MRSA screening: incidence and maternal postpartum outcomes in an obstetric population at a tertiary care center

PURPOSE

To assess the incidence of MRSA positive patients in pregnancy, as well as the postpartum outcomes in MRSA positive patients.

METHODS

This is a retrospective cohort study of women who underwent universal MRSA universal at a tertiary medical center. A MRSA swab was routinely collected as part of the patient's prenatal care at 35-37 weeks gestation or on admission to labor and delivery. Demographic information and decolonization antibiotics were collected by electronic medical record review, using ICD-9 codes. Outcome data were collected, including mode of delivery, hospital length of stay, endometritis, wound cellulitis, and wound infection. p < 0.05 was considered significant. A univariate logistic regression and a multivariable binary logistic regression model were used to analyze the strength of association between outcomes and MRSA status. Statistical analysis was performed with SAS, version 9.4.

RESULTS

The incidence of MRSA during the 4 year study period was 1.9% (82 MRSA positive out of 4369 total patients). 90.2% (74/82) of MRSA positive patients received decolonization antibiotics. No difference was noted in mode of delivery. Logistic regression failed to identify any significant differences in other relevant outcomes for MRSA positive women including endometritis 1.1 (0.1-17.5) [positive 0, versus negative 0.6% (n = 24)], wound cellulitis 5.9 (0.4-82.1) positive 0, versus negative 0.1% (Gorwitz et al. in J Infect Dis 197:1226-1234, 2008) and wound infection 3.3 (0.6-16.9) [positive 1.2%, versus negative 0.5% ( in Am J Infect Control 32:470-85, 2004)] when compared to MRSA negative women.

CONCLUSION

When universal MRSA screening was performed at an academic tertiary care center, the overall incidence of MRSA was low. MRSA positive and subsequently decolinzed patients did not have any identified increase in postpartum infectious morbidity, as compared to MRSA negative patients.

Preventing caesarean section wound complications: use of a silver-impregnated antimicrobial occlusive dressing

OBJECTIVE

To investigate the role of an adherent soft silicone antimicrobial occlusive foam silver-impregnated dressing for reduction of surgical site infections (SSI) in primary low-transverse caesarean section (1°LTCS) delivery.

METHOD

Women aged 18-45 years admitted to the labour and delivery or the antepartum unit undergoing a 1°LTCS were recruited. Exclusion criteria included repeat caesarean, vertical skin incision, intrapartum fever and closure with staples. Consented participants delivered by scheduled or unscheduled 1°LTCS received the silver-impregnated dressing. Those who declined to participate and were delivered by scheduled or unscheduled caesarean received a standard gauze with tape dressing (controls). Surgical preparation and preoperative antibiotics were administered as per hospital policy.

RESULTS

A total of 362 participants were consented for use of the silver-impregnated dressing, with 190 participants undergoing 1°LTCS, of whom 185 were included in the final analysis. Of those who declined to participate, 190 ultimately underwent 1°LTCS during the same time period. Cases and controls were similar in demographics, body mass index, diabetes status, labour and procedure length, and tobacco use. The overall incidence of SSI was 3.7%. A 50% reduction in incidence of SSI was observed in the silver-impregnated dressing group compared with control group (2.7% versus 4.7%, respectively), but this was not statistically significant (p=0.08; odds ratio 0.55; 95% confidence interval: 0.18-1.67).

CONCLUSION

Among women undergoing 1°LTCS with subcuticular closure of a transverse incision, use of a silver-impregnated dressing reduced the rate of SSI by >50% but was not statistically significant.

Weight gain in twin gestations: are the Institute of Medicine guidelines optimal for neonatal outcomes?

OBJECTIVE

To assess neonatal outcomes according to gestational weight gain (GWG) in twins.

STUDY DESIGN

This was a retrospective cohort study of twins delivered at ⩾24 weeks. GWG was defined using the Institute of Medicine (IOM) guidelines as the referent. Birthweight and neonatal intensive-care unit (NICU) admissions were compared with ≥(2)- and analysis of variance tests, stratified by body mass index (BMI).

