Search

Objective: To assess the effectiveness of a community-based HIV prevention intervention for adolescents in terms of its impact on (1) HIV and Herpes simplex virus type 2 (HSV-2) incidence and on rates of unintended pregnancy and (2) reported sexual behaviour, knowledge and attitudes.Methods: Cluster randomised trial of a multi-component HIV prevention intervention for adolescents based in rural Zimbabwe. Thirty communities were selected and randomised in 2003 to early or deferred intervention implementation. A baseline bio-behavioural survey was conducted among 6791 secondary school pupils (86% of eligibles) prior to intervention implementation.Results: Baseline prevalences were 0.8% (95% CI: 0.6-1.0) for HIV and 0.2% (95% CI: 0.1-0.3%) for HSV-2. Four girls (0.12%) were pregnant. There was excellent balance between study arms. Orphans who made up 35% of the cohort were at increased risk of HIV [age-sex adjusted odds ratio 3.4 (95% CI: 1.7-6.5)]. 11.9% of young men and 2.9% of young women reported that they were sexually active (P < 0.001); however, there were inconsistencies in the sexual behaviour data. Girls were less likely to know about reproductive health issues than boys (P < 0.001) and were less likely to have used and to be able to access condoms (P < 0.001).Conclusion: This is one of the first rigorous evaluations of a community-based HIV prevention intervention for young people in southern Africa. The low rates of HIV suggest that the intervention was started before this population became sexually active. Inconsistency and under-reporting of sexual behaviour re-emphasise the importance of using externally validated measures of sexual risk reduction in behavioural intervention studies. [ABSTRACT FROM AUTHOR]

PURPOSE: To describe young people's knowledge and use of contraceptive services over initial stages of England's Teenage Pregnancy Strategy, and to investigate factors associated with use of different services. METHODS: A random location sample of young people aged 13-21 years (n = 8879) was interviewed in 12 waves over 2000-2004. Individual data were analysed to investigate factors associated with knowledge and use of contraceptive services and to observe trends over time. Area-level data were analyzed to explore differences in key variables. RESULTS: In all, 77% of young women and 65% of young men surveyed knew a service they could use to obtain information about sex. Amongst those who had had vaginal sexual intercourse, the most common source of contraceptive supplies was general practice for young women (54%) and commercial venues for young men (54%). Young women's use of school-based services to obtain supplies increased significantly from 15.4% in Year 1 to 24.4% in Year 4, p < .001. Young men's use of the commercial sector declined significantly over the same time period (60.3% to 50.6%, p = .002), while their use of general practice and family planning clinics increased (from 8.9% to 12.4%, p = .008, and 21.2% to 29.1%, p = .054, respectively). Use of family planning clinics and designated young people's clinics was associated with first vaginal intercourse before the 16th birthday and living in a deprived area. CONCLUSIONS: Young people's patterns of contraceptive service use have changed since implementation of the Strategy; although no increase in overall service use was observed. The contribution of school-based services needs further exploration. [ABSTRACT FROM AUTHOR]

STUDY OBJECTIVE: The UK government argues that 'social exclusion' increases risk of teenage pregnancy and that educational factors may be dimensions of such exclusion. The evidence cited by the government is limited to reporting that socioeconomic disadvantage and educational attainment influence risk. Evidence regarding young people's attitude to school is not cited, and there is a lack of research concerning the UK. This paper develops hypotheses on the relation between socioeconomic and educational dimensions of social exclusion, and risk of teenage pregnancy, by examining whether dislike of school and socioeconomic disadvantage are associated with cognitive/behavioural risk measures among 13/14 year olds in English schools. DESIGN: Analysis of data from the baseline survey of a study of sex education. SETTING AND PARTICIPANTS: 13/14 year old school students from south east England. Main results: The results indicate that socioeconomic disadvantage and dislike of school are associated with various risk factors, each with a different pattern. Those disliking school, despite having comparable knowledge to those liking school, were more likely to have sexual intercourse, expect sexual intercourse by age 16, and expect to be parents by the age of 20. For most associations, the crude odds ratios (ORs) and the ORs adjusted for the other exposure were similar, suggesting that inter-confounding between exposures was limited. CONCLUSIONS: It is hypothesised that in determining risk of teenage pregnancy, the two exposures are independent. Those disliking school might be at greater risk of teenage pregnancy because they are more likely to see teenage pregnancy as inevitable or positive. [ABSTRACT FROM AUTHOR]

Inflammation is a significant driver of ischemic stroke pathology in the brain. To identify potential regulators of inflammation, we performed single-cell RNA sequencing (scRNA-seq) of young and aged mouse brains following stroke and found that interferon alpha-inducible protein 27 like 2 A (Ifi27l2a) was significantly up-regulated, particularly in microglia of aged brain. Ifi27l2a is induced by interferons for viral host defense and has been linked with pro-inflammatory cellular mechanisms. However, its potential role in neurodegeneration is unknown. Using a combination of cell culture, experimental stroke models in mice, and human autopsy brain samples, we demonstrated that induction of Ifi27l2a occurs in microglia in response to aging, ischemic stroke, and pro-inflammatory molecules. We further showed that induction of Ifi27l2a in microglia was sufficient to stimulate mitochondrial ROS production and promote a pro-inflammatory phenotype. Lastly, using an ischemic stroke model, we demonstrated that hemizygous deletion of Ifi27l2a (Ifi27l2a +/- mice) reduced gliosis (microgliosis and astrogliosis), acute and chronic brain injury, and motor function deficits. Together, these findings identify Ifi27l2a as a critical neuroinflammatory mediator in ischemic stroke and provide support for the therapeutic strategy of disrupting Ifi27l2a to attenuate inflammation in the post-stroke brain., Competing Interests: Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Competing Interests: Competing interests: None declared.

