Dirk Avonts

Incidence of uncomplicated genital infections in women using oral contraception or an intrauterine device: a prospective study

&NA; Over a period of 2 years, the authors prospectively followed a cohort of 123 women using an intrauterine device (IUD) and 108 women using oral contraception (OC) in one family practice. They found nine new episodes of cervical chlamydial infection in OC users (7/100 Woman years (WY)) as compared to 1 new episode in IUD users (0.8/100 WY), yielding a relative risk (RR) for OC users of 8.8 (95% confidence interval (CI): 1.3‐59.0). During the 24 months of observation, 15% of OC and 2% of IUD users acquired at least one episode of Chlamydia trachomatis infection (P = .01). Bacterial vaginosis occurred more frequently in IUD users (25/100 WY) than in OC users (9/100 WY) (RR = 2.8; 95% CI: 1.5‐5.1). During the 24‐month period, 50% of women using an IUD had at least one episode of bacterial vaginosis, compared with 20% of the OC users (P = .001). Symptomatic bacterial vaginosis was associated with the use of an IUD (RR for IUD users was 7.7; 95% CI: 2.1‐28.4), whereas asymptomatic bacterial vaginosis was associated with sexual promiscuity.

Chlamydial infection: an accurate model for opportunistic screening in general practice

Objectives: To estimate the prevalence of Chlamydia trachomatis in women in general practice and to assess risk factors associated with infection. Methods: The study was carried out in 2001–2 in different general practices in Antwerp, Belgium. Sexually active women, visiting their general practitioner for routine gynaecological care (mostly pill prescription or PAP smear), were offered opportunistic screening for chlamydia. 787 participants aged 15–40 delivered a self taken vaginal sample and filled in a questionnaire which included questions on demographic variables, urogenital symptoms, sexual history, and sexual behaviour. Samples were tested for presence of chlamydial DNA by means of a ligase chain reaction (LCR) assay, and positives were confirmed by two other amplification assays (PCR and SDA). Results: Overall prevalence was 5.0% (95% CI: 3.5 to 6.5). Determinants of infection in logistic regression analysis were age 18–27 years, >1 partner in the past year, no use of contraceptives, frequent postcoital bleeding, having a symptomatic partner, painful micturition, and living in the inner city. The area under the ROC curve in the full model was 0.88. Selective screening based on a combination of the five first determinants detects 92.3% of infections in this sample; 37.5% of the population would need to be screened. Conclusion: Targeted screening for chlamydial infection is possible, even in a heterogeneous group of general practice attendants. Implementing this model would require considerable communication skills from healthcare providers.

Contraceptive knowledge and expectations by adolescents: an explanation by focus groups.

To determine the needs and expectations of adolescent girls concerning contraceptive use as well as their attitude to health care providers, a qualitative research was performed with four focus groups of 17-year-old girls of different education levels. All 26 girls except one were of Belgian origin. There was a fixed scenario for each group. The discussions were tape-recorded, transcribed and analysed via content analysis. Knowledge concerning the daily use and side-effects of contraceptives was insufficient. A school physician is not the person they want to talk to. The influence of the peer in the group is very important. The general practitioner is the most frequently consulted health care provider for the first pill prescription, but for a gynaecological examination they thought they had to visit a gynaecologist. The girls expected confidentiality from their general practitioner and wanted sufficient consultation time. Factors inhibiting the visits for obtaining contraceptives were the cost, waiting time and fear of the gynaecological examination. Adolescents intended to visit their general practitioner for contraceptives, but the family practice had to be easily accessible. It is a challenge for general practitioners to provide good contraceptives to adolescents and to promote compliance.

Syphilis, hepatitis A, hepatitis B, and cytomegalovirus infection in homosexual men in Antwerp.

In a homosexual communication centre in Antwerp 196 homosexual men were screened for seromarkers of syphilis, hepatitis A (HAV), hepatitis B (HBV) and cytomegalovirus (CMV). A comparison group consisted of 118 heterosexual men attending a venereal disease clinic in Antwerp. Treponemal antibodies were found in 7.1% of homosexual men, of whom half gave no history of past or present infection. Anti HAV was present in 43.3%, HBV seromarkers in 34.4%, and CMV antibodies in 71.2% of homosexual men. Hepatitis B surface antigen (HBsAg) was detected in eight homosexual men, but not in the heterosexual control group. Prevalence rates of infections other than HAV were significantly higher in homosexual men than in heterosexual men. Answers to a questionnaire were used to evaluate risk factors for different diseases, which were: duration of active homosexuality for all infections, promiscuity (greater than or equal to 10 partners in the past six months) for syphilis and hepatitis B, and anal intercourse for hepatitis B. Visiting saunas and travelling for sexual contacts also indicated a higher risk for STD, but were an indirect expression of promiscuity.

