Local Gynecologists Research Articles

Steel magnolias - shared telehealth for multidisciplinary gynecologic cancer survivorship: an innovative model for addressing geographic barriers to guideline adherent survivorship for rural patients (136)

Objectives: Geographic disparities are linked to suboptimal cancer care. We aimed to describe our experience with our Shared TElEheaLth for MultidisciplinAry GyNecOLogIc cAncer Survivorship (SM) program with regards to financial toxicity, patient satisfaction, and travel burden. We also performed initial comparisons to rural patients who traveled to our clinic. Methods: After IRB approval, women in remission and on surveillance from gynecologic cancer living in a rural region with no practicing gynecologic oncologist were approached for enrollment after a clinic visit. After consent, the Patient Satisfaction Questionnaire Short Form 18 (PSQ-18) and the Comprehensive Score for Financial Toxicity- Functional Assessment of Chronic Illness Therapy (COST FACIT) questionnaires were administered. Women in the SM program were seen in person by a gynecologist close to home with a concomitant hospital-supplied tablet-based virtual visit by a gynecologic oncologist to address cancer-related survivorship issues. Others surveyed traveled (T) for surveillance to visit our gynecologic oncologists in person. Fisher’s exact tests were used for categorical comparisons and Wilcoxon Rank-Sum tests for continuous comparisons. Conclusions: We describe our initial experience with an innovative hybrid-virtual surveillance visit concept. Collaboration with the patients’ local gynecologists allowed for an in-person gynecology visit with an in tandem tablet-based gynecologic oncology session during the same visit. In this diverse, rural patient population, we demonstrated that this novel survivorship care delivery model resulted in fewer miles and shorter time traveled for patients. Financial toxicity was high overall. There were no early signals that financial toxicity or patient satisfaction was compromised. A considerable portion of the women we served reported a lack of access to amenities necessary for travel or self-guided telemedicine visits. We were able to overcome many of these transportation and technology barriers with the STEEL MAGNOLIAS program, ensuring more equitable delivery of gynecologic oncology care in the survivorship period. Objectives: Geographic disparities are linked to suboptimal cancer care. We aimed to describe our experience with our Shared TElEheaLth for MultidisciplinAry GyNecOLogIc cAncer Survivorship (SM) program with regards to financial toxicity, patient satisfaction, and travel burden. We also performed initial comparisons to rural patients who traveled to our clinic. Methods: After IRB approval, women in remission and on surveillance from gynecologic cancer living in a rural region with no practicing gynecologic oncologist were approached for enrollment after a clinic visit. After consent, the Patient Satisfaction Questionnaire Short Form 18 (PSQ-18) and the Comprehensive Score for Financial Toxicity- Functional Assessment of Chronic Illness Therapy (COST FACIT) questionnaires were administered. Women in the SM program were seen in person by a gynecologist close to home with a concomitant hospital-supplied tablet-based virtual visit by a gynecologic oncologist to address cancer-related survivorship issues. Others surveyed traveled (T) for surveillance to visit our gynecologic oncologists in person. Fisher’s exact tests were used for categorical comparisons and Wilcoxon Rank-Sum tests for continuous comparisons. Conclusions: We describe our initial experience with an innovative hybrid-virtual surveillance visit concept. Collaboration with the patients’ local gynecologists allowed for an in-person gynecology visit with an in tandem tablet-based gynecologic oncology session during the same visit. In this diverse, rural patient population, we demonstrated that this novel survivorship care delivery model resulted in fewer miles and shorter time traveled for patients. Financial toxicity was high overall. There were no early signals that financial toxicity or patient satisfaction was compromised. A considerable portion of the women we served reported a lack of access to amenities necessary for travel or self-guided telemedicine visits. We were able to overcome many of these transportation and technology barriers with the STEEL MAGNOLIAS program, ensuring more equitable delivery of gynecologic oncology care in the survivorship period.

Access to Fertility Care in Geographically Underserved Populations, a Second Look.

