High prevalence of ceftriaxone-resistant and XDR Neisseria gonorrhoeae in several cities of Cambodia, 2022-23: WHO Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP)

Objectives

Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a global public health concern. Ceftriaxone is the last effective and recommended option for empirical gonorrhoea therapy worldwide, but several ceftriaxone-resistant cases linked to Asia have been reported internationally. During January 2022-June 2023, the WHO Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) investigated N. gonorrhoeae AMR and epidemiological factors in patients from 10 clinical sentinel sites in Cambodia.

Methods

Urethral swabs from males with urethral discharge were cultured. ETEST determined the MIC of five antimicrobials, and EGASP MIC alert values and EUCAST breakpoints were used. EGASP demographic, behavioural and clinical variables were collected using a standardized questionnaire.

Results

From 437 male patients, 306 had positive N. gonorrhoeae cultures, AMR testing and complete epidemiological data. Resistance to ceftriaxone, cefixime, azithromycin and ciprofloxacin was 15.4%, 43.1%, 14.4% and 97.1%, respectively. Nineteen (6.2%) isolates were resistant to all four antimicrobials and, accordingly, categorized as XDR N. gonorrhoeae. These XDR isolates were collected from 7 of the 10 sentinel sites. No EGASP MIC alert values for gentamicin were reported. The nationally recommended cefixime 400 mg plus azithromycin 1 g (65.4%) or ceftriaxone 1 g plus azithromycin 1 g (34.6%) was used for treatment.

Conclusions

A high prevalence of ceftriaxone-resistant, MDR and XDR N. gonorrhoeae in several cities of Cambodia were found during 2022-23 in WHO EGASP. This necessitates expanded N. gonorrhoeae AMR surveillance, revision of the nationally recommended gonorrhoea treatment, mandatory test of cure, enhanced sexual contact notification, and ultimately novel antimicrobials for the treatment of gonorrhoea.

Internalized Sexual Orientation Stigma and Mental Health in a Religiously Diverse Sample of Gay and Bisexual Men in Lebanon

This study explores the correlates of internalized sexual orientation stigma, psychological distress and depression in a religiously diverse sample of gay and bisexual men in Lebanon. A convenience sample of 200 participants completed a cross-sectional survey. Bisexual men reported greater internalized sexual orientation stigma and less outness to their family and were more likely to face family pressure to have a heterosexual marriage than gay men. People of no religion reported more outness than Muslims and Christians but also higher psychological distress and depression. Multiple regression analyses showed that religiosity, outness, family pressure to marry and being bisexual were positively associated with internalized sexual orientation stigma; and that frequency of attending one's place of worship was negatively associated with psychological distress and depression. Individuals may be coping with adversity through engagement with institutionalized religion, which also appears to be a source of negative social representations concerning their sexuality.

Predicting sexual risk and sexual health screening in a sample of university students in Lebanon: a cross-sectional study

OBJECTIVE

The present study focuses on factors that predict sexual risk behaviors and sexual health screening behaviors in a sample of university students in Lebanon.

PARTICIPANTS

A convenience sample of 250 undergraduate students was recruited at a private university in Beirut, Lebanon.

METHODS

Students completed measures of religiosity, psychological distress, contraceptives usage, human immunodeficiency virus (HIV)/sexually transmitted infections (STI) screening, and sexual risk behaviors.

RESULTS

Religiosity was negatively associated with a range of risky sexual behaviors whereas psychological distress was positively associated with these behaviors. Sex under the influence of alcohol/drugs, discussing methods of contraception, and engaging in sexual activities later regretted had significant effects on having had condomless vaginal sex. Gender (being female) and sex under the influence of alcohol had significant effects on STIs screening.

CONCLUSION

Interventions that focus on managing drug and alcohol use in students, unwanted pregnancy, religion, stigma related to screening, and sexual health education are recommended.

