Molecular methods for the diagnosis of genital ulcer disease in a sexually transmitted disease clinic population in northern Thailand: predominance of herpes simplex virus infection

A multiplex polymerase chain reaction (M-PCR) assay that simultaneously detects the three major causes of genital ulcer disease (GUD), Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus, was used to evaluate swab specimens for 38 sequential patients with GUD at a Thai sexually transmitted disease clinic. Subjects received clinical diagnoses and syndromic treatment. Swab specimens for H. ducreyi cultures and M-PCR were obtained. No H. ducreyi cultures were positive. Of 38 M-PCR specimens, 31 (81.6%) were positive for HSV, 1 (2.3%) for both HSV and T. pallidum, and none for H. ducreyi or T. pallidum alone; 6 (15.8%) were negative for all 3 pathogens. Clinical diagnoses corresponded poorly to M-PCR findings; none of 5 suspected cases of chancroid were positive by M-PCR and none of 1 for syphilis, but 21 of 24 suspected herpes lesions were confirmed by M-PCR. Human immunodeficiency virus infection status was known for 24 of 38 subjects; 11 (45.8%) were seropositive, and all 11 had HSV by M-PCR. HSV appeared to be the most common pathogen overall.     

Comparison of clinical diagnosis and standard laboratory and molecular methods for the diagnosis of genital ulcer disease in Lesotho: association with human immunodeficiency virus infection

A multiplex polymerase chain reaction (M-PCR) assay for Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV) was compared with clinical and standard laboratory methods for the diagnosis of genital ulcer disease (GUD) in 105 patients; 36% were human immunodeficiency virus (HIV)-seropositive. Chancroid (80%), syphilis (8%), and genital herpes (8%) were the most frequent diagnoses. H. ducreyi and HSV were isolated from ulcers of 43% and 18% of patients, respectively; in 35%, all cultures were negative and the laboratory diagnosis indeterminate. M-PCR detected H. ducreyi, T. pallidum, and HSV in 56%, 23%, and 26% of patients, respectively; (no definitive diagnosis, 6%). The proportion of patients with more than one agent was 4% by culture and 17% by M-PCR (P = .002). Resolved sensitivities of M-PCR for H. ducreyi and HSV cultures were 95% and 93%, respectively. The sensitivities of H. ducreyi and HSV cultures were 75% and 60%, respectively. HSV, detected in 47% of specimens from HIV-infected versus 16% from HIV-uninfected patients (P < .001), may be emerging as a more frequent cause of GUD.     

Comparison of enzyme immunoassays for antibodies to Haemophilus ducreyi in a community outbreak of chancroid in the United States

The performance of two EIAs (adsorption EIA and lipooligosaccharide [LOS] EIA) that detect antibodies to Haemophilus ducreyi was evaluated with serum specimens obtained from 163 patients (96 with genital ulcer disease [GUD]). Paired serum specimens (initial and follow-up) were obtained from 52 of the GUD patients. By use of initial serum specimens from 82 GUD patients whose etiologic agents for their ulcers had been identified, the adsorption EIA had a sensitivity and specificity for chancroid of 53% and 71%, while the LOS EIA had a sensitivity and specificity of 48% and 89%, respectively. Sensitivity and specificity of the adsorption EIA increased to 78% and 84%, respectively, when the results of follow-up serum specimens were used to calculate optimal performance. The proportion of patients testing positive for H. ducreyi who had anti-H. ducreyi IgG antibodies, as determined by adsorption EIA, increased with the duration of infection, thus limiting the role of EIAs in the diagnosis of chancroid.     

