Smooth muscle tumours of the vulva in Jamaica

Smooth muscle tumours of the vulva are uncommon and their behaviour is unpredictable. A 30-year retrospective analysis of the pathology files and patient records revealed 10 cases diagnosed at the University Hospital of the West Indies, Kingston, Jamaica, with one malignant and one recurrent tumour. Size, infiltrating margins and mitotic count are important parameters to determine prognosis. Although these tumours are of low malignancy, mitotic count may be mandatory in determining their potential for recurrence.

Cervical pregnancy. Case report and literature review

Cervical pregnancy is an uncommon life threatening form of ectopic pregnancy that is associated with the unexpected occurrence of uncontrollable haemorrhage from the cervix. To avoid hysterectomy and to maintain fertility, several conservative methods of termination have been used. We present herein, one such case which relates to a young woman who had successful conservative management of a cervical pregnancy using vasopressin infiltration of the cervix, a McDonald cerclage and cervical curettage followed by balloon tamponade. Subsequently, she became pregnant again with a normal intra-uterine pregnancy and had a successful vaginal delivery.

Operative morbidity and reproductive outcome in secondary myomectomy: a prospective cohort study

BACKGROUND

This prospective study was designed to evaluate the operative morbidity and reproductive outcome in patients who had secondary myomectomy for recurrent symptomatic uterine fibroids.

METHODS

A total of 58 women were subjected to a secondary myomectomy via the abdominal route. The operative morbidity such as blood loss, presence of adhesions and febrile index were estimated and the pregnancy outcome over a 2-4 year period of follow-up.

RESULTS

The mean age and standard deviation (+/- SD) of the women was 35 (+/- 2.4) years. Nineteen patients (33%) had a postoperative temperature vertical line 100 degrees F and the estimated blood loss ranged from 159-2500 ml (median 700 ml). Seven patients (12%) required blood transfusion and one had a hysterectomy due to haemorrhage. Nine women (15.5%) became pregnant but only five (56%) had live births. Those with successful pregnancies tended to be younger with a mean age of 31.8 (+/- 2.6) years versus 35 (+/- 1.8) years, (P = 0.08, non-significant) and had fewer uterine leiomyomata; median with range values, 2 (1-6) versus 7 (6-15). The variables which best predicted the postoperative likelihood of pregnancy were; age, presence of tubal adhesions and the number of uterine fibroids.

CONCLUSION

This prospective study showed a high operative morbidity and a poor fertility outcome after a repeat myomectomy. The factors affecting successful outcome in a logistic regression model were age, tubal adhesions and number of uterine fibroids.

A randomised controlled trial of outpatient versus inpatient cervical cerclage

Fifty patients with cervical incompetence were randomised to have cervical cerclage either as inpatients, spending 3 days in hospital post-procedure on supervised bed rest or as outpatients spending the time at home on bed rest. Both groups had a clinical diagnosis of cervical incompetence and both had either McDonald or Shirodkar cerclage with mersilene tape. Both groups were given salbutamol tablets for tocolysis, postoperatively. There were no significant difference in the demographic variables between the groups such as previous cerclage, gestational age at insertion, parity and gestational age at delivery. There were also no significant differences in early complications such as bleeding. Most late complications were also not different, including the spontaneous abortion rate, premature rupture of membranes, cervical dystocia and preterm delivery. However, more patients in the outpatient group had premature contractions (26.1% vs. 4.3% P=0.0479). More patients in the inpatient group had a delivery of a live neonate, 86.9% vs. 78.3%, but the difference was not statistically significant. In conclusion, out patient cerclage appears to be a valid option, the higher rate of premature contraction in this group is not a cause for concern in view of the similar mean gestational age at delivery.

