bluuebunny/crossref_metadata_2025 huggingface dataset:
Gynaecological conditions associated with HIV infection in women who are partners of HIV-positive Thai blood donors
Authors: Rugpao S , Srisomboon J , Chaiyarassamee O , Nelson K E , Nagachinta T , Suriyanon V , Prasertwitayakij W , Vernon S D , Wanapirak C , Sirirojn B , Celentano D D , Duerr A
Published: October 2002

Women who were partners of HIV-positive blood donors were enrolled in a study of heterosexual HIV transmission between March 1992 and December 1996 and were interviewed and examined. Gynaecological conditions, including cervical dysplasia, human papillomavirus (HPV) infection, gonorrhoea, chlamydial infection, trichomoniasis, bacterial vaginosis, vaginal candidiasis and syphilis were assessed in addition to HIV status and CD4 level. Of 481 women enrolled, 224 (46.6%) were HIV seropositive. HIV-infected women were more likely to have abnormal vaginal discharge on physical examination (OR=2.6, P 0.01), HPV infection with a high-risk type (OR=6.9, P 0.01), and cervical dysplasia (OR=5.3, < P 0.01). The prevalence of other gynaecological conditions detected at the enrolment visit did not differ by HIV status. History of prior STD (OR=2.0, < P 0.01) was more common among HIV-infected women. The median CD4 count mu was 400 cells/ l among HIV-infected women. The prevalence of abnormal vaginal discharge and bacterial vaginosis increased significantly with decreasing CD4 count. The prevalence of ectopy, vaginal candidiasis, and cervical dysplasia increased with decreasing CD4 count, but these trends were not significant. We conclude that HIV-infected Thai women appear to have increased prevalences of abnormal vaginal discharge, squamous intraepithelial lesions and self-reported history of STD. < <
Perceptions and patterns of reproductive tract infections in a young rural population in North-West Namibia
Authors: Harms G , Radebe F , Iyambo S N , Fehler H G , Ballard R C , Corea A
Published: October 2002

Syndromic management of sexually transmitted diseases (STDs) is strongly promoted in Namibia. However, no data are available on rates of asymptomatic reproductive tract infections (RTIs) which would remain undetected and thus untreated in the general population. This study was aimed at assessing the prevalence of RTIs in a young rural population and to gain an insight into their health-care seeking behaviour for RTIs. A total of 97 patients (44 male, 53 female) < 30 years of age attending the outpatient clinic of a rural hospital in Northern Namibia for problems unrelated to RTIs were interviewed and examined. Specimens were taken for investigation of RTIs according to a non-invasive diagnostic schedule. Laboratory examinations revealed 58 infections of the reproductive tract in 42 of the 97 patients (43%). In addition, HIV infection was detected in 13 cases (13%). RTI rates were highest in female teenagers (68%), but no infections were detected in their male counterparts. Of those 42 patients with a laboratory-diagnosed infection, 7 had both symptoms and signs (symptomatic), 16 had neither symptoms nor signs (asymptomatic), and 19 had signs on examination but no symptoms (inapparent). Awareness and perception of symptoms and signs of RTIs were low in the studied population. Provision of adequate treatment for RTIs alone is unlikely to have a major impact on the overall burden of disease since the largest burden of disease was found among those patients (predominantly females) with inapparent infections. Health education on RTIs including STDs and the symptoms they cause together with the importance of early attendance at health facilities and improved access to treatment need to be addressed urgently.
An audit of emergency contraception: A look at patient characteristics and the effects of a consultation proforma
Authors: Nanthakumaran H , Sullivan A K , Boag F C
Published: October 2002

The aim of this study was to examine the characteristics of patients requesting emergency postcoital contraception at a genitourinary medicine (GUM) clinic. We also compared the quality of information obtained during the consultation, before and after a proforma was introduced. A retrospective review of all clinical notes of patients who attended for postcoital contraception between January and December 1994 and April to June 1995 was performed. Eighty-three per cent of patients were aged 17–29 years, 68.8% were in relationship, 41.3% were not using regular contraception, 33.8% accepted a sexual health screen and of these, 14.8% had a concurrent sexually transmitted disease (STD). The introduction of a consultation proforma significantly improved certain areas of the consultation. The results suggest that sexual health screens should be encouraged in women attending GUM clinics for postcoital contraception and that the use of a proforma improves the quality of information obtained.
Outcomes in genitourinary medicine: Whose priority?
Authors: Johnson Anne M
Published: October 2002

The primary role of genitourinary medicine (GUM) services in the UK is the treatment and control of sexually transmitted diseases (STDs). The origins of the service lie in its public health function, yet measuring outcomes locally and nationally is not straightforward. Difficulties arise from the complex interactions between sexual behaviour, the biology of STDs and the role of clinical services; from the potential consequences of the National Health Service (NHS) internal market on national STD control; and from the limitations of information and surveillance systems.

