Transverse vaginal septae: management and long-term outcomes.

OBJECTIVE: To examine the management and long-term outcomes of transverse vaginal septae. DESIGN: Observational study with cross-sectional and retrospective arms. SETTING: Tertiary referral centre specialising in Müllerian anomalies. POPULATION: Forty-six girls and women with a transverse vaginal septum. METHODS: Data from medical records of all cases (1998-2013) of transverse vaginal septae were collected and reviewed. Patients over 16 years of age also completed a questionnaire. MAIN OUTCOME MEASURES: Presentation, examination findings, investigations, surgery, and long-term reproductive outcomes. RESULTS: The septae in the study were described as follows: 61% (95% CI 0.46-0.74) were imperforate, and presented with obstructed menstruation; 39% (95% CI 0.26-0.54) were perforate, and presented with a variety of concerns; 72% (95% CI 0.57-0.83) were low, 22% (95% CI 0.12-0.36) were mid-vaginal, and 6% (95% CI 0.02-0.18) were high; 33% were managed via an abdominoperineal approach, 59% were managed via a vaginal approach, and 6% had laparoscopic resection (one patient did not have surgery); 11% (95% CI 0.05-0.23) of patients presented with reobstruction, all following abdominoperineal vaginoplasty; 7% presented with vaginal stenosis, two following vaginal resection and one following the abdominoperineal approach; 61% of questionnaires were returned. These results showed that 22/23 patients were menstruating and one had a hysterectomy, 74% had been sexually active, 35% had dyspareunia, and 36% complained of dysmenorrhoea. There were seven pregnancies, with one termination and six live births, all following the vaginal excision of a transverse vaginal septum. CONCLUSIONS: Transverse vaginal septae resected vaginally or laparoscopically have low complication rates and good long-term outcomes. Complex septae require more extensive surgery, with an increased risk of complications.

Triple negative breast cancer in a male-to-female transsexual.

There is limited published literature on the risk of breast cancer in transgender patients. We report a case of an aggressive triple negative inflammatory breast cancer in a male-to-female transsexual. This patient had a complicated psychiatric history with significant antipsychotic use, and the case raises several questions about the pathogenesis of this breast cancer. The literature on breast cancer in transgender patients and in relation to hyperprolactinaemia is reviewed.

Crime and health: a preliminary study into the effects of crime on the mental health of UK university students.

In this paper we report on the findings from a preliminary study in the UK into the effects of crime on health. The aim of the study was to investigate what victims of crime report to be the effects of both actual crime and the fear of crime on their physical and psychological health (as well as social well-being) and what actions they take (if any) to deal with these effects. A survey method was adopted using a modified version of the 'Health, Quality of Life and Crime Questionnaire' with 866 undergraduate student respondents from three UK universities. University students were selected as the sample population because, as a group, they form a specific 'victim community'. Conclusions extrapolated from the respondents' replies were first, there are serious negative health effects (particularly on psychological health) of a considerable minority of those students who are victims of crime. Second, the vast majority of the victims did not initiate any health intervention. Third, a large minority of the victims did not report the crime to the police. Fourth, a majority of both victims and non-victims suffered psychological negative effects from the fear of crime. Fifth, there is a huge gender imbalance among those affected by crime with female students much more fearful of crime than men. Moreover, female students were much more likely to use specific strategies to lower the risk of crime. These conclusions suggest that there may be important policy implications for universities, the police, victim support organizations and mental health services, regarding the effects of crime on students. This study is intended as a preliminary stage for subsequent in-depth and larger projects.

Cause for concern: the absence of consideration of public and ethical interest in British public policy.

