Universal prophylaxis for Chlamydia trachomatis and anaerobic vaginosis in women attending for suction termination of pregnancy: an audit of short-term health gains

A previous study of infection and morbidity in 400 women attending for termination of pregnancy (TOP) had shown that 32 (8%) harboured cervical Chlamydia trachomatis and 112 (28%) had anaerobic (bacterial) vaginosis (AV). Fifty-three per cent of the women with preoperative C. trachomatis had AV. Thirty of the 32 women with chlamydial infection were followed up and 19 (63%) of these developed post-abortion upper genital tract infection, 7 of whom needed readmission1. In view of the high morbidity in women with chlamydial infection attending for TOP, anti-bacterial prophylaxis with metronidazole suppositories and oral oxytetracycline was introduced for women attending for suction termination of pregnancy (STOP). An audit of the clinical and financial benefits and/or losses was carried out. The audit of 1951 consecutive patients attending for STOP revealed that 132 (6.8%) had chlamydial infection with equivocal results reported in a further 2 patients. One hundred and eight of the 134 women responded to recall. Full genital tract infection screening was carried out in 105 of the 108 recalled patients of whom 5 had repeat positive cervical swabs for C. trachomatis, one had Trichomonas vaginalis, 24 had candidiasis and 17 had anaerobic vaginosis, none had gonorrhoea. Thirteen (12%) of the 108 women had pelvic infection as previously defined1, none of whom required re-admission. At least £20,000 has been saved each year in our Trust following the introduction of pre-abortion chlamydial screening and universal antichlamydial and anti-anaerobe prophylaxis.

The introduction of universal prophylaxis against C. trachomatis and AV has profoundly reduced morbidity in patients attending for TOP and has also resulted in substantial financial savings.

A high-dose preparation of lactobacilli and bifidobacteria in the prevention of antibiotic-associated and Clostridium difficile diarrhoea in older people admitted to hospital: a multicentre, randomised, double-blind, placebo-controlled, parallel arm trial (PLACIDE)

BACKGROUND

Antibiotic-associated diarrhoea (AAD) occurs most commonly in older people admitted to hospital and within 12 weeks of exposure to broad-spectrum antibiotics. Although usually a mild and self-limiting illness, the 15-39% of cases caused by Clostridium difficile infection [C. difficile diarrhoea (CDD)] may result in severe diarrhoea and death. Previous research has shown that probiotics, live microbial organisms that, when administered in adequate numbers, are beneficial to health, may be effective in preventing AAD and CDD.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of a high-dose, multistrain probiotic in the prevention of AAD and CDD in older people admitted to hospital.

DESIGN

A multicentre, randomised, double-blind, placebo-controlled, parallel-arm trial.

SETTING

Medical, surgical and elderly care inpatient wards in five NHS hospitals in the UK.

PARTICIPANTS

Eligible patients were aged ≥ 65 years, were exposed to one or more oral or parenteral antibiotics and were without pre-existing diarrhoeal disorders, recent CDD or at risk of probiotic adverse effects. Out of 17,420 patients screened, 2981 (17.1%) were recruited. Participants were allocated sequentially according to a computer-generated random allocation sequence; 1493 (50.1%) were allocated to the probiotic and 1488 (49.9%) to the placebo arm.

INTERVENTIONS

Vegetarian capsules containing two strains of lactobacilli and two strains of bifidobacteria (a total of 6 × 10(10) organisms per day) were taken daily for 21 days. The placebo was inert maltodextrin powder in identical capsules.

MAIN OUTCOME MEASURES

The occurrence of AAD within 8 weeks and CDD within 12 weeks of recruitment was determined by participant follow-up and checking hospital laboratory records by research nurses who were blind to arm allocation.

RESULTS

Analysis based on the treatment allocated included 2941 (98.7%) participants. Potential risk factors for AAD at baseline were similar in the two study arms. Frequency of AAD (including CDD) was similar in the probiotic (159/1470, 10.8%) and placebo arms [153/1471, 10.4%; relative risk (RR) 1.04; 95% confidence interval (CI) 0.84 to 1.28; p = 0.71]. CDD was an uncommon cause of AAD and occurred in 12/1470 (0.8%) participants in the probiotic and 17/1471 (1.2%) in the placebo arm (RR 0.71; 95% CI 0.34 to 1.47; p = 0.35). Duration and severity of diarrhoea, common gastrointestinal symptoms, serious adverse events and quality of life measures were also similar in the two arms. Total health-care costs per patient did not differ significantly between the probiotic (£8020; 95% CI £7620 to £8420) and placebo (£8010; 95% CI £7600 to £8420) arms.

