Staphylococcal aureus outbreaks in neonatal intensive care units: strategies, nuances, and lessons learned from the frontline.

Methicillin-resistant Staphylococcus aureus (MRSA) infections in neonates can result in significant morbidity and mortality. However, comparatively to adults, neonatal MRSA data remains relatively scarce. Additionally, while evidence-driven practices for adults have seen considerable progress, neonatal infection prevention strategies remain poorly described. The Leeds Newborn Service adopted a series of infection prevention and control (IPC) measures following a rise in MRSA cases in 2008-2009. This narrative review presents IPC measures for neonatal MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) infections and reflects upon local challenges and successes of these interventions. Our experience underscores the importance of an adaptive, evidence-based strategy, tailored to the neonatal population. Effectively addressing MRSA/MSSA requires continuous monitoring with sustained targeted interventions. Our key learning points highlight the intertwined difficulties of specific neonatal requirements and lack of definitive IPC guidance, suggesting a holistic approach is key for successful IPC outcomes in the neonatal intensive care unit setting.

'What is my risk really?': a qualitative exploration of preventive interventions among individuals at risk of rheumatoid arthritis.

Objectives: Intervention in the pre-arthritis phase of RA could prevent or delay the onset of disease. The primary aim of this study was to explore perspectives of being at risk and potential preventive interventions among individuals at risk of developing RA and to identify factors influencing their engagement with prevention. A secondary aim, established during the analytical process, was to understand and compare different approaches to health-related behaviours related to prevention of RA. Methods: Anti-CCP-positive (CCP+) at-risk individuals with musculoskeletal symptoms but no synovitis participated in semi-structured interviews. Data were analysed using reflexive thematic analysis, followed by a secondary ideal-type analysis. Results: Nineteen CCP+ at-risk individuals (10 women; age range 35-70 years) participated. Three overarching themes were identified: being CCP+ at risk; aiming to prevent RA; and influencers of engagement. Participants described distress related to symptoms and uncertainty about disease progression. Many participants had concerns about medication side effects. In contrast, most participants expressed willingness to make lifestyle changes with the aim of preventing RA. Engagement with preventive measures was influenced by symptom severity, personal risk level, co-morbidities, experiences of taking other medications/supplements, knowledge of RA, risk factors and medications, and perceived effort. Three types of participants were identified from the data: proactive preventers, change considerers and fearful avoiders. Overall orientation to health behaviours also impacted the attitude towards preventing RA. Conclusion: Findings could inform recruitment and retention in RA prevention research and promote uptake of preventive interventions in clinical practice.

Elevated Serum Levels of Zonulin Family Peptides in Anticitrullinated Protein Antibody-Positive At-Risk Individuals Without Arthritis.

OBJECTIVE: Recent advances imply that early events triggering rheumatoid arthritis (RA) occur at mucosal surfaces. We aimed to evaluate whether intestinal permeability is altered in patients at increased risk of RA, and/or predicts the development of clinical arthritis, by measuring serum zonulin family peptides (ZFP) levels, which are shown to reflect intestinal barrier integrity. METHODS: Two independent prospective observational cohorts were studied, including subjects with musculoskeletal symptoms and anticitrullinated protein antibodies (ACPA), but without clinical arthritis at baseline. In Sweden, 82 such at-risk patients were compared to 100 age-matched healthy blood donors. In the UK, 307 at-risk patients were compared to 100 ACPA-negative symptomatic controls. ZFP was measured in baseline sera by enzyme-linked immunoassays. RESULTS: In the Swedish at-risk cohort, ZFP levels were significantly increased in patients compared to controls (mean 41.4 vs 33.6 ng/mL, P < 0.001) and Cox regression analysis showed prognostic value of ZFP for arthritis development (hazard ratio [HZ] 1.04 per ng/mL ZFP increase, 95% CI 1.01-1.07, P = 0.02). Elevated ZFP levels among ACPA-positive at-risk patients compared to symptomatic ACPA-negative controls were confirmed in the UK at-risk cohort (mean 69.7 vs 36.0 ng/mL, P < 0.001), but baseline ZFP were not associated with arthritis development (HR 1.00 per ng/mL ZFP increase, 95% CI 1.00-1.01, P = 0.30). CONCLUSION: Serum ZFP levels are elevated in ACPA-positive at-risk patients when compared to both healthy blood donors and symptomatic ACPA-negative controls. Thus, gut barrier function may be of importance in RA-associated autoimmunity. A possible prognostic value of serum ZFP merits further investigation, preferably in larger prospective cohorts.

