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Background: Trichomonas vaginalis (TV) infection, which is associated with poor reproductive tract health outcomes, is the most common curable nonviral STI globally with increasing evidence of treatment failure. TV epidemiology can be highly sub-structured and linked to low socio-economic status, older age in women and female sex work. However, the large highly repetitive genome makes whole genome sequencing approaches to describe TV transmission challenging. We use nested-PCR multi-locus sequence typing (MLST) of TV directly from clinical samples to describe strain diversity among two different groups of at-risk female sexworkers (FSWs) in Ecuador. Methods: DNA was extracted from self-collected vaginal swab samples from two groups of consenting FSWs: street-based workers (SBWs) and brothelbased workers (BBWs). Behavioural and demographic data were collected. Extracts were tested for TV using real-time PCR, TV-positive extracts amplified using a previously published twostep nested PCR for seven TV genes and MLSTamplicon libraries sequenced using Illumina MiSeq. Following alignment to reference genes, strain types were assessed using MLST software and a partition model phylogenetic tree built using IQTREE. Results: Among 250 FSWs, 35/205 (17%) and 23/45 (51%) BBWs and SBWs respectively were positive for TV (p < 0.001). A subset of 35 TV-positive vaginal DNA extracts were sequenced, of which 13/35 were SBWs and 22/35 BBWs. Compared with BBWs, SBWs were older (median age 42 vs 28; p < 0.001), earnt less (median 60US$ (IQR;45-125) vs 200US$ (IQR;100-300)), had higher rates of partner turnover and were more likely to work in one location. MLST typing appeared to show considerable numbers of possible new alleles. Sequences separated into one major (A) and three minor clades (B). All SBW sequences were clade A whereas clades A and B were found among BBWs. The possible influence of mixed infections in these 'high TV exposure' FSWs is under investigation. Conclusion: This study of TV strain diversity among FSWs in north-west Ecuador suggests a high level of allelic diversity. There appeared to be complete clade homogeneity among the poorer, single location, high client-turnover SBWs, compared to BBWs. TV-typing methods may be useful for identification of population structure in TV infection. [ABSTRACT FROM AUTHOR]

Much anecdotal evidence exists regarding the managed care backlash of the late 1990s, but limited empirical evidence is available.Using a unique series of employer surveys, we examined trends in enrollment rates in health maintenance organizations (HMOs) and other plan types between 1997 and 2003.We present enrollment rates in employer-sponsored health plans by plan type. These plan-level enrollment rates are disaggregated by whether or not enrollees had a choice of plan types and by firm size and year.Employees who were enrolled in employer-sponsored health insurance in private sector establishments.Although we found evidence of a decline in the popularity of HMOs, it occurred later than indicated in earlier studies. In our data, HMO enrollment rates fell from roughly 32% to 26% between 1997 and 2003, with most of the decline occurring after 2001. Earlier studies reported that the decline in HMO enrollment rates occurred between 1996 and 1998, and between 2000 and 2001. In addition, an interesting story emerged when we examined trends by firm size. We found evidence of a decline in the HMO enrollment rate for large employers starting in 1998. However, this was offset by an increase in the HMO enrollment rate in small employers, which explains the stability in our figures before 2002. Our data also indicated that when workers were given a choice between an HMO and other plan types, workers increasingly opted for the non-HMO plan during this time period. [ABSTRACT FROM AUTHOR]

Many proposed policy initiatives involve subsidies directed toward encouraging employers to offer coverage and toward workers to encourage enrollment in offered plans. Given that insurance coverage reflects employers' decisions to offer coverage, eligibility requirements for such coverage, and employees' take-up decisions, all three elements are important when considering mechanisms to decrease the number of uninsured individuals.In this study, we examine the relationship between workers' decisions to take-up offers of health insurance and annual out-of-pocket contributions, total premiums, and employer and workforce characteristics. We model the take-up decision using cross-sectional data from approximately 18,000 establishments per year from the 1997 to 1999 Medical Expenditure Panel Survey - Insurance Component.We find that workers are less likely to enroll in coverage as single employee contributions increase. Our results for family contributions are much smaller than for single contributions and are not statistically significant in all years. Our simulation results suggest that reducing employee contribution levels for single coverage from existing levels in 1999 to zero would yield an increase in take-up rates of roughly 6% points in establishments that had required a positive level of contributions. Our results also indicate that of the 13.8 million private sector workers who decline coverage from their employers, 2.5 million would potentially enroll in employer-sponsored coverage if the cost of single coverage were to fall to zero.Reducing employee contributions will increase take-up rates; however, even when employees pay nothing for their coverage, some employees elect not to enroll. [ABSTRACT FROM AUTHOR]

The authors present a report of 12 patients with anal melanoma (AM) and review 255 cases reported since 1947. Combining these patients with those from the literature, the authors analyze several aspects of AM that are controversial or have not been studied in a systematic manner. The mean clinical tumor size was 4.1 cm. Seventy per cent were grossly pigmented, 63 per cent were polypoid, and 44 per cent were prolapsed. Two-thirds of AM were located in the proximal pecten, at or near the level of the anal valves. Microscopically, the most useful diagnostic criteria were melanin production, junctional change, and a nesting growth pattern. In four of the authors' cases, atypical junctional change extended laterally from the overt invasive neoplasm for distances up to 1 cm. Approximately 60 per cent of patients had metastases at the time of diagnosis. There was no statistical difference in determinate survivals of patients treated for cure by local excision and abdominoperineal resection. Neither tumor size nor configuration affected survival. The choice of therapy was not influenced by tumor size. [ABSTRACT FROM AUTHOR]