Relative efficiency of chlamydia screening in non-clinical settings in two California counties.

We examined the relative efficiency of non-clinical sites to screen for chlamydia in youth and young adults. Chlamydia screening targeting youth (under 30 years of age) was performed at non-clinical sites in high-morbidity neighbourhoods of two California counties. Venues were subdivided into community outreach, schools, parenting centres and drug treatment/correctional facilities. Relative efficiency was estimated with multivariate Poisson regression using incidence of chlamydia per person-hours labour adjusting for strategy and county. Among the 1514 youths screened, the overall prevalence of chlamydia was 5.5%. By venue, the highest prevalence was in drug treatment/correction facilities at 11.1% followed by parenting centres at 6.3%, community outreach at 4.9% and schools at 4.6%. Drug treatment/correctional facilities were the most labour time efficient at 9.9 person-hours per chlamydia case. Schools and parenting centres had the lowest cost per screen at 0.9 person-hours per screen. Adjusted relative labour time efficiency (chlamydia cases per paid person-hour) was significantly higher in schools, 2.0 (95% confidence interval [CI] 1.0-4.2), parenting centres, 3.2 (95% CI 1.6-6.6) and drug treatment/correctional facilities, 2.9 (95% CI 1.0-7.8), compared with community outreach. In conclusion, parenting centres and drug treatment centres and correctional facilities are the most efficient venues for chlamydia screening.

Using strain typing to characterise a fluoroquinolone-resistant Neisseria gonorrhoeae transmission network in southern California.

OBJECTIVE: We investigated the initial outbreak of fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) in southern California with analysis of transmission using strain typing. METHODS: Surveillance for QRNG was conducted between 2000 and 2002 in southern California, including epidemiology and strain typing by a combination of antibiogram, auxotype, serovar, Lip type and amino acid alteration patterns in the quinolone-resistance determining region of GyrA and ParC. Combining epidemiological data with strain typing, we describe the emergence of QRNG outbreak strains using risk factor analysis and transmission networks. RESULTS: Two outbreak strains accounted for 82% of isolates. Both strains required proline, were Lip type 17c, had amino acid alterations 91> Phe in GyrA and 87> Arg in ParC, but they differed by their serovar, IB-3C8 versus IB-2H7, 2G2. Outbreak strains were positively associated with men who have sex with men (MSM), adjusted odds ratio (AOR) 23.9 (95% confidence interval (CI) 2.2 to 261) and negatively associated with travel history: AOR 0.05, (95% CI 0.0 to 0.6). Network analysis demonstrated that 17 cases were connected by sexual contacts and/or public venues including bars, bathhouses/sex clubs, and internet sites. CONCLUSIONS: QRNG may have become established among Californian MSM through an identified transmission network of southern Californian bars, bathhouses and internet sites.

Determinants of genital human papillomavirus infection in young women.

Carcinoma of the cervix has several well-established epidemiologic risk factors, including multiple sexual partners and early age at first intercourse. Human papillomavirus (HPV) infection appears to have an etiologic role in the development of cervical neoplasia, but evidence linking HPV infection to known risk factors for cervical cancer has been inconsistent. The lack of expected correlations may be due to the inaccuracy of HPV assays previously used. A polymerase chain reaction DNA amplification method for the detection of HPV was used to investigate the determinants of genital HPV infection in a cross-sectional sample of 467 women attending a university health service. In contrast to studies using less accurate detection methods, the risk factors for HPV infection found here were consistent with those for cervical neoplasia. The risk of HPV infection was strongly and independently associated with increasing numbers of sexual partners in a lifetime, use of oral contraceptives, younger age, and black race. Age at first intercourse, smoking, and history of a prior sexually transmitted disease were correlated with, but not independently predictive of, HPV infection. These results demonstrate that the key risk factors for cervical carcinoma are strongly associated with genital HPV infection. This correlation suggests that HPV has an etiologic role in cervical neoplasia and reaffirms the sexual route of HPV transmission.

Epidemiologic evidence showing that human papillomavirus infection causes most cervical intraepithelial neoplasia.

