A rapid review of antenatal hepatitis C virus testing in the United Kingdom.

BACKGROUND: The United Kingdom (UK) has committed to the World Health Organization's viral hepatitis elimination targets. New case finding strategies, such as antenatal testing, may be needed to achieve these targets. We conducted a rapid review to understand hepatitis C-specific antibody (anti-HCV) and HCV RNA test positivity in antenatal settings in the United Kingdom to inform guidance. METHODS: Articles and conference abstracts published between January 2000 and June 2022 reporting anti-HCV testing in antenatal settings were identified through PubMed and Web of Science searches. Results were synthesised using a narrative approach. RESULTS: The search identified 2,011 publications; 10 studies were included in the final synthesis. Seven studies used anonymous testing methods and three studies used universal opt-out testing. Anti-HCV test positivity ranged from 0.1 to 0.99%, with a median value of 0.38%. Five studies reported HCV RNA positivity, which ranged from 0.1 to 0.57% of the testing population, with a median value of 0.22%. One study reported cost effectiveness of HCV and found it to be cost effective at £9,139 per quality adjusted life years. CONCLUSION: The relative contribution of universal opt-out antenatal testing for HCV should be reconsidered, as antenatal testing could play an important role in new case-finding and aid achieving elimination targets.

HIV prevalence and HIV clinical outcomes of transgender and gender-diverse people in England.

OBJECTIVES: We provide the first estimate of HIV prevalence among trans and gender-diverse people living in England and compare outcomes of people living with HIV according to gender identity. METHODS: We analysed a comprehensive national HIV cohort and a nationally representative self-reported survey of people accessing HIV care in England (Positive Voices). Gender identity was recorded using a two-step question co-designed with community members and civil society. Responses were validated by clinic follow-up and/or self-report. Population estimates were obtained from national government offices. RESULTS: In 2017, HIV prevalence among trans and gender-diverse people was estimated at 0.46-4.78 per 1000, compared with 1.7 (95% credible interval: 1.6-1.7) in the general population. Of 94 885 people living with diagnosed HIV in England, 178 (0.19%) identified as trans or gender-diverse. Compared with cisgender people, trans and gender-diverse people were more likely to be London residents (57% vs. 43%), younger (median age 42 vs. 46 years), of white ethnicity (61% vs. 52%), under psychiatric care (11% vs. 4%), to report problems with self-care (37% vs. 13%), and to have been refused or delayed healthcare (23% vs. 11%). Antiretroviral uptake and viral suppression were high in both groups. CONCLUSIONS: HIV prevalence among trans and gender-diverse people living in England is relatively low compared with international estimates. Furthermore, no inequalities were observed with regard to HIV care. Nevertheless, trans and gender-diverse people with HIV report poorer mental health and higher levels of discrimination compared with cisgender people.

The people living with HIV stigma survey UK 2015: HIV-related sexual rejection and other experiences of stigma and discrimination among gay and heterosexual men.

We aim to understand the difference in stigma and discrimination, in particular sexual rejection, experienced between gay and heterosexual men living with HIV in the UK. The People Living with HIV StigmaSurvey UK 2015 recruited a convenience sample of persons with HIV through over 120 cross sector community organisations and 46 HIV clinics to complete an online survey. 1162 men completed the survey, 969 (83%) gay men and 193 (17%) heterosexual men, 92% were on antiretroviral therapy. Compared to heterosexual men, gay men were significantly more likely to report worrying about workplace treatment in relation to their HIV (21% vs. 11%), worrying about HIV-related sexual rejection (42% vs 21%), avoiding sex because of their HIV status (37% vs. 23%), and experiencing HIV-related sexual rejection (27% vs. 9%) in the past 12 months. In a multivariate logistic regression controlling for other sociodemographic factors, being gay was a predictor of reporting HIV-related sexual rejection in the past 12 months (aOR 2.17, CI 1.16, 4.02). Both gay and heterosexual men living with HIV experienced stigma and discrimination in the past 12 months, and this was higher for gay men in terms of HIV-related sexual rejection. Due to the high proportion of men reporting sexual rejection, greater awareness and education of the low risk of transmission of HIV among people on effective treatment is needed to reduce stigma and sexual prejudice towards people living with HIV.

