Action of some proteic and carbohydrate components of Symphytum officinale upon normal and neoplastic cells

OBJECTIVES: To describe the distribution of nosocomial infections among surgical patients by site of infection for different types of operations, and to show how the risk of certain adverse outcomes associated with nosocomial infection varied by site, type of operation, and exposure to specific medical devices. DESIGN: Surveillance of surgical patients during January 1986-June 1992 using standard definitions and protocols for both comprehensive (all sites, all operations) and targeted (all sites, selected operations) infection detection. SETTING AND PATIENTS: Acute care US hospitals participating in the National Nosocomial Infection Surveillance (NNIS) System: 42,509 patients with 52,388 infections from 95 hospitals using comprehensive surveillance protocols and an additional 5,659 patients with 6,963 infections from 11 more hospitals using a targeted protocol. RESULTS: Surgical site infection was the most common nosocomial infection site (37%) when data were reported by hospitals using the comprehensive protocols. When infections reported from both types of protocols were stratified by type of operation, other sites were most frequent following certain operations (e.g., urinary tract infection after joint prosthesis surgery [52%]). Among the infected surgical patients who died, the probability that an infection was related to the patient's death varied significantly with the site of infection, from 22% for urinary tract infection to 89% for organ/space surgical site infection, but was independent of the type of operation performed. The probability of developing a secondary bloodstream infection also varied significantly with the primary site of infection, from 3.1% for incisional surgical site infection to 9.5% for organ/space surgical site infection (p < .001). For all infections except pneumonia, the risk of developing a secondary bloodstream infection also varied significantly with the type of operation performed (p < .001) and was generally highest for cardiac surgery and lowest for abdominal hysterectomy. Surgical patients who developed ventilator-associated pneumonia were more than twice as likely to develop a secondary bloodstream infection as nonventilated pneumonia patients (8.1% versus 3.3%, p < .001). CONCLUSIONS: For surgical patients with nosocomial infection, the distribution of nosocomial infections by site varies by type of operation, the frequency with which nosocomial infections contribute to patient mortality varies by site of infection but not by type of operation, and the risk of developing a secondary bloodstream infection varies by type of primary infection and, except for pneumonia, by type of operation.     

Toward further reducing wound infections in cardiac operations

BACKGROUND: Serious wound infections such as mediastinitis still occur at a rate of 0.8% to 2.0%, according to the most recently published cardiac operative series. METHODS: Data from careful surveillance for infection have been collected prospectively during a 4.5-year period on 1,717 patients who underwent cardiac operations performed under direct ultraviolet C radiation. RESULTS: The rate for mediastinitis was 0.23%, and for deep incisional infection without mediastinitis, 0.12%; these rates are significantly lower than those for eight of nine of the most recently published cardiac series. When our infection rates were stratified using the National Nosocomial Infection Surveillance risk index, they were also significantly lower in the most important risk categories than the corresponding stratified rates collected from the participating hospitals of the Centers for Disease Control and Prevention National Nosocomial Infection Surveillance system. CONCLUSIONS: Though we lack the proof that only a large, randomized study might provide, certainly, one possible explanation for our lower wound infection rate was the use of bactericidal ultraviolet C radiation during operation. This is a simple and effective means of minimizing operating room airborne bacteria as one possible source of these infections.     

Magnitude and prevention of nosocomial infections in the intensive care unit

Nosocomial infections among intensive care unit (ICU) patients usually are related to the use of invasive devices (e.g., mechanical ventilators, urinary catheters, or central venous catheters). This article discusses the impact of these devices and other risk factors for nosocomial infection in ICU patients. Data on etiologic pathogens and device-related infection rates from the National Nosocomial Infection Surveillance System are presented, general infection control guidelines for ICUs are reviewed, and special infection control problems encountered in ICUs are discussed.     

