Infection with Chlamydia Trachomatis Serovars D to K in Women

Chlamydia trachomatis (KT) najčešća je spolno prenosiva bakterija, jedan od vodećih uzroka zdjelične upalne bolesti (engl. pelvic infl ammatory disease - PID) i neplodnosti žena. Malena je, gram-negativna, obligatno intracelularna bakterija, koja najčešće infi cira skvamokolumnarni epitel. Jedna je od četiri specijesa koji pripada koljenu Chlamydia, porodici Chlamydiaceae i redu Chlamydiales. Infekcija je najčešća u adolescentica. Treba razlikovati nekompliciranu, kompliciranu i perzistentnu klamidijsku infekciju. U više od 80% žena je asimptomatska, pa se naziva i tiha infekcija. Može se manifestirati: mukopurulentnim cervicitisom, uretritisom, proktitisom (nekomplicirana). Može uzrokovati ozbiljne komplikacije (komplicirana infekcija): PID, bartolinitis, perihepatitis (Fitz-Hugh- Curtisov sindrom), reaktivni artritis, tubarnu neplodnost, ektopičnu trudnoću i bolest novorođenčeta. Infekcija KT-om može se dijagnosticirati: kulturom stanica, direktnom imunofluorescencijom, enzimskim testovima, tekućinskom hibridizacijom i testovima amplifi kacije nukleinske kiseline koji su zbog praktičnosti, osjetljivosti i specifi čnosti najprihvatljiviji. Ligase chain reaction iz obriska rodnice danas je test izbora. U liječenju akutne infekcije 1 gram azitromicina per os jednokratno liječenje je izbora, dok optimalno liječenje perzistentne infekcije do danas nije egzaktno definirano. Liječiti treba sve spolne partnere, uz apstinenciju od spolnog odnosa 7 dana nakon liječenja, radi sprečavanja reinfekcije. Ako se akutna infekcija liječi antibioticima prvog izbora (azitromicin i doksiciklin), ponovno testiranje nije potrebno. Upotreba kondoma je najbolja zaštita. Probir rizičnih skupina je važna mjera u sprečavanju ozbiljnih posljedica.Chlamydia trachomatis (CT) is the most common sexually transmitted bacterium, one of the leading causes of pelvic inflammatory disease (PID) and infertility in women. Chlamydiae are small gram-negative obligate intracellular microorganisms that preferentially infect squamocolumnar epithelial cells. CT is one of the four species which belong to the genus Chlamydia, the family Chlamydiaceae and the order Chlamydiales. The rates of Chlamydia infections are the highest in adolescent women. We must differentiate between non-complicated, complicated and persistent chlamydial infections. In more than 80% of women the infection is asymptomatic, also known as silent infection. The infection could be manifested as urethritis, proctitis, and mucopurulent cervicitis (noncomplicated). It may cause a wide spectrum of serious complications (complicated infections): PID, bartholinitis, perihepatitis (Fitz-Hugh-Curtis syndrome), reactive arthritis, ectopic pregnancy and disease in newborn. The CT infection can be diagnosed by cell-culture, direct immunofluorescence, enzyme immunoassay, direct DNA hybridization and more recently by nucleic acid amplification, a test currently considered to be the most acceptable thanks to its simplicity, sensitivity and specificity. Vaginal smear LCR is currently considered to be the test of choice. The preferred treatment for acute infection today is a single oral dose of 1g azithromycin, while the optimal treatment for persistent infection has not been yet established. All partners should be treated as well as abstain from sexual intercourse during 7 days after treatment in order to prevent reinfection. If treating the acute infection with first line antibiotics, retesting is not necessary. The use of condoms provides the best protection. Screening of risk groups is an important measure in preventing serious consequences

Primjena azitromicina u ginekologiji

Azitromicin se u ginekološkoj praksi često rabi. Lijek je izbora u liječenju infekcija uzrokovanih sljedećim bakterijama: Chlamydia trachomatis serovarâ D-K, Neisseria gonorrhoeae, Haemophilus ducreyi i genitalnih mikoplazmi (Mycoplasma hominis, Mycoplasma genitalium, Ureaplasma spp.). Alternativni je lijek u liječenju infekcija uzrokovanih sljedećim uzročnicima: Chlamydia trachomatis serovar L, Treponema pallidum, Calymmatobacterium granulomatis i Toxoplasma gondii. U hrvatskoj ginekološkoj praksi sve su spomenute infekcije rijetke, osim one uzrokovane klamidijom i eventualno mikoplazmama. Nove smjernice u liječenju infekcija u ginekologiji sve više preporučuju promptno i empirijsko liječenje. Razlozi su ozbiljne potencijalne komplikacije i odnos cijene i učinka. Naime, cijena same laboratorijske dijagnostike često višekratno premašuje cijenu liječenja. Stoga se azitromicin u ginekološkoj praksi često empirijski rabi kao lijek izbora za niz infekcija. Osobito danas kada mu je cijena višestruko niža i može se propisivati jednokratno, što značajno utječe na djelotvornost liječenja, a u novije se vrijeme daje i trudnicama

