Obesity in relation to endometrial cancer risk and disease characteristics in the Women's Health Initiative

OBJECTIVE

Obesity increases endometrial cancer risk, yet its impact on disease stage and grade is unclear. We prospectively examined the effects of body mass index (BMI) and waist-to-hip ratio (WHR) on incidence, stage, and grade of endometrial cancer.

METHODS

We studied 86937 postmenopausal women enrolled in the Women's Health Initiative. Height, weight, and waist and hip circumference were measured at baseline. Endometrial cancer cases were adjudicated by trained physicians and pathology reports were used to determine stage and grade. Cox proportional hazards models generated hazard ratios (HR) for associations between BMI and WHR and risk of endometrial cancer. Logistic regression was used to evaluate associations between BMI and WHR and disease stage and grade.

RESULTS

During a mean 7.8 (standard deviation 1.6) years of follow-up, 806 women were diagnosed with endometrial cancer. Although incidence was higher among Whites, stage and grade were similar between Whites and Blacks. Elevated BMI (HR 1.76, 95% confidence interval [CI] 1.41-2.19) and WHR (HR 1.33, 95% CI 1.04-1.70) increased endometrial cancer risk when comparing women in the highest and lowest categories. No associations were observed between BMI or WHR and disease stage or grade.

CONCLUSIONS

Obesity increases endometrial cancer risk independent of other factors but is not associated with stage or grade of disease. These findings support and validate previous reports. Future research should evaluate the impact of obesity on racial disparities in endometrial cancer survival.

Hormone therapy and physical function change among older women in the Women's Health Initiative: a randomized controlled trial

OBJECTIVE

Although estrogen may be linked to biological pathways that maintain higher physical function, the evidence is derived mostly from observational epidemiology and therefore has numerous limitations. We examined whether hormone therapy affected physical function in women 65 to 79 years of age at enrollment.

METHODS

This study involves an analysis of the Women's Health Initiative randomized controlled trials of hormone therapy in which 922 nondisabled women who had previous hysterectomies were randomized to receive estrogen therapy or a placebo and 1,458 nondisabled women with intact uteri were randomized to receive estrogen + progestin therapy or a placebo. Changes in physical function were analyzed for treatment effect, and subgroup differences were evaluated. All women completed performance-based measures of physical function (grip strength, chair stands, and timed walk) at baseline. These measures were repeated after 1, 3, and 6 years.

RESULTS

Overall, participants' grip strength declined by 12.0%, chair stands declined by 3.5%, and walk pace slowed by 11.4% in the 6 years of follow-up (all P values <0.0001). Hormone therapy, as compared with placebo, was not associated with an increased or decreased risk of decline in physical function in either the intention-to-treat analyses or in analyses restricted to participants who were compliant in taking study pills.

CONCLUSIONS

Hormone therapy provided no overall protection against functional decline in nondisabled postmenopausal women 65 years or older in 6 years of follow-up. This study did not address the influence of hormone therapy for women of younger ages.

Correlates of sexual satisfaction among sexually active postmenopausal women in the Women's Health Initiative-Observational Study

BACKGROUND

Satisfaction with sexual activity is important for health-related quality of life, but little is known about the sexual health of postmenopausal women.

OBJECTIVE

Describe factors associated with sexual satisfaction among sexually active postmenopausal women.

DESIGN

Cross-sectional analysis.

PARTICIPANTS

All members of the Women's Health Initiative-Observational Study (WHI-OS), ages 50-79, excluding women who did not respond to the sexual satisfaction question or reported no partnered sexual activity in the past year (N = 46,525).

MEASUREMENTS

PRIMARY OUTCOME

dichotomous response to the question, "How satisfied are you with your sexual activity (satisfied versus unsatisfied)?" Covariates included sociodemographic factors, measures of physical and mental health, and gynecological variables, medications, and health behaviors related to female sexual health.

RESULTS

Of the cohort, 52% reported sexual activity with a partner in the past year, and 96% of these answered the sexual satisfaction question. Nonmodifiable factors associated with sexual dissatisfaction included age, identification with certain racial or ethnic groups, marital status, parity, and smoking history. Potentially modifiable factors included lower mental health status and use of SSRIs. The final model yielded a c-statistic of 0.613, reflecting only a modest ability to discriminate between the sexually satisfied and dissatisfied.

CONCLUSIONS

Among postmenopausal women, the variables selected for examination yielded modest ability to discriminate between sexually satisfied and dissatisfied participants. Further study is necessary to better describe the cofactors associated with sexual satisfaction in postmenopausal women.

Conjugated equine estrogens and colorectal cancer incidence and survival: the Women's Health Initiative randomized clinical trial

BACKGROUND

In separate Women's Health Initiative randomized trials, combined hormone therapy with estrogen plus progestin reduced colorectal cancer incidence but estrogen alone in women with hysterectomy did not. We now analyze features of the colorectal cancers that developed and examine the survival of women following colorectal cancer diagnosis in the latter trial.

PARTICIPANTS AND METHODS

10,739 postmenopausal women who were 50 to 79 years of age and had undergone hysterectomy were randomized to conjugated equine estrogens (0.625 mg/d) or matching placebo. Colorectal cancer incidence was a component of the monitoring global index of the study but was not a primary study endpoint. Colorectal cancers were verified by central medical record and pathology report review. Bowel exam frequency was not protocol defined, but information on their use was collected.

RESULTS

After a median 7.1 years, there were 58 invasive colorectal cancers in the hormone group and 53 in the placebo group [hazard ratio, 1.12; 95% confidence interval (95% CI), 0.77-1.63]. Tumor size, stage, and grade were comparable in the two randomization groups. Bowel exam frequency was also comparable in the two groups. The cumulative mortality following colorectal cancer diagnosis among women in the conjugated equine estrogen group was 34% compared with 30% in the placebo group (hazard ratio, 1.34; 95% CI, 0.58-3.19).

CONCLUSIONS

In contrast to the preponderance of observational studies, conjugated equine estrogens in a randomized clinical trial did not reduce colorectal cancer incidence nor improve survival after diagnosis.

Randomized trial of medical treatment versus hysterectomy for abnormal uterine bleeding: resource use in the Medicine or Surgery (Ms) trial

OBJECTIVE

This study was undertaken to compare resource use outcomes for participants in the Medicine or Surgery (Ms) randomized trial.

STUDY DESIGN

In a randomized controlled trial, we compared resources used during a 24-month follow-up period by women with abnormal uterine bleeding who were randomly assigned to either expanded medical treatment or hysterectomy.