Chlamydial genital infections and laparoscopic findings in infertile women

Several studies have shown that previous chlamydial genital infection, reflected by serological markers, is strongly associated with tubal damage leading to tubal infertility. In 105 women undergoing laparoscopy, multiple samples were collected from the lower (urethra and cervix) and upper (endometrium, peritoneal fluid, tubal lumen) genital tract, in order to isolate Chlamydia trachomatis in cell culture. Chlamydia trachomatis was isolated from at least one site in 13 (30.9%) of 42 infertile women with tubal infertility, in 5 (12.1%) of 41 women with unexplained infertility, in 1 of 4 women affected by acute salpingitis and in 1 (5.5%) of 18 women with endometriosis or uterine malformations. The latter group was the control group. Thirteen (65%) of the 20 positive women harboured Chlamydia trachomatis in their upper genital tract alone and 16 women were positive in one or both tubes. Only one of the positive women showed laparoscopic signs of acute pelvic infection. Four of the 5 positive women with unexplained infertility harboured Chlamydia trachomatis in the tubal lumen. This study confirms that chlamydial infection is strongly associated with tubal damage. It suggests that cervical cultures are inadequate for excluding a tubal infection and that chlamydial colonization of the tubal mucosa is possible in the absence of symptoms and laparoscopic signs of active infection.     

Comparison of performances of two commercially available tests, a PCR assay and a ligase chain reaction test, in detection of urogenital Chlamydia trachomatis infection

The diagnostic performance of a PCR test (Roche Cobas Amplicor CT/NG Test) and that of a ligase chain reaction (LCR) test (Abbott LCx Chlamydia trachomatis assay) were compared by using endocervical and urethral swab specimen culture as a reference test. First-void urine (FVU) and endocervical and urethral swab specimens were collected from 1,015 unselected patients attending a sexually transmitted disease clinic and a clinic for adolescents in Helsinki, Finland. Chlamydia trachomatis was cultured from samples from the endocervix or urethra. PCR was performed with fresh and frozen urine and the culture transport medium. LCR was performed with fresh and frozen urine and LCx swab transport medium. Diagnostic consistency and diagnostic accuracy were statistically tested. The test results were identical for 984 patients (97%). Discrepant results were observed for 31 patients. Overall, LCR and PCR showed excellent kappa coefficients of consistency for both swab and FVU specimens (0.93 and 0.95, respectively). Sixty-one patients (6%) were culture positive. Testing of FVU by LCR or PCR increased the overall positivity rates to 7.0 and 7.7%, respectively. While PCR of FVU detected the greatest number of C. trachomatis infections (sensitivity, 96.1%), for some PCR-positive FVU specimens the results could not be confirmed (specificity, 99.6%). PCR and LCR were more sensitive than culture (sensitivities, 92 and 93% versus 79% for culture) in the diagnosis of genital C. trachomatis infection. In conclusion, both tests can be recommended for use in the clinical laboratory and for the screening of asymptomatic C. trachomatis infections.     

Retrospective comparison of photorefractive keratectomy and radial keratotomy

BACKGROUND: The efficacy and predictability of photorefractive keratectomy and radial keratotomy become increasingly relevant. This retrospective study compares one surgeon's experience with photorefractive keratectomy and radial keratotomy over a 3-year period from 1990 to 1993. METHODS: Photorefractive keratectomy was performed on 103 eyes of 76 patients that met the inclusion criteria for the phase IIb, phase III, and phototherapeutic keratectomy studies as delineated by the United States Food and Drug Administration. Radial keratotomy was performed on 117 eyes of 81 patients with up to 9.00 diopters (D) of myopia. RESULTS: In the photorefractive keratectomy group, 83% of the eyes achieved uncorrected visual acuity of at least 20/40; 37% saw 20/20; 88% had a refraction within 1.00 D of emmetropia, and 63% within 0.50 D of emmetropia. For the radial keratotomy group, 85% of the eyes achieved an uncorrected visual acuity of 20/40 or better; 27% saw 20/20; 88% had a refraction within 1.00 D of emmetropia; and 55% within 0.50 D of emmetropia. There were no serious complications, and only one single eye in each of the photorefractive keratectomy and radial keratotomy groups lost two lines or more of spectacle-corrected visual acuity. CONCLUSION: Photorefractive keratectomy and radial keratotomy are both effective procedures, and result in similar refractive outcomes for myopia of -1.00 to -9.00 D.     