European Practice for CDI Treatment.

Clostridioides difficile infection (CDI) remains a significant cause of morbidity and mortality worldwide. Historically, two antibiotics (metronidazole and vancomycin) and a recent third (fidaxomicin) have been used for CDI treatment; convincing data are now available showing that metronidazole is the least efficacious agent. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) management guidance for CDI were updated in 2021. This guidance document outlines the treatment options for a variety of CDI clinical scenarios and for non-antimicrobial management (e.g., faecal microbiota transplantation, FMT). One of the main changes is that metronidazole is no longer recommended as first-line CDI treatment. Rather, fidaxomicin is preferred on the basis of reduced recurrence rates with vancomycin as an acceptable alternative. Recommended options for recurrent CDI now include bezlotoxumab as well as FMT.A 2017 survey of 20 European countries highlighted variation internationally in CDI management strategies. A variety of restrictions were in place in 65% countries prior to use of new anti-CDI treatments, including committee/infection specialist approval or economic review/restrictions. This survey was repeated in November 2022 to assess the current landscape of CDI management practices in Europe. Of 64 respondents from 17 countries, national CDI guidelines existed in 14 countries, and 11 have already/plan to incorporate the ESCMID 2021 CDI guidance, though implementation has not been surveyed in 6. Vancomycin is the most commonly used first-line agent for the treatment of CDI (n = 42, 66%), followed by fidaxomicin (n = 30, 47%). Six (9%) respondents use metronidazole as first-line agent for CDI treatment, whereas 22 (34%) only in selected low-risk patient groups. Fidaxomicin is more likely to be used in high-risk patient groups. Availability of anti-CDI therapy influenced prescribing in six respondents (9%). Approval pre-prescription was required before vancomycin (n = 3, 5%), fidaxomicin (n = 10, 6%), bezlotoxumab (n = 11, 17%) and FMT (n = 10, 6%). Implementation of CDI guidelines is rarely audited.Novel anti-CDI agents are being evaluated; it is not yet clear what will be the roles of these agents. The treatment of recurrent CDI is particularly troublesome, and several different live biotherapeutics are being developed, in addition to FMT.

The impact of testing and infection prevention and control strategies on within-hospital transmission dynamics of COVID-19 in English hospitals.

Nosocomial transmission of SARS-CoV-2 is a key concern, and evaluating the effect of testing and infection prevention and control strategies is essential for guiding policy in this area. Using a within-hospital SEIR transition model of SARS-CoV-2 in a typical English hospital, we estimate that between 9 March 2020 and 17 July 2020 approximately 20% of infections in inpatients, and 73% of infections in healthcare workers (HCWs) were due to nosocomial transmission. Model results suggest that placing suspected COVID-19 patients in single rooms or bays has the potential to reduce hospital-acquired infections in patients by up to 35%. Periodic testing of HCWs has a smaller effect on the number of hospital-acquired COVID-19 cases in patients, but reduces infection in HCWs by as much as 37% and results in only a small proportion of staff absences (approx. 0.3% per day). This is considerably less than the 20-25% of staff that have been reported to be absent from work owing to suspected COVID-19 and self-isolation. Model-based evaluations of interventions, informed by data collected so far, can help to inform policy as the pandemic progresses and help prevent transmission in the vulnerable hospital population. This article is part of the theme issue 'Modelling that shaped the early COVID-19 pandemic response in the UK'.