RESULTS

Women randomly assigned to hysterectomy used significantly more resources (medicine = $4479, hysterectomy = $6777; P = .03), with almost all the difference caused by the hysterectomy procedure. Fifty-three percent of women randomly assigned to medicine had a hysterectomy during the follow-up period; women who were able to continue on medical therapy had mean total resource use of $2595 compared with $6128 for medicine patients who eventually had surgery.

CONCLUSION

For women with abnormal uterine bleeding refractory to cyclic medroxyprogesterone acetate, compared with expanded medical treatment, hysterectomy increases resource use significantly and results in better clinical and 6-month quality-of-life outcomes.

Effectiveness of Treatment Strategies of Some Women With Pelvic Inflammatory Disease

OBJECTIVE

Among all women with pelvic inflammatory disease (PID), prevention of adverse reproductive consequences appears to be similarly achieved by outpatient treatment and inpatient treatment. We assessed whether outpatient is as effective as inpatient treatment in relevant age, race, and clinical subgroups of women with PID.

METHODS

Women with clinical signs and symptoms of mild-to-moderate pelvic inflammatory disease (n = 831) were randomized into a multicenter trial of inpatient treatment, initially employing intravenous cefoxitin and doxycycline compared with outpatient treatment consisting of a single intramuscular injection of cefoxitin and oral doxycycline. Comparisons between treatment groups during a mean of 84 months of follow-up were made for pregnancies, live births, time to pregnancy, infertility, PID recurrence, chronic pelvic pain, and ectopic pregnancy.

RESULTS

Outpatient treatment assignment did not adversely impact the proportion of women having one or more pregnancies, live births, or ectopic pregnancies during follow-up; time to pregnancy; infertility; PID recurrence; or chronic pelvic pain among women of various races; with or without previous PID; with or without baseline Neisseria gonorrhoeae and/or Chlamydia trachomatis infection; and with or without high temperature/white blood cell count/pelvic tenderness score. This was true even in teenagers and women without a previous live birth. Ectopic pregnancies were more common in the outpatient than the inpatient treatment group, but because these were so rare, the difference did not reach statistical significance (5 versus 1, odds ratio 4.91, 95% confidence interval 0.57-42.25).

CONCLUSION

Among all women and subgroups of women with mild-to-moderate PID, there were no differences in reproductive outcomes after randomization to inpatient or outpatient treatment.

LEVEL OF EVIDENCE

I.

Sexual Functioning After Total Compared With Supracervical Hysterectomy: A Randomized Trial

OBJECTIVE

To compare sexual functioning and health-related quality-of-life outcomes of total abdominal hysterectomy (TAH) and supracervical hysterectomy (SCH) among women with symptomatic uterine leiomyomata or abnormal uterine bleeding refractory to hormonal management.

METHODS

We randomly assigned 135 women scheduled to undergo abdominal hysterectomy in 4 U.S. clinical centers to either a total or supracervical procedure. The primary outcome was sexual functioning at 2 years, as assessed by the Medical Outcomes Study Sexual Problems Scale. Secondary outcomes included specific aspects of sexual functioning and health-related quality-of-life at 6 months and 2 years.

RESULTS

Sexual problems improved dramatically in both randomized groups during the first 6 months and plateaued by 1 year. Health-related quality-of-life scores also improved in both groups. At 2 years, both groups reported few problems with sexual functioning (mean score on the Sexual Problems Scale for SCH group 82, TAH group 80, on a 0-to-100 scale with 100 indicating an absence of problems; difference = +2.95% confidence interval -8 to +11), and there were no significant differences between groups.

CONCLUSION

Supracervical and total abdominal hysterectomy result in similar sexual functioning and health-related quality of life during 2 years of follow-up. This information can help guide physicians as they discuss surgical options with their patients.

Effects of estrogen with and without progestin on urinary incontinence

CONTEXT

Menopausal hormone therapy has long been credited with many benefits beyond the indications of relieving hot flashes, night sweats, and vaginal dryness, and it is often prescribed to treat urinary incontinence (UI).

OBJECTIVE

To assess the effects of menopausal hormone therapy on the incidence and severity of symptoms of stress, urge, and mixed UI in healthy postmenopausal women.

DESIGN, SETTING, AND PARTICIPANTS

Women's Health Initiative multicenter double-blind, placebo-controlled, randomized clinical trials of menopausal hormone therapy in 27,347 postmenopausal women aged 50 to 79 years enrolled between 1993 and 1998, for whom UI symptoms were known in 23,296 participants at baseline and 1 year.

INTERVENTIONS

Women were randomized based on hysterectomy status to active treatment or placebo in either the estrogen plus progestin (E + P) or estrogen alone trials. The E + P hormones were 0.625 mg/d of conjugated equine estrogen plus 2.5 mg/d of medroxyprogesterone acetate (CEE + MPA); estrogen alone consisted of 0.625 mg/d of conjugated equine estrogen (CEE). There were 8506 participants who received CEE + MPA (8102 who received placebo) and 5310 who received CEE alone (5429 who received placebo).

MAIN OUTCOME MEASURES

Incident UI at 1 year among women without UI at baseline and severity of UI at 1 year among women who had UI at baseline.

RESULTS

Menopausal hormone therapy increased the incidence of all types of UI at 1 year among women who were continent at baseline. The risk was highest for stress UI (CEE + MPA: relative risk [RR], 1.87 [95% confidence interval {CI}, 1.61-2.18]; CEE alone: RR, 2.15 [95% CI, 1.77-2.62]), followed by mixed UI (CEE + MPA: RR, 1.49 [95% CI, 1.10-2.01]; CEE alone: RR, 1.79 [95% CI, 1.26-2.53]). The combination of CEE + MPA had no significant effect on developing urge UI (RR, 1.15; 95% CI, 0.99-1.34), but CEE alone increased the risk (RR, 1.32; 95% CI, 1.10-1.58). Among women experiencing UI at baseline, frequency worsened in both trials (CEE + MPA: RR, 1.38 [95% CI, 1.28-1.49]; CEE alone: RR, 1.47 [95% CI, 1.35-1.61]). Amount of UI worsened at 1 year in both trials (CEE + MPA: RR, 1.20 [95% CI, 1.06-1.36]; CEE alone: RR, 1.59 [95% CI, 1.39-1.82]). Women receiving menopausal hormone therapy were more likely to report that UI limited their daily activities (CEE + MPA: RR, 1.18 [95% CI, 1.06-1.32]; CEE alone: RR, 1.29 [95% CI, 1.15-1.45]) and bothered or disturbed them (CEE + MPA: RR, 1.22 [95% CI, 1.13-1.32]; CEE alone: RR, 1.50 [95% CI, 1.37-1.65]) at 1 year.

