The epidemiology of HIV infection in Zambia.

Population surveys of health and fertility are an important source of information about demographic trends and their likely impact on the HIV/AIDS epidemic. In contrast to groups sampled at health facilities they can provide nationally and regionally representative estimates of a range of variables. Data on HIV-sero-status were collected in the 2001 Zambia Demographic and Health Survey (ZDHS) and made available in a separate data file in which HIV status was linked to a very limited set of demographic variables. We utilized this data set to examine associations between HIV prevalence, gender, age and geographical location. We applied the generalized geo-additive semi-parametric model as an alternative to the common linear model, in the context of analyzing the prevalence of HIV infection. This model enabled us to account for spatial auto-correlation, non-linear, location effects on the prevalence of HIV infection at the disaggregated provincial level (nine provinces) and assess temporal and geographical variation in the prevalence of HIV infection, while simultaneously controlling for important risk factors. Of the overall sample of 3950, 54% was female. The overall HIV-positivity rate was 565 (14.3%). The mean age at HIV diagnosis for male was 30.3 (SD=11.2) and 27.7 (SD=9.3) for female respectively. Lusaka and Copperbelt have the first and second highest prevalence of AIDS/HIV (marginal odds ratios of 3.24 and 2.88, respectively) but when the younger age of the urban population and the spatial auto-correlation was taken into account, Lusaka and Copperbelt were no longer among the areas with the highest prevalence. Non-linear effects of age at HIV diagnosis are also discussed and the importance of spatial residual effects and control of confounders on the prevalence of HIV infection. The study was conducted to assess the spatial pattern and the effect of confounding risk factors on AIDS/HIV prevalence and to develop a means of adjusting estimates of AIDS/HIV prevalence on the important risk factors. Controlling for important risk factors, such as geographical location (spatial auto-correlation), age structure of the population and gender, gave estimates of prevalence that are statistically robust. Researchers should be encouraged to use all available information in the data to account for important risk factors when reporting AIDS/HIV prevalence. Where this is not possible, correction factors should be applied, particularly where estimates of AIDS/HIV prevalence are pooled in systematic reviews. Our maps can be used for policy planning and management of AIDS/HIV in Zambia.

Determinants of post-partum maternal mortality at Queen Elizabeth Central Hospital, Blantyre, Malawi: a case-control study 2001-2002.

The aim of this research is to identify the clinical, demographic and service-based determinants of postpartum maternal mortality within Queen Elizabeth Central Hospital, Blantyre, Malawi, during 2001 and 2002. The study uses a case-control design using all postpartum maternal deaths in 2001 and 2002 as cases, with analysis conducted using conditional logistic regression. The results indicate that the mothers' reason for admission into hospital and the outcome of the birth were significantly related to maternal death when analysing all potential explanatory variables in one model. A group of high-risk mothers can be identified using these factors. If these criteria were applied as a predictive tool in the clinical setting the resulting sensitivity and specificity would be over 85%. Identification within the hospital setting of a group of very high-risk mothers in whom serious complications are aggressively managed in a coordinated way across the medical specialties may reduce maternal mortality.

Determinants of post-partum maternal mortality at Queen Elizabeth Central Hospital, Blantyre, Malawi: a case-control study 2001-2002

The aim of this research is to identify the clinical, demographic and service-based determinants of postpartum maternal mortality within Queen Elizabeth Central Hospital, Blantyre, Malawi, during 2001 and 2002. The study uses a case-control design using all postpartum maternal deaths in 2001 and 2002 as cases, with analysis conducted using conditional logistic regression. The results indicate that the mothers' reason for admission into hospital and the outcome of the birth were significantly related to maternal death when analysing all potential explanatory variables in one model. A group of high-risk mothers can be identified using these factors. If these criteria were applied as a predictive tool in the clinical setting the resulting sensitivity and specificity would be over 85%. Identification within the hospital setting of a group of very high-risk mothers in whom serious complications are aggressively managed in a coordinated way across the medical specialties may reduce maternal mortality (Afr J Reprod Health 2008; 12[3]:35-48)

Doctors and the chronic pelvic pain patient.

