Evidence-based review of aetiopathogenic theories of congenital and acquired cholesteatoma.

Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquired. Congenital cholesteatoma develops behind a normal, intact tympanic membrane, whilst acquired cholesteatoma is associated with a defect in the tympanic membrane. The pathological substrate of cholesteatoma is keratinising stratified squamous epithelium, but the origin of this epidermal tissue in the middle ear is controversial. Here, we review the most relevant and recent evidence for the principal aetiopathogenic theories of both forms of cholesteatoma, in the light of recent otopathological findings. Congenital cholesteatoma is most plausibly explained by the persistence of fetal epidermoid formation. Conclusive 'proof' awaits the unambiguous demonstration of the metamorphosis of an epidermoid nidus into a lesion in vivo. Acquired cholesteatoma may develop by various mechanisms: immigration, basal hyperplasia, retraction pocket and/or trauma (iatrogenic or non-iatrogenic). However, squamous metaplasia of the normal cuboidal epithelium of the middle ear is a highly unlikely explanation. Chronic inflammation seems to play a fundamental role in multiple aetiopathogenic mechanisms of acquired cholesteatoma. Therefore early treatment of inflammatory conditions might reduce their sequelae, perhaps by preventing the development of hyperplastic papillary protrusions. Continued otopathological, cellular and molecular research would enhance our limited understanding of cholesteatoma and may lead to new therapeutic strategies for this erosive disease, which often defies surgical treatment.

Genital tract infections and the specialist gynaecologist: a survey of perception, diagnosis and treatment.

The study was designed to investigate the attitude of gynaecologists to the management of genital tract infections in the North West Region of England. A postal questionnaire was sent to all members and fellows of The Royal College of Obstetricians and Gynaecologists with addresses in the region. A response rate of 71% was achieved. Of these 67% were male and more than 97% had been in the speciality for more than 5 years. Only 90.5% routinely obtain swabs from the posterior fornix; none from the pharynx. Forty-two per cent thought there might be a role for the genitourinary physician in the management of genital tract infections. Nineteen per cent engaged in consort tracing and only 22.6% carried out tests of cure before discharging the patients. Fifty-one per cent thought there could be grounds for litigation for not carrying out contact tracing and 27.4% agreed that not doing tests of cure may be regarded as negligence. This study revealed that there is a need for adequate training of gynaecologists with regards to the facilities available within the National Health Service.

Emergency unit care of sexually transmitted infections.

The aim of the study was to assess provisions for management of sexually transmitted infections (STIs), emergency contraception and pregnancy test in UK emergency departments. Postal questionnaires were sent to all consultant-led emergency departments in the UK in January 1996. The response rate was 64%. Most departments made direct referrals to genitourinary medicine (GUM) clinics and most had access to appropriate clinics. While 55% had facilities for diagnosis of at least one of the 3 common STIs (Chlamydia trachomatis, Neisseria gonorrhoeae and herpes simplex), only 6.25% had facilities for all 3. A minority of units provided training in the management of STIs. Emergency physicians should be trained in the early management of STIs and a coordinated working relationship should be developed between emergency and GUM departments to provide optimal sexual health care.

Detection of male genital infection with Chlamydia trachomatis and Neisseria gonorrhoeae using an automated multiplex PCR system (Cobas Amplicor).

We evaluated Cobas Amplicor, a highly automated polymerase chain reaction (PCR) system, to test first-void urine (FVU) and urethral swab specimens for Chlamydia trachomatis and Neisseria gonorrhoeae in men attending a sexually transmitted infection (STI) clinic. Results were compared against an in-house radioimmune dot blot (DB) test for C. trachomatis and selective culture for N. gonorrhoeae. Three hundred and ninety sets of specimens were obtained from 378 consecutive new and returned-new patients. Gonorrhoea prevalence was 9.49%, with no significant difference in sensitivity or specificity between culture and PCR. Chlamydia prevalence was 15.4%, with sensitivities of: DB 55%, PCR of FVU 86.7%, urethral swab PCR 90%. The specificity of PCR on FVU and urethral swabs was 100%. We have shown that Cobas Amplicor PCR is highly sensitive and specific in the diagnosis of chlamydia and gonorrhoea in men attending an STI clinic. Further economic and scientific studies are needed to determine the cost-effectiveness of this technique for screening in primary care settings.

Ofloxacin in the treatment of uncomplicated gonorrhea and chlamydial genital infection.

