Optimizing statin prescriptions for people living with HIV: Evidence for improved communication and shared care between primary care and specialist HIV services.

OBJECTIVES: Our objective was to assess the numbers of eligible people living with HIV attending one HIV clinic and receiving statins, the factors increasing the likelihood of statin prescription, the knowledge and involvement of primary care in cardiovascular risk prevention in people living with HIV, and the barriers to and drivers of shared care between general practitioners (GPs) and an HIV centre. METHODS: This was a retrospective case note review identifying cardiovascular risk, medications, and communication between the HIV clinic and GPs via an electronic survey of GPs identifying their knowledge about statin indications in people living with HIV. RESULTS: In total, 62% of GPs were unaware of the indication for statins in people living with HIV aged >40 years. A total of 33% of patients received statins, rising to 61% of patients with independent indications for statins. 92% of all statin prescriptions were provided by the GP. Statins were recommended in 25% of clinic letters but were not prescribed in 72% of these cases. There was discordance between antiretrovirals prescribed by the HIV clinic and those documented on the GP record in 60% of cases and in 40% of non-antiretroviral medications. CONCLUSIONS: Our results indicate that GPs can engage people living with HIV in cardiovascular risk reduction measures but may not consider HIV a cardiovascular risk. Written communication alone is insufficient to improve safe patient care. Shared HIV care needs bidirectional shared medical records. Ongoing work needs to ensure that HIV is recognized as an independent cardiovascular risk factor.

Transverse vaginal septae: management and long-term outcomes.

OBJECTIVE: To examine the management and long-term outcomes of transverse vaginal septae. DESIGN: Observational study with cross-sectional and retrospective arms. SETTING: Tertiary referral centre specialising in Müllerian anomalies. POPULATION: Forty-six girls and women with a transverse vaginal septum. METHODS: Data from medical records of all cases (1998-2013) of transverse vaginal septae were collected and reviewed. Patients over 16 years of age also completed a questionnaire. MAIN OUTCOME MEASURES: Presentation, examination findings, investigations, surgery, and long-term reproductive outcomes. RESULTS: The septae in the study were described as follows: 61% (95% CI 0.46-0.74) were imperforate, and presented with obstructed menstruation; 39% (95% CI 0.26-0.54) were perforate, and presented with a variety of concerns; 72% (95% CI 0.57-0.83) were low, 22% (95% CI 0.12-0.36) were mid-vaginal, and 6% (95% CI 0.02-0.18) were high; 33% were managed via an abdominoperineal approach, 59% were managed via a vaginal approach, and 6% had laparoscopic resection (one patient did not have surgery); 11% (95% CI 0.05-0.23) of patients presented with reobstruction, all following abdominoperineal vaginoplasty; 7% presented with vaginal stenosis, two following vaginal resection and one following the abdominoperineal approach; 61% of questionnaires were returned. These results showed that 22/23 patients were menstruating and one had a hysterectomy, 74% had been sexually active, 35% had dyspareunia, and 36% complained of dysmenorrhoea. There were seven pregnancies, with one termination and six live births, all following the vaginal excision of a transverse vaginal septum. CONCLUSIONS: Transverse vaginal septae resected vaginally or laparoscopically have low complication rates and good long-term outcomes. Complex septae require more extensive surgery, with an increased risk of complications.

Developing a comprehensive, effective patient-friendly website to enhance decision making in predictive testing for Huntington disease.

PURPOSE: Predictive testing for Huntington disease is a complex decision, requiring in-depth counseling, education, and evaluation. Despite the growth in Web-based decision aids and educational resources, such tools for those considering Huntington disease testing are not available. The main objective of this project was to develop a patient-friendly, comprehensive, accessible Web-based tool to provide accurate information about testing for Huntington disease. METHODS: A semistructured interview study was conducted to determine the informational, educational, and support needs of those considering Huntington disease testing. A dedicated predictive testing website was subsequently developed and pilot tested. RESULTS: The interview study revealed that an effective website should include interactive diagrams, video documentaries, and personal stories of others who had considered testing. The pilot test revealed that the multidimensional site was easy to navigate and understand and provided an accurate, unbiased overview of the important factors to be considered before undergoing predictive testing. CONCLUSION: This project demonstrates the use of a mixed-method approach to develop the first tailored website dedicated to predictive testing for Huntington disease. Such an approach enabled the development of a comprehensive, accurate, and effective educational tool that supports informed decision making for people considering predictive testing for Huntington disease in an accessible, nonthreatening manner.

