Comparison of an alcohol-based hand sanitation product with a traditional chlorhexidine hand scrub technique for hand hygiene preparation in an equine hospital

AIMS

To investigate the efficacy of an alcohol gel-based hand antisepsis protocol compared with a traditional chlorhexidine-based protocol under conditions of routine clinical contamination, and following heavy faecal contamination.

METHODS

Twelve adult participants were recruited and on four separate days completed a hand sanitation protocol using a chlorhexidine scrub or an alcohol-based gel, with hands that were grossly clean but contaminated or with faecal contamination. Bacterial samples were obtained from participants' hands before sanitation, immediately after and then 2 hours later. All samples were cultured on blood and MacConkey agar and bacterial colonies counted after 48 hours.

RESULTS

for clean contaminated hands, the percentage reduction in bacterial colonies on blood agar immediately after hand sanitation was similar for both protocols (p=0.3), but was greater for the alcohol gel than chlorhexidine after 2 hours (p=0.005). For hands with faecal contamination, the percentage reduction in bacterial colonies on blood agar was similar for both protocols immediately and 2 hours after sanitation (p>0.2), but positive cultures were obtained on blood agar from samples collected after both protocols, for almost all participants.

CONCLUSIONS

The results indicate equivalent efficacy of the alcohol-based gel and the pre-surgical chlorhexidine protocol.

CLINICAL RELEVANCE

The alcohol-based gel protocol is an effective hand asepsis technique for grossly clean contaminated hands and those following faecal contamination, with comparable efficacy to chlorhexidine based scrub.

MOS HIP: McMaster outcome study of hypertension in pregnancy

BACKGROUND

The offspring of women with hypertension during pregnancy are at increased risk of low birthweight, preterm birth, diseases of prematurity and death. The risk of developing these outcomes among women with either preeclampsia or chronic hypertension, relative to those with gestational hypertension, is not known.

STUDY DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 1948 singleton women seen at a large tertiary care obstetrical center, whose blood pressure was greater than 140/90 mm Hg during pregnancy. The four types of hypertension were strictly defined: 864 women (44.4%) had gestational hypertension, 459 (23.6%) isolated chronic hypertension, 501 (25.7%) isolated preeclampsia, and 124 (6.4%) chronic hypertension with superimposed preeclampsia.

OUTCOME MEASURES

The primary outcome of the study was a composite of the diseases of prematurity, need for assisted ventilation for greater than 1 day, or perinatal death. The secondary outcomes were each of those included in the primary endpoint, as well as admission to the neonatal ICU, small for gestational age (SGA) birthweight and preterm birth. We controlled for the effects of other maternal risk factors, such as age, parity, history of preterm delivery, cigarette smoking, pre-pregnancy weight, diabetes mellitus (DM), renal dysfunction, and current use of an antihypertensive agent or prednisone.

RESULTS

For the primary composite outcome, compared to the offspring of women with gestational hypertension, the adjusted odds ratio was 1.9 (95% confidence interval 1.2 to 3.0) in the preeclamptic group and 2.0 (95% confidence interval 1.0 to 4.0) for those with chronic hypertension plus superimposed preeclampsia. Those with preeclampsia were at increased risk for small for gestational age birthweight (odds ratio 2.2, 95% confidence interval 1.5 to 3.1), as were the offspring of mothers who had chronic hypertension with superimposed preeclampsia (odds ratio 2.1, 95% confidence interval 1.2 to 3.8). Similarly, the rate of preterm birth before 32 weeks was highest among the infants of both preeclamptic mothers (28.5%; odds ratio 4.7, 95% confidence interval 2.9 to 7.6) and those with chronic hypertension and preeclampsia (30.5%; odds ratio 3.5, 95% confidence interval 1.8 to 6.7). The perinatal mortality rate was highest in the group of women with chronic hypertension plus preeclampsia (9.2%; odds ratio 3.2, 95% confidence interval 1.2 to 9.1). Other significant risk factors for the primary composite outcome included previous preterm delivery (odds ratio 2.7, 95% confidence interval 1.4 to 5.2), smoking (odds ratio 1.8, 95% confidence interval 1.1 to 3.0) and use of an antihypertensive agent during pregnancy (odds ratio 1.8, 95% confidence interval 1.2 to 2.7). Prednisone use was strongly associated with risk for perinatal death (odds ratio 4.9, 95% confidence interval 1.4 to 17.1).

