How is depression experienced around the world? A systematic review of qualitative literature

To date global research on depression has used assessment tools based on research and clinical experience drawn from Western populations (i.e., in North American, European and Australian). There may be features of depression in non-Western populations which are not captured in current diagnostic criteria or measurement tools, as well as criteria for depression that are not relevant in other regions. We investigated this possibility through a systematic review of qualitative studies of depression worldwide. Nine online databases were searched for records that used qualitative methods to study depression. Initial searches were conducted between August 2012 and December 2012; an updated search was repeated in June of 2015 to include relevant literature published between December 30, 2012 and May 30, 2015. No date limits were set for inclusion of articles. A total of 16,130 records were identified and 138 met full inclusion criteria. Included studies were published between 1976 and 2015. These 138 studies represented data on 170 different study populations (some reported on multiple samples) and 77 different nationalities/ethnicities. Variation in results by geographical region, gender, and study context were examined to determine the consistency of descriptions across populations. Fisher's exact tests were used to compare frequencies of features across region, gender and context. Seven of the 15 features with the highest relative frequency form part of the DSM-5 diagnosis of Major Depressive Disorder (MDD). However, many of the other features with relatively high frequencies across the studies are associated features in the DSM, but are not prioritized as diagnostic criteria and therefore not included in standard instruments. The DSM-5 diagnostic criteria of problems with concentration and psychomotor agitation or slowing were infrequently mentioned. This research suggests that the DSM model and standard instruments currently based on the DSM may not adequately reflect the experience of depression at the worldwide or regional levels.

Work Relative Value Units Generated by Pediatric Urologists

INTRODUCTION

As more physicians are employed by health care organizations and hospitals, salaries are often linked to productivity. To our knowledge there are no published data on RVUs (relative value units) generated by the average pediatric urologist. We sought to determine the typical work load of a pediatric urologist.

METHODS

We reviewed de-identified billing logs submitted during 2007 and 2008 to the American Board of Urology by 230 applicants for a subspecialty certificate in pediatric urology. We analyzed wRVUs (work load RVUs), including wRVUs generated by nurse practitioners/physician assistants billing incident to the physician, for evaluation and management, ultrasound, urodynamic, biofeedback and operative codes. The relationship of wRVUs to self-reported information on practice demographics was examined.

RESULTS

The median was 8,156 wRVUs per year with the majority (4,756) generated from operative procedures and the next largest amount (2,551) generated from evaluation and management codes for office visits. The 202 men generated more wRVUs than the 28 women (median 8,303 vs 6,705 wRVUs, p <0.02). The 104 private practitioners generated more than the 108 academicians (median 9,359 vs 7,443 wRVUs, p <0.005). There was also a difference by experience. The median for 75 physicians with less than 10 years in practice vs 60 with 10 to 20 years vs 95 with more than 20 years was 7,027 vs 8,972 vs 8,291 wRVUs (p <0.001). The median was similar in 145 physicians in metropolitan areas and 77 in nonmetropolitan areas (8,279 vs 7,410 wRVUs, p = 0.30).

CONCLUSIONS

Pediatric urologists generated an average of 8,156 wRVUs per year. Most wRVUs are generated from operative procedures. Women and academic practitioners had lower median wRVUs. The most productive pediatric urologists were in practice between 10 and 20 years.

Feasibility of using CT volume as a predictor of specimen weight in a subgroup of patients with low risk Wilms tumors registered on COG Study AREN03B2: implications for central venous catheter placement

OBJECTIVE

Patients with stage I Wilms tumor, age ≤ 2 years, tumor ≤ 550 g may not require therapy beyond nephrectomy. This study's aims were to determine: (1) if a linear relationship exists between tumor weight and computed tomography (CT) estimated volume; (2) describe the accuracy of a slope-intercept equation in estimating weight; and (3) determine the potential impact of weight estimation on port placement decisions.

MATERIALS AND METHODS

Tumor weight and port placement information were abstracted from 105 patients, age ≤ 2 years, with tumors ± 550 g, enrolled in COG AREN03B2. One radiologist estimated tumor size from CT scan. Prolate ellipse volume (PEV) was calculated, linear regression performed, slope-intercept equation calculated, equation estimated weight determined, and potential impact of the on port placement evaluated.

