Search

Funder: Victorian Cancer Agency, Funder: NIHR Manchester Biomedical Research Centre, Funder: Cancer Research UK, Funder: Cancer Council Tasmania, Funder: Instituto de Salud Carlos III, Funder: Cancer Australia, Funder: NIHR Oxford Biomedical Research Centre, Funder: Fundación Científica de la Asociación Española Contra el Cáncer, Funder: Cancer Council South Australia, Funder: Swedish Cancer Society, Funder: NIHR Cambridge Biomedical Research Centre, Funder: Institut Català de la Salut, Funder: Cancer Council Victoria, Funder: Prostate Cancer Foundation of Australia, Funder: National Institutes of Health, BACKGROUND: Lynch syndrome is a rare familial cancer syndrome caused by pathogenic variants in the mismatch repair genes MLH1, MSH2, MSH6, or PMS2, that cause predisposition to various cancers, predominantly colorectal and endometrial cancer. Data are emerging that pathogenic variants in mismatch repair genes increase the risk of early-onset aggressive prostate cancer. The IMPACT study is prospectively assessing prostate-specific antigen (PSA) screening in men with germline mismatch repair pathogenic variants. Here, we report the usefulness of PSA screening, prostate cancer incidence, and tumour characteristics after the first screening round in men with and without these germline pathogenic variants. METHODS: The IMPACT study is an international, prospective study. Men aged 40-69 years without a previous prostate cancer diagnosis and with a known germline pathogenic variant in the MLH1, MSH2, or MSH6 gene, and age-matched male controls who tested negative for a familial pathogenic variant in these genes were recruited from 34 genetic and urology clinics in eight countries, and underwent a baseline PSA screening. Men who had a PSA level higher than 3·0 ng/mL were offered a transrectal, ultrasound-guided, prostate biopsy and a histopathological analysis was done. All participants are undergoing a minimum of 5 years' annual screening. The primary endpoint was to determine the incidence, stage, and pathology of screening-detected prostate cancer in carriers of pathogenic variants compared with non-carrier controls. We used Fisher's exact test to compare the number of cases, cancer incidence, and positive predictive values of the PSA cutoff and biopsy between carriers and non-carriers and the differences between disease types (ie, cancer vs no cancer, clinically significant cancer vs no cancer). We assessed screening outcomes and tumour characteristics by pathogenic variant status. Here we present results from the first round of PSA screening in the IMPACT study. This study is registered with ClinicalTrials.gov, NCT00261456, and is now closed to accrual. FINDINGS: Between Sept 28, 2012, and March 1, 2020, 828 men were recruited (644 carriers of mismatch repair pathogenic variants [204 carriers of MLH1, 305 carriers of MSH2, and 135 carriers of MSH6] and 184 non-carrier controls [65 non-carriers of MLH1, 76 non-carriers of MSH2, and 43 non-carriers of MSH6]), and in order to boost the sample size for the non-carrier control groups, we randomly selected 134 non-carriers from the BRCA1 and BRCA2 cohort of the IMPACT study, who were included in all three non-carrier cohorts. Men were predominantly of European ancestry (899 [93%] of 953 with available data), with a mean age of 52·8 years (SD 8·3). Within the first screening round, 56 (6%) men had a PSA concentration of more than 3·0 ng/mL and 35 (4%) biopsies were done. The overall incidence of prostate cancer was 1·9% (18 of 962; 95% CI 1·1-2·9). The incidence among MSH2 carriers was 4·3% (13 of 305; 95% CI 2·3-7·2), MSH2 non-carrier controls was 0·5% (one of 210; 0·0-2·6), MSH6 carriers was 3·0% (four of 135; 0·8-7·4), and none were detected among the MLH1 carriers, MLH1 non-carrier controls, and MSH6 non-carrier controls. Prostate cancer incidence, using a PSA threshold of higher than 3·0 ng/mL, was higher in MSH2 carriers than in MSH2 non-carrier controls (4·3% vs 0·5%; p=0·011) and MSH6 carriers than MSH6 non-carrier controls (3·0% vs 0%; p=0·034). The overall positive predictive value of biopsy using a PSA threshold of 3·0 ng/mL was 51·4% (95% CI 34·0-68·6), and the overall positive predictive value of a PSA threshold of 3·0 ng/mL was 32·1% (20·3-46·0). INTERPRETATION: After the first screening round, carriers of MSH2 and MSH6 pathogenic variants had a higher incidence of prostate cancer compared with age-matched non-carrier controls. These findings support the use of targeted PSA screening in these men to identify those with clinically significant prostate cancer. Further annual screening rounds will need to confirm these findings. FUNDING: Cancer Research UK, The Ronald and Rita McAulay Foundation, the National Institute for Health Research support to Biomedical Research Centres (The Institute of Cancer Research and Royal Marsden NHS Foundation Trust; Oxford; Manchester and the Cambridge Clinical Research Centre), Mr and Mrs Jack Baker, the Cancer Council of Tasmania, Cancer Australia, Prostate Cancer Foundation of Australia, Cancer Council of Victoria, Cancer Council of South Australia, the Victorian Cancer Agency, Cancer Australia, Prostate Cancer Foundation of Australia, Asociación Española Contra el Cáncer (AECC), the Instituto de Salud Carlos III, Fondo Europeo de Desarrollo Regional (FEDER), the Institut Català de la Salut, Autonomous Government of Catalonia, Fundação para a Ciência e a Tecnologia, National Institutes of Health National Cancer Institute, Swedish Cancer Society, General Hospital in Malmö Foundation for Combating Cancer.

