The effect of electronic patient records (EPR) on the time taken to treat patients with genital Chlamydia infection.

OBJECTIVES: To measure the time taken to recall and treat patients with untreated Chlamydia attending a sexual-health clinic before and after the introduction of electronic patient records (EPR). METHODS: 52 consecutive qualifying patients were identified for January to March 2007 (paper case records) and 2009 (EPR). For each, the patient time intervals were measured between each of following dates: first attendance, first positive result received, first attempted patient contact and attendance for treatment. RESULTS: Between 2007 and 2009, the median time taken to treat a patient after receipt of a positive Chlamydia result fell by 11.5 days (median 15 days in 2007, 3.5 days in 2009). The time between first attendance and treatment was reduced by 9.5 days (median 21 days in 2007, 11.5 days in 2009) despite results taking 2 days longer to arrive in 2009. The proportion of patients treated within 2 weeks of a positive result rose from 38% in 2007 to 94% in 2009. Compared with paper notes, EPR decreased the time to recall, by eliminating three time-delaying patient recall processes. By ensuring more accurate patient recall information, EPR also lead to a higher proportion of patients successfully recalled by telephone (26/44, 59% vs 46/52, 88% in 2007 and 2009 respectively), leading to earlier treatment. CONCLUSIONS: The 'time to treat' interval was dramatically reduced following the introduction of EPR. Clinics using paper notes should consider switching to EPR as a means of improving STI recall efficiency.

Trends in HIV testing and recording of HIV status in the UK primary care setting: a retrospective cohort study 1995-2005.

OBJECTIVES: To provide nationally representative data on trends in HIV testing in primary care and to estimate the proportion of diagnosed HIV positive individuals known to general practitioners (GPs). METHODS: We undertook a retrospective cohort study between 1995 and 2005 of all general practices contributing data to the UK General Practice Research Database (GPRD), and data on persons accessing HIV care (Survey of Prevalent HIV Infections Diagnosed). We identified all practice-registered patients where an HIV test or HIV positive status is recorded in their general practice records. HIV testing in primary care and prevalence of recorded HIV positive status in primary care were estimated. RESULTS: Despite 11-fold increases in male testing and 19-fold increases in non-pregnant female testing between 1995 and 2005, HIV testing rates remained low in 2005 at 71.3 and 61.2 tests per 100,000 person years for males and females, respectively, peaking at 162.5 and 173.8 per 100,000 person years at 25-34 years of age. Inclusion of antenatal tests yielded a 129-fold increase in women over the 10-year period. In 2005, 50.7% of HIV positive individuals had their diagnosis recorded with a lower proportion in London (41.8%) than outside the capital (60.1%). CONCLUSION: HIV testing rates in primary care remain low. Normalisation of HIV testing and recording in primary care in antenatal testing has not been accompanied by a step change in wider HIV testing practice. Recording of HIV positive status by GPs remains low and GPs may be unaware of HIV-related morbidity or potential drug interactions.

Is accelerated partner therapy a feasible and acceptable strategy for rapid partner notification in the UK?: a qualitative study of genitourinary medicine clinic attenders.

Partner notification (PN) in the UK is of limited effectiveness. Expedited partner therapy improves PN outcomes but does not comply with existing UK professional guidance. We developed two new strategies, known as accelerated partner therapy (APT), based on elements of PN practice for which there is evidence of efficacy, and which conform to UK prescribing guidance. We explored the acceptability and feasibility of these models qualitatively in genitourinary medicine clinic attenders. Both strategies were viewed favourably. Preference was influenced by age, relationship type, whether participants were delivering or receiving APT and whether the sex partner was aware of the participant's clinic visit. APT provides a new approach to PN, which has strong patient support and complies with existing UK regulations. The complex factors that influence patients' choice of PN method suggest that provision of a range of PN options including APT may be central to improving the effectiveness of PN in the UK.

Management of rape/sexual assault cases within genitourinary medicine clinics: results from a study in North Thames.

A regional audit was undertaken to evaluate current practice in the management of survivors of sexual assault (SA) seen in genitourinary (GU) medicine clinics in the North Thames. The majority of the survivors were women. Most were fast-tracked, or seen in dedicated SA clinics. Over 60% of staff had specific training in management of SA. Core services provided included screening and treatment for sexually transmitted infections, emotional support, emergency contraception and hepatitis B vaccination. The sexual health needs of these survivors of SA are being met by most clinics. The development and use of a standardized care proforma across the region may be a means to further improve the care provided.

Survey of HIV and hepatitis B or C co-infection management in the UK 2004.