RESULTS

A strong relationship exists between PEV and weight (R(2) = 0.87). The slope-intercept equation for weight was: weight = 1.04(PEV) + 58.75. Overall median relative error for the equation was 0.9%, and -3% in tumors weighing 350-750 g. Fifty-five ports were placed, 29 in patients with tumor weight ≤ 550 g, and six not placed in patients with tumor weight > 550 g.

CONCLUSIONS

The relationship between PEV and weight produced a reliable weight prediction equation. Preoperative consideration of specimen weight may diminish the number of ports placed in this population.

OHVIRA with a twist: obstructed hemivagina ipsilateral renal anomaly with urogenital sinus in 2 patients

BACKGROUND

OHVIRA syndrome is a rare diagnosis involving the triad of obstructed hemivagina, uterine anomaly, and ipsilateral renal anomaly. OHVIRA syndrome can be associated with other anomalies due to abnormal embryologic development of the urogenital system.

CASES

A 14-year-old female with known left renal agenesis, long-standing urinary incontinence, and history of recurrent urinary tract infections presented with abdominal distention. A 4-year-old female with known right renal agenesis and urinary incontinence was found to have a single common channel at the introitus that communicated with the bladder and a hemivagina on the left.

SUMMARY AND CONCLUSION

It is important to identify the presence of a urogenital sinus in the OHVIRA setting, as surgical management for these patients may be affected. In both cases, the urogenital sinus was preserved as the vaginal opening.

Image based feasibility of renal sparing surgery for very low risk unilateral Wilms tumors: a report from the Children's Oncology Group

PURPOSE

Nephrectomy with lymph node sampling is the recommended treatment for children with unilateral Wilms tumor under the Children's Oncology Group protocols. Using radiological assessment, we determined the feasibility of performing partial nephrectomy in a select group of patients with very low risk unilateral Wilms tumor.

MATERIALS AND METHODS

We reviewed imaging studies of 60 patients with a mean age of less than 2 years with very low risk unilateral Wilms tumor (mean weight less than 550 gm) to assess the feasibility of partial nephrectomy. We evaluated percentage of salvageable parenchyma, tumor location and anatomical features preventing a nephron sparing approach.

RESULTS

A linear relationship exists between tumor weight and computerized tomography estimated tumor volume. Mean tumor weight in the study population was 315 gm. Partial nephrectomy was deemed feasible in only 5 of 60 patients (8%).

CONCLUSIONS

When considering a select population with very low risk unilateral Wilms tumor (lower volume tumor), only a small percentage of nonpretreated patients are candidates for nephron sparing surgery.

Current management of wilms' tumor

Wilms' tumor is the most common malignant renal tumor in children. Survival has improved dramatically over time as a result of prospective randomized clinical trials conducted by the pediatric cooperative cancer groups. Current research is directed toward identifying low-risk patients for whom a reduction in treatment intensity would decrease long-term morbidity. This article reviews the most recent advances in the biology and treatment of children with Wilms' tumor.

Late effects on the urinary bladder in patients treated for cancer in childhood: a report from the Children's Oncology Group

Childhood cancer survivors who have had pelvic or central nervous system surgery or have received alkylator-containing chemotherapy or pelvic radiotherapy as part of their cancer therapy may experience urinary bladder late effects. This article reviews the medical literature on long-term bladder complications in survivors of childhood cancer and outlines the Children's Oncology Group Long-Term Follow-up (COG LTFU) Guidelines related to bladder function. An overview of the treatment of bladder late effects and recommended counseling for survivors with these complications are presented.

Hyperplastic perilobar nephroblastomatosis: long-term survival of 52 patients

BACKGROUND

This study provides insight into the clinical behavior, diagnostic complexities, and long-term management of patients with hyperplastic perilobar nephroblastomatosis (HPLN).

PROCEDURE

Fifty-two patients with HPLN with available long-term follow-up were retrospectively analyzed for pathologic, radiologic, and clinical features.

RESULTS

The mean age at diagnosis was 16 months; the lesions were bilateral in 49 patients. Of 33 patients who initially underwent diagnostic biopsy and adjuvant chemotherapy, 18 (55%) developed Wilms tumor (WT) at a mean of 35 months from diagnosis. Of 16 patients whose initial therapy included nephrectomy and adjuvant therapy, three (19%) developed WT at a mean of 36 months from diagnosis. All three patients who underwent initial diagnostic biopsy and received no adjuvant therapy during their initial course developed WT 4, 4, and 10 months following diagnosis. 24/52 patients developed either a single (13 patients) or multiple (11 patients) WT throughout their course; 8/24 (33%) of WT were anaplastic. The time from initial diagnosis to the development of the last WT ranged from 13 to 116 months (mean 42 months). Three children with HPLN died of WT at 3, 5, and 6 years of age; 2/3 were anaplastic.