CONCLUSION

We found no evidence that probiotic administration was effective in preventing AAD. Although there was a trend towards reduced CDD in the probiotic arm, on balance, the administration of this probiotic seems unlikely to benefit older patients exposed to antibiotics. A better understanding of the pathogenesis of AAD and CDD and the strain-specific effects of probiotics is needed before further clinical trials of specific microbial preparations are undertaken. Evaluation of the effectiveness of other probiotics will be difficult where other measures, such as antibiotic stewardship, have reduced CDD rates.

TRIAL REGISTRATION

This trial is registered as ISRCTN70017204.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 57. See the NIHR Journals Library website for further project information.

Effects of short-term therapy with glibenclamide and repaglinide on incretin hormones and oxidative damage associated with postprandial hyperglycaemia in people with type 2 diabetes mellitus

AIM

To examine the effects of glibenclamide and repaglinide on glucose stimulated insulin release, incretins, oxidative stress and cell adhesion molecules in patients with type 2 diabetes suboptimally treated with metformin.

METHODS

A randomized clinical trial was performed recruiting 27 subjects (HbA(1c) between 7.5 and 10.5%) free from cardiovascular and renal disease. Glucose, insulin, C-peptide, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic peptide (GIP), total antioxidant status, F(2)-isoprostane, interleukin-6 and cell adhesion molecules were measured during an oral glucose load at baseline and after eight weeks of treatment. The areas under the curve were analysed at 45, 60 and 120 min (AUC(45), AUC(60), AUC(120)).

RESULTS

Significant improvements in glucose were observed with repaglinide (HBA(1c): -1.5%, fasting glucose: -2.8 mmol/L, 2-h glucose: -3.7 mmol/L, AUC(120): -18.9%) and glibenclamide (-1.0%, -2.2 mmol/L, -2.5 mmol/L, -17.5%). Repaglinide was also associated with an increase in the AUC(60) and AUC(120) for insulin (+56%, +61%) and C-peptide (+41%, +36%). GLP-1, GIP, IL-6, ICAM-1 and E-selectin levels did not change in either group. No association was observed between GLP-1, GIP-1 and plasma markers of oxidative stress.

CONCLUSION

Repaglinide is associated with improved postprandial glycaemic control via insulin and C-peptide release. We observed no direct effects of glibenclamide or repaglinide on plasma levels of GLP-1 or GIP. We observed no associations of GLP-1 and GIP with plasma markers of oxidative stress.

A Randomised, Cross-Over, Placebo-Controlled Study of Aloe vera in Patients with Irritable Bowel Syndrome: Effects on Patient Quality of Life

Background. Irritable bowel syndrome (IBS) is a chronic, difficult to treat condition. The efficacy of Aloe vera in treating IBS symptoms is not yet proven. The purpose of this study was to determine if Aloe vera is effective in improving quality of life. Methods. A multicentre, randomised, double-blind, cross-over placebo controlled study design. Patients were randomised to Aloe vera, wash-out, placebo or placebo, washout, Aloe vera. Each preparation (60 mL) was taken orally twice a day. Patient quality of life was measured using the Gastrointestinal Symptoms Rating Score, Irritable Bowel Syndrome Quality of Life, EuroQol and the Short-Form-12 at baseline and treatment periods 1 and 2. Results. A total of 110 patients were randomised, but only 47 completed all questionnaires and both study arms. Statistical analysis showed no difference between the placebo and Aloe vera treatment in quality of life. Discussion. This study was unable to show that Aloe vera was superior to placebo in improving quality of life. Drop outs and other confounding factors may have impacted on the power of the study to detect a clinically important difference. Conclusion. This study failed to find Aloe vera superior to placebo in improving quality of life proven Irritable Bowel Syndrome patients.

A randomised controlled trial comparing TVT, Pelvicol and autologous fascial slings for the treatment of stress urinary incontinence in women

OBJECTIVE

To compare TVT(TM) , Pelvicol(TM) and autologous fascial slings (AFSs).

DESIGN

A multicentre randomised control trial.

SETTING

Four units in the UK.

POPULATION

Women requiring primary surgery for stress urinary incontinence (SUI).

