Cumulative assessment of Diplectanum spp. occurrence, prevalence, and pathological impact in Dicentrarchus labrax from varied Egyptian fish farms.

Monogenean trematodes, particularly those belonging to the Diplectanidae family, are significant metazoan parasites with substantial implications for aquaculture expansion. This study, investigatied the occurrence, prevalence, and pathological impact of Diplectanum spp. in European seabass (Dicentrarchus labrax) across three distinct Egyptian fish farms. During 2021-2022, we sampled 1800 European seabass (Dicentrarchus labrax) from three Egyptian fish farms (600 fish per farm). Farms 1 and 2 used semi-intensive earthen pond systems, while Farm 3 utilized an intensive floating cage system. Employing Clinical, post-mortem, parasitological, and molecular examination technique. Pathological lesions were identified, including skin and gill discoloration, emaciation, and internal organ abnormalities. Seasonal prevalence exhibited significant variations between farms, with highest rates observed in spring and Farm 3 reached an overall peak prevalence of 84.67 %. Parasitological examination distinguished two Diplectanum species morphologically, while molecular techniques exhibited limited specificity. Histopathology unveiled damage to gill, liver, spleen, kidney, and intestine, attributed to Diplectanum haptors including inflammation and internal bleeding, potentially leading to secondary infections. Molecular identification via PCR targeting ITS and 28SrDNA genes, revealing similar band sizes for the two Diplectanum species, indicating limited intraspecific genetic diversity. The study emphasizes investigating parasitic infections' prevalence and impact in aquaculture, necessitating robust molecular techniques for species differentiation. This study underscores the importance of investigating the prevalence and impact of parasitic infections in aquaculture. It highlights the need for robust molecular techniques to differentiate species. By focusing on Diplectanum spp. infections in D. labrax, the study offers valuable insights into managing parasites in aquaculture effectively.

The association between serum progesterone and outcome of medical management of early fetal demise: a pilot study.

The study objective was to determine the relationship between serum progesterone level and the outcome of mifepristone-misoprostol regimen for medical management of missed miscarriage up to 12 weeks. A blood sample was collected just before mifepristone administration for serum progesterone assay. After 48 h, misoprostol 800 µg was administered vaginally; further 400 µg was administered 4 h later if necessary. Treatment was classed as a success if retained tissues were expelled within 72 h (Group 1), and a failure if this did not occur (Group 2). Of 52 analysed cases, complete medical evacuation occurred within 72 h in 40 (76.9%) women (serum progesterone ranged 13-90 nmol/l). Serum progesterone between the two groups were statistically significant (p < 0.001), by Mann-Whitney test. Of the 12 patients who did not respond, nine (75%) women had serum progesterone < 10 nmol/l. We found mifepristone-misoprostol regimen is less effective in missed miscarriage when serum progesterone is < 10 nmol/l.

Potentially avoidable emergency department attendance: interview study of patients' reasons for attendance.

OBJECTIVES: To explore the reasons for attendance at the emergency department (ED) by patients who could have been managed in an alternative service and the rate of acute admissions to one acute hospital. DESIGN: Interview study. SETTING: One acute hospital (University Hospitals of Leicester) in the East Midlands. PARTICIPANTS: 23 patients and/or their carers. METHODS: A purposive sample of patients attending the ED and the linked urgent care centre was identified and recruited. Patients in the sample were approached by a clinician and a researcher and invited to take part in an interview. Patients of different ethnicities and from different age groups, arriving at the ED via different referral routes (self-referral, emergency ambulance, GP referral, out-of-hours services) and attending at different times of the day and night were included. The interviews were recorded and transcribed with the individuals' permission and analysed using the framework analysis approach. RESULTS: Patients' anxiety or concern about the presenting problem, the range of services available to the ED and the perceived efficacy of these services, patients' perceptions of access to alternative services including general practice and lack of alternative pathways were factors that influenced the decision to use the ED. CONCLUSIONS: Access to general practice, anxiety about the presenting problem, awareness and perceptions of the efficacy of the services available in the ED and lack of alternative pathways are important predictors of attendance rates.