CONCLUSIONS

Conjugated equine estrogen alone and CEE + MPA increased the risk of UI among continent women and worsened the characteristics of UI among symptomatic women after 1 year. Conjugated equine estrogen with or without progestin should not be prescribed for the prevention or relief of UI.

Resource Use for Total and Supracervical Hysterectomies: Results of a Randomized Trial

OBJECTIVE

Hysterectomy is the most common major surgical procedure performed in the United States for nonobstetric reasons. Although most hysterectomies include removal of the cervix, the rate of supracervical procedures has increased in recent years. To provide evidence about the outcomes of both types of hysterectomy, we conducted a randomized clinical trial of total (TAH) or supracervical (SCH) hysterectomy (the "TOSH" trial). We report here an analysis of 24-month resource use by patients in this trial.

METHODS

A randomized controlled trial was performed at 3 clinical centers to compare resources used by 120 patients who received a total or supracervical abdominal hysterectomy. Service use during a 24-month follow-up period was identified from medical and billing records and patient reports. Each service used was assigned a relative value, which was then converted into 2002 U.S. dollars.

RESULTS

Overall resource use was similar in the 2 study groups in the first 12 months after randomization (TAH 5,870 US dollars; SCH 6,018 US dollars; 95% confidence interval for difference -960 US dollars, 1,255 US dollars; P <.79) and for the full 24 months (TAH 6,448 US dollars; SCH 7,479 US dollars; 95% confidence interval for difference -533 US dollars, 2,616 US dollars; P <.20). In exploratory multivariable analyses, resource use was significantly associated with baseline body mass index greater than or equal to 35 kg/m(2) (8,440 US dollars versus 6,398 US dollars, P =.02) and heavy bleeding (7,550 US dollars versus 5,368 US dollars, P =.02).

CONCLUSION

We conclude that the use of medical care resources over a 24-month period is comparable for total and supracervical hysterectomy. The association of a woman's weight and bleeding pattern with subsequent resource use requires further investigation.

Effects of estrogen plus progestin on gynecologic cancers and associated diagnostic procedures: the Women's Health Initiative randomized trial

CONTEXT

The effects of continuous combined hormone therapy on gynecologic cancers have not been investigated previously in a randomized trial setting.

OBJECTIVE

To determine the possible associations of estrogen plus progestin on gynecologic cancers and related diagnostic procedures.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, placebo-controlled trial of 16 608 postmenopausal women, who had not had a hysterectomy at baseline and who had been recruited from 40 US clinical centers between September 1993 and October 1998 (average follow-up, 5.6 years).

INTERVENTION

One tablet per day containing 0.625 mg of conjugated equine estrogens plus 2.5 mg of medroxyprogesterone acetate (n = 8506) or placebo (n = 8102).

MAIN OUTCOME MEASURE

Incident invasive cancer of the ovary and endometrium.

RESULTS

In 5.6 years of follow-up, there were 32 cases of invasive ovarian cancer, 58 cases of endometrial cancer, 1 case of nonendometrial uterine cancer, 13 cases of cervical cancer, and 7 cases of other gynecologic cancers. The hazard ratio (HR) for invasive ovarian cancer in women assigned to estrogen plus progestin compared with placebo was 1.58 (95% confidence interval [CI], 0.77-3.24). The HR for endometrial cancer was 0.81 (95% CI, 0.48-1.36). No appreciable differences were found in the distributions of tumor histology, stage, or grade for either cancer site. The incidence of other gynecologic cancers was low and did not differ by randomization assignment. More women taking estrogen plus progestin required endometrial biopsies (33% vs 6%; P<.001).

CONCLUSIONS

This randomized trial suggests that continuous combined estrogen plus progestin therapy may increase the risk of ovarian cancer while producing endometrial cancer rates similar to placebo. The increased burden of endometrial biopsies required to assess vaginal bleeding further limits the acceptability of this regimen. These data provide additional support for caution in the use of continuous combined hormones.

A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes

OBJECTIVE

To compare surgical complications and clinical outcomes after total versus supracervical abdominal hysterectomy for control of abnormal uterine bleeding, symptomatic uterine leiomyomata, or both.

METHODS

We conducted a randomized intervention trial in four US clinical centers among 135 patients who had abdominal hysterectomy for symptomatic uterine leiomyomata, abnormal uterine bleeding refractory to hormonal treatment, or both. Patients were randomly assigned to receive a total or supracervical hysterectomy performed using the surgeon's customary technique. Using an intention-to-treat approach, we compared surgical complications and clinical outcomes for 2 years after randomization.

RESULTS

Sixty-eight participants were assigned to supracervical hysterectomy (SCH) and 67 to total abdominal hysterectomy (TAH). Hysterectomy by either technique led to statistically significant reductions in most symptoms, including pelvic pain or pressure, back pain, urinary incontinence, and voiding dysfunction. Patients randomly assigned to (SCH) tended to have more hospital readmissions than those randomized to TAH, but this difference was not statistically significant. There were no statistically significant differences in the rate of complications, degree of symptom improvement, or activity limitation. Participants weighing more than 100 kg at study entry were twice as likely to be readmitted to the hospital during the 2-year follow-up period (relative risk [RR] 2.18, 95% confidence interval [CI] 1.06, 4.48, P=.034).

CONCLUSION

We found no statistically significant differences between (SCH) and TAH in surgical complications and clinical outcomes during 2 years of follow-up.

Statin use, clinical fracture, and bone density in postmenopausal women: results from the Women's Health Initiative Observational Study

BACKGROUND

3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) have been shown to stimulate bone formation in laboratory studies, both in vitro and in vivo. While early epidemiologic studies showed lower risk for hip fracture among statin users than nonusers, subsequent studies have produced mixed results.

OBJECTIVE

To examine the association of statin use with incidence of hip, lower arm or wrist, and other clinical fractures and with baseline levels of bone density.

DESIGN

Prospective study.

SETTING

Women's Health Initiative Observational Study conducted in 40 clinical centers in the United States.

PARTICIPANTS

93 716 postmenopausal women ages 50 to 79 years.

MEASUREMENTS

Rates of hip, lower arm or wrist, and other clinical fractures were compared among 7846 statin users and 85 870 nonusers over a median follow-up of 3.9 years. In 6442 women enrolled at three clinical centers, baseline levels of total hip, posterior-anterior spine, and total-body bone density measured by using dual-energy x-ray absorptiometry were compared according to statin use.

