Suture placement for hemostasis during laparoscopy using the Stamey needle.

Bleeding at cannula insertion sites during laparoscopic procedures often is difficult to manage. The few published techniques for controlling abdominal wall bleeding include suturing under direct observation, electrocoagulation, and placement of a Foley catheter. These methods may provide less than adequate hemostasis, however. We developed a technique of direct suture placement under laparoscopic guidance using an absorbable monofilament suture and the Stamey needle as a ligature carrier.

Resident research in obstetrics and gynecology.

Mandatory research in an obstetrics-and-gynecology residency can be an effective tool for teaching physicians the skills needed for them to become intelligent readers of the medical literature. We present our 15-year experience with a resident research program. We discovered that in addition to achieving the primary goal in resident education, structured resident research has many other benefits.

Bilateral tubal ectopic pregnancies after bilateral partial salpingectomy. A case report.

The incidence of bilateral tubal ectopic pregnancies is reported to range from 1/725 to 1/1,580 extrauterine pregnancies. We report a case of bilateral ectopic pregnancies in a patient who had previously undergone bilateral partial salpingectomies for contraception. An extensive literature review identified one patient with a similar sterilization history in whom a bilateral ectopic pregnancy occurred.

Small cell carcinoma of the ovary with hypercalcemia responsive to sequencing chemotherapy.

Small cell carcinoma of the ovary with hypercalcemia is a rare neoplasm that has been exceedingly difficult to treat. It tends to occur in young women, and we have found no reports of survivors when this neoplasm has spread beyond the ovary. We have described a patient who has had long-term survival despite extraovarian disease. We conclude that aggressive sequencing chemotherapy followed by irradiation may be of value in treating this neoplasm.

Confidentiality in the age of AIDS.

Confidentiality is a fundamental rule of medicine and has been specifically defined in many codes of medical ethics. A changing clinical environment both because of diseases such as AIDS, which were not anticipated when these clinical codes were created, and because of the changing relationship between the physician, the patient, and the payor for the physician's care creates dilemmas concerning the rule of confidentiality.

Clindamycin vaginal cream versus oral metronidazole in the treatment of bacterial vaginosis: a prospective double-blind clinical trial.

Bacterial vaginosis is common among patients seen by gynecologists. Several types of therapy have been proposed. The purpose of this prospective, randomized, double-blind clinical trial was to examine the efficacy of clindamycin vaginal cream for the treatment of bacterial vaginosis. Sixty patients with symptoms of bacterial vaginosis were randomized into the study, and 46 completed the protocol. Twenty-three patients received 2% clindamycin vaginal cream (5 g applied intravaginally at bedtime for 7 days), with placebo oral tablets twice daily for 7 days. The other 23 patients received oral metronidazole tablets (500 mg twice a day for 7 days) and placebo vaginal cream (5 g intravaginally for 7 days). The cure rates for the two regimens were comparable. Twenty-two (97%) of the patients treated with clindamycin vaginal cream had improvement or cure at the first follow-up visit versus 19 (83%) of those taking metronidazole. There was no statistically significant difference between the two results. Side effects for both regimens were comparable. We conclude that 2% clindamycin vaginal cream offers similar efficacy and safety to standard oral metronidazole therapy for bacterial vaginosis.

Single dose oral fluconazole vs intravaginal terconazole in treatment of Candida vaginitis. Comparison and pilot study.

Candida vaginitis develops in approximately one-fourth of women in their childbearing years. Conventional management consists of antifungal creams or tablets/suppositories administered intravaginally. Many patients have stated preferences for oral therapy. A randomized, double-blind placebo trial compared the efficacy of a single oral 200 mg dose of fluconazole with the application of terconazole 80 mg vaginal suppository daily for 3 days. Twenty-two patients (fluconazole = 12, terconazole = 10) were evaluated during a four-month period and favorable clinical responses were observed at both early and late evaluations. Mycologic cure was attained by 75% of the fluconazole group and 50% of the terconazole group at the early evaluation. At the late evaluation, mycologic cure was 75% and 100% respectively. The mean time to onset of symptom relief was 2.4 (1.7) days for the fluconazole group and 1.8 (1.8) days for the terconazole group. The mean time to complete relief of symptoms was 6.08 (2.84) and 6.6 (2.95) days respectively. A statistically significant difference did not exist for any of these measures. Seventy-three percent of the patients preferred oral therapy.

Epidemiology of pelvic inflammatory disease at University Medical Center, Jacksonville.

Patients hospitalized with acute pelvic inflammatory disease at University Medical Center of Jacksonville had a mean age of 26.8 years. Contraception use was minimal and mean gravidity was two. Hospitalized patients had a high incidence of peritonitis and tubo-ovarian abscess. N. gonorrhoeae was cultured in 50%. Mean temperature on admission was 100.5 degrees and mean white blood cell count 15,400. Mean hospitalization was 5.5 days. Two of nine patients tested for HIV were positive (22% of those tested, 2% of all patients reviewed).