CONCLUSIONS

Relative to women with isolated gestational hypertension, those who develop preeclampsia, either with or without underlying chronic hypertension, experience worse perinatal outcomes. A history of previous preterm delivery and maternal smoking increase the rate preterm birth and major perinatal disease. Antihypertensive and prednisone therapy may be important risk factors for adverse perinatal events, but further research is needed to confirm these findings.

A randomised double-blind placebo controlled trial of low molecular weight heparin as prophylaxis in preventing venous thrombolic events after caesarean section: a pilot study

OBJECTIVE

To pilot a protocol for a national multicentre randomised trial in which a low molecular weight heparin will be compared with placebo for prevention of venous thrombotic events occurring within six weeks after caesarean section.

DESIGN

Double-blind randomised controlled trial.

SETTING

Tertiary care centre.

PARTICIPANTS

Seventy-six women having had a caesarean section, 37 in the control group and 39 in the Dalteparin group.

METHODS

Consenting patients having had an emergency or elective caesarean section were commenced on study medication 6-24 hours post-operatively. The study medication, dalteparin 2,500 iu or saline, was given subcutaneously once daily for four or five days post-operatively depending on the patient's length of stay. Patients were reviewed in hospital for operative outcomes and contacted at two and six weeks post-operatively.

RESULTS

Of the 141 women given information about the trial, 76 (54%) consented to participate. Follow up to six weeks was achieved in all women who were recruited. More women in the placebo arm had general anaesthesia, but otherwise the two groups had similar characteristics at randomisation. There was only one occurrence of a deep vein thrombosis during the study. This patient was in the treatment arm and the thrombosis occurred between two and six weeks post-operatively. All other outcomes were similar in the two groups.

CONCLUSION

Our experience of a 26% recruitment rate, the thrombosis rate of 1.3% (95% CI 0.03-7.1%) and the contactability of all participants two and six weeks post-operatively, indicates that this study is feasible.

Platelet count may predict abnormal bleeding time among pregnant women with hypertension and preeclampsia

BACKGROUND

Anesthesiologists often require laboratory data to estimate the bleeding risk among hypertensive pregnant women prior to administering regional anesthesia. Many rely on the bleeding time (BT) in making this determination. We examined whether the platelet count can adequately predict BT among a group of hypertensive parturients.

METHODS

This retrospective subgroup analysis, taken from a cohort of 2,051 hypertensive pregnant women, comprises 87 individuals who underwent both a BT and platelet count prior to delivery. We calculated the correlation between the platelet count and BT at three platelet cut-off points with respect to prolonged BT of eight minutes or more.

RESULTS

There was a significant negative correlation between platelet count at delivery and BT [r= -0.45, 95% confidence interval (CI) -0.26 to -0.60; P <0.0001]. All three platelet cut-off points had a sensitivity of less than 66% with negative predictive values below 75% for an abnormal BT. A platelet count > or =75 x 109/L [corrected] was specific for the presence of an abnormal BT (specificity 97.8%, 95% CI 91.7-100.0), with a positive predictive value of 95.5% (95% CI 83.1-100.0) and a positive likelihood ratio of 24 (95% CI 3.3-168).

CONCLUSIONS

In a group of hypertensive parturients, the platelet count appears to be very specific for predicting a prolonged BT The platelet count may aid the anesthesiologist in determining the risk of bleeding from regional anesthesia. Given the study's potential for bias future research is needed to validate these findings.

Paroxysmal nocturnal hemoglobinuria and the risk of venous thrombosis: review and recommendations for management of the pregnant and nonpregnant patient

BACKGROUND

Paroxysmal nocturnal hemoglobinuria is a rare, clonal primitive hematopoietic cell disorder, often affecting middle-aged adults, including women of reproductive age. Major morbidity and mortality with this disease are often ascribed to the development of venous thromboembolism. We reviewed the current literature on the risk of venous thrombosis among nonpregnant and pregnant patients, and generated recommendations for the prevention of venous thromboembolism, as well as duration of treatment for affected patients who develop thrombotic disease.

METHODS

We searched Medline for papers published between January 1966 and April 1999. We also requested relevant unpublished data from speakers who attended a recent international workshop of paroxysmal nocturnal hemoglobinuria. References from all primary data and review publications were also examined. Only English language publications were included. Event rates for venous thromboembolism and death were pooled using a random effect technique. Reports of paroxysmal nocturnal hemoglobinuria during pregnancy were summarized using descriptive statistics only.

