Optimising antimicrobial drug use in surgery: an intervention study in a Dutch university hospital.

Following a one-month prospective study of antimicrobial drug use in surgical departments, new guidelines were implemented. The review was repeated after two years. In both study periods, one third of patients were prescribed antimicrobial drugs. Prophylactic antibiotic consumption decreased from 0.75 to 0.53 defined daily doses/operation. Compliance with guidelines improved from 32% to 79%. Duration of prophylaxis > 24 h decreased from 21% to 8%. Single dose prophylaxis increased from 34% to 80%. Quality of the prophylactic courses improved, as evaluated by experts using established criteria. For prophylaxis, cost savings amounted to 57%. Better quality of therapeutic courses was associated with a cost increase of 15%. Indicators of satisfactory outcome with the new policy were a stable median length of stay (5.5 days in the first review and 5.0 days after intervention) and a reduction in the number of nosocomial infections treated with antimicrobial drugs/100 bed days (1.0 before intervention vs 0.77 after intervention).

[Non-hysteroscopic thermodestruction of the endometrium using radio waves in the treatment of menorrhagia]. / Niet-hysteroscopische thermodestructie van het endometrium door radiogolven ter behandeling van menorragie.

OBJECTIVE: To test non-hysteroscopic thermodestruction of the endometrium for safety and efficiency. DESIGN: Prospective pilot study from February 1991 to July 1992. SETTING: University Hospital Nijmegen. PATIENTS AND METHOD: There were 68 patients aged 30-55 years with menorrhagia, who did not want children but wished to retain the uterus. There were two patients with a subserous myoma but with a normal uterine cavity. Patients with hypergonadotropism, a markedly enlarged uterus, abnormalities at cytological examination of the cervix, adnexal lesions, prolapse, intrauterine lesions and coagulation disorders were excluded. By way of preparation, danazol was administered for 4 weeks before the intervention (36 patients). Three patients with side effects were given lynestrenol. From January 1992, an LH-RH analogue was administered (29 patients) for 6 weeks prior to the intervention or in the patients with a subserous myoma for 12 weeks. Thermodestruction of the endometrium by means of radio waves was carried out according to a standard protocol under general or epidural spinal anaesthesia. The intracavitary temperature measured was 62-65 degrees C, mean duration of the treatment 20 minutes. RESULTS: The patients were discharged 10-24 hours after the intervention. A non-disturbing watery discharge of 3-6 weeks' duration was reported. Normal activities were resumed after one week. Success (duration of follow-up 3-21 months) was defined as amenorrhoea (6 patients; 9%) or a markedly reduced menstruation or duration of menstruation (48 patients; 70%). Six patients (9%) reported no improvement and of eight patients (12%) with slight, unsatisfactory improvement three were treated again, with success (4%). During the trial period the method was further adjusted and perfected. There were no complications. CONCLUSION: This preliminary experience shows that thermodestruction with radio waves is simple, safe and efficient.

Improvement of cervical mucus viscoelasticity and sperm penetration with sodium bicarbonate douching.

The aim of the study was to evaluate the influence of vaginal douching with sodium bicarbonate (NaHCO3) upon cervical mucus viscoelasticity and sperm penetration in vitro and in vivo. Twenty-five couples with primary infertility for greater than 12 months participated in the study. The selection criteria were: (i) semen quality compatible with conception, (ii) regular ovulatory cycles and (iii) repeated negative post-coital test (PCT). After at least one inventory cycle, three consecutive cycles were studied. In the second and third cycles, vaginal douching was performed with either 1.5% (w/v) NaHCO3 or 0.9% (w/v) NaCl (randomized procedure). The viscoelasticity of the cervical mucus, sperm penetration tests (SPT) and PCTs were analysed. The viscoelasticity of mucus samples after NaHCO3 douching was significantly lower than the viscosity after NaCl douching (P less than 0.001, n = 16) and in the control cycles (P = 0.003). The SPT scores were significantly higher in the NaHCO3 cycles than in the NaCl cycles (P = 0.004, n = 22) and in the control cycles (P less than 0.001). The PCT scores proved to be significantly higher after NaHCO3 douching than after NaCl douching (P = 0.002, n = 21). Comparison of NaHCO3 and control cycles also showed a significant improvement of the PCT score after NaHCO3 douching (P less than 0.001).

