Ectopic Pregnancy in an Adolescent: A Case Report and Review of Literature.

Ectopic pregnancy continues to be the leading cause of death in the first trimester. Here, we report the case of a 17-year-old female who presented with vaginal bleeding and a positive serum beta-human chorionic gonadotropin level. In addition, we review the literature, focusing on the early diagnosis and management with the increasing preference for nonsurgical management of ectopic pregnancy, particularly in adolescents.

The efficacy of the use of presumptive antibiotics in tube thoracostomy in thoracic trauma-results of a meta-analysis.

INTRODUCTION: The purpose of this study was to determine the impact of presumptive antibiotics, used in chest traumas requiring thoracostomies, in preventing infections such as empyema and pneumonia. METHODS: According to PRISMA guidelines, a systematic search of PubMed, Embase and Cochrane Library databases was conducted by two independent reviewers. Studies evaluating the role of antibiotics were included. RESULTS: Antibiotic administration was associated with a lower incidence of overall infectious complications (OR:0.6, 95%CI: 0.43 to 0.84, p = 0.003). Subgroup analysis revealing that the best protective effect against empyema (OR:0.35, 95%CI to 0.65, p = 0.001). When stratified by trauma type, antibiotic use was protective in penetrating injuries, against empyema (OR:0.14, 95%CI: 0.04 to 0.47, p = 0.001) and pneumonia (OR:0.24, 95%CI:, 0.12 to 0.53, p = 0.001) while there was no protective effect in blunt trauma against empyema (OR:0.25 95%CI: 0.03 to 1.73, p = 0.16) or pneumonia (OR:1.22, 95%CI: 0.38 3.90, p = 0.72). CONCLUSION: Presumptive antibiotic use in thoracostomies has a clear role in preventing infectious complications in trauma patients. This role is primarily attributed to their protective effect on penetrating trauma patients.

Prognostic Factors of Mortality in Vibrio vulnificus Sepsis and Soft Tissue Infections: Meta-Analysis.

Background: Vibrio vulnificus is a rare but life-threatening infection that effects the population near warm coastal areas. This infection could be fulminant and rapidly progress to severe sepsis and necrotizing soft tissue infection. Early diagnosis and treatment are critical to saving patients' lives. With multiple studies reporting discrepancies in prognostic factors and different treatment protocols, we aimed through this meta-analysis to assess these factors and protocols and the impact on the outcome of the infection. Materials and Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of PubMed, Embase, and Cochrane Library databases by two independent reviewers was reported. Studies evaluating prognostic factors and treatment outcomes of Vibrio vulnificus infections were included. Comprehensive Meta-Analysis, version 3.0 was used. Results: Two hundred eleven studies were identified. Of those, eight studies met our inclusion criteria. The following factors on presentation were associated with higher mortality rates; concomitant liver disease (odds ratio [OR], 4.38; 95% confidence interval [CI], 2.43-7.87; p < 0.001), renal disease (OR, 3.90; 95% CI, 1.37-11.12; p = 0.011), septic shock (OR, 2.82; 95% CI, 1.84-4.31; p < 0.001), higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 3.40; 95% CI, 2.26-5.12; p < 0.001), elevated band cells count (OR, 2.61; 95% CI, 1.13-6.0; p = 0.024), hypoalbuminemia (OR, 3.41; 95% CI, 1.58-7.35; p = 0.002), and infection involving multiple limbs (OR, 4.36; 95% CI, 1.72-11.07; p = 0.002). Interestingly, different antibiotic regimens did not have any impact on outcomes, however, delayed surgical intervention after the first 12 or 24 hours was associated with higher mortality rates (OR, 2.64; 95% CI, 1.39-5.0; p = 0.003 and OR, 2.99; 95% CI, 1.54-5.78; p = 0.001, respectively). Conclusion: The presence of liver or renal disease, higher APACHE II scores, septic shock, hypoalbuminemia, or elevated band cell on presentation should alert the physician to the higher risk of mortality. Different antibiotic regimens did not impact the outcomes in these patients and delayed surgical intervention is associated with worsening of mortality.

