Different labour outcomes in primiparous women that have been subjected to childhood sexual abuse or rape in adulthood: a case-control study in a clinical cohort.

OBJECTIVE: To compare the duration and outcome of the first labour in women who have been subjected to childhood sexual abuse (CSA) and women who have been raped in adulthood (RA). DESIGN: Case-control study in a clinical cohort. SETTING: University Hospital of North Norway. SAMPLE: In all, 373 primiparas: 185 subjected to CSA, 47 to RA and 141 controls without a history of abuse. METHODS: Data on birth outcomes were retrieved from the patient files. Information on sexual abuse was reported in consultation with specialised midwives in the mental health team. Birth outcomes were analysed by multinominal regression analysis. MAIN OUTCOME MEASURES: Vaginal births, delivery by caesarean section, operative vaginal delivery and duration of labour. RESULTS: As compared with controls, the RA group showed a significantly higher risk for caesarean section (adjusted OR 9.9, 95% CI 3.4-29.4) and operative vaginal delivery (adjusted OR 12.2, 95% CI 4.4-33.7). There were no significant differences between the CSA and the control group. The RA group displayed significantly longer duration of labour in all phases as compared with the control and CSA groups. CONCLUSIONS: There were major differences in the duration of labour and birth outcomes in the two abuse groups. Despite a higher proportion of obstetric risk factors at onset of labour in the CSA group, women subjected to CSA had shorter labours and less risk for caesarean section and operative vaginal deliveries than women subjected to RA. The best care for birthing women subjected to sexual abuse needs to be explored in further studies.

Birth outcomes in primiparous women who were raped as adults: a matched controlled study.

OBJECTIVE: To compare the duration of labour and the birth outcome in a group of primiparous women who had been raped after the age of 16, with a control group from the same birth cohort. DESIGN: Cohort study. SETTING: University Hospital of North Norway. SAMPLE: Fifty women raped as adults and 150 controls. METHODS: Data about birth outcomes in the first pregnancy were collected from the patient files and data concerning the assault were obtained in a subsequent pregnancy through consultations with the women who had been raped. Birth outcomes in the group of women who had been raped were compared with matched controls using a multivariable logistic regression model. MAIN OUTCOME MEASURES: Caesarean section, operative vaginal delivery and duration of labour. RESULTS: During their first delivery, the women who had been raped had an increased risk for caesarean section (adjusted odds ratio 15.7, 95% CI 5.0-49.1) and for assisted vaginal delivery (adjusted odds ratio 13.1, 95% CI 4.9-34.5) when compared with controls. The group of women who had been raped had a longer second stage of labour than the control group (120 versus 55 minutes, P < 0.01). They were more often single mothers, unemployed and smokers, and had a higher body mass index and more previous pregnancy terminations and miscarriages than the control group. CONCLUSIONS: The women who had been raped had a longer second stage of labour, and an increased risk of caesarean section and operative vaginal delivery compared with controls from the general birth cohort. These findings indicate that the consequences for delivery for women who had been raped as adults could be specific and may warrant particular attention. The birth experience of women who had been raped should also be illuminated in future studies.

Prevention of relapse in reflux esophagitis: a placebo controlled study of ranitidine 150 mg bid and 300 mg bid.

OBJECTIVE: To compare the efficacy and safety of long term use of ranitidine 150 mg bid, 300 mg bid and placebo in prevention of endoscopic and symptomatic relapse of reflux esophagitis in an international, double-blind, placebo controlled, parallel group study. PATIENTS AND METHODS: A total of 279 patients at least 18 years old from hospital out-patient departments with healed esophagitis (grade 0) with no or mild symptoms entered the study. Patients were randomly allocated to receive ranitidine 150 mg, 300 mg placebo twice daily for 48 weeks. Patients returned for symptom assessments at eight-week intervals and for re-endoscopy every 16 weeks. RESULTS: Both ranitidine regimens were significantly more effective than placebo in preventing endoscopic and symptomatic relapse of reflux esphagitis (p = 0.003 for ranitidine 150 mg bid; P < 0.001 for ranitidine 300 mg bid). No statistically significant differences were observed in relapse rates between the two ranitidine regiments. The percentage of patients with endoscopic relapse (grade 2) after 48 weeks were 60%, 37% and 27% for placebo, ranitidine 150 mg bid and ranitidine 300 mg bid, respectively (P = 0.002 for ranitidine 150 mg bid versus placebo; P < 0.001 for ranitidine 300 mg bid versus placebo). Ranitidine was well tolerated. CONCLUSIONS: Ranitidine 150 mg bid and 300 mg bid are safe and effective treatments in the prevention of reflux esophagitis relapse.

