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In April 2013, local authorities gained responsibility for commissioning sexual health services in England. With many services going out to tender and resultant change in services or service provider, there is anecdotal evidence that this has impacted on the education, training and morale of genitourinary medicine (GUM) trainees. The aim of this study was to evaluate the impact of tendering on GUM trainees. An electronic survey designed by the British Association for Sexual Health and HIV Trainees' Collaborative for Audit, Research and Quality Improvement Projects (T-CARQ) was distributed to GUM trainees and newly appointed consultants. Eighty-two individuals responded (74% GUM trainees, 25% newly appointed consultants, 1% locum appointed for service). Sixty-three per cent (45/72) had experience of training within a service which was being tendered. Of these, 59% (24/41) felt their training was not considered during the tendering process and 20% (8/41) felt that it was. Forty-four per cent (18/41) felt adequately supported. Thirty per cent (12/40) reported active participation in the tendering process. On a scale of 0 (no impact) to 5 (major impact), the median score for impact of tendering on training was 2. The positive/negative impact of tendering on different training elements was rated: other than management experience the overall impact on all parameters was negative, namely morale, senior support and education. In conclusion, this survey describes the variable impact of service tendering on GUM training. Our recommendations for maintaining training standards despite tendering include actively involving trainees and education partners, inclusion of specialist GUM training in service specifications, development of guidance for commissioners and services for the management of GUM training within tendering.

Prosthetic hip dislocation is a common but unfortunate complication in patients who have undergone total hip arthroplasty. Successful closed reduction in the emergency department leads to a reduced length of stay and rate of hospitalization.1,2 The use of regional anesthesia by femoral nerve block represents a novel approach for controlling pain in patients with hip pathologies.3 Ultrasound-guided approaches have been used with great success for controlling pain in patients with hip fractures.4,5 Here we report the case of a 90-year-old male who presented with a dislocated hip prosthesis, which was subsequently corrected with closed reduction following delivery of regional anesthesia to the femoral nerve under ultrasound guidance. To our knowledge, this represents the first reported use of an ultrasound-guided femoral nerve block to facilitate closed reduction of a dislocated prosthetic hip, and highlights a novel approach that avoids the use of procedural sedation in an elderly patient., Competing Interests: Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

Sexually acquired reactive arthritis (SARA) may present acutely to general physicians. It is important to consider the condition and to identify key features in the history and examination so that appropriate investigations are taken and optimum treatment is given. Involvement of relevant specialists in the management is essential and where sexually transmitted infections are identified, partner notification is required., (© 2016 Royal College of Physicians.)

Although there is now considerable experience in obtaining sperm from a cadaver, there is little or no published data regarding pregnancy, birth and long-term childhood health and development outcomes when posthumous sperm is used in in vitro fertilisation (IVF). We report the results from treatment of four women undergoing IVF treatment using posthumously acquired human sperm from their deceased partners. In all cases, testicular tissue was obtained in a mortuary setting, and the duration from death to posthumous sperm retrieval ranged from 12 to 48 h. The age of women treated ranged from 31 to 41 years. Fertilization rates ranged from 40 to 100%. Singleton pregnancies were obtained for each of the four women. One pregnancy was complicated by preterm birth at 31 weeks; the other three delivered at term. One baby was growth restricted but morphologically normal; the other children had term birthweights in the normal range. All four children were have shown normal health and developmental outcomes, with the follow-up ranging from 1 to 7 years., (© The Author 2015. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background and Aim: Anti-ZnT8 antibodies (ZnT8A) were recently proposed as a new independent serological marker in Type 1 diabetes (T1D), leading to a significant improvement of the positive predictive value of autoantibody measurement in this setting. The aim of this retrospective multicentre study was to investigate ZnT8A as a complement to the current T1D autoantibody assays in a large cohort of paediatric Italian patients., Methods: ZnT8A were assessed by ELISA in 213 T1DM paediatric patients referred to six different centres in North-East Italy. Fifty-four were analysed at disease onset, 79 within 4 years from diagnosis and 80 after 5 or more years from diagnosis. Retrospective data about islet cell autoantibodies (ICA), anti-insulin (IAA), anti-glutamate decarboxylase (GADA) and anti-protein tyrosine phosphatase IA-2 (IA-2A) antibodies were collected and compared., Results: Overall, ZnT8A showed positive results in 106/213 (49.8 %) T1D patients and were found in 10 (4.7 %) subjects previously classified as autoantibody negative based on the existing markers (GADA, IA-2A, IAA and ICA), increasing the overall diagnostic sensitivity from 85.9 to 90.6 %. ZnT8A disclosed the same sensitivity (61.1 %) at disease onset as GADA (61.1 %) and higher than IA-2A (53.7 %), with only GADA showing much persistence in the long-term follow-up. Focusing on patients at disease onset, all the ICA positive were associated with at least one positive autoantibody among GADA, IA-2A and ZnT8A, 16.7 % of whom presenting only anti-ZnT8-positive antibodies., Conclusion: This study confirms ZnT8A as an important additional and independent diagnostic marker of T1D and supports its introduction in the routine diagnostic process to replace less sensitive methods and improve the overall autoantibody sensitivity.