Although there is good evidence that the progestogen-only injectable is associated with a decrease in bone mineral density (BMD), there is a lack of data pertaining to lower dose progestogen-only methods.1 2 The recent guidance from the Clinical Effectiveness Unit of the Faculty of Sexual and Reproductive Healthcare advises that current evidence is too limited to confirm or exclude an association between implant use and a reduction in BMD.3 Amenorrhoea results from suppression of ovarian follicle growth and of oestrogen secretion.4 It is therefore possible that amenorrhoeic women using any systemic progestogen-only contraception that suppresses ovarian activity may be more at …

INTRODUCTION: Unless women start effective contraception after using emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies that are unable to provide ongoing contraception (apart from barrier methods which have high failure rates). This means that women need an appointment with a general practitioner or at a sexual and reproductive health clinic. We conducted a pragmatic cluster randomised cohort crossover trial to determine whether or not pharmacist provision of a bridging supply of a progestogen-only pill plus the invitation to attend a sexual and reproductive health clinic resulted in increased subsequent use of effective contraception (hormonal or intrauterine). METHODS: Twenty-nine pharmacies in three UK cities recruited women receiving emergency contraception (levonorgestrel). In the intervention, women received a 3-month supply of the progestogen-only pill (75 µg of desogestrel) plus a card that provided rapid access to a local sexual and reproductive health clinic. In the control arm, pharmacists advised women to attend their usual contraceptive provider. The primary outcome was reported use of an effective contraception (hormonal and intrauterine methods) at 4 months. Process evaluation was also conducted to inform any future implementation. RESULTS: The study took place December 2017 and June 2019 and recruited 636 women to the intervention (n = 316) and control groups (n = 320). There were no statistically significant differences in demographic characteristics between the groups. Four-month follow-up data were available for 406 participants: 63% (198/315) of the control group and 65% (208/318) of the intervention group. The proportion of participants reporting use of effective contraception was 20.1% greater (95% confidence interval 5.2% to 35.0%) in the intervention group (58.4%, 95% confidence interval 48.6% to 68.2%) than in the control group (40.5%, 95% confidence interval 29.7% to 51.3%) (adjusted for recruitment period, treatment arm and centre; p = 0.011). The proportion of women using effective contraception remained statistically significantly larger, when adjusted for age, current sexual relationship and history of past use of effective contraception, and was robust to the missing data. There were no serious adverse events. CONCLUSION: Provision of a bridging supply of the progestogen-only pill with emergency contraception from a pharmacist and the invitation to a sexual and reproductive health clinic resulted in a significant increase in self-reported subsequent use of effective contraception. This simple intervention has the potential to prevent more unintended pregnancies for women after emergency contraception. TRIAL REGISTRATION: Current Controlled Trials ISRCTN70616901. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 27. See the NIHR Journals Library website for further project information.The emergency contraceptive pill can prevent pregnancy following unprotected sex or a burst condom; however, unless women start a regular method of contraception they remain at risk of pregnancy. Most women obtain emergency contraception from a community pharmacy (chemist), but then require an appointment with a general practitioner or at a sexual and reproductive health clinic for ongoing contraception. Getting an appointment can take time and unintended pregnancies can occur during this time. If a pharmacist could give women a small supply of a progestogen-only pill or ‘mini-pill’ with their emergency contraception, together with help to get an appointment at a clinic, then this might help more women to start effective contraception. We undertook a study in 29 pharmacies in Lothian, Tayside and London among women receiving emergency contraception. Pharmacists provided either their standard advice about contraception (control group) or the intervention. The intervention was a 3-month supply of the progestogen-only pill plus a rapid-access card, which, if presented at a sexual and reproductive health clinic, would help women get an appointment for contraception. The order in which the pharmacy provided either control or intervention was randomised. We conducted telephone interviews with the women 4 months later to find out what contraception they were using. A total of 636 women took part in the study, 316 in the intervention group and 320 in the control group. The proportion who said that they were using an effective method of contraception was around 20% larger in the intervention group. In addition, fewer women in this group said that they had used emergency contraception again. This study shows that community pharmacy provision of a small supply of progestogen-only pills and the invitation to attend a sexual and reproductive health clinic results in a large increase in the use of effective contraception after emergency contraception. If this became routine practice then it could help prevent unintended pregnancies.