METHODS

A total of 201 women with urodynamically proven stress incontinence were randomised into three groups and assessed at baseline, 6 weeks, 6 months and 1 year.

MAIN OUTCOME MEASURE

The primary outcome was patient-reported improvement rates. Secondary outcomes included operative complications/time, intermittent self-catheterisation (ISC) and re-operation rates. The quality-of-life tools used were the Bristol Female Lower Urinary Tract Symptoms (BFLUTS) and EuroQoL.

RESULTS

Fifty women had a Pelvicol(TM) sling, 79 had AFSs and 72 had TVT(TM). At 6 months the Pelvicol(TM) arm had poorer improvement rates (73%) than TVT(TM) (92%)/AFS (95%); P=0.003. At 1 year only 61% of the Pelvicol(TM) slings remained as improved, versus 93% of TVTs and 90% of AFSs (P<0.001). Pelvicol(TM) has poorer dry rates (22%) than TVT(TM) (55%)/AFS (48%) (P=0.001) at 1 year; hence, the Pelvicol(TM) arm was suspended following interim analysis. There is no difference in the success rates between TVT(TM) and AFS. One in five women in the Pelvicol(TM) arm had further surgery for SUI by 1 year, but none required further surgery in the other arms. AFS took longer to do (54 minutes versus 35 minutes for TVT(TM) /36 minutes for Pelvicol(TM) ) and had higher ISC rates (9.9 versus 0% Pelvicol(TM) /TVT(TM) 1.5%). Hospital stay was shortest for TVT(TM) (2 days). Most BFLUTS domains showed improvement in all three arms. The improvement for women in the Pelvicol(TM) arm, however, was less than for women in the other arms in several key domains.

CONCLUSIONS

Pelvicol(TM) cannot be recommended for the management of SUI. TVT(TM) does not have greater efficacy than AFS, but does utilise fewer resources.

Social health outcomes following thermal injuries: a retrospective matched cohort study

INTRODUCTION

Over 50% of children admitted with burns are aged under 3 years. US studies suggest that up to 26% of childhood burns are non-accidental, although UK reports are lower (1-16%).

OBJECTIVES

To determine the social health outcomes of burned children as regards the number of children abused, neglected or "in need" before the age of 6 years compared with matched controls.

METHODS

A retrospective matched cohort study. 145 children aged under 3 years admitted for burns in 1994-1997 were matched with controls for sex, age and enumeration district and followed up until 2003. Electronic routine databases provided study data on local authority care episodes and Social Services referrals by age 6 years.

RESULTS

89.0% of cases had accidental burns and four cases (2.8%) had non-accidental burns. No case was attributed to neglect. By their sixth birthday cases were statistically more likely to have been referred to Social Services with 14 (9.7%) of the burned children having been abused or neglected versus two (1.4%) controls (95% CI 0.030 to 0.13, p = 0.004). Forty six (32%) cases versus 26 (18%) controls were defined as "in need" (95% CI 0.047 to 0.23, p = 0.006).

CONCLUSION

Although most burns were deemed accidental, 2.8% were categorised as non-accidental at presentation. Almost a third of the burned children went on to be "in need". Children with a burn appear to be at higher risk of further abuse or neglect compared with controls. A burn therefore could be a surrogate marker indicating need for closer supervision and follow-up by professionals.

Extracorporeal magnetic energy stimulation of pelvic floor muscles for urodynamic stress incontinence of urine in women

The aim of this study was to assess the efficacy, side effects and drop out rate of extra-corporeal magnetic energy stimulation of pelvic floor muscles for urodynamic stress incontinence of urine in women. It was a prospective non-controlled study at 2 district general hospitals in South Wales. It included 48 female patients with urodynamic stress incontinence of urine, who had 16, twice weekly treatment sessions. Pad test was the primary outcome measure and continence diary, King's Health and EuroQol quality of life questionnaires, side effects and drop out were the secondary outcome measures. Assessment was made on recruitment, at the end of treatment sessions and at 3 months follow up. Thirty one patients completed treatment sessions and 27 attended for follow up at 3 months. There was no significant change in outcome measures at the end of treatment or at 3 months follow up. Side effects were encountered by 52.1% of patients and the drop out rate was 35.4%.

Functional evidence for the expression of P2X1, P2X4 and P2X7 receptors in human lung mast cells

BACKGROUND AND PURPOSE

P2X receptors are widely expressed in cells of the immune system with varying functions. This study sought to characterize P2X receptor expression in the LAD2 human mast cell line and human lung mast cells (HLMCs).

