Managing STIs identified after testing outside genitourinary medicine departments: one model of care

OBJECTIVES: To develop a local strategy for managing cases of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) which have been identified in the departments of obstetrics and gynaecology (O&G). METHODS: Weekly notification from the local microbiology laboratory to genitourinary medicine (GUM) departments of all positive CT and GC results generated by tests performed in the two local O&G departments. Direct contact made by GUM departments to index patients identified and "fast track" appointments made. Data recorded for future audit include numbers attending, details of health adviser input, and success of contact tracing. RESULTS: Over 18 months, 294 women were identified and 231 (78%) attended GUM departments; 142 (48%) had received antibiotics before attending GUM departments and of these, 58 (41%) had risked reinfection by an untreated partner and 48 (20%) were found on screening to have a previously undiagnosed genital infection. Over 90% were interviewed by a health adviser. Appropriate follow up was achieved in 87% of index cases. Of the contacts, 194 were treated--150 in the local GUM department. Of these 150 men, 99 (66%) had an identifiable genital infection and 84% of those with CT/non-gonococcal urethritis were asymptomatic. There have been no complaints either formal or informal, by women managed by this system. CONCLUSIONS: GUM clinics are the ideal setting to achieve successful treatment of patients with sexually acquired infections, which must include notification and treatment of their partners if reinfection is to be avoided. For patients with infections diagnosed on other settings, such as O&G, a system of direct notification of results to GUM departments by an agreed protocol can be highly successful. For such a system to work, close cooperation and trust between departments is essential.




     

Oral sex and transmission of non-viral STIs

OBJECTIVES: To review the literature on the role of oral sex in the transmission of non-viral sexually transmitted infections (STIs). METHOD: A Medline search was performed using the keywords oro-genital sex, and those specific to each infection. Further references were then taken from each article read. CONCLUSIONS: Oral sex is a common sexual practice between both heterosexual and homosexual couples. Oro-genital sex is implicated as a route of transmission for gonorrhoea, syphilis, Chlamydia trachomatis, chancroid, and Neisseria meningitidis. Other respiratory organisms such as streptococci, Haemophilus influenzae, and Mycoplasma pneumoniae could also be transmitted by this route. Fellatio confers risk for acquisition of infection by the oral partner. Cunnilingus appears to predispose to recurrent vaginal candidiasis although the mechanism for this is unclear, while a link between oro-genital sex and bacterial vaginosis is currently being studied. Oro-anal sex is implicated in the transmission of various enteric infections. In view of the increased practice of oral sex this has become a more important potential route of transmission for oral, respiratory, and genital pathogens.


     

Oral sex and the transmission of viral STIs

OBJECTIVE: To review the literature on the role of oral sex in the transmission of viral sexually transmitted infections (STIs). METHOD: A Medline search was performed using the keywords oro-genital sex, and those specific to each infection. Further references from each article identified by Medline were also included, as were relevant references from "Current contents". CONCLUSIONS: Oral sex is a common sexual practice among both heterosexual and homosexual couples. The evidence suggests that HIV transmission can take place through oro-genital sex from penis to mouth and vagina to mouth. Case reports describe apparent transmission from mouth to penis although this appears less likely. The risk of oro-genital transmission of HIV is substantially less than from vaginal and anal intercourse. Receptive oro-genital sex carries a small risk of human papillomavirus infection and possibly hepatitis C, while insertive oro-genital contact is an important risk factor for acquisition of HSV 1. Oro-anal transmission can occur with hepatitis A and B. The transmission of other viruses may occur but is unproved. The relative importance of oral sex as a route for the transmission of viruses is likely to increase as other, higher risk sexual practices are avoided for fear of acquiring HIV infection.


     

Sensitivity requirements for the point of care diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in women

BACKGROUND/OBJECTIVES: Most current tests for Neisseria gonorrhoeae and Chlmydia trachomatis require the support of a laboratory, and results are not usually available before the patient has left the clinic. This delay can lead to patients not returning for treatment and may allow further STI transmission to occur. Current rapid point of care (POC) STI tests and the syndromic approach are less sensitive than gold standard tests, but allow treatment at the initial visit. This study estimates the required sensitivity of POC tests that ensures as many STIs are averted as with current gold standard tests. METHODS: A mathematical model is developed to compare the STIs averted using different STI diagnostic methods. Data from Benin, South Africa, Tanzania, and England are used to explore how the required sensitivity differs between settings. RESULTS: The required sensitivity of a POC test is low if there is significant STI transmission during the delay in treatment for the gold standard test and/or few women return for treatment. For example, the required sensitivity of a POC test for C trachomatis is 50% (gold standard test sensitivity is 90%) if either 55% return for treatment and there is no STI transmission, or 80% return for treatment and 50% of infected women infect their partner during the delay in treatment. Furthermore, in these settings a POC test of moderate sensitivity can lead to significantly more STI averted than the gold standard test. CONCLUSIONS: These results support the use of moderate sensitivity POC tests in scenarios where many women will not return for treatment, and in populations where the delay in treatment would result in significant STI transmission.     