Many women with chronic pelvic pain (CPP) turn out not to have any identifiable pathology despite having undergone multiple investigations. There is no consensus as to the best management for women in this group. Although a multidisciplinary approach to diagnosis and care has been advocated as best practice, it is costly and not practical in most units in the United Kingdom, and many other countries. Clinicians need to be aware of the importance of attitude and medical consultation as factors influencing patients' outcome from investigation and treatment. While consulting styles reflect the individual personality of the doctor, we need to be aware of our own underlying attitudes and how these might enter into the dynamics of the consultation. Some patients may want to have open, non-directive consultations, some more directive consultation styles. It is, therefore, essential for the physicians to identify patients' expectations or preferences and then try to meet them, in order to attain "concordance" in communication. In this chapter, we will examine some studies that relate to the doctor-patient relationship in women with CPP.

Dyspareunia and urinary sensory symptoms in India: population-based study.

INTRODUCTION: Population level estimates of sexual dysfunction in less developed settings where sexuality is not openly discussed or is culturally constrained are lacking. AIM: To determine the prevalence of dyspareunia and identify associated symptoms and sociocultural factors. METHODS: Data from a population-based national level family health sample survey conducted in Indian states from 1998 to 1999 which collected sexual and reproductive health information from 84,644 currently married women. The main outcome measure was dyspareunia. RESULTS: The overall prevalence of dyspareunia was 12.6%, with a higher prevalence in the central region, among newly married and younger women, among Muslims, rural residents, and among nonusers or traditional contraceptive method users. Dyspareunia was significantly more common among respondents who had urinary sensory symptoms when compared with their counterparts (adjusted odds ratio: 6.57, 95% confidence interval: 6.28, 6.87). CONCLUSION: Dyspareunia prevalence and the associated symptoms reported in this analysis could be underestimates because of possible underreporting. There is a substantial hidden burden of sexual health problems especially affecting younger women.

Sources of AIDS awareness among women in India.

Sources of AIDS awareness among rural and urban Indian women were analysed using data from the National Family and Health Survey (1998-2000). Two measures were developed to study the impact each source had on knowledge. 'Effectiveness' was defined as the proportion of women who had heard of AIDS from only one source, from among women who had heard of AIDS from that particular source and other sources. 'Independent effect' was the proportion who had heard of AIDS from only one source in relation to all women who had heard of AIDS. Television was the most effective medium, and also had the highest independent effect. Radio and print had very low effectiveness and independent effect. Although television and print audiences are growing in India, it is likely a sub-group of women will continue to lack media access. There is an urgent need to disseminate AIDS awareness to this 'media underclass'. Since the media will not reach this group, other sources including health workers, community level activities such as adult education programmes, and networks of friends and relatives need to be explored.

GyneFix: a UK experience.

OBJECTIVES: To present the experience of family planning providers and clients in the UK with the GyneFix intrauterine implant device. METHOD: Audit of 138 GyneFix insertions at the Ella Gordon Family Planning Unit in Portsmouth, from 1997 to 1999. RESULTS: Of 138 attempts at GyneFix insertion, 134 were successful. Forty per cent were inserted in nulliparous women. The removal rate was 15%, half of which were due to unacceptable side-effects. The expulsion rate was 8% ranging over a period of a few days to 12 months after insertion. There were no reported perforations or accidental pregnancies with GyneFix in situ in this series. There were no reported pregnancies as a result of unnoticed expulsion. CONCLUSIONS: The results obtained in this study are minimal estimates obtained from a retrospective analysis. The numbers are small but they are comparable to results reported from other family planning centers in the UK. Although GyneFix clearly has a useful role, there is a need for a large-scale prospective randomized study to establish the benefits and potential disadvantages of the GyneFix device.

Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea.

