2nd BASHH Oxford Diagnostics Course, November 2015.

The second British Association for Sexual Health and HIV Oxford Diagnostics Course of 2015 focussed on recent challenges and emerging concepts within diagnostics and service design. In response to increasing sexually transmitted infection rates and subsequent demand on UK sexual health services, multiple approaches to improving patient flow and reducing waiting times were presented. The value of novel remote sexually transmitted infection testing was explored, with a description of the patient journey, emerging demographics and rates of testing uptake for the UK's leading National Health Service provider. A cost-benefit evaluation was made for the use of nucleic acid amplification tests versus traditional microscopy and culture for detecting Trichomonas vaginalis, with practical consideration of application to higher risk groups. Two speakers stressed the importance of vigilance against growing antimicrobial resistance. The significance of testing for genotypic markers for antimicrobial resistance, and the emergence of point-of-care tests for resistance were also presented. The meeting closed with a first-hand account of tendering, and practical advice on rebuilding professional relationships and services after a competitive process.

Tranexamic acid in life-threatening military injury and the associated risk of infective complications.

BACKGROUND: Tranexamic acid (TXA) has been shown to reduce mortality from severe haemorrhage. Although recent data suggest that TXA has anti-inflammatory properties, few analyses have investigated the impact of TXA on infectious complications in injured patients. The aim was to examine the association between TXA administration and infection risk among injured military personnel. METHODS: Patients who received TXA were matched by Injury Severity Score with patients who did not receive TXA. Conditional logistic regression was used to examine risk factors associated with infections within 30 days. A Cox proportional analysis evaluated risk factors in a time-to-first-infection model. RESULTS: A total of 335 TXA recipients were matched with 626 patients who did not receive TXA. A greater proportion of TXA recipients had an infection compared with the comparator group (P < 0·001). Univariable analysis estimated an unadjusted odds ratio (OR) of 2·47 (95 per cent c.i. 1·81 to 3·36) for the association between TXA and infection risk; however, TXA administration was not significant in multivariable analysis (OR 1·27, 0·85 to 1·91). Blast injuries, intensive care unit (ICU) admission, and receipt of 10 units or more of blood within 24 h after injury were independently associated with infection risk. The Cox proportional model confirmed the association with ICU admission and blood transfusion. Traumatic amputations were also significantly associated with a reduced time to first infection. CONCLUSION: In life-threatening military injuries matched for injury severity, TXA recipients did not have a higher risk of having infections nor was the time to develop infections shorter than in non-recipients. Extent of blood loss, blast injuries, extremity amputations and ICU stay were associated with infection.

Mental health nurse prescribing: the emerging impact.

Some mental health nurses have now been prescribing for their clients for several years. When suitably qualified they can prescribe the same range of medication as medical staff. Concern was expressed that nurse prescribers might become more like doctors and as a result would sacrifice their nursing skills. The views of those who have their medication prescribed by mental health nurses as well as views of nurse prescribers, pharmacist prescribers, nurse managers and doctors were explored by using interviews and focus groups. Most participants saw the inclusion of prescribing in the nursing role as a benefit to clients. Rather than detracting from the nurse patient relationship, results from this study suggest that the nurse patient relationship was improved and more holistic care was provided. Nurse prescribing is well received by those who have experienced it. As nurse prescribing effects a change of power dynamics this could result in the need for less involvement of the medical profession in clients' care. As clients found nurses easier to talk to about their medication than doctors, medication concordance could be increased. Medication reconciliation could also be increased as medications no longer required by clients were more likely to be reduced or stopped by nurse prescribers. Discontinuing medication may indicate a new culture around mental health nurse prescribing. It may be that this trend has an impact on future service provision to clients. Results suggest that clients prefer to have their medication prescribed by nurses. Mental health nurse prescribing has been established in some areas in the UK for quite some time. Other than speculation that nurse prescribing would have a detrimental effect on the nurse-patient relationship, little has been written about the impact of nurse prescribing to date. Bradley and Nolan found that prescribing allowed nurses to overcome difficulties in the health-care system which would have previously delayed clients' access to medicines. Prescribing was believed to compliment many aspects of nursing and integrated previously diffuse aspects of the nursing role. Latter and Courtenay found that clients were generally satisfied with nurse prescribing. The aim of this study was to explore the impact mental health nurse prescribing has had on those involved. The views of clients, nurse prescribers, pharmacist prescribers, nurse managers and doctors were investigated. Questionnaires were used to gather demographic data and basic qualitative data. Focus groups and interviews were undertaken with 57 participants. The study was undertaken within one National Health Service Foundation Trust in England. Data analysis was guided by a framework approach. The majority of participants believed that the inclusion of prescribing in mental health nurses' roles improved the nurse-patient relationship, and five themes including the relationship, concordance, power, treatment approach and 'unprescribing' emerged. Trust was highly valued, and clients found nurses easier to talk to about their medication than doctors. Rather than detracting from the nurse-patient relationship, results from this study suggest that nurse prescribing enables mental health nurse prescribers to provide more holistic care than previously.

