Rectovaginal endometriosis – a frequently missed diagnosis

To assess the proportion of women found to have rectovaginal endometriosis who underwent a previous laparoscopy with negative findings, a 5-year retrospective observational study was carried out at the University Hospital of Wales, Cardiff UK, from 2001 to 2005. A total of 61 cases with potential symptoms of rectovaginal endometriosis who underwent laparoscopy were identified. Rectovaginal endometriosis was identified in 16 of these cases. Previous laparoscopy was carried out in 33 of these 61 cases. In the group of women found to have rectovaginal endometriosis, 14 cases of rectovaginal endometriosis were not identified by pre-referral laparoscopy. This study supports the anecdotal idea that rectovaginal endometriosis is an often missed diagnosis at the time of laparoscopy. Diagnostic laparoscopy by generalist gynaecologists frequently fails to diagnose rectovaginal endometriosis. The routine use of rectal probes at laparoscopy is recommended to increase diagnostic accuracy.

A prospective observational study of emergency caesarean section rates and the effect of the labour ward experience

The National Sentinel Audit found that one in five births in England and Wales was by caesarean section. The reasons for the increase in caesarean section rates are multi-factorial. Anecdotally, it is suggested that obstetric intervention rates and caesarean section rates vary among obstetricians without a difference in fetal and maternal outcomes. The aim of this prospective observational study of 817 deliveries was to assess the effect of experience on the caesarean section rates for different obstetricians. Obstetricians with greater than 3 years of 2nd on-call labour ward experience had a statistically significant lower caesarean rate than less experienced obstetricians 10.25% vs 25.49%, respectively (p < 0.05). Differences in instrument deliveries was also studied.

Predicting the presence of rectovaginal endometriosis from the clinical history: a retrospective observational study

Rectovaginal endometriosis is a severe variant of endometriosis. Common presenting symptoms for endometriosis include dysmenorrhoea, pelvic pain and dyspareunia. It is now recognised that there are other less traditional symptoms of endometriosis that are also relatively common. The aim of this study is to assess the relative strength of each of the potential symptoms of rectovaginal endometriosis and compare these with the laparoscopic and histological findings. In this retrospective, observational study the overall prevalence of rectovaginal endometriosis in the group was 31.4%. The presence of dyschesia gave a likelihood ratio of 1.27 (95% CI: 0.56 - 2.89) with a predictive prevalence of rectovaginal endometriosis of 37%. Apareunia and nausea or abdominal bloating were particularly strong markers for rectovaginal disease with a predictive prevalence of 87% and 89%, respectively. The classical symptoms often attributed to irritable bowel syndrome are also common in women with rectovaginal disease.

Should we actively screen for urinary and anal incontinence in the general gynaecology outpatients setting?--A prospective observational study

The Department of Health in the UK recommends as good practice in continence services that opportunistic screening for urinary and anal incontinence is carried out by all healthcare professionals. The aim of this study was to record the prevalence of urinary and anal incontinence in a general gynaecology clinic. In addition, to ascertain the proportion of women with incontinence who wish further help and assess the current opportunistic screening for incontinence. Overall, the prevalence of urinary incontinence is 26.8% and the prevalence of mixed (urinary and anal) incontinence is 8.4% of women attending a general gynaecology clinic. The prevalence of both types of incontinence increases with the age of the women. Although a significant proportion wished to receive help, 61.6% of women with urinary incontinence were not specifically asked about urinary incontinence and 66.6% of women with anal or mixed incontinence were not specifically asked about anal incontinence. Our current screening for incontinence is unsatisfactory.