BackgroundIn response to the COVID-19 pandemic, legislation and guidance were introduced in Scotland permitting medical abortion at home by telemedicine for pregnancies at less than 12 weeks’ gestation. Women had a telephone consultation with a clinician. Routine ultrasound was not performed. Medications and a low-sensitivity pregnancy test to confirm success of treatment were collected by or delivered to the woman, with telephone support provided as needed.MethodsA prospective cohort study of 663 women choosing medical abortion at home via the NHS Lothian telemedicine abortion service between 1 April and 9 July 2020. Interviewer-administered questionnaires were completed 4 and 14 days following treatment. Regional hospital databases were reviewed to verify abortion outcomes and complications within 6 weeks. Outcome measures included efficacy, complications and acceptability.ResultsAlmost all (642/663, 98.2%) the women were under 10 weeks’ gestation. For 522/663 (78.7%) women, gestation was determined using last menstrual period alone. Some 650/663 (98%) women had a complete abortion, 5 (0.8%) an ongoing pregnancy and 4 (0.6%) an incomplete abortion. No one was treated inadvertently beyond 12 weeks’ gestation, but one woman was never pregnant. One woman who had a pre-abortion ultrasound was later managed as a caesarean scar ectopic. There were two cases of haemorrhage and no severe infections. Some 123 (18.5%) women sought advice by telephone for a concern related to the abortion and 56 (8.4%) then attended a clinic for review. Most (628, 95%) women rated their care as very or somewhat acceptable.ConclusionsThis model of telemedicine abortion without routine ultrasound is safe, and has high efficacy and high acceptability among women.

BACKGROUND: Unless women start effective contraception after oral emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies. We hypothesised that pharmacist provision of the progestogen-only pill as a bridging interim method of contraception with emergency contraception plus an invitation to a sexual and reproductive health clinic, in which all methods of contraception are available, would result in increased subsequent use of effective contraception.METHODS: We did a pragmatic cluster-randomised crossover trial in 29 UK pharmacies among women receiving levonorgestrel emergency contraception. Women aged 16 years or older, not already using hormonal contraception, not on medication that could interfere with the progestogen-only pill, and willing to give contact details for follow-up were invited to participate. In the intervention group, women received a 3-month supply of the progestogen-only pill (75 μg desogestrel) plus a rapid access card to a participating sexual and reproductive health clinic. In the control group, pharmacists advised women to attend their usual contraceptive provider. The order in which each pharmacy provided the intervention or control was randomly assigned using a computer software algorithm. The primary outcome was the use of effective contraception (hormonal or intrauterine) at 4 months. This study is registered, ISRCTN70616901 (complete).FINDINGS: Between Dec 19, 2017, and June 26, 2019, 636 women were recruited to the intervention group (316 [49·6%], mean age 22·7 years [SD 5·7]) or the control group (320 [50·3%], 22·6 years [5·1]). Three women (one in the intervention group and two in the control group) were excluded after randomisation. 4-month follow-up data were available for 406 (64%) participants, 25 were lost to follow-up, and two participants no longer wanted to participate in the study. The proportion of women using effective contraception was 20·1% greater (95% CI 5·2-35·0) in the intervention group (mean 58·4%, 48·6-68·2), than in the control group (mean 40·5%, 29·7-51·3 [adjusted for recruitment period, treatment group, and centre]; p=0·011).The difference remained significant after adjusting for age, current sexual relationship, and history of effective contraception use, and was robust to the effect of missing data (assuming missingness at random). No serious adverse events occurred.INTERPRETATION: Provision of a supply of the progestogen-only pill with emergency contraception from a community pharmacist, along with an invitation to a sexual and reproductive health clinic, results in a clinically meaningful increase in subsequent use of effective contraception. Widely implemented, this practice could prevent unintended pregnancies after use of emergency contraception.FUNDING: National Institute for Health Research (Health Technology Assessment Programme project 15/113/01).

The progestogen-only intramuscular injectable Depo-ProveraExisting users of Depo-ProveraGlobal unavailability of the product during the study adversely affected recruitment and retention. 50 women were recruited. Only 48 injections were delivered at the pharmacy out of a possible 150 (34%). About 26 participants received no injections at the pharmacy and only seven (14%) participants received all three injections at the pharmacy. Participants reported mixed experiences, with some welcoming the intervention but others experiencing difficulty with pharmacist availability. Pharmacists were enthusiastic about this expansion of their role, and did not view their availability as a barrier to service delivery.Delivery of the subcutaneous contraceptive injectable from a community pharmacy may be feasible but availability of sufficient numbers of pharmacists trained in this technique is necessary for a robust model of service delivery.

Introduction We conducted a prospective health service evaluation to assess the feasibility and acceptability of routinely offering insertion of intrauterine contraception at cesarean section in a maternity setting in the UK. Material and methods One month before scheduled cesarean section, women were sent information about postpartum contraception including the option of insertion of an intrauterine contraception at cesarean. Women choosing intrauterine contraception (copper intrauterine device or levonorgestrel intrauterine system) were followed up in person at six weeks, and telephone contact was made at three, six and 12 months postpartum. Our main outcome measures were uptake of intrauterine contraception and complications by six weeks. Secondary outcomes were continuation and satisfaction with intrauterine contraception at 12 months. Results 120/877 women opted to have intrauterine contraception (13.7%), of which 114 were fitted. By six weeks, there were seven expulsions (6.1%). The expulsion rate by one year was 8.8%. There were no cases of uterine perforations and one case of infection (0.8%). Follow-up rates were 82.5% at 12 months, and continuation rates with intrauterine contraception at 12 months were 84.8% of those contacted. At 12 months, 92.7% of respondents asked were either ‘very’ or ‘fairly’ happy with their intrauterine contraception. Conclusions Routine provision of intrauterine contraception at elective cesarean for women in a public maternity service is feasible and acceptable to women. It is associated with good uptake and good continuation rates for the first year. This could be an important strategy to increase use of intrauterine contraception and prevent short inter-pregnancy intervals and unintended pregnancies.