Perturbations of the gut microbiome in anti-CCP positive individuals at risk of developing rheumatoid arthritis.

OBJECTIVE: Individuals with newly diagnosed RA have a distinct microbiome when compared with healthy controls. However, little is known as to when these microbiome perturbations begin. Using a prospective at-risk cohort of individuals positive for anti-citrullinated protein (anti-CCP) antibody with new onset musculoskeletal symptoms, but without clinical arthritis, we investigated for the presence of a gut dysbiosis before the onset of RA. METHODS: The gut microbiota of 25 anti-CCP positive individuals without clinical synovitis were sequenced targeting the V4 region of the 16S rRNA gene. Using a publicly available database, a control population of 44 individuals, approximately matched in age, gender, diet and ethnicity was selected for comparison, using the same sequencing methodology. Median interval between sample collection and progression to RA was 188 days. Taxonomic analysis was performed using QIIME and MEGAN, and statistical analysis using R software. RESULTS: There were significant differences (P =0.01) at family level in gut microbiomes of anti-CCP positive individuals vs controls. The anti-CCP positive population had an overabundance of Lachnospiraceae, Helicobacteraceae, Ruminococcaceae, Erysipelotrichaceae and Bifidobacteriaceae, among others. Five individuals progressed to RA between sample collection and analysis. Clustering of the progressor population was observed on a phylogenetic network created using a probabilistic similarity index (Goodall's index). CONCLUSIONS: Anti-CCP positive at-risk individuals without clinical synovitis appear to have a distinct gut microbiome compared with healthy controls. Phylogenetic clustering was observed in individuals who progressed to RA, suggesting that distinct taxa are associated with the development of RA many months before its onset.

Tracking COVID-19 via sewage.

PURPOSE OF REVIEW: We discuss the potential role of the faecal chain in COVID-19 and highlight recent studies using waste water-based epidemiology (WBE) to track severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). RECENT FINDINGS: WBE has been suggested as an adjunct to improve disease surveillance and aid early detection of circulating disease. SARS-CoV-2, the aetiological agent of COVID-19, is an enveloped virus, and as such, typically not associated with the waste water environment, given high susceptibility to degradation in aqueous conditions. A review of the current literature supports the ability to detect of SARS-CoV-2 in waste water and suggests methods to predict community prevalence based on viral quantification. SUMMARY: The summary of current practices shows that while the isolation of SARS-CoV-2 is possible from waste water, issues remain regarding the efficacy of virial concentration and subsequent quantification and alignment with epidemiological data.

Snapshot PCR surveillance for SARS-CoV-2 in hospital staff in England.

BACKGROUND: Significant nosocomial transmission of SARS-CoV-2 has been demonstrated. Understanding the prevalence of SARS-CoV-2 carriage amongst HCWs at work is necessary to inform the development of HCW screening programmes to control nosocomial spread. METHODS: Cross-sectional 'snapshot' survey from April-May 2020; HCWs recruited from six UK hospitals. Participants self-completed a health questionnaire and underwent a combined viral nose and throat swab, tested by Polymerase Chain Reaction (PCR) for SARS-CoV-2 with viral culture on majority of positive samples. FINDINGS: Point prevalence of SARS-CoV-2 carriage across the sites was 2.0% (23/1152 participants), median cycle threshold value 35.70 (IQR:32.42-37.57). 17 were previously symptomatic, two currently symptomatic (isolated anosmia and sore throat); the remainder declared no prior or current symptoms. Symptoms in the past month were associated with threefold increased odds of testing positive (aOR 3.46, 95%CI 1.38-8.67; p = 0.008). SARS-CoV-2 virus was isolated from only one (5%) of nineteen cultured samples. A large proportion (39%) of participants reported symptoms in the past month. INTERPRETATION: The point-prevalence is similar to previous estimates for HCWs in April 2020, though a magnitude higher than in the general population. Based upon interpretation of symptom history and testing results including viral culture, the majority of those testing positive were unlikely to be infectious at time of sampling. Development of screening programmes must balance the potential to identify additional cases based upon likely prevalence, expanding the symptoms list to encourage HCW testing, with resource implications and risks of excluding those unlikely to be infectious with positive tests. FUNDING: Public Health England.