Feedback to nurse managers about staff nurses'' perceptions of their jobs

Perioperative antibiotic administration can decrease surgical morbidity, shorten hospitalization, while lowering the overall costs attributable to infections. Its use in surgery is widespread and often inappropriate. In this study, the authors evaluate the guidelines for selection and use of prophylactic antibiotics in surgical cancer patients at the Hospital of Cancer in Rio de Janeiro, Brazil. During 36 non-consecutive months, 1681 cancer patients submitted to surgical procedures were prospectively followed-up by members of the Hospital Infection Control Committee. The overall surgical site infection (SSI) and mortality rates were 17.7% and 4.8% respectively. Prophylactic antibiotics were used in 1262 elective surgeries (75.1%), and their use was not considered to be in accordance with the recommended protocol in 37.6% of the cases. The inadequate antimicrobial prophylaxis resulted in higher incidence of SSI than did prophylaxis in according to the protocol (21.7% vs. 16.4, Relative Risk 1.32; 95% Confidence Internal 1.05-1.67; p0.01). This study calls the attention for the need of a more strict and determined educational program in order to provide mechanisms for an adequate administration of prophylactic antibiotics to patients submitted to high-risk surgeries.     

Laparoscopy-assisted and -prepared hysterectomy. A series of 80 cases

OBJECTIVE: Our objective was to determine the interest of laparoscopic assisted vaginal hysterectomy. STUDY DESIGN: Between January 1991 to december 1994, 80 patients had laparoscopically assisted vaginal hysterectomy. We reviewed with particular emphasis characteristic indications, complications. RESULTS: Eighty were performed as laparoscopically assisted vaginal hysterectomy. 14 patients (17.5%) had laparotomy conversion; because of size of uterus in 3 cases, suspected ovarian tumor in 3 cases. Pelvic adherences in 4 cases, urinary tract injuries in 1 case, hypercapnia in 1 case, hemorrhage in 2 cases. 9 patients experienced febrile morbidity and 1 urinary infection. 1 patient received 2 units of packed red blood cells. The hospital stay was 5 days for laparoscopically assisted vaginal hysterectomy versus 5.9 for laparotomic hysterectomy. CONCLUSION: Laparoscopically assisted vaginal hysterectomy offers a technique to convert certain abdominal hysterectomies into vaginal hysterectomies with a 17.5% laparoconversion rate.     

Vaginal and abdominal hysterectomy: comparison and perspectives. Apropos of 385 consecutive cases

Hysterectomy is the most common non-pregnancy related surgical procedure. However, given the lack of final guidelines on indications, alternative therapies, surgical approach and outcomes, it is desirable to keep its use under constant monitoring. We reviewed 385 hysterectomies for benign conditions-divided according to surgical approach-performed in the Gynaecological Department of San Daniele del Friuli (Udine-Italy) in 1991-1993, and with one-year follow-up. Traditional approaches, i.e. abdominal (39.2%) and vaginal (60.2%), were used. Colporraphy was performed in 79 cases (33.8% of vaginal hysterectomies); 73.4% of colporraphies were followed by urethral suspension. We reviewed population's patterns, indications and surgical outcomes according to Dicker's suggestions. Vaginal hysterectomy with associated colporraphy concerned a population of patients with average age and parity significantly different from patients who underwent simple vaginal or abdominal hysterectomy. These last two groups, on the other hand, have similar characteristics making them comparable. In abdominal hysterectomy and simple vaginal hysterectomy we reported a complication rate respectively of 21.9% and 7.1%. The advantages of simple vaginal hysterectomy include shorter operating time, reduction in antibiotic drugs usage, earlier hospital discharge and quicker recovery, with obvious cost saving. Our experience therefore supports the view that the balance between abdominal and vaginal hysterectomy could safely be shifted in favour of the last one, the advantages of which could then be made available to a larger number of patients.     

Abdominal hysterectomy versus transvaginal morcellation for the removal of enlarged uteri