IntroductionOral emergency contraception (EC) can prevent unintended pregnancy but it is important to start a regular method of contraception. Women in the UK usually access EC from a pharmacy but then need a subsequent appointment with a general practitioner or a sexual and reproductive health (SRH) service to access regular contraception. Unintended pregnancies can occur during this time.Methods and analysisBridge-It is a pragmatic cluster randomised cohort cross-over trial designed to determine whether pharmacist provision of a bridging supply of a progestogen-only pill (POP) plus rapid access to a local SRH clinic, results in increased uptake of effective contraception and prevents more unintended pregnancies than provision of EC alone. Bridge-It involves 31 pharmacies in three UK regions (London, Lothian and Tayside) aiming to recruit 626–737 women. Pharmacies will give EC (levonorgestrel) according to normal practice and recruit women to both intervention and the control phases of the study. In the intervention phase, pharmacists will provide the POP (desogestrel) and offer rapid access to an SRH clinic. In the control phase, pharmacists will advise women to attend a contraceptive provider for contraception (standard care).Women will be asked 4 months later about contraceptive use. Data linkage to abortion registries will provide abortion rates over 12 months. The sample size is calculated on the primary outcome of effective contraception use at 4 months (yes/no) with 90% power and a 5% level of significance. Abortion rates will be an exploratory secondary analysis. Process evaluation includes interviews with pharmacists, SRH clinicians and women. Cost-effectiveness analysis will use a healthcare system perspective and be expressed as incremental cost-effectiveness ratio.Ethics and disseminationEthical approval was received from South East Scotland REC June 2017. Results will be published in peer-reviewed journals and conference presentations.Trial registration numberISRCTN70616901.

IntroductionIn October 2017, Scotland legalised the home use of misoprostol for the purpose of early medical abortion (EMA). Women up to 9+6 weeks’ gestation can now self-administer the drug at home, 24–48 hours after receiving mifepristone in the clinic.ObjectiveTo evaluate the impact of this change on the uptake and success rate of EMA, and on the provision of effective contraception on discharge.MethodsA prospective observational study was conducted to compare the outcomes of two cohorts of women in the 6 months before and 6 months after the introduction of home administration of misoprostol. The main outcome measures were uptake of EMA, success of EMA and provision of long-acting reversible contraception (LARC) to women undergoing EMA.ResultsThere was a statistically significant increase in the uptake of EMA from 698/1075 (64.9%) women in the first study period to 823/1146 (71.8%) in the second study period. There was no statistically significant difference in the success rate of EMA: 99.3% and 98.9% in clinic and home misoprostol cohorts, respectively. There was also no statistically significant difference in the proportion of women provided with LARC: 37.7% and 33.7% in clinic and home misoprostol cohorts, respectively.ConclusionsSelf-administration of misoprostol at home increased uptake of EMA, with no effect on the high success rate that was previously seen with clinic administration of misoprostol. In addition, the reduced number of visits associated with home use of misoprostol has not affected the provision of effective contraception to women.

Background Community sexual and reproductive health (SRH) services are well placed to deliver abortion assessment services and early medical abortion (EMA), but comparative data on safety and acceptability from both settings are important for future service planning. Methods Retrospective review of computerised records of 1342 women undergoing outpatient EMA (≤9 weeks) in a community SRH or hospital department of gynaecology in the same city, and a self-completed, anonymous survey of 303 women requesting abortion at both sites. Primary outcome was safety in terms of re-attendance rates for a complication related to EMA. Secondary outcomes were telephone contact with each site for an EMA-related concern and satisfaction with information about abortion (defined as score out of 10) received at each site. Results There was no difference in re-attendance rates to either service for a complication following outpatient EMA (2.7%). A higher proportion of women undergoing EMA at the SRH site made telephone contact compared to women at the hospital site (18.8% vs 10.8%; p =0.033). Women rated both settings highly in terms of information received before abortion (9.2 and 9.6 out of 10) at the hospital and SRH sites, respectively. Conclusions This study suggests that provision of outpatient EMA in a community SRH setting is as safe as that delivered from a hospital setting, and that women are similarly satisfied with the information they receive about abortion from each setting. More abortion assessment and outpatient EMA services in Great Britain could shift from hospital to community SRH settings.

Background Pre-termination counselling is currently voluntary in the UK; however, there has been political debate regarding the introduction of mandatory pre-termination counselling as well as who should be providing the abortion counselling services. Objective To quantify the proportion of women who use pre-termination counselling services and to evaluate their experience. Method An anonymous self-administered questionnaire of women requesting an abortion at Chalmers Sexual Health Centre and the Royal Infirmary of Edinburgh NHS Lothian from 6 October to 2 December 2014. Results Only 18 (9%) of the 201 women surveyed reported using pre-termination counselling. The majority of women did not feel counselling was necessary because they were already certain of their decision. Nearly a quarter (22%) of women claimed to not know counselling was available. Women who did use counselling were satisfied with the services they received. The majority of counselling services were provided by the National Health Service and only one woman used a ‘pro-life’ charity. Women stated that they would prefer face-to-face counselling rather than telephone or Internet-based counselling. Conclusions Most women do not seem to want or need pre-termination counselling therefore policies aimed at mandatory counselling, would be contrary to women9s wishes. Counselling should be targeted at women with risk factors for psychological complications post-termination.