Mortality Risk in Necrotizing Fasciitis: National Prevalence, Trend, and Burden.

Background: Necrotizing fasciitis (NF) is a fulminant, life-threating infection of fascia and subcutaneous tissue. Because of the low incidence, previous studies were statistically underpowered to assess factors associated with the risk of mortality. The aim of this study is to identify the risk factors associated with mortality in this select group of patients. Methods: A retrospective cross-sectional study was performed utilizing the Nationwide Readmissions Database, 2010-2014. The database captures 56.6% of all U.S. annual hospitalizations. Study population included inpatients admitted emergently with NF. Results: A total of 4,178 cases were included, of which 2,061(48.9%) patients had a history of diabetes mellitus (DM). The most common presentation was septicemia (39.5%) and 9.2% were admitted initially as cellulitis/abscess. Overall mortality risk was 12.6% with no substantial change in the annual trend. Mortality in patients with diabetes was substantially lower (8.5% vs. 16.5%, odds ratio [OR]: 0.44, 95% confidence interval [CI] = [0.34, 0.56], p < 0.001). Factors associated with a higher mortality risk included: older age, chronic liver diseases, disseminated intravascular coagulopathy, septic shock, pulmonary complications, acute renal failure, and not undergoing surgical intervention (p < 0.05 each). Patients who did not undergo surgical debridement were more likely to be ≥65 years of age and have multiple comorbidities. Hyperbaric oxygen therapy and intravenous immunoglobulin were used in 1.3% and 0.3% of the sample, respectively, with no reported use among patients who died. Conclusions: This study provides a new and updated perspective on the prevalence, trend, and outcomes of NF in the United States. Necrotizing fasciitis is associated with septicemia and lack of surgical intervention is associated with a higher mortality.

Current U.S. Pre-Operative Bowel Preparation Trends: A 2018 Survey of the American Society of Colon and Rectal Surgeons Members.

Background: The effect of an oral antibiotic preparation prior to colorectal surgery was first examined and exalted in the 1973 paper by Nichols et al. Since this commencement, enthusiasm for the oral antibiotic regimen has waxed and waned reflecting the literature focused on this topic over the past 40 years. Polling colorectal surgeons of define current practices has been performed at intervals throughout the years and has demonstrated a trend to decline in the practice. The most recent publication surveying U.S. practices was in 2010, which reported a minority, 36%, use of oral antibiotics prior to elective colorectal surgery; a marked downtrend from the 88% use described in 1990. Since this last survey, the colorectal surgery community has performed considerable research examining the benefit of oral antibiotic and mechanical bowel preparation. This manuscript evaluates the current use of oral antibiotics in colorectal surgery in the U.S. and how practice trends have developed in response to current recommendations in the literature. Methods: An electronic survey was created and distributed to U.S. colorectal surgeons to evaluate current opinions and practice trends. A total of 359 American Society of Colon and Rectal Surgeons members responded. A review of the recent literature pertaining to pre-operative bowel practices and outcomes was performed to compare with current practices. Results: A significant majority (83.2%) of respondents use pre-operative oral antibiotics routinely, and 98.6% routinely use mechanical bowel preparation. The use of a combination of parenteral antibiotics, oral antibiotics, and mechanical bowel preparation is reported by 79.3%. The most commonly employed oral antibiotic regimen is neomycin and metronidazole. The most common mechanical bowel preparation is polyethylene glycol (PEG). The most common parenteral antibiotics are cefazolin and metronidazole. There was no statistically significant difference in this practice by geographic region, Board-certified status, or practice setting. Conclusion: The majority of colorectal surgeons employ a combination of oral antibiotics, mechanical bowel preparation, and parenteral antibiotics prior to colorectal surgery. This is consistent across geographic regions, despite Board certification status or practice setting, and is reflective of the recommendations based on recent literature.

Post-Operative Infections: Trends in Distribution, Risk Factors, and Clinical and Economic Burdens.

