Biomedical subjects
D Mercey
Publications and source records attributed to D Mercey.
We should routinely offer HIV screening in pregnancy. Pregnancy Subgroup of the Herpes Simplex Advisory Panel.
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How to assess an article on economic evaluation.
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Antenatal testing for HIV: to opt in or opt out, that is the question.
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A family clinic--optimising care for HIV infected children and their families.
A family clinic providing specialist paediatric and adult medical, testing, counselling, and terminal care services for families living with HIV was set up at a paediatric tertiary care hospital in London in 1991. During the first five years, until April 1996, 185 children from 149 families attended, including 119 infected children, of whom 32 have died. Only 5% of mothers were born in the UK; the rest were born in 24 different countries, the majority in sub-Saharan Africa. Less than a quarter of children were cared for by both parents, 61% by mothers alone, and 11% by guardians or foster parents. Of the adult attendees, 76% were women, and more than half were untested when they first attended the clinic. Provision of a family planning service within the family clinic was initiated as a result of women presenting with unplanned pregnancies. Shared care with local clinics is increasing, but with the complexity around the management of paediatric HIV infection, particularly with regard to antiretroviral treatments, there is need for continued specialist input. Coordination among specialist and locally based family services is required to provide flexible, accessible, and up to date care for families living with HIV infection in London.
Behavioural and demographic characteristics of attenders at two genitourinary medicine clinics in England.
OBJECTIVES: To investigate how attenders with sexually transmitted disease (STD) differ from the general population with respect to sexual behaviour, and to identify which attenders at genitourinary medicine (GUM) clinics are at particular behavioural risk for acquiring STD. DESIGN: Multicentre cross sectional survey. SETTING: Two genitourinary medicine clinics, one in London and one in Sheffield SUBJECTS: 20,516 patients attending the two clinics over an 18 month period. MAIN OUTCOME MEASURES: Behavioural and demographic characteristics and clinical diagnoses were recorded for each patient. RESULTS: 8862 patients, in whom 12,506 diagnoses were made, were seen in the Sheffield clinic, and 11,654 patients, in whom 20,243 diagnoses were made, were seen in the London clinic. When compared with the reported results from a general population survey, there were higher proportions of clinic attenders reporting two or more sexual partners in the preceding 12 months (p < 0.001), and a higher proportion of males reporting homosexual contact (13% compared with 1%, p < 0.001). Only age and number of sexual partners in the past 12 months were significantly associated with acute STDs for each sex in each clinic. Acute STDs tended to occur with greater frequency in the younger age groups, peaking among 16-19 year olds, particularly among females. CONCLUSIONS: The results have confirmed that patients with STDs exhibit higher risk sexual behaviour than the general population, and have highlighted the problem of continuing high risk behaviour among younger attenders, particularly younger homosexual men. This study has demonstrated that among GUM clinic attenders age and number of sexual partners are key risk factors for the acquisition of an acute STD. The results of this survey also indicate, however, that half of the females and more than one quarter of males with acute STDs reported only one sexual partner in the past 12 months, suggesting that health education messages should point out that it is not only those who have multiple recent sexual partners, or who have recently changed sexual partner, that are at risk of STD, including HIV.
Voluntary universal antenatal HIV testing.