Providing predictive testing for Huntington disease via telehealth: results of a pilot study in British Columbia, Canada.

Predictive testing (PT) for Huntington disease (HD) usually requires several in-person appointments which acts as a barrier to testing for those from remote regions. This pilot study reports the use of telehealth PT to examine whether such telehealth testing improves access to HD PT while maintaining quality of care and support. Individuals underwent PT via the telehealth protocol or standard in-person protocol and were asked to complete surveys regarding their experience. Results reveal no significant differences between the in-person-tested and telehealth-tested groups with respect to quality of care, information, counselling and support. The majority of participants in both groups stated that pre-test counselling had provided them with sufficient knowledge about the advantages and disadvantages of undergoing testing, the opportunity to ask questions, and the ability to make an informed decision. The majority of participants in both groups were satisfied by the manner in which results were delivered and stated they had received sufficient information regarding the implications of these results. This study reveals that telehealth PT improves access while maintaining quality of care and support.

A comparison of genital sensory and motor innervation in women with pelvic organ prolapse and normal controls including a pilot study on the effect of vaginal prolapse surgery on genital sensation: a prospective study.

OBJECTIVE: To study genital sensory and motor innervation in women with pelvic organ prolapse and to determine the effect of vaginal prolapse surgery on genital sensation. DESIGN: A prospective observational study. SETTING: A tertiary referral unit in northwest England. POPULATION: Twenty women complaining of prolapse symptoms (including seven undergoing vaginal prolapse repair) and a control group of ten healthy women. METHODS: Women attended a research clinic where genital sensory thresholds were determined by quantitative sensory testing and motor innervation was assessed by concentric needle electromyography (EMG) of the pelvic floor muscles. Women undergoing surgery were assessed preoperatively and postoperatively at 6 months. MAIN OUTCOME MEASURES: Primary outcome measure was change in genital vibration threshold and the percentage of polyphasic potentials on EMG. RESULTS: Healthy control women had normal vibration detection thresholds at the vagina and clitoris. Thresholds in the majority of women with prolapse were abnormal and in all women with prolapse over the age of 50 years. Women with prolapse had a significantly larger percentage of polyphasic potentials of the left pubococcygeus but not the right. There was no significant change in genital sensory thresholds at 6 months postoperatively following vaginal repair. CONCLUSIONS: The majority of women with prolapse have abnormal genital vibration detection, which is particularly evident after the age of 50 years. Impaired sensory function does not correlate with EMG markers of partial motor denervation. In women with abnormal sensory thresholds, no additional effect was detected following vaginal prolapse repair.

Quality of obstetric and midwifery care for pregnant women who have undergone female genital mutilation.

Despite the availability of professional guidelines for the pregnancy management of women affected by female genital mutilation (FGM), this study demonstrated major deficits in identification, management and safeguarding.

The normal vulva in medical textbooks.

When a healthy woman expresses concerns about her vulva, the doctor's response should be informed by clinical knowledge. For many doctors, accumulation of such knowledge would have begun with undergraduate teaching and medical textbooks. The aim of this study is to examine the information on female genital morphology in medical textbooks. A total of 59 gynaecology and anatomy textbooks were searched for information on the dimensions of vulval constitutent parts. No textbook gave measurements for all vulval structures. Vaginal length was reported in 21/59 textbooks, clitoral size in 15/59 and labia minora in 1/59. Where measurements appear, they suggest narrower ranges than recent reports. Information of vulval morphology is scanty and inaccurate in medical textbooks. The general lack of professional resources means that doctors may consciously or non-consciously rely upon personal experiences and popular culture to form their opinions, as do their patients.

Adult recall of childhood female genital cutting and perceptions of its effects: a pilot study for service improvement and research feasibility.

