Community based study of treatment seeking among subjects with symptoms of sexually transmitted disease in rural Uganda

This paper presents a community based study of treatment seeking among people with symptoms of sexually transmitted diseases (STDs) in rural Uganda. The effects of asymptomatic infections and treatment seeking behavior on control of sexually transmitted disease were quantified. The study suggests that treating only individuals with STD symptoms results in only a small proportion of the infected population being reached. This situation leads to fewer people receiving effective health care. Thus, STD control programs in medically underserved populations must take into account the prevalence of asymptomatic infections and the health related practices of people with STDs symptoms to design strategies for reducing transmission of these diseases.     

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.     

Ventricular remodeling in coronary artery disease

OBJECTIVE: To examine knowledge and practices in relation to sexually transmissible diseases (STDs) of general practitioners (GPs) in Victoria, Australia. METHOD: A questionnaire was distributed to 520 Victorian GPs randomly selected from the Australian Medical Publishing Company (AMPCo) database of Australian medical practitioners. RESULTS: A response rate of 85% was obtained. While sexual health consultations were common for Victorian GPs, STD caseloads were generally low. Knowledge of clinical features of symptomatic STDs and of important STD epidemiology was generally good although there was a lower awareness of the asymptomatic nature of the most prevalent STDs in Victoria. Diagnostic tests were generally selected appropriately although many GPs did not perform the gold standard combination of tests required for adequate differential diagnosis. Level of STD STD knowledge was related to frequency of advising about safe sex, diagnosing STDs, and younger practitioner age. Attendance at any of a number of postgraduate courses of relevance to the management of STDs was not related to better STD knowledge overall. CONCLUSIONS: Prevention and detection of STDs in general practice involve risk assessment and screening of asymptomatic patients as well as effective treatment of symptomatic patients and their contacts. Results presented here suggest that GPs have good knowledge and use appropriate investigations for patients presenting with symptoms of an STD. The low levels of awareness of the asymptomatic nature of many STDs and other particular aspects of STD knowledge and practice should be addressed in undergraduate and postgraduate medical education programmes.     

Pregnant women as a reservoir of undetected sexually transmitted diseases in rural South Africa: implications for disease control

OBJECTIVES: This study was undertaken to determine the prevalence of sexually transmitted diseases (STDs) in pregnant women in rural South Africa and to determine the value of using abnormal urogenital symptoms to identify infected women. METHODS: This was a cross-sectional study of 327 patients attending prenatal clinics. RESULTS: Of the 271 women with complete data, 141 (52%) had at least 1 STD and 49 (18%) had more than 1. Abnormal symptoms were common (n = 225; 83%), but associations were weak, and the positive predictive value of different symptoms for infection ranged from 2% to 54%. CONCLUSIONS: Most STDs in rural South African women remain undetected and untreated. As the scope for laboratory diagnosis in resource-poor settings is limited, presumptive treatment of pregnant women and their partners may be a cost-effective option to reduce transmission of STDs and HIV infection.     

Clinical studies on ceftriaxone in respiratory tract infections. CTRX Study Group

We report that the results of clinical studies on ceftriaxone (CTRX) in respiratory tract infections (RTIs). Clinical efficacies and side effects of CTRX were as follows; 1. Clinical efficacies of CTRX in a total of 61 cases with RTIs were excellent in 11 cases, good in 23, fair in 11, poor in 12 and unknown in 4. Thus the overall clinical efficacy rate was 59.6%. In cases of patients with lung cancers, the efficacy rate was 42.9%. 2. Clinical efficacy rates with once daily dosage were 50.0% with a dose level of 1 g CTRX and 54.8% with that of 2 g CTRX. 3. Side effects were observed in 2 cases (3.1%) and laboratory abnormalities were observed in 1 case (1.6%). They were not serious, however. These data suggest that CTRX is one of the useful cephalosporins in treatment of RTIs.     

