Clinical aspects of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a common and poorly managed condition. Untreated or inadequately treated, it leads to tubal infertility, ectopic pregnancy and chronic pelvic pain. Diagnostic difficulties are compounded by the wide variety of clinical presentations and the insensitivity and poor specificity of laboratory tests. Better recognition of mild and atypical disease needs a high index of suspicion whenever young, sexually active women present with gynaecological symptoms. Laparoscopy supplemented by microbiological tests and fimbrial minibiopsy should be regarded as the diagnostic 'gold standard' for research studies; new studies are required to identify techniques which might reduce under- and over-diagnosis. Early treatment reduces the risk of an adverse effect on fertility. Any therapeutic regimen selected should be effective against the common aetiological agents Chlamydia trachomatis, Neisseria gonorrhoeae, genital mycoplasmas and aerobic and anaerobic bacteria. Since at least 60% of cases of PID can be attributed to infection with a sexually transmitted organism, partner notification forms an essential part of management.      

多重-PCR检测CTX-M超广谱β-内酰胺酶基因

目的建立一种多重PCR方法在肠杆菌中检测所有组的CTX-M基因。方法设计两组引物可分别在两个区域检测所有CTX-M组的大多数blaCTX-M基因。一条四组CTX-M基因的共同保守区引物与另外四条逆向引物或五条逆向引物一起同时使用可分别检测出每一组特异性CTX-M基因。PCR反应混合物体积25 ul含每条引物25 pM。对6株标准菌株(产CTX-M-26的肺炎克雷伯菌1株,分别产CTX-M-3,CTX-M-9及CTX-M-15的大肠杆菌各1株,产CTX-M-14的大肠杆菌2株)和90株临床分离株进行CTX-M检测。结果已知携带CTX-M的菌株作为标准均获得预期PCR产物,对90株临床分离株应用多重-PCR扩增,有68株获得阳性结果。进一步测序及分析显示,这些基因均为编码CTX-M-15超广谱β-内酰胺酶的基因。结论我们已成功设计一种多重PCR在单一反应管可同时检测多种CTX-M基因无须多次PCR反应。此方法可以快速准确检测出ESBLs表型阳性菌中CTX-M基因。     

Focused parathyroid surgery with intraoperative parathyroid hormone measurement as a day-case procedure

BACKGROUND: This study assessed the feasibility, efficacy and safety of focused parathyroidectomy combined with intraoperative parathyroid hormone (IOPTH) measurement in a day-case setting. METHODS: Over 28 months 50 consecutive patients (mean age 63 (range 33-92) years) with clear evidence of unifocal disease on sestamibi scanning or ultrasonography underwent unilateral neck exploration via a small lateral incision. Blood samples for measurement of IOPTH were taken at induction of anaesthesia, before adenoma excision and after adenoma excision (at 5, 10 and 20 min). Ten patients were discharged within 23 h and 40 patients on the day of surgery. RESULTS: A solitary adenoma was identified in all but one patient, with a mean operating time of 30 (range 16-57) min. After parathyroidectomy, IOPTH levels fell appropriately except in one patient with multiglandular hyperplasia. No patient developed symptomatic hypocalcaemia during the 2 weeks after operation, enabling cessation of oral supplements. All patients remained normocalcaemic on follow-up (mean 26 (range 8-84) weeks) and histological examination confirmed parathyroid adenoma (48 patients), hyperplasia (one) or carcinoma (one). CONCLUSION: After accurate preoperative localization of uniglandular disease, patients with primary hyperparathyroidism may be managed successfully and safely by focused parathyroidectomy with IOPTH measurement as a day-case procedure.     

Effects of cyclo-oxygenase inhibition on vasodilatory response to acetylcholine in patients with type 1 diabetes and nondiabetic subjects

OBJECTIVE: Studies examining vasodilatory responses to acetylcholine (ACh) and its derivatives have been conflicting. Enhanced activation of the cyclo-oxygenase pathway and increased availability of vasodilatory prostanoids may occur in type 1 diabetes, and this may compensate for the observed reduction in nitric oxide (NO) activity We examined the role of cyclo-oxygenase inhibition on vasodilatory responses in 12 healthy normotensive type 1 diabetic adults and 12 nondiabetic control subjects of similar age, sex, and BMI. RESEARCH DESIGN AND METHODS: Forearm blood flow was measured using a venous occlusion plethysmography technique at baseline and after brachial artery infusions of ACh (7.5, 15, and 30 microg/min). Forearm blood flow at baseline and after ACh was then reexamined after local intra-arterial infusion of indomethacin (0.3 mg/100 ml forearm volume), a cyclo-oxygenase inhibitor. RESULTS: Baseline blood flow in the diabetic and control groups were similar (2.65 +/- 0.26 vs. 2.59 +/- 0.20 ml/min per 100 ml, respectively; P = 0.4). After indomethacin infusion, the vasodilatory responses to all doses of ACh were reduced in both the diabetic (by 25.30 +/- 4.90%) and control group (by 11.23 +/- 5.45%). However, the reduction in blood flow response to ACh after indomethacin was greater in diabetic patients compared with control subjects (P = 0.03). CONCLUSIONS: Our findings suggest that vasodilatory, prostanoids are important in determining endothelial response to ACh in diabetic and nondiabetic subjects. Increased prostaglandin-mediated vasodilation may compensate for attenuated responses to NO previously reported in diabetic subjects. These findings may partly explain the conflicting reports of endothelial dysfunction in patients with type 1 diabetes.     

Right unilateral electroconvulsive therapy at six times seizure threshold

OBJECTIVE: To examine the clinical practice of right unilateral electroconvulsive therapy (ECT) administered at six times seizure threshold (6 x RUL ECT). METHOD: A retrospective review of all patients who received 6 x RUL ECT between July 2000 and June 2002. RESULTS: Twenty-one patients across a range of ages and diagnostic groups received D'Elia unilateral ECT at a seizure dosage at or above 388.8 milliCoumbs (mC). In order to sustain predetermined criteria for seizure adequacy, energy was increased in 71% of patients. Final seizure lengths of 45 s electroencephalographic (EEG) activity, 28 s motor activity (cuffed) and a post-ictal suppression index (PSI) of 83% were recorded. Eighty percent of patients responded after a mean of 7.0 treatments. Cognitive side-effects were noted in 21% of patients. Fifty-two percent relapsed on average 6.3 months after the last treatment despite continuation pharmacotherapy. CONCLUSIONS: 6 x RUL ECT was found to be clinically effective, associated with cognitive side-effects and relapse. The debate over electrode placement is likely to continue.