School-linked sexual health services for young people (SSHYP): a survey and systematic review concerning current models, effectiveness, cost-effectiveness and research opportunities

BACKGROUND

Report based on a service-mapping study and a systematic review concerning sexual health services for young people, either based in or closely linked to schools.

OBJECTIVES

To identify current forms of school-based sexual health services (SBSHS) and school-linked sexual health services (SLSHS) in the UK, review and synthesise existing evidence from qualitative and quantitative studies concerning the effectiveness, acceptability and cost-effectiveness of these types of service and to identify potential areas for further research.

DATA SOURCES

Electronic databases were searched from 1985 onwards. For published material: the Cochrane Library (1991-), MEDLINE, PREMEDLINE (2007-), CINAHL, EMBASE, AMED, ASSIA (1987-), IBSS, ERIC, PsycINFO, Science Citation Index (SCI) and Social Sciences Citation Index. For unpublished material and grey literature: the Social Care Institute of Excellence Research Register; the National Research Register (1997-), ReFeR; Index to Theses, and HMIC.

REVIEW METHODS

A service-mapping questionnaire was circulated to school nurses in all parts of the UK, and semistructured telephone interviews with service coordinators in NHS and local authority (LA) roles were conducted. An evidence synthesis was performed based on a systematic review of the quantitative evidence about service effectiveness, qualitative evidence about user and professional views and a mixed-methods synthesis. A proof-of-concept model for assessing cost-effectiveness was drawn up.

RESULTS

Three broad types of UK sexual health service provision were identified. Firstly, SBSHS staffed by school nurses, offering 'minimal' or 'basic' levels of service. Secondly, SBSHS and SLSHS staffed by a multiprofessional team, but not medical practitioners, offering 'basic' or 'intermediate' levels of service. Thirdly, SBSHS and SLSHS staffed by a multiprofessional team, including medical practitioners offering 'intermediate' or 'comprehensive' levels of service. The systematic review showed that SBSHS are not associated with higher rates of sexual activity among young people, nor with an earlier age of first intercourse. There was evidence to show positive effects in terms of reductions in births to teenage mothers, and in chlamydial infection rates among young men, although this evidence coming primarily from the USA. Therefore, the findings need to be tested in relation to UK-based services. Also evidence to suggest that broad-based, holistic service models, not restricted to sexual health, offer the strongest basis for protecting young people's privacy and confidentiality, countering perceived stigmatisation, offering the most comprehensive range of products and services, and maximising service uptake. Findings from the mapping study also indicate that broad-based services, which include medical practitioner input within a multiprofessional team, meet the stated preferences of staff and of young people most clearly. Partnership-based developments of this kind also conform to the broad policy principles embodied in the Every Child Matters framework in the UK and allied policy initiatives. However, neither these service models nor narrower ones have been rigorously evaluated in terms of their impact on the key outcomes of conception rates and sexually transmitted infection (STI) rates, in the UK or in other countries. Therefore, appropriate data were not found to support cost-effectiveness modelling.

LIMITATIONS

Low response rate to the questionnaire. Scotland, Wales and Northern Ireland were under-represented. Also, the distinction made in the questionnaire between 'general health' and 'sexual health' services did not prove robust.

CONCLUSIONS

There is no single, dominant service model in the UK. The systematic review demonstrated that the evidence base for these services remains limited and uneven, and draws largely on US studies. Qualitative research is needed to develop robust process and outcome indicators for the evaluation of SLSHS/SBSHS in the UK. These indicators could then be used both in local evaluations, and in large, longitudinal studies of service effectiveness and cost-effectiveness. Future research should examine the impact of the differing types of services currently evolving in the UK, encompassing school-based and school-linked models, as well as models with and without medical practitioner involvement.

Timing of mid-trimester cervical length shortening in high-risk women

OBJECTIVE

To examine the natural history of cervical length shortening in women who had experienced at least one prior spontaneous preterm birth at between 17+0 and 33+6 weeks' gestation.

METHODS

This was an analysis of prerandomization data from the multicenter Vaginal Ultrasound Cerclage Trial. Serial cervical length was measured by transvaginal sonography in 1014 high-risk women at 16+0 to 22+6 weeks. We performed survival analyses in which the outcome was cervical length shortening<25 mm and data were censored if this did not occur before 22+6 weeks' gestation. The incidence of cervical length shortening and the time to shortening were compared for women whose earliest prior preterm birth was in the mid-trimester, defined as <24 weeks, vs. those at weeks 24-33. Similar comparisons were performed based on each patient's most recent birth history.

