Estimating the balance of general practice versus family planning clinic coverage of contraception services in London

OBJECTIVE: To compare levels of provision of contraception from general practice and family planning clinics for the populations of the 32 London Boroughs. METHOD: Retrospective analysis of routine activity data, including the estimated numbers of first attendance, for 295 family planning clinics (managed by 28 NHS Trusts) and more than 1800 GP partnerships in Greater London, supplemented by data from a survey of family planning clinics. The results were expressed as the estimated percentage of women aged 16-49 obtaining advice on contraception from GPs and family planning clinics. These results were compared to those expected based on results in the General Household Survey. RESULTS: Across London in 1995/96, 12% of women aged 16-49 obtained contraception services from family planning clinics, and 24% obtained contraception services from a GP. At a borough level there was variation from 11% to 25% in coverage by family planning clinics, and from 11% to 41% in coverage by GPs. Estimates of the proportion of women in this age group not using NHS-provided medical or surgical contraception ranged from 0 to 30%. Across all boroughs, there was no consistent relationship between levels of GP activity and family planning clinic activity. CONCLUSION: The results indicate substantial variations between boroughs in the proportion of women using NHS-provided medical or surgical methods of contraception. The absence of any clear inverse relationship between activity in family planning clinics and activity in general practice suggests that changes to one will not be compensated by changes in the other. More specifically, health authorities that opt to purchase lower levels of family planning clinic activity cannot assume that women may opt to use GPs as an alternative. Such a strategy may increase the likelihood that women who would have used family planning clinic services will either not use contraception at all, or will use less effective 'over the counter' methods.     

Sildenafil: a urologist's view

Erectile dysfunction (ED) is a common problem with a multifactorial aetiology. The treatment of ED has been revolutionised by the introduction of intracavernosal injections some two decades ago. However, the recent development of the orally-administered drug sildenafil (Viagra) has had a major impact on the treatment of ED. We discuss the trials with sildenafil with special reference to cardiovascular risk factors associated with ED.     

The treatment of hypertension in patients with erectile dysfunction

Hypertension is another predictor of erectile dysfunction (ED). This is further evidence supporting a link between the pathogenesis of atherosclerotic disease and ED. In one study (TOMHS) involving hypertensive patients, the incidence of ED was 14.4%. The drugs used to treat hypertension may cause ED. However, there is little trial-based evidence to indicate which drugs are more likely to cause this side effect. In general, thiazide diuretics and beta-blockers seem to cause ED more often. In contrast, the alpha-blocker, doxazosin, has not been associated with an increased incidence of ED as a side effect. Doxazosin also improves urinary flow in patients with benign prostatic hyperplasia (BPH). This condition is common in elderly men as is hypertension and ED. Therefore, doxazosin may present a special advantage among this group of patients. This alpha-blocker would also be a good choice in patients with impaired glucose tolerance/diabetes because it improves insulin sensitivity. Moreover, ED and hypertension are more prevalent among diabetics. On a more speculative note, doxazosin may potentiate the therapeutic impact of specific treatments for ED.     

Chemical labyrinthectomy and cochlear implantation for Menière's disease--an effective treatment or a last resort?

The surgical management of Menière's disease presents a difficult and controversial problem and includes various procedures ranging from 'placebo operations' to vestibular nerve section. The situation is even more complex in the case where the only hearing ear is affected. We present a case of severe debilitating vertigo due to Menière's disease that was treated by chemical labyrinthectomy and cochlear implantation. This unique management strategy allowed restoration of useful hearing and relief of vertigo.     

Endoscopic resection of fibro-osseous lesions of the paranasal sinuses

Fibro-osseous tumors, including osteomas, ossifying fibromas, and fibrous dysplasia, are not uncommon benign lesions arising in the paranasal sinuses. Conventional wisdom advocates resection when these lesions are symptomatic, or when they exhibit rapid growth. Traditionally, resection has been performed via a variety of open approaches. With the advent of sinonasal endoscopy in the mid 1980s, and subsequent advances in technology and surgical techniques, endoscopic management of some of these lesions is now feasible. To date, a search of the literature reveals only three case reports of osteomas resected with endoscopic guidance. We present a series of 10 symptomatic fibro-osseous lesions (nine osteomas and one fibrous dysplasia) occurring in nine patients in which endoscopic techniques were used. Seven ethmoid and frontal recess osteomas were resected transnasally and one sphenoid sinus fibrous dysplasia was resected using a transseptal transsphenoidal approach with the assistance of direct endoscopic visualization. There were two anticipated CSF leaks that were recognized and repaired at the time of surgery. There were no other complications and no tumor recurrence. All patients noted improvement in preoperative symptoms. We discuss patient selection, operative techniques and strategies, and the advantages and disadvantages of the endoscopic approach in the management of paranasal sinus fibro-osseous lesions.     

