Post-operative serious adverse events in a mixed surgical population - a retrospective register study.

BACKGROUND: The number of surgical procedures is increasing, and knowledge of surgical risk factors, post-operative mortality and serious adverse events (SAE) is essential. The aim with our study was to determine the risk of a composite outcome of post-operative: death; myocardial infarction; pulmonary embolism; stroke; gastrointestinal bleeding; dialysis or reoperation. METHODS: Data of surgical procedures in the period from January 1, 2012 to June 30, 2012 were retrieved from the Danish Anaesthesia Database (DAD). Follow-up of all patients undergoing hip or knee replacement, abdominal or gynaecological surgery was conducted retrieving data from The Danish Civil Registration System and the National Patient Register. Total observation time was from January 1, 2012 to June 6, 2013. RESULTS: A total7449 adult patients were included in the final analysis. The risk of the composite outcome during a follow-up until 342 days after inclusion of the last patient was estimated to 8.3%, 95% Confidence Intervals (CI) (7.8-9.0), with a median observation time of 437 days (IQR 387-485, range 0-522). The risk of the composite outcome within 90- and 180-day follow-up of each patient was 4.8% (4.4-5.3) and 5.9% (5.4-6.5), respectively. Mortality within longest follow-up as well as 90 and 180 days post-operatively was 3.6% (3.1-4.0), 1.7% (1.4-2.0), and 2.2% (1.9-2.6), respectively. CONCLUSION: We found a risk of one or more events in the composite outcome within 342 days after inclusion of the last patients of 8.3% (7.8-9.0). The results are applicable in estimations of adequate sample sizes in future clinical trials investigating effects of interventions on SAEs.

[Vulvar biopsy as the basis of effective therapy]. / Die Vulvabiopsie als Grundlage einer rationalen Therapie.

Clinical and microbiologic examinations are not always sufficient for a correct and specific diagnosis of diseases of the vulva. In the case of an unusual clinical presentation or an unusual course of the disease, a histopathologic examination is warranted. Importance, technique, and limitations of biopsies of the vulva are illustrated on the basis of three case reports.

[Genital infections and their diagnosis in general practice]. / Genitalinfektionen und ihre Diagnostik in der Praxis.

Infections are among the frequent disorders which cause patients to consult a gynaecologist. The spectrum of microorganisms in this area is broad, but only few pathogens are capable of causing an inflammatory infection without previous damage of the epithelium. A-Streptococci are the most dangerous pathogens in the genital area, especially in pregnancy and can only be detected by means of bacteriological culture. Most frequently isolated bacteria in the genital tract are facultative pathogenic bacteria deriving from the intestine. They are not always the reason for discharge or burning. An overview of the diagnostic procedures is given.

[Differential severe inflammation of external genitalia diagnosis]. / Differentialdiagnostik schwerer Entzündungen im äusseren Genitalbereich.

The most important diseases with considerable vulva inflammation are presented by means of clinical pictures. The spectre reaches from infection to immune deficiency.

Isolated erythema (cellulitis) of the breast.

This paper reports nine cases of breast cellulitis in women patients (four cases in pregnancy, four postmenopausal cases following hormone replacement therapy and one case of unilateral breast oedema following a mediastinal lymphoma). Biopsies were obtained from the erythematous area in one pregnant patient, one postmenopausal patient and the patient with breast oedema associated with the mediastinal lymphoma. Histology revealed unspecific dermatitis with extensive perivascular lymphoplasmocellular infiltrates. Histopathological examination of biopsies obtained from the underlying mammary tissue along with the corresponding mammographic data gave no evidence of mastitis or mammary carcinoma. The patients complained of sensitivity to touch, a feeling of local tightness or a burning sensation. These findings were reported in both breasts in the pregnant patients, but were unilateral in the others. The submammary fold was unremarkable, that is, no intertrigo was detected. The aetiology of the erthyema is probably associated with swelling of the breast tissue and a causal link with a specific endocrine constellation (pregnancy, postmenopausal HRT) can be postulated. A common factor in all cases presented here is the relatively long period of 4 to 13 weeks before healing of the lesion. Therapeutic intervention with antibiotics or dopamine agonists failed to influence the course. Similarly, steroid cream appeared to be of no value in these cases. Extensive erythema of the breast skin is a benign disease, for which there is still no known effective therapy. The lack of mammographic evidence and, especially, of positive palpatory findings make breast cancer highly improbable as the underlying cause.