Infertility has a prevalence of up to 16% worldwide and is on the rise in developed nations, largely due to pursuing childbearing at advanced reproductive ages. Advances in assisted reproductive technology have benefitted socioeconomically advantaged patients disproportionately. High costs of fertility care are largely responsible for this disparity; however, patients in rural areas also face barriers in accessing both gynecology and reproductive endocrinology subspecialty care. Here, focusing on the USA, we discuss fertility care in geographically underserved areas and low-resource settings, and the impact on reproductive outcomes. Increased innovation to improve patient access to fertility care such as assisted reproductive technology is critical for ensuring equity. Remote monitoring is frequently performed by fertility centers, but partnership with local gynecologists has also been demonstrated to be an effective assisted reproductive technology monitoring method. Telehealth is now in mainstream use and the continued application to reduce geographic barriers to infertility patients is imperative. Partnership between local gynecologists and reproductive endocrinology and infertility specialists may improve patient access to fertility care and provide the unique benefits of continuity and ongoing local social support.

Pelvic organ prolapse surgical training program in Bangladesh and Nepal improves objective patient outcomes

Introduction and hypothesisThe DAK Foundation (Sydney) has facilitated pelvic organ prolapse (POP) repairs performed by local gynecologists for underprivileged women in Bangladesh and Nepal since 2014. Initially, there was no long-term patient follow-up. When 156 patients were examined at least 6 months after their surgery, an unacceptably high rate of prolapse recurrence and shortened vaginas was identified. This demonstrated the need for surgical up-skilling in both countries. Our hypothesis is that the introduction of a surgical training program in low-resource countries can significantly improve patient outcomes after pelvic floor surgery.MethodsOne-on-one surgical re-training was undertaken to up-skill the gynecologists in fascial vaginal repair and vaginal apical reconstruction utilizing sacrospinous fixation (SSF). Following the surgical up-skilling, a further 289 women (between 6 and 18 months post-operatively) were examined to determine patient outcomes. Outcome measures were:Prolapse recurrence: POPQ (pelvic organ prolapse quantification [1]) ≥ stage 2Vaginal length < 4 cmResultsPrior to implementation of the surgical training program, 76% of patients had recurrent prolapse ≥ stage 2, and 56% had a vagina < 4 cm in length. Following the training program, prolapse recurrence was reduced to 45% with significant reductions in the apical, anterior and posterior compartments. The incidence of unacceptable vaginal shortening was 4%. We could not rely on patient symptoms to determine whether they had recurrences.ConclusionClinical patient follow-up to determine surgical outcome is essential in low-resource settings. We have demonstrated that surgical up-skilling in vaginal hysterectomy, vaginal repair and introduction of SSF were necessary to achieve acceptable prolapse recurrence rates in our programs in Bangladesh and Nepal.

Von Willebrand Disease Minimize Menorrhagia (VWDMin) Trial

Von Willebrand Disease Minimize Menorrhagia (VWDMin) Trial

Fistula Prevention Awareness

Aim: Genital tract fistula is a known tragedy in Pakistan. We know the causes of this tragedy and we also know the methods to eradicate this curse from the community. Despite the initiative from UNFPA, Islamic Development Bank and other concerned stake holders the government of Pakistan has failed to address the issue and an organized system is not developed to reduced maternal death rate and maternal morbidity in Pakistan. It’s a common practice to exploit the sad situation of victims of fistula and run ghost campaigns to eradicate genital tract fistula from the community.&#x0D; Methods:In depth analysis on intersections of social inequities in health, polices in Pakistan. The review carried out on the available literature / reports around the theme of women health &amp; rights responsiveness in health systems. This analysis also includes the role and support of the donor agencies working on maternal health in Pakistan. &#x0D; Results: An overall unfairness prevailing in the healthcare system which is affecting women health resulting a very high maternal mortality ratio (MMR) maternal morbidity like fistula. The health policy is a highly complex phenomenon needs a multi-disciplinary approach to develop public policy that aims to explain the interaction between institutions, interests and ideas in the policy process. Health policies must reflect the specific steps to address the issue of gender based discrimination.&#x0D; Conclusion: The politics of fistula is serving people to become rich in vested interest group, its providing platform to governments to make their image in front of donor countries. It’s also providing opportunity to people working in donor agencies to get involve in corruption at the cost of poor patients of fistula. Prevention of fistula is ultimate goal to get rid of this morbidity need department of health for provision of basic health facilities specially availability of SBA BUT there is no such policy intervention to produce competent midwives local community level. The existing fistula cases are not treated at district level due to lack of skill of local gynecologists to repair the fistula at district level.