Learning intimate examinations with simulated patients: the evaluation of medical students' performance

Background: For fifth-year undergraduates of the medical school, a project with simulated patients (Intimate Examination Associates, IEA) was implemented in 2002 at the University of Antwerp. In this project, students from the new curriculum (NC) learned uro-genital, rectal, gynaecological and breast examination in healthy, trained volunteers and received feedback focused on personal attitude, technical and communication skills. Former curriculum (FC) students however trained these skills only during internship in the sixth year after a single training on manikins. Aims: This study assessed the effect of learning intimate examinations with IEAs by comparing students from FC and NC on four different outcome parameters. Methods: Three groups were compared: FC after internships without IEA training, NC after internships with IEA training and fifth year NC immediately after the IEA training. Four assessment instruments: an OSCE using checklists and global rating scales to assess the technical skills, a score list on students attitudes and performance filled in by the IEAs, a student questionnaire on self-assessed competence and a questionnaire on the frequency of performing intimate skills during internships. Results: Both NC groups scored globally better in the OSCE (significance for male examination). Sub-scores for ‘completeness’ and ‘systematic’ approach was significantly higher in both NC groups for male and female examinations. NC students reported better self-assessed competence and performance concerning gynaecological and urological clinical and communication skills during internship. The best results were obtained after IEA training and internship was done for the four outcomes. IEAs are influenced by the ‘experienced’ students after internship: FC and NC after internship both scored better than the fifth year NC who only received the IEA training so far. Conclusion: Learning intimate examinations with IEAs has a positive effect on the performance of medical students. This beneficial effect is on its turn reinforced during internships.

Treatment of genital chlamydial infection with ofloxacin.

Summary42 men and women with a genital chlamydial infection were randomly treated with a single dose of 200 mg doxycycline daily for ten days or with 200 mg ofloxacin twice a day for nine days. Two weeks after starting treatment 40 patients were able to be reassessed. All 12 men and all seven women treated with doxycycline had clinically improved or healed and had negative cultures forChlamydia trachomatis. Among the patients treated with ofloxacin, all 11 males had improved or healed andC. trachomatis was not reisolated. These data are promising but larger numbers of patients and a longer follow-up are needed in order to confirm the efficacy of ofloxacin for the treatment of genital chlamydial infections.Zusammenfassung42 Männer und Frauen mit genitaler Chlamydieninfektion wurden zufallsgemäß entweder zehn Tage lang mit einer Einzeldosis von 200 mg Doxycyclin täglich oder neun Tage lang mit 200 mg Ofloxacin zweimal täglich behandelt. Zwei Wochen nach Behandlungsbeginn konnten 40 der Patienten nachuntersucht werden. Bei allen 12 Männern und sieben Frauen, die Doxycyclin erhalten hatten, war eine klinische Besserung oder Heilung aufgetreten, der kulturelle Nachweis von Chlamydien war negativ. Bei allen mit Ofloxacin behandelten Männern war eine Besserung oder Heilung mit negativenC. trachomatis- Kulturen festzustellen. Diese Daten sind vielversprechend, doch müssen größere Patientengruppen untersucht und längere Zeit nach der Behandlung beobachtet werden, um die Wirksamkeit von Ofloxacin in der Therapie genitaler Chlamydieninfektionen zu belegen.

The Prevalence of the Human Papillomavirus in Cervix and Vagina in Low-risk and High-risk Populations

Concordance of HPV between vagina and cervix may be influenced by sample taking and by differences in flow of cervical epithelial cells. To investigate the latter aspect, from 96 women visiting their general practitioner, and 63 sex workers visiting a STI clinic, both vaginal and cervical samples for HPV detection were obtained by the doctor to standardize sample taking. To identify factors that may influence the flow of cervical epithelial cells to the vagina, a questionnaire on intimate hygiene was obtained. The overall HPV prevalence was 22.8%; 14.3% in the general population (14.3% in the cervix, 11.9% in the vagina), compared with 34.4% in sex workers (31.1% in the cervix, 27.9% in the vagina). There was excellent agreement between HPV prevalence in vaginal and cervical samples. The overall agreement was 94.5% (kappa=0.83, 95% CI: 0.77–0.89); in the general population agreement reached 97.6%, compared with 90.0% in sex workers. Vaginal infection may influence concordance, but for validation of this finding larger studies are necessary. The high concordance found between HPV prevalence in vagina and cervix warrants further study of the applicability of self-sampling to improve coverage rates by attracting women who would otherwise not obtain a pap test.