Experiences of stigma and discrimination in social and healthcare settings among trans people living with HIV in the UK.

The People Living with HIV StigmaSurvey UK 2015 was a community led national survey investigating experiences of people living with HIV in the UK in the past 12 months. Participants aged 18 and over were recruited through over 120 cross-sector community organisations and 46 HIV clinics to complete an anonymous online survey. Trans is an umbrella term which refers to individuals whose current gender identity is different to the gender they were assigned at birth. Trans participants self-identified via gender identity and gender at birth questions. Descriptive analyses of reported experiences in social and health care settings were conducted and multivariate logistic regression analyses were used to identify sociodemographic predictors of reporting being treated differently to non-HIV patients, and being delayed or refused healthcare treatment in the past 12 months. 31 out of 1576 participants (2%) identified as trans (19 trans women, 5 trans men, 2 gender queer/non-binary, 5 other). High levels of social stigma were reported for all participants, with trans participants significantly more likely to report worrying about verbal harassment (39% vs. 23%), and exclusion from family gatherings (23% vs. 9%) in the last 12 months, compared to cisgender participants. Furthermore, 10% of trans participants reported physical assault in the last 12 months, compared to 4% of cisgender participants. Identifying as trans was a predictor of reporting being treated differently to non-HIV patients (48% vs. 30%; aOR 2.61, CI 1.06, 6.42) and being delayed or refused healthcare (41% vs. 16%; aOR 4.58, CI 1.83, 11.44). Trans people living with HIV in the UK experience high levels of stigma and discrimination, including within healthcare settings, which is likely to impact upon health outcomes. Trans-specific education and awareness within healthcare settings could help to improve service provision for this demographic.

Utility of surgical lung biopsy in critically ill patients with diffuse pulmonary infiltrates: a retrospective review.

BACKGROUND: There are conflicting reports regarding the role of surgical lung biopsies in patients who present to the intensive care unit (ICU) with unexplained respiratory failure and diffuse pulmonary infiltrates on imaging. AIM: To describe the utility of surgical lung biopsies in patients presenting to the ICU with unexplained respiratory failure and diffuse pulmonary infiltrates. METHODS: A retrospective cohort study was performed. All patients admitted to the ICU who underwent a surgical lung biopsy for the investigation of respiratory failure and unexplained pulmonary infiltrates between 1998 and 2012 were included. The primary outcome measures for this descriptive study were the biopsy histopathology, changes in patient management following biopsy and in-hospital mortality. RESULTS: A total of 30 patients was included in the review. Biopsies in 22 patients (73%) demonstrated diffuse alveolar damage (DAD), with 15 of these biopsies (50%) suggesting a specific underlying aetiology. In 73% of cases (n = 22), the biopsy finding was associated with a change in management, although this generally involved the escalation of an existing therapy rather than initiation of a new treatment. Biopsies were performed at a median 10 days after admission (interquartile range 5-17 days), with the majority of patients being treated empirically prior to the biopsy with systemic steroids and broad-spectrum antimicrobials. Mortality was 53%. CONCLUSION: In this series, DAD was the most frequent pathology. The biopsy result was associated with a change in management in a majority of the subjects, most frequently an escalation of prior empiric therapy. Mortality was high.

Telehealth: experience of the first 120 consultations delivered from a new refugee telehealth clinic.