Beneficial UVB phototherapy preceding a fractional CO2 laser-UVB protocol in refractory non-segmental vitiligo

OBJECTIVES

To explore the short- and long-term effects of UVB phototherapy preceding a fractional CO₂ laser-UVB protocol in patients with resistant nonsegmental vitiligo.

MATERIALS AND METHODS

This single-center, prospective, split-face/body, evaluator-blinded study included adult patients with stable vitiligo refractory to conventional treatments. Two symmetrical lesions were selected. Phototherapy was delivered with one side covered, until minimal erythema. Within 3 days, 31-month-apart sessions of laser were performed on both sides. After each laser session, phototherapy was resumed three times weekly, with all lesions uncovered, until 8 weeks after the last laser session. At baseline, at the end of treatment, and 5 years later, a Mean Improvement Score by Physician (MISP) and a patient satisfaction 10-point visual analog score (VAS) were recorded.

RESULTS

Ten patients (8 women and 2 men) were included; their mean age was 32.9 years; phototype III was predominant; the mean duration of vitiligo was 3 years. At the end of treatment and 5 years later, scores of lesions treated with UVB-CO₂ -UVB (mean MISP 3.0 and 2.9, mean ΔVAS 4.5 and 3.9, respectively), were higher than those of lesions treated only with CO₂ -UVB (mean MISP 2.5 and 2.4, mean ΔVAS 4.1 and 3.6, respectively). After 5 years, one patient lost his partial response and two patients developed light hyperpigmentation on both sides.

CONCLUSION

Exposure to UVB before CO₂ -UVB explains the higher scores as it was the only variable between the two sides. It may improve the response of resistant lesions with a constantly sustained result over 5 years.

The Treatment Decision-making Preferences of Patients with Prostate Cancer Should Be Recorded in Research and Clinical Routine: a Pooled Analysis of Four Survey Studies with 7169 Patients

Different patients want to take different roles in the treatment decision-making process; these roles can be classified as passive, collaborative, and active. The aim of this study was to investigate the correlation between decision-making preferences among patients with prostate cancer and personal, disease-related, and structural factors. In four survey studies, we asked 7169 prostate cancer patients about their decision-making preferences using the Control Preferences Scale (CPS) and collected clinical, psychological, and quality-of-life measures. Most patients (62.2%) preferred collaborative decision-making, while 2322 (32.4%) preferred an active role, and only 391 (5.5%) preferred a passive role. Age (p < 0.001), data collection mode (p < 0.001), peer-to-peer support (p = 0.018), treatment status (p < 0.001), performed or planned radical prostatectomy (p < 0.001), metastatic disease (p = 0.001), and quality of life (p < 0.001) showed significant associations with patients' preferred decision-making roles. Oncologic risk group, anxiety, and depression were not significant in the model. In particular, younger prostate cancer patients with higher quality of life completing an online survey want to play a more active role in treatment decision-making. Before treatment has started, patients tend to prefer collaborative decision-making. Few prostate cancer patients in Germany prefer a passive role. These patients are mostly older patients, patients with a metastatic disease, and patients who have opted for prostatectomy. Whether this finding reflects a generational effect or a tendency by age group and disease phase should be investigated. Further research is also needed to describe the causalities of these relationships. The CPS offers valuable information for personal counselling and should be applied in clinical routine. In a large group of patients with prostate cancer, we found that there is a strong desire for joint decision-making with the physician before the actual treatment. Especially younger men, men with active online behaviour, and men with a high quality of life want to be actively involved in therapy decision-making processes.

Big toenail onychomycosis features associated with response to 1064 nm Nd: YAG laser treatment

BACKGROUND

A few studies discussed the factors correlated to response in laser treatment of onychomycosis.

OBJECTIVE

This study aimed to seek big toenail onychomycosis features that correlate with response to 1064 nm Nd: YAG laser treatment.