BackgroundThe phrase ‘termination of pregnancy’ has recently been adopted by a number of British medical institutions as a preferred descriptor of induced abortion. How it is used by abortion care providers is unclear, although the ongoing stigmatisation of abortion may play a role.MethodsA mixed methods study of the views of abortion care providers in Scotland, UK. Self-administered anonymous questionnaires were distributed to abortion care providers at a national conference (Scottish Abortion Care Providers). The main outcomes measured were the proportion of respondents reporting that they found the terms ‘abortion’ and ‘termination of pregnancy’ to be distressing, and their preferred terminology for use in consultations with women. In-depth interviews were conducted with 19 providers from a single clinic in Scotland to contextualise use of the terminology.ResultsThe questionnaire was completed by 90/118 delegates (76%). More respondents indicated they found the term ‘abortion’ distressing (28%), compared with those who found ‘termination of pregnancy’ distressing (6%; PConclusions‘Termination of pregnancy’ is the most commonly used term to describe induced abortion in patient consultations in Scotland. This and the term ‘abortion’ appear to play different roles, with the former being used euphemistically, and the latter as a more emphatic term. Further research is warranted to investigate how this interacts with patient care, service provision, and abortion stigma.

The consequences of mild traumatic brain injury (TBI) on neuronal functionality are only now being elucidated. We have now examined the changes in sensory encoding in the whisker-recipient barrel cortex and the brain tissue damage in the acute phase (24 h) after induction of TBI (n=9), with sham controls receiving surgery only (n=5). Injury was induced using the lateral fluid percussion injury method, which causes a mixture of focal and diffuse brain injury. Both population and single cell neuronal responses evoked by both simple and complex whisker stimuli revealed a suppression of activity that decreased with distance from the locus of injury both within a hemisphere and across hemispheres, with a greater extent of hypoactivity in ipsilateral barrel cortex compared with contralateral cortex. This was coupled with an increase in spontaneous output in Layer 5a, but only ipsilateral to the injury site. There was also disruption of axonal integrity in various regions in the ipsilateral but not contralateral hemisphere. These results complement our previous findings after mild diffuse-only TBI induced by the weight-drop impact acceleration method where, in the same acute post-injury phase, we found a similar depth-dependent hypoactivity in sensory cortex. This suggests a common sequelae of events in both diffuse TBI and mixed focal/diffuse TBI in the immediate post-injury period that then evolve over time to produce different long-term functional outcomes.

th , 2013; revised March 5 th , 2013; accepted March 15 th , 2013 Despite extensive research into the toll of persistent psychosocial stress on individual physiology and health, little is known about the effects of chronic biosocial stress for immigrant populations. In the pre- sent paper, the authors review challenges encountered when integrating minimally-invasive stress-related biomarkers (e.g., blood pressure, Epstein-Barr Virus (EBV) antibodies, C-reactive protein (CRP), and salivary cortisol), as well as anthropometric (e.g., height, weight, waist circumference) and metabolic measures (e.g., glucose, cholesterol), into research with Latino immigrant adults and families in Oregon, USA. Finally, the authors present lessons learned and discuss strategies to support the full engagement of Latino immigrants as participants in studies that rely on the collection of biological data as a central component of research into psychosocial stress and its effects.

Telephone follow-up with a self-performed low-sensitivity urine pregnancy (LSUP) test was introduced at the Royal Infirmary of Edinburgh, Scotland, as an alternative to routine ultrasonography for confirming successful abortion at 2 weeks following early medical abortion (9 weeks' gestation). Women who screened 'positive' at telephone follow-up on the basis of ongoing pregnancy symptoms, scant bleeding or LSUP test result subsequently attended the clinic for a confirmatory ultrasound.A service evaluation was conducted of the first 8 months of telephone follow-up consisting of a review of the numbers choosing this method of follow-up, the proportion successfully contacted and the efficacy for detecting ongoing pregnancies. In the last 3 months of the study, women were surveyed about their satisfaction with this method of follow-up.Opting for telephone follow-up were 476 out of 619 women (77%). Four women (1%) attended the clinic before telephone follow-up because of pain or bleeding. A total of 410 (87%) of the remaining 472 women were successfully contacted by telephone. Sixty women (15%) screened 'positive', three of whom had ongoing pregnancies, and one woman falsely screened 'negative'. The sensitivity of the telephone follow-up was 75% [95% confidence interval (CI) 30.1-95.4], and specificity was 86% (95% CI 82.2-89). The negative predictive value was 99.7% (95% CI 98.4-99.9), and positive predictive value was 5% (95% CI 1.7-13.7). All women surveyed (n=75) would recommend telephone follow-up to a friend.A telephone follow-up and an LSUP test at 2 weeks are effective for detecting ongoing pregnancy, have good follow-up rates and are popular choices for women.

