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This guideline offers recommendations on the diagnosis, treatment and health promotion principles needed for the effective management of human papillomavirus (HPV)-related warts at anogenital sites including the external genitals, vagina, cervix, urethra, perianus and anal canal. The guideline is aimed primarily at patients aged 16 years or older presenting to healthcare professionals working in level 3 sexual health services in the United Kingdom. However, the principles of the recommendations may be applied in other care settings, including in primary care, using locally adapted care pathways where appropriate. The management of HPV-related anogenital dysplasia or warts at other extragenital sites is outside the scope of this guideline.

Roadmapping is a well-established technique in the context of innovation and strategy, with the potential to support organizations address the complex transformative challenges facing humanity in the 21st century. This is enabled by its systems-based architecture and visual form of roadmaps, supporting communication and reduction of information asymmetries in complex sociotechnical systems. This paper focuses on an adaptation of the roadmapping method to support strategic planning for roadmapping systems in organizations, addressing implementation challenges. This represents a novel application of roadmapping to business processes and systems, demonstrating the flexibility of the roadmapping approach. A workshop template (‘R2’) and process for supporting the roadmapping of roadmapping systems is presented, developed and refined through a series of six industrial cases, and illustrated with an application example in the additive manufacturing sector.

ObjectivesInternet-based testing for sexually transmitted infections allows individuals to order a self-sampling kit online, send samples to a central laboratory and receive their results electronically, reducing the need to attend a clinic unless for treatment. Its usage has grown rapidly in many high-income countries, such as England, where it now accounts for 44% of tests within the National Chlamydia Screening Programme. However, there is limited data on the experiences of service users, which may offer insights into low uptake and poor return rates among some high-incidence populations.MethodsParticipants were recruited via sexual health clinics and the website of an internet-based testing service. Purposive sampling was used to ensure a diversity of genders, sexualities and ethnic backgrounds were included. Semistructured interviews were conducted by phone, email and messenger services and explored participants’ perceptions and experiences of both internet-based and clinic-based testing. Data underwent thematic analysis.ResultsWe interviewed 17 participants. Internet-based testing appealed to many due to the privacy and convenience it offered over clinic-based testing. Although most were positive about their experience of internet-based testing, many found the process of finger-prick blood sampling extremely challenging and this contributed to concerns from some participants that test results may be inaccurate. A minority of participants missed the opportunity that clinic-based testing offered to discuss symptoms or concerns with staff. Participants overwhelmingly found the process of receiving test results by short message service (SMS) acceptable and preferable to alternatives.ConclusionsInternet-based testing is viewed positively by most users but uptake may be improved if providers emphasise the privacy and convenience it offers, as well as the accuracy of self-sampling. Providers should also consider measures to address user concerns around blood sampling and access to specialist advice.

Background The tolerability of metronidazole is often perceived as being poor and in particular as being a cause of gastrointestinal side effects, but the frequency, severity and duration of adverse effects (AE) is not well characterised. This study assessed the frequency and type of metronidazole associated AEs in women treated for bacterial vaginosis.Methods An exploratory study of participants from the lactic acid gel versus metronidazole for treating bacterial vaginosis (VITA) randomised controlled trial. In this sub-study, women aged ≥16 years, diagnosed with bacterial vaginosis and who received oral MTZ (400 mg twice daily, for 7 days) were followed up prospectively over 2 weeks. Baseline demographic and clinical data, and self-reported data on the incidence, time to onset, and duration of AEs were analysed.Results 155 women were included, of whom 64% (99/155) reported at least one metronidazole AE, including 47% (72/155) who reported gastrointestinal symptoms (nausea and/or vomiting [52/155], abdominal pain [31/154] or diarrhoea [31/154]) mostly within 3 days of starting treatment and resolving within 5 days of onset. Treatment discontinuation occurred in 8% (12/148) overall and AEs were given as the reason for discontinuing in only 3% (4/148).Conclusion Overall, metronidazole side effects occurred commonly, but resolved within a few days and had a limited impact on treatment completion.

