Promoting sexual health and wellbeing: the role of the nurse.

Anecdotal evidence from clinical practice, classroom learning and research studies suggests most aspects of sexual health and wellbeing are addressed inadequately or not at all. Some nurses may feel ill-equipped or underprepared to explore private or intimate aspects of a patient's sexual health or relationships, or may be too embarrassed to talk to the individual about the personal side effects of medical conditions or treatment regimens. This article identifies strategies to assist healthcare professionals in addressing patients' sexual health needs as part of holistic care.

Psychological and psychiatric morbidity in lichen sclerosus in a cohort recruited from a genitourinary medicine clinic.

Forty-five cases of lichen sclerosus (LS) were retrospectively found between 2000 and 2008 among those attending an associate university teaching hospital sexually transmitted infection (STI) clinic (genitourinary [GU] medicine clinic) and 26 responders of the 45, to a questionnaire about psychological morbidity and psychiatric morbidity, were evaluated. Sixteen percent of the patients were worried about the possibility of infecting their partners with the condition, despite counselling to the contrary. Twenty-seven percent felt that the condition's cosmetic appearance adversely affected libido. There was moderate to severe anxiety at one time or another in 58% while 27% experienced depression at one time or another; 19% admitted to insomnia as a result of the condition; 23% were stressed while 11.5% were worried about starting a new relationship. LS has a profound effect on mental health. Selected patients with LS may benefit from routine referral to a clinical psychologist, within the sexually transmitted disease setting to elaborate and institute coping strategies.

Long-term suppressive therapy for herpes simplex - an audit.

A retrospective analysis of patients, who have been on long-term suppressive therapy for recurrent episodes of herpes simplex (HSV) in a university hospital, was performed and the findings were documented and orchestrated into bar graphs. The study involved patients between the years 2000 and 2007, both inclusive. The results were compared with the British Association for Sexual Health and HIV guidelines. Eighty-two percent (57) had had the infection for at least 12 months at the start of therapy and 78.2% (54) had at least six recurrences per year before the start of treatment. Indeed, only four patients (5.8%) had a treatment interruption at 12 months or less; also only 11 patients (15.9%) had less than six outbreaks per year at the start of treatment. The former is not in-line and the latter is in-line with the guidelines.

Retrospective review of clinical practice in chronic pelvic pain syndrome i.e. category III chronic prostatitis at two hospital sites over five years 2000-2005 (an audit).

All category III chronic prostatitis cases in two hospital sites were retrospectively reviewed from the year 2000 until 2005. The mean age of the patients was 38.7 years. Of these, 56.6% were St Bartholomew's Genitourinary Medicine Department patients and 43.5% were Southend Genitourinary Medicine Clinic patients. We observed that 33.1% of these had at least one transrectal ultrasound of the prostate. The commonest abnormal findings in transrectal ultrasounds of the prostate of the series were focal calcification (16.2%), calculi (9.3%) and inflammatory changes (5.4%). Of this series, 35% were lost to follow-up. The vast majority of the remainder got better over periods ranging from approximately two weeks to approximately three years.

Immune evasion strategies of the primate lentiviruses.

Individuals infected with human immunodeficiency virus (HIV) and macaques infected with simian immunodeficiency virus (SIV) make vigorous virus-specific antibody and cellular immune responses. Despite these responses, virus replication continues at all stages of infection and ultimately leads to immunological collapse, onset of opportunistic infections and death of infected hosts. Thus, the strategies by which HIV and SIV evade antiviral immune surveillance are fundamental to understanding lentiviral pathogenesis and crucial for our ability to develop effective strategies. It has become increasingly clear that the primate lentiviruses have evolved multiple and complementary mechanisms to circumvent host immune responses. Here we review these mechanisms of immune evasion considering contributions from both human and non-human primate systems.

Definition of five new simian immunodeficiency virus cytotoxic T-lymphocyte epitopes and their restricting major histocompatibility complex class I molecules: evidence for an influence on disease progression.