Mental health nurse prescribing: using a constructivist approach to investigate the nurse-patient relationship.

Nurse prescribing has been embraced in many areas of nursing, but less so in mental health. Relatively few studies have been published in this field with even fewer asking clients who have their medication prescribed by a mental health nurse about their views. This paper reports findings concerning the mental health nurse prescriber-patient relationship. It draws on data from a qualitative study, which was undertaken in one mental health National Health Service Foundation Trust in England to ascertain the views of clients and other stakeholders (nurse prescribers, pharmacist prescribers, nurse managers and doctors) about nurse prescribing. Data were collected by interview (either face to face or telephone) or focus group. Following Framework analysis, findings revealed that clients liked to have their nurse prescribe for them as they valued the pre-established relationship. They also valued the consistency of seeing the same person and the relative ease of access to appointments. Doctors and nurse managers were aware of positive feedback from clients. Nurse prescribers believed that nurse prescribing provided an enhanced service to clients.

Does the '2012 IUSTI ECCG report on the diagnosis and management of Neisseria gonorrhoeae infections in Europe' depict the situation in Europe?

Gonorrhoea is a major public health concern globally. Of particular grave concern is that resistance to the third generation cephalosporins has been identified during recent years. This paper summarises and discusses the results of the '2012 IUSTI European Collaborative Clinical Group (ECCG) report on the diagnosis and management of Neisseria gonorrhoeae infections in Europe'. Although high quality care was reported in many settings, in several other countries the testing, diagnostics, antimicrobial treatment and follow-up of gonorrhoea patients need to be optimized. This, together with increased access to and use of antimicrobial susceptibility testing, is crucial in controlling the emergent spread of cephalosporin-resistant and multidrug-resistant gonorrhoea.

Intra-operative correction of acidosis, coagulopathy and hypothermia in combat casualties with severe haemorrhagic shock.

We assessed acidosis, coagulopathy and hypothermia, before and after surgery in 51 combat troops operated on for severe blast injury. Patients were transfused a median (IQR [range]) of 27 (17-38 [5-84]) units of red cell concentrate, 27 (16-38 [4-83]) units of plasma, 2.0 (0.5-3.5 [0-13.0]) units of cryoprecipitate and 4 (2-6 [0-17]) pools of platelets. The pH, base excess, prothrombin time and temperature increased: from 7.19 (7.10-7.29 [6.50-7.49]) to 7.45 (7.40-7.51 [7.15-7.62]); from -9.0 (-13.5 to -4.5 [-28 to -2]) mmol.l⁻¹ to 4.5 (1.0-8.0 [-7 to +11]) mmol.l⁻¹; from 18 (15-21 [9-24]) s to 14 (11-18 [9-21]) s; and from 36.1 (35.1-37.1 [33.0-38.1]) °C to 37.4 (37.0-37.9 [36.0-38.0]) °C, respectively. Contemporary intra-operative resuscitation strategies can normalise the physiological derangements caused by haemorrhagic shock.

Development of a validated patient satisfaction survey for HIV clinic attendees.

Patients are becoming more actively involved in decisions about their care and have greater influence to change and improve the quality of services by reporting their experiences. A recent systematic review failed to reveal a method of measuring HIV patient satisfaction that reflects their experience of contemporary treatment and care. The aim of this study was to design a specific HIV patient satisfaction questionnaire that can be used as a patient reported outcome measure. Key themes in the systematic review were identified and used as a topic guide for focus group discussion to confirm their relevance and importance. HIV patients were also interviewed about their motivation to complete a questionnaire. The data from the focus groups and interviews were used to develop an initial questionnaire and cognitive testing was used to provide face validity for the questionnaire design, layout and wording. A revised version was used in a pilot study of 80 respondents, which demonstrated that the questionnaire's completion rate and content validity were high.

Mental health nurse independent prescribing: what are nurse prescribers' views of the barriers to implementation?