Parent-child relationship quality has critical implications for parental emotional well-being across the lifespan. The present study assessed how relationship quality is related to daily encounters between parents and children, how those encounters are linked with parents' mood, and how these associations vary by age. Participants (N = 129, ages 33-91) reported baseline relationship quality with a total of 337 children (ages 1-69). In ecological momentary assessments, participants reported encounters with their children and their mood every 3 h for 4 days (N = 2220). Analyses revealed that relationship quality was not associated with whether parents had contact with their children. More negative relationship quality was positively associated with unpleasant encounters and negatively associated with pleasant encounters with children. Pleasant encounters with a child were associated with a more positive mood regardless of relationship quality. Unpleasant encounters were associated with a more negative mood, particularly when parents had a more negative relationship with their children. These associations varied significantly by age. Parents were more likely to have contact with more irritating adolescent children than less irritating adolescents and were less likely to have unpleasant encounters with children in emerging adulthood compared to childhood. Older parents' moods were not as strongly associated with unpleasant encounters, though the likelihood of experiencing unpleasant encounters was more closely tied to relationship quality for older parents than younger parents. These findings have important implications for understanding the relationship between family conflict and emotional well-being across the life course., (© 2025 The Author(s). Family Process published by Wiley Periodicals LLC on behalf of Family Process Institute.)

Background: Clinicians and women of reproductive age would benefit from a reliable way to identify who is likely to become pregnant in the next year, in order to direct health advice. The 14-item Desire to Avoid Pregnancy (DAP) scale is predictive of pregnancy; this paper compares it with other ways of assessing pregnancy preferences to shortlist options for clinical implementation., Methods: A cohort of 994 UK women of reproductive age completed the DAP and other questions about pregnancy preferences, including the Attitude towards Potential Pregnancy Scale (APPS), at baseline and reported on pregnancies quarterly for a year. For each question, DAP item and combinations of DAP items, we examined the predictive ability, sensitivity, specificity, area under the receiver operating curve (AUROC), and positive and negative predictive values., Results: The AUROCs and predictive ability of the APPS and DAP single items were weaker than the full DAP, though all except one had acceptable AUROCs (>0.7). The most predictive individual DAP item was 'It would be a good thing for me if I became pregnant in the next 3 months', where women who strongly agreed had a 66.7% chance of pregnancy within 12 months and the AUROC was acceptable (0.77)., Conclusion: We recommend exploring the acceptability to women and healthcare professionals of asking a single DAP item ('It would be a good thing for me if I became pregnant in the next 3 months'), possibly in combination with additional DAP items. This will help to guide service provision to support reproductive preferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Study Question: Does maternal infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the first trimester affect the risk of miscarriage before 13 week's gestation?, Summary Answer: Pregnant women with self-reported diagnosis of SARS-CoV-2 in the first trimester had a higher risk of early miscarriage., What Is Known Already: Viral infections during pregnancy have a broad spectrum of placental and neonatal pathology. Data on the effects of the SARS-CoV-2 infection in pregnancy are still emerging. Two systematic reviews and meta-analyses reported an increased risk of preterm birth, caesarean delivery, maternal morbidity and stillbirth. Data on the impact of first trimester infection on early pregnancy outcomes are scarce. This is the first study, to our knowledge, to investigate the rates of early pregnancy loss during the SARS-CoV-2 outbreak among women with self-reported infection., Study Design, Size, Duration: This was a nationwide prospective cohort study of pregnant women in the community recruited using social media between 21 May and 31 December 2020. We recruited 3545 women who conceived during the SARS-CoV-2 pandemic who were <13 week's gestation at the time of recruitment., Participants/materials, Setting, Methods: The COVID-19 Contraception and Pregnancy Study (CAP-COVID) was an on-line survey study collecting longitudinal data from pregnant women in the UK aged 18 years or older. Women who were pregnant during the pandemic were asked to complete on-line surveys at the end of each trimester. We collected data on current and past pregnancy complications, their medical history and whether they or anyone in their household had symptoms or been diagnosed with SARS-CoV-2 infection during each trimester of their pregnancy. RT-PCR-based SARS-CoV-2 RNA detection from respiratory samples (e.g. nasopharynx) is the standard practice for diagnosis of SARS-CoV-2 in the UK. We compared rate of self-reported miscarriage in three groups: 'presumed infected', i.e. those who reported a diagnosis with SARS-CoV-2 infection in the first trimester; 'uncertain', i.e. those who did not report a diagnosis but had symptoms/household contacts with symptoms/diagnosis; and 'presumed uninfected', i.e. those who did not report any symptoms/diagnosis and had no household contacts with symptoms/diagnosis of SARS-CoV-2., Main Results and the Role of Chance: A total of 3545 women registered for the CAP-COVID study at <13 weeks gestation and were eligible for this analysis. Data for the primary outcome were available from 3041 women (86%). In the overall sample, the rate of self-reported miscarriage was 7.8% (238/3041 [95% CI, 7-9]). The median gestational age (GA) at miscarriage was 9 weeks (interquartile range 8-11). Seventy-seven women were in the 'presumed infected' group (77/3041, 2.5% [95% CI 2-3]), 295/3041 were in the uncertain group (9.7% [95% CI 9-11]) and the rest in the 'presumed uninfected' (87.8%, 2669/3041 [95% CI 87-89]). The rate of early miscarriage was 14% in the 'presumed infected' group, 5% in the 'uncertain' and 8% in the 'presumed uninfected' (11/77 [95% CI 6-22] versus 15/295 [95% CI 3-8] versus 212/2669 [95% CI 7-9], P = 0.02). After adjusting for age, BMI, ethnicity, smoking status, GA at registration and the number of previous miscarriages, the risk of early miscarriage appears to be higher in the 'presumed infected' group (relative rate 1.7, 95% CI 1.0-3.0, P = 0.06)., Limitations, Reasons for Caution: We relied on self-reported data on early pregnancy loss and SARS-CoV-2 infection without any means of checking validity. Some women in the 'presumed uninfected' and 'uncertain' groups may have had asymptomatic infections. The number of 'presumed infected' in our study was low and therefore the study was relatively underpowered., Wider Implications of the Findings: This was a national study from the UK, where infection rates were one of the highest in the world. Based on the evidence presented here, women who are infected with SARS-CoV-2 in their first trimester may be at an increased risk of a miscarriage. However, the overall rate of miscarriage in our study population was 8%. This is reassuring and suggests that if there is an effect of SARS-CoV-2 on the risk of miscarriage, this may be limited to those with symptoms substantial enough to lead to a diagnostic test. Further studies are warranted to evaluate a causal association between SARS-CoV-2 infection in early pregnancy and miscarriage risk. Although we did not see an overall increase in the risk of miscarriage, the observed comparative increase in the presumed infected group reinforces the message that pregnant women should continue to exercise social distancing measures and good hygiene throughout their pregnancy to limit their risk of infection., Study Funding/competing Interest(s): This study was supported by a grant from the Elizabeth Garrett Anderson Hospital Charity (G13-559194). The funders of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. J.A.H. is supported by an NIHR Advanced Fellowship. A.L.D. is supported by the National Institute for Health Research University College London Hospitals Biomedical Research Centre. All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi&#95;disclosure.pdf and declare: support to J.A.H. and A.L.D. as above; no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work., Trial Registration Number: N/A., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.)