Human papillomatous virus infection update: impact on women's health

Human papilloma virus (HPV) is one of the sexually transmitted diseases (STDs) seen throughout the population. More than 60 types of HPV have been identified, and 20 are known to cause genital warts; other types of HPV have an oncogenic potential. During pregnancy, genital warts may grow (possibly due to a suppressed immune system) and the neonate may become exposed. Several cofactors that have been identified in the development of HPV include oral contraceptive use, pregnancy and parity, nutrition, smoking, unsafe sex practices, and immunosuppression. Treatment options are aimed at destroying the visible lesions and include topical therapy, laser vaporization, cryocautery, liquid nitrogen, or simple excision. Health care providers have an important role in counseling about HPV infections. This includes educating clients about risk factors, prevention, signs and symptoms of STDs including HPV, safe sex practices, and the importance of regular examinations. Empowerment and a positive approach must be taken to help the client understand that she has a right to protect herself from STDs including HPV.     

Radiation-induced malignant fibrous histiocytoma of the head and neck

OBJECTIVE: To compare in a randomized prospective study the infective complication rates of a single intravenous dose of co-amoxiclav given alone before transrectal prostatic biopsy with an intravenous dose followed by oral co-amoxiclav for 24 h. PATIENTS AND METHODS: Eighty-three patients undergoing prostatic biopsy were randomized to receive 1.2 g co-amoxiclav intravenously and then either three further doses of oral co-amoxiclav (Group 1) or no further antibiotics (Group 2). The evaluation included analysis of a mid-stream urine (MSU) sample before and 72 h after biopsy, and the recording of oral temperatures and symptoms in the first 44 patients. Patients with symptomatic urinary tract infections (UTIs), prostatitis, indwelling catheters, diabetes and those receiving steroid therapy were excluded. RESULTS: Eight patients, four from each treatment arm, were found to have asymptomatic UTIs from their MSU before biopsy. Excluding these patients, four patients (11%) from Group 1 and six from Group 2 (16%) had positive MSUs at 72 h; two patients from Group 2 and one from Group 1 required admission to hospital. Of the patients returning symptom and temperature charts, a further six (14%; three from each group) reported signs and symptoms suggestive of infection despite negative urine cultures. CONCLUSIONS: There was no statistically significant difference in the rate of positive MSUs between the groups. The incidence of infections was considerably higher than in previously published series where other antibiotics were used, suggesting that co-amoxiclav is not the drug of choice for transrectal prostatic biopsy.     

Reversal of blood flow in experimental branch retinal vein occlusion

BACKGROUND: The consequences and management of asymptomatic Actinomyces-like organisms detected on cervical cytologic smears continue to be controversial. CASE: A unilateral tuboovarian actinomycotic abscess was discovered in a woman who had undergone a hysterectomy for uterine leiomyomas. She had had an intrauterine device in place for many years without any symptoms of pelvic inflammatory disease. CONCLUSION: Ascending infection of the upper genital tract by Actinomyces may be clinically inapparent. When Actinomyces-like organisms aer detected on cervical cytologic smears, removal of an intrauterine device should be considered.     

Direct observation of DNA translocation and cleavage by the EcoKI endonuclease using atomic force microscopy

