Gender differences in final year medical students' experience of teaching of intimate examinations: a questionnaire study.

OBJECTIVES: To examine final year medical students' experience of being taught to conduct intimate examinations. DESIGN: Prospective questionnaire study. SETTING: Medical school in the UK. POPULATION: Medical students in the final year cohort 2005/06. METHODS: Questionnaires were distributed to students in the final week of a final year obstetrics and gynaecology course. Responses to questions about course experience were analysed using frequencies and single-variable analyses. MAIN OUTCOME MEASURES: Students' experience of and satisfaction with the teaching of intimate examinations and differences between male and female students. RESULTS: Male and female students performed similar numbers of intimate examinations, but clinical tutors were significantly more likely to introduce female students to patients (76 versus 52%; P = 0.001) and obtain consent on their behalf (75 versus 53%; P = 0.009) when compared with male students. Male students reported a greater degree of embarrassment (mean score 2.41 +/- 1.25 versus 1.69 +/- 0.90; P = 0.002), and a higher number of patients refusing consent to examination (median 2; range 0-12 versus 0; range 0-6; P = 0.0001). CONCLUSIONS: Gender discrimination in the behaviour of tutors may impact on students' experience of intimate examinations. It is highly improbable that differences in behaviour are deliberately intended to disadvantage male students, and further research is needed to understand why tutors behave differently with them. In the meantime, tutors need to be aware of potential bias and ensure appropriate support is provided for both male and female students.

Telomere length in small-for-gestational-age babies.

OBJECTIVE: Short telomeres are associated with adult cardiovascular disease. Our aim was to determine whether small-for-gestational-age (SGA) newborns have shortened telomeres compared with appropriately grown controls. DESIGN: Prospective cohort study. SETTING: Large tertiary referral unit in Trent, UK. POPULATION: Seventy-two women who delivered at 35-42 weeks of gestation were recruited; 34 delivered SGA babies (less than or equal to the third birthweight centile) and 38 had appropriately grown babies (greater than the tenth centile). METHODS: Maternal and cord blood samples were collected at delivery. A Southern blot of DNA from these samples was hybridised with a 32P-labelled telomeric probe and telomere length was measured. MAIN OUTCOME MEASURES: Mean maternal and newborn telomere length. RESULTS: Maternal and newborn telomere lengths were significantly correlated in both the SGA and the control groups (r2 = 0.25, P < 0.0001). Telomere lengths were similar in both maternal (control 8.41 +/- 0.9 kb versus SGA 8.29 +/- 1.0 kb, P = 0.57) and newborn (control 10.36 +/- 1.5 kb versus SGA 10.33 +/- 1.3 kb, P = 0.93) cohorts in the two groups. CONCLUSIONS: Intrauterine events associated with impaired fetal growth do not appear to be associated with increased telomere shortening.

Women's accounts of consenting to surgery: is consent a quality problem?

BACKGROUND: Consent has been placed at the centre of doctor-patient relationships. Attempts to improve the consent process in medicine have drawn on bioethical and legal traditions. Current approaches to consent emphasise the provision of information and have, in the UK, resulted in a single standardised format and process for both elective and emergency situations. Investigation of patients' perceptions and priorities are important in understanding the quality of the consent process. METHODS: In this qualitative study, semi-structured interviews were conducted with 25 women. Eleven had elective and 14 had emergency operations in obstetrics and gynaecology. All interviews were recorded and transcribed verbatim. Data analysis was based on the constant comparative method. RESULTS: Participants' perceptions of surgery strongly influenced the meanings they gave to consent. Some, particularly those undergoing elective operations, wanted surgery. Others were uncertain of their desire for surgery or felt that it was imposed on them. Consenting was interpreted as a ritualistic legal procedure. There was an overwhelming tendency to view consent as not primarily serving patients' needs, although some advantages of the consent process were identified. Accounts made no reference to ethics. CONCLUSION: Countering paternalism will remain difficult to achieve if issues surrounding consent continue to be debated between professionals without due effort to reflect patients' own views and values and to appreciate the circumstances under which consent is sought.

Intrapartum care for women on full anticoagulation.

Women requiring full anticoagulation in pregnancy and labour present their care providers with complex management problems, particularly during the peripartum period. Available guidelines often fail to address the practical issues of balancing the risks of recurrent thrombotic events and haemorrhage during labour. This is especially the case in women at high risk of recurrent thromboembolism, in whom the usually recommended temporary peripartum reduction in the level of anticoagulation may be considered unsafe. In order to achieve a satisfactory outcome without undue intervention, multidisciplinary management involving obstetricians, haematologists and anaesthetists is essential. Intrapartum care plans should be made during pregnancy to address the conduct of labour and delivery, anticoagulation, analgesia in labour and the management of any arising obstetric, anaesthetic or haematological complications. In the following we address the practical issues requiring particular attention, as well as management options, in fully anticoagulated patients using a clinical case for illustration.

