The glitz and glamour randomized trial: the effect of fingernail polish on post-caesarean surgical site infection.

Current surgical scrub guidelines suggest that fingernail polish should not be worn by healthcare providers despite collective evidence not demonstrating a relationship between fingernail polish and surgical-site infection (SSI). The purpose of this study was to determine the effect of surgical staff wearing nail polish on the incidence of SSI after caesarean delivery. In this calendar block-randomised clinical trial, surgical staff were assigned to wear nail polish or to have unpainted nails for alternating two-week periods. The primary outcome was surgical site infection within 6 weeks of caesarean delivery. There were 372 patients in the nail polish arm and 465 in the polish-free arm. The rate of SSIs was not significantly different between the nail polish arm and the polish-free arm (1.3% vs 2.8% p = .155). We found the rate of SSI following caesarean delivery is not significantly affected by surgical staff wearing fingernail polish.Impact StatementWhat is already known on this subject? Current surgical scrub guidelines state that fingernail polish should not be worn by healthcare providers even though the collective evidence has not been able to show the relationship between fingernail polish and surgical site infection. Previous studies have only used bacterial colony count after handwashing as a primary endpoint. The evidence they provide for developing scrub guidelines have been contradictory and inconclusive.What do the results of this study add? To better inform surgical scrub guidelines, evidence is needed that evaluates the effect of fingernail polish on clinically significant endpoints. Our study, Glitz & Glamour, examined 885 non-emergent Caesarian sections using a calendar-block schedule to determine if wearing nail polish had an impact on rates of surgical site infection.What are the implications of these findings for clinical practice and/or further research? Results suggested that fingernail polish had no difference on frequency of surgical site infections, and neither condition of the polish (chipped vs. freshly applied) nor the type of polish (gel vs. regular) had any impact either.

Fetal and maternal inflammatory response in the setting of maternal intrapartum fever with and without clinical and histologic chorioamnionitis.

BACKGROUND: Both infectious and noninfectious causes of maternal fever have been linked to adverse neonatal outcomes including low Apg0ar scores, respiratory distress, hypotonia, and neonatal seizures. Even in the absence of infection, the occurrence of intrapartum fever is a strong risk factor for poor long-term neonatal developmental outcomes, including encephalopathy, cerebral palsy, and neonatal death. OBJECTIVE: The primary objective of this study was to compare intrapartum and postpartum maternal and fetal umbilical cord serum levels of cytokines RANTES, interferon-É£, interleukin-1ß, interleukin-2, interleukin-4, interleukin-6, interleukin-8, interleukin-10, interleukin-13, and tumor necrosis factor-α among nonfebrile patients, febrile patients without clinical chorioamnionitis, and febrile patient with clinical chorioamnionitis. STUDY DESIGN: This study was conducted at the Richmond University Medical Center from May 15, 2020 to July 16, 2019. During this time, we recruited 30 nonfebrile patients at >36 gestational weeks who were in labor and collected umbilical cord and pre- and postdelivery maternal serum samples to evaluate the cytokine levels. Placentas were collected for pathologic review and to evaluate the histopathologic findings. These results were compared with 121 patients who developed a fever of >38°C during labor. The febrile patients were further divided based on the presence or absence of clinical chorioamnionitis. A secondary analysis was performed based on the presence of absence of histologic chorioamnionitis. Statistical analysis was performed using IBM Statistical Package for the Social Sciences version 25.0. For the 3 group comparisons, a P value of <.017 was considered statistically significant after application of a Bonferroni correction. RESULTS: A total of 151 patients were included in the study; 30 were nonfebrile patients, 46 were febrile patients with a diagnosis of clinical chorioamnionitis, and 75 were febrile patients without clinical chorioamnionitis. Compared with nonfebrile patients, umbilical cord serum interferon-É£, interleukin-1ß, interleukin-6, interleukin-8, RANTES, and tumor necrosis factor-α levels were elevated in the presence of maternal hyperthermia irrespective of the diagnosis of clinical chorioamnionitis. Interleukin-6 umbilical cord levels were more than doubled from 63.60 pg/mL (6.09-1769.03 pg/mL) in febrile patients with no clinical chorioamnionitis to 135.77 pg/mL (1.86-6004.78 pg/mL) in febrile patients with clinical chorioamnionitis, making it the only cytokine that was significantly different between these 2 groups. When comparing the intrapartum maternal serum, we found a significant elevation in the interleukin-10, RANTES, and tumor necrosis factor-α levels in the febrile group irrespective of the presence of clinical chorioamnionitis when compared with the nonfebrile group. In the postpartum maternal blood evaluations, tumor necrosis factor-α was the only cytokine that was significantly higher in febrile patients than in nonfebrile controls. CONCLUSION: In the setting of intrapartum fever, maternal cytokine profiles were similar irrespective of the diagnosis of clinical chorioamnionitis. Even in the absence of clinical or histologic chorioamnionitis, maternal hyperthermia induced elevations in fetal cytokines.

