Opportunistic screening for genital chlamydial infection. II: prevalence among healthcare attenders, outcome, and evaluation of positive cases

OBJECTIVES

To determine the prevalence and treatment outcomes among young women screened opportunistically for genital Chlamydia trachomatis and to evaluate the impact of screening in those participating.

DESIGN

An opportunistic screening programme (1 September 1999 to 31 August 2000) using urine samples, tested by ligase chain reaction (LCR). In-depth interviews were used for programme evaluation.

SETTING

Screening was offered in two health authorities at general practice, family planning, genitourinary medicine (GUM), adolescent sexual health, termination of pregnancy clinics and women's services in hospitals (antenatal, colposcopy, gynaecology and infertility clinics). Main participants: Sexually active women (16-24 years) attending for any reason.

MAIN OUTCOME MEASURES

Screening data: prevalence of infection by age and healthcare setting; proportion of positive patients attending for treatment. Evaluation data: participants' attitudes and views towards screening and follow up.

RESULTS

In total, 16 930 women (16-24 years) were screened. Prevalence was higher in younger women (16-20) than those aged 21-24 years and was highly variable at different healthcare settings (range 3.4%-17.6%). Prevalence was approximately 9% in general practice. The role of the project health advisers in managing results and coordinating treatment of positive individuals was essential; the vast majority of all positives were known to be treated. Women felt that screening was beneficial. Improving awareness and education about sexually transmitted infections is required to alleviate negative reactions associated with testing positive for infection.

CONCLUSIONS

Prevalence of infection outside GUM clinics is substantial and opportunistic screening using urine samples is an acceptable method of reaching individuals with infection who do not normally present at specialist clinics.

Issues in the demography of Mongolian nomadic pastoralism

"Taking a historical perspective this paper examines the ecological and political influences on Mongolian demography. Changes in political policy, domestic economy, health services, venereal diseases and shortages of men are considered in examining the unusual pattern of very low fertility, followed by a rise in the 1950s and 1960s and a gradual fertility decline, even in the absence of modern contraception. It is concluded that the lack of simultaneity between major political and demographic changes suggest that there are no direct responses to policy, despite the strong pronatalist stance, but that health services, particularly in the realms of venereal disease treatment, have had a major influence on Mongolian demographic patterns. The indirect consequences of government policy--education, health services in rural areas, rapid urbanisation--appear to have a stronger influence than the pronatalism, and ironically have led to rapid fertility decline."

GyneFix: a UK experience

OBJECTIVES

To present the experience of family planning providers and clients in the UK with the GyneFix intrauterine implant device.

METHOD

Audit of 138 GyneFix insertions at the Ella Gordon Family Planning Unit in Portsmouth, from 1997 to 1999.

RESULTS

Of 138 attempts at GyneFix insertion, 134 were successful. Forty per cent were inserted in nulliparous women. The removal rate was 15%, half of which were due to unacceptable side-effects. The expulsion rate was 8% ranging over a period of a few days to 12 months after insertion. There were no reported perforations or accidental pregnancies with GyneFix in situ in this series. There were no reported pregnancies as a result of unnoticed expulsion.

CONCLUSIONS

The results obtained in this study are minimal estimates obtained from a retrospective analysis. The numbers are small but they are comparable to results reported from other family planning centers in the UK. Although GyneFix clearly has a useful role, there is a need for a large-scale prospective randomized study to establish the benefits and potential disadvantages of the GyneFix device.

Apolipoprotein E is upregulated in olfactory bulb glia following peripheral receptor lesion in mice

Apolipoprotein E (apoE), a lipid transporting protein, has been postulated to participate in nerve regeneration. To better clarify apoE function in the olfactory system, we evaluated the amount and distribution of apoE in the olfactory bulb following olfactory nerve lesion in mice. Olfactory nerve was lesioned in 2- to 4-month-old mice by intranasal irrigation with Triton X-100. Olfactory bulbs were collected at 0, 3, 7, 21, 42, and 56 days postlesion, and both apoE concentrations and apoE distribution were determined. ApoE levels, as determined by immunoblot analysis, were twofold greater than normal during nerve degeneration at 3 days. ApoE levels remained elevated by approximately 1.5 times normal levels at 7 through 21 days after injury and returned to baseline by 56 days. Immunocytochemical studies supported these observations. ApoE immunoreactivity was prominent on the olfactory nerve at 3 days after lesion and decreased to baseline levels at later time periods. Double-labeling immunocytochemical studies confirmed that both reactive astroglia and microglia produced detectable amounts of apoE following the lesion. Return of apoE expression to baseline paralleled measures of olfactory nerve maturation as measured by olfactory marker protein. These data suggest that apoE increases concurrent with nerve degeneration. ApoE may facilitate efficient regeneration perhaps by recycling lipids from degenerating fibers for use by growing axons. The association of apoE genotype with dementing illnesses may represent a diminished ability to support a lifetime of nerve regeneration.