Background Bacterial vaginosis (BV) is a common condition, yet accurate diagnosis remains a challenge. We explored symptom and microscopy-based diagnosis of BV and assessed the influence of these diagnostic approaches on treatment response.Methods BV diagnosis based on patient-reported symptoms, and vaginal swab gram stain microscopy at local laboratories and a central laboratory were compared for women recruited into the VITA trial in England. Multivariable analysis was used to assess the association between the method of diagnosis and symptom resolution 2 weeks after metronidazole treatment.Results 517 women presenting with vaginal discharge (470/517 [91%]) and/or malodour (440/517 [85%]) were included. The accuracy of patients’ vaginal symptoms compared to local laboratory microscopy for BV diagnosis were —discharge, sensitivity 90% and specificity 5%; malodour, sensitivity 84% and specificity 12%, and compared to a central laboratory diagnosis were —discharge, sensitivity 91% and specificity 8%; malodour, sensitivity 88% and specificity 18%. 143/204 (70%) participants reported symptom resolution after treatment and this was associated with a positive baseline local laboratory diagnosis (adjusted relative risk—aRR 1.64 [1.02 to 2.64]), but not with a positive central laboratory diagnosis (aRR 1.14 [0.95 to 1.37]). Symptom resolution occurred in 75% (83/111) of women who were symptom positive/central laboratory BV positive compared to 65% (58/89) who were symptom positive/microscopy negative.Conclusion Symptoms correlated poorly with microscopy-based BV diagnosis but two-thirds of women with a symptom positive/microscopy negative diagnosis experienced symptom resolution following metronidazole treatment. Further studies are needed to determine the optimal investigation and treatment for microscopy-negative women with typical BV symptoms.

I. Sixty Years of the Council of Europe: A Common Achievement in Democracy and Human Rights The Council of Europe is the oldest international organization founded for political cooperation in [...]

Background The scale and extent of sexual violence perpetrated in the United Kingdom is being increasingly acknowledged. Support after the initial disclosure is often sought in NHS sexual health clinics. The purpose of this service evaluation was to explore patient satisfaction and experience amongst sexual health clinic attendees who disclosed sexual violence and were subsequently managed in a specialist sexual abuse survivors clinic.Methods Semi-structured interviews were conducted with ten service users and interview transcripts were analysed using interpretative phenomenological analysis (IPA) to assess users’ experiences within the clinic.Results Participants were all female (aged 18–54 years) and had experienced sexual violence between 2 weeks and 15 years prior to interview, and the majority self-identified as White British (6/10). IPA analysis revealed three distinct overarching themes which were important to this group of patients when evaluating their care: delivery of care in the context of judgement and stigma, aspects of care identified as healing or harmful to recovery, and the importance of the processes of providing care.Conclusion Understanding the experiences of sexual violence survivors in healthcare settings can optimise the provision of patient-oriented care and support. This includes ensuring the service user is in control of the consultation, the risks of re-traumatisation are minimised, and individuals receive relevant and accurate information but in a manageable volume and format.

ABSTRACTIntroductionDespite the existence of over 30 anti-seizure medications (ASM), including 20 over the last 30 years, a third of patients with epilepsy remain refractory to treatment, with no disease-modifying or preventive therapies until very recently. The development of new ASMs with new mechanisms of action is therefore critical. Recent clinical trials of new treatments have shifted focus from traditional common epilepsies to rare, genetic epilepsies with known mechanistic targets for treatment and disease-specific animal models.Areas coveredASMs in phase 2a/b-3 clinical trials target cholesterol, serotonin, sigma-1 receptors, potassium channels and metabotropic glutamate receptors. Neuroinflammation, protein misfolding, abnormal thalamocortical firing, and molecular deficiencies are among the targeted pathways. Clinically, the current phase 2a/b-3 agents hold promise for variety of epilepsy conditions, from developmental epileptic encephalopathies (Dravet Syndrome, Lennox-Gastaut syndrome, CDKL5 and PCDH19, Rett’s Syndrome), infantile spasms, tuberous sclerosis as well as focal and idiopathic generalized epilepsies and acute rescue therapy for cluster seizures.Expert opinionNew delivery mechanisms increase potency and site-specificity of existing drugs. Novel mechanisms of action involve cholesterol degradation, mitochondrial pathways, anti-inflammation, and neuro-regeneration. Earlier identification of genetic conditions through genetic testing will allow for earlier use of disease specific and disease-modifying therapies.