This study aimed to gather information from service users of an African Women's Clinic for the purposes of planning service improvement and estimating research feasibility. The report is based on 17 interviews with Somali speaking women who had experienced female genital cutting in childhood. With language barriers removed, a high percentage of clinic attendees responded positively to the invitation to participate in research. They willingly discussed their experiences of FGM and expressed their negative viewpoints about the practice of FGM, suggesting that psychosocial and psychosexual research may be feasibly carried out in specialist contexts. The results also point to the need for psychological and educational input for service improvement.

Testing the fathers: carrying out HIV and STI tests on partners of pregnant women.

OBJECTIVES: Opt out antenatal HIV testing has significantly reduced mother to child transmission of HIV, but seroconversion during pregnancy from undiagnosed HIV positive male partners remains a risk. The authors report on a pilot initiative for sexual health and HIV screening for male partners of women attending antenatal ultrasound examination at Homerton Hospital, London. METHODS: Men attending with their female partners for routine ultrasound examination between 1 August 2010 and 31 January 2011 were offered on-site serology for HIV, syphilis, hepatitis B and hepatitis C and urine testing for Neiserria gonorrhoeae and Chlamydia trachomatis. RESULTS: were followed up through the genitourinary medicine service. Referral pathways were established for men with positive results. RESULTS: 1243 male partners of 2400 women attended ultrasound examinations, of whom 430 accepted testing (acceptance rate 35% and coverage rate 18%). Median age was 32 years (range 19-52). 112/430 (26%) male partners were of black ethnicity. 41% had previously had a HIV test. There was no difference in prior HIV testing between whites and non-whites. 16 infections were diagnosed, including two cases of hepatitis C, eight cases of hepatitis B and six cases of C trachomatis. No HIV diagnoses were made. CONCLUSIONS: The authors have shown that it is acceptable and feasible to engage heterosexual men for testing in this setting. Of those men who accepted HIV testing, more than half had never been previously tested. 4% of men tested had an infection, which had the potential to affect the outcome of the pregnancy.

False-positive pregnancy tests following enterocystoplasty.

People with major congenital urological or neurological malformations invariably require bladder reconstruction with enterocystoplasty in early childhood. The improvement of the surgical management of these children has reflected significantly on their life expectancy. As a result, more young people with enterocystoplasty are being transitioned to adolescent clinics where they receive the usual counselling about sexual health and pregnancy risks. However, the possibility of false-positive urinary pregnancy tests in these young women remains an overlooked but essential message. The lack of awareness about this fact can result in significant patient anxiety and the potential for unnecessary interventions as exemplified by the three cases we have encountered.

Androgen-dependent measurements of female genitalia in women with complete androgen insensitivity syndrome.

Measurements of clitoral length and clitoral to urethral distance were made and analysed for a relationship in a group of 19 women with complete androgen insensitivity syndrome (CAIS)attending a specialist clinic for adult women with disorders of sexual development. These were compared with a control group of 50 women attending hospital for a gynaecological procedure.There was a positive correlation between clitoral length and clitoral to urethral distance for women with CAIS. In contrast, a negative correlation was seen between clitoral length and clitoral to urethral distance for women in the control group. Women with CAIS had a reduced mean clitoral length compared with controls(P = 0.001), but no difference was observed for the clitoral to urethral distance between the two groups (P = 0.116).

Clinical characteristics of well women seeking labial reduction surgery: a prospective study.

OBJECTIVE: To assess clinical characteristics and expectations in well women requesting elective labial reduction surgery. DESIGN: Prospective study of women attending an outpatient gynaecology clinic. SETTING: General gynaecology clinic at a Central London teaching hospital. SAMPLE: Women requesting labial reduction surgery and referred by their general practitioner. METHODS: The labia minora width and length were measured for all participants for comparison with published normal values. The presenting complaint was recorded, along with demographic details, expectations of surgery and sources of information regarding appearance of the labia. MAIN OUTCOME MEASURES: Labial measurements, reported symptoms and expectations of surgery. RESULTS: The labia of all participants were within normal published limits, with a mean (SD) of 26.9 (12.8) mm (right labia), and 24.8 (13.1) mm (left labia). The majority of complaints were regarding appearance or discomfort. Expectations were to alter the appearance with surgery. CONCLUSIONS: All women seeking surgery had normal-sized labia minora. Clear guidance is needed for clinicians on how best to care for the worried well woman seeking surgery.