Discordant prevalence of chlamydia trachomatis in asymptomatic couples screened using urine ligase chain reaction.

The following study was conducted to determine whether there would be an effect on the prevalence of Chlamydia trachomatis if both partners in a sexual relationship, rather than only one, underwent screening. First-void urine samples were collected from 1,690 asymptomatic women (mean age, 30 years; range, 15-70 years) and their male sex partners (mean age, 33 years; range, 16-71 years). The duration of sexual partnership for these subjects ranged from 2 months to more than 10 years.. At the time of testing, 687 of the women were pregnant. Ligase chain reaction testing revealed that 42 (2.5%) female and 63 (3.7%) male urine samples were positive. Detection rates for Chlamydia trachomatis differed for males and females, a difference that was found to be significant (P<0.0046, McNemar chi-square). Both partners tested positive in 27 (1.6%) couples, whereas at least one partner tested positive in 78 (4.6%) couples. Thus, screening males for Chlamydia trachomatis would have identified 63 (81%) of these 78 couples compared with only 42 (54%) couples had females been screened exclusively. In standard clinical practice, women most often undergo screening. The results of this study underscore the need to screen both males and females for Chlamydia trachomatis.

Hydrodynamic and mass transfer characteristics of three-phase gaslift bioreactor systems.

This review focuses on the hydrodynamic and mass transfer characteristics of various three-phase, gaslift fluidized bioreactors. The factors affecting the mixing and volumetric mass transfer coefficient (k(L)a), such as liquid properties, solid particle properties, liquid circulation velocity, superficial gas velocity, bioreactor geometry, are reviewed and discussed. Measurement methods, modeling and empirical correlations are reviewed and compared. To the authors' knowledge, there is no 'generalized' correlation to calculate the volumetric mass transfer coefficient, instead, only 'type-specific' correlations are available in the literature. This is due to the difficulty in modeling the gaslift bioreactor, caused by the variation in geometry, fluid dynamics, and phase interactions. The most important design parameters reported in the literature are: gas hold-up, liquid circulation velocity, 'true' superficial gas velocity, mixing, shear rate, aeration rate and volumetric mass transfer coefficient, k(L)a.

Detection of seroconversion and persistence of Chlamydia trachomatis antibodies in five different serological tests.

Microimmunofluorescence (MIF), a Chlamydia trachomatis species-specific enzyme immunoassay incorporating lipopolysaccharide-extracted Chlamydia trachomatis L2 elementary bodies, two different synthetic peptide-based species-specific tests, and a recombinant lipopolysaccharide genus-specific test were performed on multiple follow-up sera (n = 104 total) from 16 women with Chlamydia trachomatis-positive cervical swabs. These women included five with IgG seroconversions, five with Chlamydia trachomatis reinfections after initial therapy, and six with serologic follow-up of more than 6 years after antibiotic therapy. Of all the tests employed in this study, MIF IgG reverted earliest to negative titers, while MIF IgA was the least sensitive. The lipopolysaccharide-extracted elementary body enzyme immunoassay exhibited the closest correlation with the MIF test. The highest test sensitivity was observed in one of the synthetic peptide-based tests, which detected earliest seroconversions and longest IgG persistence. The other synthetic peptide-based test gave false-negative results in 2 of 16 women and did not detect seroconversion earlier than the MIF test. Seroconversion and persistence of genus-specific IgG--cross-reactivity with Chlamydia pneumoniae--against lipopolysaccharide were similar to species-specific IgG. A significant serologic response to reinfection was observed only in women with signs of pelvic inflammatory disease. Species-specific tests of high sensitivity and reproducibility are best suited for gynecological diagnostic purposes.