METHODS

This single-center, retrospective study included patients who had only one big toenail onychomycosis, with a confirmed mycological diagnosis and/or a high clinical suspicion. Patients had three sessions 1 month apart. The following characteristics were collected from the patients' files: age, sex, smoking and arterial hypertension statuses, results of baseline mycological culture, Onychomycosis Severity Index (OSI) score at baseline and at the end of the 6-month follow-up, as well as the reported side effects.

RESULTS

We included 105 patients, 86 women and 19 men, with a mean age of 43 years. Demographics have shown that 73.6% of patients were smokers, 17.9% had arterial hypertension, 61.9% had a culture positive for Trichophyton species, and 9.4% had a culture positive for Candida species. According to the OSI score, onychomycosis was mild in 18.9%, moderate in 39.6%, and severe in 41.5% of patients. At 6 months, clinical cure was achieved in 57.1% of patients.

CONCLUSION

The OSI decrease after 3 sessions of Nd: YAG laser was significantly more important in women and in patients with positive mycology culture, smaller affected area of the nail, no subungual hyperkeratosis, and no nail matrix involvement. Age, smoking, hypertension, and side effects were not shown to significantly correlate with the decrease of the OSI score.

Community-led HIV self-testing for men who have sex with men in Lebanon: lessons learned and impact of COVID-19

Background

In Lebanon, HIV is concentrated in both native and refugee communities of men who have sex with men (MSM). For over 10 years, the National AIDS Program (NAP) has offered HIV voluntary counselling and testing through a partnership with nongovernmental organizations (NGOs). In 2018, implementation of HIV self-tests (HIVST) was introduced, and this self-care intervention has been further scaled up during the coronavirus disease 2019 (COVID-19) pandemic. This paper (1) describes the effectiveness of implementing HIVST in Lebanon, and (2) discusses how the success of HIVST implementation has been reflected during the COVID-19 pandemic.

Methods

The NAP conducted a series of workshops (July–November 2018) to introduce HIVST services for healthcare workers working at different NGOs. The workshops highlighted that HIVST would be distributed for free, that it would be confidential and voluntary, and that participants were encouraged to notify the NGOs of their results, which would be kept strictly confidential. NGOs collected data anonymously and confidentially from beneficiaries (age, consistency of condom use and HIV testing history), who were asked to call back with the results of their HIVST. At the NAP, data were combined, aggregated and analysed.

Results

In 2019, the NGOs distributed 1103/1380 (79.9%) HIVST kits to their beneficiaries. The NGOs collected feedback on 111 kit results, of which two were HIV-positive. Feedback about HIVST results from beneficiaries was low (111/1103) due to noncompliance of beneficiaries and the lack of human and financial resources in the NGOs. From January through May 2020, a total of 625/780 HIVST kits (80.1%) were distributed. This period was divided into pre-COVID-19 and during COVID-19. The follow-up with the beneficiaries during COVID-19 was much improved because of the absence of on-site activities, shifting more efforts towards HIVST (449/625). There have been no reports of social harm related to HIVST.

Conclusion

HIVST implementation in Lebanon serves as an example of introducing a self-care intervention as part of a community-led effort. In order to maintain HIVST services at the same improved level, reorganization of care is needed within each NGO following the adaptation process due to COVID-19, along with continuous monitoring and evaluation of HIVST reported data.

Dermoscopy for venereologists: an update on patterns of tumors, inflammatory and infectious diseases of the genitalia, and tips for differential diagnosis

INTRODUCTION

Dermoscopy is an integrative part of clinical dermatologic examination. For clinicians mainly dealing with genital dermatoses and other venereal diseases, the differential diagnosis includes a broad spectrum of neoplastic, inflammatory, and infectious entities. Dermoscopy might have a valuable role to enhance the clinical differential diagnosis and help avoid some biopsies done for diagnostic purposes. Although the dermoscopic patterns of most tumors and inflammatory diseases of the trunk/face have been described, their manifestations on genital areas are less elucidated. We aimed to provide a succinct summary of existing data on dermoscopy of dermatologic diseases on genital areas.