Clinical governance: learning and changing practice

CONTEXT

This paper describes a very simple, non-threatening method for improving communication and sharing learning points.

OBJECTIVE

To test whether sharing anonymised reporting of problems and helpful hints is acceptable and useful to staff.

DESIGN

A pink slip (pinkie) was designed and made available in every clinic venue. All staff were asked to write about any episodes where practice was less than optimum or to share good clinical experiences. The forms could be completed anonymously if preferred. A senior nurse collated the reports monthly and fed them back to all staff as a report. In May 2000 all staff were surveyed for their opinion of the scheme.

RESULT

Over 22 months, 139 'pinkies' were returned. Fifty-six of the 100 'less than optimum' events were classified as 'system failures'. The response to the staff survey was very positive, with 62% of staff replying. Fifty-four of the 55 staff found the scheme helpful. A third of those who responded had contributed and all but two individuals felt able to contribute if the situation arose again.

CONCLUSION

This simple system of self completed pink slips has allowed examples of less than optimum practice and helpful suggestions to be shared across a large service that has a predominantly part time work force providing services from over 15 venues. The system is seen as non-threatening and was acceptable to over 95% of the staff who responded to the survey. Fifty percent of doctors and nurses had made a submission. Changes in practice have resulted since its introduction.

Valrubicin: an alternative to radical cystectomy for carcinoma in situ of the bladder

Treatment options for patients who fail BCG therapy are limited. While cystectomy may be curative, not all patients can withstand the medical and/or psychologic stresses associated with surgery or resection. Valrubicin represents a safe and effective second-line intravesical therapy.

NKIATRE is a novel conserved cdc2-related kinase

The mitogen-activated protein kinases (MAPKs) and the cyclin-dependent kinases (CDKs) are key mediators of cell proliferation in response to extracellular signals. Recent additions to each of these families and the identification of kinases with structural features of both have provided insights into fundamental processes, such as cell division and differentiation. To identify novel serine kinases with features of MAPKs or CDKs, a degenerate PCR-based amplification approach was undertaken. The 57- and 52-kDa isoforms of a novel protein kinase, termed NKIATRE, were molecularly cloned from rat brain and jejunum cDNA libraries. Like the MAPKs, NKIATRE has a Thr-Xaa-Tyr motif in kinase subdomain VIII. NKIATRE also shows close homology to the cyclin-dependent kinase class of protein kinases and the cdc2-related kinases NKIAMRE, KKIALRE, and KKIAMRE, containing both conserved inhibitory phosphorylation sites and a putative cyclin-binding domain. Two isoforms of NKIATRE that differ in their carboxy-terminal ends have been identified. A functional nuclear localization signal is specific to the longer 57-kDa alpha isoform. Sequence similarity to the putative human tumor suppressor gene NKIAMRE, which is lost in leukemic patients with chromosome 5q deletions, suggests that NKIATRE may have a role in restricting cell growth or maintaining differentiation.

Pastoralists, agropastoralists and migrants: interactions between fertility and mobility in northern Burkina Faso

Seasonal rural to urban migration of young men is becoming an increasingly important part of the rural economy of the West African Sahel, yet little is known about how the short-term contact of men with urban centres might affect reproductive decisions and outcomes in sending areas. In northern Burkina Faso, substantial variation in short-term migration rates of young Fulani men to cities provides an opportunity to explore interactions between migration and fertility in this area. The groups most involved in seasonal labour migration experience substantially lower fertility than non-migrating groups. Fertility differentials arise largely from higher rates of secondary sterility among migrating groups, probably caused by an increased incidence of sexually transmitted diseases. Such mechanisms as changes in attitudes and knowledge regarding birth control, and the undermining of traditional practices of marriage, breastfeeding, and sexual abstinence are far less important.

