Post-cesarean surgical site infections according to CDC standards: rates and risk factors. A prospective cohort study

OBJECTIVES: The aim of this study was to document the true incidence of post-cesarean surgical site infections (SSI), according to the definition of the US Centers for Disease Control and Prevention (CDC), and to identify independent risk factors for infection. DESIGN: Prospective population-based cohort study in Norway. Setting. Sykehuset Asker og Baerum HF, a secondary community hospital, associated with the University of Oslo (UiO), Norway, accounting for 2,000 deliveries per year. Participants. All cesarean deliveries during a 12-month period from September 2003. Main outcome measures. Rate and risk factors for SSI. RESULTS: The total rate of SSI was 8.9%, with an observation period of 30 days post-operatively, compared to 1.8% registered at hospital discharge. The total response rate was 100%. There was no significant difference in SSI rate in elective or emergency cesarean section (CS), respectively. All SSI were superficial. We found 2 significant independent risk factors: operating time > or =38 min and body mass index (BMI) >30. CONCLUSION: The rate of SSI is underestimated if the observation time is limited to the hospital stay. Operating time exceeding 38 min substantially increases the risk of SSI. The finding of no significant difference in SSI rate between elective and emergency CS should lead to a different approach concerning the use of antibiotics: subgroup at risk (operating time > or =38 min and BMI >30) may benefit from antibiotics in relation to the operation, whether the CS is an emergency or elective operation.     

GRADE guidelines: 13. Preparing Summary of Findings tables and evidence profiles—continuous outcomes

Presenting continuous outcomes in Summary of Findings tables presents particular challenges to interpretation. When each study uses the same outcome measure, and the units of that measure are intuitively interpretable (e.g., duration of hospitalization, duration of symptoms), presenting differences in means is usually desirable. When the natural units of the outcome measure are not easily interpretable, choosing a threshold to create a binary outcome and presenting relative and absolute effects become a more attractive alternative.When studies use different measures of the same construct, calculating summary measures requires converting to the same units of measurement for each study. The longest standing and most widely used approach is to divide the difference in means in each study by its standard deviation and present pooled results in standard deviation units (standardized mean difference). Disadvantages of this approach include vulnerability to varying degrees of heterogeneity in the underlying populations and difficulties in interpretation. Alternatives include presenting results in the units of the most popular or interpretable measure, converting to dichotomous measures and presenting relative and absolute effects, presenting the ratio of the means of intervention and control groups, and presenting the results in minimally important difference units. We outline the merits and limitations of each alternative and provide guidance for meta-analysts and guideline developers.     

Obesity and estrogen as risk factors for gastroesophageal reflux symptoms

Context  Gastroesophageal reflux and obesity are both increasing in prevalence. The scientific evidence for an association between these conditions is sparse and contradictory. A difference between sexes concerning this relation has been proposed. Objective  To evaluate the relation between body mass and gastroesophageal reflux symptoms and determine how this relation is influenced by female sex hormones. Design  Population-based, cross-sectional, case-control study. Setting  Two consecutive public health surveys within the county of Nord-Trondelag, Norway, conducted in 1984-1986 and 1995-1997. Participants  Among 65 363 adult participants in the second survey, 3113 individuals who reported severe heartburn or regurgitation during the last 12 months were defined as cases, whereas 39 872 persons without reflux symptoms were defined as controls. Main Outcome Measure  Risk of reflux, estimated using multivariate logistic regression, with odds ratios (ORs) and 95% confidence intervals (CIs) as measures of association. Results  There was a dose-response association between increasing body mass index (BMI) and reflux symptoms in both sexes (P for trend <.001), with a significantly stronger association in women (P<.001). Compared with those with a BMI less than 25, the risk of reflux was increased significantly among severely obese (BMI >35) men(OR, 3.3; 95% CI, 2.4-4.7) and women (OR, 6.3; 95% CI, 4.9-8.0). The association between BMI and reflux symptoms was stronger among premenopausal women compared with postmenopausal women (P<.001), although use of postmenopausal hormone therapy increased the strength of the association (P<.001). Reduction in BMI was associated with decreased risk of reflux symptoms. Conclusions  There is a significant association between body mass and symptoms of gastroesophageal reflux. The association is stronger among women, especially premenopausally, and use of hormone therapy strengthens the association, suggesting that estrogens may play an important role in the etiology of reflux disease.      

Single-Incision Laparoscopic Cholecystectomy Versus Conventional Laparoscopic Cholecystectomy: Meta-analysis and Systematic Review of Randomized Controlled Trials

Background

The objective of this study was to analyze systematically the randomized, controlled trials that compared single-incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC).

