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Author: Brigham-Faulkner OB/GYN Associates

Outcomes for critically ill patients with HIV and severe sepsis in the era of highly active antiretroviral therapy.

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Outcomes for critically ill patients with HIV and severe sepsis in the era of highly active antiretroviral therapy.

J Crit Care. 2012 Feb;27(1):51-7

Authors: Greenberg JA, Lennox JL, Martin GS

Abstract
RATIONALE: With the advent of highly active antiretroviral therapy (HAART), sepsis has become a more frequent ICU diagnosis for patients with HIV infections. Yet, little is known about the etiologies of acute infections in critically ill patients with HIV and the factors that affect in-hospital mortality.
METHODS: Cases of patients with HIV requiring intensive care specifically for severe sepsis were identified over 27 months. Demographic information, variables related to acute illness severity, variables related to HIV infection, and all acute infections contributing to ICU stay were recorded.
RESULTS: Of 990 patients admitted to the ICU with severe sepsis, 136 (13.7%) were HIV-infected. There were 194 acute infections among the 125 patients with full data available; 112 of the infections were nosocomial/health care-associated, 55 were AIDS-related, and 27 were community-acquired. Patients with nosocomial/health care-associated and AIDS-related infections had lower CD4 counts and were less likely to be on HAART (P < .05). The inpatient mortality was 42%. In a multivariable logistic regression model, only the APACHE II score (odds ratio, 1.12; 95% confidence interval, 1.02-1.23) was significantly associated with hospital mortality, although any HAART use (odds ratio, 0.53; 95% confidence interval, 0.22-1.33, P = .18) approached statistical significance.
CONCLUSIONS: In this large cohort study, nosocomial/health care-associated infections were common in ICU patients with HIV and severe sepsis. Hospital mortality was associated with acute illness severity, but not clearly associated with variables related to HIV infection. Interventions that aim to prevent or more effectively treat nosocomial infections in critically ill patients with HIV may favorably impact clinical outcomes.

PMID: 22033058 [PubMed – in process] ]]>

Is an episiotomy necessary with a shoulder dystocia?

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Is an episiotomy necessary with a shoulder dystocia?

Am J Obstet Gynecol. 2011 Sep;205(3):217.e1-3

Authors: Paris AE, Greenberg JA, Ecker JL, McElrath TF

Abstract
OBJECTIVE: The objective of the study was to determine whether a decrease in the use of episiotomy was associated with a change in the frequency of brachial plexus injury.
STUDY DESIGN: All births at Brigham and Women’s Hospital from Sept. 1, 1998, through Aug. 31, 2009, were reviewed. The total number of births, mode of delivery, shoulder dystocias, episiotomies with and without shoulder dystocias, and brachial plexus injuries were recorded. A nonparametric test of trend was performed.
RESULTS: There were a total of 94,842 births, 953 shoulder dystocias, and 102 brachial plexus injuries. The rate of episiotomy with shoulder dystocia dropped from 40% in 1999 to 4% in 2009 (P = .005) with no change in the rate of brachial plexus injuries per 1000 vaginal births.
CONCLUSION: Despite historical recommendations for an episiotomy to prevent brachial plexus injury when a shoulder dystocia is encountered, the trend we observed does not suggest benefit from this practice.

PMID: 21620364 [PubMed – indexed for MEDLINE] ]]>

A comparison of barbed and smooth sutures for ovine cesarean delivery.

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A comparison of barbed and smooth sutures for ovine cesarean delivery.

Int J Gynaecol Obstet. 2011 Jun;113(3):215-7

Authors: Greenberg JA, Walden S, Hammer CM, Grazul-Bilska AT, Vonnahme KA

Abstract
OBJECTIVE: To determine the adequacy of barbed and smooth sutures for closing the uterus and fascia in pregnant ewes.
METHODS: Nine ewes that underwent cesarean delivery were randomized to each receive 2 different suture materials for both the uterus and the fascia. The sutures used were: barbed poliglecaprone 25, smooth poliglecaprone 25, braided polyglactin 910, and smooth chromic sutures on the uterus; and barbed polydioxanone (PDO), barbed poliglecaprone 25, braided polyglactin 910, and smooth chromic sutures on the fascia.
RESULTS: In 4 of the ewes, the fascia suture line failed prematurely, leading to dehiscence prior to planned euthanasia and necropsy. The remaining 5 ewes were euthanized on days 2, 7, or 28. All suture materials (smooth and barbed) were adequate for uterine closures. Barbed PDO, smooth poliglecaprone 25, and braided polyglactin 910 were adequate for fascia closures, whereas both barbed poliglecaprone 25 and smooth chromic resulted in premature suture line ruptures and fascia dehiscence.
CONCLUSION: In a small pilot study, absorbable knotless barbed suture was adequate and equivalent to absorbable knotted smooth suture for closing the uterus following ovine cesarean delivery. On the rectus fascia, however, sutures-whether barbed or smooth-with lower tensile strength resulted in fascial dehiscence.

PMID: 21457976 [PubMed – indexed for MEDLINE] ]]>

The use of barbed sutures in obstetrics and gynecology.

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The use of barbed sutures in obstetrics and gynecology.

Rev Obstet Gynecol. 2010;3(3):82-91

Authors: Greenberg JA

Abstract
Despite the multitude of different procedures performed with a host of different wound closure biomaterials, no study or surgeon has yet identified the perfect suture for all situations. In recent years, a new class of suture material-barbed suture-has been introduced into the surgeon’s armamentarium. This review focuses on barbed suture to better understand the role of this newer material in obstetrics and gynecology.

PMID: 21364859 [PubMed] ]]>

A pilot study to assess the adequacy of the Brigham 20 Kit for cesarean delivery.

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A pilot study to assess the adequacy of the Brigham 20 Kit for cesarean delivery.

Int J Gynaecol Obstet. 2012 Feb 17;

Authors: Greenberg JA, Wylie B, Robinson JN

Abstract
OBJECTIVE: To determine whether a kit of only 20 instruments could be used to perform cesarean deliveries in a consistently safe manner for the purpose of providing better surgical instruments to healthcare providers in limited-resource environments. METHODS: In a small pilot study, 10 obstetricians in 2 hospitals in Boston, USA, used and evaluated the adequacy of the Brigham 20 Kit for cesarean delivery among 10 women. RESULTS: On average, the obstetricians rated the Brigham 20 Kit 8.7 out of 10 for adequacy and made some minor suggestions regarding the kit’s instrumentation configuration. CONCLUSION: The limited-instrument Brigham 20 Kit seemed adequate to perform cesarean deliveries safely. Larger clinical trials are needed to assess the value of this new concept for cesarean delivery in limited-resource environments.

PMID: 22342056 [PubMed – as supplied by publisher] ]]>

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