Evaluation of clinical coding data to determine causes of critical bleeding in patients receiving massive transfusion: a bi-national, multicentre, cross-sectional study

OBJECTIVES

To evaluate the use of routinely collected data to determine the cause(s) of critical bleeding in patients who receive massive transfusion (MT).

BACKGROUND

Routinely collected data are increasingly being used to describe and evaluate transfusion practice.

MATERIALS/METHODS

Chart reviews were undertaken on 10 randomly selected MT patients at 48 hospitals across Australia and New Zealand to determine the cause(s) of critical bleeding. Diagnosis-related group (DRG) and International Classification of Diseases (ICD) codes were extracted separately and used to assign each patient a cause of critical bleeding. These were compared against chart review using percentage agreement and kappa statistics.

RESULTS

A total of 427 MT patients were included with complete ICD and DRG data for 427 (100%) and 396 (93%), respectively. Good overall agreement was found between chart review and ICD codes (78·3%; κ = 0·74, 95% CI 0·70-0·79) and only fair overall agreement with DRG (51%; κ = 0·45, 95% CI 0·40-0·50). Both ICD and DRG were sensitive and accurate for classifying obstetric haemorrhage patients (98% sensitivity and κ > 0·94). However, compared with the ICD algorithm, DRGs were less sensitive and accurate in classifying bleeding as a result of gastrointestinal haemorrhage (74% vs 8%; κ = 0·75 vs 0·1), trauma (92% vs 62%; κ = 0·78 vs 0·67), cardiac (80% vs 57%; κ = 0·79 vs 0·60) and vascular surgery (64% vs 56%; κ = 0·69 vs 0·65).

CONCLUSION

Algorithms using ICD codes can determine the cause of critical bleeding in patients requiring MT with good to excellent agreement with clinical history. DRG are less suitable to determine critical bleeding causes.

Improving outcomes for hospital patients with critical bleeding requiring massive transfusion: the Australian and New Zealand Massive Transfusion Registry study methodology

Background

The Australian and New Zealand (ANZ) Massive Transfusion (MT) Registry (MTR) has been established to improve the quality of care of patients with critical bleeding (CB) requiring MT (≥ 5 units red blood cells (RBC) over 4 h). The MTR is providing data to: (1) improve the evidence base for transfusion practice by systematically collecting data on transfusion practice and clinical outcomes; (2) monitor variations in practice and provide an opportunity for benchmarking, and feedback on practice/blood product use; (3) inform blood supply planning, inventory management and development of future clinical trials; and (4) measure and enhance translation of evidence into policy and patient blood management guidelines. The MTR commenced in 2011. At each participating site, all eligible patients aged ≥18 years with CB from any clinical context receiving MT are included using a waived consent model. Patient information and clinical coding, transfusion history, and laboratory test results are extracted for each patient’s hospital admission at the episode level.

Results

Thirty-two hospitals have enrolled and 3566 MT patients have been identified across Australia and New Zealand between 2011 and 2015. The majority of CB contexts are surgical, followed by trauma and gastrointestinal haemorrhage. Validation studies have verified that the definition of MT used in the registry correctly identifies 94 % of CB events, and that the median time of transfusion for the majority of fresh products is the ‘product event issue time’ from the hospital blood bank plus 20 min. Data linkage between the MTR and mortality databases in Australia and New Zealand will allow comparisons of risk-adjusted mortality estimates across different bleeding contexts, and between countries. Data extracts will be examined to determine if there are differences in patient outcomes according to transfusion practice. The ratios of blood components (e.g. FFP:RBC) used in different types of critical bleeding will also be investigated.

Conclusions

The MTR is generating data with the potential to have an impact on management and policy decision-making in CB and MT and provide benchmarking and monitoring tools for immediate application.

Elucidating the clinical characteristics of patients captured using different definitions of massive transfusion

BACKGROUND AND OBJECTIVES

The type and clinical characteristics of patients identified with commonly used definitions of massive transfusion (MT) are largely unknown. The objective of this study was to define the clinical characteristics of patients meeting different definitions of MT for the purpose of patient recruitment in observational studies.