Vulvovaginal Candidiasis

Vulvovaginalna je mikoza, nakon bakterijske, najčešća vaginalna infekcija. Česta je bolest mladih žena i nalazi se u 15-30% simptomatskih žena koje posjećuju liječnika. Prevalencija u općoj populaciji iznosi 5-15%. Najčešći uzročnik je Candida albicans i odgovorna je za 80-92% epizoda vulvovaginalne mikoze. Vulvovaginalna kandidoza nije spolno prenosiva bolest. Candida spp. čini dio fiziološke flore rodnice u 20-50% zdravih asimptomatskih žena. Glavni simptom je svrbež, s malo vaginalnog sekreta ili bez njega koji je tipično bijel, grudast i sirast. Mogu biti prisutni i bolnost, nadražaj, pečenje, disurija i dispareunija. Dijagnoza se postavlja nalazom gljive na mokrom preparatu iscjetka s dodatkom 10%-tnog kalijeva hidroksida. Mikroskopija je lažno negativna u 50% bolesnica s potvrđenom vulvovaginalnom kandidozom. Potrebno je napraviti kulturu bolesnicama s karakterističnim simptomima i negativnom mikroskopijom. Asimptomatska kolonizacija nije indikacija za liječenje. Vrsta i trajanje liječenja simptomatske bolesti određuju se temeljem osnovne podjele na nekomplicirani i komplicirani oblik bolesti. Nekomplicirani se oblik podjednako uspješno liječi lokalnim i sistemskim lijekovima. Optimalno je liječenje jednokratna primjena oralnog flukonazola (Zenafluk®, PLIVA) u dozi od 150 mg. Komplicirane infekcije liječe se dulje.Following bacterial, vulvovaginal mycosis is the most common vaginal infection. It is a common disease in young women, found in about 15% to 30% of symptomatic women visiting a clinician. The overall prevalence of the disease is estimated at 5% to 15%. The most common causative agent is Candida albicans, responsible for 80% to 92% of episodes. Vulvovaginal mycosis is not considered a sexually transmitted disease. Candida spp. form part of normal vaginal flora in 20% to 50% of healthy asymptomatic women. The dominant symptom is pruritus with little or no discharge. When present, vaginal discharge is characteristically white, clumpy and curdlike. Other possible symptoms include pain, irritation, vulvar burning, dysuria and dyspareunia. Diagnosis is made by finding yeast on a wet mount of the discharge, adding 10% potassium hydroxide. Microscopy is negative in up to 50% of patients with confirmed vulvovaginal candidiasis. A culture is necessary in patients with characteristic symptoms and negative microscopy. Asymptomatic colonisation is not an indication for treatment. We differentiate between uncomplicated and complicated forms of the disease, and the type and duration of treatment are based on this classification. Uncomplicated forms are equally well treated by vaginal and oral preparations. The optimal treatment is oral fluconazole (Zenafluk®, PLIVA) in a single 150 mg dose. Complicated infections require longer courses of treatment

