Contraceptive provision in genitourinary medicine clinics in the UK.

The objective of this study was to assess current and future contraceptive provision in genitourinary (GU) medicine clinics in the United Kingdom. Questionnaires were sent to 18 British Co-Operative Clinical Group regional representatives for distribution to clinical leads. Of 185 clinics, 124 (67%) responded. All clinics provided condoms, 116 (94%) the 'morning after' pill and 31 (25%) would fit an intrauterine contraceptive device (IUCD) for emergency contraception. Twenty-three (18.5%) regarded their clinic as already providing a comprehensive service and most of these could provide a wide range of contraceptive methods. Of all clinics, which included eight (34%) clinics already providing a comprehensive service, 69 (56%) anticipated developing their contraceptive provision within the next five years. In conclusion, contraceptive provision varies between clinics. A reduction in unwanted pregnancies and sexually transmitted infections (STIs) would most likely be achieved if clinics expanded their provision of contraceptive services.

Are women with chlamydia infection who self-refer to genitourinary medicine clinics different?

The objective of this study was to explore whether patients with Chlamydia trachomatis infection who self-refer to genitourinary medicine clinics have different demographic characteristics to those who initially attend other agencies. This study took place in three genitourinary medicine clinics from Birmingham, Nottingham and Sheffield. Demographic and post-code data were collected from female patients diagnosed with genital chlamydia infection in 2000. Townsend scores, as an index of socioeconomic status, were derived from post-codes from a subset of the cohort (from Birmingham). Comparison was made between those who were diagnosed by genitourinary medicine clinics and those diagnosed in the community and referred to genitourinary medicine clinics for further management. Data were collected from 1047 genitourinary medicine and 816 non-genitourinary medicine women, of whom 686 (84.1%) attended genitourinary medicine clinics following referral. After excluding those with incomplete data, 1614 (987 genitourinary medicine and 627 non-genitourinary medicine) patients were included in the study. Using logistic regression analysis, we were unable to demonstrate any significant differences in age or Townsend scores between genitourinary medicine and non-genitourinary medicine patients. However, significantly more Black Caribbean (odds ratio [OR] = 2.72, 95% confidence interval [CI]: 2.22, 3.20) and single women (OR = 1.97, 95% CI: 1.64, 2.29) self-referred to genitourinary medicine clinics compared with other health-care settings. This trend was consistent between Birmingham and Nottingham. In Sheffield, there was no difference in marital status. Ethnicity was not a factor as there were no Black Caribbean patients in the Sheffield cohort. Women who were diagnosed with genital chlamydia infection in genitourinary medicine clinics have some different demographic characteristics to those who were diagnosed in the community.

The chlamydia screening studies: rationale and design.

BACKGROUND: Screening has been recommended to reduce the prevalence and morbidity associated with genital chlamydia infection in the United Kingdom. METHODS: We describe the rationale and study design of the Chlamydia Screening Studies (ClaSS), a collaborative project designed to evaluate screening outside genitourinary medicine clinics. A non-selective, active screening approach in 16-39 year olds randomly sampled from 27 general practice lists in the Bristol and Birmingham areas formed the basis of interlinked studies: a case-control study was used to investigate factors to improve the targeting of screening; participants with chlamydia were invited to enroll in a randomised controlled trial to evaluate partner notification conducted in primary care; and laboratory based studies were used to assess the best specimens and tests. We also explored psychosocial effects of screening and partner notification and modelled the cost effectiveness of the programme. CONCLUSION: Results from four pilot practices show that mailing of specimens for chlamydia testing is feasible but that it is difficult to achieve high response rates with postal screening. The high prevalence of asymptomatic infection in men suggests that efforts to screen men for chlamydia should be strengthened.

Central pontine myelinolysis complicating treatment of multicentric Castleman's disease and Kaposi's sarcoma in a patient with AIDS.