BACKGROUND: Dysmenorrhoea is the occurrence of painful menstrual cramps of the uterus. Medical therapy for dysmenorrhoea commonly consists of nonsteroidal anti-inflammatory drugs or the oral contraceptive pill both of which work by reducing myometrial (uterine muscle) activity. However, these treatments are accompanied by a number of side effects, making an effective non-pharmacological method of treating dysmenorrhoea of potential value. Transcutaneous electrical nerve stimulation (TENS) is a treatment that has been shown to be effective for pain relief in a variety of conditions. Electrodes are placed on the skin and electric current applied at different pulse rates (frequencies) and intensities is used to stimulate these areas so as to provide pain relief. In dysmenorrhoea. TENS is thought to work by alteration of the body's ability to receive or perceive pain signals rather than by having a direct effect on the uterine contractions. Acupuncture may also be indicated as a useful, non-pharmacological method for treating dysmenorrhoea. Acupuncture is thought to excite receptors or nerve fibres which, through a complicated interaction with mediators such as serotonin and endorphins, blocks pain impulses. Acupuncture typically involves penetration of the skin by fine, solid metallic needles, which are manipulated manually or by electrical stimulation. OBJECTIVES: To determine the effectiveness of high and low frequency transcutaneous electrical nerve stimulation and acupuncture when compared to each other, placebo, no treatment, or medical treatment for primary dysmenorrhoea. SEARCH STRATEGY: Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group Register of controlled trials, CCTR (Cochrane Library Issue 3, 2001), MEDLINE, EMBASE, CINAHL, Bio extracts, PsycLIT and SPORTDiscus were performed in August 2001 to identify relevant randomised controlled trials (RCTs). The Cochrane Complementary Medicine Field's Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the UK National Research Register, the Clinical Trial Register and the citation lists of review articles and included trials. In most cases, the first or corresponding author of each included trial was contacted for additional information. SELECTION CRITERIA: The inclusion criteria were randomised controlled trials of transcutaneous electrical nerve stimulation and acupuncture that compared these treatments to each other, placebo, no treatment, or medical treatment for primary dysmenorrhoea. Exclusion criteria were: mild, infrequent or secondary dysmenorrhoea and dysmenorrhoea associated with an IUD. DATA COLLECTION AND ANALYSIS: Nine RCTs were identified that fulfilled the inclusion criteria for this review, seven involving TENS, one acupuncture, and one both treatments. Quality assessment and data extraction were performed independently by two reviewers. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis was reported as descriptive data and was also included for discussion. The outcome measures were pain relief (dichotomous, visual analogue scales, descriptive), adverse effects, use of analgesics additional to treatment and absence from work or school. MAIN RESULTS: Overall high frequency TENS was shown to be more effective for pain relief than placebo TENS. Low frequency TENS was found to be no more effective in reducing pain than placebo TENS. There were conflicting results regarding whether high frequency TENS is more effective than low frequency TENS. One small trial showed acupuncture to be significantly more effective for pain relief than both placebo acupuncture and two no treatment control groups. REVIEWER'S CONCLUSIONS: High frequency TENS was found to be effective for the treatment of dysmenorrhoea by a number of small trials. The minor adverse effects reported in one trial requires further investigation. There is insufficient evidence to determine the effectiveness of low frequency TENS in reducing dysmenorrhoea. There is also insufficient evidence to determine the effectiveness of acupuncture in reducing dysmenorrhoea, however a single small but methodologically sound trial of acupuncture suggests benefit for this modality.

Randomized placebo controlled trial of lofexidine hydrochloride for chronic pelvic pain in women.

BACKGROUND: We hypothesised that the orally-active alpha(2)-adrenoceptor agonist lofexidine hydrochloride would ameliorate chronic pelvic pain in women. METHODS: A randomized placebo-controlled parallel group trial was undertaken in the University Hospital Gynaecology Clinic. Women with pelvic pain of at least 6 months duration were eligible, and were randomized using a sealed envelope system to receive up to 600 mg lofexidine hydrochloride twice daily over 8 weeks or placebo. Outcome measures were summary and daily diary visual analog scales for pain (VAS) and a 5 point self rating scale. RESULTS: 9/19 women randomized to lofexidine completed the study compared to 14/20 of those randomized to placebo. Intention-to-treat analysis showed that 4/19 in the lofexidine group achieved 50% or greater reduction in VAS compared with 8/20 in the placebo group (OR 2.5, 95% CI 0.6--10.3). Summary and diary VAS were closely correlated. CONCLUSIONS: Within the limits of a small study with power to detect only a substantial effect, we conclude that lofexidine hydrochloride is not effective for the treatment of chronic pelvic pain.

