Henry Klapholz

Changing surgical antimicrobial prophylaxis practices through education targeted at senior department leaders.

Prescribing antibiotics for perioperative prophylaxis in common surgical procedures presents an ideal target for educational intervention. In this situation, antibiotics are often used inappropriately, with consequent excess expense and risk of morbidity. We developed an educational intervention aimed at the choice and appropriate dosing of antibiotics for the prophylaxis of cesarean sections. Person-to-person educational messages targeted at authoritative senior department members were supplemented by brief reminders on a structured antibiotic order form. Time-series analyses were conducted on 34 months of antibiotic use data for 2,783 cesarean sections to estimate the trend of magnitude and significance of discontinuities associated with the start of the program. Prior to the intervention, 95% of sections receiving prophylaxis were given cefoxitin and 3% were given cefazolin. After the intervention, these proportions were reversed, with the shift in use occurring immediately after the intervention (p less than .001). Two years after the intervention, virtually all patients undergoing cesarean sections who receive antibiotic prophylaxis are given cefazolin. Savings from this change alone accounted for over

Surveillance for transmission and antibiotic adverse events among neonates and adults exposed to a healthcare worker with pertussis.

26,000 each year, or

Sonographic appearance of uterine scar dehiscence

47.36 per patient-day of prophylaxis. Substantial changes in prescribing practices for routine procedures can be accomplished through the implementation of a coordinated educational program that enlists influential senior staff members in a department in which policy-making is highly centralized, coupled with a structured educational ordering system. Lasting improvements in clinical practices may be brought about by means that are noncoercive, inexpensive and well-accepted by medical staff.

The incidence of intrapartum fetal distress with advancing gestational age.

BACKGROUND During a hospital obstetric rotation, a medical student demonstrated classic symptoms of pertussis. The diagnosis was confirmed by isolation of Bordetella pertussis. Because this exposure occurred in a high-risk hospital setting, control measures were undertaken to prevent transmission and illness. OBJECTIVES To identify secondary cases of pertussis, to determine compliance with chemoprophylaxis recommendations, and to monitor for adverse events associated with chemoprophylaxis following a hospital exposure to pertussis. PATIENTS More than 500 individuals were potentially exposed, including 168 neonates; antimicrobial chemoprophylaxis was administered to 281 individuals. Fifty-eight neonates and 194 adults began azithromycin chemoprophylaxis; 18 neonates and 2 adults began erythromycin chemoprophylaxis. METHODS Active surveillance was instituted for (1) secondary cases of pertussis among healthcare coworkers, obstetric patients, their neonates, and labor companions and (2) antibiotic compliance and tolerance. RESULTS No secondary cases of pertussis were confirmed by laboratory tests; however, 26 suspected cases and 5 clinically compatible cases were identified. Antibiotic courses were completed by 95% of the individuals who initiated therapy. Neonates taking azithromycin had statistically significantly less gastrointestinal distress compared with neonates taking erythromycin (12% vs 50%; P = .002); there were no cases of infantile hypertrophic pyloric stenosis. CONCLUSIONS Although it was not possible to assess the effectiveness of the antibiotic regimens, the lack of laboratory-confirmed secondary cases suggests control measures were successful. Data from the 58 neonates who received azithromycin suggest it may be well tolerated in this age group.

Tarlov cysts : a cause of complex bilateral adnexal masses on pelvic sonography

We describe the sonographic appearance of two cases of uterine scar separation in patients with prior cesarean deliveries. In the first case, the anteriorly located placenta appeared to be a placenta previa with accreta and in the second case the placenta was also located directly beneath the uterine scar thus masking a separation until the third stage of labor was complete. These two cases demonstrate an unusual sonographic and clinical presentation of uterine scar separation involving anteriorly located placentas.

A computerized aid to Ball pelvimetry

A total of 679 fetal monitoring records were carefully reviewed in order to determine the incidence of occurrence of late and variable deceleration patterns with respect to advancing gestational age. No statistically significant increase in occurrence of these patterns could be detected in gestations that progressed beyond 42 weeks. The previously held concept that routine prophylactic intervention in gestations of 42 weeks or more must be challenged.

The Medical Examination

Sonography is the most commonly used modality in the evaluation of the female pelvis. When a pelvic mass is encountered, the differential diagnosis is based largely on the sonographic appearancenamely, the cystic, solid, or complex nature of the mass. When adnexal masses are seen sonographically, it is easy to assume that they are of ovarian origin. There are, however, many other causes for pelvic masses, such as abscesses, retroperitoneal tumors, retroperitoneal cysts, and neural abnormalities. Images of the ovaries should always be sought, even in the presence of adnexal masses, as identification of discrete ovary unconnected to the mass would suggest a nonovarian cause. We present a case of bilateral adnexal masses seen sonographically, for which the diagnosis of giant Tarlov cysts was made using CT and MR imaging.

ROLE OF MATERNAL ARTIFACT IN FETAL HEART RATE PATTERN INTERPRETATION

A computer program is presented that will generate a table of capacities and volumes for use with the Ball technique for cephalopelvimetry. The technique of Ball pelvimetry is reviewed and directions for use are described. This table may be produced on any medium or large-scale digital computer equipped with a FORTRAN compiler and a standard page printer. Its use eliminates many errors inherent in previous methods of volume computation. Physician acceptance has been excellent.

Blood transfusion in contemporary obstetric practice

Fear of the hospital has kept many rape victims from seeking appropriate and timely medical attention. To some women, the gynecological examination can seem like a reenactment of the rape itself. As one rape victim put it, “The pelvic examination was quite depressing at the time. To have to get undressed again and get up on that table and go through almost the same thing again of something being stuck into you was awful.” A proper, thoughtful, well-explained examination is essential if the gynecologist is to deliver good medical care to the victim, and good medical care should be his first priority.

Autologous blood donation during pregnancy: analysis of safety and blood use.

Electronic fetal heart rate monitoring has been accepted as the best means of, assessing fetal well-being in utero. Nevertheless, characteristics of the fetal monitoring equipment may lead to errors in diagnosing the condition of the fetus. Three cases illustrative of such shortcomings are presented. In 2 cases, maternal QRS complexes which were detectable at the fetal scalp electrode were counted, resulting in misleading recordings. In one of these, the heart rate of the mother was obtained from a dead fetus. In the other, the instrument produced an incomprehensible record as a result of counting both maternal and fetal complexes. In the third case, a heart rate recording thought to demonstrate fetal distress was obtained with the ultrasound probe of the monitor. Subsequent investigation demonstrated that the monitor was detecting the maternal pulse. With either direct or indirect monitoring technics the suspicion of fetal death, apparent fetal bradycardia, or apparent fetal arrhythmia requires simultaneous maternal and fetal heart rate and/or ECG recordings.