OBJECTIVE: The purpose of this study was to compare the intraoperative and postoperative complications of transvaginal morcellation and abdominal hysterectomy for the removal of moderately enlarged uteri. STUDY DESIGN: An observational study was performed on all uteri weighing > 200 gm removed transvaginally from July 1, 1987, to June 30, 1993. An abdominal hysterectomy control group was selected. RESULTS: There were 50 patients in the vaginal group and 112 in the abdominal group. At a p value < 0.05 there was no statistically significant difference between the two groups for age, parity, obesity, hypertension, insulin-dependent diabetes mellitus, or prior genitourinary surgery. The mean operative time in the vaginal hysterectomy group was 122 minutes and in the abdominal hysterectomy group 148 minutes (p < 0.05). The mean estimated blood loss was 527 and 586 ml, respectively (not significant). Twenty-two percent of the vaginal group and 70% of the abdominal group underwent bilateral oophorectomy (p < 0.05). The mean uterine weights were 335 and 336 gm, respectively (not significant). The mean day of starting a regular diet was 2.1 and 3.6, respectively (p < 0.05). The mean day of discharge was 3.6 and 5.1, respectively (p < 0.05). Complications were similar for the two groups. CONCLUSIONS: In selected patients transvaginal morcellation is a safe and effective alternative to abdominal hysterectomy for the removal of moderately enlarged uteri. The two procedures are comparable in operative time, blood loss, and complications. Both ovaries are more likely to be removed with abdominal hysterectomy. Cosmesis and recuperation may be advantages of the vaginal approach.     

Posthysterectomy fallopian tube herniation. A report of two cases

BACKGROUND: Tubal herniation as a complication of hysterectomy is a rare phenomenon, markedly more frequent after vaginal hysterectomy. With the increasing use of the vaginal route, the ratio between tubal herniation after vaginal versus abdominal hysterectomy may exceed 3:1. CASE: We report two cases of tubal herniation into the vagina, one after vaginal hysterectomy and the other after total abdominal hysterectomy, in two patients, aged 36 and 37 years. CONCLUSION: A tubal prolapse in the vagina may be considered a hernia and occurs only if a communication exists between the peritoneal cavity and vaginal canal. It can be an early or late prolapse. Symptoms consist almost exclusively of persistent blood loss and/or leukorrhea, dyspareunia and chronic pelvic pain. Whether the abdominal or vaginal approach should be used in surgical correction of prolapsed tubes must be decided in each case according to the patient's individual characteristics. Both histologic pictures described merit careful attention, distinguishing between the terminal tubal segment and the more cranial tract (above the vaginal strangulation).     

Hypertension in the elderly: attitudes of British patients and general practitioners

The question of why vancomycin-resistant enterococci (VRE) became epidemic in the United States can be answered on at least three basic levels: (1) molecular and genetic, (2) factors affecting host-microbe interactions, and (3) epidemiological. This article will address the epidemiological issues and seek to defend the assertion that, once VRE had evolved, its spread throughout hospitals in the United States was all but assured. Nosocomial VRE outbreaks were reported first in the mid- and late-1980s. Since that time, scientific reports of VRE have increased over 20-fold. Among hospitals participating in the National Nosocomial Infection Surveillance System from 1989 to 1997, the percentage of enterococci reported as resistant to vancomycin increased from 0.4% to 23.2% in intensive-care settings and from 0.3% to 15.4% in non-intensive-care settings. Factors leading to the spread of VRE in US hospitals include (1) antimicrobial pressure, (2) sub-optimal clinical laboratory recognition and reporting, (3) unrecognized "silent" carriage and prolonged fecal carriage, (4) environmental contamination and survival, (5) intrahospital and interhospital transfer of colonized patients, (6) introduction of unrecognized carriers from community settings such as nursing homes, and (7) inadequate compliance with hand washing and barrier precautions. Guidelines developed by the Centers for Disease Control and Prevention's Hospital Infection Control Practices Advisory Committee address each of these factors. The impact of these guidelines on the spread of VRE within individual institutions has been variable, and the overall impact of the guidelines nationally is unknown.     

Intravenous administration of Augmentin in the prevention of infectious complications in abdominal hysterectomy

Amoxycillin-clavulanate was used in prophylaxis of infectious complications after abdominal hysterectomy. A group of 29 patients was treated routinely with metronidazol introduced vaginally 2-3 days before surgery. This group was compared with 40 patients who received two perioperative doses of Augmentin intravenously. The incidence of febrile morbidity, urinary tract infection, following antibiotic treatment and pelvic infection were followed in both groups. Patients in the amoxycillin-clavulanic acid group had significantly less infectious morbidity than those in the metronidazol group. The results suggest that antibiotic prophylaxis for abdominal hysterectomy is effective. The prophylactic agent should be bactericide against aerobic and anaerobic bacteria and non-toxic. Amoxycillin-clavulanate (Augmentin) meets all these criteria.     