RESULTS

Time to cervical length shortening by survival analysis was significantly shorter (hazard ratio (HR)=2.2, P<0.0001) and the relative risk (RR) of shortening significantly higher (RR=1.8, P<0.0001) for women whose earliest prior spontaneous preterm birth was at <24 weeks. A larger effect was observed for women whose most recent birth was at <24 weeks (HR=2.8, P<0.0001; RR=2.1, P<0.0001). The observed hazard ratios remained significant after adjusting for confounders in a multivariable Cox proportional hazards model.

CONCLUSION

Women with a prior spontaneous preterm birth at <24 weeks are at a higher risk of cervical shortening, and do so at a higher rate and at an earlier gestational age, than do women with a later preterm birth history.

Empowering interventions in health and social care: recognition through 'ecologies of practice'

This article considers findings from two recent qualitative studies in the UK, identifying parallels in the ways in which 'ecologies of practice' in two high-profile areas of health-related intervention underpin processes of empowerment and recognition. The first project focused on policy and practice in relation to teenage motherhood in a city in the North of England. The second project was part of a larger research programme, Changing Families, Changing Food, and investigated the ways in which 'family' is constructed through policy and practice interventions concerning food and health. While UK Government health policy stresses that health and social care agencies should 'empower' service users, it is argued here that this predominantly reflects a managerialist discourse, equating citizenship with individualised self-sufficiency in the 'public' sphere. Drawing critically on Honneth's politics of recognition (Honneth, A. (2001). Recognition or redistribution? Changing perspective on the moral order of society. Theory, Culture and Society, 18(2-3), 43-55.), we suggest that formal health policy overlooks the inter-subjective processes that underpin a positive sense of self, emphasising instead an individualised ontology. While some research has positioned practitioners as one-dimensional in their adherence to the current audit culture of the public sector in the UK, our study findings demonstrate how practitioners often circumvent audit-based 'economies of performance' with more flexible 'ecologies of practice.' The latter open up spaces for recognition through inter-subjective processes of identification between practitioners and service users. Ecologies of practice are also informed by practitioners' experiential knowledge. However, this process is largely unacknowledged, partly because it does not fall within a managerialist framework of 'performativity' and partly because it often reflects taken-for-granted, gendered patterns. It is argued here that a critical understanding of 'empowerment', in community-based health initiatives, requires clear acknowledgment of these inter-subjective and gendered dimensions of 'ecologies of practice'.

Comparative transcriptomic responses to chronic cadmium, fluoranthene, and atrazine exposure in Lumbricus rubellus

Transcriptional responses of a soil-dwelling organism (the earthworm Lumbricus rubellus) to three chemicals, cadmium (Cd), fluoranthene (FA), and atrazine (AZ), were measured following chronic exposure, with the aim of identifying the nature of any shared transcriptional response. Principal component analysis indicated full or partial separation of control and exposed samples for each compound but not for the composite set of all control and exposed samples. Partial least-squares discriminant analysis allowed separation of the control and exposed samples for each chemical and also for the composite data set, suggesting a common transcriptional response to exposure. Genes identified as changing in expression level (by the least stringent test for significance) following exposure to two chemicals indicated a substantial number of common genes (> 127). The three compound overlapping gene set, however, comprised only 25 genes. We suggest that the low commonality in transcriptional response may be linked to the chronic concentrations (approximately 10% EC50) and chronic duration (28 days) used. Annotations of the three compound overlapping gene set indicated that genes from pathways most often associated with responses to environmental stress, such as heat shock, phase I and II metabolism, antioxidant defense, and cation balance, were not represented. The strongest annotation signature was for genes important in mitochondrial function and energy metabolism.

