Multiple approaches to surface water quality assessment provide insight for small streams experiencing oil and natural gas development.

Historic, current, and future oil and natural gas development can affect water quality in streams flowing through developed areas. We compared small stream drainages in a semiarid landscape with varying amounts of disturbance from oil and natural gas development to examine potential effects of this development on surface water quality. We used physical, chemical, and biological approaches to assess water quality and found several potential avenues of degradation. Surface disturbance likely contributed to elevated suspended sediment concentrations and spill history likely led to elevated stream polycyclic aromatic hydrocarbon concentrations. In combination, these environmental stressors could explain the loss of aquatic macroinvertebrate taxon at sites highly affected by oil and natural gas development. Our results provide insight into advantages and disadvantages of approaches for assessing surface water quality in areas affected by oil and natural gas development. Integr Environ Assess Manag 2019;00:000-000. © 2019 SETAC.

The financial and service implications of splitting fixed-dose antiretroviral drugs - a case study.

In 2010/2011, regional commissioners withdrew payment for the fixed-dose combination Combivir, forcing a switch to component drugs. This was deemed clinically acceptable and annual savings of £44 k expected. We estimated the true costs of switching and examined patient outcomes. Information for 46 patients using Combivir was extracted from case notes for each clinical contact in the 12 months pre- and post-switch (clinician seen, tests, antiretrovirals). Post-switch care costs £93/patient more annually versus pre-switch (95% CI £424 to £609), yielding £4278/year more post-switch for all patients. Drug and pathology costs were more expensive post-switch and extra clinical visits required. None of these results were statistically significant. Forty-two per cent of patients switched directly or in the subsequent year to an alternative fixed-dose combination rather than generics. Costs in this group were significantly higher post-switch driven by drug cost. Six patients (13%) reported problems with the switch including confusion around dosing and new side effects. As less-expensive generic antiretroviral drugs become available, it may appear cheaper to switch from fixed-dose combinations to component drugs. However, the additional clinical costs involved may outweigh the initial cost savings of the drugs and switching may cause confusion for some patients, risking loss of adherence.

Pregnancy outcomes of HIV-positive women in a tertiary centre in the UK.

With the advent of highly active antiretroviral therapy (HAART), the mother-to-child HIV transmission rate in the UK has reduced to less than 2%. A review of delivery outcomes of 106 HIV-positive pregnant women in a tertiary centre between January 2005 and December 2010 was conducted. A total of 20 women had detectable plasma viral load at 36 weeks, or before in the two women who delivered preterm. Various peripartum management measures were undertaken in women with detectable viral load close to delivery, to accelerate reduction in plasma viral load and to reduce the risk of HIV transmission to the fetus. In our review, the overall mother-to-child transmission rate was less than 1% and in women with undetectable viral load at 36 weeks, it was 0% (zero), which signifies the importance of strict virological control and a multidisciplinary approach, which plays an important role in the successful achievement of this.

Specialty and Associate Specialist doctors: still the dependable backbone of genitourinary medicine.

Workforce planning is an inexact science. Specialty and Associate Specialist (SAS) doctors are rarely included in workforce analyses. Past studies have shown that SAS doctors are significant contributors to the work in genitourinary (GU) medicine clinics. This survey confirms the large amount of clinical work undertaken by SAS doctors. It appears that 51% of SAS doctors in GU plan to retire in the next 15 years and it is uncertain what effect the 2008 SAS contract will have on SAS recruitment. This information should be taken into consideration in future GUM workforce planning.

Survey of lactation suppression in HIV-positive pregnant women.

The risk of HIV transmission via breastfeeding is well reported. We conducted a national survey in the UK to look at the current knowledge and postpartum practice of HIV physicians caring for HIV-positive pregnant women. In total, 167 questionnaires were distributed, 85 (51%) questionnaires were returned. All the respondents advised their patients against breastfeeding, 17 (23%) respondents routinely prescribed drugs for postpartum lactation suppression and 32 (43%) detailed awareness of interactions between antiretroviral therapy and dopaminergic lactation suppression agents. Thirteen respondents reported awareness of guidance on lactation suppression. The knowledge and use of lactation suppression agents appears to be low. However, its use will not only reduce postnatal mastitis and breast engorgement but will also help women deal with social pressures to breastfeed. Increased use in specific circumstances will improve the postnatal care of HIV-positive pregnant women in the UK.

Uptake of 48-hour access appointments in genitourinary medicine.

