Sexual partner concurrency among STI clinic patients with a steady partner: correlates and associations with condom use.

OBJECTIVES: Partner concurrency facilitates the transmission of HIV and other sexually transmitted infections (STIs). In this study, we sought to (1) determine the correlates of concurrency among patients with a steady partner, and (2) identify correlates of condom use among patients reporting concurrent steady and non-steady partners. METHODS: Patients recruited from an STI clinic (n = 973; 48% female; 68% African-American) completed a survey that assessed demographic characteristics, substance use, sexual partnerships and sexual behaviour, including condom use. Patients reporting a steady sexual partner for 3 months or longer were included in the analyses. Those who also reported a non-steady partner in the past 3 months, in addition to a steady partner, were considered to have engaged in concurrency. RESULTS: Nearly two-thirds (64%) of patients reported both steady and non-steady partners in the past 3 months. Steady/non-steady concurrency was associated with being male, not cohabitating with a partner, use of alcohol and other drugs, and thinking their steady partner was monogamous. Patients with steady and non-steady partners reported that they seldom used condoms consistently with steady (5%) or non-steady (24%) partners. Compared to patients who did not report concurrency, patients who reported steady/non-steady concurrency reported more episodes of unprotected sex in the past 3 months. Among patients reporting concurrency, consistent condom use with non-steady partners was more likely among individuals who (a) used less alcohol and (b) thought that their steady partner was non-monogamous. CONCLUSIONS: To reduce risk for HIV and other STIs, behavioural interventions need to address partner concurrency and its correlates, including alcohol and other drug use.

HIV testing among individuals with a severe mental illness: review, suggestions for research, and clinical implications.

BACKGROUND: The prevalence of human immunodeficiency virus (HIV) is elevated among individuals with a severe mental illness (SMI). Because of the benefits of HIV testing, it is important for individuals with SMI to have routine access to testing. The goals of this review are: to summarize knowledge about HIV testing prevalence, correlates, and interventions among individuals with an SMI; to identify research needs; and to discuss clinical implications of the studies reviewed.MethodLiterature searches were conducted using PsycINFO, PubMed, and Medline. Additional articles were obtained from reference lists of relevant articles. RESULTS: Fewer than one-half of individuals with an SMI have been tested for HIV in the past year. Engaging in sex or drug risk behavior was the only consistent correlate of HIV testing. Interventions for promoting HIV testing among individuals with an SMI have not been well developed or evaluated. CONCLUSIONS: Research on HIV testing among individuals with an SMI is needed. Mental health settings may be opportune venues for HIV testing, even though providers face ethical challenges when implementing testing programs in these settings.

Predictive factors for faecal incontinence after third or fourth degree obstetric tears: a clinico-physiologic study.

OBJECTIVE: This is a prospective study to review the natural history of anorectal dysfunction after primary repair for third or fourth degree obstetric tear and to identify the predictive factors for significant faecal incontinence. METHOD: From January 2003 to December 2005, 121 consecutive women (mean age 29.9 +/- 4.7) who sustained third or fourth degree obstetric tears were assessed. All had primary repair by obstetricians. They were assessed using anorectal physiology testing and endoanal ultrasound. Short-term (3-month postpartum) and medium-term (mean 18.8 +/- 7.7 months) Wexner's continence scores were obtained. RESULTS: Among the 121 women, seven were excluded because of incomplete follow-up. At short-term assessment, 25 out of 114 women were incontinent. One of them underwent another sphincter repair for significant faecal incontinence. Twenty-one and three patients respectively, had mild (Wexner's score 1-4) and moderate (Wexner's score 5-8) symptoms. At medium-term assessment, 24 patients remained incontinent; of these, 20 had mild symptoms (Wexner's score 1-4) and four had moderate incontinence (Wexner's score 5-8). The parity (P = 0.04), degree of obstetric tear (P = 0.036) and short-term Wexner's scores at 3 months postpartum (P < 0.0001) were significantly related to the change in Wexner's scores at medium-term assessment. However, the short-term Wexner's score was the only identifiable predictive factor for significant faecal incontinence. CONCLUSION: Most women suffering from third or fourth degree obstetric tear were continent or mildly incontinent. Poor Wexner's score at short-term assessment at 3 months postpartum was predictive of faecal incontinence in the medium-term.