Objective: To present process evaluation results from the Bridge-it Study, a pragmatic cluster randomised cross-over trial to improve effective contraception uptake through provision of the progestogen only pill (POP) plus sexual and reproductive health (SRH) clinic rapid-access to women presenting to community pharmacies for emergency contraception (EC)., Research Design and Methods: A multimethod process evaluation was conducted to assess intervention implementation, mechanisms of change and contextual factors. Data were gathered from screening logs (n=599), observations of pharmacist training, analysis of data from 4-month follow-up questionnaires (n=406), monitoring of contemporaneous events and qualitative interviews with 22 pharmacists, 5 SRH clinical staff and 36 study participants in three participating UK sites in Lothian, Tayside and London., Results: The intervention was largely delivered as intended and was acceptable. Pharmacists', SRH clinical staff and participants' accounts highlighted that providing a supply of POP with EC from the pharmacy as routine practice may have positive impacts on contraceptive practices in the short term, and potentially longer term. Key mechanisms of change included ease of access, increased awareness of contraception and services, and greater motivation and perceptions of self-efficacy. Few participants took up the offer to attend an SRH service (rapid-access component), and existing barriers within the SRH context were apparent (eg, lack of staff). Participant accounts highlight persistent barriers to accessing and using routine effective contraception remain., Conclusions: Implementation appeared to be acceptable and feasible, highlighting the potential for provision of POP within EC consultations as routine practice in community pharmacies. However, lack of engagement with the rapid access component of the intervention and existing barriers within the SRH context suggest that signposting to SRH services may be sufficient. Wider implementation should consider ways to address key implementation challenges to increase effectiveness and sustainability, and to overcome persistent barriers to accessing and using effective contraception., Trial Registration Number: ISRCTN70616901., Competing Interests: Competing interests: STC reports grants from the National Institute for Health Research (Health Technology Assessment (NIHR HTA) Programme), during the conduct of the study. AG is a consultant to HRA Pharma. AR reports receiving research grants from Gilead Sciences, Bristol-Myers Squibb, AbbVie and Roche; honorariums from Gilead Sciences; and personal fees from AbbVie. AM reports grants from NIHR HTA during the conduct of this study. AM is a clinical support bank midwife for SH:24 and a research midwife at Oxford University. All other authors declare no competing interests., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: CD146 is a tight junction-associated molecule involved in maintaining endothelial barrier, and balancing immune-inflammation response, in cardiovascular disease. Notably, peripheral CD146 + cells significantly upsurge under vessel dyshomeostasis such as acute myocardial injury (AMI), appearing to be a promising therapeutic target. In this study, with a new view of gene correlation, we aim at deciphering the complex underlying mechanism of CD146 + cells' impact in the development of AMI., Methods: Transcription dataset GSE 66,360 of CD146 + blood cells from clinical subjects was downloaded from NCBI. Pearson networks were constructed and the clustering coefficients were calculated to disclose the differential connectivity genes (DCGs). Analysis of gene connectivity and gene expression were performed to reveal the hub genes and hub gene clusters followed by gene enrichment analysis., Results and Conclusions: Among the total 23,520 genes, 27 genes out of 126 differential expression genes were identified as DCGs. These DCGs were found in the periphery of the networks under normal condition, but transferred to the functional center after AMI. Moreover, it was revealed that DCGs spontaneously crowded together into two functional models, CCL20 cluster and NR4A3 cluster, influencing the CD146-mediated signaling pathways during the pathology of AMI for the first time., (© 2021. The Author(s).)

Background: Brain temperature is a strong determinant of ischemic stroke injury. For this reason, tight management of brain or body temperature (Tcore) in experimental rodent stroke models is recommended to improve the rigor and reproducibility of outcomes. However, methods for managing Tcore during and after stroke vary widely in approach and effectiveness., New Method: We developed a low-cost warm ambient air cage (WAAC) system to provide improved temperature control during the intra-ischemic and post-ischemic recovery periods. The system is incorporated into standard holding cages for maintaining Tcore during the intra-ischemic period as well as for several hours into the recovery period., Results and Comparison With Existing Methods: We compared the WAAC system with a commonly used heat support method, consisting of a cage on a heating pad. Both heat support systems were evaluated for the middle cerebral artery occlusion (MCAo) stroke model in mice. The WAAC system provided improved temperature control (more normothermic Tcore and less Tcore variation) during the intra- ischemic period (60 min) and post-ischemic period (3 h). Mean infarct volume was not statistically different by heat support system, however, standard deviation was 54 % lower in the WAAC system group., Conclusions: Mice and other small rodents are highly vulnerable to heat loss during and after the MCAo procedure. The WAAC system provides more precise and controlled Tcore maintenance compared with frequently used induction heating methods in mice undergoing the MCAo stroke model. The improved temperature control should enhance experimental rigor and reduce the number of experimental animals needed., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Secondary injury following cortical stroke includes delayed gliosis and eventual neuronal loss in the thalamus. However, the effects of aging and the potential to ameliorate this gliosis with NMDA receptor (NMDAR) antagonism are not established. We used the permanent distal middle cerebral artery stroke model (pdMCAO) to examine secondary thalamic injury in young and aged mice. At 3 days post-stroke (PSD3), slight microgliosis (IBA-1) and astrogliosis (GFAP) was evident in thalamus, but no infarct. Gliosis increased dramatically through PSD14, at which point degenerating neurons were detected. Flow cytometry demonstrated a significant increase in CD11b + /CD45 int microglia (MG) in the ipsilateral thalamus at PSD14. CCR2-RFP reporter mouse further demonstrated that influx of peripheral monocytes contributed to the MG/Mϕ population. Aged mice demonstrated reduced microgliosis and astrogliosis compared with young mice. Interestingly, astrogliosis demonstrated glial scar-like characteristics at two years post-stroke, but not by 6 weeks. Lastly, treatment with memantine (NMDAR antagonist) at 4 and 24 h after stroke significantly reduced gliosis at PSD14. These findings expand our understanding of gliosis in the thalamus following cortical stroke and demonstrate age-dependency of this secondary injury. Additionally, these findings indicate that delayed treatment with memantine (an FDA approved drug) provides significant reduction in thalamic gliosis.

