Screening of males for Chlamydia trachomatis and Neisseria gonorrhoeae infections at STD clinics in three US cities -- Indianapolis, New Orleans, Seattle.

We assessed prevalence and risk factor data for men routinely screened for Chlamydia trachomatis and Neisseria gonorrhoeae in STD clinics in four US cities from May 1995-March 1999. Data were analysed separately for 'test-visits' (self-reported symptoms, clinical signs or sexual contact to an STD) and 'screen-visits' (STD screen only) for 32,595 men with 45,390 visits. Among test-visits in Seattle, Indianapolis and New Orleans, 8.7% (807/9285), 15.3% (1305/8519), and 10.1% (1551/15,296) of men were positive for C. trachomatis, and 10.2% (773/7543), 24.9% (2108/8478), and 30.4% (4746/ 15,629) for N. gonorrhoeae. Among screen-visits, 2.1% (88/4103), 7.3% (130/1790), and 5.6% (292/5183) of men were positive for C. trachomatis, and 1.8% (46/2576), 1.7% (31/ 1786), and 5.2% (274/5235) for N. gonorrhoeae. Positivity for screen-visits was particularly high among young men (15-24 years), and those reporting > 1 sex partner in the past 60 days. Substantial variation among sites in positivity warrants local determination of prevalence and risk factors to inform screening strategies.

Douching behaviors reported by adolescent and young adult women at high risk for sexually transmitted infections.

STUDY OBJECTIVE: To describe frequency of douching and reasons as timing to menses, vaginal symptoms, and coitus and the association of these behaviors to the diagnosis of three sexually acquired infections. DESIGN, SETTING, PARTICIPANTS: The study involved 160 females between the ages of 14 and 25 yrs attending a STD clinic and/or community adolescent health clinics. Subjects were eligible to enter the study if they had a positive test(s) for and/or were a contact of chlamydia, gonorrhea, trichomonas, and/or nongonococcal urethritis (NGU). Reevaluation for these infections occurred at the 1-month, 4-month, and 7-month visit with one-dose antibiotic treatment provided for positive tests. Data on douching was collected at the 7-month visit only. MAIN OUTCOME MEASURE: Results of tests for STI's using urine-based DNA-amplification techniques for chlamydia and gonorrhea and using self-obtained vaginal swabs for trichomonas culture. RESULTS: Nearly two-thirds (106/160) of the subjects ages 14-25 yrs completing the 7-month visit reported douching, with 67.7% (69/102) reporting douching once a month or more. Douching was more common in older, black participants, using injectable progestins for contraception. Douching was more common in those reporting more recent sexual partners. Douching related to menses was not associated with any of the three infections, while douching related to symptoms and coitus was associated with positive tests for infections. CONCLUSIONS: Results suggest that for this subset of teens at high risk for sexually acquired infections, douching is a commonly reported behavior. This study suggests that the linkage of douching and sexually acquired infections is associated with contraceptive choices, self-treatment of vaginal symptoms, and sexual risk behaviors but not menstrual hygiene.

PRINTS and PRINTS-S shed light on protein ancestry.

The PRINTS database houses a collection of protein fingerprints. These may be used to make family and tentative functional assignments for uncharacterised sequences. The September 2001 release (version 32.0) includes 1600 fingerprints, encoding approximately 10 000 motifs, covering a range of globular and membrane proteins, modular polypeptides and so on. In addition to its continued steady growth, we report here its use as a source of annotation in the InterPro resource, and the use of its relational cousin, PRINTS-S, to model relationships between families, including those beyond the reach of conventional sequence analysis approaches. The database is accessible for BLAST, fingerprint and text searches at http://www.bioinf.man.ac.uk/dbbrowser/PRINTS/.

Vaccine characteristics and acceptability of HIV immunization among adolescents.

HIV immunization programmes will only be effective if sufficient numbers of persons accept the vaccine. Our aims were to evaluate HIV vaccine acceptability among adolescents and to examine how vaccine characteristics influence acceptability. We recruited 661 adolescents from community health clinics in Indianapolis, Indiana, USA to complete either written or computerized questionnaires, both of which assessed HIV vaccine acceptability as a function of efficacy, cost, type of vaccine, mode of delivery, and parental permission for immunization (required or not required). For both the written and computer methods, efficacy had the strongest effect on acceptability, followed by type of vaccine and cost. Low efficacy, high cost, and live-attenuated vaccines were associated with lower acceptability. These findings suggest that as efforts to develop HIV vaccines continue, it will be important, in parallel, to anticipate potential obstacles to vaccine acceptance, including the belief that a less efficacious HIV vaccine is unacceptable.

