Effects of sparfloxacin, grepafloxacin, moxifloxacin, and ciprofloxacin on cardiac action potential duration

Fluoroquinolone antibiotics have been associated with QT prolongation following administration to humans. This study compares the effects of four fluoroquinolones, sparfloxacin, grepafloxacin, moxifloxacin and ciprofloxacin on action potential duration recorded from canine isolated cardiac Purkinje fibres. Left and right ventricular Purkinje fibres were isolated from canine hearts and continuously superfused with physiological salt solution. Action potential duration at 90% repolarization was recorded via intracellular microelectrodes. Sparfloxacin, grepafloxacin, moxifloxacin and ciprofloxacin prolonged action potential duration in a concentration dependent manner. Mean concentrations causing a 15% prolongation of action potential duration recorded at a stimulation frequency of 1 Hz were: sparfloxacin 4.2+/-0.7 microg/ml; grepafloxacin 9.3+/-0.9 microg/ml; moxifloxacin 9.9+/-1.6 microg/ml and ciprofloxacin 72.8+/-26.4 microg/ml. Prolongation was inverse frequency dependent with larger increases in action potential duration occurring when the stimulation frequency was reduced to 0.5 Hz. These results indicate that effects on action potential duration vary within this class of compound. Rank order of potency was sparfloxacin > grepafloxacin = moxifloxacin > ciprofloxacin.

Mifepristone versus vaginally administered misoprostol for cervical priming before first-trimester termination of pregnancy: a randomized, controlled study

OBJECTIVE

This study was undertaken to compare the effectiveness of mifepristone orally administered at 24 or 48 hours before first-trimester vacuum aspiration abortion with that of vaginally administered misoprostol as a cervical priming agent.

STUDY DESIGN

In a randomized comparative trial 90 women who requested surgical termination of pregnancy were randomly assigned to receive 200 mg mifepristone orally 24 or 48 hours before the operation or 800 microg misoprostol vaginally 2 to 4 hours before the operation. The main outcome measures were baseline cervical dilatation, cumulative force required to dilate the cervix to 9 mm, and intraoperative blood loss.

RESULTS

The baseline cervical dilatation was significantly greater among women who received mifepristone 48 hours before the operation (P =.02). This group also required the least mechanical force to dilate the cervix (P =.06). There were no significant differences among the 3 groups in the intraoperative blood loss, in the operating time, or in patient acceptability. Side effects such as hot flushes and headaches were significantly higher among women who received mifepristone 24 or 48 hours before the operation than among those who received misoprostol (P =.01 and P =. 002, respectively).

CONCLUSION

Mifepristone is an effective cervical priming agent when orally administered 48 hours before vacuum aspiration for termination of first-trimester pregnancy. Because of its cost and availability in comparison with misoprostol, however, selective use may have to be considered.

Feasibility of patient-collected vulval swabs for the diagnosis of Chlamydia trachomatis in a family planning clinic: a pilot study

This pilot study set out to determine the feasibility of using patient-collected vulval swabs, instead of urine, for the diagnosis of female Chlamydia trachomatis infection. Main outcome measures included prevalence of infection and sensitivity, specificity, and acceptability of both test methods. An assessment was also made of those who declined to be tested. Consecutive women under 25 years of age attending a single urban family planning clinic were invited to participate. Sixty-eight percent (103/152) agreed to undergo testing. Overall prevalence was 11.7%. The sensitivity/specificity for the ligase chain reaction (LCR) assayed patient-collected vulval swabs and urine was 100%/100% and 92%/100%, respectively. The acceptability of self-collection was high with 93% characterising the test as 'not bad', 79% recommending it to a friend, and 79% choosing the test next time. Significantly more women, however, would choose urine for testing on a subsequent occasion (p < 0.001). Less than 1/5 of the patients who declined did not take part because of concerns regarding the vulval swab. Patient-collected vulval swabs assayed by LCR represent a non-invasive, sensitive, and acceptable way to detect genital C. trachomatis infection in women attending a family planning clinic. Compared with urine testing, benefits in terms of transport and processing should encourage more widespread use of this approach.

