Medically sound, cost-effective treatment for pelvic inflammatory disease and tuboovarian abscess

OBJECTIVE: Our purpose was to determine the clinical effectiveness and cost-effectiveness of three antibiotic regimens for the treatment of pelvic inflammatory disease and tuboovarian abscess. STUDY DESIGN: A review of all patients' hospitalized at Hutzel Hospital, Detroit, Michigan, for treatment of pelvic inflammatory disease and tuboovarian abscess between Jan. 1, 1993, and April 30, 1997, was performed. Demographic data, antibiotic choices, changes in therapy, operative interventions, and cost of therapy were assessed. RESULTS: Two hundred three patients were admitted for treatment of pelvic inflammatory disease during the study period. We were able to evaluate the clinical efficacy of antibiotic treatment in 179 patients, including 105 patients with pelvic inflammatory disease alone (uncomplicated pelvic inflammatory disease) and 74 women whose infection was complicated by tuboovarian abscess. The three antibiotic regimens evaluated were cefotetan plus doxycycline, clindamycin plus gentamicin, and ampicillin plus clindamycin plus gentamicin. All regimens demonstrated comparable efficacy in treating uncomplicated genital tract infections. Ampicillin plus clindamycin plus gentamicin was significantly better than clindamycin plus gentamicin and cefotetan plus doxycycline in treatment of tuboovarian abscess (p = 0.001). Fifteen women with tuboovarian abscess responded to a change to ampicillin plus gentamicin plus clindamycin antibiotic therapy alone. The hospital stay was prolonged by approximately 3 days in women failing to respond to initial antibiotic therapy, and operative interventions were common in this group of patients. CONCLUSIONS: Cefotetan plus oral doxycycline is the most cost-effective regimen for treating uncomplicated pelvic inflammatory disease, whereas triple-antibiotic therapy is the treatment of choice in women with tuboovarian abscess.     

Treatment of rosacea: topical clindamycin versus oral tetracycline

BACKGROUND: A new topical antibiotic preparation, clindamycin in a lotion base, was compared with oral tetracycline in the treatment of rosacea. Forty-three patients clinically diagnosed as having rosacea were examined in an investigator-blinded study. METHODS: Patients used topical clindamycin lotion applied twice daily or the usual oral dose of tetracycline hydrochloride (250 mg four times a day for 3 weeks, then 250 mg twice a day for the remaining 9 weeks). Patients' lesions were examined clinically at 3-week intervals over a period of 12 weeks. RESULTS: Topical clindamycin treatment produced similar clinical results to oral tetracycline and was superior in the eradication of pustules. CONCLUSIONS: These results show topical clindamycin in a lotion base to be a safe and effective alternative to oral tetracycline therapy in the treatment of rosacea.     

Prevalence of hidradenitis suppurativa in Denmark

The morbidity of hidradenitis suppurativa can be considerable, but little is known about its epidemiology. Our purpose was to describe the one-year and point prevalences of hidradenitis suppurative and its potential precursor lesions. We obtained the histories and examined an unselected sample (599 persons) of the general population (one-year prevalence), and we performed physical examination for a consecutive sample of 507 persons undergoing screening for sexually transmitted diseases (point prevalence). The point prevalence was 4.1% (95% confidence interval [CI] = 3.0-6.0) on the basis of objective findings. The one-year prevalence of hidradenitis was 1.0% (CI = 0.4-2.2) on the basis of subject recollection only. The patients in the sample on which the point prevalence is based were younger than those in the unselected sample of the general population (p < 0.001). Hidradenitis was significantly more common in women (p = 0.037), which may result from a female preponderance of genitofemoral lesions (odds ratio [OR] = 5.4; CI = 1.5-19.3). No sex difference was found in the prevalence of axillary lesions. Hidradenitis suppurativa is significantly more common than hitherto estimated. A female preponderance of patients is confirmed, except for patients with axillary lesions. Additional longitudinal studies are necessary to assess the importance of potential precursor lesions such as non-inflamed nodules or comedones.     