Pelvic Inflammatory Disease

Zdjelična upalna bolest, engl. Pelvic Infl ammatory Disease (PID) upala je gornjeg dijela ženskoga spolnog sustava, koja najčešće nastaje ascendentnim širenjem mikroorganizama iz donjeg dijela spolnog sustava. Najčešći patogeni važni u etiologiji su spolno prenosive bakterije Chlamydia trachomatis i Neisseria gonorrhoeae. Manifestira se: mukopurulentnim cervicitisom, endometritisom, salpingitisom, ooforitisom, tuboovarijskim apscesom, parametritisom i pelveoperitonitisom. PID je najčešći uzrok neplodnosti, ektopične trudnoće i kronične zdjelične boli. Poštujući moguće ozbiljne komplikacije i nepreciznu dijagnostiku, danas se savjetuje empirijsko liječenje za spolno aktivne mlade žene i starije s rizikom od spolno prenosivih bolesti, koje imaju bol u zdjelici ili donjem dijelu trbuha uz jedan ili više minimalnih kriterija prisutnih pri ginekološkome bimanualnom pregledu: bolnost cerviksa pri pomicanju ili uterina ili adneksalna osjetljivost. Kriteriji za hospitalizaciju su: tuboovarijski apsces, trudnoća, rezistencija na oralno liječenje, netoleriranje oralnog liječenja, teško oboljeli, ako se ne može isključiti akutni abdomen ili ako nema poboljšanja nakon tri dana liječenja. U prevenciji je bitan probir adolescentica na klamidiju i liječenje bakterijske vaginoze.Pelvic Infl ammatory Disease (PID) is an infection of the female upper genital tract and usually results from an ascending infection of the lower genital tract. PID is commonly caused by sexually transmitted micro-organisms N. gonorrhoeae and C. trachomatis. It can include mucopurulent cervicitis, endometritis, salpingitis, oophoritis, tubo-ovarian abscess, parametritis and pelvic peritonitis. PID is the most common cause of infertility, chronic pelvic pain, and ectopic pregnancy. Empiric treatment of PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identifi ed, and if one or more of the following minimum criteria are present on pelvic examination: cervical motion tenderness or uterine tenderness or adnexal tenderness. Hospitalization is necessary for patients with tuboovarian abscess and for those who are pregnant, severely ill and unable to follow or tolerate an outpatient oral regimen. Patients should also be hospitalized if a surgical emergency cannot be excluded or if no clinical improvement occurs after three days. Routine screening for chlamydial infection and bacterial vaginosis can help prevent PID and its sequelas

Incidencija okluzije središnje mrežnične vene

Epidemiologic reports on retinal vein occlusion are quite scanty in the ophthalmologic literature. In the present study, the incidence of central retinal vein occlusion (CRVO) was assessed in a defined population of the Split - Dalmatia County, Croatia. The study was designed as a retrospective review of the medical records of inpatients and outpatients with the development of CRVO during a 15-year period (1985 - 1999). Study results revealed CRVO to have occurred in 167 subjects in the population of 465,947 during the study period, yielding an annual incidence of 2.4 per 100,000. The highest incidence of CRVO was recorded above the age of 70. The results of the study should improve the disease evaluation and planning of the ophthalmologic service for better management of this serious disease.U oftalmološkoj literaturi su rijetke epidemiološke studije o okluziji središnje mrežnične vene. U ovoj je studiji ispitana incidencija okluzije središnje mrežnične vene u definiranoj populaciji Splitsko-dalmatinske županije. Studija je bila retrospektivna, a zasnovana je na kartoteci hospitaliziranih i ambulantno pregledanih bolesnika s okluzijom središnje mrežnične vene u razdoblju od 15 godina, od 1985. do 1999. godine. U ovoj studiji je 167 od 465.947 stanovnika dobilo okluziju središnje mrežnične vene za vrijeme ispitivanog razdoblja. Godišnja incidencija bila je 2,4 na 100.000 stanovnika. Najviša incidencija okluzije središnje mrežnične vene zabilježena je iznad 70. godine života. Rezultati ovoga ispitivanja omogućiti će bolju procjenu bolesti i planiranje oftalmološke službe za rješavanje ove ozbiljne bolesti

Human Papillomavirus-Related Diseases of the Female Lower Genital Tract: Oncogenic Aspects and Molecular Interaction

The causal role of human papillomavirus (HPV) in all cancers of the uterine cervix has been firmly established biologically and epidemiologically. Most cancers of both the vulva and the vagina are also induced by HPV. Papillomaviruses are perfectly adapted to their natural host tissue, the differentiating epithelial cell of skin or mucosae, and exploit the cellular machinery for their own purposes. The infectious cycle is initiated once the infectious particles reach the basal layer of the epithelium, where they bind to and enter the cells. The critical molecules in the process of virus replication are the viral proteins E6 and E7, which interact with a number of cellular proteins. In experimental system these interactions have been shown to induce proliferation and eventually immortalization and malignant transformation of cells. Binding of E7 to pRb activates the E2F transcription factor, which then triggers the expression of proteins necessary for DNA replication. Unscheduled S-phase would normally lead to apoptosis by the action of p53. However, in HPV-infected cells, this process is counteracted by the viral E6 protein, which targets p53 for proteolytic degradation. Besides blocking p53 function in regulation of apoptosis, high-risk HPV proteins interact with both extrinsic and intrinsic apoptotic pathways. As an aberration of virus infection, constant activity of the viral proteins E6 and E7 leads to increasing genomic instability, accumulation of oncogene mutations, further loss of cell-growth control and ultimately cancer. The immune system uses innate and adaptive immunity to recognize and combat foreign agents that invade the body, but these methods are sometimes ineffective against human papillomavirus. HPV has several mechanisms for avoiding the immune system. Furthermore, HPV infections disrupt cytokine expression with the E6 and E7 oncoproteins, particularly targeting the expression of interferon genes. Approximately 10% of individuals develop a persistent infection, and it is this cohort who is at risk of cancer progression, with the development of high-grade precursor lesions and eventually invasive carcinoma