Comparison of the 2010 and 2017 Infectious Diseases Society of America guidelines on the diagnosis and treatment of Clostridium difficile infection.

PURPOSE OF REVIEW: To highlights the key changes in the updated Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines with respect to the diagnosis and treatment of Clostridium difficile infection (CDI). RECENT FINDINGS: CDI continues as a major threat to healthcare institutions and as a community-associated infection related primarily to antibiotic exposure. Infectious Diseases Society of America/Society for Healthcare Epidemiology of America produced extensive CDI guidelines in 2010; in 2018, updated guidance has been published. The new guidelines include key changes with respect to the treatment and diagnosis of CDI. SUMMARY: Updated, evidence guidelines allow optimization of the diagnosis of CDI and the use of therapeutic interventions, in particular to reduce the risk of recurrent infection.

Fibroblast Growth Factor-23 and Risks of Cardiovascular and Noncardiovascular Diseases: A Meta-Analysis.

Background Fibroblast growth factor-23 (FGF-23) has been hypothesized to play a role in the increased risk of cardiovascular disease in patients with CKD.Methods We identified prospective studies reporting associations between FGF-23 concentration and risk of cardiovascular events. Maximally adjusted risk ratios (RRs) were extracted for each outcome and scaled to a comparison of the top versus bottom third of the baseline FGF-23 concentration, and the results aggregated.Results Depending on the assay used, median FGF-23 concentrations were 43-74 RU/ml and 38-47 pg/ml in 17 general population cohorts; 102-392 RU/ml in nine cohorts of patients with CKD not requiring dialysis; and 79-4212 RU/ml and 2526-5555 pg/ml in eight cohorts of patients on dialysis. Overall, comparing participants in the top and bottom FGF-23 concentration thirds, the summary RRs (95% confidence intervals [95% CIs]) were 1.33 (1.12 to 1.58) for myocardial infarction, 1.26 (1.13 to 1.41) for stroke, 1.48 (1.29 to 1.69) for heart failure, 1.42 (1.27 to 1.60) for cardiovascular mortality, and 1.70 (1.52 to 1.91) for all-cause mortality. The summary RR for noncardiovascular mortality, calculated indirectly, was 1.52 (95% CI, 1.28 to 1.79). When studies were ordered by average differences in FGF-23 concentration between the top and bottom thirds, there was no trend in RRs across the studies.Conclusions The similarly-sized associations between increased FGF-23 concentration and cardiovascular (atherosclerotic and nonatherosclerotic) and noncardiovascular outcomes, together with the absence of any exposure-response relationship, suggest that the relationship between FGF-23 and cardiovascular disease risk may be noncausal.

European Practice for CDI Treatment.

