Delayed progression to AIDS in volunteers treated with long-term HIV-1 Immunogen (REMUNE) therapy in Thailand.

OBJECTIVES: To observe the long-term effects of an immune-based therapy HIV-1 Immunogen (REMUNE; Immune Response Corp., Carlsbad, CA, USA) as a first course of treatment designed to sustain the immune system and thus delay the initiation of therapy with antiretroviral drugs and/or delay disease progression. METHODS: In this open-label, multi-institute extended phase II P2101B study, disease progression, CD4 and CD8 T-cell counts, HIV-1 RNA levels, and genotypic antiretroviral drug resistance were examined in 223 asymptomatic HIV-1-infected Thai volunteers receiving REMUNE every 12 weeks over 132 weeks. A subset of subjects was randomly selected by the physicians to receive antiretroviral drugs for 10 months. RESULTS: Patients treated with REMUNE demonstrated a low rate of clinical disease progression (0.72 per 100 person-years), higher CD4 and CD8 T-cell counts, higher body weight before and after treatment in the same patient, and stable viral load with no serious adverse events. We found no genotypic evidence of drug resistance in subgroups of patients on REMUNE monotherapy or REMUNE plus antiretrovirals (ARTs). CONCLUSIONS: This Thai study, like previous US and European studies, confirms that therapeutic immunization of HIV-infected volunteers modifies disease progression, as evidenced by stabilization of CD4 and CD8 T-cell counts, body weight, and viral load. As the majority of asymptomatic patients demonstrated an objective response to immunization, this study suggests that REMUNE may be utilized prior to initiation of antiviral drug therapy when CD4 cell counts are still above the current ART guidelines. Further work should be carried out to examine its potential use in combination with ART in order to reduce the increasingly common occurrence of drug resistance.

Acceptability of COL-1492, a vaginal gel, among sex workers in one Asian and three African cities.

OBJECTIVES: To evaluate the acceptability of COL-1492, a vaginal gel containing 52.5 mg nonoxynol-9, in an HIV prevention trial. METHODS: Sex workers participating in a phase II/III triple blind, randomised trial in Benin, Côte d'Ivoire, South Africa, and Thailand were interviewed on the gel's acceptability at monthly scheduled clinic visits. Safer sex counselling, male condoms, and study gels were given at each monthly visit; a gynaecological examination and HIV test were performed. Phase III interviews considered the participants' appreciation of the gel. On the first, second, and fifth follow up visits, the study volunteers completed more extensive questionnaires. RESULTS: Responses were similar between treatment arms. Women indicated not liking their gel in 1.8% of the visits; 98.1% of the women found the gel easy to apply; 30.1% said that it affected sexual intercourse. These effects were mostly improvements (92.6%) by facilitating intercourse (73.6%). Intercourse was more often affected in women reporting painful sexual intercourse (OR: 2.59 (95% CI 1.63 to 4.12)) and in older women. The latter effect differed among centres. CONCLUSION: Most participants found their assigned gel acceptable and the vast majority of reported effects on intercourse were favourable. The type of gel had no significant impact on the findings.

A comparison of first-void urine, self-administered low vaginal swab, self-inserted tampon, and endocervical swab using PCR tests for the detection of infection with Chlamydia trachomatis.

BACKGROUND: Polymerase chain reaction (PCR) tests, AMPLICOR, Roche Diagnostics, were shown to be an acceptable and sensitive method of detecting Chlamydia trachomatis infection. The PCR test's ability to evaluate different specimen types is worth determining, as well as the acceptability to Thai women of the self-collection of samples. METHODS: Of the 1011 subjects interviewed, 953/1011 subjects (94.3%) agreed to self-test, 523 were commercial sex workers (CSWs) and 430 were outpatient women (OPW). More than half [570/953 (59.8%)] participated in the four-specimen collection, to be tested by PCR for C. trachomatis. Specimens were collected via first-void urine (FVU), self-administered low vaginal swab (LVS), self-inserted tampon, and endocervical swab (ES). The majority, 906/953 subjects (95.1%), had only three methods of specimen collection, LVS being excluded. RESULTS: The prevalence of positive C. trachomatis detection among the CSWs/OPW was 17.6/7.2%, 15.6/5.4%, 12.8/4.2%, and 11.6/5.7% using tampons, LVS, FUV, and ES collection methods respectively. Tampons were used to compare results from other specimen types in both groups. Significantly more OPWs were willing to use a tampon for repeat specimen collection (85.1%) than were the CSWs (62.3%). Willingness to use a LVS again was not significant, 75.2% in outpatient women and 74% in CSWs. CONCLUSIONS: Tampon and LVS, self-collection methods are acceptable to women in Thailand and are a good alternative method for detection of C. trachomatis.