RESULTS

Age-adjusted rates of hip, lower arm or wrist, and other clinical fractures were similar between statin users and nonusers regardless of duration of statin use. The multivariate-adjusted hazard ratios for current statin use were 1.22 (95% CI, 0.83 to 1.81) for hip fracture, 1.04 (CI, 0.85 to 1.27) for lower arm or wrist fracture, and 1.11 (CI, 1.00 to 1.22) for other clinical fracture. Bone density levels did not statistically differ between statin users and nonusers at any skeletal site after adjustment for age, ethnicity, body mass index, and other factors.

CONCLUSION

Statin use did not improve fracture risk or bone density in the Women's Health Initiative Observational Study. The cumulative evidence does not warrant use of statins to prevent or treat osteoporosis.

Effect of selective estrogen receptor modulators on reproductive tissues other than endometrium

The objective of this paper is to review the published and unpublished knowledge of the effect of selective estrogen receptor modulators on reproductive tissues other than endometrium. Pharmaceutical companies developing or marketing selective estrogen receptor modulators (SERMs) were identified. The investigators at each company responsible for the conduct of investigational trials were contacted and queried about reports of adverse events in any ongoing or completed trials involving SERMs produced by their company. Levormeloxifene and idoxifene trials noted a higher proportion of surgery for pelvic organ prolapse in treated versus untreated women. The development of these pharmaceutical agents was discontinued, primarily for endometrial concerns. However, pelvic organ prolapse was reported to the FDA as an adverse event associated with both drugs. Study weaknesses preclude a definitive association between the agents and pelvic organ prolapse. The treated groups were not necessarily similar for confounding factors such as age, parity, obesity, cigarette smoking, and other risk factors for pelvic organ prolapse. Tamoxifen and raloxifene increase hot flash intensity and frequency. Ovarian cyst formation and uterine fibroid growth have also been reported with some SERMs. The identification and assessment of the impact of current and future SERMs on the pelvic floor and other genital tissues will be important to understanding their potential long-term application in disease treatment and prevention.

The legendary superior strength of the Pfannenstiel incision: a myth?

OBJECTIVE

This study was undertaken to determine whether there is a difference in the frequency of fascial dehiscence between midline vertical lower abdominal and Pfannenstiel incisions among women undergoing obstetric and gynecologic operations.

STUDY DESIGN

A case-control study of 48 cases of fascial dehiscence complicating 17, 995 major operations (8950 cesarean deliveries and 9405 gynecologic procedures) during a 6-year period at Wayne State University Hutzel Hospital, Detroit, was performed. Univariate analysis identified significant independent variables related to fascial dehiscence. Stepwise logistic regression analysis then identified those risk factors that were independently associated with fascial dehiscence.

RESULTS

Among the 48 patients who underwent repair of fascial dehiscence after a major obstetric or gynecologic operation, 27 were from the obstetric service and 21 were from the benign and cancer gynecologic services. Wound dehiscence occurred in 10 vertical incisions and 17 Pfannenstiel incisions among the obstetric patients and in 12 vertical and 9 Pfannenstiel incisions among the gynecologic patients. The risk for dehiscence with vertical lower abdominal incisions was not increased with respect to that associated with Pfannenstiel incisions (P =.39, 2-tailed). This finding was true for all patients (odds ratio, 1.3; 95% confidence interval, 0.7-2.6), obstetric patients (odds ratio, 1.3; 95% confidence interval, 0.5-3.4), and gynecologic patients (odds ratio, 1.5; 95% confidence interval, 0.5-4.0). Forty-seven of the 48 case patients had documented wound infections, compared with 1 of the 144 control subjects (P <.0001, odds ratio, 37.8; 95% confidence interval, 14.8-96.8).

CONCLUSION

Wound infection was the most important risk factor for fascial dehiscence among women who underwent major obstetric and gynecologic operations. Our results do not support the long-held belief that Pfannenstiel incisions are stronger than lower abdominal vertical incisions and reduce the risk for fascial dehiscence.

Transvaginal ultrasound-guided aspiration of pelvic abscesses

OBJECTIVE

To assess the utility of a less invasive approach to the care of women with a pelvic abscess, we retrospectively reviewed the outcome of women with pelvic abscesses managed by transvaginal ultrasound-guided aspiration.

METHODS

A retrospective analysis of 27 pelvic abscesses in 22 consecutive women undergoing transvaginal drainage, including 13 tuboovarian abscesses (TOAs) and 14 postoperative abscesses (POAs). All patients received broad-spectrum intravenous antibiotics from the time infection was diagnosed to resolution of signs and symptoms. Chart review and examination of ultrasound files were utilized to extract demographic clinical, laboratory, and outcome data.

RESULTS

The mean age for the study group was 30 years old. Mean duration from diagnosis to drainage was 5.6 days (TOA) and 2.0 days (POA), P < 0.01. The mean diameter of the abscesses was 86 mm. The volume of purulent material drained ranged from 70-750 mL. Perceived adequacy of drainage was correlated with lack of abscess septation. Cultures for aerobic and anaerobic pathogens were positive in 51% of cases (79% POA versus 23% TOA, P < 0.05) with 1.9 organisms/ positive culture. Transvaginal drainage was successful in 25 of 27 abscesses. No complications were reported.

CONCLUSION

In skilled hands, transvaginal guided aspiration of pelvic abscess is a highly successful technique with minimal risk to the patient. Follow-up studies are needed to assess the long-term sequelae, such as frequency of infertility, ectopic pregnancy, and chronic pelvic pain.

Transvaginal ultrasound-guided aspiration of pelvic abscesses

OBJECTIVE

To assess the utility of a less invasive approach to the care of women with a pelvic abscess, we retrospectively reviewed the outcome of women with pelvic abscesses managed by transvaginal ultrasound-guided aspiration.

METHODS

A retrospective analysis of 27 pelvic abscesses in 22 consecutive women undergoing transvaginal drainage, including 13 tuboovarian abscesses (TOAs) and 14 postoperative abscesses (POAs). All patients received broad-spectrum intravenous antibiotics from the time infection was diagnosed to resolution of signs and symptoms. Chart review and examination of ultrasound files were utilized to extract demographic clinical, laboratory, and outcome data.

RESULTS

The mean age for the study group was 30 years old. Mean duration from diagnosis to drainage was 5.6 days (TOA) and 2.0 days (POA), P < 0.01. The mean diameter of the abscesses was 86 mm. The volume of purulent material drained ranged from 70-750 mL. Perceived adequacy of drainage was correlated with lack of abscess septation. Cultures for aerobic and anaerobic pathogens were positive in 51% of cases (79% POA versus 23% TOA, P < 0.05) with 1.9 organisms/ positive culture. Transvaginal drainage was successful in 25 of 27 abscesses. No complications were reported.