OBJECTIVES: To determine whether antibiotic prophylaxis reduces respiratory tract infections (RTI) and overall mortality in an unselected adults intensive care population. SEARCH STRATEGY: Systematic literature search in peer-reviewed journals indexed in MEDLINE, examination of relevant proceedings of scientific meetings and personal contact with trialists. SELECTION CRITERIA: All randomised clinical trials (RCTs), published and unpublished, comparing different forms of antibiotic prophylaxis used to reduce RTIs and mortality in unselected adult intensive care units (ICUs) populations. DATA COLLECTION AND ANALYSIS: Out of the 32 RCTs eligible for this review data have been extracted from published reports and then complemented with information provided by study investigators for 29 trials. Data were available only from published reports in the remaining three RCTs. For each trial the following information has been sought: a) method of randomisation; b) use of blinding techniques; c) number of randomised patients; d) number of patients with RTIs; e) number of deaths; f) number of patients excluded from the published analysis; g) number of RTIs and number of deaths among excluded patients. Pooled estimates of treatment effects across trials have been calculated after grouping RCTs in two main, mutually exclusive, categories: a) 15 trials testing the effect of a combination of a topical and a systemic antibiotic against no prophylactic treatment; b) 17 trials where the experimental treatment was a topical antimicrobial preparation. Crude proportions of RTIs and mortality were used to calculate the overall treatment effect. We also computed the number of ICU patients who need to be treated in order to prevent one infection and one death. MAIN RESULTS: Overall 32 RCTs including 5639 patients were identified. Pooled estimates of the 15 RCTs (including 3273 patients) testing the effect of the topical and systemic antibiotic combination indicate a strong significant reduction of both RTIs (OR = 0.36, 95% CI = 0.30-0.43) and total mortality (OR = 0.80, 95% CI = 0.68-0.93). Five and 23 patients need to be treated to prevent one infection and one death, respectively, using this treatment. When data on the effect of the combination based on topical antimicrobials were pooled from the 17 available trials (including 2366 patients) a marked reduction on RTIs (OR = 0.57, 95% CI = 0.46-0.69) also emerged but no corresponding effect on overall mortality (OR = 1.01; 95% CI = 0.84-1.22) was found. CONCLUSIONS: After 15 years of clinical research this meta-analysis of 32 RCTs shows that a regimen of antibiotic prophylaxis based on a combination of a systemic and topical antibiotic can reduce both RTIs and overall mortality in ICU patients in a way that is both statistically significant and humanly worthwhile. Over and above their personal opinions intensivists should take this evidence into account when defining their policies.     

The sensitivity of a syndromic management approach in detecting sexually transmitted diseases in patients at a public health clinic in Cape Town

OBJECTIVES: To evaluate the sensitivity of a syndromic diagnostic procedure in detecting and treating sexually transmitted diseases (STDs) and genital tract infections (GTIs). METHODS: All new patients presenting at an STD clinic were sampled systematically by gender over a 6-week period. After the patient's clinical consultation, the clinical records were reviewed. Thereafter all patients were given a thorough genital examination by the research physician, and specimens were collected for laboratory investigations. In a retrospective simulation clinicians' syndromic diagnoses were validated against the laboratory findings, or for genital ulcer syndrome against the findings of the research physician. RESULTS: 170 men and 161 women were included in the sample. Ninety-five per cent of patients were black and the median age was 22 years for women and 26 years for men. In this setting, the Western Cape syndromic diagnostic procedure achieved reasonable levels of sensitivity in detecting Neisseria gonorrhoeae and Chlamydia trachomatis in men and women, and in detecting Trichomonas vaginalis and bacterial vaginosis in women. However, it was estimated to be only 36.4% sensitive in detecting genital ulcers in women, and between 0% and 12.3% sensitive in detecting Candida albicans. With syndromic management 8.2% of men and 32.9% of women would leave the clinic with at least one infection inadequately treated. CONCLUSIONS: Despite the introduction of syndromic protocols, it is likely that a proportion of STDs and GTIs are not being detected and treated owing to the high prevalence of multiple syndromes and mixed infections, both symptomatic and asymptomatic.     

Retroperitoneal cystic lymphangioma in a child

The infection rate and risk factors of CTRTI among 664 married women at reporductive age in rural areas in Chengjiang county, Yunnan province were investigated. Specimens of cervical swab were detected for CT antigen using Chlamydia EIA(Syva co., USA). The selection of major risk factors was through Logistic regression and chi 2-test. The results showed that the overall infection rate of CTRTI was 5.0%, with 60.6% of these cases asymptomatic. The major risk factors include: spouse who has symptoms of RTIs; history of others vaginitis; divorce; habit of washing face, feet and vulva with the same wash basin; age of menarche; amenorrhoea during lactation; low education and living in poverty.     