RESULTS

Thirteen retrospective studies of paroxysmal nocturnal hemoglobinuria in nonpregnant individuals were found. The rates of venous thrombosis varied considerably, but were reported to affect 14.4% of all individuals [95% confidence interval (CI) 7.6-25.5]. Among patients from western nations, venous thromboembolism seemed to develop at a higher rate (30.3%, 95% CI 26. 1-34.9). The majority of venous thromboembolic events were intra-abdominal, principally within the hepatic and mesenteric veins. The likely cause of death among patients with paroxysmal nocturnal hemoglobinuria was described in nine studies: 22.2% of fatalities were due to venous thrombosis (95% CI 11.8-38.0), more commonly in western countries (event rate 37.2%, 95% CI 21.6-56.0). Another 20 published reports described the outcome of 33 pregnant women with paroxysmal nocturnal hemoglobinuria. Two women developed venous thromboembolism during pregnancy and another 2 during the postpartum state for a combined event rate of 12.1% (95% CI 3.4-25.2), three of which resulted in death. The all-cause mortality rate was 20.8% (95% CI 7.3-39.0). Both anemia (event rate 72.7%, 95% CI 56.5-86.3), and thrombocytopenia (event rate 27.3%, 95% CI 13.7-43.5) were common, often necessitating red cell or platelet transfusions. Almost half of all infants (54.8%, 95% CI 36.1-72.7) were delivered preterm, and had a mean live birth weight of 2,800 g. Three of 34 reported births ended in death (perinatal mortality rate 8.8%, 95% C 1.9-23.7).

CONCLUSION

In accordance with the apparently high rate of venous thrombosis among pregnant and nonpregnant individuals with paroxysmal nocturnal hemoglobinuria, especially for fatal thrombosis, we developed practical recommendations for the prevention and treatment of venous thromboembolic disease in these groups.

Bleeding risk and reproductive capacity among patients with factor XIII deficiency: a case presentation and review of the literature

Factor XIII deficiency is an uncommon, inherited bleeding disorder that usually manifests in infancy or early childhood, involving both boys and girls. We present the case of a woman who had experienced two previous intracranial bleeding events, and was treated before and during her current pregnancy with factor XIII concentrate. Her pregnancy was successful, and she experienced an uncomplicated vaginal delivery. To better understand the issues surrounding bleeding, reproductive capacity, and management of factor XIII deficiency during pregnancy, we conducted a systematic literature review using MEDLINE from 1966 to December 1998. We also examined the bibliographic references from all articles, and included all cases, case reports, or case series of patients with factor XIII deficiency. We retrieved data on 117 patients from 37 articles, the majority of which had type II deficiency. Among untreated patients with type II factor XIII deficiency, the literature suggests an elevated mortality rate due to uncontrolled bleeding and intracranial hemorrhage. Because of its high degree of efficacy, the evidence supports the use of life long prophylactic therapy with at least monthly infusions of factor XIII concentrate, including during pregnancy. The opinion that women with type II factor XIII deficiency have inevitable recurrent abortions, or that men are sterile, is not well substantiated. No data were found on whether treatment alters male reproductive capacity. A policy of universal factor XIII replacement, starting in childhood, will likely enable more patients to attain reproductive status. The development of an international data registry would optimally address both bleeding risk and reproductive capacity among patients with factor XIII deficiency.

"Picking winners": assessing new health technology

Are evidence-based approaches ready for health technology?

Comparison of hysterosalpingography and laparoscopy in predicting fertility outcome