Background: Emergency contraception (EC) was approved in the UK as a pharmacy medicine for purchase without prescription in 2001. Twenty years later we conducted a study to characterise routine practice pharmacy provision of EC., Study Design: Mystery shopper study of 30 pharmacies in Edinburgh, Dundee and London participating in a clinical trial of contraception after EC., Methods: Mystery shoppers, aged ≥16 years, followed a standard scenario requesting EC. After the pharmacy visit, they completed a proforma recording the duration of the consultation, where it took place, and whether advice was given to them about the importance of ongoing contraception after EC., Results: Fifty-five mystery shopper visits were conducted. The median reported duration of the consultation with the pharmacist was 6 (range 1-18) min. Consultations took place in a private room in 34 cases (62%) and at the shop counter in the remainder. In 27 cases (49%) women received advice about ongoing contraception. Eleven women (20%) left the pharmacy without EC due to lack of supplies or of a trained pharmacist. Most women were generally positive about the consultation., Conclusions: While availability of EC from UK pharmacies has undoubtedly improved access, the necessity to have a consultation, however helpful, with a pharmacist introduces delays and around one in five of our mystery shoppers left without getting EC. Consultations in private are not always possible and little advice is given about ongoing contraception. It is time to make EC available without a pharmacy consultation., Competing Interests: Competing interests: AG is a member of HRA Pharma scientific advisory board. PB is a Clinical Director of the not-for profit community interest company SH:24 that provides online sexual health services in partnership with the NHS. AR is in receipt of research grants, educational grants and consultancy with Gilead, research grants from Roche and BMS, and educational grants from Abbvie. JN is Deputy Chair of the NIHR/HTA General Board Committee. NIHR/HTA funded this research., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objective: Youth who receive services in residential programs have high rates of traumatic exposure and associated symptoms of Posttraumatic Stress Disorder (PTSD). Little information is available on specific social skills training that could be beneficial for youth in residential programs with PTSD. This study examined changes in behavioral incidents and psychopathology in youth receiving group home services based on training they received across three categories of social skills (i.e., self-advocacy, emotional regulation, problem-solving)., Method: The sample included archival data on youth ( N = 677) ages 10-18 years ( M = 15.7 years, SD = 1.53). Hierarchical Linear Modeling was used to examine the frequency of disruptive and self-injurious behaviors over 12 months as it relates to reported traumatic symptoms at admission and the presence of the three types of social skills objectives. Analysis of Covariance was conducted to test whether the social skill objectives differentially predicted changes in youth psychopathology from intake to discharge for youth with low and high trauma symptoms., Results: Youth with high trauma symptoms who received training on problem-solving skills had significantly greater decrease in emotional problems from intake to discharge compared to youth with high trauma symptoms who did not receive problem-solving training ( d = -.54)., Conclusion: Problem-solving training could be further developed and tested to maximize the support youth with trauma symptoms receive in trauma-informed residential programs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Peroxisomes exist in nearly every cell, oxidizing fats, synthesizing lipids and maintaining redox balance. As the brain ages, multiple pathways are negatively affected, but it is currently unknown if peroxisomal proteins are affected by aging in the brain. While recent studies have investigated a PEX5 homolog in aging C. elegans models and found that it is reduced in aging, it is unclear if PEX5, a mammalian peroxisomal protein that plays a role in peroxisomal homeostasis and degradation, is affected in the aging brain. To answer this question, we first determined the amount of PEX5, in brain homogenates from young (3 months) and aged (26 through 32+ months of age) wild-type mice of both sexes. PEX5 protein was decreased in aged male brains, but this reduction was not significant in female brains. RNAScope and real-time qPCR analyses showed that Pex5 mRNA was also reduced in aged male brain cortices, but not in females. Immunohistochemistry assays of cortical neurons in young and aged male brains showed that the amount of neuronal PEX5 was reduced in aged male brains. Cortical neurons in aged female mice also had reduced PEX5 levels in comparison to younger female mice. In conclusion, total PEX5 levels and Pex5 gene expression both decrease with age in male brains, and neuronal PEX5 levels lower in an age-dependent manner in the cortices of animals of both sexes., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Patients with glioblastoma (GB) are more likely to suffer cognitive deficits with poor quality of life as compared with lower-grade glioma patient groups, for whom cognition research is plentiful. The objective of this systematic review is to evaluate the cognitive function of patients with GB before and after surgery., Methods: This review was prospectively registered with PROSPERO. PubMed and EMBASE searches were performed, most recently March 15, 2018. Inclusion criteria were adult patients, histologically confirmed GB, and cognitive tests conducted before and/or after surgery. Screening and data extraction were carried out independently by 2 authors., Results: A total of 512 abstracts were screened. Nineteen studies were included with 902 participants, of whom only 423 had histologically confirmed GB. Only 11 studies tested cognitive function both before and after surgery. A total of 114 different cognitive tests were used. The most common test was used in only 9 studies; 82 tests were used only once. Follow-up time ranged from 1 week to 16 months with extremely high dropout rates. Eighteen of 19 studies reported cognitive deficits in their samples, with prevalence ranging from 22% to 100% (median 64%, interquartile range 42%). Only 1/11 longitudinal studies reported normal cognitive function, 3/11 reported initial deficits with improvement after surgery, 3/11 reported static deficits, and 4/11 reported deterioration., Conclusion: There is a consistently high risk of cognitive deficit for patients with GB undergoing surgery. The included studies showed marked heterogeneity in study design, case-mix of included diagnoses, and the type and timing of cognitive tests used. We highlight considerations for the design of future studies to avoid such bias., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Society for Neuro-Oncology and the European Association of Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Recent advances in three-dimensional (3D) fluorescence microscopy offer the ability to image the entire vascular network in entire organs, or even whole animals. However, these imaging modalities rely on either endogenous fluorescent reporters or involved immunohistochemistry protocols, as well as optical clearing of the tissue and refractive index matching. Conversely, X-ray-based 3D imaging modalities, such as micro CT, can image non-transparent samples, at high resolution, without requiring complicated or expensive immunolabeling and clearing protocols, or fluorescent reporters. Here, we compared two "homemade" barium-based contrast agents to the field standard, lead-containing Microfil, for micro-computed tomography (micro CT) imaging of the adult mouse cerebrovasculature. The perfusion pressure required for uniform vessel filling was significantly lower with the barium-based contrast agents compared to the polymer-based Microfil. Accordingly, the barium agents showed no evidence of vascular distension or rupture, common problems associated with Microfil. Compellingly, perfusion of an aqueous BaCl 2 /gelatin mixture yielded equal or superior visualization of the cerebrovasculature by micro CT compared to Microfil. However, phosphate-containing buffers and fixatives were incompatible with BaCl 2 due to the formation of unwanted precipitates. X-ray attenuation of the vessels also decreased overtime, as the BaCl 2 appeared to gradually diffuse into surrounding tissues. A second, unique formulation composed of BaSO 4 microparticles, generated in-house by mixing BaCl 2 and MgSO 4 , suffered none of these drawbacks. These microparticles, however, were unable to pass small diameter capillary vessels, conveniently labeling only the arterial cerebrovasculature. In summary, we present an affordable, robust, low pressure, non-toxic, and straightforward methodology for 3D visualization of the cerebrovasculature., (© 2019 Wiley Periodicals, Inc.)