Clostridium difficile infection (CDI) remains a significant cause of morbidity and mortality worldwide. Historically, two antibiotics (metronidazole and vancomycin) and a recent third (fidaxomicin) have been used routinely for CDI treatment; convincing data are now available showing that metronidazole is the least efficacious agent. The European Society of Clinical Microbiology and Infectious Diseases CDI treatment guidelines outline the treatment options for a variety of CDI clinical scenarios, including use of the more traditional anti-CDI therapies (e.g., metronidazole, vancomycin), the role of newer anti-CDI agents (e.g., fidaxomicin), indications for surgical intervention and for non-antimicrobial management (e.g., faecal microbiota transplantation, FMT). A 2017 survey of 20 European countries found that while the majority (n = 14) have national CDI guidelines that provide a variety of recommendations for CDI treatment, only five have audited guideline implementation. A variety of restrictions are in place in 13 (65%) countries prior to use of new anti-CDI treatments, including committee/infection specialist approval or economic review/restrictions. Novel anti-CDI agents are being evaluated in Phase III trials; it is not yet clear what will be the roles of these agents. Prophylaxis is an optimum approach to reduce the impact of CDI especially in high-risk populations; monoclonal antibodies, antibiotic blocking approaches and multiple vaccines are currently in advanced clinical trials. The treatment of recurrent CDI is particularly troublesome, and several different live bio therapeutics are being developed, in addition to FMT.

Leak point pressure does not correlate with incontinence severity or bother in women undergoing surgery for urodynamic stress incontinence.

The aim of this study was to correlate the lowest Valsalva or cough leak point pressure (LPP) with clinical measures of incontinence severity and quality of life in women with pure urodynamic stress incontinence (SUI). This is an analysis of the baseline data from a prospective, multicenter, randomized trial comparing the Monarc transobturator sling to the tension-free vaginal tape. One hundred fifty-five women with SUI underwent urodynamic evaluations including abdominal or vesical LPP determinations, and each completed the Sandvik Incontinence Severity Index, a 3-day voiding diary, and quality-of-life questionnaires. In patients with a LPP, there were no significant correlations between LPP and the above clinical measures of incontinence severity or condition-specific quality-of-life questionnaire scores. In this patient population with pure urodynamic SUI, LPP is not a useful urodynamic predictor of baseline SUI severity and its effects on quality of life.

Sexual function following anal sphincteroplasty for fecal incontinence.

OBJECTIVE: The objective of the study was to assess sexual function following anal sphincteroplasty and determine associations between sexual function and fecal incontinence. STUDY DESIGN: Women 1 year or longer following anal sphincteroplasty with or without other reconstructive surgery were matched to controls. Subjects were mailed the Female Sexual Function Index (FSFI), Fecal Incontinence Quality of Life (FIQOL), Fecal Incontinence Severity Index (FISI), and a general questionnaire. RESULTS: Twenty-six cases and 26 controls responded; 73% were sexually active. Sexual function scores were similar between the groups. Seventeen sphincteroplasty patients and 8 controls complained of fecal incontinence at follow up. Significant correlations were found between FSFI domains and the FIQOL depression/self-perception scale, FISI fecal incontinence of solid stool, and total FISI. CONCLUSION: Sexual activity and function was similar following anal sphincteroplasty, compared with controls, despite worse symptoms of fecal incontinence. Fecal incontinence of solid stool and depression related to fecal incontinence were correlated with poorer sexual function.

Sexual function after vaginal surgery for pelvic organ prolapse and urinary incontinence.

OBJECTIVE: The objective of the study was to assess sexual function following vaginal surgery and to determine the impact on postoperative sexual function in women who undergo concurrent antiincontinence procedures, compared with those who do not. STUDY DESIGN: Sexually active women undergoing vaginal repairs for prolapse or urinary incontinence were prospectively enrolled. Subjects completed the Female Sexual Function Index (FSFI), Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and a standardized questionnaire. Follow-up occurred at 6 months. RESULTS: Forty-nine subjects (96%) returned their postoperative surveys; 48 were sexually active. Improvements were noted in postoperative prolapse stage, UDI-6, and IIQ-7. However, sexual function and frequency were similar. The most bothersome barrier to sexual activity before repair was vaginal bulging; postoperatively it was vaginal pain. Twelve subjects (25%) commented on the negative impact of vaginal pain postoperatively. Finally, FSFI scores were not different based on performance of antiincontinence surgery. CONCLUSION: Sexual function was unchanged following vaginal reconstructive surgery despite anatomic and functional improvements; lack of benefit may be attributable to postoperative dyspareunia.

