Which cephalosporin for gonorrhoea?

The recommended treatment for gonorrhoea in the United Kingdom has, until recently, included the fluoroquinolone, ciprofloxacin, which consequently was used by most genitourinary medicine clinics. In 2002 national surveillance data showed that resistance to ciprofloxacin had risen to a prevalence of 9.8% (9% in 2003), indicating that the target of >95% efficacy in first line therapy was no longer achievable. The third generation cephalosporins, ceftriaxone (intramuscular) or cefixime (oral), are the recommended alternatives, but recent audit data reveal other cephalosporins are currently being used to treat gonorrhoea, notably including cefuroxime (intramuscular or, often, oral). A pharmacodynamic analysis was undertaken to determine whether all these regimens were equally potent. Ceftriaxone, 250 (or 500) mg intramuscularly, or cefixime, 400 mg orally, were calculated to give free drug concentrations above the MIC90 for 22-50 hours post dose whereas the cefuroxime regimens being used were pharmacodynamically borderline, achieving this target for only 6.8-11.2 hours and raising the spectre that continued use may select for stepwise increases in resistance, as occurred with penicillin. We therefore underscore that ceftriaxone or cefixime should be the agents of choice to replace ciprofloxacin, as recommended in the new treatment guidelines, and that cefuroxime is a poor substitute.     

How adequate is adequate for the collection of endocervical specimens for Chlamydia trachomatis testing?

BACKGROUND: Endocervical specimen adequacy has been assessed by subjective criteria that are based on arbitrarily chosen thresholds for the presence of target cells observed on microscopic slide examinations. GOAL OF THIS STUDY: To assess the relationship of chlamydia test positivity to specimen adequacy with the use of a semi-quantitative cytologic staining method for assessing endocervical specimen collection cellularity. STUDY DESIGN: Endocervical specimens for chlamydia testing (PACE 2, GenProbe, San Diego, CA) and for a slide cytologic examination (n = 3,500) were collected in parallel. A semi-quantitative cytologic examination to determine a specimen adequacy (SA) score was performed for every chlamydia-positive result (n = 163) and approximately every fifth negative result (n = 626). The Chi-square test for linear trends was used to assess the relationship between SA scores and chlamydia positivity. The median SA scores for chlamydia-positive and negative slides were compared. RESULTS: The median SA scores for chlamydia-positive and -negative slides were 27 and 20, respectively (P < 0.001). Chlamydia positivity rates increased with increasing specimen adequacy scores (0-9, 2.7%; 10-19, 15.1%; 20-29, 24.8%; and 30-45, 31.3%; Chi-square for linear trend: P < 0.001). CONCLUSION: These results demonstrate a linear relationship between the numbers of cells observed on an endocervical smear and chlamydia positivity rather than the threshold concept in practice. The semiquantitative cytologic technique offers an objective method for further evaluating specimen adequacy for Chlamydia trachomatis testing.     

Is There a Role for Antiandrogen Therapy for Hidradenitis Suppurativa? A Systematic Review of Published Data

American Journal of Clinical Dermatology - Hidradenitis suppurativa/acne inversa is a disease with deep-seated chronic painful nodules, abscesses, and draining sinus tracts, which manifests on the...     

Why do different criteria for 'cure' yield different conclusions in comparing two treatments for bacterial vaginosis?

OBJECTIVE: The objective of this study was to determine why different criteria for response to treatment of bacterial vaginosis (BV) led to markedly different conclusions about treatment efficacy in a randomized trial comparing metronidazole gel versus metronidazole/nystatin ovules. STUDY: We compared the impact of two treatment regimens on individual components of Amsel and Nugent criteria at follow-up visits 14, 42, and 104 days after initiating treatment. RESULTS: Compared with gel, ovules more effectively eliminated amines, clue cells, and Gardnerella, Prevotella, or Mobiluncus morphotypes from vaginal fluid, thus achieving cure based on "usual" criteria (absence of BV by Amsel or Nugent criteria), but did not more effectively restore Lactobacillus morphotypes or lower vaginal pH, thus not meeting Federal Drug Administration (FDA) criteria for cure. CONCLUSION: Because early vaginal recolonization by lactobacilli was poor after both gel and ovules, FDA draft criteria for cure missed marked differences in treatment efficacies against Gardnerella, clue cells, and amines. Cure defined more "usually" may give more useful information.     

Transverse sections for diagnosis of alopecia?

Several authors have claimed usage of sections cut horizontally as being preferable to conventional cuts in vertical direction in the diagnosis of alopecias. In this article, we address in critical fashion, all statements that have been made in the literature that seem to favor sections cut horizontally in contrast to sections cut conventionally (ie, vertically) in coming to a diagnosis of diseases of the scalp. Our assessment reveals that the idea of horizontal sections being advantageous compared with sections cut vertically is based largely on the assumption that counting of follicles is the key to a diagnosis with specificity of diseases of the scalp. But a quantitative approach to diagnosis of alopecias is flawed; it does not allow differential diagnosis of common alopecias to be made with certainty. A qualitative approach, however, based on reliable and repeatable criteria applied in sections cut vertically, allows in most instances a diagnosis to be rendered precisely.     

Is baldness bad for the heart?

Various skin conditions are considered to be characteristic markers for elevated coronary disease risk. Over and above these established signs there are reports on other skin signs with possible associations with elevated coronary disease risk, i.e. the horizontal earlobe crease, high breast hair density, precocious graying and male pattern hair loss. A review of the literature is presented in this article, and the relevance of these symptoms is discussed as they are related to the possible myocardial disease risk. The available data on this topic are impressive, but on close assessment most of the studies are marred by methodical errors.     

Itraconazole (Sporanox®) for seborrheic dermatitis

Seborrheic dermatitis is a common superficial dermatosis, characterized by red, flaking areas of the skin, which may in some cases be covered with yellowish flakes. The most commonly affected areas are the nasolabial folds, ears, eyebrows, scalp and chest. While seborrheic dermatitis may be easy to recognize clinically, the variability of the lesions in both appearance and location may complicate the diagnosis. Seborrheic dermatitis has been described as resembling psoriasis (in which case, the condition may be called "sebopsoriasis") and, when affecting the eyes or ears, has also been described as blepharitis and otitis, respectively. Seborrheic dermatitis tends to be chronic, though seasonal variation is common, with lesions worsening in the dry, winter months.     

Itraconazole (Sporanox®) for vulvovaginal candidiasis

Vulvovaginal candidiasis is a common occurrence among women over 25 years of age. The likelihood of developing infection increases with pregnancy, the use of oral contraceptives or antibiotics, or immune disorders. However, in many cases, the etiology of the disorder is unknown. Sobel1 suggests that some cases of reinfection may actually be cases of relapse, due to either inadequate testing methods, which result in false-negative results after treatment, or to ineffective treatments. Misdiagnosis of the causative organism may also result in ineffective treatment. The most common causal Candida species is C. albicans. However, other, less easily eradicated species may also be involved.