This paper reports a pilot study exploring mental health nurse prescribers' perceptions of barriers to prescribing independently but also includes perceptions of barriers to supplementary prescribing. Current prescribing practice as experienced by mental health nurses suggests a need to identify and highlight these barriers. A mixed methodology explanatory sequential study was carried out over 3 months in Scotland in 2008 as part of a Master's degree. A questionnaire was completed by 33 mental health nurse prescribers. A focus group was conducted with 12 mental health nurse prescribers. Participants' views exposed a number of barriers to prescribing previously unidentified in a review of the relevant literature, and concurred with some previously documented barriers. Sixty per cent of mental health nurse prescribers in the study were not prescribing. Barriers identified in the study included concern about how prescribing impacts on the therapeutic relationship, role conflict, lack of support, inappropriateness of prescriber training, remuneration, qualifying to prescribing time, supervision, prescribing policies, clinical governance and nurse management. Nurse prescribing involves increased accountability and responsibility which is not currently recognized in job status or pay banding. Mental health nurse prescribing has the potential to enhance service provision, but until barriers to prescribing have been identified and addressed as part of the process of organizational change, nurse prescribing cannot achieve its maximum potential.

Using patient experience to measure the quality of HIV care.

Measurement of health-care quality in the UK is no longer restricted to evaluating the effectiveness of treatments or the cost efficiency of services. There is a drive towards a patient-based agenda which enables them to make a clear contribution to the way services are shaped by expressing their values and sharing experiences. Positive engagement with HIV care has proven benefits to patients and the mandatory use of standardized reported outcome measures provides an opportunity to include HIV patients in the process of creating and refining an evaluation tool which places emphasis on aspects of care that are significant to them. Ultimately, this will provide services users with a stronger voice to guide appropriate service change and support the continuing improvement of HIV care.

Patient-derived outcome measures for HIV services in the developed world: a systematic review.

This review sought to establish the themes and approaches used in the measurement of patient satisfaction regarded by HIV service users as crucial to improving service quality. It also investigated how feedback has been measured previously and whether a gold standard instrument exists that is generalizable across HIV inpatient and clinic settings. Twelve databases and other sources yielded 1474 titles. Using a clinically-focused question and pre-defined inclusion and exclusion criteria, 32 articles were retrieved and reviewed for quality using a quality appraisal checklist. Two reviewers used a data extraction form to identify and verify key patient experiences. Thematic analysis revealed that clinic staffs' current knowledge of HIV was an essential factor in positive feedback. Treating patients with dignity and respecting their autonomy and confidentiality were also important. Developments in treatment, extended life expectancy and quality of life have altered patients' experience and level of satisfaction. Three instruments developed to assess patient satisfaction with HIV care were identified but there was no gold standard method of measuring it. There is a need to develop a specific, valid instrument that is easy to complete and analyse, and the data should be used to inform the redesign of services to promote a dynamic model of care.

The impact of genital warts: loss of quality of life and cost of treatment in eight sexual health clinics in the UK.

OBJECTIVES: To estimate the loss of quality of life and cost of treatment associated with genital warts seen in sexual health clinics. METHODS: A cross-sectional questionnaire study and case note review of individuals with genital warts, carried out in eight sexual health clinics in England and Northern Ireland. Individuals with genital warts attending the participating clinics were invited to take part in the questionnaire study. 895 participants were recruited. A separate sample of 370 participants who had attended a participating clinic with a first visit for a first or recurrent episode of genital warts between April and June 2007 was included in the case note review. Quality of life was measured using the EQ-5D questionnaire and the cost of an episode of care was derived from the case note review. RESULTS: The weighted mean EQ-5D index score was 0.87 (95% CI 0.85 to 0.89). The weighted mean disutility was 0.056 (95% CI 0.038 to 0.074). The estimated mean loss of quality-adjusted life-years associated with an episode of genital warts was 0.018 (95% CI 0.0079 to 0.031), equivalent to 6.6 days of healthy life lost per episode. The weighted mean cost per episode of care was £94 (95% CI £84 to £104), not including the cost of a sexually transmitted infection screen. CONCLUSIONS: Genital warts have a substantial impact on the health service and the individual. This information can be utilised for economic evaluation of human papillomavirus vaccination.

Mechanical evaluation of a tapered thread-run-out half-pin designed for external skeletal fixation in small animals.

An in vitro mechanical study was performed to compare the stiffness, maximum load, and cyclic load-to-failure of a new external fixation half-pin design utilizing a tapered thread-run-out (TRO) feature with currently available positive profile thread (PP) half-pins. Five different sizes of each of the two pin types were evaluated. Under static loading, TRO pins were significantly stiffer and had a higher maximum load compared to the similar sized PP pins (p <0.0001 for all comparisons). In cyclic fatigue testing, TRO pins lasted 2.3- to 4.9-fold more cycles than PP pins of similar size (p <0.0001 for all comparisons). The increased pin stiffness and improved cyclic lifespan provided by TRO pins may be especially valuable in the stabilization of biologically and mechanically challenging fracture cases where healing is prolonged.