Female adolescent sexuality. Promoting healthy sexual development.

Health care providers must recognize the specific challenges and rewards of providing services for adolescents. Quality care begins with the establishment of trust, respect, and confidentiality between the health care provider and the adolescent. Data suggest that the normal age for beginning puberty is decreasing, which has important clinical, educational, and social implications. The health care provider should be aware of the broad range of potential sexual behaviors involving adolescents, as well as the teen's acceptance of such behaviors, often dictated by age, gender, culture, and education. When providing gynecologic care to adolescent girls, the physician should not only provide contraception and screen for sexually transmitted diseases but should contribute to the development of the patient's sexual health. Especially when providing care for the younger teen, the health care provider must focus on involving a member of the family or another significant adult to provide needed support and guidance. Anticipatory guidance for parents should focus on assessing their parenting styles and promoting supervision. Although parents should strive to maintain open communication with their adolescents, they may not accurately estimate the sexual activity of and the sexual risk for their teenage children. Parents need to be encouraged to consider the implications of their own sexual behaviors. The provider should attempt to foster a comfortable environment in which youth may seek help and support for appropriate medical care while reserving the right to disclose their sexual identity when ready. Health care professionals cannot exclude heterosexual behavior on the basis that a young woman self-identifies as homosexual. Her reported sexual behaviors may not indicate her sexual orientation. Self-definition of sexual orientation is a dynamic process including factors such as fantasies, desires, and behaviors. Self-definition of sexual identity is affected by individual variations in sex, gender, sexual roles, and sexual orientation. Most adolescents want to discuss sexual-related issues with their health care providers and will welcome direct questions about sexual behaviors and possible risks when posed in a confidential and nonmoralistic manner. Discussion of the physical, emotional, familial, and social changes related to adolescence will encourage healthy sexual development.

Pelvic inflammatory disease in adolescents.

Pelvic inflammatory disease is the most significant consequence of sexually transmitted infections. Statistics suggest that adolescents have a significantly higher rate of PID than does any other age group. Even asymptomatic and minimally symptomatic PID can lead to adhesions, infertility, and ectopic pregnancy, so clinicians should maintain a high index of suspicion when evaluating female adolescents with lower abdominal pain. Empiric treatment, including appropriate partner notification and treatment, should be initiated early.

Comparability of a computer-assisted versus written method for collecting health behavior information from adolescent patients.

PURPOSE: To investigate the comparability of health behavior data obtained from adolescents via notebook computer versus those obtained via written questionnaire. METHODS: We interviewed adolescent patients (ages 13-20 years) receiving services at community adolescent health clinics. Participants anonymously completed either a computer-assisted self-interview (CASI) or a self-administered questionnaire (SAQ), both assessing health-protective behaviors, substance use (i.e., tobacco, alcohol, marijuana) and sexual behaviors. From a pool of 671 adolescent participants (348 completing CASI, 323 completing SAQ), we matched 194 SAQ participants with 194 CASI participants on the basis of gender and race. We could not match individually on the basis of age, but were able to match each gender-race subgroup by mean age. RESULTS: Across the majority of health behaviors (i.e., all health-protective behaviors, tobacco use, sexual behaviors), mode of administration made no significant difference in the reporting of information by adolescents. However, girls reported a greater frequency of alcohol use and marijuana use on CASI than on SAQ, whereas boys reported a lower frequency of alcohol use and marijuana use on CASI than on SAQ. CONCLUSIONS: The findings of this study suggest that there may be gender-related differences between modes of anonymous collection of specific adolescent health behaviors such as alcohol and marijuana use. Future studies should incorporate direct questions regarding adolescents' attitude and comfort levels toward completing different modes of data collection.

Patterns of sexual partnerships among adolescent females.

