other Flashcards
What are the safety concerns with moxifloxacin
Increased risk of life-threatening liver reactions
Cardiac reactions
Skin reactions
features of optiate intoxication
euphoria sedation miosis = excessive constriction of the pupil of the eye. decreased concentration hypotension bradycardia respiratory depression impaired consciousness death
features of opiate withdrawal
anxiety / aggitation anorexia + weight loss myalgia muscle weakness tremor nausea + vomiting diarrhoea + abdominal cramps yawning lacrimation / rhinorrhoea / sweating
features of alcohol withdrawal
anxiety irritability insomnia headaches malaise weakness nausea + vomiting hyperension tachycardia
What is the PPV?
The likelihood that patients with an initial positive test have the infection
What happens to the PPV as the provenance of the infection drops
PPVs become lower as prevalence drops
What is the NPV?
The likelihood that patients with an initial negative test result do not have the infection
Define sensitivity
sensitivity = ability of the test to correctly identify those patients with the disease
Define specificity
Specificity = ability of the test to correctly identify those patients without the disease
Arterial supply of the vagina
Vaginal artery
and anastomoses with the uterine artery superiorly
Dermatome supply of anterior upper arm
C5
Dermatome supply of level of the nipple
T5
Dermatome supply of level of umbilicus
T10
Dermatome supply of medial ante-cubital fossa
T1
Dermatome supply of the acromio-clavicular joint
C4
Dermatome supply of the axilla
T2
Dermatome supply of the little finger
C8
Dermatome supply of the mid anterior thigh
L2
Dermatome supply of the middle finger
C7
Dermatome supply of the perianal area
S5
Dermatome supply of the thumb
C6
Duration for spermatogenesis
70-75 days
Length of the inguinal canal in adults
4cm
Length of vagina
6 - 7.5cm anteriorly
9cm posteriorly
Lymph drainage of base of cervix
Internal iliac lymph nodes
Lymphatic drainage of the bladder
External Iliac nodes
Fundus to internal iliac nodes
Some to common Iliac and sacral
Lymphatic drainage of the distal rectum
Internal iliac nodes
Nerve root control of knee-jerk
L3/4
Nerve root of the femoral nerve
L2-4
Nerve root of the sciatic nerve
L4-5, S1-3
To what lymph group does the cervix drain to
Internal iliac
To what lymph group does the distal rectum drain to
Internal iliac
To what lymph group does the majority of the breast drain to
Pectoral group of
the axillary lymph nodes
To which lymph nodes does lymph from the scrotum and penis first pass?
Superficial inguinal lymph nodes
Venous drainage of the bladder
Internal iliac veins
Venous drainage of the right ovary
Direct into inferior Vena cava
Venus drainage of the left ovary
Left renal vein
into inferior Vena cava
Venous drainage of the vagina
Vaginal plexus
With vaginal vein to internal iliac vein or uterine vein
What are the 3 sites of constriction of the ureters
Crossing the Pelvic brim
Pelvo-ureteric junction
vesico-uretreic junction
What is the nerve root supply for the muscle group of the ankle reflex
S1-2
What is the nerve root supply for the muscle group of the biceps reflex
C5 - 6
What is the nerve root supply for the muscle group of the knee reflex
L3 - 4
What lymph group does the vulva drain to
Superficial inguinal lymph nodes
What muscle is mainly responsible for knee extension
quadriceps
What muscles does the median nerve innervate
LOAF muscles
Flexor carpi radialis
Pronator teres
What muscles does the radial nerve supply
Triceps,
brachioradialis,
supinator,
abductor pollicis longus
What nerve roots mediates the anal reflex
S3-4
What roots supply the pudendal nerve
Anterior rami of S2-4
What structures prevent prolapse of the uterus and vagina
Uterosacral ligaments
Cardinal ligaments
Levator ani muscles
Where does lymph from the Fallopian tube drain to?
Para-aortic nodes
In what patients should ciprofloxacin be avoided
fluroquinolones or quinolones
ciprofloxacin resistant bacteria unknown susceptibility previous SE from fluroquinolones / quinolones caution in >60yo or on corticosteroids or kidney disease or organ transplant
What serious side effects can occur from
fluroquinolones or quinolones
Muscle / tendon rupture
pain
peripheral neuropathy
CNS effects - hallucinations / depression
What is Chemsex
the use of drugs in a sexual context
- methamphetamine (crystal, meth, Tina)
- mephedrone (meph/drone, miaow miaow, m-cat)
- GHB/GBL (G, Gina)
What is slamming
Injecting the drugs used for chemsex
What factors contribute to the high burden of HIV among trans-women
high levels of discrimination structural barriers to healthcare violence - physical and sexual poverty high unemployment housing instability
What does Chemsex do?
