Ignac Semmelweis (1818-1865) of Budapest and the prevention of puerperal fever

Vindicating a traduced genius: Ignaz Philipp Semmelweis (1818-1865)

Anglophone narratives of Semmelweis's discovery of the cause and prophylaxis of childbed (puerperal) fever are based on a deficient historical record because important information about what happened to Semmelweis in Vienna, Austria, is contained in primary documents that had never been translated into English until very recently. The gaps in these narratives have been filled with invented facts and causal attributions that traduce Semmelweis by berating his character, education, and writing proficiency to hold him solely responsible for the rejection of his theory by most of his contemporaries and to explain the most puzzling aspect of his life: why he did not publish the results of his groundbreaking research in a medical journal for 11 years. This article presents the historical evidence contained in these primary documents that were missing from previous narratives and that provide very rational and understandable explanations for Semmelweis's actions. It also presents evidence that flatly contradicts the claims that have been made about Semmelweis's character, education, and writing skills and offers a more veridical portrayal of what happened to Semmelweis in Vienna that caused him to leave the city and delay publishing his results.

Prevention of Infection and Disruption of the Pathogen Transfer Chain in Elective Surgery

The COVID-19 pandemic has caused us all to stop our normal activities and consider how we can safely return to caring for our patients. There are many common practices (such as an increased use of personal protective equipment) which we are all familiar with that can be easily incorporated into our daily routines. Other actions, such as cleaning more surfaces with solutions such as dilute povidone iodine or changing the air filtration systems used within operating room theaters, may require more extensive efforts on our behalf. In this article, we have attempted to highlight some of the changes that arthroplasty surgeons may need to instigate when we are able to resume elective joint arthroplasty procedures in an effort to disrupt the chain of pathogen transfer.

Total Knee Replacement: The Inpatient-Only List and the Two Midnight Rule, Patient Impact, Length of Stay, Compliance Solutions, Audits, and Economic Consequences

BACKGROUND

In November 2017, CMS finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed TKA from the Medicare inpatient-only (IPO) list. This action had significant and unexpected consequences.

METHODS

We looked at 3 levels of the IPO rule impact on TKA for Medicare beneficiaries: a national comparison of FFS inpatient and outpatient classification for 2017 vs 2018; a survey of AAHKS surgeons completed in April 2019; and an in-depth analysis of a large academic medical center experience. An analysis of change in admission classification of patients with TKA over time, number of QIO audits, compliance solutions for the new rule, and cost implications of those compliance solutions were evaluated.

RESULTS

Hospital reimbursement averages $10,122 in an outpatient facility but does not include the physician payment. Average hospital reimbursement in the inpatient setting is $11,760. The difference in hospital reimbursement varies widely (90th percentile decrease, $6725 vs 10th percentile $2048). Physician payments are the same in both settings (avg $1403). Patients with TKA not designated for inpatient admissions are not eligible for bundle payment programs. Patients designated as outpatients are subjected to higher out-of-pocket expenses. Patients may have an annual Medicare Part B Deductible ($185) and a 20% copay as well as prescription and durable medical equipment costs. An AAHKS survey demonstrated that 45.08% were with inpatient designation only, 17.62% were with outpatient designation only, 25.39% were designated as necessary, and 10.1% were designated by the hospital. This survey showed that 66 of 374 (17.65%) patients had undergone a QIO audit as a result of issues with the IPO rule. An evaluation of an AMC demonstrated that since January 1, 2018, 470 of 690 (68.1%) of CMS patients with TKA left in less than 2 midnights. The institution was subjected to 2 QIO audits.

CONCLUSIONS

There are many unintended consequences to the IPO rule application to TKA.

Gender medicine: its historical roots

Gender medicine as a subject began with Bernadine Healy’s 1991 article ‘The Yentl Syndrome’ which showed that women had worse outcomes following heart attacks since their symptoms are different from men. Since then gender-specific clinical research protocols have been progressively included so that evidence for guidelines can be better informed such that women are then less disadvantaged and care become more personalised. This paper traces back the historical roots of gender bias in medicine in Western culture, which is reflected in the pictorial arts and writings of each historical period, beginning with Hippocrates. It describes the changes that have led to attempts at improving the place of women, and the treatments of disease, on an equal footing with men, precipitated by Healy’s paper.