EXPERIMENTAL APPROACH

Reverse transcriptase polymerase chain reaction (RT-PCR) and patch clamp studies were used to characterize P2X expression in mast cells using a range of pharmacological tools.

KEY RESULTS

RT-PCR revealed P2X1, P2X4 and P2X7 transcripts in both cell types; mRNA for P2X6 was also detected in LAD2 cells. Under whole-cell patch clamp conditions, rapid application of ATP (1-1000 microM) to cells clamped at -60 mV consistently evoked inward currents in both types of cells. Brief application of ATP (1 s) evoked a rapidly desensitizing P2X1-like current in both cell types. This current was also elicited by alphabetamethylene ATP (10 microM, 94% cells, n= 31) and was antagonized in LAD2 cells by NF 449 (1 microM) and pyridoxal phosphate-6-azo(benzene-2,4-disulphonic acid) (1-10 microM). A P2X7-like non-desensitizing current in response to high concentrations of ATP (1-5 mM) was also seen in both cell types (96% LAD2, n= 24; 54% HLMCs, n= 24) which was antagonized by AZ11645373 (1 microM). P2X7-like responses were also evoked in LAD2 cells by 2'(3')-0-(4-benzoylbenzoyl)ATP (300 microM). A P2X4-like current was evoked by 100 microM ATP (80% LAD2, n= 10; 21% HLMCs, n= 29), the amplitude and duration of which was potentiated by ivermectin (3 microM).

CONCLUSION AND IMPLICATIONS

Our data confirmed the presence of functional P2X1, P2X4 and P2X7 receptors in LAD2 cells and HLMCs.

Preventing fractures among older people living in institutional care: a pragmatic randomised double blind placebo controlled trial of vitamin D supplementation

INTRODUCTION

Osteoporotic fractures in older people are a major and increasing public health problem. We examined the effect of vitamin D supplementation on fracture rate in people living in sheltered accommodation.

METHODS

In a pragmatic double blind randomised controlled trial of 3 years duration, we examined 3,440 people (2,624 women and 816 men) living in residential or care home. We used four-monthly oral supplementation using 100,000 IU vitamin D(2) (ergocalciferol). As a main outcome measure, we used the incidence of first fracture using an intention to treat analysis. This was a multicentre study in 314 care homes or sheltered accommodation complexes in South Wales, UK.

RESULTS

The vitamin D and placebo groups had similar baseline characteristics. In intention-to-treat analysis, 205 first fractures occurred in the intervention group during a total of 2,846 person years of follow-up (7 fractures per 100 people per year of follow-up), with 218 first fractures in the control group over 2,860 person years of follow-up. The hazard ratio of 0.95 (95% confidence interval 0.79-1.15) for intervention compared to control was not statistically significant.

CONCLUSION

Supplementation with four-monthly 100,000 IU of oral vitamin D(2) is not sufficient to affect fracture incidence among older people living in institutional care.

A randomised controlled trial comparing two autologous fascial sling techniques for the treatment of stress urinary incontinence in women: short, medium and long-term follow-up

This randomised control trial compares full-length autologous slings (Group A: 81 women) with a modified "sling-on-a-string" (Group B: 84 women) technique for the treatment of stress urinary incontinence (SUI). Primary outcomes are quality of life (QoL) scores; Group A/Group B. The IIQ-7 scores decrease from 1.91/1.85 at baseline to 0.65/0.72 at 12 months and 0.85/0.92 at +5 years. The UDI-6 scores decrease from 1.85/1.61 at baseline to 0.66/0.62 at 12 months and 1.22/1.08 at +5 years. The incidence of SUI is 13% at 3 months but averages 53% at +5 years. Both techniques offer similar improvements. The shorter sling is quicker, less painful and with less hospital readmissions. The 'sling-on-a-string' technique is as effective as the standard technique with better short-term sequelae. The incidence of SUI post-autologous slings rises over the long term.

Botulinum Toxin B Is Not an Effective Treatment of Refractory Overactive Bladder

OBJECTIVES

To determine the efficacy and safety of botulinum toxin-B (BTX-B) in two groups of patients with urodynamically proven idiopathic detrusor overactivity (IDO) or neurogenic DO (NDO) refractory to conservative treatment.