Better sex / increased pleasure Increased stamina / longer sex / multiple partners Increase confidence Disinhibition Mild anaesthetic
What % of HIV +ve MSM report chemsex
7% HIV positive MSM report recreational drug use in past 3 months
29% engaged in chemsex in last year
10% in slamsex
What % of HIV -ve MSM report chemsex
5% during last time sex
54% engaged in chemsex in last 3 months
Risks associated with Chemsex
High risk sexual behaviour - increased number of partners / less condom use / aero-sorting Increased STI risk Delayed obtaining PEPSE Decreased adherence to ARVs for PEPSE / PrEP or HIV tx Mental health issues Physical health financial issues crime
Which patients are likely to benefit from safer sex advice?
adolescents
people from, or who have visited countries with high rates of HIV and/or other STIs
MSM
history of: frequent partner change multiple concurrent partners early onset sexual activity previous bacterial STI attendance as a contact of STI alcohol or substance abuse
What impacts condom effectiveness
late application early removal Condom slippage and errors condom associated erection loss Use of oil based lubricant -
Lubricant use reduces condom breakage for anal but not vaginal sex
The risk of condom slippage may be doubled with the use of lubricant for vaginal sex
Safer sex advice for Oral Sex
Advise of risks of transmission of STIs from oral sex
Advise condom use / dental dams for oral sex
Avoiding oral sex with ejaculation - reduces risk of HIV and possibly other infections
Insertive fellatio is lower risk than receptive
Avoid brushing teeth or flossing before oral sex reduces risk of HIV and possibly other infections
Avoiding oral sex if oral cuts / sores a or a sore throat
What STIs are transmissible through Oral Sex
Herpes simplex virus (HSV) human papilloma virus (HPV) gonorrhoea Chlamydia syphilis HIV Hepatitis B possibly Hepatitis C
Which drugs are commonly used in chemsex
GHB/GBL
Mephedrone
Crystal Methamphetamine
others - MDMA, Cocaine, Poppers, Speed, ketamine, viagra
Harm reduction advice for people using GHB / GBL
GBL is a depressant
Advise against mixing it with alcohol or ketamine due to the sedative effect
Start with small volumes (0.5ml)
Avoid re-dosing too soon (aim for 3 hours min)
Advise against using others’ G as the strength is not known
Measure using a syringe or pipette
G can become physically addictive after a short time
Signs of dependence to GHB / GBL
sweats
shaking
insomnia
anxiety
Harm reduction advice for people using Crystal Meth
Avoid injecting if possible - carries the additional risk of sharing needles, damage to veins and abscesses
Can lower inhibitions leading to more risky injecting and sexual practices. Sharing needles and equipment leads to increased risk of blood borne virus (BBV) transmission.
Can lead to hallucinations / feelings of depressions/low mood
Individuals at risk of forgetting to take ARVS / PrEP or missing window for PEPSE
Harm reduction advice for people using mephedrone
No safe way to take it
Least risk from ‘bombing it’ = swallow wrapped in paper
Causes irritation when snorted - nose bleeds
Causes a sore throat when swallowed
Try to avoid injecting - due to added risk.