IUD users in Norway are at low risk for genital C. trachomatis infection.

From May 1993 to April 1995, 30 general practitioners located at 13 general practice settings in the city of Trondheim, central Norway, recruited 957 eligible participants in a prospective use-effectiveness study on performance of two copper IUDs. In this report we focus on screening for C. trachomatis at insertion and its possible effect on cause-related terminations during the first 90 days after insertion. All women were screened at IUD insertion for C. trachomatis. All specimens were analyzed applying a nucleic acid test (rRNA, GenProbe). Five out of 957 women (0.5%) were positive for C. trachomatis. All were treated within two weeks of diagnosis. No cases of pelvic inflammatory disease were diagnosed during the first three months of the study. Screening of C. trachomatis at IUD insertion is not recommended in Norwegian women because of the extremely low prevalence of C. trachomatis in those who choose IUD as their primary contraceptive method. Recommendations for universally screening women for sexually transmitted diseases at IUD insertion should be based upon review of local/national prevalence data.

PIP: During May 1993 to April 1995, in Norway, 30 general practitioners at 13 different centers in Trondheim recruited 957 parous women, 18-45 years old, in a prospective use-effectiveness study of 2 copper releasing IUDs. They screened for Chlamydia trachomatis infection at insertion. Researchers aimed to examine the effect of C. trachomatis infection on cause-related terminations during the first 3 months of use. Five (0.5%) women tested positive for C. trachomatis infection. All 5 women received antibiotic treatment within 9-15 days after IUD insertion. One woman with chlamydia infection experienced partial IUD expulsion at 9 days. The remaining women continued IUD use without complications. 57 (6/100 women-months) women requested removal of the IUD during the first 90 days of use. No woman requested removal for pelvic inflammatory disease or bleeding and pain. Based on these findings, the authors do not recommend screening for C. trachomatis at IUD insertion in Norwegian women because the prevalence of chlamydia infection was very low in IUD users. They suggest that any recommendations for universal screening of new IUD users for sexually transmitted diseases (STDs) be based upon a review of local/national STD prevalence data.

Liver hemodynamics during portal venous endotoxemia in swine.

The acute hemodynamic response of the liver to portal endotoxemia was measured in six isoflurane anesthetized pigs in which volume support was used to maintain normal cardiac output. After baseline monitoring, bacterial endotoxin (LPS) was infused over 1 hr into a mesenteric vein at a rate of 1 microgram.kg-1.hr-1, and monitoring was continued for 1 hr postinfusion. Peak vasoconstriction occurred during LPS infusion in both the hepatic artery (resistance increases 349% of baseline, P < 0.05) and the liver's portal circulation (resistance increases 159% of baseline, P < 0.05). Increased vascular resistance was also detected in lung (increases 433% of baseline) and intestine (increases 130% of baseline) at the midpoint of the LPS infusion. The non-splanchnic circulation, defined for our analysis as all of the peripheral circulation except the portal and hepatic arterial circulation, generally exhibited little change in vascular resistance during LPS infusion. LPS was incompletely cleared by the liver, but secondary clearance by the lung prevented large increases in the LPS concentration of arterial blood. During the first hour postinfusion, the systemic vascular resistance subsequently decreased to near normal in all vascular beds, with the exception of the liver's portal circulation. A sustained and secondary increase in vascular resistance of the liver's portal circulation and portal vein pressure occurred during the first hour after LPS infusion. We conclude that most of the vasoconstriction in the acute response to portal endotoxemia occurs in the liver and lung, organs directly exposed to elevated levels of endotoxins.