This paper considers each of these areas in turn and concludes with some proposals for measuring GUM outcomes locally and nationally which might potentially satisfy the concerns of commissioners and providers.
Testosterone therapy for clinical symptoms of hypogonadism in eugonadal men with AIDS
Authors: Wagner G J , Rabkin J G
Published: October 2002

We conducted a small exploratory study to assess whether testosterone therapy is an effective treatment for clinical symptoms characteristic of hypogonadism in eugonadal men with AIDS. Treatment consisted of 12 weeks of bi-weekly intramuscular injections of testosterone cypionate. Twenty-three men enrolled in the study; mean age was 37 and 44% were ethnic minorities. All had an AIDS diagnosis and the mean CD4 cell count was 150 cells/mm3. All baseline serum testosterone levels were within the laboratory reference range and above 500 ng/dl. Diminished libido was an inclusion criterion, plus each patient had at least one additional symptom (low mood, low energy, loss of appetite and/or weight). Nineteen men completed the trial and a majority of patients responded with regard to libido (89%), mood (67%), energy (71%), and appetite (67%) as rated by the Clinical Global Impressions Scale. With the exception of appetite, self and clinician rated measures showed significant improvement in all symptom domains. Among the 14 study completers with significant weight loss, the average weight gain was 2.3 kg, with a 1.8 kg increase in body cell mass and no change in body fat. These results suggest that testosterone is as effective in treating these symptoms in eugonadal men with AIDS as we have found in our research with hypogonadal HIV+men.
Combination therapy for HIV: the effect on inpatient activity, morbidity and mortality of a cohort of patients
Authors: Brettle Ray P , Wilson Alan , Povey Sarah , Morris Sheila , Morgan Rhoda , Leen Clifford L S , Hutchinson Sharon , Lewis Steff , Gore Sheila
Published: October 2002

Summary: We set out to quantify the changes in HIV-related morbidity and mortality associated with the clinical use of antiretroviral therapy via prospectively collected patient-related events (admissions, bed days, deaths, WHO stage 3 and 4 events and drug costs) on all HIV patients known to the Regional Infectious Disease Unit (RIDU) from 1 January 1987 to 31 December 1996. The introduction of zidovudine monotherapy in 1987 for those with AIDS was associated with a subsequent decline of inpatient activity for 2 years: in 1989 there was a 23% reduction in bed days but only a 6% reduction in admissions. A further dramatic decline of patient-related events in those with AIDS was noted during 1996 following the introduction of combination therapy, a 39% reduction in admissions, 44% reduction in bed days, 54% reduction in stage 4 events, 33% reduction in WHO stage 3 events and 40% reduction in the death rate. Reductions were also observed for patients without AIDS including a 42% reduction in the rate of patients developing AIDS. Similar reductions were noted when the patients were classified by immunological instead of clinical status although data for 1997 suggest an increase in patient-related activity for those with CD4 counts 200 cells/ul possibly as a result of low levels of anti-HIV therapy. The introduction of combination therapy for HIV has to date led to a minimum saving of one inpatient bed per 100 patient years which helped defray the cost of combination therapy. Although we cannot imply causality from an observational study, dramatic reductions in patientrelated activity were associated with the introduction of combination therapy into clinical practice. The ultimate extent and duration of this effect cannot as yet be predicted and caution is required since similar reductions were noted with zidovudine therapy which were unfortunately time limited.
Prevalence and risk factors of HIV-1 and HIV-2 infection in urban and rural areas in Tamil Nadu, India
Authors: Solomon Suniti , Kumarasamy N , Ganesh A K , Amalraj R Edwin
Published: October 2002

Summary: We aim to study the factors associated with the prevalence of HIV-1 and HIV-2 infection in the urban and rural areas of Tamil Nadu, India. The population of Tamil Nadu is approximately 60 million. Between April 94 and March 95, 992 samples from 5 representative urban centres and 1071 samples from 5 representative rural centres were collected and studied. A questionnaire was administered privately and it preceded collection of each sample. Samples were screened using ELISA and antibodies to HIV-1 and HIV-2 were confirmed using Western blot. The study was anonymous and unlinked. The prevalence of HIV infection in urban and rural areas was 7.2% (95% CI=6.1 to 8.31%); HIV-1 antibodies were found in 7.4% (95% CI=5.8 to 9.2%) of urban and 7.0% (95% CI=5.6 to 8.7%) of rural population; HIV-2 antibodies were found in 0.8% of urban and 0.3% of rural population. Heterosexual transmission, more so among those with multiple partner sex, was the main mode; higher prevalence of HIV infection among divorced/single individuals both in urban (21.1%) and rural (26.1%) was found. HIV infection among housewives stood at 4.1% (urban) and 3.8% (rural). The strength of association between STDs and HIV was observed to be greater in rural subjects (OR=8.89; 95% CI=5.11 to 15.57) than in urban subjects (OR=1.9; 95% CI=1.14 to 3.18). The prevalence of condom use was found to be less than 2% in the study subjects. HIV-2 is not as widely prevalent in Tamil Nadu as HIV-1. In our study the most common risk factors for HIV infection that emerged were (a) having multiple sexual partners, and (b) history of STDs or Venereal Disease Research Laboratory (VDRL) reactivity. Mobility of individuals between urban and rural areas has furthered the dissemination of HIV infection. Low condom usage among study subjects questions the effectiveness of the existing AIDS awareness and education programme. The study indicates the importance of placing equal emphasis on HIV prevention in rural India. HIV infection among housewives in urban and rural areas is indicative of gender inequalities and the importance of empowering women to prevent infection from spouse.
Perceptions and acceptability of the female condom [Femidom ] sex workers in the Songkla province, Thailand amongst commercial
Authors: Sinpisut Piyarat , Chandeying Verapol , Skov Steven , Uahgowitchai Charn
Published: October 2002