A case of Invasive Aspergillosis in a Patient with no Identifiable Immunodeficiences

Invasive fungal infections usually affect patients with immunodeficiencies and very rarely patients with no known or identifiable risk factors. Diagnosis could be delayed in patients without previously known immunodeficiencies due to a low index of suspicion; leading to a delay in treatment and a potential poor outcome. We report a case of a postpartum woman with no history of immuno-compromised disease who developed left hemiparesis with evidence of invasive aspergollosis affecting the nervous system; and leading to fatal outcome. The patient had a mass-like lesion in the neuroimaging with soft tissue shadowing in the chest x-ray leading to initial diagnosis of tuberculosis. The brain biopsy showed changes consistent with a diagnosis of aspergillosis. The source of the aspergillus infection was not clear. Aspergillus infection should be considered in patients with no identifiable immunodeficiencies who have abnormal brain imaging and chest x-ray; as early treatment may alter the outcome

Clinical and quality-of-life outcomes in women treated by the TVT-O procedure.

OBJECTIVES: To objectively assess the success rate at 6 months after tension-free vaginal tape obturator (TVT-O) procedure. To assess subjective success rates, complications, patient satisfaction, and quality of life (QOL). DESIGN: A prospective observational study. SETTING: A tertiary referral urogynaecology practice. POPULATION: A cohort of 100 consecutive women who underwent the TVT-O procedure between March and October 2004. METHODS: The TVT-O technique was performed as described. Three standardised QOL questionnaires were completed preoperatively at 6 months and 12 months. At 6 months, a urogenital history, visual analogue scale score (VAS) for patient satisfaction, uroflow, and urinary stress test were performed. After 12 months, a urogenital history and patient satisfaction verbal analogue score (VeAS) were obtained by telephone interview. MAIN OUTCOME MEASURE: Objective success rate of the TVT-O procedure was measured by negative stress test. Secondary outcomes were subjective success rates at 6 and 12 months, pre- and postoperative comparison of urodynamic parameters, complications, postoperative symptomatology, QOL analysis, and patient satisfaction. RESULTS: Mean follow up was 18.5 months. Objective success rate was 95%. Subjective success rates were 92 and 84% at 6 and 12 months. Complications included recurrent urinary tract infection (six), voiding difficulty (two), persistent groin discomfort (three), haematoma (one), wound infection (one), vaginal tape erosion (one), and urethral irritation (one). Prevalence of de novo urge incontinence was 4.1 and 4.8% at 6 and 12 months. QOL analysis showed significant improvements in QOL scores postoperatively. Visual and verbal analogue scores indicated high patient satisfaction (VAS, VeAS >or= 80%) in 77 and 67% at 6 and 12 months. CONCLUSION: The TVT-O is a safe and effective treatment for female stress urinary incontinence.

Laparoscopic versus open Burch colposuspension: a randomised controlled trial.

OBJECTIVE: To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. DESIGN: Randomised surgical trial with single blinding. SETTING: Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. POPULATION: Two hundred women with urodynamic stress incontinence (USI). METHODS: The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. MAIN OUTCOME MEASURES: Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. RESULTS: There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P< 0.0001) but was associated with less blood loss (P = 0.03), less pain (P = 0.02), and quicker return to normal activities (P = 0.01). CONCLUSION: LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes. To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. Randomised surgical trial with single blinding. Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. Two hundred women with urodynamic stress incontinence (USI). The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P < 0.0001) but was associated with less blood loss (P= 0.03), less pain (P= 0.02), and quicker return to normal activities (P= 0.01). LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes.

A rostro-caudal dissociation in the dorsal and ventral striatum of the juvenile SHR suggests an anterior hypo- and a posterior hyperfunctioning mesocorticolimbic system.