Which women should be tested for Chlamydia trachomatis?

OBJECTIVE

To assess the prevalence of genitourinary Chlamydia trachomatis infection among women in different clinical settings, with a view to making decisions about who should be tested routinely.

DESIGN

Cross sectional study.

SETTING

One regional hospital and family planning clinic serving an urban centre. Population Two thousand thirty-five sexually active women attending various outpatient settings.

MAIN OUTCOME MEASURES

Prevalence of positivity by clinical setting, stratified by age.

RESULTS

Overall, prevalence of lower genital tract chlamydial infection was similar in a variety of clinical settings. Infertile women were the only exception, demonstrating a much lower prevalence. Stratifying the study population by age found a clear trend towards high prevalence in teenagers and virtually no infection in women over the age of 30 years.

CONCLUSIONS

The prevalence of chlamydial infection in women is related to age, regardless of clinical presentation. In practice, opportunistic screening should target sexually active women under 30 years of age.

Screening for Chlamydia trachomatis in subfertile women

Chlamydia trachomatis is the most common sexually transmitted disease in the UK and Europe. The majority of female infections are asymptomatic and recognized sequelae include pelvic inflammatory disease, infertility, and ectopic pregnancy. Women with chlamydial infection who undergo uterine instrumentation are recognized to be at risk of ascending infection. Most patients attending for infertility investigations and treatment will undergo some form of uterine instrumentation. Published data regarding the prevalence of chlamydial infection in the subfertile are few and conflicting. In this study, more than 400 consecutive women presenting for infertility investigation and treatment at a single regional fertility centre were screened for Chlamydia: Half were screened using enzyme immunoassay (EIA) and half by ligase chain reaction (LCR). Prevalence by diagnostic test was 0% with EIA and 1.9% with LCR. Overall, the low prevalence was at least partly explained by older age. Until more evidence comes from studies testing consecutive subfertile patients both with EIA and a DNA amplification method such as LCR, centres using EIA should consider using prophylactic antibiotics prior to uterine instrumentation.

The effect of drug-injection behavior on genetic evolution of HIV-1

The effect of injection-drug use on human immunodeficiency virus type 1 (HIV-1) env genetic evolution was examined in 15 seroconverting injection-drug users followed up for 4 years. After adjustment for non-drug-related independent variables significantly associated with genetic diversity (time since seroconversion and progressor status), injection frequency was positively and highly significantly associated with HIV-1 env genetic diversity (P=.003). The mutation rate in those who had injected at least once a day during the previous 6 months was estimated to be 62% greater than the rate in those who had not injected at all. If the positive effect of drug-injection frequency on env genetic diversity extends to the HIV-1 pol gene, the risk of emergence of resistance to antiretroviral drugs may be enhanced by increased drug-injection frequency, especially under the selection pressure of antiretroviral therapy.

Subspecialty training and academic careers

Subspecialty training in obstetrics and gynaecology in the UK was formulated following a report published in 1982 by a working party established by the Royal College of Obstetricians and Gynaecologists. One of the aims of subspecialization was to improve knowledge, practice, teaching and research. The three major subspecialties were maternal-fetal medicine, reproductive medicine and gynaecological oncology. The two minor subspecialties were urogynaecology and community gynaecology. Some of the requirements for training centres are adequate clinical workload, a programme which embodies teaching, training, research and audit, adequate staffing to support training; collaboration with related disciplines and a programme director responsible for supervision and training. Each programme has a well-defined syllabus. The recruitment is based on expected needs. A minimum 7 years is needed to complete the general and subspecialty training. There is a strong academic input in this training and it includes structured research training. Many of the individuals who complete the subspecialty training will take on national responsibilities and hence their clinical and research training is of the highest quality.

Misoprostol for induction of labour at term: a more effective agent than dinoprostone vaginal gel

OBJECTIVE

To compare the efficacy of vaginal misoprostol and dinoprostone vaginal gel for induction of labour at term.

DESIGN

A single-blind randomised comparative trial.

SETTING

Induction and labour wards of a UK teaching hospital.

