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Introduction: The Gynaecology Physiotherapy Assessment Service (GPAS) pilot program was implemented in October 2015. It is an initiative designed to improve the clinical outcomes for women, referred to the Gynaecology Department at the Women's and Children's Hospital (WCH), who have symptoms of incontinence (urinary and/or anal) and pelvic organ prolapse, or a combination of these conditions. Prior to implementation, women referred with these conditions were triaged in the Gynaecology Department as low priority (despite being a high priority for physiotherapy input) and often waited in excess of six months for an appointment with the gynaecology team to become available, at which point they were required to 'opt in' to the health service. Once they were seen in the gynaecology clinic, if appropriate, they were then referred to Women's Health Physiotherapy to trial a period of conservative treatment (usually 4-6 months of therapy, generally equating to 5-6 occasions of service) before surgical management was considered. The GPAS model was designed with the goals of improving the patient journey and clinical outcomes, while ensuring better use of the medical staff and to provide a more cost effective health service. By implementing a physiotherapy-led assessment service, women who were unlikely to require surgical management or would, at the very least, require a trial of conservative treatment prior to this were diverted from the waitlist to see a gynaecologist and were instead, seen in a more timely manner by a postgraduate trained senior physiotherapist. Materials & method: An extensive consultation process was undertaken in June 2015 involving key stakeholders of the pilot project from the Gynaecology, Physiotherapy and Women's Outpatient departments at the Women's and Children's Hospital. Information was also gathered from interstate colleagues with experience in implementing and evaluating similar models of advanced scope of practice in women's health physiotherapy roles. Executive approval for the pilot program was granted in September 2015 and the GPAS clinic commenced in October 2015 after careful consideration of logistical requirements. The weekly GPAS clinic was set up to run alongside a Gynaecology Consultant Clinic to ensure adequate access to the senior gynaecology registrar and staff specialist for clinical opinions and supervision as required. Colocation in the Women's Outpatient Department facilitated open communication lines between the key stakeholders. Staff and patient resources were developed to support and guide service delivery in the GPAS clinic. A key resource was the GPAS information sheet which was created for patients triaged into the GPAS pathway to outline the advantages of this model of care and importance of early physiotherapy intervention for conditions such as pelvic organ prolapse and incontinence. It was felt that it was not only important to inform patients that their first point of contact would be with a physiotherapist rather than a medical practitioner but that the opportunity to provide an early explanation of the benefits of conservative physiotherapy management may contribute to a more positive reception to the clinic. A letter was also sent to the referring medical caregiver explaining the fasttracking of the patient for physiotherapy assessment in GPAS (while they concurrently remained on the gynaecology waiting list). The validated, self-administered version of the Australian Pelvic Floor Questionnaire (APFQ) was produced in a patient friendly format and sent to patients prior to attendance at the GPAS clinic.1 By repeating this outcome measure at the second or third physiotherapy consultation appointment and again on discharge, meaningful data on clinical outcomes will be able to be collated and reported. The other outcome measure tool used throughout the 6-month pilot program was a satisfaction survey, designed specifically to analyse the patient's experience in GPAS. Ethics approval was granted by the Women's and Children's Health Network Human Research Ethics Committee in July 2015 to enable data collection for analysis of the GPAS pathway (audit 798A) and patient satisfaction for the GPAS cohort (audit 796A). A database was created to record patient demographic information for those accessing the GPAS pathway, map the patient journey from the date of medical caregiver referral to discharge from physiotherapy and/or gynaecology, and record the clinical outcome measures obtained for each patient. Ethics approval was also granted to conduct a retrospective audit to determine the patient journey for a cohort of women who met GPAS inclusion criteria but who followed the traditional referral pathway prior to the establishment of GPAS (audit 797A) to allow for comparison of the two models of care. Results: During the period 1 October 2015 to 24 March 2016, 21 clinics ran with a total of 52 patients identified as appropriate for the GPAS pathway by the triaging member of the gynaecology team. Of these, 41 women (79%) from the