Chlamydia trachomatis in subfertile women undergoing uterine instrumentation. How we can help in the avoidance of iatrogenic pelvic inflammatory disease?

Guidelines drawn up for patients undergoing termination of pregnancy state that there should be a protocol for either screening or treating for Chlamydia trachomatis. So far guidelines for other techniques that require instrumentation of the uterus (e.g. hysterosalpingography) remain unclear and controversial. By looking for other less invasive techniques we will be able to avoid these problems in a proportion of cases. Screening or treatment should be performed in those cases requiring uterine instrumentation.     

Vulvovaginal-swab or first-catch urine specimen to detect Chlamydia trachomatis in women in a community setting?

Screening for chlamydia in women is widely recommended. We evaluated the performance of two nucleic acid amplification tests for detecting Chlamydia trachomatis in self-collected vulvovaginal-swab and first-catch urine specimens from women in a community setting and a strategy for optimizing the sensitivity of an amplified enzyme immunoassay on vulvovaginal-swab specimens. We tested 2,745 paired vulvovaginal-swab and urine specimens by PCR (Roche Cobas) or strand displacement amplification (SDA; Becton Dickinson). There were 146 women infected with chlamydia. The assays detected 97.3% (95% confidence interval [CI], 93.1 to 99.2%) of infected patients with vulvovaginal-swab specimens and 91.8% (86.1 to 95.7%) with urine specimens. We tested 2,749 vulvovaginal-swab specimens with both a nucleic acid amplification test and a polymer conjugate-enhanced enzyme immunoassay with negative-gray-zone testing. The relative sensitivities obtained after retesting specimens in the negative gray zone were 74.3% (95% CI, 62.8 to 83.8%) with PCR and 58.3% (95% CI, 46.1 to 69.8%) with SDA. In community settings, both vulvovaginal-swab and first-catch urine specimens from women are suitable substrates for nucleic acid amplification tests, but enzyme immunoassays, even after negative-gray-zone testing, should not be used in screening programs.     

Urogenital Chlamydia trachomatis serovars in men and women with a symptomatic or asymptomatic infection: an association with clinical manifestations?

To determine whether certain Chlamydia trachomatis serovars are preferentially associated with a symptomatic or an asymptomatic course of infection, C. trachomatis serovar distributions were analyzed in symptomatically and asymptomatically infected persons. Furthermore, a possible association between C. trachomatis serovars and specific clinical symptoms was investigated. C. trachomatis-positive urine specimens from 219 asymptomatically infected men and women were obtained from population-based screening programs in Amsterdam. Two hundred twenty-one C. trachomatis-positive cervical and urethral swabs from symptomatically and asymptomatically infected men and women were obtained from several hospital-based departments. Serovars were determined using PCR-based genotyping, i.e., restriction fragment length polymorphism analysis of the nested-PCR-amplified omp1 gene. The most prevalent C. trachomatis serovars, D, E, and F, showed no association with either a symptomatic or asymptomatic course of infection. The most prominent differences found were (i) the association of serovar Ga with symptoms in men (P = 0.0027), specifically, dysuria (P < 0.0001), and (ii) detection of serovar Ia more often in asymptomatically infected people (men and women) (P = 0.035). Furthermore, in women, serovar K was associated with vaginal discharge (P = 0.002) and serovar variants were found only in women (P = 0.045).     

Detection of Chlamydia trachomatis antigen in spontaneous abortions. Is this organism a primary or secondary indicator of risk?

In order to investigate whether or not Chlamydia trachomatis infection is a risk factor for pregnancy loss, 77 spontaneous abortion patients (6-24 weeks gestation), admitted to gynaecology emergency of Safdarjang Hospital, New Delhi, India. Twenty-five pregnant women (6-16 weeks gestation) attending the same hospital for induced abortion, were included in the study. C. trachomatis antigen was detected in endometrial curretage tissue by enzyme immunoassay (EIA). The detection rate was 15.6% (12/77) among spontaneous abortion patients and 4% (1/25) among women undergoing induced abortion. There was no statistically significant association between the mean age/mean gestational age of those experiencing spontaneous abortion, with and without C. trachomatis infection (26.9 years versus 25.06 years and 11.1 weeks versus 9.6 weeks, respectively). High prevalence of C. trachomatis was found in multigravidae and parous spontaneous abortion patients, compared with that in primigravidae and nulliparous Chlamydia-negative spontaneous aborters (75.0% versus 25.0%; 66.7% versus 33.3%, respectively). The prevalence of chlamydial antigen in patients with no prior history of spontaneous abortion was 16.1% (10/62) compared with 18.1% (2/11) in women with one prior abortion. Further study is required to determine whether C. trachomatis infection is a primary or secondary indicator of risk.     