Changes in serum vascular endothelial growth factor following initiation of estrogen replacement after hysterectomy and oophorectomy.

BACKGROUND: Vascular endothelial growth factor has been shown to play an important role in preservation and restoration of endothelial integrity. Similar effects on endothelial function have been described with estrogen replacement. This poses the question whether some of the mechanisms ascribed to estrogen are in fact vascular endothelial growth factor mediated. The objective of this study was to examine the effect of continuous transdermal estrogen replacement on serum levels of secreted vascular endothelial growth factor in women following hysterectomy and oophorectomy. METHODS: In a nonrandomized, prospective study, 40 hysterectomized and oophorectomized women were treated with transdermal estrogen. Their serum vascular endothelial growth factor levels were measured before and six months following estrogen treatment, using a commercially available ELISA kit. RESULTS: The mean serum vascular endothelial growth factor level fell from 328 ng/ml (s.d. 164) before treatment to 285 ng/ml (s.d. 124) following six months of estrogen replacement. This decrease was statistically significant (p<0.03). CONCLUSION: Transdermal estrogen replacement in hysterectomized and oophorectomized women appears to be associated with a significant reduction in secreted serum vascular endothelial growth factor. However, the effect of hysterectomy and oophorectomy per se needs to be explained in appropriately designed trials.

Prostatic carcinoma: a nutritional disease? Conflicting data from the Kingdom of Saudi Arabia.

PURPOSE: The incidence of prostate cancer in Saudi Arabia has been reported to be low at 1.4 to 2.1/100,000 person-years. We prospectively evaluated the true incidence of this disease and its association with dietary factors. MATERIALS AND METHODS: From 1994 to 1997 inclusive Saudi men older than 50 years treated at our institution for various presenting symptoms and diseases were randomly selected from various departments. They were examined prospectively with digital rectal examination, and total and free prostate specific antigen measurement. Transrectal ultrasound and prostatic biopsy were performed when either test was abnormal. Nutrition questionnaires and detailed interviews with a nutritionist were completed to assess the type of diet, and amount of saturated and polyunsaturated fat consumption of patients with prostatic carcinoma and controls. RESULTS: For the 2,270 Saudi men screened we noted an incidence of 3.1/100,000 person-years. Our nutritional survey revealed that recent fat consumption was greater than 120 gm. per person daily, of which about 40% was from meat and dairy products. Saturated fat comprised about 50% of the total fat intake. There was no difference in the amount of fat in the diet of men with and without prostatic carcinoma. CONCLUSIONS: The incidence of prostatic carcinoma in the Kingdom of Saudi Arabia is low despite a high saturated fat diet in recent years. This finding contradicts most western clinical studies, which indicate a positive association of a high fat diet with prostatic carcinoma.

Continuous combined hormone replacement therapy compared with tibolone.

OBJECTIVE: To compare relief of vasomotor symptoms, changes in lipoproteins, and bleeding patterns in postmenopausal women receiving either continuous combined hormone replacement therapy (HRT) of estradiol valerate and norethisterone or tibolone 2.5 mg/day. METHODS: In a multicenter, randomized, open-label study, 235 postmenopausal women received one of the above-mentioned treatments. Fasting lipoproteins were measured at baseline and at 3, 6, and 12 months. At each visit, participants completed Greene climacteric questionnaires and recorded any bleeding episodes. Data are presented as mean +/- standard deviation if normally distributed, median and interquartile range if non-normally distributed, or as frequency count. For menopausal symptoms and diary card data, the differences were tested by Wilcoxon rank-sum test. RESULTS: One hundred sixteen women received continuous combined HRT and 119 women received tibolone; 72 and 76 women, respectively, completed 12 months of therapy. Both treatments effectively relieved vasomotor symptoms and reduced serum total cholesterol. Continuous combined HRT, but not tibolone, significantly reduced low-density lipoprotein levels. Both treatments reduced high-density lipoprotein levels, but the effect was more profound with tibolone. The initial bleeding score was higher for women taking continuous combined HRT; however, by the end of the study, the percentages of amenorrheal women were comparable. Endometrial histology was similar for both treatments at the end of the study, although two cases of proliferative endometrium were found in the tibolone group. CONCLUSION: Estradiol valerate-norethisterone continuous combined HRT controls symptoms and is associated with a safe lipid profile.

The effect of oestrogen on intimal hyperplasia in cultured human ovarian veins.