In the UK, many fundamentally important policy decisions that are likely to affect the relationship between citizens and care services are now made at the sublegislative level and without adequate ethical consideration and scrutiny. This is well exemplified in the proposed guidance on the disclosure of information on children. A recent consultation paper by the UK government on the subject proposes an approach that seeks a simple technical solution to a complex problem, emphasising control and surveillance. This reflects pressure to be seen to act. The document fails with regard to ethical reflection appropriate to the complexity of the issue, an appreciation of complex relationships of trust, and a proper sense of the richness and complexity of the public interest. Such policies would, if implemented, fundamentally change the relationships between citizens and their carers, and among carers and the law and the state. This and similar proposals require far more ethical scrutiny and consideration of the public interest in the widest sense.

Need humanities be so useless? Justifying the place and role of humanities as a critical resource for performance and practice.

Justifying the existence, position, and relevance of academic humanities scholarship may be difficult in the face of chronic practical needs in health care. Such scholarship may seem parasitic on human activity and performance that directly contributes to human wellbeing and health care. Here, a possible and partial justification for the importance of scholarship in the humanities as a critical resource for practice and performance is undertaken by two humanities scholars. Human identity and emotion are reflected and defined by performances, both in the traditional disciplines of the humanities, such as art and literature, and in the sciences and medicine. The critical attitude that such performances might inadvertently undermine is sustained by the humanities. The humanities disciplines ask the question: "What is it to be human?" Uncritical emotion and expression, arising, for example, from understanding developments in medicine and science, which might exclude or corrupt much that is of value in the healthcare sector and other areas of practical performance, can be constrained by this.

Putting the public back into public health. Part I. A re-definition of public health.

The practice of public health has been criticized as being too involved with a narrow, managerial agenda focused on health care rather than the wider horizons of public good. Public accountability is central to the practice of public health, but is not mentioned in current definitions. We offer a new definition that recognizes the centrality of the public, and which should help public health professionals interpret their own role: 'Use of theory, experience and evidence derived through the population sciences to improve the health of the population, in a way that best meets the implicit and explicit needs of the community (the public)'.

Putting the public back into public health. Part II. How can public health be accountable to the public?

The practice of public health involves the application of evidence to improving population health, and should be accountable to the public. Accountability to the public can be considered either at the individual doctor-patient interface or through population-level policy making. The public, at both patient and population levels, should join the professionals at each stage of the 'population health evidence cycle'-in asking for, collecting, understanding and using evidence. A greater appreciation of the non-professional, public perspective would represent a substantial commitment to transforming our understanding and needs for different kinds of evidence required to improve the health of the population.

Medical Humanities: a vision and some cautionary notes.

This article aims to engender discussion about the nature and future of medical humanities. First, a normative personal vision of medical humanities as an inclusive movement is outlined. Some of the problems that may emerge if medical humanities conceives itself too narrowly are then discussed. The case of the rise of the medical ethics movement is used to show what can happen to a movement that restricts itself too quickly and then the stages of the "death course of a discipline" are described and assayed. The article concludes with a plea for medical humanities to remain a "broad church", exploratory, pluralistic movement rather than aiming to become a paramedical academic discipline.

Regulation of gelatinase-A (MMP-2) production by ovine intervertebral disc nucleus pulposus cells grown in alginate bead culture by Transforming Growth Factor-beta(1)and insulin like growth factor-I.