Predictive risk factors of adverse perinatal outcomes following blunt abdominal trauma in pregnancy.

BACKGROUND: The primary objective was to identify predictive risk factors of preterm delivery following blunt abdominal trauma. The secondary objective was to identify risk factors of other adverse outcomes, Neonatal Intensive Care Unit (NICU) admission, placental abruption, fetal demise, and Cesarean Delivery (CD). METHODS: This retrospective study included pregnant patients with gestational age (GA) ≥23 weeks who presented after blunt abdominal trauma to Richmond University Medical Center from October 2015 to January 2020. Patients were identified using the following diagnostic International diagnostic classification (ICD-10) codes: O9A.212, O9A.213, and 071.89, and excluded if trauma did not involve the abdomen, penetrating, <23 weeks, or incomplete records. Collected data points included maternal demographic factors, clinical laboratory values, maternal clinical findings at presentation, abdominal ultrasound, results of fetal monitoring, Abbreviated Injury Score (AIS) for abdomen, and Injury Severity Score (ISS). Univariate analyses were compared using the Student's t-test or Mann-Whitney U-test. Categorical data were compared using the chi-squared test or Fisher's exact test with P-value < .05 as significant. RESULTS: 154 patients were included in the final analysis. The incidence of the primary outcome, preterm delivery before 37 weeks, was 11.0% (17/154). The incidence of secondary outcomes following blunt abdominal trauma were abruption 0% (0/154), fetal demise 0.6% (1/154), CD 44% (68/154), NICU admission 24% (37/154). Maternal demographic factors, presence of uterine contractions, maternal clinical conditions (abdominal pain, abdominal tenderness, vaginal bleeding), hematologic and coagulation studies, ultrasound findings, fetal heart rate tracing category, AIS score for abdomen, and ISS score were not predictive of preterm delivery or other secondary outcomes. CONCLUSION: The incidence of adverse maternal and neonatal outcomes is low following blunt abdominal trauma. Extended monitoring of asymptomatic patients including laboratory tests and coagulation profiles were not predictive of preterm labor or secondary adverse perinatal outcomes. LEVEL OF EVIDENCE: Therapeutic/Care management, Level III.

Randomized control trial of intravenous acetaminophen for reduction of intrapartum maternal fever.

BACKGROUND: Intravenous acetaminophen reaches a higher mean peak plasma concentration than oral acetaminophen in a shorter period of time. The favorable pharmacokinetics of intravenous acetaminophen may be beneficial for treating intrapartum maternal fever. OBJECTIVE: The primary objective was to compare intravenous and oral acetaminophen in time to defervescence (temperature <38°C). The secondary objective was to compare intravenous and oral acetaminophen in the percentage of participants being afebrile and percent reduction in maternal temperature 30 minutes after administration of first dose. Other outcomes evaluated were histopathological placental findings; neonatal outcomes; oxidative stress; and levels of RANTES, interferon-δ, interleukin 1ß, interleukin 2, interleukin 4, interleukin 6, interleukin 8, interleukin 10, interleukin 13, and tumor necrosis factor-α in maternal and neonatal blood. STUDY DESIGN: This was a randomized, comparator-controlled, double-dummy, double-blind clinical trial. At the onset of intrapartum fever ≥38°C, patients ≥36 weeks' gestation were either randomized to the control or experimental study arm. Patients in the control arm received 1000 mg of oral acetaminophen capsules and an intravenous placebo resembling intravenous acetaminophen. Patients randomized to the experimental arm received 1000 mg of intravenous acetaminophen and oral placebo capsules resembling acetaminophen. Maternal temperatures and fetal heart rates were recorded at consecutive intervals following administration of the first dose of acetaminophen. Maternal blood, collected at the onset of fever and after delivery, and neonatal cord blood collected at delivery were evaluated for oxidative stress (glutathione levels), levels of RANTES and cytokines (interferon-δ, interleukin 1ß, interleukin 2, interleukin 4, interleukin 6, interleukin 8, interleukin 10, interleukin 13, and tumor necrosis factor-α). Placentas were collected for pathologic review. A P value of <.05 was considered statically significant. RESULTS: A total of 121 patients (55 in the intravenous and 66 in the oral group) were recruited from December 1, 2016, to February 28, 2018. Patient demographics and intrapartum factors were similar between both arms. The intravenous group showed a mean time of 54.86 minutes (95% confidence interval, 20.57-39.43) to defervescence vs 52.58 minutes (95% confidence interval, 16.58-43.42) in the oral group (P=.71). In addition, intravenous and oral acetaminophen showed similar results in percentage of patients being afebrile and percent reduction in maternal temperature 30 minutes after administration of the first dose. Histopathological findings, neonatal outcomes, oxidative stress markers, and RANTES and cytokine levels were not statistically significant between intravenous and oral acetaminophen groups. CONCLUSION: Intravenous acetaminophen did not demonstrate a higher efficacy than oral acetaminophen in treating intrapartum maternal fever. Select patients may benefit from intravenous acetaminophen for treatment of intrapartum fever, including those who cannot tolerate oral medication.

