Twin pregnancies with a 'vanished' embryo: a higher risk multiple gestation group?

BACKGROUND: Prior studies have documented increased risks to the offspring of IVF singletons that result from a vanished twin pregnancy. We aim to investigate the effect on perinatal outcomes of having an early vanished triplet in IVF twins. METHODS: This is a retrospective cohort study of twins from a large academic IVF practice. Multivariate analysis was performed to examine the perinatal risks--including small for gestational age (SGA), low-birthweight (LBW), preterm delivery and early preterm delivery--in twins that resulted from an early vanished triplet compared with twins without a vanished embryo. RESULTS: Of 829 IVF twin deliveries, 59 were a result of vanished triplet pregnancies (7.1%). There was no significant increase in SGA, LBW or delivery <37 weeks in the vanished triplets compared with other twins; however, the risk of early preterm birth (<32 weeks) was significantly higher (OR 3.09, 95% CI 1.63-5.87) and the length of gestation of these pregnancies was on average 1.5 weeks shorter (P < 0.01). In addition, the unadjusted mean birthweight was lower by nearly 200 g in the vanished triplet pregnancies (P < 0.01). CONCLUSIONS: IVF twin pregnancies with a vanished triplet are at an increased risk for early preterm birth compared with other twin pregnancies. These pregnancies should be recognized at higher risk for early preterm birth and considered for increased obstetrical monitoring. A significant limitation of this study is that the cause for preterm birth was unknown.

Interventions to increase access to STI services: a study of England's 'high-impact changes' across three central London clinics.

BACKGROUND: Increasing access to sexual health services is a key objective for the Department of Health in England and Wales. In 2006 it published 10 high-impact changes (HICs) designed to enhance 48 h access to genitourinary medicine services. However, there is limited evidence on the effectiveness of the proposed interventions. OBJECTIVE: To evaluate the implementation of five HICs in three sexual health clinics over 4 years. These HICs included a text message results service, nurse-delivered asymptomatic service, clinic refurbishment, a centralised booking service and an electronic appointment system. METHODS: The effect of HICs was evaluated by measuring clinical activity, number of sexual health screens performed, and patients seen within 48 h. These data were obtained from the clinic database, mandatory reports and Health Protection Agency waiting time surveys, respectively. RESULTS: The median number of new patients seen per month increased from 3635 to 4263 following the implementation of the five HICs. The follow-up/new patient ratio fell from 0.67 to 0.21 during the study. The biggest fall corresponded to a rise in patients receiving results by text message, from 0% to 40%. Only the centralised booking service was associated with a significant increase in the number of new patients seen. DISCUSSION: Providing results by text message was associated with a reduced number of follow-up patients, while implementation of a centralised booking service coincided with a significant increase in patient access. Further research is required to evaluate the relative importance of the other HICs.

Recurrent bilateral serous cystadenomas in a premenarchal girl: a case report and literature review.

BACKGROUND: Ovarian serous cystadenomas are rare in children. No case of recurrence after surgical resection in a premenarchal girl has been published. CASE: An 8-year-old presented with abdominal pain and ultrasound showed bilateral ovarian cystic masses with normal clinical and laboratory exam. Cystectomies were performed revealing serous cystadenomas. Ten months later, her pain returned and ultrasound showed new cysts. Persistence of cysts and symptoms required repeat surgery with the same pathology. SUMMARY AND CONCLUSION: Premenarchal girls with ovarian cystic masses require surgical intervention in cases of persistent symptoms, uncertain diagnosis, or concern for ovarian torsion. With reassuring imaging and tumor markers, conservation of the ovary can be achieved with cystectomy alone. Ultrasound follow-up is recommended after surgical resection until bimanual exam can be performed.

The face of HIV and AIDS: can we erase the stigma?

Facial lipoatrophy can be obvious and stigmatising. Poly-L-lactic acid (PLLA) has been used widely for the correction of HIV-associated facial lipoatrophy. Analysis of the PLLA treatment protocols of 441 consecutive patients was undertaken. Product dilution, product volume per session, number of sessions, time between sessions, facial areas treated, plane of injection and incidence of injection-site nodules were recorded. Assessments included the Hospital Anxiety and Depression Scale and the Appearance Satisfaction Questionnaire. During the learning curve 30 patients were treated every 2 weeks for a minimum of three sessions. A 3-ml dilution was used and a total of 5 ml was injected in the deep dermis of the buccal areas. The incidence of nodule formation was 31% and 52% of patients did not achieve resolution of their facial disfigurement. A total of 411 patients were treated every 4 weeks for a minimum of four sessions. A minimum 5-ml dilution was used and a minimum total of 10-ml was injected subcutaneously in the temporal, infraorbital and buccal areas. The incidence of nodule formation was 2.9% and 10% of patients did not achieve resolution of their facial disfigurement. Patient anxiety and depression scores and appearance satisfaction scores improved significantly with treatment.