METHODS

This was a nonrandomized, prospective study. We diluted 5000 U of BTX-B in 20 mL of normal saline and injected it at 20 sites around the bladder, avoiding the trigone. The data collected at recruitment and 10 and 26 weeks postoperatively included number of incontinent episodes, frequency, and nocturia, King's Health Questionnaire score, and the urodynamic parameters of volume at the first overactive contraction and maximal cystometric capacity.

RESULTS

A total of 25 patients were recruited, 20 with IDO and 5 with NDO. Only 7 patients, all with IDO, reported symptomatic improvement at the 10-week assessment. The symptoms had returned in these 7 patients at a median of 136 days (range 106 to 151) after injection. Of the remaining 20 patients, 16 (13 with IDO and 3 with NDO) thought an initial improvement had occurred but it had worn off or was wearing off by the first assessment. Two patients (both with NDO) reported no improvement.

CONCLUSIONS

BTX-B had a limited duration of action, with most of its symptomatically beneficial effects wearing off by 10 weeks in most of our patients. The short duration of action for BTX-B suggests it is unlikely to gain widespread use in the treatment of DO.

Autologous blood transfusion in total knee replacement surgery

We compared allogeneic blood usage for two groups of patients undergoing total knee replacement surgery (TKR). Patients were randomized to receive either their post-operative wound drainage as an autotransfusion (n=115) after processing or to have this wound drainage discarded (n=116). Allogeneic blood was transfused in patients of either group whose haemoglobin fell below 9 g dl(-1). Only 7% of patients in the autotransfusion group required an allogeneic transfusion compared with 28% in the control group (P<0.001). There was no hospital mortality and only 3% mortality from all causes at the study completion, which spanned 6 months to 3 yr. There was a higher incidence of infection requiring intervention in the allogeneic group (P<0.036). Total patient costs were Pound Sterling 113 greater in the autotransfusion group. We conclude that in this type of surgery post-operative cell salvage is a safe and effective method for reducing allogeneic blood use.

Intra-operative blood salvage in abdominal trauma: a review of 5 years' experience

We performed a retrospective audit of 1235 patients presenting between 1992 and 1997, following the introduction of intra-operative blood salvage at our hospital. Twenty-two cases of severe abdominal trauma requiring emergency laparotomy and intra-operative blood salvage were identified. The impact of intra-operative blood salvage in aiding resuscitation and reducing demand on allogeneic blood supplies is discussed.

Population requirement for adult critical-care beds: a prospective quantitative and qualitative study

BACKGROUND

The provision of adult critical-care facilities is not based on a rational or scientific assessment of need. We aimed to define the numbers of adult critical-care beds required for a population of 500000.

METHODS

In five hospitals in Wales, UK, we classified patients who might be suitable for critical care in intensive-care or high-dependency units. On every 12th day for 1 calendar year, we counted the numbers of such patients admitted in a defined geographical population. A panel of ten intensivists made consensus decisions about whether individual patients were in the appropriate unit. The data were used to predict the numbers of beds and units required for the population.

FINDINGS

4058 patients were suitable for critical care, of whom 3028 lived in the study area. 56.4% were in general wards, 22.3% in high-dependency units, and 21.3% in intensive-care units. The mean risk of death was 22.0% and the in-hospital death rate 17.3%. According to the masked consensus, 41.3% of patients required high-dependency beds and 21.5% intensive-care beds. Mean risk of death increased from general wards (14.7%) to high-dependency units (19.2%) to intensive care (37.0%). Based on the consensus decisions, the average daily requirement of intensive-care beds was 21 and of high-dependency beds 43; to meet needs 95% of times required 30 and 55 beds, respectively, in a single critical-care unit.

INTERPRETATION

We estimated, scientifically, numbers of adult critical-care beds required to meet population needs. Studies are necessary periodically to track changes in admissions requiring critical care.

Universal prophylaxis for Chlamydia trachomatis and anaerobic vaginosis in women attending for suction termination of pregnancy: an audit of short-term health gains