MATERIALS AND METHODS

Data were extracted on all patients who received red blood cell (RBC) transfusions in 2010 at three tertiary Australian hospitals. MT patients were identified according to three definitions: ≥10 units RBC in 24 h (10/24 h), ≥6 units RBC in 6 h (6/6 h) and ≥5 units RBC in 4 h (5/4 h). Clinical coding data were used to assign bleeding context. Data on in-hospital mortality were also extracted.

RESULTS

Five hundred and forty-two patients met at least one MT definition, with 236 (44%) included by all definitions. The most inclusive definition was 5/4 h (508 patients, 94%) followed by 6/6 h (455 patients, 84%) and 10/24 h (251 patients, 46%). Importantly, 40-55% of most types of critical bleeding events and 82% of all obstetric haemorrhage cases were excluded by the 10/24 h definition. Patients who met both the 5/4 h and 10/24 h definitions were transfused more RBCs (19 vs. 8 median total RBC units; P < 0·001), had longer ventilation time (120 vs. 55 h; P < 0·001), median ICU (149 vs. 99 h; P < 0·001) and hospital length of stay (23 vs. 18 h; P = 0·006) and had a higher in-hospital mortality rate (23·3% vs. 16·4%; P = 0·050).

CONCLUSION

The 5/4 h MT definition was the most inclusive, but combination with the 10/24 h definition appeared to identify a clinically important patient cohort.

Clinical guidelines and off-license recombinant activated factor VII: content, use, and association with patient outcomes

BACKGROUND

Recombinant activated factor VII (rFVIIa) is increasingly being used off-license for treating critical bleeding. Guidelines may therefore be useful for improving processes and outcomes. Little is known regarding guidelines for off-license rFVIIa or their association with patient outcomes.

OBJECTIVES

To investigate the availability of hospital guidelines for off-license rFVIIa use and the association between these guidelines and mortality.

METHODS

Data were extracted from the Haemostasis Registry, which collects all cases of off-license rFVIIa use in participating institutions in Australia and New Zealand. Contributing hospitals were requested to supply a copy of the institutional guideline relating to off-license rFVIIa administration. The characteristics of patients treated in accordance with all elements of the guidelines were compared with those of patients for who one or more guideline elements had been violated. The relationship between guideline-directed treatment and 28-day mortality was investigated using stepwise logistic regression.

RESULTS

Two thousand five hundred and fifty-one patients in 75 hospitals were available for analysis. Of these hospitals, 58 provided a guideline for analysis. Patients complying with all guideline elements (n = 530) did not differ from patients receiving care that violated guidelines (n = 1035) regarding age, size of dose, or gender. Guideline-directed treatment was not found to have an association with 28-day mortality following logistic regression.

CONCLUSIONS

Few patients are treated in accordance with the criteria of rFVIIa guidelines, despite their availability in the majority of hospitals. Moreover, 28-day mortality does not appear to be associated with the use of guidelines in this patient group. Refinement of guidelines relating to the off-license use of rFVIIa is therefore required.

Mice lacking synapsin III show abnormalities in explicit memory and conditioned fear

Synapsin III is a neuron-specific phosphoprotein that plays an important role in synaptic transmission and neural development. While synapsin III is abundant in embryonic brain, expression of the protein in adults is reduced and limited primarily to the hippocampus, olfactory bulb and cerebral cortex. Given the specificity of synapsin III to these brain areas and because it plays a role in neurogenesis in the dentate gyrus, we investigated whether it may affect learning and memory processes in mice. To address this point, synapsin III knockout mice were examined in a general behavioral screen, several tests to assess learning and memory function, and conditioned fear. Mutant animals displayed no anomalies in sensory and motor function or in anxiety- and depressive-like behaviors. Although mutants showed minor alterations in the Morris water maze, they were deficient in object recognition 24 h and 10 days after training and in social transmission of food preference at 20 min and 24 h. In addition, mutants displayed abnormal responses in contextual and cued fear conditioning when tested 1 or 24 h after conditioning. The synapsin III knockout mice also showed aberrant responses in fear-potentiated startle. As synapsin III protein is decreased in schizophrenic brain and because the mutant mice do not harbor obvious anatomical deficits or neurological disorders, these mutants may represent a unique neurodevelopmental model for dissecting the molecular pathways that are related to certain aspects of schizophrenia and related disorders.