Labial surgery for well women: a review of the literature.

This review investigates the quality and content of published reports relating to labial surgery for well women. Electronic databases were searched for relevant articles between 1950 and April 2009. Forty articles were identified, 18 of which included patient data. The specification of the study design was unavailable in 15 of the 18 papers; the remaining three were retrospective reports. No prospective, randomised or controlled studies were found. All reports claimed high levels of patient satisfaction and contained anecdotes pertaining to success. Medically nonessential surgery to the labia minora is being promoted as an effective treatment for women's complaints, but no data on clinical effectiveness exist.

The clandestine uterus: or how the uterus escapes detection prior to puberty.

Uterine agenesis is one of the differential diagnoses in adolescent girls with delayed menstruation. It may also be suspected earlier in childhood during investigations for other genitourinary conditions. However, accurate confirmation that the uterus is absent can be extremely difficult before puberty because of its small size. We describe ten girls referred to a specialist centre with a presumed diagnosis of an absent uterus which was later found to be incorrect. We conclude that imaging should be undertaken by clinicians with experience in management of this age group and in some girls it may be necessary to delay final diagnosis until after puberty.

Service users' experiences of obtaining and giving information about disorders of sex development.

OBJECTIVE: To quantify participants' experiences of obtaining and giving information about disorders of sex development (DSD). DESIGN: Cross-sectional survey study that asked people about their current and past experiences relating to DSD disclosure. SETTING: A large tertiary referral centre for DSD management in the UK. POPULATION: One hundred of 126 people with a confirmed diagnosis of DSD who were invited to participate in the study formed the usable sample. METHODS: All people who attended clinic for follow-up during the study period and members of a patient support group whose annual meeting fell within the study period were asked to complete the Middlesex Communication Survey. MAIN OUTCOME MEASURES: The Middlesex Communication Survey. RESULTS: Younger participants were more likely to report having been appropriately informed about their diagnosis than older people. Nearly half of the former had been fully informed about their diagnosis by age 15 years, compared with 0% of the older age group. In terms of information sharing, mothers were most likely to be the person with whom the participant had shared (almost/all) DSD information (74%), followed by current partners (71%). Information relating to genital surgery, presence of testes and clitoral anomalies were the least likely aspects to have been unambiguously shared with even the most informed person. CONCLUSIONS: Our results suggest that difficulties in obtaining DSD information from care providers were common, and that communication has improved for younger participants. The study also confirmed that many people with DSD continue to struggle with confiding, even in those closest to them, about aspects of their diagnosis. Care protocol needs to centralise psychological adaptation, which should also be a primary focus for future research.

Testing commercial sex workers for chlamydia and gonorrhoea on outreach.

To assess the feasibility of testing indoor commercial sex workers (CSW) for Chlamydia trachomatis and Neisseria gonorrhoeae in an outreach setting. All CSW seen on outreach over a 6-week period were offered self-taken vulval swabs for chlamydia and gonorrhoea testing. Feasibility was assessed by all the outreach workers on a standardised proforma. Of the 93 women offered the service, 40 accepted, of whom five (12%) had not previously accessed sexual health services. The majority of women declining the service had recently attended a sexual health clinic. Three cases of chlamydia and one of gonorrhoea were diagnosed. The cost per sexually transmitted infection (STI) was pound 392.50. Most of this group of women were knowledgeable about sexual health and were already having regular check-ups, but a significant minority did not know how to access STI care. Offering STI testing on outreach was feasible and cost effective.

Minimal access surgery in adolescent gynaecology.

The benefits of a minimally invasive approach are now well documented in adult women, and thus surgeons have embraced the notion of expanding such expertise in adolescence with measured enthusiasm and a great sense of responsibility. Faster recovery is likely to have a positive impact on schooling, while less adhesion formation may reduce future fertility issues. Gynaecologists performing minimally invasive procedures in adolescents ought to be aware of the steep learning curve required for achieving proficiency with complex laparoscopic surgery. In the group of rare congenital anomalies and advanced endometriosis, the best surgical results can only be achieved after careful preoperative planning by a multidisciplinary team.

The evolution of an integrated sexual health service.