CONCLUSION

In skilled hands, transvaginal guided aspiration of pelvic abscess is a highly successful technique with minimal risk to the patient. Follow-up studies are needed to assess the long-term sequelae, such as frequency of infertility, ectopic pregnancy, and chronic pelvic pain.

Synthetic graft placement in the treatment of fascial dehiscence with necrosis and infection

OBJECTIVE

The objective of this study was to describe the use of synthetic grafts in repairing fascial dehiscence complicated by fascial necrosis and infection after obstetric and gynecologic operations.

STUDY DESIGN

A retrospective review of the operating room records at Hutzel Hospital (Detroit, Mich) was performed to find all cases of fascial dehiscence repaired during a 6-year period between January 1, 1991, and December 31, 1996. Patients with partial or complete disruption of the fascia with evidence of fascial necrosis and infection were included in this study. Demographic information; the initial surgical procedure, including type of incision; suture material; use of synthetic graft and closure technique for repair of dehiscence; postoperative complications, microbiologic results; antibiotic therapy; subsequent operations; length of hospital stay; and late complications were recorded.

RESULTS

During the study period 52 patients underwent repair of fascial dehiscence; 36 of these had concurrent fascial necrosis and infection, including 4 women with necrotizing fasciitis. Eighteen patients were from the obstetric service and 18 were from the benign or cancer gynecology service. Ninety-one bacterial isolates were recovered from the infected wounds. Extensive fascial resection precluded closure without tension in 18 cases and necessitated synthetic graft placement to prevent evisceration. Graft materials included polypropylene (11 cases) and polyglactin (7 cases). Late complications of graft placement included extrusion of the graft in 3 patients and incisional hernia in 1.

CONCLUSIONS

Extensive fascial débridement with resection prevents primary closure of wound dehiscence. Synthetic grafts permit primary closure of large fascial defects and can be used with extensive débridement in the presence of infection.

Medically sound, cost-effective treatment for pelvic inflammatory disease and tuboovarian abscess

OBJECTIVE

Our purpose was to determine the clinical effectiveness and cost-effectiveness of three antibiotic regimens for the treatment of pelvic inflammatory disease and tuboovarian abscess.

STUDY DESIGN

A review of all patients' hospitalized at Hutzel Hospital, Detroit, Michigan, for treatment of pelvic inflammatory disease and tuboovarian abscess between Jan. 1, 1993, and April 30, 1997, was performed. Demographic data, antibiotic choices, changes in therapy, operative interventions, and cost of therapy were assessed.

RESULTS

Two hundred three patients were admitted for treatment of pelvic inflammatory disease during the study period. We were able to evaluate the clinical efficacy of antibiotic treatment in 179 patients, including 105 patients with pelvic inflammatory disease alone (uncomplicated pelvic inflammatory disease) and 74 women whose infection was complicated by tuboovarian abscess. The three antibiotic regimens evaluated were cefotetan plus doxycycline, clindamycin plus gentamicin, and ampicillin plus clindamycin plus gentamicin. All regimens demonstrated comparable efficacy in treating uncomplicated genital tract infections. Ampicillin plus clindamycin plus gentamicin was significantly better than clindamycin plus gentamicin and cefotetan plus doxycycline in treatment of tuboovarian abscess (p = 0.001). Fifteen women with tuboovarian abscess responded to a change to ampicillin plus gentamicin plus clindamycin antibiotic therapy alone. The hospital stay was prolonged by approximately 3 days in women failing to respond to initial antibiotic therapy, and operative interventions were common in this group of patients.

CONCLUSIONS

Cefotetan plus oral doxycycline is the most cost-effective regimen for treating uncomplicated pelvic inflammatory disease, whereas triple-antibiotic therapy is the treatment of choice in women with tuboovarian abscess.

The development and implementation of normal vaginal delivery clinical pathways in a large multihospital health system

The entire country has become more concerned with healthcare costs due to managed care, capitation risk-based contracts, and the near elimination of the cost-plus reimbursement system. Clinical pathways have become one way to reduce unnecessary resource consumption by reducing provider variance, improving clinical outcomes, and reducing cost. We present here our rationale and process for developing a common clinical pathway for normal vaginal delivery in a large and varied multihospital system. We also discuss how this new pathway is expected to improve quality of care and reduce costs.

A cost-effectiveness evaluation of preoperative type-and-screen testing for vaginal hysterectomy

OBJECTIVE

Our purpose was to evaluate the usefulness and cost-effectiveness of routine preoperative type-and-screen testing before vaginal hysterectomy.

STUDY DESIGN

A retrospective review of all vaginal hysterectomies performed at Hutzel Hospital between 1988 and 1994 with an emphasis on those that required blood transfusion was done. All vaginal hysterectomies completed at Hutzel Hospital were included in this 6-year time period for all noncancerous indications, including fibroid uterus, endometriosis, menorrhagia, uterine prolapse, pelvic pain, cervical dysplasia, and adenomyosis.

RESULTS

Among 1063 patients who underwent vaginal hysterectomy, 26 needed a blood transfusion at the time of hospitalization. Medical records of the patients who needed blood transfusions were reviewed to determine the urgency and indication. Ten of the transfusions were given preoperatively because of anemia, 7 were given intraoperatively, and 9 were given postoperatively. The seven intraoperative transfusions were given because of the physician's perception of excessive blood loss; however, none of the patients received an emergency transfusion with extreme urgency. That is, the need for the intraoperative transfusion was not immediate. All patients who received a transfusion could have waited for 20 to 30 minutes for proper type and crossmatching and subsequent transfusion.

CONCLUSION

In the absence of preoperative indications, routine preoperative type-and-screen testing of blood before vaginal hysterectomy is not cost-effective, does not enhance patient care, and should be eliminated.

A cost-effectiveness evaluation of laparoscopic disposable versus nondisposable infraumbilical cannulas

STUDY OBJECTIVE

To compare the safety and cost-effectiveness of disposable and nondisposable infraumbilical laparoscopic cannulas.

DESIGN

Retrospective review of consecutive laparoscopic procedures performed from July 1, 1988, to June 30, 1994.

SETTING

A university-affiliated hospital. Patients. The 10,459 consecutive women who underwent laparoscopies.

INTERVENTIONS

A 10-mm disposable cannula was used in 529 laparoscopies and a nondisposable cannula in 9930, based on physician preference.