Etiology, diagnosis, and prognosis of positive blood cultures

The case records of 516 patients with 613 organisms from positive blood cultures at Detroit General Hospital (1975) and Harper-Grace Hospitals (first half of 1979) were analyzed. Gram-negative bacilli predominated by 46 per cent at Detroit General Hospital and 39 per cent at Harper-Grace Hospital. The gram-negative bacteremias also had higher mortality rates (47 per cent at Detroit General Hospital and 39 per cent at Harper-Grace Hospital) than the other organisms (27 per cent at Detroit Hospital and 25 per cent at Harper-Grace Hospital). The lung was the most frequent source for positive blood cultures at Detroit General Hospital (42%), whereas the urinary tract was the major primary site at Harper-Grace Hospital (30%). If sepsis was not diagnosed and operated upon aggressively prior to the development of shock or organ failure, the mortality rate rose from 12 per cent to 64-88 per cent. Increased efforts must be made to diagnose sepsis early and drain any collections of pus, particularly in anergic patients who may show little or no evidence of sepsis even after the development of multiple organ failure or shock.     

Detection of Chlamydia trachomatis in urine samples by nucleic acid tests: comparison with culture and enzyme immunoassay of genital swab specimens

Two commercially available nucleic acid-based tests, ligase chain reaction (LCR; Abbott Laboratories) and PCR (Roche Diagnostics), for the detection of Chlamydia trachomatis in male and female urine samples were compared with culture and enzyme immunoassay (EIA) (Microtrak; Syva) for C. trachomatis detection in genital samples. The samples were collected from 1,005 patients who attended a sexually transmitted disease clinic. In this study population, the prevalence of the infection was 4%. Specimens which were reactive in any of the tests were retested with a different PCR test using primers directed against the major outer membrane protein gene. With a "gold standard" of a positive culture, or any other positive test result if it was confirmed by an independent test, the Roche PCR (95% sensitive, 99.9% specific) was more sensitive than the LCR (75% sensitive, 100% specific) (chi2, P < 0.0001) while both tests were more sensitive than culture (58% sensitive, 100% specific) or EIA (45% sensitive, 100% specific) (chi2, P < 0.001). The Roche PCR and Abbott LCR tests of urine identified 65% and 30% more positive patients, respectively, than did testing by culture of urethral or cervical specimens. Nucleic acid testing of urine specimens for C. trachomatis is a more sensitive and convenient method for the detection of genital infection.     

Keratitis as a complication of bilateral, simultaneous radial keratotomy

During a one-month period, we examined four patients referred for evaluation of probable microbial keratitis after bilateral, simultaneous radial keratotomy. Each patient had midstromal infiltrates compatible with microbial keratitis that involved one or more of the radial incisions. In two patients the keratitis was bilateral. All patients had been treated empirically with antibiotic agents; superficial cultures with cotton-tipped applicators and corneal scraping by inserting a platinum spatula into the radial incisions were negative. Corneal biopsy of one patient disclosed gram-positive rods and culture of the biopsy specimen grew diphtheroids. The infiltrates gradually resolved over a period of several months with intensive antibiotic therapy. Sight-threatening infectious keratitis can occur after radial keratotomy, and we believe that simultaneous bilateral ocular surgery of any kind should be discouraged.     

Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in the emergency department

OBJECTIVES: 1) To quantify the frequency of underrecognized Neisseria gonorrhoeae and Chlamydia trachomatis cervical infections in women tested in the ED, 2) to describe and compare the characteristics of those treated and not treated during the initial visit, and 3) to quantify the delay interval until treatment was provided. METHODS: A 2-year, retrospective consecutive case series was performed from June 1, 1992, to May 31, 1994. There were 148 women with > or = 1 discrete occurrence of culture-proven cervical N. gonorrhoeae or C. trachomatis infection studied. All the patients were evaluated in a university-affiliated, tertiary care hospital-based ED with a large rural referral area. The main outcome measures were the proportions of patients with positive cultures both treated and not treated in the ED, the clinical characteristics of each group, and the proportion remaining untreated or experiencing treatment delays of > 2 weeks after attempted phone, mail, and public health follow-up. RESULTS: Of 157 occurrences of positive cultures for N. gonorrhoeae or C. trachomatis, 86 (53%) were treated with a regimen suggested by the CDC prior to ED release. The proportion of women with isolated C. trachomatis infections that were underrecognized and untreated initially was larger than the proportions with isolated N. gonorrhoeae or combined infections (79% vs 27% and 53%, respectively, p < 0.0001). Women with findings suggestive of advanced disease (history of fever or chills, or examination evidence of temperature > 38 degrees C, purulent vaginal discharge, or any uterine/salpinx/ovarian tenderness) were more often recognized and treated with appropriate antibiotics initially (p = 0.02 to < 0.00001 for all). After phone, mail, and public health follow-up, treatment could not be documented for 25% of the occurrences, in all cases due to an inability to locate the patient. An additional 20% of the women did not receive treatment for 14-60 days. CONCLUSIONS: In this population, both N. gonorrhoeae and C. trachomatis cervical infections are frequently underrecognized in the ED, with isolated C. trachomatis infections associated with significantly higher proportions of underrecognition. Many affected women remain untreated for extended intervals, creating public and individual health risks. Improved point of contact detection, follow-up, and treatment policies are needed to limit these risks.     

Reactive arthritis in patients attending an urban sexually transmitted diseases clinic

OBJECTIVE: To assess the prevalence, clinical manifestations, associated genital infections, and HLA associations of reactive arthritis (ReA) among patients attending an urban sexually transmitted diseases (STD) clinic. METHODS: Using a standardized questionnaire, 271 consecutive adults, primarily black, with possible or proven Chlamydia trachomatis genital infection were screened for symptoms of ReA. A followup questionnaire was administered 6 weeks later by mail. Patients who reported at least 1 symptom were evaluated by a rheumatologist. HLA-B typing was performed on patients with objective ReA features. RESULTS: Nine of 217 patients (4.1%) with genital infection/inflammation had objective ReA features. Chlamydial or nongonococcal STD syndromes were diagnosed in 8 of these 9 patients (88%). Genital infection/inflammation was asymptomatic in 78% of patients with ReA features. HLA-B27 or other B7-cross-reactive group antigens were not associated with the occurrence of ReA. CONCLUSION: Nongonococcal genital infections, often asymptomatic, can trigger a relatively mild ReA in a larger number of exposed patients than previously thought, irrespective of the individual's HLA status.     

Etiology of genital ulcers and prevalence of human immunodeficiency virus coinfection in 10 US cities. The Genital Ulcer Disease Surveillance Group

To determine the etiology of genital ulcers and to assess the prevalence of human immunodeficiency virus (HIV) infection in ulcer patients in 10 US cities, ulcer and serum specimens were collected from approximately 50 ulcer patients at a sexually transmitted disease clinic in each city. Ulcer specimens were tested using a multiplex polymerase chain reaction assay to detect Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV); sera were tested for antibody to HIV. H. ducreyi was detected in ulcer specimens from patients in Memphis (20% of specimens) and Chicago (12%). T. pallidum was detected in ulcer specimens from every city except Los Angeles (median, 9% of specimens; range, 0%-46%). HSV was detected in >/=50% of specimens from all cities except Memphis (42%). HIV seroprevalence in ulcer patients was 6% (range by city, 0%-18%). These data suggest that chancroid is prevalent in some US cities and that persons with genital ulcers should be a focus of HIV prevention activities.     