Epidemiology of HIV and sexually transmitted infections in Thailand.

There are very few developing countries in the world where public policy has been effective in preventing the spread of HIV/AIDS on a national scale. Thailand is an exception, a massive program to control HIV has reduced visits to commercial sex workers by half, raised condom usage, decreased sexually transmitted infections dramatically, and achieved substantial reductions in new HIV infections. However, unless past efforts are sustained and new sources of infection are addressed, the striking achievements made in controlling the epidemic could be put at risk. There is a need in Thailand to continue strong HIV/AIDS prevention and education efforts in the future, as well as to provide treatment and care for those living with HIV/AIDS.

Long-term follow-up of HIV-1-infected Thai patients immunized with Remune monotherapy.

PURPOSE: The purpose of this 2-year follow-up study was to investigate the long-term effect of Remune as monotherapy for HIV-1 infection. BACKGROUND: Participants previously enrolled in the phase II double-blind, randomized, adjuvant-controlled study of the HIV-1 Immunogen (Remune) were followed for 2 years. Open-label immunization with Remune monotherapy was given to each participant every 12 weeks. Remune, a gp 120-depleted HIV-1 that was inactivated in beta-propiolactone and irradiation, was emulsified with mineral oil (incomplete Freund's adjuvant). METHOD: In Study 2101B, the effect of four doses of Remune given every 12 weeks over 40 weeks was compared to placebo in 297 asymptomatic type E HIV-infected patients [Churdboonchart et al., 2000]. A group of 17 volunteers were separated into a subset study and another 57 were excluded from analysis due to discontinuation or addition of other treatments. This 2-year follow-up study continued with open-label dosing of HIV-1 Immunogen every 12 weeks for the remaining 223 patients. Changes in CD4+ cells, CD8+ cells, and body weight were monitored at each patient visit. RESULTS: Overall, immunizations were safe; common adverse events were tolerable injection site reactions. CD4+ T-cell counts remained stable over the 132-week observation period for this cohort with a slight increase of 36.01 cells/microL. CD8+ T-cell counts showed an increase from baseline during the follow-up period (415.21 cells/microL). Furthermore, we also observed an increase in body weight from baseline (1.08 kg) at week 132. In addition, baseline CD4 count appeared to predict CD4 count at week 132 (slope = 0.31, p <.0001). CONCLUSION: These results suggest that long-term treatment of HIV-1 infection with Remune monotherapy is safe and results in a stabilization of CD4+ counts. Furthermore, it is likely that HIV-1 therapeutic immunization may show its greatest clinical benefit in participants with higher CD4+ cell counts. Such an approach may have important ramifications in developing countries where access to antiviral drugs is limited and also in early chronic HIV-1 infection when CD4+ cells are still over 300 cells/microL in order to limit the cost and toxicity.

Acceptability of the female condom among sex workers in Thailand: results from a prospective study.

BACKGROUND: The female condom may provide women with the first female-controlled barrier method that is effective against sexually transmitted diseases, including HIV infection. GOAL: This study evaluated the acceptability of the female condom among sex workers in Thailand. STUDY DESIGN: Data on use and acceptability of the female condom were collected using a structured questionnaire during an 8-week follow-up. RESULTS: Analyses included 148 women who were still in follow-up at week 8. Sex workers used, on average, 2.8 female condoms per week. The overall satisfaction rate with the female condom was 68%, although, among users, 31% had difficulties in device insertion, 37% had pain from the inner ring, and 22% reported itching sensations. The main reason for using the female condom in the future was its perceived safety, and the main reason for not using it would be the client's refusal. CONCLUSION: Two-thirds of the sex workers were satisfied with the female condom. Difficulties at insertion, discomfort during use, and clients' attitude were potential obstacles to the use of the female condom in the future.

A double-blind, adjuvant-controlled trial of human immunodeficiency virus type 1 (HIV-1) immunogen (Remune) monotherapy in asymptomatic, HIV-1-infected thai subjects with CD4-cell counts of >300.