Interventions for treating chronic pelvic pain in women.

BACKGROUND: Chronic pelvic pain is common in women in the reproductive age group and it causes disability and distress and results in significant costs to health services. The pathogenesis of chronic pelvic pain is poorly understood. Often, investigation by laparoscopy reveals no obvious cause for pain. There are several possible explanations for chronic pelvic pain including undetected irritable bowel syndrome, the vascular hypothesis where pain is thought to arise from dilated pelvic veins in which blood flow is markedly reduced and altered spinal cord and brain processing of stimuli in women with chronic pelvic pain. As the pathophysiology of chronic pelvic pain is not well understood, its treatment is often unsatisfactory and limited to symptom relief. Currently, the main approaches to treatment include counseling or psychotherapy, attempting to provide reassurance using laparoscopy to exclude serious pathology, progestogen therapy such as medroxyprogesterone acetate, and surgery to interrupt nerve pathways. OBJECTIVES: We aimed to identify and review treatments for chronic pelvic pain in women in the reproductive years. The review included studies of patients with a diagnosis of pelvic congestion syndrome or adhesions but excluded those with pain known to be caused by i) endometriosis, ii) primary dysmenorrhoea (period pain), iii) pain due to active chronic pelvic inflammatory disease, or iv) irritable bowel syndrome. SEARCH STRATEGY: The search strategy adopted by the Cochrane Menstrual Disorders and Subfertility Group was used. SELECTION CRITERIA: Randomised controlled trials (RCTs) with women who had chronic pelvic pain, excluding endometriosis, primary dysmenorrhoea, pain due to chronic pelvic inflammatory disease, or irritable bowel syndrome. The reviewers were prepared to consider studies of any intervention including lifestyle, physical, medical, surgical and psychological treatments. Outcome measures were pain rating scales, quality of life measures, economic analyses and adverse events. DATA COLLECTION AND ANALYSIS: For each included trial, information was collected regarding the method of randomisation, allocation concealment, blinding, whether an intention to treat analysis could possibly be performed and relevant interventions and outcomes (see previous sections). Data were extracted independently by the two reviewers, using forms designed according to the Cochrane guidelines. MAIN RESULTS: Nine studies were identified of which five were of good methodological quality. Two studies were reported in a brief abstract only and were excluded. Progestogen (Medroxyprogesterone acetate) was associated with a reduction of pain during treatment. Counselling supported by ultrasound scanning was associated with reduced pain and improvement in mood. A multidisciplinary approach was beneficial for some outcome measures. Adhesiolysis was not associated with an improved outcome apart from where adhesions were severe. Sertraline was not beneficial. REVIEWER'S CONCLUSIONS: Further studies to confirm these observations are needed, together with full reporting of those studies which have been undertaken. Given the prevalence and health care costs associated with chronic pelvic pain in women, randomised controlled trials of other medical, surgical and psychological interventions are urgently required.

Psychosocial and economic impact of chronic pelvic pain.

According to a population-based estimate, chronic pelvic pain (CPP) affects approximately 15% of women aged 18-50. The psychosocial impact of CPP is reflected in mood disturbance, disruption of normal activity and relationships as well as pain. Identification of psychosocial factors as cause or effect remains problematic. Results of a study of 105 women with CPP using the British version of the SF-36 Health Survey Questionnaire are presented, together with analyses of face validity and reliability. While generally reflecting health status, specific problems with the questionnaire are identified related to the episodic nature of pelvic pain, and avoidance as a means of preventing pain exacerbations. Health economic analyses relating to CPP are reviewed and the implications for future directions in treatment strategy are discussed in the context of limited options of proven efficacy.

