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- Prioritizing dermatoses: rationally selecting guideline topics. [JOURNAL ARTICLE]
- J Eur Acad Dermatol Venereol 2014 Aug 29.
Clinical practice guideline (CPG) development starts with selecting appropriate topics, as resources to develop a guideline are limited. However, a standardized method for topic selection is commonly missing and the way different criteria are used to prioritize is not clear.To select and prioritize dermatological topics for CPG development and elucidate criteria dermatologists find important in selecting guideline topics.All 410 dermatologists in the Netherlands were asked to create a top 20 of dermatological topics for which a guideline would be desirable, regardless of existing guidelines. They also rated, on a 5-point Likert scale, 10 determinative criteria derived from a combined search in literature and across (inter)national guideline developers. Top 20 topics received scores ranging from 0.01 to 0.2 and combined scores yielded a total score.The 118 surveys (response 29%) identified 157 different topics. Melanoma, squamous cell carcinoma, basal cell carcinoma, psoriasis and atopic dermatitis are top priority guideline topics. Venous leg ulcer, vasculitis, varicose veins, urticaria, acne, Lyme borreliosis, cutaneous lupus erythematosus, pruritus, syphilis, lymphoedema, decubitus ulcer, hidradenitis suppurativa, androgenic alopecia and bullous pemphigoïd complete the top 20. A further 15 topics have overlapping confidence intervals. Mortality and healthcare costs are regarded as less important criteria in topic selection (P < 0.04), than other criteria like the potential to reduce unwanted variation in practice.Dermatological professional organizations worldwide succeeded in developing guidelines for all top 20 topics. Respondents mostly agree with (inter)national guideline programmes and literature concerning the criteria important to selecting guideline topics.
- Jarisch-Herxheimer reaction among HIV-positive patients with early syphilis: azithromycin versus benzathine penicillin G therapy. [JOURNAL ARTICLE]
- J Int AIDS Soc 2014; 17(1):18993.
Introduction: The Jarisch-Herxheimer reaction, a febrile inflammatory reaction that often occurs after the first dose of chemotherapy in spirochetal diseases, may result in deleterious effects to patients with neurosyphilis and to pregnant women. A single 2-g oral dose of azithromycin is an alternative treatment to benzathine penicillin G for early syphilis in areas with low macrolide resistance. With its potential anti-inflammatory activity, the impact of azithromycin on the incidence of the Jarisch-Herxheimer reaction in HIV-positive patients with early syphilis has rarely been investigated. Methods: In HIV-positive patients with early syphilis, the Jarisch-Herxheimer reaction was prospectively investigated using the same data collection form in 119 patients who received benzathine penicillin G between 2007 and 2009 and 198 who received azithromycin between 2012 and 2013, when shortage of benzathine penicillin G occurred in Taiwan. Between 2012 and 2013, polymerase chain reaction (PCR) assay was performed to detect Treponema pallidum DNA in clinical specimens, and PCR restriction fragment length polymorphism of the 23S ribosomal RNA was performed to detect point mutations (2058G or A2059G) that are associated with macrolide resistance. Results: The overall incidence of the Jarisch-Herxheimer reaction was significantly lower in patients receiving azithromycin than those receiving benzathine penicillin G (14.1% vs. 56.3%, p<0.001). The risk increased with higher rapid plasma reagin (RPR) titres (adjusted odds ratio [AOR] per 1-log2 increase, 1.21; confidence interval [CI], 1.04-1.41), but decreased with prior penicillin therapy for syphilis (AOR, 0.37; 95% CI, 0.19-0.71) and azithromycin treatment (AOR, 0.15; 95% CI, 0.08-0.29). During the study period, 310 specimens were obtained from 198 patients with syphilis for PCR assays, from whom T. pallidum was identified in 76 patients, one of whom (1.3%) was found to be infected with T. pallidum harbouring the macrolide resistance mutation (A2058G). In subgroup analyses confined to the 75 patients infected with T. pallidum lacking resistance mutation, a statistically significantly lower risk for the Jarisch-Herxheimer reaction following azithromycin treatment was noted. Conclusions: Treatment with azithromycin was associated with a lower risk for the Jarisch-Herxheimer reaction than that with benzathine penicillin G in HIV-positive patients with early syphilis. Previous benzathine penicillin G therapy for syphilis decreased the risk, whereas higher RPR titres increased the risk, for the reaction.
- Increasing sexually transmitted infection rates in young men having sex with men in the Netherlands, 2006-2012. [Journal Article]
- Emerg Themes Epidemiol 2014.:12.
