'I don't want anyone to know': Experiences of obtaining access to HIV testing by Eastern European, non-European Union sex workers in Amsterdam, the Netherlands.

Historically, the Netherlands has hosted a large number of migrant sex workers. Since sex work is considered a legal profession it might serve as an example of better access to health services, including HIV testing, at least for those working within the legal framework. However, migrant sex workers, especially non-European Union (EU) nationals, might not be eligible to register for official employment and thus face obstacles in obtaining access to health services, becoming essentially invisible. This study examined context-specific vulnerabilities of migrant female sex workers (FSWs) from Belarus, Moldova, Russia and Ukraine, whether and how they have access to HIV testing compared to other EE, non-EU migrant FSWs in Amsterdam in the Netherlands. We conducted a multi-stakeholder perspective study from November 2015 to September 2017 in Amsterdam. The study comprised 1) semi-structured interviews with key stakeholders (N = 19); 2) in-depth interviews with Eastern European, non-EU migrant FSWs (N = 5) and field observations of the escort agency working with them; and 3) in-depth interviews with key stakeholders (N = 12). We found six key barriers to HIV testing: 1) migration and sex-work policies; 2) stigma, including self-stigmatization; 3) lack of trust in healthcare providers or social workers; 4) low levels of Dutch or English languages; 5) negative experience in accessing healthcare services in the home country; and 6) low perceived risk and HIV-related knowledge. Having a family and children, social support and working at the licensed sex-work venues might facilitate HIV testing. However, Internet-based sex workers remain invisible in the sex-work industry. Our findings indicate the importance of addressing women's diverse experiences, shaped by intrapersonal, interpersonal, community, network and policy-level factors, with stigma being at the core. We call for the scaling up of outreach interventions focusing on FSWs and, in particular, migrant FSWs working onlin

'Virus Carriers' and HIV testing: navigating Ukraine's HIV policies and programming for female sex workers

Background: There are an estimated 80,100 female sex workers (FSWs) in Ukraine, of whom 7% are living with HIV. Early HIV diagnosis continues to be a public health priority in Ukraine as only approximately 54% of people living with HIV are diagnosed nationwide. This study aims to analyse the content, context and discourse of HIV testing policies among female sex workers in Ukraine and how these policies are understood and implemented in practice. Methods: To analyse past and current national policies, we searched the database of the Ukrainian Parliament and the Ministry of Health for relevant policy documents (e.g. legislation and orders). To analyse the day-to-day practice of those involved in the implementation of these HIV programmes, we conducted face-to-face semi-structured interviews with key stakeholders. All data were coded using deductive thematic analysis initially guided by the Policy Triangle, a framework which addresses policy content, the process of policy-making, the health policy context, actors involved in policy formulation and implementation. Results: HIV testing policies are formed and implemented in the post-Soviet context through a vertical system of AIDS clinics, resulting in the separation of key affected populations from the rest of the health system. Successive testing policies have been strongly influenced by international donors and non-governmental organisations. Furthermore, a lack of government funding for HIV prevention created a gap that international donors and local non-governmental organisations covered to ensure the implementation of testing policies. Their role, however, had limited influence on the Ukrainian government to increase funding for prevention, including testing of FSWs. Since the early 1990s, when stigmatising and discriminatory forced/mandatory HIV testing was applied, these approaches were slowly replaced with voluntary testing, self-testing and assisted HIV testing, yet stigma was found to be a barrier among FSWs to access testing. Conclusion: Poor governance and the fragmentation of the health system, ongoing health sector reforms, shrinking international funding, and persisting stigma towards people living with HIV and sex workers might impede the continuity and sustainability of HIV testing programmes. Local civil society may now have the opportunity to contribute to the development and further implementation of HIV testing policies in Ukraine

Age-related upregulation of dense core vesicles in the central inferior colliculus