Chlamydia trachomatis in the endometrium: can surgical pathologists identify plasma cells?

Chlamydia trachomatis infection is the most common bacterial sexually transmitted disease. The authors examined the relation between chronic endometritis, which they term plasma cell endometritis (PCE), and chlamydial infection using plasmid-based polymerase chain reaction (PCR) and immunohistochemical staining (IHC) of paraffin-embedded endometrial sections. C. trachomatis infection was detected in 5 (24%) of 21 cases of PCE and in 1 (4%) of histologically normal endometrium. The diagnosis of chronic endometritis (with plasma cells confirmed by methyl green pyronin staining) was correctly made in 74% of the cases originally diagnosed as PCE and in 23% of control cases originally diagnosed as normal. The authors conclude that the histopathologic finding of plasma cells in endometrial samples should encourage further examination for chlamydial infection.     

Can history, ultrasound, or ELISA chlamydial antibodies, alone or in combination, predict tubal factor infertility in subfertile women?

BACKGROUND: This study aimed to determine whether medical history, transvaginal ultrasound (TVU) or Chlamydia trachomatis antibody testing (CAT), alone or in combination, could provide a non-invasive, clinically useful screening test for predicting tubal factor infertility (TFI) in subfertile women. METHODS: Prior to tubal evaluation, relevant medical history, TVU findings, and enzyme-linked immunosorbent assay (ELISA) IgG CAT results were collected. Sensitivity, specificity, likelihood ratios (LR) and accuracy for predicting TFI, as determined by laparoscopy and dye hydrotubation, were calculated for each test alone, and in parallel and series combination. RESULTS: Thirty per cent (63/207) were diagnosed with TFI. The highest sensitivity (67%, 95% CI: 54-77) included any positive test, yet missed one in three women with TFI. The highest specificity (100%, 95% CI: 97-100) required all three tests positive, but identified only three women. Only the combination of CAT and TVU rated as a good clinical test, but confidence intervals were wide due to the small numbers affected. The combination of CAT or TVU and CAT alone reported the highest accuracy (73%, 95% CI: 66-78), misdiagnosing one in four women. CONCLUSION: Medical history, TVU appearances, and ELISA IgG CAT alone, or in combination, failed to predict accurately TFI in subfertile women.     

Distribution of Chlamydia trachomatis ompA genovars and the new variant of C. trachomatis in the Göteborg area, Sweden

The aims of this study were to assess the proportion of the new variant of Chlamydia trachomatis (nvCT) and the distribution of ompA genovars among C. trachomatis-positive patients in the Göteborg area, Sweden. Consecutive urine samples positive for C. trachomatis using BD ProbeTec ET (177 patients, 88 men and 89 women) were collected. An nvCT-specific real-time polymerase chain reaction (PCR) assay was used to investigate the nvCT prevalence. To identify the genovars, a 990-bp ompA DNA segment from 105 specimens was sequenced. Seventeen percent (30/177) of all specimens contained nvCT. Nine different genovars were identified. About 50% were of genovar E, followed by F 16%, G 11%, K 8%, and D 5%, representing about 90% of the specimens in Göteborg. The occurrence of nvCT and the dominance of genovar E in Göteborg is similar to those in other areas of Sweden. To cover about 90% of the C. trachomatis infections in Sweden, the serovars D, E, F, G, and K should be included in future vaccines based on the major outer membrane protein.     

First unprovoked seizure--to treat or not to treat?

It has always been a controversial subject whether or not to treat a patient with first episode of seizure. The actual decision whether or not to treat patients who present with initial seizure must be individualized. It depends on probability of having a recurrence and on the perceived risk/benefit ratio of treatment. In a large majority of patients, it is prudent to defer treatment with antiepileptic drugs until a second episode has occurred, unless it is a remote symptomatic seizure, associated with definite epileptiform abnormalities in EEG or a partial seizure. However, in an occasional patient, treatment may be indicated even after a first seizure; for example, in patients involved in certain occupations like driving or operating dangerous machinery.     

Aspergillus detection in airways of ICU COVID-19 patients: To treat or not to treat?

