptimal management in order to improve patient care. DESIGN: Retrospective study. SETTING: A university hospital serving a population of 1 million people. POPULATION: All women diagnosed with a cervical cancer between 2003 and 2006. METHODS: Analysis of data from invasive cervical cancer reviews. MAIN OUTCOME MEASURE: Categorisation of cervical cancer cases according to the Invasive Cervical Cancer Audit classification. RESULTS: Eighty-seven women were diagnosed with cervical cancer during the 3-year study period. The 'lapsed attender' group accounted for the greatest number of cases (30%), followed by screen detected (26%), interval cancers (13%), never attended (12%), lost to follow-up (10%) and never invited (9%). Women who had never attended for cytology presented with higher stage disease, stage-II or above, compared with the screen-detected cases: 60% were stage II or above, compared with 13.0%, Chi-square P = 0.018. The most frequently identified screening programme problem was patient compliance, which was determined to be the principle contributing factor in 39 cases (45%) and a secondary factor in a further ten cases. CONCLUSIONS: The categorisation of cervical cancer cases has the potential of yielding invaluable information for improving programme effectiveness. Patient compliance is the greatest challenge to the screening programme, and the need for regular screening and adherence to follow-up regimens needs to be reinforced in order to maximise the efficacy of the national screening programme.

Cervical cytology/histology discrepancy: a 4-year review of patient outcome.

OBJECTIVE: To investigate the diagnosis, review and management of women identified as having a cytology/histology discrepancy. METHODS: A review of all patients diagnosed with a discrepancy between referral smear and cervical histology was performed between January 2003 and December 2004. Cases were followed for a minimum of 4 years and patient management and outcome reviewed. RESULTS: A significant discrepancy was identified in 79 cases, 0.1% of all smears (n = 80,926) analysed during the study period. A discrepancy between cytology and histology, obtained from large loop excision of the transformation zone (LLETZ), was confirmed by multidisciplinary review in 42 cases (53.2%). In 37 cases (46.8%) the cytological and/or histological diagnosis was revised; the cytology was significantly more likely than the histology to be amended (chi square P = 0.005), most often because cytology had been overcalled. Of the confirmed discrepancy cases, 33 (78.6%) were due to high-grade squamous cell or glandular abnormalities on cytology with a negative, inflammatory or human papillomavirus (HPV) infection on histology (HGC/NH). HGC/NH cases were managed by cytological follow-up in 29 (87.9%), of which 72.4% of the smears were negative when performed at least 6 months post-excision. During the 4-year follow-up period six women with a confirmed HGC/NH underwent a repeat cervical excision (hysterectomy or LLETZ), and of these, HPV effect was seen in two cases but no cervical intraepithelial neoplasia was detected in any of the histological specimens. CONCLUSION: Cytology overcall was responsible for the majority of cytology/histology discrepancies. A confirmed discrepancy is not an indication for a further excisional biopsy but follow-up is essential because a small percentage of patients may have disease that has been missed.

Opportunities to enhance performance and efficiency through nutrient synchrony in concentrate-fed ruminants.

Synchronization of the ruminal degradation of carbohydrates and CP is projected to increase ruminal microbial protein synthesis and improve N use efficiency. Attempts to synchronize the fermentation of dietary carbohydrates and CP have been met with mixed results, suggesting that ruminal nutrient synchrony is not important or that physiological mechanisms work in concert to synchronize ruminal carbohydrate and N availability. Nitrogen recycling to the rumen is controlled primarily by the concentration of urea in the blood, ammonia in the gut, and the availability of fermentable energy in the gut. We hypothesized that N utilization could be improved by synchronizing the supply of nutrients in one segment of the gut with those in another segment (i.e., synchronize a ruminal N deficiency with a lower gut N excess, etc.) via oscillating the dietary CP between deficient and adequate concentrations. With corn-based diets and oil-seed-based natural protein supplements, N retention has been greater in lambs or steers fed oscillating CP concentrations (at 48-h intervals) than in animals fed a constant CP percentage. Effects of oscillating CP on cattle performance have been variable and may depend upon the fermentability of the carbohydrate source (e.g., forage vs. grain, grain processing). Studies with sheep noted that net portal uptake of urea was greater in lambs fed oscillating CP than in lambs fed constant CP concentrations. Nutrient intakes also need to be synchronized with the animals' requirements. One method to adjust nutrient intake with requirements is via phase-feeding. Results of studies with dry-rolled corn-based diets indicate that dietary CP concentrations can be decreased late in the feeding period with no adverse effects on animal performance; however, results of studies using steam-flaked corn-based diets are less consistent, possibly due to differences in the aggressiveness of the implant program used. In conclusion, ruminal nutrient synchrony is theoretically a sound principle; however, it seems that physiological mechanisms such as N recycling may mitigate effects of asynchrony. Methodologies that increase N recycling or increase the utilization of recycled N may benefit animal performance and the environment.

Influence of dietary crude protein concentration and source on potential ammonia emissions from beef cattle manure.

Emissions of ammonia, as well as other gases and particulates, to the atmosphere are a growing concern of livestock producers, the general public, and regulators. The concentration and ruminal degradability of CP in beef cattle diets may affect urinary and fecal excretion of N and thus may affect ammonia emissions from beef cattle feed yards. To determine the effects of dietary CP concentration and degradability on potential ammonia emissions, 54 steers were randomly assigned to nine dietary treatments in a 3 x 3 factorial arrangement of treatments. Treatments consisted of three dietary CP concentrations (11.5, 13, and 14.5%) and three supplemental urea:cottonseed meal ratios (100:0, 50:50, and 0:100 of supplemental N). Steers were confined to tie stalls, and feces and urine excreted were collected and frozen after approximately 30, 75, and 120 d on feed. One percent of daily urine and feces excretion were added to polyethylene chambers containing 1,550 g of soil. Chambers were sealed, and ammonia emissions were trapped in an acid solution for 7 d using a vacuum system. As the protein concentration in the diet increased from 11.5 to 13%, in vitro daily ammonia emissions increased (P < 0.01) 60 to 200%, due primarily to increased urinary N excretion. As days on feed increased, in vitro ammonia emissions also increased (P < 0.01). Potential ammonia losses were highly correlated (P < 0.01) to urinary N (r2 = 0.69), urinary urea-N (r2 = 0.58) excretion, serum urea-N concentration (r2 = 0.52), and intake of degradable protein N (r2 = 0.23). Although dietary composition can affect daily ammonia losses, daily ammonia emissions must be balanced with effects on animal performance to determine optimal protein concentrations and forms in the diet.

A case of clear cell carcinoma arising in extragonadal endometriosis.

Malignancy developing in extragonadal endometriosis is rare with the majority of cases being endometrioid adenocarcinomas. We present a 54-year-old woman who developed a clear cell carcinoma in her perineum, 25 years after excision of a perineal endometrioma in an episiotomy scar. Treatment involved radiotherapy and surgery, with a view to preserving vaginal function. Where benign extragonadal endometriosis occurs, the potential for malignant transformation persists even years after primary treatment.