Using Historical Scientific Controversies to Promote Undergraduates' Argumentation

The Covid-19 pandemic is the reason why humanity is paying more attention to the importance of regular and rigorous handwashing. Interestingly, in the nineteenth century, regular and rigorous handwashing was a key (and controversial) solution proposed by the Hungarian obstetrician Ignaz Philipp Semmelweis to cut drastically cases of puerperal fever. The purpose of this study was to provide evidence that the case of Semmelweis and puerperal fever-a crucial historical scientific controversy-can be used as a springboard to promote university student argumentation. Our study was inspired by the fact that the Organization for Economic and Cooperative Development (OECD) stressed that more efforts and resources should be invested in promoting argumentation as an essential component for scientifically literate citizens in twenty-first century societies. However, nowadays, argument and debate are virtually absent from university science education. The data was derived from 124 undergraduates' (64 females and 60 males, 15-30 years old) written responses and audio and video recordings in a university biology course in Colombia. The findings show that the articulation of this historical controversy with decision-making, small-group debate, and whole-class debate activities can be useful for promoting undergraduates' argumentation. This study contributes to the development of a research-based university science education that can inform the design of an argumentation curriculum for higher education.

Conceptual Design of a Universal Donor Screening Approach for Vaginal Microbiota Transplant

The success of fecal microbiota transplant (FMT) in treating recurrent Clostridioides difficile infection has led to growing excitement about the potential of using transplanted human material as a therapy for a wide range of diseases and conditions related to microbial dysbiosis. We anticipate that the next frontier of microbiota transplantation will be vaginal microbiota transplant (VMT). The composition of the vaginal microbiota has broad impact on sexual and reproductive health. The vaginal microbiota in the "optimal" state are one of the simplest communities, dominated by one of only a few species of Lactobacillus. Diversity in the microbiota and the concomitant depletion of lactobacilli, a condition referred to as bacterial vaginosis (BV), is associated with a wide range of deleterious effects, including increased risk of acquiring sexually transmitted infections and increased likelihood of having a preterm birth. However, we have very few treatment options available, and none of them curative or restorative, for "resetting" the vaginal microbiota to a more protective state. In order to test the hypothesis that VMT may be a more effective treatment option, we must first determine how to screen donors to find those with minimal risk of pathogen transmission and "optimal" vaginal microbiota for transplant. Here, we describe a universal donor screening approach that was implemented in a small pilot study of 20 women. We further characterized key physicochemical properties of donor cervicovaginal secretions (CVS) and the corresponding composition of the vaginal microbiota to delineate criteria for inclusion/exclusion. We anticipate that the framework described here will help accelerate clinical studies of VMT.

Biology of Hand-to-Hand Bacterial Transmission

Numerous studies have demonstrated that adequate hand hygiene among hospital staff is the best measure to prevent hand-to-hand bacterial transmission. The skin microbiome is conditioned by the individual physiological characteristics and anatomical microenvironments. Furthermore, it is important to separate the autochthonous resident microbiota from the transitory microbiota that we can acquire after interactions with contaminated surfaces. Two players participate in the hand-to-hand bacterial transmission process: the bacteria and the person. The particularities of the bacteria have been extensively studied, identifying some genera or species with higher transmission efficiency, particularly those linked to nosocomial infections and outbreaks. However, the human factor remains unstudied, and intrapersonal particularities in bacterial transmission have not been yet explored. Herein we summarize the current knowledge on hand-to-hand bacterial transmission, as well as unpublished results regarding interindividual and interindividual transmission efficiency differences. We designed a simple in vivo test based on four sequential steps of finger-to-finger contact in the same person artificially inoculated with a precise bacterial inoculum. Individuals can be grouped into one of three observed transmission categories: high, medium, and poor finger-to-finger transmitters. Categorization is relevant to predicting the ultimate success of a human transmission chain, particularly for the poor transmitters, who have the ability to cut the transmission chain. Our model allowed us to analyze transmission rate differences among five bacterial species and clones that cause nosocomial infections, from which we detected that Gram-positive microorganisms were more successfully transmitted than Gram-negative.

“No Good Deed Goes Unpunished”: Ignaz Semmelweis and the Story of Puerperal Fever

Ignác Fülöp Semmelweis was born almost 200 years ago, in 1818, to a well-to-do middle class Hungarian family. He started law school in 1837, switched to medicine a year later, and graduated in 1844.