Background A ‘fast-track’ referral system for intrauterine contraception was established in 2007 between the medical abortion service at the Royal Infirmary of Edinburgh and the principal family planning clinic (FPC) in Edinburgh. Methods Case note review of women fast-tracked for intrauterine contraception after medical abortion between January 2007 and June 2009. Main outcome measures were numbers of women referred, attendance rates, interval to insertion, devices chosen and known complication rates. Results Of the 237 women referred, 126 (53%) attended for intrauterine contraception insertion. Attenders were slightly but significantly older than non-attenders (mean ages of 30 and 27 years, respectively; p =0.003), less likely to live in an area of deprivation ( p =0.045) and were significantly more likely to have attended the FPC in the past ( p n =113) proceeded to have an intrauterine method inserted; 57% ( n =64) chose the levonorgestrel intrauterine system and 43% ( n =49) chose a copper intrauterine device. The median interval to insertion was 21 (range 0–54) days. Of those women ( n =55) who attended for routine follow-up 6 weeks later (49%), there were four (7.2%) cases of expulsion, two (3.6%) requests for removal and four (7.2%) cases of suspected infection. Conclusions Only half the women fast-tracked for intrauterine contraception actually attended and these tended to be women who were pre-existing clients of the FPC. Consideration should therefore be given to provision of immediate insertion where possible.

Background and methodology Research has shown that many women choosing an early medical abortion would prefer to be at home rather than in hospital to expel the pregnancy. A service was commenced at a hospital abortion service in Edinburgh, Scotland, UK that allowed women at up to 56 days9 gestation to be discharged home soon after misoprostol administration. During a 3-month period, an anonymous questionnaire of women9s experiences was conducted 1—2 weeks after the procedure. Results During the 3 months of the survey a total of 145 women chose to go home to abort. A total of 100 women completed questionnaires out of 145 (69%) distributed. The commonest reasons given for choosing to go home were: to get home sooner (53%) and to be in the privacy of one9s own home (47%). Most (81%) of the women stated that bleeding was either “as expected” (55%) or “not as bad as expected” (26%), and 58% of the women stated that the pain was “as expected” (40%) or “not as bad as expected” (18%). The majority (84%) of the women said that they would recommend this method to a friend. Discussion and conclusions Discharge home for the final stage of a medical abortion was highly acceptable to women. Since availability is not limited by hospital bed space, more women can be treated by medical methods.

Please cite this paper as: Cameron S, Glasier A, Muir A, Scott G, Johnstone A, Quarrell H, Oroz C, McIntyre M, Miranda D, Todd G. Expedited partner therapy for Chlamydia trachomatis at the community pharmacy. BJOG 2010;117:1074–1079. Objective Expedited partner treatment (EPT) for uncomplicated Chlamydia trachomatis at the pharmacy is an alternative approach to partner notification that has not yet been evaluated within the UK. The aim of this study was to evaluate EPT for partners using pharmacies in Lothian. Design A pilot study over 18 months. Setting Selected healthcare settings and community pharmacies in Lothian, Scotland, UK. Population Sexual partners of index cases with uncomplicated C. trachomatis. Methods Index cases with uncomplicated C. trachomatis were given a pharmacy voucher to pass onto sexual partners. Partners could redeem vouchers for free treatment (azithromycin) at one of 90 pharmacies in the area. Main outcome measures The main outcome measure was the proportion of vouchers redeemed. Secondary outcomes included patient satisfaction, as determined at a telephone follow-up of a subgroup of female index cases from one study site, 1 month later. Results In total 577 vouchers were issued to chlamydia-positive index patients of mean age 22.9 years (range 15–47 years). A total of 231 vouchers were redeemed (40%), at a median of 2 days after issue. Only 4% of partners attended a clinic for treatment. Most index patients surveyed reported that partners were satisfied with this method of treatment (48 out of 55; 87%). Conclusions Expedited partner treatment for uncomplicated chlamydia at a pharmacy is a popular choice, and increases options on where, when and how partners are treated.

Early identification and treatment of sexual partners of women with chalmydial infection is critical because of the high risk of reinfection primarily as a result of resumption of sex with an untreated partner. Management strategies used for identifying and testing sexual partners for possible infection include: (1) partner notification (patient referral) of the sexual partner to a clinic for testing and treatment; (2) patient-delivered partner medication (PDPM) which involves the delivery of antibiotics by the patient to sexual partners; and, (3) a postal testing kit which involves asking partners to mail a urine sample to a laboratory. To determine preference of patients and their sexual partners for one of these strategies, the investigators employed interviewer-conducted questionnaires in women and anonymous, self-administered questionnaires in men. The study subjects were women infected with chlamydia already participating in a study randomizing them to receive one of these strategies, and men attending genitourinary clinics, family planning clinics and hospital fracture clinics. The response rates for the women's questionnaire were 97% (174/180) at study entry and 81% (145/180) at 6-month follow up. For the men's questionnaire, the response rate was 81%. Over two-thirds of the women respondents (67%) preferred PDPM for their partner if given the choice; the majority (57%) also chose PDPM for themselves if a partner tested positive for Chlamydia. The most common reasons given by women for preference of PDPM were greater simplicity and convenience, and quicker treatment of partners. Ninety-three of 142 women (65%) reported that their partners were satisfied with whichever intervention they were randomized to receive. Of the 293 men who responded, 70% preferred patient referral for partners and 53% chose this intervention for themselves. PDPM was more likely to be the preference of men previously tested for Chlamydia (n = 22) compared to those never tested (n = 7) (P < 0.001). Less than 5% of women and 10% of men preferred postal testing kits for partners. The investigators conclude from these findings that PDPM appears to be more popular with women, and at least in theory, patient referral is more popular with men.