PP101 A Procedural Method For Networking Local And Regional Stakeholders

INTRODUCTION:In 2015, the province of Québec, Canada went through a major restructuration in its healthcare system which resulted in regional institutional merging. Our hospital-based Health Technology Assessment (HTA) unit is now part of a large network comprising fourteen institutions covering an area of 12,734 km2. This new organizational context poses major challenges in terms of addressing various local needs and for involving stakeholders into our assessments. In this paper we present how we addressed these difficulties.METHODS:This case study presents the procedural method we developed for involving local and regional stakeholders into an HTA concerning the need to extend a regional prenatal ultrasound screening program. We describe how we collected local data and networked local to regional stakeholders for producing the assessment and recommendation.RESULTS:After completion of the literature review on first trimester ultrasound screening, local data from each institution were collected using a combination of focus group meetings with local managers, gynecologists and ultrasound technologists. Overall, fifteen people were consulted on diverse regional sites, including two services users. In order to assess the perception of the results regarding efficacy, users preferences, cost and organizational impact of expanding the screening program, people were asked to complete an online survey. The results of this survey were then used to write a first draft of a recommendation. A second survey was generated in order to obtain agreement of the fifteen people regarding the recommendation. Overall, this method decreased the time required to complete the assessment and reduced project operating costs. However, divergence of opinions may be difficult to resolve by this method and many rounds of consultation may be needed.CONCLUSIONS:Our procedural method using a combination of focus groups and online surveys for collecting local and regional data and opinions from stakeholders and support recommendation, has succeeded to provide well contextualized information for supporting a decision.

Patients with Postpartum Depression in Gynaecological Practices in Germany - Results of a Representative Survey of Local Gynaecologists about Diagnosis and Management.

For the sake of pre-emptive child protection it is necessary to recognise signs of postpartum depression (PPD) in pregnant women and young mothers as early as possible and to initiate adequate assistance. Because of their high acceptance, especially in the phases of pregnancy and birth, the local gynaecologists offer ideal prerequisites for access to the parents. This study evaluates the current status of diagnosis and management of PPD in gynaecological practices. In a representative German nation-wide questionnaire survey taking the regional distribution into account n = 3000 local gynaecologists were selected at random and contacted by post. The questionnaire addressed their approaches to the diagnosis and management of PPD as well as the encountered barriers. Among the n = 1034 participating gynaecologists (response rate: 35 %) half of them dealt actively with PPD; 16 % used a questionnaire for this purpose. Consultation by the gynaecologist (84 %) or referral to therapists or hospitals (86 %) were among the most common interventions in the management of PPD. A need for improvement in the management of women with PPD was recognised equally often. As barriers the gynaecologists mentioned above all the lack of time, the low reimbursements for consultations and the lack of effective treatment options. Predictors for an active anamnesis were found to be female gender of the gynaecologist, possession of an additional psychosomatic qualification and practice located in an urban catchment area or state of the former West Germany. The results clearly demonstrate a high acceptance for the management of PPD by gynaecologists as well as the need for further action to improve the care of patients with PPD in gynaecological practices.

Vacuum-assisted breast biopsies (VAB) carried out on an open 1.0 T MR imager: Influence of patient and target characteristics on the procedural and clinical results