Chronic genital herpes and disclosure.... The influence of stigma.

The objectives of this study were to assess the nature and effect of stigma on disclosure of diagnosis to sexual partners among those with problematic disease. Data from questionnaires and semistructured interviews were collected and analysed. Data regarding anxiety were also collected using a validated tool. Ethical approval was received from the Chelsea and Westminster Healthcare National Health Service (NHS) Trust. Disclosure of diagnosis tended to occur in the context of established relationships. Herpes-related stigma was associated with non-disclosure of diagnosis to sexual partners. The point prevalence of moderate to severe anxiety in this sample was 32%. The use of suppressive medication did not affect anxiety scores. In conclusion, the reaction to a diagnosis of genital herpes is influenced by a socially constructed understanding and the decision to disclose or not is influenced by this. Stigma is a barrier to disclosure of genital herpes diagnosis. Management strategies aimed at encouraging disclosure to partners must address perceived stigma.

Is it time for the virtual chaperone in genitourinary medicine clinics?

The General Medical Council recommends that chaperones must be offered during intimate examinations. Implementation of these guidelines may serve to protect both patients and staff within the genitourinary (GU) medicine clinic, but is likely to have major ramifications from a practical, financial and staffing perspective. The Virtual Chaperone (VC) is an objective device making audio and visual recordings of patients' consultations and examinations. Information cannot be manipulated and is encrypted for security. It would not replace the human chaperone. This study investigated the attitudes of GU medicine staff and patients to the VC in an inner city sexual health clinic. Voluntary, anonymized questionnaires were distributed to all members of the multidisciplinary team and 200 patients. The patient response rate was 90% (n = 180). Only 40% of respondents felt the VC was acceptable in GU medicine clinics. Two-thirds felt unsure or were against the VC recording during consultations, and fewer wished the examination to be recorded. Most opted to switch off the video entirely. Almost 50% of respondents felt that the VC was designed to protect staff, whereas only 41% thought it would protect patients. The staff response rate was 69% (n = 35). Almost three-quarters of respondents were unsure or felt the device was unacceptable. Less than half would feel comfortable with the VC recording during consults. Overall, three-quarters of respondents were either unsure or did not support the introduction of the VC. There was a clear feeling (>80%) that the VC would protect staff and patients, 71% indicating that the trust would also benefit. Despite its success in other outpatient specialties, GU medicine staff and patients do not favour the introduction of the VC.

Poly-L-lactic acid for treating HIV-associated facial lipoatrophy: a review of the clinical studies.

Facial lipoatrophy can be associated with human immunodeficiency virus (HIV), impacting severely on quality of life. Various treatments have been investigated, including poly-L-lactic acid (PLLA). Four studies have investigated the efficacy of PLLA in the correction of HIV-associated facial lipoatrophy. The studies: VEGA, Chelsea and Westminster, APEX002 and Blue Pacific involved 50, 30, 99 and 99 patients, respectively, exhibiting HIV-associated facial lipoatrophy. Follow-up ranged from 24-96 weeks. Measures of treatment efficacy included ultrasound and subjective measures. Significant, long-lasting increases in dermal thickness were recorded and in all four studies, a subjective improvement was reported by patients and investigators in facial appearance and quality of life. Treatment was well tolerated. Small, non-bothersome subcutaneous papules were the only device-related adverse events observed. PLLA represents a promising treatment option for HIV-associated facial lipoatrophy. The procedure requires minimal "downtime" and provides long-lasting results without the need for invasive surgery.

Long-term safety and efficacy of poly-L-lactic acid in the treatment of HIV-related facial lipoatrophy.

