Vaginal Packing After Pelvic Floor Reconstructive Surgery: Does the Soaking Agent Used for Packing (Bupivacaine, Estrogen or Saline) Impact Postoperative Pain Scores?

STUDY OBJECTIVE: Vaginal packing is traditionally placed after pelvic floor reconstructive surgery (PFRS) to prevent hematoma formation. We seek to determine if there is a difference in postoperative pain scores after PFRS if vaginal packing is soaked with estrogen cream, bupivacaine, or saline. The primary outcome was pain as measured by a visual analog scale at 2 hours, 6 hours, and 1 day postoperatively. Secondary outcomes include changes in hemoglobin, urinary retention and length of stay (LOS) in hospital. DESIGN: Prospective cohort study. SETTING: Tertiary care academic teaching hospital. All PFRS is performed by fellowship-trained urogynecologists. PARTICIPANTS: Consenting patients undergoing PFRS. INTERVENTIONS: At the completion of surgery, gauze packing soaked with either estrogen cream, 0.25% bupivacaine with 1% epinephrine, or normal saline was placed inside the vagina and removed on postoperative day 1. MEASUREMENTS AND MAIN RESULTS: We included 210 patients (74 estrogen, 66 bupivacaine, 70 saline). There was no significant difference in mean postoperative pain scores between the groups (estrogen, bupivacaine, saline-soaked vaginal packs respectively) at 2 hours (2.66 ± 2.25, 2.30 ± 2.17, 2.24 ± 2.07; p = .4656), 6 hours (2.99 ± 2.38, 2.52 ± 2.30, 2.36 ± 2.01; p = .2181) or on postoperative day 1 (1.89 ± 2.01 vs 2.08 ± 2.15 vs 2.44 ± 2.19; p = .2832) as measured by visual analog scale scores (0-10). There was no difference in the secondary outcomes of change in pre/postoperative hemoglobin (21.8 ± 10.73g/L, 20.09 ± 11.55 g/L, 21.7 ± 9.62g/L, p = .68), urinary retention (37%, 45% and 48%, p = .45), LOS (1.05 ± 0.46 days, 1.02 ± 0.12, 1.03 ± 0.24, p = .97) or in-hospital opioid usage during admission (represented in morphine milligram equivalents [median (IQR1, IQR3)], Kruskal-Wallis test): 11.25 mg (0, 33), 7.5 mg (0, 22.5) and 15 mg (0, 33.88) p = .41. CONCLUSION: There was no difference found between soaking vaginal packing with estrogen cream, bupivacaine, or saline after PFRS with respect to postoperative pain scores, LOS, in-hospital opioid usage, or urinary retention. Saline-soaked packing is an equivalent alternative to estrogen or bupivacaine vaginal packing.

An optimized, synthetic DNA vaccine encoding the toxin A and toxin B receptor binding domains of Clostridium difficile induces protective antibody responses in vivo.

Clostridium difficile-associated disease (CDAD) constitutes a large majority of nosocomial diarrhea cases in industrialized nations and is mediated by the effects of two secreted toxins, toxin A (TcdA) and toxin B (TcdB). Patients who develop strong antitoxin antibody responses can clear C. difficile infection and remain disease free. Key toxin-neutralizing epitopes have been found within the carboxy-terminal receptor binding domains (RBDs) of TcdA and TcdB, which has generated interest in developing the RBD as a viable vaccine target. While numerous platforms have been studied, very little data describes the potential of DNA vaccination against CDAD. Therefore, we created highly optimized plasmids encoding the RBDs from TcdA and TcdB in which any putative N-linked glycosylation sites were altered. Mice and nonhuman primates were immunized intramuscularly, followed by in vivo electroporation, and in these animal models, vaccination induced significant levels of both anti-RBD antibodies (blood and stool) and RBD-specific antibody-secreting cells. Further characterization revealed that sera from immunized mice and nonhuman primates could detect RBD protein from transfected cells, as well as neutralize purified toxins in an in vitro cytotoxicity assay. Mice that were immunized with plasmids or given nonhuman-primate sera were protected from a lethal challenge with purified TcdA and/or TcdB. Moreover, immunized mice were significantly protected when challenged with C. difficile spores from homologous (VPI 10463) and heterologous, epidemic (UK1) strains. These data demonstrate the robust immunogenicity and efficacy of a TcdA/B RBD-based DNA vaccine in preclinical models of acute toxin-associated and intragastric, spore-induced colonic disease.

