Criterion validity, test-retest reliability and sensitivity to change of the St George Urinary Incontinence Score.

OBJECTIVE: To assess the criterion validity, test-retest reliability and the sensitivity to change after treatment of the St George Urinary Incontinence Score (SGUIS). PATIENTS AND METHODS: Women presenting with urinary incontinence completed two SGUIS tests one week apart. A frequency-volume chart (FVC) was completed before the first attendance and the women had a 1-h pad test before treatment. Patients were treated conservatively under the care of a urogynaecologist or nurse continence advisor, or surgically with an open or laparoscopic colposuspension. After treatment, the SGUIS, FVC and 1-h pad test were repeated. RESULTS: The SGUIS correlated moderately well with the number of leaks per week (Spearman's r = 0.610, 95% confidence interval 0.516-0.689, P < 0.001) but less well with the 1-h pad test loss (r = 0.257, 0.124-0.380, P = 0.002). The test-retest reliability was acceptable, as the mean (SD) difference between the first and second SGUIS was 0.337 (2.675), with limits of agreement of -5.012 to -5.686. The change in the SGUIS after treatment correlated well with the improvement in the number of leaks per week (r = 0.742, 0.662-0.805, 156 samples, P < 0.001) but not as well with the change in 1-h pad test loss (r = 0.531, 0.405-0.636, 151, P < 0.001), although the trend was similar. CONCLUSION: The criterion validity of the SGUIS appeared adequate for both the number of leaks per week on the FVC and leakage on the 1-h pad test. The statistical reproducibility of the test was adequate and appeared more responsive to change after treatment than the other measures. The score is suitable for rapid self-administration by patients with a range of incontinence types, unlike most other currently available test instruments.

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.

PIP: This paper presents an audit of the clinical and financial benefits and/or losses of a new management protocol for Chlamydia trachomatis and anaerobic vaginosis (AV) in women requesting suction termination of pregnancy (STOP). This management protocol is known as the Singleton Regimen and involves the introduction of an antibacterial prophylaxis with metronidazole suppositories and oral oxytetracycline. The audit included 1951 patients requesting STOP at the Singleton Hospital between January 1992 and October 1993; 132 of them had chlamydial infection. A total of 108 women responded to recall. Full genital tract infection screening was carried out in 105 of the 108 recalled patients. Of the 105 patients, 5 had repeat positive cervical swabs for C. trachomatis, 1 had Trichomonas vaginalis, 24 had candidiasis, and 17 had anaerobic vaginosis. 13 of the 108 women had pelvic infection; none of them required readmission. In conclusion, the introduction of universal prophylaxis against C. trachomatis and AV has significantly reduced morbidity in patients obtaining a termination of pregnancy and has also resulted in substantial financial savings.

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.

PIP: Between October 1990 and March 1991, 401 women at Hill House Hospital in Swansea, Wales, undergoing an abortion enrolled in a study to determine the prevalence and sequelae of lower genital tract infection and to assess the costs and potential benefits of screening and of prophylaxis for the most common pathogens. The physicians administered 500 mg oxytetracycline for 10 days for women with uncomplicated chlamydia infection and for 14=21 days for those with chlamydia-related pelvic inflammatory disease (PID). A 5-day course of oral metronidazole (400 mg/2/times/day) treated anaerobic vaginosis and trichomonas infections. 51.7% had at least 1 lower genital tract infection, 28% had anaerobic vaginosis, 24% had candida infection and 32 women (8%) were infected with Chlamydia trachomatis. Some of these women also had anaerobic vaginosis, anaerobic vaginosis and candidosis, Escherichia coli infection, and candidosis (15, 1, 1, and 6 women, respectively). Anaerobic vaginosis was more likely to be present in women with chlamydia infection than in those without chlamydia infection (53% vs. 26%; p .05). 19 of 30 women (63%) with chlamydia infection who could be followed postoperatively developed PID. 7 women had to be readmitted to the hospital. 9 males partners of 26 women also attended the Genito-Urinary Medicine clinic. 8 had not symptoms, but 3 had C. trachomatis infection and 1 had Neisseria gonorrhoea infection. The physicians estimated the costs of hospital admissions for pelvic infection to be 2.4 times more costly than providing routine prophylactic screening and treatment (16,800 vs. 6960 UK pounds). These results showed the need to be screen for chlamydia infection before termination of pregnancy and to provide prophylactic treatment for chlamydia infection and anaerobic vaginosis. The physicians also recommended tracing the male partners of chlamydia-infected women to prevent reinfections.

