The clinical manifestations of anorectal infection with lymphogranuloma venereum (LGV) versus non-LGV strains of Chlamydia trachomatis: a case–control study in homosexual men

Lymphogranuloma venereum (LGV) has recently been reported in men who have sex with men. In a case–control study we compared behavioural and clinical features of 32 men with LGV (cases) and 31 men with non-LGV chlamydial proctitis (controls). LGV was associated with rectal discharge (odds ratio [OR] 4.15, 95% confidence interval [CI] 1.42, 12.2), and there was a tendency to association with HIV infection (OR 3.60, CI 0.67–19.4), sexual contact in the UK (OR 3.03, CI 1.02–9.01) and fisting (OR 5.04, CI 0.98–26.1). LGV should be considered a possible diagnosis in men with rectal discharge.

Determining the validity of hospital laboratory reference intervals for healthy young adults participating in early clinical trials of candidate vaccines

This was a retrospective study to determine the validity of institutional reference intervals for interpreting biochemistry and hematology results in healthy adults in the context of clinical trials of preventive vaccines. An example population of 974 healthy adults participating in clinical trials at the Jenner Institute, Oxford, UK, between 1999 and 2009 was studied. Methods for calculating the central 95% ranges and determining the coefficients of within person variation were demonstrated. Recommendations have been made as to how these data can be usefully applied to the interpretation of blood results in healthy adult subjects for the purposes of clinical trial inclusion decisions and post-vaccination safety monitoring.

Safety and immunogenicity of an FP9-vectored candidate tuberculosis vaccine (FP85A), alone and with candidate vaccine MVA85A in BCG-vaccinated healthy adults: a phase I clinical trial

The safety and immunogenicity of a new candidate tuberculosis (TB) vaccine, FP85A was evaluated alone and in heterologous prime-boost regimes with another candidate TB vaccine, MVA85A. This was an open label, non-controlled, non-randomized Phase I clinical trial. Healthy previously BCG-vaccinated adult subjects were enrolled sequentially into three groups and vaccinated with FP85A alone, or both FP85A and MVA85A, with a four week interval between vaccinations. Passive and active data on adverse events were collected. Immunogenicity was evaluated by Enzyme Linked Immunospot (ELISpot), flow cytometry and Enzyme Linked Immunosorbent assay (ELISA). Most adverse events were mild and there were no vaccine-related serious adverse events. FP85A vaccination did not enhance antigen 85A-specific cellular immunity. When MVA85A vaccination was preceded by FP85A vaccination, cellular immune responses were lower compared with when MVA85A vaccination was the first immunisation. MVA85A vaccination, but not FP85A vaccination, induced anti-MVA IgG antibodies. Both MVA85A and FP85A vaccinations induced anti-FP9 IgG antibodies. In conclusion, FP85A vaccination was well tolerated but did not induce antigen-specific cellular immune responses. We hypothesize that FP85A induced anti-FP9 IgG antibodies with cross-reactivity for MVA85A, which may have mediated inhibition of the immune response to subsequent MVA85A. ClinicalTrials.gov identification number: NCT00653770

Incidental diagnosis in healthy clinical trial subjects

Previously unrecognized medical conditions identified in volunteers for early phase clinical studies have significant clinical and ethical implications for the participant. It is therefore crucial that the potential for unexpected diagnosis is addressed during the informed consent process. But the frequency of incidental diagnosis in healthy volunteers who attend for clinical trial screening remains unclear. To assess this we retrospectively analyzed 1,131 independent screening visits for 990 volunteers at a single academic center over a 10‐year period to describe the frequency and nature of new clinical findings. Overall 23 of 990 volunteers (2.3%) were excluded at screening for a newly diagnosed medical abnormality. Some clinically important conditions, such as nephrotic syndrome and familial hypercholesterolemia were identified. The frequency of abnormalities was associated with increasing age in males (p= 0.02 χ² for trend) but not females (p= 0.82). These data will assist those planning and conducting phase I/II vaccine trials in healthy volunteers, and importantly should strengthen the informed consent of future trial participants. Clin Trans Sci 2012; Volume 5: 348–350

Preliminary assessment of the efficacy of a T-cell-based influenza vaccine, MVA-NP+M1, in humans

A single vaccination with MVA-NP+M1 boosts T-cell responses to conserved influenza antigens in humans. Protection against influenza disease and virus shedding was demonstrated in an influenza virus challenge study.