Timely access to genitourinary (GU) medicine services is important in the control of sexually transmitted infections (STIs). A target has been set that by March 2008, 100% of patients will be offered a GU medicine appointment within 48 hours. Strategic Health Authorities have also been asked to plan for 95% of patients to be seen within 48 hours. We sought to identify why patients decline appointments offered within 48 hours by collecting prospective data over three months. Additional data was collected over 18 working days to identify if alternative options would be acceptable to decliners. Overall, 1577 patients contacted the clinic, 1524 (96.6%) were offered a 48-hours appointment, 1108 (72.7%) accepted it, 416 (27.3%) declined it and 66.3% citing work commitments as the reason. In 118 patients, who declined the appointment offered; 43.2% indicated no alternative option was acceptable, 23.7% chose a Saturday appointment, which in 78.6% would have exceeded 48 hours. Hence, 73 (61.9%) patients would not have accepted an appointment within 48 hours. The balance of public health control, mixed service provision and informed patient choice is discussed.

Does partner notification of men with asymptomatic non-gonococcal non-chlamydial urethritis identify chlamydia-positive women?

The objective of this study was to identify the proportion of female contacts of men diagnosed with non-gonococcal non-chlamydial urethritis (NGNCU) who had chlamydial infection, muco-purulent cervicitis (MPC), pelvic inflammatory disease (PID) or other genital infections, and to determine whether chlamydial rates are higher in women who are contacts of men with NGNCU. A retrospective case-note review of men with NGNCU and their traced female contacts was performed. Seventy-five men were included in the study, of whom 75% were caucasian and 49% were asymptomatic. Twenty-four women were successfully traced equating to 0.32 contacts per index man. In total, 46% of the women were contacts of asymptomatic men. Overall, 26% of women were identified with chlamydial infection, increasing to 36% in the contacts of asymptomatic men. The diagnosis and partner notification of men with asymptomatic NGNCU does identify female contacts with high chlamydial infection rates. However, such targeting is resource-intensive and invasive urethral screening may deter asymptomatic men from attending. It is likely that the needs of the whole health community will be better served by screening a greater number of men and operating an active partner notification system.

Flexible booking systems to improve genitourinary medicine access and increase patient choice.

Access to genitourinary (GU) medicine services is crucial for the effective control of infection and it is well recognized that improved access to GU medicine will be required in order to meet a 48-hour access target. The object of this study was to evaluate whether access to our GU medicine service would be improved and the observed default rates decreased by the introduction of a partial closed booking system for new patients. The system was run in parallel to our standard appointment service and triage system. Data were collected for the first six months that the new system was operational, with additional data collection over the corresponding calendar periods of the subsequent two years. Approximately 26% of new patient appointments were booked through the partial closed booking system in the time periods specified. New patient appointment default rates fell from 26.8-30.5% in the standard appointment system to 7.5-9.5% in the partial closed booking system (P < 0.0001). This study supports the importance of clinics adapting and providing a range of appointment system strategies as this may improve their clients' access to GU medicine services.

Prevalence of Giardia in symptomatic dogs and cats throughout the United States as determined by the IDEXX SNAP Giardia test.

National prevalence of Giardia infection in dogs and cats presenting to clinics with vomiting and/or diarrhea was examined using the IDEXX SNAP Giardia test kit. Veterinary practices across the United States were sent an invitation to participate in the survey and asked to use the test on fecal samples from the target population. The survey requested that the clinics report the results of 20 or more tests. A total of 21,092 results were reported, comprised of 16,114 dogs and 4,978 cats. Analysis of the data (excluding the handful of results reported from Puerto Rico) showed a Giardia prevalence of 15.6% among dogs tested, and 10.8% among cats. This difference was statistically significant (p < 0.001). Regional categorization into Northeast, Southeast, West, and Midwest drew out significant (p < 0.001) differences in prevalence in most cases for dogs; the differences were not significant for cats. These differences and other variables are currently being examined with this and additional data sets. We conclude on the basis of the SNAP test diagnostic that Giardia is a common enteric agent among dogs and cats with gastrointestinal signs.

Incidence of concurrent sexually transmitted infections in patients with genital warts.

A case-note audit of patients presenting to a genitourinary (GU) medicine clinic with external genital warts during a six-month period was conducted. Approximately 40% of patients were referred by a general practitioner or other primary care agency, and >50% were suitable for home-based treatment. Overall incidence of co-existing sexually transmitted infections (STIs) in the study population was 14.0%. Multivariate logistic regression analysis found that age<25 years and presence of other genital symptoms were risk factors for co-existing STIs. All patients with a non-chlamydial STI had genital symptoms. We recommend that patients with uncomplicated genital warts and no additional genital symptoms can be treated in primary care, with chlamydia-screening offered to those aged<25 years.