The subjects were 149 patients (96 men, 53 women) with gonorrhea only (n = 66), chlamydial infection only (n = 48), or both gonorrhea and chlamydial infection (n = 35). All patients with gonorrhea were culture positive; all isolates cultured before treatment were sensitive to ofloxacin. Chlamydial infection was diagnosed by culture, inclusions being identified by indirect immunofluorescence. The patients with gonorrhea received a single dose of 400 mg of ofloxacin. Clinical and microbiologic cure was evident in 86 of 88 patients evaluated at seven days after treatment and in 71 of 72 patients at 14 days. Three patients developed postgonococcal urethritis; the cause was chlamydial in two. The patients with chlamydial infection received 200 mg of ofloxacin twice daily for seven days. Clinical and microbiologic cure was evident in all 78 patients evaluated one day after treatment and in 73 of 74 patients at 14 days. Side effects were reported by 11 patients. It is concluded that ofloxacin is a safe and effective treatment for uncomplicated gonorrhea in patients with and without concurrent chlamydial infections.

The efficacy of ofloxacin against infection caused by Neisseria gonorrhoeae and Chlamydia trachomatis.

Ofloxacin was used to treat patients with gonorrhoea and/or Chlamydia trachomatis infection. Gonorrhoea was treated with a single 400 mg dose and chlamydial infection with a seven day course (200 mg bd). Fifty of 84 patients with gonorrhoea (60 men and 24 women) returned for two follow-up examinations 7 and 14 days after treatment, 17 patients returned for only one follow-up examination and 17 defaulted. Neisseria gonorrhoeae was re-isolated from three patients who had probably become re-infected. Treatment was successful in 64 patients, 58 of whom were assessed after a single 400 mg dose of ofloxacin. Chlamydial infection was identified in 30 patients with gonorrhoea (13 men and 17 women) and in 35 other patients (17 men and 18 women). C. trachomatis was not recovered from any of the 49 patients who returned for two follow-up examinations, or from the ten patients who attended for one follow-up visit only. Sixteen patients did not return for follow-up examination. Our results suggest a seven day course of ofloxacin would eradicate N. gonorrhoeae and C. trachomatis in patients infected with both organisms. Such treatment may be advisable in patients with gonorrhoea if microbiological tests for C. trachomatis are not available.

Leucocyte esterase test as rapid screen for non-gonococcal urethritis.

The two standard tests for the initial diagnosis of non-gonococcal urethritis (NGU), microscopic examination of gram stained urethral smears and the two glass urine test, have the disadvantage of being insensitive and subjective. The leucocyte esterase test detects enzymes specific to polymorphonuclear leucocytes and can therefore be used as a sensitive indicator of pyuria. This study sought to evaluate its use as a rapid, sensitive, and non-subjective method of screening for NGU. Of the 81 men with urethral symptoms in the study group, 26 had more than 5 polymorphonuclear leucocytes per high power field (x 1000) and all 26 were leucocyte esterase test positive; whereas 55 had fewer than 5 polymorphonuclear leucocytes per high power field, but 29 (53%) of them had a positive leucocyte esterase test result. In addition, 25 patients in the study group yielded Chlamydia trachomatis on culture. Of these 25, 24 (96%) were leucocyte esterase test positive, whereas only 11 (44%) were Gram stain positive. All 40 patients in the control group (without urethral symptoms or signs) were leucocyte esterase test negative. The leucocyte esterase test is thus a rapid, sensitive, and non-subjective screening aid in the diagnosis of NGU.

In vitro susceptibility of Gardnerella vaginalis to high concentrations of sulfonamide compounds.

The excipients of triple sulfa vaginal tablets were ineffective against Gardnerella vaginalis in vitro. The three sulfonamides, however, were inhibitory, and minimal inhibitory concentration tests showed many strains to be susceptible to 25,000 mug of sulfacetamide per ml.

Haemophilus vaginalis infection. Diagnosis and treatment.

Some 4,263 women from special, family planning and gynecologic clinics were screened at random for the presence of H. vaginalis (C. vaginale) infection. Twenty-four percent of the women from the special clinics, 6% from the family planning and 4% from the gynecology clinics were culture positive although microscopic findings were somewhat higher than this. Of 582 women attending special clinics who were infected solely with H. vaginalis, only 261 complained of having an offensive discharge. Two hundred thirty-eight women reported "no symptoms," but 116 of them did have an offensive discharge on examination. These 582 women were treated with either ampicillin, ampicillin with probenecid or sulphonamide vaginal tablets. All were largely effective. Direct microscopy was regarded as being a reliable guide to H. vaginalis infection.

Improved transport and culture system for the rapid diagnosis of gonorrhoea.

The Jembec/Neigon transport-and-culture system for the rapid diagnosis of gonorrhoea has been assessed by 167 sets of investigations in 128 named female contacts of infected men. The system offers the same advantages of efficiency and speed as the Transgrow transport-and-culture system, but it is also more flexible and much less time-consuming.