We examined the effect of a human immunodeficiency virus (HIV)-specific immune-based therapy in Thailand, where access to antiviral drug therapy is limited. A 40-week trial was conducted with 297 asymptomatic, HIV-infected Thai subjects with CD4-cell counts greater than 300 microl/mm(3). Subjects were randomized to receive either HIV type 1 (HIV-1) immunogen (Remune; inactivated HIV-1 from which gp120 is depleted in incomplete Freund's adjuvant or adjuvant control at 0, 12, 24, and 36 weeks at five different clinical sites in Thailand. Neither group received antiviral drug therapy. The a priori primary endpoint for the trial was changes in CD4-cell counts with secondary parameters of percent changes in CD8-cell counts (percent CD4, CD8, and CD4/CD8) and body weight. Subsets of subjects were also examined for changes in plasma HIV-1 RNA levels, Western blot immunoreactivity, and HIV-1 delayed-type hypersensitivity (DTH) skin test reactivity. There was a significant difference in changes in CD4-cell counts that favored the HIV-1 immunogen-treated group compared to those for the adjuvant-treated control group (P<0.05). On average, for HIV-1 immunogen-treated subjects CD4-cell counts increased by 84 cells by week 40, whereas the increase for the control group was 38 cells by week 40. This increase in CD4-cell count was associated with increased HIV-specific immunogenicity, as shown by Western blotting and enhanced HIV-1 DTH skin reactivity. No significant differences in adverse events were observed between the groups. The results of this trial suggest that HIV-1 immunogen is safe and significantly increases CD4-cell counts and HIV-specific immunity compared to those achieved with the adjuvant control in asymptomatic HIV-1-infected subjects not taking antiviral drugs.

Prevalence of sexually transmitted infections among clients of female commercial sex workers in Thailand.

BACKGROUND: Clients of commercial sex workers are considered at high risk for the acquisition and transmission of sexually transmitted diseases (STDs). Identification and treatment of infections in this group could help to reduce the transmission of STDs. GOAL: To ascertain the prevalence of sexually transmitted organisms in male clients of female sex workers in Thailand by analysis of seminal fluid collected after intercourse. STUDY DESIGN: Used condoms were collected from 291 male clients attending a brothel in Hat Yai, Thailand during a 7-day period. Nucleic acid was extracted from seminal fluid and tested by polymerase chain reaction for the presence of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus (HSV) and HIV sequences. RESULTS: Overall, 17 (6%), 47 (16%), and 2 (1%) of specimens were positive for C trachomatis, N gonorrhoeae and T vaginalis respectively. HSV sequences were found in 24 (8%) of the specimens: 14 specimens (5%) with HSV type 1, and 11 specimens (4%) with HSV type 2. HIV RNA was detected in two samples (1%). Overall, 75 specimens (26%) were positive for one or more infections, and more than one pathogen was detected in 16 specimens (5%). CONCLUSION: This study reports a high rate of STDs among clients of female sex workers in Thailand. Consequently, this population is a significant risk for transmitting STDs to commercial sex workers and to other noncommercial partners. Strategies that target this population of men are needed to reduce STD and HIV transmission.

The prevalence of urethral infections amongst asymptomatic young men in Hat Yai, southern Thailand.

The aim of this study was to survey sexual behaviour and estimate the prevalence of urethral infections amongst male vocational college students. A cross-sectional survey was performed among 479 young men attending 2 vocational colleges in Hat Yai, southern Thailand. Polymerase chain reaction (PCR) tests of first-void urine (FVU) samples were used to detect infection with Chlamydia trachomatis, Neisseria gonorrhoeae, Ureaplasma urealyticum, Mycoplasma genitalium and Mycoplasma hominis. Girlfriends were the usual sexual partners for 89% of men with only 11% regularly patronizing sex workers. Condom usage was low. The prevalence of any urethral infection was 15.9% with: C. trachomatis 4%, N. gonorrhoeae 0.2%, U. urealyticum 10.9%, M. genitalium 2.3% and M. hominis 1.3%. Infection with more than one organism was found in 2% of men. While the prevalence of infection with chlamydia or gonorrhoea was relatively low, the prevalence of 'any urethral infection' was moderately high and suggests that unprotected sexual intercourse is commonly occurring. As girlfriends were the most usual sexual partners, they must be at significant risk of pelvic infection. There is a need for programmes targeting this group of people.

