Pre-exercise screening and health coaching in CHD secondary prevention: a qualitative study of the patient experience.

Secondary prevention programmes can be effective in reducing morbidity and mortality from coronary heart disease (CHD). In particular, UK guidelines, including those from the Department of Health, emphasize physical activity. However, the effects of secondary prevention programmes with an exercise component are moderate and uptake is highly variable. In order to explore patients' experiences of a pre-exercise screening and health coaching programme (involving one-to-one consultations to support exercise behaviour change), semi-structured telephone interviews were undertaken with 84 CHD patients recruited from primary care. The interviews focused on patients' experiences of the intervention including referral and any recommendations for improvement. A thematic analysis of transcribed interviews showed that the majority of patients were positive about referral. However, patients also identified a number of barriers to attending and completing the programme, including a belief they were sufficiently active already, the existence of other health problems, feeling unsupported in community-based exercise classes and competing demands. Our findings highlight important issues around the choice of an appropriate point of intervention for programmes of this kind as well as the importance of appropriate patient selection, suggesting that the effectiveness of health coaching may be under-reported as a result of including patients who are not yet ready to change their behaviours.

Identifying opportunities for sexually transmitted infection prevention: analysis of critical points in the care pathways of patients with gonorrhoea.

We applied the principles of Hazard Analysis and Critical Control Points (HACCP) to systematically analyse the care pathway of patients diagnosed with gonorrhoea to identify potential intervention opportunities for preventive action. Data were collected on individuals with culture-positive gonococcal infection during 27 February 2003 to 08 January 2004. Qualitative data were gathered within individual semi-structured interviews. Two hundred and twenty-three gonorrhoea patient episodes were evaluated. The median interval between presentation and treatment was significantly longer in females and men having sex with men (MSM), compared with heterosexual men (P = 0.002). Females were significantly more likely to be in regular relationships at the timepoint of perceived infection acquisition than heterosexuals or MSM (P < 0.0001). Four major themes emerged from the interviews: life-stage and infection risk, determinants of risk perception around sexual encounters, attitudes to preventing re-infection and condom use. These informed three potential 'critical control points': health-related attitudes/behaviours preceding infection; access to appropriate care and optimizing health promotion to prevent further infection.

To what extent does Neisseria gonorrhoeae multiantigen sequence typing of gonococcal isolates support information derived from patient interviews?

Gonococcal isolates from genitourinary (GU) medicine clinic attendees in Glasgow, Scotland were typed using Neisseria gonorrhoeae multiantigen sequence typing (NG-MAST). Correlation between named partners (contacts) and NG-MAST type was sought and associations between specific NG-MAST types, and the social, epidemiological and geographical data were explored. We found NG-MAST typing to be a supportive and confirmatory tool for contact tracing. Specific NG-MAST types were found to be associated with distinct characteristics such as sexuality or chlamydial co-infection. An increased number of gonococcal infections were reported from those resident in deprived areas of Glasgow than from those resident in more affluent areas. However, there was no clear geographic clustering of specific NG-MAST types found within the city. Routinely observing the spread of common strains of gonorrhoea is likely best done from a larger geographical perspective unless a specific outbreak occurs.

What is the excess risk of infertility in women after genital chlamydia infection? A systematic review of the evidence.

OBJECTIVE: To summarise evidence on the attributable risk of infertility after chlamydial infection in women. METHODS: Twelve databases were searched, limited to peer-reviewed literature published from January 1970 to September 2007. Conference abstracts and reference lists from reviews published since 2000 and from key articles were hand-searched. Studies were selected for review if they met the following criteria: (1) the study population comprised women of child-bearing age (defined as 15-45 years) and incorporated a comparison group of women documented as "chlamydia negative"; (2) the study outcomes included either infertility or successful pregnancy; and (3) the study design was one of the following: cohort, randomised controlled trial, "before and after" study, screening trial and systematic review. Studies were excluded if they described genital infections that either did not include Chlamydia trachomatis or described genital chlamydial co-infection, in which no data were available for C trachomatis infection alone. RESULTS: 3349 studies were identified by the search. One study satisfied the inclusion criteria, a longitudinal investigation measuring pregnancy rates in adolescent women with and without current chlamydial infection at baseline. That study reported no significant difference in subsequent pregnancy rates; however, it had serious methodological limitations, which restricted its conclusions. CONCLUSIONS: This systematic review demonstrates the absence of valid evidence on the attributable risk of post-infective tubal factor infertility after genital chlamydial infection. The findings contribute empirical data to the growing debate surrounding previous assumptions about the natural history of chlamydial infection in women.