Circulating antibodies to Chlamydia trachomatis in women: relationship to antisperm and antichlamydial antibodies in semen of male partners

The relation between antibodies to Chlamydia trachomatis and spermatozoa in sera of 112 asymptomatic female partners of infertile couples with no history of C.trachomatis infections and antichlamydial antibodies in semen or antisperm antibodies on ejaculated spermatozoa of their male partners was examined. Samples were tested for immunoglobulin (Ig)A and IgG antibodies to C.trachomatis by enzyme-linked immunosorbent assay; antisperm antibodies in sera and on motile spermatozoa were assayed by immunobead binding. IgG antibodies to C.trachomatis were detected in 24 (21.4%) of the women; only five (4.5%) women were positive for antichlamydial IgA. Antichlamydial IgG was detected in sera from 10 (40.0%) of 25 women whose partners had antichlamydial IgA in semen as opposed to 14 (16.1%) of 87 women whose partners' semen were negative for this antibody (P = 0.02). Similarly, antichlamydial IgG was detected in sera from five (50%) of 10 women whose partners had antichlamydial IgG in semen as opposed to 19 (18.6%) of 102 women whose partners' semen lacked this antibody (P = 0.03). There was no relation between antichlamydial antibodies in women and circulating antichlamydial antibodies in men. A strong correlation (P = 0.001) was observed between IgG antichlamydial antibodies in a woman's serum and antisperm antibodies on ejaculated spermatozoa of her partner [8 of 14 (57.1%) versus 16 of 98 (16.3%)]. Conversely, antichlamydial antibodies in a woman's serum was unrelated to the presence of antisperm antibodies in either her own serum or her partner's serum. The data demonstrate that chlamydial infections of the male genital tract, which are associated with antisperm antibody formation on ejaculated spermatozoa, are likely to be transmitted to the female partner. In contrast, the presence of antichlamydial antibodies in sera does not necessarily appear to indicate an infection of the genital tract and is not associated with the heterosexual transmission of C.trachomatis.     

Antibodies to chlamydia trachomatis in semen and relationship with parameters of male fertility

To screen for infection with Chlamydia trachomatis in semen samples from asymptomatic men in couples consulting for infertility and to determine the relationship of seminal chlamydial antibodies with clinically relevant parameters of male fertility, 197 randomly chosen patients were enrolled in a prospective study. The median duration of infertility was 4 years (range 1-18). Screening for C. trachomatis and chlamydial antibodies of the immunoglobulin (Ig) A and IgG classes were performed in ejaculates and, in parallel, endocervical material from the partners of the patients and serum samples from both partners were evaluated. A comprehensive examination of semen quality included sperm analyses, semen cultures, local antisperm antibody (ASA) testing, the determination of potential infection markers, and sperm-cervical mucus interaction testing in vitro (SCMPT) and in vivo (post-coital testing). Chlamydial IgA antibodies were found in the semen samples of 18.8% (37/197) of the patients, while chlamydial IgG antibodies were found in 8.1% (16/197) of the patients. Screening for C. trachomatis was negative in all semen and cervical specimens. Only 5.5% of men remembered a past genital infection. Chlamydia antibodies (IgA/Ig/G) in semen were significantly correlated with chlamydia IgG antibodies in serum samples (P < 0.001). No marked relationship was found between the presence of seminal chlamydial antibodies and the major parameters of sperm analysis, semen cultures, local ASA and sperm penetration testing as an indicator of functional capacity. Seminal chlamydial antibodies were not significantly associated with potential infection or inflammation markers in aliquots of the same ejaculates. However, a significant relationship of chlamydial antibodies in patients' semen with past genital infections of their female partners was found with clinical relevance for a tubal infertility factor. The results indicate that in asymptomatic patients the presence of chlamydial antibody IgA or IgG in semen is not associated with reduced semen quality, potential seminal infection markers or impaired functional capacity as important determinants of male fertility; however, seminal chlamydial antibodies suggesting a previous sexually transmitted disease are significantly related to a tubal infertility factor of female partners.     

