2016 European guideline for the management of vulval conditions.

Vulval conditions may present to a variety of clinicians, such as dermatologists, gynaecologists and general practitioners. Women with these conditions are best managed by a multidisciplinary approach, which includes clear referral pathways between disciplines or access to a specialist multidisciplinary vulval service. Informed consent is a prerequisite for all examinations, investigations and treatments. Consent is particularly important for intimate examinations of the anogenital area, and a chaperone should be offered in all cases. All efforts should be made to maintain a patient's dignity. Depending on symptoms and risk factors, screening for sexually transmitted infections (STI) should be considered. If the patient presents with vulval itch, particularly if also complaining of increased vaginal discharge, vulvaginal candidiasis should be excluded. Sexual dysfunction should be considered in all patients with vulval complaints, either as the cause of the symptoms or secondary to symptoms, and assessed if appropriate. This guideline covers several aspects, such as diagnosis and treatment, of the more common vulval conditions (relatively) often encountered at vulval clinics, i.e. vulval dermatitis (eczema), psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, vulvodynia and vulval intraepithelial neoplasia (VIN).

The use of prophylaxis against HIV after sexual exposure in pregnancy to reduce the risk of vertical transmission.

We present a case demonstrating the use of HIV prophylaxis post-sexual exposure in pregnancy. This has not been presented before but has certainly been discussed.

Syphilis in pregnancy and the neonatal period.

The recent increase in the number of cases of syphilis in the UK, including among women of reproductive age, has stimulated the need for a review of practices concerning assessment and management of syphilis in pregnancy and the neonatal period. This paper summarizes available evidence from published guidelines, primary and secondary research. Optimal management of syphilis in pregnancy and the neonatal period relies on the early diagnosis and staging of maternal disease, prompt treatment to prevent congenital syphilis, and timely assessment of newborns.

The impact of the 2011 UK post-exposure prophylaxis for HIV following sexual exposure guidelines: a regional retrospective audit.

A re-audit of prescribing of post-exposure prophylaxis for HIV following sexual exposure in the Thames Valley demonstrated that an updated proforma has led to significant improvements in clinician-led outcomes, but had no impact on completion or follow-up rates.

Accuracy and consistency of KC60 diagnoses and coding in a department of genitourinary medicine.

The accuracy and completeness of KC60 coding is important to ensure that accurate local, regional and national data on sexually transmitted infections (STIs) are produced. Following alterations to the codes in 1995 a review of the process and accuracy in one department of genitourinary medicine was undertaken. Over a 6-month period 239 episodes and 407 diagnoses were reviewed in the notes of 172 patients. An error was found in 17.9% of diagnoses, and 32.6% of episodes had at least one error. Only one episode had been diagnosed but not coded. Subsequently the procedure for diagnosing episodes was altered and a subsequent review of 122 episodes and 239 diagnoses in the notes of 94 patients identified only 4 errors.

PPNG at St Thomas' Hospital--a changing provenance.

Between 1986 and 1992, 15% of all cases of penicillinase-producing Neisseria gonorrhoeae (PPNG) notified in the UK were seen at our central London clinic. During this time the geographical provenance of PPNG has changed. Africa and SE Asia have been supplanted by the Caribbean as the predominant source, with 21.4% of all cases being directly imported from there in 1992. If all gonococcal infections acquired outside the UK had been assumed to be PPNG, together with those occurring in patients with family origins in Africa or SE Asia, some 60% of cases of PPNG could have been predicted before laboratory confirmation of resistance. There is little evidence that PPNG has become endemic in the United Kingdom.

Men with repeated episodes of gonorrhoea 1990-1992.

Patients who acquire repeated infections of gonorrhoea are well described. A study was undertaken of male patients attending a central London clinic in an attempt to identify features of those acquiring repeated infections to facilitate risk reduction strategies. During the 3 years 1990 to 1992, 18.8% of patients contributed 35.8% of episodes with a mean time between episodes of 10.5 weeks. Those with repeat infections were more likely to be black and to have had more than one episode of gonorrhoea prior to the study period. They are also more likely to have had 3 or more recent partners. While those with repeated infections do not form a homogeneous group there are certain characteristics that should enable targeting of a subgroup.