In this study, we compare the prognostic significance of hysterosalpingography (HSG) and laparoscopy for fertility outcome. In a prospective cohort study in 11 clinics participating in the Canadian Infertility Treatment Evaluation Study (CITES), consecutive couples who registered between 1 April 1984 and 31 March 1987 for the evaluation of subfertility and who underwent HSG and laparoscopy were included. Unilateral and bilateral tubal occlusion at HSG and laparoscopy were related to treatment-independent pregnancy. Cox regression was used to calculate fecundity rate ratios (FRR). Of the 794 patients who were included, 114 (14%) showed one-sided tubal occlusion and 194 (24%) showed two-sided tubal occlusion on HSG. At laparoscopy, 94 (12%) showed one-sided tubal occlusion and 96 (12%) showed two-sided tubal occlusion. Occlusion detected on HSG and laparoscopy showed a moderate agreement beyond chance (weighted kappa-statistic 0.42). The adjusted FRR of one-sided tubal occlusion at HSG was 0.80, whereas two-sided tubal occlusion showed an FRR of 0.49. For laparoscopy, the FRR were 0.51 and 0.15 respectively. After a normal or one-sided occluded HSG, laparoscopy showed two-sided occlusion in 5% of the patients, and fertility prospects in these patients were virtually zero. If two-sided tubal occlusion was detected on HSG but not during laparoscopy, fertility prospects were slightly impaired. Fertility prospects after a two-sided occluded HSG were strongly impaired in cases where laparoscopy showed one-sided and two-sided occlusion, with FRR of 0.38 and 0.19 respectively. Although laparoscopy performed better than HSG as a predictor of future fertility, it should not be considered as the perfect test in the diagnosis of tubal pathology. For clinical practice, laparoscopy can be delayed after normal HSG for at least 10 months, since the probability that laparoscopy will show tubal occlusion after a normal HSG is very low.

Assessing the teratogenic potential of angiotensin-converting enzyme inhibitors in pregnancy

To assess the teratogenic potential of angiotensin-converting enzyme (ACE) inhibitors, we report on 20 prospective pregnancies and 85 identified from articles in the literature. The anomaly rate was 20.6% in small series <10 entrants (95% CI 8.7-37.9%) and 1.4% in larger series > or =10 entrants (95% CI 0.03-7.3%) p=0.0016. The most consistent anomaly seen, skull hypoplasia, along with renal dysfunction appear to be more related to prolonged or late pregnancy exposure than to first trimester exposure. There is little supportive evidence that ACE inhibitors (captopril or enalapril) are teratogenic. There seems to be no absolute reason to discontinue these 2 medications prior to pregnancy, nor to create anxiety when a patient is identified with the combination of early pregnancy and treatment with these medications. There appears to be reason to discontinue the medication in pregnancy but the adverse event rate cannot be assessed because of inadequate prospective information.

The feasibility of a control population for a randomized control trial of seizure prophylaxis in the hypertensive disorders of pregnancy

OBJECTIVE

To document the feasibility of a control population for a randomized controlled trial, we report our experience in managing hypertensive pregnancies without seizure prophylaxis.

STUDY DESIGN

An 8-year cross-sectional study in one institution was performed of all hypertensive patients.

RESULTS

Of 467 patients with preeclampsia or superimposed preeclampsia managed without seizure prophylaxis, 18 had seizure activity, 3.9% (95% confidence interval 2.3% to 6.0%). There was no seizure-related maternal mortality or major morbidity, and the perinatal mortality rate after 28 gestational weeks was the same in patients with or without seizures. By logistic regression seizures were 17.4 times more likely in preeclampsia and 8.1 times more likely in chronic hypertension with superimposed preeclampsia, compared with gestational or chronic hypertension alone.

CONCLUSION

The rate of seizures in patients with preeclampsia or superimposed preeclampsia managed without seizure prophylaxis was low and unassociated with an increase in maternal or perinatal mortality. A control arm is feasible in a randomized, controlled trial to address the issue of whether antiseizure medication can prevent eclampsia.

The prognosis for live birth among untreated infertile couples

OBJECTIVE

To estimate the likelihood of live birth and the impact of prognostic factors among untreated infertile couples.

DESIGN

Cohort follow-up study.

SETTING

Eleven infertility clinics in academic medical centers.

PATIENTS

Two thousand one hundred ninety-eight couples with infertility of > 1 year in duration. Untreated months of observations on 873 untreated couples (18,364 months) were combined with observations before the first treatment among 1,325 treated couples (9,761 months).

INTERVENTIONS

Diagnostic tests as indicated.

MAIN OUTCOME MEASURES

Time to conception for live birth; effect of baseline characteristics estimated by means of proportional hazards analysis.

RESULTS

There were 263 live birth conceptions during 28,125 months of untreated observations. The cumulative rate of conceptions leading to live birth was 14.3% at 12 months. The relevant prognostic factors were pregnancy history, duration of infertility, female partner's age, male defect, endometriosis, and tubal disease. A prediction score based on these factors would be accurate in approximately 62% of cases.

CONCLUSIONS

The estimation of live birth among untreated infertile couples is sufficiently accurate to be useful in the clinical management of infertility and in the planning of clinical trials.