Can a two-glass urine test or leucocyte esterase test of first-void urine improve syndromic management of male urethritis in southern Thailand?

The goal of this study was to determine whether a urine two-glass test or a leucocyte esterase (LE) test of first-void urine (FVU) improve the sensitivity or specificity of the World Health Organization (WHO) algorithm for the syndromic management of men with urethritis in southern Thailand. A secondary aim was to determine whether infection with Trichomonas vaginalis was sufficiently common to include treatment for it in a syndromic management protocol. One hundred and twenty-nine men with symptoms of urethritis seen at 2 STD clinics in Songkla Province, Thailand were enrolled. Symptoms and signs of each man were recorded and a urethral swab collected for microscopy and culture for Neisseria gonorrhoeae. A two-glass urine test and an LE test of an FVU specimen were performed. The FVU was tested by polymerase chain reaction (PCR) for N. gonorrhoeae, Chlamydia trachomatis and T. vaginalis. Dysuria was a symptom in 78% of men. A urethral discharge was a symptom in 68% but was evident on examination in 95% of the men. The prevalences of infection were 32.6% for N. gonorrhoeae, 23.3% for C. trachomatis, 1.6% for T. vaginalis and 51.9% for any infection. The sensitivities and specificities of urethral discharge on examination, two-glass test and LE test of FVU as indicators of infection with either or both of N. gonorrhoeae or C. trachomatis were 97% and 8%; 57% and 83%; and 59% and 78% respectively. Combinations of urethral discharge on examination and one of the other indicators were more specific but much less sensitive than the presence of discharge alone. Culture for N. gonorrhoeae was found to be only 43% sensitive compared with an expanded gold standard involving a PCR test. Our analysis demonstrates that neither the two-glass test nor the LE test of FVU were useful in improving on the WHO algorithm for management of men with urethritis. T. vaginalis was not common enough to include in a first-line syndromic management protocol for male urethritis. We recommend that, in southern Thailand, men with symptoms of urethritis in whom a urethral discharge is present on examination be offered immediate treatment for both N. gonorrhoeae and C. trachomatis as per the WHO algorithm.

Safety of multiple daily applications of COL-1492, a nonoxynol-9 vaginal gel, among female sex workers. COL-1492 Phase II Study Group.

RATIONALE: COL-1492 is a nonoxynol-9 (N-9)-containing vaginal gel and may be a potential microbicide. As part of an effectiveness trial, an initial toxicity study was conducted. OBJECTIVES: The main objective of the reported study was the assessment of the toxicity of a 52.5 mg N-9 gel, COL-1492, when used a number of times each day by female sex workers. METHODS: This was a randomized, placebo-controlled triple-blinded trial among female sex workers. The participants were asked to use the product for each vaginal sexual act. At each monthly visit a gynaecological examination with sexually transmitted disease sampling and colposcopy was performed. Venous blood was drawn for syphilis and HIV serology. All women received intensive counselling on condom use. Male condoms and sexually transmitted disease treatment were given free of charge. RESULTS: Only blinded results on the colposcopic examinations are reported. The incidence of lesions with or without an epithelial disruption was low: 0.06 and 0.29, respectively, per 100 woman-days in group A; 0.09 and 0.26 respectively per 100 woman-days in group B. There was no significant difference between the two arms. CONCLUSION: The multiple daily use of COL-1492 by female sex workers did not show an increase of local toxicity over that of a placebo. Colposcopy was discontinued in the autumn of 1997 in accordance with a Data Safety Monitoring Board decision. In the currently ongoing effectiveness trial the assessment of the product's toxicity continues to be monitored by simple visual examination.

Challenges in the conduct of vaginal microbicide effectiveness trials in the developing world.

Conducting a phase III trial of a vaginal microbicide in a developing country poses several important and complex ethical challenges. As part of a process to bridge the gap between ethical theory and practice, we share our experiences in performing a phase III trial of Col 1492 (Advantage S) among female sex workers at four sites world-wide; Durban, Abidjan, Cotonou and Hat Yai. The ethical challenges included: (i) difficulties in obtaining informed consent. Participants were unable to grasp the concepts of a clinical trial for several weeks to months. In Cotonou, 30% of the women did not know the gel was tested for HIV prevention. Only 25% understood what a placebo was. In Durban, 70% of the women did not fully understand the study after 3 months; (ii) in sustaining the use of known HIV prevention strategies. Participants at the Durban site had difficulty in sustaining condom use due to financial and client preferences. Sex without condoms was worth more ($20) than sex with condoms ($10); (iii) in maintaining the confidentiality of the subject's HIV status. Novel approaches such as role plays and emphasis on other exclusion criteria were needed to maintain the confidentiality of women not included in the trial due to their HIV status; (iv) in providing care and support to the subjects who became infected with HIV during the trial. Women could only be offered routine sexually transmitted disease treatment and counselling. Anti-retrovirals were not offered. The successes and failures of the solutions attempted are described.

