S Samraj

Pearly penile papules regress in older patients and with circumcision

This study assesses the prevalence and correlates of pearly penile papules (PPP) in two non-genitourinary (GU) medicine male cohorts (<25 and >50 years). PPP were categorised in 188 university students (<25 years), based on self-examination, and 70 patients (>50 years), based on clinician examination. PPP were categorised from 1 to 4, based on increasing papule size and distribution. An anonymous questionnaire was used to identify associations with PPP prevalence. The prevalence of PPP was 38.3% in <25 years, and 11.4% in >50 years (P < 0.001). The prevalence of categories 3 and 4 PPP was 8.5% in <25 years, and 1.4% in >50 years (P < 0.05). In the younger age group, the prevalence of PPP was 26.5% in circumcised participants, and 42.4% in uncircumcised participants (P < 0.05), but was unrelated to either frequency of sexual intercourse or time since first sexual intercourse. In conclusion, PPP disappear with age, and any PPP in patients >50 years are less marked than those in patients <25 years. Patients should be advised accordingly. PPP are less prevalent in circumcised men. Patients could be advised to wear the foreskin rolled back – this may maximize exposure of the coronal area to normal abrasion, which may hasten PPP regression.

Compliance with hand hygiene in a genitourinary medicine department

The ability to control hospital-acquired infections is highly dependent upon control of cross-contamination from health-care workers to patients, and from one anatomical area of the patient to another anatomical area. Hand hygiene has been demonstrated to be an essential prerequisite in preventing cross-contamination. Wearing gloves does not afford complete protection against cross-contamination. Hand hygiene includes handwashing between patients, the use of alcohol-based skin cleansers and changing or removing gloves between examining different anatomical sites. There are no previously published audits regarding compliance to hand hygiene in genitourinary (GU) medicine clinics. A validated observation tool was employed in this audit. Doctors and nurses were observed in clinical practice. The adherence to hand hygiene protocols was overall poor. Doctors were more likely to adhere to protocols than nurses (83.3% vs. 66%). However, techniques of glove removal were universally satisfactory. Strategies for improvement in hand hygiene are suggested. These include performance feedback and use of posters.

An Unusual Case of Pelvic Pain: Retention of Fetal Bone after Abortion:

We present a 21-year-old woman with a short history of pelvic pain. The history was unremarkable apart from that of undergoing a surgical termination of pregnancy (TOP) some three-and-half years ago. Examination revealed a foreign body at the cervical os. Subsequent investigations revealed more foreign bodies within the cervical canal and uterine cavity, which were removed. Histologically these were found to be bones. Removal of the bone fragment initially discovered lead to an improvement of symptoms. Although the patient was treated for pelvic-inflammatory disease, no infective cause could be established. The condition of intrauterine retained fetal bones is recognized, but rare. Patients experiencing pelvic pain usually present sooner after TOP than did this patient. Although rare, it is an important condition to diagnose as it represents a treatable cause of infertility.

Increasing screening frequency in men who have sex with men: impact of guidance on risk profiling on workload and earlier diagnosis of sexually transmitted infection and HIV

Summary Increasing screening frequency in men who have sex with men (MSM) engaging in high-risk behaviours can reduce prevalence of sexually transmitted infections (STIs). This evaluation investigated the impact of applying stricter screening guidelines for MSM on service workload and earlier STI diagnoses. A validated risk assessment tool (RAT) was distributed to MSM attending a level 3 sexual health service over three months. Australian screening guidelines were applied to the data to identify MSM requiring more frequent screening and data projected to the larger MSM population. The RAT identified a 2–5-fold increase in the number of STI and HIV screenings required based on six- and three-monthly screening intervals, respectively, in the MSM cohort. When screening intervals are reduced from three-monthly to six-monthly there is a potential loss of 66.7% of earlier HIV diagnoses. The use of RATs will increase workload in sexual health services, but potentially diagnose a large proportion of disease earlier.

Patient-initiated delay at a genitourinary medicine clinic: are there public health consequences?

Objectives: To assess the public health consequence of patients electing not to be seen within 48 hours in a genitourinary medicine (GUM) clinic. Methods: A 3-month retrospective case notes review was carried out for 310 new and re-book patients who chose to wait for more than 48 hours to be seen. Results: Altogether, 10% (310/3110) of patients opted to be seen beyond 48 h. Their median wait was 6 days including weekends and 4 days excluding weekends. Demographic details did not vary except for the male to female ratio of 1:1.7 (1:1 in patients seen within 48 h). We found that no symptomatic patients or asymptomatic contacts of those with known sexually transmitted infections (STIs) reported sex with a new partner after booking their appointment. No patient reported sex with a recently treated partner who consequently required re-treatment and none suffered a complication of a STI. In addition, there were no cases of new HIV infection in this group and the rates of STIs were similar compared with patients seen within 48 hours of contacting the unit. Conclusions: Despite 10% of patients choosing to delay attendance beyond 48 h, no adverse public health outcomes were demonstrated.

Audit of the effect of electronic patient records on uptake of HIV testing in a level 3 genitourinary medicine service

This audit aimed to measure the impact of introducing and then modifying an electronic patient record (EPR) system on the uptake of HIV testing at a level 3 genitourinary medicine service. It was a retrospective case note review of all new and rebook patients attending our service in 2007 (paper records) and 2010 (EPR), and a prospective review in 2012 (following modification of the EPR). The uptake of HIV testing increased significantly from 72.8% to 78.1% following introduction of the EPR (p = 0.009), and increased further to 86.6% (p < 0.0001) following modification of the EPR. Clinics using paper notes should consider switching to EPR as a means of increasing HIV testing uptake.