Effects of an educational workshop on performance of fourth-degree perineal laceration repair.

OBJECTIVE: To develop a valid and reliable tool to objectively measure surgical skill necessary for repair of fourth-degree perineal lacerations and then to use this tool to measure improvement after a workshop. METHODS: We measured baseline surgical ability and clinical knowledge of 26 residents (postgraduate year [PGY]-1 to PGY-4) using the Objective Structured Assessment of Technical Skills (OSATS) and a written examination. The OSATS consists of a global surgical skills assessment (OSATS-G), a procedure checklist (OSAT-C), and pass/fail grade. Five weeks after our baseline evaluation, a 1.5-hour workshop was administered to approximately half of the 26 residents (n=14). One week after this intervention, the residents were re-examined using the same assessment tools. RESULTS: The OSATS demonstrated construct validity as scores on the examination increased on both the OSATS-G and the OSATS-C from PGY-1 through PGY-4 (P=.001 and P=.041, respectively). Reliability indices for the OSATS were high. Eighty-one percent of the residents failed the OSATS before intervention because of failure to identify and repair the internal anal sphincter. After educational intervention, senior residents improved on all assessments (OSATS-G, P=.041; OSATS-C, P=.004; written examination, P=.008), and all residents passed the OSATS. CONCLUSION: A valid and reliable OSATS and written examination were developed to assess surgical skills, knowledge, and judgment necessary to properly manage fourth-degree perineal lacerations. Residents improved on the OSATS and the written examination after undergoing a structured educational workshop. LEVEL OF EVIDENCE: II.

Effects of sacral neuromodulation on female sexual function.

The aim of this prospective study was to determine if sacral neuromodulation has an effect on the patient's subsequent sexual function. Sexually active patients that underwent an Interstim Sacroneuromodulator implantation (Medtronic, Minneapolis, MN) for control of bladder symptoms were enrolled. A Female Sexual Function Index (FSFI) was completed before surgery and at a mean of 5.7 months postoperatively. Eleven subjects proceeded to permanent implantation, seven of these were sexually active before and after placement. Three subjects (43%) felt the device impacted on their sexual function in a positive way (1) by decreasing urgency and (2) by increasing desire. Overall sexual frequency increased significantly after the surgery (p=0.047). There were also significant increases in the FSFI total (p=0.002), and domain scores for desire (p=0.004), lubrication (p=0.005), orgasm (p=0.043), satisfaction (p=0.007), and pain (p=0.015). There was no correlation between patient report of urinary symptom improvement and FSFI scores. In conclusion, sacral neuromodulation may improve sexual frequency and sexual function scores in subjects with urgency frequency and urge incontinence.

Uterosacral ligament vault suspension: five-year outcomes.

OBJECTIVE: To evaluate the five-year anatomic and functional outcomes of the high uterosacral vaginal vault suspension. METHODS: One hundred ten patients with advanced symptomatic uterovaginal or posthysterectomy prolapse treated between January 1997 and January 2000 were identified and 72 (65%) consented to participate in this study. Anatomic outcomes were obtained by Pelvic Organ Prolapse Quantification. Functional results were obtained subjectively and with quality-of-life questionnaires, including the short-form Incontinence Impact Questionnaire (IIQ) and Urogenital Distress Inventory (UDI), and Female Sexual Function Index. RESULTS: The mean follow-up period was 5.1 years (range 3.5-7.5 years). Vaginal hysterectomy (37.5%), anterior colporrhaphy (58.3%), posterior colporrhaphy (87.5%), and suburethral slings (31.9%) were performed as indicated. Surgical failure (symptomatic recurrent prolapse of stage 2 or greater in one or more segments) was 11 of 72 (15.3%). Two patients (2.8%) had recurrence of apical prolapse of stage 2 or greater. For those sexually active preoperatively and postoperatively (n=34), mean postoperative Female Sexual Function Index scores for arousal, lubrication, orgasm, satisfaction, and pain were normal, whereas the desire score was abnormal (mean= 3.2). However, 94% (n=29) were currently satisfied with their sexual activity. Postoperative IIQ/UDI scores were significantly improved in all three domains (irritative, P= .01; obstructive, P<.001; stress, P=.03) and overall (IIQ-7, P<.001; UDI, P<.001) compared with preoperatively. Bowel dysfunction occurred 33.3% preoperatively compared with 27.8% postoperatively (P=.24). CONCLUSION: Uterosacral ligament vaginal vault fixation seems to be a durable procedure for vaginal repair of enterocele and vaginal vault prolapse. Lower urinary tract, bowel, and sexual function may be maintained or improved.