Concomitant Chlamydia trachomatis and human papilloma virus infection cannot be attributed solely to sexual behaviour

Human papillomavirus (HPV) is a common genital sexually transmitted infection, and persistent high-risk HPV infection is strongly linked to cervical cancer [1]. However, infection with HPV is mainly transient and only a small proportion of women infected with HPV have persistent infection that progresses to cervical intraepithelial neoplasia and invasive cervical cancer. Therefore, it is likely that cofactors are involved, which increase susceptibility to HPV infection by facilitating HPV persistence or by inducing progression to invasive cancer [2]. A correlation between Chlamydia trachomatis (CT) infection and dysplastic or neoplastic cervical abnormalities has been observed by several authors [3–7] and this finding has led to the hypothesis that CT is a cofactor in HPVrelated carcinogenesis. However, it has also been suggested that the association between CT and HPV may merely be a reflection of their shared route of sexual transmission and the fact that both are markers of sexual risk behaviour [8, 9]. The availability of a large database of 825 women under the age of 40 years, who participated in a CT prevalence study [10], made it possible for us to examine a possible association between CT and HPV infection in a study that controlled for sexual behaviour. The database used in this study contained stored vaginal samples that had been taken by the patients themselves and detailed information, including data on various markers of sexual behaviour, from patient questionnaires. Using this database, we conducted a cross-sectional study in which patient data pertaining to 22 stored CT-positive samples (i.e., all available) were matched with the data related to 44 samples from women without chlamydial infection. Women with and without CT were individually matched for age (±1 year), age at time of first sexual encounter with penetration (±1 year), number of partners in the past year, and condom use in order to obtain two groups of patients that were as similar as possible, except for their CT status. Matching was performed to maximise equality between CT-positive and CT-negative subjects with regard to relevant sexual behaviour characteristics. This strategy was preferred because of the limited number of cases available. HPV detection was performed using probes for all known high-risk types as well as for eight low-risk types. Diagnostic accuracy was maximised by use of highstandard molecular diagnostic methods for CT and HPV detection as described elsewhere [11, 12]. Stepwise logistic regression analysis was performed using SPSS package version 11.5 (SPSS, Chicago, IL, USA) to examine the association between HPV and CT. In addition to the matching variables, other determinants of sexual behaviour and possible confounders were included, i.e., history of sexually transmitted disease diagnoses, history of emergency contraception use, history of unintended pregnancy, marital status, education, and parity [1]. The baseline characteristics of the study participants are shown in Table 1. Concordance between CT-positive and CT-negative subjects with respect to the matching variables was satisfactory: 84.1% for age ±1 year (95.5% for age ±2 years), 86.4% for age at time of first sexual intercourse ±1 year (93.2% for age ±2 years), 95.5% for number of partners, and 97.8% for condom use. Matching variables were added to the multivariate analysis to account for possible residual confounding. V. Verhoeven (*) . D. Avonts . P. Van Royen Academic Centre for General Practice, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium e-mail: veronique.verhoeven@ua.ac.be Tel.: +32-3-8202518 Fax: +32-3-8202526

Ramadan fasting and diabetes: An observational study among Turkish migrants in Belgium

AIMS To investigate (i) Ramadan participation, (ii) provision of Ramadan-related advice by healthcare providers, (iii) medication use during Ramadan fasting among Turkish migrants with diabetes in Belgium. METHODS This pilot observational study was conducted among a convenience sample of 52 Turkish migrants with diabetes in Belgium. Two questionnaires collected information on socio-demographic characteristics, diabetes-related characteristics, current hypoglycaemic medication with dosing regimen, participation in the past Ramadan, reasons for (non-)participation, use of hypoglycaemic medication during the past Ramadan, advice from their healthcare providers about fasting during Ramadan and follow-up of this advice. RESULTS Sixteen patients (31%) had fasted during the past Ramadan. Main reason for Ramadan participation was reinforcement of faith (12/15), while the main reason for non-participation was having diabetes (34/36). About 56% of the study population had received recommendations from their healthcare provider(s) about fasting and diabetes during Ramadan. The most commonly provided advice was not to participate in Ramadan, followed by modification of drug therapy. Only 3 patients ignored the advice of their health professionals. In addition, only 60% of those who actually fasted received recommendations about intake of diabetes medication during the Ramadan. Most fasters continued their medication dose unchanged (87% of OHA users and 80% of the insulin users). CONCLUSIONS This pilot study found a low prevalence of Ramadan fasting among Turkish migrants with diabetes in Belgium. We also found that provision of advice by healthcare providers could be improved. Larger scale studies are warranted to confirm these findings.

The profile of emergency contraception users in a chlamydia prevalence study in primary care in Belgium.

Introduction We describe the use of emergency contraception (EC) and its association with sociodemographic, contraceptive and behavioural characteristics in a sample of family practice attendants in Belgium. Methods The study was part of a large Chlamydia trachomatis (CT) prevalence study in general practice. Sexually active women under 40 who consulted their general practitioner for routine gynaecological care were enrolled in the study. Participants completed a questionnaire on sociodemographic variables, urogenital symptoms, sexual history and sexual behaviour, and delivered a sample for CT testing. Logistic regression analysis was performed to identify determinants of a history of EC use in women in this sample. Results Of 815 questioned women, 23.5% had ever used EC. EC users were a heterogeneous group with respect to educational level, age and ethnicity. The use of emergency contraception was associated with the level of urbanisation, condom use, not having children yet, young age of first sexual intercourse, having had multiple partners in the past year, a history of unintended pregnancy, and current or previous STI. Discussion Information on availability and correct use of EC, and on the need for additional testing for STI, are necessary to help primary care attendees to preserve their future reproductive health.