An HIV positive black African woman presented with widespread lymphadenopathy and pancytopenia that had been ascribed to tuberculosis. Lymph node biopsy showed both Kaposi's sarcoma and multicentric Castleman's disease. Despite antiretroviral therapy and chemotherapy the patient deteriorated, developing confusion and dysphasia. A cranial magnetic resonance scan showed central pontine myelinolysis. Despite supportive therapy the patient died.

Audit of official STD returns from genitourinary medicine.

We audited the accuracy of KC 60 coding in our department over a two-week period in 1999. Case notes of 400 consecutive new and rebook patients who attended during each of the audit periods were reviewed, and their clinical diagnosis was compared with KC 60 returns entered into the computer and sent to the Department of Health. We concentrated on four KC 60 diagnoses of positive sexually transmitted infections: uncomplicated gonorrhoea (B1) and chlamydia (c4a), first episodes of anogenital warts (C 11 a) and herpes (C 10 a). At the end of the audit, specific recommendations were introduced, aiming at improving accuracy of KC 60 coding, and a re-audit was carried out in 2000, using identical methodology. In the first audit period there were 106 positive diagnoses, of which 41 (38.7%) were not recorded in the KC 60 returns. In the second audit period there were 149 positive diagnoses, of which 20 (13%) were not recorded, showing a significant improvement (Chi square P = 0.0005).

Thermosensory threshold: a sensitive test of HIV associated peripheral neuropathy?

The purpose of the study was to assess the prevalence of thermosensory abnormalities in patients infected with HIV infection. Using a Thermo Sensory Analyser, we assessed thermosensory threshold for warm sensation (WS) and cold sensation (CS) of the forearm and foot in 40 controls and 75 HIV positive patients, including five patients with clinically evident peripheral neuropathy, three with AIDS-related dementia and 20 with AIDS. We found that thermosensory threshold is a reproducible test. The 95th centile for normal WS of the forearm was 1.4 degrees C above and CS 0.9 degrees C below the baseline temperature of 32 degrees C, and for WS of the foot was 5.3 degrees C and CS 4.4 degrees C respectively. The median WS of the foot for controls was 1.4 (IQR 0.7-2.8) degrees C, for asymptomatic HIV positive patients was 1.9 (1.1-4.2) degrees C, for patients with AIDS was 3.5 (1.6-5.7) degrees C and for those with peripheral neuropathy was 5.4 (1.7-14.9) degrees C (P< 0.05 compared to controls). A higher threshold was also evident for CS in patients with advanced HIV disease. These findings suggest that thermosensory testing is a sensitive tool in detecting early, small nerve fibre disease before the onset of clinically evident peripheral neuropathy.

Liaison between gynaecologists, microbiologists and genitourinary medicine clinics in the management of patients with genital chlamydia and gonococcal infections.

Inadequate treatment and follow-up of women with genital infection with Chlamydia trachomatis and Neisseria gonorrhoeae can cause long-term morbidity. Inadequate contact tracing can predispose to re-infection. As some women with genital infections present to agencies other than genitourinary medicine (GUM) clinics, improved liaison between these and GUM departments are important in safeguarding proper follow-up and contact tracing.

Serum kynurenine-to-tryptophan ratio increases with progressive disease in HIV-infected patients.

An alternative pathway of Trp metabolism involves the conversion of Trp to kynurenine by indoleamine-2,3-dioxygenase, which leads to synthesis of the neurotoxin, quinolinic acid. This study explores the relationship of indoleamine-2,3-dioxygenase activity with stages of HIV infection. Sera from 206 HIV-positive and 72 seronegative subjects were analyzed for Trp and kynurenine. The kynurenine-to-Trp (KT) ratio was calculated. The mean KT ratio of seronegative controls was 36.6 +/- 10.9, and the median ratio was 34.9. The upper limit of the seronegative KT ratio, defined as mean + 2 SD, was 58.4. Patients with HIV infection showed a reciprocal relationship between the KT ratio, the CD4 count, and the stage of the disease. The median KT ratios for asymptomatic and AIDS patients were 50.5 and 117.0, respectively. This study shows that the serum Trp concentration is markedly decreased and that the kynurenine concentration is increased with immune stimulation in HIV infection. This may lead to changes in quinolinic acid and explain some of the pathogenesis of AIDS dementia.