Chlamydia trachomatis infections

Chlamydia trachomatis is the most common bacterial cause of sexually transmitted disease in the developed countries. The most important implications of genital chlamydia infections involve the reproductive health sequalae of upper genital tract infections in women: pelvic inflammatory disease, ectopic pregnancy, and infertility, infection by this organism is insidious, symptoms are absent or minor among most infected women and many man. This large group of asymptomatic and infectious persons sustains transmission within a community. This review discusses the epidemiology, of sexually transmitted chlamydial infections, the spectrum of clinical manifestations and their sequelae, the laboratory diagnosis of genital chlamydiasis, antibiotic treatment and prevention.     

Alport syndrome with a peculiar pattern of distribution of the alpha3-alpha6 chains of type IV collagen in renal basement membrane

Chronic bacteriuria is a common occurrence among spinal-cord injury patients and others with neuropathic bladders. If bacteria are present in the urinary tract, the patient may develop symptoms of infection or remain asymptomatic. We have compared virulence properties of 28 Escherichia coli isolates from patients with symptomatic urinary tract infections (UTI) and 29 E. coli isolates from patients with asymptomatic bacteriuria (ABU). Bacteria from patients with symptomatic UTI were more likely to be hemolytic than isolates from patients with ABU (P = 0.05) or fecal isolates obtained from healthy volunteers (P < 0.001). Bacteria from patients with symptomatic UTI were also more likely than strains isolated from patients with ABU (P = 0.08) or fecal strains (P < 0.001) to exhibit D-mannose-resistant hemagglutination of human erythrocytes. The results suggest that E. coli isolates from nonimmunocompromised patients who require intermittent catheterization and who develop symptomatic UTI may be distinguished from bacteria recovered from patients who remain asymptomatic and possibly from normal fecal E. coli.     

Oral immunotherapy of recurrent urinary tract infections: a double-blind placebo-controlled multicenter study

We treated 166 patients suffering from recurrent urinary tract infections under double-blind conditions for 3 months with 1 capsule daily of either the immunostimulating bacterial extract (85) or a placebo (81), followed by a 3-month observation period without the test drugs. The bacterial extract exerted a significant beneficial curative action and long-term consolidative effect on the frequency of recurrent urinary tract infections with marked improvements in the characteristic signs and symptoms. It was significantly superior to placebo for the majority of the assessed parameters: number of recurrent urinary tract infections, bacteriuria, leukocyturia, erythrocyturia, nitrituria, albuminuria and casts in urine. Consumption of antibiotics, chemotherapeutics, urinary antiseptics or disinfectants was significantly less under active drug therapy compared to placebo. Tolerance was good with only 2 side effects reported in 2 patients (2%) in the active group compared to 11 among 5 (6%) in the placebo group. Therefore, the bacterial extract can be considered an efficient and well tolerated drug for the treatment of urinary tract infections, and their accompanying signs and symptoms, as well as for decreasing the risk of recurrences and the need for antibiotics and other antibacterial drugs.     

Insertion of a double pigtail ureteral stent for the prevention of urological complications in renal transplantation: a prospective randomized study

PURPOSE: Urologists successfully use ureteral stents to protect the ureterovesical anastomosis in nontransplant patients. MATERIALS AND METHODS: We determined the value of ureteral stents in transplant patients. The frequency of urological complications (leaks, obstructions and urinary tract infections) was compared in a prospective randomized series of 194 kidney transplantations (97 with and 97 without a double pigtail ureteral stent). RESULTS: In the stent group 1 patient had a urinary leak and 35 had urinary tract infections (including 2 cases of Corynebacterium cystitis). In the no stent group 6 patients had urinary leaks, 4 had obstructions and 32 had urinary tract infections. The 1-year patient and graft survival rates were similar in both groups, and renal function at 1 year was also similar (229 versus 208 mumol./l. creatinine in the stent and no stent groups, respectively). A small number of stent related complications occurred (2 stent breakages and 1 stent migration). No stones formed in any case. CONCLUSIONS: Ureteral stent insertion significantly decreases the rate of vesicoureteral leakage and obstruction in renal transplantation.     