Comparative Studies on The Efficiency of Neem Leaves Azadirachta indica and Flubendazole Treatment Against Diplectanum in Sea Bass Dicentrarchus labrax.

PURPOSE: Diplectanum is a life-threatening metazoan infecting the gills of Sea bass Dicentrarchus labrax causing a wide-ranging extensive economic loss in the aquaculture sector. This study has focused on verifying the most effective non-toxic dose of the Neem (Azadirachta indica) and (flubendazole) bath treatment on infested D. labrax fingerlings. METHODS: In the first phase of the experiment, a total of 180 apparently healthy fingerlings were subdivided into six groups for each treatment. The tested concentrations were 0, 50, 100, 150, 200, and 250 mg L-1 for A. indica and 0, 10, 20, 30, 40, and 50 mg L-1 for flubendazole. The second phase was conducted for one week in five groups for each treatment. The first group was untreated healthy. The remaining groups were infested and received different concentrations of 0, 50, 100, and 150 mg L-1 & 0, 10, 20, and 30 mg L-1 for A. indica and flubendazole, respectively. RESULTS: The most toxic dose exhibited high mortality rates at 200 & 250 and 40 & 50 mg L-1 for A. indica and flubendazole, respectively. In the second phase of the experiment, the most effective dose was 150 and 30 mg L-1; for A. indica and flubendazole, respectively. They demonstrated the lowest mortality rates 20.00 & 20.00 %, prevalence rates 43.33 & 23.33%, and mean parasitic intensities were 2.35 & 2.00 accompanied by the highest therapeutic efficacy value 67.85 & 74.6% for both treatments; respectively. CONCLUSION: The most effective anthelmintic efficacy has been assigned for flubendazole and A. indica at 30 and 150 mg L-1.

Characteristics of general practices associated with emergency admission rates to hospital: a cross-sectional study.

OBJECTIVES: To identify characteristics of general practices associated with emergency hospital admission rates, and determine whether levels of performance and patient reports of access are associated with admission rates. DESIGN: A cross-sectional study. SETTING: Two primary care trusts (Leicester City and Leicestershire County and Rutland) in the East Midlands of England. PARTICIPANTS: 145 general practices. METHODS: Hospital admission data were used to calculate the rate of emergency admissions from 145 practices, for two consecutive years (2006/7 and 2007/8). Practice characteristics (size, distance from principal hospital, quality and outcomes framework performance data, patient reports of access to their practices) and patient characteristics (deprivation, ethnicity, gender and age), were used as predictors in a two-level hierarchical model, developed with data for 2007/8, and evaluated against data for 2006/7. RESULTS: Practice characteristics (shorter distance from hospital, smaller list size) and patient characteristics (higher proportion of older people, white ethnicity, increasing deprivation, female gender) were associated with higher admission rates. There was no association with quality and outcomes framework domains (clinical or organisation), but there was an association between patients reporting being able to see a particular general practitioner (GP) and admission rates. As the proportion of patients able to consult a particular GP increased, emergency admission rates declined. CONCLUSIONS: The patient characteristics of deprivation, age, ethnicity and gender are important predictors of admission rates. Larger practices and greater distance from a hospital have lower admission rates. Being able to consult a particular GP, an aspect of continuity, is associated with lower emergency admission rates.

Neonatal administration of tamoxifen causes disruption of myometrial development but not adenomyosis in the C57/BL6J mouse.