Human rabies therapy: lessons learned from experimental studies in mouse models

Ketamine was one of the therapeutic agents used as a therapy for a human rabies survivor who did not receive rabies vaccine. Ketamine therapy is re-examined here in infected mouse primary neuron cultures and in adult ICR mice using the CVS strain with both intracerebral and peripheral routes of inoculation with ketamine vs. vehicle given intraperitoneally. No significant beneficial therapeutic effects of ketamine in the cultures or mouse model were observed. This team does not recommend further widespread clinical use of ketamine on human rabies patients until further experimental work demonstrates therapeutic efficacy. Because of the potential neuroprotective and anti-apoptotic properties of minocycline, minocycline therapy was assessed in infected primary neuron cultures and in neonatal ICR mice infected by peripheral inoculation with a highly attenuated rabies virus strain. No beneficial effect of minocycline was observed in the primary neuron cultures. In the mouse model, minocycline therapy aggravated the clinical neurological disease and resulted in higher mortality. An anti-apoptotic effect of minocycline was noted in the brains of infected mice, which may have very mildly increased viral spread. An anti-inflammatory effect was also noted in the brain using a CD3 T cell marker. These effects likely aggravated the disease. This team recommends that empirical therapy with minocycline be avoided in the management of rabies and viral encephalitis in humans until more information becomes available.

Accumulation of potentially toxic metals in the liver tissue of sheep grazed on sewage sludge-treated pastures

Concentrations of potentially toxic metals (PTMs) in the livers of pregnant, mature ewes and their 110 day foetuses, and in 6-month old lambs born to other ewes, were determined. The animals had been reared on pastures fertilized for 5 years with either sewage sludge (treated; T) or conventional inorganic fertilizer (control; C). The effects of treatment on patterns of accumulation of PTMs differed with stage of development and with individual PTM. In the liver of lambs, concentrations of Pb were elevated in T compared with C liver (P < 0·01), while Cu and Zn were lower (P < 0·001) in T than C liver. By contrast, in ewe liver, Cu concentrations were lower in T than C liver (P < 0·05), as in lambs, but there were no other treatment differences in PTM concentration. Ewe and lamb tissue data were not directly comparable because they were exposed to different diets but mean concentrations of Cd, Ni and Pb were approximately two- to four-fold higher in ewe than lamb liver while mean Cu concentrations were approximately five-fold lower, suggesting that more prolonged exposure to PTMs may have enhanced treatment differences in tissue PTM concentrations. Mean foetal PTM concentrations were not significantly affected by treatment. It is concluded that the repeated application of sludge to pasture is associated with altered, but not necessarily increased, rates of accumulation of PTMs in liver tissue, that rates of accumulation depend on the individual PTM measured and that they are probably influenced by duration and route of exposure and source of nutrient. Limited observations suggested that there was little effect of year, and associated variation in climatic conditions and herbage growth, on PTM accumulation.

Altered fractionated radiotherapy is cost-effective in the treatment of locally advanced head and neck cancer: An economic analysis of Radiation Therapy Oncology Group (RTOG) 90–03

6007

Background: RTOG 9003 compared altered fractionated radiotherapy (AIFX) to standard radiotherapy (SFX). Overall and disease-free survival was improved in the AIFX schedules but with increased toxicity. The specific aim of this study was to compare the cost-effectiveness of AIFX to SFX. Methods: Costs data included Medicare Part A and Part B costs from all providers—inpatient, outpatient, skilled nursing facility, home health, hospice, and physicians and other Part B providers were obtained from the Centers for Medicare & Medicaid Services (CMS) for patients treated on RTOG 9003 from 1992–1996. Claims were restricted to those with a diagnosis of head and neck cancer. We calculated 56-month expected discounted costs for each arm of the trial in 1996 dollars, with Kaplan-Meier sampling average estimates of survival probabilities for each month and mean monthly costs. Costs were discounted back to the time of entry onto the trial, using an annual discount rate of 3% and indexed to 1996 dollars using the Consumer Price Index. The analysis was performed from a payer’s perspective. Incremental cost-effective ratios were calculated comparing AIFX schedules to SFX. Results: Of the 1,130 patients entered, 1,073 patients were analyzable for outcomes and Medicare cost data and clinical outcomes were available for 130 patients. The expected mean 56-month cost and incremental cost-effectiveness ratios (ICER) compared to SFX are presented in the table . Sensitivity analysis and 95% confidence ellipses will be presented. Conclusions: Although more toxic altered fractionated radiotherapy schedules were found to be cost-effective using a willingness to pay of $50,000/life year in patients >65 years old. These results need to be confirmed in a cohort of younger patients.