An exploration into occupational stress experienced by HIV health care professionals who work within genitourinary medicine settings.

The present study investigates the occupational stress of health care workers involved with HIV care in genitourinary medicine (GUM) outpatient departments. Sixteen nursing and 14 medical staff completed the P. Gray-Toft and J. G. Anderson (1981) occupational stress inventory. This assesses 7 potential sources of stress (death and dying, uncertainty regarding treatment, inadequate preparation, lack of support, conflict with others, conflict with physicians, and workload). The mean scores obtained revealed a preponderance of low-stress scores for both medical and nursing staff. Analyses of variance and covariance further demonstrated that, in general, levels of stress did not differ within or between the occupational groups. However, sources and characteristics of stress were different between nurses and doctors. In this group of health care professionals, their work with HIV-positive patients within the GUM outpatient setting may be instrumental in limiting levels of stress.

How well is pelvic inflammatory disease managed in general practice? A postal questionnaire survey.

OBJECTIVE: Many patients with pelvic inflammatory disease (PID) present to their general practitioners. Chlamydia trachomatis is the organism most commonly implicated in this condition. This study aims to examine how well PID is managed in the primary care setting and highlight areas for improvement. METHODS: The study was performed by sending postal questionnaires to 180 randomly selected general practitioners in Birmingham. Given the example of a woman presenting clinically with PID, the doctors were asked questions on diagnosis and treatment. To assess factors that may influence the answers, they were also asked about their sex, year of qualification, and postgraduate training. RESULTS: 139 questionnaires (77%) were returned. 91.4% of the respondents feel confident in managing patients with PID, and only 9.3% would usually refer these patients on. However, 54.7% do not perform an endocervical swab for C trachomatis, 37.4% do not include anti-chlamydial antibiotics in their treatment regimen, and 24.5% do not advise sexual partners to be screened. Female doctors, those with higher degrees, or obstetrics and gynaecology experience were more likely to give anti-chlamydial therapy, but no factors of the respondents significantly influenced contact tracing behaviour. CONCLUSIONS: The management of a patient presenting with PID should include investigation for C trachomatis and treatment with an appropriate antibiotic. As PID is often a sexually transmitted disease, contact tracing of sexual partners should be undertaken. The study suggests that a significant proportion of general practitioners would not have offered optimal management to patients with PID.

Response to influenza immunisation in asymptomatic HIV infected men.

OBJECTIVE: This study aimed to determine if patients with HIV infection can develop a significant antibody response to influenza immunisation, and whether such immunisation is detrimental to the progression of their HIV illness. DESIGN: Prospective, non-randomised study. METHODS: The titres of antibody response to influenza immunisation were determined in 44 asymptomatic HIV positive men and compared with 16 HIV presumed seronegative controls. The magnitude of response were correlated with patients' CD4 lymphocyte counts. The rate of CD4 lymphocyte count decline over a median of 12 months before and after immunisation were also evaluated. RESULTS: Thirty-two of the 44 HIV positive subjects (73%) were able to mount a four-fold or greater response to at least one of the influenza strains, and 14 of them (32%) did so to all four strains. In comparison, 15 of the 16 controls (93.5%) had a four-fold or greater response to at least one, and six of them (38%) to all influenza strains, which was not significantly different from the HIV positive group. The magnitude of increase in antibody titre was not significantly different between the two groups either. CD4 lymphocyte count change for a median of 12 months after immunisation was not different from a median of 12 months before immunisation. CONCLUSIONS: Asymptomatic HIV infected patients are able to mount antibody response to influenza immunisation, which appears to be safe in respect to HIV illness progression in the short term.