Imali Fernando

Genitourinary medicine clinic and general practitioner contact: what do patients want?

Objectives: While genitourinary medicine (GUM) records have historically been kept separate from other medical data, patient information is increasingly shared across the NHS. There are advantages to this in GUM: GPs are increasingly involved in delivering targets for STI screening and sexual health services. We ascertained patient attitudes to proposals to routinely send clinic letters to GPs and to share GUM data on common IT systems. Methods: Clinic attendees in the period 24 March to 5 April 2006 completed a questionnaire concerning their opinion on letters to GPs, GUM data sharing and personal presumptions about the implications of having HIV testing. Patient demographic data, clinic test results and questionnaire answers were analysed using SPSS. Results: Of 527 patients who completed the questionnaire, 187 (35%) agreed to GP contact, 337 (64%) declined and 3 (1%) failed to express a preference. Factors significantly associated with agreement to GP contact included heterosexual orientation (p<0.05), initial GP referral (p<0.001) and not considering HIV testing to have negative implications for future mortgage and life insurance applications (p<0.05). When questioned on attitudes to GP access of computerised results, 291 patients (55%) approved, 231 (44%) disagreed and 5 (1%) failed to reply; 128 patients (24%) said that they would be less likely to attend GUM if this occurred. Conclusions: Mode of referral and concerns about the implications of HIV testing affect patient preference on information sharing. A significant proportion of patients still want GUM visits to be anonymous and a policy of sharing GUM data on common IT systems may deter patient attendance.

Comparing HIV viral load assays and frequency of low level virological rebound in clinical practice

Research suggests that some low-level virological rebound results occurring for no obvious clinical cause, in patients stable on antiretroviral therapy (ART), may be a consequence of the viral load assay used. We compared the relative frequency of clinically unexplained low-level virological rebound results when using the Roche HIV Taqman version-1 (CTM v1), the Roche HIV Taqman version-2 (CTM v2) and the Abbott RealTime (Abbott RT) assays in clinical practice. In all, 247 patients from our centre who had their viral loads measured by the three different assays over a period of 3 consecutive years (each assay used for a period of 1 year each) were included in the study. Low-level virological rebound was defined as <1000 copies/ml. Over similar time periods, there was significant discrepancy between the three assays when considering the proportion of clinically unexplained low-level virological rebound results in patients stable on ART: the CTM v2 assay produced the highest percentage (93%), CTM v1 much lower (65%) and Abbott RT even less (35%). There is further research required regarding what, if any, implications this has for patients who experience clinically unexplained low-level virological rebound on the more sensitive assays.

Audit of syphilis treatment, follow-up and contact-tracing rates

An audit of diagnoses of syphilis infection managed at the Edinburgh genitourinary (GU) medicine clinic for the period 1 October 2001–31 October 2004. In all, 101 patients were identified as untreated carriers or contacts requiring treatment, partner notification and follow-up. Treatment rate was 100% in the audit population. Among this patient group, 90% were offered testing for other sexually transmitted infections (STIs) with a positivity rate of 24%. The HIV testing rate was 85%, resulting in five new diagnoses.

UK national guideline for the management of Genital Molluscum in adults, 2014 Clinical Effectiveness Group, British Association for Sexual Health and HIV:

This guideline offers recommendations ondiagnosis, treatment regimens andhealth promotionprinciplesneeded for the effective management of genital molluscum, including management of the initial presentation and recurrences. It primarily focuses on infection that affects the genital area and has a sexual mode of transmission. It is aimed primarily at patients aged 16 years or older presenting to health care professionals working in departments offering level 3 care in sexually transmitted infection (STI) management within the United Kingdom. However, the principles of the recommendations should be adopted across all levels – level 1 and 2 providers may need to develop local care pathways where appropriate.

Testing times: testing patient acceptance and ability to self-screen for a No-Talk Testing service

Summary Genitourinary medicine (GUM) departments need to be resource efficient to manage the increasing numbers of patients seeking to access services. At the Edinburgh GUM department, we wished to develop a new No-Talk Testing (NTT) clinic for asymptomatic, low-risk patients attending for routine sexually transmitted infection (STI) screening. We undertook a questionnaire feasibility study to determine patient acceptability and ability to self-screen for this service. A total of 267 respondents completed questionnaires regarding acceptability of a future NTT service; 227 agreed to comparison of their self-screen with clinician risk-assessment. Overall, patient acceptability for a future NTT service was high, with an average of 7.8/10 awarded for opinion. Seventy-three percent of patients agreed they would consider utilizing such a service in the future. Sixty-one percent of respondents suggested at least one benefit to a future NTT service; principally, prospects for increased speed, efficiency, capacity and reduced waiting times. Comparing STI risk self-assessment with clinician assessment, discrepancies were identified for 37% of individuals. However, a majority (70%) of the discrepancies identified were due to a risk being noted in the self-screen alone, and missed from clinician notes. In summary, the study demonstrated NTT as acceptable and feasible. Based on these results, we have now successfully introduced such a service within our department.