In the present feasibility study, e-supervision was used to provide university liaison supervision to speech-language pathology (SLP) graduate students enrolled in student teaching practica. Utilizing a mixed methodology approach, interview and survey data were compared in order to identify similarities and differences between in-person and e-supervision, and guide future practice. Results showed e-supervised graduate students perceived that they received adequate supervision, feedback, support, and communication. Further, e-supervision provided additional benefits to supervisors, children on the caseload, and universities. Despite the benefits, disadvantages emerged. Implications for future practice and limitations of the study were identified.

This report examines the protective role of motherhood against suicidal ideation among low-income African American women with a history of suicide attempts. Findings from previous studies examining the relations between family factors and suicide risks are inconsistent in this population, indicating that family could both exacerbate and reduce risks. Research on the link between motherhood-status specifically and suicide risk is rare, but family and child-related concerns have been identified as unique reasons for living associated with reduced risk of suicide attempt. Self-identified African American women (N = 146), ages 18-64, who attempted suicide within the previous 12 months were recruited from a large urban public hospital. A bootstrapping mediation model was tested using motherhood status from the demographics measure as the predictor, the Reasons for Living (RFL) scales as the mediator, and the Beck Suicidal Ideation Scale as the outcome. The model accounted for 41% of the variance in suicidal ideation and the indirect effect of RFL was statistically significant. These findings provide empirical support for the hypothesis that motherhood is protective against suicidal ideation among African American women with a history of suicide attempts. Future research should seek to determine how incorporating the protective function of motherhood status in clinical interventions with this high-risk population might help to improve treatment effectiveness., (© 2013 American Psychological Association)

Background: Spinal commissural axons represent a model system for deciphering the molecular logic that regulates the guidance of midline-crossing axons in the developing central nervous system (CNS). Whether the same or specific sets of guidance signals control the navigation of molecularly distinct subtypes of these axons remains an open and largely unexplored question. Although it is well established that post-crossing commissural axons alter their responsiveness to midline-associated guidance cues, our understanding of the repulsive mechanisms that drive the post-crossing segments of these axons away from the midline and whether the underlying guidance systems operate in a commissural axon subtype-specific manner, remains fragmentary at best., Results: Here, we utilize axonally targeted transgenic reporter mice to visualize genetically distinct dorsal interneuron (dI)1 and dI4 commissural axons and show that the repulsive class 3 semaphorin (Sema3) guidance receptor Neuropilin 2 (Npn2), is selectively expressed on the dI1 population and is required for the guidance of post-crossing dI1, but not dI4, axons. Consistent with these observations, the midline-associated Npn2 ligands, Sema3F and Sema3B, promote the collapse of dI1, but not dI4, axon-associated growth cones in vitro. We also identify, for the first time, a discrete GABAergic population of ventral commissural neurons/axons in the embryonic mouse spinal cord that expresses Npn2, and show that Npn2 is required for the proper guidance of their post-crossing axons., Conclusions: Together, our findings indicate that Npn2 is selectively expressed in distinct populations of commissural neurons in both the dorsal and ventral spinal cord, and suggest that Sema3-Npn2 signaling regulates the guidance of post-crossing commissural axons in a population-specific manner.