BackgroundThe UK National Chlamydia Screening Programme uses an opportunistic approach. Many programmes use campaigns to raise awareness of chlamydia screening in young people. This review aimed to assess the effectiveness of campaigns on uptake of chlamydia screening in young people.MethodsWe conducted a mixed-methods systematic review of articles assessing the outcomes of community-based health-promotion campaigns to increase chlamydia screening in young people, their experiences of the campaigns and other facilitators and barriers to the conduct of the campaigns. We searched four databases for quantitative and qualitative studies with no language restrictions.Main resultsFrom 10 329 records identified, 19 studies (20 articles) were included in the review: 14 quantitative, 2 qualitative and 3 mixed methods. All studies with quantitative outcomes were before-after study designs or interrupted time series. The prediction interval for relative change (RC) in test counts ranged from 0.95 to 1.56, with a summary pooled estimate of RC 1.22 (95% CI 1.14 to 1.30, 13 studies, I2=97%). For test positivity rate, 95% prediction interval was 0.59 to 1.48, with a summary pooled estimate of RC 0.93 (95% CI 0.81 to 1.07, 8 studies, I2=91.8%). Large variation in characteristics between studies precluded exploring outcomes by type of campaign components. Seven major qualitative themes to improve screening were identified: targeting of campaigns; quality of materials and message; language; anonymity; use of technology; relevance; and variety of testing options.ConclusionsHealth promotion campaigns aiming to increase chlamydia testing in those aged 15–24 years may show some effectiveness in increasing overall numbers of tests, however numbers of positive tests do not follow the same trend. Qualitative findings indicate that campaigns require clear, relevant messaging that displays the full range of testing options and assures anonymity in order to be effective.

ObjectivesWe explored sexual contact in the interval between the treatment for gonorrhoea and attending for a test of cure (ToC) and identified factors associated with sexual contact in this period.MethodsMultivariable analysis of demographic, behavioural and clinical data with self-reported sexual contact prior to attending for a gonorrhoea ToC evaluation among participants recruited into the ‘Gentamicin for the Treatment of Gonorrhoea’ trial in England, between October 2014 and November 2016. Associations with sexual contact were expressed as prevalence ratios (PR) and their corresponding 95% CI.ResultsThe median time to ToC was 15 days (interquartile range 14–20 days). 197/540 (37%) participants reported sexual contact in the time between treatment and ToC. Of these, 173/197 (88%) participants reported inconsistent condom use, including with previous partners (133/197 (68%)). A history of gonorrhoea (adjusted PR (aPR) 1.32 (1.03 to 1.69)) or syphilis (aPR 1.19 (1.08 to 1.32)), being in regular (aPR 1.71 (1.41 to 2.09)) sexual relationships, high number of partners in the last 3 months (aPR 1.77 (1.25 to 2.51))—‘more than 5 partners’ vs ‘0 to 1 partner’, and attending for a ToC more than 14 days after treatment (aPR 1.40 (1.08 to 1. 81)) were associated with reporting sexual contact before the ToC appointment. However, age (aPR (1.00 (0.99 to 1.01)) and presenting with specific symptoms at baseline (aPR 1.17 (0.95 to 1.44)) were not associated with sexual contact by the ToC attendance.ConclusionSexual activity after receiving treatment for gonorrhoea and prior to a ToC evaluation was common. This was associated with previous infection history and specific behavioural characteristics. Knowledge of these factors can help guide safe sex counselling at the time of treatment.

While courts must take care not to base custody decisions on white middle-class norms that may disparately affect racial, ethnic, and cultural minorities, courts should consider parental conduct that clearly places the child at risk of physical, mental, or emotional harm. The court of appeals upheld the trial court's termination of the father's in-person visitation, even though the father's conduct was based on religious beliefs, because the father's conduct placed the children at risk of harm. Although the trial court's decision was reversed on appeal, the trial court never acknowledged that its cultural (and possibly racial and ethnic) biases influenced its decision to award the white foster parents custody. [Extracted from the article]

THE MOFTEC RULES: IMPRACTICAL AND IN NEED OF REVISION Since the Establishment of Foreign-funded Venture Investment Enterprises Tentative Provisions (hereafter the MOFTEC Rules (1)) became effective on September 1 2001, [...]