Fusobacterium nucleatum bacteraemia with multiple liver abscesses in an HIV-I antibody positive man with IgG2 deficiency.

Liver abscess formation due to Fusobacterium nucleatum is rare. We describe an HIV-I antibody positive man, with normal surrogate markers of cell-mediated immunity, who presented with F. nucleatum bacteraemia and liver abscess formation. He was found to have IgG2 subclass deficiency. This case illustrates the clinical importance of altered B-cell function in patients who are at an early stage of HIV disease.

Chlamydia trachomatis in primary care: knowledge and practice in Glasgow.

A recent Department of Health report recommended the establishment of a selective screening programme for Chlamydia trachomatis infection. We report a survey which suggests that primary care clinicians may not yet be prepared for this task.

The sexual behaviour of international travellers at two Glasgow GUM clinics. Glasgow genitourinary medicine.

A survey of patients attending 2 Glasgow genitourinary medicine (GUM) clinics was conducted in 2 3-month periods in 1993 and 1994. Three hundred and twenty-five attendees who had travelled abroad in the preceding 3 months completed anonymous self-administered questionnaires about their sexual behaviour during these recent journeys abroad. There were 112 women and 213 men (185 heterosexuals and 28 homosexuals). Twenty-two (19.6%) women, 56 (31%) heterosexual men and 13 (42%) homosexual men had a sexual contact with a new partner while abroad. Of those who had had a new sexual contact abroad, 11 women (50% of those who had sex with a new partner) and 33 heterosexual men (59% of those who had sex with a new partner) were inconsistent users of condoms. Analysis of data found that homosexual and heterosexual men, and business travellers, are at increased risk of exposure to sexually transmitted diseases, including HIV infection, and should be targeted with safer sex health promotion prior to travel.

Hepatitis C virus among genitourinary clinic attenders in Scotland: unlinked anonymous testing.

Our objective is to gauge the prevalence of hepatitis C virus (HCV) antibodies among a population at risk of contracting sexually transmitted infections (STIs) and, thus, the efficiency with which the virus is transmitted sexually. The investigators undertook an unlinked anonymous HCV antibody testing study of residual syphilis serology specimens taken from attenders of genitourinary clinics in Glasgow, Edinburgh and Aberdeen during 1996/97. The results were linked to non-identifying risk information. Anti-HCV prevalences among non-injecting heterosexual men and women, and non-injecting homosexual/bisexual males ranged between 0 and 1.2%; the only exception to this was a 7.7% (4/52) prevalence among homosexual/bisexual males in Aberdeen. The overall anti-HCV prevalence for homosexual/bisexual males was 0.6% (4/668), for heterosexual males 0.8% (32/4135), for heterosexual females 0.3% (10/3035) and for injecting drug users 49% (72/148). Only 3 (all female) of the 46 non-injectors who were antibody positive were non-UK nationals or had lived abroad. HCV antibody positive injectors were less likely to have an acute STI and more likely to know their HCV status than non-injectors; no differences in these parameters were found between positive and negative non-injectors on anonymous HCV antibody testing. Our findings are in keeping with the prevailing view that HCV can be acquired through sexual intercourse but, for most people, the probability of this occurring is extremely low. Interventions to prevent the spread of HCV should be targeted mainly at injecting drug user (IDU) populations.

Detection of Chlamydia trachomatis in genitourinary medicine clinic attendees: comparison of strand displacement amplification and the ligase chain reaction.