Workforce planning is an inexact science. Specialty and Associate Specialist (SAS) doctors are rarely included in workforce analyses. Past studies have shown that SAS doctors are significant contributors to the work in genitourinary (GU) medicine clinics. This survey confirms the large amount of clinical work undertaken by SAS doctors. It appears that 51% of SAS doctors in GU plan to retire in the next 15 years and it is uncertain what effect the 2008 SAS contract will have on SAS recruitment. This information should be taken into consideration in future GUM workforce planning.

The risk of HIV transmission via breastfeeding is well reported. We conducted a national survey in the UK to look at the current knowledge and postpartum practice of HIV physicians caring for HIV-positive pregnant women. In total, 167 questionnaires were distributed, 85 (51%) questionnaires were returned. All the respondents advised their patients against breastfeeding, 17 (23%) respondents routinely prescribed drugs for postpartum lactation suppression and 32 (43%) detailed awareness of interactions between antiretroviral therapy and dopaminergic lactation suppression agents. Thirteen respondents reported awareness of guidance on lactation suppression. The knowledge and use of lactation suppression agents appears to be low. However, its use will not only reduce postnatal mastitis and breast engorgement but will also help women deal with social pressures to breastfeed. Increased use in specific circumstances will improve the postnatal care of HIV-positive pregnant women in the UK.

Nutritional status is known to have profound effects on immune function and resistance to infections, particularly in the elderly. We investigated the effect of a complex micronutrient supplement in elderly people on the changes in some of the cellular components of the immune system, on lymphocyte function, and on the antibody response to influenza vaccination. One-hundred-six subjects aged 62 to 98 were randomly assigned to receive a complex micronutrient supplement or a placebo for three months. Subjects were vaccinated against influenza after eight weeks. Clinical parameters, lymphocyte subsets, in vitro lymphocyte activation, and influenza antibody titers were assessed at baseline and after 90 days of supplementation. A significant increase in total lymphocytes (p=0.034) and white blood cells (WBC) (p=0.03) in the supplemented group was observed. A shift from CD4+/CD45RO+ "memory" cells to CD4+/CD45RA+ "naïve" T-cells in favor of CD4+/CD45RA+ "naïve" T-cells took place. The group consuming additional micronutrients showed an increase in CD45RA+ subsets (p=0.032) compared to the control group. A decrease of total cholesterol (from 228.72 + or - 56.11 to 210.74 + or - 52.58, p=0.002) and low-density lipoprotein (LDL) (from 145.75 + or - 48.86 to 125.47 + or - 41.72, p<0.001) was observed. Influenza antibody titers showed no correlation with micronutrient intake. We conclude that supplementation with a complex micronutrient formulation increases the number of various types of immune cells and decreases total cholesterol and LDL in elderly people. No beneficial effect on specific antibody response to influenza vaccination was observed. Further research is needed to evaluate whether enhanced cellular immune responses decrease the incidence of infections in elderly people.

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.