BACKGROUND: Post-operative infection (POI) is a serious complication in all surgical disciplines and can derail a patient's treatment and recovery course. In this analysis, we examine national trends, risk factors, and costs associated with POI. METHODS: Using the Nationwide Inpatient Sample (NIS) for the years available for data analysis at the time of this study (2003-2010), we performed a cross-sectional study of adult (≥18 years) inpatients with POI and designated Clinical Classification Software (CCS) procedural class codes for the operations performed. A comparison group was selected randomly from patients with the same CCS codes who underwent the same procedures but did not experience POI. As the NIS represents 20% of U.S. hospital admissions, excess cost and stay were calculated on the basis of the average difference between cost and duration of stay for POI cases and the cost and duration of stay for the comparison group, then extrapolated to estimate the national burden for the remaining 80% of stays nationwide. RESULTS: Sample admissions included 139,652 cases of POI and 941,670 comparison subjects. The POIs were most common in procedures involving the digestive tract (46.5%), cardiovascular system (16.3%), or musculoskeletal system (11.2%). Older age, male gender, high Charlson Comorbidity Index Score (CCIS), and teaching, urban, or large hospitals were independent risk factors for POI in the multivariable model (p < 0.05). A POI was associated with a higher risk of death (odds ratio 2.93; 95% confidence interval 2.82-3.04, p < 0.001). Nationally, we estimate that POI resulted in an annual average of 1.04 million days of excess hospital stay and $2.72 billion excess cost. CONCLUSIONS: Identification of independent risk factors suggests areas for quality improvement initiatives. Post-operative infection carries substantial clinical and financial burdens in the United States, and further analysis of the associated costs is needed to identify areas for intervention to reduce this burden.

Defending the scientific foundations of the firearms and tool mark identification discipline: responding to recent challenges.

Recent challenges have brought the discipline of firearms and tool mark identification to the forefront in recent court cases. This article reviews those challenges and offers substantial support for the scientific foundations of the firearms and tool mark identification discipline. A careful review of the available literature has revealed that firearms and tool mark identification is rooted in firm scientific foundations, critically studied according to the precepts of the scientific method culminating in the Association of Firearms and Toolmark Examiners' Theory of Identification. Firearms and tool mark identification has been validated in a manner appropriate for evidence of the kind to be expected in firearms and tool mark examinations. Proficiency tests and error rates have been studied and can provide consumers of the disciple with a useful guide as to the frequency with which misidentifications are reported in the community using appropriate methodologies and controls. As a result, the primary issues in recent challenges do not invalidate the firearms and tool mark discipline as a science nor should it detract it from its admissibility in a court of law.

Interleukin-33-induced expression of PIBF1 by decidual B cells protects against preterm labor.

Preterm birth (PTB) is a leading cause of neonatal death worldwide. Intrauterine and systemic infection and inflammation cause 30-40% of spontaneous preterm labor (PTL), which precedes PTB. Although antibody production is a major immune defense mechanism against infection, and B cell dysfunction has been implicated in pregnancy complications associated with PTL, the functions of B cells in pregnancy are not well known. We found that choriodecidua of women undergoing spontaneous PTL harbored functionally altered B cell populations. B cell-deficient mice were markedly more susceptible than wild-type (WT) mice to PTL after inflammation, but B cells conferred interleukin (IL)-10-independent protection against PTL. B cell deficiency in mice resulted in a lower uterine level of active progesterone-induced blocking factor 1 (PIBF1), and therapeutic administration of PIBF1 mitigated PTL and uterine inflammation in B cell-deficient mice. B cells are a significant producer of PIBF1 in human choriodecidua and mouse uterus in late gestation. PIBF1 expression by B cells is induced by the mucosal alarmin IL-33 (ref. 9). Human PTL was associated with diminished expression of the α-chain of IL-33 receptor on choriodecidual B cells and a lower level of active PIBF1 in late gestation choriodecidua. These results define a vital regulatory cascade involving IL-33, decidual B cells and PIBF1 in safeguarding term pregnancy and suggest new therapeutic approaches based on IL-33 and PIBF1 to prevent human PTL.