METHODS

A literature search was performed on PubMed using the terms dermoscopy OR dermatoscopy OR videodermoscopy OR video dermoscopy AND genital. All studies reporting on dermoscopic findings of at least one case of a dermatologic disease on genital areas were included in the review. Unless otherwise indicated, ×10 was the magnification used in the reported studies. The main outcome was to describe the dermoscopic feature of each disease.

RESULTS

A total of 31 articles were identified and analyzed. They included single case reports and case series. The described entities were categorized into anatomical variants, vascular and lymphatic lesions, tumors, inflammatory disorders, and infectious conditions.

CONCLUSION

In diseases of the genital area, dermoscopic findings can be highly diagnostic and might establish a confident diagnosis. Limitation is that most of the criteria are based on case series, and few of them have been validated.

A case of Mycoplasma genitalium possible resistance in a woman

Mycoplasma genitalium (MG) is an increasingly recognized sexually transmitted infection. In women, MG is particularly associated with endometritis, cervicitis, pelvic inflammatory disease, HIV, and long-term negative reproductive health and obstetric outcomes. In addition, MG has the potential to show resistance to antibiotics. We present here a case of possibly resistant MG in Lebanon, where MG prevalence and MG antibiotic resistance status are unknown.

Antiretroviral-responsive confluent and reticulated papillomatosis: a case report of an unusual association

This is the case of a 29-year-old male newly diagnosed with advanced HIV (CD₄ < 35cells/mm³), presenting to us with hyperpigmented and scaly non-pruritic macules over his chest and upper abdomen of several weeks duration. Woodlamp examination was negative, but a skin biopsy suggested confluent and reticulated papillomatosis (CRP). Given his lack of any of the condition’s identifiable triggers and the unusually rapid resolution of his lesions shortly after antiretroviral therapy initiation, an immunodeficiency-related etiology for his CRP was entertained. Autoimmune disorders and atopic conditions have been well reported previously as possible triggers of CRP. However, in this report, we raise immunodeficiency as a possible trigger of CRP as well, such that immune dysregulation overall (autoimmunity or immunodeficiency) can contribute to CRP ontogenesis. To our best knowledge, this is the first report to date suggesting a possible association between CRP, a rare dermatological condition, and acquired immunodeficiency syndrome.

Onychoscopic evaluation of distal and lateral subungual onychomycosis: A cross-sectional study in Lebanon

Background and Purpose:

The aim of this study was to evaluate the onychoscopic patterns associated with distal lateral subungual onychomycosis (DLSO) in Lebanon.

Materials and Methods:

The present study was conducted on 45 patients with clinical DLSO attending two dermatology clinics in Beirut, Lebanon, between January 2018 and April 2018. The patients were subjected to dermoscopy to identify the onychoscopic patterns.

Results:

The DLSO was predominantly associated with white, yellow, and brown color changes (P<0.05). Dermoscopic patterns of longitudinal striae (n=31; 68.75%), spiked pattern (n=25; 55.5%), and jagged pattern (n=25; 55.5%) were significantly correlated with DLSO (P<0.001). Our findings are in accordance with five previous reports in which dermoscopic findings are discussed in onychomycosis.

Conclusion:

It is recommended to perform further studies on homogeneous groups with different clinical subtypes of onychomycosis including patients with suspected traumatic onycholysis or other nail diseases. Identification of onychoscopic patterns would offer the clinicians a quick, simple, and complementary tool for the diagnosis of onychomycosis.

Isotretinoin-induced urethritis versus non-gonococcal urethritis in a man who has sex with men: an open debate

This is the case of a young man presenting with urethritis despite a negative infectious work-up. Careful history taking elucidated a strong correlation between symptom onset and a recent dose escalation of isotretinoin for treatment of his refractory cystic acne. The urethral symptoms quickly resolved with dose reduction, suggesting urethritis as a rare adverse reaction of isotretinoin.