PARTICIPANTS

Two hundred and eleven pregnant women at term in whom induction of labour was indicated, and with no contra-indication to the use of prostaglandins for the induction of labour.

INTERVENTION

The women were randomly assigned to receive vaginal administration of either misoprostol 50 microg four hourly (to a maximum of four doses) or dinoprostone gel 1 mg six hourly (to a maximum of three doses).

MAIN OUTCOME MEASURES

Time from induction to delivery, oxytocin requirement in labour, analgesic requirement, mode of delivery, neonatal outcome.

RESULTS

The misoprostol group had a highly significant reduction in median induction-delivery interval compared with the dinoprostone group (14.4 hours vs 22.9 hours; P < 0.00001). In addition, more women delivered after only one dose (77% vs 49%; P < 0.0001, OR 3.51, 95% CI 1.94-6.35), and within 12 and 24 hours. There was a reduced need for oxytocin augmentation in labour (21% vs 47%; P < 0.0001, OR 0.30, 95% CI 0.16-0.54). There was no difference in analgesia requirement in labour, or in mode of delivery. There were no adverse neonatal outcomes associated with the use of misoprostol. Women in the misoprostol group experienced more pain in the interval between induction and being given analgesia in labour, but this did not reach statistical significance.

CONCLUSIONS

Misoprostol 50 microg vaginally is a more effective induction agent than 1 mg dinoprostone vaginal gel, with no apparent adverse effects on mode of delivery, or on the fetus. The higher pain scores in the misoprostol group must be balanced against the reduction in time spent having labour induced, and the reduction in need for intravenous oxytocin augmentation. Further randomised studies must continue to exclude the possibility of rare adverse side effects.

Nonsurgical mid-trimester termination of pregnancy: a review of 500 consecutive cases

OBJECTIVE

To assess the effectiveness of a regimen comprising mifepristone followed by a combination of the vaginal and oral administration of misoprostol for mid-trimester medical termination of pregnancy.

DESIGN

Retrospective analysis of prospectively collected data in women undergoing mid-trimester medical termination of pregnancy.

SETTING

Aberdeen Royal Infirmary, Scotland.

SAMPLE

A consecutive series of 500 women with pregnancies of 13-21 weeks of amenorrhea undergoing legally induced abortion in one Scottish NHS hospital.

METHODS

Each woman received a single oral dose of mifepristone 200 mg and 36-48 h later vaginal misoprostol 800 microg. Three hours following the first dose of misoprostol, 400 microg doses were administered orally at three hourly intervals, to a maximum of four doses. Success was defined as abortion occurring with five doses of prostaglandin, or within 15 h of administration of the first dose of prostaglandin.

RESULTS

Ninety-seven percent aborted successfully. The median dose of misoprostol required was 1200 microg and the median induction-to-abortion interval after first prostaglandin administration was 6.5 h. The median number of doses of misoprostol required to induce abortion, and the induction-to-abortion interval, was statistically significantly higher among women at gestations 17-21 weeks than among those at 13-16 weeks (P = 0.0001). A total of 9.4% required surgical evacuation of the uterus under general anaesthesia and 66.4% of the women were managed as day cases.

CONCLUSIONS

The combination of oral mifepristone 200 mg followed by vaginally and orally administered misoprostol provides a noninvasive and effective regimen for second trimester termination of pregnancy.

Ignorance about Chlamydia among sexually active women--a two centre study

Chlamydia trachomatis is the micro-organism causing the most common sexually transmitted disease in the UK and Europe. The majority of female infections are asymptomatic and recognized sequelae include pelvic inflammatory disease, infertility, and ectopic pregnancy. Over 1200 sexually active women from two urban centres in the UK were questioned about awareness and knowledge of Chlamydia genito-urinary infection. Awareness was poor, as half of the study population had never heard of Chlamydia. Overall, less than one-quarter demonstrated adequate knowledge regarding transmission, immunity, symptoms, and sequelae. Better knowledge was found in women over the age of 25 years, in those cohabiting, in those with a professional/management occupation, and in those attending family planning clinics. The Chief Medical Officer's Expert Advisory Group on Chlamydia (1998) has recommended opportunistic screening of asymptomatic sexually active women in the UK. This study gives insight into the considerable task facing the Department of Health, as only an informed public will take up the offer of screening. Research is urgently needed to assess the impact of different approaches to education regarding sexually transmitted infection.

