The crisis in sexual health and developing genitourinary medicine services: lessons from a primary care trust.

The House of Commons Health Select Committee recently described a national crisis in sexual health. Alarmed by dramatic increases in the rates of sexually transmitted infections (STIs) and appalled by over-stretched, under-resourced genitourinary (GU) medicine services, the committee has called for urgent action. The increasing rates of STIs locally, a significant cluster of syphilis cases, and an over-burdened GU medicine service prompted Walsall primary care trust to undertake an evaluation of local service provision. The results were used to inform the development of GU medicine services locally and Walsall's sexual health strategy. This paper reports the results of the evaluation and the implications for service development. The Walsall GU medicine service was evaluated using three approaches, based on standards for GU medicine service provision identified from the literature. Routine data were used to analyse trends in STIs and service activity, including access times. These data further informed the evaluation process. Local stakeholder views on GU medicine service provision were sought using semi-structured interviews. Most standards relating to the provision of core services, including those for the management of patients with HIV infection, were met. High levels of patient satisfaction were reported. However, under-staffing, inadequate clinic facilities, and limited joint working with other agencies were highlighted as key concerns. Tackling sexual health inequalities and improving the sexual health of the population requires investment in resources and manpower, improved partnership working, and configuring services around the needs of patients. In addition, and perhaps most importantly, it will require a shift in how both health professionals and the public perceive and utilize sexual health services.

Are we falling at the first hurdle? Estimating under-recording of falls in Accident and Emergency.

BACKGROUND: Accident and Emergency (A and E) is the first port of call for most people who have experienced an injurious fall. This provides the potential for identifying patients who may benefit from preventative interventions. This study aims to estimate the percentage of falls attendances that are not recorded on computerised A and E records. METHODS: A retrospective cohort study design was used to study patients attending A and E with falls related injuries. RESULTS: The survey revealed poor recording of falls with 38 per cent (95 per cent CI +/- 8.82 per cent) of patient reported falls not recorded on computerised A and E records. More than half of those reporting a fall as the reason for attendance at A and E, reported previous falls, with 21 per cent reporting subsequent falls. CONCLUSIONS: A and E could play an important role in secondary falls prevention. Improving recording of falls in A and E is an essential prerequisite.

Mycobacterial interspersed repetitive unit typing of Mycobacterium tuberculosis compared to IS6110-based restriction fragment length polymorphism analysis for investigation of apparently clustered cases of tuberculosis.

An evaluation of the utility of IS6110-based restriction fragment length polymorphism (RFLP) typing compared to a combination of variable number tandem repeat (VNTR) typing and mycobacterial interspersed repetitive unit (MIRU) typing was undertaken. A total of 53 patient isolates of Mycobacterium tuberculosis from four presumed episodes of cross-infection were examined. Genomic DNA was extracted from the isolates by a cetyl trimethylammonium bromide method. The number of copies of tandem repeats of the five loci ETR(A) to ETR(E) and 12 MIRU loci was determined by PCR amplification and agarose gel electrophoresis of the amplicons. VNTR typing identified the major clusters of strains in the three investigations in which they occurred (each representing a different evolutionary clade: 32333, 42235, and 32433). The majority of unrelated isolates (by epidemiology and RFLP typing) were also identified by VNTR typing. The concordance between the RFLP and MIRU typing was complete, with the exception of two isolates with RFLP patterns that differed by one band each from the rest of the major epidemiologically linked groups of isolates in investigation A. All of these isolates had identical MIRU and VNTR types. A further pair of isolates differed in the number of tandem repeat copies at two MIRU alleles but had identical RFLP patterns. The speed of the combined VNTR and MIRU typing approach enabled results for some of the investigations to be supplied in "real time," influencing choices in contact tracing. The ease of comparison of results of MIRU and VNTR typing, which are recorded as single multidigit numbers, was also found to greatly facilitate investigation management and the communication of results to health care professionals.

An outbreak of mumps in the metropolitan area of Walsall, UK.

OBJECTIVE: To describe the epidemiology of excessive mumps cases during the year 2000, within the metropolitan area of Walsall, UK; to assess the impact of the mumps outbreak on morbidity; and to inform future communicable disease control strategy. METHODS: Demographic records, school attendance, uptake of the measles-mumps-rubella (MMR) vaccine, and mumps-associated admission to hospital, were reviewed for all Walsall residents diagnosed and notified with mumps during the year 2000. RESULTS: There were 200 mumps notifications in 2000 (76.6 per 100,000), representing the highest incidence in England. Only 91 of the notified cases were salivary antibody positive for mumps IgM, and 32 were negative, although 77 were not tested. Since 1990, annual totals have never previously exceeded 20. Over 90% of patients were <20 years old, with a peak age group of 10-14 years; 88% attended schools located within Walsall. The pattern of spread suggested that the outbreak proceeded through schools from north to south in the more deprived western half of the metropolitan area. Most cases (136, 68%) had received one (99, 49.5%) or two (37, 18.5%) doses of MMR vaccine; cases > or =20 years old had never received MMR. Six cases (aged 4-14 years) were admitted to hospital, all with a successful outcome, including one male with meningitis and one female with pancreatitis. Current uptake of the MMR vaccine at 24 months has dropped to below 90% in recent years, as in most parts of the UK. CONCLUSIONS: Future mumps outbreaks in schools, and among older age groups, can be predicted, since most older children and young adults have received only one dose of MMR vaccine or no vaccination at all. Primary vaccine failure is well described in mumps, and cases during outbreaks can include recipients of two MMR vaccine doses. It was fortunate that no severe morbidity was associated with this outbreak (prior to MMR, two to four mumps deaths occurred annually in England and Wales). Measures to restore the uptake of MMR to the previous levels of above 90-95% will be necessary to reduce the risk of the mumps virus circulating within communities. Older children are susceptible, and it may be advisable to ensure second-dose MMR uptake while they are still at or when they leave school, or when they enter college, university or the military.