Words matter: the importance of nondirective language in first-trimester assessments for Down syndrome.

To the Editors:Your concerns regarding the recently published study, ‘‘A randomized trial that compared povidone iodine and chlorhexidine as antiseptics for vaginal hysterectomy,’’ are appreciated. First, by way of clarification, the literature search to which you refer did retrieve studies in which vaginal chlorhexidine had been used. In fact, we found 3 studies (including a total of more than 4500 patients) in which chlorhexidine had been used as a vaginal preparation. The decision to use chlorhexidine as a vaginal antiseptic for our study was based on 1) a review of those studies, 2) a policy in our institution that already called for chlorhexidine to be used whenever a patient was allergic to iodine, and 3) an extensive literature review indicating that chlorhexidine has outperformed povidone iodine as an antiseptic many times in studies of other surgical sites. Chlorhexidine is typically not used on mucosal surfaces. Although ‘‘vaginal mucosa’’ is a commonly used term, the vagina is an epithelial surface. Perhaps this simple misunderstanding has led to the commonly held belief that chlorhexidine should not be used in the vagina. The literature suggests that this belief is unfounded. As for the scrubbing technique, we did not specifically follow the manufacturer’s chlorhexidine instructions listed in your letter. We chose to use identical techniques when using the 2 antiseptics. Patients who were randomized to receive povidone iodine received a vigorous 2-minute scrub in and around the vagina using disposable spongesdfollowed by application of a povidone iodine ‘‘paint’’ solution in and around the vagina using disposable ‘‘stick sponges.’’ This technique represented our standard procedure in the hospitals involved in the study. For patients who were randomized to receive chlorhexidine, no ‘‘paint’’ solution was available. Therefore, the patients received the same vigorous scrub followed by a less vigorous ‘‘paint’’ application with the same solution. Throughout the study, there were no protocol deviations. Therefore, the study offered a fair comparison between two antiseptic solutions applied via a standardized technique.