Survival, fecundity, and development of Dermatophagoides farinae (Acari: Pyroglyphidae) at fluctuating relative humidity

OBJECTIVE: To determine the impact of margin status on disease recurrence and the incidence of occult cancer in women diagnosed with vulvar intraepithelial neoplasia (VIN) III and treated with surgical excision. METHODS: Between 1989 and 1995, 73 women were diagnosed preoperatively with VIN III by vulvar biopsy and were treated with surgical resection. Patients were examined postoperatively, and recurrence was diagnosed when a biopsy of suspicious lesions confirmed VIN III. RESULTS: The mean age was 45 years; 81% of the patients were white, and 18% were black. Eighty-two percent of the women had used tobacco, 56% had prior cervical dysplasia, and 37% had prior genital warts. An underlying squamous vulvar cancer was found in 22% of patients at initial treatment for VIN III. Fifty-nine women had follow-up of at least 7 months. Of these, 66% (39 of 59) had positive surgical margins, 31% (18 of 59) had negative margins and 3% had unknown margins (two of 59). With positive margins, 46% (18 of 39) suffered recurrent disease; with negative margins, only 17% (three of 18) had recurrent disease (P = .03). Multifocal disease and a history of genital warts also correlated with VIN III recurrence (P = .03 for both). CONCLUSION: A significant number of women diagnosed initially with VIN III on a vulvar biopsy harbored occult vulvar cancer. Recurrences were almost threefold higher when margins were positive for residual VIN III. We conclude that surgical resection is an appropriate method of treatment of VIN III for both diagnostic and therapeutic purposes.     

Family planning services in developing countries: an opportunity to treat asymptomatic and unrecognised genital tract infections?

OBJECTIVE: To determine the prevalence of asymptomatic and unrecognised genital tract infections among women attending a family planning clinic in rural South Africa. METHODS: 189 consecutive women had genital samples taken to diagnose infection with Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Candida albicans, Treponema pallidum, and HIV, and to diagnose bacterial vaginosis. RESULTS: Mean age was 25 years; 155 (82%) were unmarried, 156 (83%) were currently using contraception, and 41 (22%) reported having an STD treated in the preceding 12 months. Although none volunteered abnormal urogenital symptoms, 74 (39%) had at least one elicited by direct questioning. 119 women (63%) had at least one genital infection: N gonorrhoeae (eight; 4%), C trachomatis (14; 8%), T vaginalis (26; 14%), C albicans (56; 30%), active syphilis (15; 8%), HIV (44; 24%), and bacterial vaginosis (29; 15%). 49 women (26%) had multiple infections. Most infections (71; 60%) were asymptomatic. Symptomatic women failed to recognise and report their symptoms, and routine services failed to detect the infections. CONCLUSION: Prevalence of genital tract infection is high among these women, most infections are asymptomatic, and symptomatic infections are frequently not recognised. Women attending family planning clinics in such settings should be screened for syphilis and offered testing for HIV infection. Strategies to detect and treat other genital infections need to be developed.     

Podiatric medical resources on the Internet

PURPOSE: To determine utility of polymerase chain reaction (PCR)-based urine screening for Chlamydia trachomatis in the care of adolescent females in an urban clinic. METHODS: Females > or = 15 years of age attending an adolescent clinic were approached consecutively. Each enrollee was interviewed to determine the primary reason(s) for the clinic visit and was queried about genitourinary symptoms. Nonsterile voided urine specimens were tested for C. trachomatis using PCR-based analysis. Endocervical C. trachomatis cultures were obtained from the subjects who had a pelvic examination. Main outcome measures were chlamydia infection rates in clinic attendees whether a pelvic examination was performed or not. RESULTS: A total of 315 (99.4%) of 317 patients approached agreed to participate. Overall, 47 (14.9%) patients had positive urine PCR tests. The chlamydia infection rate detected by urine PCR was 22.1% (19 of 86) among those who had pelvic examinations performed and 12.2% (28 of 229) among those who did not (p = .03; odds ratio 2.04; 95% confidence interval 1.02, 4.06). Sixty percent (28 of 47) of chlamydia infections identified during the study period were identified by the urine screening test. CONCLUSION: Urine screening was accepted by vast majority of female adolescents attending the clinic irrespective of reason for the clinic visit, and was highly effective in identifying unsuspected C. trachomatis infections, particularly among girls attending the clinic for reasons unrelated to reproductive health care and as an interim screening tool for adolescent family-planning clients.     

