Back to the future: breast surgery with tumescent local anesthesia (TLA)?

PURPOSE: Breast surgery is usually performed under general anesthesia. Tumescent local anesthesia (TLA) offers the possibility to anesthetize large areas with highly diluted local anesthetic. METHODS: In this paper, the implementation, and experiences with TLA in the field of breast surgery are discussed. CONCLUSION: For carefully selected indications, breast surgery in TLA represents an alternative to ITN.

Oral contraceptive use and risk of vulvodynia: a population-based longitudinal study.

OBJECTIVE: To assess whether the risk of vulvodynia is associated with previous use of oral contraceptives (OCs). DESIGN: Longitudinal population-based study. SETTING: Four counties in south-east Michigan, USA. POPULATION: A population-based sample of women, aged 18 years and older, enrolled using random-digit dialling. METHODS: Enrolled women completed surveys that included information on demographic characteristics, health status, current symptoms, past and present OC use, and a validated screen for vulvodynia. The temporal relationship between OC use and subsequent symptoms of vulvodynia was assessed using Cox regression, with OC exposure modelled as a time-varying covariate. MAIN OUTCOME MEASURE: Vulvodynia, as determined by validated screen. RESULTS: Women aged <50 years who provided data on OC use, completed all questions required for the vulvodynia screen, and had first sexual intercourse prior to the onset of vulvodynia symptoms were eligible (n = 906). Of these, 71.2% (n = 645) had used OCs. The vulvodynia screen was positive in 8.2% (n = 74) for current vulvodynia and in 20.8% (n = 188) for past vulvodynia. Although crude cross-tabulation suggested that women with current or past vulvodynia were less likely to have been exposed to OCs prior to the onset of pain (60.7%), compared with those without this disorder (69.3%), the Cox regression analysis identified no association between vulvodynia and previous OC use (HR 1.08, 95% CI 0.81-1.43, P = 0.60). This null finding persisted after controlling for ethnicity, marital status, educational level, duration of use, and age at first OC use. CONCLUSION: For women aged <50 years of age, OC use did not increase the risk of subsequent vulvodynia.

Suspicion of viral gastroenteritis does improve compliance with hand hygiene.

PURPOSE: Viral gastroenteritis is common on pediatric wards, increasing the need for adherence with hand hygiene recommendations in order to prevent cross-transmission. Therefore, we investigated hand hygiene reflecting complete work-day activities on pediatric wards and focused on the influence of viral gastroenteritis. There are, so far, no studies representing complete working days on pediatric wards or addressing the influence of viral gastroenteritis. METHODS: This was a prospective, observational study (144 h in each group) on hand hygiene behavior in the care for children with and without suspected or proven viral gastroenteritis. RESULTS: We documented 40 and 30 hand hygiene opportunities per patient-day for ward-associated healthcare workers for children with and without viral gastroenteritis, respectively (P = 0.316). Healthcare workers' compliance with hand hygiene recommendations was significantly higher in children with viral gastroenteritis compared to those without, i.e., 72 versus 67% (P = 0.033), especially among physicians, being 92 versus 50% (P = 0.032). Compliance tended to be higher after patient contact than before, especially in the children with gastroenteritis (78 vs. 62%; P = 0.083). CONCLUSIONS: We conclude that viral gastroenteritis seemed to increase the number of daily opportunities for hand hygiene and did significantly increase compliance. In particular, this effect was seen after patient contact. Further research might address the awareness of undiagnosed transmissible diseases in order to prevent cross-transmissions.

Compliance with hand hygiene in patients with meticillin-resistant Staphylococcus aureus and extended-spectrum ß-lactamase-producing enterobacteria.

