Bisexual People Experience Worse Health Outcomes in England: Evidence from a Cross-Sectional Survey in Primary Care

Persistent inequalities in relation to health outcomes continue to exist among patients identifying as lesbian, gay, and bisexual (LGB), and very little is known about outcomes specific to bisexual populations. This study's aim was to compare the health of individuals identifying as LGB with heterosexual counterparts within primary care in England. Cross-sectional survey data from the year 10 (2015/2016) English General Practice Patient Survey (GPPS) dataset, which consisted of 836,312 responses (38.9% response rate), including 23,834 people who identified as gay, lesbian, bisexual or "other" was analyzed. Health outcomes were assessed through self-reported quality of life, physical and mental health, and confidence in managing own health. Multifactorial logistic regression (adjusting for age, ethnic group, working status, and socioeconomic status) were conducted. Long-term physical and mental health problems were more than twice as likely to be reported for people within LGB groups compared to the heterosexual group for both genders, except bisexual women where the odds were more than four times greater (OR = 4.275, 95% CI, 3.896, 4.691; p < .001). Bisexual women were half as likely to report the absence of a long-term health problem (OR = 0.452, 95% CI 0.419, 0.488; p < .001). LGB groups across both genders, reported a higher proportion of individuals that did not feel confident in managing their health and experienced significantly worse quality of life compared to heterosexuals. LGB patients consistently report poorer health outcomes than heterosexual patients. Bisexual people of both genders consistently experienced worse physical and mental health outcomes compared with the other recorded sexual orientations.

Long-term treatment outcomes with zygomatic implants: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to perform a systematic review with meta-analysis on the long-term survival rates of zygomatic implants (ZI). ZI success, prostheses survival and success, sinus pathology and patient reported outcomes were also investigated.

METHODS

Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed. Embase and OvidMedline databases were searched alongside the grey literature. The systematic review was recorded in PROSPERO (CRD42022358024). Studies reporting titanium/titanium alloy ZI survival data, ZI-supported prosthesis data, ZIs directly compared to any other implant therapy including grafted sites, a minimum follow-up time of 3 years and a minimum number of 10 patients were included. All study designs were considered if they met the inclusion criteria. Studies not involving ZIs, ZIs not made from titanium/titanium alloy, a follow-up time of < 3 years or < 10 patients, animal studies and in vitro studies were excluded. Long-term follow-up has not been defined in the literature. A minimum of 3 years follow-up was considered acceptable to capture survival after initial healing, alongside in-function prosthesis data via delayed or immediate load protocols. ZI success, was predominantly defined as ZI survival without biological or neurological complications. Meta-analyses were performed for ZI survival, ZI failure incidence, ZI success, loading protocol, prosthesis survival, and prevalence of sinusitis using random effects models. Descriptive analysis was used for ZI success, prosthesis success and patient reported outcome measures.

RESULTS

Five hundred and seventy-four titles were identified, of which 18 met the inclusion criteria. Eligible studies included 1349 ZIs in 623 patients. Mean follow-up period was 75.4 months (range 36-141.6). The mean survival of ZIs was 96.2% [95% CI: 93.8; 97.7] at 6 years. Mean survival for delayed loading was 95% [95% CI: 91.7; 97.1] and 98.1% [95% CI: 96.2; 99.0] for immediate loading (p = 0.03). Annual incidence rate of ZI failure was 0.7% [95% CI 0.4; 1.0]. Mean ZI success was 95.7% [95% CI 87.8; 98.6]. Mean prosthesis survival was 94% [95% CI 88.6; 96.9]. Sinusitis prevalence was 14.2% [95% CI 8.8; 22.0] at 5 years. Patients' reported increased satisfaction with ZIs.

CONCLUSIONS

ZIs have long-term survival comparable to conventional implants. Immediate loading showed a statistically significant increase in survival over delayed loading. Prosthesis survival was similar to that of prostheses supported by conventional implants, with similar complications. Sinusitis was the most frequently encountered biological complication. Patients reported improved outcome measures with ZI use.

Transcriptomic response and immunological responses to chimpanzee adenovirus- and MVA viral-vectored vaccines for RSV in healthy adults

Cohorts of healthy younger adults (18-50yrs) and healthy older adults (60-75yrs) were immunized intramuscularly or intranasally with an adenovirus-vectored RSV vaccine (PanAd3-RSV) as a prime dose and boosted with PanAd3-RSV or a poxvirus-vectored vaccine (MVA-RSV) encoding the same insert. Whole blood gene expression was measured at baseline, 3- and 7-days post vaccination. Intramuscular prime vaccination with PanAd3-RSV induced differential expression of 643 genes (DEGs, FDR < 0.05). Intranasal prime vaccination with PanAd3-RSV did not induce any differentially expressed genes (DEGs) in blood samples at 3 days post vaccination. Intranasally primed participants showed greater numbers of DEGS on boosting than intramuscularly primed participants. The most highly enriched biological processes related to DEGs after both prime and boost vaccination were type-1 interferon related pathways, lymphocytic and humoral immune responses.

Palliative Long-Term Abdominal Drains Versus Large Volume Paracentesis in Refractory Ascites Due to Cirrhosis (REDUCe Study): Qualitative Outcomes

CONTEXT

Palliative care remains suboptimal in end-stage liver disease (ESLD).

OBJECTIVES

We report qualitative outcomes from the REDUCe study. We aimed to explore and contrast experiences/perceptions/care pathways of patients with refractory ascites due to ESLD randomized to either palliative long-term abdominal drains (LTADs) (allow home drainage) vs. large volume paracentesis (LVP) (hospital drainage).

METHODS

Concurrent embedded qualitative study in a 12-week feasibility randomized controlled trial. Telephone interviews were conducted, data being recorded, transcribed verbatim, and analyzed using applied thematic analysis, considered in terms of a pathway approach toward accessing health care. Quantitative outcomes were collected (integrated palliative outcome scale, short-form liver disease quality of life, EQ-5D-5 L, Zarit Burden Interview-12).