Uncontrolled bleeding in surgical patients: the role of recombinant activated factor VIIa

Recombinant activated factor VII (rFVIIa), developed and effective in managing inhibitors in haemophilia patients, is being widely used off-label as a "panhaemostatic agent" with ongoing controversy as to its benefits and risks in terms of controlling critical haemorrhage and improving patient outcomes. Current insights into haemostatic mechanisms have resulted in a better understanding of the central role of FVII/FVIIa and tissue factor in the localization and initiation of haemostasis. There is a plethora of case reports and series published on the use of rFVIIa in critical life-threatening haemorrhage and in perioperative settings associated with significant blood loss or the potential for catastrophic haemorrhage. Additionally, the literature is replete with reviews for the use of rFVIIa in various clinical settings, but there is a dearth of good evidence from randomized controlled trials for efficacy. Safety, especially from the thrombogenicity perspective, has been a major issue, but turns out to be less of a concern with thrombotic potential needing to be weighed against the anticipated benefits. Although there is some clinical trial and observational data supporting efficacy it has been difficult to recommend clear clinical practice guidelines, especially as clinical outcome data in terms of morbidity and mortality is limited. Some of the best evidence relates to reduction in allogeneic blood transfusion requirements. This in itself is important and probably clinically relevant in view of the accumulating evidence that allogeneic blood transfusion is an independent risk factor for poorer clinical outcome. It is unlikely that there will be adequate randomized clinical trials to better answer the question of efficacy, thus making data from registries of greater importance. Indeed, the process of establishing efficacy, safety and regulation of a therapeutic that is increasingly used off-label is not without significant difficulties.

Intracranial meningioma and ionizing radiation in medical and occupational settings

In a population-based case-control study of 200 cases and 400 controls in western Washington State, the authors assessed associations between meningioma and ionizing radiation in medical and occupational settings. No significant associations were observed for diagnostic studies or occupational settings, but associations were observed for radiation therapy to head or neck (odds ratio 3.7, 95% CI 1.5 to 9.5), especially for neoplastic conditions. Only four patients (2%) had meningiomas that followed high-dose cranial radiation.

History of head trauma and risk of intracranial meningioma: population-based case-control study

A population-based case-control study in western Washington state was performed to assess the relation between head trauma and meningioma. Based on 200 case and 400 control subjects, head trauma was associated with an increased risk of meningioma (odds ratio = 1.83; 95% CI = 1.28, 2.62), especially head traumas occurring 10 to 19 years before reference date (odds ratio = 4.33; 95% CI = 2.06, 9.10). A dose-response relationship was present for number, but not severity, of head traumas. Whether the associations observed in this study are causal remains unclear.

Chilling invokes different morphologies in two Salmonella enteritidis PT4 strains

The reduction in chemical preservatives in food processing has resulted in more refrigerated (chilled) products. However, the effect of chilling on Salmonella enteritidis PT4 isolates has received relatively little attention. This study investigates the effect of chilling on two Salm. enteritidis PT4 isolates, denoted E and I. These isolates differ in their tolerance to heat, acidification, survival on surfaces, and behaviour in animal models. E routinely shows greater tolerance and pathogenicity than I. Chilling invokes profound cell elongation and heterogeneity in E which corresponded to a 90% sublethal injury; neither such substantial cell elongation nor significant injury was seen in I. The ability to recover resistance to desoxycholate coincided with a reduction to normal cell size. Incomplete cell division and failure of the septum to form is a likely hypothesis for cell elongation although outer membrane changes could be responsible. Possible links are suggested between cell elongation of the hat- and acid-tolerant strain and pathogenicity.

