Best practice perioperative strategies and surgical techniques for preventing caesarean section surgical site infections: a systematic review of reviews and meta-analyses.

BACKGROUND: Surgical site infection (SSI) following caesarean section is a problem for women and health services. Caesarean section is a high volume procedure and the estimated incidence of SSI may be as high as 9%. OBJECTIVES: The objective of this study was to identify a suite of perioperative strategies and surgical techniques that reduce the risk of SSI following caesarean section. SEARCH STRATEGY: Six electronic databases were searched to systematically review literature reviews, systematic reviews and meta-analyses published from 2006 to 2016. Search terms included: endometritis, SSI, caesarean section, meta-analysis, review, systematic. SELECTION CRITERIA: Studies were sought in which competing perioperative strategies and surgical techniques relevant for caesarean section were identified and quantifiable infection outcomes were reported. General infection control strategies were excluded. DATA COLLECTION AND ANALYSIS: Data on study characteristics and clinical effectiveness were extracted. Quality, including bias within individual studies, was examined using a modified A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist. Recommendations for SSI risk-reducing strategies were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Of 466 records retrieved, 44 studies were selected for the evidence synthesis. Recommended strategies were: administer pre-incision antibiotic prophylaxis, prepare the vagina with iodine-povidone solution and spontaneous placenta removal. CONCLUSIONS: We recommend clinicians implement pre-incision antibiotic prophylaxis, vaginal preparation and spontaneous placenta removal as an infection control bundle for caesarean section. FUNDING: Queensland University of Technology. TWEETABLE ABSTRACT: Infection control for caesarean: pre-incision AB prophylaxis, vaginal prep, spontaneous placenta removal.

Humans, 'things' and space: costing hospital infection control interventions.

BACKGROUND: Previous attempts at costing infection control programmes have tended to focus on accounting costs rather than economic costs. For studies using economic costs, estimates tend to be quite crude and probably underestimate the true cost. One of the largest costs of any intervention is staff time, but this cost is difficult to quantify and has been largely ignored in previous attempts. AIM: To design and evaluate the costs of hospital-based infection control interventions or programmes. This article also discusses several issues to consider when costing interventions, and suggests strategies for overcoming these issues. METHODS: Previous literature and techniques in both health economics and psychology are reviewed and synthesized. FINDINGS: This article provides a set of generic, transferable costing guidelines. Key principles such as definition of study scope and focus on large costs, as well as pitfalls (e.g. overconfidence and uncertainty), are discussed. CONCLUSION: These new guidelines can be used by hospital staff and other researchers to cost their infection control programmes and interventions more accurately.

Bacterial colonization on writing pens touched by healthcare professionals and hospitalized patients with and without cleaning the pen with alcohol-based hand sanitizing agent.

This prospective study examined bacterial colonization on writing pens touched by healthcare professionals and hospitalized patients with and without cleaning the pen with alcohol-based hand sanitizing agent after each patient visit. A significant reduction in potential healthcare-associated pathogens, especially Gram-positive cocci, was observed in the intervention group.

Who bears the cost of healthcare-acquired surgical site infection?

The aim of this study was to estimate the economic costs of healthcare-acquired surgical site infection (HA-SSI) and show how they are distributed between the in-hospital and post-discharge phases of care and recovery. A quantitative model of the epidemiology and economic consequences of HA-SSI was used, with data collected from a prospective cohort of surgical patients and other relevant sources. A logical model structure was specified and data applied to model parameters. A hypothetical cohort of 10 000 surgical patients was evaluated. We found that 111 cases of infection would be diagnosed in hospital and 784 cases would first appear after discharge. Of the total costs incurred, either 31% or 67% occurred during the hospital phase, depending on whether production losses incurred after discharge were included. Most of the costs incurred by the hospital sector arose from lost bed-days and only a small proportion arose from variable costs. We discuss the issues relating to the size of these costs and provide data on where they are incurred. These results can be used to inform subsequent cost-effectiveness analyses that evaluate the efficiency of programmes to reduce the risks of HA-SSI.

Massive pneumatosis intestinalis: CT diagnosis.