OBJECTIVE: Interest in breast cancer prevention has led to the Breast Cancer Prevention Trial (BCPT), a controversial randomized trial of tamoxifen for women at risk for breast cancer. The goal of our study was to determine whether the potential benefits of enrolling in the randomized trial of prophylactic tamoxifen outweigh the potential risks. METHODS: We used a decision analytic model based on the available data on tamoxifen treatment benefits in women with breast cancer and extrapolated to its use in healthy women. RESULTS: For a 50-year-old woman with a breast cancer risk twice that of the average woman her age, the BCPT offers an increase in life expectancy of about 9 days, a gain that is modest compared with other health interventions. For women ages 35 to 60 who meet the minimum risk of breast cancer for trial eligibility, the trial increases life expectancy by about 8 or 9 days. Assumptions about the effect of tamoxifen on the incidence of endometrial and liver cancer and on quality of life associated with tamoxifen did not alter our findings. CONCLUSIONS: Advocates and opponents of the BCPT should temper their concerns to reflect the modest absolute benefits and harms associated with the trial. Although women at increased risk for breast cancer should be aware of the likely overall benefit associated with entry into the trial, for most women, entry into the BCPT is unlikely to alter substantially their length of life, in either a beneficial or harmful manner.

Nominees: Peter Foott - The Young Offenders, Vico Films for BBC Three Writing Team - Ghosts, Monumental Television for BBC One Writer - Drama Michaela Coel - I May Destroy You Various Artists/Falkna for BBC One and HBO 'This will be discussed for years to come… it is brave, poignant and highly original'. 33 Television www .rts.org.uk April 2021 BBC RTS Programme Awards 2021 Hosted by Jonathan Ross, the awards were presented on 16 March at the Grosvenor House Hotel, London, in partnership with Audio Network Michaela Coel - I May Destroy Y ou, Actor (Female); Writer - Drama and Mini-Series Hosted by Jonathan Ross, the awards were presented on 16 March at the Grosvenor House Hotel, London, in partnership with Audio Network Hosted by Jonathan Ross, the awards were presented on 16 March at the Grosvenor House Hotel, London, in partnership with Audio Network Hosted by Jonathan Ross, the awards were presented on 16 March at the Grosvenor House Hotel, London, in partnership with Audio Network 34 Actor (Female) Michaela Coel- I May Destroy You Various Artists/Falkna for BBC One and HBO 'Nothing short of electrifying… Somehow, she brought the audience into her head, heart and skin'. Nominees: ENO's Drive & Live: La Bohème, Somethin' Else for Sky Arts Election 2019 Live: The Results, ITV News for ITV Mini-Series I May Destroy You Various Artists/Falkna for BBC One and HBO 'An incredible achievement, showing us something we rarely talk about but should. [Extracted from the article]

ObjectiveTo identify economic evaluations of interventions to control STIs and HIV targeting young people, and to assess how costs and outcomes are measured in these studies.DesignSystematic review.Data sourcesSeven databases were searched (Medline (Ovid), EMBASE (Ovid), Web of Science, PsycINFO, NHS Economic Evaluation Database, NHS Health Technology Assessment and Database of Abstracts of Reviews of Effects) from January 1999 to April 2019. Key search terms were STIs (chlamydia, gonorrhoea, syphilis) and HIV, cost benefit, cost utility, economic evaluation, public health, screening, testing and control.Review methodsStudies were included that measured costs and outcomes to inform an economic evaluation of any programme to control STIs and HIV targeting individuals predominantly below 30 years of age at risk of, or affected by, one or multiple STIs and/or HIV in Organisation for Economic Co-operation and Development countries. Data were extracted and tabulated and included study results and characteristics of economic evaluations. Study quality was assessed using the Philips and BMJ checklists. Results were synthesised narratively.Results9530 records were screened and categorised. Of these, 31 were included for data extraction and critical appraisal. The majority of studies assessed the cost-effectiveness or cost-utility of screening interventions for chlamydia from a provider perspective. The main outcome measures were major outcomes averted and quality-adjusted life years. Studies evaluated direct medical costs, for example, programme costs and 11 included indirect costs, such as productivity losses. The study designs were predominantly model-based with significant heterogeneity between the models.Discussion/ConclusionNone of the economic evaluations encompassed aspects of equity or context, which are highly relevant to sexual health decision-makers. The review demonstrated heterogeneity in approaches to evaluate costs and outcomes for STI/HIV control programmes. The low quality of available studies along with the limited focus, that is, almost all studies relate to chlamydia, highlight the need for high-quality economic evaluations to inform the commissioning of sexual health services.

