Randomized clinical trial of intravenous fluid replacement during bowel preparation for surgery.

BACKGROUND: Bowel preparation using purgatives has previously been shown significantly to increase haemoglobin concentration and decrease weight. This prospective randomized study assessed the effects of administering intravenous fluid during bowel preparation. METHODS: Patients having bowel preparation with Picolax for colonic procedures were randomized prospectively to receive no intravenous fluid (group 1) or calculated intravenous crystalloid based on body-weight (group 2) during preparation. Physiological, haematological and biochemical variables were measured before and after bowel preparation. RESULTS: Forty-one patients were recruited with a median age of 69 (range 29-86) years, 22 in group 1 and 19 in group 2. There was no difference between groups in any of the variables measured before bowel preparation. On completion, there was a significant difference between groups in mean weight loss (P = 0.01), postural change in systolic pressure (P = 0.015) and serum creatinine concentration (P = 0.008). In addition there was a significant fall in erect blood pressure after bowel preparation in group 1 (P = 0.02). The mean urine output in group 1 was 982 ml and in group 2 was 1808 ml (P = 0.004). The faeces weight between groups was not significantly different. CONCLUSION: Picolax bowel preparation has a significant dehydrating effect, which can be minimized by administering a simultaneous volume of intravenous fluid (mean 2 litres in this study).

Evaluation of a unique oral contraceptive in the treatment of premenstrual dysphoric disorder.

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS). This is the first trial of a unique oral contraceptive containing a combination of drospirenone (DRSP, 3 mg) and ethinyl estradiol (EE, 30 microg) for the treatment of PMDD. DRSP is a spironolactone-like progestin with antiandrogenic and antimineralocorticoid activity. Spironolactone has been shown to be beneficial in PMS, whereas oral contraceptives have shown conflicting results. In this double-blind, placebo-controlled trial, 82 women with PMDD (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM IV]) were randomized to receive DRSP/EE or placebo for three treatment cycles. The primary end point was change from baseline in luteal phase symptom scores as assessed on the Calendar of Premenstrual Experiences (COPE) scale. Patients treated with DRSP/EE showed a numerically greater change from baseline compared with those treated with placebo on each of the 22 COPE items and each of the 4 symptom factors. Between-group differences in symptom improvement reached statistical significance in factor 3 only (appetite, acne, and food cravings, p = 0.027). The secondary end points, Beck Depression Inventory (BDI) and Profile of Mood States (PMS), were consistent with the primary end point in that patients treated with the oral contraceptive showed a numerically greater improvement from baseline compared with those treated with placebo. The results of this study show a consistent trend in the reduction of symptoms that suggested a beneficial effect of DRSP/EE for the treatment of PMDD, despite limitations of the study design.

Racial variation in wanting and obtaining mental health services among women veterans in a primary care clinic.

Epidemiologic studies suggest that African-American women may be less likely to obtain mental health services. Racial differences were explored in wanting and obtaining mental health services among women in an equal access primary care clinic setting after adjusting for demographics, mental disorder symptoms, and a history of sexual trauma. Participating in the study were women veterans at a primary care clinic at the Durham Veterans Affairs Medical Center. Consecutive women patients (n = 526) between the ages of 20 and 49 years were screened for a desire to obtain mental health services. Patients were given the Primary Care Evaluation of Mental Disorders questionnaire (PRIME-MD) and a sexual trauma questionnaire. Mental health service utilization was monitored for 12 months. The median age of the women was 35.8 years; 54.4% of them were African-American. African-American women expressed a greater desire for mental health services than whites, yet mental health resources at the clinic were similarly used by both racial groups. African-American women may want more mental health services; however, given an equal access system, there were no racial differences in mental health use.

An open-label, multicenter study to evaluate Yasmin, a low-dose combination oral contraceptive containing drospirenone, a new progestogen.