Interventions for treating chronic pelvic pain in women.

BACKGROUND: Chronic pelvic pain is common in women in the reproductive age group and it causes disability and distress and results in significant costs to health services. The pathogenesis of chronic pelvic pain is poorly understood. Often, investigation by laparoscopy reveals no obvious cause for pain. There are several possible explanations for chronic pelvic pain including undetected irritable bowel syndrome, the vascular hypothesis where pain is thought to arise from dilated pelvic veins in which blood flow is markedly reduced and altered spinal cord and brain processing of stimuli in women with chronic pelvic pain. As the pathophysiology of chronic pelvic pain is not well understood, its treatment is often unsatisfactory and limited to symptom relief. Currently, the main approaches to treatment include counselling or psychotherapy, attempting to provide reassurance using laparoscopy to exclude serious pathology, progestogen therapy such as medroxyprogesterone acetate, and surgery to interrupt nerve pathways. OBJECTIVES: We aimed to identify and review treatments for chronic pelvic pain in women in the reproductive years. The review included studies of patients with a diagnosis of pelvic congestion syndrome but excluded those with pain known to be caused by i) endometriosis, ii) primary dysmenorrhoea (period pain), iii) pain due to chronic pelvic inflammatory disease, or iv) irritable bowel syndrome. SEARCH STRATEGY: The search strategy adopted by the Cochrane Menstrual Disorders and Subfertility Group was used. SELECTION CRITERIA: Randomised controlled trials (RCTs) with women who had chronic pelvic pain, excluding endometriosis, primary dysmenorrhoea, pain due to chronic pelvic inflammatory disease, or irritable bowel syndrome. The reviewers were prepared to consider studies of any intervention including lifestyle, physical, medical, surgical and psychological treatments. Outcome measures were pain rating scales, quality of life measures, economic analyses and adverse events. DATA COLLECTION AND ANALYSIS: For each included trial, information was collected regarding the method of randomisation, allocation concealment, blinding, whether an intention to treat analysis could possibly be performed and relevant interventions and outcomes (see previous sections). Data were extracted independently by the two reviewers, using forms designed according to the Cochrane guidelines. MAIN RESULTS: Seven studies were identified of which four were of good methodological quality. One study was reported in a brief abstract only and was excluded. Progestagen (Medroxyprogesterone acetate) was associated with a reduction of pain during treatment. Counselling supported by ultrasound scanning was associated with reduced pain and improvement in mood. A multidisciplinary approach was beneficial for some outcome measures. Adhesiolysis was not associated with an improved outcome apart from where adhesions were severe. REVIEWER'S CONCLUSIONS: Further studies to confirm these observations are needed, together with full reporting of those studies which have been undertaken. Given the prevalence and health care costs associated with chronic pelvic pain in women, randomised controlled trials of other medical, surgical and psychological interventions are urgently required.

Morphology and functional characteristics of human ovarian microvascular endothelium.

Corpus luteum formation is characterized by a period of extensive vascularization, as capillaries in the thecal layer of the collapsed follicle following ovulation invade the previously avascular granulosa layer. In order to study these processes in vitro we have developed an endothelial cell preparation from the specific microvasculature of the ovarian follicle. Follicular aspirates, obtained at oocyte collection for in-vitro fertilization (IVF), were filtered to obtain fragments of follicle wall. These were set in Matrigel and then cultured allowing the growth of capillary-like structures through the matrix. Upon emergence from the Matrigel the growing cells formed monolayers with the characteristic cobble-stone morphology of endothelial cells. Immunocytochemistry demonstrated the presence of a range of endothelial-specific markers including von Willebrand factor (vWF), Ulex europeus agglutinin (UEA)-1, CD31 and E-selectin, as well as VCAM-1, which is normally associated with stimulated endothelial cells. RT-PCR analysis showed the expression of two receptors for vascular endothelial growth factor (flt-1 and KDR), and the endothelial nitric oxide synthase, adding further evidence of their identity as human ovarian microvascular endothelial cells (HOMEC). Thus, the novel preparative procedure described now allows the generation of HOMEC cultures from readily available material resulting from IVF procedures.

