Beyond Didactic Presentations in Clinical Training: Thinking Outside the Powerpoint Box March 11, 2008 Presented by the National Network of Prevention Training Centers (NNPTC) Parts I (Clinical), II (Behavioral) and III (Partner Services) Featuring … Cornelis Rietmeijer, MD, PhD Laura Bachman, MD, MPH Linda Creegan, MS, FNP M. Terry Hogan, MPH Katherine Hsu, MD, MPH Patricia Jennings, DrPH, PA-C Patricia Coury-Doniger, NP, MSN Anne Rompalo, MD, ScM

Laboratory Procedure Courses National Network of Prevention Training Centers Linda Creegan, MS, FNP California STD/HIV Prevention Training Center Oakland, CA National STD Prevention Conference Chicago, March 2008 Good afternoon, everyone, I’m Linda Creegan with the California Prevention Training Center. Next we will be talking about Laboratory Procedure Courses that the clinical training centers offer. Lab procedure courses provide very practical skills that can be used everyday when caring for patients with STDs.

CLINICIANS….. Are you new to the STD clinic? Is your clinic starting to use a new test? Herpes? Trichomoniasis? Bacterial Vaginosis? Syphilis? How many of you consider yourselves fairly new to the field of STD? And how many of you have started using some new test in your setting within the past year or so? These are two perfect instances when a lab procedure course would be ideal for improving your diagnostic skills. Rapid HIV test? Darkfield microscopy?

NNPTC Laboratory Procedure Courses Participants learn to perform..... Tests for STD specialty clinics Syphilis tests Rapid RPR test Darkfield microscopy Gram stains Saline and KOH wet mounts Other Point-of-Care (POC) tests for STD and HIV When you enroll in a Lab Procedure Course offered by any of the 10 clinical training centers, you can learn to perform.. The core diagnostic tests used in STD specialty clinics, like tests for syphilis, and the techniques for Gram stains and vaginal wet mounts, As well as other rapid point of-care tests for STDs and HIV.

Tests for STD Specialty Clinics Let’s look first at courses about tests for STD Specialty Clinics

Serologic Tests for Syphilis Utility of rapid RPR test Evaluate patients with symptoms of primary or secondary syphilis Assess contacts to syphilis infection Facilitate immediate diagnosis, treatment, and initiation of partner management activities Learn to perform and interpret qualitative and quantitated RPR tests The rapid RPR test gives results in about 20 minutes that can help as you evaluate patients with symptoms of primary or secondary syphilis, or patients who are contacts to syphilis infection. This can allow for immediate diagnosis and treatment, and the initiation of partner management efforts to prevent further spread of the infection. The course teaches participants to perform and interpret qualitative or quantitated RPR tests. In one of the breakout sessions this afternoon, Dr. Pat Jennings will teach the use of RPR in the context of a syphilis case discussion.

Darkfield Microscopy Evaluate patients with ulcers typical of primary syphilis Learn to Obtain the specimen Use the darkfield microscope Identify T. pallidum by morphology and motility An important test for the diagnosis of primary syphilis uses the darkfield microscope. With a darkfield microscope, clinicians can examine material from an ulcer, and visualize Treponema pallidum, the causative organism of syphilis. With syphilis outbreaks in many areas of the country, timely and accurate diagnosis of primary syphilis is very important. These courses prepare participants to obtain an adequate specimen, to use the darkfield microscope properly, and to identify T. pallidum. Photo credit: Dr. Joseph Engelman, San Francisco City Clinic

Identifying T. pallidum by DF Morphology Rigid, uniform, tightly-coiled spirals Length: 6-20 micrometers Width: VERY thin 0.10-0.18 micrometers, below the resolution of the light microscope Motility Exhibits three types of movement Translation: slow, forward or backwards movement Rotation: turning around the longitudinal axis Flexion: stiff bending, usually in the middle, and returning to original position Training and experience really are necessary to recognize T. pallidum organisms, which are too thin to be seen using a conventional light microscope. Using a darkfield microscope, spirochetes which maintain a tight, uniform coil, and which exhibit 3 characteristic movements: slow forward or backwards motion, rotation around the long axis, and flexion at the midpoint can be identified as T. pallidum.