Surveillance systems for STIs in the European Union: facing a changing epidemiology

OBJECTIVES: To characterise the nature, content, and performance characteristics of existing national STI surveillance systems in the European Union (EU) and Norway, to facilitate collection of comparable surveillance data. METHODS: Cross sectional survey using a structured questionnaire. RESULTS: Case reporting from clinicians and/or laboratories is the mainstay of EU surveillance systems for bacterial STIs. Coverage of case reporting varies from less than 10% to over 75%, and lack of and/or heterogeneity in case definitions affect the relative specificity and sensitivity of reporting systems. Considerable variations also exist in STI care sites; the populations who use these services; and in partner notification practices, STI screening practices, and STI laboratory diagnostic tests employed, affecting the representativeness of reported data and the sensitivity of surveillance systems for detecting the true number of STI cases. CONCLUSIONS: The heterogeneity of current surveillance systems complicates direct comparison of STI incidence rates across Europe. Introduction of standardised case definitions for reporting, and increased coverage of mandatory reporting systems where necessary, are needed. Definition of standardised minimum datasets and use of sentinel and enhanced surveillance systems to supplement universal case/laboratory notification data, could improve our understanding of the distribution and determinants of STIs across Europe, and aid in the design of effective public health responses. In the context of the changing epidemiology of STIs, systems for detection and monitoring of localised outbreaks of acute bacterial STIs (syphilis and antimicrobial resistant gonorrhoea), as well as prevalence monitoring systems for frequently asymptomatic STIs (chlamydial infection and viral STIs), are also necessary.     

Next-generation diagnostics for inherited skin disorders

Identifying genes and mutations in the monogenic inherited skin diseases is a challenging task. Discoveries are cherished but often gene-hunting efforts have gone unrewarded because technology has failed to keep pace with investigators' enthusiasm and clinical resources. But times are changing. The recent arrival of next-generation sequencing has transformed what can now be achieved.     

Vascular assessment in venous leg ulcer diagnostics and management in Australian primary care: Clinician experiences

AimIn this article, we focus on primary health clinicians’ experiences of vascular assessment in venous leg ulcer (VLU) diagnostics and management, including ankle brachial pressure index (ABPI) measurements using Doppler ultrasonography.MethodsWe conducted semi-structured face-to-face and telephone interviews with general practitioners [15] and practice nurses [20] from primary health care settings in Australia. Twenty-one participants were recruited from practices located in Melbourne metropolitan settings and 14 from rural Victoria. We used the theory driven thematic analysis as a method of data analysis. The Theoretical Domains Framework informed this analysis.ResultsFive domains were identified as relevant, including Environmental Context and Resources, Motivation and Goals, Skills, Knowledge, and Beliefs about Capabilities. Although the Australian and New Zealand clinical practice guideline for prevention and management of venous leg ulcers recommend that vascular assessment is conducted for all patients with suspected VLUs, findings from our study indicate vascular assessments are not routinely performed in many primary care settings. Our study also found that a lack of awareness of clinical practice guidelines among clinicians might be one of the main issues for not following the latest clinical recommendations for vascular assessment in venous leg ulcer diagnostics and wound management practice.ConclusionWe recommend development of theory-informed interventions for clinicians in primary health care settings to optimise VLU management and healing outcomes for patients with VLUs. Implementation and evaluation of these interventions have the potential to reduce the evidence-practice gap in VLU management and optimise healing outcomes.     

男男性接触者多重STIs/HIV感染1例

患者男,18岁,同性恋史8个月。面部、躯干、四肢、掌跖部泛发斑丘疹,肛周见数个斑块状增生物,阴茎系带旁有两个糜烂面,肛门灼痛、有脓性分泌物。TRUST1∶16(+),TPPA(+),肛周皮损组织液暗视野显微镜查螺旋体(+),直肠分泌物涂片见细胞内革兰阴性双球菌,淋球菌培养(+),CT-PCR(+),UU-PCR(-),HSV-2-PCR(+)。结合临床、组织病理及血清学等实验室检查诊断为二期梅毒、生殖器疱疹、淋菌性直肠炎等多种性传播性疾病(STDs)和HIV感染。该患者免疫功能正常,治疗方法的选择及其疗效与一般STDs患者无异。     

Oncogenetics of melanoma: basis for molecular diagnostics and therapy

Our understanding of oncogenetics and of the molecular mechanisms involved in melanoma development and signaling has dramatically changed in recent years. Today, melanomas are also classified based on molecular alterations. Emerging molecular therapies are targeted against specific mutations in melanoma. An example of targeted therapies is the successful treatment of KIT‐mutant melanoma with the kinase inhibitor imatinib. Highly selective BRAF‐inhibitors are likewise under clinical development and show encouraging clinical responses. An increasing number of targeted drugs will emerge in the coming years, based on molecular diagnostics and classification. The present article reviews signaling pathways in melanocytes and alterations in melanoma that are a prerequisite to understanding modern cancer therapies in melanoma.