Development of a validated patient satisfaction survey for sexual health clinic attendees.

Patient experience of and satisfaction with health-care services is increasingly being used to evaluate and guide health-care provision. A recent systematic review failed to identify a validated method of measuring patient satisfaction in sexually transmitted infection (STI) clinics. The aim of this study was to design and validate a specific STI clinic patient satisfaction survey that could be used as a patient-derived outcome measure. Key themes of importance to patients were identified from a recent systematic review of STI clinic patient satisfaction surveys. Semi-structured interviews were performed with patients attending a sexual health clinic to further refine these themes, and then used to compile a patient questionnaire. Cognitive testing was used to provide face validity for the questionnaire design, layout and wording. The questionnaire was further reviewed and revised by the research team prior to being piloted over a five-week period. Five key patient themes were incorporated into the questionnaire and the pilot phase included responses from 936 patients. The completion rate for individual items and the whole questionnaire (95% [885/936]) was high. Internal consistency and validity also scored highly.

Is non-invasive testing for sexually transmitted infections an efficient and acceptable alternative for patients? A randomised controlled trial.

OBJECTIVES: A randomised controlled trial was conducted to assess and quantify the efficacy and acceptability of non-invasive testing (NIT) for sexually transmitted infections (STI) in asymptomatic patients within a genitourinary medicine clinic. METHODS: Patients were randomly assigned to either standard of care (SOC-STI testing with genital examination) or NIT. The length of time patients spent in the clinic was recorded and patients were asked to complete a satisfaction survey. RESULTS: 391 participants were randomly assigned. The length of time male and female patients spent in the clinic was significantly shorter with NIT (men 26 min; women 23 min) compared with SOC (men 41 min; women 45 min, p<0.0001), but most of this decrease was due to reduced patient waiting time within the clinic, rather than less time spent with medical or nursing staff. Those randomly assigned to NIT were significantly more likely to state they were in clinic for less time than expected (p<0.01) and report that the tests were less uncomfortable than expected (p≤0.04). For both men and women, more patients in the SOC group declined testing for syphilis (14%) and HIV (20%) compared with NIT (7% and 13%, respectively), but this was only significantly different between treatments for female patients (p≤0.02). CONCLUSIONS: NIT for STI in asymptomatic patients can reduce the time patients spend in the clinic when combined with appropriate patient care pathways, and is an acceptable alternative to physician-taken genital swabs.

Previous history of gonococcal infection as a risk factor in patients presenting with gonorrhoea.

Recidivism is common in patients infected with gonorrhoea. Identifying the factors most closely associated with recurrent gonococcal infection can help to target health promotion and disease prevention interventions. A case-control study design was used to quantify the importance of past infection as a risk marker for gonorrhoea while controlling for other demographic and behavioural factors. Data were available for 134 cases of gonorrhoea and 150 controls. A history of gonorrhoea (odds ratio [OR] 4.36 [95% CI 1.78-10.71]) was the strongest predictor of current infection. The number of partners in the last month (OR 2.19 [95% CI 1.20-4.02]) was also significantly associated with a diagnosis of gonorrhoea. Patients presenting with gonorrhoea are a specific high-risk group who require additional interventions and should be prioritized for evidence-based, enhanced and interactive counselling.

A comparison of treatment outcomes for moxifloxacin versus ofloxacin/metronidazole for first-line treatment of uncomplicated non-gonococcal pelvic inflammatory disease.

Large randomized controlled trials support the efficacy of moxifloxacin for the treatment of uncomplicated pelvic inflammatory disease (PID). This study compares the clinical outcome and tolerability of treatment with moxifloxacin 400 mg once a day or ofloxacin 400 mg plus metronidazole 400 mg both twice daily in patients diagnosed with PID. A retrospective case-notes review was performed on patients diagnosed clinically with PID before and after local guidelines were changed to recommend moxifloxacin as first-line treatment for uncomplicated PID. Before the guidelines changed, 114/134 (85%) patients received the recommended first-line therapy versus 206/257 (80%) after the change, P = 0.3. There was no difference in the clinical outcomes between the two groups; significant improvement/resolved 77% versus 70%; marginal improvement 3% versus 11%; no change/worse 20% versus 18%, P = 0.14. Moxifloxacin is confirmed to be an effective alternative to ofloxacin/metronidazole for the treatment of PID in a large urban genitourinary clinic setting.

