Outcomes and experiences of using oral voriconazole with or without concomitant topical agents to treat refractory vulvovaginal yeast infections.

BACKGROUND: We describe 11 cases of refractory vulvovaginal yeast infections (RVVYI) treated using oral voriconazole with or without concomitant topical agents. METHODS: Retrospective case-note review of all women prescribed oral voriconazole to treat RVVYI in five Sexual Health Clinics from Jan 2010-March 2020. Demographic details, clinical features, diagnostic results and treatment outcomes were collected. RESULTS: 11 women with vulvovaginal symptoms for a median of 1 year were treated with voriconazole. RVVYI was diagnosed clinically and confirmed on microscopy and culture with speciation. 10/11 isolates were fluconazole resistant, 1 intermediately sensitive, 10/11 were either fully or intermediately sensitive to voriconazole. All had received prior fluconazole and clotrimazole and 10/11 had used at least 2-weeks of one or more second-line antifungals with non-clearance of the yeast. Oral voriconazole 400 mg BD day-1, then 200 mg BD 13-days was prescribed and 10/11 women completed the course. Concomitant topical treatment was used by 6/11. Liver and renal function were monitored at 0, 7, 14 days. One woman stopped voriconazole after 5-days due to perioral tingling. Other transient side-effects were nausea (n = 2), photosensitivity, muscle aches, hair thinning (all n = 1), peripheral visual disturbance (n = 2). 8/11 experienced both symptom reduction and yeast clearance. Two women had an initial partial response but experienced resolution of symptoms following a second course of voriconazole. CONCLUSIONS: Our observational data adds to the limited evidence to support voriconazole treatment for RVVYI. A 2-week course of voriconazole was tolerated and completed by 10/11 women. Eight women, five using concomitant topical agents, achieved mycological cure.

Successful treatment of high-grade vulval intra-epithelial neoplasia with imiquimod 5% in a renal transplant recipient.

Organ transplant recipients are at a higher risk of pre-malignant human papillomavirus-associated lesions due to immunosuppression. The efficacy of immunomodulants such as imiquimod 5% is not yet fully evaluated in this population. We describe a case of vulval intra-epithelial neoplasia in a renal transplant recipient which was successfully treated with topical imiquimod.

Assessing feasibility and acceptability of a brief intervention for risky alcohol consumption in sexual health clinic attendees: a randomised controlled trial.

OBJECTIVES: To assess the feasibility and acceptability of screening attendees at a sexual health clinic (SHC) for alcohol misuse, and delivering a brief intervention (BI). To explore the effect of this BI on drinking and sexual behaviour. METHODS: A consecutive sample of consenting SHC attendees aged ≥16 years were screened using Alcohol Use Disorders Identification Test Consumption (AUDIT-C). Men scoring ≥5 and women scoring ≥4 were invited to complete the full AUDIT, alcohol diary and baseline questionnaire. INTERVENTIONS: Participants were randomised to receive BI by a trained sexual health professional or a standard alcohol leaflet (usual care, UC). All were followed up for changes in alcohol and sexual behaviour at 6 weeks and 6 months. A fidelity check and staff focus group were undertaken. RESULTS: Of 664 participants screened, 215 (32%) were eligible for randomisation and 207 were included in the final analysis: 103 (BI) and 104 (UC). Follow-up rates were 54% and 47% at 6 weeks and 6 months, respectively. Both groups reduced alcohol consumption though the degree of change did not differ between them. There was some evidence of positive changes in sexual health risk in both groups. BI was delivered as intended, adding 5 minutes to the consultation, and staff feedback was positive. CONCLUSIONS: Alcohol misuse was common in SHC attendees. Systematic assessment and BI for alcohol misuse was feasible and acceptable to staff and patients. Identification and provision of standard information alone appeared to influence drinking and sexual behaviour. TRIAL REGISTRATION NUMBER: ISRCTN19452424.

Making Sense of the Chest X-ray, a hands-on Dr Paul Jenkins, Hodder Arnold Press 2005.

The chest radiograph is one of the most challenging images to interpret reliably, yet accurate film reading can be very rewarding professionally and can significantly improve patient management. These skills are important for all professionals working in acute medicine and acquiring them requires a comprehensive book collection and a wide experience but above all a good teacher.