Pre-Operative Antisepsis Protocol Compliance and the Effect on Bacterial Load Reduction.

BACKGROUND: Adequate skin preparation is essential to preventing surgical site infection. Many products are available, each with specific manufacturers' directions. This lack of standardization may lead to incorrect use of the agents and affect the bacterial load reduction. We hypothesize that a lack of adherence to utilization protocols for surgical skin antiseptics affects bacterial load reduction. METHODS: Thirty subjects who routinely perform surgical skin preparation were recruited from four hospitals. Participants completed a questionnaire of both demographics and familiarity with two of the most common skin prep formulas: Chlorhexidine gluconate-isopropyl alcohol (CHG-IPA) and povidone-iodine (PVI) scrub and paint. Randomly selecting one formula, subjects performed skin preparation for ankle surgery on a healthy standardized patient. This was repeated using the second formula on the opposite ankle. Performance was recorded and reviewed by two independent evaluators using standardized dichotomous checklists created against the manufacturer's recommended application. Swabs of the patients' first interweb space and medial malleolus were obtained before, 1 min after, and 30 min after prep, and plated on Luria Bertani agar. Bacterial loads were measured in colony forming units (CFUs) for each anatomical site. Data was analyzed using a univariate linear regression. RESULTS: Subjects had an average of 12.7 ± 2.2 y operating room experience and 8.8 ± 1.5 y of skin prep experience. Despite this, no participant performed 100% of the manufacturers' steps correctly. All essential formula-specific steps were performed 90% of the time for CHG-IPA and 33.3% for PVI (p = 0.0001). No correlation was found between experience or familiarity and number of correct steps for either formula. Average reduction in CFUs was not different between CHG-IPA and PVI at 30 min for all anatomical sites (75.2 ± 5.4% vs. 73.7 ± 4.5%, p = 0.7662). Bacterial reductions at 30 min following skin prep were not substantially correlated with operator experience, protocol compliance, or total prep time for either formula. CONCLUSION: This study demonstrates existing problems with infection prevention as those tasked with pre-operative skin preparation do so with tremendous incongruence according to manufacturer guidelines. No effect on bacterial load was identified, however with a larger sample size this may be noted. Standardization of the prep solutions as well as simplification and education of the correct techniques may enhance protocol compliance.

Infected physicians and invasive procedures: safe practice management.

There is currently no public policy that provides guidance concerning whether and when physicians infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or human immunodeficiency virus (HIV) can safely perform invasive procedures. A committee of experts in the fields of medicine, law, and biomedical ethics and 1 community member, aided by an advisory board, was established to produce recommendations for policy reform. An extensive literature review was conducted for these 3 infectious diseases, medicine, surgery, epidemiology, law, and bioethics to gather all relevant data. Special recommendations are made regarding the management of physicians who are infected with HIV, HBV, and/or HCV. This policy proposal includes a list of exposure-prone procedures and a decision chart that indicates under what conditions infected physicians can practice beyond the need for disclosure of their serological status.

Antibiotic prophylaxis in surgery--2005 and beyond.

TARGET AUDIENCE: Surgeons, pharmacists, and other physicians who prescribe prophylactic antibiotics. LEARNING OBJECTIVES: After reading this article, the reader should be able to: Outline the attributes of antibiotics that are suitable for prophylaxis; review the activity and safety profiles of commonly-prescribed prophylactic antibiotics; and discuss the importance of proper administration as well as proper choice of an agent to minimize the risk of infection. CME ACCREDITATION: The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide Continuing Medical Education (CME) for physicians. NFID takes responsibility for the content, quality, and scientific integrity of this CME activity. NFID designates this CME activity for a maximum of one (1.0) category 1 credit toward the AMA Physician's Recognition Award. Physicians should only claim those hours of credit that he/she actually spent in the educational activity. SUPPORT: This CME ctivity has been made possible by an unrestricted educational grant from Cubist Pharmcaeuticals, Inc. DISCLOSURE: Dr. Barie serves as a consultant for Cubist Pharmaceuticals, Inc. Dr. Nichols serves on the surgery advisory board for Cubist Pharmaceuticals, Inc. Dr. Condon has no financial relationship to disclose. CME INSTRUCTIONS: To receive CME credits after reading the entire publication, please go to the following website to complete the self-assessment examination and evaluation. Requests for credit must be received no later than six months following the publication date.