The objective of this study is to evaluate the current management practices of patients with HIV and hepatitis B or C co-infection. A postal survey was made of 186 clinics in the UK between October 2003 and January 2004. In total, 100/186 (54%) clinics responded: 16% estimated their hepatitis B prevalence to be above 10%, 27% estimated their hepatitis C to be above 10%. Problems were identified in a minority of clinics including: not routinely screening HIV-positive patients for hepatitis C (6%), restrictions on diagnostic tests required for the management of hepatitis infection and offering inappropriate treatment for hepatitis B infection. The use of diagnostic liver biopsies varied and clinics reported restrictions on access to hepatitis C therapy, with a consequent impact on waiting times. In conclusion, we identified several areas of concern in the diagnosis and management of HIV/hepatitis co-infection in several UK HIV treatment centres.

Assessment of the impact of the London Olympics 2012 on selected non-genitourinary medicine clinic sexual health services.

With minimal information on sexual health provision during mass-gathering events, our aim was to describe the use of sexual health, contraceptive, sex worker and sexual assault services during the London 2012 Olympics. We analysed data from five sources. One contraceptive service provider reported a 10% increase in attendance during the main Games, while emergency contraception prescriptions rose during the main Olympics, compared to the week before, but were similar or lower than at the beginning and end of the summer period. A health telephone advice line reported a 16% fall in sexual health-related calls during the main Olympics, but a 33% increase subsequently. London sexual assault referral centres reported that 1.8% of sexual assaults were Olympics-linked. A service for sex workers reported that 16% started working in the sex industry and 7% moved to London to work during the Olympics. Fifty-eight per cent and 45% of sex workers reported fewer clients and an increase in police crack-downs, respectively. Our results show a change in activity across these services during the 2012 summer, which may be associated with the Olympics. Our data are a guide to other services when anticipating changes in service activity and planning staffing for mass-gathering events.

Suppression of HIV p24 antigen and induction of HIV anti-p24 antibody by alpha interferon in patients with chronic hepatitis B.

Five HIV p24 antigen (p24Ag)-positive patients received alpha interferon during trials of therapy for hepatitis B. Four of these showed marked falls in p24Ag during treatment. One of the two patients who became p24Ag-negative [corrected] developed anti-p24 antibodies (anti-p24). Five out of nine p24Ag-negative HIV-antibody-positive patients showed a rise in anti-p24 titres during interferon therapy, whereas only two out of six untreated controls showed a similar rise. This study provides evidence that alpha interferon has anti-HIV activity in vivo.

Short report: prednisolone withdrawal followed by lymphoblastoid interferon in the therapy of adult patients with presumed childhood-acquired chronic hepatitis B virus infection.

Eighteen patients with presumed childhood acquisition of chronic hepatitis B virus infection were initially entered into this randomized controlled trial. Twelve were treated with prednisolone for 4 weeks followed, after a 2-week gap, by thrice weekly lymphoblastoid alpha-interferon for 12 weeks. Two of these had previously acted as untreated controls. Three of the 12 patients (25%) [who were initially hepatitis B virus (HBV) surface antigen (HBsAg), 'e' antigen (HBeAg) and HBV-DNA positive] became HBeAg and HBV-DNA negative during therapy and remained so after 12 months post-therapy follow-up. One of these also lost HBsAg. A further two patients lost HBeAg and HBV-DNA during therapy but relapsed 6 and 9 months later. Two additional patients were HBV-DNA negative but HBeAg positive at the end of follow-up. None of the eight untreated control patients seroconverted during an identical follow-up period. Two further patients were HBsAg and HBeAg positive but HBV-DNA negative at the start of therapy. These were omitted from the final analysis: both subsequently lost HBeAg. The treatment response was associated with a rise in aspartate aminotransferase, peaking 2-6 weeks after prednisolone withdrawal, loss of HBV-DNA 0-8 weeks later and subsequent normalization of liver function tests. Treatment was well tolerated.

Human lymphoblastoid interferon does not increase survival when added to mitozantrone in the treatment of hepatocellular carcinomas.

Human lymphoblastoid interferon, in an initial dose of 2.5 MU m-2 weekly i.m., was given with mitozantrone 12 mg m-2 i.v. every 3 weeks to 15 patients with hepatocellular carcinoma. The survival curve for these patients was worse than that of 15 patients previously treated with mitozantrone alone; there were more long-term survivors in those not given interferon; more side-effects were seen in the group given interferon. The addition of interferon to mitozantrone in the management of hepatocellular carcinoma is not recommended.