OBJECTIVES: To assess the uptake of universal voluntary named HIV testing of hospital booked antenatal women and to identify behavioural and demographic factors associated with testing. To identify the number of previously undiagnosed women detected by the new policy and to compare prevalence among those testing with that measured by unlinked anonymous monitoring. DESIGN: Self-completion questionnaire and data abstraction from structured booking forms and virology laboratory records. SETTING: Central London teaching hospital antenatal clinic. PARTICIPANTS: One thousand three hundred and seventy-four women booking with a hospital based midwife during the 49 weeks from 27 July 1993 to 1 July 1994. RESULTS: Before the introduction of the new testing policy fewer than 10 women per year had an HIV test, and during the study this rose to 41% (548/1340). In univariate analysis, caucasian and Mediterranean ethnic origin, fewer previous live births, and more than one lifetime sexual partner were associated with higher uptake of HIV testing. In a multivariate model only the number of previous live births and ethnic origin remained significantly associated with testing. Six women out of 828 (1%) who completed the question about nonprescribed drug use stated that they had injected drugs, and four of these women accepted a test. Two women, both with recognised major risk factors for HIV infection, were diagnosed HIV antibody positive (a prevalence in the tested women of 0.36%). A further three women were already known to be HIV antibody positive. During the 12 months from July 1993 seven women (0.24%) were found to be positive by unlinked anonymous testing. CONCLUSIONS: The introduction of a universal approach to antenatal HIV testing appears feasible: it increased the uptake of the test and detected previously unrecognised infections. Many women chose not to be tested, however, and cases remained undiagnosed. Further studies are required to examine different models of offering HIV testing, reasons for declining the test, and the cost-benefit of antenatal HIV screening.
Uptake of medical interventions in women with HIV infection in Britain and Ireland. Study Group for the MRC Collaborative Study of HIV Infection in Women.
OBJECTIVE: To determine the uptake of medical interventions amongst women known to be HIV positive and in contact with service providers. SUBJECTS: 400 HIV positive women from 15 STD/HIV clinics in Britain and Ireland recruited to the MRC collaborative study of HIV infection in women between June 1992 and August 1994. METHODS: Data obtained prospectively through direct questioning of all women by a physician or research nurse and review of medical and laboratory records. Data recorded on standardised forms and analysed centrally. RESULTS: Nearly one quarter (24%) of women with an AIDS diagnosis had never received Pneumocystis carinii pneumonia prophylaxis, and 24% had never received any antiretroviral therapy. Fewer than two-thirds of black African women had had a chest radiograph. Only one woman had received Pneumovax and only 4% of women had ever taken part in a clinical trial. CONCLUSIONS: A substantial proportion of women with HIV infection did not receive interventions of proven benefit, and participation in clinical trials was very uncommon. The reasons for such poor uptake should be explored among both health care workers and women with HIV infection.
The changing clinical features of HIV-1 infection in the United Kingdom.
Despite advances in antimicrobial and anti-retroviral treatment in the past decade, the natural history of HIV-1 infection remains largely unchanged. Clinical monitoring has led to the introduction of effective prophylaxis of Pneumocystis carinii pneumonia and has facilitated the early detection and treatment of opportunistic infections. Pneumocystis carinii pneumonia now makes up a smaller proportion of first AIDS defining diagnoses than before prophylaxis was introduced. The proportion made up by more unusual opportunistic infections and malignancies, that occur later in the course of the disease, is growing. Late stage HIV disease--which is now complicated by infections with organisms of low pathogenicity, often combined with systemic Kaposi's sarcoma or lymphoma--presents major problems in clinical management. Further changes in the clinical features of HIV-1 infection may be expected in the future as more effective antimicrobial and anti-retroviral treatments are developed.
Funding policies for HIV and AIDS.
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Antenatal HIV testing: the case for universal voluntary named testing.
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The prevalence of human retroviral infections in female patients attending a central London sexually transmitted disease clinic: 1985-1990.