This open-label, multicenter study evaluated the efficacy, safety, and cycle control of Yasmin, a new low-dose, monophasic oral contraceptive containing the unique progestogen drospirenone (DRSP) 3 mg and ethinyl estradiol (EE) 30 microg. DRSP is a synthetic progestogen that has antiandrogenic and antimineralocorticoid effects. In this study, 326 women were evaluated and 220 (67%) completed all 13 treatment cycles. The corrected Pearl Index was 0. 407. Of the 151 subjects who experienced intermenstrual bleeding at any time during the study, the majority (64%) had bleeding during only one or two pill cycles. Breakthrough bleeding without spotting occurred in 1% of all cycles, spotting without breakthrough bleeding in 9.3% of all cycles, and breakthrough bleeding with spotting in 3% of all cycles. Amenorrhea was observed in 3% of all cycles. In all, 20 subjects (6%) discontinued participation in the study because of adverse events. No serious adverse events related to the study drug were reported. No clinically significant changes in weight, blood pressure, or lipids were reported. The impact of the new progestogen DRSP on the women's self-perception of menstrual health was also evaluated. Subjects reported that symptoms of water retention, negative affect, and increased appetite significantly improved at cycle 6 from baseline. This study demonstrates that Yasmin is an effective oral contraceptive that is safe and well tolerated.

Validation of a Trauma Questionnaire in veteran women.

The Trauma Questionnaire (TQ) assesses a woman's history of childhood and adult sexual trauma, sexual harassment, and domestic violence. The TQ is used widely at Veterans Affairs Medical Centers, but its validity has not been thoroughly examined. In a prospective study of 127 women, we found the TQ to have good to excellent agreement with a semistructured clinician interview and good sensitivity and specificity. The TQ can be used as a valid alternative to the clinician interview in the initial elicitation of trauma history among women veterans in the primary care setting.

The development of a primary care curriculum for obstetrics/gynecology residents.

In order to develop a primary care curriculum for obstetricians and gynecologists, a needs assessment was performed to determine those topics in which additional training was needed. We used a Likert scale comfort score (0-10) for evaluating or treating 14 primary care areas. The results of the 30 completed surveys showed that topics traditionally emphasized in obstetrics/gynecology training received very high comfort scores, while scores for traditional internal medicine problems were very low. We chosesix areas with the lowest comfort scores as targets for primary care education--immunizations, skin cancer screening, diabetes mellitus, hypertension, musculoskeletal complaints, and depression--and designed a seven-week rotation for obstetrics/gynecology interns. The rotation includes practical ambulatory experiences in gynecology and internal medicine, mental health assessments, thorough breast care in the breast clinic, and individual didactic instruction. The curriculum has been well received by the interns, who report more comfort in providing general women's health care. We suggest that a systematic assessment of the weaknesses and strengths of each residency can serve as the basis for curriculum planning.

Why the Urgency for Earlier Diagnosis of HIV Infection in Women?

As our perspective of AIDS changes from a disease that affects homosexual men and intravenous drug abusers to one that spreads increasingly through heterosexual contact, greater numbers of women are being diagnosed with HIV infection. Because clinicians still may perceive AIDS to be primarily a "male" disease and may maintain a low level of suspicion of it in their female patients, HIV infection is believed to be underdiagnosed and go unrecognized for longer periods in women than in men. Early reports in the 1980s that showed a worse prognosis and shorter median survival for women than for men are now explained by factors such as later presentation and diagnosis, disparity in access to care, and reluctance of clinicians to prescribe zidovudine to pregnant patients. Recent studies show that, with early identification of infection and subsequent treatment and prophylactic therapy, there are no differences in disease progression or survival in women compared with men. Moreover, from a public health standpoint, earlier diagnosis can decrease incidence of both sexual and vertical transmission. Women may choose to undergo tubal ligation to prevent future vertical transmission; additionally, zidovudine now is used in pregnant women and has been demonstrated to decrease transmission rates from 25% to 8%

Occurrence and documentation of low-level bacteremia in a community hospital's patient population.