Occupation and the clinical characteristics of infertile couples

BACKGROUND

The influence of social class on the composition of infertile groups and on their use of health care services could reflect how the latter meet the non-urgent needs for health care in populations.

METHODS

Clinical, demographic, and occupational variables were collected prospectively from 2,198 couples newly registered in 11 infertility clinics. Time to diagnostic laparoscopy and time to treatment were evaluated with the use of proportional hazards analysis.

RESULTS

1) In the upper quartile of family income, the duration of infertility was six months less than for couples with the lowest incomes; 2) Tubal infertility was independently associated with lower family income; 3) Occupation and income were unrelated to the likelihood of either a complete diagnostic assessment or treatment for the infertility.

CONCLUSIONS

Social class seems an important factor in the distribution of infertility diagnoses, although occupation and income were not associated with important clinical management decisions.

Occupation and the follow-up of infertile couples

OBJECTIVE

To evaluate the influence of socioeconomic factors on the outcomes of infertility, including pregnancy, adoption, resolution, and loss to follow-up.

DESIGN

Prospective observational study.

SETTING

Infertility clinics in 11 teaching hospitals.

PATIENTS

Newly registered couples with infertility of > 1 year.

INTERVENTIONS

Demographic, clinical, and occupational data were recorded at registration, and events including treatment, pregnancy, adoption, and resolution were recorded during up to 7 years of follow-up.

MAIN OUTCOME MEASURES

Time to outcomes was evaluated by means of proportional hazards analyses with respect to the occurrence of conception of livebirth, adoption, resolution, or loss to follow-up.

RESULTS

[1] The clinical predictors of pregnancy included duration of infertility, pregnancy history, female partner's age, diagnosis of tubal defect or endometriosis, and treatment; [2] the likelihood of livebirth was 1.38 times greater in partnerships with a male professional; [3] adoption was 1.64 times more likely with male professional partners; [4] loss to follow-up was 1.61 times more likely if the female partner was unemployed; and [5] the likelihood of resolution was unrelated to occupation or income variables.

CONCLUSION

Socioeconomic factors, as expressed by occupation, are significantly associated with important outcomes among infertile couples.

Frequency and predictive value of antisperm antibodies among infertile couples

Although sperm-associated antibody could impair fertility through various mechanisms, the results of follow-up studies do not uniformly confirm that pregnancy rates are lower when one of the infertile partners demonstrates antibody to spermatozoa. We conducted a prospective double-blind cohort comparative analysis in which antibody assay results were not available to physicians or patients for clinical management. The diagnostic protocol included mid-luteal progesterone, semen analysis, hysterosalpingogram and laparoscopy. The serum of each partner was assayed by immunobead testing, tray agglutination testing and a gelatin agglutination test. Data on relevant clinical characteristics and events during follow-up were collected prospectively. Among 471 couples in whom both partners were evaluated, 42 (8.9%) tested positive for anti-sperm antibodies by one or more assays, including 38 (8.1%) male partners and 6 (1.3%) female partners. The number of conceptions was 118/429 (27.5%) in antibody negative couples, 9/38 (23.7%) in male partner-positive couples and 1/6 (16.7%) in female partner-positive couples. With proportional hazards analysis, antibody status in either partner was not a significant independent predictor of time to pregnancy.

Use of prescription drugs in the first trimester and congenital malformations

A prospective survey of prenatal use of prescription drugs in Tasmania yielded detailed information on drug exposure, delivery and outcome for 56,037 births from 1982 to 1989. First trimester drug use was reported by 30.9% of women, and 17.9% used only supplements of vitamins and/or minerals; 40% used alcohol during the first trimester, and 28.8% smoked cigarettes. There were 1,035 (1.85%) congenital malformations, of which 885 (85.5%) were major. The malformation rate was not significantly different in the following exposure categories: supplements only (1.62%); other pharmaceuticals (1.92%); smokers (1.88%); alcohol users (1.89%); and maternal age 35 or more years (1.95%). Adjusting for alcohol use, smoking, maternal age and diabetes mellitus, significant associations [expressed as adjusted odds ratio and 95% confidence intervals (CI)] were found between aspirin and hypospadias (3.5, 95% CI 1.4 to 8.8); dicyclomine and phocomelia (4.4, 95% CI 1.0 to 19.5); and between oral contraceptive use and pes cavus (9.7, 95% CI 2.3 to 40.4). Although significant, these associations were based on very few cases and no direct supporting evidence could be found from other data sources.