Evidence of labile inhibitors in the detection of Chlamydia trachomatis in cervical specimens by polymerase chain reaction.

A total of 276 cervical swabs (241 from first visits and 35 from follow-up visits) from 241 women were tested for Chlamydia trachomatis by polymerase chain reaction (PCR) and enzyme immunoassay (EIA). Sixty-one smears (53 from first visits and 8 from follow-up visits) from 53 women were stained by direct fluorescent antibody (DFA). Twenty-one (8.7%) women had positive swabs in at least two different tests. All follow-up swabs (collected between 3 days and 3 weeks after the first clinical visit) were positive in at least one test when the woman had been positive at the first visit and no antibiotic treatment had been initiated. Including swabs from follow-up visits and DFA results, the respective sensitivities and specificities of the assays were as follows: PCR, 75.9% and 100%; EIA, 69% and 98.4%. The seven swabs that were false negative by PCR (tested initially after thawing from -20 degrees C) were mailed nonrefrigerated to the assay manufacturer, where they tested true positive. These data point to labile inhibitors of the PCR, predominantly cervical mucus.

Chlamydia trachomatis species specific serology: ImmunoComb Chlamydia bivalent versus microimmunofluorescence (MIF).

The ImmunoComb Chlamydia Bivalent IgG/IgA (Orgenics, Israel) is a new quantitative serologic test that employs LPS extracted Chlamydia trachomatis L2 and LPS extracted Chlamydia pneumoniae elementary bodies on two separate antigenic spots. The Bivalent C. trachomatis specific test results were compared with microimmunofluorescence (MIF), the gold standard of chlamydial species specific serology. For C. trachomatis IgG the Bivalent was highly concordant with the MIF: the rate of positive titres (IgG > or = 1:8) was 10% vs. 11% in 100 blood donors, 18% vs. 16% in 111 obstetric patients (6% antigen prevalence), 26% vs. 22% in sterile women with open (n = 54) and 86% vs. 84% with occluded (n = 51) tubes, and 88% vs. 85% in 103 women with C. trachomatis positive cervical smears. Surprisingly, the Bivalent differed considerably from the MIF in IgA prevalence: in obstetric patients (8% vs. 4%), sterile women with open (13% vs. 6%) and occluded (71% vs. 20%) tubes, and women with positive cervical smears (78% vs. 24%). Bivalent IgA appeared to be more sensitive than MIF IgA and showed a stronger correlation with positive cervical smears in obstetric patients (sensitivity 67% vs. 0%, specificity 95% vs. 96%, positive prediction 44% vs. 0%, negative prediction 98% vs. 94%) and with tubal occlusion in sterile women (sensitivity 71% vs. 20%, specificity 87% vs. 94%, positive prediction 84% vs. 77%, negative prediction 76% vs. 55%). MIF IgM was of little diagnostic help. Supplemental to the often difficult C. trachomatis antigen detection, the easily performed Bivalent IgG/IgA appears to be of great value in routine diagnosis of genital chlamydial infections.

Chlamydial serology in genital infections: ImmunoComb versus Ipazyme.