Background. The novel influenza vaccine MVA-NP+M1 is designed to boost cross-reactive T-cell responses to internal antigens of the influenza A virus that are conserved across all subtypes, providing protection against both influenza disease and virus shedding against all influenza A viruses. Following a phase 1 clinical study that demonstrated vaccine safety and immunogenicity, a phase 2a vaccination and influenza challenge study has been conducted in healthy adult volunteers.

Methods. Volunteers with no measurable serum antibodies to influenza A/Wisconsin/67/2005 received either a single vaccination with MVA-NP+M1 or no vaccination. T-cell responses to the vaccine antigens were measured at enrollment and again prior to virus challenge. All volunteers underwent intranasal administration of influenza A/Wisconsin/67/2005 while in a quarantine unit and were monitored for symptoms of influenza disease and virus shedding.

Results. Volunteers had a significantly increased T-cell response to the vaccine antigens following a single dose of the vaccine, with an increase in cytolytic effector molecules. Intranasal influenza challenge was undertaken without safety issues. Two of 11 vaccinees and 5 of 11 control subjects developed laboratory-confirmed influenza (symptoms plus virus shedding). Symptoms of influenza were less pronounced in the vaccinees and there was a significant reduction in the number of days of virus shedding in those vaccinees who developed influenza (mean, 1.09 days in controls, 0.45 days in vaccinees, P = .036).

Conclusions. This study provides the first demonstration of clinical efficacy of a T-cell–based influenza vaccine and indicates that further clinical development should be undertaken.

Clinical Trials Registration. NCT00993083.

Potent CD8+ T-cell immunogenicity in humans of a novel heterosubtypic influenza A vaccine, MVA-NP+M1

Background. Influenza A viruses cause occasional pandemics and frequent epidemics. Licensed influenza vaccines that induce high antibody titers to the highly polymorphic viral surface antigen hemagglutinin must be re-formulated and readministered annually. A vaccine providing protective immunity to the highly conserved internal antigens could provide longer-lasting protection against multiple influenza subtypes.

Methods. We prepared a Modified Vaccinia virus Ankara (MVA) vector encoding nucleoprotein and matrix protein 1 (MVA−NP+M1) and conducted a phase I clinical trial in healthy adults.

Results. The vaccine was generally safe and well tolerated, with significantly fewer local side effects after intramuscular rather than intradermal administration. Systemic side effects increased at the higher dose in both frequency and severity, with 5 out of 8 volunteers experiencing severe nausea/vomiting, malaise, or rigors. Ex vivo T-cell responses to NP and M1 measured by IFN-γ ELISPOT assay were significantly increased after vaccination (prevaccination median of 123 spot-forming units/million peripheral blood mononuclear cells, postvaccination peak response median 339, 443, and 1443 in low-dose intradermal, low-dose intramuscular, and high-dose intramuscular groups, respectively), and the majority of the antigen-specific T cells were CD8⁺.

Conclusions. We conclude that the vaccine was both safe and remarkably immunogenic, leading to frequencies of responding T cells that appear to be much higher than those induced by any other influenza vaccination approach. Further studies will be required to find the optimum dose and to assess whether the increased T-cell response to conserved influenza proteins results in protection from influenza disease.

A Phase I study evaluating the safety and immunogenicity of MVA85A, a candidate TB vaccine, in HIV-infected adults

Objectives Control of the tuberculosis (TB) epidemic is a global health priority and one that is likely to be achieved only through vaccination. The critical overlap with the HIV epidemic requires any effective TB vaccine regimen to be safe in individuals who are infected with HIV. The objectives of this clinical trial were to evaluate the safety and immunogenicity of a leading candidate TB vaccine, MVA85A, in healthy, HIV-infected adults. Design This was an open-label Phase I trial, performed in 20 healthy HIV-infected, antiretroviral-naïve subjects. Two different doses of MVA85A were each evaluated as a single immunisation in 10 subjects, with 24 weeks of follow-up. The safety of MVA85A was assessed by clinical and laboratory markers, including regular CD4 counts and HIV RNA load measurements. Vaccine immunogenicity was assessed by ex vivo interferon γ (IFN-γ) ELISpot assays and flow-cytometric analysis. Results MVA85A was safe in subjects with HIV infection, with an adverse-event profile comparable with historical data from previous trials in HIV-uninfected subjects. There were no clinically significant vaccine-related changes in CD4 count or HIV RNA load in any subjects, and no evidence from qPCR analyses to indicate that MVA85A vaccination leads to widespread preferential infection of vaccine-induced CD4 T cell populations. Both doses of MVA85A induced an antigen-specific IFN-γ response that was durable for 24 weeks, although of a lesser magnitude compared with historical data from HIV-uninfected subjects. The functional quality of the vaccine-induced T cell response in HIV-infected subjects was remarkably comparable with that observed in healthy HIV-uninfected controls, but less durable. Conclusion MVA85A is safe and immunogenic in healthy adults infected with HIV. Further safety and efficacy evaluation of this candidate vaccine in TB- and HIV-endemic areas is merited.