Introduction: Oral emergency contraception (EC) can prevent unintended pregnancy but it is important to start a regular method of contraception. Women in the UK usually access EC from a pharmacy but then need a subsequent appointment with a general practitioner or a sexual and reproductive health (SRH) service to access regular contraception. Unintended pregnancies can occur during this time., Methods and Analysis: Bridge-It is a pragmatic cluster randomised cohort cross-over trial designed to determine whether pharmacist provision of a bridging supply of a progestogen-only pill (POP) plus rapid access to a local SRH clinic, results in increased uptake of effective contraception and prevents more unintended pregnancies than provision of EC alone. Bridge-It involves 31 pharmacies in three UK regions (London, Lothian and Tayside) aiming to recruit 626-737 women. Pharmacies will give EC (levonorgestrel) according to normal practice and recruit women to both intervention and the control phases of the study. In the intervention phase, pharmacists will provide the POP (desogestrel) and offer rapid access to an SRH clinic. In the control phase, pharmacists will advise women to attend a contraceptive provider for contraception (standard care).Women will be asked 4 months later about contraceptive use. Data linkage to abortion registries will provide abortion rates over 12 months. The sample size is calculated on the primary outcome of effective contraception use at 4 months (yes/no) with 90% power and a 5% level of significance. Abortion rates will be an exploratory secondary analysis. Process evaluation includes interviews with pharmacists, SRH clinicians and women. Cost-effectiveness analysis will use a healthcare system perspective and be expressed as incremental cost-effectiveness ratio., Ethics and Dissemination: Ethical approval was received from South East Scotland REC June 2017. Results will be published in peer-reviewed journals and conference presentations., Trial Registration Number: ISRCTN70616901., Competing Interests: Competing interests: AG is a member of HRA Pharma scientific advisory board. PB is a Clinical Director of the not-for profit community interest company SH:24 that provides online sexual health services in partnership with the NHS. AR received research grants, educational grants and consultancy with Gilead Research grants from Roche and BMS Educational grants from Abbvie. JN is Deputy Chair of the NIHR/HTA General Board Committee. NIHR/HTA funded this research., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Telehealth is a way to provide health-care services to a patient from a provider who is at another location. The most common methods include a live interactive visit with the patient, interpretation of imaging, and monitoring of patient progress. Principally, telehealth is a way of providing a service rather than a type of service. It is about patient care, not data care.Examples of orthopaedic applications include conducting patient examinations, interpreting imaging studies, and providing postoperative care. Teleconsultation has been shown to be cost-effective. Other examples in orthopaedic research include the application of telemedicine when measuring patient-reported outcomes. Especially in cases when the patient lives far away from the provider, telehealth reduces time, produces good patient satisfaction, and costs less than hands-on care. As in everyday life, consumers have learned to demand convenience, ease of use, choice, control, and direct access. The ubiquity of telecommunications, combined with consumer technology savviness, drives the demand for telehealth. Unfortunately, the nation's largest payer for health services is one of the most restrictive for telehealth coverage. Medicare's restrictions are mostly the work of the U.S. Congress under Part B law. Video visits are very narrowly covered. Another major policy barrier is that interstate telehealth requires multiple state licenses for the physician, who must be licensed in the jurisdiction of each patient as well as the provider's physical locations. As Medicare shifts toward capitated payment and other value-based methods, there are opportunities to remove such restrictions.Despite these challenges, some states have been proactive in implementing telehealth systems. Arkansas is one of these states, and being a rural state with 2 main population centers, specialty care is relatively sparse. Implemented in 2014, the hand trauma program has been a partnership between the University of Arkansas for Medical Sciences (UAMS) and the Arkansas Trauma Communications Center (ATCC). This program has been very successful in decreasing the rate of hand trauma transfer, allowing patients to be treated closer to home while having coordinated access to fellowship-trained hand surgeons when necessary.More widespread innovation of orthopaedic applications for telehealth requires physician buy-in and health-systems partnerships. The regulatory environment will need streamlining. Ultimately, consumer demand will drive the implementation of technology to make care more accessible, convenient, and cost-effective.

Purpose: This study aimed to update a portion of a 2008 study of patient education materials from the American Society for Surgery of the Hand Web site with new readability results, to compare the results to health literacy best practices, and to make recommendations to the field for improvement., Methods: A sample of 77 patient education documents were downloaded from the American Society for Surgery of the Hand Web site, handcare.org, and assessed for readability using 4 readability tools. Mean readability grade-level scores were derived. Best practices for plain language for written health materials were compiled from 3 government agency sources., Results: The mean readability of the 77 patient education documents in the study was 9.3 grade level. This reading level is reduced from the previous study in 2008 in which the overall mean was 10.6; however, the current sample grade level still exceeds recommended readability according to best practices., Conclusions: Despite a small body of literature on the readability of patient education materials related to hand surgery and other orthopedic issues over the last 7 years, readability was not dramatically improved in our current sample. Using health literacy as a framework, improvements in hand surgery patient education may result in better understanding and better outcomes for patients seeing hand surgeons., Clinical Relevance: Improved understanding of patient education materials related to hand surgery may improve preventable negative outcomes that are clinically significant as well as contribute to improved quality of life for patients., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: To determine women's (patients') experiences of intrauterine device (IUD) insertion under our current practice and the extent to which these agreed with the observations of the health professionals (providers) who had performed the IUD insertion procedures., Method: Questionnaires were used to collect information on women's experiences of the IUD insertion procedure from both patients and providers in a sexual and reproductive health service., Results: Overall response rates were high (77%, 284 responses in total). Seventy-three percent of patients were nulliparous and over half nulligravid. The providers predominantly used local anaesthesia for IUD insertions (93%). Most patients reported being anxious before their procedure (86%). Patients mainly described the overall experience of their IUD insertion procedure as being associated with 'minimal discomfort/nothing' (42%) or 'uncomfortable' (41%). 'Minimal discomfort/nothing' (56%) and 'uncomfortable' (33%) were the main observations of providers. When responses of patients and their providers were compared, agreement was slight for reported pain levels (k = 0.167 CI [0.13-0.24]). Patients' reported pain levels were significantly higher than those reported to have been observed by their providers (p < 0.001)., Conclusion: Patients' and providers' responses suggested that the IUD insertion procedure under our current practice appeared acceptable to most patients. However, providers were not usually accurate in their observations and tended to underestimate the degree of pain experienced by their patients during IUD insertion procedures.

