Who Performs Colonoscopy? Workforce Trends Over Space and Time.

PURPOSE: With the increased availability of colonoscopy to average risk persons due to insurance coverage benefit changes, we sought to identify changes in the colonoscopy workforce. We used outpatient discharge records from South Carolina between 2001 and 2010 to examine shifts over time and in urban versus rural areas in the types of medical providers who perform colonoscopy, and the practice settings in which they occur, and to explore variation in colonoscopy volume across facility and provider types. METHODS: Using an all-payer outpatient discharge records database from South Carolina, we conducted a retrospective analysis of all colonoscopy procedures performed between 2001 and 2010. FINDINGS: We identified a major shift in the type of facilities performing colonoscopy in South Carolina since 2001, with substantial gains in ambulatory surgery settings (2001: 15, 2010: 34, +127%) versus hospitals (2001: 58, 2010: 59, +2%), particularly in urban areas (2001: 12, 2010: 27, +125%). The number of internists (2001: 46, 2010: 76) and family physicians (2001: 34, 2010: 106) performing colonoscopies also increased (+65% and +212%, respectively), while their annual procedures volumes stayed fairly constant. Significant variation in annual colonoscopy volume was observed across medical specialties (P < .001), with nongastroenterologists having lower volumes versus gastroenterologists and colon and rectal surgeons. CONCLUSIONS: There have been substantial changes over time in the number of facilities and physicians performing colonoscopy in South Carolina since 2001, particularly in urban counties. Findings suggest nongastroenterologists are meeting a need for colonoscopies in rural areas.

Desmoplastic fibroma of the anterior mandible. Case report and review of literature.

Desmoplastic fibroma is a rare and locally aggressive lesion that affects the long bone and the jaw bones. Mandibular bone involvement has been mostly reported in the posterior segment; anterior region presentation is rare. This case report highlights the diagnosis, management and treatment of a midline mandibular involvement. It includes a literature review.

Sexual behaviour and HIV infection in black-Africans in England: results from the Mayisha II survey of sexual attitudes and lifestyles.

OBJECTIVES: To estimate HIV prevalence and the distribution of high risk sexual behaviours, sexual health service use, and HIV testing among black Africans aged 16 years or over in England. To determine demographic, behavioural and service use factors associated with HIV prevalence. METHODS: A cross-sectional community-based survey (Mayisha II) in London, Luton and the West Midlands. A short (24-item) anonymous self-completion questionnaire with linked voluntary anonymous oral fluid sampling, using an Orasure device for HIV testing. RESULTS: A total of 1359 eligible black African men (51.9%) and women (48.1%) were recruited, of whom 74% (1006) provided a sufficient oral fluid sample for HIV testing. 42.9% of men and 50.9% of women reported ever having had an HIV test. Overall, 14.0% (141, 95% CI 11.9 to 16.3) of respondents tested HIV positive (13.1% of men and 15.0% of women); 9.2% (93) had undiagnosed HIV infection, while 4.8% (48) had a diagnosed HIV infection. HIV prevalence was significantly higher in men: born in East Africa; who had had a previous STI diagnosis; or who were recruited in bars and clubs; and in women: born in East or Southern Africa; aged 25 years and over; who had had two new sexual partners in the past 12 months; or who had had a previous STI diagnosis. CONCLUSIONS: Despite about half the sample having had an HIV test at some time in the past, 9.2% of respondents had an undiagnosed HIV infection. This study supports current policy efforts to further promote HIV testing and serostatus awareness.

Mayisha II: pilot of a community-based survey of sexual attitudes and lifestyles and anonymous HIV testing within African communities in London.