HIV infection seroprevalence and risk factor study among pregnant women attending the Antenatal Clinic at the University Hospital of the West Indies, Kingston, Jamaica

The objectives of this study were to determine the seroprevalence and risk factors for Human Immunodeficiency Virus (HIV) infection among the antenatal clinic population at the University Hospital of the West Indies (UHWI). Pregnant mothers (4186) attending antenatal clinic at the UHWI were screened for HIV infection between September, 1998, and October, 2000. Tests were performed with the use of Abbott enzyme immunoassay (EIA) kits for the detection of antibodies to HIV 1 and 2. Demographic characteristics and risk factor assessments were performed using a questionnaire for all positive cases and four randomly selected negative controls matched by age to each positive case. Twenty-one women were found to be HIV positive. Nineteen of these women were not previously aware that they were HIV-positive. The seroprevalence of HIV infection among antenatal mothers was 0.5%. The mean age of cases was 29.3 +/- 4.6 years. There was no significant difference between cases and controls with regards to parity, socio-economic status and educational achievement. Women residing in urban Kingston and St Andrew (Odds ratio (OR) 5, 95% confidence interval (CI) 1.4, 18), as well as those with a higher number of lifetime sexual partners (OR 1.42, 95% CI 1.13, 1.79) and those with previous sexually transmitted diseases (OR 3.4, 95% CI 1.1, 10.6) were at greater risk for HIV infection. In contrast, women who commenced coitus at a later age were at less risk of becoming infected (OR 0.79, 95% CI 0.6, 0.97). This study demonstrates a low seroprevalence of HIV in the UHWI antenatal population compared to the reported seroprevalence of 2%-8% in pregnant women in Latin America and the Caribbean. The results from this study emphasize the continuing need for voluntary HIV testing and HIV/AIDS educational campaign for this vulnerable group.

Misoprostol use in obstetrics and gynecology in Brazil, Jamaica, and the United States

OBJECTIVES

To investigate current clinical use of misoprostol for the treatment of a range of reproductive health indications by providers in Brazil, Jamaica, and the United States.

METHODS

Using a 'snowball' sampling technique, we surveyed 228 gynecologists and obstetricians in Brazil (n=123), Jamaica (n=52), and the United States (n=53).

RESULTS

Providers use misoprostol for labor induction (46%), postpartum hemorrhage (8%), intra-uterine fetal death (61%), cervical priming (21%), missed abortion (57%), and incomplete abortion (16%) as well as first and second trimester abortion induction (27% and 13%, respectively).

CONCLUSIONS

There is considerable variation in the regimens used; moreover, the regimens commonly used in clinical practice often differ from those recommended in the medical literature. While misoprostol is an appealing alternative for many reproductive health indications in developing countries, the varied regimens and lack of registration raise critical medical and policy questions.

Relation between quality of recovery in hospital and quality of life at 3 months after cardiac surgery

BACKGROUND

Improved quality of life (QoL) is a desirable outcome of cardiac surgery. The aim of the current study was to measure the association between quality of recovery 3 days after surgery and QoL measured 3 months later.

METHODS

After obtaining ethics committee approval and consent, 120 adult cardiac surgical patients were studied. A 40-item quality of recovery score (QoR-40) was used to measure postoperative health status on days 1-3 and 1 month after surgery. QoL was measured using the short-form health survey (SF-36) at 1 and 3 months after surgery. The effect size (delta mean/SD) was used to define responsiveness, a clinically important difference in health. Associations were measured using correlation and reliability coefficients.

RESULTS

There was a significant change in the mean QoR-40 for up to 1 month after surgery (P < 0.0005). QoL was improved at 3 months (P < 0.0005) but not 1 month (P = 0.29) after surgery. There was a moderate correlation between day-3 QoR-40 and 3-month SF-36 (r = 0.39; P < 0.0005). A poor-quality recovery in hospital predicted a poor QoL at 3 months (adjusted odds ratio, 4.20; 95% confidence interval, 1.41-12.5; P = 0.01).

CONCLUSIONS

The QoR-40 is a valid measure of quality of recovery after surgery and anesthesia. When compared with the SF-36, it is a better measure of early postoperative recovery. A poor-quality recovery on the days after surgery can predict a poor QoL at 3 months after surgery. This may allow earlier and more effective support strategies while patients are still in the hospital (counseling, home assistance, local doctor notification, cardiac rehabilitation).