RESULTS

Fourteen patients (six allocated LTAD and eight LVP) and eight nurses participated in the qualitative study. The patient journey in the LVP group could be hindered by challenges along the entire care pathway, from recognizing the need for drainage to a lengthy wait in hospital for drainage and/or to be discharged. These issues also impacted upon caregivers. In contrast, LTADs appeared to transform this care pathway at all levels across the patient's journey by removing the need for hospital drainage. Additional benefits included personalized care, improved symptom control of ascites, being at home, and regular support from community nurses. Nurses also viewed the LTAD favorably, though expressed the need for additional support should this become standard of care.

CONCLUSION

Patients and nurses expressed acceptability of palliative LTAD in ESLD and preference for this approach in enabling care at home. Proceeding to a definitive trial is feasible.

TRIAL REGISTRATION

ISRCTN30697116, date assigned: 07/10/2015.

Routes to diagnosis and missed opportunities in the detection of renal cancer

AIM

To determine the proportion of renal cancers for which incidental detection was the route to diagnosis, the characteristics of tumours identified in this way, and the frequency with which opportunities to make this diagnosis were missed.

MATERIALS AND METHODS

Consecutive patients with renal cancers treated at Royal Cornwall Hospitals NHS Trust (April 2011 and July 2018 inclusive) were identified from the Trust's cancer registry database, and a retrospective review of the imaging and electronic case notes was undertaken. Mann-Whitney U-tests for comparison of patient age and tumour size at diagnosis, and chi-squared tests for comparing cell type distribution and grade were performed. Logistic regression was then used to identify the characteristics of patients in whom a renal tumour was missed initially.

RESULTS

Of 327 patients, 194 (63%) presented incidentally, and 133 (37%) symptomatically. Incidentally detected cancers were found in younger patients, (median of 65 years versus 69 p=0.01) and were smaller at presentation (median of 5.5 versus 7.2 cm, p<0.00001). Thirty-six different reporters missed opportunities to diagnose renal cancer in 50 (16%) patients on 78 occasions, 28 lesions (35%) being missed more than once. Thirty were imaged incompletely; four were visible only on a single image and three on a scout view at magnetic resonance imaging.

CONCLUSION

The commonest route to diagnosis of renal cancer is by incidental detection of a mass. In 16% of patients in whom renal cancer is diagnosed, there is at least one prior examination on which the lesion is visible at an earlier date. The clinical impact of these missed diagnostic opportunities remains uncertain.

HIV self-tests for men who have sex with men, accessed via a digital vending machine: a qualitative study of acceptability

As the number of people living with undiagnosed HIV infection in the UK declines, innovative ways to access those least engaged with services are needed. This study explores the attitudes of men who have sex with men (MSM) towards using HIV self-testing (HIVST) kits distributed via a vending machine in a sauna (a licenced sex-on-premise venue). Twenty-three MSM attending the sauna were recruited to take part in semi-structured qualitative interviews. The participants were overwhelmingly positive about the HIVST vending machine. They identified convenience and flexibility as major benefits to testing in this way. The sauna was felt to be an appropriate location for the intervention. Limitations identified included the potential to reduce screening for other sexually transmitted infections and the inappropriate use of HIVST kits as a tool for risk-assessment prior to condomless sex, with a poor understanding of the window period. The implications of receiving a positive result without immediate access to support were also a concern. HIVST vending machines are an acceptable, innovative way to encourage HIV testing. Providers need to ensure this intervention is supported by adequate information regarding the limitations of the test and how to access comprehensive services to avoid any unintended negative effects.

Nonclinical Sexual Health Support for HIV, Viral Hepatitis, and Other Sexually Transmitted Infections in Gay, Bisexual, and Other Men Who Have Sex With Men: Protocol for a European Community Health Worker Online Survey (ECHOES)

BACKGROUND

The term "community health worker" (CHW) can apply to a wide range of individuals providing health services and support for diverse populations. Very little is known about the role of CHWs in Europe working in nonclinical settings who promote sexual health and prevent HIV and other sexually transmitted infections (STIs) among gay, bisexual, and other men who have sex with men (MSM).

OBJECTIVE

This paper describes the development and piloting of the first European Community Health Worker Online Survey (ECHOES) as part of the broader European Union-funded ESTICOM (European Surveys and Trainings to Improve MSM Community Health) project. The questionnaire aimed to assess the knowledge, attitudes, and practices of CHWs providing sexual health services to gay, bisexual, and other MSM in European settings.

METHODS

ECHOES comprises three superordinate domains divided into 10 subsections with 175 items (routed) based on a scoping exercise and literature review, online prepiloting, and Europe-wide consultation. Additional piloting and cognitive debriefing interviews with stakeholders were conducted to identify comprehension issues and improve the clarity, intelligibility, accessibility, and acceptability of the survey. Psychometric properties, including internal consistency of the standardized scales used as part of the survey were examined. The final survey was available to 33 countries in 16 languages.

RESULTS

Recruitment closed on January 31, 2018. Data from 1035 CHWs were available for analysis after application of the exclusion criteria. The findings of the ECHOES survey and the wider ESTICOM project, are now available from the ESTICOM website and/or by contacting the first author.

CONCLUSIONS

The findings of this survey will help characterize, for the first time, the diverse role of CHWs who provide sexual health services to gay, bisexual, and other MSM in Europe. Importantly, the data will be used to inform the content and design of a dedicated training program for CHWs as part of the larger ESTICOM project and provide recommendations for MSM-specific strategies to improve sexual health in general and to reduce the incidence and prevalence of HIV, viral hepatitis, and other STIs in particular.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/15012.

Healthcare provider and service user perspectives on STI risk reduction interventions for young people and MSM in the UK

OBJECTIVE

Behavioural interventions have been shown to reduce sexual behaviours associated with increased risk of sexually transmitted infections in young people (<25 years) and men who have sex with men (MSM) internationally, but evidence from England is limited. We aimed to explore service provider and user experiences and perspectives on behavioural interventions to reduce sexual behaviour risks, and the use of automated methods to triage individuals to these services.

METHODS

We conducted a sequential mixed methods study with sexual health service providers and users in 2015/2016. Qualitative interviews with providers and service users (heterosexual young people and MSM) in London and Brighton allowed us to explore a range of experiences and expectations. A subsequent national web-survey of service providers measured the feasibility of delivery within existing resources and preferences for intervention attributes.