A previous study of infection and morbidity in 400 women attending for termination of pregnancy (TOP) had shown that 32 (8%) harboured cervical Chlamydia trachomatis and 112 (28%) had anaerobic (bacterial) vaginosis (AV). Fifty-three per cent of the women with preoperative C. trachomatis had AV. Thirty of the 32 women with chlamydial infection were followed up and 19 (63%) of these developed post-abortion upper genital tract infection, 7 of whom needed re-admission. In view of the high morbidity in women with chlamydial infection attending for TOP, anti-bacterial prophylaxis with metronidazole suppositories and oral oxytetracycline was introduced for women attending for suction termination of pregnancy (STOP). An audit of the clinical and financial benefits and/or losses was carried out. The audit of 1951 consecutive patients attending for STOP revealed that 132 (6.8%) had chlamydial infection with equivocal results reported in a further 2 patients. One hundred and eight of the 134 women responded to recall. Full genital tract infection screening was carried out in 105 of the 108 recalled patients of whom 5 had repeat positive cervical swabs for C. trachomatis, one had Trichomonas vaginalis, 24 had candidiasis and 17 had anaerobic vaginosis, none had gonorrhoea. Thirteen (12%) of the 108 women had pelvic infection as previously defined, none of whom required re-admission. At least pound sterling 20,000 has been saved each year in our Trust following the introduction of pre-abortion chlamydial screening and universal antichlamydial and anti-anaerobe prophylaxis. The introduction of universal prophylaxis against C. trachomatis and AV has profoundly reduced morbidity in patients attending for TOP and has also resulted in substantial financial savings.

SF-36 scores vary by method of administration: implications for study design

BACKGROUND

Previous research suggests that people respond differently to health status measures when data are collected by interview or self completion of a questionnaire. The objective of this study was to determine whether SF-36 health status scores differ systematically by method of administration.

METHOD

A randomized cross-over study was carried out on 210 new attenders at general medicine, endocrinology, gastroenterology and urological out-patient departments. The outcome was the difference in SF-36 profiles comparing clinic based interviews with self completion at home by the same subjects.

RESULTS

For seven of the eight variables of the SF-36 scores were lower in the self assessment, the differences being statistically significant in four of the eight comparisons. The largest differences were in role limitations due to emotional problems (difference 14.74, 95 per cent confidence interval (CI) 7.76-21.7) and social function (difference 7.21, 95 per cent CI 3.19-11.23).

CONCLUSIONS

Clinic based interviews systematically exaggerate health status compared with self assessment. The difference is sufficiently large to underestimate the effectiveness of health service interventions when a clinic based pre-intervention and postal self completed follow-up design is used, unless adjustment is made for this systematic bias.

Sildenafil: study of a novel oral treatment for erectile dysfunction in diabetic men

The efficacy and safety of oral sildenafil, a potent inhibitor of phosphodiesterase type 5, were evaluated in men with diabetes mellitus and erectile dysfunction (ED). Twenty-one men (aged 42-65 years) were enrolled in a double-blind, placebo-controlled, three-way crossover study conducted in two parts. In part I, the effect of a single dose (25 mg or 50 mg) of sildenafil or placebo on penile rigidity was assessed by penile plethysmography during visual sexual stimulation. In part II, daily diary records of erectile activity and a global efficacy question were used to evaluate once-daily dosing with 25 mg or 50 mg of sildenafil or placebo for 10 days. After a single 50 mg dose of sildenafil, the adjusted geometric mean duration (min) of penile rigidity >60% at the base of the penis during visual sexual stimulation was significantly increased (10.1 min) compared with placebo (2.8 min; p = 0.0053). In part II, sildenafil significantly increased the number of erections considered sufficiently hard for vaginal penetration compared with placebo (p = 0.0005). Improved erections were reported by 50% and 52% of patients treated with 25 mg and 50 mg of sildenafil, respectively, compared with 10% of those receiving placebo (p values < 0.05). Adverse events were mostly mild or moderate in nature and included muscular pains, headache, and dyspepsia. Sildenafil is a well-tolerated and potentially efficacious oral treatment for ED in men with diabetes mellitus.

Timing of removal of the laryngeal mask airway

Previous studies reported that complications associated with removal of the laryngeal mask were more frequent in awake patients than in anaesthetised patients; however, these studies did not comply with the method described in the manufacturer's instruction manual. The reported incidences of regurgitation during the use of the laryngeal mask also differ considerably between studies. We studied these factors in 66 patients in whom the method described in the manual was used. After induction of anaesthesia, the laryngeal mask and a pH probe were inserted and the cuff of the mask was inflated with a minimum volume of air. Anaesthesia was maintained with nitrous oxide and isoflurane in oxygen. At the end of the operation, we randomly allocated patients to one of two groups and the laryngeal mask was removed either while they were still deeply anaesthetised or after they had regained consciousness. No apparent regurgitation occurred in any patient during operation, but one patient in the anaesthetised group regurgitated immediately after removal of the mask. The incidence of complications during or after removal of the laryngeal mask was significantly greater in the anaesthetised group than that in the awake group (p << 0.001; difference [95% CI]: 48.5 [30.5-66.5]%). Therefore, the laryngeal mask can be safely left in place until the patient has regained consciousness after emergence from anaesthesia.