Opioid-free multimodal analgesia pathway to decrease opioid utilization after cesarean delivery.

AIM: To evaluate an opioid-free multimodal analgesic pathway (MAP) to decrease opioid utilization after cesarean delivery (CD) compared to historic data of our institution prior to using MAP for pain management (pre-MAP). METHODS: The MAP was implemented in three phases from September 2018 to August 2019. Patients received 1000 mg intravenous (IV) acetaminophen with 30 mg IV ketorolac at 0 (arrival time at recovery room), 6, 12 and 18 h of postoperative course. On the 2nd and the 3rd postoperative days, patients were monitored for pain every 6 h by Numeric Pain Intensity Scale (0 = no pain to 10 = severe pain) and administered 600 mg oral ibuprofen for a pain score between 0 and 4, 600 mg oral ibuprofen and/or 650 mg oral acetaminophen for a pain score between 5-6, 1000 mg IV acetaminophen and/or 30 mg of IV or intramuscular ketorolac for a pain score between 7 and 10. Five milligrams of oral oxycodone was reserved for rescue if all protocol options were exhausted. Patients were discharged with 600 mg oral ibuprofen without opioid prescription. Likert surveys measuring patient satisfaction of pain control were administered during phase 3. RESULTS: Inpatient and outpatient opioid consumption rates were significantly decreased from 45%, 18% to 23.8%, 8.5% after MAP implementation (P-value <0.001). More than 90% of patients reported that their pain was well controlled and willing to request the same regimen for a future CD. CONCLUSION: MAP Implementation after CD significantly reduced inpatient and outpatient opioid consumption compared to pre-MAP results while maintaining high patients' satisfaction with pain control.

A warm-up laparoscopic exercise improves the subsequent laparoscopic performance of Ob-Gyn residents: a low-cost laparoscopic trainer.

INTRODUCTION: Residents traditionally acquire surgical skills through on-the-job training. Minimally invasive laparoscopic techniques present additional demands to master complex surgical procedures in a remote 2-dimensional venue. We examined the effectiveness of a brief warm-up laparoscopic simulation toward improving operative proficiency. METHODS: Using a "Poor-Man's Laparoscopy Simulator," 12 Ob/Gyn residents and 12 medical students were allocated 10 minutes to transfer 30 tablets with a 5-mm grasper from point A to point B via laparoscopic visualization in a warm-up exercise. Participants repeated the exercise following a 5-minute pause. Mean scores, expressed in seconds/tablet, and overall improvement (percentage difference between warm-up and follow-up) were analyzed according to postgraduate standing (PGY14), dexterity skills, and pertinent vocational activities. RESULTS: Significant improvements were noted for both residents (+25%) and medical students (+29%), P<0.0001. Scores between the 2 groups, however, were not significant (P=0.677). Proficiency was not influenced by PGY standing. Interestingly, the best (8.73 sec/pill) and the worst (25 sec/pill) scores were attained by a medical student and a chief resident, respectively, suggesting the contribution of individual aptitude. CONCLUSION: A brief warm-up exercise before an actual laparoscopic surgical procedure significantly improves subsequent laparoscopic performance.

Placement of a Word catheter: a resident training model.