RESULTS

We conducted 35 service user (15 heterosexual young people; 20 MSM) and 26 provider interviews and had 100 web-survey responses. We found considerable heterogeneity in prevention services offered. Service users and providers were broadly supportive of tailoring interventions offered, but service users raised concerns about automated, data-driven triage, particularly around equity and fairness of service delivery. Digital technologies, including social media or apps, were appealing to providers, being less resource intensive. However, one-to-one talking interventions remained popular with both service users and providers, being familiar, trustworthy and personal. Key tensions between desirability of interventions and availability of resources to deliver them were acknowledged/recognised by providers and users.

CONCLUSION

Overall, behavioural interventions to reduce sexual behaviour risks were viewed favourably by service providers and users, with key considerations including: privacy, personalisation and convenience. However, introducing desirable targeted interventions within heterogeneous sexual health settings will require resources to adapt interventions and research to fully understand the barriers and facilitators to use within routine services.

Near-Infrared Spectrophotometry: A New Dimension in Clinical Chemistry

The near-infrared (NIR) spectral region (700-2500 nm) is a fertile source of chemical information in the form of overtone and combination bands of the fundamental infrared absorptions and low-energy electronic transitions. This region was initially perceived as being too complex for interpretation and consequently was poorly utilized. Advances in chemometric techniques that can extract massive amounts of chemical information from the highly overlapped, complex spectra have led to extensive use of NIR spectrophotometry (NIRS) in the food, agriculture, pharmaceutical, chemical, and polymer industries. The application of NIRS in clinical laboratory measurements is still in its infancy. NIRS is a simple, quick, nondestructive technique capable of providing clinically relevant analyses of biological samples with precision and accuracy comparable with the method used to derive the NIRS models. Analyses can be performed with little or no sample preparation and no reagents. The success of NIRS in any particular case is determined by the complexity of the sample matrix, relative NIR absorptivities of the constituents, and the wavelengths and regression technique chosen. We describe the general approach to data acquisition, calibration, and analysis, using serum proteins, triglycerides, and glucose as examples.

A-25 Paced Auditory Serial Addition Test in Individuals with Cocaine Versus Methamphetamine Dependence

Objective

Research suggests that cocaine and methamphetamine differ in their impact on executive functions (EF). The Paced Auditory Serial Addition Test (PASAT) is used to assess working memory; a component of EF. The purpose of this meta-analysis was to examine the difference between the effect of these two drugs on PASAT scores.

Data Selection

Three researchers independently searched nine databases (e.g., PsycINFO, Pubmed, ProceedingsFirst), extracted required data, and calculated effect sizes. Inclusion criteria identified studies that had (a) compared cocaine or methamphetamine dependent groups to healthy controls and (b) matched groups on either age, education, or IQ (at least 2 out of 3). Studies were excluded if participants were reported to have Axis I diagnoses (other than cocaine or methamphetamine dependence) or comorbidities known to impact neuropsychological functioning. Six articles were coded and analyzed for the current study.

Data Synthesis

Cocaine studies showed a medium statistically significant effect size (g = 0.370, p = 0.020), while methamphetamine did not (g = 0.198, p = 0.172). There was no heterogeneity in effect sizes for both drugs. Subgroup analysis found no significant difference between the two drugs on the PASAT (Q-between = 0.646, p = 0.421).

Conclusions

In contrast to methamphetamine, cocaine is associated with poorer performance on PASAT. This is in line with previous studies that found that cocaine had more significant impact on EF than methamphetamine. Given the preliminary nature of this meta-analysis and the small number of studies on the topic, future primary studies should directly contrast how these two drugs impact EF.

A-17 Category Test performance in individuals with alcohol versus methamphetamine dependence

Objective

The Category Test (CT) has consistently been found to be sensitive at detecting the effects of alcohol on the brain. However, this test has not been as widely used in examining the effects of methamphetamine. The current meta-analysis compared effect sizes of studies that have examined performance on the CT in alcohol versus methamphetamine dependent participants.

Data selection

Three researchers independently searched nine databases (e.g., PsycINFO, Pubmed, ProceedingsFirst), extracted required data, and calculated effect sizes. Inclusion criteria identified studies that had (a) compared alcohol or methamphetamine dependent groups to healthy controls and (b) matched groups on either age, education, or IQ (at least 2 out of 3). Studies were excluded if participants were reported to have Axis I diagnoses (other than alcohol or methamphetamine dependence) or comorbidities known to impact neuropsychological functioning. Sixteen articles were coded and analyzed for the current study.

Data synthesis

Alcohol studies showed a large effect size (g = 0.745, p < 0.001) while methamphetamine studies evidenced a moderate effect size (g = 0.406, p = 0.001); both without statistically significant heterogeneity (I2 = 0). Subgroup analysis revealed a statistically significant difference between the effect sizes from alcohol versus methamphetamine studies (Q-between = 5.647, p = 0.017).

Conclusions

The CT is sensitive to the effects of both alcohol and methamphetamine and should be considered when examining dependent patients who might exhibit problem solving, concept formation, and set loss difficulties in everyday living.

UK healthcare professionals' uncertainties, barriers and facilitators to the introduction of targeted human papillomavirus vaccination for men who have sex with men

BACKGROUND

Female-only human papillomavirus (HPV) vaccination will fail to protect men who have sex with men (MSM) against HPV and its sequelae (i.e. genital warts and anal cancers). In the absence of gender-neutral HPV vaccination, targeted vaccination at sexual health clinics for MSM offers a valuable preventive opportunity. This study aimed to identify sexual healthcare professionals' (HCPs) perceived barriers and facilitators for MSM-targeted HPV vaccination.

METHODS

Nineteen telephone interviews with UK-based self-referred HCPs (13 doctors, three nurses, three health advisers) were conducted in October and November 2014. The interviews were recorded and transcribed verbatim. Data were analysed thematically by two researchers.

RESULTS

HCPs were unsure about selection criteria, acceptable healthcare settings and the source of vaccination funding for the introduction of MSM-targeted HPV vaccination. Lack of political and public support, MSMs' limited access to HPV vaccination and disclosure of sexual orientation to HCPs, identification of eligible MSM, patients' poor HPV awareness and motivation to complete HPV vaccination were perceived as significant barriers. HCPs believed that the introduction of official guidelines on HPV vaccination for MSM, awareness campaigns and integrated clinic procedures could improve vaccination coverage.