Nosocomial infection in Auckland Healthcare hospitals

AIM: To determine the prevalence of nosocomial infection in Auckland Healthcare hospitals. BACKGROUND: Nosocomial infections cause patient morbidity and prolong hospital stay. Reporting surveillance results to staff has been shown to reduce nosocomial infection rates. METHOD: Point prevalence study for all patients in Auckland, Green Lane and National Women's hospitals. Standard definitions for nosocomial infections were used. RESULTS: One hundred and ten (12%) of 932 patients had 129 nosocomial infections: 27 (20%) surgical site infections; 25 (19%) lower respiratory tract infections; 23 (18%) skin/ soft tissue infections; 19 (15%) urinary tract infections; 14 (11%) bloodstream infections; and 21 (17%) other infections. Predominant organisms were: Staphylococcus aureus (29%), Escherichia coli (21%), other gram negative bacilli (14%), Pseudomonas aeruginosa (6%), streptococci (6%) and Candida albicans (6%). The prevalence of nosocomial infection was lower in National Women's Hospital (5%) than either Green Lane or Auckland hospitals (15% and 14% respectively), p < 0.01. The prevalence of nosocomial infection was the same in medical and surgical patients, 53 of 394 (14%) and 42 of 297 (14%), respectively. The highest prevalence was in intensive care unit patients, 7 of 31 (23%). The prevalence of nosocomial infection increased with patient age, 17-50 yr (8%) vs > 50 yr (14%), p < 0.01, and duration of hospitalisation 2% for < 2 days, 6% for 2-7 days vs 22% for > 7 days, p < 0.01. Risk factors for nosocomial infection were present in many patients: 339 (36%) had intravenous catheters in place; 268 (29%) patients had undergone surgery during their current admission; 122 (13%) had urinary catheters in place; and 122 (13%) had other invasive devices in situ. CONCLUSION: Our results are comparable with hospitals of similar size overseas. This study provides a base line for future studies which will enable the monitoring of trends over time and the impact of focused infection control initiatives.     

Antibiotic prophylaxis of infectious complications in gynecologic surgery]

Infections are still the most frequent postoperative complications and one of the limiting factors of successful gynaecological surgery. In recent years information on successful anti-microbial chemoprophylaxis is increasing and is associated with reduced postoperative inflammations, febrile morbidity and early complications. Views differ above all as regards indications for the use of antibiotic prophylaxis and the selection of a suitable antibiotic. Data in the literature differ also as regards achieved results. The submitted work had the objective to test on a representative group the success and rationality of medicamentous prophylaxis in gynaecological surgery and to contribute to a clearer view on controversial points. 203 women admitted to the Second Gynaecological and Obstetric Department of the First Medical Faculty Charles University and General Faculty Hospital Prague for elective abdominal or vaginal hysterectomy on account of a benign indication were divided into three groups which did not differ from the demographic or medical aspect. In group A (53 women) for prophylaxis two doses of Augmentin were used (combination of amoxycillin with clavulanic acid) i.v., patients in group M (50 women) had three doses of Mandol (Cefamandol) i.m., and in control group K (100 patients) no antibiotics were administered prophylactically. The authors investigated the postoperative course and evaluated some parameters in relation to possible postoperative infectious complications. The results proved unequivocally that prophylaxis with Augmentin reduces significantly the postoperative infectious morbidity (11.5%), febrile morbidity (5.6%) and the incidence of early infectious complications (3.8%) after abdominal or vaginal hysterectomy, as compared with the control group (35%, 31% and 11% resp.). Prophylaxis with Cefamandol reduced only in few parameters postoperative complications, but in general did not lead to a significant improvement of the postoperative course nor to a reduction of postoperative inflammatory complications. Similar results were obtained when only complications after abdominal hysterectomy were evaluated. The results of bacteriological examination confirmed the expected differences in the spectrum of efficacy of the two antibiotics on the most common microbial flora in the given area, i.e. a high sensitivity of Augmention to enterococci and bacterioids and resistance of these bacteria to Mandol. These results can be considered one of the reasons of different results of the two antibiotics. Prophylaxis with amoxycillin/clavulanic acid was found to be safe, very effective and financially feasible prevention of postoperative infectious complications after abdominal and vaginal hysterectomy. It led to a significant increase in the number of cases without any complications, when compared with the control group.     