In a prospective descriptive study on the perceptions and acceptability of the female condom in a group of Thai commercial sex workers (CSWs) in the Songkla province, we invited CSWs from selected brothels to participate. Those who used the female condom were interviewed after one week and 16 weeks of use. Focus group discussions were also conducted at the end of the study period to obtain additional information. The group comprised 56 CSWs. Only 34% of them had heard of the female condom prior to this study and none had ever used one. A high proportion of CSWs reported positive experiences and perceptions. There were no significant changes in perceptions and experiences during the study. Eighty per cent of participants said they were satisfied with the female condom and would use it again in the future and would recommend it to their friends. However, the female condom was used in only 29% of the total number of sexual acts reported, and 98% of CSWs said they would prefer to use a male condom for sex work. Many of the women were concerned that the physical appearance of the condom would reduce its acceptability to their clients. This was the most frequently cited reason for not using the female condom in the future. While a promising device, the female condom must also become more acceptable to men if it is to enable women to be in control of their own protection from pregnancy and STD/HIV.
An unusual aural presentation of Pneumocystis carinii
Authors: Khaksar S , Sullivan A , Francis N , Nelson M
Published: October 2002

Pneumocystis carinii is a common opportunistic infection in the immunocompromised, usually presenting as an interstitial pneumonia. Extrapulmonary disease is rare. We report a case of pneumocystis presenting as an isolated aural polyp.
How are men with urethral discharge managed in general practice?
Authors: Ross Jonathan D C , Champion Jennifer
Published: October 2002

Chlamydia and gonorrhoea remain major causes of morbidity despite the availability of effective therapy. Because of the asymptomatic nature of many infections, particularly in women, active case finding is necessary to trace and offer screening and treatment to sexual contacts of those infected. Genitourinary medicine (GUM) clinics provide investigation and treatment for a variety of sexual health problems but the proportion of infections treated outside these clinics is unknown. A questionnaire survey of general practitioners (GPs) was used to examine the prevalence and management of male urethritis in Scotland. Responses were received from 277/347 (80%) of GPs. A median of one case/year of male urethritis was seen and screening for gonorrhoea and chlamydia was undertaken in 82% and 63% of cases not referred to a GUM clinic respectively. Six per cent of GPs attempted to trace sexual contacts. Twenty-nine per cent (60) of patients were not referred to a GUM clinic and increasing distance to the clinic was associated with non-referral. Eleven per cent (18) of patients objected to referral to a GUM clinic. There is scope to improve the management of male urethritis by providing greater support for GPs, encouraging clinic referral where possible and appropriate investigations and treatment when not.
The management of pelvic inflammatory disease in the Central Region of Ghana is not standardized
Authors: Bosu W K , Annan J J K , Mabey D
Published: October 2002

We evaluated the management of pelvic inflammatory disease PID in 2 regional level hospitals and 4 district hospitals of the Central Region of Ghana. We retrospectively reviewed 208 case notes of inpatients clinically diagnosed with PID and interviewed 25 clinicians at these hospitals. Overall, 20 antibiotics were prescribed in 62 different regimens. Between 9 and 26 antibiotic regimens were prescribed in each hospital. Metronidazole, gentamicin, amoxycillin, ampicillin, benzylpenicillin and tetracycline were frequently prescribed while the recom mended anti gonococcal antibiotics, ciprofloxacin and ceftriaxone, were rarely prescribed. The commonest regimens were prescribed for a shorter duration than recommended. Condom promotion, partner notification and management were scarcely or never undertaken. Fifty six per cent of clinicians had never seen the national treatment guidelines; 32 had received in service training in STD case management. The findings provide the basis for improving the management of PID in the Central Region of Ghana.
A proposal for basic management of HIV disease in West Africa: use of clinical staging and haemogram data
Authors: Ledru E , Diagbouga S , Meda N , Sanou P T , Dahourou H , Ledru S , Dembele A , Zoubga A , Durand G
Published: October 2002