Pneumatosis cystoides intestinalis is a rare condition characterized by multiple subserosal or submucosal gas filled cysts within the wall of a segment of bowel. It is associated with numerous conditions, both intra and extraabdominal in nature. The condition may be asymptomatic or may present clinically as nausea, vomiting, diarrhea or other signs of intestinal obstruction. With rupture of the cysts, pneumoperitoneum may be a finding. In a patient with vague clinical presentation, this finding radiographically may lead to a clinical dilemma as many of these patients have comorbid conditions which are also associated with intestinal perforation. The authors present the case of a 47-year-old obese black female found to have massive pneumatosis intestinalis of the tranverse colon with a small amount of free intraperitoneal air. This case highlights the importance of recognizing pneumatosis intestinalis as a possible mimic of free intraabdominal air as well as a possible cause of benign pneumoperitoneum.

CT diagnosis of acquired intercostal lung herniation.

Intercostal lung herniation is a rare complication of trauma, best demonstrated by computed tomography. Most intercostal lung herniations are the result of direct trauma to the chest wall or occur at sites of prior percutaneously placed chest tubes. We present two cases of acquired intercostal lung herniation.

Detection of hepatocellular carcinoma in cirrhotic patients: sensitivity of CT and ultrasonography.

Patients with cirrhosis are at increased risk for the development of hepatocellular carcinoma. The heterogeneous hepatic parenchyma produced by cirrhosis makes detection of hepatomas more difficult. The purpose of this study was to determine the sensitivities of CT and ultrasonography for detecting hepatomas in cirrhotic patients. A retrospective analysis was performed of 733 patients who underwent liver transplantation at our institution. A study population of 21 patients was selected who met our inclusion criteria. The inclusion criteria required a pathologic diagnosis of hepatocellular carcinoma, pathologic evidence of cirrhosis, and contrast-enhanced CT and sonographic examinations performed within 1 week of each other. The sensitivities of CT and ultrasonography were determined by comparing the imaging findings with pathology findings from serially sectioned total hepatectomy specimens. A total of 40 hepatomas were detected pathologically in the 21 patients in our study population. CT identified 12 of 21 patients with hepatomas and detected 18 of 40 individual lesions (patient detection sensitivity = 57%, lesion detection sensitivity = 45%). Ultrasonography identified 14 of 21 patients with hepatomas and detected 21 of 40 individual lesions (patient detection sensitivity = 67%, lesion detection sensitivity = 51%). Combining the findings of CT and ultrasonography allowed identification of 17 of 21 patients with hepatomas and detection of 24 of 40 individual lesions (patient detection sensitivity = 80%, lesion detection sensitivity = 60%). We conclude that CT and ultrasonography have a low sensitivity for the detection of hepatocellular carcinoma in patients with cirrhosis.

Cholesterol levels in normal Irish adults: the Mater Hospital Cholesterol Screening Survey.

Serum samples from 954 Irish adults (604 males, 350 females) aged 18 to 65 years were analyzed within 24 hours of receipt for non-fasting total serum cholesterol levels. The subjects were volunteer blood donors (Blood Transfusion Service Board, Pelican House, Dublin) presenting from June 1990 to February 1991. Serum cholesterol increased significantly with age in both males and females. Mean serum cholesterol in males increased from 4.5 (+/- 0.9) mmol/l in those < 25 years, to 5.7 (+/- 1.0) mmol/l at age 55-64 years. In females, mean serum cholesterol increased from 4.3 (+/- 0.9) mmol/l less than 25 years to 6.2 (+/- 0.8) mmol/l at age 55-64 years. Options for reporting cholesterol ranges are discussed. The overall mean cholesterol concentration of 5.1 mmol/l seen in this study is lower than that reported for comparable studies of U.K. and American subjects, but higher than observed in Japanese individuals. Almost 48% of the studied population had a serum cholesterol value less than 5 mmol/l and over 56% had levels less than 5.2 mmol/l.

Systemic venous enhancement patterns during dynamic abdominal CT.

In 25 patients we assessed the enhancement of abdominal venous structures during dynamic computed tomography (CT). The degree of venous enhancement demonstrated great variation. In six instances (out of 250 observations) a vessel was visually perceived as not enhancing and potentially thrombosed, including three gonadal veins. CT measurements were helpful in identifying enhancement, but were occasionally low enough that thrombosis remained a radiological consideration. The great variation in venous enhancement makes the diagnosis of thrombosis suspect, based on CT alone. Corroboration of this finding is suggested, when clinically relevant.

Junctional parenchyma: revised definition of hypertrophic column of Bertin.