CONCLUSION

HCPs recognised a need to protect MSM against HPV. However, several challenges and obstacles associated with the introduction of MSM-targeted HPV vaccination in the UK were reported. HCPs' perspectives and concerns need to be addressed when developing policies and guidelines for a potential MSM-targeted HPV vaccination. Future research needs to examine whether negative views of HCPs towards MSM-targeted HPV vaccination are associated with lower HPV vaccine uptake and completion rates in MSM.

A randomised controlled trial of a telephone administered brief HIV risk reduction intervention amongst men who have sex with men prescribed post-exposure prophylaxis for HIV after sexual exposure in the UK: Project PEPSE

BACKGROUND

In western countries, men who have sex with men (MSM) are most affected by HIV and increasingly likely to engage in risky sexual behaviour. MSM who experience a potential sexual exposure to HIV (PEPSE) and receive a preventative regimen of anti-HIV treatment are at particularly high risk of acquiring HIV and could potentially benefit from targeted risk reduction behavioural interventions such as motivational interviewing (MI).

PURPOSE

The aim of this trial was to examine the impact of augmented MI (MI plus information provision and behavioural skills building), over and above routine care, on reducing risky sexual behaviour in MSM prescribed PEPSE. Secondary aims of the research were to examine whether the intervention reduced sexually transmitted infections (STI) and further requests for PEP.

METHODS

A parallel-group pragmatic randomised controlled trial was conducted with 175 MSM recruited from five sexual health (SH) clinics in the south east of England. The intervention was two fixed-duration sessions of telephone administered augmented MI. A manual guided the selection of individualised persuasive communication strategies based on underlying change mechanisms specified by the Information, Motivation and Behavioural Skills (IMB) model. Primary outcomes were the number of receptive and active anal intercourse (AI) partners, the use of condoms every time during receptive and active AI and the use of condoms sometimes during receptive and active AI.

RESULTS

There were no significant impacts on sexual risk behaviour or any of the psychological measures, and no discernible reduction in requests for repeat PEP or rates of STIs within a year.

CONCLUSION

Our behavioural intervention of augmented MI did not affect risky sexual behaviour, rates of further PEP and STIs, and psychological factors, in MSM prescribed PEPSE.

TRIAL REGISTRATION NUMBERS

UKCRN ID:11436; ISRCTN00746242.

Acceptability and feasibility of using digital vending machines to deliver HIV self-tests to men who have sex with men

OBJECTIVE

Technology-based approaches to distribute HIV self-tests (HIVST) have the potential to increase access to HIV testing in key populations. We evaluate the acceptability and feasibility of using vending machines (VMs) in a community setting to distribute HIVST to men who have sex with men at high-risk of HIV.

METHODS

First, a predevelopment survey of targeted potential users explored attitudes towards HIVST and the use of a VM to deliver HIVST. Second, participatory design workshops between designers and community volunteers informed the production of a bespoke VMs dispensing free BioSureHIVST. Uptake of HIVST and user experiences were evaluated using information supplied directly from the machines interface (number of tests dispensed, user demographics), an online questionnaire and semistructured interviews.

RESULTS

The predevelopment survey found that 32% of 232 sauna users had never tested for HIV, despite high-risk behaviours. A total of 265 testing kits were dispensed: mean age 31 range (18-70); 4%(n = 7) had never tested for HIV before and 11% (n = 22) had tested within the last 1-5 years. Uptake of tests was significantly higher via the VMs compared with outreach testing by community workers in the same venue during a comparable period (34 vs 6 tests per month). Qualitative interviews and online questionnaires demonstrated high acceptability for this intervention, which was considered accessible and appropriately targeted.

CONCLUSIONS

VMs to distribute HIVST was feasible and acceptable. This intervention could be used in different settings to improve access to HIV testing for key populations.

Sexual risk reduction interventions for patients attending sexual health clinics: a mixed-methods feasibility study

BACKGROUND

Sexually transmitted infections (STIs) continue to represent a major public health challenge. There is evidence that behavioural interventions to reduce risky sexual behaviours can reduce STI rates in patients attending sexual health (SH) services. However, it is not known if these interventions are effective when implemented at scale in SH settings in England.

OBJECTIVES

The study (Santé) had two main objectives - (1) to develop and pilot a package of evidence-based sexual risk reduction interventions that can be delivered through SH services and (2) to assess the feasibility of conducting a randomised controlled trial (RCT) to determine effectiveness against usual care.

DESIGN

The project was a multistage, mixed-methods study, with developmental and pilot RCT phases. Preparatory work included a systematic review, an analysis of national surveillance data, the development of a triage algorithm, and interviews and surveys with SH staff and patients to identify, select and adapt interventions. A pilot cluster RCT was planned for eight SH clinics; the intervention would be offered in four clinics, with qualitative and process evaluation to assess feasibility and acceptability. Four clinics acted as controls; in all clinics, participants would be consented to a 6-week follow-up STI screen.

SETTING

SH clinics in England.

PARTICIPANTS

Young people (aged 16-25 years), and men who have sex with men.

INTERVENTION

A three-part intervention package - (1) a triage tool to score patients as being at high or low risk of STI using routine data, (2) a study-designed web page with tailored SH information for all patients, regardless of risk and (3) a brief one-to-one session based on motivational interviewing for high-risk patients.

MAIN OUTCOME MEASURES

The three outcomes were (1) the acceptability of the intervention to patients and SH providers, (2) the feasibility of delivering the interventions within existing resources and (3) the feasibility of obtaining follow-up data on STI diagnoses (primary outcome in a full trial).

RESULTS

We identified 33 relevant trials from the systematic review, including videos, peer support, digital and brief one-to-one sessions. Patients and SH providers showed preferences for one-to-one and digital interventions, and providers indicated that these intervention types could feasibly be implemented in their settings. There were no appropriate digital interventions that could be adapted in time for the pilot; therefore, we created a placeholder for the purposes of the pilot. The intervention package was piloted in two SH settings, rather than the planned four. Several barriers were found to intervention implementation, including a lack of trained staff time and clinic space. The intervention package was theoretically acceptable, but we observed poor engagement. We recruited patients from six clinics for the follow-up, rather than eight. The completion rate for follow-up was lower than anticipated (16% vs. 46%).

LIMITATIONS

Fewer clinics were included in the pilot than planned, limiting the ability to make strong conclusions on the feasibility of the RCT.