Engineered herpes simplex virus expressing IL-12 in the treatment of experimental murine brain tumors

Genetically engineered, neuroattenuated herpes simplex viruses (HSVs) expressing various cytokines can improve survival when used in the treatment of experimental brain tumors. These attenuated viruses have both copies of gamma(1)34.5 deleted. Recently, we demonstrated increased survival of C57BL/6 mice bearing syngeneic GL-261 gliomas when treated with an engineered HSV expressing IL-4, as compared with treatment with the parent construct (gamma(1)34. 5(-)) alone or with a virus expressing IL-10. Herein, we report construction of a conditionally replication-competent mutant expressing both subunits of mIL-12 (M002) and its evaluation in a syngeneic neuroblastoma murine model. IL-12 induces a helper T cell subset type 1 response, which may induce more durable antitumor effects. In vitro studies showed that, when infected with M002, both Vero cells and murine Neuro-2a neuroblastoma cells produced physiologically relevant levels of IL-12 heterodimers, as determined by ELISA. M002 was cytotoxic for Neuro-2a cells and human glioma cell lines U251MG and D54MG. Neurotoxicity studies, as defined by plaque-forming units/LD(50), performed in HSV-1-sensitive A/J strain mice found that M002 was not toxic even at high doses. When evaluated in an intracranial syngeneic neuroblastoma murine model, median survival of M002-treated animals was significantly longer than the median survival of animals treated with R3659, the parent gamma(1)34.5(-) mutant lacking any cytokine gene insert. Immunohistochemical analysis of M002-treated tumors identified a pronounced influx of CD4(+) T cells and macrophages as well as CD8(+) cells when compared with an analysis of R3659-treated tumors. We conclude that M002 produced a survival benefit via oncolytic effects combined with immunologic effects meditated by helper T cells of subset type 1.

Assays that measure selective killing of virus-infected cells

When evaluating potential antiviral compounds, determining the effect of the drug on virus replication is usually the prime concern. However, since virus replication is dependent on the host cell, in circumstances where virus infection is not rapidly lytic to cells, the effect of these compounds on cell growth and viability merits consideration. Differential host cell metabolism has been reported for cells infected with viruses, e.g., HIV, measles, and HSV, and therefore it is possible that cells infected with viruses have different susceptibilities to antiviral drugs, depending on the their mode of action. Experience with HIV and a potential anti-HIV drug, EF13, showed that HIV-chronically infected cells were markedly more susceptible to EF13 than their parent uninfected cells (1); however, acutely HIV-infected cells showed a similar susceptibility as uninfected cells to EF13 (2). In addition, cells containing actively replicating HIV-1 were more susceptible to EF13 than either uninfected cells or cells infected with but not producing HIV-1 (3).

In utero alcohol and postnatal methylphenidate: locomotion and dopamine receptors

Prenatal alcohol exposure can cause central nervous system abnormalities and dysfunction referred to as Alcohol-Related Neurodevelopmental Disorder (ARND). Repeated intermittent methylphenidate (Ritalin) was used as a psychopharmacological challenge to reveal functional alterations in dopamine binding sites in rats exposed prenatally to alcohol. Pregnant Long-Evans dams were intubated with 0, 3, or 5 g/kg/day of alcohol from gestational day (GD) 8 to GD20. Adult offspring received repeated intraperitoneal injections of 0, 4, or 8 mg/kg of methylphenidate (MET), and were tested periodically for locomotor activity. Autoradiographic assessment of dopamine D1 and D2 receptors binding were visualized using [3H]SCH 23390 and [3H]raclopride, respectively. Prenatal alcohol did not produce significant dose-dependent effects on adult locomotor activity. Repeated MET injections produced dose-dependent sensitization of locomotor activity in all groups. The 3-g/kg prenatal alcohol group had a significantly decreased number of dopamine D2 binding sites within the dorsal and ventral striatum. This effect was reversed by MET. The neural changes detected in the lower alcohol group may indicate persistent changes within the dopaminergic system due to prenatal alcohol exposure.

Antiviral efficacy of disinfectant solution MRI-1

Disinfectant MRI-1 was prepared by dissolution of non-ionic and ionic detergent in ethanol. The disinfectant inactivated extracellular and intracellular enveloped and non-enveloped viruses including herpes viruses, influenza A and human immunodeficiency disease virus in suspension or on surfaces by pre-exposure or post-exposure to the disinfectant; in addition, cells were disabled as potential hosts for viral infection using concentrations of MRI-1 which were 50-fold less than the operative concentration for disinfection. There was no evidence of in vitro mutagenicity using Salmonella typhimurium or sensitization or other adverse effect in a guinea pig model or in human subjects.