Assessment of ochratoxin A stability following gamma irradiation: experimental approaches for feed detoxification perspectives

The present study evaluated the effect of gamma irradiation on the stability of ochratoxin A (OTA) under various conditions. The effects of the physical state of OTA (solid vs aqueous), initial OTA concentration, irradiation dose and dose rate as well as the presence of model substances simulating food matrix compounds on OTA radiostability were investigated. First, pure OTA with and without food model compounds including α-D-glucose (monosaccharide), Methyl α-D-glucopyranoside (starch) and the amino acid derivatives N-α-acetyl-L-lysine methyl ester and N-α-acetyl-L-cysteine methyl ester (protein models) were irradiated with doses of 2, 4 and 8 kGy applied at 15.117 and 108.24 Gy/min. Secondly, artificially OTA-contaminated wheat with different moisture content (11, 14 and 16%) was irradiated with doses of 2, 4 and 8 kGy applied at 63.39 Gy/min. Residual OTA levels were analysed using ultra-high performance liquid chromatography coupled with tandem mass spectrometry. Solid OTA (50 and 3,200 ng/ml)showed great irradiation stability, even with irradiation doses up to 8 kGy. Under dry conditions, the presence of food model components did not affect OTA radiostability. However, in an aqueous solution, complete reduction was achieved at the initial OTA concentration of 50 ng/ml and irradiation dose of 2 kGy. Applying gamma irradiation to cereal-based food model systems produced a significant OTA reduction (5,000 µg/kg) of 47.2% in moistened wheat kernels (16%) with an absorbed dose of 8 kGy but failed to reduce the OTA content of low moisture content wheat (11%). These model experiments offered a useful tool to assess the main key factors affecting gamma irradiation-induced OTA reduction. Gamma irradiation is promising since the irradiation doses applied could partially reduce OTA contamination. Nevertheless, its efficacy was largely affected by initial moisture content and could be dangerous if toxic by-products are produced or nutritive quality is lost and needs further study.

Fractional laser for vitiligo treated by 10,600 nm ablative fractional carbon dioxide laser followed by sun exposure

BACKGROUND

Vitiligo is an acquired disorder of the skin and mucous membranes. Many patients with vitiligo remain in the refractory state despite the availability of numerous potential treatments. To the best of our knowledge, only one trial considers ablative fractional CO2 laser in the treatment of vitiligo.

OBJECTIVE

To investigate the effects of fractional CO2 laser followed by systemic sun exposure on non-segmental vitiligo (NSV).

METHODS

Ten patients presenting refractory NSV were enrolled in this study. The patients underwent three sessions, one month apart, of fractional CO2 laser therapy on the affected areas of the skin (L-group). Five days after each laser treatment, patients were asked to expose themselves to the sun for 2 hours on a daily basis. Objective and subjective clinical assessments were performed at the beginning and at the end of the treatment. The L-group was then compared to a control group (C-group) that consisted of vitiligo lesions in the same patients but with sun exposure as the exclusive therapy.

RESULTS

Compared to the C-group, the L-group showed better improvement in both objective and subjective assessments. There were no noticeable adverse events in terms of scarring and Koebner phenomenon among others.

CONCLUSIONS

All patients treated with both, laser sessions and sun exposure, improved their chronic NSV lesions. Improvement was less significant in patients who exhibited vitiligo lesions over articular surfaces such as elbows and underarms. The best results were observed in vitiligo plaques located on the face, neck and legs. Consequently, fractional CO2 laser followed by sun exposure could be considered as an alternative modality for the treatment of refractory vitiligo, especially in sunny regions.

The origins of the condom

We know little about the origins of one of the oldest forms of contraception in medicine, the condom. Condoms were initially recognised as being useful for the prevention of sexually transmissible infections. Later on, they were used as contraceptives. We present here a short presentation of the condom’s history.