The pilot aim was to assess the feasibility and acceptability of undertaking anonymous HIV testing using oral fluid samples as part of a community-based survey of sexual attitudes and lifestyles of black African communities in London. The three components of the study were administered in various venues across London: (1) a cross-sectional self-completion anonymous questionnaire survey, (2) an optional oral fluid sample for anonymous HIV testing and (3) a nested in-depth interview study in a sub-set of respondents. A total of 114 black African men and women were recruited. A large number of African countries were represented among respondents from newly-migrant and well-established communities. The response rate to the oral fluid sample was high at 82% and all samples collected were of sufficient quality to be tested for HIV. In-depth interviews with respondents revealed positive views and experiences about participating in the study whilst understanding of the questionnaire was good. We therefore conclude that anonymous HIV testing as part of a community-based survey is feasible and acceptable, whilst a set of recommendations was produced to refine the survey methodology and questionnaire. Participatory research methods are essential for achieving successful community-based surveys among black Africans in Britain.

British HIV Association (BHIVA)/British Association for Sexual Health and HIV (BASHH) guidelines on provision of adherence support to individuals receiving antiretroviral therapy (2003).

The widespread use of highly active antiretroviral therapy (HAART) has dramatically reduced HIV-associated morbidity and mortality where treatment has been made available. Very high levels of adherence to HAART are a prerequisite for a successful virological and immunological response. Low adherence increases the risk of treatment failure and disease progression. It is also likely to lead to further transmission of resistant viruses, and to have a negative impact on the cost effectiveness of HAART. Low adherence is difficult to predict, and this has two key implications for service provision. Firstly, HAART should not be withheld on the basis of assumptions about adherence. Secondly, support with adherence should be provided to all patients prescribed HAART. Our understanding of barriers to and enablers of high adherence, and the evidence base regarding effective interventions, is limited. Meta-analysis of randomized controlled trials available from the general literature suggests multiple interventions are required to maintain high adherence to chronic therapy. This document recommends a series of measures for adoption within HIV clinical care settings, based on evaluation of existing data. High adherence is a process, not a single event, and therefore adherence support must be integrated into clinical follow up. Every prescribing unit should have a written policy on provision of adherence support, and ensure that staff are appropriately trained to make delivery of such services possible.

Is use of antiretroviral therapy among homosexual men associated with increased risk of transmission of HIV infection?

BACKGROUND/OBJECTIVE: There is concern that use of highly active antiretroviral therapy (HAART) may be linked to increased sexual risk behaviour among homosexual men. We investigated sexual risk behaviour in HIV positive homosexual men and the relation between use of HAART and risk of HIV transmission. METHODS: A cross sectional study of 420 HIV positive homosexual men attending a London outpatient clinic. Individual data were collected from computer assisted self interview, STI screening, and clinical and laboratory databases. RESULTS: Among all men, sexual behaviour associated with a high risk of HIV transmission was commonly reported. The most frequently reported type of partnership was casual partners only, and 22% reported unprotected anal intercourse with one or more new partners in the past month. Analysis of crude data showed that men on HAART had fewer sexual partners (median 9 versus 20, p=0.28), less unprotected anal intercourse (for example, 36% versus 27% had insertive unprotected anal intercourse with a new partner in the past year, p=0.03) and fewer acute sexually transmitted infections (33% versus 19%, p=0.004 in the past 12 months) than men not on HAART. Self assessed health status was similar between the two groups: 72% on HAART and 75% not on HAART rated their health as very or fairly good, (p=0.55). In multivariate analysis, differences in sexual risk behaviour between men on HAART and men not on HAART were attenuated by adjustment for age, time since HIV infection. CD4 count and self assessed health status. CONCLUSION: HIV positive homosexual men attending a London outpatient clinic commonly reported sexual behaviour with a high risk of HIV transmission. However, behavioural and clinical risk factors for HIV transmission were consistently lower in men on HAART than men not on HAART. Although use of HAART by homosexual men with generally good health is not associated with higher risk behaviours, effective risk reduction interventions targeting known HIV positive homosexual men are still urgently needed.

HIV testing and high risk sexual behaviour among London's migrant African communities: a participatory research study.

