The treatment of non-gonococcal urethritis with single dose oral azithromycin

In an uncontrolled study, the efficacy of azithromycin in the treatment of non-gonococcal urethritis was assessed in 41 male patients aged between 20 and 40 years with a mean age of 27 +/- 5 years. Clinical and microbiological diagnosis confirmed that 28 men were found positive for Chlamydia trachomatis, 10 for Ureaplasma urealyticum and three for both C. trachomatis and U. urealyticum. All patients received 1 g azithromycin orally (four 250 mg capsules). The length of time between the treatment and following visits were 7-10 days and 14-21 days for second and third visits, respectively. Complete eradication was achieved in 27 out of 41 patients. Of the remaining 14, six were found positive for C. trachomatis and were excluded as they did not return for the follow-up visit, one patient did not achieve complete eradication, one patient infected with both C. trachomatis and U. urealyticum failed to achieve complete eradication, and six patients infected with U. urealyticum failed to be completely cured. No adverse effects were reported in any patient. Single dose administration of 1 g azithromycin appears to be an effective and well-tolerated treatment for chlamydial urethritis and an advantage in terms of patient compliance.     

ECS-induced dopamine release: effects of electrode placement, anticonvulsant treatment, and stimulus intensity

BACKGROUND AND OBJECTIVES: The detection of asymptomatic urethritis using a leukocyte esterase (LE) strip may have a role in primary care screening to select men who need diagnostic testing for Chlamydia trachomatis and Neisseria gonorrhoeae. STUDY DESIGN: Eight-hundred and eighty-two men, 16 to 35 years of age were studied when they attended their family physician or university health clinic for nongenitourinary complaints. First void urine (FVU) was tested by an LE strip (Chemstrip 2 LN, Boehringer Mannheim Corp., Indianapolis, IN), Chlamydiazyme (Abbott Laboratories, N. Chicago, IL) enzyme immunoassay with confirmatory blocking and polymerase chain reaction (PCR) with chlamydial plasmid primers. RESULTS: Forty-five men (5.1%) were positive (> trace) by LE strip. Of the LE-positive urines, 9 (20.0%) were positive by EIA or PCR, and none of the LE-negatives were positive by EIA or PCR. Twenty-three LE positives (5 EIA/PCR-positive; 1 PCR-positive; 17 EIA/PCR-negative) were able to be followed with a second urine and 2 urethral swabs. All of the 6 chlamydia-positives who had follow-up tests were positive by both immunoassay and PCR on urine. Based on the FVU results, the prevalence of asymptomatic chlamydial infection was 1.0% (9/88) (95% CL, 0.5 to 1.9) for which the LE urine strip was 100% (9/9) sensitive and 95.9% (837/873) specific. Analyses based on screening 1,000 men, 16 to 25 years of age, showed that the cost per case detected was $192.00 using the LE strip (> 1+) to select urine specimens for EIA testing, compared to $1,326.00 using the EIA to test all urine specimens. CONCLUSION: In this low prevalence, primary care setting, the LE urine strip was an accurate screening test, which if used to preselect urine specimens for subsequent chlamydial testing, would be less costly per case detected than assaying each specimen for chlamydia.     

Paediatric HIV update

OBJECTIVES: The aetiology of non-gonococcal urethritis (NGU) in a considerable proportion of men remains unaccounted for. We wished to investigate the possible aetiological role of bacterial vaginosis (BV), the commonest cause of abnormal discharge in women, in this condition. METHODS: We carried out two studies. In the first, case-control, study, we recruited men with and without NGU and examined their female partners for evidence of BV. The second, cohort design, study which ran concurrently with the first study involved recruiting women with and without BV and examining their male partners for evidence of NGU. The diagnoses of both NGU and BV were made microscopically to include symptomatic and asymptomatic individuals in both disease categories. RESULTS: In the case-control study 51 couples were recruited. Of these 39 men had NGU and 12 (31%) of their female contacts had BV. In contrast, of 12 men without NGU, only one (8%) of the female partners had BV (odds ratio 4.89, 95% CI: 0.51-42.27). When only Chlamydia trachomatis negative patients were considered, the odds ratio for an association between BV and NGU was increased to 6.77, 95% CI: 0.73-62.68). Thirty eight couples were recruited to the cohort design study. Of 17 women with BV, 12 (71%) of their male partners had NGU. In contrast, of 21 women without BV, seven (33%) of their male partners had NGU (p = 0.049, odds ratio 4.8). When only C trachomatis negative patients were considered, the significance of the association was increased (p = 0.037; odds ratio 5.42). CONCLUSIONS: An association exists between NGU and BV, and vice versa. If BV arises de novo the findings could help to explain the development of urethritis in stable sexual relationships.     