The objective of this study was to identify the proportion of female contacts of men diagnosed with non-gonococcal non-chlamydial urethritis (NGNCU) who had chlamydial infection, muco-purulent cervicitis (MPC), pelvic inflammatory disease (PID) or other genital infections, and to determine whether chlamydial rates are higher in women who are contacts of men with NGNCU. A retrospective case-note review of men with NGNCU and their traced female contacts was performed. Seventy-five men were included in the study, of whom 75% were caucasian and 49% were asymptomatic. Twenty-four women were successfully traced equating to 0.32 contacts per index man. In total, 46% of the women were contacts of asymptomatic men. Overall, 26% of women were identified with chlamydial infection, increasing to 36% in the contacts of asymptomatic men. The diagnosis and partner notification of men with asymptomatic NGNCU does identify female contacts with high chlamydial infection rates. However, such targeting is resource-intensive and invasive urethral screening may deter asymptomatic men from attending. It is likely that the needs of the whole health community will be better served by screening a greater number of men and operating an active partner notification system.

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.

Introduction: The number of overweight children is constantly increasing in both developed and underdeveloped countries. Most epidemiological surveys consider school age children with little attention being given to preschool age children. This study was undertaken to define the prevalence of being overweight or obese in a population of children 3-6 years of age, living in North-East Italy. We also identified differences when comparing body mass index (BMI) data against three different national and international standards., Subjects and Methods: The study involved 258 children (124 males and 134 females) with an average age of 4.8 years. Weight and height were obtained for each child and BMI was calculated according to the formula weight (kg)/height (m)(2). The prevalence of overweight and obese subjects was then determined using the growth curves of the Centers for Disease Control and Prevention (CDC), the growth curves of the International Obesity Task Force (IOTF) and the curves published in 2003 by Luciano et al., Results: All three methods gave similar, but not identical, estimates of the prevalence of overweight in both boys and girls. However, when determining the prevalence of obesity, the use of the CDC curves led to a significantly higher prevalence of obesity in both males and females when compared to the growth charts of the IOTF and Luciano et al., Background: The use of the CDC growth curves leads to an increase in the prevalence of obesity when evaluating children under 5 years of age. The lower cut-off values inherent in the CDC charts, in contrast to the ones proposed by the IOTF, allow for earlier identification of a larger number of subjects with weight problems and therefore provide the potential for earlier intervention.

National prevalence of Giardia infection in dogs and cats presenting to clinics with vomiting and/or diarrhea was examined using the IDEXX SNAP Giardia test kit. Veterinary practices across the United States were sent an invitation to participate in the survey and asked to use the test on fecal samples from the target population. The survey requested that the clinics report the results of 20 or more tests. A total of 21,092 results were reported, comprised of 16,114 dogs and 4,978 cats. Analysis of the data (excluding the handful of results reported from Puerto Rico) showed a Giardia prevalence of 15.6% among dogs tested, and 10.8% among cats. This difference was statistically significant (p < 0.001). Regional categorization into Northeast, Southeast, West, and Midwest drew out significant (p < 0.001) differences in prevalence in most cases for dogs; the differences were not significant for cats. These differences and other variables are currently being examined with this and additional data sets. We conclude on the basis of the SNAP test diagnostic that Giardia is a common enteric agent among dogs and cats with gastrointestinal signs.

A case-note audit of patients presenting to a genitourinary (GU) medicine clinic with external genital warts during a six-month period was conducted. Approximately 40% of patients were referred by a general practitioner or other primary care agency, and >50% were suitable for home-based treatment. Overall incidence of co-existing sexually transmitted infections (STIs) in the study population was 14.0%. Multivariate logistic regression analysis found that age<25 years and presence of other genital symptoms were risk factors for co-existing STIs. All patients with a non-chlamydial STI had genital symptoms. We recommend that patients with uncomplicated genital warts and no additional genital symptoms can be treated in primary care, with chlamydia-screening offered to those aged<25 years.