Hand hygiene is considered to be the single most effective measure to prevent healthcare-associated infection. Although there have been several reports on hand hygiene compliance, data on patients with multidrug-resistant (MDR) organisms in special isolation conditions are lacking. Therefore, we conducted a prospective observational study of indications for, and compliance with, hand hygiene in patients colonised or infected with meticillin-resistant Staphylococcus aureus (MRSA) or extended-spectrum ß-lactamase (ESBL)-producing enterobacteria in surgical intensive and intermediate care units. Hand disinfectant used during care of patients with MRSA was measured. Observed daily hand hygiene indications were higher in MRSA isolation conditions than in ESBL isolation conditions. Observed compliance rates were 47% and 43% for the MRSA group and 54% and 51% for the ESBL group in the surgical intensive care unit and the intermediate care unit, respectively. Compliance rates before patient contact or aseptic tasks were significantly lower (17-47%) than after contact with patient, body fluid or patient's surroundings (31-78%). Glove usage instead of disinfection was employed in up to 100% before patient contact. However, compliance rates calculated from disinfectant usage were two-fold lower (intensive care: 24% vs 47%; intermediate care: 21% vs 43%). This study is the first to provide data on hand hygiene in patients with MDR bacteria and includes a comparison of observed and calculated compliance. Compliance is low in patients under special isolation conditions, even for the indications of greatest impact in preventing healthcare-associated infections. These data may help to focus measures to reduce transmission of MDR bacteria and improve patient safety.

Acral lentiginous melanoma: conventional histology vs. three-dimensional histology.

BACKGROUND: Patients with acral lentiginous melanoma (ALM) seem to have a poor prognosis. ALMs represent 4-10% of cutaneous melanomas in white populations. Surgery is mostly based on conventional histological evaluation. With micrographic surgery, continuously spreading tumours can be excised with smaller excision margins for better cosmesis and function. OBJECTIVES: Clinical parameters and surgical strategies influencing the prognosis of patients with ALM were evaluated. METHODS: Two hundred and forty-one patients (44% male, 56% female) with stage I/II ALM were recorded during 1980-2006. One hundred and thirty-three patients underwent complete histology of three-dimensional excision margins (3D histology) using the paraffin technique. Risk factors for disease-specific and recurrence-free survival were estimated. RESULTS: Patients were aged 26-87 years (median 63) with median tumour thickness of 2.0 mm. The median follow-up was 41 months. Multivariate analysis identified ulceration, conventional histology and tumour thickness as risk factors for recurrence-free and disease-specific survival. Using 3D histology, excision margins were significantly smaller (median 7 vs. 20 mm) without an increased risk of local recurrences. Patients with 3D histology had a 5-year survival of 81% compared with 63% with conventional histology. Retrospective analysis with immunohistological methods (anti-Melan-A) could improve the diagnostic specificity in detecting further melanocytic cell nests. CONCLUSIONS: Clinical and surgical risk factors seem to have different influences on the outcome of ALM. 3D histology allows reduction of excision margins by two-thirds without an increased risk of local recurrences and with better prognosis. 3D immunohistology could be a valuable diagnostic tool to reduce the rate of local recurrences.

Impact of multiresistance of gram-negative bacteria in bloodstream infection on mortality rates and length of stay.

BACKGROUND: Bloodstream infections (BSI) with gram-negative bacteria (GNB) are one of the most serious infections in the hospital setting, a situation compounded by the increasing antibiotic resistance of gram-negative bacteria causing BSI. The aim of the study was to assess the impact of antibiotic multiresistance of GNB in BSI on mortality rates and length of stay (LOS). MATERIALS AND METHODS: The setting was the University Hospital Aachen, a 1,500-bed tertiary-care hospital with over 100 ICU beds providing maximal medical care in all disciplines. We performed a 5-year hospital-wide matched cohort study (January 1996 to February 2001) in which 71 cases and 99 controls were enrolled. Matching criteria were sex, age and GNB isolated in blood cultures. Multiresistance was defined as resistance against at least two different classes of antibiotics such as penicillins (+beta-lactamase-inhibitor), third-generation cephalosporins, fluoroquinolones or carbapenems. RESULTS: BSI were mainly nosocomially acquired, and cases of BSI with multiresistant bacteria were associated with a higher mortality (p=0.0418) and a prolonged LOS in the intensive care unit (ICU) (p=0.0049). Risk factors for BSI with multiresistant GNB were antibiotic treatment (p=0.0191) and mechanical ventilation (p=0.0283). CONCLUSION: Multiresistance of GNB causing BSI was associated with higher mortality rates and longer LOS in ICU. The initial antibiotic therapy was significantly more often inadequate and might have had an impact on overall mortality. Thus, an effective strategy to administer an appropriate initial empirical antibiotic therapy, especially in patients with risk factors, must be sought. Moreover, the overall usage of antimicrobials must be limited and infection control guidelines should be followed to reduce the emergence and transmission of multiresistant GNB.

[Diagnostics and therapy for invasive fungal infections in an intensive care unit]. / Diagnostik und Therapie invasiver Pilzinfektionen auf der Intensivstation.

