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Whistletop tour

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This month’s journal is rich in articles exploring uncertainties and encouraging reflection on clinical practice and research methods. Three papers address the vexed question of the significance of Mycobacterium genitalium in various populations. Gaydos et al (see p 438) report a prevalence of 15.2% in urethritis, while Bradshaw’s group (see p 432) report its asymptomatic character in the rectum and urethra of men who have sex with men (MSM), and absence from the pharynx. Ross et al (see p 436) report a prevalence of 4.5% in asymptomatic clinic attendees. Clearly some definitive, well-designed research studies will be necessary if we are to answer fundamental questions about this organism.

Some tricky clinical cases of missed gonococcal septicaemia in a patient with lupus (see p 441), and syphilis masquerading as warts (see p 484) provide useful clinical reminders. Other clinical highlights include the continuing evolution of herpes simplex, with an increasing proportion of first episodes due to herpes simplex virus type 1 (HSV 1) among younger patients (see p 416).

Two Scottish studies demonstrate the value of a forensic approach to delineating transmission. Cole et al (see p 447) report a predominance of Treponema Pallidum subtype 14d, while Fernando and colleagues compared patient characteristics for unique, paired and clustered sequence types of Neisseria gonorrhoeae using NG-MAST (see p 443). A detailed analysis of organism strains, routine in the investigation of food poisoning incidents, can determine not only membership of an outbreak but proximity to high risk networks. How can we use this as a tool in clinical practice? What do we need to do to turn these findings into public health tools both for controlling outbreaks and identifying links to higher risk networks?

Another theme is our increasing realisation of the complexity of risk and of self-protection. An editorial by Boily et al (see p 408) comments on research by Kalichman et al (see p 411) on rates and associations of heterosexual anal sex in Cape Town, South Africa. The editorial discusses the challenges in achieving an understanding of the role of heterosexual anal intercourse in HIV transmission in developing countries. Snowden et al (see p 469) describe and classify the various degrees and modes of serosorting among MSM and, in doing so, demonstrates the Byzantine levels of detail needed to describe risk behaviours in the presence of manifold risk reduction strategies. Challenges in understanding risk also emerge in the work of Ojeda et al (see p 420), which demonstrates higher self-protective behaviour, and possibly lower rates of sexually transmitted infections, among migrant female sex workers in Mexico who would normally be expected to be at higher risk than local peers. The “healthy migrant” effect familiar to epidemiologists isn’t usually thought to apply to vulnerable populations such as sex workers and we need to understand better what is going on here. British backpackers in Australia, on the other hand, typically acquire 0.3 new partners a month, while 24% had unprotected sex with multiple partners–the authors wonder whether this might relate to lower risk perceptions of Australia than other destinations (see p 477).

Comparison with wider populations is a theme of Williamson et al’s comparison of mortality rates in migrant populations within Portugal to the indigenous population (see p 427). Death rates are higher than for the Portugese-born both for AIDS and other infectious diseases, and the authors emphasise the need to collect ethnicity data in surveillance systems.

A review of patient satisfaction measures by Weston et al (see p 459) draws attention to the need for validated and standardised measures, while pulling together key themes. In a commentary, French and Mercer (see p 467) suggest how this could be achieved, while emphasising the need for measurement instruments that can be used across a variety of different settings.

Figure 1

Schema of seroadaptive behaviours of HIV positive men who have sex with men (MSM), San Francisco, 2004. AI, anal intercourse; UAI, unprotected anal intercourse; serodiscordant refers to partners of unknown or opposite serostatus (see p 469)

Two papers look at chlamydia screening, with Mossong’s group (see p 455) demonstrating the feasibility of screening in community settings but with very low prevalence yields in schools. Meanwhile, authors from Waikato, New Zealand, report high testing rates (36.9%) among young females, but lower uptake in males (see p 452).

No journal is complete without an oddity, and Tremayne (see p 483) describes the potential for partner notification challenges of a fetish for used condoms, referring to a letter in this journal,1 which reported transmission of gonorrhoea through an inflatable doll. Interestingly, our electronic submission system lists “Inflatable doll” as a term of expertise for reviewers (don’t all rush at once)… Take a moment to look back in history on our archive, which goes back to 1925.


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  • Provenance and peer review Not commissioned; not externally peer reviewed.

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