Establishing a Long-Term Model for Analysis and Improvement of Underfilled Blood Culture Volumes.

Objectives: Underfilling of blood culture bottles decreases the sensitivity of the culture. We attempt to increase average blood culture fill volumes (ABCFVs) through an educational program. Methods: Partnerships were established with four hospital units (surgical intensive care unit [SICU], medical intensive care unit [MICU], medical intermediate care unit [MIMCU], and hematology and oncology unit [HEME/ONC]). ABCFVs were continuously tracked and communicated to each unit monthly. Educational sessions were provided to each unit. Results: ABCFVs for the SICU, MICU, MIMCU, and HEME/ONC were 4.8, 5.0, 5.0, and 6.3 mL/bottle, respectively. After the final education session, the SICU, MICU, MIMCU, and HEME/ONC were able to maintain an ABCFV of 6.8, 8.1, 7.9, and 8.2 mL/bottle, respectively. Conclusions: Partnering with a specific unit and providing monthly volume reports with educational sessions has a direct positive correlation on increasing ABCFVs. Increasing ABCFVs has the potential to decrease false-negative blood cultures, time to detection of positive blood cultures, and time to appropriate and specific antimicrobial therapy, as well as improve patient outcomes in high-acuity patient care units.

A novel endoscopic treatment for ureteric remnant hemorrhage post laparoscopic radical nephrectomy.

Laparoscopic radical nephrectomy is commonly used to treat renal masses. Given the ubiquitous presence of this technique, rare complications are becoming more commonplace. It is thus essential that practicing urologists be aware of all possible complications as well as the novel management approaches that exist. This report presents a situation in which a patient developed rapid-onset, postoperative gross hematuria. This complication is rare and multiple sources of bleeding must be considered. In the situation reported here, the ureteric remnant was the cause of the unremitting gross hematuria. While others have described surgical exploration as the primary treatment, the authors were successful in using a minimally invasive endoscopic approach with fulguration and instillation of a fibrin sealant. Indeed, they propose that the endoscopic approach described herein may be considered first line in cases of unremitting gross hematuria originating from the ureteric remnant.

"Hyper-warburgism," a cause of asymptomatic hypoglycemia with lactic acidosis in a patient with non-Hodgkin's lymphoma.

CONTEXT: In cancer cells, the Warburg effect is defined as the avid consumption of glucose through the glycolytic pathway with concomitant lactate production, even under aerobic conditions. CASE: We report a 64-yr-old woman who was referred to our institution for pancytopenia and hypoglycemia. Physical examination demonstrated hepatosplenomegaly and petechiae. She had no clinical manifestation of neuroglycopenia, despite serum glucose of 26 mg/dl (1.4 mmol/liter) and serum lactate of 28.5 mmol/liter (normal range, 0.5-3.4 mmol/liter). Bone marrow biopsy demonstrated diffuse large B-cell lymphoma. Staging (18)F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography showed increased FDG avidity in an enlarged spleen and absent FDG uptake in the brain. Despite dextrose infusions up to 30 g/h, there was no increase in serum glucose, but there was a paradoxical increase in serum lactate. Immunochemotherapy improved the hematological and metabolic abnormalities. Follow-up FDG-positron emission tomography/computed tomography showed a decrease in splenic avidity and an increase in brain FDG avidity. The patient refused further chemotherapy and died 1 wk after discharge. METHODS: Literature review of cases of lymphoma with lactic acidosis, with and without hypoglycemia, demonstrated that these combinations occurred in multiple categories of B- and T-cell lymphoma. There was no difference in the mortality rate in those with (75%) or without (74%) concomitant hypoglycemia. CONCLUSION: This case represents an exaggerated Warburg effect, or "hyper-warburgism," characterized by excessive lactate production and overwhelming glucose consumption. We speculate that the decreased brain FDG uptake, despite the lack of neuroglycopenic symptoms, supports the hypothesis that lactate served as a fuel for the brain, thus protecting against hypoglycemia.