Mastopathy in insulin-requiring diabetes mellitus

Diabetic mastopathy is a recently described collection of histopathological features found in dense fibrous breast masses in insulin-requiring diabetics. Fifty-seven breast biopsy specimens showing nonspecific benign disease were examined in a blinded fashion from 21 diabetics (seven insulin-requiring, 14 non-insulin-requiring), 30 age-matched controls and six patients with thyroid disease. Five diabetics had the constellation of extensive keloidal fibrosis, mononuclear perivasculitis, and mononuclear ductitis and/or lobulitis, whereas none of the controls or patients with thyroid disease had all of these features. All five patients with diabetic mastopathy were insulin-requiring (two type I, three type II). Epithelioid fibroblasts in the stroma, a previously described component of this constellation, were present in three of the five cases but do not appear to be essential in making the diagnosis. Four of the five diabetics were hypertensive, and three had secondary diabetic complications. The mean duration of diabetes in the five patients was greater than 13 years. Based on a previous report and the current study, this constellation of histological features appears to be relatively specific for insulin-requiring diabetes mellitus. The single clinical factor common to all patients with diabetic mastopathy in this article and in a previous study was exogenous insulin use.

Results of a double-blind, placebo-controlled clinical trial program of single-dose ceftizoxime versus multiple-dose cefoxitin as prophylaxis for patients undergoing vaginal and abdominal hysterectomy

In a series of three double-blind, controlled, clinical studies, the efficacy and safety of a single 1 gram dose of ceftizoxime were compared with those of a standard regimen, three 2 gram doses of cefoxitin, for prophylaxis of perioperative infection in women undergoing abdominal or vaginal hysterectomy. Two hundred and twenty-seven patients received ceftizoxime prophylaxis and 234 patients received cefoxitin prophylaxis. Study 1 entered 110 patients in Dallas, Texas and Los Angeles, California. Study 2 entered 242 patients in Canada. Study 3 entered 109 patients in Denver, Colorado. Within studies, the distribution of surgical procedures was comparable between antibiotic groups. The groups were similar for demographic and medical factors at each center and overall. Analyses were performed within and across studies, applying consistent criteria to the selection of evaluable patients and to the definitions of prophylactic success and primary and secondary prophylactic failure. Three hundred and sixteen patients were evaluable, 160 who received ceftizoxime and 156 who received cefoxitin. Overall, complete prophylactic success occurred in 138 of 160 evaluable patients (86.3 percent) receiving ceftizoxime and 128 of 156 evaluable patients (82.1 percent) receiving cefoxitin. Prophylactic success rates differed by study as well as by type of hysterectomy. In studies 1 and 2, prophylactic success rates for ceftizoxime were 95.1 and 87.6 percent, respectively, versus 93.1 and 87.8 percent for cefoxitin. In study 3, success rates were lowest, 70.0 percent for ceftizoxime and 59.5 percent for cefoxitin. Among evaluable patients overall, prophylactic success rates after vaginal hysterectomy were 91.0 percent for those receiving ceftizoxime and 85.1 percent for those receiving cefoxitin. After abdominal hysterectomy, success rates were 78.3 percent for both groups. Febrile morbidity rates and duration of hospitalization were comparable for both groups across all studies and within individual studies. Ceftizoxime and cefoxitin were safe and well tolerated. The results of these controlled studies indicate that single-dose ceftizoxime is as effective and safe as multiple-dose cefoxitin when used as adjunctive chemoprophylaxis in patients at risk of postoperative infection after vaginal or abdominal hysterectomy.

Growth and adhesion of Enterococcus faecium L-forms

Comparisons of growth and surface colonisation of Enterococcus faecium L-forms and their cell-walled forms were undertaken to produce information about their ability to form sessile cells. The growth of L-forms in liquid culture was slower than that of the parent. This was reflected in their longer lag phase and slower specific growth rates: 0.16 h-1 for the L-form and 0.81 h-1 for the parent. Although E. faecium L-forms attached to a silastic rubber surface, the attached population density was 10-100-fold less than that of the parent. Confluent biofilms on the silastic surfaces were not observed for either bacterial form. Comparison of the attachment of E. faecium L-form and parent may provide important information on how bacteria overcome host defence mechanisms and antibiotic treatment.