Molecular diagnostic measurements are currently underpinned by the polymerase chain reaction (PCR). There are also a number of alternative nucleic acid amplification technologies, which unlike PCR, work at a single temperature. These 'isothermal' methods, reportedly offer potential advantages over PCR such as simplicity, speed and resistance to inhibitors and could also be used for quantitative molecular analysis. However there are currently limited mechanisms to evaluate their quantitative performance, which would assist assay development and study comparisons. This study uses a sexually transmitted infection diagnostic model in combination with an adapted metric termed isothermal doubling time (IDT), akin to PCR efficiency, to compare quantitative PCR and quantitative loop-mediated isothermal amplification (qLAMP) assays, and to quantify the impact of matrix interference. The performance metric described here facilitates the comparison of qLAMP assays that could assist assay development and validation activities.

Objective: To determine Mycoplasma genitalium infection and correlates among young women undergoing population-based screening or clinic-based testing for Chlamydia infection., Design: Cross-sectional study., Setting: National Chlamydia Screening Programme (NCSP) and two London sexually transmitted infection (STI) clinics., Participants: 2441 women aged 15-64 years who participated in the NCSP and 2172 women who attended two London STI clinics over a 4-month period in 2009., Outcome Measures: (1) M genitalium prevalence in defined populations (%). (2) Age-adjusted ORs (aORs) for correlates of M genitalium infection., Results: The overall frequency of M genitalium and Chlamydia trachomatis was 3% and 5.4%, respectively. Co-infection was relatively uncommon (0.5% of all women); however 9% of women with C trachomatis also had M genitalium infection. M genitalium was more frequently detected in swab than urine samples (3.9 vs 1.3%, p<0.001) with a significantly higher mean bacterial load (p ≤ 0.001). Among NCSP participants, M genitalium was significantly more likely to be diagnosed in women of black/black British ethnicity (aOR 2.3, 95% CI 1.2 to 4.5, p=0.01). M genitalium and C trachomatis and were both significantly associated with multiple sexual partners in the past year (aOR 2.4, 95% CI 1.3 to 4.4, p=0.01 and aOR 2.0, 95% CI 1.4 to 2.8, p<0.01). Among STI clinic attendees, M genitalium was more common in women who were less than 25 years in age., Conclusions: M genitalium is a relatively common infection among young women in London. It is significantly more likely to be detected in vulvovaginal swabs than in urine samples. Co-infection with Chlamydia is uncommon. The clinical effectiveness of testing and treatment strategies for M genitalium needs further investigation.

Background: Pain associated with the insertion of an intrauterine device (IUD) is a known barrier to intrauterine contraception use in the UK. It is good practice for health professionals to discuss pain relief and use with women prior to the insertion of an IUD., Objectives: This study aimed to determine the prevalence of and reasons for and against the use of local anaesthesia (LA) for IUD insertion., Methods: A survey was undertaken using paper questionnaires to determine LA use for IUD insertion by UK health professionals., Results: Overall, approximately one quarter (n=129) of all respondents use LA routinely, one quarter hardly ever or never use LA, while the remaining half use it sometimes. Use of LA was more prevalent among health professionals who worked in integrated sexual and reproductive health and contraception-only services, compared to general practice. UK health professionals who hardly ever or never used LA for the insertion of IUDs were more likely to be working in general practice., Conclusions: The results of this survey suggest that more UK health professionals need to routinely discuss pain relief and offer this to their patients prior to IUD insertion as part of the care pathway for patients who choose to use intrauterine contraception.

Background: Chlamydia is the most commonly reported bacterial sexually transmitted infection in Europe. The objective of the Screening for Chlamydia in Europe (SCREen) project was to describe current and planned chlamydia control activities in Europe., Methods: The authors sent a questionnaire asking about different aspects of chlamydia epidemiology and control to public health and clinical experts in each country in 2007. The principles of sexually transmitted infection control were used to develop a typology comprising five categories of chlamydia control activities. Each country was assigned to a category, based on responses to the questionnaire., Results: Experts in 29 of 33 (88%) invited countries responded. Thirteen of 29 countries (45%) had no current chlamydia control activities. Six countries in this group stated that there were plans to introduce chlamydia screening programmes. There were five countries (17%) with case management guidelines only. Three countries (10%) also recommended case finding amongst partners of diagnosed chlamydia cases or people with another sexually transmitted infection. Six countries (21%) further specified groups of asymptomatic people eligible for opportunistic chlamydia testing. Two countries (7%) reported a chlamydia screening programme. There was no consistent association between the per capita gross domestic product of a country and the intensity of chlamydia control activities (P = 0.816)., Conclusion: A newly developed classification system allowed the breadth of ongoing national chlamydia control activities to be described and categorized. Chlamydia control strategies should ensure that clinical guidelines to optimize chlamydia diagnosis and case management have been implemented before considering the appropriateness of screening programmes.