Functional molecular neuroimaging techniques have been applied to the study of the neural substrates of Attention-Deficit Hyperactivity Disorder (ADHD) in an animal model, the juvenile SHR rat. They include quantitative receptor autoradiography and immunocytochemistry for neuronal markers such as Ca2+/Calmodulin Dependent Kinase II (CaMKII) and transcription factors. Multiple evidence emerges for a rostro caudal dissociation within the dorsal (DS) and ventral striatum (VS) (n. accumbens) and olfactory tubercle (OT). It consists in (i) a higher density of dopamine (DA) D-1/D-5 receptor binding sites in a discrete segment of the anterior forebrain that comprises the DS, VS and OT, (ii) a lower density of DA D-2/D-3 autoreceptors in the caudal portion of the n. accumbens shell subterritory, (iii) a reduced number of CaMKII and c-FOS positive elements only in the anterior portion of DS and VS (iv) reversal by repeated injections of methylphenidate (MP) (3 mg/kg, 14 days) with 'downregulation' in SHR and 'up-regulation' in the WKY control rats of DS and VS of DA D-1/D-5 receptors. Thus, under basal conditions the mesocorticolimbic (MCL) DA system appears to be hyperfunctioning rather than hypofunctioning, as demonstrated (i) by subsensitivity of presynaptic D-3 autoreceptors and (ii) by phasic inhibition of MCL activity induced by acute blockade of endocannabinoid reuptake using AM404. Following MP treatment, the hyperfunctioning MCL DA system turns into a hypofunctioning one, as earlier suggested by Solanto. Since the target neurons of MCL fibers seem to be uncoupled to D-1 receptors, the medium spiny GABA neurons projecting to the ventral pallidum and ventral tegmental area (VTA) exert a weak feedback inhibition on the neurons of origin of MCL system. Therefore, MCL neurons maintain a high basal activity with consequences on the cortico-striato-pallido-thalamo-cortical system and amygdala complex through the 'extended amygdala system'. While the former explains the attention, motivation and activity alterations of this rat model of ADHD, the latter explains the emotional symptoms of the syndrome. It remains to be ascertained the starting point in the network leading eventually to the segmental defect as well as its significance in humans.

Effects of a brief, theory-based STD-prevention program for female college students.

PURPOSE: To evaluate a brief, theoretically guided sexually transmitted disease (STD) risk-reduction intervention tailored to college-aged women. METHODS: The participants were 78 undergraduate females (M = 20 years; 76% European-American) who reported inconsistent condom use or multiple sexual partners. Participants were randomly assigned to one of three groups: (a) a one-session intervention based on the information-motivation-behavioral skills (IMB) model, (b) a one-session information-only intervention (INFO), or (c) a wait-list control (WLC) group. Consistent with Fisher and Fisher's (1992) IMB model, we predicted that risk reduction would be greater when information about HIV was supplemented with motivational enhancement strategies and skills training. To evaluate this hypothesis, groups were compared at the post-intervention assessment and at a 2-month follow-up using analyses of covariance and log odds ratios. RESULTS: At the post-intervention assessment, the IMB and INFO groups demonstrated increased STD-related knowledge. At 2-month follow-up, the IMB and INFO groups showed sustained STD-related knowledge, and the IMB group showed reductions in number of sexual partners compared to the WLC group. CONCLUSIONS: These results provide partial support for the hypothesis that an IMB model-based intervention leads to reductions in sexual risk behavior and suggest directions for future research.

Prevalence and correlates of sexual activity and HIV-related risk behavior among psychiatric outpatients.

This study investigates the prevalence and correlates of sexual activity and HIV-risk behavior among adults with a mental disorder. Demographic, psychiatric, sexual behavior, and substance-use data were available for 1,558 outpatients. During the past year, 69% were sexually active and 23% engaged in risky behavior. Risk markers included multiple sexual partners (19%), a sexually transmitted disease (4%), sex trading (3%), injection drug use (1%), and needle sharing (<1%). Being sexually active and being at risk for HIV infection were associated with alcohol and drug use, psychiatric diagnoses other than schizophrenia, and younger age. Married patients were more likely to be sexually active but less likely to engage in risk behavior. Screening for HIV risk in psychiatric settings can identify patients who may benefit from risk reduction programs.

Genital prolapse: vaginal versus abdominal route of repair.

In the presence of an ageing population, we can expect to see a dramatic increase in the prevalence of genital prolapse including vault and recurrent vaginal prolapse. The best approach for managing upper genital prolapse remains controversial. We review the surgical management of genital prolapse, with a focus on comparing the vaginal and abdominal approaches.

Conducting meta-analyses of HIV prevention literatures from a theory-testing perspective.