CONCLUSIONS

HPLN is a self-limited, pre-neoplastic proliferative process associated with a high risk of developing WT. The accurate diagnosis and the choices of therapy during the often-complex course of HPLN depend on the availability and accurate interpretation of a combination of pathologic, radiologic, and clinical information. When such information is appropriately obtained, the long-term survival of patients with HPLN is excellent.

The value of surgery in directing therapy for patients with Wilms' tumor with pulmonary disease. A report from the National Wilms' Tumor Study Group (National Wilms' Tumor Study 5)

BACKGROUND/PURPOSE

Computed tomography (CT) of the chest with its increased sensitivity frequently identifies lesions not visible on chest radiograph. Treatment of such lesions is controversial. A recent review suggests that patients with Wilms' tumor with pulmonary lesions detected only by CT, who were treated with dactinomycin and vincristine, have an inferior outcome compared with those who also received pulmonary radiation therapy (RT) and doxorubicin. It is important to determine if these small lesions seen only on CT represent metastatic disease and whether patients with these lesions require RT and/or doxorubicin for optimal outcome.

METHODS

Patients with Wilms' tumor with lung metastasis, registered on National Wilms' Tumor Study 5, were reviewed, and those with CT-only lesions who had a radiology and surgical checklist submitted were identified. The treatment regimens of these patients and the histological findings of the pulmonary lesions are presented. We analyzed the pathological findings by whether the patients had single or multiple lesions.

RESULTS

Of 2498 patients registered on National Wilms' Tumor Study 5, 252 had pulmonary metastases. Of these patients, 129 (5.2%) had CT-only lesions (<1 cm). Forty-two of these patients (20 boys and 22 girls) underwent lung biopsy at the discretion of the attending physicians. The local tumor stages in these patients were stage I (7%), II (34%), and III (59%). The treatment stages in these patients were stage I (n = 3, 2 drugs), II (n = 3, 2 drugs), III (n = 12, 3 drugs); and IV (n = 24, 3 drugs + RT). There were 16 patients with isolated lung lesions and 26 with multiple lesions, average size 5.8 +/- 0.5 mm. Of 16 isolated lesions, 13 patients (82%) and 69% (18/26) with multiple lesions had tumor on biopsy. Of the 24 who received RT, 8 had a negative biopsy and, thus, may not have needed the RT. Five of 6 treated with just 2 drugs may have been undertreated. Nine of 12 treated with 3 drugs had tumor on biopsy.

CONCLUSIONS

Computed tomography-only pulmonary lesions are not invariably tumor, demonstrating the need for histopathological confirmation. Biopsy remains critical until radiographic techniques allow differentiation between benign and malignant lesions to optimally direct therapy.

Treatment outcomes in adults with favorable histologic type Wilms tumor—an update from the National Wilms Tumor Study Group

PURPOSE

To describe the clinical outcomes in adults with favorable histologic type (FH) Wilms tumor (WT) registered in the National Wilms Tumor Studies (NWTS) 4-5. We also describe the results of patients treated in the "modern era" (1979-2001) with surgical staging, central pathology review and stage-appropriate multimodality treatment.

METHODS AND MATERIALS

Twenty-three adult patients (> or =16 years of age) with FHWT after central pathology review were registered on NWTS 4-5. The tumor stage distribution was Stage I in 5, Stage II in 8, Stage III in 6, and Stage IV in 4 patients. All patients underwent primary nephrectomy followed by multiagent chemotherapy and/or radiotherapy (RT). All patients underwent tumor stage-based chemotherapy that generally followed existing NWTS Group (NWTSG) protocols. To analyze the outcomes of adult patients treated in the "modern era," the data from this report were combined with the data from 22 patients with FHWT previously reported in 1990 by the NWTSG.

RESULTS

The 5-year relapse-free survival, overall survival, and disease-specific survival (DSS) rate was 77.3%, 82.6%, and 95.7%, respectively, for patients registered in the NWTS 4-5 protocols. Three patients (13%) died of chemotherapy-induced hepatic venoocclusive disease. For a total of 45 adults with FHWTs treated in the "modern era," the overall survival rate was 82%. The survival rate for those with Stage I, II, III, and IV disease was 100%, 92%, 70%, and 73%, respectively. Of the 12 Stage I-II patients treated with two drugs and no RT, the survival rate was 100%. The survival rate for Stage III and IV patients treated with three drugs and RT was 63% and 70%, respectively.