To document the incidence of low-level bacteremia in the patient population of this study, two blood culture sets were collected from symptomatic patients weighing more than 80 pounds. Each blood culture set consisted of a lysis-centrifugation tube and three bottles containing different culture broths, each inoculated with 10 mL blood. Pathogens from 63 (26.4%) and 48 (20.1%) of the 239 culture-positive patients were recovered from only one and two of the eight culture devices, respectively, representing low-level bacteremia. Isolates from another 60 (25.1%) of the 239 patients were recovered from all eight of the culture devices, representing high-level bacteremia. Whether patients had low-level or high-level bacteremia, there were mostly insignificant differences in the types of species recovered, in the percentages of patients for whom therapy was initiated or changed following the laboratory's reports, and in the clinical signs, symptoms, and characteristics of the patients. Clinically documented, low-level bacteremia is relatively common in this community hospital's patient population. Culturing of up to 80 mL of blood was required for detection of all pathogens from patients weighing more than 80 pounds.

Corynebacterium pseudodiphtheriticum: a respiratory tract pathogen in adults.

Corynebacterium pseudodiphtheriticum has been reported to be an uncommon respiratory pathogen. We describe the clinical and microbiologic features of 17 patients from whose sputum C. pseudodiphtheriticum was isolated. Patients were identified through a review of the reports from the clinical microbiology laboratory at York Hospital, a community teaching hospital, from October 1990 through April 1993; 17 patients with respiratory infection caused by C. pseudodiphthriticum were identified. There were 12 cases of bronchitis and five of pneumonia. An underlying systemic condition, particularly congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, or malignancy, was common. Onset of symptomatology was acute for most patients, but fever was noticeably absent in almost two-thirds of the cases. Isolates were uniformly susceptible to the beta-lactam antibiotics, vancomycin, and trimethoprim-sulfamethoxazole, but resistance to clindamycin and erythromycin was common. The isolation of diphtheroids from a properly obtained sputum sample from a patient with respiratory tract infection should not always be dismissed as due to contamination. The isolation, identification, and susceptibility testing of C. pseudodiphtheriticum from respiratory tract specimens may provide information useful for treatment of patients.

Clinical comparison of isolator and thiol broth with ESP aerobic and anaerobic bottles for recovery of pathogens from blood.

The recovery of pathogens and the speed of their detection were determined for our conventional blood culture system (an Isolator [Wampole] and a 100-ml Thiol bottle [Difco]) compared with automated ESP aerobic and anaerobic bottles (80 ml each; Difco). Each of the four culture devices was inoculated with approximately 10 ml of blood from symptomatic patients weighing more than 80 lb (ca. 36 kg). From 7,070 sets of cultures for 2,841 patients, 607 clinically significant isolates were recovered: 456 (75.1%) from the Isolator, 353 (58.2%) from Thiol, 377 (62.1%) from ESP aerobic bottles, and 346 (57.0%) from ESP anaerobic bottles. Of the 607 isolates, 149 (24.5%) were detected only with the conventional system (Isolator and/or Thiol), and 65 (10.7%) were detected only with the ESP two-bottle system (P < 0.001). Our conventional system allowed for detection of significantly more isolates of members of the family Enterobacteriaceae (P < 0.001), Staphylococcus aureus (P < 0.01), Staphylococcus spp. (coagulase-negative) (P < 0.01), and Enterococcus spp. (P < 0.05), and ESP facilitated detection of significantly more isolates of S. pneumoniae (P < 0.01). When all four devices in a culture set were positive for the same isolate, no microbial species or group was detected significantly earlier ( > or = 24 h) by either blood culture system. The Isolator contamination rate (4.8%) was > or = 6 times the rate for any of the bottles. Of pathogens detected by the Isolator, 50% were recovered in counts of < or = 1.0 CFU/ml and 18% were recovered only as a single colony. The ESP system offered an automated, less labor-intensive blood culture system for which routine subcultures were not required, but the important considerations of culturing large volumes of blood and of obtaining at least two sets from each patient in our population were reemphasized.