Background The aim of this study was to determine whether postal testing kits (PTKs) or patient-delivered partner therapy (PDPT) for partners of women with Chlamydia trachomatis reduce re-infection rates in women, compared with partner notification by patient referral. Methods Three hundred and thirty women testing positive for chlamydia, at clinics for genitourinary medicine, family planning and termination of pregnancy in Edinburgh, were randomized to one of three partner interventions: patient referral, PTK (partners post urine for testing) or PDPT (1 g azithromycin for partners). Women submitted urine for chlamydia testing every 3 months. The primary outcome was re-infection assessed as time to first positive result by the Cox proportional hazard regression. The proportion of partners tested or treated with each intervention was determined. Results Out of 330 women, 215 (65%) were retested over 12 months. There were 32 of 215 women (15%) who retested positive (7, 15 and 10 women from the patient referral, PTK and PDPT groups, respectively). There was no significant difference in re-infection between PDPT versus patient referral (HR 1.32, 95% CI 0.50-3.56), PTK versus patient referral (HR 2.35, 95% CI 0.94-5.88) or PDPT versus PTK (HR 0.55, 95% CI 0.24-1.24). There was no significant difference in the proportion of partners confirmed tested/treated between the patient referral (34%) and PTK (41%, P = 0.32) or PDPT (42%, P = 0.28) groups. Conclusions PTK and PDPT do not reduce re-infection rates in women with chlamydia compared with patient referral. However, PDPT may offer other advantages such as simplicity and cost compared with patient referral.

Objective To determine willingness of health professionals to adopt new interventions for treating sexual partners of women with chlamydia. Design Anonymous, self-administered questionnaires of doctors, practice nurses and community pharmacists regarding novel testing/treatment options for partners of women with chlamydia. Setting Local (Scotland) and national (UK) clinical meetings in reproductive health, and community pharmacy (Lothian). Population Doctors (general practice, gynaecology, family planning) and practice nurses who were delegates at selected meetings in reproductive health and community pharmacists attending pharmacy meetings. Methods Doctors and nurses were invited to complete a questionnaire indicating their preferred strategy for testing/treating sexual partners of women with chlamydia if given choice of partner notification, postal testing kit (PTK), patient delivered partner medication (PDPM) with azithromycin or combined PDPM and PTK. Community pharmacists were invited to complete a questionnaire regarding their willingness to introduce chlamydia testing and treatment services. Main outcome measures Reported preferences of doctors and nurses for partner testing/treatment strategies and willingness of pharmacists to offer new services. Results Questionnaires were completed by 211 doctors, 73 practice nurses and 50 pharmacists. The most popular choice of doctors (30%) and nurses (23%) was a combination of PDPM with PTK, with partner notification the least popular (8 and 3%, respectively). One in four doctors had previously used PDPM for treating partners. Most pharmacists were willing to supply free PTKs (98%), offer testing (75%) and treatment services (100%) and give women PDPM for partners (80%). Conclusion Relevant health professionals, who are increasingly involved in managing chlamydia, are largely in favour of introducing new strategies for treating sexual partners.

Uptake of the most effective long-acting reversible methods of contraception (LARC) immediately after abortion has been shown to reduce a woman's risk of further abortion. We aimed to compare the uptake of LARC at abortion services from a hospital department of obstetrics and gynaecology and a specialist contraceptive setting of a community sexual and reproductive health (SRH) service within the same city.Retrospective database review of women (n=2473) requesting abortion who were assessed at either a community SRH service or a hospital department of obstetrics and gynaecology, in the same UK city over a period of 1 year. The main outcome measures were immediate post-abortal uptake of LARC from each site.A higher proportion of women assessed at the SRH service received LARC after abortion [50.2%; 95% confidence interval (CI) 0.47-0.53%] compared to those attending the hospital site (39.2%; 95% CI 0.36-0.42%; p0.0001). Amongst women having an outpatient early medical abortion, LARC uptake at the SRH was twice that of the hospital setting (48.4% vs 23.3%; p0.0001).Higher uptake of immediate post-abortal LARC was observed amongst women who were assessed at the specialist contraceptive service in the community SRH setting compared to the hospital setting. Further research is required to determine the reasons for these observations since all abortion services should provide the same high-quality contraceptive service to women undergoing abortion.

Introduction Throughout Great Britain, increasing numbers of women having an early medical abortion are choosing to go home soon after administration of misoprostol, to expel the pregnancy at home (early medical discharge, EMD), rather than remain upon the hospital premises (day case). However, data are lacking on how this impacts upon an abortion service in terms of unscheduled re-attendance rates and contraception provision at discharge. Methods A retrospective audit was carried out of women undergoing medical abortion (up to 64 days9 gestation) over 9 months at a National Health Service hospital in Scotland, to determine (1) unscheduled re-attendance rates within 6 weeks of the procedure for an abortion-related complication and (2) method of contraception provided at discharge. Results Over the audit period 1128 women had an early medical abortion of whom 590 (52%) chose EMD. There was no significant difference in unscheduled re-attendance rates between EMD ( n =23, 4%) and day case groups ( n =20, 4%). There was no significant difference in the proportion of women in each group who left hospital with an effective method of contraception ( n =362, 61% and n =355, 60% for EMD and day case groups, respectively). Conclusions Women undergoing early medical abortion who choose to expel the pregnancy at home are no more likely to re-attend hospital with a post-abortal complication and are just as likely to receive effective contraception than those who remain on hospital premises.