PurposeThe study was conducted in order to assess the clinical impact of MRI-guided vacuum-assisted breast biopsies carried out using an open 1.0T open MRI-system. Material and methodsThe clinical, imaging, interventional and histological data of all 132 patients with a first MRI-guided vacuum-assisted breast biopsy carried out between 07/2005 and 03/2012at the Radiological Department were extracted from the clinical files. The clinical outcome of patients with benign histological findings was assessed based on the clinical files and queries of the local gynecologists in charge. In the 103 interventional image data sets available target localization and target size were evaluated by two board-certified senior radiologists. Clinical data, lesion characteristics and interventional results were evaluated statistically using subgroup analyses. Results131 of 132 MRI-guided breast biopsies (99.2%) were carried out successfully. The median interventional duration was 30min (25%-percentile 25min, 75%-percentile 35min, maximum 75min). Minor complications occurred in 12 interventions of the 131 (9.2%). The histological work-up of the biopsy specimen showed benign results in 98 of 131 interventions (74.8%), lesions with uncertain biological potential in 5 biopsies (3.8%) and malignant findings in 28 biopsies (21.4%). There were 2 false negative histological findings. Neither the patient age nor the medical history nor the anticipated risk of developing breast cancer had an impact on the success rates and the complication rates. In the 103 interventions with available image data sets the maximum target lesion diameters were 1–5mm in 16 lesions (15.5%), 6–10mm in 41 lesions (39.8%) and 11–15mm in 29 lesions (28.2%). There was a positive correlation between the maximum diameters and the rate of malignancy of the target lesions (p=0.020) as well as a trend towards longer interventional procedure durations in smaller target lesions (p=0.183). ConclusionMRI-guided vacuum-assisted breast biopsy for suspicious breast lesions is a clinically safe and feasible method even in small target lesions when using an open high-field MRI-system.

Pragmatic prevention, permanent solution: Women's experiences with hysterectomy in rural India

Hysterectomy appears to be on the rise amongst low-income, rural women in India as routine treatment for gynaecological ailments. This paper explores the individual, household, socio-economic and health system factors that influenced women's decisions to undergo hysterectomy in rural Gujarat, with a focus on women's perspectives. Interviews were conducted with 35 rural, low-income women who had undergone hysterectomy, local gynaecologists and other key informants, alongside observation of daily life and health-related activities. Inductive, open coding was conducted within a framework analysis to identify thematic influences on the decision to undergo hysterectomy. Women underwent hysterectomy at an average age of 36, as treatment for typically severe gynaecological ailments. I argue that women, faced with embedded social inequality in the form of gender biases, lack of labour security and a maternal-centric health system, demonstrated pragmatic agency in their decision to remove the uterus. When they experienced gynaecological ailments, most sought two to three opinions and negotiated financial and logistical concerns. The health system offered few non-invasive services for non-maternal health issues. Moreover, women and health care providers believed there is limited utility of the uterus beyond childbearing. Women's responsibilities as caretakers, workers and producers drove them to seek permanent solutions that would secure their long-term work and health security. Thus, hysterectomy emerged as a normalised treatment for gynaecological ailments, particularly for low-income women with limited resources or awareness of potential side effects. In this setting, hysterectomy reflects the power structures and social inequalities in which women negotiated medical treatment – and the need to reverse a culture of permanent solutions for low-income women.

P3.037 High Prevalence of Genital Warts Among Young Women in Italy

BackgroundWorldwide, several million cases of genital warts occur each year. The objective of this study was to estimate the prevalence and the incidence of external genital warts (eGW) in a...

Vaginal mesh repair: is it appropriate for pelvic organ prolapse in a nulliparous female following pelvic ring fracture?

Pelvic organ prolapse (POP) in a nulliparous woman is a rare sequela of high-energy pelvic trauma. We report a case of a 26-year-old nulliparous woman who developed stage III pelvic organ prolapse two decades after pelvic ring disruption. Abdominal wall cervicopexy was performed as a primary procedure by her attending local gynecologist. Recurrence occurred in early postoperative period following which she was referred to our institute. Examination revealed 5-cm pubic symphysis widening and stage III pelvic organ prolapse with deficient perineal body. Widened levator hiatus with atrophic pelvic floor muscles were confirmed on MRI. The patient was successfully managed by sacrospinous hysteropexy using predesigned vaginal mesh kit along with anterior colporrhaphy and colpoperineorrhaphy. Mesh exposure detected at the 6th year of follow-up required partial excision of the exposed mesh.