Using illustrations from HIV prevention research, the current article advocates approaching meta-analysis as a theory-testing scientific method rather than as merely a set of rules for quantitative analysis. Like other scientific methods, meta-analysis has central concerns with internal, external, and construct validity. The focus of a meta-analysis should only rarely be merely describing the effects of health promotion, but rather should be on understanding and explaining phenomena and the processes underlying them. The methodological decisions meta-analysts make in conducting reviews should be guided by a consideration of the underlying goals of the review (e.g., simply effect size estimation or, preferably theory testing). From the advocated perspective that a health behavior meta-analyst should test theory, the authors present a number of issues to be considered during the conduct of meta-analyses.

HIV risk behavior and psychological correlates among native American women: an exploratory investigation.

Native American women are at increased risk for HIV infection, but few studies have studied this threat. To address this gap in the literature, we assessed HIV risk behavior and explored the hypothesized psychological antecedents of risk behavior in 53 Native American women. Survey results indicated that women's HIV-related knowledge was incomplete and many women still held misconceptions about HIV. One third of the sample reported having two to five sexual partners in the past 5 years, and 30% of the women reported alcohol use prior to sexual intercourse. Women who were classified at higher risk, that is, who did not use condoms consistently, felt less vulnerable to HIV and were less ready to change their risky sexual behaviors compared with their lower-risk counterparts. These findings indicate that Native American women are at risk for HIV infection and can no longer be neglected by those seeking to prevent HIV infections. Culturally congruent and gender-specific interventions that provide information and behavioral skills to Native American women as well as increase their motivation to adopt safer sexual behaviors are needed.

Enhancing readiness-to-change substance abuse in persons with schizophrenia. A four-session motivation-based intervention.

This article describes a four-session intervention designed for persons with co-occurring substance abuse and schizophrenia-spectrum disorders, to be administered as an add-on module to supplement ongoing mental health treatment in an outpatient setting. The intervention targets those dually diagnosed individuals with low readiness-to-change as indicated by current use, and/or low level of engagement in treatment for substance abuse. The intervention is designed to increase problem recognition, to enhance motivation to change maladaptive patterns of substance use, and to facilitate engagement in substance abuse treatment. To achieve these goals, the authors have adopted constructs from the Transtheoretical Model of Change, the authors used principles of motivational and harm reduction interventions, and tailored them to the target population.

Iliococcygeus or sacrospinous fixation for vaginal vault prolapse.

OBJECTIVE: To compare iliococcygeus (prespinous) and sacrospinous fixation for vaginal vault prolapse. METHODS: Between 1994 and 1998, 78 women underwent sacrospinous colpopexy and 50 underwent iliococcygeus fixation for the management of symptomatic vaginal vault prolapse. A matched case-control study was designed to compare the two approaches. The matched variables included age, parity, body mass index, degree of vault prolapse, menopause, sexual activity, constipation, previous prolapse or continence surgery, stress incontinence, and length of review. Thirty-six matched pairs were isolated, resulting in a study with a power of 50% to detect a 20% difference in the success rates between the two groups. RESULTS: The subjective success rate for the iliococcygeus group was 91%; it was 94% for the sacrospinous group (P =.73). The objective success rate was 53% and 67% (P =.36), and the patient satisfaction with surgery was 78 of 100 and 91 of 100 (P =.01) on a visual analogue scale. The mean length of postoperative follow-up was 21 months for the iliococcygeus group and 19 months for the sacrospinous group (P =.52). The recovery time was 54 days in the iliococcygeus group and 39 days in the sacrospinous group (P =.04). No significant difference was seen in the incidence of postoperative cystoceles or damage to the pudendal neurovascular bundle. CONCLUSION: Sacrospinous and iliococcygeus fixation are equally effective procedures for vaginal vault prolapse and have similar rates of postoperative cystocele, buttock pain, and hemorrhage requiring transfusion. The sacrospinous ligament fixation should not be discarded in favor of the iliococcygeus fixation in the management of vaginal vault prolapse.

Laparoscopic suture hysteropexy for uterine prolapse.