In the UK there are high rates of sexually transmitted infections and unintended pregnancies amongst young people. There is limited and contradictory evidence that current sexual health education interventions are effective or that they improve access to appropriate sexual health services. This paper describes the outcome of focus group work with young people that was undertaken to inform the design of an Interactive Multimedia Learning Environment that incorporates message framing, intended for use in sexual health promotion. The focus group work addressed sexual attitudes, behaviour, risk perception, and knowledge of sexual health and sexual health services in Nottingham. The results provided new insights into young peoples' sexual behaviour, and their diversity of knowledge and beliefs. Common themes expressed regarding sexual health services included concerns about confidentiality, lack of confidence to access services and fear of the unknown. The results showed that while the adolescents are reasonably knowledgeable about infection, they do not know as much about the relevant services to treat it. This work emphasizes the need for user involvement throughout the design and development of a sexual health intervention, and will form the basis of the next part of the project.

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.

Objectives: To evaluate the relative contributions of peers cannabis use or non use, parental approval of such use, adolescents' own beliefs about use, self-esteem, and depressive and symptoms of borderline personality disorder, in the prediction of cannabis use and dependence., Method: Participants were 257 high-school students who completed questionnaires assessing cannabis use frequency, cannabis dependence, the number of peers using cannabis, the number of peers opposed to cannabis use, parental attitude toward cannabis use, participants' attitude toward use, self-esteem, depressive and borderline symptomatology. Logistic regression analyses were conducted to predict cannabis use, daily use and dependence., Results: The number of peers using cannabis, participants' approval of cannabis use, and the intensity of symptoms of borderline personality disorder were risk factors for use whereas the number of peers opposed to cannabis use was a protective factor. Parental attitudes toward use and participants' depressive symptomatology were not significant independent predictors of use. There were no significant predictors of probable cannabis dependence., Conclusion: To inform adolescents that a significant proportion of them disapprove of cannabis use may be an effective component of prevention of use. Symptoms of borderline personality disorder may account for the association between depression and cannabis use. The social influences and psychopathological factors evaluated in this study did not appear to play a major role in the development of cannabis dependence.

A comparison of the prevalence of health anxiety in genitourinary medicine (GUM) clinics in two UK centres was carried out using a new rating scale, the Health Anxiety Inventory (HAI). The relationship of health anxiety to demographic and clinical variables, and its impact on service contacts, was also examined in one of these centres. 694 patients were assessed and significant health anxiety was identified in 8-11%. HAI scores were stable over time and high levels persisted in the absence of treatment. Attenders with sexually transmitted infections had significantly lower levels of health anxiety than those with other conditions. Contacts with clinic doctors and health advisors in the nine months before and after assessment were significantly greater in those with high health anxiety, with doctor appointments 37% higher in the high HAI group (P = 0.005). Health anxiety is a source of considerable morbidity in GUM clinics deserving further study.

We sought to investigate contraceptive use in women attending a genitourinary medicine (GUM) clinic, and to assess the need for a contraceptive service in this setting. Female attendees at Nottingham GUM clinic were invited to complete an anonymous questionnaire regarding past and present contraceptive use and whether a contraceptive service within GUM would be utilized. Four hundred and eighty-nine questionnaires were analysed. The majority had previously used condoms (89.8%) or the combined oral contraceptive pill (COCP) (74.6%), and 46.6% and 37.4%, respectively were currently using these methods. Contraception was frequently used for the dual aims of avoiding both pregnancy and infection (48.5%). General practitioners (GPs) and family planning clinics were most frequently cited as sources of regular contraceptive advice, 58.1% and 47.2% respectively, and emergency contraception 50.8% and 37.3%, respectively. If a contraceptive service was available within GUM 56.9% of respondents indicated they would use it.