It is now well known that patients with severe COVID-19 are at risk for developing invasive pulmonary aspergillosis (IPA). Nevertheless, the symptomatology of IPA is often atypical in mechanically ventilated patients and the radiological aspects of SARS CoV-2 pneumonia and IPA are difficult to differentiate. In this context, the significance of the presence of Aspergillus in respiratory tract samples (detected by culture, galactomannan antigen, or specific PCR) is not yet fully understood. Here we report two cases of intubated and mechanically ventilated ICU patients with SARS-CoV-2 pneumonia, in whom Aspergillus was detected in respiratory samples, who had a favorable outcome in the absence of antifungal treatment. These two cases highlight the difficulty of using the new definitions of COVID-19 associated pulmonary aspergillosis for routine management of patients.     

Primary HIV-1 infection: to treat or not to treat?

Treatment of primary HIV-1 infection with HAART may represent a unique opportunity to alter the course of this chronic disease. In spite of this, enthusiasm for the "ht early, hit hard" approach has waned over time, given the lack of data showing long-term clinical benefit. This article will examine the risks and benefits of starting HAART during acute HIV-1 disease.     

Characterization of Chlamydia trachomatis omp1 gene among sexually transmitted disease patients in south China

Chlamydia trachomatisinfections are the leadingcause of bacterial sexually transmitted diseases(STD) [1] .Fifteen prototypic serovarslabelled Ato Kand L1,L2,and L3were initiallyrecognisedby polyclonal antibodies ,and additional immuno-variants (Ba ,Da ,Ia ,L2a ,etc) ,whichin somepublications are referred to as distinct serovars ,have been identified by monoclonal antibodies .Most serovars can cause urogenital infections andare associated with a spectrumof clinical diseases[2] ,including ur…     

Helminth infection in populations undergoing epidemiological transition: a friend or foe?

Helminth infections are highly prevalent in developing countries, especially in rural areas. With gradual development, there is a transition from living conditions that are dominated by infection, poor sanitation, manual labor, and traditional diet to a situation where burden of infections is reduced, infrastructure is improved, sedentary lifestyle dominates, and processed food forms a large proportion of the calorie intake. The combinations of some of the changes in lifestyle and environment are expected to result in alteration of the landscape of diseases, which will become dominated by non-communicable disorders. Here we review how the major helminth infections affect a large proportion of the population in the developing world and discuss their impact on the immune system and the consequences of this for other infections which are co-endemic in the same areas. Furthermore, we address the issue of decreasing helminth infections in many parts of the world within the context of increasing inflammatory, metabolic, and cardiovascular diseases.     

Testosterone and the aging male: To treat or not to treat?

It is well-established that total testosterone (TT) in men decreases with age and that bioavailable testosterone (bio-T) falls to an even greater extent. The clinical relevance of declining androgens in the aging male and use of testosterone replacement therapy (TRT) in this situation is controversial. Most studies have been short term and there are no large randomized placebo-controlled trials. Testosterone has many physiological actions in: muscles, bones, hematopoietic system, brain, reproductive and sexual organs, adipose tissue. Within these areas it stimulates: muscle growth and maintenance, bone development while inhibiting bone resorption, the production of red blood cells to increase hemoglobin, libido, enhanced mood and cognition, erectile function and lipolysis. Anabolic deficits in aging men can induce: frailty, sarcopenia, poor muscle quality, muscle weakness, hypertrophy of adipose tissue and impaired neurotransmission. The aging male with reduced testosterone availability may present with a wide variety of symptoms which in addition to frailty and weakness include: fatigue, decreased energy, decreased motivation, cognitive impairment, decreased self-confidence, depression, irritability, osteoporotic pain and the lethargy of anemia. In addition, testosterone deficiency is also associated with type-2 diabetes, the metabolic syndrome, coronary artery disease, stroke and transient ischemic attacks, and cardiovascular disease in general. Furthermore, there are early studies to suggest that TRT in men with low testosterone levels may improve metabolic status by: lowering blood sugar and HbA1C in men with type-2 diabetes, reducing abdominal girth, ameliorating features of the metabolic syndrome, all of which may be protective of the cardiovascular system. The major safety issue is prostate cancer but there is no evidence that supports the idea that testosterone causes the development of a de novo cancer. So on balance in a man with symptoms of hygonadism and low or lowish levels of testosterone with no evidence of prostate cancer such as a normal PSA a therapeutic (4–6 months) trial of TRT is justified. Treatment and monitoring of this duration will determine whether the patient is responsive.     