Summary: Our objective was to propose a strategy to screen HIV infected African people for biological immunodeficiency easily. In a cross sectional study, we analysed the patterns of diseases and of CD4 counts among 266 HIV infected adults. Peripheral facial paralysis and chronic cutaneo mucous diseases were the earlier B stage diseases. Pulmonary tuberculosis was close to B stage diseases, and chronic diarrhoea was borderline between B and C stages. Cachexia was the most frequent C stage symptom 47.8 . Ninety per cent of CDC C stage people had CD4 counts below 350 mul, whereas only 75 had CD4 counts below 200 mul. Regression analysis identified the lymphocyte count, clinical stage and platelet count as predictors of CD4 count below 350 mul. A simple score lymphocyte count 2500 mul and clinical stage B is proposed to determine this CD4 threshold positive predictive value: 83 and to determine those patients needing treatment to prevent wasting and opportunistic infections.
Bronchopulmonary Kaposi s sarcoma in 106 HIV 1 infected patients
Authors: Hannon Frances B , Easterbrook Philippa J , Padley Simon , Boag Fiona , Goodall Ruth , Phillips Robert H
Published: October 2002

The objectives of this study were to describe the clinical and radiological features at presentation, and the natural history of HIV related bronchopulmonary Kaposi s sarcoma. A retrospective review of medical records and chest radiographs was performed in 106 HIV infected homosexual men with bronchopulmonary Kaposi s sarcoma diagnosed at bronchoscopy between September 1988 and November 1994. The majority of patients had evidence of advanced HIV disease at diagnosis median CD4 cell count was 15 106 l, range 0-288 , and 93 had had a diagnosis of cutaneous Kaposi s sarcoma for a median duration of 11 months prior to diagnosis of their bronchopulmonary disease. The most frequent symptoms at presentation were cough 92 , dyspnoea 69 , pleuritic pain 20 , haemoptysis 13 and wheezing 10 . The most common radiological finding in 73 of our series was of poorly defined and confluent opacities, with predominant middle and lower zone involvement. Median survival was 4 months range 0-37 months from diagnosis and 9 months range 1-25 from the onset of symptoms. Treatment with either chemotherapy or radiotherapy was associated with a significantly reduced risk of death hazards ratio HR =0.48, 95 CI=0.26-0.87 . Factors associated with a poor survival, after adjustment for treatment effect were older age HR=1.79, 95 CI=1.22-2.84 for each 10 year increase in age; a history of pleuritic pain HR=2.97, 95 CI=1.39-6.32 ; presence of pleural effusion on X ray HR=2.01, 95 CI=1.13- 3.59 and a prior diagnosis of cutaneous Kaposi s sarcoma HR=1.8, 95 CI=1.00, 3.24 . Bronchopulmonary Kaposi s sarcoma occurs mainly in patients with advanced HIV disease and a prior history of cutaneous disease. Survival is poor, and adverse prognostic factors include older age at diagnosis and the presence of pleural disease.
Emergency unit care of sexually transmitted infections
Authors: Rani Ranjana , Jebakumar Jarvis S. , Jones Kevin Mackway , Bhattacharyya Mukti N.
Published: October 2002

The aim of the study was to assess provisions for management of sexually transmitted infections STIs , emergency contraception and pregnancy test in UK emergency departments. Postal questionnaires were sent to all consultant led emergency departments in the UK in January 1996. The response rate was 64 . Most departments made direct referrals to genitourinary medicine GUM clinics and most had access to appropriate clinics. While 55 had facilities for diagnosis of at least one of the 3 common STIs Chlamydia trachomatis , Neisseria gonorrhoeae and herpes simplex , only 6.25 had facilities for all 3. A minority of units provided training in the management of STIs. Emergency physicians should be trained in the early management of STIs and a coordinated working relationship should be developed between emergency and GUM departments to provide optimal sexual health care.
‘Face up to the Truth’: Helping Gay Men in Vietnam Protect Themselves from AIDS
Authors: Wilson David , Cawthorne Paul
Published: October 2002

Appropriate AIDS prevention information is not available in Vietnam for men who have sex with men. Current AIDS prevention messages can be misunderstood with potentially dangerous results. We outline some features of gay culture in a provincial city in Vietnam. We describe the activities of a peer educator who made contact with a small group of young gay men during 1996 and 1997. All the young men were ill-informed about AIDS. Their attitudes and sexual practices made them vulnerable to AIDS. The peer educator provided clear informtion and emotional support. The peer education was done without government endorsement and on a very low budget.
How Effective are Complementary Therapies for HIV and AIDS?—a Systematic Review
Authors: Özsoy Metin , Ernst Edzard
Published: October 2002

Complementary treatments are often used by HIV-infected individuals. Yet little is known about their effectiveness. The aim of this systematic review was therefore to summarize the published evidence for or against the effectiveness of complementary therapies in HIV-positive people. A comprehensive literature search was conducted to locate all randomized clinical trials (RCTs) of complementary therapies. Data were extracted in a standardized fashion and evaluated critically. Fourteen studies met our pre-de® ned inclusion/exclusion criteria; 2 of herbal treatments, 5 of vitamins and other supplements, 5 of stress management, one of massage therapy, and one of acupuncture. They fall into 2 broad categories of ‘cure’ and ‘care’. While the former category yields few encouraging results, the latter group of studies is more promising. In particular, stress management may prove to be an effective way to increase the quality of life. It is concluded that few rigorous trials of complementary treatments for HIV exist. The domain of complementary medicine may lie in the care for HIV-infected individuals with a view of increasing their quality of life. This notion requires further rigorous investigation.
Subtyping of High-Level Plasmid-Mediated Tetracycline Resistant Neisseria Gonorrhoeae Isolated in Scotland between 1992 and 1998
Authors: Beattie T , Moyes A , Patrizio C , Young H
Published: October 2002