Occult fever in surgical intensive care unit patients is seldom caused by sinusitis

Febrile intensive care unit (ICU) patients were evaluated prospectively for sinusitis. Of 598 admissions, 26 patients with transnasal cannulas, ICU stays over 48 hours, and occult fevers were identified. These 26 underwent physical examinations and sinus computed tomographic (CT) scans. Maxillary centeses and cultures were done in patients with CT abnormalities. Patients with positive scans had nasal tubes removed and received decongestants. Scans were abnormal in 19 (73%). All patients with major CT changes had positive maxillary taps. Most infections were polymicrobial; enteric bacilli were common. Fever resolved with nonoperative care in 18 (95%) patients; in only 1 patient was fever primarily from sinusitis. Sinus CT scans are often abnormal in ICU patients with occult fevers and transnasal cannulas. Pneumatic otoscopy can serve as a screening tool. Most patients respond to nonoperative management. Remote infections are often present. Although radiographic nosocomial ICU sinusitis is common, it is seldom the sole source of fever or the proximate cause of significant morbidity.     

Comparing the efficacy of pefloxacin and ciprofloxacin in the treatment of acute uncomplicated gonococcal urethritis in males

The aim of this study was to compare the efficacy of single-dose pefloxacin 400 mg and ciprofloxacin 250 mg in the treatment of acute uncomplicated gonococcal urethritis in males. One hundred and twenty male patients with uncomplicated gonococcal urethritis were assigned alternately to receive single oral doses of either pefloxacin 400 mg or ciprofloxacin 250 mg. Forty-one out of 43 patients (95.3%) of the pefloxacin group and 46 of 47 (97.9%) of the ciprofloxacin group were cured of gonorrhoeae. The rates of post-gonococcal urethritis were 57.7% and 53.3% in the pefloxacin and ciprofloxacin groups respectively. There was a high incidence of penicillinase-producing gonococci (34.2%). High level resistance to pefloxacin (minimum inhibitory concentration [MIC] >1.0 mg/l) resulting in clinical failure on 400 mg stat dose was noted in 1 isolate. It also showed decreased susceptibility to ciprofloxacin (MIC 0.25 mg/l). Another isolate showed high-level resistance (MIC 0.06 mg/l) to ciprofloxacin 250 mg stat dose with concomitant decreased susceptibility to pefloxacin (MIC >1.0 mg/l). Ciprofloxacin 250 mg stat dose is still useful for the treatment of uncomplicated gonococcal urethritis in males. The cure rate of 95.3% with pefloxacin at 400 mg stat dose is acceptable, but needs to be monitored with caution. The emergence of a more resistant strain of Neisseria gonorrhoeae to fluoroquinolones calls for vigilance in the monitoring of antimicrobial susceptibility.     