Serotonin dilemma in postmenopausal women: Is it low or high?

OBJECTIVE: In this study, we have studied with premenopausal (PM), naturally menopausal (NM) and surgically induced menopausal (SM) women in order to investigate the differences in serum cortisol, dehydroepiandrosterone sulfate (DHEA-S), follicle stimulating hormone (FSH) and estradiol (E2) levels on serum serotonin levels. METHODS: Forty premenopausal (36.7+/-3.5 years), 40 naturally menopausal (54.2+/-8.4 years) and 38 surgically induced menopausal (55.4+/-11.2 years) women were included in the study. None of the subjects were using antidepressants or hormone replacement therapy. In NM and SM, years since menopause (YSM) were 3.16+/-1.58 and 3.36+/-1.89, respectively. Cortisol, DHEA-S, FSH and E2 levels were determined by immunochemiluminisence while serotonin levels were determined by HPLC. RESULTS: Serum serotonin levels in NM women were higher than the other two groups [144.23+/-45.29 microg/L vs 61.35+/-37.72 microg/L in SM women and 98.74+/-50.29 microg/L in PM women]. E2 and DHEA-S were positively correlated, while FSH and cortisol were negatively correlated with serotonin in NM and SM. There was no significant correlation between serotonin and age or YSM. In the PM group, there was no significant correlation between serotonin and the hormones. CONCLUSION: In conclusion, increased serotonin levels in naturally menopausal women may be a compensatory mechanism to decreased E2 levels as it is postulated that there is strong interaction between E2 and the serotoninergic system.     

Malignant biphasic uterine tumours: carcinosarcomas or metaplastic carcinomas?

Uterine carcinosarcomas (malignant mixed Mullerian tumours) are highly aggressive and have traditionally been regarded as a subtype of uterine sarcoma. However, in recent years convincing evidence has suggested that most, but not all, are monoclonal in origin rather than true collision tumours. Data confirm that the carcinomatous element is the "driving force" and that the sarcomatous component is derived from the carcinoma or from a stem cell that undergoes divergent differentiation. Thus, uterine carcinosarcomas are best regarded as metaplastic carcinomas, although the designation carcinosarcoma is likely to remain. Adjuvant treatment for uterine carcinosarcoma should probably be similar to that directed against aggressive high grade endometrial carcinomas rather than being sarcoma based. Importantly, a small proportion of uterine carcinosarcomas are true collision tumours and should be recognised as such because, in some instances, the prognosis may be better than for a similar stage carcinosarcoma.     

Promise of uterine transplant – Myth or a reality?

The scientific basis of uterus transplantation has been developing in parallel to other organ transplants throughout the modern period of transplant medicine. Immunosuppression and surgical techniques have been adequate for at least a decade; ethics and society have been less clearly developed. To many observers, it is still unclear if the endeavor is an overall positive or negative. Although scientific and technical challenges have been overcome, the ethical determinations will be a dynamic process while more experience continues to be gained. The most significant experience still lacking is a term gestation. Undoubtedly during a nine-month gestation, unforeseen challenges will test scientific processes and ethical assumptions. Despite dozens of animal experiments and a few animal births, no human birth has occurred to allow any definitive conclusions.     

Surrogate end-points or primary outcomes in clinical trials in women with polycystic ovary syndrome?

There are multiple surrogate variables in polycystic ovary syndrome (PCOS), including biometric and biochemical parameters. The number of surrogate variables and their poor validity in relationship to primary clinical end-points pose major problems to conducting a trial in women with PCOS. The aim of this review is to discuss the use of surrogate variables compared with primary clinical end-points in women with PCOS. Arguably the best documented correlation between a surrogate variable and a primary clinical end-point is that between ovulation and pregnancy in women with PCOS. Good correlation has been noted between the increase in ovulation frequency with clomiphene citrate and the chance of pregnancy in women with PCOS. However, ovulation cannot be equated with pregnancy, as a host of other factors may affect the true outcome of interest: a healthy liveborn child. Pregnancy and an improvement in hirsutism are clinical end-points that have been successfully studied in past and ongoing clinical trials in women with PCOS. Many other clinical end-points, such as endometrial cancer and cardiovascular disease, are rare in premenopausal women with PCOS, and may not be suitable as the primary outcome of clinical studies. Future multicentre trials in women with PCOS should focus on primary clinical end-points.