Uptake of 48-hour access appointments in genitourinary medicine.

Timely access to genitourinary (GU) medicine services is important in the control of sexually transmitted infections (STIs). A target has been set that by March 2008, 100% of patients will be offered a GU medicine appointment within 48 hours. Strategic Health Authorities have also been asked to plan for 95% of patients to be seen within 48 hours. We sought to identify why patients decline appointments offered within 48 hours by collecting prospective data over three months. Additional data was collected over 18 working days to identify if alternative options would be acceptable to decliners. Overall, 1577 patients contacted the clinic, 1524 (96.6%) were offered a 48-hours appointment, 1108 (72.7%) accepted it, 416 (27.3%) declined it and 66.3% citing work commitments as the reason. In 118 patients, who declined the appointment offered; 43.2% indicated no alternative option was acceptable, 23.7% chose a Saturday appointment, which in 78.6% would have exceeded 48 hours. Hence, 73 (61.9%) patients would not have accepted an appointment within 48 hours. The balance of public health control, mixed service provision and informed patient choice is discussed.

Flexible booking systems to improve genitourinary medicine access and increase patient choice.

Access to genitourinary (GU) medicine services is crucial for the effective control of infection and it is well recognized that improved access to GU medicine will be required in order to meet a 48-hour access target. The object of this study was to evaluate whether access to our GU medicine service would be improved and the observed default rates decreased by the introduction of a partial closed booking system for new patients. The system was run in parallel to our standard appointment service and triage system. Data were collected for the first six months that the new system was operational, with additional data collection over the corresponding calendar periods of the subsequent two years. Approximately 26% of new patient appointments were booked through the partial closed booking system in the time periods specified. New patient appointment default rates fell from 26.8-30.5% in the standard appointment system to 7.5-9.5% in the partial closed booking system (P < 0.0001). This study supports the importance of clinics adapting and providing a range of appointment system strategies as this may improve their clients' access to GU medicine services.

Health advisor workload.

Health advisors (HAs) are an integral part of the multidisciplinary team within genitourinary (GU) medicine clinics, with a pivotal role in the National Sexual Health Strategy by enhancing liaison between community sexual health provision and GU medicine services. Greater clarity is needed about HAs' current activities and workload in order to enable benchmarking and ensure accurate workforce planning. We describe a tool for assessing HA workload and activity and evaluating its use in real clinic environments through a prospective time and motion model. Ten centres (63% of those invited to participate) within a single region did so. Median HA working times were calculated at almost 15 min/patient consultation and approximately 10 min/telephone call. Although there were strong positive correlations between HA availability and some markers of clinical activity, these were weaker than similar correlations applied to medical staff, raising the possibility of suboptimal HA workforce planning.

Availability of dental services for patients with blood-borne viruses.

Dental practitioners were surveyed, using a self-completed postal questionnaire, to assess their attitudes to managing patients with blood-borne viruses (BBV) and to identify dental services available for such patients in North Nottinghamshire. Questionnaires were completed by 79 (65.3%) of the 121 practitioners from 43 (82.7%) of the 52 study practices. Previous BBV experience was reported by 44 (55.7%), 31 (39.2%), 20 (25.3%) respondents for hepatitis B (HBV), hepatitis C (HCV), HIV, respectively. Over two-thirds would maintain existing patients with subsequently diagnosed BBV on their lists, approximately one-third would accept new BBV patients. Risk factors for BBV of homo/bisexuality and injecting drug use were not asked by 71 (89.9%) and 49 (62.0%) practitioners, respectively. Universal precautions were employed by 67 (84.8%) practitioners regardless of the patient's status and by seven practitioners for known BBV patients. The advice of the General Dental Council, British Dental Association, and the use of universal precautions are discussed.

Knowledge of genital Chlamydia trachomatis infection in family planning clinic attenders.