A longitudinal study of maternal serum inhibin-A, inhibin-B, activin-A, activin-AB, pro-alphaC and follistatin during pregnancy

Maternal serum concentrations of inhibin-A, inhibin-B, activin-A, activin-AB, pro-alphaC-related inhibin forms, total follistatin, steroids and gonadotrophins were measured longitudinally in six normal singleton pregnancies. Maternal venous blood was collected randomly during a spontaneous follicular phase prior to donor insemination, at 5, 7, 9, 11, 16, 20, 24, 28, 32 and 36 weeks after the first missed menses and in the early puerperium. Steroid and gonadotrophin profiles conformed to previous reports. While at week 5 of gestation inhibin-A, activin-A and follistatin concentrations were similar to those at the follicular phase, all three increased progressively (P < 0.001) to maximal concentrations in week 36: approximately 48-fold (3740 +/- 1349 ng inhibin-A/ml), approximately 22-fold (6109 +/- 1443 ng activin-A/ml) and approximately 10-fold (3563 +/- 418 ng follistatin/ml) higher. Pro-alphaC concentrations reached a maximum in weeks 5 (approximately 5-fold, P < 0.001) and 36 (1027 +/- 174 pg/ml, P < 0.01). Inhibin-B (71 +/- 23 pg/ml prior to pregnancy) was undetectable (<12 pg/ml) between week 5-16 of gestation but increased slightly in the third trimester (26 +/- 7 pg/ml in week 36). Activin-AB was undetectable throughout pregnancy. Post-partum concentrations of inhibin-A (41 +/- 12 ng/ml), inhibin-B (<12 pg/ml), activin-A (950 +/- 149 pg/ml), pro-alphaC (128 +/- 22 pg/ml) and follistatin (990 +/- 79 ng/ml) were substantially lower than at week 36 of gestation. The activin-A:follistatin ratio increased from 0.5 in week 5 to 1.8 in week 36, suggesting that more free activin-A is available in the maternal circulation during late pregnancy.

Patterns of HIV-1 evolution in individuals with differing rates of CD4 T cell decline

Evolution of HIV-1 env sequences was studied in 15 seroconverting injection drug users selected for differences in the extent of CD4 T cell decline. The rates of increase of either sequence diversity at a given visit or divergence from the first seropositive visit were both higher in progressors than in nonprogressors. Viral evolution in individuals with rapid or moderate disease progression showed selection favoring nonsynonymous mutations, while nonprogressors with low viral loads selected against the nonsynonymous mutations that might have resulted in viruses with higher levels of replication. For 10 of the 15 subjects no single variant predominated over time. Evolution away from a dominant variant was followed frequently at a later time point by return to dominance of strains closely related to that variant. The observed evolutionary pattern is consistent with either selection against only the predominant virus or independent evolution occurring in different environments within the host. Differences in the level to which CD4 T cells fall in a given time period reflect not only quantitative differences in accumulation of mutations, but differences in the types of mutations that provide the best adaptation to the host environment.

An effective regimen for early medical abortion: a report of 2000 consecutive cases

A combination of the anti-progesterone mifepristone and gemeprost provides an effective non-surgical method for the induction of abortion at gestations up to 63 days, achieving complete abortion rates of over 95%. We report our experience with an alternate regimen, comprising a reduced dose of mifepristone in combination with vaginal misoprostol. A consecutive series of 2000 women requesting early medical abortion at gestations up to 63 days was studied retrospectively. Each woman received mifepristone 200 mg orally, followed 36-48 h later by misoprostol 800 microg vaginally. Of the 2000 women, 39 (2.0%) aborted completely following administration of mifepristone alone and a further 1912 experienced complete abortion following administration of misoprostol (a complete abortion rate of 97.5%). Surgical intervention was required in 49 women (2.5%): for incomplete abortion in 27 (1.4%), for missed abortion in seven (0.4%), for continuing pregnancy in 11 (0.6%) and to exclude ectopic pregnancy in four (0.2%). The surgical intervention rate was significantly higher among women at gestations > or = 49 days than among those at < or = 49 days (3.3 versus 1.5%, P = 0.0193). The regimen appears as effective, in terms of high complete abortion rate and low continuing pregnancy rate, as any published alternative. This regimen has the benefit of being less costly as the dose of mifepristone is 67% lower and misoprostol is substantially less expensive than gemeprost. Additionally, misoprostol does not require special transport or storage requirements. As such, the combination of mifepristone and misoprostol may be preferable to mifepristone and gemeprost.