The beneficial effect of oestrogen on blood vessels may include modulation of vascular response to injury. In this experiment we set out to develop an in-vitro model, using all human materials, for the study of vascular changes in culture, and their response to oestrogen treatment. Human ovarian vein segments were obtained from 15 hysterectomy specimens, and cultured with and without the addition of 17beta-oestradiol. Paired control veins were cultured with the inert 17alpha-oestradiol. The veins were stained with anti-alpha-smooth muscle actin and Miller's elastin, and intimal thickness measured. Cultured veins developed a significant degree of intimal thickening [15.7 versus 8.25 microm in fresh veins, 95% confidence intervals (CI) 13.6, 17.8 and 6.3, 10.2 respectively; P = 0.0001]. The addition of 17beta-oestradiol, but not 17alpha-oestradiol, led to a significant reduction in intimal hyperplasia (intimal thickness 8.85 microm; 95% CI 6.9, 10.8; P = 0.008). The mean number of nuclei per high-power field was also significantly lower in the intima of oestrogen-treated compared to untreated veins (11.6; 95% CI 9.9, 13.26 versus 14.05; 95% CI 12.5, 15.6; P = 0.001). Our data suggest that intimal hyperplasia in cultured ovarian veins is effectively reduced by oestrogen.

Differing responses in blood pressure over 24 hours in normotensive women receiving oral or transdermal estrogen replacement therapy.

OBJECTIVE: To examine the effects of oral and transdermal estrogen replacement therapy (ERT) on ambulatory 24-hour blood pressure (BP) recordings. METHODS: In a nonrandomized, prospective study, 90 normotensive, oophorectomized women, ages 30-59 years, underwent ambulatory 24-hour BP measurements at study entry and after 3 and 6 months of either oral (n = 50) or transdermal (n = 40) ERT. RESULTS: In the women receiving transdermal estrogen, we observed a change in mean nighttime systolic BP of -4.2 mmHg (95% confidence interval [CI] -7.7, -0.7; P = .039) after 6 months, treatment. There was a change in mean daytime diastolic BP after 3 months (-3.3 mmHg; 95% CI -5.5, -0.9; P = .016) and 6 months (-4 mmHg; 95% CI-6.8, -1.2; P = .014), and in mean nighttime diastolic BP after 3 months (-3.8 mmHg; 95% CI -6.6, -0.9; P = .027) and 6 months (-4.4 mmHg; 95% CI -7.1, -1.7; P = .005). No significant BP changes were observed in the women taking oral estrogen. Although the statistical power to detect a change of 4 mmHg at the 5% significance level was 90% for diastolic BP, it was weaker for systolic BP (63%) in this group. However, in more than one-third of the women receiving either treatment, a statistically significant increase in BP was observed. CONCLUSIONS: Transdermal ERT was associated with a reduction in mean ambulatory BP, whereas oral treatment did not alter BP. Although the overall effect of estrogen was to lower BP, individual responses were variable, and BP increased in more than one-third of the women on either treatment. Therefore, long-term monitoring of ambulatory measurements may be required.

Immunohistochemical and hysteroscopic assessment of postmenopausal women with uterine bleeding whilst taking Tibolone.

The gonadomimetic steroid Tibolone, is currently widely used for the treatment of menopausal symptoms. Up to 20% of women have been reported to have episodes of bleeding whilst on therapy. We investigated 37 cases who experienced bleeding episodes whilst on Tibolone and compared these to six cases who experienced no bleeding whilst on therapy and who underwent similar investigations in the course of a clinical study. All women underwent a diagnostic hysteroscopy and an endometrial biopsy, under a local anaesthetic. The endometrium was assessed by histology and with immunohistochemical markers for cellular proliferation (Ki67, PCNA), Heat Shock Protein 27 (HSP27) and bcl-2. There were 17 women with intracavitary lesions on hysteroscopy (including one in the control group), 10 with polyps, five with fibroids, two with congenital uterine anomalies. Histological diagnosis was not obtained in 16 cases. The high incidence of uterine polyps in the group who bled on Tibolone suggests an etiologic relation. The staining pattern with HSP27 demonstrated an oestrogenic effect. There were no differences in the bcl-2 immunoreactivity between those who bled and those who did not bleed on treatment which suggests absence of a link. Similarly, there were no differences in the expression of the proliferation markers. We conclude that episodes of bleeding in patients receiving Tibolone for hormone replacement therapy, whilst warranting investigation, should not cause undue concern.

Carotid plaque regression on oestrogen replacement: a pilot study.