BACKGROUND: In 2011, the Australian Government introduced Medicare item numbers for telehealth consultations. This is a rapidly expanding method of healthcare provision. AIMS: We assessed the demographic and disease profile of refugee patients attending a new telehealth clinic, and calculated the patient travel avoided. We examined technical challenges and assessed the performance of two videoconferencing solutions using different bandwidth and latencies. METHODS: We audited the first 120 patients attending the telehealth clinic. During consultations, the patient was with the general practitioner (GP) and linked by internet videoconference using VIDYO, GoToMeeting or Skype, to the specialist at a tertiary referral hospital. Travel avoided was calculated and technical problems were assessed by the participating specialist. Bandwidth and latency variations were examined within a university broadband testing facility. RESULTS: The two most frequently managed conditions were hepatitis C and latent tuberculosis. Twenty-nine different GP were included and 42 consultations required an interpreter. Nearly 500 km of travel and 127 kg of CO(2) production was avoided per consultation. Technical issues were faced in 25% of consultations, most frequently sound problems and connections dropping out. A bandwidth of at least 512 kbps and latency of no more than 300 ms was necessary to conduct an adequate multipoint videoconference. CONCLUSIONS: Telehealth using videoconferencing adds a new component to care of refugee and immigrant patients settling in regional areas. Telehealth will be improved by changes to improve simplicity and standardisation of videoconferencing, but requires ongoing Medicare funding to allow sufficient administrative support.

Omental herniation through a 3-mm umbilical trocar site: unmasking a hidden umbilical hernia.

BACKGROUND: The incidence of umbilical hernia following laparoscopic surgery varies from 0.02-3.6%. The incidence of pre-existing fascial defects, however, may be as high as 18% in patients undergoing abdominal laparoscopic surgery. Previous recommendations have been made to close any fascial defect greater than or equal to 10 mm. Reported here is a case of herniation through a 3-mm trocar site incision and the discovery of a pre-existing fascial defect. CASE REPORT: A 32-year-old female underwent an uncomplicated laparoscopic tubal ligation using a 3-mm umbilical port. Prior to umbilical trocar removal at the completion of the case, the carbon dioxide was evacuated from the abdomen and the sleeve was withdrawn under direct vision. Neither the fascial nor skin incisions were sutured. On postoperative day two, the patient returned with omentum herniating from the 3-mm site. At surgery, a 1.5-cm pre-existing fascial defect was discovered adjacent to the trocar site. The hernia sac tracked laterally to the base of the umbilicus, and the omentum had slid into the sac and out the skin opening. CONCLUSION: As this report illustrates, herniation associated with laparoscopic trocar sites can occur with incisions as small as 3 mm. The presence of pre-existing fascial defects can cause increased morbidity in any laparoscopic surgery, and as illustrated in this report, may predispose the patient to site herniation. The detection and management of these defects is crucial in preventing postlaparoscopic complications.

Gender reassignment surgery and the gynecological patient(1).

With the increasing number of open transsexuals in the population and the advances in reconstructive surgical techniques, gender reassignment surgery has been increasing since the 1960s. Secondary to the increase in patients undergoing gender reassignment surgery, the practicing gynecologist is more likely to encounter a transsexual patient. A 49-year-old, nulligravid, white female presented to the gynecology clinic for her annual gynecological exam. Her past surgical history was significant for male to female gender reassignment surgery in 1991. Her hormonal medications included levothyroxine and estrogen. She described a strong family history of breast cancer for which she was being followed in our institutional Breast Watch Clinic. On physical examination, findings were notable for surgically constructed female external genitalia and a neovagina. The rectal exam was normal and failed to demonstrate any prostate pathology. It is important for the experienced gynecologist to be familiar with transsexualism, the reconstructive surgery involved, the surgical complications, and gender identity support groups and clinics available to these patients. Transsexuals should be treated to the extent possible like other female gynecological patients, while care is taken not to overlook underlying or preexisting medical conditions, including conditions unique to the prior and new genders.

Sources of uncertainty and coping strategies used by family members of individuals living with end stage renal disease.