Our objective was to describe how genitourinary medicine (GUM) clinics in the North Thames region manage sexually acquired reactive arthritis (SARA), and to compare management with national guidelines. A self-completed questionnaire survey and retrospective case note review was conducted between September and October 2001. Clinicians in 33 clinics were asked to describe their clinic's policy on the management of SARA, and to review the last five cases seen or the last cases seen in the preceding two years, if less than five. Nineteen (58%) clinics took part. There were inter-clinic variations in the investigation and management of patients, with only 63% (12/19) of clinics offering non-steroidal anti-inflammatory drugs (NSAIDs) and 58% (11/19) giving doxycycline 1001mg. twice daily for two weeks for urethritis - the rest using any of three other antibiotic regimens. There was no consistent policy of referral between other specialties and GUM for genital screening and partner notification. A total of 36 male and female case notes were reviewed. Patients without arthritis or joint swelling (5/38, 13%), or with non-typical symptoms such as diarrhoea (5/38, 13%) were diagnosed inappropriately with SARA. Only 33 (87%) had evidence of a sexually transmitted infection (STI) with at least two (5%) of patients being treated with antibiotics despite no apparent indication being present. Only 21 (55%) had documented NSAID therapy. Case identification was difficult due to the lack of a national disease code (KC60) for SARA. The data suggest that a diagnosis of SARA is sometimes being made with no identifiable STI, or where symptoms are more suggestive that another route of infection is likely. A clear guideline within clinics to standardize prescribing of antibiotics is needed and collaborative policies with GUM are needed for other specialties to use when investigating and managing patients with seronegative arthritis. GUM should consider re-introducing a KC60 code for SARA for better case identification.

Quality issues are becoming increasingly relevant to the working lives of health care staff. We sought to assess the perceived work-related quality of life of staff working in a genitourinary medicine (GUM) department using a self-administered anonymous questionnaire focusing on areas from the Trust's staff charter. Over two-thirds (69%) of the staff members participated. Perceptions of working life were generally good within GUM. In particular staff felt valued as a resource with free expression of ideas, involvement in decision making, fair treatment and respect. Weaker areas were identified enabling a plan to be developed to address these. It is important to address quality in working life in order to achieve improvements.

Objectives: To assess Internet use amongst young people to determine whether it would be a practical way to provide sex education and information., Methods: Year 10 students (aged 14-15 years) from North Nottinghamshire schools were asked to participate in focus groups to discuss the Internet. A series of predefined questions were directed to the whole group to generate debate. Areas explored included: Internet access and site; frequency and purpose of Internet use; websites visited; ideas for a genitourinary medicine (GUM) website. Responses were recorded by a hand count or as individual verbal responses., Results: Thirteen focus groups were held involving 287 students of approximately equal sex distribution. All had access to Internet facilities at school and 224 (78.0%) had access elsewhere. Access was at least once a week by 178 (62.0%) mostly for e-mail, games, chatlines and homework. No one accessed for health information. One hundred and seventy-nine (62.4%) participants said they would use a GUM website. A 'question line' where they could e-mail questions to a health care professional was of interest to 202 (70.4%) participants., Conclusions: The Internet would be a practical and accessible way of delivering sexual health education to young people, particularly if it is incorporated into activities and websites they enjoy.

The diagnosis of Trichomonas vaginalis (TV) infection in women may be made by observing motile trichomonads in wet-mount preparations of vaginal discharge. The duration for which these organisms can be identified in such samples is unknown. We sought to assess this by performing wet-mount microscopy on samples from female patients immediately, and then in positive samples, every 10 minutes until motile trichomonads could no longer be identified. Of the 65 wet-mount specimens positive for TV, a cumulative total of 13 (20%) samples had become negative by 10 minutes, 23 (35%) samples by 30 minutes and 51 samples (78%) by two hours, with the remainder exceeding two hours. We conclude that one-fifth of wet-mount vaginal preparations initially positive for motile TV become negative within 10 minutes of the initial, immediate reading. In order to maximize the sensitivity of this widely used test it is recommended that all specimens be examined immediately after they are taken.

Women with an early coitarche may be less connected to home than those with a later coitarche and are more at risk of sexually transmitted infections (STIs). Children in care or the 'looked after' system feel less connected. We investigated whether women ever in care (WEIC) differed from women never in care (WNIC) in terms of coitarche and STIs using self-reported data from women attending Genitourinary Medicine clinics. Of the 336 women participating 17 women had experienced care, of whom 13 (76.5%) had coitarche below 16 years of age; of these five (38.5%) had used a condom at coitarche and three (60%) with genital infections had gonorrhoea, chlamydial infection or pelvic inflammatory disease. This compared with 112 (35.1%), 70 (62.5%) and 29 (40.8%), respectively for WNIC. WEIC are more likely to have early coitarche; if this is below 16 years subsequent genital infections are more likely to be fertility-threatening.