CONCLUSION

The results of this report demonstrate that adults with FHWT treated with a multimodality approach similar to NWTSG protocols have good survival. We recommend that all adult patients be treated with stage-appropriate combined modality therapy, and furthermore, be entered in current Children's Oncology Group WT protocols so that coherent data can be gathered for this relatively rare tumor. Finally, all patients should be monitored for signs and symptoms of hepatic venoocclusive disease.

Transurethral Resection Syndrome After Bladder Perforation

The use of irrigating solutions is essential for distension of mucosal surfaces and visualization of the surgical field during resectoscopic resection of bladder tumors (TURBT). TURBT resection may be complicated with bladder perforation associated with intraperitoneal extravasation of irrigant fluid, which may rarely evolve in specific hydroelectrolyte imbalance characterized with hyponatremia, intravascular volume deficit, and renal impairment. We report four cases of TURBT syndrome during bladder surgery complicated by bladder perforation and discuss issues relevant to pathophysiology, diagnosis, and treatment of this rare condition.

Influence of radiation therapy delay on abdominal tumor recurrence in patients with favorable histology Wilms' tumor treated on NWTS-3 and NWTS-4: a report from the National Wilms' Tumor Study Group

PURPOSE

This study was undertaken to determine whether radiation therapy (RT) delay of >or=10 days had an adverse impact on abdominal tumor recurrence among children with favorable histology (FH) Wilms' tumor enrolled in National Wilms' Tumor Study (NWTS) 3 and 4.

METHODS AND MATERIALS

A total of 1226 patients with Stage II-IV FH tumors who received flank or abdominal RT in NWTS-3 and NWTS-4 were included in this analysis. Recurrent disease in the operative bed was classified as flank recurrence. Abdominal recurrence included all infradiaphragmatic tumor recurrences, including flank recurrences. This analysis included all flank/abdominal tumor recurrences, regardless of whether they might have been the initial or subsequent site of relapse. Based on the NWTS-1 results, RT delay was analyzed in two categories: 0-9 days and >or=10 days.

RESULTS

The mean RT delay was 10.9 days; median delay was 9 days (range: 1-277 days). The RT delay was concentrated in a relatively narrow range of 8 to 12 days after nephrectomy in the majority of patients (59%). Univariate and multivariate analysis did not reveal RT delay of >or=10 days to significantly influence flank and abdominal tumor recurrence rates in NWTS-3 or NWTS-4. The 8-year flank tumor recurrence rates for 0-9 days and 10+ days RT delay were 1.9% and 1.2%, respectively (p value = 0.3). The 8-year abdominal tumor recurrence rates for 0-9 days and 10+ days RT delay were 4.8% and 5.3%, respectively (p value = 0.7).

CONCLUSIONS

RT delay of >or=10 days did not significantly influence flank or abdominal tumor recurrence rates among children with FH tumors treated on NWTS-3 and NWTS-4. However, we were unable to test for a meaningful difference, because of the concentration of RT delay close to 10 days.

Caudal block in children: ropivacaine compared with bupivacaine

BACKGROUND

Bupivacaine provides reliable, long-lasting anesthesia and analgesia when given via the caudal route. Ropivacaine is a newer, long-acting local anesthetic that (at a concentration providing similar pain relief) has less motor nerve blockade and may have less cardiotoxicity than bupivacaine.

METHODS

In a double-blind trial, 81 healthy children, undergoing ambulatory surgical procedures, were randomly allocated to receive caudal analgesia with either bupivacaine or ropivacaine, 0.25%, 1 mVkg. All blocks were placed by an attending anesthesiologist or an anesthesia fellow after induction of general anesthesia.

RESULTS

Data were available for 75 children. There were no significant differences between the two groups in baseline characteristics or in anesthesia, surgery, recovery room, or day surgery unit durations. The quality and duration of postoperative pain relief did not differ. Motor and sensory effects were similar. Time to first micturition did not differ.

CONCLUSION

Ropivacaine (0.25%, 1 ml/kg) provided adequate postoperative analgesia with no difference from bupivacaine (0.25%, 1 ml/kg) in quality and duration of pain relief, motor and sensory effects, or time to first micturition in our study children.