This article presents an analysis of the experience of family members of individuals with chronic renal disease undergoing dialysis therapy. Themes are derived from interviewing family members regarding the sources of uncertainty experienced and the types of coping strategies used to manage the stress related to uncertainty. The sample consisted of 41 family members including spouses, adult children, siblings, a niece, and a daughter-in-law from Eastern Canada. Data were collected from focus group interviews and thematic analysis was used to derive the themes. Emerging themes of uncertainty arose from many sources including: the patient's health, dialysis treatment, potential loss of the patient, and/or the availability of a kidney transplantation. The family members coped with the stress generated by the uncertainty by living each day as it comes, finding positive meaning, hoping for a transplant, and/or drawing on God's strength. Findings from this study provide direction for renal health care professionals to assist family members to prepare for, to understand, and to adapt to constant sources of uncertainty in their lives.

Credentialing residents for intraoperative cystoscopy.

OBJECTIVE: To determine whether incorporation of routine intraoperative cystoscopy for evaluation of potential urinary tract injury into gynecologic residency training provides sufficient experience to justify hospital credentials after graduation. METHODS: We developed a curriculum to train residents in intraoperative cystoscopic evaluation of potential lower urinary tract injury. Cystoscopy was performed when indicated with hysterectomy and routinely in conjunction with pelvic reconstruction. Faculty members evaluated conceptual and technical proficiency by oral examination and direct observation in the operating room. Once the resident demonstrated a thorough understanding and proficiency in performing intraoperative cystoscopy, a competency certification document was issued by the Program Director. This certification was transmitted to the postresidency hospital credentials committee to justify granting privileges. RESULTS: Since 1994 over 400 transurethral cystoscopic evaluations have been done in conjunction with major gynecologic abdominal and vaginal surgeries, and since 1997 an additional 50 transvesical microcystoscopies have been done in selected abdominal cases. Twenty-five residency graduates have been certified as fully trained in intraoperative diagnostic cystoscopy. All these graduates have been granted intraoperative cystoscopy privileges at their subsequent hospital practice. CONCLUSION: Incorporation of cystoscopic urinary tract evaluation into routine gynecologic surgical training is good medical practice and provided a mechanism whereby obstetrics and gynecology residents could obtain intraoperative cystoscopy hospital privileges after graduation. (Obstet Gynecol 2000;96:1014-7.)

Serial serum human chorionic gonadotropin (hCG) levels in ectopic pregnancy and first trimester miscarriage.

Serial serum hCG levels were measured in 50 patients with a tubal ectopic pregnancy and 50 patients with spontaneous miscarriage of an intrauterine pregnancy. Serum samples were obtained at intervals of 3-5 d and more frequently if clinically indicated. The final diagnosis was confirmed by laparoscopy and/or dilatation and curettage. Data were analyzed using a linear regression model. Initial hCG concentrations ranged from 91 to 3,050 mIU/mL. Eighty percent of ectopic pregnancies and 35% of miscarriages were associated with rising hCG concentrations and no significant differences were noted in daily increments of hCG in the two groups (210 +/- 30 mIU/mL/day for ectopic pregnancies versus 311 +/- 55 mIU/mL/d for miscarriages). Twenty percent of ectopic pregnancies and 65% of miscarriages had falling hCG concentrations and significant differences were noted in the daily decrements of hCG for EP and AB (270 +/- 52 mIU/mL/day for ectopic pregnancies versus 578 +/- 28 mIU/mL/d for miscarriages (P < or = 0.05).

Uterine perforation resulting in bowel infarction: sharp traumatic bowel and mesenteric injury at the time of pregnancy termination.

BACKGROUND: By law, elective terminations of pregnancy are not performed in U.S. military institutions. However, in the civilian sector, more than a million abortions are performed each year, some of which are on military beneficiaries. Although complications are relatively rare, patients not uncommonly present for follow-up care to their military installation. We report the case of a patient who presented after a second-trimester elective abortion and was found to have suffered uterine perforation with mesenteric and bowel injury that required bowel resection. CASE: An 18-year-old gravida 1 para 0 female presented from an outlying facility 1 week after elective termination at 18 weeks of gestation with complaints of severe abdominal pain, nausea, and vomiting. Exploratory laparotomy for presumed bowel obstruction revealed uterine perforation and bowel devitalization and necrosis, which required small bowel resection. Fetal bones were discovered within the surgical specimen. CONCLUSION: Morbid, even potentially fatal, complications can occur as a result of pregnancy termination. With second-trimester procedures, perforation can result in injury to abdominal viscera from the perforating instruments or even from sharp fetal bony structures. Military gynecologic surgeons, who are not in abortion practice, must nevertheless be cognizant of the potential for perforation leading to serious visceral injury.