Streptococcus group B and pregnancy: the therapeutic role of topical intravaginal clindamycin

OBJECTIVE: To evaluate the clinical and therapeutic efficacy of 2% clindamycin vaginal cream in pregnant women heavily colonized with group B streptococci (GBS). STUDY DESIGN: A prospective, clinical trial in which carriers of group B streptococci were randomized to receive topical intravaginal clindamycin or oral amoxicillin. PATIENTS: We randomized 105 pregnant women: 55 received 2% clindamycin vaginal cream (100 mg/day for 7 days) and 50 oral amoxicillin (2 g/day for 7 days). INTERVENTIONS: Patients were treated during pregnancy, none of them received intrapartum chemoprophylaxis. On the other hand, all the neonates, within 24 hours from delivery, were studied from the microbiological point of view, carrying out auricolar, nasal, oropharyngeal and umbilical cultures. RELIEFS: The eradication of the microorganism was evaluated by performing a vaginal culture after 6 weeks from the beginning of antibiotic therapy. RESULTS: The eradication rate of the microorganism was significantly higher in women treated with topical clindamycin compared with the group receiving oral amoxicillin (71% versus 36%; p < 0.05). The neonatal outcome was similar in the two groups in terms of gestational age at delivery and mean birthweight. None of the neonates was admitted to the neonatal intensive care unit and no cases of neonatal sepsis were recorded. CONCLUSIONS: From our experience we can conclude that, during pregnancy, a treatment with topical intravaginal clindamycin may be useful in the eradication of GBS.     

Suppurative hidradenitis

An obese woman aged 18 years had been suffering for several years from axillary hidradenitis suppurativa. Repeated incision and drainage never gave lasting results and the patient became socially isolated. Hidradenitis suppurativa is a chronic suppurative inflammation of skin areas containing apocrine glands: the skin of the axillae, of the breasts and of the anogenital region. Treatment in the first instance consists of general hygienic measures. Pharmaceuticals used include antibiotics, antiandrogens and oestrogens. Surgery is performed when the condition is at an advanced stage, with cellulitis and scarring; ample excision is necessary to reduce the risk of recurrence. CO2 laser therapy is a new method of treatment that shows good results in incipient and advanced lesions.     

An unusual presentation of hidradenitis suppurativa: case report and review of the literature

Hidradenitis suppurativa is a chronic suppurative and cicatricial process of apocrine gland-bearing skin. The clinical course can range from mild to severe. We present a case of a urethral fistula and phimosis occurring secondary to hidradenitis suppurativa, and review the literature.     

Combined therapy with 5-aminosalicylic acid tablets and enemas for maintaining remission in ulcerative colitis: a randomized double-blind study

OBJECTIVES: To assess the efficacy of a combination of oral and topical 5-aminosalicylic acid (5-ASA) for the maintenance treatment of ulcerative colitis, we undertook a double-blind randomized clinical trial. METHODS: Patients aged 18 to 65 yr (with disease extent greater than proctitis only) were eligible for inclusion in the study if they met the following criteria: (a) history of two or more relapses in the last year; (b) achievement of remission in the last 3 months (with maintenance of remission for at least 1 month). Patients enrolled in the study were randomly assigned to one of the two following 1-yr treatments: (1) combined therapy with 5-ASA tablets 1.6 g/day and 5-ASA enemas 4 g/100 ml twice weekly; (2) oral therapy with 5-ASA tablets 1.6 g/day and placebo enemas/twice weekly. The main end point of the study was the maintenance of remission at 12 months. RESULTS: Upon completion of the study, relapse occurred in 13 of 33 patients in the combined treatment group versus 23 of 36 patients in the oral treatment group (39 vs 69%; p = 0.036). No significant side effects related to treatment were observed in either group. A simplified pharmacoeconomic analysis shows that this form of combined treatment can have a favorable cost-effectiveness ratio. CONCLUSIONS: Our results indicate that 5-ASA given daily by oral route and intermittently by topical route can be more effective than oral therapy alone. This form of combination treatment can be appropriate for patients at high risk of relapse.     