Tetracycline resistant Neisseria gonorrhoeae (TRNG) contain a 25.2 MDa TetM plasmid encoding a 68KDa cytoplasmic protein which confers high-level tetracycline resistance. The aim of this study was to subtype all TRNG isolated in Scotland between 1992 and 1998. Subtyping was performed by a polymerase chain reaction (PCR) assay which characterizes the TetM plasmid as either the Dutch variant (443 base pair product) or the American variant (777 base pair product). Of the 78 TRNG isolates, 35 were the American variant and 43 were the Dutch variant. TRNG were distributed amongst 30 serovar/auxotype classes, the most common being 1A6/NR (11.5%), 1A6/P (14.1%) and 1B4/NR (14.1%). The country where infection was acquired was known for 36 of the 46 TRNG strains isolated between 1996 and 1998. All infections acquired in Asia and South America were the Dutch variant whereas all infections acquired in Africa were the American variant. A penicillinase plasmid was present in 66% (23/35) of the American variant TRNG compared with 51% (22/43) of the Dutch variant: the 3.2 MDa penicillinase plasmid was found in 87% of the American variant TRNG whereas the 4.4 MDa penicillinase plasmid was found in 68% of the Dutch variant TRNG. We conclude that subtyping of TRNG by PCR is a useful tool in studying the epidemiology of gonococcal infection due to plasmid-mediated resistant isolates.
Genitourinary Chlamydial Infection: A Reappraisal and Hypothesis
Authors: Morton R S , Kinghorn G R
Published: October 2002

Our understanding of genitourinary chlamydial infection and disease remains limited. That natural defences and/or apparently adequate treatments leave some patients with latent disease is suspected. There is, however, no consensus as to its nature. Furthermore, many patients, most obviously males, presenting with similar or identical symptoms and signs remain unexplained in microbiological terms; this in spite of many years of dedicated research endeavour.

The recent trend towards an impasse has coincided with a growing acquaintance with the immunobiology and immunopathology of chlamydial infections. The time would seem to have arrived for a reappraisal of available clinical and laboratory observations.

A hypothesis with research suggestions is presented for discussion.
HIV-Related Malignancies: Community-Based Study using Linkage of Cancer Registry and HIV Registry Data
Authors: Cooksley Catherine D , Hwang Lu-Yu , Waller D Kim , Ford Charles E
Published: October 2002

For people immunosuppressed by human immunodeficiency virus (HIV), we expect an increase in cancer incidence similar to that documented in transplant patients. We examined the cancer spectrum in an HIV-infected cohort, specifically malignancies not currently associated with acquired immunodeficiency syndrome (AIDS), in relation to the general population. Cancer incidence data for residents of Harris County, Texas, diagnosed between 1975 and 1994, were linked to HIV/AIDS registry data by Soundex code and date of birth to identify malignancies in an HIV-infected cohort of 14,986 persons. Incidence of cancer in this cohort was compared to the general population by standardized incidence ratio (SIR) analysis. From the HIV-infected cohort, 2289 persons (15%) were identified as having one or more malignancies, with 97% occurring in males. The linkage alone identified 29.5% of the malignancies, of which only 28.7% were diagnosed in males. Adjusting for age, HIV-infected men and women had incidences of cancer that were 16.7 [95% confidence interval (CI) 16.1–17.3] and 2.9 (95% CI 2.3–3.7) times that expected for the general population of Harris County, Texas. Besides Kaposi's sarcoma, non-Hodgkin's lymphoma, cervix cancer and brain lymphoma, non-AIDS related malignancies of Hodgkin's lymphoma, non-melanotic skin cancer in males and colon cancer in females, exhibited significant SIRs of 5.6 (95% CI 3.6–8.4), 6.9 (95% CI 4.8–9.5) and 4.0 (95% CI 1.1–10.2). Increased incidences of lung, prostate and breast malignancies were not seen in this HIV cohort. Persons infected with HIV appear to be at increased risk for the non-AIDS related malignancies, Hodgkin's lymphoma, non-melanotic skin cancer in males and colon cancer in females
Migration and HIV: An Epidemiological Study of Montrealers of Haitian Origin
Authors: Adrien A , Leaune V , Remis R S , Boivin J-F , Rud E , Duperval R , Noël G E
Published: October 2002