Chlamydia trachomatis during genital tract infection and in imminent abortion

Chlamydia trachomatis (Ch.t.) is suspected to be a dominant factor in the etiology of genito-urinary tract infectious diseases. The aim of the authors work was the evaluation of the Ch. t. presence in the cervix of women with adnexitis or with the imminent abortion. 300 women were investigated for the Ch.t. detection. The smear taken from the cervical canal was evaluated with 3 methods: direct immunofluorescence assay. Chlamydiazine test and culture. Ch.t. infection was detected in 27% of examined patients. The positive results was observed the more frequently in the patients showing the clinical symptoms of infection (42%) and in the pregnant women with imminent abortion symptoms (26%). The obtained results seem to confirm the pathogenic role of Ch.t. in the genital tract infectious diseases. Authors are postulating them the necessity of the prophylactic Ch.t. detection in the pregnant women.     

An analysis of bacteremias during dental extractions. A double-blind, placebo-controlled study of chlorhexidine

BACKGROUND: The literature is unclear concerning the nature and incidence of bacteremias from oral surgical procedures, the relationship of these bacteremias to dental disease, and the preventive benefit of antibacterial mouth rinses. OBJECTIVE: To determine the incidence and nature of bacteremias during single-tooth extractions in adults. METHODS: A double-blind, randomized placebo-controlled study of 70 patients in which the status of dental disease was compared with the incidence and nature of aerobic and anaerobic bacteremias following a single-tooth extraction and the antibacterial effect of rinses with chlorhexidine hydrochloride. Multiple indicators of dental disease were evaluated and recorded before the surgical procedure. Timing of the mouth rinses, the steps in the surgical procedure, and the two blood drawings were controlled for. RESULTS: Thirty-one (94%) of 34 control patients and 62 (89%) of 70 patients overall had blood cultures positive for organisms at either the 1-minute and or 3-minute mark following the initiation of surgery. The majority of cultures yielded gram-positive cocci. Cultures yielded polymicrobial organisms in 17 patients (24%). Although there was a wide range of severity of odontogenic disease, this did not correlate with results of blood cultures. However, there was a statistically significant difference in the incidence of blood cultures positive for organisms at both shorter (<3 minutes, P=.04) and longer (>6 minutes, P=.04) surgery times. There was not statistically significant difference in either the incidence of blood cultures positive for organisms or in the nature of organisms identified between the chlorhexidine and placebo groups. CONCLUSIONS: Single-tooth extraction should be expected to cause a bacteremia regardless of the status of the dentition or periodontium. Mouth rinses with chlorhexidine not significantly alter the number of positive blood cultures or the nature of the organisms at either of the two blood drawings.     

Refractive outcome following radial keratotomy and combined radial and astigmatic keratotomy

PURPOSE: To determine whether the visual and refractive outcomes of combined astigmatic and radial keratotomy (AK/RK) procedures was different from that following RK for the correction of naturally occurring compound myopic astigmatism and spherical myopia. SETTING: Private professional practice, San Diego, California, USA. METHODS: The computer database of all incisional procedures performed by one surgeon over 10 years was reviewed to compare the visual acuity outcome of AK/RK and RK procedures. Enhancement procedures were excluded. Only data from the last office visits were analyzed to establish the relationship between visual acuity and type of keratotomy procedure performed. A multiple regression model was constructed, which included covariates of age, postoperative keratometric cylinder, and postoperative refraction. RESULTS: After controlling for covariates, the AK/RK population had significantly lower postoperative uncorrected visual acuity levels than the RK population (P < .03) after one operation (prior to enhancement surgery). CONCLUSIONS: Using the nomograms for myopia correction for unenhanced RK cases, combined AK and RK procedures appeared to reduce the expected visual results. Surgeons may consider modifying surgical nomograms to account for the expected spherical undercorrection that can occur when myopia and astigmatism are corrected simultaneously.