Effect of duration of treatment on treatment outcome and cost of treatment for Wilms' tumor: a report from the National Wilms' Tumor Study Group

PURPOSE

National Wilms' Tumor Study (NWTS)-4 was designed to evaluate the efficacy, toxicity, and cost of the administration of different regimens for the treatment of Wilms' tumor (WT).

PATIENTS AND METHODS

Between August 6, 1986 and September 1, 1994, 905 previously untreated children aged younger than 16 years with stage II favorable histology (FH) WT (low-risk [LR]), stages III to IV FH WT, or stages I to IV clear-cell sarcoma of the kidney (high-risk[HR]) were randomized after the completion of 6 months of chemotherapy to discontinue (short) or continue for 9 additional months (long) treatment with chemotherapy regimens that included vincristine and either divided-dose (standard [STD]) courses (5 days) or single-dose (pulse-intensive [PI]) treatment with dactinomycin. HR patients also received either divided-dose (STD) courses (3 days) or single-dose (PI) treatment with doxorubicin.

RESULTS

The 4-year relapse-free survival (RFS) rates after the second randomization for LR patients were 83.7% for the 190 patients treated with short and 88.2% for the 187 patients treated with long chemotherapy (P = .11). The 4-year RFS rates after the second randomization for HR FH patients were 89.7% for the 256 patients treated with short and 88.8% for the 246 patients treated with long chemotherapy (P = .87). The charge for treatment with the short PI treatment regimens for all children with stages I through IV FH WT was approximately one half of that with the long STD treatment regimens.

CONCLUSION

The short administration schedule for the treatment of children with WT is no less effective than the long administration schedule and can be administered at a substantially lower total treatment cost.

Long-term renal function in patients with irradiated bilateral Wilms tumor. National Wilms' Tumor Study Group

The treatment of bilateral Wilms tumor (BWT) involves a multidisciplinary approach including surgery, chemotherapy, and radiation therapy. The long-term renal function in patients receiving all three treatment modalities has not been evaluated. Long-term renal function was evaluated in 81 children with synchronous BWT who received radiation therapy as part of their treatment. Renal function was assessed by measuring blood urea nitrogen (BUN) and serum creatinine (Cr). The normal range for the BUN was defined as 10-24 mg/dl, and the Cr was considered normal at levels of <1.5 mg/dl. Moderate elevations were defined as a BUN of 25-50 mg/dl and/or a Cr of 1.6-2.5 mg/dl and marked elevations as a BUN of >50 mg/dl and/or a Cr of >2.5 mg/dl. BUN and Cr levels were measured prior to treatment and at the following intervals: 6 months after treatment, 1 year after treatment, 2 years after treatment, and at last follow-up. Any elevation during the posttreatment follow-up period was considered abnormal. A total of 28 children (34.6%) had elevated BUN and/or Cr levels, and 18 had moderate and 10 had marked renal insufficiency. No dose-response relationship was established when comparing the radiation doses of those with elevated values to those with normal values. The renal complication rate was moderate, and other factors including surgery, extent and nature of chemotherapy, and recurrent tumor must also be taken into account. The elevations present in several children could be attributed to tumor recurrence and in one case to gentamicin toxicity. The management of children with BWT should consider all of these risks, and attempts to preserve renal parenchyma are warranted.

Clinical assessment of urethral sphincter function

Measurements of urethral pressures, such as maximum urethral pressure, are widely believed to have relevance in the management of urinary incontinence despite evidence to the contrary. In this study maximum urethral pressure and the abdominal pressure required to cause stress incontinence were measured in 125 women with stress incontinence. In women the abdominal pressure required to cause stress incontinence was unrelated to maximum urethral pressure. These findings indicate that maximum urethral pressure has little relationship to urethral resistance to abdominal pressure. In the 9 children with myelodysplasia we compared the detrusor pressure with the abdominal pressure required to induce urethral leakage. These values also were quite different, indicating that as far as the urethra is concerned abdominal pressure and detrusor pressure are not equivalent forces.