We aimed to determine the prevalence of HIV infection and associated risk factors among Montrealers of Haitian origin. We carried out a voluntary, anonymous survey in 7 primary care medical clinics in Montreal among 5039 persons aged 15 to 49 years born in Haiti or with at least one parent born in Haiti. The participation rate was 94.3%. Overall, HIV prevalence was 1.3% (1.6% in men and 1.1% in women). The HIV prevalence was lower among those born in Canada or who had resided in Canada longer. The prevalence among subjects who had travelled to Haiti in the previous 5 years was 2.0%, twice the rate of those who had not. The adjusted population attributable fraction of HIV infections associated with having had unprotected sex in Haiti was 10.2%. This study identified risk factors which will help in the design of more effective prevention programmes among Montrealers of Haitian origin.
An Epidemiological Evaluation of the use of Microbiological Tools for Identifying Gonorrhoea Infection Networks
Authors: Pierce Richard L , Thomas James C , Sparling P Frederick , Fisher William , Davis Rachel H , Alcorn Timothy , Cohen Myron
Published: October 2002

We aimed to assess the utility of various techniques for identifying gonorrhoea infection networks. All residents of a non-metropolitan North Carolina county visiting a sexually transmitted disease (STD) clinic during a 17-month period were screened for gonorrhoea. Infection networks were estimated by serovar type combined with antibiotic resistance, arbitrarily primed polymerase chain reaction (AP-PCR), or temporal clustering. The residential addresses of infected patients were geocoded and mapped. Among 2 serovar types, the presence of distinguishing characteristics of a network, based on questionnaire data, was assessed with prevalence ratios and 95% confidence intervals (CIs) relative to those not in the network. Twenty-five serovar types were identified among 759 gonorrhoea infections. In one serovar, the networks further delineated by temporal clusters correlated with particular AP-PCR types. In most instances, however, different typing techniques painted different network pictures. No refined serovar network stood out as having a particular set of characteristics that could be used to shape intervention. Teasing out an individual infection network with unique characteristics will require the development and use of other microbiological tools.
Gay men's stereotypes about who is HIV infected: a further study
Authors: Gold Ron S , Skinner Michael J , Hinchy John
Published: October 2002

Gay men's stereotypes about who is HIV-infected were investigated. Young uninfected (n=62), older uninfected (n=61), and infected (n=65) gay men read brief descriptions of men they did not know and estimated the likelihood that they were infected. Each description highlighted one characteristic of the man described. There were 3 versions of each sketch; the versions highlighting preferred sexual practice, for example, described the man as either preferring insertive anal intercourse, preferring receptive anal intercourse, or liking both equally. Results were largely the same for the 3 sample groups. For 6 of the 9 characteristics investigated- preferred haunts, preferred sexual practice, dress code, access to gay venues, occupation, and sexual orientation- significantly different estimates were given for the different versions. Results are discussed in relation to how AIDS education might counter the use by gay men of stereotypes to infer whether a given sex partner is infected. It is suggested that these stereotypes are likely to be present 'on line' (during actual sexual encounters), rather than 'off line' (in the cold light of day), thereby complicating the task of AIDS educators.
Improving referrals for glue ear from primary care: are multiple interventions better than one alone?
Authors: Bennett Kathleen , Haggard Mark , Churchill Richard , Wood Stuart
Published: October 2002

Objectives: To evaluate the effect of a risk factor checklist and training video for general practitioners in reducing inter-practice variation and improving the appropriateness of referrals (assessed by their positive predictive value or PPV) of patients with suspected otitis media with effusion (OME or 'glue ear') to secondary care.

Methods: Fifty general practices (177 practitioners) from the NHS Trent region and the West of Scotland were cluster-randomised either to a control group ( n = 12) or to one of three intervention groups (training video ( n = 16), checklist ( n = 11), or both ( n = 11)). Data on all paediatric ear, nose and throat (ENT) referrals and diagnostic results at ENT clinics were collected for a one-year period pre- and post-intervention. Referral rates for OME and for closely related conditions were calculated for children aged 0-15 years, based on each practice's list size. PPV was defined as the proportion of referrals resulting in bilateral hearing loss ≥ 20 dB at the ENT outpatient department.

Results: There was a significant improvement in the PPV, adjusted for patients' waiting time between general practitioner (GP) referral and being seen at the ENT department. The improvement in PPV pre- and postintervention was 15% (95% confidence interval, CI: -12.1% to 41.7%) for the practices receiving both interventions, compared with a degradation of 20% pre- and post-intervention (95% CI: -32.9% to

-6.4%) for practices receiving only one intervention and a degradation of 34% for those receiving no intervention.

Conclusions: Disseminating a risk factor checklist and training video on glue ear to GPs using a multi-channel approach can improve the quality of referrals to ENT.
Public release of information on quality of care: how are health services and the public expected to respond?
Authors: Marshall Martin , Davies Huw
Published: October 2002

Public disclosure of the comparative performance of health care providers has been proposed as one mechanism of improving the quality of care. Performance data have been made public in the USA for over a decade and the provision of comparative information about quality of care is a central feature of current UK government health policy. The balance between the advantages and risks of pursuing such a policy in a publicly funded health service is largely unknown. Advocates of public disclosure cite the role that comparative data can play in ensuring accountability, shifting the ownership of information (and therefore power) from professionals to service users and encouraging improvements in the processes and outcomes of care. However, these expectations are not necessarily realistic. There is some evidence that the public make little use of comparative data and there is a risk that public release may result in a loss of confidence in the health system and demoralisation of health service staff. In addition, there is a legitimate doubt that any early impact of disclosure will not be sustained and that the outcomes will not justify the necessary expenditure. In conclusion, we suggest that the theoretical benefits of promoting public disclosure as voiced by advocates of the policy may not be realised in practice.
When research knowledge is unwelcome: studying the health effects of in vitro fertilization
Authors: Hemminki Elina
Published: October 2002

Objectives: To illustrate the complexity of setting up evaluative research when it is perceived to threaten professional and financial interests.