Nucleic acid amplification (NAA) methods for the diagnosis of genital Chlamydia trachomatis infection perform well but are technically demanding. Strand displacement amplification (SDA) assay is a new NAA method that offers technical simplicity but its comparative diagnostic performance is unknown. Here, we compare the diagnostic performance of ligase chain reaction with that of SDA in first-catch urine (FCU) samples from both male and female patients and in endocervical swab (ECS) specimens. Attendees (715 men, 291 women) of a city-centre genitourinary medicine clinic were studied. FCU specimens were collected from all the men and from 205 of the women in the study. Two ECS specimens were collected from each of the women. Discordant results were resolved using an in-house nested polymerase chain reaction technique. Samples positive in two out of the three assays were considered positive. Prevalence of C. trachomatis infection was 9.2% and 9.1% in the men and women, respectively. Sensitivity, specificity, positive predictive value and negative predictive value of SDA in FCU specimens from the men were 95.5%, 100%, 100% and 99.5%, respectively. In the female group, the figures for FCU and ECS specimens were 77.3%, 100%, 100% and 97.3%, and 90.9%, 100%, 100% and 97.3%, respectively. In this high-prevalence population, SDA assay is an effective method for the detection of C. trachomatis in FCU specimens in men and in ECS (but not FCU) specimens in women. Further studies in lower-prevalence populations are required.

Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening.

OBJECTIVES: To investigate the psychosocial impact for women of a diagnosis of Chlamydia trachomatis and discuss the implications for the proposed UK chlamydia screening programme. DESIGN: Qualitative study with semistructured interviews. Interview transcripts analysed to identify recurrent themes. PARTICIPANTS: Seventeen women with a current or recent diagnosis of chlamydia. SETTING: A family planning clinic and a genitourinary medicine clinic in Glasgow. RESULTS: Three themes were identified: perceptions of stigma associated with sexually transmitted infection, uncertainty about reproductive health after diagnosis, and anxieties regarding partner's reaction to diagnosis. Most women had not previously perceived sexually transmitted infections as personally relevant; this was a function of stereotypical beliefs about who was "at risk" of sexually transmitted infection. These beliefs were pervasive and negatively affected reactions to diagnosis and produced anxiety about disclosure of the condition to others (particularly sexual partners) and future reproductive morbidity. This anxiety, given the uncertain natural history of chlamydia, may prove difficult to dispel. CONCLUSIONS: There are three primary areas of concern for women after a diagnosis of chlamydia which need to be examined in the proposed screening programme. Information provided should normalise and destigmatise chlamydial infection and positively promote genitourinary medicine services. Support services should be available because notification of partner can cause anxiety. Uncertainty about future reproductive morbidity may be inevitable; staff providing screening will require guidance in providing advice under such conditions.

Using the evidence base on genital herpes: optimising the use of diagnostic tests and information provision.

There have been several important advances in the range of available diagnostic tests for genital herpes simplex virus (HSV) infection in recent years; polymerase chain reaction (PCR) is emerging in routine clinical use and the potential role of type specific serological tests is currently under debate. Several large trials of prophylactic vaccines, subsequently proved to be ineffective, have expanded knowledge of the transmission and epidemiology of HSV infection. This article discusses optimal application of recent research evidence to clinical care, structured around the key issues for patients and their partners. These include acquisition and transmission of genital HSV-1 and HSV-2 infection, the natural history of genital herpes, and the role of partner notification.

British Co-operative Clinical Group national survey on diagnostic issues surrounding genital herpes. MSSVD Special Interest Group on Genital Herpes and the British Co-operative Clinical Group.

OBJECTIVES: To investigate the current use of diagnostic methods for genital herpes simplex virus (HSV) infection, to determine how information from these tests influences clinical practice, and to identify areas for future guideline development within genitourinary medicine (GUM) clinics in the United Kingdom. METHODS: National survey of 173 consultants in UK GUM clinics. RESULTS: Completed questionnaires were returned by 146 (84%) consultants. Cell culture was the first line diagnostic method for 133 (91%) respondents, the remaining 13 (9%) used antigen detection tests. Typing of isolates (HSV-1 or HSV-2) was available in their local laboratory to 109 (75%) clinicians; however, less than two thirds routinely pass this information on to their patients. Although 74 (51%) respondents had access to serological diagnosis, the majority of methods described were non-specific; only three (2%) had access to type specific tests. Only 81 (56%) respondents frequently (> 90% of the time) recommend notification of recent sexual partners of genital herpes patients. CONCLUSIONS: While access to culture based diagnosis is widespread, type specific serology has limited availability. Information on typing of isolates as HSV-1 or 2, although available in three quarters of centres, is underutilized in counselling patients. As HSV type influences both clinical and subclinical reactivation rates and may also affect probability of transmission, this is an important omission. Future guidelines need to address the optimal use of viral typing and new diagnostic tests to optimise health gain; there is also a need for evidence based recommendations about partner notification in genital herpes.

