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BACKGROUNDRepeat chlamydia detection after treatment is common, and there is concern that treatment failure may be a cause. METHODSWithin a randomized trial, we established a prospective cohort of 600 participants with anogenital chlamydia diagnoses (200 each of women, heterosexual men, and men who have sex with men [MSM]). Participants were invited for repeat testing at 3 months and to complete a behavioral survey at 4 months. Positive samples were analyzed for organism DNA load and genovar. We estimated repeat chlamydia positivity, reinfection and treatment failure rates, and investigated the biological and behavioral factors associated with a repeat positive test. RESULTSA total of 290 participants (100 women, 89 heterosexual men, 101 MSM) were retested at 1 to 4 months, with 43 repeat positives, including 26 classed as reinfection and 9 as treatment failures. Comparing MSM with heterosexual men and women combined, repeat positivity was higher (20.8% vs 11.6%, P = 0.04), and treatment failure was higher (6.9% vs 1.1%, P = 0.01), but there was no difference in reinfection rates (11.9% vs 7.4%, P = 0.21). Among MSM, the odds of repeat positivity increased by 90% with each additional log organism load in the original specimen (baseline) (adjusted odds ratio, 1.9; 95% confidence interval, 1.1–3.2). Among heterosexuals, the odds of repeat positivity decreased by 10% with each additional week delay in being retested for chlamydia (adjusted odds ratio, 0.9; 95% confidence interval, 0.8–0.9). CONCLUSIONSPositive retests were more common among MSM than heterosexuals. Treatment failure was more common in MSM with rectal chlamydia, reinforcing concerns about azithromycin treatment failure.

In this phase 2, randomized, placebo-controlled trial of 111 patients who had Behçet's syndrome with oral ulcers, apremilast, an oral phosphodiesterase-4 inhibitor that modulates several inflammatory pathways, reduced the number of ulcers and pain from ulcers at 12 weeks. The mucocutaneous lesions of Behçet’s syndrome include oral ulcers, genital ulcers, and papulopustular and nodular lesions. Recurrent oral ulcers can be disabling and have a substantial effect on quality of life. The current first-line therapy for the mucocutaneous lesions of Behçet’s syndrome includes colchicine and topical agents (e.g., glucocorticoids). 1 The efficacy of colchicine has been debated. 2 – 4 For lesions that are resistant to these treatments, azathioprine, interferon-α, thalidomide, and tumor necrosis factor α (TNF-α) antagonists are prescribed. There remains a need for a safe and effective treatment, and any new drug that is effective against oral ulcers (the hallmark lesion . . .

Anogenital warts (AGWs) are a common therapeutic challenge. All therapies are associated with burning, pain, and frustrating high rate of recurrence. The search for a new alternative continues. Recently, a diterpene ester extracted from the Euphorbia peplus plant (ingenol mebutate [IM]) has been shown to possess activity against AGWs. This study aimed to compare and evaluate the therapeutic efficacy and safety of topical 0.05% ingenol gel with another herbal extract medication (topical 25% podophyllin solution) in treatment of AGWs. This was a comparative single blinded nonrandomized, 2-arm trial of ingenol 0.05% gel versus podophyllin solution 25% administered up to 6 times to patients with AGWs. To evaluate the therapeutic efficacy, the complete clearance rate and recurrence rate were assessed 1 and 12 weeks after last treatment, respectively. Safety was assessed by occurrence and severity of pain and local skin reaction (LSR). Of 31 and 36 patients in the IM group and podophyllin group who completed the study, initial complete resolution was observed in 20 (64.5%) and 14 (38.9%) patients, respectively (P = 0.03). The initial clearance was faster in the IM group (2.00 ± 0.91 weeks) compared with the podophyllin group (4.21 ± 1.05 weeks, P = 0.00). After 3 months, recurrence was seen in 13 (65.0%) of 20 patients in the IM group and 6 (42.8%) of 14 in the podophyllin group (P = 0.20). The number of patients with complete resolution after 3 months was not different between the 2 groups (7/31 in the IM group and 8/36 in the podophyllin group, P = 0.97). The mean ± SD severity scores for LSR and pain in the IM group were 6.65 ± 1.76 and 6.13 ± 2.57, respectively, which was significantly higher than their scores (3.39 ± 1.57 and 2.58 ± 1.38) in the podophyllin group (P = 0.00). Ingenol mebutate 0.05% gel is effective as podophyllin 25% solution in treating AGWs, with further benefit of being much more rapid. However, high recurrence rate, sever pain, and LSR limit its use.