CERVICAL CERCLAGE IN COUNTY HOSPITAL LIVNO 1986–2002 YEAR

Cilj rada. Ustanoviti indikacije, nužnost i učinkovitost primjene serklaže cerviksa. Metode. Retrospektivnom studijom je u Županijskoj bolnici Livno obrađeno 756 trudnica sa serklažom cerviksa u razdoblju od 1986. do 2002. godine. Analizirani su: dob trudnice, gestacijska dob primjene serklaže, trajanje trudnoće poslije zahvata te broj trudnoća dovršenih prije navršenog 37. tjedna trudnoće. Trudnice su podijeljene prema indikacijama za serklažu u tri skupine. Prvu je skupinu činilo 68 ispitanica u kojih je anamneza opterećena pobačajem ili preranim porodom u prethodnoj trudnoći, u drugoj skupini 125 s palpacijskim nalazom dilatacije unutarnjeg ušća cerviksa, a u trećoj skupini su 563 trudnice kojima je indiciran postupak iz drugih razloga. Rezultati. U 19% trudnica s anamnezom pobačaja u drugom trimestru ili preranog poroda trudnoća je završila prijevremeno, što je značajno više u odnosu na ostale skupine (p=0,017). Trudnice iz druge skupine nisu češće imale prijevremeno dovršene trudnoće u odnosu na trudnice sa zatvorenim unutarnjim ušćem cerviksa. Zaključak. Ovo ispitivanje pokazalo je kako je opravdana serklaža samo onim trudnicama kojima bi prijevremeni porod nastupio zbog urođene ili stečene anatomske slabosti fibromuskularnog prstena vrata maternice. Ostvarivi utjecaj na tijek trudnoće primjenom serklaže i mirovanja je vjerojatno manji od 1%.Aim of the study. To establish the indications, necessity and efficiency of the cerclage. Methods. In retrospective study at the county hospital Livno the 756 pregnant women who had undergone cervical cerclage from 1986 till the year 2002 were analyzed. The age of pregnant women, gestational age when the cerclage was performed, the lasting of pregnancy after the procedure, as well as the number of labors that occurred prior to 37 completed weeks of gestation were analyzed. Patients have been divided into three groups, according to the indications for the procedure. First group of patients, 68 of them, had history of abortion or preterm labor. In the second group there were 125 with a dilatation of internal os of the cervix, whereas in the third group of 563 pregnant women cervical cerclage was performed for other reasons. Results. In 19% of patients with history of abortion or preterm labor pregnancies finished in preterm labor, that is a statistically significant higher rate (p=0.017). In other groups there were no significant results. Conclusion. According to our results cervical cerclage is indicated in the cases of incompetent cervical os, either congenital or acquired. Before performing it, all laboratory and clinical tests, in order to exclude different reasons of cervical incompetence, should be done. Output of cervical cerclage on the outcome of pregnancy is probably less than 1%

A Study of Replacement of Timolol-Pilocarpine with Latanoprost in Pseudoexfoliation Glaucoma

The aim of the study was to evaluate the efficacy of replacing current dual local therapy (timolol and pilocarpine) with latanoprost 0.005% in 71 pseudoexfoliation glaucoma patients with controlled intraocular pressure (IOP). 39 patients switched to latanoprost 0.005%) and 32 patients continued timolol-pilocarpine therapy. Mean diurnal (IOP) was measured at baseline, after 0.5, 1, 3 and 6 months of treatment. After 6 months 38 patients with latanoprost and 30 patients with timolol-pilocarpine had completed the study. At baseline the mean diurnal IOP was 20.4±2.0 mmHg for patients in latanoprost treatment group and 21.4±2.1 mmHg for patients in timolol- pilocarpine group. At the end of the study, after 6 months of treatment, the mean diurnal IOP values were 16.6±2.4 and 17.9±2.0 mmHg respectively. IOP was statistically significantly reduced from baseline (p<0.001). The mean diurnal IOP change from baseline was –3.3±0.5 mmHg (mean±SEM, ANCOVA) for the patients treated with latanoprost and –3.2±0.4 mmHg for the patients treated with timolol+pilocarpine. This difference in IOP reduction between groups was not statistically significant (z=0.69; p= 0.49). This study showed that combination therapy (timolol plus pilocarpine) in pseudoexfoliation glaucoma can effectively be replaced by latanoprost monotherapy