Microscopy detection of rectal gonorrhoea in asymptomatic men

This audit aimed to determine the usefulness of microscopy to detect presumptive rectal gonorrhoea (GC) infection in asymptomatic men. We retrospectively audited more than 400 male patients attending a London genitourinary medicine clinic from January 2005 to March 2007 who tested rectal culture positive for Neisseria gonorrhoeae and compared this with the microscopy detection rate. In total, 123/423 (29%) of culture positive samples were microscopy positive. Of those that tested microscopy negative (300/423), 64 (21%) were symptomatic and 236 (79%) asymptomatic. In addition, a time and motion study examined 81 rectal slides over a two-week period to identify microscopy reading time required to make a presumptive diagnosis of GC. Three slides were positive, resulting in six hours and 45 minutes to detect one positive sample. Given the low sensitivity for rectal microscopy coupled with the length of time required to obtain a presumptive positive rectal GC result, we believe rectal microscopy is no longer a cost-effective tool screening for asymptomatic men, and this report supports the BASHH guideline that it is not recommended in the management of asymptomatic rectal infection.

Trends in HIV testing and recording of HIV status in the UK primary care setting: a retrospective cohort study 1995-2005

OBJECTIVES

To provide nationally representative data on trends in HIV testing in primary care and to estimate the proportion of diagnosed HIV positive individuals known to general practitioners (GPs).

METHODS

We undertook a retrospective cohort study between 1995 and 2005 of all general practices contributing data to the UK General Practice Research Database (GPRD), and data on persons accessing HIV care (Survey of Prevalent HIV Infections Diagnosed). We identified all practice-registered patients where an HIV test or HIV positive status is recorded in their general practice records. HIV testing in primary care and prevalence of recorded HIV positive status in primary care were estimated.

RESULTS

Despite 11-fold increases in male testing and 19-fold increases in non-pregnant female testing between 1995 and 2005, HIV testing rates remained low in 2005 at 71.3 and 61.2 tests per 100,000 person years for males and females, respectively, peaking at 162.5 and 173.8 per 100,000 person years at 25-34 years of age. Inclusion of antenatal tests yielded a 129-fold increase in women over the 10-year period. In 2005, 50.7% of HIV positive individuals had their diagnosis recorded with a lower proportion in London (41.8%) than outside the capital (60.1%).

CONCLUSION

HIV testing rates in primary care remain low. Normalisation of HIV testing and recording in primary care in antenatal testing has not been accompanied by a step change in wider HIV testing practice. Recording of HIV positive status by GPs remains low and GPs may be unaware of HIV-related morbidity or potential drug interactions.

Evaluation of a home-delivery service for HIV-infected patients attending an inner London HIV treatment centre

Home delivery (HD) of medication is a goal of the Department of Health's Pharmacy in the Future; Implementing the NHS Plan. We evaluated the safety and effectiveness of an HD service for antiretroviral therapy (ART). Patients on ART with stable viral load (VL) <50 were identified. Comparison was made between patients using HD and those using the clinic-based pharmacy (CP). The primary endpoint was HIV virological failure (VF) (HIV VL >400 copies/mL on two consecutive occasions). Secondary endpoints included frequency of outpatient attendances (OPA) and an incidence of adverse events. Cumulative incidences (Culmln) for each outcome event were calculated. Incidence-rate ratios (IRR) were obtained using Poisson regression. Of 1663 patients identified; 450 received HD and 1213 used CP. Culmln of VF was =4% in those using HD and =7% in those using CP (IRR [95% confidence intervals, CI] =0.53, 0.32-0.90). HD patients had fewer OPA, less frequent blood test monitoring and less frequent abnormal liver function results (IRR [95% Cl]= 0.63 [0.59-0.67] and 0.59 [0.53-0.67], 0.68 [0.65-0.71] and 0.64 [0.53-0.78], respectively). Patients deemed stable enough on social, psychological and medical grounds to receive HD of ART had a lower risk of VF, fewer OPA and no increase in adverse events when compared with patients using CP.