Invasive fungal infections are associated with a high mortality and have been increasing in incidence over the last few decades. Candidemia and, less commonly, invasive pulmonary aspergillosis are the most relevant fungal infections in critical care medicine. Risk factors for systemic Candida infections are the use of broad-spectrum antibiotics, a prolonged stay in an intensive care unit and gastrointestinal injury or surgery. Invasive aspergillosis usually occurs in immunocompromised patients. The diagnosis of invasive fungal infections remains challenging. The therapeutic spectrum includes fluconazol, conventional and liposomal amphotericin B, and the recently introduced agents caspofungin and voriconazol. For rational and cost-effective use, the clinician requires precise knowledge of the indications and limitations of these agents. This review focuses on the diagnostic and therapeutic options in severe Candida infections and invasive aspergillosis.

Comparison of microscopic examination and human papillomavirus DNA subtyping in vulvar lesions of premenarchal girls.

STUDY OBJECTIVE: The purpose of this study is to compare the microscopic examination and human papillomavirus (HPV) DNA subtyping of vulvar specimens from premenarchal girls clinically diagnosed with condyloma to determine whether DNA subtyping aids in the diagnostic process. DESIGN: A retrospective chart review was performed on all premenarchal girls who underwent surgical treatment of clinically diagnosed condyloma between 1993 and 1999 at the University of Michigan Medical Center by the Pediatric and Adolescent Gynecology Service. Tissue was sent for pathologic evaluation and in 10 patients the specimens also underwent DNA subtyping. One patient had prior DNA subtyping. All the other lesions were surgically ablated. The microscopic slides were reviewed by a single pathologist blinded to the study. SETTING: The study was performed in a tertiary care university hospital. PARTICIPANTS: The study group included 11 premenarchal girls with an average age of 2.3 yr. MAIN OUTCOME MEASURES: The charts were reviewed for previous HPV treatment, maternal history of HPV, history of sexual abuse, microscopic diagnosis, and HPV DNA subtyping. RESULTS: Four patients had prior surgical treatment and two patients had undergone prior medical treatment. The microscopic diagnosis was condyloma in 8 patients, chronic dermatitis in 2 patients, and 1 patient had VIN 2-3. All 11 specimens tested positive for HPV DNA, 10 specimens contained at least one of the low-risk subtypes (6, 11, 42, 43, 44), and 1 tested positive for low-risk as well as intermediate/high-risk HPV subtypes (16, 18, 31, 33, 35, 45, 51, 52, 56). CONCLUSIONS: Although all the patients with a clinical diagnosis of condyloma tested positive for HPV DNA, only 9 of 11 were definitely diagnosed with HPV-related pathology by microscopic examination. Therefore, in premenarchal patients with verrucous lesions in the anogenital area, microscopic evaluation alone may be inadequate as a confirmatory test when a positive clinical diagnosis has been made, and HPV DNA subtyping should be considered to avoid confusion with the diagnosis.

Home study course: spring 2001.

OBJECTIVE: The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category 1 of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.

Psychosocial and sexual functioning in women with vulvodynia and chronic pelvic pain. A comparative evaluation.

OBJECTIVE: To determine whether women with vulvodynia differ from women with chronic pelvic pain and normal controls in their psychological functioning, somatic preoccupation, pain experience and sexual functioning. STUDY DESIGN: Cross-sectional, self-report study of women presenting to University of Michigan specialty and general clinics for the treatment of vulvodynia or chronic pelvic pain or seeking a routine gynecologic examination. All subjects completed questionnaires assessing demographic characteristics, pain, depressive symptoms, general affective state, marital adjustment, functional activity, somatic complaints, exposures, and medical and sexual history. Univariate analyses, chi 2 tests, analyses of variance and logistic regression were used to assess associations between these variables and the diagnostic category. RESULTS: Women with vulvodynia (n = 31) were similar to asymptomatic control women (n = 23) in demographic characteristics, sexual relationship variables, sexual behaviors, current and past depression, somatic sensitivity, and history of sexual or physical abuse. Women with chronic pelvic pain (n = 18) were younger and less educated than the other two groups and were more likely to have a history of physical and sexual abuse, to report recent depression and to screen positive for current depression, to have more work absences and to have more somatic complaints. CONCLUSION: Women with vulvodynia are psychologically similar to control women but differ significantly from women with chronic pelvic pain. A primary psychological cause of vulvodynia is not supported.