MEASUREMENTS AND MAIN RESULTS

The only intraabdominal injuries associated with insertion of disposable and nondisposable cannulas were bowel injuries in one and three patients, respectively. The injury rates for the instruments were 19 and 3/10,000 cases, respectively, but were not statistically different (P <0.05, Fisher's two-tail exact test). The hospital cost per disposable cannula in 1994 was $63.71; the cost per procedure with the nondisposable cannula was amortized and was less than $1.35, including maintenance.

CONCLUSION

Disposable cannulas were not cost effective and were associated with a higher but not statistically significant complication rate. Therefore, the more expensive disposable cannulas are not recommended.

A cost analysis of endometrial ablation, abdominal hysterectomy, vaginal hysterectomy, and laparoscopic-assisted vaginal hysterectomy in the treatment of primary menorrhagia

STUDY OBJECTIVE

To assess the cost of four procedures performed to treat primary menorrhagia.

DESIGN

Retrospective analysis. Setting. A 394-bed womens' teaching hospital.

PATIENTS

Eighty healthy women undergoing one of the four procedures. Interventions. The study patients were equally divided among vaginal hysterectomy (VH), total abdominal hysterectomy (TAH), laparoscopic-assisted vaginal hysterectomy (LAVH), and endometrial ablation (EA).

MEASUREMENTS AND MAIN RESULTS

Endometrial ablation was associated with significantly reduced hospital costs and a shorter recovery period than the other modalities. Hospital costs were less for VH and return to work was quicker after LAVH and VH. This study did not evaluate long-term failures or complications unless they occurred within the first 2 months after the procedure.

CONCLUSION

Among women who could be treated by any of these techniques, VH was significantly more cost effective for the permanent management of primary menorrhagia than LAVH and TAH. The cost efficiency of EA was clearly implied, but further studies must be completed to evaluate the long-term costs associated with treatment failures. Although physicians should not choose a procedure based exclusively on cost, the expense of a less efficient or more costly procedure may affect a hospital's competitiveness in this era of managed care.

The effect of capitated and fee-for-service remuneration on physician decision making in gynecology

OBJECTIVE

To evaluate the variations in physician behavior leading to performance of gynecologic surgical procedures related to fee-for-service and capitation reimbursement systems.

METHODS

This study compared the physician practice utilization of surgical services for fee-for-service and capitated contract reimbursement systems within a gynecology clinic. Attending gynecologists were reimbursed on a fee-for-service basis for all surgical services performed during a 6-month interval; subsequently, the same physicians were reimbursed on a capitated basis for 6 months and received a fixed payment for the clinical and surgical services provided.

RESULTS

Three thousand seven hundred eighty consecutive outpatient gynecology visits were evaluated at the university gynecology clinic during 1994. We found a 15% overall decrease in the number of surgical procedures that were performed during the capitated reimbursement period compared with the fee-for-service time interval. The procedure most responsible for the reduction of surgical services was elective sterilization by laparoscopy, which underwent a statistically significant decrease (P < .01).

CONCLUSION

The remuneration system in our review seemed to affect physician decision making for only the most elective procedures, whereas physicians maintained similar practice patterns for more severe conditions. Fee-for-service seems to encourage, whereas capitation seems to discourage, gynecologist from performing elective procedures.

Cost-effectiveness of routine blood type and screen testing before elective laparoscopy

OBJECTIVE

To evaluate the usefulness and cost-effectiveness of the routine preoperative evaluation of blood type and screen testing before laparoscopy.

METHODS

A retrospective review was conducted in patients transfused with blood during or after laparoscopy over a 3-year period at Hutzel Hospital, Detroit, Michigan; Grace Hospital, Southfield, Michigan; and Bixby Medical Center, Adrian, Michigan.

RESULTS

Of 7529 women receiving laparoscopic procedures, 57 required blood transfusion at laparoscopy. Medical records of the 57 patients requiring blood transfusion were evaluated as to urgency and indication. All 57 subsequent blood transfusions were found to be the result of previously identifiable problems, including ectopic pregnancy and preoperative anemia. No patient required transfusion for a vascular injury.

CONCLUSION

In the absence of preoperative indications, routine preoperative type and screen testing for elective and emergency laparoscopic procedures does not enhance patient care and should be eliminated.

Primary and preventive care in a university obstetrics and gynecology group practice

OBJECTIVE

Our purpose was to determine whether primary and preventive care is practiced by a university obstetrician-gynecologist group practice.

STUDY DESIGN

A retrospective chart review spanning 2 years of four academic physicians' private practices was performed. A total of 335 patients were reviewed with 739 patient encounters and 1032 patient problems identified. The definition of a primary care physician according to The American College of Obstetricians and Gynecologists was used to standardize data collection and evaluation.

RESULTS

Obstetric complaints accounted for 27.7% of all visits, whereas 65.4% were for gynecologic problems. Almost 7% of all complaints were neither obstetric nor gynecologic, and of those 74.6% were primary care problems completely managed by the obstetrician-gynecologist. Only 19.7% of these were referred for management. More than 89% of all encounters (659/739) involved some element of primary care.

CONCLUSION

This study provides evidence that the majority of health care provided by the obstetrician-gynecologist is primary care.

Antiendotoxin antibody is protective against tubal damage in an Escherichia coli rabbit salpingitis model

OBJECTIVE

This study was designed to determine whether pretreatment with an endotoxin antibody reduces tubal damage and tumor necrosis factor-alpha production in an Escherichia coli rabbit salpingitis model.

STUDY DESIGN

Twenty New Zealand White rabbits underwent laparotomy with direct inoculation of Escherichia coli into the fallopian tube. The animals were given either antibody and antibiotic, antibiotic alone, or no treatment. At 7 days the degree of tubal damage was measured by gross observation, light microscopy, and electron microscopy. Serum tumor necrosis factor-alpha levels were also assayed at 0, 2, 4, and 36 hours.

RESULTS

Animals pretreated with antiendotoxin antibody demonstrated significantly less damage on the basis of gross observation and electron microscopy compared with both antibiotic alone and untreated animals. Tumor necrosis factor-alpha levels were also significantly reduced at 2 and 4 hours in the antibody-treated group.

CONCLUSIONS

Endotoxin plays a direct role in tubal damage in this Escherichia coli salpingitis model, and damage can be blocked, in part, by pretreatment with antiendotoxin antibody. Tumor necrosis factor-alpha appears to play a significant role in mediating tubal damage resulting from endotoxin.