BACKGROUND: Experimental studies have provided strong evidence that human papillomavirus (HPV) is the long-sought venereal cause of cervical neoplasia, but the epidemiologic evidence has been inconsistent. PURPOSE: Given improvements in HPV testing that have revealed a strong link between sexual activity history and cervical HPV infection, we conducted a large case-control study of HPV and cervical intraepithelial neoplasia (CIN) to evaluate whether sexual behavior and the other established risk factors for CIN influence risk primarily via HPV infection. METHODS: We studied 500 women with CIN and 500 control subjects receiving cytologic screening at Kaiser Permanente, a large prepaid health plan, in Portland, Ore. The established epidemiologic risk factors for CIN were assessed by telephone interview. We performed HPV testing of cervicovaginal lavage specimens by gene amplification using polymerase chain reaction with a consensus primer to target the L1 gene region of HPV. Unconditional logistic regression analysis was used to estimate relative risk of CIN and to adjust the epidemiologic associations for HPV test results to demonstrate whether the associations were mediated by HPV. RESULTS: The case subjects demonstrated the typical epidemiologic profile of CIN: They had more sex partners, more cigarette smoking, earlier ages at first sexual intercourse, and lower socioeconomic status. Statistical adjustment for HPV infection substantially reduced the size of each of these case-control differences. Seventy-six percent of cases could be attributed to HPV infection; the results of cytologic review suggested that the true percentage was even higher. Once HPV infection was taken into account, an association of parity with risk of CIN was observed in both HPV-negative and HPV-positive women. CONCLUSION: The data show that the great majority of all grades of CIN can be attributed to HPV infection, particularly with the cancer-associated types of HPV. IMPLICATIONS: In light of this conclusion, the investigation of the natural history of HPV has preventive as well as etiologic importance.

In-vitro platelet-neutrophil adherence.

The specific adherence of platelets to neutrophils in vitro has been noted with increasing frequency and with increasing interest, but its significance remains obscure. Two cases in which this event occurred are presented, and the literature is reviewed.

Comparative analysis of human papillomavirus detection by PCR and non-isotopic in situ hybridisation.

AIMS--To assess the relative diagnostic performance of the polymerase chain reaction (PCR) and non-isotopic in situ hybridisation (NISH) and to correlate these data with cytopathological assessment. METHODS--Paired analysis of human papillomavirus (HPV) detection was performed by PCR and NISH on exfoliated cervical cells from 122 women attending a routine gynaecological examination. PCR amplification followed by generic and HPV type specific hybridisation was compared with NISH on a parallel cervical smear. RESULTS--Overall, 32 cases were positive by NISH and 61 positive by PCR. Of the 105 cases in which both PCR and NISH were interpretable, 76 (26%) were normal smears, 20 of which were HPV positive by NISH and 37 (49%) by PCR. Of 17 borderline smears, two were NISH positive and 12 PCR positive. Eight of nine smears containing koilocytes were positive by NISH and seven by PCR. Of three dyskaryotic smears, none were NISH and two were PCR positive. The concordance of NISH and PCR in these samples was 57%. To assess sampling error, NISH and PCR were performed on an additional 50 cases using aliquots from the same sample. This increased the concordance between assays to 74%. Filter hybridisation of PCR products with the cocktail of probes used in NISH (under low and high stringency conditions) demonstrated that several cases of NISH positivity could be accounted for by cross-hybridisation to HPV types identified by PCR but not present in the NISH probe cocktail. CONCLUSIONS--Sampling error and potential cross-hybridisation of probe and target should be considered in interpretation of these techniques. PCR is more sensitive because it provides for the amplification of target DNA sequences. In addition, the PCR assay utilised in this study detects a wider range of HPV types than are contained in the cocktails used for NISH. However, PCR assays detect viral DNA present both within cells and in cervical fluid whereas NISH permits morphological localisation.

A community-based collaboration to assess and improve medical insurance status and access to health care of Latino children.