OBJECTIVE: We evaluated the long-term safety and efficacy of injectable poly-L-lactic acid (PLLA) for the correction of facial lipoatrophy. METHODS: This was a randomized, open-label, comparative, single-centre study of injected PLLA in patients with HIV-related facial lipoatrophy. Thirty subjects were randomized to immediate or delayed PLLA treatments, administered as three sets of bilateral injections, 2 weeks apart, into the deep dermis above the buccal fat pad. Week 24 results have been published previously (Moyle et al, HIV Medicine 2004, Vol. 5, pp. 82-87). Long-term efficacy was assessed at a recall visit using visual analogue scales (VASs) to record patient satisfaction, and by the Hospital Anxiety and Depression Scale (HADS). Patients also reported any adverse events (AEs) during the treatment period and at the recall visit. RESULTS: Twenty-seven patients returned for the recall visit, a minimum of 18 months post final study treatment. Fourteen of these patients were excluded from the recall visit because of additional treatment with PLLA. Improvements in VAS scores for facial appearance were sustained from baseline to the recall visit in both randomization groups (P<0.05 and P<0.001). Trends in improvement in HADS scores were also noted, with patients in the delayed group experiencing significant improvements in depressive symptoms (P<0.05). One case of injection-site induration and nine cases of injection-site nodules were noted at the recall visit, none of which was described as serious or severe. CONCLUSIONS: Physical and psychological benefits of PLLA are sustained over at least 18 months. Delayed AEs include mild nodularity at the treatment site.

Betadine for herpes simplex infection.

The clinical value of aciclovir, oral or topical, in the episodic treatment of recurrent herpes virus infection is limited. Betadine (povidone-iodine) could provide a cheap, effective alternative for managing symptomatic recurrences. We describe a case where povidone-iodine was used successfully to treat a recurrence of genital herpes simplex and review the literature supporting povidone-iodine in the treatment of genital tract infections.

The value of anal cytology and human papillomavirus typing in the detection of anal intraepithelial neoplasia: a review of cases from an anoscopy clinic.

BACKGROUND: Previous studies have reached differing conclusions about the utility of anal cytology as a screening tool for anal intraepithelial neoplasia (AIN). There is a need also to establish whether HPV typing offers a useful adjunct to screening. METHODS: We analysed data from 99 consecutive homosexual/bisexual male patients (89 HIV-1 positive) who underwent high resolution anoscopy. Follow up visits for these patients were also included, giving a total of 160 anoscopic procedures. Comparison was made between results of anal cytology using the sampling method of Palefsky, and histological findings of biopsies taken from abnormal areas seen on high resolution anoscopic examination of the anal canal. Swabs taken concurrently with the cytology were analysed for the presence of human papillomavirus (HPV) DNA and compared with the cytological and histological findings. RESULTS: The sensitivity of the cytology was 83%, and the specificity 38% when compared with histology. At screening of 34 asymptomatic men, 83% had anal cytological dysplasia and 78% had AIN. There were no significant differences in the prevalence of hrHPV genotypes between different cytological or histological grades of abnormalities. CONCLUSION: Anal cytology by the Palefsky method is simple to undertake, has a sensitivity and specificity comparable with cervical cytology, and can therefore be used as the basis of a pilot screening project in centres with large cohorts of HIV positive homosexual men who have a high risk of developing anal carcinoma. HPV genotyping is not a useful adjunct to cytological screening.

Seeking and engaging in internet sex: a survey of patients attending genitourinary medicine clinics in Plymouth and in London.

We conducted a survey of patients attending two GUM clinics to evaluate the use of the internet for seeking sexual partners and for seeking on-line sexual health information. Prevalence of internet sex-seeking (ISS) was 11% (57/500) in Plymouth and 21% (50/237) in London. ISS was more common among men who have sex with men (MSM) (43/92 = 47%) than men who have sex with women (MSW) (38/280 = 14%, P < 0.0001) and more common amongst MSW than women who have sex with men (WSM) (25/350 = 7%, P = 0.007). In both samples, accessing sexual health information online was associated with ISS (Plymouth, P = 0.05 and London, P = 0.001), as was reporting more than 10 sexual partners per year (Plymouth and London, P < 0.001). It remains to be seen whether the potential sexual health promotion benefits of the internet could balance potential risks of STI acquisition.

A randomized open-label study of immediate versus delayed polylactic acid injections for the cosmetic management of facial lipoatrophy in persons with HIV infection.