Sex differences in cocaine-induced behavioral sensitization

To further understand how sex differences affect the development and maintenance of sensitization, 48 adult Fischer rats (24 female and 24 male) received chronic administration (14 days) of cocaine (15 mg/kg, i.p.) or saline or a challenge dose (7 days after chronic cocaine administration). Sex differences were observed in the development and maintenance of cocaine-induced total locomotor, ambulatory and rearing activity. Although, overall cocaine administration increased stereotypic activity in both male and female rats, female rats had significantly higher stereotypic activity than male rats across the three behavioral test days (1, 7 and 14). Female rats had statistically significant higher benzoylecognine levels after acute cocaine administration than male rats. However, no differences between male and female rats in benzoylecognine plasma levels were observed after chronic and challenge doses of cocaine administration. Interestingly, after acute and challenge cocaine administration, corticosterone levels were significantly higher in female rats when compared to male rats. This study confirms previous reports that there are sex differences in the behavioral response to cocaine. Moreover, this study expands previous studies by demonstrating that sex differences occur in only certain aspects of cocaine-induced behavioral activation and the development and maintenance of cocaine-induced behavioral sensitization.

Adding ketamine to morphine for patient-controlled analgesia after major abdominal surgery: a double-blinded, randomized controlled trial

In this double-blinded, randomized controlled trial we tested if the addition of ketamine to morphine for patient-controlled analgesia (PCA) resulted in improved analgesic efficacy and lower pain scores compared with morphine PCA alone after major abdominal surgery. Seventy-one patients were randomly allocated to receive either morphine 1 mg/mL (Group M) or morphine 1 mg/mL plus ketamine 1 mg/mL (Group MK) delivered via PCA after surgery. No other analgesics or regional blocks were permitted during the 48-h study period. Postoperatively there were no differences between the groups for subjective assessment of analgesic efficacy, pain scores at rest, and on movement, opioid consumption, or adverse events. Group MK patients performed worse in cognitive testing (P = 0.037). There was an increased risk of vivid dreaming in patients who received ketamine (relative risk = 1.8, 95% confidence interval 0.78-4.3). We conclude that small-dose ketamine combined with PCA morphine provides no benefit to patients undergoing major abdominal surgery.

IMPLICATIONS

We performed a randomized, controlled trial comparing the use of ketamine and morphine with morphine alone to relieve pain after major abdominal surgery.Ketamine did not improve pain relief and merely increased side effects.

Ovarian hormones modulate cocaine-induced locomotor and stereotypic activity

Interactions between ovarian hormones and cocaine may underlie gender and estrous cycle differences in cocaine-induced behavioral and neurochemical alterations. The aim of this study was to further understand how ovarian hormones modulate cocaine-induced behavioral alterations. Ovariectomized rats received acute or chronic saline or cocaine (15 mg/kg i.p.) administration and were further subdivided into one of four hormone-treatment conditions: cholesterol (vehicle-control), estrogen, progesterone, or estrogen + progesterone. Overall, acute and chronic cocaine administration increased all locomotor measurements (total locomotor, ambulatory, and rearing counts). Estrogen administration augmented cocaine-induced increases in ambulatory and rearing activity. After chronic cocaine administration, rats in the vehicle-control group developed behavioral tolerance (exhibited by a decrease in activity) in rearing and ambulatory activity. Estrogen replacement not only prevented the development of tolerance in ambulatory and rearing activities, but also enhanced total locomotor activity (sensitization) in response to chronic cocaine. Progesterone treatment did not alter the behavioral responses to acute or chronic cocaine administration. Estrogen + progesterone-treated animals had higher counts of locomotor activity in response to chronic cocaine than did vehicle-control or progesterone-treated rats. In stereotypic behaviors, the different hormonal treatments did not affect activity in cocaine- or saline-treated rats after acute or chronic drug administration. Plasma levels of cocaine did not change after different hormonal treatments. Interestingly, animals' coadministered chronic cocaine and estrogen had higher levels of corticosterone than did nonestrogen cocaine-treated rats. Thus, it is likely that alterations in HPA activation may underlie the observed behavioral differences. In summary, these data suggest that there are interactions between ovarian hormones and cocaine-induced behavioral alterations in female rats, and they extend previous results by showing that estrogen and progesterone affect the development of sensitization.