OBJECTIVES: To determine the prevalence of infection with HIV-1, HIV2, HTLV-1 and HTLV-2 in female attenders at a central London sexually transmitted disease clinic in an 8 week period in 1989-1990, and compare it with similar samples studied between 1985 and 1987. DESIGN: Anonymous testing of serum samples from consecutive female patients having routine serological investigation for syphilis. Testing was for clinically important retroviruses, Hepatitis B core antibodies (anti-HBc), and p24 and reverse transcriptase (RT) antigens. Age (in 5 year bands), nationality (in broad geographical zones), diagnosis on the day of presentation, and history of intravenous drug usage were recorded for each patient. Annual gonorrhoea rates were analysed from 1981 to 1990. SETTING: Outpatients of the department of genitourinary medicine. PATIENTS: A total of 850 females attending consecutively and having routine syphilis serology. MAIN RESULTS: The prevalence of anti-HIV-1 in female attenders in 1989-1990 was 0.35% (3/850). Prevalence in the same clinic has remained statistically unchanged since the first female cases were identified in 1986. No cases of HIV-2, HTLV-1 or HTLV-2 were identified, and no early HIV-1 infection evidenced by the presence of p24 or RT antigenaemia was found. Female gonorrhoea rates continued to decline but other STD monthly/annual rates have remained unchanged. CONCLUSIONS: Over the last 5 years prevalence of HIV-1 infection in females in our clinic has remained unchanged and other retroviral infections have remained absent. However, the unaltered rates of other genital infections, their potential role in the heterosexual spread of HIV-1 infection, and the lack of evidence for any major changes in female sexual behaviour suggests there is a need to remain vigilant. This work complements the MRC multicentre, unlinked, genitourinary medicine clinic, anonymous testing programme, and our group will continue to apply this simple methodology to specimens from female attenders to contribute to the surveillance of the evolving HIV-1 epidemic.
Unusual non-toxigenic Corynebacterium diphtheriae in homosexual men.
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Clinical audit in genitourinary medicine "why, who, what, how and when?".
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Screening pregnant women for genital herpes.
Neonatal herpes leads to serious morbidity and high mortality. The true incidence is unknown due to under reporting and difficulties in diagnosing the condition, but may be increasing. Mothers with primary disease, at term, present a greater infection risk to their offspring than mothers with recurrent disease, but the exact risks remain unknown. Existing prevention policies are inefficient, time-consuming for the doctor and the patient and, where caesarean section is offered to at-risk mothers, potentially hazardous. Anti-viral therapy offers a rational alternative and requires urgent evaluation.
Non-condylomatous, perianal disease in homosexual men.
This retrospective study details the findings and outcome in 34 homosexual men, out of a total of 177 patients, who underwent surgery for non-condylomatous perianal disease over a 2-year period. Of 34 homosexuals 20 presented with anorectal sepsis compared with 11 of 79 heterosexual male patients (X2 = 24.07, P less than 0.001). Lesions included chronic intersphincteric abscess (eight patients), anal fistula (seven patients) and chronic intersphincteric abscess and fistula (five patients). Anal fissure occurred in 15 patients, anal ulcer in three, skin tags in six, haemorrhoids in two and Kaposi's sarcoma in one. Eight patients were human immunodeficiency virus (HIV) antibody negative, four were asymptomatic HIV antibody positive, 12 had symptomatic HIV infection using the Centers for Disease Control classification and in ten patients HIV status was unknown. Irrespective of the type of surgery performed, healing occurred within 6 weeks of operation in all HIV antibody negative patients, all asymptomatic HIV antibody positive and in only one of nine patients with symptomatic HIV infection. Eight of nine patients with symptomatic HIV infection failed to heal by this time (X2 = 8.98, P less than 0.05). These findings suggest that the prevalence of anorectal sepsis in homosexual men is high and that symptomatic HIV infection is an important determinant of progress after surgery.
Aldosterone responsiveness to metoclopramide in hyperprolactinaemia.
Basal serum aldosterone levels in 13 hyperprolactinaemic females did not differ significantly from those of nine control individuals. There was increased responsiveness of circulating aldosterone levels to the long acting dopamine antagonist metoclopramide (10 mg intravenously) in the hyperprolactinaemic patients as compared with the controls. Prolactin responsiveness to metoclopramide was reduced in the patients as compared with the controls, such being considered characteristic of a prolactinoma. Basal serum thyrotrophin (TSH) levels, although within the euthyroid range, were increased in the patients as compared with the controls. There was no significant difference in the TSH responsiveness to metoclopramide between the study groups. However, in the five patients with exaggerated responses of TSH to metoclopramide, basal TSH levels were significantly higher than in the other patients. One explanation for these results is that prolactin can directly or indirectly modulate the aldosterone response to metoclopramide.