OBJECTIVES: To describe the demographic and behavioural factors associated with HIV testing among migrant Africans in London. METHODS: A cross sectional survey of migrants from five sub-Saharan African communities (Congo, Kenya, Uganda, Zambia, Zimbabwe) resident in London was carried out. The study formed part of a larger community based participatory research initiative with migrant African communities in London-the MAYISHA project. Trained, ethnically matched interviewers recruited study participants in a variety of community venues. A brief self completion questionnaire collected data on demographic characteristics, utilisation of sexual health services, HIV testing history, sexual behaviour, and attitudes. RESULTS: Valid questionnaires were obtained from 748 participants (396 men and 352 women), median ages 31 and 27 years, respectively. Median length of UK residence was 6 years. 34% of men and 30% of women reported ever having had an HIV test. HIV testing was significantly associated with age and previous STI diagnosis among women; and additionally, nationality, education, employment, and self perceived risk of acquiring HIV among men. After controlling for significant demographic variables, previous diagnosis of an STI (adjusted odds ratio and 95% confidence interval for men: 2.96, 1.63 to 5.38, and women 2.03, 1.06 to 3.88) and perceived risk of acquiring HIV for men (adjusted OR 2.28, 95%CI 1.34 to 3.90) remained independently associated. CONCLUSION: Among these high HIV prevalence migrant communities, these data suggest that HIV testing remains largely associated with an individual's STI history or self perceived risk. This strategy may be inappropriate given the potential for onward and vertical transmission. Antenatal HIV testing combined with proactive targeted HIV testing promotion should be prioritised.

HIV transmission risk among sub-Saharan Africans in London travelling to their countries of origin.

Migrant black African communities bear the brunt of heterosexual HIV/AIDS epidemic in the UK. This study confirms the close links that exist between UK resident black Africans and their countries of origin. A total of 43% of men and 46% of women visited their home countries within the last five years. While there, men were more likely than women to have acquired a new sexual partner. Previous diagnosis with a sexually transmitted disease, and the use of condoms at last intercourse were independently associated with this practice. This represents a potential risk of HIV transmission, and highlights an area for targeted health promotion within these communities.

Legal pitfalls of psychiatric research.

BACKGROUND: The increasing complexity of psychiatric research, including recent attempts to evaluate mental health legislation, suggests legal advice may be valuable in a wide range of research contexts. AIMS: We aim to illustrate both the legal pitfalls of research in psychiatry and the potential for solutions if the methods are carefully chosen. METHOD: Two examples of research are subject to legal analysis, one involving advance directives, the other the random discharge of compulsory out-patients. RESULTS: This analysis illustrates that participation in research may expose clinicians to additional forms of liability, but the legal risks can be minimised through changes in the methods or additional safeguards. CONCLUSIONS: Collaboration between academic law and psychiatry can enrich research agendas and avoid serious legal pitfalls. We argue that sound legal advice should be sought at the planning stage of research in psychiatry, but the fear of liability should not lead to overly defensive research practices. The aim should be to strike the right balance between avoiding unacceptable exposure to liability and stifling innovative research.

Remedial self-fulfilling prophecy: two field experiments to prevent Golem effects among disadvantaged women.

The Pygmalion effect is a self-fulfilling prophecy (SFP) in which raising leader expectations boosts subordinate performance. Although attempts to produce Pygmalion effects have been successful repeatedly among men, attempts to produce Pygmalion effects with female leaders have yielded null results. Also, only 1 experiment has demonstrated the Golem effect (i.e., negative SFP in which low leader expectations impair subordinate performance). In 2 field experiments testing the SFP hypothesis among women leading disadvantaged women, experimental leaders were led to believe that their trainees had higher than usual potential. In reality, the trainees had been assigned randomly. Manipulation checks confirmed that the treatment raised leader expectations toward experimental trainees. Analysis of variance of performance detected the predicted SFP effects in both experiments. These were the first-ever experimental confirmations of SFP among women as leaders.

Treating infertility. Controlled ovarian hyperstimulation using human menopausal gonadotropin in combination with intrauterine insemination.