Pentapotassium dodecatungstoborate(III) hexadecahydrate

The title compound, K(5)[BW(12)O(40)].16H(2)O, contains a [BW(12)O(40)](5-) polyanion of 222 crystallographic symmetry, with a central tetrahedrally coordinated B(III) atom surrounded by four groups of three edge-sharing octahedra (W(3)O(13) subunits), which are linked in turn to each other and to the central BO(4) tetrahedron by shared O atoms at the vertices. There is a crystallographically unique B-O bond of 1.554 (10) A, while the average W-O distances are 2.344 (17) A for four coordinate O atoms, 1.917 (12) and 1.89 (2) A for two coordinate O atoms within and connecting the W(3)O(13) subunits, respectively, and 1.709 (8) A for terminal O atoms. Not all of the K(+) ions and H(2)O groups were located.

Design, synthesis, SAR, and biological evaluation of highly potent benzimidazole-spaced phosphono-alpha-amino acid competitive NMDA antagonists of the AP-6 type

A series of 2-amino-(phosphonoalkyl)-1H-benzimidazole-2-alkanoic acids was synthesized and evaluated for NMDA receptor affinity using a [3H]CPP binding assay. Functional antagonism of the NMDA receptor complex was evaluated in vitro using a stimulated [3H]TCP binding assay and in vivo by employing an NMDA-induced seizure model. Several compounds of the AP-6 type demonstrated potent and selective NMDA antagonistic activity both in vitro and in vivo. In particular, [R(-)]-2-amino-3-(5-chloro-1-phosphonomethyl-1H-benzoimidazol-2-yl)-propionic acid (1) displayed an IC(50) value of 7.1 nM in the [3H]CPP binding assay and an ED(50) value of 0.13 mg/kg (ip) in the NMDA lethality model. Compound 1, when administered intravenously as a single bolus dose of 3 mg/kg following permanent occlusion of the middle cerebral artery in the rat, reduced the volume of infarcted brain tissue by 45%. These results support a promising therapeutic potential for compound 1 as a neuroprotective agent.

A retrospective review of pregnancy outcome after misoprostol (prostaglandin E1) induction of labour

This retrospective study looked at the outcome of using 50-100 micrograms misoprostol once daily to induce labour compared to the outcome of the overall patient population delivered during the same period (1994-1996). During that period 11,255 patients were delivered and 1037 (9.2%) were induced with misoprostol. Results showed a significantly lower mean Caesarean section rate: 9.3% for the misoprostol group versus 13.3% for the overall population (p = 0.002, Odds Ratio (OR) 0.67, 95% CI 0.53, 0.83). The abruption rates were not significantly different: 0.8% for misoprostol versus 0.4% (p = 0.09, OR 1.86, 95% CI 0.81, 4.09). There was more postpartum haemorrhage in the misoprostol group: 5.6% versus 3.5% (p = 0.0006, OR 1.63, 95% CI 1.22, 2.19); a higher incidence of Apgar scores less than 6 at one minute 10.2% versus 7.9% (p = 0.0093, OR 1.33, CI 1.06, 1.65) but not at five minutes 2.9% versus 2.4% (p = 0.674, OR 1.09, CI 0.73, 1.61) and a higher perinatal mortality rate 55/1000 versus 16.3/1000 (p = 0.00, OR 3.5, 95% CI 2.55, 4.80). The rate remained higher but not significantly so when a correction was made to eliminate the high number of intrauterine deaths induced with misoprostol 18/1000 versus 16.3/1000 (p = 0.69, OR 1.11, 95% CI 0.66, 1.84). There were no cases of uterine rupture in either group. In conclusion, there was a significantly lower Caesarean section rate among patients who had once daily misoprostol induction of labour. Close monitoring of the foetus, in patients with misoprostol induction, is needed to detect foetal distress and prophylaxis against postpartum haemorrhage is still mandatory.