Role of Neisseria gonorrhoeae and Chlamydia trachomatis in intraabdominal abscess formation in the rat

Our concept of the pathogenesis of acute salpingitis and advanced pelvic infection, such as tuboovarian abscess, is evolving. Although Neisseria gonorrhoeae and Chlamydia trachomatis are thought to play a significant role in acute pelvic inflammatory disease, other microorganisms, such as aerobes and anaerobes, have repeatedly been reported to play a significant role, also, particularly in the patient with advanced disease. A study was designed to evaluate the pathogenesis, and particularly any synergistic role, of some aerobes and anaerobes with N gonorrhoeae and C trachomatis abscess formation. Using the rat model developed by Weinstein and Onderdonk, the study demonstrated that N gonorrhoeae and C trachomatis alone do not produce abscesses. However, when combined with facultative or anaerobic bacteria, synergism with abscess formation is noted frequently. The data support the hypothesis that N gonorrhoeae and C trachomatis initiate infection and that aerobic and anaerobic bacteria act synergistically to produce abscesses. In addition, microorganisms not inoculated were found to be recruited into the infectious process. The organisms may gain access to the peritoneal cavity via the lower genital tract or from transmucosal migration from the intestinal flora.

Sexually transmitted disease treatment and return for test of cure of adolescents in a family planning clinic

This retrospective study assessed the return for treatment and test-of-cure rates for gonorrhea and chlamydial infection among 154 adolescents and young adults attending a family planning clinic. Eighty-four percent returned for treatment and 57% of those returned for a test of cure. No statistical differences in race/ethnicity, marital status, gravida, age, presence of symptoms, or type of infection were found between those returning and those not returning for treatment. Issues associated with sexually transmitted disease treatment and follow-up in the family planning clinic setting are discussed.

Ortho enzyme immunoassay versus McCoy cell monolayers stained by iodine or fluorescent antibody for detection of Chlamydia trachomatis

We compared a new enzyme immunoassay (Ortho Diagnostics Systems, Inc., Raritan, N.J.) (EIA) with iodine and fluorescent-antibody staining of inoculated McCoy cell monolayers for detection of Chlamydia trachomatis in our female outpatient populations. EIA was more sensitive than iodine at a statistically significant level, but there were no statistically significant differences between EIA results and those for fluorescent-antibody staining.

Comparison of two endometrial sampling devices. Cotton-tipped swab and double-lumen catheter with a brush

The potential for bacterial contamination during transvaginal recovery of endometrial samples in patients with postpartum endomyometritis spawned an investigation into various protective measures and techniques. The confirmation and determination of the extent of contamination was attempted in 120 postpartum women with the diagnosis of postpartum endometritis. Each woman underwent endometrial sampling for bacterial culturing utilizing two devices--an unprotected, cotton-tipped swab and a protective, double-lumen catheter with a brush. Although a statistically greater number of bacterial species were recovered with the swab than with the brush (2.4 vs. 1.6, respectively [P less than .001]), they were not representative of species commonly thought of as causing cervicovaginal contamination. Individual species found with greater frequency with the swab were Streptococcus faecalis (P = .023), Escherichia coli (P = .007), Proteus mirabilis (P = .025), Bacteroides bivius (P less than .001 and Bacteroides melaninogenicus (P = .02). Thus, with proper cervical preparation and an extended-reach, transvaginal, cotton-tipped swab, true fundal specimens were obtained that provided a representative and cost-efficient sample of the infected endometrial cavity.

Ticarcillin/clavulanic acid versus clindamycin and gentamicin in the treatment of post-cesarean endometritis following antibiotic prophylaxis

One hundred fifty-two women who received cefazolin prophylaxis and subsequently developed postpartum endometritis were randomized to treatment with either ticarcillin/clavulanic acid (75) or clindamycin-gentamicin (77). Bacteria isolated from the endometrium were predominantly facultative anaerobic bacteria. The ratio of facultative anaerobes to obligate anaerobes was 3:1. Nineteen percent of the women were bacteremic, with mycoplasma the organism most frequently isolated from venous blood specimens. Cure rates were similar for both groups: ticarcillin/clavulanic acid 85% and clindamycin-gentamicin 81%. The advantages of ticarcillin/clavulanic acid are an increased spectrum of activity against beta-lactamase-producing bacteria, less toxicity, and lower cost.