Is previous cesarean section a risk for incidental cystotomy at the time of hysterectomy? A case-controlled study.

OBJECTIVE: The purpose of this study was to determine if previous cesarean section is an independent risk factor for incidental cystotomy at the time of hysterectomy. STUDY DESIGN: This is a case-controlled study that evaluated all cases of incidental cystotomy at the time of hysterectomy between January 1998 and December 2001. Five thousand and ninety-two hysterectomies were performed in the time period mentioned above, and 51 cases of incidental cystotomy were identified. Each case of incidental cystotomy was then matched to 3 controls with similar patient characteristics, medical histories, and surgical histories, as well as the absence of incidental cystotomy at the time of hysterectomy. RESULTS: Overall, 5092 hysterectomies were performed during the study period (total abdominal hysterectomy [TAH] 3140 [61.7%], total vaginal hysterectomy [TVH] 1519 [29.8%], laparoscopically-assisted vaginal hysterectomy [LAVH] 433 [8.5%]). Fifty-one cases of incidental cystotomy were identified (TAH: 24 [47.1%], TVH: 19 [37.3%], LAVH: 8 [15.7%]). The overall incidence of cystotomy was 1.0%. When considering TAH, there were 24/3141 (0.76%) cases of incidental cystotomy, with 8 (33%) of these patients with a history of previous cesarean section. During TVH, we encountered 19/1519 (1.3%) cases of incidental cystotomy, with 4 (21%) of these women having undergone a previous cesarean. Finally, during LAVH, there were 8/433 (1.8%) cases of incidental cystotomy. Five (62.5%) of these patients had a previous history of cesarean section. In comparison, 19/72 (26.4%) TAH controls had a previous history of cesarean. Four out of 57 (7.0%) TVH controls had a history of cesarean section. Finally, 2/24 (8.3%) LAVH controls had a history of previous cesarean. CONCLUSION: Previous cesarean section is indeed a significant risk factor for damage to the lower urinary tract at the time of hysterectomy (odds ratio [OR] 2.04; 95%CI 1.2-3.5). When analyzed separately, the OR of incidental cystotomy at the time of TAH, TVH, and LAVH in a woman with a history of previous cesarean was 1.26, 3.00, and 7.50, respectively. Only the value for LAVH was statistically significant (P = .005; 95%CI 1.8-31.4).

Entero mesh vaginal fistula secondary to abdominal sacral colpopexy.

BACKGROUND: Abdominal sacral colpopexy is a popular method for resupporting the vaginal apex. Bleeding and infection are the most common complications. We report a complication resulting in a small bowel fistula. CASE: A 48-year-old woman developed a chronic vaginal discharge 4-6 months after routine abdominal sacral colpopexy in which a velour mesh remained exposed in the pelvis. Conservative measures failed to control the intermittent copious discharge from the upper vaginal vault where the mesh was visualized. At laparotomy, an entero mesh vaginal fistula was discovered. Excellent long-term results were obtained by removal of the mesh along with resection of the involved small intestine. CONCLUSION: At the time of abdominal sacral colpopexy, we recommend that mesh not remain exposed in the pelvis.