An audit of partner notification for syphilis and HIV.

Partner notification (PN) is a vital tool used by genitourinary (GU) medicine services in the public health control of sexually transmitted infections. We audited our PN outcomes for syphilis and HIV, over an 18-month period, at the Edinburgh GUM clinic. Follow-up information on testing was only available for 58% of traceable syphilis contacts and 59% of traceable HIV contacts, though substantially larger percentages in each case, respectively 78% and 90%, were informed regarding their risk of exposure. Furthermore, the department achieved screening verification in 78% of identifiable syphilis contacts and 94% of identifiable HIV partners.

A case of multicentric Castleman’s disease in HIV infection with the rare complication of acquired angioedema

Multicentric Castleman’s disease (MCD), a polyclonal lymphoproliferative disorder of unknown aetiology, is a well-recognised complication of HIV disease. We present a case of MCD in an HIV-positive patient that is unusual on two counts: our patient’s MCD first presented in the context of an immune restoration inflammatory syndrome (IRIS), following the initiation of highly active antiretroviral therapy (HAART). In addition, her MCD was associated with the unusual complication of acquired angioedema (AAE), which resolved following treatment of the MCD. While AAE is frequently found to have an underlying diagnosis of a lymphoproliferative disease, this is the first reported case linking AAE to MCD.

Importance of genitourinary and urology colleagues working in harmony

We disagree with Arya and colleagues’ conclusion, based on just one paper, that initial referral to specialties other than urology is an “error.”1 One of us (CB) runs a penile clinic in a genitourinary service that refers patients to the regional centre surveyed in that paper but was not asked about reasons for …

P49 Toxic cardiomyopathy in a stable hiv patient with a history of amphetamine misuse-a case report

Background/introduction Amphetamine (AM) use is associated with HIV infection among MSM. There are various toxic effects of AM, cardiotoxicity being one of them. Aim(s)/objectives To present a case of report of cardiomyopathy secondary to AM misuse in a patient with well-controlled HIV. Case report A 51 year old HIV positive MSM was admitted to hospital with dyspnoea, orthopnoea and decreased exercise tolerance. He was HIV positive since 1990 and this is stable on ARVs. CD4 count pre-admission was 514 with undetectable viral load. He used 25–30 grams of AM per week over a period of 20 years and had multiple casual unprotected MSM partners. On admission, the patient was tachycardic and hypoxic. Chest X-Ray on admission showed cardiomegaly and bi-basal opacification. Echocardiogram demonstrated severe left and right ventricular dysfunction, at a level requiring cardiac transplant. ECG showed prolonged QT interval. The patient was diagnosed with toxic dilated cardiomyopathy secondary to long term AM abuse. UK guidelines for Heart transplantation in adults deem chronic viral infection and ongoing substance misuse as relative contraindications to transplant. He was consequently commenced on medication for cardiac failure and received benzodiazepine as inpatient for managing withdrawal symptoms. On discharge, psychiatry follow-up was organised for support to help reduction of AM. At follow up, the patient reported reduced AM use by quarter, but felt he could never abstain. Discussion/conclusion AM related cardiac fatalities are caused by acute myocardial necrosis, ventricular rupture, cardiomyopathy or arrhythmia. Evidence is mostly derived from case-reports. Patients using AM should be fully counselled regarding possible toxic effects.

‘All singing, all dancing’: staff views on the integration of family planning and genitourinary medicine in Lothian, UK

Background UK policy documents advocate integrated approaches to sexual health service provision to ensure that everyone can access high-quality treatment. However, there is relatively little evidence to demonstrate any resultant benefits. The family planning and genitourinary medicine services in Lothian have been fully integrated and most care is now delivered from a purpose-built sexual health centre. We wished to study the views of staff on integrated sexual and reproductive care. Methods Staff completed anonymous questionnaires before and after integration, looking at four main aspects: the patient pathway, specific patient groups, their own professional status, and their working environment. The surveys used a mixture of five-point Likert-type scales and open-ended questions. Results Over 50% of staff completed the surveys on each occasion. Six months after the new building opened, staff attitudes about the integrated service were mixed. Staff reported more stress and less opportunity for specialisation but there was no change in their sense of professional status or development. There were concerns about how well the integrated service met the needs of specific patient groups, notably women. These concerns co-existed with a verdict that overall service quality was no worse following integration. Conclusions Staff views should form an important part of service redesign and integration projects. Although the results from the Lothian surveys suggest a perceived worsening of some aspects of the service, further evaluation is needed to unpick the different problems that have appeared under the catch-all term of ‘integration’.