Micro-hydrovaginoscopy in examining children.

BACKGROUND: The gynecologic evaluation of children is challenging and requires mastery of special examination techniques. TECHNIQUE: small-diameter endoscopic trocar sleeves and endoscopes (2 or 3 mm) were used in conjunction with hydrodistention with normal saline, to view atraumatically the entire vagina and cervix. EXPERIENCE: During the past 3 years we have used micro-hydrovaginoscopy (2-mm trocar sleeve and endoscope, with hydrodistention) for vaginal examination of young girls and in selected cases of young adolescents and virginal adults in whom traditional speculum examination proved difficult or impossible. This technique was effective for (1) confirming diagnosis of cribriform hymen and facilitated hymenotomy; (2) diagnosis of vaginal discharge unresponsive to medical treatment caused by an intravaginal foreign body (color crayon), which was removed under direct endoscopic view; (3) suspected müllerian agenesis and persistent vaginal discharge confirming absence of the cervix and ruling out foreign body in the urogenital portion of the vagina; and (4) a vulvar straddle injury and urinary retention in which vaginal laceration and hematoma were excluded. CONCLUSION: Micro-hydrovaginoscopy is simple, minimally invasive, and effective for vaginal examination in prepubertal girls. It permits precise and complete diagnosis, directs and assists treatment, and has potential for well- tolerated office use in cooperative patients.

Abdominal pregnancy in a 67-year-old woman undetected for 37 years. A case report.

BACKGROUND: Abdominal pregnancy is an exceedingly rare occurrence, but even more unusual is prolonged retention of an advanced abdominal pregnancy with lithopedion formation. We present the case of prolonged retention of an advanced abdominal pregnancy in an elderly women. CASE: A 67-year-old, white woman presented to the emergency department with abdominal pain. An acute abdominal series revealed a fetal skeleton extending from the patient's pelvis to her lower costal margins. Pelvic examination revealed a normal postmenopausal uterus, and human chorionic gonadotropin was negative. On further questioning the patient reported that she had become pregnant 37 years earlier and was diagnosed as having a "missed" pregnancy. She refused intervention at that time but suffered no untoward consequences. She reported having had later a healthy intrauterine pregnancy, delivered vaginally at term. No attempt was made to remove the prior missed abdominal pregnancy. The acute pain episode resolved, and there was no surgical intervention. CONCLUSION: Abdominal pregnancies can have a complex course, and management decisions can be difficult. This case presents an unusual outcome of an advanced abdominal pregnancy and illustrates a unique approach to management.

Decline in bone mineral density with stress fractures in a woman on depot medroxyprogesterone acetate. A case report.

BACKGROUND: Depot medroxyprogesterone acetate is a popular contraceptive among young, physically active women. However, its administration has been linked to a relative decrease in estrogen levels. Since bone resorption is accelerated during hypoestrogenic states, there has been growing concern about the potential development of osteoporosis and fractures with the use of this contraceptive method. CASE: A physically active, 33-year-old woman demonstrated a 12.4% drop in femoral neck bone mineral density (BMD), 6.4% drop in lumbar BMD and 0.8% drop in total BMD with the subsequent development of a tibial stress fracture while on depot medroxyprogesterone acetate. Bone mineralization rapidly improved, and the stress fracture resolved with discontinuation of the medication. CONCLUSION: The long-term effects of depot medroxyprogesterone acetate on bone mineralization in physically active women should be evaluated more thoroughly.

