Page 340 - TNFlipTest

FM42 Family Medicine
Common Presenting Problems Toronto Notes 2019 • CBC,Cr,correctedCa2+,ALP,TSH,25-OH-D(after3-4moofadequatesupplementation),andserum
protein electrophoresis if there are vertebral fractures
Indications for Bone Mineral Density Testing and Management
• seeEndocrinology,E41
Palliative and End-of-Life Care
• seeGeriatricMedicine,GM11 Rash
• seeDermatology,D13
Sexually Transmitted Infections
• seeGynecology,GY26
Definition
• diversegroupofinfectionscausedbymultiplemicrobialpathogens • transmittedbyeithersecretionsorfluidsfrommucosalsurfaces
Epidemiology
• highincidenceratesworldwide
• Canadianprevalenceinclinicalpractice
■ common: chlamydia (most common), gonorrhea (2nd most common), HPV, genital herpes ■ less common: hepatitis B, HIV, syphilis, trichomoniasis
■ rare: chancroid, granuloma inguinale, lymphogranuloma venereum
• non-sexuallytransmittedgenitaltractinfections:vulvovaginalcandidiasis(VVC),bacterialvaginosis (BV)
• three most common infections associated with vaginal discharge in adult women are BV, VVC, and trichomoniasis
History
• sexualhistory
■ age of first intercourse, sexual orientation, sexual activity (oral, anal, and/or vaginal intercourse),
sexual activity during travel
■ total number of partners in the past year/month/week and duration of involvement with each
• STIhistory
■ STI awareness, contraception, previous STIs and testing (including Pap tests), partner
communication regarding STIs
■ local symptoms such as burning, itching, discharge, sores, vesicles, testicular pain, dysuria,
abdominal pain
■ systemic symptoms such as fever, lymphadenopathy, arthralgia
Investigations/Screening
• individualsatincreasedriskshouldbescreenedforchlamydia,gonorrhea,hepatitisB,HIV,andsyphilis • Paptestifnoneperformedinthepreceding12mo
Management
• primarypreventionisvastlymoreeffectivethantreatingSTIsandtheirsequelae
• offer hepatitis B vaccine if not immune
• offer Gardasil® to women over 9 years of age (can be offered to men as well but not covered by OHIP) • discussSTIriskfactors(e.g.decreasingthenumberofsexualpartners)
• directadvicetoALWAYSusecondomsortoabstainfromintercourse
• condomsarenot100%effectiveagainstHPVorHSV
• an STI patient is not considered treated until the management of his/her partner(s) is ensured (contact
tracing by Public Health)
• patientsdiagnosedwithbacterialSTIortrichomonalinfectionshouldabstainfromsexualactivityuntil
treatment completion and for 7 d after treatment for both partners, or until test of cure completed • mandatoryreporting:chlamydia,gonorrhea,hepatitisB,HIV,syphilis
Investigations
When an STI is detected in a child, evaluation for sexual abuse is mandatory
STI Risk Factors
• Sexually active males and females <25 yr old
• Unprotected sex, sexual contact with a known case of STI, previous STI
• New sexual partner or >2 sexual partners in the past 12 mo
• Street involved, homeless, and/or substance abuse
Sexual History
5 P’s
Partners (numbers, gender)
Practices (vaginal, oral, anal insertive/ receptive)
Protection
Past history of STIs
Pregnancy prevention
Efficacy of Human Papillomavirus Vaccines – A Systematic Quantitative Review
Int J Gynecol Cancer 2009;19:1166-1176
Purpose: To evaluate two vaccines for human papillomavirus (HPV) in terms of efficacy, safety and immunogenicity.
Methods: Systematic review of RCTs involving women between the ages of 9 and 26 years, randomly assigned to receive vaccination with HPV L1 virus-like particle in either quadrivalent (HPV 6,
11, 16, 18), bivalent (HPV 16, 18), or univalent (HPV 16) form or placebo. Main outcomes were prevention of cytologically and/or histologically proven lesions (including LSIL, HSIL, VIN, VAIN, AIN, adenocarcinoma in situ of the cervix, or cancer of the cervix associated with HPV infection).
Results: Six studies involving 47,236 women were included. Bivalent and quadrivalent vaccines reduced the rate of lesions in the cervix, vulva, vagina, and anogenital region with efficacy of 93% (95% CI 87-96%) and 62% (95% CI 27-70), respectively. More symptoms were found in the bivalent vaccine group (35%, 5-73%) compared to control groups.
Conclusion: Prophylactic vaccination can prevent HPV infection in women aged 9 to 26 years not previously infected with HPV subtypes covered by the vaccines.