Pelvic inflammatory disease

Pelvic inflammatory disease is a common serious complication of the sexually transmitted pathogens Neisseria gonorrhoeae and Chlamydia trachomatis. There are more than 800,000 cases of pelvic inflammatory disease annually accounting for approximately 200,000 hospital admissions for acute and chronic infections. Early accurate diagnosis and treatment are essential to prevent the serious sequelae including ectopic pregnancy, tubal disease infertility, chronic pain, and disability requiring multiple hospitalizations and surgery. Although clinical models to aid in the diagnosis and management of pelvic inflammatory disease have been developed by numerous investigators, all have lacked the sensitivity and specificity to be helpful to the clinician. Laparoscopy, considered by many to be the "gold standard" for diagnosis, is underutilized, and the definition of pelvic infection differs between investigators. Improved patient compliance and safety may be seen if single-agent therapy for acute pelvic inflammatory disease becomes a reality. In a small prospective randomized study, oral ofloxacin was as effective as cefoxitin plus doxycycline for outpatient treatment of chlamydial and gonococcal pelvic inflammatory disease. Treatment of tuboovarian abscess appears to be successful with single agent and combination therapy. Risk factors for developing postabortion endometritis continue to be identified, and the most efficacious prophylactic antibiotic regimen has not been determined to date.

Prevention of osteoporosis by medroxyprogesterone acetate in postmenopausal women

The effect of medroxyprogesterone acetate 10 mg BID alone, conjugated estrogens alone or in a combination regimen for the prevention of osteoporosis was determined in 36 postmenopausal women using single photon densitometry. No significant differences in cortical or trabecular bone mass over time were detected in women between the three treatment groups, although a slight increase in bone mass was noted in women with the combined therapy. Medroxyprogesterone acetate appears efficacious in preventing postmenopausal osteoporosis, and may be especially useful in women with contraindications to estrogen replacement therapy.

Outpatient sedation: an essential addition to gynecologic care for persons with mental retardation

Routine gynecologic care for persons with mental retardation may be difficult to provide, especially to those women who do not allow a pelvic examination to be performed. Of 275 women referred to a multidisciplinary clinic addressing the reproductive health concerns of mentally retarded women, 61 patients (22%) did not allow a gynecologic examination to be performed. The administration of ketamine alone, midazolam alone, or a combination of midazolam and ketamine allowed for the successful performance of a gynecologic examination in 81% of previously uncooperative women. No adverse effects of the medications were noted. We conclude that sedation of difficult-to-examine, mentally handicapped women can be safely performed in the outpatient setting, thus avoiding the need for general anesthesia and its inherent risks.

Reproductive health concerns in Down syndrome. A report of eight cases

People with Down syndrome represent a wide variety of mental and social ranges in functional capacity. Eight cases illustrate the range of reproductive health concerns seen in that group.

Infection on a gynecologic oncology service

Little information is available pertaining to infectious morbidity in women with genital malignancy. To define the magnitude of this problem, all patients admitted to the gynecologic oncology services at the University of Michigan Medical Center between January 1, 1986, and December 31, 1986, were followed prospectively for the development of infectious morbidity. One hundred nine bacteriologically confirmed infections occurred in 297 patients during 510 admissions. An additional 31 postoperative patients received empiric therapy for presumed infection. Urinary tract (54) and wound (22) infections were the most commonly confirmed infections. The pathogens isolated from oncology patients were significantly different in frequency of isolation and antibiotic sensitivity when compared with pathogens isolated from women developing infections on the benign gynecology service. Women with genital malignancies are at high risk for the development of a variety of infections by resistant pathogens, emphasizing the importance of obtaining cultures prior to initiation of therapy and carefully selecting the antibiotics to be prescribed.

Chlamydia trachomatis infection in pregnancy and effect of treatment on outcome

The effect of Chlamydia trachomatis on pregnancy outcome and the effect of treatment of positive cervical cultures was studied by culturing 11,544 women for chlamydia at their first prenatal visit. Chlamydia culture was positive in 2433 (21.08%) and prevalence was related to age and race. Of the positive cultures, 1110 were classified as untreated. The untreated group demonstrated a significant increase in the incidence of premature rupture of the membranes and low birth weight and a decrease in survival when compared with either those with positive cultures who received treatment (N = 1323) or those with negative cultures (N = 9111). Screening of populations at high risk of chlamydia is recommended and treatment of chlamydia-positive patients may improve pregnancy outcome.

Gonococcal infections in women

Gonorrhea is the most common sexually transmitted disease in the United States. This article discusses the epidemiology, pathogenesis of Neisseria gonorrhoeae, diagnosis, clinical manifestations, and treatment of this important disease.

Gynecologic surgery and surgical morbidity in mentally handicapped women

A multidisciplinary clinic recognizing the reproductive health concerns of mentally handicapped women was organized in 1985. Thirty-three of the 300 women seen in the clinic required surgery. Thirty-seven operations, including 13 major abdominal and two major vaginal operations, were performed. Uterine leiomyoma and ovarian neoplasm were the most common gynecologic conditions requiring major surgery. No complications developed in women undergoing minor procedures; however, six patients undergoing major abdominal procedures developed significant postoperative complications. Because thorough and complete pelvic examinations are often difficult to accomplish in mentally handicapped women, these patients may have increased risk for the delayed diagnosis of gynecologic conditions that require major abdominal or vaginal surgery. Mentally handicapped women with significant physical handicaps are at increased risk of developing postoperative complications, and the postoperative stay may be prolonged.

Treatment of chlamydial infections of the cervix during pregnancy

Chlamydia trachomatis infections in pregnancy are associated with a high rate of transmission to the newborn and may be associated with poor obstetrical outcome including low birth weight, premature delivery, stillbirth and neonatal death. This prospective study of 99 chlamydia infected women assessed the clinical efficacy of treating chlamydial infections diagnosed at the initial obstetrical visit. Twelve women had concomitant gonococcal and/or urinary tract infections. Seven day regimens of erythromycin 1 gm per day and erythromycin 2 gm per day appear to be equally effective (95.1% and 92.3% respectively) in the treatment of chlamydial infections in pregnancy. Successive therapy did not vary with gestational age when treated. Four of 91 erythromycin treated women discontinued therapy due to gastrointestinal distress. Eight women received sulfisoxazole 4 gm per day and all responded to therapy. Additional controlled studies are needed to determine the most efficacious treatment for chlamydial infections in pregnancy.