Methods: A case study based on participatory observation of attempts to study the delivery and health consequences of in vitro fertilization (IVF). Two research projects were observed: one used well-baby clinic records and this project was completed; the other project aimed to use national data and record linkage to study the patterns of use of IVF, the IVF success rate, and the health effects on women and on children. This project could not be carried out as planned. The reasons for this were studied. Observations, documents and notes on discussions were analysed.

Results: IVF clinicians were not interested in the second project until faced with a concrete request to provide data. Tactics to avoid providing data included asking for more information on the project, transferring the request from one person to another, and arguing against the project. The arguments used and conditions set by different clinics were similar and centred around data confidentiality and authorship of the anticipated research reports. This case illustrated features that occur when health care is evaluated by non-clinicians: quarrels over mandate and ownership; and conflicts between the different research traditions of clinicians and epidemiologists.

Conclusions: To facilitate evaluation by outsiders, new norms are needed and outside researchers need institutional back-up. Outside evaluation may need a determined push from health care funders and a cultural change within the clinical community itself.
Organization and financing of British primary care groups and trusts: observations through the prism of US managed care
Authors: Weiner Jonathan , Gillam Steve , Lewis Richard
Published: October 2002

There are many parallels between the UK's new primary care commissioning organizations and the managed care organizations and integrated delivery systems that have evolved in the USA over the last three decades. Those building primary care groups and trusts (PCG/Ts) can learn from the American experience with health maintenance organizations and other similar entities. These lessons should also be relevant to those in other countries interested in establishing innovative primary care led organizations within the broader structure of a socialized health care system. Following an overview of US managed care and an update of the progress of the UK's PCG/Ts, we go on to suggest how new consortia of PCG/Ts might be developed and how budgets and provider incentives could be structured. This international comparison suggests that the resources needed to support the development of effective PCG/Ts will be considerable, as will the need to maintain organizational flexibility. If primary care organizations are to thrive, it will be essential to develop truly integrated budgets for primary and secondary care.
Updating evidence-based clinical guidelines
Authors: Eccles Martin , Rousseau Nikki , Freemantle Nick
Published: October 2002

Objectives: To report on the updating of two evidence-based guidelines.

Methods: Development of multi-disciplinary evidence-based guidelines within the North of England Evidence Based Guideline Development Programme.

Results: The guideline updating groups were multi-disciplinary although the balance of disciplines was different from the original development groups; the convening of the updating groups allowed refinement of both the skills within the groups and the overall size of the groups. As both groups were starting with a previous version of the guideline, defining the scope of the guideline was more straightforward and faster than when developing the guideline de novo. The process of evidence identification for both guidelines was again by systematic review. Updating the guidelines influenced recommendations in two ways: new evidence required new recommendations; and supplementary evidence in an existing area allowed refinement of recommendations. Overall savings within the guideline updating process (compared with initial development) were modest. The major costs of both the initial guideline development and the updating process were staff costs, which were identical for the two processes.

Conclusions: There is little other experience to set alongside this paper. There is a need for further sharing of experiences and the development of explicit methods for informing decisions on when and how to update evidence-based guidelines.
Which sorts of pharmacies provide more patient counselling?
Authors: Norris Pauline
Published: October 2002

Objective

This paper investigates the characteristics of pharmacies that are associated with the degree of counselling provided to customers purchasing medicines.

Methods

Twelve ‘mystery shoppers’ (research assistants posing as normal customers) purchased restricted medicines at 180 pharmacies around New Zealand. One drug (diclofenac) and one class of drugs (vaginal antifungals) were purchased. The amount of counselling provided was recorded, and linked to profile data on the pharmacies, obtained through a questionnaire, from Census data, and from direct observations of pharmacies.

Results

Location within a city, a large town, or strip shopping did not affect the level of counselling pharmacies provided. Pharmacies adjacent to medical centres gave significantly less counselling to diclofenac purchasers than other pharmacies. No consistent relationship was found between pharmacy size and the level of counselling provided. There were large differences between areas of the country. A strong negative relationship was found between the amount of counselling given about thrush, and the proportion of Pacific Island people in the population around the pharmacy. Although only some results reached statistical significance, there seems to have been a similar trend for pharmacies to provide less counselling in areas with more Maori people and with higher levels of social deprivation.

