1. 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

2. 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.

3. 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?

4. 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.

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

6. 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.

7. 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

8. Identifying T. pallidum by DF
Morphology
Rigid, uniform, tightly-coiled spirals
Length: 6-20 micrometers
Width: VERY thin
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.

9. 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

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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?