We previously demonstrated that in the CD-1 mouse, which exhibits a high incidence of age-related adenomyosis, neonatal exposure to tamoxifen induced premature uterine adenomyosis and was associated with abnormal development particularly of the inner myometrium. In the present study, we examined the effect of neonatal tamoxifen administration upon uterine development in the C57/BL6J mouse strain that is not known to develop uterine adenomyosis. Female C57/BL6J pups (n=20) were treated with oral tamoxifen (1 mg/kg) from age 1 to 5 days. Uteri from control and treated mice were obtained on days 5, 10, 15 and 42 of age. We examined sections histologically using image analysis and immunohistochemistry for alpha-smooth muscle actin (ACTA2, alpha-SMA), desmin, vimentin, laminin, fibronectin and oestrogen receptor-alpha (ESR1). Following tamoxifen exposure, all uteri showed inner myometrium thinning, lack of continuity, disorganisation and bundling. However, adenomyosis was not seen in any uterus. ACTA2 immunostaining was less in the circular muscle layer of treated mice. The temporal pattern of desmin immunostaining found in control mice was absent in tamoxifen-treated mice. There was no difference in the localisation of laminin or fibronectin between control and tamoxifen-treated groups. However, laminin immunostaining was reduced in the circular muscle layer of treated mice. Vimentin could not be detected in either group. In conclusion, our results demonstrate that the development of the inner myometrium is particularly sensitive to oestrogen antagonism, and is affected by steroid receptor modulation. Although tamoxifen induces inner myometrial changes including that of ACTA2, desmin, ESR1 and laminin expression in C57/BL6J neonatal mice similar to those induced in CD-1 mice, C57/BL6J mice did not develop premature adenomyosis. Thus, disruption of the development and differentiation of the inner myometrium cannot alone explain the development of tamoxifen-associated adenomyosis, and this must be dependent upon its interaction with strain-dependent factors.

The effects of tamoxifen and estradiol on myometrial differentiation and organization during early uterine development in the CD1 mouse.

We used a neonatal mouse model to examine the histogenesis of uterine adenomyosis, and to test whether adenomyosis is due to an abnormality in myometrial differentiation, or in extracellular matrix proteins expression. We also studied the effects of tamoxifen and estradiol on uterine development, myometrial differentiation, and organization. Female CD1 pups were treated with oral tamoxifen (1 mg/kg) (n=27) or estradiol (0.1 mg/kg) (n=24) from age 1 to 5 days. Uteri from control (n=27) and treated mice were obtained on days 2, 5, 10, 15, and 42 of age. We examined the sections histologically, using image analysis and immunohistochemistry for alpha-smooth muscle actin (alpha-SMA), desmin, vimentin, laminin, fibronectin, and estrogen receptor-alpha. Following tamoxifen exposure, all uteri showed adenomyosis by 6 weeks of age (seen as early as day 10). The inner myometrium showed thinning, lack of continuity, disorganization, and bundling. alpha-SMA expression was normal. Desmin expression normally showed a wave of maturation that was absent in tamoxifen-treated mice. In the estradiol group, adenomyosis was not observed. All uterine layers were normally developed, but hypertrophied. The inner myometrium retained its circular arrangement. There was no difference in the localization of laminin or fibronectin between groups (laminin expression was reduced in the tamoxifen treated uteri). Vimentin could not be detected in all groups. Our results suggest that the development of the inner myometrium is particularly sensitive to estrogen antagonism, and can be affected by steroid receptors modulation. Disruption of the inner myometrium may play a role in the development of uterine adenomyosis.

Late termination of pregnancy: a comparison of obstetricians' experience in eight European countries.

OBJECTIVE: To compare the experience and attitude of obstetricians in Europe towards late termination of pregnancy and the factors affecting their responses. DESIGN: Cluster sampling cross-sectional survey. All neonatal intensive care unit (NICU)-associated maternity units were recruited (census sampling) in Luxembourg, the Netherlands and Sweden. In France, Germany, Italy, Spain and the UK, units were selected at random. In every recruited unit, all obstetricians with at least 6 months' experience were invited to participate. SETTING: NICU-associated maternity units in eight European countries. POPULATION: Obstetricians with at least 6 months' clinical experience. METHODS: An anonymous, self-administered questionnaire was used. Multinomial logistic analysis was used to identify factors predicting the obstetricians' views about modifying the law governing late termination in their country. MAIN OUTCOME MEASURE: Obstetricians' experience of late termination of pregnancy and views about national policies. RESULTS: One hundred and five units and 1530 obstetricians participated (response rates 70 and 77% respectively). The most common indications for late termination were congenital anomalies and women's physical health. Feticide was not common except in France, Luxembourg and the UK. Active euthanasia of a liveborn was practiced in France and the Netherlands. Obstetricians in Germany were more likely to feel that late termination should be more severely restricted, the opposite was true in Spain and the Netherlands. In Italy, there was dissatisfaction with current status, but opinion was divided, reflecting views on both sides of the debate. CONCLUSIONS: This research outlines current practice in a difficult and sensitive area and suggests the need for more discussion and support for all those who were involved.