CONCLUSION

We were unable to conclude whether or not a definitive RCT would be feasible because of challenges in implementation of a pilot, but have laid the groundwork for future research in the area.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16738765.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 12. See the NIHR Journals Library website for further project information.

A retrospective, observational study of supine percutaneous nephrolithotomy

Objective:

The objective of this study is to assess stone clearance and perioperative complication rates of supine percutaneous nephrolithotomy (PCNL).

Methods:

This was a retrospective, observational study of supine PCNL performed in a surgical unit at a district general hospital by two surgeons in the United Kingdom. Data collected included patient demographics, comorbidities, complexity of renal calculi, perioperative complications and stone clearance rates.

Results:

A total of 112 supine PCNL procedures were observed in this study. The mean (SD) American Society of Anesthesiologists (ASA) grade and Guy’s Stone Score were 2.0 (0.75) and 2.3 (1.06) respectively. The median (interquartile range (IQR)) duration of in-patient admission was four (one) nights. Complete stone clearance was achieved in 74 (67.3%) of the procedures, while more than 90% clearance of the renal stone burden was achieved in a further eight (7.3%). The most common perioperative complications recorded were blood loss requiring blood transfusion (three (2.7%)) and postoperative fever (two (1.8%)).

Conclusion:

This case series shows that supine PCNL can lead to good stone clearance and low complication rates.

Designing a brief behaviour change intervention to reduce sexually transmitted infections: a discrete choice experiment

To understand whether people attending sexual health (SH) clinics are willing to participate in a brief behavioural change intervention (BBCI) to reduce the likelihood of future sexually transmitted infections (STIs) and to understand their preferences for different service designs, we conducted a discrete choice experiment (DCE) with young heterosexual adults (aged 16-25 years), and men who have sex with men (MSM) aged 16 or above, attending SH clinics in England. Data from 368 participants showed that people particularly valued BBCIs that involved talking (OR 1.45; 95%CI 1.35, 1.57 compared with an 'email or text'-based BBCIs), preferably with a health care professional rather than a peer. Findings also showed that 26% of respondents preferred 'email/texts' to all other options; the remaining 14% preferred not to participate in any of the offered BBCIs. These results suggest that most people attending SH clinics in England are likely to participate in a BBCI if offered, but the type/format of the BBCI is likely to be the single important determinant of uptake rather than characteristics such as the length and the number of sessions. Moreover, participants generally favoured 'talking'-based options rather than digital alternatives, which are likely to require the most resources to implement.

Syndemics of stigma, minority-stress, maladaptive coping, risk environments and littoral spaces among men who have sex with men using chemsex

There has been a steep rise in the use of drugs during sex (chemsex) by some men who have sex with men in economically developed countries, with associated increases in sexual risk for HIV and other STIs. This paper presents data from telephone interviews with 15 men attending sexual health clinics for post-exposure prophylaxis following a chemsex-related risk for HIV and discusses some of the theoretical approaches that have been employed to understand chemsex and inform interventions. Interviews were conducted as part of a larger intervention study, which used an adapted version of motivational Interviewing to explore risk behaviour and support change. Participants conceptualised their chemsex and HIV-related risks in a psycho-social context, highlighting the influences of psycho-socio-cultural challenges of homophobic marginalisation and the 'gay scene' on behaviour. Multiple influences of stigma, marginalisation, minority stress and maladaptive coping (including drug-use) contribute to syndemic 'risk-environments' and 'littoral spaces' in which chemsex and risk behaviours are played out.

Sexual orientation disclosure in health care: a systematic review

BACKGROUND

Significant health disparities between sexual minority individuals (that is, lesbian, gay, bisexual, or transgender [LGBT]) and heterosexual individuals have been demonstrated.

AIM

To understand the barriers and facilitators to sexual orientation (SO) disclosure experienced by LGBT adults in healthcare settings.

DESIGN AND SETTING

Mixed methods systematic review, including qualitative, quantitative, and mixed methods papers following PRISMA guidelines.

METHOD

Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT) and a qualitative synthesis was performed. Studies were included if their participants were aged ≥18 years who either identified as LGBT, had a same-sex sexual relationship, or were attracted to a member of the same sex.

RESULTS

The review included 31 studies representing 2442 participants. Four overarching themes were identified as barriers or facilitators to SO disclosure: the moment of disclosure, the expected outcome of disclosure, the healthcare professional, and the environment or setting of disclosure. The most prominent themes were the perceived relevance of SO to care, the communication skills and language used by healthcare professionals, and the fear of poor treatment or reaction to disclosure.

CONCLUSION

The facilitators and barriers to SO disclosure by LGBT individuals are widespread but most were modifiable and could therefore be targeted to improve healthcare professionals' awareness of their patients' SO. Healthcare professionals should be aware of the broad range of factors that influence SO disclosure and the potential disadvantageous effects of non-disclosure on care. The environment in which patients are seen should be welcoming of different SOs as well as ensuring that healthcare professionals' communication skills, both verbal and non-verbal, are accepting and inclusive.

Patients' perspectives on the development of HIV services to accommodate ageing with HIV: a qualitative study

The objective of this study was to identify the aspects of healthcare that are most valued by people with HIV and to describe their concerns and preferences for the future delivery of services for non-HIV-related illness. Twelve focus groups of people receiving HIV care were conducted in community settings in South-East England. Groups were quota sampled based on age, gender, sexual orientation and ethnicity. Data were analysed using Framework Analysis. The results showed that among the 74 respondents (61% male), a preference for maintaining all care within specialist HIV clinics was commonplace, but was highest among participants with more extensive histories of HIV and comorbidities. Participants valued care-coordination, inter-service communication and timely updates to medical notes. There were high levels of concern around HIV skills in general practices and the capacity of general practitioners to manage patient confidentiality or deal appropriately with the emotional and social challenges of living with HIV. Participants valued, and had an overall preference for, the specialist knowledge and skills of HIV services, suggesting that non-HIV-specialist services will need to build their appeal if they are to have a greater future role in the care of people with HIV. Particular concerns that should be addressed include: patient confidence in the HIV knowledge and skills of non-specialist service providers; clear processes for prescribing and referrals; improved levels of care-coordination and communication between services and increased patient confidence in the capacity of primary care to maintain confidentiality and to appreciate the stigma associated with HIV.