Gram Stains Evaluate male urethral specimens Learn to Obtain the specimen Identify polymorphonuclear leukocytes (PMNs) and Gram-negative intracellular diplococci (GNID) Diagnose gonococcal vs non-gonococcal urethritis The Gram stain technique allows for rapid evaluation of urethral samples from men with symptoms of urethritis. Identification of inflammatory cells, or PMNs, and gonococcal bacteria, the Gram negative diplococci you see here, differentiates cases of gonococcal from non-gonococcal urethritis. STD Atlas, 1997

Saline and KOH Wet Mounts Vaginal Specimens Differentiate the causes of vaginal discharge Learn to Obtain the specimen Use the light microscope Identify findings (clue cells, yeast forms, trichomonads) Diagnose bacterial vaginosis, yeast, trichomoniasis For your females patients, microscopic evaluation of vaginal specimens using Saline and Potassium Hydroxyde aids in reaching a correct diagnosis of vaginitis. In these courses, you’ll work with vaginal specimens to recognize diagnostic features including clue cells, yeast buds or hyphae, and motile trichomonads. The weblink at the bottom of the slide links to an online video about interpreting wet mount specimens. Photo credit: Seattle STD/HIV Prevention Training Center http://depts.washington.edu/nnptc/online_training/wet_preps_video.html

Other Rapid Point-of-Care Tests for STD In addition to these STD tests, newer rapid diagnostics, called point-of-care tests, are commercially available for many STDs.

What are Point-of-Care tests? Run in clinic or field setting Provide results at same clinic visit Very easy to perform Usually require only microscope or simple lab equipment Often CLIA waived What are point-of-care tests? Probably most of the tests we order are sent to a lab, and the results come back to us on a delayed basis. In contrast, point-of-care tests are run on-site by the clinician or other staff, and provide results very quickly. They are designed to be almost foolproof to perform, and are often CLIA waived. These tests can be performed even when an on-site lab is not available.

Point-of-Care STD Tests: A Paradox Generally not as sensitive/specific as delayed lab tests Not intended to replace traditional STD tests, where these are available HOWEVER… In populations of patients less likely to return for results or when F/U is difficult, higher treatment levels can be achieved with POC than with delayed tests Homeless clinics Emergency rooms Correctional facilities However, these point-of care tests are generally less sensitive and/or specific than are the lab-based tests. So why would any clinician want to use a less sensitive test? Well, if your patients are not likely to return in a week for results, or if follow-up on the clinic’s end is going to be time-intensive and difficult, higher levels of treatment can actually be achieved using POCs, and getting the result while the patient is there with you, rather than risking the loss to follow-up. So these tests could be especially useful with homeless patients, in ERs, or in jails, where patients are often released before a test result comes back from the lab.

Point-of-Care STD Tests Learn about Lab regulatory issues (CLIA) Obtaining specimens Using test kits Interpreting results Maintaining quality assurance POC tests for common STD HSV 2 Bacterial vaginosis Trichomoniasis Chlamydia Gonorrhea In these courses, participants learn to use point-of-care test kits for diagnosis of genital herpes, bacterial vaginosis, trhichomoniasis, chlamydia and gonorrhea. Important issues regarding laboratory regulations and quality assurance reguirements are also covered.

Rapid HIV Tests Learn about….. Performing oral fluid and fingerstick tests Giving positive and negative test results Finally, rapid HIV tests are becoming widely used, and are wee-accepted by both patients and clinicians. Courses about rapid HIV tests teach not only how to perform the actual tests, but also how to talk with your patient about the result, whether negative or positive.

Enroll in a Lab Procedure Course offered by your regional Prevention Training Center! So there’s a quick look at the lab procedure courses offered by the Regional PTCs. Next we’ll hear about interactive approaches in clinical training. Terry?