Evaluation of two clinical protocols for the management of women with vaginal discharge in southern Thailand.

OBJECTIVES: (1) To compare the effectiveness of two clinical protocols for the management of vaginal discharge in the situations where no laboratory facilities are available but speculum examination is possible and where basic laboratory facilities are available. (2) To determine clinical and simple laboratory indicators for diagnosis of patients with vaginal discharge in the local setting. DESIGN: Alternate allocation of subjects to one of two management protocols. SUBJECTS: Women presenting to university gynaecology outpatients department with a complaint of vaginal discharge. METHODS: Subjects were alternately allocated management according to one of two protocols: one without (group A) and one with (group B) immediate access to results of basic laboratory tests. Full clinical assessment including speculum examination and microbiological assessment for infection with gonorrhoea, chlamydia, candida, trichomonas, and bacterial vaginosis was performed on all women. Follow up assessment of clinical and microbiological response was performed 1-2 weeks later. RESULTS: At initial assessment, both groups were similar in all respects except that more group B women had inflammation of the vulva. The prevalences of various conditions were: candidiasis 22%, bacterial vaginosis 38%, trichomoniasis 4%, chlamydia 4%, gonorrhoea 0.4%. There was no association between any demographic characteristic and diagnosis of cause of the discharge. Both protocols resulted in clinically and statistically significant improvements for women with candidiasis, bacterial vaginosis, and trichomoniasis. There were no clinically important differences in outcomes between the two protocols. The sensitivities and specificities of various indicators were: curd-like vaginal discharge for candidiasis, 72% and 100%; homogeneous vaginal discharge for bacterial vaginosis or trichomoniasis, 94% and 88%; absent or scanty lactobacilli for bacterial vaginosis, 99% and 68%; > 20% clue cells for bacterial vaginosis, 81% and 99%; visible endocervical mucopus for chlamydia or gonorrhoea, 36% and 86%; microscopic endocervical mucopus for chlamydia or gonorrhoea, 64% and 69%. CONCLUSIONS: Both protocols were equally effective in managing women with abnormal vaginal discharge. Simple clinical indicators for candidiasis, bacterial vaginosis, or trichomonas as in protocol A are sufficiently sensitive and specific for use in situations with no laboratory support. A modification to protocol A could increase detection of bacterial vaginosis at basic health service level. Further work is needed to identify appropriate indicators for infection with chlamydia or gonorrhoea.

Perceptions and acceptability of the female condom [Femidom] amongst commercial sex workers in the Songkla province, Thailand.

In a prospective descriptive study on the perceptions and acceptability of the female condom in a group of Thai commercial sex workers (CSWs) in the Songkla province, we invited CSWs from selected brothels to participate. Those who used the female condom were interviewed after one week and 16 weeks of use. Focus group discussions were also conducted at the end of the study period to obtain additional information. The group comprised 56 CSWs. Only 34% of them had heard of the female condom prior to this study and none had ever used one. A high proportion of CSWs reported positive experiences and perceptions. There were no significant changes in perceptions and experiences during the study. Eighty per cent of participants said they were satisfied with the female condom and would use it again in the future and would recommend it to their friends. However, the female condom was used in only 29% of the total number of sexual acts reported, and 98% of CSWs said they would prefer to use a male condom for sex work. Many of the women were concerned that the physical appearance of the condom would reduce its acceptability to their clients. This was the most frequently cited reason for not using the female condom in the future. While a promising device, the female condom must also become more acceptable to men if it is to enable women to be in control of their own protection from pregnancy and STD/HIV.

Symptomatology and hormonal levels among Thai women with natural menopause.