OBJECTIVE: To develop a multidimensional classification of sexual partnerships. METHODS: Eighty-two female subjects (ages 15-20 years; 77% African American) used coital logs to record dates of 1265 coital events, partner initials, and condom use. Logs were collected at 1-, 3-, 9-, 15-, and 21-month return visits. Three adolescent health professionals independently classified partnership patterns of each subject; classification schemes were revised until complete consensus for each subject was obtained. RESULTS: Complete agreement in partnership classification was reached after 3 rounds. The consensus partnership classification had three dimensions: number (1, > or = 2 partners), pattern (1 partner, serially exclusive, concurrent), and duration (any partnership < or = 21 days, all partnerships >21 days). A total of 34 of 82 (34%) of subjects had > or = 2 partners; 11 of 34 (32%) had concurrent partnerships. Twenty of 82 (24%) had only partnerships lasting >21 days. Condom use was less common for subjects in only longer-term (>21 days) partnerships, but did not significantly vary by number or pattern. CONCLUSION: Multiple dimensions of adolescent sexual partnerships may be identified. Detailed research and clinical assessments along these dimensions may improve understanding of protective behaviors such as condom use.

Subsequent sexually transmitted infections among adolescent women with genital infection due to Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis.

OBJECTIVE: To identify factors associated with subsequent sexually transmitted infection (STI) (within 1 year of initial infection) due to Chlamydia trachomatis, Neisseria gonorrhoeae or Trichomonas vaginalis. DESIGN: Prospective cohort study. SETTING: A sexually transmitted diseases clinic and four community-based primary care clinics for adolescents. PARTICIPANTS: Female patients (ages 15 to 19 years) with initial diagnosis of chlamydia, gonorrhea, or trichomonas. MAIN OUTCOME MEASURES: Subsequent infection by chlamydia, gonorrhea, or trichomonas. RESULTS: More than 40% of subjects were subsequently infected by at least one STI. Reinfection was common, but infections with sexually transmitted organisms other than the initial infecting organism were also common. Predictors of subsequent infection were black race, gonorrhea as the initial infection, two or more sex partners in the previous 3 months, and inconsistent condom use. CONCLUSIONS: Subsequent STI frequently follow an initial STI, but there is substantial variation in the causal organism. These data suggest the importance of comprehensive STI prevention programs for adolescents rather than organism-specific interventions.

PIP: Factors associated with subsequent sexually transmitted infection due to Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis were investigated in a prospective study of 236 female adolescents 15-19 years of age who had presented to US sexually transmitted disease (STD) and adolescent health clinics with one of these infections within the previous 12 months. At the second visit, 58 (29.7%) of 195 initially infected women were again infected; 13 were infected with more than one organism. At the third visit, 59 (37.6%) of 157 subjects were reinfected, 20 with more than one organism. Overall, 97 (41.1%) of 236 subjects were again infected within 12 months of an initial STD. Many subsequent infections were due to a sexually transmitted pathogen other than the one causing the index STD. The risk of a subsequent infection was significantly elevated among Blacks, those with gonorrhea at enrollment, and women with 2 or more sex partners in the previous 3 months and significantly reduced among condom users. These findings suggest that organism-specific screening programs would fail to detect a substantial number of subsequent infections due to the presence of other organisms.

Preventing teenage pregnancy.

Teenage pregnancy is still a medical and economic concern. Early anticipatory counseling with an emphasis on abstinence is helpful. Contraception information and sexually transmitted disease prevention should be part of the counseling. This article reviews common contraception methodology.

PIP: The topic of preventing adolescent pregnancy in developed countries is introduced by noting that 1) adolescent pregnancy in the US, the UK, and Canada is associated with financial dependence on social services and with increased health risks for the mother and child; 2) these negative outcomes call for preventive efforts that target adolescents at risk and provide contraceptive information to adolescents at an early age; 3) poverty is the most prevalent risk factor; and 4) one screening technique, dubbed HEADS, considers home life, education, activities, drug use, sex behavior, and suicidal tendencies. After recommending that primary care givers first emphasize abstinence and then give accurate and complete information about contraceptive methods, the remainder of the article reviews the following methods: barrier methods, IUDs, oral contraceptives (OCs), Norplant, injectable progesterone, and postcoital (emergency) contraception. The text is illustrated with tables that 1) compare female barrier methods, 2) describe OC contraindications, 3) compare hormonal components in common OCs, 4) list the contraindications to Norplant, 5) show OC noncompliance rates among adolescents, 6) show barrier method noncompliance rates among adolescents, and 7) illustrate the failure rates of different contraceptive methods. The article concludes by recommending that counseling on prevention of sexually transmitted diseases should accompany contraceptive counseling and by noting that increased knowledge is not associated with increased sex behavior or decreased age of initial intercourse.

Pelvic inflammatory disease in the adolescent population.