Usefulness of BTA Stat test (Bard) in the diagnosis of bladder cancer. Preliminary results and comparison with cytology and cystoscopy]

Risk factors associated with surgical infections are related to many events that modulate the immune system and affect the surgical procedure. The aim of this study was to determine the influence of low CD4+ lymphocyte counts in 24 patients with human immunodeficiency virus (HIV) undergoing abdominal surgery. Blood samples were obtained, and the lymphocyte population was evaluated perioperatively, as was the nutritional status of the patient. All the patients received selective antibiotic prophylaxis depending on the surgical procedure performed: (1) clean surgery: splenectomies (n = 8); (2) clean-contaminated: cholecystectomy and biliary tract surgery (n = 8); and (3) contaminated: appendectomy (n = 8). Depending on their CD4 count, two groups were formed: one with 200 to 500 cells/ml (n = 11) and the other with < 200 cells/ml (n = 13). When surgical infection was suspected, surgical drainage and microbiologic cultures were undertaken. For statistical evaluation of the groups ANOVA and the chi-square test were used; p < 0.05 was considered significant. Altogether 14 patients (58.3%) had a wound infection, and the mean (+/- SD) CD4 count in those patients was decreased (221.7 +/- 75.1) compared with that of the 10 patients in the uneventful group (386 +/- 81.2). Surgical infection rates were 50% for clean procedures, 62.5% for clean-contaminated procedures, and 62.5% for contaminated surgery. The group of patients with CD4 counts of < 200 cell/ml had an increased incidence of surgical infection, regardless of the type of surgery (p = 0.002). Thus the surgical infection rates with HIV patients undergoing abdominal surgery are dramatically increased. The CD4 and subsequently depressed neutrophil populations increase the risk of surgical infection during major procedures regardless of the type of surgery performed.     

Routine perioperative antibiotic prophylaxis in renal transplantation

BACKGROUND: Perioperative antibiotic prophylaxis may prevent infection following renal transplantation but it also contributes to development of resistant microorganisms. With refined surgical techniques, improved graft preservation, and immunosuppressive monitoring during recent decades one can question the present use of perioperative antibiotic prophylaxis. We retrospectively evaluated the incidence of infection in our renal transplant centre where antibiotic prophylaxis is not routinely used in renal recipients. Concurrently we performed a survey of perioperative antibiotic use to establish the current world-wide practice. METHODS: Infection episodes were evaluated from records of 448 adult renal transplant recipients (January 1994 to August 1996) at our centre. A questionnaire was mailed to 103 centres addressing the number of kidney transplantations in 1995, donor source (living vs cadaveric) and details on use of perioperative antibiotic prophylaxis. RESULTS: Single-centre study. Renal transplantation was performed without antibiotic prophylaxis in 377 patients (84%). Thirteen patients (3.4%) had early postoperative infections, nine with urinary-tract infection tended to have urinary catheter for a longer period than those without infection (5.0 +/- 2.7 vs 3.4 +/- 1.4 days, P = 0.27) and cadaveric kidney recipients to have higher incidence of infections (4.5 vs 1.5% P = 0.14). All infection episodes were successfully treated. The infection incidence in 71 (16%) 'high-risk' patients selected for antibiotic treatment was 4.2%. World-wide survey. Data were obtained from 101 centres in five continents representing 10532 renal transplants. Ninety centres (89%) used perioperative antibiotic prophylaxis. CONCLUSION: The infection incidence in patients who did not receive perioperative antibiotic prophylaxis was the same as in a small group of selected patients who received prophylaxis. The incidence was lower than usually reported in the literature. In contrast perioperative antibiotic prophylaxis is given to all patients in almost 90% of transplant centres worldwide. A reduction of prophylactic antibiotic use is encouraged.     