Background Subcutaneous depo-medroxyprogesterone acetate (DMPA-SC) offers the possibility of self-administration. Study Design This is a pilot study of self-administration of DMPA-SC. Existing users of the intramuscular preparation (DMPA-IM) who wished to self-inject ( n =64) were taught self-administration using DMPA-SC. The main outcome was the continuation rate of the method at 12 months compared to a control group of existing users of DMPA-IM ( n =64) who continued to attend a clinic to receive the method. Women's satisfaction with the method and the proportion of self-injections given at correct time were also determined. Results The 12-month discontinuation rate of the DMPA-SC group (12%) did not differ significantly from that of the DMPA-IM group (22%) (95% confidence intervals of 13%���33% and 6%���23% for DMPA-SC and DMPA-IM, respectively; p=.23). All self-injections were given within the appropriate interval. There was no significant difference in the proportion of women in either group who were satisfied with the method. Conclusion Self-administration of DMPA-SC for contraception is feasible and is associated with similar continuation rates and satisfaction to clinician-administered DMPA-IM.

Background A consultation for emergency contraception (EC) gives way to an opportunity to provide women with an ongoing effective method of contraception. Study Design A review of the case notes of women seeking EC from a large family planning clinic in Edinburgh, Scotland, was conducted to determine what percentage of women were provided with an effective method of ongoing contraception. Results Case notes of 460 women presenting for EC over a 2-year period were reviewed. Women were of mean age 26 years (range 15���49 years) and presented because they had used no contraception (47%), experienced condom failure (42%) or missed oral contraceptive pills (9%). Only 2% ( n =11) were given an intrauterine device for EC. All women who had missed contraceptive pills prior to taking EC opted to continue this method. Only 23% ( n =89) of women using no method or condoms at EC received supplies of an effective contraceptive method (pills, patch, injectable). Two thirds ( n =263) of the women chose condoms for ongoing contraception. Conclusion Research is required to develop strategies to improve the uptake of effective contraception after EC.

Please cite this paper as: Cameron S, Glasier A, Muir A, Scott G, Johnstone A, Quarrell H, Oroz C, McIntyre M, Miranda D, Todd G. Expedited partner therapy for Chlamydia trachomatis at the community pharmacy. BJOG 2010;117:1074–1079. Objective Expedited partner treatment (EPT) for uncomplicated Chlamydia trachomatis at the pharmacy is an alternative approach to partner notification that has not yet been evaluated within the UK. The aim of this study was to evaluate EPT for partners using pharmacies in Lothian. Design A pilot study over 18 months. Setting Selected healthcare settings and community pharmacies in Lothian, Scotland, UK. Population Sexual partners of index cases with uncomplicated C. trachomatis. Methods Index cases with uncomplicated C. trachomatis were given a pharmacy voucher to pass onto sexual partners. Partners could redeem vouchers for free treatment (azithromycin) at one of 90 pharmacies in the area. Main outcome measures The main outcome measure was the proportion of vouchers redeemed. Secondary outcomes included patient satisfaction, as determined at a telephone follow-up of a subgroup of female index cases from one study site, 1 month later. Results In total 577 vouchers were issued to chlamydia-positive index patients of mean age 22.9 years (range 15–47 years). A total of 231 vouchers were redeemed (40%), at a median of 2 days after issue. Only 4% of partners attended a clinic for treatment. Most index patients surveyed reported that partners were satisfied with this method of treatment (48 out of 55; 87%). Conclusions Expedited partner treatment for uncomplicated chlamydia at a pharmacy is a popular choice, and increases options on where, when and how partners are treated.

This study assesses the effect of using different phonological units on parsing a given string of phonemes into words in a continuous speech recognizer. It is shown that when an input utterance is encoded using a representation intermediate between the broad-classes, in Huttenlocher & Zue 1984, and the 44 phonemes of Received Pronunciation, the input can be parsed into more than 10 million different word-strings; and that even when all 44 phonemes are implemented, some input utterances can still be parsed into in excess of 10 000 different word-strings. The results suggest that there is insufficient information in a mid-class representation for post-lexical processing to identify the target word-string.

This paper reflects the view that the decoding of speech, either by computer systems or people, must to a large extent be determined by the ways in which the speaker has encoded the information necessary for its comprehension. We therefore place great emphasis on the use of psycholinguistics as a tool for the construction of models essential to the characterisation of the speech understanding task.We are primarily concerned with the interactions between the various levels at which a fragment of speech can be described (e.g. acoustic-phonetic, lexical, syntactic, etc), and the ways in which the knowledge bases associated with each of these "levels" contribute towards a final interpretation of an utterance. We propose to use the Chart Parser as a general computational framework for simulating such interactions, since its flexibility allows various models to be implemented and evaluated.Within this general framework we discuss problems of information flow and search strategy in combining evidence across levels of description and across time, during the extension of an hypothesis. We stress the importance of both psychological and computational theory in developing a particular control strategy which could be implemented within the framework.

The language of speculation journals and the teaching of English journals and the arts and humanities journals and the quantitative disciplines.