The hormonal levels and symptoms after natural menopause have been studied in 100 patients. The mean age was 56.8 years while menopausal age was 50.3 years. Postmenopausal symptoms presented 55.0 per cent with the three most common complaints of hot flushes, emotional lability and vaginal dryness, respectively. The levels of plasma FSH, estradiol and testosterone were also reported corresponding to the years after menopause. Both gonadotropins reach a maximum concentration at two to three years after the menopause and then gradually declined. The LH/FSH ratio was 0.6. The mean concentration of estradiol was 10.07 pg/ml, the level remained consistently low during the menopausal period. Testosterone concentration declined little in postmenopausal women.

The comparison of the efficacy among three different nimorazole regimens in the treatment of bacterial vaginosis.

The efficacy of 3 different nimorazole regimens in treating bacterial vaginosis in women was evaluated. The regimens consisted of: Nimorazole 2 g single dose (Group I), 1 g per day for 3 days (Group II), and 1 g per day for 7 days (Group III) orally. In a simple randomized trial of 90 cases (30 cases in each group) with demonstrated clinical bacterial vaginosis on the presence of 3 of 5 of the following signs: (1) Characteristic thin homogenous discharge; (2) vaginal pH greater than 4.5; (3) release of a fishy amine odor from vaginal fluid mixed with 10% KOH; (4) presence of clue cells (usually representing at least 20% of vaginal epithelial cells); and (5) vaginal fluid contains few or no lactobacilli. Cure rates for bacterial vaginosis by nimorazole were 70.0% (21/30), 83.3% (25/30), and 90.0% (27/30) in Group I, II, and III, respectively. Thus nimorazole is another effective drug for the treatment of bacterial vaginosis.

Postmenopausal sexuality in Thai women.

We evaluate sexuality in 100 natural menopausal women as pertains to hormones, symptoms related to intercourse, and marital relationship with sexual desire, orgasm and coital frequency. The mean age was 56.8 years while menopausal age was 50.3 years. The postmenopausal syndrome presented 55.0% occurring 1 to 7 years after menopause (mean 3.4 years). The common sexual problems after menopause were loss of libido, orgasmic dysfunction, and dyspareunia. Both sexual desire and activity decreased when compared with premenopausal period. Ninety percent of the subjects had sexual desire less than once a month. Only 14% of the subjects occasionally reached orgasm while the other 86% never had orgasm after menopause. The levels of FSH, LH, estradiol and testosterone were also reported. There was no correlation of hormone estradiol and testosterone, symptoms related to intercourse and marital relationship with sexual desire, orgasm, or coital frequency.

Efficacy of cefoxitin for the prevention of postoperative infection in abdominal hysterectomy.

Prophylactic effect of cefoxitin against postoperative infection at a dose of 2 g intravenous (single dose 30 minutes before the operation) was investigated using fever index in patients who underwent the elective, nonradical abdominal hysterectomy. The results obtained are summarized as follows. Total fever index values were 12.9 +/- 10.0 degree-hours in the control group (n = 39), 11.3 +/- 9.7 degree-hours in the study group (n = 39). There were no statistical significance between both groups. Data from this investigation does not suggest the concept that prophylactic antibiotics are beneficial in the reduction of postoperative infection. The results of this prospective study reflected in unnecessity of antibiotic prophylaxis in abdominal hysterectomy.

Seven day metronidazole versus single dose tinidazole as therapy for nonspecific vaginitis.

A comparative study of the treatment of nonspecific vaginitis was carried out in 171 reproductive-aged women. The patients were randomly treated with either metronidazole or tinidazole (Ninety-three patients in Group I, received oral metronidazole 1 g daily for 7 days. Another 78 patients in Group II, received oral tinidazole 2 g single dose. The patients were advised to return for follow-up examinations 1-2 weeks after treatment in their nonmenstrual period. Of these, 50 patients in each group were subject to complete study. The cure rates were 92 per cent in Group I and 86 per cent in Group II. The difference was not significant statistically. The adverse drug reactions among the two groups were 22 and 8 per cent respectively. Tinidazole is another effective drug for the treatment of nonspecific vaginitis.

Incidental appendectomy at cesarean section: a prospective study.

In conclusion, the present study describes a controlled series and demonstrates the safety of incidental appendectomy at cesarean section. A slight increase in operative time accompanied appendectomy group, but the length of hospital stay and postoperative morbidity were not different. It's our recommendation that at cesarean section if the abnormal appendix is found, appendectomy should be done. Normal appendix can also be removed whenever the opportunity presents in non-risk patients.