Factors influencing outcome in consultations for chronic pelvic pain.

We aimed to document the demographic and clinical characteristics of women referred by primary care physicians for investigation of chronic pelvic pain to a university hospital gynecology outpatient clinic and to test the hypothesis that specific patient features and the quality of doctor/patient communication at the initial consultation would influence pain outcomes. A clinical questionnaire, visual analog scales for pain, and instruments for hostility and the experience of the consultation were administered at the initial clinic attendance to 105 consecutive women. Follow-up pain scores were obtained 6 months later from 98 women. The mean hostility score was highly significantly elevated compared with normative data (p < 0.001). In a logistic regression model, a favorable patient rating of the initial consultation was associated with complete recovery at follow-up and interacted significantly with whether or not exercise was impaired (p < 0.005). For those in whom symptoms persisted, significant factors found by multiple regression models to predict continuing pain levels were the initial level of pain, the number of functions of daily life impaired, endometriosis, and the doctor who carried out the initial consultation. Patient hostility scores and the doctor's level of experience or gender were not significantly associated with continuing pain. This study highlights the importance of good communication as a basis for successful treatment of a group of hostile patients and indicates the influence in individual doctors of subtle attitudinal and personality factors that modify patients' experience of the medical consultation.

Release of vasoactive agents from the isolated perfused human ovary.

OBJECTIVE: To investigate local vascular control in the isolated perfused premenopausal human ovary by measuring flow-induced release of vasoactive substances. DESIGN: Release of adenosine 5' triphosphate (ATP), substance P (SP), endothelin (ET), and vasopressin (AVP) from the ovarian vascular endothelium was estimated in perfusate under basal conditions and during two periods of increased flow. MAIN OUTCOME MEASURES: Vascular resistance; ATP, SP, ET and AVP release. RESULTS: The mean ratio (pressure/flow during increased flow):(pressure/flow at basal flow) was 1.27 +/- 0.04 for the first, and 1.15 +/- 0.05 for the second period of increased flow (n = 10), indicating significant vasoconstriction (P < 0.01 and 0.05, respectively), present to a greater extent during the first period of increased flow compared to the second (P < 0.05). ATP release was seen in response to increased flow (n = 8, P < 0.05). From 12 ovarian bed preparations, five released ET and SP and three of these released AVP. Four of the five perfused ovaries that released peptides contained either a developing follicle or a corpus luteum while all those that showed no peptide release were inactive. CONCLUSIONS: ATP release may play a role in the local control of the human premenopausal ovarian vasculature independent of ovulatory status. Peptides may also contribute to local vascular control in the ovary and their release from predominantly active ovaries suggests a relationship between ovulation and vascular endothelial function.

Innervation of vasculature and microvasculature of the human vagina by NOS and neuropeptide-containing nerves.

The aims of the present study were to determine whether nerves that contain nitric oxide synthase (NOS), calcitonin gene-related peptide (CGRP) or substance P (SP) are present in the human vagina and, if so, to determine the pattern of innervation relative to that of other neurotransmitters, particularly vasoactive intestinal polypeptide (VIP) and neuropeptide Y (NPY). Surgical specimens of vaginal tissue (n = 10) from pre- and postmenopausal women were fixed and processed for immunohistochemistry of peptides and NOS and for histochemistry of NADPH-diaphorase. SP-immunoreactive nerves were very sparse, being absent from 9 of the 10 tissue samples. For other peptides and NOS, the innervation of the deep arteries and veins was greater than that of blood vessels in the propria. Capillaries in the epithelial papillae also appeared to be innervated by nerves containing NOS, CGRP, NPY and VIP. Beneath the epithelium nerve fibres formed a subepithelial plexus; no nerve cell bodies were seen. The relative density of innervation by immunoreactive fibres was PGP-9.5 > NPY > VIP >> NOS > CGRP > SP. These results imply that nerves that utilise nitric oxide or NPY, VIP or CGRP as a neurotransmitter may play a role in controlling blood flow and capillary permeability in the human vagina. The origin and function of all these nerves is discussed.