Activation and detoxification of dinitropyrenes by cytosol and microsomes from Aroclor-pretreated rats in the Ames and umu assays

PURPOSE: To evaluate the efficacy of topical mitomycin C in treating conjunctival and corneal epithelial dysplasia and neoplasia. METHODS: Seven eyes of seven patients with conjunctival and corneal epithelial dysplasia and neoplasia were treated with one drop of topical mitomycin C 0.04% four times a day for 7 days in alternate weeks. The patients' charts were reviewed retrospectively. Patients with either multiple recurrences or extensive ocular surface involvement were treated. In all eyes, the diagnosis of epithelial dysplasia or neoplasia was confirmed by histopathology before the onset of therapy. Patients were examined at least every 14 days during treatment and examined at intervals after completion of treatment. RESULTS: With topical mitomycin C, six eyes of seven patients had complete clinical regression of their conjunctival and corneal epithelial dysplasia and neoplasia. One eye of one patient had partial clinical regression of conjunctival and corneal epithelial dysplasia. Follow-up after completion of topical mitomycin C therapy and excision of residual disease ranged from 2 to 16 months (mean, 9 months; SD, 4.3 months) and was without clinical sign of recurrence. Topical mitomycin C therapy was associated with transitory ocular discomfort, conjunctival injection, tearing, photophobia, and punctate epithelial keratopathy. CONCLUSION: In this small series of eyes, topical mitomycin C was effective as a treatment for conjunctival and corneal epithelial dysplasia and neoplasia.     

Hidradenitis suppurativa

BACKGROUND: Hidradenitis suppurativa (HS) is a recurrent, suppurative disease manifested by abscesses, fistulas, and scarring. METHODS: We reviewed the literature to identify reliable information regarding epidemiology, pathogenesis, clinical manifestations, evaluation and differential diagnosis, treatment, complications, and prognosis. RESULTS: Hidradenitis suppurativa usually affects young women, with a prevalence of 0.3% to 4% in industrialized countries. Once considered to be "apocrine acne," HS is actually a defect of terminal follicular epithelium. Obesity, chemical irritants, or hyperandrogenism are not consistently associated; bacterial involvement is secondary. Hidradenitis suppurativa should be suspected in young adults with recurrent, deep furuncular lesions in flexural sites, especially when such lesions respond poorly to antibiotic therapy. Clindamycin and isotretinoin may be useful, though wide excision with healing by granulation is considered most efficacious. Anemia, arthropathy, and squamous cell carcinoma are potential complications. CONCLUSIONS: Since spontaneous resolution is rare and progressive disability the rule, early definitive surgical treatment of HS is advisable.     

Cost-effectiveness of preference-based antithrombotic therapy for patients with nonvalvular atrial fibrillation

BACKGROUND AND PURPOSE: Recent atrial fibrillation guidelines recommend the incorporation of patient preferences into the selection of antithrombotic therapy. However, no trial has examined how incorporating such preferences would affect quality-adjusted survival or medical expenditure. We compared 10-year projections of quality-adjusted survival and medical expenditure associated with two atrial fibrillation treatment strategies: warfarin-for-all therapy versus preference-based therapy. The preference-based strategy prescribed whichever antithrombotic therapy, warfarin or aspirin, had the greater projected quality-adjusted survival. METHODS: We used decision analysis stratified by the number of stroke risk factors (history of stroke, transient ischemic attack, hypertension, diabetes, or heart disease). The base case focused on compliant 65-year-old patients who had nonvalvular atrial fibrillation and no contraindications to antithrombotic therapy. RESULTS: In patients whose only risk factor for stroke was atrial fibrillation, preference-based therapy improved projected quality-adjusted survival by 0.05 quality-adjusted life year (QALY) and saved $670. For patients who had atrial fibrillation and one additional risk factor for stroke, preference-based therapy improved quality-adjusted survival by 0.02 QALY and saved $90. In patients who had atrial fibrillation and multiple additional risk factors for stroke, preference-based therapy increased medical expenditures and did not improve quality-adjusted survival substantially. The benefits of preference-flexible therapy arose from the minority of patients who would have had a longer quality-adjusted survival if they had been prescribed aspirin rather than warfarin. CONCLUSIONS: As do risks of stroke and of hemorrhage, patients' preferences help to determine which antithrombotic therapy is optimal. Preference-based treatment should improve quality-adjusted survival and reduce medical expenditure in patients who have nonvalvular atrial fibrillation and not more than one additional risk factor for stroke.     