OBJECTIVES: Despite eligibility for subsidized insurance, low-income Latino children are at high risk of being medically uninsured. The authors sought to understand and improve access to medical insurance for Latino children living in a California community of predominantly low-income immigrant families. METHODS: During the summer of 1999, trained women from the community conducted interviews in Spanish with 252 randomly selected mothers of 464 children younger than age 19. Mothers provided information about family demographics, children's medical insurance, health care access, and experiences obtaining and maintaining children's insurance. RESULTS: Most children (83.3%) were eligible for subsidized medical insurance (48.4% Medi-Cal eligible; 35.0% Healthy Families eligible). Twenty-eight percent of eligible children were not enrolled. Non-enrolled eligible children were older (median age 7) than enrolled children (median age 4) and more likely to be born outside the U.S. (22.2%) than enrolled children (4.8%). Among children ages 3-18, those not enrolled were less likely to have visited a doctor in the past 12 months (58% compared to 78.7%) and less likely to have a usual source of care (96.3% compared to 99.5%). Mothers of non-enrolled children were more likely than mothers of enrolled children to have less than seven years of education (47.8% compared to 36.4%). Families with non-enrolled children were more likely to report out-of-pocket medical expenses (84.1% compared to 53%). Families with non-enrolled children were more likely to report barriers to the enrollment process, such as problems providing required documents (39.7% compared to 15.1%), problems understanding Spanish forms (19.4% compared to 8.9%), and confusing paperwork (39.7% compared to 24.7%). Most mothers (75.9%) reported that community organizations provided very useful help with children's insurance enrollment. Almost half (48.6%) preferred to receive enrollment assistance from community organizations. Only 43.3% of mothers had heard of the Healthy Families program. CONCLUSIONS: To reach the majority of uninsured Latino children, community-based outreach and insurance application assistance are crucial. Most important, the process of applying for and maintaining coverage in Medi-Cal or Healthy Families must be simplified.

Barriers to health care for abused Latina and Asian immigrant women.

This study identifies social, political, and cultural barriers to help seeking from health care organizations faced by abused Latina and Asian immigrant women. Qualitative data were collected through four semistructured ethnic-specific focus group interviews with 28 abused Latina and Asian immigrant women. Participants who had suffered intimate partner abuse were recruited through urban community-based organizations in San Francisco, California. Sociopolitical barriers to help seeking and patient-provider communication included social isolation, language barriers, and, for some, discrimination and fears of deportation. Sociocultural barriers included dedication to the children and family unity, shame related to the abuse, and the cultural stigma of divorce. Abused Latina and Asian immigrant women face significant social, cultural, and political barriers to patient-provider communication and help seeking. Medical and social service providers and policy makers may improve the quality of care for these women by understanding and addressing these barriers.

Mucocutaneous lymph node syndrome in an adult receiving diphenylhydantoin.

A woman who had been taking diphenylhydantoin presented with a classic picture of mucocutaneous lymph node syndrome, which has heretofore been reported exclusively in infants and children. The clinical history is presented herein.

Bilateral chylothorax associated with sclerosing mediastinitis.

A 14-year-old female developed a sequential bilateral chylothorax from a complication of idiopathic mediastinal fibrosis. To the best of our knowledge, there has not been a published report of idiopathic mediastinal fibrosis followed by chylothorax. The recurrent bilateral chylothorax was treated successfully with a closed thoracostomy.

Factors affecting patient-physician communication for abused Latina and Asian immigrant women.

BACKGROUND: Domestic violence is one of today's most serious health issues. Abused Latina and Asian immigrant women face unique barriers to the discussion of abuse with health care providers. This research was undertaken to identify any provider-related factors that may affect patient-provider communication for these women. METHODS: Qualitative data were collected using semistructured focus group interviews with abused Latina and Asian immigrant women. Participants were recruited through urban community-based organizations. Twenty-eight immigrant women with histories of domestic violence participated in four focus groups: two groups of Latina women and two groups of Asian women. Iterative readings by independent researchers identified provider-related factors affecting patient-provider communication. RESULTS: The study participants identified the provider behaviors that demonstrate trust, compassion, and understanding as elements that improve patient-provider communication. In addition, participants wanted providers to initiate discussions about partner abuse. CONCLUSIONS: Improved understanding of factors that may affect abused immigrant patients' communication may assist health care providers in offering meaningful support and assistance to these patients. Providers, administrators, policy makers, and educators should consider these factors when developing policy, protocols, and educational curricula for a variety of health care settings.