A case of usual (basaloid)-type vulvar intraepithelial neoplasia that failed to respond to imiquimod cream: clinical implications

The authors report a case of usual-type (basaloid-type) vulvar intraepithelial neoplasia (VIN) 3 that failed to respond to imiquimod cream. A 51-year-old Japanese woman visited her local gynecologist complaining of vulvar itching. Atypical cells were noted in cytology smears, but nine vulvar biopsy specimens showed benign proliferation of epithelial tissue. The patient was placed under careful observation for 8months, when the vulvar smears once again showed atypical cells and biopsy specimens revealed VIN3. The patient was then referred to our hospital where she was given a diagnosis of VIN 3, basaloid type of usual type. The biopsy specimens were positive for p16 and the lesions were confirmed to be human papilloma virus (HPV)-related. We recommended simple vulvectomy but the patient requested conservative treatment with imiquimod cream. With her written informed consent, we prescribed imiquimod cream to be self-administered 3 times a week. Colposcopy and pap smear test were performed every 2weeks. Four weeks after the start of treatment, a fingertip-sized papule was detected at the patient's vaginal introitus. By 6weeks, the lesion had enlarged, and biopsy specimens revealed invasive squamous cell carcinoma. At 7weeks, we performed simple vulvectomy. The surgical specimen showed stage pT1b keratinizing-type squamous cell carcinoma. HPV-16 DNA was detected in the specimen.

Recurrent Vulvar Itching

CASE: A 25-year-old woman requests a second opinion about management of recurrent vaginal infections. Her local gynecologist suspects a “resistant infectious process” because the patient has recurrent vulvovaginal discharge and irritation despite the use of “various topical and oral anti-infectives.” Over the past 18 months, she has been treated with 7 courses of antibiotics, with either a brief response or no improvement of her symptoms. On questioning, the patient describes severe intermittent vulvar burning, intermittent itching, and constant mild-to-moderate vulvar pain. Additionally, she notes occasional dysuria and urinary frequency, but urine cultures have been negative. She denies urinary or fecal incontinence. Although she is currently using no medications or over-the-counter products, over the past half year she has used metronidazole and clindamycin vaginal creams, clindamycin vaginal ovules, Burow’s solution (Bayer Consumer Care, Morris Township, NJ) soaks, over-the-counter vaginal moisture solution, perineal cleansing pads, and panty shields with baking soda. Her medical history is remarkable for migraines and a laparoscopic tubal ligation. She is married, monogamous, and does not smoke, drink alcohol, or use illicit drugs. The patient reports using the following household products: scented dryer sheets, various laundry detergents depending on which is on sale, deodorant soap, scented liquid body wash, and topical lubricating jelly before intercourse. On examination (Fig.1), the vulva is markedly erythematous, without lesions, ulcerations, or excoriations. The skin markings are exaggerated, and there is mild edema. When the labia minora are separated, significant erythema is noted. The vestibule is also erythematous. Microscopy is normal, without yeast, clue cells, trichomonads, or inflammatory changes. The maturation is normal, and lactobacilli are present. A yeast culture is subsequently found to be negative. The woman is referred to a specialist in vulvar disease.

Theory-based identification of barriers to quality improvement: induced abortion care

The UK Royal College of Obstetricians and Gynaecologists published the clinical guideline, The Care of Women Requesting Induced Abortion, to address recognized variations in care. There is little empirical evidence on factors that influence compliance with the guideline. A better understanding of such factors is needed for quality improvement initiatives. To identify factors that influence compliance with two key guideline recommendations: offer of an assessment appointment within 5 days of referral, and supply of contraceptives at discharge. Thirteen hospital gynaecology units in Scotland. Guideline compliance was measured by a case note review. Barriers and facilitators were identified using a combination of approaches: semi-structured interviews with local gynaecologists and a survey of clinical staff. The questionnaire, based upon constructs from the Theory of Planned Behaviour, measured behavioural intention, attitude, subjective norm (perceived social pressure), and perceived behavioural control. Of 507 cases reviewed, median unit compliance was 46% for the assessment appointment and 59% for contraceptive supplies. Questionnaires were returned by 151 (74%) of 205 staff in 12 units. The interviews and open-ended questions highlighted organizational barriers to guideline implementation. Staff generally had strong intentions and positive attitudes to follow both recommendations. For the assessment appointment, perceived behavioural control was low. The Theory of Planned Behaviour accounted for 27% of the variation in intentions, with subjective norm being the strongest predictor. Intention and perceived behavioural control best explained unit compliance, together explaining 15% of the variation. For contraceptive supplies, the theory accounted for 34% of the variation in intentions, with perceived behavioural control being the strongest predictor. Clinical staff were highly motivated to implement the guideline but hindered by organizational constraints. Quality improvement initiatives need to target organizational barriers as well as individual professionals.