Use of the McGill Pain Questionnaire to compare women with vulvar pain, pelvic pain and headaches.

OBJECTIVE: To assess differences between women with three distinct types of chronic pain conditions using a modified McGill Pain Questionnaire. STUDY DESIGN: Data by self-administered questionnaire were collected on patients presenting to the University of Michigan Medical Center with chronic vulvar pain (144 patients), pelvic pain (198 patients) or headaches (130 patients). Data for analysis included: patient demographics, duration of pain and modified McGill Pain Questionnaire scores. Univariate and multivariate analyses were performed. RESULTS: Patients with vulvar pain had more formal education (P < .001), were more likely to be married (P < .001) and were less likely to be African American (P = .003) as compared to those with chronic pelvic pain and headaches. Chronic pelvic pain patients were younger than those in the other two groups (P = .002), and headache patients were likely to have had their chronic pain for a shorter duration than those with vulvar or pelvic pain (P < .001). Patients with vulvar pain had lower total scores on the McGill Pain Questionnaire as well as on the four subsets of variables: affective, sensory, cognitive and miscellaneous indexes (P < .001). They also chose fewer words to describe their symptoms from the 20-word lists (P < .001) and had lower average scores in each of the 20 categories as compared to the other two groups (P < .0001). Controlling for age, ethnicity and marital status did not alter this significance. CONCLUSION: Patients with vulvar pain were a unique groups when compared to other chronic pain populations. Evaluation of the demographics and McGill Pain Questionnaire scores confirmed the distinct qualities of women with vulvar pain.

Current evaluation and management of vulvovaginitis.

There are many problems in the diagnosis and treatment of vaginitis. Often, the patient is not examined (telephone treatment) or examined improperly with lack of attention to the wet prep. In patients with recurrent vaginitis, it should not be assumed that the current infection is the same as a previous infection without a thorough examination. At times, there is an overuse of topical steroids for all vulvar symptoms or use of antifungals for all vulvar symptoms. The various abnormalities in vulvovaginitis have unique physical findings, laboratory tests, and treatments. It should be remembered that unusual conditions of the vagina and vulva may resemble vulvovaginitis. Many vulvar conditions must be considered when a patient reports discharge and itching. It is important to remember that if the treatment is not working, reconsider the diagnosis.

Epidemiology of vulvar vestibulitis syndrome: an exploratory case-control study.

BACKGROUND: Vulvar vestibulitis syndrome (VVS) is a chronic, persistent syndrome characterised by vestibular pain, tenderness, and erythema. The aetiology of VVS is unknown and few of the hypothesised risk factors have been tested in controlled studies. METHODS: Using a matched case-control study design, medical, sexual, health behaviour, and diet history of 28 women with VVS were compared with 50 friend controls without VVS to identify possible causal factors. RESULTS: Cases were more likely than controls to report every vaginal and urinary symptom at the time of interview measured, particularly vaginal soreness or pain (60.7%) and pain during intercourse (64.3%). There were no significant differences between cases and controls with respect to sexual behaviour. Cases were more likely than controls to report self reported history of physician diagnosed bacterial vaginosis (OR = 22.2, 95% CI = 2.8, 177.2, p value = 0.0001), vaginal yeast infections (OR = 4.9, 95% CI = 1.4, 18.0, p value = 0.01), and human papillomavirus (OR = 7.1, 95% CI = 0.6, 81.2, p value = 0.08). There were no differences between cases and controls with respect to dietary intake of oxalate. Cases were more likely than controls to report poor health status (OR = 5.7, 95% CI = 1.1, 28.7, p value = 0.02) and history of depression for 2 weeks or more during the past year (OR = 4.4, 95% CI = 1.6, 12.3, p value = 0.002). CONCLUSION: Self reported history of bacterial vaginosis, yeast infections, and human papillomavirus were strongly associated with VVS. An infectious origin for VVS should be pursued in larger controlled studies, using questionnaire and laboratory measures.

Lichen sclerosus in pregnancy: presentation of two cases.