The factors associated with disclosure of intimate partner abuse to clinicians.

OBJECTIVE: Our goal was to identify the prevalence, determinants of, and barriers to clinician-patient communication about intimate partner abuse. STUDY DESIGN: We conducted telephone interviews with a random sample of ethnically diverse abused women. POPULATION: We included a total of 375 African American, Latina, and non-Latina white women aged 18 to 46 years with histories of intimate partner abuse who attended 1 of 3 primary care clinics in San Francisco, California, in 1997. OUTCOMES MEASURED: We measured the relevance and determinants of past communication with clinicians about abuse and barriers to communication. RESULTS: Forty-two percent (159) of the patients reported having communicated with a clinician about abuse. Significant independent predictors of communication were direct clinician questioning about abuse (odds ratio [OR]=4.6; 95% confidence interval [CI] 3.2-6.6), and African American ethnicity (OR=1.8; 95% CI, 1.1-2.9). Factors associated with lack of communication about abuse included immigrant status (OR=0.6; 95% CI, 0.3-1.0) and patient concerns about confidentiality (OR=0.7; 95% CI, 0.5-0.9). Barriers significantly associated with lack of communication were patients' perceptions that clinicians did not ask directly about abuse, beliefs that clinicians lack time and interest in discussing abuse, fears about involving police and courts, and concerns about confidentiality. CONCLUSIONS: Clinician inquiry appears to be one of the strongest determinants of communication with patients about partner abuse. Other factors that need to be addressed include patient perceptions regarding clinicians' time and interest in discussing abuse, fear of police or court involvement, and patient concerns about confidentiality.

Breaking the silence. Battered women's perspectives on medical care.

OBJECTIVE: To determine the barriers to identification and management of domestic violence from the battered women's perspective. DESIGN: Qualitative research methods using semistructured focus groups. SETTING: Urban and suburban community-based organizations serving women and their families in the San Francisco Bay (Calif) area. PARTICIPANTS: Fifty-one women with histories of domestic violence comprised eight focus groups divided as follows: two groups of Latino (n=14), two groups of white (n=14), Asian (n=14), and two groups of African-American (n=9) women. RESULTS: Participants from all ethnic groups identified major factors that affect identification and management of battered women in the health care setting. Factors that interfere with patient disclosure included threats of violence from the partner, embarrassment, adherence to gender roles, concerns about police involvement and lack of trust in the health care provider. One factor that predisposed a woman to seek help from providers was a need for the providers to exhibit compassion, awareness, and respect for the patient's need to make the final decisions about her situation. Most participants said that providers should take the initiative to ask directly about domestic violence, establish a supportive patient-provider relationship, and refer battered women to available community resources. The major institutional barriers to using the health care system included the high cost of medical care and long waiting periods. CONCLUSIONS: Many battered women experience social, institutional, and provider barriers to obtaining help from the health care system for problems related to domestic violence. Providers as well as institutions can overcome these barriers through an understanding of the social context of domestic violence and the victim's needs. Identification may be improved through a trusting patient-provider relationship and by direct questioning about domestic violence.

Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians.