Lansoprazole versus omeprazole in short-term treatment of reflux oesophagitis. Results of a Scandinavian multicentre trial.

To evaluate the therapeutic potential of the newly developed proton pump inhibitor lansoprazole in patients with reflux oesophagitis, we performed a double-blind randomized clinical trial comparing 20 mg omeprazole and 30 mg lansoprazole, involving 229 patients at 9 Scandinavian hospitals. The treatment period was 4 or 8 weeks, and main efficacy variables were healing of endoscopic changes, relief of reflux symptoms, and occurrence of adverse events. No significant difference in terms of healing was found, either after 4 or after 8 weeks' treatment. Patients receiving lansoprazole experienced a greater improvement in heartburn after 4 weeks (p = 0.03), and there was a similar trend for acid regurgitation. Lansoprazole was found to be an effective and safe alternative to omeprazole in short-term treatment of moderate reflux oesophagitis.

[Which women should be tested for Chlamydia trachomatis in general practice?]. / Hvilke kvinner bør undersøkes for Chlamydia trachomatis i allmennpraksis?

Specimens to test for Chlamydia trachomatis and Neisseria gonorrhoeae were collected as a routine from female patients undergoing gynecological examinations in general practice. In 3.9% of 517 non-pregnant women the culture for C trachomatis was positive. None were infected with N gonorrhoeae. C trachomatis was detected in ten of 138 (7.2%) women with genital symptoms, compared with ten of 379 (2.6%) without symptoms. The annual incidence rate for C trachomatis in asymptomatic patients was 0.3% for women older than 25 years, and 5.4% for women younger than 25 years. Routine testing for C trachomatis is recommended during gynecological examination in general practice of asymptomatic women younger than 25 years. Tests should be taken at minimum two-year intervals. Routine tests for N gonorrhoeae are not recommended.

[Health services for physicians in Rogaland. A questionnaire study]. / Helsetjeneste for leger i Rogaland. En spørreskjemaundersøkelse.

In order to investigate the need for a health service for doctors a questionnaire was mailed to all doctors in Rogaland county. 84% of the respondents were in favour of such a service. It is necessary not only to provide a general medical examination but to focus also on work-related and psychosocial factors.

Dose response characteristics of hypertonic saline dextran solutions.

In an effort to find the best hypertonic saline-dextran solution (HSD) for prehospital use, 33 chronically catheterized sheep were bled using a fixed pressure shock model (50 mm Hg x 2 hours) and resuscitated with 4 ml/kg of HSD solution (2-minute bolus). In the first set of experiments colloid was varied and sodium chloride was held constant, as 7.5% NaCl was paired with either 0%, 6%, or 12% dextran 70. A dose-response relationship existed, with cardiac output increasing 20% with each sequential dextran 70 concentration. Mean arterial blood pressure was higher in animals that were resuscitated with either the 7.5% NaCl/6% dextran 70 or 7.5% NaCl/12% dextran 70 solution (p less than 0.05). Using the optimal dextran 70 concentration from the first set of experiments (i.e., 12%), solute was varied in a second set of experiments comparing 0.9%, 3.8%, 7.5%, or 10% NaCl/12% dextran 70. Again, dose-response features were demonstrated, as cardiac output increased as a function of NaCl concentration. However, this response plateaued with the 7.5% NaCl concentration and no advantage was obtained by increasing the NaCl concentration to 10%. We conclude that a 4-ml/kg bolus of 7.5% NaCl/12% dextran 70 solution may be a more effective form of therapy than those previously evaluated. This new solution is now being included in our ongoing clinical trials.

Evaluation of an intraosseous infusion device for the resuscitation of hypovolemic shock.