RESULT

In all three BMI groups, mean birth weight of the larger and smaller twin increased as GWG increased, P<0.01. For the underweight/normal-weight group, both twins <2500 g, <1500 g and small for gestational age decreased significantly as GWG increased. Birthweight <2500 g increased in all groups with GWG below the IOM guidelines, P<0.01. In the multivariate analysis, both twins <2500 g were significantly decreased with GWG above IOM guidelines. There was no difference in NICU admissions with GWG above the IOM guidelines.

CONCLUSION

GWG above the IOM guidelines may improve twin birth weights, with the findings most significant in underweight/normal-weight women.

Effect of Age, Sex and Pregnancy on Levels of Urinary Inhibitors of mineralization in Human Beings

Background: Based upon the differences observed in the level of urinary inhibitors between adult normal subjects of both sexes and kidney stone patients of identical sex, it has been postulated that urinary inhibitors play an important role in the control of pathological mineralization. Review of literature revealed that corresponding studies on the level of urinary inhibitors in children of both sexes and during various stages of pregnancy are not available. These studies, so important to investigate the role of inhibitors in physiological mineralization, formed the objective of the present study.  Materials and Methods:  Homogenous system of In vitro mineralization was employed to study not only the extend of  mineralization and the effect of various urine samples obtained from normal subjects of both sexes and pregnant females at various trimesters of pregnancy on extend of mineralization but also to quantify the level of the inhibitors.  Results:  Using in vitro system of mineralization (precipitation of Ca2+ or HPO4 2- ions as mineral phase), it has been shown that in contrast to the adult human beings, in children of less than 13 years of age no significant differences exists in the level of the urinary inhibitors between males and females children provided experimental support to the epidemiological studies on the occurrence of the renal calculosis problem in both sexes of children and adult human beings. The findings that the level of the urinary inhibitors of mineralization in both sexes of children is as high as present in adult females and that a highly significant decrease in their levels occurs during the 3rd trimester of pregnancy strongly suggests that hormones may be playing an important role in regulating their levels. Conclusion: Inhibitors of mineralization excreted in urine of normal healthy subjects of both sexes of Children (<13 years), adults (>20 years), kidney stone patients at these ages, non pregnant and pregnant females (during various trimesters of pregnancy) have been postulated to play an important role in the control of both physiological and pathological mineralization.DOI: http://dx.doi.org/10.3126/nje.v4i4.11360 Nepal Journal of Epidemiology 2014; 4(4):399-404

Induction of labor compared to dilation and evacuation for postmortem analysis

OBJECTIVE

This study aimed to evaluate the ability to obtain autopsy and cytogenetics after midtrimester termination.

METHODS

A retrospective cohort study of women undergoing termination, via induction or dilation and evacuation (D&E), at 16 0/7-23 6/7 weeks was performed. Exclusion criteria were elective termination, preterm labor, PPROM, and no autopsy or cytogenetic exam performed. The ability to obtain cytogenetics and autopsy as well as complications rates were compared between the two groups with Chi-square tests.

RESULTS

Of the 469 women who met the inclusion criteria, 158 had an induction and 312 had a D&E. The induction of labor group had higher mean gestational ages, p < 0.01. Successful autopsy was more likely in the induction group, 94.3%, versus D&E group, 34.7%, p = 0.01. There was no difference in ability to obtain cytogenetics between the two groups, 89.1% in the induction group, and 92.3% in D&E group, p = 0.4. There was a difference in the total complication rates between the groups, 9.8% (26) in the induction versus 6.4% (20) in the D&E group, p < 0.01; however, there was no difference in major complications.

CONCLUSIONS

Midtrimester terminations by induction were more likely to have successful autopsies when compared with D&E. The ability to obtain cytogenetics was similar regardless of termination mode.