CONTEXT: Although practice guidelines encouraging the screening of patients for intimate partner abuse have been available for several years, it is unclear how well and in which circumstances physicians adhere to them. OBJECTIVE: To describe the practices and perceptions of primary care physicians regarding intimate partner abuse screening and interventions. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey of a stratified probability sample of 900 physicians practicing family medicine, general internal medicine, and obstetrics/gynecology in California. After meeting exclusion criteria, 582 were eligible for participation in the study. MAIN OUTCOME MEASURE: Reported abuse screening practices in a variety of clinic settings, based on a 24-item questionnaire, with responses compared by physician sex, practice setting, and intimate partner abuse training. RESULTS: Surveys were completed by 400 (69%) of the 582 eligible physicians, including 149 family physicians, 115 internists, and 136 obstetrician/gynecologists. Data were weighted to estimate the practices of primary care physicians in California. An estimated majority (79%; 95% confidence interval [CI], 75%-83%) of these primary care physicians routinely screen injured patients for intimate partner abuse. However, estimated routine screening was less common for new patient visits (10%; 95% CI, 7%-13%), periodic checkups (9%; 95% CI, 6%-12%), and prenatal care (11%; 95% CI, 7%-15%). Neither physician sex nor recent intimate partner abuse training had significant effects on reported new patient screening practices. Obstetrician/gynecologists (17%) and physicians practicing in public clinic settings (37%) were more likely to screen new patients. Internists (6%) and physicians practicing in health maintenance organizations (1%) were least likely to screen new patients. Commonly reported routine interventions included relaying concern for safety (91%), referral to shelters (79%) and counseling (88%), and documentation in the medical chart (89%). Commonly cited barriers to identification and referral included the patients' fear of retaliation (82%) and police involvement (55%), lack of patient disclosure (78%) and follow-up (52%), and cultural differences (56%). CONCLUSIONS: These findings suggest that primary care physicians are missing opportunities to screen patients for intimate partner abuse in a variety of clinical situations. Further studies are needed to identify effective intervention strategies and improve adherence to intimate partner abuse practice guidelines.

Virginity examinations in Turkey: role of forensic physicians in controlling female sexuality.

CONTEXT: Although the Turkish Medical Association has deemed "virginity examinations" a form of gender-based violence, women in Turkey are often subjected to such examinations by forensic physicians for both legal and social reasons. Little is known about these physicians' role and attitudes in this practice. OBJECTIVES: To assess forensic physicians' experiences and attitudes regarding virginity examinations in Turkey and suggest potential solutions to the problems identified. DESIGN: Cross-sectional self-administered survey. SETTING: Surveys were completed during the Forensic Science Congress held in Kusadasi in April 1998 as well as in urban academic and medical practice settings between April and October 1998. PARTICIPANTS: Of 158 physicians who practice, are formally trained in, or are in training for forensic medicine, 118 completed the survey (response rate, 74.7%). MAIN OUTCOME MEASURES: Frequency and circumstances of conducting virginity examinations, opinions regarding beneficial and adverse consequences of these examinations, and recommendations for changing the practice, as measured by a 100-item questionnaire. RESULTS: Overall, survey respondents reported conducting 5901 examinations in the previous 12 months; 4045 were conducted because of alleged sexual assault and 1856 for social reasons. Although 68% of forensic physicians indicated that they believed virginity examinations are inappropriate in the absence of an allegation of sexual assault, 45% had conducted examinations for social reasons. The majority of the respondents (93%) agreed that the examinations are psychologically traumatic for the patient. In addition, more than half (58%) reported that at least 50% of patients undergo examinations against their will. CONCLUSIONS: Nearly half of forensic physicians in Turkey conduct virginity examinations for social reasons despite beliefs that such examinations are inappropriate, traumatic to the patient, and often performed against the patient's will. Physicians' participation in such practices is inconsistent with principles of bioethics and international human rights.

Patient attitudes about mandatory reporting of domestic violence. Implications for health care professionals.

As of January 1994, California physicians are required to report to police all patients who are suspected to be victims of domestic violence. This article describes the results from a focus group study of abused women (n = 51) that explored their experiences with and perspectives on medical care. The eight focus groups included two Latina (total n = 14), two Asian (total n = 14), two African-American (total n = 9), and two Caucasian (total n = 14) groups of women who had been the victims of domestic abuse within the previous 2 years. The women were recruited through community-based organizations in the San Francisco Bay Area. With regard to physician reporting of domestic violence to police, five themes were identified: fear of retaliation by the abuser, fear of family separation, mistrust of the legal system, desire for police protection, and preference for confidentiality and autonomy in the patient-health professional relationship. Our results indicate that mandatory reporting may pose a threat to the safety and well-being of abused women and may create barriers to their seeking help and communicating with health care professionals about domestic violence.