An intraosseous infusion device designed for the prehospital administration of hypertonic saline-dextran solutions was evaluated by resuscitating hemorrhaged conscious sheep. Eight animals underwent 2 hours of hemorrhagic hypotension (50 mm Hg, bled volume = 43 +/- 7 ml/kg). This was followed by the intraosseous infusion of 200 ml (4-5 ml/kg) of 7.5% NaCl-6% dextran 70 into the bone marrow of the sternum. Results were compared to seven control animals (bled volume = 31 +/- 6 ml/kg) resuscitated through a central venous catheter. Despite the small volumes infused, mean arterial blood pressure and cardiac output were rapidly normalized in both groups by 10 minutes post resuscitation (p less than 0.01). Plasma sodium concentration increased an average of 12 mEq/L and plasma volume was rapidly expanded regardless of route. The metabolic acidosis of hemorrhagic shock was rapidly corrected, pulmonary pressures remained normal, and hypoxemia did not occur after intraosseous resuscitation. The device provided safe and rapid vascular access via the sternal bone marrow space. The use of intraosseous infusion of hypertonic saline dextran solutions via the sternal bone marrow may allow prehospital rescuers to consistently incorporate fluid replacement therapy into 'scoop and run' policies by avoiding the time delays associated with failures in IV access.

Should asymptomatic patients be tested for Chlamydia trachomatis in general practice?

Routine testing for Chlamydia trachomatis during gynaecological examinations has been suggested as a preventive measure against pelvic inflammatory disease and other health risks associated with chlamydial genital infections. This study examined the cost and effectiveness of routine testing for C trachomatis in general practice. An epidemiological model was used to predict how routine testing and treatment of positive cases would affect the future number of cases of pelvic inflammatory disease, infertility and ectopic pregnancy in a general practice population. The cost of routine test and treatment, and savings resulting from prevented future morbidity, were also estimated. For the population under study, a routine test for chlamydial infections in asymptomatic 18-24 year old women during gynaecological examinations was found to be cost effective but this was not the case for older women. At least two years should elapse between repeated tests.

Duodenal ulcer treated with omeprazole: healing and relapse rates. Does treatment duration influence subsequent remission?

One hundred and twenty-nine patients were studied with regard to healing of duodenal ulcers with 30 mg omeprazole once daily, recurrence rates after 2 and 4 weeks' treatment in patients with ulcers healed after 2 weeks, and recurrences in rapid and slow healers. Cumulative healing rates were 77% and 98% after 2 and 4 weeks, respectively. Eighty-one patients (65%) were without ulcer symptoms after 2 weeks, and 43 (34%) were improved. Seven of 45 patients (16%; 95% confidence limits, 6-30%) with ulcers healed after 2 weeks had relapsed after another 2 weeks of placebo; 3 were asymptomatic. The overall relapse rate after 6 months was 62%. There were no statistically significant differences in relapse rates between 2 and 4 weeks' treatment of patients with ulcers healed after 2 weeks or between rapid and slow healers. Ulcer size, smoking habits, and alcohol consumption were not significantly related to healing or relapse.

Acute treatment of reflux oesophagitis: a multicentre study to compare 150 mg ranitidine twice daily with 300 mg ranitidine at bedtime.

A randomized, double-blind, clinical trial was undertaken to compare 150 mg ranitidine b.d. with 300 mg ranitidine nocte in the treatment of reflux oesophagitis. Endoscopy data were evaluable for 336 patients after 8 weeks of treatment. At this time 75% of patients who received 150 mg ranitidine b.d., and 73% of those who received 300 mg nocte, had healed or showed endoscopic improvement to grade I oesophagitis. At 12 weeks these rates had increased to 89 and 88%, respectively. Oesophageal biopsies from 258 patients at 8 weeks showed histological improvement in 44 and 47% of those treated with 150 mg ranitidine b.d. and 300 mg ranitidine nocte, respectively. After 12 weeks histological improvement was apparent in 57 and 54% of biopsies from each group, respectively. Symptom severity and frequency was reduced to a similar extent by both treatments. Adverse events were reported by 15 patients. A 300-mg bedtime dose of ranitidine was found to be a well-tolerated, effective alternative to twice daily treatment in reflux oesophagitis.