Laparoscopic appendectomy in women without identifiable pathology undergoing laparoscopy for chronic pelvic pain

Laparoscopic appendectomy is suggested to be effective therapy for women with chronic pelvic pain of unknown etiology.

Objectives:

To assess the effectiveness of appendectomy in women undergoing laparoscopy for chronic pelvic pain without identifiable pathology.

Methods:

This retrospective cohort study included women aged 15 to 50 years who underwent laparoscopic surgery for chronic pelvic pain without identifiable pathology. The cohort was divided into 2 groups: women who underwent appendectomy and women who had not undergone appendectomy at laparoscopic surgery. Postoperative pain was assessed at 6-week follow-up and by subsequent mailed questionnaire.

Results:

Women who underwent appendectomy (n = 19) were significantly more likely to report improvement in pain at 6-week follow-up than women who did not undergo appendectomy (n = 76) (93% vs 16%; P < .001). Thirty-six patients (38%) responded to the questionnaire at a median of 4.2 years after surgery, when the median change (improvement) in reported pain was greater in the appendectomy group than in the nonappendectomy group.

Conclusion:

Appendectomy is effective therapy for patients with chronic pelvic pain of unknown etiology who are undergoing laparoscopy.

The intrapartum use of antithrombin III in an antithrombin III-deficient patient: a case report and review of the literature

Background: Antithrombin III deficiency is an inherited thrombophilia that places pregnant patients at an increased risk of venous thromboembolism and adverse outcomes in pregnancy. Antithrombin III-deficient patients undergoing obstetric procedures may benefit from antithrombin III infusions during labor and delivery.

Case: The patient is a 32-year-old G2P1000 with known antithrombin III deficiency and factor V Leiden heterozygosity with a prior intrauterine fetal demise. The patient was managed with therapeutic enoxaparin until 37 weeks’ gestation when she was changed to IV heparin and plasma-derived antithrombin III. She underwent successful induction of labor, epidural anesthesia, and had an uncomplicated vaginal delivery.

Conclusion: Plasma-derived antithrombin III can be used intrapartum for successful delivery in a patient with antithrombin III deficiency.

Resolution of complete placenta previa: does prior cesarean delivery matter?

OBJECTIVES

The purpose of this study was to prospectively assess the rate of resolution of complete placenta previa diagnosed at second-trimester sonography in patients with and without previous cesarean delivery.

METHODS

This prospective study evaluated patients at 3 institutions with complete placenta previa diagnosed at second-trimester screening sonography. All patients were followed with sonography every 4 to 6 weeks until either resolution of the previa or delivery occurred. Patients with persistent/nonresolving complete placenta previa underwent cesarean delivery.

RESULTS

A total of 67 patients were enrolled in the study; 18 patients had a prior cesarean delivery. Resolution of placenta previa occurred in 11 of 18 patients (61%) with a prior cesarean delivery, whereas 44 of 49 patients (90%) without a prior cesarean delivery had resolution of placenta previa (P = .012, Fisher exact test). Placental location per se (anterior or posterior) was not associated with resolution of placenta previa (P = .22). Complete placenta previa persisted to delivery in 5 of 9 patients (56%) with a prior cesarean delivery and an anterior placental location.

CONCLUSIONS

This prospective study indicates that patients with a prior cesarean delivery and complete placenta previa diagnosed at second-trimester sonography are less likely to have subsequent resolution of the previa when compared to those without a history of cesarean delivery.

Omega speckles - a novel class of nuclear speckles containing hnRNPs associated with noncoding hsr-omega RNA in Drosophila