PIP: This case report illustrates the potential development of osteoporosis and fractures with the use of depot medroxyprogesterone acetate (DMPA), a popular contraceptive among young women. The case of a physically active 33-year-old woman who received 150 mg DMPA intramuscularly every 10 weeks, for a total of 3 injections, is presented. She demonstrated a 12.4% drop in femoral neck bone mineral density (BMD), a 6.4% drop in lumbar BMD, and a 0.8% drop in total BMD with the subsequent development of a tibial stress fracture while on DMPA. Bone mineralization rapidly improved, and stress fracture resolved with discontinuation of the medication. Women using DMPA are in a state of relative estrogen deficiency, which may not be adequate to maintain BMD in some patients. The long-term effects of DMPA on bone mineralization in physically active women should be evaluated more thoroughly.

Urinary incontinence among female soldiers.

A self-administered questionnaire was developed to assess the prevalence of urinary incontinence among active duty female soldiers. The questionnaire also addressed basic demographic information, including height, age, weight, and the subjects' present and past military activities. Adaptive measures that the soldiers commonly used to continue exercising and perform their duties were also explored. Seven hundred thirteen questionnaires were handed out to female soldiers at Fort Lewis (Washington), Fort Benning (Georgia), and Fitzsimons Army Medical Center (Colorado) during preparation for physical fitness tests. Of the 563 soldiers (79%) who returned completed questionnaires, 31% indicated that they commonly experienced urinary incontinence during duty and/or training to the extent that it interfered with job performance, hygiene, or was socially embarrassing. Thus, urinary incontinence is a pervasive problem among female soldiers.

Enhancing advanced surgical laparoscopy. Combined, routine use of microlaparoscopes and macrolaparoscopes.

OBJECTIVE: To describe a variety of techniques for using the microlaparoscope in conjunction with a standard-sized laparoscope for simplifying and enhancing advanced laparoscopic surgery. STUDY DESIGN: Descriptive study of microlaparoscopic techniques for enhancing macrolaparoscopic procedures. RESULTS: The microlaparoscope facilitates macrolaparoscopy by permitting: (1) specimen removal and use of 10-mm instruments without secondary, large ports; (2) performance of laparoscopic vaginal hysterectomy with the endoscopic stapler using only one 12-mm port; (3) lysis of difficult pelvic and periumbilical adhesions; (4) enhancement of visual access to difficult operative sites; (5) closure of large umbilical and secondary port sites under direct monitoring; (6) visualization from the left upper quadrant when umbilical adhesions are suspected; and (7) use as the initial entry laparoscope when extensive surgery is not anticipated. CONCLUSION: The routine, combined use of the microlaparoscope and 10-mm laparoscope significantly expands the capabilities of the advanced laparoscopic surgeon. Procedures are simplified, facilitated and made less invasive.

Female circumcision: the prevalence and nature of the ritual in Eritrea.

This study evaluates the prevalence, complications, and attitudes concerning the practice of female circumcision among the women of Eritrea. Four hundred thirty-six Eritrean women from rural and urban environments were questioned about their perceptions and beliefs concerning female circumcision. Eighty-eight percent of those interviewed had undergone some form of female circumcision. Those who favored the continuation of the practice were more likely to be rural dwellers with little formal education, and they did so primarily out of tradition or cultural conformity. The direct and indirect consequences of this practice to the health of women and infants are considerable and as complex as the social, religious, and traditional factors that have led to its preservation.

PIP: This paper evaluates the current practice of female circumcision in Eritrea. The study, in particular, examined the extent of the practice, its immediate and long-term complications, and attitudes towards the practice among women in Eritrea. The sample population comprised 436 Eritrean women from rural and urban environments. About 88% had undergone some form of female circumcision, while 63% were circumcised during infancy or early childhood. Although 73% of the women believed that female circumcision should be abandoned, 79% preferred to have their daughters circumcised. Those women who favored the continuation of female circumcision were primarily rural dwellers with little formal education. The immediate complications of this practice were hemorrhage, infection, trauma, and shock, while the long-term complications include psychological, hematocolpos, keloid formation, obstructed labor injury complex, pelvic contractures, infertility, and fistula formation. The consequences of this practice were considerable and as complex as the social, religious, and traditional factors behind its preservation.