Reducing the risk of multiple births by transfer of two embryos after in vitro fertilization

BACKGROUND

In vitro fertilization is associated with a high risk of multiple births, which is a direct consequence of the number of embryos transferred. However, other factors that contribute to the risk are not well defined.

METHODS

Using the data base established by the Human Fertilization and Embryology Authority in the United Kingdom, we studied the factors associated with an increased risk of multiple births in 44,236 cycles in 25,240 women. The factors included the woman's age, the cause and duration of infertility, previous attempts at in vitro fertilization, previous live births, number of eggs fertilized, and number of embryos transferred.

RESULTS

Older age, tubal infertility, longer duration of infertility, and a higher number of previous attempts at in vitro fertilization were all associated with a significantly decreased chance of a birth and of multiple births. Previous live birth was associated with an increased chance of a birth but not of multiple births. The higher the number of eggs fertilized, the higher the likelihood of a live birth. When more than four eggs were fertilized, there was no increase in the birth rate for women receiving three transferred embryos as compared with those receiving two, but there was a considerable increase in the rate of multiple births when three were transferred (odds ratio, 1.6; 95 percent confidence interval, 1.5 to 1.8).

CONCLUSIONS

Among women undergoing in vitro fertilization, the chances of a live birth are related to the number of eggs fertilized, presumably because of the greater selection of embryos for transfer. When more than four eggs are fertilized and available for transfer, the woman's chance of a birth is not diminished by transferring only two embryos. Transferring more embryos increases the risk of multiple births.

Immediate colposcopy or cytological surveillance for women with mild dyskaryosis: a cost effectiveness analysis

BACKGROUND

The aim of the study was to compare the cost effectiveness of immediate diagnosis and treatment of mild dyskaryosis compared with the usual policy of cytological surveillance.

METHODS

A cost effectiveness analysis was carried out alongside a randomized clinical trial.

RESULTS

Immediate diagnosis and treatment increased total costs by 50 per cent from 54.42 pounds per treated woman [95 per cent confidence interval (CI) 48.85 pounds-59.98 pounds] in the surveillance group to 82.02 pounds per woman in the immediate diagnosis and treatment group with an incremental cost of 27.60 pounds (95 per cent CI 22.04 pounds-33.17 pounds). However, the number of cases of CIN III detected increased by 69 per cent for the policy of immediate diagnosis and treatment. This led to an average cost effectiveness ration of 180.18 pounds for the immediate diagnosis and treatment group and 199.94 pounds per case of CIN III detected for the surveillance group, with a marginal cost effectiveness ratio of 148.22 pounds (95 per cent CI 94.01 pounds-309.33 pounds) for the immediate diagnosis and treatment group.

CONCLUSION

Immediate diagnosis and treatment increases the total cost of managing mildly dyskaryotic smears but this increased cost is offset by a sharp increase in the number of cases of CIN III detected.

Gastric inlet patch containing submucosally infiltrating adenocarcinoma

We describe a patient with an unusual segment of ectopic gastric mucosa in the proximal esophagus. The gastric heterotopia was circumferential and unusually long at 7 cm. It contained benign rugal-type folds, a stricture at the mid-portion of the gastric inlet patch was lined by normal antral-type gastric mucosa but harbored submucosally infiltrating adenocarcinoma. There was no evidence of Helicobacter pylori infection by biopsy or serologic screening. Malignancy, including submucosally infiltrating adenocarcinoma, should be considered in patients with strictures involving ectopic gastric mucosa in the proximal esophagus.