Compliance among patients with high alcohol consumption in genitourinary medicine.

complication rates in evaluations of Chlamydia trachomatis screening programmes – implications for cost-effectiveness analyses. Int J Epidemiol 2004;33:416–23 8 Low N. Screening programmes for chlamydial infection: when will we ever learn? BMJ 2007;334:725–8 9 Boeke AJP, van Bergen JEAM, Morre SA, van Everdingen JJE. The risk of pelvic inflammatory disease associated with urogenital infection with Chlamydia trachomatis; literature review. Ned Tijdschr Geneeskd 2005;149:878–84

P166 Increasing screening frequency in men who have sex with men (MSM): impact of explicit guidance on risk profiling on UK service

Background STI and HIV diagnoses are increasing among MSM. Mathematical modelling shows increasing screening frequency can reduce STI prevalence, especially targeting MSM engaging in risk behaviours. International guidelines from both the CDC and Australasian Society for HIV Medicine clearly define risk behaviours with adapted screening intervals—contrary to the UK where NICE guidance is vague. Objectives To investigate impact of applying stricter international screening guidelines for MSM, on service workload and earlier STI diagnosis in a UK level 3 service [L-3S]. Methods A validated risk questionnaire distributed to MSM attending a large provincial L-3S over a 3-month period explored their actual screening frequency, STI diagnoses and risk behaviours in the prior 12 months. Australian screening guidelines were applied to the data to identify MSM needing more frequent screening. Projections to the larger MSM population attending over 12 months were modelled, based on the demographics of the respondents. Results 126/357 completed the questionnaire, 89 were identifiable. There was no statistically significant difference between STI rates (p=0.18) and HIV diagnoses (p=0.62) between identifiable questionnaire respondents and other MSM clinic attendees. Demographic analysis showed the sample group was representative of the larger cohort. In 2011, applying Australasian Society for HIV Medicine risk profiling for the 793 MSM who attended the unit, 26% would require one additional 6-monthly attendance for HIV screening, while 6% would require two visits. Additional STI screening visits would be needed by 25% (1 visit) and 10% (2 visits). 29% of STI diagnoses were in infrequent attendees. Conclusions Stricter UK screening guidelines for MSM defining and weighting risk behaviours explicitly in line with other international guidelines, would increase L-3S MSM visits by 30% and potentially diagnose a large proportion of disease earlier. In light of the results UK guidelines may benefit from review.

‘Don't forget the children’ – test before it is too late

In 2009, ‘Don’t forget the children’ guideline recommended that all new HIV-positive patients attending adult HIV services should have any existing children identified and tested for HIV alongside a coherent documentation process. A retrospective case note review was performed on 173 HIV-positive women registered at the Royal South Hants adult HIV service until 31 January 2014. Data were assessed as a whole (n = 173) and, in addition, two comparator groups were formulated: (a) pre-guidelines (n = 108) and (b) post-guidelines (n = 65). Out of 80 children eligible for HIV testing, only 43 (54%) had clear documentation of a test result, and in the remaining 37 (46%), it was either not considered or not followed through. Documentation of need for testing increased significantly from 67% in pre-guideline group to 100% in the post-guideline group (p < 0.001). The median time from recognition of need to test to actual testing remained 24 months in both groups. Although this audit demonstrated improvement in identification of at-risk children and their testing, there is still need for improvement.

P109 Introduction of an electronic patient proformer contributes to an increase in uptake of HIV testing

Background The BASHH MEDFASH Standards for the Management of STIs 2010 recommend that 100% of GUM patients should be offered an HIV test with a minimum uptake of 60% at their first STI screen. Aim To assess whether the introduction of an electronic patient proformer resulted in an improvement in the uptake of HIV testing in a level 3 GUM service, and whether there was scope for further improvement. Methods Retrospective case note review of new and rebook (patients who had not attended in the past 3 months) patients attending a level 3 GUM service in October 2007 (when a paper patient record was kept) and October 2010 (following introduction of an electronic patient proformer with a prompt for HIV test offered). Data on uptake of HIV testing was collected, and further data on the reasons for not being tested for HIV was collected on patients seen in October 2010. Results 772 new or rebook patients were seen in October 2007, of whom 562 (72.8%) accepted HIV testing. 1141 new or rebook patients were seen in October 2010 of whom 891 (78.1%) accepted HIV testing, with a p value (calculated using Fishers Exact test) of 0.009. Of 250 (21.9%) patients not tested for HIV in October 2010, 41.6% were not tested for clinical reasons, such as the patient having had a recent HIV test or being known HIV positive. 35.2% of patients not tested for HIV declined the test. Evidence of suboptimal management was also found, with 6.8% of patients not tested as they were within the window period, and 6% not tested due to needle phobia. Conclusion The introduction of the electronic patient proformer with a prompt for HIV testing has improved uptake. There is further room for improvement including offering POCT to needle phobic patients, and testing those within the window period prior to follow-up testing. Adding a mandatory field to the patient proformer with reasons for declining may allow improved understanding of reasons for declining, which may then modify future practice.