Implementing a Bundle to Improve Surgical Site Infection Rates for Patients Undergoing Nonvaginal-Approach Hysterectomy at a Midwestern Teaching Hospital.

Accrediting organizations, third-party payers, and patients review the surgical site infection (SSI) rates of health care organizations. Infection preventionists collaborate with perioperative personnel to decrease SSI rates; they also monitor and report SSI information to national organizations. The standard infection ratio is a comparison of the observed number of SSIs to the predicted number of SSIs based on national benchmark data. Leaders of a midwestern teaching hospital convened an interdisciplinary team (eg, surgeons, perioperative leaders, infection preventionists) to address a standard infection ratio after hysterectomies that was greater than 1.0. The team reviewed national guidelines and published articles on decreasing SSIs (including recommendations for vaginal preparation) before developing and implementing a hysterectomy-specific bundle for SSI prevention. The rate of SSIs decreased 68% after the implementation of the bundle. Perioperative personnel at this facility continue to use the bundle and infection preventionists monitor and report compliance with the bundle's elements.

Extensive postoperative ecchymosis in a patient taking dabigatran.

Herein we present the case of a 71-year-old woman who had a severe postoperative ecchymotic reaction. Our patient had a history of atrial fibrillation, for which she was given dabigatran etexilate mesylate as an anticoagulant. She discontinued her anticoagulant therapy 2 days before undergoing total laparoscopic hysterectomy with pelvic and periaortic lymph node sampling for uterine endometrioid adenocarcinoma. Despite an uneventful surgical procedure, she had widespread ecchymosis, edema, and anemia.

Postmenopausal bleeding due to a Cu-7 intrauterine device retained for thirty years.

BACKGROUND: A retained intrauterine device is a rare, but easily correctable, cause of postmenopausal bleeding (PMB). CASE: A 64-year-old woman presented to her gynecologist with PMB. Sonographic evaluation of the endometrium revealed the presence of a Cu-7 IUD retained for at least 30 years. Hysteroscopically assisted retrieval of the IUD resulted in complete resolution of symptoms. CONCLUSION: A retained IUD should be considered in the differential diagnosis for PMB. In addition, the authors recommend pelvic sonography as the first-line diagnostic modality for PMB to aid the diagnosis of retained IUD as well as other pathology.

Unilateral placement of the Adiana device after failed bilateral placement of the Essure device for hysteroscopic sterilization.

This case report outlines the successful completion of hysteroscopic sterilization using the Adiana Permanent Contraception device (Hologic, Inc., Bedford, MA) after failure of multiple attempts to bilaterally place the Essure Permanent Birth Control system (Conceptus Inc., Mountain View, CA). The patient desired hysteroscopic sterilization using the Essure system. Although the first coil was easily placed in the right ostium, the second coil could not be passed beyond 2.4 cm into the left ostium. Inasmuch as the Adiana system needs to be passed only 1.4 cm into the ostium, this was found to be adequate for appropriate placement of the implant. Adiana may be an effective alternative to Essure, especially in patients in whom tubal stricture or spasm prevents Essure placement.

3-hydroxy-3-methylglutaryl-coenzyme A reductase in the lobster mandibular organ: regulation by the eyestalk.

The mandibular organ (MO) of the lobster, Homarus americanus, produces the isoprenoid methyl farnesoate (MF), a compound related to insect juvenile hormone (JH). To better understand the synthesis and regulation of MF, we studied 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase (HMGR), the rate-limiting enzyme in isoprenoid biosynthesis. Lobster HMGR had a Km of 11.4 microM for HMG-CoA, a Km of 14.8 microM for NADPH, and was at least 2000-fold more selective for this cofactor than for NADH. Lovastatin and mevalonic acid inhibited HMGR, with KI values of 1.3 nM and 25.3 microM, respectively, whereas MF, farnesoic acid, cholesterol, 20-hydroxyecdysone, and progesterone had no effect. Approximately 75% of the HMGR activity in lobster MO was soluble. Similar levels of HMGR activity were observed in all regions of the MO. Eyestalk removal increased MF synthesis and the activity of farnesoic acid O-methyltransferase (FAOMeT, the final step in MF synthesis) in the MO by 10.7- and 5.7-fold, respectively, and caused a 3.1-fold increase of HMGR activity. Injection of the eyestalk ablated lobsters with an extract of two sinus glands (SG), a neuroendocrine organ in the eyestalk, decreased MF synthesis, FAOMeT activity and HMGR activity to 3, 8, and 20%, respectively, of the levels observed in saline-treated animals. The regulation of crustacean HMGR by the SG suggests that the lobster MO is a useful model system for investigating the cellular regulation of HMGR activity.