CELSS system control: issues, methods, and directions.

In the general control perspective, the CELSS concept implies a very complex system and presents challenges at every level. These challenges are generated by: (1) the prospect that the system will be inherently unstable, (2) the prospective difficulty of establishing an adequate mathematical model of the system for the purpose of control law synthesis (dimensionality is high, and the dynamics and interactive processes of some of the subsystems are not understood well), (3) assuring control law robustness (assuring that the resulting control law(s) will be effective over the domain of the specified uncertainties), (4) hardware realization of the control law, (5) hardware system robustness ("fault tolerance") and (6) achieving the logistics of the automation (or "management") aspects of the problem. A suggested organization of the problem, a sketch of the issues related to perceived difficulties, a commentary/evaluation of the issues, a review of methods available to address the issues, and a suggested strategy to address the broad CELSS systems control problem are presented.

STD and contraception in adolescents.

The prevalence of sexually transmitted diseases (STDs) in adolescents is poorly documented, as published studies consider single diseases or subgroups of adolescents. To obtain a broader view we examined STDs in unselected adolescent boys and girls at two contrasting genitourinary medicine (GUM) clinics, a large one at St Thomas's Hospital in inner London, which serves commuters and an inner city population, the other a smaller one at Swansea in south Wales, which serves a mixed urban and rural population. Contraception was also assessed in the girls. The STDs in adolescents were compared with the total diagnoses in patients of all ages attending the two GUM clinics, and with total diagnoses in all patients attending GUM clinics in England and Wales. The most striking finding was that all adolescents had at least one infection, whereas 18% of diagnoses in patients of all ages were of no infection. This contrasts with results of previous studies of selected groups, which suggested that the prevalence of STDs is similar in adults and adolescents. The percentages of infections, other than herpes at both clinics and trichomoniasis at Swansea, were higher in adolescents than in patients of all ages. High incidences of pelvic inflammatory disease in London and genital warts at Swansea suggest future problems. Only 66% of adolescent girls practised contraception, and only 8% stated that condoms were used. All people caring for adolescents should consider whether they are sexually active and, if they are, whether they need contraceptive advice or referral to a GUM clinic.

Paediatric gonorrhoea: non-venereal epidemic in a household.

Household epidemics of gonorrhoea are relatively rare in the United Kingdom. We report a cluster of cases of gonococcal infection in four children living in one household. The cases show the importance of full screening, including pharyngeal cultures, of all family members when paediatric gonorrhoea is diagnosed. Our cases also suggest that both boys and girls should be screened for gonorrhoea when gonococcal infection is found in an adult member of the household.

Anaerobic vaginosis. Clinical and diagnostic aspects.

Anaerobic vaginosis (non-specific vaginitis) is a common vaginal infection in patients attending departments of genito-urinary medicine. Clinical features, including signs and symptoms, are described, as also are the simple tests which can be used in the clinic to confirm the diagnosis. It is suggested that greater agreement on the precise nature of these clinical features will facilitate comparison of results from different centres. The close correlation between the results of in-clinic tests (microscopy, amine-testing and pH measurement) and laboratory investigations shows these latter, expensive tests to be unnecessary.

Anaerobic vaginosis (non-specific vaginitis): clinical, microbiological, and therapeutic findings.

The effect of metronidazole on anaerobic vaginosis (non-specific vaginitis) was assessed in a double-blind, placebo-controlled study of 40 women. 19 of 20 women given metronidazole 400 mg twice a day for seven days were clinically and microbiologically cured by the time they completed treatment. All 20 women given a placebo were treatment failures, but when they were given a single 2 g dose of metronidazole, 15 showed clinical and microbiological cure a week later. 14 of the responders showed a recurrence of infection a month after treatment; this was probably due to reinfection, although persistence of infection cannot be ruled out. Findings in the clinic correlated closely with subsequent microbiological results in 133 out of 140 patient-visits, which suggests that there is no need for expensive and time-consuming laboratory investigations in this condition.