Perceptions of HPV and attitudes towards HPV vaccination amongst men who have sex with men: A qualitative analysis

OBJECTIVES

Men who have sex with men (MSM) are at risk of genital warts and anal cancer due to human papillomavirus (HPV) infection. This study explores MSMs' perceptions of HPV and HPV vaccination prior to the introduction of this programme.

DESIGN

Focus groups and one-to-one interviews with self-identified MSM were conducted between November 2014 and March 2015 in Brighton, UK.

METHODS

Participants were recruited from community-based lesbian-gay-bisexual-transgender (LGBT) venues and organizations. Discussions were recorded, transcribed verbatim, and analysed using framework analysis.

RESULTS

Thirty-three men took part (median age 25 years, IQR: 21-27), most of whom (n = 25) did not know about HPV, anal cancer (31), or HPV vaccination (26). While genital warts and anal cancer were perceived as severe, men did not perceive themselves at risk of HPV. All MSM would accept the HPV vaccine if offered by a health care professional. The challenges of accessing sexual health services or openly discussing same-sex experiences with health care professionals were perceived as barriers to accessing HPV vaccination. Two participants were concerned that selective HPV vaccination could increase stigma and prejudice against MSM, comparable to the AIDS epidemic. Ten MSM were unsure about the effectiveness of HPV vaccination for sexually active men and were in favour of vaccinating all adolescent boys at school.

CONCLUSIONS

Most MSM have poor knowledge about HPV and associated anal cancer. Despite the lack of concern about HPV, most MSM expressed willingness to receive HPV vaccination. There is a need for health education about the risks of HPV and HPV-related diseases so that MSM can appraise the benefits of being vaccinated. Concerns about HPV vaccine effectiveness in sexually active men and possible stigmatization need to be addressed to optimize HPV vaccine acceptability. Statement of contribution What is already known on this subject? Men who have sex with men (MSM) have poor knowledge about HPV and HPV-related diseases. Perceived risk of HPV and attitudes towards HPV vaccination are associated with HPV vaccine acceptability amongst MSM in the United States. There is a gap between acceptability and uptake of HPV vaccination amongst MSM. What does this study add? Due to concerns about compromised effectiveness of the HPV vaccine in sexually active men, most MSM would recommend vaccination of all adolescent boys. Restricted access to sexual health services and the inability to discuss same-sex experiences were perceived as barriers to HPV vaccination. While the HPV vaccine is acceptable amongst MSM, the motivation to be vaccinated and complete the three-dose series might be low.

Which aspects of health care are most valued by people living with HIV in high-income countries? A systematic review

BACKGROUND

Increasing numbers of people with HIV are living into older age and experiencing comorbidities. The development of new models of care to meet the needs of this population is now a priority. It is important that the views and preferences of patients inform the development of services in order to maintain high levels of patient satisfaction and engagement. The aim of this systematic review was to determine which aspects of healthcare are particularly valued by people living with HIV.

METHODS

We searched electronic databases and reference lists of relevant articles. The search strategy was developed to identify articles reporting on HIV positive patients' perceptions, evaluations or experiences of healthcare services and factors associated with satisfaction with care. Peer-reviewed papers and conference abstracts were included if the study reported on aspects of health care that were valued by people living with HIV, data were collected during the era of combination therapy (from 1996 onwards), and the paper was published in English. A thematic approach to data synthesis was used.

RESULTS

Twenty-three studies met the inclusion criteria. Studies used both qualitative and quantitative methods. Six studies specifically reported on relative importance to patients of different aspects of care. The valued aspects of care identified were grouped into seven themes. These highlighted the importance to patients of: a good health care professional-patient relationship, HIV specialist knowledge, continuity of care, ease of access to services, access to high quality information and support, effective co-ordination between HIV specialists and other healthcare professionals, and involvement in decisions about treatment and care. We were unable to determine the relative importance to patients of different aspects of care because of methodological differences between the studies.

CONCLUSIONS

This review identified several attributes of healthcare that are valued by people living with HIV, many of which would be relevant to any future reconfiguration of services to meet the needs of an ageing population. Further research is required to determine the relative importance to patients of different aspects of care.

Understanding HIV-positive patients' preferences for healthcare services: a protocol for a discrete choice experiment

INTRODUCTION

While the care of HIV-positive patients, including the detection and management of comorbidities, has historically been provided in HIV specialist outpatient clinics, recent years have seen a greater involvement of non-HIV specialists and general practitioners (GPs). The aim of this study is to determine whether patients would prefer to see their GP or HIV physician given general symptoms, and to understand what aspects of care influence their preferences.

METHODS/ANALYSIS

We have developed and piloted a discrete choice experiment (DCE) to better understand patients' preferences for care of non-HIV-related acute symptoms. The design of the DCE was informed by our exploratory research, including the findings of a systematic literature review and a qualitative study. Additional questionnaire items have been included to measure demographics, service use and experience of non-HIV illnesses and quality of life (EQ5D). We plan to recruit 1000 patients from 14 HIV clinics across South East England. Data will be analysed using random-effects logistic regression and latent class analysis. ORs and 95% CIs will be used to estimate the relative importance of each of the attribute levels. Latent class analysis will identify whether particular groups of people value the service attribute levels differently.

ETHICS/DISSEMINATION

Ethical approval for this study was obtained from the Newcastle and North Tyneside Research Ethics Committee (reference number 14/NE/1193). The results will be disseminated at national and international conferences and peer-reviewed publications. A study report, written in plain English, will be made available to all participants. The Patient Advisory Group will develop a strategy for wider dissemination of the findings to patients and the public.

Opt-out testing for HIV: perspectives from a high prevalence community in south-east England, UK

Peoples' perspectives and attitudes towards being offered opt-out HIV testing were explored in a geographical area of high HIV prevalence. Users (n = 31) of sexually transmitted infection (STI) testing services took part in community focus groups in the south-east of England, UK. There was broad support for opt-out HIV testing based on public health and individual health benefits. For this sample, opt-out HIV testing when registering with a general practice surgery and on elective or emergency admission to a general hospital was acceptable, although there were concerns about the rigour of informed consent. Heterosexual participants' criticism of people from higher prevalence groups for HIV declining tests, while maintaining their own right to opt-out, suggested that attitudes towards testing may be influenced by levels of perceived risk. Innovations in HIV testing policies to increase testing rates will benefit from an acknowledgement of the different meanings that testing has.