Background: Our objective was to estimate for the first time the prevalence and determinants of human immunodeficiency virus type 1 (HIV-1) and sexually transmitted infections (STIs) among male migrants in India., Methodology/principal Findings: We conducted a multi-stage stratified probability sample survey of migrant (defined as not born in Surat city) men aged 18 to 49 years working in the diamond and textile industries in Surat city. Behavioural and biological data were collected. Biological data included laboratory diagnosed herpes simplex virus type 2 (HSV-2), syphilis, chlamydia, gonorrhoea, Trichomonas vaginalis (together defined as 'any STI') and HIV-1. Likely recently acquired STIs included chlamydia, gonorrhoea, T. vaginalis and syphilis with rapid plasma reagin ≥1:8. The response rate was 77% (845/1099). Among 841 participants, HIV-1 prevalence was 1.0%, 'any STI' prevalence was 9.5% and 38.9% of these STIs were likely to have been recently acquired. Being a diamond worker, Surat resident for 10+ years and recent antibiotic use were each associated with higher odds of 'any STI' (aORs 1.83 (95% CI 1.09-3.09), 1.98 (95% CI 1.22-3.22) and 2.57 (95% CI 1 .17-5.64), respectively) after adjusting for the other two factors and age. The main study limitation was social desirability bias for self-reported sexual behaviour; STIs were diagnosed in some self-reported virgins., Conclusions/significance: HIV and STI prevalence were lower than expected, but prevention interventions remain necessary in Surat since almost 40% of STIs among participants were probably recently acquired and sentinel surveillance HIV prevalence remains high. The participants had a similar HIV prevalence to Surat antenatal clinic attendees, a proxy for the general population. This suggests migrants are not always at higher risk of HIV compared to the general population in their migration destination. Our findings highlight the need to contextualise research findings from a specific setting with other local information to guide HIV/STI prevention interventions.

Objective: To explore key factors influencing young women when choosing between two methods of emergency contraception (EC)., Methods: We interviewed 26 young women who accessed community sexual and reproductive health services for emergency contraception after they had chosen an EC., Results: Most women had an unrealistically high expectation about efficacy of the emergency contraceptive pill (ECP) and lacked knowledge of the intrauterine device (IUD) as an alternative method of EC. Previous use, easy accessibility, ease of use, and advice from peers, influenced women to choose the ECP, whereas past experience of abortion, firm motivation to avoid pregnancy, presentation after 72 hours, and considering that an IUD may provide long-term contraception as well, inclined women to choose the IUD. When participants were shown the IUD, many found it to be smaller and less frightening than they had imagined., Conclusions: Women need better information and education about the IUD as a highly effective method of EC. Health professionals must provide such information at every opportunity. Showing the IUD during counselling might help correct misconceptions and would improve acceptability. Wider availability of expertise concerning EC-IUDs is essential to assist more women in making informed decisions when choosing a method for EC.

Background: HIV prevention among young people in southern Africa is a public health priority. There is little rigorous evidence of the effectiveness of different intervention approaches. We describe findings of a cluster randomized trial of a community-based, multicomponent HIV, and reproductive health intervention aimed at changing social norms for adolescents in rural Zimbabwe., Methods: Thirty rural communities were randomized to early or deferred implementation of the intervention in 2003. Impact was assessed in a representative survey of 18-22-year-olds after 4 years. Participants self-completed a questionnaire and gave a dried blood spot sample for HIV and herpes simplex virus-2 (HSV-2) antibody testing. Young women had a urinary pregnancy test. Analyses were by intention-to-treat and were adjusted for clustering., Findings: Four thousand six hundred and eighty-four, 18-22-year-olds participated in the survey (97.1% of eligible candidates, 55.5% women). Just over 40% had been exposed to at least 10 intervention sessions. There were modest improvements in knowledge and attitudes among young men and women in intervention communities, but no impact on self-reported sexual behavior. There was no impact of the intervention on prevalence of HIV or HSV-2 or current pregnancy. Women in intervention communities were less likely to report ever having been pregnant., Interpretation: Despite an impact on knowledge, some attitudes, and reported pregnancy, there was no impact of this intervention on HIV or HSV-2 prevalence, further evidence that behavioral interventions alone are unlikely to be sufficient to reverse the HIV epidemic. The challenge remains to find effective HIV prevention approaches for young people in the face of continued and unacceptably high HIV incidence, particularly among young women.

Background: Screening programmes are promoted to control transmission of and prevent female reproductive tract morbidity caused by genital chlamydia. The objective of this study was to examine the effectiveness of register-based and opportunistic chlamydia screening interventions., Methods: We searched seven electronic databases (Cinahl, Cochrane Controlled Trials Register, DARE, Embase, Medline, PsycINFO and SIGLE) without language restrictions from January 1990 to October 2007 and reference lists of retrieved articles to identify studies published before 1990. We included studies examining primary outcomes (pelvic inflammatory disease, ectopic pregnancy, infertility, adverse pregnancy outcomes, neonatal infection, chlamydia prevalence) and harms of chlamydia screening in men and non-pregnant and pregnant women. We extracted data in duplicate and synthesized the data narratively or used random effects meta-analysis, where appropriate., Results: We included six systematic reviews, five randomized trials, one non-randomized comparative study and one time trend study. Five reviews recommended screening of women at high risk of chlamydia. Two randomized trials found that register-based screening of women at high risk of chlamydia and of female and male high school students reduced the incidence of pelvic inflammatory disease in women at 1 year. Methodological inadequacies could have overestimated the observed benefits. One randomized trial showed that opportunistic screening in women undergoing surgical termination of pregnancy reduced post-abortal rates of pelvic inflammatory disease compared with no screening. We found no randomized trials showing a benefit of opportunistic screening in other populations, no trial examining the effects of more than one screening round and no trials examining the harms of chlamydia screening., Conclusion: There is an absence of evidence supporting opportunistic chlamydia screening in the general population younger than 25 years, the most commonly recommended approach. Equipoise remains, so high-quality randomized trials of multiple rounds of screening with biological outcome measures are still needed to determine the balance of benefits and harms of chlamydia screening.

Purpose of Review: The purpose of this review was to synthesize major research findings in relation to young people and sexual behaviour from the period 2006-2007., Recent Findings: We found several key reviews that advance knowledge in the field of young people and sexual behaviour, including observational studies, both qualitative and quantitative, and intervention studies designed to reduce sexual transmission of HIV in both developed and developing countries. Other reviews focused on same-sex behaviours, victimization within relationships, HIV infection/sexually transmitted infection in travellers, prevention of HIV/sexually transmitted infection and the determinants of sexual behaviour in young people., Summary: Powerful and consistent forces sustain gender differences in sexual behaviour. The design of interventions to reduce sexual risk behaviour should take account of these forces that help explain young people's sexual behaviour. Knowledge about the kind of interventions that reduce risk behaviour and should be implemented has improved, although the impact on health outcomes such as pregnancy and HIV/sexually transmitted infection is often uncertain. Effective school sex education needs to be part of much broader strategies to improve sexual health, and there is an urgent need for better evaluation of interventions, especially community interventions. Further longitudinal studies are needed to provide insight into the development of relationships and sexual behaviour as well as the course of acculturation.

