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• W2080396589 abstract "In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed:Bjartling C, Osser S, Persson K. Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecological outpatient service. Am J Obstet Gynecol 2012;206:476.e1-8. In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Bjartling C, Osser S, Persson K. Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecological outpatient service. Am J Obstet Gynecol 2012;206:476.e1-8. Discussion Questions ■What was the aim of this study?See related article, page 476For a summary and analysis of this discussion, see page 532■What was the study design?■What were the results?■What is the difference between incidence and prevalence?■What direction might future research take?IntroductionMycoplasma genitalium (M genitalium) is a fairly unfamiliar entry in the catalog of sexually transmitted microorganisms. In fact, information on its role in urethritis and cervicitis is new to the Center for Disease Control and Prevention's most recent Sexually Transmitted Diseases (STDs) Treatment Guidelines.1Centers for Disease Control and PreventionSexually Transmitted Diseases Treatment Guidelines, 2010.MMWR. 2010; 59 (Accessed April 4, 2012): 1-110http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdfPubMed Google Scholar Yet, this parasitic bacterium is now linked to 15-25% of the nongonoccocal urethritis cases that occur in the United States. Limited data also indicate that like Chlamydia trachomatis (C trachomatis) and Neisseria Gonorrhoeae, M genitalium can be a culprit in cervicitis and pelvic inflammatory disease (PID). In a new study, Bjartling and colleagues determined the prevalence of M genitalium in a gynecologic emergency clinic and then assessed all associated outcomes.George A. Macones, MD, MSCE, Associate EditorStudy DesignMacones: Thank you for discussing this interesting article on M genitalium. What was the aim of this study?Cahill: The study focused on M genitalium and its potential connection to cervicitis and PID. Prior work on this had been conflicting, and importantly, had been conducted among high-risk women; ie, women who presented to an STD clinic. This study aimed to improve on prior data by examining the infection's prevalence in a heterogeneous population, including women who were in the early months of pregnancy.Macones: Do you think this is an important question?Cahill: Absolutely. I think understanding potential etiologic factors for both cervicitis and PID is quite important. These health outcomes can be associated with long-term sequelae, such as infertility. Thus, I do think that careful study in this area is important.Macones: What was the study design?Odibo: The authors describe this as a cross-sectional case-control study. They assessed factors associated with the presence or absence of M genitalium and also looked at outcomes associated with M genitalium infection. The assessment of PID and cervicitis in those with M genitalium resembled a cohort study, but I do believe it was more cross-sectional in nature.Macones: Who was included in this study?Odibo: The authors recruited women from an emergency gynecologic clinic at University Hospital of Skane in Malmo, Sweden. A high proportion of women who were approached agreed to enroll in the study (89.6%), which I think is a major strength. The methods of collection and testing for chlamydia and M genitalium were described in great detail, and I have great confidence that this was done well. Importantly, the results from M genitalium testing were not disclosed until the study was over, so essentially, providers and women were blinded to infection status. Subjects with chlamydia and M genitalium were compared to women who had neither of these infections.Macones: What types of data were collected?Odibo: There seemed to be very robust data collection on the infected women, as well as the uninfected. This included information on demographics, clinical diagnosis, and clinical signs and symptoms—the primary outcomes of interest.Macones: How were the data analyzed?Cahill: The analysis was very straightforward. It included bivariate analysis and appropriate multivariable models that controlled for confounding factors.ResultsMacones: Let's go through the results. What were they?Cahill: First, the enrollment rate was very high—almost 90%. There were 106 subjects with M genitalium, 116 with chlamydia, and 10 with both infections. Thus, the prevalence of M genitalium was 2.1% and of chlamydia, 2.8%. Table 1 compares women with M genitalium to women with C trachomatis and to negative controls for selected characteristics. Overall, the groups were fairly similar, except with regard to some small differences in specific methods of contraceptive utilization. Table 2 demonstrates the unadjusted results for the comparisons between patients with M genitalium infection and controls, patients with C trachomatis infection and controls, and patients with M genitalium infection and those with C trachomatis. Infection with M genitalium and C trachomatis each had significant associations with PID and cervicitis compared with controls. The association between infection and each condition was greater for C trachomatis than for M genitalium. A number of differences in clinical signs and symptoms existed between the groups as well.Macones: What does Table 