Treatment of acne with a combination clindamycin/benzoyl peroxide gel compared with clindamycin gel, benzoyl peroxide gel and vehicle gel: combined results of two double-blind investigations

BACKGROUND: It has previously been shown that a combination of erythromycin and benzoyl peroxide is superior to either ingredient when used alone in the treatment of acne. A clindamycin/benzoyl peroxide combination gel might have an advantage over erythromycin/benzoyl peroxide gel because the former does not require refrigeration after it is dispensed. OBJECTIVE: Our purpose was to determine the efficacy and safety of a combination clindamycin/benzoyl peroxide gel when compared with benzoyl peroxide, clindamycin, or vehicle gels. METHODS: In two double-blind, randomized, parallel, vehicle-controlled trials, patients were treated for 11 weeks with once-nightly application of one of the above preparations. Evaluations were performed at 2, 5, 8, and 11 weeks and included lesion counts and assessment of global responses and irritant effects. RESULTS: A total of 334 patients completed the study. All three active preparations were significantly superior to the vehicle in global improvement and in reducing inflammatory lesions and noninflammatory lesions. The combination gel was significantly superior to the two individual agents in global improvement and reduction of inflammatory lesions and also to the clindamycin gel in reducing noninflammatory lesions. There was no significant difference in tolerance to the active gels versus the vehicle gel. CONCLUSION: In the treatment of acne, topical clindamycin/benzoyl peroxide combination gel is well tolerated and superior to either individual ingredient.     

Response to prophylactic treatment of benign headache in children

INTRODUCTION: Common childhood headaches seldom require prophylactic treatment which, nevertheless, is quite often unsatisfactory. OBJECTIVE: To study drug and non-drug related factors that may influence the therapeutic response. MATERIAL AND METHODS: A four-month follow-up study of all patients attended during a year at the neuropediatric, outpatient hospital-based clinic, with > or = 2 monthly migraine without aura attacks, > or = 10 tension-type headaches, or both types of headaches. Patients were randomized to be treated on an open basis, placebo controlled, with flunarizine or piracetam. Headache frequency was evaluated according to treatment and patients' basal characteristics. RESULTS: 98 patients studied (56 migraine without aura, 24 tension-type headache, 18 mixed). 33% dropped out; they were school underachievers more frequently than those that completed the protocol. Of those completing the protocol and treated with placebo as the first choice of therapy, 27% reported total remission of symptomatology; those not remitting with placebo were high achievers at school significatively more frequently. At the end of the trial, 43% of the initially randomized patients still complained of headaches, regardless of treatment, showing a seasonal relationship. CONCLUSIONS: Prophylaxis of benign childhood headaches is needed in less than half of those reporting a high headache frequency; school achievement should be taken into consideration as another clue to compliance and headache persistence. On a short-term basis only the seasonal influence and the placebo effect can be held responsible for amelioration of symptomatology.     

Treatment of proctalgia fugax with topical nitroglycerin: report of a case

PURPOSE: We report a single case of proctalgia fugax that responded to 0.3 percent nitroglycerin ointment. METHODS: Case report. RESULTS: A single case of proctalgia fugax responded to topical application of 0.3 percent nitro glycerin ointment with no significant side effects. CONCLUSIONS: Nitroglycerin ointment is a newly described treatment for several painful anal conditions. We describe a single case of levator spasm or proctalgia fugax responding to topical application of nitroglycerin. This is only a single case report, and conclusive evidence awaits completion of a controlled clinical trial.     

Preliminary study of a new intraocular method in the diagnosis and treatment of Propionibacterium acnes endophthalmitis following cataract extraction

Late endophthalmitis, due to Propionibacterium acnes, developed in three patients following uncomplicated extracapsular cataract extraction and posterior chamber intraocular lens (PC-IOL) insertion. Cultures from the capsular bag yielded P. acnes in all three. With topical anesthesia and through an anterior chamber paracentesis, culture specimens were taken from and clindamycin irrigated into the capsular bag. Filtered 100% oxygen was introduced into the anterior chamber in two; the third also received an injection of gentamicin and dexamethasone into the capsular bag. After treatment, two patients received oral antibiotics; one received hyperbaric oxygen therapy. Visual acuity was improved and inflammation reduced in all three. However, after treatment, ocular toxic effects due to clindamycin were suspected in one. This approach offers several clear advantages, including topical anesthesia, outpatient management, elimination of the need for vitrectomy, and retention of the intraocular lens (IOL).     