Presbycusis is one of the most prevalent disabilities in aged populations of industrialized countries. As we age less excitation reaches the central auditory system from the periphery. To compensate, the central auditory system [e.g., the inferior colliculus (IC)], downregulates GABAergic inhibition to maintain homeostatic balance. However, the continued downregulation of GABA in the IC causes a disruption in temporal precision related to presbycusis. Many studies of age-related changes to neurotransmission in the IC have therefore focused on GABAergic systems. However, we have discovered that dense core vesicles (DCVs) are significantly upregulated with age in the IC. DCVs can carry neuropeptides, co-transmitters, neurotrophic factors, and proteins destined for the presynaptic zone to participate in synaptogenesis. We used immuno transmission electron microscopy across four age groups (3-month; 19-month; 24-month; and 28-month) of Fisher Brown Norway rats to examine the ultrastructure of DCVs in the IC. Tissue was stained post-embedding for GABA immunoreactivity. DCVs were characterized by diameter and by the neurochemical profile (GABAergic/non-GABAergic) of their location (bouton, axon, soma, and dendrite). Our data was collected across the dorsolateral to ventromedial axis of the central IC. After quantification, we had three primary findings. First, the age-related increase of DCVs occurred most robustly in non-GABAergic dendrites in the middle and low frequency regions of the central IC during middle age. Second, the likelihood of a bouton having more than one DCV increased with age. Lastly, although there was an age-related loss of terminals throughout the IC, the proportion of terminals that contained at least one DCV did not decline. We interpret this finding to mean that terminals carrying proteins packaged in DCVs are spared with age. Several recent studies have demonstrated a role for neuropeptides in the IC in defining cell types and regulating inhibitory and excitatory neurotransmission. Given the age-related increase of DCVs in the IC, it will be critical that future studies determine whether (1) specific neuropeptides are altered with age in the IC and (2) if these neuropeptides contribute to the loss of inhibition and/or increase of excitability that occurs during presbycusis and tinnitus

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

Background and Aims The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases yet standard ERCP is not possible due to surgically altered gastroduodenal anatomy. Laparoscopic-ERCP (LA-ERCP) has been proposed as an option but supporting data are derived from single center small case-series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. Methods This is retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all of the following were achieved: reaching the papilla, cannulating the desired duct and providing endoscopic therapy as clinically indicated. Results A total of 579 patients (median age 51, 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (IQR 109-210) with median ERCP time 40 minutes (IQR 28-56). Median hospital stay was 2 days (IQR 1-3). Adverse events were 18% (laparoscopy-related 10%, ERCP-related 7%, both 1%) with the clear majority (92%) classified as mild/moderate whereas 8% were severe and 1 death occurred. Conclusion Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher due to the added laparoscopy-related events

Percutaneous transhepatic vs. endoscopic retrograde biliary drainage for suspected malignant hilar obstruction: study protocol for a randomized controlled trial

Abstract Background The optimal approach to the drainage of malignant obstruction at the liver hilum remains uncertain. We aim to compare percutaneous transhepatic biliary drainage (PTBD) to endoscopic retrograde cholangiography (ERC) as the first intervention in patients with cholestasis due to suspected malignant hilar obstruction (MHO). Methods The INTERCPT trial is a multi-center, comparative effectiveness, randomized, superiority trial of PTBD vs. ERC for decompression of suspected MHO. One hundred and eighty-four eligible patients across medical centers in the United States, who provide informed consent, will be randomly assigned in 1:1 fashion via a web-based electronic randomization system to either ERC or PTBD as the initial drainage and, if indicated, diagnostic procedure. All subsequent clinical interventions, including crossover to the alternative procedure, will be dictated by treating physicians per usual clinical care. Enrolled subjects will be assessed for successful biliary drainage (primary outcome measure), adequate tissue diagnosis, adverse events, the need for additional procedures, hospitalizations, and oncological outcomes over a 6-month follow-up period. Subjects, treating clinicians and outcome assessors will not be blinded. Discussion The INTERCPT trial is designed to determine whether PTBD or ERC is the better initial approach when managing a patient with suspected MHO, a common clinical dilemma that has never been investigated in a randomized trial. Trial registration ClinicalTrials.gov, Identifier: NCT03172832 . Registered on 1 June 2017.https://deepblue.lib.umich.edu/bitstream/2027.42/142379/1/13063_2018_Article_2473.pd