Numerous skin diseases occurring in the pregnant patient have been reported. Some of these diseases are unique to pregnancy and some, including vulvar varicosities, vulvar edema, postpartum labial adhesions, and hematomas, are a result of physiological changes of pregnancy or the birth process. In addition, a variety of viral and bacterial infectious diseases of the vulva may occur during pregnancy. Vulvar neoplasms may also be found in pregnancy. In two patients, ages 27 and 31, lichen sclerosus first was diagnosed during their initial prenatal visits. Only one of the patients was symptomatic. The symptomatic patient used topical steroids for relief of vulvar itching. Two patients with lichen sclerosus of the vulva in pregnancy are reported, with emphasis on the diagnosis and treatment of this condition.

Vulvar conditions and their treatment. Evaluation of a patient information booklet.

OBJECTIVE: To identify the effectiveness of a patient information booklet on vulvar conditions and to evaluate future patient needs. STUDY DESIGN: A patient education booklet and satisfaction survey were distributed to 75 new patients with various vulvar conditions who were seen at the University of Michigan Center for Vulvar Diseases in 1996. This population's desire for health and disease information was analyzed. The 48-page booklet contains information on specific vulvar conditions most often seen, their common manifestations and treatment options. A survey with an attached, stamped envelope addressed for return to the Center for Vulvar Diseases was given to the patient along with the booklet during her initial visit to the clinic. Factors evaluated included the usefulness of the material, ease of reading, need for additional information and enhancement of communication with health care providers. RESULTS: Fifty-six percent of the surveys were returned. The majority of the patients found the material to be very useful and easy to read and understand. The booklet allowed better communication between patients and their health care providers. All the patients surveyed would recommend the booklet to a friend. Several of the patients utilize and desire computerized patient education. CONCLUSION: There is great consumer interest in patient education. A comprehensive booklet such as ours provides consistent information. Evaluation of patient education can provide important quality-improvement information to optimize health care services. Future patient needs are important factors to consider. The information in the booklet is available to the public on the internet at http:/(/)www.med.umich.edu/obgyn/vulva/ vulvedu.html.

Literature-filing system for vulvar conditions.

OBJECTIVE: To develop a classification system for the retrieval of stored material on various vulvar conditions. STUDY DESIGN: The major subject areas of vulvar conditions and management were identified. They were further classified into categories and subcategories. A numbering system was chosen for coding. The information was formatted to allow retrieval from the Internet in a framework ready for label printing. RESULTS: The classification system developed provides guidelines that are useful in making retrieval of stored material on various vulvar conditions more efficient. It can be expanded and personalized to fit the practitioner's needs and can be obtained from the Internet in the following manner by opening Netscape and entering the location: http:/(/)www.med.umich.edu/obgyn/vulva/ vulvalit.html. The filing system was formatted to allow standard, 5266, file-folder-sized label sheets to be inserted into the printer, allowing access to pretyped labels. A total of 464 labels will be printed. CONCLUSION: This system for retrieving vulvar information will be useful to many people, including clinicians, educators and researchers. The information is easily obtained from the Internet and printed in label form. It aids in the development of a system for life-long learning.

Comparison of the ultrasonic scalpel to CO2 laser and electrosurgery in terms of tissue injury and adhesion formation in a rabbit model.

OBJECTIVE: To determine the relative effect of an ultrasonic scalpel on reproductive tissue compared with CO2 laser and electrosurgery. DESIGN: Prospective, randomized animal study. SETTING: University laboratory setting. ANIMALS: Sixteen New Zealand White rabbits. INTERVENTION(S): A steel scalpel, an ultrasonic scalpel, a CO2 laser, or electrosurgery were used to perform an ovarian wedge resection and to remove the distal uterine horn. A 3-cm longitudinal incision also was made in the uterine horn. MAIN OUTCOME MEASURE(S): The number of 1-second bursts of needle-tip electrosurgery required for hemostasis, the depth and degree of coagulation necrosis, degree of fibrin deposition, and postoperative adhesion formation. RESULT(S): The amount of electrosurgery needed to achieve hemostasis was less for any of the four power techniques than for the steel scalpel, with the exception of the ultrasonic scalpel at level 5 when used on the ovary. The depth (range: 0.30 to 0.38 mm) and the degree of coagulation necrosis was not different for any of the power techniques. The fibrin score was greatest for the ultrasonic scalpel at level 5 in both the ovarian tissue and the uterine tissue. There was no difference in adhesion scores for the power techniques and the steel scalpel. CONCLUSION(S): The ultrasonic scalpel at level 3 is not different from either CO2 laser or electrosurgery in terms of hemostatic properties, coagulation necrosis, or adhesion formation in the rabbit model.