The purpose of this study was to determine the level of awareness of genital Chlamydia infection and level of knowledge related to this infection in family planning (FP) clinic attenders. Clients attending FP clinics during a 3 month study period were invited to complete an anonymous self-administered questionnaire. Five hundred and sixteen questionnaires from female attenders were analysed. Results showed that 54% of respondents had heard of Chlamydia. Subjective knowledge assessment for Chlamydia was low compared to that for other infections. Mean knowledge scores relating to genital chlamydial infection were low. There was no significant age-related trend in knowledge scores. The implications of these findings are discussed in relation to increased Chlamydia screening activity in FP clinics.

Antimicrobial susceptibility testing of Chlamydia trachomatis using a reverse transcriptase PCR-based method.

The conventional method for antimicrobial susceptibility testing of Chlamydia trachomatis is subjective and potentially misleading. We have developed a reverse transcriptase PCR (RT-PCR)-based method which is more sensitive and less subjective than the conventional method. Using 16 strains of C. trachomatis in triplicate assays, we found the RT-PCR method consistently more sensitive than the conventional technique for all eight antimicrobials tested, with resultant MICs determined by RT-PCR ranging from 1.6-fold higher (erythromycin) to >/=195-fold higher (amoxicillin).

Knowledge of Chlamydia trachomatis infection in genitourinary medicine clinic attenders.

OBJECTIVES: To determine the level of awareness of genital chlamydial infection, and level of knowledge related to this infection, in genitourinary medicine (GUM) clinic attenders. METHODS: 500 consecutive patients attending a GUM clinic for the first time during a 3 month study period were invited to complete an anonymous self administered questionnaire on aspects of chlamydial infection. RESULTS: 482 (96.4%) questionnaires were available for analysis (57% female). 289 (60%) respondents had heard of Chlamydia trachomatis compared with 472 (98%) for thrush, 467 (97%) for HIV/AIDS, and 434 (90%) for gonorrhoea. Subjective knowledge of chlamydia, relative to the other infections, was poor. Overall, the mean chlamydial knowledge score was 0.38 (range 0.0-1.0). Females scored significantly higher than males (0.45 v 0.26; p < 0.00001) and younger females scored significantly higher than older females (p = 0.001). More females had experienced genital chlamydial infection than males (22.4% v 12.1%, p = 0.004). Those with prior exposure to C trachomatis had higher mean knowledge scores than those without (males 0.55 v 0.25, p < 0.00001; females 0.68 v 0.37, p < 0.00001). CONCLUSION: Even for a population considered as "high risk" by their attendance at a GUM clinic, there was poor awareness of genital chlamydial infection, and mean knowledge scores were low. Whether increased knowledge was due to successful health education at the time of diagnosis in those with previous infection remains to be determined. In the future, one would hope for increased knowledge scores in those at risk before the acquisition of infection, which may be achieved by national health education programmes for C trachomatis.

A comparison audit of a genitourinary medicine colposcopy service against nationally agreed quality standards.

The National Health Service Cervical Screening Programme (NHSCSP) recently published their document Standards and Quality in Colposcopy outlining recommendations for standards in the service provided by colposcopists. In this first audit of colposcopic practice measured against these agreed UK national guidelines, the authors discuss the standards, their attainability, and their relevance to genitourinary medicine (GUM) colposcopy services.

Attitudes to HIV testing in general practice.

Newer therapies for the treatment of HIV infection and the effectiveness of zidovudine in reducing vertical transmission mean that it is becoming increasingly important to diagnose HIV infection earlier. General practitioners (GPs) attending a local study day on sexually transmitted diseases (STDs) were asked about their likelihood of raising the subject of HIV antibody testing, and their anxiety when doing so, for different patient groups. A high level of anxiety was found when raising this topic in certain patient groups, and a proportion of GPs would never discuss HIV testing, even in very high-risk groups. No respondents were aware that vertical transmission could be reduced by antiretroviral drug therapy. These data advocate that the barriers to raising the issue of HIV testing and the methods of reducing GPs' anxiety associated with it, need to be addressed.

Lymphogranuloma venereum: biopsy, serology, and molecular biology.

A 21 year old woman presented with painful groin lymphadenopathy and malaise. Lymph node biopsy, to exclude atypical infection and malignancy, suggested the diagnosis of lymphogranuloma venereum. This diagnosis was confirmed by serology and polymerase chain reaction, with the patient subsequently admitting to a casual sexual contact within the United Kingdom. Alternative methods of investigation of this disease are discussed.