Survey of veterinary clients' perceptions of informed consent at a referral hospital.

This retrospective questionnaire study evaluates the perceptions of veterinary clients of the informed consent process and the consent form in a veterinary referral hospital. Replicating a validated perception survey from human medicine, 470 clients at the Queen Mother Hospital for Animals were surveyed on their perceptions during the consenting process through postal survey examining their understanding, experience and recall of informed consent. Of the 165 responses (35 per cent response rate), the majority of clients recalled the process and signing the form; however, half of the clients did not feel in control (51 per cent) or reassured (53 per cent) by the process. There was limited understanding of the purpose of consent, with 45 per cent thinking it removed their right to compensation for negligence and 31 per cent thought the veterinarian could do something different from the agreed procedure. Sixty per cent of clients did not read the form, as they trusted their veterinarian, but 33 per cent of clients felt frightened by the process. This survey highlights the need to understand the process of consent from the client's perspective, and adapt the consenting process to incorporate this into professional communication to ensure that the professional and contractual objectives of consent are met fully.

Identification of a cycle-modulated 200-kDa endometrial antigen by a monoclonal antibody LDS60.

We have developed a mouse monoclonal antibody, LDS60, against a cycle-dependent antigen by immunising (MF1 x BALB/c)F1 mice with a human endometrial membrane preparation. In formalin fixed paraffin embedded sections, LDS60 identified an epithelial specific antigen which exhibited a specific pattern of expression during the menstrual cycle. It was only occasionally expressed during the proliferative phase. During the early-secretory phase, there was intracytoplasmic staining in about half of the glands examined. This was in the form of small microvesicles, either near the base of the cell or supranuclear. In the mid-secretory phase the same proportion of glands exhibited staining in the form of micro-vesicles that were noted to accumulate nearer to the cell apices. In the late-secretory phase, there was no intracytoplasmic staining and the antigen was localised to the luminal border of the glandular epithelium and some staining appeared within the gland lumen of approximately 20% of glands. It is also diffusely expressed in some mucous secreting cells in the tongue, stomach and colon, as well as lung pneumocytes. The antigen has a molecular weight of approximately 200 kDa as identified by immunoblotting. This antigen exhibits similarities to MUC-1 which is involved in uterine receptivity and could therefore have a similar role. Its cycle modulation suggests that it could be used to monitor the uterine response to steroids.

The Leicester Endometrial Needle Sampler: a novel device for endometrial and myometrial junctional zone biopsy.

A 48-cm-long, fine (16 gauge) needle was purpose-built to our design for full-thickness endometrial sampling. It is driven by a high-speed cutting device that has a two-step action-loaded spring, and is adjusted to a penetration depth of 16 mm. Pain and tolerance were assessed on a visual analogue scale. The histologic diagnosis obtained by this device, the Leicester Endometrial Needle Sampler, was compared with that of Pipelle endometrial sampling in 40 patients at the end of panoramic hysteroscopy under local anesthesia. The patients' mean age was 51 years (range 39-60) and the mean parity was 2.4 (range 0-6). The mean (+/-standard deviation) pain score was 3.7 +/- 2.2 and the mean tolerability score was 4.4 +/- 3.6. The technique helped to procure a full-thickness endometrial biopsy in all cases, from targeted areas including the myometrial junctional zone, with 100% efficiency.

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.

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.

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.

Analysis of menstrual calendars and serum alpha 2-PEG in women on hormone replacement therapy for 12 months.