Part I: propofol, thiopental, sevoflurane, and isoflurane-A randomized, controlled trial of effectiveness

When compared with thiopental and isoflurane, propofol and sevoflurane are associated with a faster return to wakefulness after anesthesia. Yet their wider usage in inpatient surgery has been restrained by concerns regarding their acquisition costs and by lack of studies demonstrating improved patient outcome. We randomly allocated 453 adult surgical inpatients to one of four anesthetic regimens (thiopental-isoflurane, propofol-isoflurane, propofol induction and maintenance, or sevoflurane induction and maintenance) and measured their rate and quality of recovery. We found no significant differences in the rate and quality of recovery between groups. Propofol was associated with more pain on injection (P: < 0. 0005), but less cough during induction (P: = 0.003), and less early postoperative nausea and vomiting (P: = 0.003). We could not detect any significant advantages with propofol and sevoflurane, when compared with thiopental and isoflurane in adults undergoing elective inpatient surgery.

IMPLICATIONS

Propofol and sevoflurane do not offer any significant advantages over thiopental and isoflurane in adults undergoing elective inpatient surgery.

Systemic phaeohyphomycosis in pregnancy and the puerperium

Systemic fungal infections are rare. In pregnancy, treatment is problematic because of the risk of possible teratogenic effects of the antifungal drugs. We present the case of a 32 year-old woman who presented during pregnancy with a two-month history of painless subcutaneous nodules. Excision biopsy of one lesion showed dematiaceous fungal elements. Anti-fungal treatment was deferred and the pregnancy proceeded uneventfully. The remaining nodules were excised at the time of caesarean section delivery. Three weeks into the puerperium, she developed generalised seizures and investigations indicated systemic fungal infection with positive cultures for Aureobasidium spp which responded to appropriate antifungal therapy of flucytosine and itraconazole.

Synthesis and SAR of adatanserin: novel adamantyl aryl- and heteroarylpiperazines with dual serotonin 5-HT(1A) and 5-HT(2) activity as potential anxiolytic and antidepressant agents

Several novel functionalized adamantyl aryl- and heteroarylpiperazine derivatives were prepared and examined in various receptor binding and behavioral tests to determine their serotonin receptor activities. Many compounds demonstrated modest to high affinity for 5-HT(1A) receptors, with compounds 9, 13, 23, 33, 34, and 43 being the most potent at this site. Compound 1, 2-[4-(2-pyrimidinyl)-1-piperazinyl]ethyl adamantyl-1-carboxylate, demonstrated relatively high affinity for 5-HT(1A) receptors (K(i) = 8 nM) and acceptable selectivity versus D(2) receptors (K(i) = 708 mM); however, it lacked in vivo activity in serotonergic behavioral models. In contrast, compounds 9 (WY-50,324, SEB-324, adatanserin), adamantyl-1-carboxylic acid 2-[4-(2-pyrimidinyl)-1-piperazinyl]ethylamide, and 13, adamantyl-1-carboxylic acid 2-[4-(2-methoxyphenyl)-1-piperazinyl]ethylamide, demonstrated high affinity for 5-HT(1A) binding sites (K(i) = 1 nM for both) and moderate affinity for 5-HT(2) receptors (K(i) = 73 and 75 nM, respectively). Both compounds also demonstrated partial 5-HT(1A) agonist activity in vivo in rat serotonin syndrome and 5-HT(2) antagonist activity in quipazine- and DOI-induced head shake paradigms. The selective 5-HT(1A) partial agonist and 5-HT(2) antagonist activity of 9 was accompanied by significant anxiolytic activity in an animal conflict model. On the basis of this profile, compound 9 entered development as a combined anxiolytic and antidepressant agent.