Amniotic fluid endothelin levels and the incidence of premature rupture of membranes

Objective. The purpose of this prospective study was to record Endothelin 1 (ET1) concentrations in the second trimester amniotic fluid and in women who develop premature rupture of membranes (PROM), preterm premature rupture of the membranes (PPROM) and in women with uneventful pregnancies. Method. Amniotic fluid was retrieved by amniocentesis from 125 women in the second trimester of pregnancy. The levels of Endothelin were measured by a sensitive and specific radioimmunoassay. Results. From the 125 women included in the study 20 developed PROM and preterm PROM (13 PPROM and 7 PROM). The ET1 concentration was significantly higher (P<0.001) in PROM and PPROM than in normal pregnancy (96.4 vs. 43 pg/ml). The sub-analysis of the two rupture of membranes groups found that the concentration of ET1 was higher in the PPROM than in PROM (118 vs. 72 pg/ml). Conclusion. The amniotic fluid concentration of ET1 is elevated by the second trimester in women who later develop preterm PROM or term PROM.

Warming Echovist contrast medium for hysterocontrastsonography and the effect on the incidence of pelvic pain. A randomized controlled study

BACKGROUND

Hysterocontrastsonography (HyCoSy) is a simple effective investigation of tubal patency. One common side effect is pelvic pain at the time of the procedure. The temperature of the contrast media used may be a causative agent for pelvic pain. This study was designed to assess the effect of warming the contrast to body temperature compared to room temperature on the incidence of pelvic pain.

METHODS

A randomized controlled trial was carried out at the Cardiff Assisted Reproduction Unit. Following ethical approval, all women having HyCoSy for tubal assessment were asked if they would be willing to participate in the study. Computer-generated numbers were placed in opaque sealed envelopes, which were opened by the fertility nurse at the time of procedure. The women were randomized into two arms to receive the contrast medium at either room temperature or at body temperature. Randomization was done according to CONSORT guidelines. The pain experienced was then recorded by the patient on a 10-cm visual analogue scale.

RESULTS

The mean pain scores in the room temperature and the body temperature arms were 5.1 and 3.86, respectively. This was statistically significant (P = 0.006).

CONCLUSION

Warming of Echovist contrast media to body temperature is a simple and effective intervention in reducing discomfort at the time of HyCoSy.

Survey of antenatal women's knowledge of maternal and fetal risks of tobacco smoking and acceptability of nicotine replacement products in pregnancy

A survey was carried out of 145 pregnant women in the third trimester in pregnancy to assess motivators to stop tobacco smoking and assess women's knowledge of fetal and maternal risk of smoking. In addition, the survey was to assess the acceptability of nicotine replacement products use in pregnancy. The findings of this survey show that pregnant women tend to know about the maternal risks of smoking but their knowledge is deficient about fetal risks. The knowledge of the association of cot death risk and tobacco smoking appears to be the greatest motivator to stop smoking. Overall, 74% wished to stop smoking in pregnancy and 68% would accept a nicotine replacement product.

Clinical pharmacology of enalkiren, a novel, dipeptide renin inhibitor

Enalkiren (A-64662), a potent, dipeptide renin inhibitor, mimics the transition state of the human renin substrate, angiotensinogen. Enalkiren has been shown to produce dose-related suppression of plasma renin activity (PRA) and angiotensin II when administered intravenously. Doses of enalkiren of less than 0.1 mg/kg induced little hemodynamic response in normotensive and hypertensive volunteers despite marked suppression of PRA. However, at doses of 0.3 and 1.2 mg/kg, enalkiren produced significant, dose-related decreases in systolic and diastolic blood pressure (BP) in hypertensive patients, and the BP response was enhanced by pretreatment with hydrochlorothiazide. The effects of enalkiren on PRA and BP are prolonged despite its relatively short elimination phase plasma half-life (1.6 h). Persistent pharmacologic activity without evidence of tachyphylaxis was demonstrated during 1 week of treatment in hypertensive patients. The observed dissociation between suppression of PRA and BP response and the recruitment of dose-related BP decrements, despite complete suppression of PRA, are unexplained phenomena. The results of clinical trials with enalkiren are encouraging, and suggest that renin inhibitors may be safe, useful therapeutic agents in the management of hypertension.