Cell salvage auto transfusion in total knee replacement surgery

We conducted a prospective, randomized study to assess the impact of cell salvage, auto transfusion on the requirements for allogeneic blood for patients undergoing a total knee replacement (TKR). One hundred consecutive TKR patients were randomly allocated to receive either autologous blood (using cell salvage) or an allogeneic blood transfusion as necessary. Patients allocated to the autologous group were rescued with allogeneic blood if the postoperative haemoglobin fell below 9 g dL-1. Forty-two (84%) of 50 patients in the autologous group required no supplementary blood transfusion. Forty (80%) of 50 patients allocated to receive allogeneic blood required transfusion. There were no detrimental effects of autologous blood transfusion. We conclude that autologous blood transfusion, using the cell saver system, is a safe and effective method of reducing the need for allogeneic blood transfusion and, in doing so, reduces the risk of transmission of infections associated with allogeneic blood transfusion, whilst decreasing demand on precious allogeneic blood reserves.

Practice characteristics associated with audit activity: a medical audit advisory group survey

AIM

A survey of general practices in West Glamorgan was carried out to assess the development of record systems and practice organization and to relate this to audit activity.

METHOD

Following mutual agreement practices were visited by two assessors. Visits were conducted using an agreed protocol and practice data were recorded on a semi-structured questionnaire, which had been sent to the practices in advance of the visits. Practices varied from single handed practices to group practices with six partners.

RESULTS

Fifty seven of the 63 practices in the county suitable for inclusion were visited (90%). Data were analysed from 54 practices (three visits were regarded as a pilot). The practices more likely to be involved in audit were those with three or more partners and which had modern medical record systems. Audit activity had occurred in 87% of practices who kept clinical summaries in the notes (compared with 38% who did not), in 87% of practices with long-term medication summaries in the notes (compared with 40% with no summaries) and in 85% of practices with a computerized age-sex register (compared with 50% with no register). All training practices had undertaken audit compared with 63% of non-training practices.

CONCLUSION

The survey enabled the medical audit advisory group to identify the type and degree of audit undertaken locally and highlighted the characteristics which encourage this activity. As a consequence the group is able to target practices who have limited or no involvement in audit and to offer assistance and advice on record modification likely to enhance audit activity.

A comparative study of the incidence of sore throat with the laryngeal mask airway

In a prospective study of 150 patients randomly assigned to three groups, we have compared the incidence and duration of sore throat after a standard anaesthetic regimen using three different methods of airway management: facemask; laryngeal mask, and laryngeal mask with insertion aid. The insertion aid is currently being developed by Portex Ltd and is intended both to facilitate accurate placement of the laryngeal mask and to reduce trauma during insertion. All the patients were women undergoing short operative procedures requiring minimal postoperative analgesia. The incidence of sore throat was significantly less with a facemask (8%) than with the laryngeal mask when used without the insertion aid (28.5%) (p < 0.02). When using the insertion aid the incidence was 18% and this was not statistically different from the facemask. The presence of blood on the laryngeal mask (22%) was less likely when the insertion aid was used (4%) (p < 0.02).

Intra-ocular pressure changes in patients with glaucoma. Comparison between the laryngeal mask airway and tracheal tube

We performed a randomised prospective study in 20 patients with glaucoma to examine the effects of tracheal intubation and laryngeal mask insertion on intra-ocular pressure, mean arterial blood pressure and heart rate. After induction of anaesthesia with propofol, intra-ocular pressure decreased significantly below baseline values in both the laryngeal mask and tracheal tube groups. After insertion of the laryngeal mask, intra-ocular pressure remained significantly below baseline values in all patients. In contrast, tracheal intubation was associated with a significant increase in intra-ocular pressure to above baseline values in three out of eight patients. Insertion of the laryngeal mask had minimal effects on mean arterial blood pressure and heart rate, whereas tracheal intubation significantly increased both factors relative to pre-intubation values.