Methaemoglobinaemia causing progressive dyspnoea and cyanosis during treatment of Pneumocystis jirovecii pneumonia

An HIV-infected man became increasingly breathless and cyanosed while receiving clindamycin and primaquine treatment for Pneumocystis jirovecii pneumonia. He was found to have 11.4% methaemoglobinaemia and recovered with conservative management.

Orogenital ulceration with overlapping tuberculosis: epiphenomenon or expanding spectrum of Behçet disease?

Tuberculosis (TB) has rarely been reported in the context of Behçet disease. We present two cases of recurrent orogenital ulceration predating the onset of TB. No relapses of orogenital symptoms have occurred after successful TB chemotherapy.

The usefulness of a diagnostic biopsy clinic in a genitourinary medicine setting: recent experience and a review of the literature

Genital diseases include a wide range of lesions e.g. infectious and inflammatory. In most cases a clinical diagnosis is reached without the need for a biopsy. Nonetheless, a genital biopsy is safe and may help to confirm the diagnosis. We established a dedicated diagnostic biopsy clinic in 2003. Our objective was to evaluate the effectiveness of our diagnostic biopsy clinic and compare it with other Genitourinary medicine (GUM) clinics in the UK. A retrospective case-note study was performed on 71 patients referred to the biopsy clinic with persistent genital lesions over a 12-month period. Forty-seven biopsies were performed (71% biopsy rate). 43 specimens (92%) were appropriate for histopathological diagnosis. Of these 15% were lichen planus, 15% lichen sclerosis, 10% psoriasis, 7.5% each: eczema, Zoon's and non-specific balanitis. The remainder represented a variety of other conditions. In 27 cases (68%) the clinical diagnosis was consistent with the histological result. The possibility of self-referral and walk-in nature of our GUM service substantially decrease the waiting times for assessment of anogenital disorders. We had a lower biopsy rate for the diagnosis of non-specific balanitis (7.5%) compared with the average rate (21.5%) in 14 UK GUM clinics and good agreement between clinical and histological diagnosis. An empirical first treatment, with simple emollients before biopsy, appears to be a safe clinical approach for the treatment of non-specific balanitis. A multidisciplinary approach (GUM physicians, dermatologists and urologists/gynaecologists) could help prevent unnecessary biopsies and improve correlation between clinical and histological diagnosis.

Incentives for voluntary HIV testing in NHS staff

BACKGROUND

HIV seroprevalence is rising in the United Kingdom. While acceptability of HIV testing has been explored among many groups there is a paucity of data regarding voluntary HIV counselling and testing (VCT) among NHS staff.

AIMS

To understand the barriers to HIV testing among NHS employees. To observe how these may be overcome. To assess which factors would motivate staff to undergo VCT and which would be a disincentive.

METHODS

Completion of a cross-sectional anonymous postal questionnaire survey of new employees at a London district general hospital. Demographic and attitudinal factors were collected. Respondents were able to give multiple responses to questions regarding reasons for and against VCT. Those unable to communicate in English were excluded.

RESULTS

There was a 63% response rate; of 69 respondents, 76% were female, 72% had English as their first language and 30% self-identified as white British. Thirty-nine percent were nurses, 19% doctors and the remainder a variety of professions. Of these, 41% had had a previous HIV test; none were known positive. Sixty-two percent would consider future testing. The commonest reasons to consider testing were knowledge of status (79%), treatment benefit (40%) and to inform family members (44%). The commonest reasons not to test were already tested negative (30%) and rather not know (26%).

CONCLUSIONS

Since the NHS is recruiting staff from areas of high HIV prevalence, VCT should be encouraged. NHS staff require information on how to access testing as well as the benefits of early detection of blood-borne viruses.

Management of recurrent genital herpes: a survey of UK genitourinary medicine clinics in 2003

We carried out a survey of all UK genitourinary (GU) medicine clinics, via postal questionnaire, in order to evaluate the current management of recurrent genital herpes (RGH) in the GU medicine setting. Respondents were invited to answer questions regarding various aspects of herpes simplex virus (HSV) management. There was a 62% response rate. Analysis of the returned surveys revealed that the vast majority of clinics (96%) provided drug treatment for RGH, with 81% having a clinic policy for the management of genital herpes (GH). A majority (64%) of clinics had access to some type of counselling or psychological therapy and 47% encouraged collaboration with primary care for follow-up prescribing. Of the clinics providing drug therapy for RGH, 80% used aciclovir alone with smaller numbers having access to aciclovir, famciclovir and valaciclovir. While many clinics are meeting the British Association of Sexual Health and HIV (BASHH) guidelines, improvements can be made to increase the availability of psychological support to patients with HSV and improve links with primary care.