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.

A wide range of patients present to genitourinary medicine (GUM) clinics with diverse conditions, many of which may not be infective. One such condition, albeit rare, is penile fracture. This is a traumatic rupture of the corpus cavernosum usually associated with blunt trauma to the erect penis. Prognosis and management issues are discussed.

Initial steps in investigating gene function often include deleting and overexpressing the gene of interest and identifying the subcellular location of the gene product. To facilitate these procedures, a number of new PCR modules, which contain selectable markers and in some cases other genetic elements (e.g promoter elements, epitope tags, and reporter genes) have been developed. These modules are used as PCR substrates to create products that can be targeted to specified locations in the yeast genome, thus modifying that genomic locus. We describe here a series of plasmids that contain a truncated version of the strong ADH1 promoter with and without amino-terminal 3HA and GST tags. Because these plasmids contain the same vector sequences as the GAL1 promoter plasmids, a constitutive and an inducible promoter can now be integrated with a minimal number of primers., (Copyright 2001 John Wiley & Sons, Ltd.)

Women are an increasing proportion of the HIV-infected population. In addition, compared with their HIV-negative counterparts, they have a greater incidence of both cervical intraepithelial neoplasia (CIN) and invasive cervical cancer, which tends to be more progressive and aggressive. The development of invasive cervical carcinoma in an HIV-infected woman is an AIDS-defining diagnosis. However, what is not clear is whether women who are identified with cervical carcinoma should be offered screening for HIV infection. This review addresses these issues and provides a cost-effectiveness assessment.

Human parainfluenza viruses types 1, 2 and 3 (HPF 1, 2 and 3) are important pathogens in children. While these viruses share common structures and replication strategies, they target different parts of the respiratory tract; the most common outcomes of infection with HPF3 are bronchiolitis and pneumonia, while HPF 1 and 2 are associated with croup. While the HPF3 fusion protein (F) is critical for membrane fusion, our previous work revealed that the receptor binding hemagglutinin-neuraminidase (HN) is also essential to the fusion process; interaction between HN and its sialic acid-containing receptor on cell surfaces is required for HPF3 mediated cell fusion. Using our understanding of HPF3 HN's functions in the cell-binding and viral entry process, we are investigating the ways in which these processes differ in HPF 1 and 2, in part by manipulating receptor availability. Three experimental treatments were used to compare the HN-receptor interaction of HPF 1, 2 and 3: infection at high multiplicity of infection (m.o.i.); bacterial neuraminidase treatment of cells infected at low m.o.i.; and viral neuraminidase treatment of cells infected at low m.o.i. (using Newcastle disease virus [NDV] neuraminidase or UV irradiated HPF3 as sources of neuraminidase). In cells infected with HPF3, we have shown that infection with high m.o.i. blocks fusion, by removing sialic acid receptors for the viral HN. However, in cells infected with HPF 1 and 2, infection with high m.o.i. did not block fusion; the fusion increases with increasing m.o.i. In cells infected with HPF 1 and 2, neither bacterial nor NDV neuraminidase blocked cell fusion, using amounts of neuraminidase that completely block fusion of HPF3 infected cells. However, when inactivated HPF3 was used as a source of viral neuraminidase, the treatment inhibited fusion of cells infected with HPF 1 and 2 as well as 3. The differences found between these viruses in terms of their interaction with the cell, ability to modulate cell-cell fusion and response to exogenous neuraminidases of various specificities, may reflect salient differences in biological properties of the three viruses., (Copyright 1999 Academic Press.)