Management of HIV-related lymphoma in HIV treatment centres in North Thames Region.

We describe an audit of lymphoma care in HIV-positive patients. In the smaller units (< 500 patients) areas of potentially sub-optimal care were identified.

Management of HIV and hepatitis B or C co-infection in 15 HIV treatment centres. Disparity between protocols and practice.

Our aim was to ascertain current guidelines and clinical practices prevalent in HIV treatment centres in the North Thames Region of England on the care of patients co-infected with HIV and hepatitis B or C. A self-completed postal survey of clinic guidelines and retrospective case-note reviews was performed. Fifteen of the 27 units completed the survey and generally had clinic guidelines consistent with current national guidelines. Stated policy was usually to screen HIV patients for hepatitis B virus (HBV) and hepatitis C virus (HCV) and to offer specific therapy for the hepatitis as well as the HIV. Many units were unable to contribute cases to the case-note review, probably through lack of case-identification, and therefore 11 units contributed 27 case-note reviews on HIV/HBV and five units contributed 11 case-note reviews on HIV/HCV. Fifty-six percent (25/45) of patients of HBV patients were HBeAg+ve and 88% (22/25) of these had received specific hepatitis B therapy although for 59% (13/22) this was with lamivudine as part of a highly active antiretroviral therapy regimen. None of the HIV/HCV patients had received or been referred for HCV-specific therapy. Testing for hepatitis A immunity in HBV or HCV patients with a view to vaccination was done in only 50% although 96% of HIV/HCV patients had been screened for HBV. There are significant differences between the clinics' intended and actual management of HIV and chronic viral hepatitis co-infection.

Management of Chlamydia trachomatis genital tract infection in Genitourinary Medicine clinics in the United Kingdom's North Thames Region 1999.

Assessment of clinical management of Chlamydia trachomatis genital tract infection was made, with particular regard to the UK National Guideline. Questionnaires for self-completion, mailed to lead clinicians in 31 Genitourinary Medicine (GUM) clinics in the North Thames Region between May and June 1999, focused on policies and practice. Audit of actual management of up to 10 most recent cases (5 male and 5 female) attending each clinic within the past 2 years was also undertaken. Twenty-two units (71% response) completed the survey questionnaire and 23 units (74% response) audited a total of 229 cases (males=108, females=118, sex not stated=3). Findings indicate that GUM clinics are managing these infections largely as recommended in the national guideline. Nucleic acid amplification techniques will supersede established diagnostic tests for GUM clinics in North Thames, increasing costs for the service, but also sensitivity of detection.

Management of epididymo-orchitis in Genitourinary Medicine clinics in the United Kingdom's North Thames region 2000.

A questionnaire survey and case notes audit reviewing management of epididymo-orchitis (E-O) by 34 Genitourinary Medicine (GUM) clinics located in the North Thames was undertaken. Twenty-two clinics (65%) returned completed questionnaires and audited a total of 83 newly diagnosed cases. All participating clinics offer microscopy of urethral smears and screening for Neisseria gonorrhoeae and Chlamydia trachomatis to all patients, regardless of age. However, greater numbers of clinics would offer routine microbiology of mid-stream urine (MSU) samples (20/22, 91% versus 16/22, 73%) and scrotal ultrasound (5/22, 23% versus 1/22, 5%) to patients aged over 35, compared with men under 35. Half of the cases audited were due either to sexually transmitted infections (STIs) (41/83, 49%), or associated with ascending urinary tract infections (4/83, 5%). No obvious infectious cause was identified for 38/83 cases (46%). Reported management was appropriate for the causative conditions diagnosed and accorded with the UK National Guidelines for this and related conditions.

Diagnosis of Chlamydia trachomatis in North Thames region 2003.

A multi-centre re-audit of tests used for chlamydia diagnosis in GU medicine clinic attendees from February 2003 to March 2003 in the North Thames region showed improvements since our previous audit in 1999, with a significant increase in the proportion of clinics using nucleic acid amplification tests and non-invasive testing.

Treatment of Chlamydia trachomatis in North Thames region 2003.

Following on from the survey of techniques used for testing chlamydia, a multi-centre re-audit of the treatment of C. trachomatis in genitourinary clinic attendees in the North Thames region from February to March 2003 was performed. This showed an improvement since our previous audit with a significant increase in the number of centres following national guidelines in antibiotic prescribing and offering test of cure in clinically indicated cases.

Adherence to highly active antiretroviral therapy in the real world: experience of twelve English HIV units.