Predominant sexually transmitted diseases among different age and ethnic groups of indigent sexually active adolescents attending a family planning clinic

The present study analyzed a group of 113 sexually active, indigent female adolescents attending a family planning clinic, for age, ethnic, or racial trends in the recovery of Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma species, and Ureaplasma urealyticum. The overall recovery rate for N. gonorrhoeae was 8/112 (7.1%), with the highest rate occurring in black patients (7/82, 8.5%). The overall recovery rate for C. trachomatis was 31/113 (27.4%), with the highest rate occurring in Hispanics (7/21, 33.3%). The isolation of C. trachomatis was evenly divided among patients grouped by reason for visit. Neisseria gonorrhoeae, on the other hand, was isolated more frequently from patients coming for a sexually transmitted disease screen than from those attending for other reasons. There was a significant (p less than 0.05) increase in isolation of Mycoplasma species from 18-19-year-old patients, but no such difference was observed for U. urealyticum when compared to younger age groups. Factors associated with venereal disease prevalence in our teenage indigent population as well as implications for the future reproductive health of such patients are discussed.

Premarket evaluation of Monofluor reagent for detecting Chlamydia trachomatis in adolescent outpatients

A new direct fluorescent antibody reagent, Monofluor, was evaluated for detecting Chlamydia trachomatis in fresh specimens. Monofluor was compared with Micro Trak and with cultivation in McCoy cells. Both direct systems were slightly less sensitive than culture, but no significant differences in specificity or sensitivity were noted between culture, Monofluor, or Micro Trak results.

Ticarcillin disodium/clavulanate potassium versus clindamycin/gentamicin in the treatment of postpartum endometritis

Ticarcillin disodium/clavulanate potassium was compared to clindamycin/gentamicin in the treatment of post-cesarean-section endometritis in 133 evaluable patients. All patients received three 1-g doses of cefazolin for prophylaxis. There was no statistically significant difference in the cure rates between the ticarcillin disodium/clavulanate potassium group (84%) and the clindamycin/gentamicin group (81%). Bacteremia occurred in 21% of the patients, with Mycoplasma the most frequent isolate. Ticarcillin disodium/clavulanate potassium was found to be as efficacious as clindamycin/gentamicin in the treatment of postpartum endometritis.

Microwave sterilization of Candida on underwear fabric. A preliminary report

Candida-contaminated underwear might not be sterilized by ordinary laundering. The effectiveness of microwaving against Candida albicans on fabric was therefore determined. Swatches of Candida-impregnated cotton underpants fabric were subjected to domestic microwaving at the high setting for up to 30 minutes. If the fabric was microwaved dry, the Candida organisms survived. If the fabric was moistened, sterilization occurred within five minutes. Microwaving wet, freshly laundered cotton underpants should sterilize residual Candida and reduce the risk of reinfection.

Correlation of ultrasonography and bacteriology of the endocervix and posterior cul-de-sac of patients with severe pelvic inflammatory disease

We evaluated 30 patients admitted with a diagnosis of pelvic inflammatory disease (PID) by culdocentesis and ultrasonography to determine the severity of disease in relation to endocervical and culdocentesis bacteriology. Specimens from the endocervix were cultured for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis, and Ureaplasma urealyticum. In addition, culdocentesis fluid was cultured for aerobes and anaerobes. Patients with N. gonorrhoeae or C. trachomatis had significantly milder disease (P less than 0.05) compared with patients whose specimens were negative for those organisms. Furthermore, those patients with ultrasound confirmation of a tubo-ovarian complex had significantly (P less than 0.0001) greater recovery of aerobes and anaerobes from culdocentesis fluid than did patients with milder disease.