OBJECTIVE: Vaginal hysterectomy remains the accepted surgical treatment for women with uterine prolapse. The Manchester repair is favored in women wishing uterine preservation. Vaginal hysterectomy alone fails to address the pathologic cause of the uterine prolapse. The Manchester repair has a high failure rate and may cause difficulty sampling the cervix and uterus in the future. The laparoscopic suture hysteropexy offers physiologic repair of uterine prolapse. METHOD: At the laparoscopic suture hysteropexy, the pouch of Douglas is closed and the uterosacral ligaments are plicated and reattached to the cervix. RESULTS: Forty-three women with symptomatic uterine prolapse were prospectively evaluated and underwent laparoscopic suture hysteropexy with a mean follow-up of 12 +/- 7 months (range 6-32). The mean operating time for the laparoscopic suture hysteropexy alone was 42 +/- 15 minutes (range 22-121), and the mean blood loss was less than 50 mL. On review, 35 women (81%) had no symptoms of prolapse and 34 (79%) had no objective evidence of uterine prolapse. Two women subsequently completed term pregnancies and were without prolapse. Both underwent elective cesarean delivery. CONCLUSION: The laparoscopic suture hysteropexy is effective and safe in the management of symptomatic uterine prolapse. The result is physiologically correct, without disfiguring the cervix. This may be an appropriate procedure for women with uterine prolapse wishing uterine preservation.

Prevalence of sexual dysfunctions: results from a decade of research.

Ten years of research that has provided data regarding the prevalence of sexual dysfunctions is reviewed. A thorough review of the literature identified 52 studies published in the 10 years since an earlier review by Spector and Carey (Arch. Sex. Behav. 19(4): 389-408, 1990). Community samples indicate a current prevalence of 0%-3% for male orgasmic disorder, 0%-5% for erectile disorder, and 0%-3% for male hypoactive sexual desire disorder. Pooling current and 1-year figures provides community prevalence estimates of 7%-10% for female orgasmic disorder and 4%-5% for premature ejaculation. Stable community estimates of the current prevalence of other sexual dysfunctions remain unavailable. Prevalence estimates obtained from primary care and sexuality clinic samples are characteristically higher. Although a relatively large number of studies has been conducted since the earlier review, the lack of methodological rigor of many studies limits the confidence that can be placed in these findings.

Psychiatric outpatients report their experiences as participants in a randomized clinical trial.

We conducted exit interviews with 45 outpatients with severe and persistent mental illness (SPMI) who had participated in a randomized clinical trial. The interviews followed a semistructured format and were audiotaped for later transcription and rating by two independent raters. Content analyses of the interviews revealed that most participants evaluated their experiences quite favorably. For example, most noted that the assessment process was thought-provoking and motivational and that the intervention groups led to increased self-confidence and new friendships. Although a few participants noted that the assessment contained sensitive material, all appreciated the frequent reminders that information disclosed was strictly confidential. These results indicate that persons living with a SPMI often enjoy participating in behavioral research, which can yield immediate benefits to patient-participants. Exit interview research such as this can help investigators to understand reasons for consent and participation, to identify needs for protocol modifications, and to facilitate the integration of evidence-based interventions into the mental health care systems.

Assessing sexual risk behaviour with the Timeline Followback (TLFB) approach: continued development and psychometric evaluation with psychiatric outpatients.

This paper describes a series of 4 studies, designed to provide evidence of the feasibility, reliability, and validity of the Timeline Followback (TLFB) method when used to assess sexual risk behaviour with psychiatric outpatients. This population was selected because patients often have difficulty completing assessments of sexual risk behaviours due to deficits in attention, memory, and communication skills. All 4 studies demonstrated the feasibility of the HIV-risk TLFB. Study 1 also demonstrated that it can be completed in 20 min, and scored in less than 10 min. Qualitative data revealed that both patients and assessors found the features of the TLFB helpful. Study 2 provided evidence that the HIV-risk TLFB can be reliably scored by interviewers whereas Study 3 demonstrated that this measure can be completed reliably by patients and that TLFB of sexual behaviour were consistent over time. Study 4 provided initial evidence for the validity of the HIV-risk TLFB but also suggested that the TLFB may yield frequency estimates that are slightly less than those obtained with single-item measures. We conclude that the TLFB is feasible, reliable, and valid, even in a population known to have difficulty with self-report measures.