Lupus anticoagulant in Jamaican primiparae and the clinical significance in asymptomatic patients

Sera from one thousand pregnant primiparous women from the antenatal clinic of the University Hospital of the West Indies (UHWI) were screened for lupus anticoagulant. Twenty-three women (2.3%) were seropositive. A review was performed after delivery and eight hundred and sixty-eight (87%) of the case notes were found: 20/23 (87%) of those with positive tests and 848/977 (87%) of those with negative tests. The outcome variables examined were pre-eclampsia, postpartum haemorrhage, type of delivery, birth weight of the baby, foetal outcome, foetal distress, still birth, neonatal death, Apgar score at birth and need for admission to the special care nursery. No differences were found between the two groups for any of these variables.

Massive ascites secondary to severe endometriosis

Massive ascites is an unusual association with endometriosis. This case report is of such a condition in an Afro-Jamaican woman. The diagnosis was made at laparotomy and conservative treatment was adopted allowing for retention of reproductive function. Postoperative therapy was Goserelin, a Gonadotropin Releasing Hormone (GnRH) agonist, for six months. This relieved all of her symptoms. However, long term follow-up is needed, as recurrence is possible.

Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults

A variety of methods have been used to quantify aspects of recovery after anesthesia. Most are narrowly focused, are not patient-rated, and have not been validated. We therefore set out to develop a patient-rated quality of recovery score. We constructed a 61-item questionnaire that asked individuals (patients and relatives, medical and nursing staff; total n = 136) to rate various postoperative items describing features a patient may experience postoperatively. The most highly ranked items were included in a final nine-point index score, which we called the "QoR Score." We then studied two cohorts of surgical patients (n = 449). There was good convergent validity between the QoR Score and the visual analog scale score (rho = 0.55, P < 0.0001). Discriminant construct validity was supported by comparing resultant QoR Scores in patients undergoing day-stay, minor, and major surgery (P = 0.008), as well as a negative correlation with duration of hospital stay (rho = -0.20, P < 0.0001), and, using multivariate regression, demonstrating a significant negative relationship between QoR Score and female gender (P = 0.048) and older age (P = 0.041). There was also good interrater agreement (rho = 0.55, P < 0.0001), test-retest reliability (median rho = 0.61, P < 0.0001), and internal consistency (alpha = 0.57 and 0.90, P < 0.0001). There was a significant difference between the groups of patients recovering from major and minor surgery (P < 0.001). This study demonstrates that the QoR Score has good validity, reliability, and clinical acceptability in patients undergoing many types of surgery.

IMPLICATIONS

We set out to develop a patient-rated quality of recovery score (QoR) that could be used both as a measure of outcome in perioperative trials and for clinical audit. We first surveyed patients and staff to identify important aspects of recovery, then developed a nine-point QoR Score. This was then compared with other measures of postoperative outcome. We found that the QoR Score is a useful measure of recovery after anesthesia and surgery.

Successful pregnancy outcome after hysteroscopic adhesiolysis in Asherman's syndrome

Asherman's syndrome is an uncommon finding at hysterosalpingography for infertility. Modern day management entails hysteroscopic confirmation and adhesiolysis. We present one such case of a young woman who had secondary infertility after dilatation and curettage, and who was diagnosed and treated with a successful outcome.

A randomized comparison of vasopressin and tourniquet as hemostatic agents during myomectomy

OBJECTIVE

To assess the comparative efficacy of perivascular vasopressin and tourniquet in minimizing bleeding and its sequelae at myomectomy.