Technetium-99m-HMPAO brain SPECT in Beh?et's disease

Beh?et's disease (BD) is an idiopathic multisystem disorder. Involvement of the central nervous system (CNS) occurs in 4%-48% of cases. The aim of this study was to evaluate 99mTc-hexamethyl propyleneamine oxime (HMPAO) SPECT findings in BD patients and eventually to detect CNS involvement by depicting cerebral blood flow disturbances. METHODS: Technetium-99m-HMPAO brain SPECT was performed on 33 consecutive BD patients. Qualitative and quantitative evaluation of the cortical uptake was done using an automatic program that generated 32 regions of interest (ROIs). An uptake index for each ROI was obtained. Reference values were obtained from a healthy control group (n = 20). Twenty-five patients also had an MRI study. RESULTS: Twelve of 32 patients (36%) presented with a clinical neurological disorder. SPECT and visual evaluation revealed that 17 patients (51.5%) had abnormalities; 9 of 25 MRI studies (36%) were abnormal. Using the quantitative approach for SPECT, 23 patients (69.7%) had abnormally low values. Six of 12 patients with neurological symptoms had a visually abnormal SPECT scan, whereas quantitative analysis showed abnormalities in 11 patients. Of the 21 patients with no neurological findings, 9 had abnormal SPECT results, and 12 had low uptake indexes. CONCLUSION: HMPAO brain SPECT shows high rates of cerebral blood flow abnormalities in BD patients presenting with neuropsychiatric symptoms, and it also is frequently abnormal in asymptomatic BD patients who have no abnormalities on MR scans. Compared with visual analysis, quantitative analysis detects an even higher rate of SPECT changes in BD patients.     

High-resolution CT of the lung: determination of the usefulness of CT scans obtained with the patient prone based on plain radiographic findings

OBJECTIVE: We assessed the usefulness of chest radiographs for predicting whether high-resolution CT scans obtained with the patient prone would be valuable in assessing suspected diffuse lung disease. MATERIALS AND METHODS: In 100 consecutive patients undergoing high-resolution CT, findings on plain chest radiographs were classified as normal, possibly abnormal, or abnormal. CT scans obtained with the patient supine were assessed for the presence and distribution of lung abnormalities without knowledge of the plain radiographic classification. A second review of the CT scans was done with equal numbers of scans obtained with the patient prone and with the patient supine. The usefulness of the CT scans obtained with the patient prone for detecting lung disease was determined and related to the plain radiographic classifications. RESULTS: High-resolution CT scans obtained with patients prone were helpful in excluding or confirming posterior lung abnormalities in 10 (28%) of 36 patients who had normal findings on chest radiographs, five (28%) of 18 patients who had possibly abnormal findings on chest radiographs, and only two (4%) of 46 patients who had abnormal findings on chest radiographs. The proportion of patients who benefited from high-resolution CT scans obtained with the patient prone was significantly lower among the patients with abnormal findings on chest radiographs than among the patients with normal (p = .008) or possibly abnormal (p = .02) findings on chest radiographs. The two patients with abnormal findings on radiographs in whom CT scans obtained with the patient prone were helpful had minimal radiographic abnormalities. CONCLUSION: In patients with suspected diffuse lung disease, obtaining high-resolution CT scans with the patient prone may be useful when chest radiographs show normal findings, possibly abnormal findings, or minimal abnormalities indicative of diffuse lung disease. However, such scans are of little value in patients whose radiographs show abnormalities indicative of diffuse lung disease.     

Value of perfusion lung scan in the diagnosis of pulmonary embolism: results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED)

To assess the value of perfusion lung scan in the diagnosis of pulmonary embolism, we prospectively evaluated 890 consecutive patients with suspected pulmonary embolism. Prior to lung scanning, each patient was assigned a clinical probability of pulmonary embolism (very likely, possible, unlikely). Perfusion scans were independently classified as follows: (1) normal, (2) near-normal, (3) abnormal compatible with pulmonary embolism (PE+: single or multiple wedge-shaped perfusion defects), or (4) abnormal not compatible with pulmonary embolism (PE-: perfusion defects other than wedge-shaped). The study design required pulmonary angiography and clinical and scintigraphic follow-up in all patients with abnormal scans. Of 890 scans, 220 were classified as normal/or near-normal and 670 as abnormal. A definitive diagnosis was established in 563 (84%) patients with abnormal scans. The overall prevalence of pulmonary embolism was 39%. Most patients with angiographically proven pulmonary embolism had PE+ scans (sensitivity: 92%). Conversely, most patients without emboli on angiography had PE- scans (specificity: 87%). A PE+ scan associated with a very likely or possible clinical presentation of pulmonary embolism had positive predictive values of 99 and 92%, respectively. A PE- scan paired with an unlikely clinical presentation had a negative predictive value of 97%. Clinical assessment combined with perfusion-scan evaluation established or excluded pulmonary embolism in the majority of patients with abnormal scans. Our data indicate that accurate diagnosis of pulmonary embolism is possible by perfusion scanning alone, without ventilation imaging. Combining perfusion scanning with clinical assessment helps to restrict the need for angiography to a minority of patients with suspected pulmonary embolism.     