Conclusions

Regional variation in the provision of pharmacy services, and in particular the tendency for pharmacies to provide less counselling in areas that are likely to have higher health care needs, must be addressed if pharmacies are to fulfil their potential as health care providers.
Strengths and limitations of competitive versus non-competitive models of integrated capitated fundholding
Authors: Segal Leonie , Donato Ron , Richardson Jeffrey , Peacock Stuart
Published: October 2002

Integrated budget-holding (fundholding) based on risk-adjusted capitation is commonly proposed as a central element of health system reform. Two contrasting models have been developed: the competitive model where fundholders or health plans compete for enrollees; and the non-competitive model, where plan membership is determined according to an objective attribute such as place of residence.

Under the competitive model, efficiency is sought through consumer choice of plan. A range of regulatory elements may also be introduced to moderate undesirable elements of competition. Under the non-competitive model, efficiency is achieved through government regulation and the fact that the fundholder has continuing responsibility for the health of a defined population, supported by micro-management tools (such as quality assurance and selective payment arrangements). In theory, the non-competitive model encourages population-based health services planning. While both models assume risk-adjusted capitated funding, the requirements of any formula are more stringent under the competitive model.

Economic theory, as well as documented health system experience, can help identify the relative strengths and limitations of each model. Concerns with the competitive model relate primarily to the capacity to develop robust risk adjusters for capitation sufficient to reduce the incentives for patient risk selection. Possible reductions in the quality of care are also a concern, compounded by difficulties for consumers in discriminating between plans. Efficiency under the non-competitive model requires a strong and appropriate regulatory/policy framework and effective use of micro-management tools. Funding equity objectives can be met through either model by the adoption of income-related contributions, but under the competitive model this may be compromised by incentives for the fundholders to select low-risk patients.

Evidence drawn from regional fundholding in New South Wales (NSW, Australia), the US Veterans Health Agency and the literature on managed care in the USA illustrate these concerns.

The problem of risk selection in the competitive model is a major theoretical concern, confirmed by the empirical evidence. This, together with concerns regarding other aspects of performance, suggests that the non-competitive model may be preferable, at least as an interim step in reform in public or mixed systems. Future research on this issue is clearly required.
Could a low-cost audio-visual link be useful in rheumatology?
Authors: Graham L E , Mcgimpsey S , Wright S , Mcclean G , Carser J , Stevenson M , Wootton R , Taggart A J
Published: October 2002

We have investigated prospectively the diagnostic accuracy, specialist satisfaction and patient–specialist rapport of a low-cost audio-visual link between a junior doctor with a patient and a consultant rheumatologist. Using a telephone link and subsequently a video-phone link, 20 patients, with various rheumatological problems, were presented by a junior doctor to the consultant rheumatologist for provisional diagnosis. All patients were then seen face to face by the consultant, when a final diagnosis was made. An independent consultant rheumatologist made a ‘gold standard’ diagnosis. Thirty-five per cent of diagnoses were made correctly over the telephone and 40% over the video-phone – there was no significant difference in the diagnostic accuracy between these two methods of communication. Rapport over the video-phone was universally poor. Where it was important, clinical signs could not be visualized over the video-phone and in more than 85% of cases small joint swellings could not be seen clearly.
A review of telemedicine cost-effectiveness studies
Authors: Mair F S , Haycox A , May C , Williams T
Published: October 2002

As interest in telemedicine grows, many of its proponents and vendors increasingly suggest that it is now time to move to full-scale implementation of telemedicine services in a variety of contexts throughout the world, and question the need for further evidence of its utility and cost-effectiveness. We have reviewed the published literature relating to cost-effectiveness studies in telemedicine and have identified some important weaknesses. Ten recommendations regarding the design of economic evaluations of telemedicine are suggested.
Supervising trauma life support by telemedicine
Authors: Tachakra Sapal , Jaye Peter , Bak Julie , Hayes Jesus , Sivakumar Alganandan
Published: October 2002

The resuscitation room in a community hospital was linked with a main hospital accident and emergency department using telemedicine equipment working at 384 kbit/s. Fifteen simulated casualties replicated the ‘moulage’ scenarios in the Advanced Trauma Life Support Course Manual of the American College of Surgeons. Each of the 15 scenarios was broken down into three main parts: the primary survey, resuscitation and the secondary survey. While a physician in the community hospital undertook each task, a senior doctor in the accident and emergency department recorded his degree of confidence in the supervision of the task on a five-point scale. There were features of the management which the supervisor found difficult, mainly related to the camera view and the use of a proxy examiner. However, supervising major trauma management by telemedicine was feasible. The average scores were mostly above 3 and often above 4 in the assessment of the primary survey and the resuscitation. The average scores were mostly above 3 for the secondary survey but were less often above 4 than for the primary survey and the resuscitation. Trials of remote trauma management with real patients appear to be justified.
Transforming local care
Authors: Dennis Terry , Owens David
Published: October 2002

The prevalence of diabetes mellitus is steadily increasing in Western society, with obvious implications for costs to health-care providers. A project plan to transform local care has been established in Wales to enable diabetic patients to self-manage their disease by improving education and access to information and tests locally. The plan involves the establishment of local diabetes centres providing educational resources to the patients, carers and health professionals. It envisages that the local diabetes community centres will provide all aspects of diabetic care, from diagnosis to continuing management, with the aid of modern communications technology.