Efficacy of double gloving with an intrinsic indicator system.

BACKGROUND: Blood-borne infection is an ever-present fear for medical professionals, especially surgeons and operating room personnel. Safety is paramount, and the reliability and efficacy of surgical gloves are crucial, as gloves are the most important barriers protecting hospital personnel and patients. Unfortunately, glove perforation rates are as high as 78% in high-risk procedures. As well as being efficacious, surgical gloves must be comfortable and easy to don, and when holes are present, it is imperative they be detected expeditiously. The purpose of this double-blind randomized study was to evaluate the ability of participants to locate 30-micron laser holes in surgical gloves while performing simulated surgery and to evaluate the Biogel Indicator Glove System, which reveals punctures. METHODS: Twenty glove configurations (eight single, twelve double) were tested, half of which had laser-created holes. Each of the 25 participants tested and evaluated 20 configurations randomly. Simulated surgery terminated when a hole was identified by the participant or at the end of two minutes, whichever occurred first. Participants also rated their perceptions of each glove's features on questionnaires, all of which were returned, with 95.8% being complete. RESULTS: Participants found 84% and 56% of the holes in the two indicator systems, latex and synthetic, in an average of 22 seconds and 42 seconds, respectively. In the worst-performing latex and synthetic glove configurations, participants found only 8% and 12% of the holes at an average of 47 seconds and 67 seconds, respectively. Indicator gloves were highly rated for comfort and ease of use. CONCLUSIONS: Double gloving with an indicator system provides the best protection and allows the timeliest identification of perforations. Participants failed to identify most of the holes in the non-indicator gloves.

Ertapenem once daily versus piperacillin-tazobactam 4 times per day for treatment of complicated skin and skin-structure infections in adults: results of a prospective, randomized, double-blind multicenter study.

We conducted a prospective, randomized, double-blind trial comparing ertapenem (1 g once daily) with piperacillin-tazobactam (3.375 g every 6 h) as parenteral treatment for 540 adults with complicated skin and skin-structure infections. The most common diagnoses were skin or soft-tissue abscesses and lower-extremity infections associated with diabetes. The mean duration (+/- standard deviation) of therapy was 9.1+/-3.1 days for ertapenem and 9.8+/-3.3 days for piperacillin-tazobactam. At the assessment of primary efficacy end point, 10-21 days after treatment, 82.4% of those who received ertapenem and 84.4% of those who received piperacillin-tazobactam were cured. The difference in response rates, adjusting for the patients' assigned strata, was -2.0% (95% confidence interval, -10.2% to 6.2%), indicating that the response rates in the 2 treatment groups were equivalent. Cure rates for the 2 treatment groups were similar when compared by stratum, diagnosis, and severity of infection. The frequency and severity of drug-related adverse events were similar in the treatment groups.

Once-daily, high-dose levofloxacin versus ticarcillin-clavulanate alone or followed by amoxicillin-clavulanate for complicated skin and skin-structure infections: a randomized, open-label trial.

This study tested whether levofloxacin, at a new high dose of 750 mg, was effective for the treatment of complicated skin and skin-structure infections (SSSIs). Patients with complicated SSSIs (n=399) were randomly assigned in a ratio of 1:1 to 2 treatment arms: levofloxacin (750 mg given once per day intravenously [iv], orally, or iv/orally) or ticarcillin-clavulanate (TC; 3.1 g given iv every 4-6 hours) followed, at the investigator's discretion, by amoxicillin-clavulanate (AC; 875 mg given orally every 12 hours). In the clinically evaluable population, therapeutic equivalence was demonstrated between the levofloxacin and TC/AC regimens (success rates of 84.1% and 80.3%, respectively). In the microbiologically evaluable population, the overall rate of eradication was 83.7% in the levofloxacin treatment group and 71.4% in the TC/AC treatment group (95% confidence interval, -24.3 to -0.2). Both levofloxacin and TC/AC were well tolerated. These data demonstrate that levofloxacin (750 mg once per day) is safe and at least as effective as TC/AC for complicated SSSIs.