Nosocomial infections in an oncology intensive care unit

INTRODUCTION: Treatment of cancer has contributed to a growing number of immunocompromised patients with life-threatening nosocomial infections (NI). High mortality with considerable cost is observed when they are admitted to the intensive care unit (ICU). Few studies on infection control and surveillance have been undertaken in this population group. METHODS: All patients treated at a six-bed medical-surgical oncology ICU for > 48 hours were prospectively observed for the development of an NI and the influence of device utilization on infection rates. The analysis used the standard definitions of the National Nosocomial Infection Surveillance System Intensive Care Unit surveillance component. RESULTS: From September 1993 through November 1995, 370 infections occurred in 623 patients during 4034 patient-days, for an overall rate of 50.0 per 100 patients or 91.7 per 1000 patient-days. Pneumonia (28.9%), urinary tract infections (25.6%), and bloodstream infections (24.1%) were the main types of infection. The most common microorganisms isolated were Enterobacteriaceae (29.7%), fungi (22.2%), and Pseudomonas aeruginosa (13.2%). The median device utilization ratios were 0.63, 0.83, and 0.86 for ventilator, indwelling urinary catheter, and central venous catheter, respectively. The highest median device-specific associated infection rate was 41.7 for ventilator. The median for the average length of stay was 8.8 days, and the average severity of illness score was 4.0. There was a strong positive correlation between the overall NI patient rate and device utilization (r = 0.56, p < 0.01), average severity of illness score (r = 0.54, p < 0.01), and average length of stay (r = 0.67, p < 0.01). No correlations were statistically significant when patient-days were used in the denominator. Among the devices only the number of central venous catheter days was significantly correlated with infections (r = 0.51, p = 0.01). The NI patient-day rates were progressively higher the longer the patients stayed in the ICU. CONCLUSIONS: The high rates reported in this study may reflect a combination of several factors related to the underlying illness, neutrophil count, and exposure to invasive procedures. The adjusted infection rates described here provide specific surveillance data for further interhospital comparisons and also to assess the influence of invasive medical interventions, allowing the implementation of preventable measures to control infections.     

Teaching smoking-cessation counseling to medical students using simulated patients

The controversy continues over the appropriate use of vaginal hysterectomy for many indications that were previously treated only with abdominal or laparoscopic methods. Current outcomes data have pointed up the need for established guidelines to ensure that patients receive appropriate surgical treatment that is most cost-effective and that meets the standard of quality care. Dr Kovac reviews recent data regarding the various surgical options for hysterectomy and offers guidelines based on objective pathologic criteria.     

Costs and charges associated with three alternative techniques of hysterectomy

BACKGROUND: Many hysterectomies are now performed by a laparoscopically assisted vaginal technique. This procedure is controversial, partly because of concern about cost. We studied hospital charges and costs for the procedure as compared with those for total abdominal hysterectomy and total vaginal hysterectomy in clinically similar groups of patients. METHODS: From hospital-discharge data and patients' charts, we identified hysterectomies performed in 1993 and 1994 by 96 surgeons at a community teaching hospital to treat benign conditions. The patients were grouped according to the surgical procedures performed in conjunction with the hysterectomy. Data on hospital charges and cost-to-charge ratios for 64 hospital cost centers were used to assess charges and costs for specific resources, as well as for the hospitalization overall. RESULTS: Of 1049 patients studied, 26 percent underwent laparoscopically assisted vaginal hysterectomy, 54 percent underwent abdominal hysterectomy, and 20 percent underwent vaginal hysterectomy. The average hospital stays were 2.6, 3.9, and 2.9 days, respectively, and the mean total charges (facility charges plus professional fees) for the hospitalizations were $6,116, $5,084, and $4,221 (P<0.001 for the comparison of the laparoscopic technique with both other techniques). The mean facility costs were $4,914, $3,954, and $3,116, respectively (P<0.001 for the same comparison), with similar findings in all subgroups. The higher charges and costs for laparoscopically assisted vaginal hysterectomy were due to higher supply costs, particularly when disposable supplies were used, and to longer operating-room time. CONCLUSIONS: Despite shorter hospital stays, in-hospital charges and costs for laparoscopically assisted vaginal hysterectomy are higher than for either alternative procedure, because of the disposable supplies that are typically used and the longer operating-room time.     