OBJECTIVE: The present study developed and evaluated a practical teaching model and training protocol for Word catheter placement in the treatment of a Bartholin gland cyst. STUDY DESIGN: Residents were asked to treat a model of the female perineum, fashioned from harvested porcine tissue, with a simulated Bartholin cyst via Word catheter placement and drainage. Each resident was evaluated for procedural competence. They were retested after the viewing of a continuous 59-second video demonstrating catheter placement. RESULTS: The model's resemblance to female genitalia was confirmed by 68% of residents. Correct diagnosis and treatment of a Bartholin gland cyst was made by 61%. The mean pretraining score was 5.5 +/- 1.46, while the post-training average was 8.2 +/- 1.20, indicating an approximate 58% increase in resident proficiency (P < .05). CONCLUSION: A model of the female perineum fashioned from harvested porcine tissue is a suitable instructional aid in the recognition and treatment of a Bartholin cyst. Proficiency in Word catheter placement is improved through the use of the model and instructional video.

Sexual response in the patient after hysterectomy: total abdominal versus supracervical versus vaginal procedure.

OBJECTIVE: The present study examines the patient's own appraisal of her sexual responsiveness after hysterectomy. STUDY DESIGN: Four hundred women who had undergone hysterectomy within a 3-year period were selected randomly and asked to respond to a questionnaire that was devised to ascertain the patient's own objective evaluation of self-image, sexuality, and sexual response before and after hysterectomy. The confidential responses were analyzed, noting the presence of any significant divergence between demographic and procedural cohorts. RESULTS: Of 126 respondents, 48.4% underwent total abdominal hysterectomy; 34.1% underwent vaginal hysterectomy, and 17.4% underwent supracervical hysterectomy. The mean patient age was 49.7+/-8.7 years. No direct correlation was found between hysterectomy type and age. Most women did not report any significant deterioration in mental attitude after the procedure (P =.788). Self and body image also remained consistent, with only 25.3% indicating a change for the worse. Only 10.3% of respondents felt less feminine after hysterectomy; nearly 70% of the respondents did not feel less feminine. Responses that pertained to libido, sexual activity, or feelings of femininity did not reveal significant changes (P >.05). Satisfaction with procedural choice was positive (54.8%), with only 7.1% responding unfavorably. CONCLUSION: The responses suggest that neither self-image nor sexuality need diminish after hysterectomy. The type of hysterectomy that was performed did not appear to affect the attitudes of the respondents.

Obstetric predictors of placental/umbilical cord blood volume for transplantation.

OBJECTIVE: Umbilical cord blood is an effective alternative to bone marrow as a source of hematopoietic stem cells in transplantation. However, the amount of donor blood and the cell content that are collected may be insufficient for engraftment in some adult recipients. This study identifies obstetric factors that affect retrievable placental cord blood volume. STUDY DESIGN: A retrospective analysis of factors that were obtained by direct observation or medical record review that were related to harvested cord blood volume was conducted; the analysis involved 9205 deliveries from mothers who donated placental cord blood through the obstetric services of two New York City hospitals between 1993 and 1999. RESULTS: Obstetric factors that influenced significantly the total volume of blood that was collected were route of delivery, induction of labor, presence of a nuchal cord, infant birth weight, multiple births, placental weight, and duration of labor. The length of the umbilical cord from the venipuncture site and the length of time to cord blood collection also affected the volume that was retrieved. Maternal ethnicity was associated with cord blood yield; Caucasian mothers provided larger quantities than either African American or Asian mothers. CONCLUSION: Our results confirm that the volume of residual placental cord blood that is collected for hematopoietic stem cell transplantation is influenced by several factors, the presence of which predict the likelihood of an adequate collection. Collected volumes can be improved when a longer length of the cord is left with the placenta and when there is a shorter time between the delivery of the placenta and the collection.

Placental/umbilical cord blood for unrelated-donor bone marrow reconstitution: relevance of nucleated red blood cells.

Placental/umbilical cord blood (PCB) is a source of hematopoietic stem cells for bone marrow reconstitution. Engraftment speed and survival are related to the total nucleated cell (TNC) dose of the graft. This study explored the possible influence on engraftment of nucleated red blood cells (NRBCs) in the graft. Automated hematology analyzers were used to enumerate TNCs. NRBCs were counted by visual examination or by using an automated analyzer. Hematopoietic progenitor cells were enumerated as either colony-forming cells or CD34(+) cells. Transplant centers reported on transplant outcome in 1112 patients given PCB grafts through September 2001. NRBCs correlated with progenitor cell numbers. Both white blood cell and NRBC dose were independently predictive of myeloid engraftment speed. Because NRBC dose predicted engraftment speed, inclusion of NRBCs in the TNC count does not reduce the effectiveness of the prefreezing TNC count as an index of the quality of a PCB unit as a graft. The correlation between the number of NRBCs and the number of hematopoietic progenitor cells probably reflects the involvement of early stem cells in erythroid responses.