ObjectivesTo explore the utilisation of pharmacy-based sexual and reproductive health services (SRHS) in order to optimise delivery and identify barriers to access.MethodsThe health provider Umbrella offers six SRHS from over 120 pharmacies in Birmingham (England). In this retrospective study, data collected between August 2015 and August 2018 were used to analyse uptake, user characteristics and attendance patterns according to day of the week.ResultsA total of 60 498 requests for a pharmacy service were included in the analysis. Emergency contraception (50.4%), condoms (33.1%) and STI self-sampling kits (9.6%) accounted for more than 90% of all requests. A lower uptake of services was observed for the contraceptive injection (0.6%), oral contraception (5.4%) and chlamydia treatment (1.0%). Services were most likely to be requested by those self-identifying as female (85.6%), and those aged 16–24 years (53.8%). Based on available ethnicity data (n=54 668), most requests for a service were made by White/White British individuals (43.4%) and Asian/Asian British people (23.1%). The largest number of services were delivered on Mondays (20.9%) and the lowest on Sundays (5.0%). A high proportion of requests for services on Saturdays (57.0%), Sundays (67.6%) and Mondays (54.4%) were made by females presenting for emergency contraception.ConclusionThe evaluation of healthcare utilisation is important to help refine and optimise the delivery of services. However, information relating to pharmacy-based SRHS is scarce and often limited to a single type of service provision. Overall, a wide range of pharmacy-based services were accessed by a diverse range of people, suggesting that pharmacies are a suitable provider of many SRHS. However, the routinely collected data analysed in the study had several limitations restricting the analysis. Sexual health providers should ensure they collect data which are as comprehensive as is possible in order to help understand the utilisation of services.

ObjectivesTo determine the time to resolution of symptoms (TTR) following treatment of uncomplicated gonorrhoea and to identify factors associated with TTR in a cohort of sexual health clinic attendees.MethodsParticipants were recruited from 14 clinics across England into the ‘Gentamicin for the Treatment of Gonorrhoea (GToG)’ trial between October 2014 and November 2016. We analysed demographic, behavioural and clinical data in a subset of the GToG study cohort presenting with genital discharge and/or dysuria, who subsequently experienced microbiological clearance of Neisseria gonorrhoeae2 weeks after treatment. Testing for gonorrhoea was performed using a nucleic acid amplification test. The results were expressed as median TTR (IQR) and HRs with 95% CIs for resolution of symptoms.Results216 participants (89% male) with a mean age of 32 years reported genital discharge (204/216 (94%)) or dysuria (173/216 (80%)) at their baseline visit. Symptom resolution occurred in 202/216 (94%) at the 2-week follow-up appointment. The median TTR was 2 days (IQR 1–3 days). 50/216 (23%) patients presented with gonorrhoea–chlamydia coinfection at their baseline attendance and in this group symptom resolution was slower (3 days for gonorrhoea–chlamydia coinfection compared with 2 days for gonorrhoea only, HR 0.68 (95% CI 0.48 to 0.95)). TTR was also longer in women (4 days for females compared with 2 days for males, HR 0.47 (95% CI 0.29 to 0.77)).ConclusionsThe time to resolution of genital symptoms following effective treatment of gonorrhoea is variable, but 90% of patients report symptom resolution within 1 week. Concurrent chlamydia infection and being female were associated with prolonged TTR.