Methods

The meta-analysis was conducted according to the Quality of Reporting of Meta-analysis (QUORUM) standards. The included studies were analyzed systematically using the statistical software package RevMan. The summated outcomes were expressed as the risk ratios (RR) for dichotomous variables and standardized mean differences (SMD) for continuous variables.

Results

Eleven randomized trials encompassing 858 patients were retrieved from the electronic databases. In the random effects model, postoperative pain, postoperative complications, length of hospital stay, cosmesis score, conversion rate, and time to return to normal activities were statistically comparable between the two cholecystectomy techniques. SILC was associated with a longer operating time [SMD 0.71; 95?% confidence interval (CI) 0.38, 1.05; z?=?4.18; p?<?0.0001) and an increased requirement for additional port insertion (RR 6.54; 95?% CI 2.19, 19.57; z?=?3.36; p?<?0008). However, there was significant heterogeneity among the trials.

Conclusions

SILC does not offer any advantage over CLC for treating benign gallbladder disorders. CLC may be used assiduously for this purpose.     

Arterial thrombotic manifestations in young women associated with the lupus anticoagulant

Summary To demonstrate the wide variety of clinical syndromes associated with the lupus anticoagulant (LAC), we report the case histories of three young females with arterial thrombosis in whom LAC was demonstrated. Two patients had a diagnosis of systemic lupus erythematosus and mixed connective tissue disease respectively; the other patient had no signs of underlying auto-immune disease. Arterial thrombotic events in young females should arouse suspicion of the presence of LAC although its pathophysiological significance is not established.     

Diabetes mellitus and psychological well-being. Change between 1984-1986 and 1995-1997. Results of the Nord-Trøndelag Health Study

Previous research has documented that people with diabetes report lower psychological well-being than do people with no reported disease. In recent years, new treatment regimens for diabetes have been introduced, including improved insulin and tablet treatment, easier blood sugar tests, and transfer of responsibility from doctor to patient. Have these improved methods for controlling diabetes resulted in enhanced psychological well-being for this group of patients? In this paper, we analyze changes in psychological well-being between 1984-1986 and 1995-1997 among diabetic patients. On these two occasions, the entire adult population of one county in Norway was invited to a health screening (the Nord-Tr?ndelag Health Studies, HUNT 1 and HUNT 2). Participants reached 77,224 and 65,599 persons, respectively (90.7% in HUNT 1 and 71.0% in HUNT 2). The participants responded to questionnaires, including questions on several diseases and impairments, as well as self-assessed health and psychological well-being. People with diabetes reported significantly lower well-being than people with no reported diabetes in HUNT 1 as well as in HUNT 2. However, the relationship between diabetes and well-being was significantly weaker in HUNT 2 than in HUNT 1. Self-reported Subjective health, the feeling of being strong and fit, the use of Tranquilizers, and Psychological distress had improved between the two surveys, for people with diabetes compared to people with no reported diabetes. Other outcome variables - Calmness, Cheerfulness, and Life satisfaction - were only weakly related to diabetes, and the relationship did not change significantly from HUNT 1 to HUNT 2.     

Bacterial cholangitis causing secondary sclerosing cholangitis: A case report

Background  

Although bacterial cholangitis is frequently mentioned as a cause of secondary sclerosing cholangitis, it appears to be extremely rare, with only one documented case ever reported.     

Costs of COPD in Sweden according to disease severity

OBJECTIVES: COPD is a common and disabling disease that entails high costs for society. The objectives of this study were to measure the societal costs of COPD in Sweden, and to examine the relationship between severity of illness and costs. METHODS: The costs of COPD were examined using a well-defined and representative cohort of subjects with mild, moderate, and severe COPD. Regular telephone interviews regarding resource utilization were made to a cohort of 212 subjects with COPD derived from studies of the general population in Northern Sweden. RESULTS: The annual per capita cost for COPD in Swedish crowns (SEK) was estimated at SEK 13,418 (1,284 US dollars (USD); 1,448 euros (EUR). The direct and indirect costs were SEK 5,592 (42%) and SEK 7,828 (58%), respectively. A highly significant relationship was found between severity of disease and costs. Costs for severe disease were 3 times as high as costs for moderate disease and > 10 times as high as for mild disease. Large individual variations in the level of costs were found. CONCLUSION: Assuming that the prevalence and treatment patterns are representative of Sweden as a whole, the total costs of COPD to society in 1999 were estimated at SEK 9.1 billion (USD 871 million; EUR 982 million). Subjects with mild disease (83%) accounted for 29%, while subjects with moderate disease (13%) accounted for 41% of the total costs. The subjects with severe disease (4%) accounted for the remainder (30%). Prevention, early diagnosis, and postponement of disease progression should have large monetary and policy implications.