Incidental appendectomy during nephrectomy for Wilms' tumor

Incidental appendectomy is frequently performed during nephrectomy for Wilms' tumor. The rationale for this approach is that the onset of appendicitis during a period of neutropenia after chemotherapy may cause increased morbidity. Additionally, children receiving chemotherapy or radiation therapy, or both, may experience abdominal pain, producing a diagnostic dilemma if the appendix is still present. We reviewed the charts of 1,910 children enrolled in the Third National Wilms' Tumor Study who underwent primary nephrectomy. Four hundred and fifty-five patients (23.8 percent) had appendectomy at the time of nephrectomy. An inversion appendectomy was performed upon 188 patients, and the appendix was excised in 267. Infectious complications and postoperative intestinal obstructions occurred with equal frequency in children who did or did not undergo appendectomy. The median follow-up period for the entire group of patients was 5.1 years. Only three of the 1,455 children (0.2 percent) who did not have an incidental appendectomy had appendicitis at two, seven and ten months after nephrectomy. None of the three children experienced any perioperative morbidity after appendectomy. These data suggest that incidental removal of the appendix is not essential for children undergoing removal of a Wilms' tumor.

Adventitious knots in urethral catheters: report of 5 cases

Urethral catheterization with 5 or 8F feeding tubes in 5 boys was complicated by stochastic knotting within the bladder thereby impeding removal. The common factor in these patients was insertion of excessive length within the bladder. Percutaneous endoscopic retrieval was done successfully in 1 child. This technique may avoid urethral trauma associated with catheter removal, particularly in younger boys.

Sabin inactivated trivalent poliovirus vaccine: first clinical trial and seroimmunity survey

The most widely used poliovaccine in the United States contains the three live attenuated strains originally produced by Sabin. An inactivated ("killed") formulation of this trivalent polio vaccine has now been prepared. Before testing this new vaccine, we assessed the poliovirus immune status of 39 healthy adult males between the ages of 20 and 44 years and found that 69% had detectable (titer greater than or equal to 1:4) neutralizing antibody to all three types of poliovirus, whereas 31% lacked antibody to 1 or more types even though they had a history of childhood polio immunization. Of interest, the lowest levels of neutralizing antibody were found among young adults in their late 20s, 2 of whom lacked antibody to all 3 polio types. When the Sabin inactivated trivalent poliovirus vaccine was initially administered to 12 seropositive volunteers, all responded with rising titers of neutralizing antibody that persisted for at least 18 months (range, 1:249 to 1:4948). The new vaccine was also given to a second group of 9 individuals with little or no detectable neutralizing antibody to at least one poliovirus type and again all vaccinees manifested a humoral immune response to poliovirus. Except for transient local tenderness at the injection site, no untoward reactions to immunization were observed. Thus, this Phase I study (1) confirmed earlier reports that titers of poliovirus antibody may decline to undetectable levels by early adulthood and (2) demonstrated that adults previously immunized with poliovirus vaccine responded rapidly to all 3 poliovirus types (within 7 days) upon reimmunization with Sabin inactivated trivalent vaccine whether or not there was preexisting detectable antibody.

A case of pediatric ureteroscopic lasertripsy

The standard treatment for ureteral calculi in children has been open surgical removal. Recently, we removed successfully a lower ureteral calculus in a young child with ureteroscopy and the pulsed dye laser. The improvements in smaller rigid and flexible ureteroscopes, in conjunction with lasertripsy, will expand its applications in the treatment of pediatric urolithiasis.

Treatment of Chlamydia trachomatis infections: comparison of 1- and 2-g doses of erythromycin daily for seven days

Erythromycin is recommended as the alternative to tetracyclines for the treatment of Chlamydia trachomatis infections. However, the usual dose of erythromycin (2 g daily for a week) is frequently associated with gastrointestinal side effects. The goal of this study was to determine whether 1 g of erythromycin daily for a week would be as effective as the 2-g daily dose but without the adverse gastrointestinal effects associated with the larger dose. A total of 114 patients were entered into a randomized double-blind study; 76 patients completed treatment, 13 patients discontinued treatment because of adverse effects, and 25 failed to complete therapy or to return after treatment was initiated. Twelve (27%) of the 45 patients treated with 1 g of erythromycin had cultures positive for C. trachomatis after therapy, as compared with three (10%) of 31 patients treated with a 2-g dose. Only 34% of those treated with 1 g of erythromycin developed adverse gastrointestinal effects, as compared with 71% of those who received 2 g of the drug. Of the 13 patients who discontinued treatment because of side effects, 11 were receiving the 2-g dose. This study indicates that the smaller 1-g dose of erythromycin is inadequate therapy for C. trachomatis infections and that the standard 2-g dose is frequently associated with adverse effects that require discontinuation of therapy.