The aetiology of urgency urinary incontinence is a matter of debate. Current treatment options are based on the hypothesis of a neurological disorder of bladder innervation. However, it has also been hypothesised that one main cause is the reduced function of the bladder-holding apparatus, that is, insufficient suspension of the vesico-urethral junction. This study compared the effects of surgical apical vaginal elevation with those of solifenacin on urgency urinary incontinence in women. Women with mixed and urgency urinary incontinence were randomised to either an established pharmacological arm (10 mg/day solifenacin) or the surgical arm (bilateral uterosacral ligament replacement, cervicosacropexy, CESA; or vaginosacropexy, VASA. Clinical and objective outcomes were assessed at 4 months after each type of intervention. The study was terminated early; 55 patients were operated on and 41 patients received pharmacological treatment. After surgical treatment, 23 patients (42%, 95% confidence intervaI=29-55%) became continent compared to four patients (10%, 95% confidence intervaI=1-19%) during solifenacin treatment. Compared to pharmacological treatment, the surgical repair of the apical vaginal end restored urinary continence in significantly more patients.

Background Single-dose azithromycin is recommended over multi-dose doxycycline as treatment for chlamydial infection. However, even with imperfect adherence, doxycycline is more effective in treating genital and rectal infection. Recently, it has been suggested that autoinoculation from the rectum to the genitals may be a source of persistent chlamydial infection in women. We estimated the impact autoinoculation may have on azithromycin and doxycycline effectiveness. Methods We estimate treatment effectiveness using a simple mathematical model, incorporating data on azithromycin and doxycycline efficacy from recent meta-analyses, and data on prevalence of rectal infection in women with genital chlamydial infection. Results When the possibility of autoinoculation is taken into account, we calculate that doxycycline effectiveness may be 97% compared to just 82% for azithromycin. Conclusions Consideration should be given to re-evaluating azithromycin as the standard treatment for genital chlamydia in women.

Aim The aim of this study was to compare the efficiency of dopamine agonist, Cabergoline, in decreasing the size of endometrioma, with that of luteinizing hormone releasing hormone (LHRH) agonist, triptorelin acetate. Study This was a prospective, randomized study. Setting The setting was in two private medical centers in the UAE, from January 2011 to February 2012. Patients and methods One hundred and forty patients complaining of endometrioma, and fulfilling the eligibility criteria, were chosen and divided into two groups as follows: Group I comprised 71 patients; all of them received Cabergoline tablets, 0.5 mg tablets, twice per week for 12 weeks. Group II comprised 69 patients; all of them received LHRH agonist, decapeptyl, 3.75 mg subcutaneous, single injection, once a month for 3 months. All patients underwent vaginal ultrasound before and after the treatment period to compare the change in the size of endometrioma by the same sonography team in each hospital that was blind to the treatment groups. Outcome The outcome was measured by the changes in the endometrioma size by vaginal ultrasound after completion of the 3 months’ treatment period. The management line was considered to be significantly effective if the endometrioma size was reduced by more than 25 % of its original pretreatment size. Results Group I: 46 out of the 71 patients (64.7 %) had significant decrease in endometrioma size. Group II: 15 out of 69 patients (21.7 %) had significant decrease in endometrioma size. Paired t test to compare the means of the two groups was highly significant ( p  < 0.05) Conclusion Cabergoline (dostinex) yields better results in decreasing the size of endometrioma, compared to LHRH-agonist by exerting antiangiogenic effects through vascular endothelial growth factor receptor-2 (VEGFR-2) inactivation. It has no major side effects, easier to administer, and cheaper than LHRH agonists.