Chlamydia trachomatis detection--is it doctor dependent?

The accuracy of tests for chlamydia depends, among other things, upon the quality of the clinical specimen. Most chlamydia tests do not allow comment on specimen quality. It has been shown that examination of Papanicolaou stains or Diff-Quik stains of endocervical secretions can be used to assess the quality of endocervical sampling. This study has found that by analysing surrogate markers, such as the rates of inadequate cervical cytology and chlamydia detection rates in patients not identified as chlamydia contacts, it is possible to identify doctors performing less well in cervical sampling without the need for extra tests.

Blood-borne virus infection: the occupational risks.

Healthcare workers who are in contact with patients and/or clinical material are at continuous risk of acquiring blood-borne viral infections, in particular, infection with hepatitis B virus, hepatitis C virus and the human immunodeficiency virus (HIV). Prevention of occupational exposure is dependent on education. Prevention strategies include immunization, exposure avoidance by the use of universal precautions at all times, and post-exposure advice and prophylaxis. This article will review the risks to healthcare workers associated with exposure to hepatitis B, hepatitis C, and HIV. It will discuss post-exposure management in the United Kingdom (UK) and briefly outline the risks to patients from infected healthcare workers.

Survey of risk behaviour and HIV prevalence in an English prison.

An anonymous, voluntary, linked cohort study was undertaken to determine the prevalence of HIV infection and identify risk factors for the spread of infection in an English prison. Three hundred and seventy-eight (68%) of the inmates participated. The HIV point prevalence was 0.26%. Injecting drug use (IDU) was the most significant HIV risk factor within 20% admitting IDU at any time, of whom 58% injected whilst in prison. Of those injecting in prison 73% shared needles. Two inmates admitted having sex with a male partner in prison. This study demonstrates that the potential exists in this setting for an outbreak of blood-borne virus infection; hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV infection. Injecting drug use and needle sharing represent the greatest risk.

'Get it on' in the millennium.

Over the Christmas and New Year period the Health Education Authority launched a sexual health promotion campaign aimed at increasing the awareness of and reducing the incidence of sexually transmitted infections (STIs) and unwanted pregnancy. We undertook a study to assess the effect of this campaign locally in 2 genitourinary medicine (GUM) clinics. From our study we concluded the following: (1) Although rarely performed, it is possible to assess the effectiveness of health promotion campaigns. (2) Genitourinary medicine clinics provide a good forum for the assessment of such campaigns. (3) The information obtained from such assessments can be valuable for effective targeting of future campaigns.

Clinical management of HIV disease in intravenous drug-users.

Intravenous drug-users comprise a major group of HIV-infected individuals in the developed world and, whilst progression of HIV disease in them appears little different from other risk groups, their medical presentations may be altered by continuing drug use. Drug-users are particularly susceptible to bacterial infections irrespective of their HIV status; they may present with symptoms directly caused by their drugs, which can be difficult to differentiate from non-drug-related causes and may closely resemble symptoms directly attributable to HIV. In addition, the life style associated with drug use can make compliance difficult, but in clinics combining HIV care and methadone prescribing these problems can be overcome.

Injury mortality in adults 25-64 years of age: implications for prevention.

The aim of this retrospective study was to identify major categories of death from injury in the age range 25 to 64 years and their potential for prevention. We analysed the Victorian Coroner's database of deaths from injury for the three years from 1989-90 to 1991-92. The major causes of death were suicide (39.9 per cent) and transport-related injury (30.2 per cent). Males accounted for 75.4 per cent of injury deaths. The highest mortality rate was in the youngest age group, 25 to 29 years. Deaths from injury in the study age range accounted for slightly more than half of all deaths from injury in Victoria, although this age group had a lower mortality rate than other age groups. Specific issues for prevention programs include reduction of access to carbon monoxide car emissions and prevention of transport-related injury to motor vehicle occupants. Data reliability issues identified in this study have implications for refinements of the Victorian Coroner's database and hence for the National Coronial Information System currently under development.

Injury prevention during physical activity in the Australian Defence Force.

