HIV, hepatitis and syphilis prevalence and correlates of condom use during anal sex among men who have sex with men in the Republic of Moldova

Limited data on HIV prevalence and related risks among men who have sex with men (MSM) exist in the Republic of Moldova. In Chisinau and Balti, 188 and 209, respectively, men who reported having anal or oral sex in the last six months with another man, aged ≥16 years were recruited into a study in 2010 using respondent-driven sampling methods. MSM reported having multiple male and female partners and inconsistent condom use. In Chisinau, 2% of MSM were HIV seropositive, 3.7% had antibodies to hepatitis C (HCV), 5.7% had antibodies to hepatitis B (HBV) and 12.1% had syphilis. In Balti, less than 1% of MSM were HIV seropositive, 1.2% had antibodies to HCV, 3.2% had antibodies to HBV and only 0.5% had syphilis. MSM who used a condom at last anal sex with a man were less likely to reside in Chisinau, to have casual sex partners and to have had an HIV test in the last year and were more likely to know where to get an HIV test. Although HIV prevalence was low, MSM practice a number of risky sexual behaviours that may heighten the risk of further HIV transmission in this population and to the wider population.

Five-year results of a randomised controlled trial comparing mobile and fixed bearings in total knee replacement

There is conflicting evidence about the merits of mobile bearings in total knee replacement, partly because most randomised controlled trials (RCTs) have not been adequately powered. We report the results of a multicentre RCT of mobile versus fixed bearings. This was part of the knee arthroplasty trial (KAT), where 539 patients were randomly allocated to mobile or fixed bearings and analysed on an intention-to-treat basis. The primary outcome measure was the Oxford Knee Score (OKS) plus secondary measures including Short Form-12, EuroQol EQ-5D, costs, cost-effectiveness and need for further surgery. There was no significant difference between the groups pre-operatively: mean OKS was 17.18 (sd 7.60) in the mobile-bearing group and 16.49 (sd 7.40) in the fixed-bearing group. At five years mean OKS was 33.19 (sd 16.68) and 33.65 (sd 9.68), respectively. There was no significant difference between trial groups in OKS at five years (-1.12 (95% confidence interval -2.77 to 0.52) or any of the other outcome measures. Furthermore, there was no significant difference in the proportion of patients with knee-related re-operations or in total costs. In this appropriately powered RCT, over the first five years after total knee replacement functional outcomes, re-operation rates and healthcare costs appear to be the same irrespective of whether a mobile or fixed bearing is used.

An observational study exploring amplitude-integrated electroencephalogram and spectral edge frequency during paediatric anaesthesia

Processed electroencephalography is used in adults to guide anaesthesia, but the algorithms used may not apply to infants. Knowledge of infants' electroencephalogram (EEG) responses to anaesthetics is fragmentary. An earlier pilot study suggested amplitude-integrated EEG (aEEG) may be a useful measure of anaesthetic effect. The aim of this study was to determine how aEEG changes between awake and anaesthetised children of varying ages and to compare the response to that seen with Spectral Edge Frequency 90% (SEF90). A prospective observational study of children receiving a general anaesthetic was conducted. Anaesthetic regimen remained at the discretion of the treating anaesthetist. EEG data were collected using the BrainZ ReBrim(TM) monitor using forehead and biparietal montages. SEF90 and aEEG were compared across age groups, EEG montage and between awake and anaesthetised states. A total of 178 children (aged 24 days to 14 years) were recruited. All aEEGs were greater during anaesthesia compared to when awake and this difference varied with age. Only children older than two years showed lower SEF90 while anaesthetised compared to when awake. SEF90 from children younger than six months was higher during anaesthesia compared to when awake. Analysis of parietal and forehead EEG montages revealed age-related differences. These findings suggest that SEF90 and aEEG can discriminate between awake and anaesthetised states in older children. In younger children aEEG changes are less pronounced and SEF90 either cannot discriminate between states or responds paradoxically. The aEEG may be marginally better than other EEG parameters in measuring anaesthetic depth in children.

The nature, frequency and course of psychiatric disorders in the first year after traumatic brain injury: a prospective study

BACKGROUND

Psychiatric disorders are common following traumatic brain injury (TBI). However, few studies have examined the course of disorder development and the influence of pre-injury psychiatric history. The present study aimed to examine the frequency of, and association between, psychiatric disorders occurring pre- and post-injury, and to examine the post-injury course of disorders.