gynaecology waitlist were assessed in GPAS, all of whom were appropriate for referral to the Physiotherapy Department to commence conservative management. Feedback on the GPAS consult was received via 30 confidential and voluntary evaluation forms and was overall extremely positive, with 100% of respondents rating the overall quality of care they received as very good to excellent. During the GPAS pilot, the average length of time between general practitioner (GP) referral to GPAS appointment was 27.3 days (range 8 to 62 days) compared with 169.6 days (range 49 to 351 days) for GP referral to gynaecology clinic appointment during the pre-GPAS audit period. The quickest individual pathway from GP referral to physiotherapy input (via GPAS) was 42 days and the longest pathway was 151 days, with an average of 75.3 days. In contrast, data from the pre-GPAS audit showed the quickest pathway to physiotherapy input (via gynaecology) was 64 days and the longest was 402 days. The time constraints of the pilot program evaluation report and the time required to achieve an adequate trial of conservative management has limited the ability to report on the clinical success of this pathway. What is evident is that 100% of eligible patients were able to access a trial of conservative physiotherapy management, compared to only 50% in the pre-GPAS audit, and this access was provided in a timely manner. Adherence to the conservative management pathway improved in the GPAS cohort at the time of the review. Attendance at the compulsory preliminary group education session -- the "Pelvic Floor Class" - was 78.6% for GPAS patients, compared with 64.5% in the pre-GPAS audit. Most pleasingly, was the number of women persevering with the conservative management pathway and attending their individual consultation appointment following group attendance - with attendance figures for individual appointments rising from 55% in the pre-GPAS cohort to 90% in the GPAS cohort. Conclusions: The GPAS pathway resulted in an improved patient journey for women referred with incontinence and/or pelvic organ prolapse symptoms, with much more timely screening of patients and a significantly faster pathway to access conservative physiotherapy management. Access to conservative management for eligible women rose from 50% to 100%, meaning that, in line with best practice evidence, these women should proceed to a more favourable outcome whether they do go on to require surgical and/or medical input or not. Furthermore, the GPAS pathway appeared to reduce the natural patient attrition rate which can sometimes be seen with the slower, more arduous task of rehabilitation (as a component of conservative physiotherapy management) when it is compared to the perceived 'quick fix' of surgery. Though we cannot comment on clinical outcomes of the GPAS pathway at this point in time, it is our hope that improved access to conservative management through a faster, more patient friendly pathway, will translate to more positive clinical outcomes for these women. [ABSTRACT FROM AUTHOR]

The rosetting of sheep erythrocytes (SRBC) coated with non-haemagglutinating monoclonal antibodies rather than conventional haemagglutinating antisera revealed readily detectable FcR on most splenic natural killer (NK) cells since 76% of splenic lymphocytes forming conjugates with YAC also rosetted with SRBC coated with high concentrations of monoclonal anti-SRBC antibody of the IgG2b subclass and since Ficoll depletion or enrichment of splenic lymphocytes rosetting with IgG2b-coated SRBC resulted in a corresponding 4-fold decrease or increase in conjugate-forming cells and a 10-fold decrease or increase in NK cylolytic activity. NK cells bound much less readily to monoclonal IgG2a and not at all to monoclonal IgG1 or IgM. but the degree of binding was directly proportional to the amount of antibody on the erythrocytes and was not isotype-restricted. In addition, immunofluorescent studies revealed that YAC-1-conjugated lymphocytes were Lyt-1 , Lyt-2 , partially Thy-1 (60%) asialo-GM1+ (80%), Qa-4+ (77%), Qa-5+ (79%), and Ly-5+ (94%). In comparison, a proportion (39%) of alloimmune peritoneal exudale cells which conjugated with P815-2 also stained by immunofluorescence with anti-asialo GM1 antisera. Most (>90%) P815-conjugated cells were Thy-1+, Lyt-2+, and a subpopulation of Lyt-1+2+ conjugates was observed (25%). Qa-5 and Ly-5 were also expressed on most (two-thirds) cytolytic T lymphocytes (CTL) conjugates, whereas Qa-4 and FcR for IgG2b were not detected. The best phenotypic distinctions between NK cells and CTL were therefore based on the presence or absence of Lyt-2, Qa-4, and FcR for IgG2b on most effector cells, Anti-asialo-GM1 or monoclonal anti-Qa-4 and complement treatment greatly diminished both the frequency of NK conjugates and the percentage of conjugates with detectable IgG2b FcR or asialo-GM1. These results confirm that NK cells co-express asialo-GM1 and Fc receptors, at the single-cell level, and provide a simple method for greatly enriching NK populations at least 10-fold. [ABSTRACT FROM AUTHOR]