Men having sex with men (MSM) remain the largest high-risk group involved in on-going transmission of sexually transmitted infections (STI), including HIV, in the Netherlands. As risk behaviour may change with age, it is important to explore potential heterogeneity in risks by age. To improve our understanding of this epidemic, we analysed the prevalence of and risk factors for selected STI in MSM attending STI clinics in the Netherlands by age group.Analysis of data from the national STI surveillance system for the period 2006-2012. Selected STI were chlamydia, gonorrhoea, infectious syphilis and/or a new HIV infection. Logistic regression was used to identify factors associated with these selected STI and with overall STI positivity. Analyses were done separately for MSM aged younger than 25 years and MSM aged 25 years and older.In young MSM a significant increase in positivity rate was seen over time (p < 0.01), mainly driven by increasing gonorrhoea diagnoses, while in MSM aged 25 and older a significant decrease was observed (p < 0.01). In multivariate analyses for young MSM, those who were involved in commercial sex were at higher risk (OR: 1.5, 95% CI: 1.2-1.9). For MSM aged 25 years and older this was not the case. Having a previous negative HIV test was protective among older MSM compared to those not tested for HIV before (OR: 0.8, 95% CI: 0.8-0.8), but not among younger MSM.MSM visiting STI clinics remain a high-risk group for STI infections and transmission, but are not a homogenous group. While in MSM aged older than 25 years, STI positivity rate is decreasing, positivity rate in young MSM increased over time. Therefore specific attention needs to be paid towards targeted counselling and reaching particular MSM sub-groups, taken into account different behavioural profiles.
- High HIV seroprevalence, rectal STIs and risky sexual behaviour in men who have sex with men in Dar es Salaam and Tanga, Tanzania. [JOURNAL ARTICLE]
- BMJ Open 2014; 4(8):e006175.
To assess HIV and sexually transmitted infection (STI) prevalence and associated risk factors in men who have sex with men (MSM) in two cities in mainland Tanzania.We conducted respondent-driven sampling of 300 MSM in Dar es Salaam and Tanga.In Dar es Salaam, 172 (86%) men (median age 23, IQR 21-28) consented to HIV/STI testing, and 30.2% were HIV seropositive. Only five reported a previous positive HIV test: >90% were new HIV detections. 2.5% were syphilis-exposed and none hepatitis B positive, but 21.4% had a curable STI. Over 90% of the gonorrhoea and chlamydia was rectal. In Tanga, 11.1% of MSM were HIV seropositive, 8% hepatitis B positive and 0% were syphilis-exposed, with 4.4% having a curable STI. Predictors of HIV infection were number of MSM known, city, identifying as gay and having first sex with a man. Predictors for STIs were recent unprotected receptive anal intercourse, and number of MSM seen in the last month. 30% of the sample reported that they sold sex. There was no significant association between HIV and STI infection.HIV and STI rates were substantially lower in MSM in a provincial city than in a large metropolis and rates appear to depend on larger numbers of MSM known. Most HIV detected were new cases, and there was a high burden of asymptomatic curable rectal STIs (>1 in 5 MSM). Owing to stigma, MSM may not report homosexuality and thus not have rectal STIs treated. High need for tailored HIV testing and STI screening and treatment of MSM in Tanzania is apparent.
- Association of HIV and syphilis seropositivity with transit stay in urban areas among Ethiopian immigrants to Israel. [Journal Article]
- Isr Med Assoc J 2014 Jul; 16(7):427-30.
Ethiopian immigration to Israel was initiated in 1981. Most immigrants were rural dwellers who migrated first to Addis Ababa or Gondar, where they waited for eligibility status from Israel to leave Ethiopia. Soon after arriving in Israel, all immigrants were offered screening tests for human immunodeficiency virus (HIV) and syphilis.To evaluate the association of age, gender, marital status and length of time spent in urban areas in Ethiopia with the prevalence of HIV and syphilis seropositivity.All adult Ethiopian immigrants who arrived at the Jerusalem immigration center between 1999 and 2002 and consented to HIV and syphilis screening tests were interviewed.Altogether, 678 immigrants (51% females) were screened; 39 (5.8%) were seropositive for HIV and 33 (4.9%) for syphilis. The length of time the immigrants spent in Ethiopian cities before leaving for Israel was significantly associated with HIV: odds ratio (OR) 2.76, 95% confidence interval (CI) 1.13-6.71, and syphilis seropositivity OR 3.87, 95%CI 1.56-9.62.The length of transit time Ethiopian immigrants from rural areas spend in Ethiopian cities is significantly associated with HIV and syphilis seropositivity. Efforts should be made to shorten this time in order to reduce the risk of infection
- Scale-Up, Retention and HIV/STI Prevalence Trends among Female Sex Workers Attending VICITS Clinics in Guatemala. [JOURNAL ARTICLE]
- PLoS One 2014; 9(8):e103455.