[Table: see text]

No significant financial relationships to disclose.

Population pharmacokinetics of trabectedin (ET-743) in subjects with cancer

2030

Background: Trabectedin (T) is a DNA minor-groove intercalating agent. The objective of this study is to characterize the population pharmacokinetics of T in cancer subjects. Methods: A total of 603 subjects (945 cycles) receiving intravenous T as monotherapy at doses ranging from 0.024 to 1.8 mg/m2 and given as 1, 3 or 24 hrs infusion every 21 days; 3 hrs infusion on day 1, 8, 15 every 28 days; or 1 hr infusion daily for 5 consecutive days every 21 days were included in the analysis. An open four-compartment pharmacokinetic model with linear elimination, linear and non-linear distribution to the deep and shallow peripheral compartments, respectively, and a catenary compartment off the shallow compartment was developed to best describe a total of 4251 concentrations from 274 subjects (Index Dataset) using NONMEM V. The effect of selected covariates on T pharmacokinetics was investigated. Model was evaluated using goodness of fit plots and relative error measurements for 2362 concentrations from 329 subjects (Test Dataset). Computer simulations were undertaken to evaluate the covariate effects on T pharmacokinetics. Results: Mean (SD) of T terminal half-life was ≈180 (61.4) h. Plasma accumulation was limited when T was given every three weeks. Systemic clearance, 31.5 L/h (CV = 51%), was 19.2% higher in subjects receiving concomitant dexamethasone. Typical values of volume of distribution at steady-state for males and females were 6070 L and 5240 L, respectively. Age, body size variables, AST, ALT, LDH, creatinine clearance, albumin, total protein and presence of liver metastases were not related to T pharmacokinetics. No difference in model parameters was observed for the infusion durations evaluated. T AUC and Cmax were dose proportional for each schedule evaluated and consistent across cancer types. Conclusions: The integration of phase I/II pharmacokinetic data demonstrated T linear elimination, dose-proportionality up to 1800 μg/m2, and time-independent pharmacokinetics. Given the moderate to large interindividual variability in T pharmacokinetics, the clinical relevance of dexamethasone and gender covariates is probably limited since a substantial overlap in simulated concentration-time profiles was observed.

[Table: see text]

Predictors of autologous stem cell transplant related mortality in older adults

16509

Background: Autologous stem cell transplantation (ASCT) is increasingly performed in older adults. Predictors of transplant related mortality (TRM) are not well established in this population. Our objective was to identify characteristics associated with TRM in older adults treated with ASCT. Methods: A retrospective chart review was conducted to identify all patients ≥ 60 years of age treated with ASCT at our institution between July 1990 and July 2005. We used logistic regression to investigate the effect of baseline characteristics and of transplant complications on TRM. Results: 143 patients met eligibility criteria of whom 139 were evaluable for the 100 day mortality outcome. The median age was 64.5 (range 60–76.6) years, 34% were female. Primary diagnoses included non-Hodgkin’s lymphoma (55%), multiple myeloma (29%), acute myelogenous leukemia (8%), breast cancer (5%), and Hodgkin’s lymphoma (3%). 100 day TRM was 7.9%. The mean time to engraftment (absolute neutrophil count >1000) was 12.2 ± 5.5 days. Complications included bacteremia (26.3%), cardiac events (myocardial infarction, congestive heart failure or arrhythmia) (11.5%), renal failure (7.4%), and respiratory failure (6.7%). Multivariate analysis including age, sex, diagnosis, number of comorbidities, number of medications, congestive heart failure, coronary artery disease, diabetes mellitus, hemoglobin, and creatinine at the time of transplant did not identify any baseline predictors of 100 day TRM (p > .05 for all). Development of renal failure or respiratory failure during transplantation was associated with increased TRM with an odds ratio of 11.2 (CI 2.5, 49.2) and 13.6 (CI 3.0, 62.2) respectively. Peritransplant cardiac events or bacteremia were not associated with increased TRM. Conclusions: Development of renal failure or respiratory failure is associated with increased TRM in this study. However, age and baseline comorbidities are not predictive of TRM. Future prospective studies should incorporate specific measures of functional and cognitive status which may be more reflective of decreased physiologic reserve in older adults being considered for ASCT.

No significant financial relationships to disclose.