Statistics suggest that the adolescents have a higher rate of diagnosis of pelvic inflammatory disease than any other age group. Early recognition improves the chances of preventing the long-term consequences of ectopic pregnancy and tubal infertility. For a significant number of teens, the symptoms are mild or vague, requiring a high index of suspicion by the physician to initiate treatment. The purpose of this article is to review the currently accepted guidelines for diagnosis and management of pelvic inflammatory disease in the adolescent patient.

Sex under the influence. A diary self-report study of substance use and sexual behavior among adolescent women.

OBJECTIVE: To evaluate the potential causal relationship between alcohol and drug use and behavior that increases the risk of sexually transmitted diseases. STUDY DESIGN: Longitudinal study conducted at a sexually transmitted diseases clinic and four community-based primary care clinics for adolescents. The participants were 82 female adolescents (age 16-19 years) who agreed to complete diaries recording each coital event. Subjects were participants in a larger study of prevention of reinfections by sexually transmitted organisms. The main outcome measure was condom use at each coital event. Predictor variables were usual pattern of condom use (when substances were not involved) and two event-specific measures: sex partner change and use of alcohol or drugs before intercourse. RESULTS: Average time span of the diaries was 9.2 weeks. Subjects recorded 1,265 coital events. Ninety-three substance-associated coital events were recorded by 22 subjects. Event-specific condom use was associated with usual pattern of condom use, but not with event-specific variables of partner change or substance use before intercourse. CONCLUSIONS: These data do not support the hypothesis that substance use causes alteration of adolescent women's behavior in a manner that increases risk of sexually transmitted diseases.

Weekly and seasonal variation in sexual behaviors among adolescent women with sexually transmitted diseases.

PURPOSE: The objective of this research is to describe aspects of the organization of adolescent sexual behavior in order to understand factors associated with risk for sexually transmitted diseases (STD). METHODS: Subjects were 82 females (ages 16-19 years; 77% African-American) participating in a larger STD study. Subjects completed diaries for each coital event, recording date of event, partner initial, condom use, and use of drugs or alcohol before intercourse. Partner change was defined as any event for which the sex partner initials differed from those listed for the most recent previous coital event. RESULTS: The 82 subjects recorded 1265 coital events; the average span of the records was 10 weeks. Intercourse was least likely on Sundays (154 of 1265; 12.2%) and most common on Friday and Saturday (221 of 1265 for each day; 17.5%). The proportion of coital events associated with drugs or alcohol increased from Sunday to Saturday, although the proportion of coital events in which a condom was used did not vary significantly. Intercourse was most common in spring and summer, and least frequent in winter. CONCLUSIONS: These data indicate substantial temporal organization of adolescent sexual behaviors that may be related to risk of sexually transmitted diseases. Some STD-preventive interventions may be most effective when targeted to higher risk times.

Validity of self-reported sexual behaviors in adolescent women using biomarker outcomes.

OBJECTIVES: To determine the criterion-related validity of alternative approaches to the measurement of sexual intercourse using sexually transmitted diseases (STD) as a biomarker (the criterion). STUDY DESIGN: Analyses are based on an urban sample of 255 adolescent women, 15 to 19 years of age, treated for genitourinary infections with Neisseria gonorrhoeae, Chlamydia trachomatis or Trichomonas vaginalis who returned 3 months later for reexamination. Subjects completed self-administered questionnaires at enrollment and at 3 months. Genitourinary cultures were obtained at enrollment, 2 to 4 weeks later at a test-of-treatment visit (TOT), and at 3 months. RESULTS: Two hundred fourteen of the 255 adolescents also returned for a TOT culture; 186 of these 214 (73%) were free of infection 2 to 4 weeks after enrollment and 30% (56/186) acquired a subsequent STD by 3 months. The validity of questions about sexual behavior differed. No adolescent who denied interim intercourse by reporting "0" sexual partners or "0" coitions acquired an interval STD. Adolescents who denied regular intercourse (vaginal sex) or failed to indicate the number of interim coitions were at high risk for new STD-23% and 21%, respectively. A new measure of sexual intercourse using both the number of sexual partners and the number of coitions contained no missing data; adolescents classified as not having had interim sexual intercourse were free of infection at 3 months, whereas 32% of those who reported intercourse acquired an interim infection. CONCLUSIONS: These data suggest that high-risk urban adolescent women can accurately report whether they have engaged in vaginal intercourse. The validity of the report appears sensitive to the wording and content of the questions.

Declining prevalence of chlamydial infection among adolescent girls.