METHOD

Participants were 102 adults (75.5% male) with predominantly moderate-severe TBI. Participants were initially assessed for pre-injury and current disorders, and reassessed at 3, 6 and 12 months post-injury using the Structured Clinical Interview for DSM-IV Disorders (SCID).

RESULTS

Over half of the participants had a pre-injury psychiatric disorder; predominantly substance use, mood, and anxiety disorders. In the first year post-injury, 60.8% of participants had a psychiatric disorder, commonly anxiety and mood disorders. Post-injury disorders were associated with the presence of a pre-injury history (p<0.01), with 74.5% of participants with a pre-injury psychiatric history experiencing a post-injury disorder, which commonly presented at initial assessment or in the first 6 months. However, 45.8% of participants without a pre-injury history developed a novel post-injury disorder, which was less likely to emerge at the initial assessment and generally developed later in the year.

CONCLUSIONS

Despite evidence that most post-injury psychiatric disorders represent the continuation of pre-existing disorders, a significant number of participants developed novel psychiatric disorders. This study demonstrates that the timing of onset may differ according to pre-injury history. There seem to be different trajectories for anxiety and depressive disorders. This research has important implications for identifying the time individuals are most at risk of psychiatric disorders post-injury.

Sirolimus and mycophenolate mofetil as GVHD prophylaxis in myeloablative, matched-related donor hematopoietic cell transplantation

We investigated sirolimus and mycophenolate mofetil (MMF) as graft-versus-host disease (GVHD) prophylaxis in patients with advanced hematologic malignancies receiving myeloablative hematopoietic cell transplantation (HCT) from HLA-identical sibling donors. Based on pre-study stopping rules, the trial was closed to accrual after enrollment of 11 adult patients. Seven of the 11 patients received busulfan-containing preparative regimens. Sirolimus was discontinued in 3 patients due to toxicity-related events of severe sinusoidal obstructive syndrome, portal vein thrombosis, altered mental status and in 1 patient due to risk of poor wound healing. Six of the 11 patients developed grade II-IV acute GVHD (AGVHD) a median of 15.5 days post-HCT. Two of 3 patients with grade IV AGVHD had sirolimus discontinued by 9 days post-HCT. All patients responded to AGVHD therapy without GVHD-related deaths. There were 2 nonrelapse- and 2 relapse-related deaths. At a median follow-up of 38 months (2–47 months), 7 of 11 patients were alive without disease. MMF and sirolimus GVHD prophylaxis did not reduce the risk of acute GVHD, however, there were no GVHD-related deaths. The severe toxicities in the patients receiving the busulfan-containing preparative regimens limited the continued use of sirolimus and MMF for the prevention of AGVHD.

Clomifene citrate and intrauterine insemination as first-line treatments for unexplained infertility: are they cost-effective?

BACKGROUND

First-line treatments for unexplained infertility traditionally include clomifene citrate (CC) or unstimulated intrauterine insemination (IUI). A recently published randomized controlled trial considered the effectiveness of CC and IUI in patients with unexplained infertility and found that neither treatment offered a superior live birth rate when compared with expectant management (EM). This paper reports the economic evaluation conducted alongside this trial in order to assess whether health care providers are gaining value for money in this clinical area.

METHODS

Five hundred and eighty women across five Scottish hospitals were randomized to either EM, CC or IUI for 6 months. The primary outcome measure was live births. Resource-use data were collected during the trial and costs were calculated from a UK National Health Service (NHS) perspective. Incremental cost-effectiveness ratios were calculated, expressed as cost per live birth, in order to compare the cost-effectiveness of CC and IUI with that of EM to treat unexplained infertility.

RESULTS

Live birth rates in the three randomized groups were: EM = 32/193 (17%), CC = 26/194 (13%) and IUI = 43/193 (22%). The mean (standard deviation) costs per treatment cycle were £0 for EM, £83 (£17) for CC and £98 (£31) for IUI. The mean treatment costs per patient for EM, CC and IUI were £12 (£117), £350 (£220) and £331 (£222), respectively. The cost per live birth for EM, CC and IUI was £72 (95% confidence interval £0-£206), £2611 (£1870-£4166) and £1487 (£1116-£2155), respectively. The incremental cost-effectiveness ratio for IUI versus EM was £5604 (-£12204 to £2227), with CC dominated by IUI.

CONCLUSIONS

Despite being more expensive, existing treatments such as empirical CC and unstimulated IUI do not offer superior live birth rates compared with EM of unexplained infertility. They are unlikely to be a cost-effective use of limited NHS resources. The study's main limitation is that it did not consider the psychological effects on couples. ISRCT Number: 71762042.