ObjectiveA multicentre, randomised non-inferiority trial compared the efficacy and safety of 14 days of ofloxacin and metronidazole (standard-of-care (SoC)) versus a single dose of intramuscular ceftriaxone followed by 5 days of azithromycin and metronidazole (intervention arm (IA)) in women with mild-to-moderate pelvic inflammatory disease (PID).MethodsWomen with a clinical diagnosis of PID presenting at sexual health services were randomised to the SoC or IA arms. Treating clinicians and participants were not blinded to treatment allocation but the clinician performing the assessment of primary outcome was blinded. The primary outcome was clinical cure defined as ≥70% reduction in the modified McCormack pain score at day 14–21 after starting treatment. Secondary outcomes included adherence, tolerability and microbiological cure.ResultsOf the randomised population 72/153 (47.1%) reached the primary end point in the SoC arm, compared with 68/160 (42.5%) in the IA (difference in cure 4.6% (95% CI −15.6% to 6.5%). Following exclusion of 86 women who were lost to follow-up, attended outside the day 14–21 follow-up period, or withdrew consent, 72/107 (67.3%) had clinical cure in the SoC arm compared with 68/120 (56.7%) in the IA, giving a difference in cure rate of 10.6% (95% CI −23.2% to 1.9%). We were unable to demonstrate non-inferiority of the IA compared with SoC arm. Women in the IA took more treatment doses compared with the SoC group (113/124 (91%) vs 75/117 (64%), p=0.0001), but were more likely to experience diarrhoea (61% vs 24%, p<0.0001). Of 288 samples available for analysis, Mycoplasma genitaliumwas identified in 10% (28/288), 58% (11/19) of which had baseline antimicrobial resistance-associated mutations.ConclusionA short-course azithromycin-based regimen is likely to be less effective than the standard treatment with ofloxacin plus metronidazole. The high rate of baseline antimicrobial resistance supports resistance testing in those with M. genitaliuminfection to guide appropriate therapy.Trial registration number2010-023254-36.

ObjectivesTo determine the variation in the time from onset of symptoms to clinical presentation (time to presentation [TTP]) in a cohort of sexual health attendees with symptomatic uncomplicated genital gonorrhoea and to identify factors associated with TTP.MethodsParticipants were recruited from 14 clinics across England into the ‘Gentamicin for the Treatment of Gonorrhoea (GToG)’ trial between October 2014 and November 2016. Multivariable analysis was performed using prospectively collected demographic, behavioural and clinical data in a subset of the GToG study cohort presenting with genital discharge and/or dysuria who tested positive for Neisseria gonorrhoeaeusing a nucleic acid amplification test. The results were expressed as geometric mean ratios (GMR) with 95% CI for time to presentation after onset of symptoms.Results316 participants (269 men and 47 women) with a median age of 27.6 years (IQR 23.0–34.8) were included. 194 (61%) were Caucasian, 29 (9%) Black African, 27 (9%) Asian and 66 (21%) of other ethnicities. Median TTP was 3 days for men (IQR 2–7) and 14 days for women (IQR 7–21). Participants reported genital discharge (297/316 [94%]), dysuria (251/316 [79%]), both genital discharge and dysuria (232/316 [73%]) and other concurrent symptoms 76/316 (24%) (e.g., rectal bleeding or genital itching). 45/316 (14%) participants reported sexual contact while symptomatic, of whom TTP was more than 7 days in 32/45 (71%). A longer TTP was associated with gender (female cf. male, GMR 2.34 [1.67 to 3.26]), no prior history of gonorrhoea (GMR 1.46 [1.15 to 1.86]), ‘regular’ or ‘ex-regular’ sexual relationship (regular cf. one off GMR 1.35 [1.05 to 1.72]); ex-regular cf. one off GMR 1.88 [1.12 to 3.14]), and being heterosexual (GMR 1.69 [1.31 to 2.19]).ConclusionSpecific demographic and behavioural factors are associated with a longer TTP in individuals with symptomatic genital gonorrhoea. Detailed knowledge of these factors can be used to prioritise and optimise gonorrhoea management and prevention.