Imiquimod, an immune response modifier, has been demonstrated to be safe and effective in the treatment of external genital and perianal warts caused by human papillomavirus (HPV). To identify the molecular mechanism(s) by which condylomata acuminata clear during topical treatment with imiquimod, wart skin biopsies were taken from patients before treatment, at treatment week 6, and at the end of treatment. Tissues were analyzed for HPV DNA and for mRNA of several cytokines and HPV gene products. Wart clearance was associated with evidence of tissue production of interferon-α, -β, and -γ and tumor necrosis factor-α. Regression of warts was strongly associated with a decrease in HPV DNA and in mRNA expression for both early and late viral proteins. Thus, topical imiquimod treatment of anogenital warts led to significant increases in local production of multiple interferon mRNAs and a significant reduction in virus load as measured by decreases in HPV DNA and mRNA for early HPV proteins.

Chancroid is a sexually transmitted disease (STD) caused by the Gram negative bacterium Haemophilus ducreyi and is characterised by necrotising genital ulceration which may be accompanied by inguinal lymphadenitis or bubo formation. H ducreyi is a fastidious organism which is difficult to culture from genital ulcer material. DNA amplification techniques have shown improved diagnostic sensitivity but are only performed in a few laboratories. The management of chancroid in the tropics tends to be undertaken in the context of syndromic management of genital ulcer disease and treatment is usually with erythromycin. A number of single dose regimens are also available to treat H ducreyi infection. Genital ulceration as a syndrome has been associated with increased transmission of human immunodeficiency virus (HIV) infection in several cross sectional and longitudinal studies. Effective and early treatment of genital ulceration is therefore an important part of any strategy to control the spread of HIV infection in tropical countries.

By a randomised, double-blind, placebo-controlled trial of aciclovir 800 mg twice daily for 5 days added to the syndromic management of genital ulcer disease (GUD) to determine the impact on ulcer healing and HIV outcomes. Patients presenting with GUD in Malawi were evaluated for HIV and herpes simplex virus type-2 (HSV-2) serologies, ulcer aetiology, lesional, genital and plasma HIV-1 RNA and CD4+ count. Patients were followed up at days 2, 4, 7, 14 and 28. The primary study outcome was ulcer healing at day 14, with secondary outcomes being lesional and genital HIV-1 shedding at day 14 and HIV-1 plasma viral load at day 28 among HIV-1/HSV-2 co-infected individuals. Four hundred and twenty-two patients (74% male) were randomised (208 to aciclovir, 214 to placebo), of whom 61% were HIV-1 seropositive and 72% HSV-2 seropositive; 67% (267/398) had HSV-2 ulcers. 85% of ulcers were healed at day 14 with no difference between treatment arms (risk ratio (RR)=1.02, 95% CI 0.93 to 1.11). Among 244 HIV-1/HSV-2 co-infected individuals, aciclovir reduced lesional HIV-1 RNA (adjusted RR=0.64, 95% CI 0.41 to 0.99) and seminal HIV-1 RNA (adjusted RR=0.59, 95% CI 0.40 to 0.88), but not cervical HIV-1 RNA or plasma HIV-1 RNA. Episodic HSV treatment with aciclovir added to syndromic management did not produce a significant clinical benefit in this African population.

Background: Recurrent and painful genital ulcers are the hallmark of Behçet’s disease. Objective: To determine the efficacy of pimecrolimus (PIM) cream on the pain and healing time of genital ulcers. Methods: A total of 76 patients were randomized to either receive PIM cream plus colchicine (COL) tablets (1–2 g/day) or COL tablets (1–2 g/day) alone for 1 month. Clinical evaluations were performed in 68 patients at the baseline and on the 3rd, 7th, 10th, 14th and 28th days of treatment. Also, genital ulcer pain was evaluated using a verbal pain score at each visit. Safety was monitored through adverse event reporting and laboratory tests. Results: The mean healing time of genital ulcers was shorter in the PIM + COL group (4.2 ± 1.5 days) than the COL group (4.7 ± 1.8 days), without statistical significance (p = 0.399). Visual analog scale scores decreased in both groups significantly. Neither of the treatment modalities was found to be superior to the other; however, pain was relieved in 4.2 ± 0.5 days in PIM + COL group and in 5.5 ± 1.2 days in COL group in the intention to treat population (p = 0.023). Observed adverse events were transient. Conclusion: Compared to COL alone, COL + PIM cream shortens the pain duration without any significant effect on healing time.