The ImmunoComb Chlamydia trachomatis IgG/IgA (Orgenics, Israel) is a new serologic test using C. trachomatis L2 elementary bodies (Washington Research Foundation, Seattle) as antigen. The Ipazyme IgG/IgA test (Savyon, Israel) employs whole cells with C. trachomatis L2 inclusions, i.e. elementary and reticulate bodies. Theoretically, the ImmunoComb is expected to be less cross-reactive (LPS) with Chlamydia pneumoniae than the Ipazyme (LPS and reticulate body group specific antigens). Compared with the Ipazyme, the ImmunoComb IgA showed both a higher positive predictive value (36% versus 25%) and sensitivity (67% versus 33%) for antigen detection in a control group of 100 post partum women with a 6% prevalence of C. trachomatis positive cervical smears. In sterility patients (45 cases with occluded and 53 with open fallopian tubes) the tube status was predicted by the ImmunoComb (Ipazyme) with 74% (72%) positive predictive value, 87% (80%) sensitivity, and 87% (81%) negative predictive value. IgG/IgA prevalence in 118 patients with C. trachomatis positive cervical smears was 85%/55% for the ImmunoComb and 84%/49% for the Ipazyme. The ImmunoComb is considerably faster and easier in handling and less subjective in reading than the Ipazyme.

Efficacy of clindamycin vaginal cream versus oral metronidazole in the treatment of bacterial vaginosis.

OBJECTIVE: To compare the efficacy and tolerance with 2% clindamycin vaginal cream versus oral metronidazole for the treatment of bacterial vaginosis. METHODS: This was a multicenter, randomized, double-blind study in which patients were randomly assigned to one of the following two regimens in a 1:1 ratio: clindamycin phosphate vaginal cream 2% (5 g intravaginally at bedtime for 7 days) plus two placebo capsules (twice a day for 7 days) or metronidazole 500 mg (two 250-mg capsules orally twice a day for 7 days) plus placebo vaginal cream (5 g intravaginally at bedtime for 7 days). The patients were seen for follow-up at 5-10 days and 25-39 days after completion of therapy. RESULTS: Seven investigators, four in Germany, two in Austria, and one in Switzerland, enrolled 407 patients. Four patients never received either protocol drug, leaving 403 evaluable for safety. Two hundred thirty-four patients were evaluable for efficacy. The analysis for all evaluable patients showed no significant difference between treatment groups. The cure or improvement rate at 1 month after therapy was 83% in the clindamycin group versus 78% in the metronidazole group. The incidence of drug-related adverse medical events was approximately 12% in both groups. CONCLUSIONS: Oral metronidazole and intravaginal clindamycin cream had a similar efficacy of 78 to 83%. Both drugs were tolerated, with vaginal candidiasis developing in 8.5 and 4.7% of the patients in the clindamycin and metronidazole groups, respectively.

[Bacterial infections in pregnancy]. / Bakterielle Infektionen in der Schwangerschaft.

The spectrum of bacterial infections during pregnancy is broad. Among blood-transmitted infections especially listeriosis endangers the child. More frequent are ascending and peripartal infections, which imperil both mother and child. The disturbed vaginal flora, which occurs in 10-30% of all pregnant women, has to be regarded as its reservoir. Cervicitis caused by gonococci or chlamydiae, but also high concentrations of facultative pathogenic bacteria are regarded as the main cause of the preterm rupture of membranes leading to preterm delivery. Especially feared is the group-A-streptococci infection, which appears more frequently. In 5% of all pregnant women a chlamydial cervicitis is found.

Hepatitis B and C in heterosexual patients with various sexually transmitted diseases.

The seroprevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections were prospectively assessed in 356 heterosexuals with STDs (sexually transmitted diseases) and compared to a control group of 381 healthy first-time blood donors. Eighty-one of 356 STD patients were anti-HBC positive (22.8%) compared to 14/381 blood donors (3.8%; p less than 0.001). In addition, 18 of the 81 anti-HBC positive STD patients, but none of the controls, were positive for HBSAg (p = 0.06). The prevalence for anti-HCV was also significantly higher in the STD group than in the controls (5.3% vs. 0.5%; p less than 0.001). Among the various STDs syphilis (anti-HBC: 67.5%; anti-HCV: 12.5%) and Chlamydia trachomatis infections (anti-HBc: 20.2%, anti-HCV: 8.1%) had the highest prevalence for both infections. This study provides strong evidence of heterosexual transmission of hepatitis B and C virus infections. Thus, heterosexuals with STDs or multiple partners should be actively vaccinated against hepatitis B.