The aim of this study was to gain information relevant to disc repair processes. Limited degradation of the collagen matrix by matrix metalloproteases (MMPs) may facilitate the loosening of cell-cell and cell-matrix interactions within the injured intervertebral disc (IVD) to favour the penetration of blood vessels and migration of fibroblasts into the defect to promote repair processes. Gelatinase A (MMP-2) has a particularly important role to play in angiogenesis, in the present study we investigated the in vitro regulation of MMP-2 by Transforming Growth Factor-beta 1 (TGF-beta 1) and Insulin-like Growth Factor-1 (beta IGF-I) in cells from the nucleus pulposus (NP) of the ovine IVD. Ovine NP cells were grown in alginate bead cultures in complete medium (10% foetal calf serum) for 7 days, established in serum-free conditions for 24 h, then stimulated with TGF-beta 1 (0.1 or 10 ng/ml) or IGF-I (2 or 50 ng/ml) +/-Concanavalin A (20 microg/ml) for an additional 48 h. Conditioned medium was examined for matrix metalloproteases using gelatin zymography, Tissue Inhibitor of Metalloproteinase 2 (TIMP-2) and Membrane Type 1 Matrix Metalloproteinase (MT1-MMP) were immunolocalised in beads. Pro (72 kDa) and active (59 kDa) MMP-2 were the major gelatinolytic MMPs detected in control cultures, the TGF-beta 1 and IGF-I treatments significantly decreased levels of the active MMP-2, inclusion of Concanavalin A resulted in a complete reversal of this trend with IGF-I, and to a lesser extent with TGF-beta 1. Cell surface levels of TIMP-2 and MT1-MMP were decreased by the TGF-beta 1 treatment while IGF-I only appeared to decrease TIMP-2 expression. The findings of this study provide some insight as to why dense avascular connective tissues such as the intervertebral disc have such a poor healing potential.

Spirituality. Come all ye faithful.

A growing body of research suggests that religion and spirituality can have a positive effect on mental and physical health. Like any other powerful belief system, they also have potential for harm. Further research is needed if they are to be understood and therapeutically incorporated into healthcare.

Are nursing codes of practice ethical?

This article provides a theoretical critique from a particular 'ideal type' ethical perspective of professional codes in general and the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) Code of professional conduct (reprinted on pp. 77-78) in particular. Having outlined a specific 'ideal type' of what ethically informed and aware practice may be, the article examines the extent to which professional codes may be likely to elicit and engender such practice. Because of their terminological inexactitudes and confusions, their arbitrary values and principles, their lack of helpful ethical guidance, and their exclusion of ordinary moral experience, a number of contemporary professional codes in health and social care can be arraigned as ethically inadequate. The UKCC Code of professional conduct embodies many of these flaws, and others besides. Some of its weaknesses in this respect are anatomized before some tentative suggestions are offered for the reform of codes and the engendering of greater ethical awareness among professionals in the light of greater public ethical concerns and values.

Insulin-like growth factor binding protein-3 is regulated by dihydrotestosterone and stimulates deoxyribonucleic acid synthesis and cell proliferation in LNCaP prostate carcinoma cells.

We have investigated the production and actions of a growth regulatory protein, insulin-like growth factor binding protein (IGFBP)-3, in the androgen-responsive prostate carcinoma cell line LNCaP. Confluent monolayers of cells secreted approximately 0.7 ng/ml IGFBP-3 over 24 h. Dihydrotestosterone (DHT, 10 nM) and 1,25-dihydroxyvitamin D3 (vitamin D, 10 nM) increased IGFBP-3 in media to 149 +/- 15% and 206 +/- 18% of control, respectively, when added separately, and to 453 +/- 28% of control when used in combination. IGFBP-2, secreted at approximately 25-fold higher concentrations than IGFBP-3, was increased 50% by 10 nM DHT, but there was no effect of vitamin D on IGFBP-2 production in the absence or presence of DHT. Cell-associated IGFBP-3, and immunoreactive IGFBP-3 species of 20 kDa and 30 kDa were also increased in response to vitamin D plus DHT. A combination of vitamin D and DHT increased DNA synthesis in LNCaP cells 3-fold, and this was at least partly mediated by endogenous IGFBP-3 because anti-IGFBP-3 IgG, but not nonimmune serum IgG, reduced the stimulatory effect of vitamin D and DHT from 293 +/- 11.6% to 161 +/- 30.7% of control levels (P < 0.0001). Basal and DHT plus vitamin D-stimulated thymidine incorporation was significantly increased by 50 ng/ml human plasma-derived purified IGFBP-3. After 4 days treatment with vitamin D plus DHT, or pure IGFBP-3, LNCaP cell numbers were increased relative to control. These results indicate a role for IGFBP-3 in the proliferation of androgen-responsive prostate carcinoma cells.