3 tell us?Cahill: This is an important table, because it demonstrates the adjusted odds ratios for the main outcomes, PID and cervicitis. As you can see, M genitalium and C trachomatis were both independently associated with PID and cervicitis, though the magnitude of the association was greater for C trachomatis. I would add that the confidence intervals, while not crossing 1.0, were quite wide.Macones: Why might that be?Cahill: While a large number of women were enrolled in the study, there were actually a small number of cases of PID and cervicitis. The degree of precision of a point estimate is largely driven by the number of events. Thus, in this case, the confidence intervals are quite wide.Macones: I think an essential point to understand in this article is the difference between incidence and prevalence. Can you explain these concepts?Odibo: Absolutely. These are important concepts. Incidence is defined as a measure of the risk of developing some new condition within a specified period of time. It would be measured by dividing the number of new cases identified in a population over a particular period of time by the number of people in that population. Prevalence is the ratio of the total number of cases to the total population at a specific time, and it is more a measure of the burden of the disease on society. In this case, the prevalence would be determined by dividing the number of people who are infected by the total number of people who were examined.Macones: Do you use incidence and prevalence data differently?Odibo: Incidence is usually more useful than prevalence in understanding the disease etiology. Prevalence data is about the burden of disease in a population.ConclusionsMacones: Great. Are there any comments on possible strengths and weaknesses of this study?Cahill: In terms of strengths, I think recruiting from a gynecologic emergency facility rather than an STD clinic is a strength and an improvement over prior work. Second, a relatively large number of subjects were recruited, and the enrollment rate was incredible—almost 90%. The high enrollment rate really reassures me about the absence of selection bias in the study. So, I see that as a huge strength. I also thought that the methods for diagnosis were very clearly stated, and given that this is a key component of the study, I was glad to see this. In terms of weaknesses, I think, as we previously mentioned, the confidence intervals around some of the estimates were quite wide. However, the point estimates were rather high, so it seems likely that these are real associations. I just wish there was more precision.Macones: Are there any comments on future directions for research?Odibo: Well, first I think this is an excellent addition to the literature. I would say that in terms of future directions, it would be helpful to first see information on infection in other populations. Then I think the next step would be some prospective studies following women with M genitalium. Lastly, I was very interested in the small number of women who had both C trachomatis and M genitalium—this would be a very interesting group to study further to see if any synergies exist and what the effect of co-infection might be on clinically relevant outcomes.Macones: Well, thanks. This was a terrific discussion of an excellent article. Discussion Questions ■What was the aim of this study?See related article, page 476For a summary and analysis of this discussion, see page 532■What was the study design?■What were the results?■What is the difference between incidence and prevalence?■What direction might future research take? ■What was the aim of this study?See related article, page 476For a summary and analysis of this discussion, see page 532■What was the study design?■What were the results?■What is the difference between incidence and prevalence?■What direction might future research take? See related article, page 476 See related article, page 476 For a summary and analysis of this discussion, see page 532 For a summary and analysis of this discussion, see page 532 IntroductionMycoplasma genitalium (M genitalium) is a fairly unfamiliar entry in the catalog of sexually transmitted microorganisms. In fact, information on its role in urethritis and cervicitis is new to the Center for Disease Control and Prevention's most recent Sexually Transmitted Diseases (STDs) Treatment Guidelines.1Centers for Disease Control and PreventionSexually Transmitted Diseases Treatment Guidelines, 2010.MMWR. 2010; 59 (Accessed April 4, 2012): 1-110http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdfPubMed Google Scholar Yet, this parasitic bacterium is now linked to 15-25% of the nongonoccocal urethritis cases that occur in the United States. Limited data also indicate that like Chlamydia trachomatis (C trachomatis) and Neisseria Gonorrhoeae, M genitalium can be a culprit in cervicitis and pelvic inflammatory disease (PID). In a new study, Bjartling and colleagues determined the prevalence of M genitalium in a gynecologic emergency clinic and then assessed all associated outcomes.George A. Macones, MD, MSCE, Associate Editor" @default.
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• W2080396589 title "Discussion: ‘Mycoplasma genitalium in cervicitis and pelvic inflammatory disease’ by Bjartling et al" @default.
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