Comparison of copolymer staple versus chromic suture during hysterectomy: gross, histologic, and microbiologic findings

Mechanical stapling of the vaginal cuff during hysterectomy has been proposed as a way to minimize bacterial contamination, thereby reducing infectious morbidity and hospital stay. Twenty-four pathogen-free New Zealand white rabbits underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy using either chromic suture or copolymer staple to close the vaginal cuff. Aerobic and anaerobic cultures were obtained from the peritoneal cavity upon entering, and from the vaginal cuff during the initial operation and on postoperative day 3 or 8. When compared with chromic suture, stapling of the vaginal cuff during hysterectomy did not result in significant reduction of postoperative bacteria isolated from the vaginal cuff or peritoneal cavity. In addition, copolymer staples were associated with histologic evidence of more extensive necrosis and cellular exudate while significantly increasing adhesion formation between the vaginal apex and surrounding viscera. Stapling the vaginal cuff does not significantly reduce bacterial count after hysterectomy, significantly increases adhesion formation, and may interfere with normal wound healing in an animal model.

Treatment of urinary tract infections during pregnancy

Urinary tract infections complicate 7-10% of pregnancies. Early detection and treatment of bacteriuria prevents most cases of pyelonephritis and its associated maternal and neonatal morbidity. The high risk for recurrence of bacteriuria and pyelonephritis mandate close monitoring of previously infected women and may require chronic suppressive therapy through the remainder of pregnancy. Acute cystitis is a distinct syndrome with a low recurrence rate and rarely associated with pyelonephritis.

Assessment of intraperitoneal adhesion formation in a rat model: can a procoagulant substance prevent adhesions?

Previous studies have shown oxidized cellulose to decrease adhesion formation in rats. A recent report showed a decrease in adhesions after application of a fibrin sealant containing thrombin, fibrinogen, and aprotinin, raising the question of whether procoagulants block adhesions by something other than a mechanical barrier effect. To assess the value of a procoagulant in preventing adhesion formation, we compared the efficacy of thrombin with that of oxidized cellulose in decreasing postoperative adhesions in rats. Eighty-five Sprague-Dawley rats underwent midline abdominal incisions and subsequent removal of a small area of right anterior abdominal wall peritoneum. Defects were left open or were closed with interrupted sutures and then treated with thrombin, oxidized cellulose, or nothing. Results obtained at postmortem seven days later showed a decrease in adhesion number and severity among animals treated with oxidized cellulose. No such effect was noted in the thrombin group. No treatment increased adhesion formation. We conclude that although oxidized cellulose appears to be of some benefit in decreasing postoperative adhesion formation in the rat, thrombin alone shows no similar effect. Further conclusions regarding adhesion induction, histologic correlates of adhesion formation, and validity of some methods of adhesion analysis are also addressed.

Adhesion formation and prevention after peritoneal injury and repair in the rabbit

Fifteen rabbits were used to assess peritoneal healing and adhesion formation after suturing and stapling peritoneal edges or excising, cauterizing and abrading areas of peritoneum. Two weeks after peritoneal injury, the amount of adhesions formation was noted. Resection of peritoneal tissue with natural rehealing was preferable to reapproximation of free peritoneal edges with either staples or sutures.

A comparison of nonculture-dependent methods for detection of Chlamydia trachomatis infections in pregnant women

Two nonculture-dependent methods for the detection of Chlamydia trachomatis in endocervical samples from obstetric patients were compared with routine isolation in McCoy cell cultures. When compared with culture, the sensitivities and specificities of the methods were: direct fluorescent antibody staining (MicroTrak [Syva Co.]) 98.1 and 95.4%, and enzyme immunoassay (Chlamydiazyme [Abbott Laboratories]) 96.3 and 92.9%, respectively. In 89% of apparent false-positive direct fluorescent antibody cases and 64% of enzyme immunoassay cases, an additional positive nonculture result was considered to indicate infection missed by culture. Considering these data, revised sensitivities were 84.4% for culture, 95.2% for direct fluorescent antibody, and 95.3% for enzyme immunoassay. Revised specificities were 99.5% for direct fluorescent antibody and 97.3% for enzyme immunoassay. Both nonculture tests appear acceptable for screening high-risk obstetric patients, and may be more sensitive than routine cell culture.

Cost savings with a new combination clindamycin-gentamicin admixture policy

Clindamycin and gentamicin are frequently prescribed by obstetricians and gynecologists (OB-GYN) for various pelvic infections in women. These two antibiotics maintain chemical stability when admixed in a small-volume parenteral. The institution of an admixture policy that recommends combining these agents when both drugs are prescribed in OB-GYN patients would decrease the frequency of administration, improve patient convenience, reduce risk of administration errors and intravenous line contamination, and reduce costs of antibiotic therapy. The authors analyzed antibiotic use in OB-GYN patients over a 3-month period and found that the anticipated cost savings appeared sufficient to warrant an admixture policy change. Six months after initiating the new policy, the authors found an increase in the use of clindamycin and gentamicin, but a decrease in the overall cost for providing antibiotic therapy to OB-GYN patients. Savings for the second quarter were due to the pharmacy providing less expensive clindamycin-gentamicin therapy.

An evaluation of two rapid bacteriuria screening procedures

Two commercially available rapid bacteriuria screening procedures were evaluated for routine screening for 10(4) or more colony forming units per milliliter of pathogenic bacteria in two female patient populations. In 694 obstetric patients with 56 cases of significant bacteriuria, the sensitivity, specificity, positive predictive, and negative predictive values, respectively, were as follows: for Chemstrip LN, 69.6, 83.4, 26.9, and 96.9%; and for Bac-T-Screen, 96.4, 56.0, 16.1, and 99.4%. In 143 nonpregnant females with 32 cases of significant bacteriuria, these values were: for Chemstrip LN, 71.9, 75.7, 46.0, and 90.3%; and for Bac-T-Screen, 84.4, 65.8, 41.5, and 93.6%. These results indicate that the LN strip did not have acceptable sensitivity in either patient group. The Bac-T-Screen had better sensitivity, particularly for obstetric patients; however, a high false-positive rate and high cost per test may restrict its use in those clinical settings where culture is available and cost-effective.

A comparison of piperacillin, cephalothin and cefoxitin in the prevention of postoperative infections in patients undergoing vaginal hysterectomy

A randomized, double-blind, multicenter trial was initiated to compare the safety and efficacy of piperacillin, cephalothin and cefoxitin in the prophylactic treatment of patients undergoing vaginal hysterectomy. The total dose of each antibiotic was 6 grams given in three equally divided doses. A satisfactory prophylactic response was obtained in 143 of 151 (95 per cent) patients treated with piperacillin, in 82 of 87 (94 per cent) patients treated with cephalothin and in 57 of 60 (95 per cent) patients treated with cefoxitin. The pooled data indicated that the piperacillin treatment group did not differ from the combined cephalosporin treatment groups with respect to prophylactic response, presence of febrile morbidity, fever index, duration of postoperative hospitalization and incidence of reported adverse experiences.