Phenylephrine and the prevention of postoperative tympanostomy tube obstruction

OBJECTIVE: To determine the efficacy of phenylephrine hydrochloride, a topical vasoconstrictor, in preventing tympanostomy tube obstruction. DESIGN: Prospective, randomized, double-blind, controlled trial of patients undergoing myringotomy with tympanostomy tube insertion. SETTING: Academic, tertiary referral medical center. PATIENTS: Two hundred eight patients were enrolled in the study; 157 patients (310 ears) returned for postoperative evaluation. INTERVENTIONS: Myringotomy with tympanostomy tube insertion was performed in all ears: 139 control ears received ototopical antibiotics and 171 treatment ears received ototopical antibiotics plus topical phenylephrine. MAIN OUTCOME MEASURE: Postoperative tympanostomy tube obstruction. RESULTS: The overall incidence of tympanostomy tube obstruction was 5.2%: 8.6% in the control group and 2.3% in the treatment group. The treatment group demonstrated an odds ratio of 0.25 (95% confidence interval, 0.08-0.78; P= .02). CONCLUSION: The use of phenylephrine following tympanostomy tube insertion greatly reduces the incidence of tube obstruction.     

Pilot trial of ribavirin for the treatment of laryngeal papillomatosis

The antiviral drug ribavirin was used as an adjunct to laser surgery for the treatment of patients with laryngeal papillomatosis (LP). An uncontrolled clinical trial for four patients with ribavirin treatment at a daily dose of 23 mg/kg was performed. Three adults received drug prior to laser surgery and continuing orally for 6 months. One infant was treated for 3 months. Two adults achieved complete remissions for at least 2 consecutive months, and both patients developed only minimal recurrent disease in 4 months of follow-up. The other adult and the child sustained a partial response and an increased interval between the required surgeries. Ribavirin caused only a mild, reversible reduction in hemoglobin and reticulocytosis. This preliminary trial shows that ribavirin may be an effective therapy in combination with surgery for LP in a larger controlled clinical trial.     

Efficacy of estrogen therapy in urinary incontinence. A meta-analytic study

OBJECTIVE: To analyze by meta-analysis the results of randomized controlled clinical trials on the efficacy of estrogen treatment in menopausal patients with urinary incontinence. STUDY DESIGN: Meta-analysis. MATERIALS AND METHODS: Randomized controlled clinical trials, published from January 1965 to December 1996, on estrogen therapy in patients with urinary incontinence, were selected. They included: trials with placebo vs estrogen therapy, studies on menopausal patients with confirmed diagnosis of urinary incontinence based on clinical and/or urodynamic tests, studies with sufficient statistical informations on the results obtained and with information about subjective and objective outcome. RESULTS: Out of 72 articles reviewed, 7 were selected and only 4 were considered on the basis of the requested criteria. Subjective outcome was statistically different in patients treated with estrogen therapy compared with patients treated with placebo. Objective clinical and urodynamic outcome was not statistically different in the two types of treatment (estrogen vs placebo treatment). CONCLUSIONS: There were few published randomized controlled studies on estrogen therapy in patients with urinary incontinence in medical literature. Different results between subjective and objective outcome showed by meta-analysis, could be explained either by an estrogen induced unperceivable improvement not registered by clinical and instrumental parameters or by insufficient systems used to collect subjective data. Therefore, it is suggested that, for future research, randomized controlled clinical trials on topical or transcutaneous systemic estrogen treatment with a more than 6 months follow-up will be carry out.     