Advise re local needle exchanges and drug services
contraindications to Azithromycin
Severe hepatic impairment
drugs which prolong the QT interval
hypokalaemia (risk of QT prolongation)
history of prolonged QT interval
mechanism of action of Azithromycin
bacteriostatic
Inhibits some gram -ve, some gram +ve and many aytipicals
Azalide = type of macrolide
Side effects of Azithromycin
<1% stop azithromycin due to SE
Nausea / vomiting diarrhoea abdo discomfort pseudomembranous colitis (c. diff) anaphylaxis hepatotoxicity +/- jaundice
drug interactions with Azithromycin
warfarin - may increase INR
statins - increased risk of rhabdomyolysis
Ciclosporin - affects clearance of cyclosporin
any drugs which prolong the QT interval (amiodarone, sotalol, amisulpride, terfenadine)
Any drugs which cause hypokalaemia (risk long QT)
What type of drug is doxycycline
+ MOA
Tetracycline class broad spectrum bacteriostatic
Contraindications to doxycycline
Pregnancy breastfeeding liver disease SLE Myasthenia Porphyria
Side effects of doxycycline
Nausea / vomiting
diarrhoea
photosensitivity
benign intracranial hypertension (rare)
Drug interactions with doxycycline
accelerated metabolism of doxycycline is caused by - pentobarbital / carbemazebine / phenytoin / primidone
Decreased levels of doxycycline caused by - Rifampicin
Decreased absorption of doxycycline - Sucralfate / antacids
What impact does doxycycline use in pregnancy have on the infant
Affects feral tooth and bone development
FDA category D
History to determine risk for MSM
frequency and number of condomless anal sex partners
serosorting
seropositioning
negotiated safety
understanding of ARVs as HIV treatment-as-prevention
Knowledge / use of PrEP and PEPSE
Sexual activities conferring risk for enteric infections and Hepatitis C or hepatitis A = oro-anal sex (rimming) / fisting;
Discuss ways of meeting partners - use of internet/ apps
sex-on- premises or cruising venues
alcohol intake
use of recreational drugs during sex
problems with sexual dysfunction
What is negotiated safety
Partners begin the relationship exclusive and stay monogamous
Both partners test for HIV and repeat this after the window period and share their results
Both partners use condoms until both partners know they’re HIV-negative
Both partners develop a clear spoken / written agreement about their sex practices within and outside of the relationship
e.g. not having other sexual partners / not having anal sex outside the relationship / only having oral sex outside the relationship / always using condoms for sex outside the relationship.
Agreement kept by both partners.
If the agreement is broken it’s discussed right away.
And condoms are used until both partners test HIV negative after the window period
In men with rectal symptoms, the presence of tenesmus and constipation is significantly associated with which infection
lymphogranuloma venereum
LGV
Why should GUM clinics routinely ask about drug and alcohol use
Excessive alcohol use is associated with STI diagnosis
Alcohol use is more common among adult and adolescent MSM
Binge drinking, use of inhaled nitrites and methamphetamine are markers of increased STI risk in MSM
Ask re injected drug use and equipment sharing +/- offer Hep B / C tests
Asymptomatic screening offered to MSM
CT and GC NAAT from all sites = urethra, pharynx and rectum - irrespective of HIV status or sexual history HIV and STS serology \+/- Hep B - unless immunity known \+/- Hep C \+/- Hep A
Risk factors for LGV
MSM HIV-positive practicing higher risk sex. Hepatitis C infection Chemsex (specifically the use of GHB) condomless anal sex fisting
When is routine LGV typing recommended
In HIV positive MSM with symptomatic or asymptomatic CT
But NOT in HIV-negative MSM with CT (unless symptomatic proctitis)
A bidirectional transmission synergy exists between HIV infection and which type of HSV
HSV-2
3 monthly STI screening including HIV should be offered to which MSM
- Unprotected anal intercourse with partner(s) of unknown or serodiscordant HIV status over last 12 months
- > 10 sexual partners in last 12 months
- Drug use (methamphetamine, inhaled nitrites) during sex over last 6 months (Or GBL, ketamine, other NPSs - evidence less robust)
- Multiple or anonymous partners since last tested
- Any unprotected sexual contact (oral, genital or
anal) with a new partner since last tested
Causes of sexually transmitted enteric infections
Shigella spp. VTEC Campylobacter spp. Salmonella spp. Entamoeba histolytica Cryptosporidium spp. Cytomegalo virus Giardia duodenalis Microsporidium spp Hepatitis A
Infectious causes of gastrointestinal infections in MSM
- Viruses - Hepatitis A / norovirus
- Bacteria: Campylobacter spp., E. coli, Salmonella spp., Shigella spp., Yersinia enterocolitica
- Parasites: Cryptosporidium spp., Entamoeba histolytica, Giardia lamblia/intestinalis, Blastocystis spp., Dientamoeba fragilis, Isospora spp., Microsporidium spp.
