Effective use of an audit tool devised to optimize the management of syphilis in an integrated sexual health clinic

The objective of this study was to audit the management of syphilis in our integrated sexual health clinic according to the British Association for Sexual Health and HIV (BASHH) guideline using the ‘Treponemal Infection Care’ (TIC) audit tool devised by our clinic. The case notes of patients diagnosed with all stages of syphilis during an 18-month period were reviewed. At the time of diagnosis, the departmental TIC proforma was filled in: this proforma details BASHH auditable outcomes. The case notes of 83 patients diagnosed with syphilis during the audit period were reviewed. The majority of patients were men (76), men who had sex with men (69), HIV-negative (59) and were British (68). In line with current guidance all patients had a baseline Venereal Disease Research Laboratory (VDRL) titre at the start of treatment (target: 100%) and 97% of diagnosed patients completed treatment (target: 95%). A ‘response to treatment’ according to the decrease in VDRL was demonstrated in 50 (60%) patients with two (2%) patients failing to respond according to these criteria. However, 19 (23%) patients failed to return for their VDRL tests before demonstrating an adequate response to treatment, despite repeated attempts to contact them by letter and telephone. Fifty-four patients had at least 50% of their partners documented as traceable. Of those who were contactable, 100% attended for screening or treatment (target: 60%). In conclusion, our department performed well against BASHH auditable outcome targets. The introduction of the TIC proforma greatly facilitated the ease of audit and is a valuable tool within our clinic setting, which may have positively influenced our audit outcomes. Further action is required to highlight the importance of follow-up VDRLs to patients.

Refined tuberculosis contact tracing in a low incidence area

Our aim was to evaluate the efficacy of a revised tuberculosis (TB) contact tracing procedure in South Glamorgan whereby routine annual radiological surveillance was abandoned and contacts were either discharged or referred to chest clinic following their initial screening. We reviewed and evaluated data from the TB contact tracing clinic, the Public Health Service Mycobacterium Reference Unit, Cardiff and the Consultant in Communicable Diseases Control, South Glamorgan Health Authority and compared these results with those of our previous study. One hundred and three index cases and 732 contacts were identified. Seven hundred and seven contacts, 526 close and 181 casual, were screened, of whom 102 casuals should not have been. One hundred and sixty-one contacts were given BCG vaccination. Fifty-four contacts were referred to the chest clinic. Seven cases of TB were detected, all in young, unvaccinated, close contacts of pulmonary disease. Twenty-one contacts were given chemoprophylaxis, 20 of whom were close contacts of pulmonary TB and one of extrapulmonary disease. Five contacts who were screened and initially discharged developed TB later: in two the protocol had not been followed and three presented with extrapulmonary TB. Compared with the results of the previous protocol fewer contacts were unnecessarily screened and referrals to the chest clinic increased, as did the number given chemoprophylaxis. The case finding rate is similar to that found prior to the revision of the protocol. The yield from tracing casual contacts continues to be nil. It is very low in contacts of extrapulmonary disease. When the protocol was followed no case of pulmonary TB was missed. The revised protocol seems to be as effective as the previous, more complex protocol. In our area, one of low incidence of TB, screening of casual contacts and of contacts of extrapulmonary TB is not cost-effective. We will concentrate even more on screening close contacts of pulmonary TB.

Assessment of patients with memory problems using a nurse-administered instrument to detect early dementia and dementia subtypes

BACKGROUND

With the development of pharmacological treatments for Alzheimer's disease there will be an increase in the numbers of patients requiring assessment from specialist services. Could the role of the specialist clinician be supported by other health professionals screening those who might benefit from treatment?

METHOD

Sixty-four consecutive referrals to the Leicester University Memory Clinic were assessed at home by a community psychiatric nurse using a semi-structured interview. The nurse then reported her findings to a psychiatrist and a diagnosis was agreed. This diagnosis was then compared to the Memory Clinic diagnosis and a standardized (ICD-10) diagnosis recorded by another psychiatrist examining the clinic records.

RESULTS

The nurse assessment procedure performed well in detecting dementia, with a kappa statistic (k) of 0.75 when compared to the standardized and Memory Clinic diagnoses. There was, however, only moderate concordance between the ICD-10 diagnosis and nurse (k = 0.46) and the Memory Clinic and nurse (k = 0.60) for Alzheimer's disease. The relatively low k value for Alzheimer's disease was principally a result of difficult in differentiating vascular dementia.

CONCLUSIONS

A single supervised community psychiatric nurse, using a structured assessment instrument, can adequately detect early dementia in a sample of patients referred with memory problems. Subtypes of dementia are not, however, accurately differentiated.

Neurocircuitry of illness-induced hyperalgesia

We have previously demonstrated that illness-inducing agents such as lithium chloride (LiCl) and the bacterial cell wall endotoxin lipopolysaccharide (LPS) produce hyperalgesia on diverse pain measures. The present series of studies attempted to identify the neurocircuitry mediating these effects. These studies have demonstrated that illness-inducing agents produce hyperalgesia by activating: (a) peripheral nerves rather than by generating a blood-borne mediator (Expt. 1); (b) vagal afferents, specifically afferents within the hepatic branch of the vagus (Expt. 2); (c) as yet unidentified brain site(s) rostral to the mid-mesencephalon (Expt. 6); (d) a centrifugal pathway that arises from the nucleus raphe magnus, and not from the adjacent nucleus reticularis paragigantocellularis pars alpha (Expts. 4 and 5); (e) a centrifugal pathway in the dorsolateral funiculus of the spinal cord (Expt. 3); and (f) the same centrifugal pathways for diverse illness inducing agents (Expts. 3, 7 and 8). These data call for the re-evaluation of a number of assumptions inherent in previous studies of hyperalgesia.