Perspectives on the bacteriology of postoperative obstetric-gynecologic infections

The development of postoperative infections is influenced by both host and external factors. The present report focuses on the influence of prophylactic agents on the apparent cause of infection after cesarean section and vaginal hysterectomy. The correlation between in vitro susceptibility patterns of potential pathogens and normal flora and in vivo response is also considered.

Gardnerella vaginalis chorioamnionitis: a report of two cases and a review of the pathogenic role of G. vaginalis in obstetrics

Two patients with chorioamnionitis due to Gardnerella vaginalis are described. Institution of tocolytic therapy for preterm labor is associated with maternal complications of septic hypotension and pulmonary edema in one patient. Diagnostic modalities, specifically culturing techniques, are discussed, as well as suspected pathophysiologic mechanisms.

Postcesarean wound infection by Mycoplasma hominis in a patient with persistent postpartum fever

Mycoplasma hominis was isolated in pure culture from a wound infection following delivery by cesarean section. The importance of recognizing this organism as a potential pathogen of the female genital tract is emphasized. Two commercially available isolation systems that allow the recovery of this organism are also described.

Comparative efficacy and safety of mezlocillin, cefoxitin, and clindamycin plus gentamicin in postpartum endometritis

The efficacy of mezlocillin versus cefoxitin versus clindamycin plus gentamicin was evaluated in 152 patients with postpartum endometritis. There were no statistically significant differences in rate of cure among the three groups (87% with mezlocillin, 82% with cefoxitin, and 92% with clindamycin-gentamicin). There were no severe adverse reactions observed in any of the three treatment regimens. Mezlocillin is as safe and effective as cefoxitin and clindamycin-gentamicin for treatment of postpartum endometritis.

Severe uterine hemorrhage from blastomycosis of the endometrium. A case report

A 32-year-old black woman presented in the emergency room with vaginal bleeding. Physical examination revealed a granulomatous lesion on the thigh and a breast abscess. Histopathologic examination and culture of an endometrial biopsy revealed Blastomyces dermatitidis. The breast abscess and thigh lesion were found to contain B. dermatitidis as well.

Is mandatory continuing education working?

Mandatory continuing education (MCE) has been implemented by the states as a means of strengthening the relicensure process by requiring all licensees to participate in certain amounts of continuing education (CE) in hopes that such participation would enhance their performance. After two decades this somewhat controversial method for relicensure is still being questioned though there is evidence that benefits are being derived from such requirements. Licensees who do not actively participate voluntarily in CE are most affected, and they are developing renewed interest in their professions. Research studies are proving that well-designed CE programs do change behavior. Many additional programs become available when MCE is implemented and MCE, also, is helping to focus attention on other ways to improve performance. Information has been drawn from 16 different professions, though this article focuses on the health professions where the MCE movement has slowed significantly.

Treatment of disseminated herpes simplex virus in pregnancy with parenteral acyclovir. A case report

Disseminated herpes simplex virus infection in a pregnant woman was successfully treated with acyclovir. Similar reported cases have suggested that acyclovir may be suitable for the treatment of disseminated or severe primary herpes in pregnant women.

Isolation of Mycoplasma species and Ureaplasma urealyticum from obstetrical and gynecological patients by using commercially available medium formulations

One hundred duplicate endocervical specimens from obstetrical and gynecological patients were cultured for Mycoplasma spp. and Ureaplasma urealyticum. Rates of recovery of these organisms from commercially prepared A7 medium and the Mycotrim-GU system were compared. We detected 14 (93%) of the total 15 isolates of Mycoplasma spp. on A7 plates and 11 (73%) in the Mycotrim-GU system. We detected 34 (89%) of the total 38 isolates of U. urealyticum on A7 plates and 32 (84%) in the Mycotrim-GU system. The times of detection for both types of organism were similar in the two systems. We conclude that cultivation on A7 medium as described is a more cost-effective method of recovery of Mycoplasma spp. and U. urealyticum than the Mycotrim-GU system.

Lactobacillemia of amniotic fluid origin

Four cases of amnionitis due to Lactobacillus sp and three cases of bacteremia are reported. Postpartum endometritis developed in all four cases. Lactobacillus bacteremia occurred in two infants. A review of the literature on serious infections due to Lactobacillus sp is also presented. The importance of considering the clinical role of any microorganism isolated in pure culture from symptomatic patients is discussed.