ObjectivesNeisseria gonorrhoeae(NG) infection can resolve without antibiotic treatment, however the literature describing the frequency of clearance at individual sites, how rapidly it occurs and potential predictive factors is limited. In this analysis of a subpopulation identified from a large multicentre UK cohort, we describe the overall rate of spontaneous clearance of infection and explore factors associated with this.MethodsData from the Gentamicin compared with Ceftriaxone for the Treatment of Gonorrhoea randomised controlled trial consisting of 720 patients with NG were analysed. A subgroup of individuals had both a pretrial test sample and a trial enrolment sample taken. Those who had cleared NG between initial presentation and subsequent entry into the trial without antibiotic treatment were deemed to have spontaneously cleared. Sociodemographic characteristics, sexual history and sites of infection for those who spontaneously cleared infection were compared with that of those who did not. We also estimated the time interval to clearance.ResultsOverall, the proportion who had spontaneous clearance was 20.5% (83/405). Clearance of infection occurred over a median of 10 days (IQR 7–15 days). The cohort who spontaneously cleared were similar to those who did not in terms of age, gender, sexual orientation, HIV status and previous NG infection. Chlamydia coinfection was more frequent in the ‘no spontaneous clearance group’ (11.1% (9/83) cf 22.0% (69/322)) (p=0.029). Dysuria was reported more often in the ‘no spontaneous clearance group’ (4.8% (4/83) cf 13.0% (42/322)) (p=0.035).ConclusionWe present data from a large cohort of NG-infected individuals, of whom a significant proportion had spontaneous clearance of infection. This is consistent with previous smaller studies. If this is indicative of cure, point-of-care testing prior to treatment has the potential to reduce unnecessary exposure to antimicrobials. Further work to assess the importance of bacterial load, genotype and host immune response on spontaneous clearance of infection is required.Trial registration numberISRCTN51783227

Like scientists tinkering in a lab with a petri dish, growing and testing exotic cultures to produce something new, exhibitors around the world are experimenting with a wide range of [...]

75 Years of Marvel Comics: From the Golden Age to the Silver Screen Roy Thomas Taschen, 722pp, 135 £ All the best comic books have an origin story. It tells [...]

Gonorrhoea is a common sexually transmitted infection for which ceftriaxone is the current first-line treatment, but antimicrobial resistance is emerging. The objective of this study was to assess the effectiveness of gentamicin as an alternative to ceftriaxone (both combined with azithromycin) for treatment of gonorrhoea.

BackgroundObtaining perspectives from those seeking healthcare after sexual violence on care and how it is delivered is important.ObjectivesTo systematically identify any existing patient-reported outcome and experience measures (PROMs and PREMs) for patients attending healthcare services after sexual violence. Also, to identify key themes regarded by patients as priorities for delivering a high-quality service.DesignSystematic review (PROSPERO registration RD42016050297).Data sourcesEight electronic bibliographic databases from inception to March 2017. ‘Grey’ literature also searched. Search words included patient view, patient experience, PROM/PREM, sexual violence, rape.Review methodsStudies of any design, with participants of any gender and aged 13 years or older were included; studies only assessing the views of service providers were excluded. Appraisal tools assessed for study quality. Healthcare outcome data were assessed across the quantitative studies and key experiences across qualitative papers; Framework Analysis was used to synthesise the qualitative studies.ResultsFrom 4153 identified papers, 20 fulfilled criteria for inclusion: 10 qualitative, 8 quantitative and 2 mixed methods. No validated measure of assessing patient experience or outcome was identified. The synthesis of qualitative studies led to the assignment of two overarching themes around the importance of patient-focused and trauma-focused communication, and of care which enhances patient empowerment. A paucity of research within certain patient groups who experience sexual violence, in particular men and LGBT (lesbian, gay, bisexual and trans) patients was noted.LimitationsA broad definition of ‘healthcare setting’ incorporated a wide variety of venues limiting the applicability of findings in specific settings.ConclusionA validated and standardised approach to assess patient experience and outcome in healthcare settings after sexual violence is needed. Themes identified should be incorporated into PROM or PREM development. The review also suggests the need for a change in approach towards those who attend for healthcare after sexual violence to ensure patient autonomy.

BackgroundPharmacies are increasingly providing services related to contraception and STIs. Identifying pharmacy staff’ and users’ experiences and attitudes relating to sexual health services is critical to understand users’ needs and examining how pharmacy staff can most effectively contribute to patient-centred care. This systematic review aimed to examine pharmacy staff and pharmacy users’ experiences and attitudes towards the delivery of a large range of sexual health services.MethodsSeven electronic databases and the reference lists of all included studies were searched in September 2018. Studies giving insight into pharmacy users’ and pharmacy staff’s experiences and attitudes towards the delivery of services related to contraception and STIs were included. The Mixed Methods Appraisal Tool was used to assess the quality of included studies and a narrative synthesis applied to analyse evidence.ResultsNineteen studies were included. Eleven studies looked at pharmacy staff, four at users and four at both groups. Users found services accessible and convenient and staff found service provision feasible. However, several barriers to service delivery were identified including lack of privacy for delivering services, lack of trained staff available to provide services and subjective judgements being made on who should be provided or offered a service.DiscussionBarriers to service delivery need to be addressed to allow pharmacies to deliver their full potential. Future research on pharmacy-based gonorrhoea and syphilis screening, and hepatitis B vaccination is needed.PROSPERO registration numberCRD42018106807.