A Nationwide Analysis of Complications Associated With the Tension-Free Vaginal Tape (TVT) Procedure

This study presents a series of all patients in Finland who underwent the tension-free vaginal tape (TVT) procedure for urinary stress incontinence before the end of 1999. Data regarding numbers of operations and complication rates were collected via questionnaires sent to the 38 hospitals whose staff were trained to perform TVT. The process for teaching this operation was carefully planned. First, urogynecologists from four of the five university hospitals in Finland underwent an extensive training program held at the fifth hospital, where this procedure was developed. Each doctor was approved to perform the procedure only after the main instructor visited his or her facility and observed the local team at work through several TVT operations. The university hospital-based urogynecologist was authorized to train local gynecologists after successfully performing 20 TVT operations with no major problems in 6 months of follow-up. Eventually, a TVT-certified urogynecologist was on the staff at all central and local hospitals in Finland. In all, there were 1455 TVT operations performed in Finland by the end of 1999. The overall rate of complications was 255 per 1000 procedures, including 206 per 1000 in university hospitals, 253 per 1000 in central hospitals, and 283 per 1000 in local hospitals. In the 1455 cases, there were five major complications that required laparotomy (case of arterial bleeding, two undetected bladder perforations, one vesicovaginal fistula, and one case of severe urinary retention) and 362 minor complications that necessitated some form of intervention. Intraoperative blood loss greater than 200 ml was noted in 27 patients (incidence 19/1000). Five cases resolved with minimal vaginal packing. Manual compression, intravenous tranexamic acid, and/or blood transfusion were required in three women. One woman underwent laparotomy for arterial bleeding behind the symphysis with removal of the TVT tape. Bladder perforation occurred in 56 women (38/1000). In 39 cases, the injury was recognized by cystotomy. The TVT needle was removed and reinserted in 36 of these; in 2 others interruption of the operation was required. One perforation was so near the urethral orifice that the TVT tape had to be removed. Nine perforations were noted after the TVT needle had been pulled through the bladder, requiring removal of the tape in two cases and partial removal (behind a midline cut) with reattachment of new tape in seven cases. In six women, the injury to the bladder was not recognized at the time of surgery. The TVT tape had to be partially or wholly removed in all of these patients. Injury of the epigastric vessel injury, which was treated with simple ligation, occurred in one patient. One woman sustained an injury of the obturator nerve that caused her to limp and led to adhesion formation at the Achilles tendon. Surgical evacuation was required for treatment of vagina hematoma in one patient, and the TVT procedure was interrupted in another patient because of a urethral lesion. Postoperatively, 34 women experienced complete urinary retention, with only 1 persisting beyond 3 months (incidence 23/1000). Minor voiding difficulties were reported by 111 patients (incidence 76/1000), 108 of whom resolved spontaneously or with conservative treatment. Two patients were treated by cutting the TVT tape at the midline, and one resolved after 4 months of repeated catheterization.