Simian immunodeficiency virus (SIV) infection of the rhesus macaque is currently the best animal model for AIDS vaccine development. One limitation of this model, however, has been the small number of cytotoxic T-lymphocyte (CTL) epitopes and restricting major histocompatibility complex (MHC) class I molecules available for investigating virus-specific CTL responses. To identify new MHC class I-restricted CTL epitopes, we infected five members of a family of MHC-defined rhesus macaques intravenously with SIV. Five new CTL epitopes bound by four different MHC class I molecules were defined. These included two Env epitopes bound by Mamu-A*11 and -B*03 and three Nef epitopes bound by Mamu-B*03, -B*04, and -B*17. All four restricting MHC class I molecules were encoded on only two haplotypes (b or c). Interestingly, resistance to disease progression within this family appeared to be associated with the inheritance of one or both of these MHC class I haplotypes. Two individuals that inherited haplotypes b and c separately survived for 299 and 511 days, respectively, while another individual that inherited both haplotypes survived for 889 days. In contrast, two MHC class I-identical individuals that did not inherit either haplotype rapidly progressed to disease (survived <80 days). Since all five offspring were identical at their Mamu-DRB loci, MHC class II differences are unlikely to account for their patterns of disease progression. These results double the number of SIV CTL epitopes defined in rhesus macaques and provide evidence that allelic differences at the MHC class I loci may influence rates of disease progression among AIDS virus-infected individuals.

Speaking of sex: the need to dispel myths and overcome fears.

Myths and fears are intimately associated with issues of sex, sexuality and sexual health. Many myths and fears, present in both the education and clinical settings, prevent health carers from maximizing the potential for wholeness and wellness, for both themselves and their clients. In order for nurses, midwives and health visitors to take their role in therapeutic communication around the sex issues seriously, these myths must be dispelled and the fears overcome. Many of the hindrances to communication are shrouded in other people's taboos and morals, and hidden within the languages of clinical terminology and silence. This leads numerous clinicians and educators to an incommensurate fear of dealing with the sexual issues of life. This article argues that this is an example of institutionalized erotophobia (fear of sex), which results in a barrier to genuine, therapeutic, communication. For the sake of brevity, 'sex' will refer to sex, sexuality and sexual health. Likewise, unless a clear distinction is being made, 'nurse' will include midwives and health visitors.

From 'nits' to 'crabs'?: school nurses and sexual health.

The state of education and service provision relating to young people and sex, sexualities, and sexual health is currently a major national challenge. Nurses working in the compulsory education sector are at the direct interchange between clients and their obvious experiential and academic needs, and attitudes and systems that frequently seem to fail them. From concerned parents and members of the public, through the teaching and nursing professions, to the UK Government, the message is the same: something must be done to improve the current status quo. The problem lies in the different beliefs about what to do and how to do it. School nurses are in a prime position to improve sexual health education and services for young people. However, it is unreasonable to expect school nurses, who are frequently overburdened with task-oriented jobs, to be effective with an additional remit for sexual health education without adequate support, resources and effective professional training. This article explores the role of school nurses as it develops to encompass numerous aspects of sexual health care. In order to enhance and promote these changes in line with client needs the article examines the strengths, weaknesses, opportunities and threats (SWOT analysis) of this changing role.

Virus-specific cytotoxic T-lymphocyte responses select for amino-acid variation in simian immunodeficiency virus Env and Nef.

Cytotoxic T-lymphocyte (CTL) responses to human immunodeficiency virus arise early after infection, but ultimately fail to prevent progression to AIDS. Human immunodeficiency virus may evade the CTL response by accumulating amino-acid replacements within CTL epitopes. We studied 10 CTL epitopes during the course of simian immunodeficiency virus disease progression in three related macaques. All 10 of these CTL epitopes accumulated amino-acid replacements and showed evidence of positive selection by the time the macaques died. Many of the amino-acid replacements in these epitopes reduced or eliminated major histocompatibility complex class I binding and/or CTL recognition. These findings strongly support the CTL 'escape' hypothesis.

Major histocompatibility complex class I genes in primates: co-evolution with pathogens.

The major histocompatibility complex (MHC) is the most polymorphic genetic system known, playing a central role in the cellular immune response to pathogens. The relationship between the MHC of humans and non-human primates has increased our understanding of MHC evolution and how polymorphism of this gene family may have been generated. We will review MHC class I evolution in great apes and Old World and New World primates and discuss new data from the simian immunodeficiency virus/rhesus monkey animal model that demonstrate the role of MHC class I alleles in selecting for new populations of viruses. This suggests that certain pathogens co-evolve with the MHC class I molecules they encounter in a population.

Three different MHC class I molecules bind the same CTL epitope of the influenza virus in a primate species with limited MHC class I diversity.