Genital Chlamydia trachomatis infections in patients with abnormal cervical smears: effect of tetracycline treatment on cell changes.

A group of 1760 women aged 14-35 years were examined for the concurrent presence of Chlamydia trachomatis and cellular atypia of cervical smears. Positive tests for C trachomatis were found in 126 women (7.2%). Cell changes were found in 85 women (4.8%), and 25 of these were C trachomatis-positive. Slight cellular atypia was the major finding in the smears from 22 of the C trachomatis-positive women, whereas three patients had more pronounced cell changes. Smears reverted to normal in 18 of the 23 patients who returned for tetracycline treatment and follow-up cytology. All 18 patients had smears showing slight cellular atypia prior to therapy. In five patients who also had cellular changes suggesting a human papillomavirus infection, the smears did not revert to normal after antibiotic therapy during the observation period. These findings suggest that patients with C trachomatis and mild cellular atypia should have antibiotic therapy and repeat smears taken before further treatment is considered. More advanced cellular atypia is unlikely to be caused by C trachomatis.

Correction of hypothermia by continuous pleural perfusion.

Hypothermia to less than 30 degrees C is associated with significant harmful effects, including ventricular fibrillation. None of the currently used techniques for core rewarming is entirely satisfactory. Continuous perfusion of the pleural space with warm saline solution has been studied as a method of core rewarming. Pigs were cooled to 28 degrees to 30 degrees C. The pleural space was continuously perfused with fluid at a temperature of 42 degrees C. Five hypothermic control pigs did not achieve a temperature of 32 degrees C in 3 hours of spontaneous rewarming. The rise in 1 hour was 0.34 degrees C. In 10 pigs that underwent continuous pleural perfusion the temperature exceeded 32 degrees C in a mean time of 56 minutes. The rise in temperature in the first hour of rewarming was 5.05 degrees C. Continuous pleural perfusion is a rapid and effective technique for core rewarming of the hypothermic pig.

Massive haemobilia in a patient with residual stone after choledochoduodenostomy. Case report: treatment with endoscopic papillotomy.

Anastomotic bleeding and haemobilia after choledochoduodenostomy have been only sporadically reported in the literature. We present a case of massive haemobilia due to residual stone after choledochoduodenostomy, a complication that to our knowledge has not previously been described. The patient has been asymptomatic for 2 years following endoscopic papillotomy.

Local disodium cromoglycate is ineffective in ulcerative proctosigmoiditis.

Conflicting results have emerged from studies using oral and rectal disodium cromoglycate (DSCG) in inflammatory bowel disease. In the present double-blind study, 43 patients with active ulcerative proctosigmoiditis received either placebo (n = 22) or 600 mg DSCG (n = 21) rectally as enemas for eight weeks. Assessment was made from clinical investigations, endoscopy, laboratory tests, biopsies, and diary cards. No statistically significant differences in bowel frequency, rectal bleeding, general well-being, abdominal pain, and severity and extent of the disease were found between the groups during the study. There was no significant change in the histologic parameters. No side-effect was encountered. It is concluded that DSCG did not improve symptoms or inflammatory changes in ulcerative proctosigmoiditis.

The rate of healing of duodenal ulcers during omeprazole treatment.

We have studied the rate of healing of duodenal ulcers in 44 patients treated with omeprazole, 40 mg once daily for 4 weeks, with or without an 80-mg loading dose on day 1. Fourteen patients (32%) had healed by the end of the 1st week's treatment and a further 27 after a further week (giving a cumulative total of 93%). All patients (100%) had healed by the end of the treatment period. There was no significant difference in healing rate between the two treatment groups. Ulcer symptoms were relieved rapidly, and the drug was well tolerated.