Therapy for genital herpes in immunocompromised patients: a national survey. The Herpes Simplex Advisory Panel.

OBJECTIVES: To estimate the extent of aciclovir refractory herpes simplex virus (HSV) infection in HIV coinfected patients in the United Kingdom and survey clinicians on their approaches to its management. DESIGN: Questionnaire survey of representative sample of one third of United Kingdom HIV physicians. MAIN OUTCOME MEASURES: Use of antiviral therapies for genital HSV infections in HIV positive patients, reported frequency of aciclovir refractory HSV infection, its therapy, and access to antiviral susceptibility testing facilities. RESULTS: 53 responses were obtained (response rate 61%), representing a sample size of 23% of United Kingdom HIV physicians. Use of non-standard antiviral regimens for HSV infections in HIV coinfected patients was widely practised, irrespective of the clinical characteristics of the HSV infection. Aciclovir refractory HSV infection has been observed by 37 (70%) respondents. Although foscarnet was the most frequently used therapy, used by 27/37 (73%) respondents, in only seven of these 27 (19%) was it a first line treatment for aciclovir refractory cases, frequently being used at a late stage in the clinical course. Antiviral susceptibility testing facilities were available to 46 (87%) clinicians. No respondents reported any evidence of transmission of aciclovir resistant strains. CONCLUSIONS: HIV coinfection has a stronger influence on therapeutic choice than clinical immunosuppression or severity of herpetic infection. Aciclovir treatment failure is commoner than hitherto recognised. There is a need for wider awareness of use of foscarnet at an earlier stage in management of refractory HSV infection.

Group B streptococcus carriage and vulvovaginal symptoms: causal or casual? A case-control study in a GUM clinic population.

OBJECTIVES: The isolation of group B streptococcus (GBS) on routine swabs taken from genitourinary medicine (GUM) clinic attendees is a common finding. The relation of GBS to vulvovaginal symptoms is unclear, creating confusion about management. This case-control study tested the hypothesis that detection of GBS on routine clinical specimens is not causally related to vulvovaginal symptoms in female GUM clinic attendees. METHODS: Data were collected on all female GUM clinic attendees who had GBS isolated from anogenital swabs between July 1999 and July 2001. Controls were randomly selected from all new and rebooking female GUM clinic attendees. Controls were group matched for age with cases and were included only if a sexual health screen was performed and the results of this were available. RESULTS: 118 cases and 308 controls were identified during the study period. There was no significant difference between cases and controls in patient demographic or behavioural characteristics, the presence of genital co-infection, or vulvovaginal symptoms. There was no relation between symptoms and quantitative growth of GBS reported by the laboratory in either cervical or urethral swabs. Only nine cases had high vaginal swabs taken, in whom there was a significant association between a heavy growth of GBS and vulvovaginal symptoms (p=0.008). CONCLUSION: The isolation of GBS from routinely collected genital swabs in female attendees of a GUM clinic is not causally related to vulvovaginal symptoms. We recommend that patients should receive this advice and should not be treated with antibiotic therapy for this indication.

Mycobacterium avium-intracellulare infection in the acquired immunodeficiency syndrome.

Disseminated infection with Mycobacterium avium and M. intracellulare (MAI) is increasingly recognized as a significant contributor to both increased illness and death in patients with acquired immunodeficiency syndrome. Early reports of treatment of MAI were disappointing but recent studies have shown that combination antimycobacterial therapy may provide symptomatic relief and an improvement in mycobacteraemia.