One of the most remarkable features of the MHC class I loci of most outbred mammalian populations is their exceptional diversity, yet the functional importance of this diversity remains to be fully understood. The cotton-top tamarin (Saguinus oedipus) is unusual in having MHC class I loci that exhibit both limited polymorphism and sequence variation. To investigate the functional implications of limited MHC class I diversity in this outbred primate species, we infected five tamarins with influenza virus and defined the CTL epitopes recognized by each individual. In addition to an immunodominant epitope of the viral nucleoprotein (NP) that was recognized by all individuals, two tamarins also made a response to the same epitope of the matrix (M1) protein. Surprisingly, these two tamarins used different MHC class I molecules, Saoe-G*02 and -G*04, to present the M1 epitope. In addition, CTLs from one of the tamarins recognized target cells that expressed neither Saoe-G*02 nor -G*04, but, rather, a third MHC class I molecule, Saoe-G*12. Sequence analysis revealed that Saoe-G*12 differs from both Saoe-G*02 and -G*04 by only two nucleotides and was probably generated by recombination between these two alleles. These results demonstrate that at least three of the tamarin's MHC class I molecules can present the same epitope to virus-specific CTLs. Thus, four of the tamarin's 12 MHC class I molecules bound only two influenza virus CTL epitopes. Therefore, the functional diversity of cotton-top tamarin's MHC class I loci may be even more limited than their genetic diversity suggests.

Rapid and slow progressors differ by a single MHC class I haplotype in a family of MHC-defined rhesus macaques infected with SIV.

Highly polymorphic HLA class I molecules may influence rates of disease progression of HIV-infected individuals. Recent evidence suggests that individuals who mount vigorous CTL responses to multiple HIV-1 epitopes have reduced viral loads, and survive longer than individuals that make a less robust or less diverse CTL response. It has been difficult, however, to define associations between particular HLA class I alleles and rates of disease progression. This may be due, in part, to the uncontrolled variables associated with naturally acquired HIV infections. Studies using MHC-defined, non-human primates infected with well characterized viral stocks should help to clarify this relationship. To explore the possibility that MHC class I polymorphism can influence disease progression, we infected four Mamu-DRB-identical individuals from a family of MHC-defined rhesus macaques intravenously with 40 TCID50SIVmac239. Two of these macaques developed severe wasting and were euthanized within 80 days of infection, while the other two survived for more than 400 days without showing any symptoms of disease. Since all four of these macaques were Mamu-DRB-identical, we were able to exclude the MHC class II DRB loci as determinant of disease progression. Interestingly, both of the slow progressors made CTL responses to the same three SIV CTL epitopes, which were restricted by two molecules (Mamu-B*03 and B*04) encoded by their common maternal haplotype. The two rapid progressors did not share this haplotype with the slow progressors, and we were unable to detect CTL responses in these two siblings. These observations implicate products of the Mamu-B*03 and B*04 alleles in resistance to disease progression in this family of SIV-infected macaques, and provide additional evidence that certain MHC class I-restricted CTL responses may play a significant role in delaying the onset of AIDS.

Two different primate species express an identical functional MHC class I allele.

The products of the highly polymorphic and variable major histocompatibility complex (MHC) class I loci play a crucial role in host defenses against infectious disease. While similar alleles have been found in closely related species, sharing of a functional MHC class I allele between two species has never been reported. Here we show that an identical functional MHC class I molecule is present in two different primate species with an approximate divergence time of 0.7 million years. Lymphocytes from the red-crested tamarin (Saguinus geoffroyi) expressed an MHC class I allele (Sage-G*01) that was identical in coding sequence to an MHC class I allele (Saoe-G*08) found in the cotton-top tamarin (Saguinus oedipus). Furthermore, influenza virus-specific cytotoxic T lymphocytes (CTLs) generated in the cotton-top tamarin killed lymphocytes expressing the influenza virus nucleoprotein (NP) from the red-crested tamarin. Since the influenza virus NP epitope is bound by Saoe-G*08 in the cotton-top tamarin, it is likely that this molecule is functional in both species. These data provide the first evidence that functional MHC class I molecules can be maintained entirely intact in two separate species.

Multicenter evaluation of the Clostridium difficile TOX A/B TEST.