Since 2007, Guatemala integrated STI clinical service with an HIV prevention model into four existing public health clinics to prevent HIV infection, known as the VICITS strategy. We present the first assessment of VICITS scale-up, retention, HIV and STI prevalence trends, and risk factors associated with HIV infection among Female Sex Workers (FSW) attending VICITS clinics in Guatemala.Demographic, behavioral and clinical data were collected using a standardized form. Data was analyzed by year and health center. HIV and STI prevalence were estimated from routine visits. Retention was estimated as the percent of new users attending VICITS clinics who returned for at least one follow-up visit to any VICITS clinic within 12 months. Separate multivariate logistic regression models were conducted to investigate factors associated with HIV infection and program retention.During 2007-2011 5,682 FSW visited a VICITS clinic for the first-time. HIV prevalence varied from 0.4% to 5.8%, and chlamydia prevalence from 0% to 14.3%, across sites. Attending the Puerto Barrios clinic, having a current syphilis infection, working primarily on the street, and using the telephone or internet to contact clients were associated with HIV infection. The number of FSW accessing VICITS annually increased from 556 to 2,557 (361%) during the period. In 2011 retention varied across locations from 7.7% to 42.7%. Factors negatively impacting retention included current HIV diagnosis, having practiced sex work in another country, being born in Honduras, and attending Marco Antonio Foundation or Quetzaltenango clinic sites. Systematic time trends did not emerge, however 2008 and 2010 were characterized by reduced retention.Our data show local differences in HIV prevalence and clinic attendance that can be used to prioritize prevention activities targeting FSW in Guatemala. VICITS achieved rapid scale-up; however, a better understanding of the causes of low return rates is urgently needed.
- Relationship between disclosure of same-sex sexual activity to providers, HIV diagnosis and sexual health services for men who have sex with men in Vancouver, Canada. [Journal Article]
- Can J Public Health 2014; 105(3):e186-91.
Men who have sex with men (MSM) report challenges to accessing appropriate health care. We sought to understand the relationship between disclosure of same-sex sexual activity to a health care practitioner (HCP), sexual behaviour and measures of sexual health care.Participants recruited through community venues and events completed a questionnaire and provided a blood sample. This analysis includes only individuals with self-reported HIV negative or unknown serostatus. We compared participants who had disclosed having same-sex partners with those who had not using chi-square, Wilcoxon Rank Sum and Fisher's exact tests and used logistic regression to examine those variables associated with receiving an HIV test.Participants who had disclosed were more likely to have a higher level of education (p<0.001) and higher income (p<0.001), and to define themselves as "gay" or "queer" (p<0.001). Those who had not disclosed were less likely to report having risky sex (p=0.023) and to have been tested for HIV in the previous two years (adjusted odds ratio 0.23, 95% confidence interval: 0.16-0.34). There was no difference in undiagnosed HIV infection (3.9% versus 2.6%, p=0.34). Individuals who had disclosed were also more likely to have been tested for gonorrhea and syphilis, and more likely to have ever been vaccinated against hepatitis A and hepatitis B (p<0.001 for all).While generally reporting lower risk behaviour, MSM who did not disclose same-sex sexual activity to their HCP did have undiagnosed HIV infections and were less likely to have been tested or vaccinated. Strategies to improve access to appropriate sexual health care for MSM are needed.
- Service delivery through public health care system to control sexually transmitted infections in Himachal pradesh. [Journal Article]
- Indian Dermatol Online J 2014 Jul; 5(3):271-5.
