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IMAGINE A BEACH...
No, not a new competition to win a luxury holiday, but an image conjured up by Phil Hay to help us understand bacterial vaginosis (BV). The vagina, he points out, is not a steady state ecosystem. Like life in the littoral zone of the sea shore, it faces a constant ebb and flow of hormones, mucus, blood, semen, and soap, among other things. Perhaps understanding these changes may help us with unanswered questions about the aetiology of BV, including how lactobacilli colonise the vagina, why they are tolerated, how they are reduced in BV, and how they change in the frequent cycles of occurrence, persistence, and spontaneous recurrence of BV that have been found in studies of asymptomatic women. See p 100
WHO DO YOU THINK SHOULD BE TESTED?
Standard partner notification is of limited use in outbreaks of STI, particularly those affecting marginalised groups or anyone with large numbers of temporary partnerships. Ogilvie and colleagues in British Columbia report results from their attempts to manage a syphilis outbreak among heterosexuals. They used a social networking approach to supplement standard case finding and partner notification. Street nurses took testing and treatment out to the affected communities, and asked cases about their friends, regular meeting places and other social groups, and who they thought should be tested for syphilis. Through this work they were able to link more cases, and a higher proportion were identified by the street nurses; but as with many such novel interventions, it is very hard to say how much it led to improved control of syphilis. See p 124
BEWARE THE CHAMELEON
Early neurosyphilis and neurological complications of syphilis are commoner in HIV infected patients. Winston et al describe an HIV infected patient whose presentation with early syphilis was with a radiculopathy. This case serves to remind physicians that early syphilis may present with a radiculopathy, that this may occur before classical manifestations of syphilis, and that serology may be negative at presentation in the HIV infected patient. See p 133
SIMPLE IS BEST
The value of anal cytology as a screening tool for anal intraepithelial neoplasia (AIN) is uncertain, as is the role of adjunctive HPV typing. Fox et al examined 99 consecutive homo/bisexual males (89 were HIV infected) and compared anal cytology (Palefsky’s method) with histology of abnormalities identified at anoscopy. Swabs obtained concurrently were analysed for HPV DNA. Compared with histology, cytology had a sensitivity of 83% and a specificity of 38%. No specific hrHPV genotypes were associated with specific cytological/histological grades of abnormality. The authors conclude that anal cytology examined by Palefsky’s technique is simple to perform and that typing of hrHPV did not appear to be a useful adjunct to screening. See p 142
NURSES DO IT BETTER
Keane et al performed a postal survey of practice in GUM clinics in the UK in order to identify current diagnostic practice for bacterial vaginosis (BV). They identified that use of Ansel’s criteria for diagnosis was unsatisfactory as the majority of clinics do not use all criteria—an essential pre-requisite of the method. Most UK clinics use the Gram stain appearances of a vaginal smear to make the diagnosis, but there appears to be little consensus on the scoring methods used. Nurses provide the bulk of the microscopy service within GUM clinics, yet this group lacks ongoing training and support. The authors recommend adoption of the Ison-Hay scoring system in order to provide consistency across clinics and to facilitate audit and internal/external quality control. See p 155
“TEACHING YOUNG PEOPLE IS FORBIDDEN”
Most research on ethnicity and STI has focused on variations in STI risks and sexual behaviours, with far less work on cultural factors that have an impact on access to services. One clinic in London serves a local population where 35% of residents are of Bangladeshi origin, yet only 6% of clinic users are from this background. Beck et al carried out participatory research with the local community, using individual interviews and focus groups to explore the problems and suggest solutions. Some participants found health promotion campaigns problematic as they thought teaching young people about sex and condoms was wrong, and would bring shame. Unfortunately the investigators were not able to interview many young people, some of whom may have had different views. Overall they identified four problem areas: concerns about confidentiality, lack of relevance of services, problems discussing sex, and previous bad experiences with health promotion. See p 158