Clostridium difficile, the primary cause of nosocomial diarrhea in the United States and many other industrialized countries, is recognized as a major health concern because of its ability to cause severe intestinal disease leading to complications such as relapses and infections due to vancomycin-resistant enterococci. The disease results from two toxins, toxins A and B, produced by this pathogen. In this study, we evaluated the TOX A/B TEST, a new 1-h enzyme immunoassay (EIA) that detects toxins A and B. We compared the test with the tissue culture assay, which is recognized as the "gold standard" for C. difficile testing. Evaluations were performed in-house at TechLab, Inc. (Blacksburg, Va.) and off-site at four clinical laboratories. Of 1,152 specimens tested, 165 were positive by the TOX A/B TEST and tissue culture and 973 were negative by both tests. The sensitivity and specificity were 92.2 and 100%, respectively. The positive and negative predictive values were 100 and 98.6%, respectively, and the correlation of the TOX A/B TEST with tissue culture was 98.8%. When discrepant samples were resolved by culture, the sensitivity and specificity were 93.2 and 98.9%, respectively. The positive and negative predictive values were 100 and 98.8%, respectively, with a correlation of 99.0%. There were no specimens that were positive by the TOX A/B TEST and negative by tissue culture. Fourteen specimens were negative by the TOX A/B TEST but positive by tissue culture. Of these, two were negative by toxigenic culture, five were positive by toxigenic culture, and seven were not available for further testing. There were no indeterminate results, since the test does not have an indeterminant zone. In a separate study, 102 specimens that were positive by tissue culture and the TOX A/B TEST were examined in toxin A-specific EIAs. Two specimens that presumptively contained toxin A-negative, toxin B-positive (toxA-/toxB+) isolates were identified. One specimen was from a patient with a clinical history consistent with C. difficile infection. Isolates obtained from these specimens by selective culture on solid media and in broth tested toxA-/toxB+ when grown in brain heart infusion dialysis flasks, which stimulate in vitro production of both toxins. Our findings show that the TOX A/B TEST is suitable as a diagnostic aid for C. difficile disease because it correlates well with tissue culture and detects isolates that may be missed with toxin A-specific EIAs.

Immunodominance of a single CTL epitope in a primate species with limited MHC class I polymorphism.

MHC class I molecules play a crucial role in immunity to viral infections by presenting viral peptides to cytotoxic T lymphocytes. One of the hallmarks of MHC class I genes in outbred populations is their extraordinary polymorphism, yet the significance of this diversity is poorly understood. Certain species with reduced MHC class I diversity, such as the cotton-top tamarin (Saguinus oedipus), are more susceptible to fatal viral infections. To explore the relationship between this primate's limited MHC class I diversity and its susceptibility to viruses, we infected five cotton-top tamarins with influenza virus. Every tamarin recognized the same immunodominant CTL epitope of the influenza nucleoprotein. Surprisingly, this nucleoprotein peptide was bound by Saoe-G*08, an MHC class I molecule expressed by every cotton-top tamarin. Two tamarins also made a subdominant response to an epitope of the matrix (M1) protein. This peptide appeared to be bound by another common MHC class I molecule. With the exception of an additional subdominant response to the polymerase (PB2) protein in one individual, no other influenza-specific CTL responses were detected. In populations or species with limited MHC class I polymorphism like the cotton-top tamarin, a dependence on shared MHC class I molecules may enhance susceptibility to viral infection, since viruses that evade MHC class I-restricted recognition in one individual will likely evade recognition in the majority of individuals.

Are you sure it's syphilis? A review of false positive serology.

This article on false positive serological reactions for syphilis reviews the rapid developments which have taken place in the serodiagnosis of syphilis in recent years since the advent of the AIDS epidemic. An overview of non-specific and specific treponemal serological tests in relation to acute and chronic biological false positive reactions is followed by closer consideration of syphilis serology in the context of HIV infection, pregnancy and other conditions which may produce false positive reactions.

Dorsal vein thrombosis of the penis presenting to an STD clinic.

OBJECTIVE: To describe the clinical assessment, diagnosis and differential diagnosis of dorsal vein thrombosis of the penis (DVTP) and to observe its natural course over time. DESIGN: A descriptive study of six patients presenting with penile swelling to an STD clinic over a twenty month period. SUBJECTS: Six male patients between the ages of 22 and 46 years who self-presented to an STD clinic in Perth, Western Australia during a period from October 1991 to June 1993. METHODS: Initial history, examination and follow up were undertaken as routine for all STD clinic patients. This was supplemented with later exhaustive history taking; full cardiovascular, fundoscopic, abdominal and genital examination; blood screening for coagulation defects, glucose level, autoantibodies, ESR, urea, electrolytes, calcium, creatinine and liver function test; and duplex doppler ultrasound scanning. RESULTS: No consistent abnormalities were detected on clinical examination, nor on blood testing. Ultrasound revealed one case of rupture of the corpus cavernosum, with haematoma and thrombus formation. There were two cases of pure DVTP demonstrable with ultrasound and two cases in which spontaneous resolution of clinical DVTP has occurred. The sixth patient declined further investigation and followup, but also displayed the clinical features of DVTP. Coagulation abnormalities as seen in elevated antithrombin III levels are of unknown significance. CONCLUSIONS: DVTP and ruptured corpus cavernosum should be considered in the differential diagnosis of gradual onset penile swelling and/or deformity. Its natural course tends to be one of spontaneous resolution. No sexual or urinary symptoms or dysfunction were experienced, even in the presence of persistent thrombus. Directed and specific investigation only, depending on the clinical state of the patient, should be carried out.