OBJECTIVE: To determine the effectiveness of human menopausal gonadotropin (hMG) with intrauterine insemination (IUI) for the treatment of various causes of infertility and to identify prognostic factors for the success of this treatment. STUDY DESIGN: Retrospective chart analysis. RESULTS: Of the 271 cycles initiated, 247 were completed in 104 couples, and analysis of these cycles showed that the overall cycle fecundity rate was 10% and the pregnancy rate 22%. The miscarriage rate was 8% and the ectopic pregnancy rate 4%. The multiple pregnancy rate was 29%. For the various causes of infertility, we found that the cycle fecundity rate was 7% for male factor, 11% for oligoovulation, 8% for tubal/pelvic factor, 13% for minimal endometriosis, 18% for mild endometriosis, 17% for moderate endometriosis, 3% for women aged > or = 40 years, 75% for myoma, and 7% for idiopathic infertility. We also found that one IUI timed at 36-48 hours was as effective as two IUIs timed at 18-24 and 36-48 hours after human chorionic gonadotropin (hCG) administration. Poor prognostic factors that were elicited from this study were: (1) failure of pregnancy in three cycles of treatment, (2) female age > or = 40 years, (3) requirement of > 300 IU of hMG daily, and (4) presence of more than eight mature follicles at the time of hCG administration. CONCLUSION: HMC and IUI are effective treatment of some causes of infertility.

Artificially induced menstrual cycle with natural estradiol and progesterone.

In order to study the feasibility and efficacy of using natural 17 beta-estradiol (E2) and progesterone (P) to induce endometrial changes, a group of patients with history of premature ovarian failure and bilateral oophorectomy, also interested in the embryo transfer program with donor ovum, were given transdermal E2 (Estraderm, Ciba Pharmaceutical Co., Summit, NJ), and vaginal progesterone suppositories. Serial serum E2, P, follicle-stimulating hormone, and luteinizing hormone were determined by radioimmunoassays. The dosages of E2 and P were adjusted according to the levels of E2 and P so that their changes could follow the same pattern as that of a normal spontaneous menstrual cycle. Serial ultrasonic evaluation of the endometrium and endometrial biopsy during the late luteal phase also was performed. Preliminary data indicated that transdermal E2 patches and vaginal P suppositories, while being as effective in inducing endometrial development for the embryo transfer procedure with donor ovum as synthetic steroids, can also provide a more physiologic approach that may conveniently and safely be extended into the second trimester of pregnancy.

Cognitive and motor dysfunction in Parkinson's disease. Clinical, performance, and computed tomographic correlations.

The neuropathologic and pathophysiological relationship of specific to more generalized cognitive dysfunction in Parkinson's disease (PD) remains incompletely understood. This issue was examined in a study of 39 patients with PD, utilizing standardized clinical measures, computerized neuropsychological tests, and quantitative computed tomography. Disorders of visuospatial discrimination and perceptual-motor function closely paralleled motor scores, suggesting a common neuropathologic basis. Caudate nuclear and mesocortical dopamine depletion play a role in this context. More generalized cognitive dysfunction occurred in older patients with a somewhat longer disease duration, more advanced parkinsonism, and computed tomographic evidence of subcortical and frontal cortical atrophy but without significant cerebral atrophy when compared with age-matched controls. Further prospective clinicopathologic studies will be required to clarify the relative contribution of the primary dopaminergic dysfunction, age-related changes, Alzheimer-type pathologic condition, and other coexisting neurotransmitter deficits to the dementia seen in PD.

Acalculia following a dominant-hemisphere subcortical infarct.

A 60-year-old, right-handed woman experienced persistent impairment of calculating ability following a subcortical infarct involving the head of the left caudate nucleus, the anterior superior putamen, and the anterior limb of the internal capsule extending superiorly into the periventricular white matter. Acalculia resulted from defects of numerical syntax, the loss of ability to manipulate mathematical concepts, and impaired working memory.