Pilot study in the development of an interactive multimedia learning environment for sexual health interventions: a focus group approach.

In the UK there are high rates of sexually transmitted infections and unintended pregnancies amongst young people. There is limited and contradictory evidence that current sexual health education interventions are effective or that they improve access to appropriate sexual health services. This paper describes the outcome of focus group work with young people that was undertaken to inform the design of an Interactive Multimedia Learning Environment that incorporates message framing, intended for use in sexual health promotion. The focus group work addressed sexual attitudes, behaviour, risk perception, and knowledge of sexual health and sexual health services in Nottingham. The results provided new insights into young peoples' sexual behaviour, and their diversity of knowledge and beliefs. Common themes expressed regarding sexual health services included concerns about confidentiality, lack of confidence to access services and fear of the unknown. The results showed that while the adolescents are reasonably knowledgeable about infection, they do not know as much about the relevant services to treat it. This work emphasizes the need for user involvement throughout the design and development of a sexual health intervention, and will form the basis of the next part of the project.

Health advisor workload.

Health advisors (HAs) are an integral part of the multidisciplinary team within genitourinary (GU) medicine clinics, with a pivotal role in the National Sexual Health Strategy by enhancing liaison between community sexual health provision and GU medicine services. Greater clarity is needed about HAs' current activities and workload in order to enable benchmarking and ensure accurate workforce planning. We describe a tool for assessing HA workload and activity and evaluating its use in real clinic environments through a prospective time and motion model. Ten centres (63% of those invited to participate) within a single region did so. Median HA working times were calculated at almost 15 min/patient consultation and approximately 10 min/telephone call. Although there were strong positive correlations between HA availability and some markers of clinical activity, these were weaker than similar correlations applied to medical staff, raising the possibility of suboptimal HA workforce planning.

Prevalence and service implications of health anxiety in genitourinary medicine clinics.

A comparison of the prevalence of health anxiety in genitourinary medicine (GUM) clinics in two UK centres was carried out using a new rating scale, the Health Anxiety Inventory (HAI). The relationship of health anxiety to demographic and clinical variables, and its impact on service contacts, was also examined in one of these centres. 694 patients were assessed and significant health anxiety was identified in 8-11%. HAI scores were stable over time and high levels persisted in the absence of treatment. Attenders with sexually transmitted infections had significantly lower levels of health anxiety than those with other conditions. Contacts with clinic doctors and health advisors in the nine months before and after assessment were significantly greater in those with high health anxiety, with doctor appointments 37% higher in the high HAI group (P = 0.005). Health anxiety is a source of considerable morbidity in GUM clinics deserving further study.

Genitourinary medicine: an opportunity to reduce unwanted pregnancy.

We sought to investigate contraceptive use in women attending a genitourinary medicine (GUM) clinic, and to assess the need for a contraceptive service in this setting. Female attendees at Nottingham GUM clinic were invited to complete an anonymous questionnaire regarding past and present contraceptive use and whether a contraceptive service within GUM would be utilized. Four hundred and eighty-nine questionnaires were analysed. The majority had previously used condoms (89.8%) or the combined oral contraceptive pill (COCP) (74.6%), and 46.6% and 37.4%, respectively were currently using these methods. Contraception was frequently used for the dual aims of avoiding both pregnancy and infection (48.5%). General practitioners (GPs) and family planning clinics were most frequently cited as sources of regular contraceptive advice, 58.1% and 47.2% respectively, and emergency contraception 50.8% and 37.3%, respectively. If a contraceptive service was available within GUM 56.9% of respondents indicated they would use it.

Quality of working life in genitourinary medicine.

Quality issues are becoming increasingly relevant to the working lives of health care staff. We sought to assess the perceived work-related quality of life of staff working in a genitourinary medicine (GUM) department using a self-administered anonymous questionnaire focusing on areas from the Trust's staff charter. Over two-thirds (69%) of the staff members participated. Perceptions of working life were generally good within GUM. In particular staff felt valued as a resource with free expression of ideas, involvement in decision making, fair treatment and respect. Weaker areas were identified enabling a plan to be developed to address these. It is important to address quality in working life in order to achieve improvements.