Treatment of vaginal vault prolapse.

Vaginal vault prolapse is mostly a preventable complication of hysterectomy. Adequate suspension of the vaginal apex after hysterectomy with use of shortened cardinal and uterosacral ligaments will draw the proximal vagina over the levator plate. This results in support for the distal vagina. The essence of surgical repair of vaginal vault prolapse is to create a new suspension with the same vaginal support. Transvaginal sacrospinous fixation and transabdominal sacrocolpo-suspension accomplish this.

[Fecal incontinence following obstetrical injury; significance of damaged pelvic floor innervation and results of surgical treatment]. / Incontinentie voor faeces na obstetrisch letsel; betekenis van beschadigde bekkenbodeminnervatie en resultaten van chirurgische behandeling.

During the last 5 years 33 patients with faecal incontinence due to childbirth were investigated. Ages varied from 23 to 61 and duration of symptoms from 0.3 to 25 years. Anal manometry was performed in all patients and electromyography was performed in 21 cases. Twenty-seven patients underwent delayed sphincter repair. Continence was restored in 21 (81%). Post-operatively performed EMG in the patients who remained incontinent demonstrated severe denervation but sphincter mapping did not demonstrate muscle discontinuity. Continence improved in three patients within one year as results of reinnervation. Faecal incontinence after childbirth may be due to either obstetric rupture or denervation. Both disorders may coexist. Sphincter repair gives excellent results provided denervation is not present. Preoperative assessment by EMG is mandatory.

Prevention of group B streptococci transmission during delivery by vaginal application of chlorhexidine gel.

In a prospective study in 227 parturients, carriership of group B streptococci was established to be 25%. In carriers, transmission of streptococci to the newborn occurred in 50%. 10 ml of a chlorhexidine gel containing hydroxypropylmethylcellulose was introduced into the vagina during labor in 17 parturients, who were known to be carriers of group B streptococci from the first trimester of pregnancy. In none of the newborns from these mothers colonization by group B streptococci did occur. Vaginal application of chlorhexidine may prevent transmission of group B streptococci, and serve as an alternative to intrapartum prophylaxis using antibiotics. A large multicenter randomized controlled study should be performed to confirm this hypothesis.

Maternal survival after acute haemorrhagic pancreatitis complicating late pregnancy.

In the 41st week of her first pregnancy, a 25-year-old woman presented abdominal complaints. After the Caesarean delivery of an healthy child, the mother developed a severe hypoglycaemia and septic shock. Although normal serum and urine amylase values were obtained, an exploratory laparotomy disclosed acute haemorrhagic pancreatitis. Clinical treatment was complicated by repeated sepsis, multiple organ failure and ARDS, requiring the patient to receive intensive care for 3.5 months. To control abdominal sepsis and bleeding complications, an additional ten laparotomies were carried out. During this period the abdomen was kept closed by means of a nylon mesh. Although according to present day criteria the prognosis was fatal, the patient ultimately fully recovered. By exclusion, the cause of the pancreatitis was ascribed to the pregnancy itself. The medical, obstetric and surgical aspects of the management of acute pancreatitis complicating pregnancy and puerperium are reviewed.

Buffering substances of human semen.

The quantitative contribution of several components to the BC of human semen has been investigated. The role of spermatozoa is negligible (less than 2%). Both the high-molecular components (proteins) and the HCO3-/CO2 system contribute about 25% to the BC. Therefore, about 50% of the BC of semen must be due to low molecular weight components other than HCO3-/CO2.

Buffering capacity of human semen.

The buffering capacity of 270 semen samples derived from 196 men of infertile couples was determined from titration curves. The average buffering capacity in the physiologic range (pH 7.0 to 6.0) was 41.1 slyke (standard deviation [SD], 9.9), which is significantly higher (P less than 0.01) than that in serum (23.3 slyke; SD, 7.5; n = 42). When the buffering capacity of several semen samples of one man in the course of time was measured, the variation between these samples was larger than the determination error. No correlation was found between the buffering capacity of serum and semen of the same man, nor between the buffering capacity of semen and the fertility grade determined by physical and morphologic analysis of the samples.

Effect of chronic aromatase inhibition by delta 1-testolactone on pituitary-gonadal function in oligozoospermic men.