Efficacy of gadolinium in MR brain imaging of HIV-infected patients

PURPOSE: To determine the value of gadolinium in routine head MR imaging of HIV-infected patients. METHODS: One hundred and three consecutive human immunodeficiency virus-infected patients referred for head MR imaging were scanned without and with intravenous gadopentetate dimeglumine (Gd-DTPA) contrast. RESULTS: The precontrast scans of 82 patients were either normal, or had atrophy or diffuse white matter changes only. Sixteen of these 82 demonstrated enhancing abnormalities: eight meningeal/ependymal enhancement and eight focal enhancing lesions. Twenty-one of the 103 scans had focal or mass lesions on the precontrast images; in eight of these scans, new information was obtained with Gd-DTPA. Of the 24 patients in both groups where new information was obtained with Gd-DTPA, the information contributed to a change in the clinical care of nine patients. CONCLUSION: Gadolinium-enhanced MR is useful in the management of selected patients with human immunodeficiency virus infection, for example those with symptoms suggesting meningeal involvement, focal brain lesions, or if the unenhanced MR does not explain all the patient's symptoms.     

Detection of Chlamydia trachomatis antibodies by 2 novel tests: rELISA and peptide EIA

The performance of 2 newly developed enzyme immunoassays (EIAs) intended for the routine serological diagnosis of chlamydial infections was evaluated. rELISA is based on a recombinant lipopolysaccharide antigen which detects chlamydia genus-specific antibodies, and Chlamydia trachomatis EIA is based on a peptide derived from major outer membrane protein and is therefore species-specific. Both tests distinguished patients with tubal factor infertility (TFI) or pelvic inflammatory disease (PID) from the controls. The prevalence of IgA antibodies was higher for the PID patients than for the TFI patients; the finding indicates a more active state of infections for the PID patients. Furthermore, C. trachomatis EIA detected more IgG antibodies in the TFI patients than in patients with non-tubal factor infertility. In conclusion, rELISA detected chlamydial antibodies in general, and C. trachomatis EIA detected species-specific antibodies. These EIA tests may be useful in the serodiagnosis of chlamydial infection.     

Panic disorder in cardiac outpatients

OBJECTIVE: Continuing the long history of interest in the relation of anxiety disorders to cardiovascular function and symptoms, this study investigated the level of anxiety and prevalence of panic disorder in cardiac patients and the possible associations between specific abnormal ECG results and a diagnosis of panic disorder. METHOD: Consecutive patients referred for ambulatory ECG recordings were assessed with the seven anxiety items of the Hospital Anxiety and Depression Scale. Then, 50 patients with scores higher than 8 (the anxious group) were interviewed with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version Modified for the Study of Anxiety Disorders (SADS-LA). RESULTS: Of the 50 anxious patients (26 male and 24 female) interviewed with the SADS-LA, 62% (N = 31) met the DSM-III-R criteria for panic disorder. Patients with panic disorder had a higher mean maximal heart rate and a shorter P-R interval than patients without panic disorder. Unlike the patients without panic disorder, the patients with panic disorder showed no correlation between maximal heart rate and minimal P-R interval. CONCLUSIONS: The rate of panic disorder was high in the patients referred for ECG. Moreover, the prevalence of panic disorder was similar in the patients with and without ECG abnormalities, indicating that in anxious patients the presence of panic disorder does not rule out organic cardiac disease. On the other hand, the higher maximal heart rate and shorter P-R interval of the panic patients may be attributable to hypersensitivity of beta-adrenergic receptors in panic disorder.     