Objectives: To quantify the contribution of patient delay, provider delay, and diversion between services to delayed access to genitourinary medicine (GUM) clinics. To describe the factors associated with delay, and their contribution to STI transmission., Methods: Cross-sectional survey of 3184 consecutive new patients attending four GUM clinics purposively selected from across England to represent different types of population. Patients completed a short written questionnaire that collected data on sociodemographics, access, and health-seeking behaviour. Questionnaires were then linked to routinely collected individual-level demographic and diagnostic data., Results: Patient delay is a median of 7 days, and does not vary by demographic or social characteristics, or by clinic. However, attendance at a walk-in appointment was associated with a marked reduction in patient delay and provider delay. Among symptomatics, 44.8% of men and 58.0% of women continued to have sex while awaiting treatment, with 7.0% reporting sex with >1 partner; 4.2% of symptomatic patients reported sex without using condoms with new partner(s) since their symptoms had begun. Approximately 25% of all patients had already sought or received care in general practice, and these patients experienced greater provider delay., Conclusions: Walk-in services are associated with a reduction in patient and provider delay, and should be available to all populations. Patients attending primary care require clear care pathways when referred on to GUM clinics. Health promotion should encourage symptomatic patients to seek care quickly, and to avoid sexual contact before treatment.

Objective: To investigate factors associated with pelvic inflammatory disease (PID)., Methods: A case-control study was used to investigate demographic and behavioural factors, and causative agents associated with PID., Results: A total of 381 participants were recruited: 140 patients, and 105 and 136 controls in tubal ligation and general practice groups, respectively. When compared with a PID-free tubal ligation control group, increased risk of PID was associated with: age <25 years; age at first sexual intercourse <20 years; non-white ethnicity; not having had children; a self-reported history of a sexually transmitted disease; and exposure to Chlamydia trachomatis. When compared with a general practice control group, increased risk was associated with: age <25 years; age at first sexual intercourse <15 years; lower socioeconomic status; being single; adverse pregnancy outcome; a self-reported history of a sexually transmitted disease; and exposure to C trachomatis. Of the cases, 64% were not associated with any of the infectious agents measured in this study (idiopathic)., Conclusions: A high proportion of cases were idiopathic. PID control strategies, which currently focus on chlamydial screening, have to be reviewed so that they can prevent all cases of PID. Behavioural change is a key factor in the primary prevention of PID, and potential modifiable risk factors were associated with PID.

Objective: To explore the associations between self reported high risk sexual behaviours and subsequent diagnosis with hepatitis C virus (HCV) infection., Methods: The Sex, Health and Anti-Retrovirals Project (SHARP) was a cross sectional study of sexual behaviour in HIV positive, men who have sex with men (MSM) attending a London outpatient clinic. From July 1999 to August 2000 participants completed a computer assisted self interview questionnaire (CASI) on recent sexual behaviour, recreational drug use, and detailed reporting of the last two sexual episodes involving different partners. Results were combined with routine clinic data and subsequent testing for HCV up to 21 April 2005. A new HCV diagnosis was defined as anti-HCV antibody seroconversion or positive HCV RNA following a previous negative. Incident rate ratios (IRR) were calculated using Poisson regression in Stata (version 9). Men contributed time at risk from interview until either their diagnosis or their last negative test result., Results: Of the 422 men who completed questionnaires, 308 (73%) had sufficient clinical and HCV testing data available for analysis. Incident HCV infection was identified in 11 men. Unprotected anal intercourse, more than 30 sex partners in the past year, higher numbers of new anal sex partners, rimming (oro-anal sex), fisting, use of sex toys, and intranasal recreational drug use were associated with HCV. In multivariate analysis only fisting remained associated with HCV (adjusted IRR 6.27, p = 0.005)., Conclusions: In this study of HIV positive MSM, fisting is strongly associated with HCV infection. Where individuals report high risk sexual behaviours, clinicians should offer appropriate testing for HCV infection.

Objectives: To examine various models of integrated and/or one stop shop (OSS) sexual health services (including general practice, mainstream specialist services, and designated young people's services) and explore their relative strengths and weaknesses., Methods: Literature review and interviews with key informants involved in developing the National Strategy for Sexual Health and HIV (n = 11)., Results: The paper focuses on five broad perspectives (logistics, public health, users, staff, and cost). Contraceptive and genitourinary medicine issues are closely related. However, there is no agreement about what is meant by having "integrated" services, about which services should be integrated, or where integration should happen. There are concerns that OSSs will result in over-centralisation, to the disadvantage of stand alone and satellite services. OSS models are potentially more user focused, but the stigma that surrounds sexual health services may create an access barrier. From staff perspectives, the advantages are greater career opportunities and increased responsibility, while the disadvantages are concern that OSSs will result in loss of expertise and professional status. Cost effectiveness data are contradictory., Conclusion: Although there is a policy commitment to look at how integrated services can be better developed, more evidence is required on the impact and appropriateness of this approach.

Objective: To describe the contribution of primary care to the diagnosis and management of sexually transmitted infections in the United Kingdom, 1990-2000, in the context of increasing incidence of infections in genitourinary medicine clinics., Design: Population based study., Setting: UK primary care., Participants: Patients registered in the UK general practice research database., Main Outcome Measures: Incidence of diagnosed sexually transmitted infections in primary care and estimation of the proportion of major such infections diagnosed in primary care., Results: An estimated 23.0% of chlamydia cases in women but only 5.3% in men were diagnosed and treated in primary care during 1998-2000, along with 49.2% cases of non-specific urethritis and urethral discharge in men and 5.7% cases of gonorrhoea in women and 2.9% in men. Rates of diagnosis in primary care rose substantially in the late 1990s., Conclusions: A substantial and increasing number of sexually transmitted infections are diagnosed and treated in primary care in the United Kingdom, with sex ratios differing from those in genitourinary medicine clinics. Large numbers of men are treated in primary care for presumptive sexually transmitted infections.