Hostility and doctor-patient interaction in chronic pelvic pain.

BACKGROUND: Interaction in medical consultations is of interest for many reasons and has long been thought an important variable in determining outcomes. Relatively few methods or instruments exist that attempt to access this phenomenon. The design, validation and possible application of a simple instrument to assess doctor-patient interaction are reported. Rapport and hostility may be related and we hypothesised that interaction between doctor and patient would be related in part to hostility. METHODS: A simple instrument to assess doctor-patient interaction was designed based on 4 areas related to interaction and perception of 'the other'. These were the areas of communication, rapport, trust and sense of ease. The instrument was compared with an external previously validated measure of hostility. Data were obtained from 74 women attending initial and follow-up consultations for chronic pelvic pain during the course of a larger study. RESULTS: The instrument had acceptable reliability and a single-factor structure. Patients' assessment of the initial consultation as unsatisfactory correlated with inwardly directed hostility (Spearman correlation coefficient, r = 0.30, p = 0.011). Patients' tendency to rate the consultation worse than the doctor was correlated with inwardly directed hostility (r = 0.42, p < 0.001). Pain outcomes were not directly related to the variables studied. CONCLUSIONS: This instrument offers a simple method of assessing some interactional aspects of a medical consultation.

Substance P: endothelial localization and pharmacology in the human ovarian vein.

OBJECTIVE: To investigate the possible role of substance P as an endothelial factor in the local regulation of vascular tone in the human ovarian vein. METHODS: We performed immunolocalization of substance P in human ovarian venous endothelium in situ and in culture, and observed responses to substance P in preconstricted ring preparations of human ovarian vein in the presence of either the prostaglandin synthesis inhibitor indomethacin or the inhibitor of nitric oxide synthesis L-nitro arginine methyl ester (L-NAME), with and without luminal rubbing. RESULTS: Substance P was localized in a subpopulation of ovarian vein endothelial cells. Maximal relaxation induced by substance P was not significantly affected by indomethacin (10 mumol/L), but was reduced from 58.7% (95% confidence interval [CI] 41.3-76.1) in control experiments to 24.7% (95% CI 18.3-31.1) after luminal rubbing and to 32.3% (95% CI 19.8-44.8) after exposure to L-NAME (0.1 mmol/L) (P = .001). CONCLUSION: The localization of substance P in ovarian vein endothelium together with vasodilator effects mediated partially via the endothelium suggests that the peptide has a role in the local control of vascular tone in this vessel.

The fine structure of the human ovarian vein.

The human ovarian vein is of particular interest as an adult vessel which changes with the different phases of reproductive life. At the ultrastructural level we have characterised the endothelium, vascular smooth muscle and autonomic innervation of the human ovarian vein. Transmission electron micrographs were prepared from surgical specimens of the human ovarian vein (n = 11) to demonstrate the features of the vessel wall. The pattern of innervation was investigated using an image analysis system which was also used with high-magnification micrographs to count and measure axonal vesicle types. Possible relationships between ultrastructural features and age and reproductive history were investigated. Endothelial cells contained Weibel-Palade bodies and numerous microfilaments. There were 3 muscle coats: no elastic lamina separated the endothelium from an inner layer of smooth muscle; a middle smooth muscle layer consisted of cells orientated in a circular fashion; an outer smooth muscle layer was made up of longitudinally arranged smooth muscle bundles with collagen and nerves penetrating throughout. The percentage of the vessel thickness occupied by the middle circular smooth muscle layer ranged from 0 to 33% and fell with increasing age (r = -0.67, P < 0.05). Penetration of nerves into the circular layer was observed only in 2 of 9 specimens. The observed ultrastructural features are consistent with the ability of the ovarian vein to distend substantially in response to changing circulatory demands. The vascular endothelium may have a role in the local control of haemostasis via the synthesis and storage of von Willebrand factor.(ABSTRACT TRUNCATED AT 250 WORDS)