BACKGROUND AND OBJECTIVES: Chlamydial control programs that identify and treat infected persons have been used as a means of reducing prevalence and morbidity. The overall objective of the current study was to examine the prevalence of chlamydial infection during the course of such a program. GOALS: To determine whether a reduction in isolation rates was evident among adolescent girls during the 8.75 years that the control program has been in place. STUDY DESIGN: The study population consisted of all 4,329 sexually active girls between the ages of 13 and 19 attending the four adolescent health clinics in Indianapolis, Indiana, during the period beginning October 1, 1985, and ending June 30, 1994. All girls were cultured for Chlamydia trachomatis, and behavioral data were collected for those attending the clinics before 1989. The trend in quarterly isolation rates was examined using linear regression analysis. RESULTS: Results showed that there was a significant decrease (P = 0.0001), from 25.9% to 9.7%, in the first-visit chlamydial isolation rate over the study period. Behavioral data showed decreases in the frequency of sexual intercourse and in lifetime years of sexual activity, as well as an increase in condom use. CONCLUSIONS: The quarterly isolation rates showed that there has been a 63% decline in chlamydial infection among adolescent girls attending the clinics for the first time.

Recurrent genitourinary chlamydial infections in sexually active female adolescents.

To determine the recurrence rate of chlamydial infections, we initially screened an urban population of 1308 sexually active female adolescents for chlamydial infection at the urethral and endocervical sites; these young women were followed and had additional examinations for infection. Chlamydial infection was documented by tissue culture in 31.1% (407) of them at some time during the study. After appropriate antibiotic treatment, 68.3% (278/407) returned for test-of-cure cultures within 3 months of their initial infection; of those 278, a total of 254 had sterile cultures. These patients were followed to determine the recurrence rate of chlamydial infections. Of these 254 patients, 177 (69.7%) had one or more follow-up visits; 38.4% (68/177) had a recurrent chlamydial infection. The majority of recurrent infections were documented within 9 months of the initial infection. Recurrent infections with the same serovar were frequent, suggesting reinfection by untreated partners or possible relapse of the initial chlamydial infection. This high rate of recurrent infection suggests that female adolescents should be rescreened frequently for genitourinary chlamydial infections.

Historical and clinical factors associated with Chlamydia trachomatis genitourinary infection in female adolescents.

Five hundred sixty-eight adolescent female patients receiving routine gynecologic care at urban clinics were screened by culture for Chlamydia trachomatis infection at both the urethra and endocervix. Culture results for 562 were available from either or both sites. Positive cultures were obtained from 139 (25%). Urethral infection was not associated with either urinary tract symptoms or sterile pyuria, but urethral or endocervical infection was associated with cervical friability (P = less than 0.0001), endocervical mucopus (P = 0.0001), cervical erythema (P = 0.0002), and cervical ectopy or erosion (P = 0.01). Increased chlamydial infection rates were associated with older age (P = 0.01), history of more frequent intercourse (P = 0.01), and history of more than one lifetime partner (P = 0.023), with a marginal association for being black (P = 0.05). Method of contraception, reason for attending clinic, age at menarche, age at first intercourse, years sexually active, number of sexual partners in preceding 6 months, parity, and prior history of sexually transmitted disease were not associated with having chlamydial genitourinary infection.

The avian inflammatory response: adaptation and utilization of skin windows.

A modified skin window system was developed and utilized for examination of the local inflammatory response in the chicken. Data were collected at 2, 4, 6, 8, 12, 24, 28, 32 and 48 hours following wing-web scarification. The first cells observed were heterophils and they remained the predominant type through 32 hours. Mononuclears began infiltrating at a rapid rate of 8 to 12 hours, and by 48 hours they represented slightly more than one-half of the total cells observed. The total number of cells present increased rapidly to a peak at 24 hours, and then declined during the 24 to 48 hour period. The percentage of heterophils and mononuclears showed an inverse relationship throughout the 48 hour period, as appreciable numbers of eosinophils and basophils were not observed. Macrophages were the predominant mononuclear cells. Degranulation of heterophils was extensive in the 2 to 4 hour periods, but was much less common thereafter. As the time after scarification increased, macrophages exhibited; (1) increased cytoplasm to nucleus ratio, (2) increased numbers of phagocytic vacuoles, and (3) a marked tendency to form giant cells. The results obtained in this study were similar to those recorded for mammals, except that the percentage shift toward mononuclears occurred at a faster rate in mammals.