The National AIDS Control Organization has designed multiple synergistic interventions to identify and control curable sexually transmitted infections (STIs).To assess the impact of services offered at designated STI clinics in the state of Himachal Pradesh, India and the profile of the attending clients.This was a two-year prospective study, conducted from April 2011 to March 2013. Training on delivering STI/RTI services was imparted to the staff of 16 designated STI clinics including recording of data. The staff in each STI clinic comprises of one doctor, one counselor, one nurse, and one laboratory technician. The clients attending these designated clinics were offered counseling, syndromic case management (SCM), and diagnostic services wherever possible. Monthly data of STI clinic attendees was collected, compiled, and analyzed.A total of 65,760 clinic visits were reported, of which 32,385 (49%) visits were for index STI/RTI complaint(s). The ratio of male to female attendees was 1:2. The commonest age group accessing the STI clinics was 25-44 years (n = 38,966; 59.3%). According to SCM, 52.9% clients were managed. The commonest presenting syndrome was urethral discharge (n = 4,500; 41%) in males, and vaginal discharge (n = 13,305; 56%) in females. Genital ulcer disease was treated in 2099 cases. Laboratory tests were performed only in 6466 patients, and 39,597 antenatal mothers were screened for syphilis. Counseling services were provided to 51,298 (f = 34,804; 68%: m = 16,494; 32%) clients and of these, 48% (n = 25,056) of the clients were referred to integrated counseling and testing centers. Forty-three clients (m = 24: f = 19) were detected positive for HIV infection.Uniform and standardized services delivered to clients attending public health clinics can gather reliable data to monitor trends of STI infection.
- Neurosyphilis in a man with human immunodeficiency virus. [Journal Article]
- J Clin Aesthet Dermatol 2014 Aug; 7(8):35-40.
The authors describe a 33-year-old man with human immunodeficiency virus who developed erythematous macules on the palms and soles with subsequent headaches, papilledema, and iritis. They review the salient characteristics of neurosyphilis with a focus on human immunodeficiency virus-positive individuals. The incidence of syphilis has increased since the year 2000 in African Americans, Hispanics, and men who have sex with men. Treponema pallidum is the causative agent of this disease-a fastidious, slowly growing, microaerophilic spirochete. Sexual contact is the most common mode of transmission. The rapid plasma reagin, Venereal Disease Research Laboratory assay, and fluorescent treponemal antibody absorption assay are commonly used to diagnose syphilis. The mainstay treatment is penicillin. Special considerations exist in the natural history and management of syphilis in the setting of human immunodeficiency virus.
- Treponema pallidum hemagglutination assay seroreactivity among healthy Indian donors and its association with other transfusion transmitted diseases. [Journal Article]
- Asian J Transfus Sci 2014 Jul; 8(2):109-12.
The aim of the present study was to determine the prevalence of syphilis infection by Treponema pallidum hemagglutination assay (TPHA) among blood donors in Delhi and to study their correlation with other markers of transfusion transmitted infections such as hepatitis C virus (HCV), human immunodeficiency virus (HIV) and hepatitis B surface antigen (HBsAg) so as to establish the utility of TPHA over and above venereal diseases research laboratory test (VDRL), not only as a marker for testing T. pallidum infection, but also as a marker of high risk behavior.This prospective study was carried out in the Regional Blood Transfusion Centre, Lady Hardinge Medical College and associated Sucheta Kriplani Hospital, New Delhi for a period of 2 years. Donated blood was screened for TPHA seroreactivity along with screening for anti HIV I and II, anti-HCV, HBsAg by third generation enzyme-linked immunosorbent assay test. A total of 8082 serum samples of blood donors were collected from healthy blood donors in our blood bank. They were classified into two groups- test group and control group based on TPHA positivity. The co-occurrence of HBsAg, HIV and HCV infection were determined in TPHA positive blood donors (test group) in comparison with TPHA negative blood donors (control group).We found the TPHA seroreactivity to be 4.4% in Delhi's blood donors. Nearly 8.2% (663/8082) of the donated blood had serological evidence of infection by at least one pathogen (syphilis/HIV/hepatitis B virus/HCV) and 6.63% (44/663) donors with positive serology had multiple infections (two or more). Quadruple infection was seen in one donor, triple infection was seen in three donors and double infection was seen in 40 donors. Prevalence of HIV seroreactivity was found to be statistically significant and HCV seroreactivity statistically insignificant in TPHA positive group in comparison to TPHA negative group.In our study, the TPHA seropositivity correlated with higher HIV and HCV seropositivity and the same correlation has been observed by several other studies also. In view of these observations, we propose that testing for syphilis by more sensitive and specific treponemal markers like TPHA rather than VDRL, rapid plasma reagin tests; as TPHA also has the added advantage of picking up all the high risk donors, whereas, VDRL picks up only currently infected donors. Moreover, TPHA should be continued as a marker of high risk behavior especially in high prevalence areas like India where we don't have universal access to markers like nucleic acid amplification technique.