This study was conducted to assess endometrial protection in women on a cyclical combined hormone replacement regimen with 1 mg norethisterone BP, and to evaluate the use of the bleeding pattern and serum alpha 2-PEG in monitoring the endometrial response to exogenous hormone therapy. Fifty-one postmenopausal women attending the Menopause Research Unit at Leicester Royal Infirmary, UK, completed the study. All patients were at least 1 year after the menopause, with an average of 26 months since the last menstrual period. All women were prescribed a regimen of two tablets of Hormonin (oestriol 0.27 mg, oestrone 1.4 mg, and oestradiol 0.6 mg) continuously, with 1 mg of norethisterone added for 12 days out of each 28-day treatment cycle. Menstrual diaries were collected and analysed. The secretory changes were assessed by histology, menstrual bleeding pattern and a biological marker of secretory activity (alpha 2-PEG). Withdrawal bleeding occurred on average on days 11, 12, 11, 12 and 13 on months 2, 3, 6, 9 and 12, respectively. There was a poor degree of consistency in the bleeding pattern. The level of alpha 2-PEG increased from the average baseline measurement of 2.7 ng/ml (S.D., 4.12) to 8.5 ng/ml (S.D., 4.16) after progestogen treatment. This rise, although significant, did not correlate with the uterine bleeding pattern. There was no statistically significant correlation between the level of alpha 2-PEG and endometrial histology. The findings highlight the fact that cycle predictability on HRT, as exemplified in this regimen, is poor. The level of alpha 2-PEG is a poor predictor of the endometrial histology and has a poor correlation with the day of onset of bleeding.

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.

Thrombophilia and lipid profile in post-menopausal women using a new transdermal oestradiol patch.

OBJECTIVE: To assess the changes, over a 6-month period, in serum lipoproteins, apoproteins and coagulation factors, induced in post-menopausal women treated by a new transdermal oestradiol patch. METHODS: Fifty-three hysterectomised, healthy, post-menopausal women were treated by a new transdermal patch designed to deliver 50 micrograms of 17 beta oestradiol per day (Gynaderm, Shire Developments). One patch was applied twice weekly. RESULTS: Forty-two patients completed the study. There was no significant change in the level of total cholesterol, triglycerides, HDL or LDL. There was a significant rise in the level of ApoAI after 3 months on therapy but this was not sustained after 6 months; there was also a significant drop in the level of ApoAII after 6 months on treatment. The changes in ApoB and Lp(a) were not statistically significant. There was a significant drop in the level of antithrombin III and of protein S, and a significant rise in factor VII. The drop in the level of fibrinogen and of protein C were not statistically significant. CONCLUSION: The transdermal route of oestradiol administration causes minimal changes in lipoprotein metabolism. The statistically significant changes in the thrombophilia profile parallel those observed with oral HRT, but, similarly, may not reflect clinical significance. The potential of transdermal oestrogens as cardioprotective agents is yet to be determined.

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.

Home monitoring of blood pressure in pregnancy at high risk of pre-eclampsia.

The early detection of pre-eclampsia is a major challenge in obstetric care. We report a case where pre-eclampsia was detected by home blood pressure monitoring between routine antenatal visits. This novel management approach allows early diagnosis and optimises antenatal care in fulminating disease.

Characteristics of general practices associated with emergency-department attendance rates: a cross-sectional study.

BACKGROUND: Strategies are needed to contain emergency-department attendance. Quality of care in general practice might influence the use of emergency departments, including management of patients with chronic conditions and access to consultations. AIM: The aim was to determine whether emergency-department attendance rates are lower for practices with higher quality and outcomes framework performance and lower for practices with better patient reported access. DESIGN: A cross-sectional study. SETTING: Two English primary-care trusts, Leicester City and Leicestershire County and Rutland, with 145 general practices. METHOD: Using data on attendances at emergency departments in 2006/2007 and 2007/2008, a practice attendance rate was calculated for each practice. In a hierarchical negative binomial regression model, practice population characteristics (deprivation, proportion of patients aged 65 or over, ethnicity, gender) and practice characteristics (total list size, distance from the emergency department, quality and outcomes framework points, and variables measuring satisfaction with access) were included as potential explanatory variables. RESULTS: In both years, greater deprivation, shorter distance from the central emergency department, lower practice list size, white ethnicity and lower satisfaction with practice telephone access were associated with higher emergency-department attendance rates. CONCLUSIONS: Performance as indicated by the quality and outcomes framework did not predict rates of attendance at emergency departments, but satisfaction with telephone access did. Consideration should be given to improving access to some general practices to contain the use of emergency departments.