A randomized double-blind comparison of moxifloxacin and doxycycline/metronidazole/ciprofloxacin in the treatment of acute, uncomplicated pelvic inflammatory disease.

This multicentre, double-blind study was undertaken to demonstrate non-inferiority of once-daily oral moxifloxacin compared with combination therapy in the management of acute, uncomplicated pelvic inflammatory disease (PID). Women aged >or=18 years with PID were randomized to receive moxifloxacin (400 mg once daily) for 14 days or comparator treatment (doxycycline [100 mg twice daily] plus metronidazole [400 mg three times daily] for 14 days, plus one single 500-mg ciprofloxacin dose). Of the 434 valid per protocol (PP) patients, the overall clinical success rates at 2-14 days post-therapy were 96.6% (moxifloxacin) and 98.0% (comparator); moxifloxacin was non-inferior to the comparator regimen both in the PP (95% confidence interval [CI]: -4.5, 1.6) and intent-to-treat (95% CI: -5.8, 6.9) populations. Clinical success rates at 21-35 days post-therapy were 93.8% (166/177; data missing for 47 patients) for moxifloxacin and 91.3% (147/161; data missing for 37 patients) for the comparator. Bacteriological success rates at 2-14 days post-therapy were 92.5% (moxifloxacin) and 88.2% (comparator). Once-daily dosing and proven efficacy suggest that moxifloxacin may be of value in acute, uncomplicated PID.

Measuring patient satisfaction in sexually transmitted infection clinics: a systematic review.

OBJECTIVES: Measuring patient satisfaction is an important aspect of making services attractive to patients and improving service delivery, and outpatient-based clinics are increasingly assessing service quality using patient-based outcome measures. No systematic review of patient satisfaction in sexually transmitted infection clinics has previously been performed. The objectives of the review were: (1) to establish how patient satisfaction with sexual health services has been defined and measured; (2) to identify whether a "gold standard" method exists; and (3) to identify the themes regarded by patients as priorities for delivering a quality service within a sexually transmitted infection clinic setting. METHODS: A search of eight electronic journal databases and unpublished data sources was used to identify studies measuring patient satisfaction in a sexually transmitted infection clinic setting. Following initial review of each abstract, data from eligible studies were extracted by two independent reviewers and content analysis used to identify common themes. RESULTS: Eighteen questionnaire-based studies, nine semistructured interviews and four other studies, including three focus groups, fulfilled the selection criteria for inclusion. Three studies incorporated more than one method of analysis. No common validated method of assessing patient satisfaction was identified. Themes reported to be of greatest importance were the convenience of clinic location, availability of appointments, staff attitude to patients, effective provision of information and maintenance of confidentiality. CONCLUSIONS: This review has identified the need for a validated and standardised approach to assess patient satisfaction in sexually transmitted infection clinics. Comparing studies which have measured satisfaction, clear themes for the provision of a high quality service, from a patient perspective, have emerged. These themes should be incorporated into assessment tools, such as questionnaires, when reviewing service delivery.

Mycoplasma genitalium in asymptomatic patients: implications for screening.

OBJECTIVES: Mycoplasma genitalium is well established as a cause of urethritis and has also been associated with cervicitis, endometritis and pelvic infection. Low rates of infection suggest screening may be inappropriate in the general population, but it remains unclear whether asymptomatic patients attending a sexual-health clinic should be tested routinely. The objective of this study was to measure the positivity rate of M genitalium infection in asymptomatic individuals presenting to a sexual-health clinic to inform the need for screening in this population. METHODS: Asymptomatic patients were identified using a structured questionnaire and tested for M genitalium from genital swabs or urine using two separate polymerase chain reaction (PCR) assays incorporating different primer sequences. RESULTS: 1304 patients were approached over a 6-month period. 743 (57%) patients were symptomatic, and 168 (13%) refused consent, leaving 394 (30%) patients who entered the study. Residual samples were available for 308 (79%) patients, 168 (54%) men and 140 (46%) women. 14/308 (4.5%, 95% CI 2.2 to 6.9%) asymptomatic patients were infected with M genitalium, and an additional 2 (0.6%, 95% CI 0.2 to 2.3%) patients had discrepant PCR results. No significant associations were found between M genitalium infection and age, gender, ethnicity or isolation site. CONCLUSION: The positivity rate of M genitalium infection in asymptomatic sexual-health clinic attendees is comparable with that of gonorrhoea or chlamydia, and, if evidence of pathogenicity continues to accumulate, a further assessment of the role of routine screening in this setting would be appropriate.