The so-called hypertrophic column of Bertin is a normal variation and simply represents unresorbed polar parenchyma of one or both of the two subkidneys that fuse to form a normal kidney. It contains renal cortex, pyramids, and columns (septa) of Bertin. (Since all elements of the tissue are normal, that is, neither hypertrophic nor a displaced or embryonic rest, it is referred to as "junctional parenchyma.") When a masslike lesion is suspected at sonography or excretory urography, diagnosis of junctional parenchyma can be made with a high degree of certainty when sonography shows that the structure (a) is located between the overlapping portion of two renal sinus systems, (b) is bordered by a junctional parenchymal line and defect, (c) contains renal cortex, pyramids, and columns of Bertin, and (d) contains renal cortex that is continuous with the adjacent renal cortex of the same subkidney.

Seminoma of the testis presenting as an ulcerating mass of the duodenum.

Germ cell tumors (GCT) arising in the testes secondarily involve bowel in 5% of patients (1), and such involvement is usually via extension from adjacent metastatic lymphadenopathy. While this involvement often causes obstruction and gastrointestinal bleeding, radiologic identification of bowel ulceration has not been reported. We report an unusual case of small bowel invasion and ulceration, identified on CT examination, due to adenopathy resulting from testicular carcinoma.

Milk of calcium in renal cysts: new sonographic features.

Milk of calcium (MOC) in a small renal cyst or calyceal diverticulum is quite common. Ninety-one small renal cysts with MOC in 61 patients were found within a period of 4 years and 7 months. The main sonographic features are echogenic material layering in the dependent portion of a cyst, associated with reverberation echoes without shadowing. Shadowing was seen when MOC was present in larger amounts. Because MOC is usually asymptomatic and requires no treatment, differentiation from other lesions such as calculi or angiomyolipomas is important for proper patient management. MOC is detected more readily by ultrasonography than by radiography or CT.

CT manifestations of infectious mononucleosis.

A case of infectious mononucleosis (IM) which, on computed tomography (CT) scan, mimicked the morphologic features of lymphoma is reported. The CT findings in this case include generalized lymphadenopathy, splenomegaly, and focal low-attenuation splenic lesions in a fifty-three year old woman; these findings have not previously been described in patients with IM. This is most likely because IM is usually a clinical diagnosis confirmed by serologic testing. Imaging modalities such as CT scan have not routinely been utilized to support this diagnosis.

Primary endobronchial actinomycosis in association with foreign body aspiration.

A 66-year-old diabetic man presented with a bilobar pneumonia two months after aspiration of a chicken bone. Flexible fiberoptic bronchoscopy demonstrated a mass in the bronchus intermedius. Histologic examination of endobronchial biopsy specimens revealed bone fragments, vegetable matter, and sulfur granules containing Actinomyces organisms. The patient responded to bronchoscopic removal of the foreign body and penicillin therapy. To our knowledge, the association of actinomycotic infection with an aspirated endobronchial foreign body has not previously been reported.

Nonpalpable ductal carcinoma in situ versus infiltrating carcinoma of the breast--can they be differentiated by mammography?

The radiologic patterns of 193 consecutive women with nonpalpable breast carcinoma were evaluated. The results were correlated with patient age and with the histopathologic diagnosis. Of the 193 women in the study, 135 (70%) were older than 50 years; 102 women had ductal carcinoma in situ, and 67 (62%) of them were over age 50; the remaining 91 women had infiltrating carcinoma, and 73 (80%) of these patients were older than 50 years. Of the 58% of women who presented with microcalcifications, 75% had ductal carcinoma in situ and 25% infiltrating carcinoma. Of the 36% of patients who presented with a mass, 87% had infiltrating carcinoma and 90% were over age 50. Six percent presented with a mass with microcalcifications; 75% of these masses were found to be infiltrating carcinoma. Most of the masses were infiltrating carcinoma, and of these 90% were high-density masses. The small number of masses representing ductal carcinoma in situ were proportionately of low density.

Anatomic variations and abnormalities in the diaphragm seen with US.

The authors report their experience with diaphragmatic structures that simulate intrahepatic masses at abdominal ultrasonography (US). In a series of 74 patients, diaphragmatic slips were the most common finding (34 patients). The slips could be differentiated from masses by scanning along their long axis to demonstrate elongated structures with multiple linear echoes. Scalloping of the diaphragm, associated with multiple slips, was seen in 10 patients. Partial eventration was found in 23. Inversion of a hemidiaphragm, caused by a large pleural effusion or intrathoracic mass, was seen in 13 patients. Pleural masses affecting the diaphragm were seen in 13 patients; focal hypertrophy of a diaphragmatic crus simulated a mass in three. Real-time US allowed the differentiation of diaphragmatic abnormalities from lesions.