Aromatase inhibition by delta 1-testolactone (Teslac, 500 mg twice daily) for 6 months in 9 patients with idiopathic oligozoospermia lowered the levels of serum estradiol (E2) and thereby sex hormone binding globulin (SHBG) (rS = +0.40, p less than 0.025) to values -35 and -25%, respectively, below the pretreatment values (P less than 0.001 and less than 0.005). The E2 decrease was accompanied by a temporary increase (+50%) in the levels of follicle stimulating hormone (FSH), not of luteinizing hormone (LH), and of 17 alpha-hydroxyprogesterone (17 alpha-OHP), but less of testosterone (T) (+30%), which led to a transient rise in the 17 alpha-OHP/T ratio. The T/E2 ratio and "free T" index (T/SHBG) almost doubled until the end of the treatment period. During delta 1-testolactone treatment the mean sperm density gradually rose from 8.1 +/- 1.3 (SEM) before to 21.3 +/- 6.7 X 10(6)/ml after 6 months (P less than 0.01), whereas the total sperm count almost threefold increased (P less than 0.05). Sperm concentrations exceeding 20 X 10(6)/ml were achieved in 4 of the 9 patients. Two of these patients' wives became pregnant. Although the data point to a pivotal role of estrogens in the pathogenesis of the spermatogenic lesion in some patients with idiopathic oligozoospermia, the lack of a beneficial effect of estrogen lowering in others points to a multicausal nature of the disease entity.

Testicular steroid response to continuous and pulsatile intravenous luteinizing hormone-releasing hormone administration in normal men.

In 18 healthy normal men Leydig cell response was examined following intravenous luteinizing hormone-releasing hormone (LH-RH) administration under standardized conditions. The same total amount of LH-RH was administered for 3 hours both in a continuous (1 microgram/min; C (1,1)) and in a pulsatile fashion, by giving a 20 micrograms dose at 20 minutes intervals, P (20, 20), and a 60 micrograms dose at 60 minutes intervals, P (60, 60). Following the different modes of LH-RH administration which all caused 3-4 fold elevations of the mean endogenous luteinizing hormone (LH) concentrations and 1.7-2 fold elevations of the mean follicle-stimulating hormone (FSH) serum levels, an overt increase of the mean testosterone (T) levels was noticed up to 1.5 X the baseline value. No difference was observed in the total amount of T release among the investigated groups. The patterns of the T response, however, clearly differed from one another with a rapid increase, during the C (1, 1) and the P (20, 20) LH-RH administration, and a delayed but persistent T increase in the P (60, 60) experiment. The mean 17-hydroxyprogesterone (17-OHP) concentrations demonstrated a similar course to T in the P (60,60) experiment, while significant increases of the oestradiol (E 2) levels were never observed in all three experiments. In view of the comparable LH and FSH increments in response to LH-RH administration in either experiment the differences in T responses may be explained by assuming a direct effect of LH-RH on Leydig cell steroidogenesis in the men.

Serum luteinizing hormone-releasing hormone (LH-RH) and gonadotropic hormones in men after a bolus dose of LH-RH: comparison of different doses and routes of administration.

Serum levels of luteinizing hormone-releasing hormone (LH-RH), LH, and follicle-stimulating hormone (FSH) were measured for 60 minutes after 5- and 20-micrograms bolus doses of LH-RH given either intravenously or subcutaneously to 20 healthy men, for the study of LH-RH pharmacokinetics and the corresponding pituitary gonadotropin release. Intravenous (5- and 20-micrograms) LH-RH administration revealed much sharper LH-RH pulses, with significantly higher levels between 1 and 5 minutes (P less than 0.001) but lower levels between 30 and 60 minutes (P less than 0.05), compared with the subcutaneous route. No statistically significant differences were observed in the magnitude and time occurrence of maximum LH release or in the area under the LH response curves between intravenous and subcutaneous LH-RH administration, either in the 5-micrograms or in the 20-micrograms group. FSH responses were small and insignificant in all the performed tests. The intravenous route of administration seems preferential in therapeutic regimens that use pulsatile exogenous LH-RH, because the conditions of intermittent pituitary stimulation are more adequately fulfilled and the risk of dose accumulation is reduced. Furthermore, LH-RH doses of 5 micrograms are capable of producing adequate pituitary LH release, whereas increases in the pulse dose up to 20 micrograms seem to have no additional effects.