Patients support innovative models of care in recurrent genital herpes clinics: results from a patient satisfaction study

Genital herpes is one of the most common sexually transmitted infections and is characterized by recurrent, painful, ulcerative lesions. Severe psychosocial disturbance has been described in a variety of settings and there are well-documented associations with poor self-esteem, centred around contagion and stigma. Recurrent genital herpes (RGH) is traditionally managed by doctors in the genitourinary medicine clinic setting; we wanted to evaluate patient's opinions on alternative models of care. We performed a questionnaire of patients attending our RGH clinic to ascertain patients' opinions and preferences. Seventy four percent of patients expressed a wish to see the same health-care professional at follow-up visits and 62% supported the idea of a nurse-led clinic. One-third found the concept of group sessions acceptable. Regarding GP follow-up management and prescribing, there was a split response with almost equal numbers accepting and rejecting this proposition (42 versus 45%). Seventy-six percent of patients thought that RGH had important psychological impact on their lives and 58% found the prospect of psychological referral acceptable.

An association between HIV/HCV co-infection and diabetes mellitus—is there a need for routine blood glucose monitoring?

We describe two cases of HIV/HCV co-infected patients developing adult onset diabetes mellitus. Neither was taking a protease inhibitor based regimen. We review the current recommendations for diabetes screening in this subset of patients and suggest that those managing co-infected patients pay particular attention to screening for abnormal glucose metabolism and elicit a full family history of metabolic disorders.

Ethical and legal issues in caring for asylum seekers and refugees in the UK

Inward migration to the UK remains topical and controversial as numbers continue to increase. Many immigrants have specific health care needs and may shoulder a large burden of infectious disease. Imposition of legal constraints can have a huge impact on the medical care afforded to immigrants. Currently UK policy is to treat, free of charge and with NHS resources, those who fulfil specific criteria. However an increasing number are being asked to pay for their treatment. Many health care professionals are confused as to current legal restrictions and require guidance on the associated ethical issues. We concentrate on provision of care to HIV positive individuals and use cases to illustrate some of the issues. However these issues are equally pertinent to practitioners in all branches of medicine.

Sweet's syndrome and a Mirena intrauterine system

A woman fitted with a Mirena intrauterine system (IUS) for menorrhagia presented with a short history of fever and progressive skin lesions. Histological examination of a skin biopsy was compatible with the clinical diagnosis of Sweet's syndrome. Treatment was with topical and oral steroids, however the condition relapsed on reduction of the steroid dose. Symptoms finally resolved on removal of the IUS and the patient remained symptom free at 9-month follow-up. There have been previous reports of Sweet's syndrome in association with hormonal contraceptives, however this is believed to be the first reported case in association with a Mirena IUS.

Incidence and perioperative management of tension pneumocephalus following craniofacial resection

This study is a retrospective review to evaluate factors associated with the risk of pneumocephalus following craniofacial resection and the management of tension pneumocephalus. Twenty-two craniofacial operative procedures were reviewed in 18 patients entered into the Neurosciences Critical Care Unit, Johns Hopkins Hospital, during a 54 month period, from 1986-1991. Pneumocephalus developed after 7 of 22 operations; of these seven, two developed tension pneumocephalus. The use of lumbar cerebral spinal fluid (CSF) drainage during the operation correlated most strongly with the development of pneumocephalus. The diagnosis of esthesioblastoma also correlated significantly. Both episodes of tension pneumocephalus occurred after craniofacial resection in which lumbar drainage of CSF was performed. Tension pneumocephalus was successfully treated in these two patients with a combination of air evacuation and medical management of raised intracranial pressure. Transient diabetes insipidus developed in both patients. The risk of pneumocephalus following craniofacial procedures is significant, and may be increased by the use of lumbar drainage of CSF intraoperatively. Rapid neurologic deterioration following craniofacial resection may be caused by the development of tension pneumocephalus. Early diagnosis of tension pneumocephalus and aggressive management of raised intracranial pressure may be important in preventing serious neurological complications.