Firearm and toolmark identification criteria: a review of the literature, part II.

An update to a previously published review of articles pertaining to firearm and toolmark identification criteria is presented. In this update, 22 additional articles were reviewed, including works of a general nature, studies critically assessing the theory of consecutive matching striations, empirical studies involving various firearm components, toolmark studies, as well as articles discussing the utility of statistics in the firearms and toolmark identification discipline. These articles have been reviewed in a format to permit others to learn what has been published in the field in an effort to educate interested parties. Further, a discussion of the importance of articulation and communication within the discipline is presented.

Clinical update on the use of moxifloxacin in the treatment of community-acquired complicated intraabdominal infections.

BACKGROUND: Community-acquired complicated intraabdominal infections (cIAIs) present problems for clinicians and have substantial impact on hospital resources. Because of the polymicrobial nature of these infections, successful management of cIAIs depends on timely and appropriate use of antisepsis and antiinfective strategies. METHODS: The literature pertinent to this article was reviewed. RESULTS: The Surgical Infection Society and the Infectious Disease Society of America guidelines recommend a variety of single and combined antimicrobial therapies, including fluoroquinolone therapy, for prophylactic and definitive treatment of cIAIs with different severities. Moxifloxacin, a fluoroquinolone, demonstrates a broad spectrum of antimicrobial (including anaerobic) activity, good tissue penetration into the gastrointestinal tract, and a good tolerability profile. Clinical data also have demonstrated that moxifloxacin is effective as monotherapy for patients with cIAIs. This review identifies the clinical issues impacting antimicrobial selection in cIAI and discusses data on the role of moxifloxacin in light of the current guidelines for management of these patients. CONCLUSION: Moxifloxacin provides clinicians with a convenient monotherapy option for the treatment of mild-to-moderate cIAIs.

Mechanical and antibacterial bowel preparation in colon and rectal surgery.

Colorectal surgery performed prior to 1970 was fraught with postoperative infectious complications which occurred in more than 30-50% of all operations. Diversion of the fecal stream appeared mandatory when operating on an urgent or emergent basis, thereby requiring the performance of multiple, staged operations instead of a single surgery encompassing resection and primary anastomosis as is performed commonly today. Multiple studies conducted in the early 1970s determined that anaerobic colonic microflora were causative agents in postoperative infections in colon and rectal surgery, and these studies initiated the development of effective oral preoperative antibiotic prophylaxis in combination with preoperative mechanical bowel preparation. This dual-tier regimen significantly reduced the incidence of postoperative infectious complications, thus allowing most uncomplicated colon and rectal surgeries to be performed in a single stage without the need for the diversion of the fecal stream and multiple operations. Therefore, a preoperative mechanical and antibacterial bowel regimen serves as the cornerstone of modern elective colorectal surgery, and these regimens now comprise three therapeutic directives. The first step is preoperative mechanical cleansing of the bowel, which is then followed by preoperative oral antibiotic prophylaxis. Finally, perioperative parenteral antibiotics directed against aerobic and anaerobic colonic microflora are utilized.

Current Strategies for Prevention of Surgical Site Infections.

Surgical site infections (SSIs) are a common complication that follows all types of operative procedures. These infections are usually caused by the exogenous and endogenous microorganisms that enter the operative wound during the course of surgery. The general and procedure-specific risk factors for the development of SSI have been identified and are discussed in this article. Factors that influence the SSI rate and the current strategies for prevention of SSIs are also presented. Emphasis is placed on the efficacious use of antibiotic prophylaxis in surgery. A discussion of the principles of antibiotic prophylaxis, including choice of agents, route of administration, and timing, is offered. It appears that the use of less invasive laparoscopic surgical approaches, as practiced widely today, will be associated with an overall decreased incidence of SSI.