ObjectiveTo assess the effectiveness and safety of antibiotic regimens used to treat pelvic inflammatory disease (PID).DesignThis is a systematic review and meta-analysis of randomised controlled trials (RCTs). Risk of bias was assessed using the criteria outlined in the Cochrane guidelines. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation.Data sourcesEight electronic databases were searched from date of inception up to July 2016. Database searches were complemented by screening of reference lists of relevant studies, trial registers, conference proceeding abstracts and grey literature.Eligibility criteriaRCTs comparing the use of antibiotics with placebo or other antibiotics for the treatment of PID in women of reproductive age, either as inpatient or outpatient treatment.ResultsWe included 37 RCTs (6348 women). The quality of evidence ranged from very low to high, the main limitations being serious risk of bias (due to poor reporting of study methods and lack of blinding), serious inconsistency and serious imprecision. There was no clear evidence of a difference in the rates of cure for mild-moderate or for severe PID for the comparisons of azithromycin versus doxycycline, quinolone versus cephalosporin, nitroimidazole versus no use of nitroimidazole, clindamycin plus aminoglycoside versus quinolone, or clindamycin plus aminoglycoside versus cephalosporin. No clear evidence of a difference between regimens in antibiotic-related adverse events leading to discontinuation of therapy was observed.ConclusionsWe found no conclusive evidence that one regimen of antibiotics was safer or more effective than any other for the treatment of PID, and there was no clear evidence for the use of nitroimidazoles (metronidazole) compared with the use of other drugs with activity against anaerobes. More evidence is needed to assess treatments for women with PID, particularly comparing regimens with or without the addition of nitroimidazoles and the efficacy of azithromycin compared with doxycycline.

The message The law on interference with neighbouring land has changed. The case The Supreme Court has reviewed the law on private nuisance and whether an injunction should be the [...]

The message Sometimes it is better to leave an issue well alone. The case The Upper Tribunal has determined whether a flat let to the lessee as a private dwelling [...]

Objective: To determine the prevalence of type III hyperlipoproteinaemia in a cohort of HIV infected patients taking protease inhibitors and its correlation with the apolipoprotein-E2 isoform. Design: Gross sectional study [...]

Extracts from 'Clinical Evidence' Interventions Unknown effectiveness: Empirical antibiotic treatment Different durations of antibiotic treatment Oral versus parenteral antibiotics Background Definition Pelvic inflammatory disease (PID) is inflammation and infection of [...]

Continued use of oral doxycycline and metronidazole is hard to justify Standing at the therapeutic crossroads trying to choose a path for outpatients with pelvic inflammatory disease, a clinician may [...]

There are probably more operations described for correcting hypospadias than for any other congenital anomaly, and while some are no longer employed, a variety of approaches still exist. Until recently, [...]

Introduction State supported gambling has long been an alluring financial cure-all, a quick fix for raising revenues. Both public and private betting have been popular in America since colonial times. [...]

The message: The court can see the wood from the trees The case: In an important case for practitioners and insurers, the court has made clear when a homeowner will [...]

The message The law will seek to let justice triumph over technicalities The case In another break notice dispute, the court has reached a decision based on the merits--rather than [...]

The message A tenant can remove substantial plant and equipment from premises. The case In an important case for tenants who cease to trade, the court has clarified the law [...]

The message Any material variation can discharge a guarantor. The case A guarantor has successfully challenged its liability to meet substantial liabilities under a 1981 lease in Topland Portfolio No [...]

The message Dilapidations claims should not be overestimated The case The third reported dilapidations case in as many months was Hammersmatch Properties (Welwyn) vs Saint-Gobain Ceramics & Plastics (14.05.13). A [...]

The message failure to respond or negotiate before proceedings can prove costly. The Court of Appeal considered whether a successful defendant should be punished with costs because of unreasonable behaviour [...]