Practice patterns of obstetricians and gynecologists in Jacksonville, Florida.

Ninety members of the Jacksonville Obstetrical and Gynecological Society were surveyed as to their practice patterns; 55 responded. Due to fear of litigation, 34% had stopped delivering obstetrical care and 63% plan to discontinue perinatal care during the next ten year. At least one malpractice claim had been filed against 51%; 9% had two, and 11% three or more. Prenatal and intrapartum testing has increased primarily because of fear of litigation. Obstetric fees increased 44% during the last five years, according to the survey, compared to a Consumer Price Index rise of 20%. Mean malpractice premiums rose 42% during the same interval.

Antibiotic therapy in preterm premature rupture of membranes: a randomized, prospective, double-blind trial.

The use of antibiotics in the management of preterm, premature rupture of membranes remains controversial. By use of a prospective randomized double-blind design we investigated the maternal-fetal benefits associated with antibiotic therapy in 85 women with premature rupture of membranes at 34 weeks' estimated gestational age. In the treatment group 40 patients received intravenous mezlocillin for 48 hours followed by oral ampicillin until delivery. In the control group 45 patients received intravenous and oral placebo. Patients who received antibiotics had chorioamnionitis and endometritis less frequently than the control group (p less than 0.01 and p less than 0.05). Pathologic examination of the placentas showed a lower incidence of chorioamnionitis in the treatment group (p less than 0.05). The period from premature rupture of membranes to delivery (latency) was prolonged with antibiotics (p less than 0.05) and resulted in significant weight gain in the infants in the antibiotic group (p less than 0.0001). These infants also had higher 1- and 5-minute Apgar scores. Clinically suspected sepsis, respiratory distress syndrome, intraventricular hemorrhage, perinatal death rate, and prolonged hospitalization (greater than 30 days) were also increased in the control group.

Comparison of one dose cefazolin versus one dose cefotetan for cesarean section prophylaxis.

During one year, 646 women who delivered by cesarean section entered into a prospective randomized clinical trial to determine if a single intraoperative dose of cefazolin was as effective as cefotetan in the prevention of postoperative endomyometritis. Of 336 patients receiving 2 gm cefazolin intravenously at the time of clamping of the cord, endomyometritis developed in 30 (8.91%), and of 310 patients who received 2 gm cefotetan intravenously at the time of clamping of the cord, endomyometritis developed in 36 (11.6%). There was no statistically significant difference in the incidence of endomyometritis between the two groups (p = .269). We conclude that since the two drugs are equal in efficacy 2 gm of cefazolin is a cost effective method of prophylaxis for cesarean section.

Premature rupture of membranes prior to 34 weeks gestational age. One year experience at a tertiary center.

Records were reviewed of all patients with premature rupture of the membranes (PROM) at or less than 34 weeks estimated gestational age (EGA) who delivered at University Hospital of Jacksonville, Florida, during 1987. That year 132 patients were identified, 3.1% of all deliveries. The mean time from membrane rupture to delivery was three days, and the duration of PROM seven or more days in 9% of cases. Chorioamnionitis was diagnosed in 20% of the mothers. Delivery was by cesarean section in 30% of cases, twice the primary rate at University Hospital for 1987. Sixty-five percent of infants were male, and 13 males and four females of the 132 infants died before or after birth, the majority due to prematurity. Respiratory distress syndrome (RDS) was found in 35 infants and in 80% of these cases the membrane ruptured at 30 weeks or less. Intraventricular hemorrhage (IVH) was diagnosed in 8% of cases. Neonatal sepsis was a common diagnosis (41% of deliveries) with incidence being similar at all gestational ages. The length of membrane rupture was not statistically significant when compared with neonatal sepsis (P = 0.39).

Efficacy of prophylactic antibiotics for the prevention of endomyometritis after forceps delivery.

The purpose of this prospective randomized controlled clinical trial was to determine whether prophylactic antibiotics reduce the incidence of endomyometritis after forceps delivery. Of the 393 patients studied, 192 received 2 gm of intravenous cefotetan after forceps delivery, and 201 patients received no antibiotics. There were seven cases of endomyometritis in the group given no antibiotic and none in the cefotetan group, a statistically significant difference (P less than .01). We conclude that prophylactic antibiotics are effective in reducing the incidence of endomyometritis after forceps delivery. We believe this is the first published study demonstrating this benefit.

Clinical correlation of hormone receptor status in epithelial ovarian cancer.

Cytoplasmic estrogen receptor (ER) and progesterone receptor (PR) levels were measured in ovarian epithelial carcinomas from 37 patients using a dextran-coated charcoal assay prior to any treatment. Sixty-eight percent of the tumors were ER positive, forty-nine percent were PR positive, forty-one percent were positive for both receptors, and twenty-seven percent were negative for both receptors. Receptor status in epithelial ovarian carcinomas was found to have no clinical significance when correlated with age, parity, race, cigarette smoking, surgical stage, histologic type, histologic grade, progression-free interval, or patient survival.