The objective of the study was to assess the contributions of different providers across an integrated sexual health-care network to the diagnosis of sexually transmitted infections (STIs). The method employed was retrospective cross-sectional survey of laboratory tests for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis between 01 April 2004 and 31 March 2007. The total number of STI screens in all venues rose from 17,126 to 23,679. The proportion of STI screens occurring in the genitourinary (GU) medicine clinic fell from 75% to 55% (P < 0.0001). There was an 11% increase in male screens performed in the community. The number of STIs diagnosed rose from 2354 in 2004 to 3128 in 2007, with an upward trend of community-diagnosed STIs. In conclusion, the role of community services increased during the evolution of the integrated sexual health network, although the majority of STIs were diagnosed within in the GU medicine clinic. Male screens accounted for one-third of those performed. A gap in male attendances remains despite the plurality of services.

Concordance between nucleic acid amplification technique and culture for the diagnosis of gonorrhoea.

The objective of the study was to evaluate the concordance between nucleic acid amplification technique (NAAT) and culture for the diagnosis of Neisseria gonorrhoeae among attendees at a genitourinary medicine clinic in East London. All patients testing positive for N. gonorrhoeae on NAAT and/or culture between 1 April 2007 and 31 August 2008 at the Department of Sexual Health at Homerton University Hospital were included. Male patients had a first void urine sample for NAAT and urethral culture; female patients had a self-taken vulval swab or endocervical sample sent for NAAT and an endocervical culture sample. After interim analysis, discrepant results had both NAAT and culture repeated prior to treatment. Of 159 male patients with a positive NAAT, 22 (13%) had a negative culture. Among 135 female patients with a positive NAAT, 36 (27%) had a negative culture. Three men had a positive culture and negative NAAT. Nineteen of the discrepant samples were retested prior to treatment and 12 (63%) had spontaneously revered to negative. In conclusion, there was concordance in 84% of male and 67% of female samples. In two-thirds of the discrepant cases, the previously positive NAAT had become negative prior to treatment. This study highlights the importance of consideration of the clinical picture when assessing results.

Augmentation vaginoplasty with buccal mucosa for the surgical revision of postreconstructive vaginal stenosis: a case series.

BACKGROUND: Vaginal stenosis is a common consequence of vaginal reconstruction in childhood. Significant scarring can make dilation ineffective, and there maybe a paucity of skin to create perineal skin flaps. Numerous vaginoplasty techniques exist, including perineal skin flaps for distal stenosis and intestinal vaginoplasty requiring laparotomy and bowel anastomosis. Buccal mucosa graft is widely used in urethroplasty and has been reported in neovaginal construction. It is easily accessible with minimal graft site morbidity and provides a close functional replica to vaginal mucosa. AIM: The aim was to describe the use of buccal mucosa grafts for the surgical revision of postreconstructive vaginal stenosis. METHOD: The study setting was a tertiary centre for congenital gynaecological anomalies. Buccal mucosa grafting was provided to women with vaginal stenosis unsuitable for perineal skin flaps and in whom intestinal vaginoplasty was the next option. Four cases have been performed, and the medical notes were reviewed for clinical data. RESULTS: Mean age at buccal mucosa vaginoplasty was 21 years (range 18-26 years). Two patients had a cloacal anomaly, one had mosaic Turner syndrome and one had postradiation vaginal stenosis. All four had undergone previous vaginal reconstruction. In all cases, there was a tight band of vaginal stenosis either too proximal or with insufficient perineal tissue to allow a perineal flap vaginoplasty. There were no immediate complications. Mean clinic follow-up was 16 months (3 months-4 years). Two patients were able to have penetrative sexual intercourse, and two were using vaginal dilators successfully. Patients have an email contact for the team nurse specialist and therefore are able to contact before clinical review if they develop concerns. DISCUSSION: The use of buccal mucosal grafts for vaginoplasty is increasingly reported. This is the first detailed case series describing its use for augmentation vaginoplasty with postreconstructive/stenosis. CONCLUSIONS: All patients had a successful outcome with a normal capacity vagina, and two were able to have penetrative intercourse. This suggests that buccal mucosal graft vaginoplasty is a safe and effective alternative for women with previous vaginal reconstruction requiring surgery for vaginal stenosis.