In order to describe how human immunodeficiency virus (HIV) clinics in and around London are trying to optimize their patients' adherence to highly active antiretroviral therapy (HAART), we performed a survey of practice and policy in the clinics using a postal questionnaire. Clinics were also asked to review up to 10 randomly selected case notes of patients receiving HAART and complete a questionnaire on each about how adherence was encouraged and assessed. Twelve clinics took part in the project and surveyed the notes of 89 patients. The results show that several clinics define adequate adherence as taking more than 95% of prescribed doses although there was no uniform definition across the participating units. Adherence was encouraged through simplifying HAART regimens, providing dose-dispensing boxes and alarms, arranging early follow-up for patients starting treatment, and offering continuing support through specific health care workers. Adequate discussion and provision of written information was seen as an important aid to adherence but the case note survey showed evidence of deficiencies in this area in approximately 40% of patients. Assessed levels of adherence were less than 95% in 27% of patients. The main reasons for suboptimal adherence were found to be lack of motivation to take treatment by the patients, high pill burden, and drug side effects although there were several other contributing factors. This study shows that the HIV units take HAART adherence seriously but there are several deficiencies in putting policy into practice.

Provision of Chlamydia trachomatis screening in family planning clinics and emergency contraception in genitourinary medicine clinics: a collaborative cross-speciality survey.

Two surveys were undertaken to review (1) provision of Chlamydia trachomatis screening by family planning (FP) clinics in the London region and (2) access to emergency contraception (EC) from genitourinary#10; medicine (GUM) clinics within the former North Thames region. The findings from the first survey suggest that there is insufficient screening (and treatment) in vulnerable groups attending FP clinics. Results#10; from the second survey show that hormonal EC is widely available from within GUM clinics, and those clinics also provide a range of other contraception services. However, these details may not be widely#10; recognised either by policymakers or the general public. #10;

Randomised controlled trial of lymphoblastoid interferon alfa in Europid men with chronic hepatitis B virus infection.

OBJECTIVE: To confirm the findings of pilot studies that interferon alfa is an effective treatment of Europid men with chronic hepatitis B virus infection. DESIGN: Randomised controlled trial of three months treatment with interferon alfa followed by 12 months of observation. SETTING: Outpatient clinic of a tertiary referral centre. PATIENTS: 37 Treated men (six anti-HIV positive) and 34 untreated men (nine anti-HIV positive) who met the criteria for the trial. Four controls failed to complete follow up. INTERVENTIONS: The treated group received subcutaneous injections of 5-10 MU interferon alfa/m2 daily for five days, then 10 MU/m2 thrice weekly for 11 weeks. Follow up continued at monthly intervals for 12 months. Untreated controls were monitored over the same period. MAIN OUTCOME MEASURE: Hepatitis B e antigen and hepatitis B virus DNA state after 15 months of observation. RESULTS: 12 Of the 37 treated patients cleared hepatitis B e antigen and hepatitis B virus DNA, whereas only one of 30 untreated controls seroconverted over the same period--an increased response rate of 29% (95% confidence interval 13% to 45%). The life table estimate of response at 15 months was 35% in treated patients, an increase of 32% above controls (95% confidence interval 16% to 48%). The response rates in groups by predictive pretreatment variables were 12 of 31 anti-HIV negative patients (excess response 34%; 95% confidence interval 14% to 54%), 12 of 26 with chronic active hepatitis before treatment (excess response 46%; 27% to 65%), and 12 of 21 with a pretreatment serum aspartate aminotransferase activity greater than 70 IU/l (excess response 46%; 16% to 76%). The combination of these factors predicted response with a sensitivity of 100% and a specificity of 80%. Four of the 12 responders, who had all been infected for less than two years, also lost hepatitis B surface antigen. Treatment was well tolerated. CONCLUSIONS: Interferon alfa is effective in the treatment of a proportion of Europid men with chronic hepatitis B virus infection, who might be identified before treatment. Additional strategies are required to improve the rate of response.

The use of an electronic checklist in the electronic patient record to achieve annually recommended outcomes based on British HIV Association guidelines.

An electronic search was performed of the electronic patient record (EPR) system to identify whether each of 13 key interventions recommended by the British HIV Association (BHIVA) had been performed for all eligible patients attending in 2009 and 2010 at one of our HIV clinics: 345 and 358 eligible HIV-positive patients were identified in 2009 and 2010, respectively. The success rates for having completed each intervention in 2009 and 2010, respectively, were all better for 2010 and none was <94%. These improved results in 2010 over those of 2009 could be attributed to the clinicians' improved experience in using the checklist and the facility of EPR to provide flagged reminders.