Testing for sexually transmitted infections among students: a discrete choice experiment of service preferences

OBJECTIVES

To assess preferences among students for sexually transmitted infection (STI) testing services, with a view to establishing strength of preference for different service attributes.

DESIGN

Online discrete choice experiment (DCE) questionnaire.

SETTING

South East of England.

PARTICIPANTS

A convenience sample of 233 students from two universities.

OUTCOMES

Adjusted ORs in relation to service characteristics.

RESULTS

The study yielded 233 responses. Respondents' ages ranged from 16 to 34 years with a mean age of 22 years. Among this sample, the respondents demonstrated strong preferences for a testing service which provided tests for all STIs including syphilis, herpes and HIV (OR 4.1; 95% CI 3.36 to 4.90) and centres staffed by a doctor or nurse with specialist knowledge of STIs (OR 2.1; 95% CI 1.78 to 2.37). Receiving all test results, whether positive or negative, was also significantly preferable to not being notified when tests were all negative ('no news is good news'; OR 1.3; 95% CI 1.16 to 1.5). The length of time waiting for an appointment and the method by which results are received were not significant service characteristics in terms of preferences. Patient level characteristics such as age, sex and previous testing experience did not predict the likelihood of testing.

CONCLUSIONS

This study demonstrates that of the examined attributes, university students expressed the strongest preference for a comprehensive testing service. The next strongest preferences were for being tested by specialist STI staff and receiving negative as well as positive test results. However, it remains unclear how strong these preferences are in relation to characteristics which were not part of the study design and whether or not they are cost-effective.

Effects of external intermittency and mean shear on the spectral inertial-range exponent in a turbulent square jet

This study investigates by experiment the dependence of the inertial-range exponent m of the streamwise velocity spectrum on the external intermittency factor γ (≡ the fraction of time the flow is fully turbulent) and the mean shear S in a turbulent square jet. Velocity measurements were made using hot-wire anemometry in the jet at 15 < x/D(e) < 40, where D(e) denotes the exit equivalent diameter, and for an exit Reynolds number of Re = 50,000. The Taylor microscale Reynolds number R(λ) varies from about 70 to 450 in the present study. The TERA (turbulent energy recognition algorithm) method proposed by Falco and Gendrich [in Near-Wall Turbulence: 1988 Zoran Zariç Memorial Conference, edited by S. J. Kline and N. H. Afgan (Hemisphere Publishing Corp., Washington, DC, 1990), pp. 911-931] is discussed and applied to estimate the intermittency factor from velocity signals. It is shown that m depends strongly on γ but negligibly on S. More specifically, m varies with γ following m=m(t)+(lnγ(-0.0173))(1/2), where m(t) denotes the spectral exponent found in fully turbulent regions.

Assessing user preferences for sexually transmitted infection testing services: a discrete choice experiment

OBJECTIVE

To assess user preferences for different aspects of sexually transmitted infection (STI) testing services.

DESIGN

A discrete choice experiment.

SETTING

14 centres offering tests for STIs in East Sussex, England.

PARTICIPANTS

People testing for STIs.

MAIN OUTCOME MEASURE

(Adjusted) ORs in relation to preferred service characteristics.

RESULTS

3358 questionnaires were returned; mean age 26 (SD 9.4) years. 70% (2366) were recruited from genitourinary medicine (GUM) clinics. The analysis suggested that the most important characteristics to users were whether 'staff had specialist STI knowledge' compared with 'staff without it' (OR 2.55; 95% CI 2.47 to 2.63) and whether 'tests for all STIs' were offered rather than 'some' (OR 2.19; 95% CI 2.12 to 2.25). They remained the most important two service characteristics despite stratifying the analysis by variables such as age and sex. Staff levels of expertise were viewed as particularly important by people attending CASH centres, women and non-men who have sex with men. A 'text or call to a mobile phone' and 'dropping in and waiting' were generally the preferred methods of results reporting and appointment system, respectively.

CONCLUSIONS

This study suggests that people testing for STIs place particular importance on testing for all infections rather than some and staff with specialist STI knowledge. Thus, targets based purely on waiting up to 48 h for an appointment are misguided from a user perspective.

Understanding patient choices for attending sexually transmitted infection testing services: a qualitative study

Objectives

To establish which aspects of sexually transmitted infection (STI) testing services are important to STI testing service users.

Methods

10 focus groups consisting of previous or existing users of STI testing services were conducted in community settings in the south east of England. Groups were quota sampled based on age, gender and sexual orientation. Data were analysed using Framework Analysis.

Results

65 respondents (58% men) participated. Perceived expertise of staff was the key reason for attendance at genitourinary medicine services rather than general practice. Although some respondents voiced a willingness to test for STIs within general practice, the apparent limited range of tests available in general practice and the perceived lack of expertise around sexual health appeared to discourage attendance at general practice. The decision of where to test for STIs was also influenced by past experience of testing, existing relationships with general practice, method of receiving test results and whether the patient had other medical conditions such as HIV.

Conclusions

No one type of STI testing service is suitable for all patients. This is recognised by policymakers, and it now requires commissioners and providers to make services outside of genitourinary medicine clinics more acceptable and attractive to patients, in particular to address the perceived lack of expertise and limited range of STIs tests available at alternative testing sites.

Abstract PD08-10: Breast Cancer Survivors Healthy Lifestyle Study: A Randomised Controlled Pilot To Test the Effects of a Behavioural Intervention (Information and Advice) on Uptake of Physical Activity in Breast Cancer Survivors

Background: Physical activity (PA) is a potentially modifiable behavioural risk factor for breast cancer recurrence. It declines during treatment, and most breast cancer survivors do not engage in PA at recommended levels. Effective interventions to increase PA after primary treatment for early stage breast cancer are needed.

Materials and Methods: Between November 2008 and January 2010, women who had completed primary treatment for early stage breast cancer, and not currently meeting PA guidelines, were randomly assigned to one of three conditions; 1) control group (UC) received a self-care fact sheet, or an intervention group 2) which received a theory based information booklet, diary and pedometer (INFO), or an alternate intervention group 3) which also received theory based information, diary and pedometer combined with a behavioural planning intervention (INFO+BPI). Measures (self reported PA, six minute walk test, mood, and quality of life) were collected at baseline (T1) and at 12 weeks (T2). The primary endpoint was self reported minutes of moderate to strenuous PA per week, secondary endpoints included mood and quality of life. A linear mixed models analysis approach was used to analyse data.