METHODS

Between March 1994 and February 1995, 52 women with symptomatic uterine leiomyomas scheduled for myomectomy were entered into a randomized trial comparing vasopressin (26 patients) and tourniquet (26 patients) for hemostasis. Myomectomy was performed after either the perivascular injection of 20 U of vasopressin diluted to 20 mL with normal saline or with the use of a Foley catheter tourniquet around both uterine vessels. The efficacy of each method was measured by comparing differences in pre- and postoperative hemoglobin levels, intraoperative blood pressure, measured blood loss, need for blood transfusion, evidence of postoperative febrile morbidity, complications, and length of hospital stay.

RESULTS

Vasopressin resulted in less blood loss (mean 287.3 mL [standard deviation (SD) 195] versus 512.7 mL [SD 400] for tourniquet [P = .036]). Six of 26 patients in the tourniquet group lost more than 1000 mL of blood, whereas all of the vasopressin subjects lost less than this amount (P = .023). However, there were no significant differences between the two groups in the fall in the hemoglobin level, number of blood transfusions given, intraoperative blood pressure, highest postoperative pulse and temperature, or other complications.

CONCLUSION

Vasopressin prevents blood loss better than using the tourniquet during myomectomy.

Intramyometrial vasopressin as a haemostatic agent during myomectomy

OBJECTIVE

To assess the efficacy of intramyometrial vasopressin for minimising bleeding and its sequelae at myomectomy.

DESIGN

A randomised placebo controlled trial.

SETTING

University Hospital of the West Indies, Kingston, Jamaica.

SUBJECTS

Twenty women with symptomatic uterine fibroids scheduled for myomectomy who satisfied entry criteria: 10 randomised to the vasopressin group and 10 to the control group.

INTERVENTION

Myomectomy was performed after the intramyometrial injection of either 20 units vasopressin diluted to 20 ml in normal saline or placebo (20 ml normal saline).

MAIN OUTCOME MEASURES

The efficacy of vasopressin was measured by comparing pre- and post-operative haemoglobin levels and haematocrit, changes in intra-operative pulse and blood pressure, measured blood loss, need for blood transfusion and post-operative febrile morbidity in the treatment and control groups.

RESULTS

The use of vasopressin resulted in median blood loss of 225 ml (range 150-400 ml) compared with 675 ml (range 500-800 ml) in the placebo group (P < 0.001). The vasopressin group had a correspondingly lower fall in haemoglobin level (median 1.7 g/dl vs 5.3 g/dl, P < 0.001) and haematocrit (median 5% vs 13%, P < 0.001) compared with the controls. Fifty percent of the placebo group had blood transfusions compared with none in the vasopressin group (P = 0.03). There were no significant differences between the groups in intra-operative pulse and blood pressure or post-operative white blood cell counts or temperature.

CONCLUSION

The results indicate that vasopressin is effective in preventing blood loss and reducing the need for blood transfusion during myomectomy.

Intravaginal misoprostol versus dinoprostone as cervical ripening and labor-inducing agents

OBJECTIVE

To compare dinoprostone (prostaglandin E2) and misoprostol (prostaglandin E1) for ripening the cervix and inducing labor at term.

METHODS

Sixty-three women were randomized to receive 100 micrograms misoprostol or 3 mg dinoprostone, both as intravaginal tablets.

RESULTS

There was no statistical difference between the groups for pre-induction status. The mean Bishop scores before drug insertion were almost identical. Twelve hours after insertion, the mean change in the Bishop score was significantly higher in those receiving misoprostol (5.0 versus 3.3) (P = .008). However, there were no significant differences in induction-to-delivery interval, spontaneous labor rates, type of delivery, fetal outcome, or maternal complications.

CONCLUSION

Misoprostol is as effective as dinoprostone for inducing labor at term.

Radical vulvectomy--a 21-year review

The factors surrounding patients subjected to radical vulvectomy were examined. Most patients were over the age of 40 years. The standard butterfly incision was used in all but 2 cases. The histology in all cases was invasive squamous cell carcinoma. The main complications were primary haemorrhage, urinary tract infection and wound dehiscence. The mean hospital stay was 50 days and the mortality rate was 4 per cent.