Metabolic and monetary costs of avoidable parenteral nutrition use

BACKGROUND

We prospectively collected data on in patients receiving parenteral nutrition to determine the magnitude of potentially preventable metabolic and monetary costs associated with parenteral nutrition.

METHODS

Parenteral nutrition was prescribed by the treating physicians with optional consultation from a multidisciplinary metabolic support service. Days on parenteral nutrition, appropriateness of parenteral nutrition, metabolic complications, and avoidable parenteral nutrition charges were determined. Parenteral nutrition use was considered "indicated" or "not indicated" based on the American Society for Parenteral and Enteral Nutrition guidelines and "preventable" if the gastrointestinal tract was functional but not accessed when possible.

RESULTS

Of the 209 parenteral nutrition starts, 62% were indicated, 23% were preventable, and 15% were not indicated. Parenteral nutrition starts were deemed indicated in 82% of instances in which a metabolic support service consult was obtained, compared with 56% in which a consultation was not obtained (p = .004). Hyperglycemia was the most common metabolic complication, with an overall incidence of 20%. Metabolic complications occurred less frequently in patients who received a metabolic support service consultation compared with patients who did not (34% vs 66% of parenteral nutrition days, respectively; p = .004). Parenteral nutrition use of < or =5 days duration was significantly less frequent among patients who received metabolic support service consultation (16% vs 35%; p = .002). Parenteral nutrition that was not indicated or preventable resulted in excess annualized patient charges of more than one half million dollars not accounting for charges related to treatment of potentially avoidable parenteral nutrition complications.

CONCLUSIONS

This study illustrates that not-indicated and preventable parenteral nutrition initiation, short-term parenteral nutrition use, and metabolic complications are less likely when patients receive consultation by a multidisciplinary team with expertise in nutrition and metabolic support. Furthermore, the avoidance of inappropriate parenteral nutrition use translates into substantial cost savings.

Bone density in long term users of depot medroxyprogesterone acetate

OBJECTIVE

To identify any adverse effect on bone density in long term users of depot medroxyprogesterone acetate (DMPA) for contraception.

DESIGN

Cross-sectional measurement of bone density in users with amenorrhoea of more than one year or any woman using DMPA for more than five years.

SETTING

Community Family Planning Clinics in Portsmouth and Manchester.

POPULATION

One hundred and eighty-five women aged 17-52 years (mean 33.3 years) who had used DMPA for between 1 and 16 years and were attending the clinics for further injections, between August 1994 and August 1996.

METHODS

Dual energy X-ray measurement of bone density of femoral neck and lumbar spine, and venous blood sample taken just prior to the next injection of DMPA.

MAIN OUTCOME MEASURES

Bone density of femoral neck and lumbar spine and serum oestradiol in relationship to years of DMPA use and duration of amenorrhoea.

RESULTS

Most women (n=153) had serum oestradiol levels < 150 pmol/l. Despite this, the mean bone density of the lumbar spine compared with the population mean for women aged 20-59 years gave a Z score (95% CI) of -0.332 (-0.510 to -0.154). There was no significant difference in the mean density of the femoral neck from the normal population mean.

CONCLUSION

Despite amenorrhoea and low serum oestradiol, this sample of long term DMPA users had bone density only minimally below the normal population mean. We therefore found no clinically important adverse effect on bone density and therefore no reason to recommend bone conserving measures, such as add-back oestrogen.

The influence of the milieu on the rate of neutralisation of herpes simplex virus 1

The rate of neutralisation of herpes simplex virus 1 was increased by up to more than five hundred-fold when the virus suspension and antiserum were each diluted to one hundred-fold in water instead of phosphate buffered saline. This phenomenon, which was observed for two human positive sera and a rabbit purified polyclonal antibody, may represent an unrecognised homeostatic mechanism where neutralising antibody is 'dilution-fast' under physiological conditions of transudation or pathological conditions of inflammation.

A system for isolation, transport and storage of herpes simplex viruses

A major difficulty with diagnostic virus isolation concerns the relative thermolability of certain viruses, e.g. herpes simplex virus type 2, which may, therefore, lose infectivity during transport to the laboratory. This study describes a system of virus isolation and transport, which depends on direct inoculation at the bedside or clinic, to a monolayer or suspension of susceptible cells with subsequent incubation for 10 h at approximately 32 degrees C, whereupon the newly synthesised virus becomes very stable if the cells are subsequently maintained at room temperature. This system was found to increase the sensitivity of isolation of herpes simplex virus, particularly under conditions of asymptomatic virus excretion or if there was significant delay in transportation of clinical samples to the virus laboratory. It is envisaged that this system will allow clinical self-sampling by the patient with application to epidemiological surveys in both the developed and underdeveloped world.

