Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in the emergency department.

OBJECTIVES: 1) To quantify the frequency of underrecognized Neisseria gonorrhoeae and Chlamydia trachomatis cervical infections in women tested in the ED, 2) to describe and compare the characteristics of those treated and not treated during the initial visit, and 3) to quantify the delay interval until treatment was provided. METHODS: A 2-year, retrospective consecutive case series was performed from June 1, 1992, to May 31, 1994. There were 148 women with > or = 1 discrete occurrence of culture-proven cervical N. gonorrhoeae or C. trachomatis infection studied. All the patients were evaluated in a university-affiliated, tertiary care hospital-based ED with a large rural referral area. The main outcome measures were the proportions of patients with positive cultures both treated and not treated in the ED, the clinical characteristics of each group, and the proportion remaining untreated or experiencing treatment delays of > 2 weeks after attempted phone, mail, and public health follow-up. RESULTS: Of 157 occurrences of positive cultures for N. gonorrhoeae or C. trachomatis, 86 (53%) were treated with a regimen suggested by the CDC prior to ED release. The proportion of women with isolated C. trachomatis infections that were underrecognized and untreated initially was larger than the proportions with isolated N. gonorrhoeae or combined infections (79% vs 27% and 53%, respectively, p < 0.0001). Women with findings suggestive of advanced disease (history of fever or chills, or examination evidence of temperature > 38 degrees C, purulent vaginal discharge, or any uterine/salpinx/ovarian tenderness) were more often recognized and treated with appropriate antibiotics initially (p = 0.02 to < 0.00001 for all). After phone, mail, and public health follow-up, treatment could not be documented for 25% of the occurrences, in all cases due to an inability to locate the patient. An additional 20% of the women did not receive treatment for 14-60 days. CONCLUSIONS: In this population, both N. gonorrhoeae and C. trachomatis cervical infections are frequently underrecognized in the ED, with isolated C. trachomatis infections associated with significantly higher proportions of underrecognition. Many affected women remain untreated for extended intervals, creating public and individual health risks. Improved point of contact detection, follow-up, and treatment policies are needed to limit these risks.

Comparison of hyperbaric oxygen and dapsone therapy for loxosceles envenomation.

OBJECTIVE: To determine whether hyperbaric O2 (HBO), dapsone, or HBO plus dapsone affects lesion size in a swine model of Loxosceles envenomation. METHODS: In a randomized controlled animal laboratory experiment, 32 piglets were assigned to 1 of 4 equal groups. Each piglet received 15 microliters, of purified venom intradermally on day zero. Group 1 received no treatment; group 2 received HBO at 2 atm for 2 hours on days 1-3; group 3 received 50 mg of dapsone orally on days 1-3; and group 4 received dapsone 50 mg orally and HBO at 2 atm for 2 hours on days 1-3. On days 1-7, 14, and 21, an investigator blinded to the treatment groups measured necrosis and induration. Mean necrosis and induration rates were compared using analysis of variance for repeated measures. RESULTS: Comparing groups on any day, no significant difference was noted in necrosis, induration, reduction in necrosis from day 1, or rate of change in lesion size from days 1-7. A difference was seen in the reduction of induration between all 3 treatment groups and the control group on days 7 and 14 only. The sample size permitted a power of 0.8 to detect a 12-mm mean change in lesion size. CONCLUSION: Compared with the control, neither dapsone, HBO, nor the combination of dapsone and HBO reduced necrosis from Loxosceles envenomation on days 3-21. An increase was seen in the rate of reduction in induration between all 3 treatment groups and the control group on days 7-21. However, the magnitude of this effect was clinically insignificant. In this animal model, treatment with either dapsone or HBO or a combination offers little clinical benefit in Loxosceles envenomation.