Common bacterial urinary tract infections in women

Unfortunately, there is no general consensus as to how long patients with bacteriuria or urinary tract infections should be monitored and certainly there is no agreement on how long recurrent episodes should be treated beyond ten days to two weeks. The most important points to remember are: 1. Culture the urine both at the time of therapy and during follow-up. The patient should be examined periodically for the presence of bacteruria. If bacteria cannot be eradicated, at least the physician is aware of the organism most likely causing the patient's symptoms. 2. Do not subject the patient with frequent recurrent (chronic) and complicated infections to continual antibacterial therapy, but rather, manage the acute episodes. 3. Use prophylaxis, particularly single bed-time doses for dysuria and frequency symptoms. 4. Screen for bacteriuria during pregnancy. 5. Avoid the use of catheters except where absolutely necessary. 6. Avoid systemic prophylaxis of infection in patients with catheters; rather, use closed-system drainage with antibacteri-irrigation. It is to be hoped within the next few years, studies now underway will allow specific recommendations regarding the management of asymptomatic bacteruria, the duration of therapy for recurrent infections, the prevention and treatment of L-form bacterial infections, and indications for urologic procedures.     

Clinical features of small hepatocellular carcinomas as assessed by histologic grades

This paper outlines three important issues in the clinical management of sexually transmitted diseases (STDs) in Papua New Guinea which have, until now, gone unrecognized or been neglected. Suggestions for possible solutions are made. The high prevalence of both chlamydial and trichomonal infections in women cannot be ignored. Both of these infections have been shown to increase the transmission of HIV. The current algorithm for the treatment of vaginal discharges does not include treatment for trichomonal infection in the first instance, yet trichomoniasis has been shown to be the most common STD in community studies both here and elsewhere. Trichomoniasis is usually asymptomatic in men, but still increases the risk of HIV transmission; furthermore, it causes illness in their female partners and thus needs to be treated. The current recommended regimens for the treatment of gonococcal and chlamydial infection are complex due to the number of drugs recommended for gonorrhoea to combat the problem of drug resistance, and the length of therapy for chlamydia. Compliance with such a regimen is likely to be poor, particularly in asymptomatic partners. We need to consider the relative advantages provided by a drug which could be given as a single oral dose for chlamydia, and perhaps for both infections. Azithromycin is one possibility, as it has been shown to be effective for chlamydial infection in numerous studies, and has been found satisfactory for gonorrhoea where local isolates were susceptible. Testing of a small number of isolates from Papua New Guinea has shown that azithromycin may be suitable for use here, but further susceptibility testing needs to be performed. Utilization of services for STDs, particularly by women, is extremely low. This is due to a combination of factors involving limited knowledge of symptomatology and its significance, the asymptomatic nature of many infections, the structure of the services, health worker behaviour, and social attitudes. To address these issues we must make modifications to STD service provision, as well as provide widespread information about the potentially serious consequences of contracting STDs, including both infertility and AIDS. Possible modifications to the services are discussed, and include making routine screening available for women through currently existing services such as family planning and antenatal clinics and considering the possibility of establishing Women's Health Clinics which would provide all primary reproductive health services in an integrated manner.     

Urethral diverticula in women. Apropos of 15 cases

Urethral diverticulum is a rare disease, arising in the urethrovaginal septum and communicating with the urethra through an orifice. Characterised by clinical polymorphism, it is diagnosed by urethrocystography and transvaginal ultrasound. We report a series of 15 cases of urethral diverticulum over a 10-year period. The mean age of the patients was post-voiding was 36 years (range 24-50). The symptoms were recurrent urinary tract infections (66%), post-voiding urethral leakage (22%), vaginal pain (22%). Clinical examination found a vaginal mass in all patients. Retrograde urethrocystography showed the diverticulum in every cases, while IVP confirmed the diagnosis in only 62% of cases. Treatment is surgical and consists of removing the diverticulum via a vaginal approach. Short and long-term course is favourable. All patients were asymptomatic and the follow-up urethrocystography showed no diverticular recurrence.     

Temporary seronegativity in a human immunodeficiency virus type 1-infected man

In addition to financial constraints there are significant social, educational, moral and religious barriers to the prevention and treatment of reproductive tract infections in rural India. A pilot project aimed at achieving progress in this field is reported below.