Hepatitis due to herpes simplex virus in a nonpregnant patient: treatment with acyclovir

A previously healthy 19-year-old nonpregnant woman had disseminated infection with herpes simplex virus. The disseminated disease was accompanied by hepatitis. The patient was treated with parenteral acyclovir (5 mg/kg) given every 8 hr. The patient's symptoms resolved after three days of therapy. A review of five similar cases that were observed in healthy nonpregnant and nonimmunosuppressed individuals showed that all five patients died. Thus, rapid diagnosis of this potentially fatal condition is important, and the possible use of acyclovir for such cases should be considered.

Reactivity of microhemagglutination, fluorescent treponemal antibody absorption, Venereal Disease Research Laboratory, and rapid plasma reagin tests in primary syphilis

Seroreactivity of sera from 109 patients with first-infection primary syphilis was 98.2% in the fluorescent treponemal antibody absorption test, 92.7% in the rapid plasma reagin 18-mm circle card test, 72.5% in the microhemagglutination test (MHA-TP), and 72.5% in the Venereal Disease Research Laboratory test. Seroreactivity of sera from 18 patients with primary syphilis with documented previous infection(s) was 100% in the fluorescent treponemal antibody absorption test, the rapid plasma reagin 18-mm circle card test, and the MHA-TP test and 88.9% in the Venereal Disease Research Laboratory test. The MHA-TP test failed to confirm reactivity in 13 of 79 sera which were reactive in the Venereal Disease Research Laboratory test and in 24 of 101 sera which were reactive in the rapid plasma reagin 18-mm circle card test. Testing another production lot of MHA-TP reagents resulted in even poorer correlation. The reactivity of the MHA-TP test in primary syphilis appeared to vary with the sensitivity of the production lot of reagents.

Assays of serum aminoglycoside levels by BACTEC 460 in the presence of cefamandole and cefoxitin

The effects of cefamandole and cefoxitin on the assays of serum containing gentamicin, tobramycin, or amikacin by the BACTEC 460 (Johnston Laboratories, Cockeysville, Md.) were studied. The results were analyzed to determine whether the presence of the test substances, cefamandole or cefoxitin, caused a statistically different mean value of aminoglycoside or increase in variance as compared with serum assayed in their absence. The results were then considered in light of medical significance to see whether the difference observed would have any real effect on patient care. The results of each analyses dictate that serum of patients treated with both amikacin and cefamandole be tested in triplicate.

Assay of serum tobramycin levels with the Bactec 460

Serum tobramycin levels of synthetic and patient specimens were determined by the Bactec 460. The results were compared with those obtained from the same specimens by radioimmunoassay. These studies suggest that assays performed by either method should be run in duplicate or triplicate to achieve maximum accuracy. The studies also suggest that results obtained by the Bactec method are at least as reliable as those obtained by the radioimmunoassay method.

Continuing Education Unit: a new dimension in continuing education

The rapid expansion of continuing education within the professions has evolved with little continuity and structure, a fact which impedes the professional's ability to develop a long-range plan of continued professional development. A major weakness stems from society's lack of uniform standards to measure and certify continuing education. A new unit of measure, the continuing education unit (CEU), has been developed as a voluntary national effort for a uniform unit of measure for noncredit continuing education, which will both quantify programs and ensure a reasonable degree of program quality. Effective implementation and use of the CEU requires consumers of continuing education to assume a greater role in program planning and development in conjunction with program producers. The CEU provides a valuable tool for the professions to effectively use continuing education; however, improved competency requires more than the mere accumulation of CEU.

Study of phenoloxidase activity during the reproductive cycle in Schizophyllum commune

A study of the temporal relationship between the appearance of phenoloxidase activity and the formation of fruiting bodies in Schizophyllum commune was undertaken. The results indicate that phenoloxidase activity increases in colonies subsequent to the formation of aggregate masses of hyphae, continues to increase until mature, sporulating fruiting structures are produced, and then declines significantly.