OBJECTIVE: To investigate the effect of unopposed oestrogen on atheromatous carotid plaques. SUBJECTS: Seventeen postmenopausal women with known carotid disease. METHODS: Carotid intimal thickness and plaque length and thickness were measured prior to and following 3 and 6 months of treatment, using Duplex ultrasound. A total of 22 plaques were followed up. RESULTS: There was a reduction in plaque length after 3 (-8.14%, p = 0.001) and 6 months (-28%, p = 0.001) of treatment. The reduction in plaque thickness (-18%, p = 0.004) was significant after 6 months of treatment. Reductions in intimal thickness were not statistically significant. CONCLUSION: Our results suggest that oestrogen replacement is associated with significant plaque regression.

Abnormal uterine bleeding on hormone replacement: the importance of intrauterine structural abnormalities.

OBJECTIVE: To examine the importance of submucous myomas and endometrial polyps before and after menopause and in abnormal withdrawal bleeding on hormone replacement therapy (HRT). METHODS: Between May 1991 and May 1993, women presenting with abnormal withdrawal bleeding on HRT (n = 106), menstrual problems in pre-menopause (n = 92), or postmenopausal bleeding (n = 33) underwent diagnostic outpatient hysteroscopy for the presence of intrauterine structural abnormalities. The findings were compared with a control group of post- and perimenopausal women without bleeding problems (n = 183). RESULTS: When compared with women who had normal uterine cavities, the presence of submucous myomas was associated with a threefold increase in the risk of abnormal menstrual bleeding in premenopausal women (odds ratio [OR] 3.34, 95% confidence interval [CI] 1.77-6.43; P < .001) and a twofold increase in the risk of abnormal withdrawal bleeding in post- and perimenopausal women (OR 2.4, 95% CI 1.25-4.53; P = .004). This did not seem to be related to the number of myomas detected. The frequency of endometrial polyps was not found to be significantly higher in women who had menstrual disorders or abnormal withdrawal bleeding on HRT. Postmenopausal bleeding without hormonal stimulation was not significantly associated with submucous myomas or polyps. CONCLUSION: As increasingly more women request HRT, bleeding problems presenting pre-menopause can no longer be expected to resolve "naturally" after menopause. In the presence of submucous myomas, these women will continue to have a higher risk of abnormal withdrawal bleeding when treated with hormone replacement, whereas endometrial polyps are not associated with an increased bleeding risk. Hysteroscopic assessment of the uterine cavity and subsequent counseling as to the risk of heavy or prolonged bleeding will be helpful in their future management and may improve compliance.

Effect of a new cyclical sequential postmenopausal HRT on lipoprotein, apoprotein and thrombophilia profile.

We examined the changes in lipoprotein, apoprotein, and thrombophilia profile in postmenopausal women using a new cyclical sequential combined HRT regimen. The study medication consisted of two tablets of Hormonin (oestriol 0.27 mg, oestrone 1.4 mg and oestradiol 0.6 mg), daily and norethisterone (1 mg) BP (Shire Developments) for the last 12 days of every 28 day cycle. Serial fasting blood samples were collected at the beginning of the study and, thereafter, at 3-monthly intervals for 1 year, each patient acting as her own control. Thirty-five healthy postmenopausal women completed 1 year of follow-up and had a complete set of fasting blood samples. The lipid profile; total cholesterol, triglycerides, HDL, LDL, Apo AI, Apo AII, Apo B and Lp(a), as well as the coagulation parameters; antithrombin III, factor VII, fibrinogen, protein C and protein S, were measured at each occasion. There was a statistically significant drop in total cholesterol and LDL levels. Lp(a) level dropped after commencing treatment and remained below baseline for the rest of the study. The initial increase in Apo AII was not maintained for the duration of the treatment. The changes in Lp(a) and Apo AII were not statistically significant. The level of protein S dropped significantly throughout the study. The changes in other coagulation factors were not statistically significant. The effect of this hormonal combination on the lipid parameters is favourable, and although the change in protein S is striking, its clinical significance remains unclear.

A controlled field trial of a serogroup A meningococcal polysaccharide vaccine.

A controlled field trial of a serogroup A meningococcal polysaccharide vaccine was conducted at three locations in Egypt during the winter cerebrospinal meningitis (CSM) season of 1971-72. The study population consisted of schoolchildren 6-15 years of age. No cases of serogroup A meningococcal CSM occurred in the group of students vaccinated with the test vaccine whereas 8 cases occurred in the control group vaccinated with tetanus toxoid, and 151 cases occurred in an unvaccinated contrast group. The case rate was significantly different between the test and control groups as well as between the test and contrast groups but was similar between the control and contrast groups. The previously demonstrated safety of the vaccine was confirmed. A significant serological response was elicited in the majority of the vaccinated students.