Fluorescence RNA:RNA in situ hybridization studies in various larval and adult cell types of Drosophila melanogaster showed that the noncoding hsr-omega nuclear (hsromega-n) transcripts were present in the form of many small speckles. These speckles, which we name ‘omega speckles’, were distributed in the interchromatin space in close proximity to the chromatin. The only chromosomal site where hsromega-n transcripts localized was the 93D locus or the hsromega gene itself. The number of nucleoplasmic speckles varied in different cell types. Heat shock, which inhibits general chromosomal transcription, caused the individual speckles to coalesce into larger but fewer clusters. In extreme cases, only a single large cluster of hsromega-n transcripts localizing to the hsromega locus was seen in each nucleus. In situ immunocytochemical staining using antibodies against heterogenous nuclear RNA binding proteins (hnRNPs) like HRB87F, Hrp40, Hrb57A and S5 revealed that, in all cell types, all the hnRNPs gave a diffuse staining of chromatin areas and in addition, were present as large numbers of speckles. Colocalization studies revealed an absolute colocalization of the hnRNPs and the omegaspeckles. Heat shock caused all the hnRNPs to cluster together exactly, following the hsromega-n transcripts. Immunoprecipitation studies using the hnRNP antibodies further demonstrated a physical association of hnRNPs and hsromega transcripts. The omegaspeckles are distinct from interchromatin granules since nuclear speckles containing serine/arginine-rich SR-proteins like SC35 and SRp55 did not colocalize with the ω speckles. The speckled distribution of hnRNPs was completely disrupted in hsromega nullosomics. We conclude that the hsromega-n transcripts play essential structural and functional roles in organizing and establishing the hnRNP-containing omega speckles and thus regulate the trafficking and availability of hnRNPs and other related RNA binding proteins in the cell nucleus.

Interactions of aldolase and glyceraldehyde-3-phosphate dehydrogenase: molecular mass studies

A gel penetration technique, that measures the dilution undergone by protein equilibrium on a short tightly packed gel column, has been employed to determine the molecular masses of aldolase (160 kDa), glyceraldehyde-3-phosphate dehydrogenase (GPDH; 145 kDa) in the absence and presence of each other and of other proteins. The dilution factor (concentration of protein applied/concentration of protein after equilibration) was found to be inversely related to the molecular mass of the protein. In equimolar mixtures of aldolase and GPDH, 0.5-2.5 microM each, the two enzymes exhibited a common molecular mass value of 309-316 kDa. These enzymes did not undergo any self association or disassociation in this concentration range. Moreover, their molecular masses were unaffected by the presence of other proteins tested. When the concentration of one of these enzymes (aldolase or GPDH) was held constant and that of the other varied, the dilution factor of the former was decreased as the concentration of the latter was increased until it corresponded to a molecular mass of ca. 310 kDa at equimolar concentrations of the two enzymes. Further increase in the concentration of the variable enzyme had no effect. It has been suggested that aldolase and GPDH form a 1:1 complex of dissociation constant equal to or less than 5 x 10(-8) M. The complex was found to dissociate in the presence of KCl, (NH4)2SO4, ATP and NADH whereas its formation was favoured by fructose-1,6-bisphosphate, glyceraldehyde-3-phosphate, NAD+, ADP, AMP and phosphate ions.

Purification and properties of glutathione peroxidase from human placenta

Glutathione peroxidase (glutathione--H2O2 oxidoreductase; EC 1.11.1.9) was purified to homogeneity from human placenta by using (NH4)2SO4 precipitation, ion-exchange chromatography, Sephadex gel filtration and preparative polyacrylamide-disc-gel electrophoresis. Glutathione peroxidase from human placenta is a tetramer, having 4g-atoms of selenium/mol of protein. The molecular weight of the enzyme is about 85000 with a subunit size of about 22,000. Kinetic properties of the enzyme are described. On incubation with cyanide, glutathione peroxidase is completely and irreversibly inactivated and selenium is released as a low-molecular-weight fragment. Reduced glutathione, beta-mercaptoethanol and dithiothreitol protect the enzyme from inactivation by cyanide and the release of selenium. Properties of human placental glutathione peroxidase are similar to those of isoenzyme A reported earlier by us from human erythrocytes. The presence of isoenzyme, B, reported earlier by us in human erythrocytes, was not detected in placenta. Also selenium-independent glutathione peroxidase (isoenzyme II), which is specific for cumene hydroperoxide, was not present in human placenta.