Necropsies in HIV medicines.

OBJECTIVE: The objective of this study was to determine the availability of necropsy services to departments dealing with HIV positive patients, and to assess their satisfaction with, and utilisation of, these services. METHOD: Confidential questionnaires were sent to 187 consultants in genitourinary medicine and infectious diseases departments within the United Kingdom and Ireland. One hundred and forty four (77%) replies were suitable for analysis. RESULTS: Seventy five (52.1%) centres had a routine necropsy service, compared with 59 (41.0%) which did not, including 15 (10.4%) with no service provision. Sixty one (42.4%) centres were satisfied with their current service; however, 31 (21.5%) clinics were not satisfied. The majority of service users considered necropsies to be beneficial in the subsequent management of HIV positive patients. CONCLUSION: The provision of services for HIV necropsies varies considerably. We advocate that they should be uniformly available, and that the dissatisfaction with current services should be addressed.

Sexually acquired metronidazole-resistant trichomoniasis in a lesbian couple.

A lesbian couple in a monogamous relationship each presented with vaginal discharge demonstrable on culture to contain Trichomonas vaginalis. Their symptoms had failed to respond to standard regimens of metronidazole, and subsequent microbiological sensitivities confirmed resistance of the trichomonads to metronidazole (minimum inhibitory concentrations in aerobic conditions > 8 mcg/ml). In addition, the couple denied use of penetrative sex toys or recent male partners, supporting the concept of transmission through mutual masturbation.

Proliferating cell nuclear antigen (PCNA) and nucleolar organiser regions in Hodgkin's disease: correlation with morphology.

AIM: To define the distribution of proliferating cell nuclear antigen (PCNA) and silver staining nucleolar organiser regions (AgNORs) in Hodgkin's disease. METHODS: PCNA was shown in a series of 34 cases of Hodgkin's disease using immunohistochemical methods. In a second series of 46 cases the AgNOR technique for interphase nucleolar organiser regions was studied. Both series comprised routinely fixed and processed paraffin wax sections of three main Rye subtypes. RESULTS: In all cases, regardless of Rye subtype, most Sternberg-Reed cells and mononuclear Hodgkin cells showed nuclear PCNA immunoreactivity and such cells had 15 or more AgNOR sites. The Hodgkin cells had, in general, about half the number of AgNORs seen in Sternberg-Reed variants. CONCLUSIONS: These data support the notion that Hodgkin's disease can be regarded as a high grade lymphoma, the large Hodgkin's and Sternberg-Reed cells being the (PCNA positive and AgNOR rich) neoplastic elements with high proliferative capacity. A smaller proportion of the associated cells also showed evidence of proliferation.

Proliferating cell nuclear antigen (PCNA) immunolocalization in paraffin sections: an index of cell proliferation with evidence of deregulated expression in some neoplasms.

Proliferating cell nuclear antigen (PCNA) is a 36 kD nuclear protein associated with the cell cycle. A monoclonal antibody, PC10, that recognizes a fixation and processing resistant epitope has been used to investigate its tissue distribution. Nuclear PCNA immunoreactivity is found in the proliferative compartment of normal tissues. PCNA immunoreactivity is induced in lectin stimulated peripheral blood mononuclear cells in parallel with bromodeoxyuridine incorporation and the number of cells with PCNA immunoreactivity is reduced by induction of differentiation in HL60 cells. In non-Hodgkin's lymphomas a linear relation between Ki67 and PCNA staining was demonstrated. These data suggest that in normal tissues and lymphoid neoplasms, PCNA immunolocalization can be used as an index of cell proliferation. However, in some forms of neoplasia, including breast and gastric cancer and in vitro cell lines, the simple relation between PCNA expression and cell proliferation is lost. In some breast and pancreatic tumours there is apparent deregulation of PCNA with increased expression in tissues adjacent to the tumours. The over-expression in some tumours and in adjacent morphologically normal tissue may represent autocrine or paracrine growth factor influence on PCNA gene expression.