The effects of repeated doses of temazepam and nitrazepam on several measures of human performance

The effects of six nightly doses of temazepam (20 mg), nitrazepam (10 mg) and placebo on saccadic eye movements, critical flicker fusion threshold, choice reaction time and mood were studied in eight volunteers. Performance was measured on nights 1 and 6 of each treatment. Nitrazepam produced a residual performance impairment on night 1 that disappeared by night 6, despite higher serum concentrations of the drug on the sixth night of treatment. Temazepam, with a shorter elimination half-life, produced no significant performance impairment on night 1, but by night 6 a significant impairment of saccadic eye movements (p less than 0.05) was seen 1 hour after drug intake. We conclude that tolerance to the sedative action of nitrazepam developed over the 6-night period of the study. No evidence of tolerance was seen with temazepam. No residual effects of temazepam (20 mg) were seen the morning after the night-time drug administration.

Zopiclone produces effects on human performance similar to flurazepam, lormetazepam and triazolam

The cognitive function and psychomotor performance of 10 healthy male volunteers were measured following single oral doses of: zopiclone (7.5 mg), flurazepam (15 mg), lormetazepam (1 mg), triazolam (0.25 mg) and placebo. The performance tests selected (stroop task, five choice serial reaction time, memory span, logical reasoning, mood and saccadic eye movement analysis) were thought to reflect aspects of normal daily activity. The tests demonstrated a clear reduction of performance for all active treatments. No drug emerged as the most potent sedative overall, as each of the tests was affected to a different degree by each drug. Drug effects were not qualitatively different between active treatments so that zopiclone was indistinguishable from the three benzodiazepines with which it was compared.

Human cognitive function following binedaline (50 mg and 100 mg) and imipramine (75 mg): results with a new battery on tests

The effects of two single oral doses of binedaline (50 and 100 mg), imipramine (75 mg) and placebo were compared on a range of psychological tasks (logical reasoning, the Stroop test, and five-choice serial reaction) in healthy young volunteers. The tasks, together with a mood adjective check-list, were completed prior to drug administration and 1, 2, 4 and 8 h post-dose. Binedaline had no significant effect on any of the task parameters. Imipramine impaired performance on all but the Stroop test at 2 h after drug administration. At 1, 2 and 4 h, ratings on the "deactivation" dimension of the mood adjective check-list were significantly higher following imipramine when compared to placebo. The results are discussed in terms of some general considerations about the selection and scoring of tasks to be used in the screening of drugs.

The effect of repeated doses of temazepam and nitrazepam on human psychomotor performance

The effects of six nightly doses of temazepam (20 mg), nitrazepam (10 mg) and placebo on saccadic eye movements, critical flicker fusion, choice reaction time and on subjective feelings were studied in a double blind cross-over study in eight volunteers. Testing was performed on nights 1 and 6 of treatment. Nitrazepam, a benzodiazepine with a long elimination half-life produced a residual performance impairment on night 1 that had disappeared by night 6, despite higher serum concentrations of the drug on the sixth night of treatment. Temazepam, with a shorter elimination half-life produced no significant performance impairment on night 1, but by night 6 a significant impairment of saccadic eye movements (P less than 0.05), was seen 1 h after drug intake. We conclude that tolerance developed to the sedative action of nitrazepam over the 6 night period of the study. No evidence of tolerance was seen with temazepam.

Saccadic eye movement analysis as a measure of drug effects on human psychomotor performance

Analysis of human horizontal saccadic eye movements can provide measurements of central nervous system depression and stimulation. Effects on saccadic eye movements have been observed in normal volunteers with barbiturates, benzodiazepines, opiates and related compounds, carbamazepine, amphetamine and ethanol. A suite of programmes have been developed to allow the generation, collection and analysis of saccadic eye movements using a CBM 3032, 8032 or BBC B microcomputer. The system allows almost continuous sampling and rapid analysis of movements.