Symptoms of proctitis
rectal pain
rectal discharge
rectal bleeding
+/- tenesmus
aetiology is usually classic STI pathogens
Symptoms of enteric infections
diarrhoea and/or dysentery
abdominal pain
usually have colitis or enterocolitis that is caused by enteric pathogens
Investigations for proctitis
full sexual health screen
Microscopy of a Gram-stained rectal smear - >5 or >10 polymorphonuclear cells/high power field = proctitis
culture for NG from all sites prior to treatment
swabs for HSV PCR and T. pallidum PCR
Empirical therapy in symptomatic men with proctitis
Cover CT, LGV and GC
(treatment for LGV also covers STS)
Doxycycline 100 mg twice daily orally for 21 days
+ Ceftriaxone 1g IM STAT
Risk factors for AIN
HPV Receptive anal intercourse immunosupression (including HIV) smoking increased age
Anal cancer is usually what type
SCC
usually preceded by AIN
Symptoms of AIN
pruritus anal discharge suspicious skin lesions (white / erythematous / scaly / pigmented) fissures eczematous changes
Diagnosis of AIN
biopsy
Management of AIN
Observation - may spontaneously regress - FU every 6-12months
local excision if <1/3 of anal circumference
imiquimod 5%
Symptoms of anal cancer
Anal pain bleeding discharge pruritus ulceration
if anal sphincter infiltrated –> faecal incontinence and tenesmus
Characteristics of enteric infections
sudden onset diarrhoea
with or without vomiting
usually transient
due to enteric infection with viruses, bacteria or protozoa,
typically affect large bowel (the colon)
less commonly - small bowel
Other symptoms =
- blood and/or mucous in the faeces (dysentery)
- fever
- malaise
History required for a MSM presenting with acute diarrhoea
Question re severity of illness medication hx - incl recent abx exposure to untreated water animals occupational risk of transmission risk factors - including travel abroad / food history
Sexual risks in 2 weeks preceding onset
- receptive oro-anal (both direct and indirect, i.e. performing oral sex after anal penetration)
- multiple sexual partners
- group sex
- chemos sex
- sexual activities involving faeces (e.g. scat play).
Investigations for acute onset diarrhoea in MSM
Full sexual health screen
Microbiology examination of stool
- for ova, cysts + parasites
- culture + antibiotic susceptibility testing
Management of patients with STEI
conservative management
Oral rehydration
+/- use oral rehydration salts after each loose stool passed for up to 48 h
AVOID Antidiarrhoeal drugs e.g. loperamide = contraindicated in infectious diarrhoea
AVOID empirical antibiotic therapy,
Consider empirical therapy guided by microbiology advice when:
• patient pyrexial (temperature >38C)
• stools are bloody
• Diarrhoea lasts > 7 days
• Co-morbidities (frailty, IBD, immunocompromised)
Advice on sexual practices for preventing spread of enteric infections
- Wash hands, genitals and perianal skin before and after sexual activities - including intercourse / rimming / fingering / handling used condoms or sex toys.
- Use condoms for anal sex
- Use latex gloves for digital penetration or fisting
- Dental dams or a condom cut into a square as a barrier for rimming
- Avoid sharing sex toys or douching equipment.
- Avoid sexual contact until 7 days after the last episode of diarrhoea
Ovarian blood supply
Right + left ovarian arteries - arise from descending abdominal aorta
Right + left ovarian veins
Rt ovarian vein drains to IVC
Lt ovarian vein drains to Lt renal vein then IVC
which ligament do the ovarian arteries and veins travel in
infundibula-pelvic ligament
blood supply to the fallopian tubes
Uterine artery and ovarian artery
Ovarian veins + uterine veins
arterial supply to the penis
3 arteries - arise from internal pudendal artery
= dorsal artery of penis
+ deep cavernosal artery
+ bulbo-urethral artery
venous drainage of penis
superficial dorsal vein of penis
deep dorsal vein of penis
lymphatic drainage of penis
skin + prepuce drain to superficial inguinal lymph nodes
glans drains to
- superficial inguinal lymph nodes
- or directly into deep inguinal nodes
- or into external iliac nodes
Treatment of acute bacterial prostatitis
4 weeks of antibiotics
e.g. trimethoprim
check sensitivities
Common organisms causing acute bacterial prostatitis
60% = E.coli / proteus / klebsiella
enterococci
anaerobes
urethral GC
Chronic bacterial prostatitis symtoms and treatment
recurrent UTI
persistent focus of infection in prostate
treatment = 4 weeks of ciprofloxacin 500mg BD
or 4 weeks Ofloxacin 200-400mg BD