Chlamydia infection and CIN

Under the hypothesis that a chronic infection of the cervical epithelium leads to a reduction in the immunological response, a study was carried out to compare the possible relationship between chlamydial infection and CIN. 187 patients were referred to hospital for histological confirmation because of a cytological smear result (PAP III and IV a). Smears were examined for chlamydia antigens using immunofluorescence. The presence of antichlamydial IgA and IgG was performed in serum using an indirect immunohistochemical method. These tests confirmed CIN in 163 patients. The infection rate with chlamydia was 52.9%, 15.9% of CIN patients showing an active chlamydial infection. Inclusion of topographical findings, together with differential evaluation of colposcopic results, with reference to the transformation zone, allow for a separation between inflammation and dysplasia. The confirmation of a positive chlamydial infection and colposcopic criteria may help to reduce the high percentage of false-positive findings in the problem-group of PAP III patients. It appears that reservations about smear controls after doxycyclin therapy--including treatment of sexual partners--is justified.     

Intravenous urography pre prostatectomy: an evaluation of its use

The pre-operative intravenous urograms of 120 consecutive patients who had prostatectomy for benign prostatic hypertrophy (BPH) were studied. Of these, seventy eight patients (65%) had normal intravenous urograms (IVU) while 42 patients had abnormal IVU. In this study serum creatinine above 2.0mg/dl and blood urea above 35mg/dl proved valuable indices for possible selection of patients with BPH likely to show significant obstructive disease on IVU. This is not only cost saving, but also reduces unnecessary radiation to the patient.     

Inflammatory pseudotumor of the pancreas

OBJECTIVE: To assess the incidence of lupus anticoagulant (LAC) in patients with peripheral vascular disease. DESIGN: Prospective clinical study. SETTING: University Hospital. MATERIALS: 20 patients with claudication (group 2), 20 patients with critical ischaemia (group 3) and 20 patients prior to elective abdominal aortic aneurysm surgery (group 4) were compared to 20 general surgical controls (group 1). CHIEF OUTCOME MEASURES: Venous blood samples for coagulation assay. MAIN RESULTS: Positive results for LAC by the Dilute Russell's viper venom time (DRVVT) with the platelet neutralisation procedure were present in 26 out of 60 vascular patients compared with none of the 20 general surgical controls. The three vascular groups showed a similar prevalence of LAC and this differed significantly from that in the control group (chi 2 = 10.94, p = 0.0009). Of the 26 positive results only three were associated with an abnormal activated partial thromboplastin time (APTT), which has previously been used as a marker for the presence of LAC activity. Fibrinogen levels were raised in seven of 20 patients in group 2 but were normal in the remaining vascular groups (p = 0.001). The mean factor VII level (124.1 units dl-1) in group 2 was higher than the mean of the remaining vascular patients (109.3 units dl-1, p < 0.05). CONCLUSIONS: The high prevalence of LAC in patients with peripheral vascular disease and the associated increased risk of early graft thrombosis may justify routine testing by DRVVT prior to reconstructive vascular surgery. Treatment of these patients with antiplatelet agents or formal anticoagulation perioperatively should be considered.     