Infections following cesarean section

Postpartum endomyometritis and abdominal wound infection remain the most common infectious complications following childbirth. New information now suggests that incipient infection of the myometrium explains why patients develop postpartum endometritis despite antibiotic prophylaxis. Clinical predictors of postpartum endometritis continue to suffer from low sensitivity. However, use of a Gram stain of the amniotic fluid may be helpful in identifying a subset of women that may benefit from a therapeutic course of antibiotics initiated immediately after cesarean section. Broad-spectrum antimicrobial therapy is the mainstay of therapy for postpartum endometritis. Two newer extended spectrum cephalosporins, cefotetan and ceftizoxime, appear to be as effective as cefoxitin in the treatment of these infections. Abdominal wound infection is a common cause of antimicrobial failure in patients treated for post-cesarean endomyometritis. The genital mycoplasmas, usually resistant to the penicillins and cephalosporins, are commonly isolated from infected wounds following cesarean section. Wound infection surveillance has been shown to decrease infection incidence rates by providing feedback to the operating surgeon.     

Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials

BACKGROUND: A systematic review was carried out to assess the relative efficacy of antimicrobial prophylaxis for the prevention of postoperative wound infection in patients undergoing colorectal surgery. METHODS: MEDLINE, EMBASE, the Cochrane Trials Register and the references cited in retrieved studies were searched to identify relevant trials published between 1984 and 1995. RESULTS: Some 147 relevant trials were identified. The quality of trials has improved over the past 12 years. The results confirm that the use of antimicrobial prophylaxis is effective for the prevention of surgical wound infection after colorectal surgery. There was no significant difference in the rate of surgical wound infections between many different regimens. However, certain regimens appear to be inadequate (e.g. metronidazole alone, doxycycline alone, piperacillin alone, oral neomycin plus erythromycin on the day before operation). A single dose administered immediately before the operation (or short-term use) is as effective as long-term postoperative antimicrobial prophylaxis (odds ratio 1.17 (95 per cent confidence interval (c.i.) 0.90-1.53)). There is no convincing evidence to suggest that the new-generation cephalosporins are more effective than first-generation cephalosporins (odds ratio 1.07 (95 per cent c.i. 0.54-2.12)). CONCLUSION: Antibiotics selected for prophylaxis in colorectal surgery should be active against both aerobic and anaerobic bacteria. Administration should be timed to make sure that the tissue concentration of antibiotics around the wound area is sufficiently high when bacterial contamination occurs. Guidelines should be developed locally in order to achieve a more cost-effective use of antimicrobial prophylaxis in colorectal surgery.     

The effect of intrathecal and epidural narcotic analgesia on the length of labor

OBJECTIVE: Long-term results after different types of operations for urinary stress incontinence (minimum follow-up: 18 months) as well as multiple risk factors for the pelvic floor were analysed in a retrospective study. STUDY DESIGN: Between 1980 and 1992 1283 patients underwent surgery because of urinary stress incontinence at the University Women's Hospital in Heidelberg. The data of 478 patients, 430 of these after primary and 48 after recurrent surgery, were evaluated by questionnaires with regard to the long-term-results. RESULTS: 57% of patients after primary surgical therapy and 37% after recurrent surgery were cured for longer than 5 years or since the operation. A cure or improvement of the incontinence could be observed in 80% after primary and in 73% after recurrent surgery. Among the vaginal approaches for primary surgery the hysterectomy combined with colporrhaphy was most successful (60% cured or more than 5 years continent, 80.5% at least improved). The Burch colposuspension revealed even better results among the abdominal approaches (64% cured or longer than 5 years continent, 86% at least improved) compared to the Marshall-Marchetti-Krantz procedure with a cure rate of 33%. For therapy of the recurrent urinary incontinence the abdominal Burch colposuspension showed the best results with cure rates of 50% and cure or improvement in 75%. Therefore the abdominal approach seems to be superior to vaginal techniques such as sling operations (33% cure rate, 67% at least improved) or only re-colporrhaphy (27% cure rate, 78% at least improved). CONCLUSION: For primary incontinence the hysterectomy with vaginal repair or the Burch colposuspension have proved to be most successful. For recurrent urinary incontinence the abdominal colposuspension (Burch procedure) seems to be superior to other approaches.