The KC60 diagnostic code information provides an epidemiological monitor of sexually transmitted infection (STI) and a means of standardizing clinical workload in genitourinary medicine (GUM) departments. We aimed to assess the coding process and its uniformity within the Trent region by means of a confidential self-administered coding exercise with simulated case presentations. The correct coding for STIs ranged from 59.4% to 100% in different scenarios. Difficulty was identified in the coding of vulvitis and balanitis where no organism was isolated, as represented by a wide range of codes. HIV pre-test counselling without testing was coded by only 57.8% of respondents. Over 95% indicated correctly the first hepatitis B vaccine dose but 21% failed to code once only for the course. Coding practice also varied within individual sites with a 21-100% discordance. In parts diagnostic accuracy was good but there were areas of non-uniformity both within sites and cross-regionally. Regional discussions have resulted in increased training opportunities and guidelines have been developed to increase uniformity and achieve consensus in uncertain areas.

Mycobacterium avium is the causative agent of the avian mycobacteriosis commonly known as avian tuberculosis (ATB). This infection causes disseminated disease, is difficult to diagnose, and is of serious concern because it causes significant mortality in birds. A new method was developed for processing specimens for an antemortem screening test for ATB. This novel method uses the zwitterionic detergent C18-carboxypropylbetaine (CB-18). Blood, bone marrow, bursa, and fecal specimens from 28 ducks and swabs of 20 lesions were processed with CB-18 for analysis by smear, culture, and polymerase chain reaction (PCR). Postmortem examination confirmed nine of these birds as either positive or highly suspect for disseminated disease. The sensitivities of smear, culture, and PCR, relative to postmortem analysis and independent of specimen type, were 44.4%, 88.9%, and 100%, respectively, and the specificities were 84.2%, 57.9%, and 15.8%, respectively. Reductions in specificity were due primarily to results among fecal specimens. However, these results were clustered among a subset of birds, suggesting that these tests actually identified birds in early stages of the disease. Restriction fragment length polymorphism mapping identified one strain of M. avium (serotype 1) that was isolated from lesions, bursa, bone marrow, blood, and feces of all but three of the culture-positive birds. In birds with confirmed disease, blood had the lowest sensitivity and the highest specificity by all diagnostic methods. Swabs of lesions provided the highest sensitivity by smear and culture (33.3% and 77.8%, respectively), whereas fecal specimens had the highest sensitivity by PCR (77.8%). The results of this study indicate that processing fecal specimens with CB-18, followed by PCR analysis, may provide a valuable first step for monitoring the presence of ATB in birds.

Isolates of the Mycobacterium avium complex were examined for hemolysin expression. Only invasive isolates of M. avium were observed to be hemolytic (P < 0.001), with activity the greatest for isolates of serovars 4 and 8. Thus, M. avium hemolysin appears to represent a virulence factor necessary for invasive disease.

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.

A randomized double-blind, placebo-controlled study was performed to determine the safety, efficacy, and effect of thalidomide on a variety of immunological and biochemical parameters in asymptomatic human immunodeficiency virus (HIV)-positive patients. Nineteen male patients with elevated markers of immune activation and CD4 cell counts above 400/mm3 were randomized to either placebo or thalidomide at 100 mg/day for 24 weeks. However, only 3 (of 10) patients receiving thalidomide completed all 24 weeks compared to 6 (of 9) patients receiving placebo. This was mainly due to fatigue (somnolence is a recognized side effect), although this was also seen to a lesser extent in the placebo group and so may not be drug attributable. No significant changes in CD4/CD8 count, activation markers, TNF-alpha, or TNFR1 were observed. However, a nonsignificant trend toward inhibition of mitogen-induced TNF-alpha production was observed in the thalidomide arm. The lack of systemic effect and the lower tolerance of thalidomide (at this dose) in asymptomatic patients highlights the need for pharmacokinetic analysis to address possible absorption problems and the need for more potent and less toxic TNF-alpha inhibitors to be developed for use in this type of study.