Results: 118 women were randomized and 107 completed T2 measures. The average age of participants was 54.6 years (Range 32-74), 31.8% had stage I disease, 38.3% had stage II disease, 15% had stage IIIa disease and 15% had DCIS, 58% had received adjuvant chemotherapy. Motivation (intention) to increase PA did not differ between groups at T1. There were no differences between groups in PA at T1. PA levels increased in all groups between T1 and T2 (P&lt;0.0001), but PA in the two intervention groups increased significantly more than in controls (+113.9 and +139.9 min per week increase in INFO and INFO + BPI respectively compared to +61.3 min per week in UC), such that at T2, there was a statistically significant difference between the intervention groups versus controls with +65 min per week increase on average (95% CI 25.3 to 104.8, p=0.02). There was no significant difference between the two intervention groups, with +25.9 min difference on average (95% CI -73.4 to 21.6, p=0.25). There were no significant differences in quality of life, anxiety or depression between groups at T1. No adverse events were reported.

Discussion: Minimally intensive, theory-based interventions increased PA participation over a 12 week period in this single centre study. The addition of a behavioural planning intervention to the INFO intervention did not significantly improve PA participation. Results of a T3, 12 month, follow up will be important in determining sustainability of the behaviour change following these interventions. A larger multicentre study is warranted to confirm the efficacy of the intervention.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD08-10.

Are home sampling kits for sexually transmitted infections acceptable among men who have sex with men?

Objective:

There is an urgent need to increase opportunistic screening for sexually transmitted infections (STIs) in community settings, particularly for those who are at increased risk including men who have sex with men (MSM). The aim of this qualitative study was to explore whether home sampling kits (HSK) for multiple bacterial STIs are potentially acceptable among MSM and to identify any concerns regarding their use. This study was developed as part of a formative evaluation of HSKs.

Methods:

Focus groups and one-to-one semi-structured interviews with MSM were conducted. Focus group participants (n = 20) were shown a variety of self-sampling materials and asked to discuss them. Individual interviewees (n = 24) had experience of the self-sampling techniques as part of a pilot clinical study. All data were digitally recorded and transcribed verbatim. Data were analysed using a framework analysis approach.

Results:

The concept of a HSK was generally viewed as positive, with many benefits identified relating to increased access to testing, enhanced personal comfort and empowerment. Concerns about the accuracy of the test, delays in receiving the results, the possible lack of support and potential negative impact on ‘others’ were raised.

Conclusion:

The widespread acceptability of using HSKs for the diagnosis of STIs could have important public health impacts in terms of earlier diagnosis of asymptomatic infections and thus a decrease in the rate of onward transmission. In addition, HSKs could potentially optimize the use of genitourinary medicine services and facilitate patient choice.

Automated PCR setup for forensic casework samples using the Normalization Wizard and PCR Setup robotic methods

Human genome, pharmaceutical and research laboratories have long enjoyed the application of robotics to performing repetitive laboratory tasks. However, the utilization of robotics in forensic laboratories for processing casework samples is relatively new and poses particular challenges. Since the quantity and quality (a mixture versus a single source sample, the level of degradation, the presence of PCR inhibitors) of the DNA contained within a casework sample is unknown, particular attention must be paid to procedural susceptibility to contamination, as well as DNA yield, especially as it pertains to samples with little biological material. The Virginia Department of Forensic Science (VDFS) has successfully automated forensic casework DNA extraction utilizing the DNA IQ(trade mark) System in conjunction with the Biomek 2000 Automation Workstation. Human DNA quantitation is also performed in a near complete automated fashion utilizing the AluQuant Human DNA Quantitation System and the Biomek 2000 Automation Workstation. Recently, the PCR setup for casework samples has been automated, employing the Biomek 2000 Automation Workstation and Normalization Wizard, Genetic Identity version, which utilizes the quantitation data, imported into the software, to create a customized automated method for DNA dilution, unique to that plate of DNA samples. The PCR Setup software method, used in conjunction with the Normalization Wizard method and written for the Biomek 2000, functions to mix the diluted DNA samples, transfer the PCR master mix, and transfer the diluted DNA samples to PCR amplification tubes. Once the process is complete, the DNA extracts, still on the deck of the robot in PCR amplification strip tubes, are transferred to pre-labeled 1.5 mL tubes for long-term storage using an automated method. The automation of these steps in the process of forensic DNA casework analysis has been accomplished by performing extensive optimization, validation and testing of the software methods.

Effect of Formulation and Manufacturing Parameters on Process Cheese Food Functionality—I. Trisodium Citrate

The objective of this research was to use a Rapid Visco Analyzer to study the effect of natural cheese age, trisodium citrate (TSC) concentration, and mixing speed on process cheese food (PCF) functionality. In this study 3 replicates of natural cheese were manufactured, and a portion of each cheese was subjected to 6 different PCF manufacturing treatments at 2, 4, 6, 12, and 18 wk of ripening. These treatments were factorial combinations of 3 levels of TSC (i.e., 2.0, 2.5, and 3.0%) and 2 mixing speeds during manufacture (450 and 1,050 rpm). Functional properties of the PCF evaluated included manufacturing properties [apparent viscosity after manufacture (VAM)], unmelted textural properties (firmness), melted cheese flow properties [hot apparent viscosity (HAV)], and cheese thickening during cooling [time at 5000 cP (T5)]. All 4 parameters (VAM, firmness, HAV, and T5) were significantly affected by natural cheese age and mixing speed, whereas VAM, HAV, and T5 were also significantly influenced by the amount of TSC. The VAM and firmness decreased as cheese age increased, whereas T5 values increased as cheese age increased. Similarly, VAM, HAV, and firmness values increased because of the increased mixing speed, whereas T5 values decreased. The age x mixing speed interaction was significant for VAM and firmness. The age x concentration of the TSC interaction term was significant for VAM, whereas the age x age x TSC concentration term was significant for HAV. The results demonstrate that natural cheese age, mixing speed during manufacture, and concentration of TSC have a significant impact on process cheese functionality.