Prediction of delivery among women with early preterm labor by means of clinical characteristics alone

OBJECTIVE: This study was undertaken to assess whether individual clinical factors or combinations thereof could be used to accurately predict the risk of delivery within 1 week of admission among women with preterm labor and minimal cervical dilatation. STUDY DESIGN: We performed a case-control study of patients admitted to our institution with preterm labor and minimal cervical dilatation. A case patient was a patient who sought treatment with uterine contractions between 24 and 34 weeks' gestation with cervical dilatation 70 potential predictors was recorded. Statistical analysis consisted of bivariate and multivariable methods. We also generated a multivariable clinical predictive model with the purpose of detecting a proportion as high as possible of those destined to be delivered within 1 week (high sensitivity). We estimated that we would need 50 case patients and 150 control subjects to detect an odds ratio of 2.5 for risk factors with a prevalence of 20%, an alpha error of.05, a beta error of.20, and a control subject/case patient ratio of 3:1. RESULTS: Three variables were eligible for inclusion in our logistic models according to the bivariate analyses-bleeding on admission, substance abuse, and admission white blood cell count >/=14,000 cells/microL. The simplest and most favorable model included only 2 variables, bleeding and substance abuse, and yielded a sensitivity of 46% and a specificity of 76%. The full 3-variable model had similar test characteristics. For no model were we able to achieve a sensitivity >/=50%. CONCLUSION: The results of this case-control study suggest that combinations of clinical factors do not yield an adequate level of discrimination to be used alone for predicting the likelihood of delivery within 1 week among patients with minimal degrees of cervical dilatation.     

Eating disorders and reproduction

Eating disorders are common and characteristically affect young women at what would otherwise be their peak of reproductive functioning. Anorexia nervosa and bulimia nervosa impinge on reproduction both behaviourally and physiologically, with effects on menstruation, ovarian function, fertility, sexuality and pregnancy. This review presents a summary of current knowledge and makes suggestions for future research, along with some clinical recommendations for the management of eating disorders in pregnancy.     

FLUDAP: salvage chemotherapy for relapsed/refractory aggressive non-Hodgkin's lymphoma

The aim of this study was to investigate the combination of fludarabine phosphate, dexamethasone, cytosine arabinoside and cis-platinum (FLUDAP) in the treatment of patients with relapsed/refractory aggressive non-Hodgkin's lymphoma (NHL). This regimen comprises: dexamethasone 100 mg/d continuous infusion (cont. inf.) d1-3; cytosine arabinoside (ara-C) 1 g/m2/d cont. inf. d 2,3; fludarabine phosphate 30 mg/m2 short inf. 4hr prior to each 24hr ara-C inf.; cis-platinum 50 mg/m2 4hr inf. at the start of each 24hr ara-C inf. G-CSF (lenograstim, Granocyte) is given at 263 microg s.c. daily from day 7 until the neutrophil count reaches 1.0x10(9)/l. The regimen repeats at 21 day intervals. A total of 33 patients were registered (median age 47 years; 24 males, 9 females); the majority (73%) were refractory to their previous treatment and most had advanced disease by Ann Arbor stage. Thirteen (39%) of the 33 enrolled patients (52% of the 25 fully evaluable patients who received at least 2 courses of FLUDAP) responded to treatment. A maximum response of complete remission was achieved in 5 patients, good partial remission in 3, and partial remission in 5. Twelve patients went on to successful stem cell supported intensification therapy. Median survival times were higher in the responding patients, and in those patients transplanted post-FLUDAP. The toxicity associated with the FLUDAP regimen was generally predictable; frequently reported severe events included haematological toxicity and infection. In conclusion, the FLUDAP regimen shows promise as a salvage regimen and increases the available therapeutic options in the treatment of recurrent/refractory aggressive NHL.