Current status of advanced gastrointestinal endoscopy training fellowships in the United States

Stephen J Heller, Jeffrey L TokarDepartment of Medicine, Fox Chase Cancer Center, Philadelphia, PA, USAAbstract: Rapid growth in the field of advanced gastrointestinal endoscopy has led to an increase in specialized therapeutic endoscopy fellowships. The cornerstones of these programs are training in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound. These procedures are more complex and challenging to master than routine colonoscopy and upper endoscopy, and in the case of ERCP, higher risk. The concentration of the educational experience in the hands of relatively fewer trainees with specialized interest in advanced endoscopy has resulted in providing a focused cohort of graduating fellows with higher case volumes in training, which likely enhances diagnostic and therapeutic success and safer performance of these procedures. Endoscopic simulators, although not currently in widespread use, have the potential to improve advanced procedural training without jeopardizing patient safety.Keywords: gastrointestinal endoscopy, training, procedures, safety&nbsp

Diagnostic evaluation of solid pancreatic masses.

Determining the etiology of a solid pancreatic lesion is a critical first step toward developing an appropriate treatment plan for patients with a benign or malignant pancreatic mass. Technological advances in cross-sectional and endoscopic imaging modalities offer pancreatic imaging options with degrees of resolution that were not available even 15-20 years ago. In most cases, the nature of a solid pancreatic mass can be determined using computerized tomography, magnetic resonance imaging, and endoscopic ultrasound with fine-needle aspiration. Knowledge about the basics of these modalities, as well as their strengths and limitations, plays an important role in understanding how patients with solid pancreatic masses should be evaluated

'I don't want anyone to know': Experiences of obtaining access to HIV testing by Eastern European, non-European Union sex workers in Amsterdam, the Netherlands

Historically, the Netherlands has hosted a large number of migrant sex workers. Since sex work is considered a legal profession it might serve as an example of better access to health services, including HIV testing, at least for those working within the legal framework. However, migrant sex workers, especially non-European Union (EU) nationals, might not be eligible to register for official employment and thus face obstacles in obtaining access to health services, becoming essentially invisible. This study examined context-specific vulnerabilities of migrant female sex workers (FSWs) from Belarus, Moldova, Russia and Ukraine, whether and how they have access to HIV testing compared to other EE, non-EU migrant FSWs in Amsterdam in the Netherlands. We conducted a multi-stakeholder perspective study from November 2015 to September 2017 in Amsterdam. The study comprised 1) semi-structured interviews with key stakeholders (N = 19); 2) in-depth interviews with Eastern European, non-EU migrant FSWs (N = 5) and field observations of the escort agency working with them; and 3) in-depth interviews with key stakeholders (N = 12). We found six key barriers to HIV testing: 1) migration and sex-work policies; 2) stigma, including self-stigmatization; 3) lack of trust in healthcare providers or social workers; 4) low levels of Dutch or English languages; 5) negative experience in accessing healthcare services in the home country; and 6) low perceived risk and HIV-related knowledge. Having a family and children, social support and working at the licensed sex-work venues might facilitate HIV testing. However, Internet-based sex workers remain invisible in the sex-work industry. Our findings indicate the importance of addressing women's diverse experiences, shaped by intrapersonal, interpersonal, community, network and policy-level factors, with stigma being at the core. We call for the scaling up of outreach interventions focusing on FSWs and, in particular, migrant FSWs working online

Lymphoma Causing Gastrosplenic Fistula Revealed by FDG PET/CT

A 73-year-old man presented with fatigue and weight loss. He had CT-proven splenic mass with fistulous connection to the greater curvature of the stomach, which suggested abscess. FDG PET/CT confirmed gastrosplenic fistula in addition to active lymph nodes in the gastrohepatic ligament and epigastric region. Pathological examination after the biopsy of the spleen was consistent with diffuse large B-cell lymphoma. Chemotherapy was administered with close clinical follow-up and resulted in the resolution of fistula without requirement for surgery