Necrotizing genital ulcerations in a premenarcheal female with mononucleosis

<h3>Background</h3> Two cases of genital ulceration caused by Epstein-Ban virus(EBV) have p-evicudy been reported, one in a sexually active 23 year-old and another in a 14 year-old practicing cunnilingus. <h3>Case</h3> A 13 year-old premenarcheal Caucasian female developed vulvar ptin and edema several days after symptoms of mild pharyngitis and fatigue. She was seen first by a local gynecologist who diagnosed her with herpes and treated her with topical and parenteral Zovirax. Bilateral necrotizing ulcerations of her labia minora developed within five days of this treatment and preceded oral lesions by nine days. Cultures for gonorrhea, chlamydia, HSV and aerobic bacteria were negative. She was admitted to the hospital for ten days and treated with intravenous Cefoxitin, sharp detridements and aggressive local care. Given mild. malaise. an alkaline phosphatase elevated to 248(with a normal GGT) and 5% atypical lymphocytes, a monospot was ordered and returned positive. Viral capsid antigen specific antibodies drawn 6 days after lesions appeared were IGM 1:217 and IGG 1:889. Repeat liters 10 days later were 1:35 and 1:1051 respectively. Antibody titers to early antigen (EA) were 1:20 and to nuclear antigen (EBNA) were 1:277. Vulvar pathology was noospecific. Tissue from the ulcer base was insufficient to perform PCR of EBV or to evaluate the presence of the virus in the epithelium. The patient was discharged on oral Augmentin, Nystatin suspension, analgesics ar local care. After 25 days, her vulvar ulcerations were less than 1mm. deep and preroarin cream was initiated to minimize labial agglutination. This was continued for two weeks at which time, healing was complete. She never developed cervical adenopathy, fever or hepatosplenomegaly. She adamantly denied sexual activity but admitted to "french(oral)kissing.". <h3>Conclusion</h3> Genital ulcerations can be the initial manifestation of EBV in adolescents neither sexually active nor immuno compromised. EBV was not likely inoculated onto our patient's genitalia. We postulate that she was exposed to EBV via saliva and that the virus hematologically spread to the vulva. There the virus replicated inside of either infected B-lymphocytes and/or epithelial cells and caused cytotysis evidenced as labial ulcerations.

Physicians' perception of urinary incontinence as a health care problem in women

A mailed questionnaire was sent to 1500 family physicians and general practitioners in Ontario, Canada, to determine the primary care physician's perception of urinary incontinence as a health care problem. Questions involved their exposure to female patients with urinary incontinence, management of urinary incontinence, estimation of the extent of urinary incontinence as a health care problem, and the estimation of treatment success. The response rate to the survey was 18%. Fifty per cent of physicians see more than 1 patient per week with incontinence; 85% of physicians underestimated the prevalence of incontinence in the female population aged 25–64; 29% do not routinely ask about incontinence. In those patients complaining of urinary incontinence, 71% of physicians perform a physical examination and 32% try to demonstrate incontinence. Seventy per cent refer on to local urologists, and 58% to local gynecologists. The mean estimation for cure or significant improvement is 68%. It was concluded that, there is room for improved education of primary care physicians regarding the health care problem of female urinary incontinence.

The organisation of abortion services

The availability and genuine accessibility of abortion varies widely throughout the United Kingdom depending mainly on the commitment and interests of local gynaecologists. In most districts in England and Wales availability falls far short of that recommended by successive governments. Arguments can be made in support of the provision of abortion either as part of general gynaecology services or within dedicated units. Within each district one consultant should have a special responsibility for all aspects of fertility control including abortion. The establishment of a service for medical termination of pregnancy in each district is desirable and may reduce the burden on surgical gynaecology. Medical abortion is only available to women referred in early pregnancy, so that efficient referral is in the interests of the patient and the service. This may be best achieved by some form of centralisation of appointments.

ALTERNATIVE PATHWAYS FOR ABORTION SERVICES

The interests of women seeking abortion and of doctors opposed to abortion are best served by alternative referral abortion facilities. Of 22 area health authorities in England with day-care gynecology in 1977, only 13 had day-care abortion units. The 2 abortion charities were doing about 3 times as many abortions as all National Health Service Hospitals put together. At day-care abortion facilities, part-time nurses and doctors sympathetic to abortion are supportive to women in a vulnerable situation. There is no pressure for valuable hospital beds. Women being treated for infertility are not housed next to abortion patients. Resources are not available for women seeking abortion under the 1967 Abortion Act. In 1 district 66% women succeeded in obtaining their abortion through the National Health Service (NHS). Over half the women in Wessex had to go to another region to obtain abortions. Many local gynecologists have conscientious objections to abortion. Subcontracting or referral of NHS patients to charitable organizations running day-care facilities is one answer to the lack of facilities.