Mammalian mitogen-activated protein kinase pathways are regulated through formation of specific kinase-activator complexes

Mammalian cells contain at least three signaling systems which are structurally related to the mitogen-activated protein kinase (MAPK) pathway. Growth factors acting through Ras primarily stimulate the Raf/MEK/MAPK cascade of protein kinases. In contrast, many stress-related signals such as heat shock, inflammatory cytokines, and hyperosmolarity induce the MEKK/SEK(MKK4)/SAPK(JNK) and/or the MKK3 or MKK6/p38(hog) pathways. Physiological agonists of these pathway types are either qualitatively or quantitatively distinct, suggesting few common proximal signaling elements, although past studies performed in vitro, or in cells using transient over-expression, reveal interaction between the components of all three pathways. These studies suggest a high degree of cross-talk apparently not seen in vivo. We have examined the possible molecular basis of the differing agonist profiles of these three MAPK pathways. We report preferential association between MAP kinases and their activators in eukaryotic cells. Furthermore, using the yeast 2-hybrid system, we show that association between these components can occur independent of additional eukaryotic proteins. We show that SAPK(JNK) or p38(hog) activation is specifically impaired by co-expression of cognate dominant negative MAP kinase kinase mutants, demonstrating functional specificity at this level. Further divergence and insulation of the stress pathways occurs proximal to the MAPK kinases since activation of the MAPK kinase kinase MEKK results in SAPK(JNK) activation but does not cause p38(hog) phosphorylation. Therefore, in intact cells, the three MAPK pathways may be independently regulated and their components show specificity in their interaction with cognate cascade members. The degree of intermolecular specificity suggests that mammalian MAPK signaling pathways may remain distinct without the need for specific scaffolding proteins to sequester components of individual pathways.

Antiviral properties of extract of Opuntia streptacantha

An extract of the cactus plant Opuntia streptacantha inhibited intracellular virus replication and inactivated extracellular virus. Inhibition of virus replication also occurred following pre-infection treatment--a favourable finding in terms of in-vivo limitation of virus disease. There was inhibition of both DNA and RNA virus replication, for example, herpes simplex virus, equine herpes virus, pseudorabies virus, influenza virus, respiratory syncytial virus and human immunodeficiency virus, with normal protein synthesis in uninfected cells at extract concentrations which were 15-fold in excess of 50% viral inhibitory concentrations (1 mg/ml). The active inhibitory component(s) of the extract appeared to be protein in nature and resided mainly in the wall of the plant rather than in the cuticle or inner sap. The extract was non-toxic on oral administration to mice, horses and human patients; the non-toxicity of intravenous administration of 70 mg to a mouse representing at least fifty tissue culture 50% viral inhibitory dosages encourages clinical trial of this extract in virus disease of human and veterinary species.

Immunological studies of herpes simplex virus infection in children with atopic eczema

This study examines the role of immune defence mechanisms in herpes simplex virus (HSV) infections in atopic eczema and whether impairment of these mechanisms explains the susceptibility of some children with atopic eczema to cutaneous HSV infections. Ten children with eczema herpeticum and 13 with atopic eczema and recurrent HSV infection affecting multiple skin sites were studied, together with relevant control groups. In all children with atopic eczema, in vitro lymphoproliferation in response to stimulation with concanavalin A (Con A) was significantly decreased and natural killer (NK) cells (CD16 + 56) were reduced compared with non-atopic controls. IL-2 receptors, a marker for lymphocyte activation, were decreased during the acute phase of eczema herpeticum, and for 1 month thereafter. A positive stimulation index (> 3) to HSV antigen, and high HSV IgG antibody titres measured by ELISA, Western blotting and neutralization assay, were seen in children with eczema herpeticum by 6 weeks, and also in children with atopic eczema and recurrent HSV infections. No evidence of an HSV-specific immune defect (either cell-mediated or humoral) was found in atopic eczema. Impairment of cell-mediated immunity in atopic eczema was suggested by the reduced response to Con A. It is likely that reduced numbers of circulating NK cells and a decrease in IL-2 receptors during early eczema herpeticum contribute to the susceptibility of children with atopic eczema to cutaneous HSV infections.