Prevalence and duration of postoperative pneumoperitoneum: sensitivity of CT vs left lateral decubitus radiography

OBJECTIVE: The purpose of this study was to evaluate the prevalence, location, and duration of pneumoperitoneum in postoperative patients and to compare the sensitivities of CT and left lateral decubitus radiography in the detection of postoperative pneumoperitoneum. SUBJECTS AND METHODS: Twenty-seven CT scans and 27 abdominal radiographs with the patient in the left lateral decubitus position were obtained prospectively in 17 patients after uncomplicated abdominal surgery. Fifteen patients were examined 3 days after surgery and 12 were examined 6 days after surgery. The studies were evaluated in a blinded fashion for the presence, location, and volume of free air. The presence of air on the radiographs and the presence and quantity of air on the CT scans were correlated with each subject's surgical procedure, age, sex, and body habitus. RESULTS: Pneumoperitoneum was seen on 13 (87%) of 15 CT scans and eight (53%) of 15 radiographs obtained 3 days after surgery and on six (50%) of 12 CT scans and one (8%) of 12 radiographs obtained 6 days after surgery. The calculated volume of free air seen on the CT scans ranged from 0.3 to 5.8 ml. Sixty-two percent of collections by volume were located in the midline/parahepatic space, 22% in the pelvis, and 16% in the mesentery. Radiographs showed pneumoperitoneum in only nine (47%) of 19 examinations in which the corresponding CT scans showed free air. Findings on radiographs were false-negative in seven (87%) of eight obese patients in whom pneumoperitoneum was detected on CT scans. CONCLUSION: The prevalence of pneumoperitoneum in the postoperative period based on CT findings is greater than that previously reported. Small amounts of pneumoperitoneum frequently collect along the anterior abdominal wall in two preferential spaces, the pararectus and midrectus recesses. The results of this study show that CT is significantly more sensitive than plain radiography for detecting small amounts of free intraperitoneal air in postoperative patients. Radiography is particularly insensitive for imaging obese and heavy patients.     

Prevalence and horizontal propagation of gonococcal infections among Nigerian children

The prevalence and mode of spread of gonococcal infections was studied among prepubertal children in Nigeria. Of 16 children with symptoms suggestive of sexually transmissible diseases (STD), 9 (56%) had gonorrhoea, while no causative organism was found in 7. The majority (7; 78%) of the gonococcal isolates produced penicillinase. Three of the cases were by child-to-child transmission, with female peers as the initiators. Prepubertal children should no longer be ignored as propagators of STD.     

Chlamydial and gonococcal serology in women with tubal infertility

Sera from 81 infertile women with tubal pathology and 40 controls were tested for the presence of antibodies against Chlamydia trachomatis & Neisserria gonorrhoeae. Indirect immunoperoxidase test (Ipazyme kit) & Enzyme linked immuno sorbent assay (ELISA kit) were used for detection of chlamydial & gonococcal antibodies respectively. Antibodies to Ch. trachomatis were found in 74.07% of the infertile women and 5% in control group. Only a very low prevalence (4.93%) of antibodies to N. gonorrhoeae was found is infertile women as compared to nil in control group. Antibodies detection is a sensitive, specific and noninvasive test for diagnosing infertility.     

Gastrointestinal transit in patients with idiopathic megarectum

PURPOSE: In patients with idiopathic megarectum, it is unknown whether abnormality is limited to the dilated large bowel or whether the upper gut is abnormal, as in the various forms of chronic intestinal pseudo-obstruction. This has important implications for treatment, especially surgery. METHODS: Ten patients (4 females; median age, 18 (range, 17-26) years) with idiopathic megarectum had contrast studies of the upper and lower gut, radioisotope (technetium-99m liquid and indium-111 solid phase) measurement of gastric, small-bowel, and colonic regional transit, and radiopaque marker colonic studies. RESULTS: All patients had a dilated large bowel. No patient had radiographic evidence of upper gut dilation. Four patients had normal and six patients had abnormally slow gastric emptying. Both the radioisotope scans and radiopaque marker studies showed abnormal colonic transit. Regions of delay corresponded with the region of dilated bowel. Symptoms of abdominal distention and bloating did not correspond to abnormalities of gastric emptying but rather with effectiveness of rectal evacuation. CONCLUSION: Patients with idiopathic megarectum have abnormal colonic transit, delay occurring predominantly in the dilated gut. Marker studies are less sensitive than isotope studies but provide adequate information for clinical purposes. Although motility abnormalities of the upper gut are common, symptoms correlate with large-bowel abnormalities.