INTRODUCTION: Injuries sustained by Australian Defence Force (ADF) personnel during non-combat military training and sports activity are associated with increasing costs due to work days lost, medical treatment, compensation, and early retirement. In 2001, the ADF commissioned a systematic review of the evidence-base for reducing injuries associated with physical activity, while at the same time improving physical activity participation rates to sustain a trained, fit and deployable workforce. METHOD: Literature from on-line library databases, relevant unclassified military reports, and material from previously published sport-specific injury countermeasure reviews were systematically and critically analysed to address the study aims. RESULTS: Modification of intensity, frequency and duration of basic military training activities and improved equipment is likely to reduce injury occurrence. Sports injury countermeasures used for the civilian population have merit for the ADF physical activity program. Injury countermeasures should be designed to minimise any possible deterrent effect on the motivation to participate in regular physical activity. Increasing the participation of ADF personnel in physical activity in the presence of evidence-based injury prevention strategies has the potential to increase health, fitness and deployability with minimal impact on injury frequency. CONCLUSION: Recommendations arising from the review include injury intervention trials in basic military training and sports. These and other interventions should be supported by refinement to ADF injury surveillance systems. Research should focus on interventions with the greatest gain for fitness, deployability, and cost effectiveness.

Hypophosphataemia with non-tenofovir-containing antiretroviral therapy.

Hypophosphataemia with tenofovir (TDF) treatment has been well described. The role of HIV infection and of other antiretroviral (ART) agents in hypophosphataemia has received less attention. The aim of this study was to determine the prevalence of hypophosphataemia in HIV-positive adults. We measured the fasting plasma phosphate level and estimated glomerular filtration rate (eGFR) in 123 HIV-positive patients. A total of 26% had hypophosphataemia and 11% had hypophosphataemia of grades 2-4 (0.65 mmol/L or less). Hypophosphataemia of any grade was more frequent in those who were ART-treated than ART-naive (35% versus 10%; P = 0.0001). Multiple linear regression analysis showed no significant association between phosphate level and gender, TDF status, duration of ART, duration of HIV infection and eGFR. Increasing age was significantly associated with a very small rise in phosphate level. Isolated hypophosphataemia was significantly more frequent in HIV-positive subjects receiving ART than ART-naive individuals, irrespective of the drug regimen.

Field vaccination of sheep with a larval-specific antigen of the gastrointestinal nematode, Haemonchus contortus, confers significant protection against an experimental challenge infection.

The availability of effective vaccines would add a valuable tool to the management of gastrointestinal nematode infections in livestock. While some experimental vaccines have shown protection in laboratory trials, few have been tested in the field. In the present study, eight month old sheep kept on pasture were treated with anthelmintic 8 weeks before vaccination with a larval surface antigen of the nematode parasite, Haemonchus contortus, under a commercially acceptable protocol, i.e. 2 immunizations using a commercial adjuvant; they were then given a controlled challenge infection 4 weeks later in indoor pens. Vaccination of sheep with 4 increasing doses of antigen resulted in significant reductions of 61% and 27% in cumulative faecal egg counts in the two highest dose groups, and a 69% reduction in worm burden in the highest dose group. Blood loss, as determined by packed cell volume, was also significantly reduced in the highest dose group of sheep. One outlier sheep showed an unusual increase in egg count without a concomitant increase in worm burden compared to the control sheep, indicating a vaccine-induced stress response. Antigen-specific serum antibody levels steadily increased in sheep while on pasture and decreased when transported to indoor pens. No difference in antibody levels could be detected between vaccinated and unvaccinated sheep, but all showed increased antibody levels compared to uninfected control sheep kept in indoors pens for 2-3 months, suggesting sheep were sensitized to the larval antigen either from low dose pasture contamination or cross reaction with pasture-related antigens. The results of these studies confirm the protective properties of the larval surface antigen and its protective effect when vaccinations are performed in the field.

European (IUSTI/WHO) guideline on the management of vaginal discharge, 2011.

Three common infections are associated with vaginal discharge: bacterial vaginosis, trichomoniasis and candidiasis, of which trichomoniasis is a sexually transmitted infection (STI). This guideline covers the presentation and clinical findings of these infections and outlines the differential diagnoses. Recommendations for investigation and management based on currently available evidence are made, including the management of persistent and recurrent infections.