Group A Streptococcal Infection in Pregnancy and the Puerperium

There has been an increasing incidence worldwide of invasive group A streptococcal disease in pregnancy and the puerperal period over the past 30 years. Group A Streptococcus (GAS) was identified as the major cause of maternal morbidity and mortality from sepsis before the identification that hand washing techniques could prevent the transmission of the bacteria. Hand washing remains the cornerstone of prevention as transmission can occur directly from an asymptomatic colonized healthcare provider, other patients, or a community-acquired source. Pregnancy and the puerperal period are associated with significant maternal physiologic changes that must be identified and clarified to identify signs and symptoms of GAS so that treatment can be initiated at the earliest moment. Treatment of group A streptococcal sepsis follows the guidelines developed under the Surviving Sepsis Campaign model. Maternal outcomes are improved by identifying risk factors and working with the perinatal team to implement rapid intervention. Even with prompt treatment of invasive group A Streptococcus, it remains the most common cause of infection that results in severe maternal morbidity and death in the world.

From joint thinking to joint action: a call to action on improving water, sanitation, and hygiene for maternal and newborn health

Yael Velleman and colleagues argue for stronger integration between the water, sanitation, and hygiene (WASH) and maternal and newborn health sectors. Please see later in the article for the Editors' Summary.

Cytokine immunomodulation for the treatment of infectious diseases: lessons from primary immunodeficiencies

Traditionally, management of infectious diseases focuses on identification of the causative microbe and the use of pathogen-targeted therapy. With increasing antimicrobial resistance, novel approaches are required. One strategy is to modulate those natural host immune responses that critically mediate resistance to specific microbes. Clinically, this host-directed tactic could be used either alone or in combination with antimicrobial therapy. While conceptually attractive, there is potential concern that the pathways governing host resistance to pathogens in animal models may not extrapolate linearly to humans. Targeting these immune processes clinically may precipitate damaging, epiphenomenal responses. The field of Primary Immunodeficiencies focuses on the characterization of humans with inborn errors of immunity. These rare conditions permit the identification of those molecular and cellular processes that are central to human susceptibility to microbes. In efforts to compensate for defective host responses, this field has also provided a wealth of clinical experience in the effective use of cytokines to treat various active infections, while demonstrating their safety. In this review, we provide a historical perspective of the treatment of infectious diseases, evolving from a focus on the microbe, to an understanding of human immunity; we then outline the growing contribution of Primary Immunodeficiencies to the rational use of adjunctive cytokine immunotherapy in the management of infections.

The "hands together" method of nonsterile scalpel blade mounting and removal

Scalpels are utilized by many different user groups for such purposes as medical procedures and dissection. Injuries caused by scalpels are a potential risk for scalpel users, and include injuries that may occur while mounting and removing the scalpel blade. Between 10% and 20% of all scalpel injuries in education and healthcare settings are reported to occur while scalpel blades are being mounted or removed. At present there are few published or "best practice" demonstrations of safe technique for scalpel blade mounting and removal. This brief article outlines a variation of the procedure for scalpel blade mounting and removal. It includes strategies developed to minimize risk or injury for the scalpel user, including providing a stable base for the hands and arms so as to prevent unnecessary large amplitude movements that may lead to injury of the scalpel user or a third party. Such a technique may promote scalpel safety, contribute to the development of "best practice" scalpel use, and help decrease injuries that may be caused while mounting or removing scalpel blades.

[A look into the past: improves in obstetrical and neonatal outcome in maternity since the 19th century]

OBJECTIVE

Evaluate changes in obstetrical and neonatal outcome of women who delivered in maternity hospital since the 19(th) century.

MATERIALS AND METHODS

Data from a historic cohort of 1022 women who delivered between 1871 and 1874 in the hôtel Dieu hospital of Marseille were compared to those from 1159 women who delivered from 2005 to 2006 in the level 3 maternity of Nord hospital of Marseille (contemporary cohort). Deliveries that had occured before 22 weeks and/or with a foetal birth weight of less than 500 g were excluded.

RESULTS

A total of 2131 pregnancies were included: 1011 and 1120 in historic and contemporary cohort, respectively. Despite comparable mean term of delivery, mean birth weight of neonates from historic cohort were significantly lower: 2971 g (550-4900 g) vs 3250 g (500-5375 g), respectively (p<0.001). Stillbirths were reported in 72 (7.1%) cases in historic cohort compared to nine (0.8%) in contemporary cohort (p<0.001). Neonatal mortality was 3.7% in historic cohort and 1.9% in contemporary cohort (p=0.012). A total of 99 (9.8%) maternal deaths were reported in historic cohort, while none in contemporary cohort (p<0.001). A wide majority of maternal deaths were caused by maternal infection (72.9%); 5.2% were caused by postpartum haemorrhage.