Long-term outcomes of high-dose therapy using busulfan, etoposide, and cyclophosphamide followed by allogeneic hematopoietic cell transplantation for patients with high-risk or advanced stages of myeloid malignancies

7033

Patients (pts) with high risk (HR) or advanced myeloid malignancies have limited effective treatment options. These include high-dose therapy followed by allogeneic hematopoietic cell transplantation (HCT). We report a single institution long-term follow-up of 96 pts, median age 50 (20–60) yrs, who received HLA matched related HCT between 1992 and 2007. All pts were treated with a uniform preparatory regimen: busulfan 16.0 mg/kg (d-8 to-5), etoposide 60mg/kg (d-4), cyclophosphamide 60mg/kg (d-2), and graft-versus-host-disease (GVHD) prophylaxis of cyclosporine and prednisone. Disease status at transplantation was induction failure (IF) acute myeloid leukemia (AML) (n = 10), HR AML in 1st complete remission (CR1) n = 11, in CR2 (n = 5), in CR3 (n = 2), relapsed refractory (RR) AML (n = 14), chronic myeloid leukemia (CML) in second chronic phase (n = 6), blast crisis (n = 2), myelofibrosis (n = 6), myeloproliferative disorders (n = 2), and MDS (n = 38). Thirty-six % (n = 35) of pts received bone marrow while 64 % (n = 61) received G-CSF mobilized peripheral blood mononuclear cells (PBMC). With a median follow up of 5.6 yrs (1.6–14.6 yrs) actuarial 5-year overall survival (OS) was 32% (95% CI 22–42%) and 5-year probability for freedom from progression (FFP) was 64% (95% CI 52%-76%). Relapse rate was 32% at 1 year and remained at 36% (95%CI 24%-48%) at 2 and 5 years with no further increase in relapse beyond two years. Non-relapse mortality (NRM) was 29 % (95% CI 20%5–38%) at day 100 and 39% (95% CI 29%-49%) at one yr. Cumulative incidence of acute (grade 3–4) and chronic GVHD was 28% (95% CI 19%-37%) and 38% (95% CI 24%-52%), respectively. There was no statistically significant difference in OS; 31% versus 32% (p = 0.89) or FFP 71% versus 60% (p = 0.29) for recipients of BM versus PBMC with similar results in IF and RR AML. These results confirm that pts with high-risk or advanced myeloid malignancies can achieve long-term survival following myeloablative allogeneic HCT with aggressive conditioning. Relapse and acute GVHD remain significant causes of mortality. Strategies to augment graft-versus-tumor reactions and reduce GVHD remain essential for improving long-term outcomes.

No significant financial relationships to disclose.

Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial

OBJECTIVE

To compare the effectiveness of clomifene citrate and unstimulated intrauterine insemination with expectant management for the treatment of unexplained infertility.

DESIGN

Three arm parallel group, pragmatic randomised controlled trial.

SETTING

Four teaching hospitals and a district general hospital in Scotland.

PARTICIPANTS

Couples with infertility for over two years, confirmed ovulation, patent fallopian tubes, and motile sperm.

INTERVENTION

Expectant management, oral clomifene citrate, and unstimulated intrauterine insemination.

MAIN OUTCOME MEASURES

The primary outcome was live birth. Secondary outcome measures included clinical pregnancy, multiple pregnancy, miscarriage, and acceptability.

RESULTS

580 women were randomised to expectant management (n=193), oral clomifene citrate (n=194), or unstimulated intrauterine insemination (n=193) for six months. The three randomised groups were comparable in terms of age, body mass index, duration of infertility, sperm concentration, and motility. Live birth rates were 32/193 (17%), 26/192 (14%), and 43/191 (23%), respectively. Compared with expectant management, the odds ratio for a live birth was 0.79 (95% confidence interval 0.45 to 1.38) after clomifene citrate and 1.46 (0.88 to 2.43) after unstimulated intrauterine insemination. More women randomised to clomifene citrate (159/170, 94%) and unstimulated intrauterine insemination (155/162, 96%) found the process of treatment acceptable than those randomised to expectant management (123/153, 80%) (P=0.001 and P<0.001, respectively).

CONCLUSION

In couples with unexplained infertility existing treatments such as empirical clomifene and unstimulated intrauterine insemination are unlikely to offer superior live birth rates compared with expectant management.

TRIAL REGISTRATION

ISRCT No: 71762042.