2-Phenyl-2-(1-hydroxycycloalkyl)ethylamine derivatives: synthesis and antidepressant activity

A series of 2-phenyl-2-(1-hydroxycycloalkyl)ethylamine derivatives was examined for the ability to inhibit both rat brain imipramine receptor binding and the synaptosomal uptake of norepinephrine (NE) and serotonin (5-HT). Neurotransmitter uptake inhibition was highest for a subset of 2-phenyl-2-(1-hydroxycyclohexyl)dimethylethylamines in which the aryl ring has a halogen or methoxy substituent at the 3- and/or 4-positions. Potential antidepressant activity in this subset was assayed in three rodent models--the antagonism of reserpine-induced hypothermia, the antagonism of histamine-induced ACTH release, and the ability to reduce noradrenergic responsiveness in the rat pineal gland. An acute effect seen in the rat pineal gland with several analogues, including 1-[1-(3,4-dichlorophenyl)-2-(dimethylamino)ethyl]cyclohexanol (23) and 1-[2-(dimethylamino)-1)-(4-methoxyphenyl)ethyl]cyclohexanol (4), was taken as a possible correlate of a rapid onset of antidepressant activity. Compound 4 (venlafaxine) is presently undergoing clinical evaluation.

Penile prostheses in the management of impotence in sickle cell disease

Priapism lasting more than 24 h in adults with homozygous sickle cell disease usually results in impotence. The dense fibrosis of the corpora cavernosa which destroys the normal vascular erectile system of the penis also complicates insertion of penile prostheses. Our experience in 5 patients is reviewed. Sharp dissection and dilatation were necessary to form a tunnel for the prosthesis, which was more easily excavated anteriorly and posteriorly through a dorsal incision than for the length of the corpora through a traditional perineal-scrotal incision. Damage to the tunica was common and subsequent migration of the prosthesis necessitated an additional 11 procedures under general anaesthesia. Despite these technical difficulties, the procedure allowed satisfactory intercourse. The average interval between onset of impotence and implantation was 4 years. Early implantation before the dense fibrosis develops might give more satisfactory results.

Emergence of isolates resistant to ampicillin

Clinical isolates of Streptococcus faecium demonstrating ampicillin resistance were recovered from eight pediatric patients. Sites of isolation included blood, surgical wound, bile drainage, urine, burns, and peritoneal fluid. Seven patients had prolonged hospitalization, and all had been treated with broad-spectrum antibiotics prior to isolation of the resistant enterococcus. One isolate was from an ill, bacteremic patient; the others were in mixed culture and were not considered causes of disease. The isolates were not epidemiologically related. Minimal inhibitory concentrations for various antibiotics included ampicillin (16 to 32 mg/L), penicillin (128 mg/L), gentamicin (16 mg/L), and vancomycin (2 mg/L). Three isolates demonstrated high-level resistance (greater than 2000 mg/L) to streptomycin; none did so to gentamicin. In vitro synergy testing performed on seven available isolates for ampicillin and gentamicin demonstrated no synergy to this combination. None produced beta-lactamase. Combined antibiogram and plasmid data showed at least five distinct patterns. These strains present a new clinical problem in their high level of resistance to ampicillin and to the combination of ampicillin and gentamicin.

Spontaneous rupture of the spleen in pregnancy with splenic conservation

Spontaneous rupture of the spleen in pregnancy is rare. It presents with severe internal haemorrhage with a high perinatal and maternal mortality. Splenic preservation is now a well-known option in dealing with splenic damage, and is recommended where possible to avoid diminished immunological competence. This is the first reported case of splenic preservation following splenic damage in pregnancy.

Penicillin tolerance in Streptococcus faecium ATCC 9790

Tolerant strains of Streptococcus faecium had higher levels of muramidase 2 and lower levels of trypsinactivable muramidase 1 than did susceptible strains. Susceptible strains lysed faster than did tolerant strains in buffer and at some antibiotic concentrations. The addition of Triton X-100 produced equal lysis rates for susceptible and tolerant cultures.