CONCLUSION

Our results illustrate the tremendous impact on maternal and neonatal outcome of advances in obstetrical management. The significant increase in the median foetal birth weight is likely to be related to wide changes in environmental conditions and behaviour.

Streptococcal A infection: reemerging and virulent

Streptococcal A infections are reemerging as a dangerous clinical problem. This particular infection is usually a problem for the postpartum mother and not usually associated with fetal or neonatal infections. Maternal morbidity and mortality are overwhelming when compared with other maternal infections. Historically, group A streptococcus was the cause of epidemic postpartum sepsis prior to the advent of proper hand-washing techniques. Currently, transmission can occur directly from a colonized healthcare provider, other patients, or a community-acquired source. The Joint Commission and the International Surviving Sepsis Campaign have placed patient safety and early recognition and treatment of sepsis as major initiatives to improving patient outcomes.

Hospital-acquired infections in the NICU: epidemiology for the new millennium

Nosocomial infections are an important cause of morbidity and mortality in the preterm neonate. Extrinsic and intrinsic risk factors make the preterm neonate particularly susceptible to infection. This review focuses on two major pathogens that cause nosocomial infection, Candida and methicillin-resistant Staphylococcus aureus. The difficult diagnosis of meningitis in the neonate also is discussed.

Puerperal Pyrexia: A Review. Part I

Puerperal pyrexia and sepsis are among the leading causes of preventable maternal morbidity and mortality not only in developing countries but in developed countries as well. Most postpartum infections take place after hospital discharge, which is usually 24 hours after delivery. In the absence of postnatal follow-up, as is the case in many developing countries, many cases of puerperal infections can go undiagnosed and unreported. Besides endometritis (endomyometritis or endomyoparametritis), wound infection, mastitis, urinary tract infection, and septic thrombophlebitis are the chief causes of puerperal infections. The predisposing factors leading to the development of sepsis include home birth in unhygienic conditions, low socioeconomic status, poor nutrition, primiparity, anemia, prolonged rupture of membranes, prolonged labor, multiple vaginal examinations in labor, cesarean section, obstetrical maneuvers, retained secundines within the uterus and postpartum hemorrhage. Maternal complications include septicemia, endotoxic shock, peritonitis or abscess formation leading to surgery and compromised future fertility. The transmissions of infecting organisms are typically categorized into nosocomial, exogenous, and endogenous. Nosocomial infections are acquired in hospitals or other health facilities and may come from the hospital environment or from the patient's own flora. Exogenous infections come from external contamination, especially when deliveries take place under unhygienic conditions. Endogenous organisms, consisting of mixed flora colonizing the woman's own genital tract, are also a source of infection in puerperal sepsis. Aseptic precautions, advances in investigative tools and the use of antibiotics have played a major role in reducing the incidence of puerperal infections. Part I of this review provides background information and definitions, discusses the incidence and risk factors, explains the microbiology and pathophysiology of various infections, and delineates the signs and symptoms of major puerperal infection.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that world wide puerperal sepsis is a leading cause of maternal mortality, state that many of the predisposing factors are preventable, explain that both nosocomial infections as well as exogenous infections are serious factors, and relate that septic techniques and antibiotics can play a major role in reducing the incidence of puerperal infections.

Semmelweis' present day follow-up: Updating bacterial sampling and enrichment in clinical hygiene

Potentially dangerous antibiotic resistant contaminants have permanently penetrated at least well-off western populations. The danger is so evident that some hospitals have started to refuse accepting patients who carry such bacteria. Sampling and enrichment measures in hygiene monitoring must be updated as they are corner stones in handling the problems and safeguarding the health care units. Their patients, when exposed to microorganisms are strenuous to treat. Sometimes even this fails, if the infections are spreading in weakened patients. The present review summarizes currently used technologies and the abilities of bacteria to avoid detection. Improved protocols on environmental monitoring in healthcare units are required. They should be comparable with contamination control in industries. Actually these measures in health care should be even stricter because human lives are directly endangered as the resistance of especially elderly patients is low.