BACKGROUND: Polylactic acid (PLA, New-Fill; Medifill, London, UK and Dermic Labs, a division of Eventis, Strasbourg, France) injections into the deep dermis increase fibroblast numbers and collagen production. The substance is widely used in medical applications including cosmetic procedures. METHODS: HIV-positive individuals with facial lipoatrophy (based on physician assessment) were randomized to immediate (weeks 0, 2 and 4) or delayed (weeks 12, 14 and 16) PLA given as three bilateral injections 2 weeks apart into the deep dermis overlying the buccal fat pad. Assessments included facial ultrasound, visual analogue scales, the Hospital Anxiety and Depression Scale (HADS) and assessment using photographs at weeks 0, 12 and 24. RESULTS: All 30 patients completed 24 weeks of treatment. The median age of the patients was 41 years, with a mean of 80 months of nucleoside reverse transcriptase inhibitor (NRTI) therapy and a mean of 44 months of prior protease inhibitor (PI) therapy. The median CD4 count was 428-460 cells/microL, with 47% of patients in the immediate-treatment group and 93% of patients in the delayed-treatment groups with <50 HIV-1 RNA copies/mL at baseline. No differences in immunological, virological, biochemical, haematological or metabolic parameters emerged during the study. Injections were well tolerated with only two adverse events (cellulitis and bruising) recorded, one of which delayed treatment by 1 week. There were no discontinuations. Patient visual analogue assessments, photographic assessments, and anxiety and depression scores improved with treatment. At week 12, immediate-treatment patients had significantly better visual analogue scores (7 vs. 1, P<0.001) and lower anxiety scores (6 vs. 9, P=0.056) than delayed-treatment patients. Benefits on visual analogue and HADS scores persisted until week 24. CONCLUSIONS: PLA injections led to improvements in patient self-perception, anxiety and depression scores in individuals with facial lipoatrophy. Adverse events were uncommon. The benefits of PLA persisted for at least 18 weeks beyond the last injection.

Is bacterial vaginosis associated with cervical intraepithelial neoplasia?

Previous research has produced conflicting results regarding the association of bacterial vaginosis (BV) and cervical intraepithelial neoplasia (CIN). These studies have been weakened in their conclusions mainly by failure to adequately control for the presence of sexually transmitted infections (STIs). One proposed mechanism suggesting that carcinogenic nitrosamines acting either independently or via human papilloma virus (HPV) has not been fully tested previously. We undertook a prospective, case-controlled, cross-sectional study where the presence of STIs, in particular human papillomavirus (HPV) which is known to be associated with the development of CIN, was controlled for. Women with BV were not found to have CIN more frequently than women with normal vaginal flora and the quantities of nitrosamines produced by women with BV did not differ significantly from women without BV. We thus found that BV is not associated with CIN.

Non-Hodgkin lymphoma in HIV-infected patients in the era of highly active antiretroviral therapy.

This study was designed to assess the influence of highly active antiretroviral therapy (HAART) on non-Hodgkin lymphoma (NHL) among patients infected with human immunodeficiency virus (HIV). Within EuroSIDA, a multicenter observational cohort of more than 8500 patients from across Europe, the incidences of NHL and subtypes (Burkitt, immunoblastic, primary brain lymphoma [PBL], and other/unknown histology) were determined according to calendar time of follow-up, and for those who initiated HAART (> or =3 drugs) also time on HAART. Potential predictive factors of NHL were evaluated in Cox proportional hazard models. Over 26 764 person-years of prospective follow-up (PYF) from May 1994 to December 2000, the incidence of NHL decreased from 1.99 (95% confidence interval, 1.51-2.47) before September 1995 to 0.30 (0.19-0.42) cases/100 (PYF) after March 1999 (P <.001). The incidence of all subtypes of NHL decreased significantly and most pronouncedly for PBL. Among patients who started HAART, the incidence of NHL decreased from 0.88 (0.60-1.16) within the first 12 months after starting HAART to 0.45 (0.31-0.60) cases/100 PYF after more than 24 months (P =.004). In an adjusted Cox model for patients on HAART, the latest CD4 cell count and plasma viral load were both significantly associated with diagnosis of NHL; the relative hazard was 1.39 (range, 1.14-1.69) per 50% lower CD4 cell count, and 1.51 (range, 1.21-1.88) per 1 log higher plasma viral load. In conclusion, the incidence of NHL among HIV-infected patients has decreased significantly after the introduction of HAART, and the decline was most pronounced for PBL. After starting HAART, patients with insufficient immunologic and virologic responses were at highest risk of NHL.