Health gains from screening for infection of the lower genital tract in women attending for termination of pregnancy

Infection of the upper genital tract after abortion is well recognised, but routine screening for infection before termination is rare, and few centres are aware of the prevalence of post-abortion complications in their population. We undertook a study to assess the prevalence and sequelae of genital-tract infection in patients undergoing termination of pregnancy and to estimate the costs and potential benefits of introducing screening and prophylaxis for the most commonly found organisms. The study in Swansea, UK, was of 401 consecutive patients attending for termination of pregnancy; only 1 patient refused to take part. Immediately before the termination procedure vaginal and cervical swabs were taken for microscopic examination and culture of Trichomonas vaginalis, Neisseria gonorrhoeae, and candida species. We sought Chlamydia trachomatis by enzyme-linked immunosorbent assay. 112 (28%) women had the typical bacterial flora of anaerobic (bacterial) vaginosis, 95 (24%) had candidal infection, 32 (8%) chlamydial infection, 3 (0.75%) trichomonas infection, and 1 (0.25%) gonorrhoea. Postoperative follow-up of 30 of the women with chlamydial infection showed that pelvic infection developed in 19 (63%), of whom 7 were readmitted to hospital. 9 male partners of women with chlamydial (plus gonococcal in 1 case) infection were examined; 8 were symptom-free, 3 had C trachomatis infection, and 1 N gonorrhoeae. Estimated costs of hospital admissions for complications of chlamydial infection were more than double the costs of providing a routine chlamydia screening programme and prophylactic treatment. Screening for chlamydial infection before termination of pregnancy is essential. Prophylactic treatment for both chlamydial infection and anaerobic vaginosis should also be considered. Male partners of women infected with chlamydia are often symptom-free, but they must be traced to avoid reinfections.

Effects of low-dose cimetidine on nocturnal acid secretion in healthy subjects

The effects of 100 mg and 200 mg bedtime doses of cimetidine on nocturnal gastric acid secretion were examined in nine healthy subjects in a double blind, placebo controlled, randomised three way crossover study. Treatment was given at 23.00 hours and the gastric contents continually aspirated from midnight until 07.00 hours the following morning. Hourly aliquots were analysed for pH and acid output. Relative to placebo the 100 mg and 200 mg doses of cimetidine respectively increased mean pH by 2.22 and 2.63 units/h (P less than 0.001) with mean acid output decreasing by 0.95 and 0.98 mmol/h (P less than 0.001). Whilst mean pH was higher and mean acid output was lower for 200 mg cimetidine compared to 100 mg cimetidine the difference was not statistically significant. Mean hourly pH was consistently above pH 3 for 100% of the time for both doses of cimetidine whereas mean pH failed to reach this value at anytime on placebo. Low doses of cimetidine taken at bedtime effectively reduced nocturnal gastric acid secretion in healthy individuals.

Reversion of the attenuated and temperature-sensitive phenotypes of the Sabin type 3 strain of poliovirus in vaccinees

Isolates of type 3 poliovirus from vaccine-recipients were characterized in terms of virulence, sensitivity of growth to high temperatures, and differences in genome structure from the Sabin type 3 vaccine strain. These included point mutations in the region of the genome coding for the structural proteins and in the 5' noncoding region, and the presence of type 1 or type 2 poliovirus genomic sequences resulting from intertypic recombination. Isolates from healthy vaccinees resembled those from vaccine-associated cases of poliomyelitis in all of these properties. Suppression of the temperature-sensitive phenotype was strictly correlated with reversion to virulence in nonrecombinant type 3 strains. Recombinant isolates were more attenuated than expected, even when they had lost all mutations known to attenuate the type 3 vaccine strain.

The temperature sensitivity of the Sabin type 3 vaccine strain of poliovirus: molecular and structural effects of a mutation in the capsid protein VP3

The growth of the Sabin strain of type 3 poliovirus is reduced at high temperatures compared to that of its virulent precursor strain Leon. Recombinant viruses have been generated from infectious cDNA clones and demonstrate that the temperature-sensitive (ts) phenotype is mainly attributable to a difference in residue 91 of the virion protein VP3. Examination of non-ts mutants derived in vitro or in vivo reveals the existence of second site mutations some of which are clearly able to suppress the ts phenotype. The location of residue 91 of VP3, and of a number of candidate suppressor mutations, in the atomic structure of the virion suggests that the ts phenotype may result in destabilization of the particle and that the suppressors may function by stabilizing specific interfaces. It is not yet clear whether the ts phenotype is expressed at the level of the particle or in the form of defects in assembly or uncoating of the virion, or all three.