Intravenous basic fibroblast growth factor does not ameliorate brain injury resulting from transient focal ischemia in cats

BACKGROUND: Babesiosis, a zoonosis caused by the protozoan Babesia microti, is usually not treated when the symptoms are mild, because the parasitemia appears to be transient. However, the microscopical methods used to diagnose this infection are insensitive, and few infected people have been followed longitudinally. We compared the duration of parasitemia in people who had received specific antibabesial therapy with that in silently infected people who had not been treated. METHODS: Forty-six babesia-infected subjects were identified from 1991 through 1996 in a prospective, community-based study designed to detect episodes of illness and of seroconversion among the residents of southeastern Connecticut and Block Island, Rhode Island. Subjects with acute babesial illness were monitored every 3 months for up to 27 months by means of thin blood smears, Bab. microti polymerase-chain-reaction assays, serologic tests, and questionnaires. RESULTS: Babesial DNA persisted in the blood for a mean of 82 days in 24 infected subjects without specific symptoms who received no specific therapy. Babesial DNA persisted for 16 days in 22 acutely ill subjects who received clindamycin and quinine therapy (P=0.03), of whom 9 had side effects from the treatment. Among the subjects who did not receive specific therapy, symptoms of babesiosis persisted for a mean of 114 days in five subjects with babesial DNA present for 3 or more months and for only 15 days in seven others in whom the DNA was detectable for less than 3 months (P<0.05); one subject had recrudescent disease after two years. CONCLUSIONS: When left untreated, silent babesial infection may persist for months or even years. Although treatment with clindamycin and quinine reduces the duration of parasitemia, infection may still persist and recrudesce and side effects are common. Improved treatments are needed.     

Clindamycin and primaquine therapy for mild-to-moderate episodes of Pneumocystis carinii pneumonia in patients with AIDS: AIDS Clinical Trials Group 044

The objective of this prospective, noncomparative study was to assess the safety and efficacy of clindamycin and primaquine therapy for mild-to-moderate pneumocystis pneumonia (defined as a difference of < 40 mm Hg between the alveolar and the arterial oxygen determinations) in patients with AIDS. In the first part of the study, 22 patients were treated with iv clindamycin (900 mg every 8 hours) for the first 10 days, and then their therapy was switched to oral clindamycin (450 mg every 6 hours) for an additional 11 days. In the second part of the study, 38 patients were treated entirely with oral clindamycin (600 mg every 8 hours). All patients were treated with oral primaquine base (30 mg once daily). Fifty-five (92%) of 60 patients responded to the study treatment. Forty-six (77%) of 60 patients completed a full course of therapy. Of the nine patients with treatment-limiting toxic effects, four had only a mild rash. This study indicates that the combination of clindamycin and primaquine is an effective and well-tolerated therapy for mild-to-moderate pneumocystis pneumonia in patients with AIDS. Entirely oral therapy appears to be as effective as initial therapy with iv clindamycin.     

Radionuclide therapy of skin cancers and Bowen's disease using a specially designed skin patch

Skin cancer is the most common malignancy in humans. Therapeutic modalities for skin cancer are local destruction, radiotherapy and surgery. External radiation therapy leads to good results, however, generally 5-6 wk of treatment is needed to deliver optimal radiation dose to tumors. In this study, a beta-emitting radionuclide, 166Ho, impregnated in a specially designed patch, was used on superficial skin cancers and Bowen's disease for local irradiation. METHODS: Ten mice with chemically induced skin tumors were studied. Five-millimeter size patches containing 22.2-72.15 MBq (0.6-1.95 mCi) 166Ho were applied to the tumor surface for 1-2 hr. In a human trial, patients with squamous-cell carcinoma (n = 3), basal cell carcinoma (n = 1) and Bowen's disease (n = 1) were treated with patches containing 273.8-999 MBq (7.4-27 mCi) of 166Ho for 30 min to 1 hr. Pathologic examination was performed 4-7 wk after treatment in an animal model. Skin biopsy was performed 8 wk post-treatment in four patients. RESULTS: Tumor destruction was seen 1 wk post-treatment, however, radiation dermatitis or ulceration developed at the site of radionuclide application. Those reactions healed gradually with fibrosis or epithelialization, which was confirmed pathologically. No significant adverse reaction to radiation except subcutaneous fibrosis was found. CONCLUSION: Superficial skin tumors could be successfully treated by topical application of beta-emitting radionuclides.