Catheter Problems Research Articles

Long-term catheter management in the community: a population-based analysis of user characteristics, service utilisation and costs in England.

Long-term urinary catheters are problematic and burdensome for patients, carers and health services. Nursing practice to improve the management of long-term urinary catheters has been held back by a lack of evidence to support policy and practice. Little is known about who uses a catheter long term and the resources and costs needed for their management. Understanding these costs will help to target innovations to improve care. There have been no substantial innovations to urinary catheters or their management recently and no publications to characterise users and costs. To describe long-term catheter users and explore catheter-related service use and costs in England. Descriptive information on the characteristics of catheter users and their use of services was obtained from: General Practice records (n = 607), district nursing records (n = 303), questionnaires to patients (n = 333) and triangulated, 2009-2012. Annual service costs (British pounds 2011) were computed. Most catheter users (59.6%) were men, nearly three-quarters (71.2%) were over 70 years and 60.8% used a urethral catheter. Women tended to be younger than men and more likely to use a suprapubic catheter. The services used most frequently over 12 months were general practitioner (by 63.1%) and out of hours services (43.0%); 15.5% accessed Accident and Emergency services for urgent catheter-related care. Hospital use accounted for nearly half (48.9%) of total health service costs (mainly due to inpatient stays by 13.6% of participants); catheter supplies/medications were next most costly (25.7%). Half of all costs were accounted for by 14.2% of users. The median annual cost of services used was £6.38, IQR: £344-£1324; district nursing services added approximately a further £200 per annum. Finding better ways to reduce catheter problems (e.g. blockage, infection) that cause unplanned visits, urgent or hospital care should be a priority to improve quality of life for long-term catheter users and reduce health service expenditure.

Analytical HDR prostate brachytherapy planning with automatic catheter and isotope selection.

High dose rate (HDR) brachytherapy is commonly used to treat prostate cancer. Existing HDR planning systems solve the dwell time problem for predetermined catheters and a single energy source. Additional degrees of freedom can be obtained by relaxing the catheters' pre-designation and introducing more source types, and may have a dosimetric benefit, particularly in improving conformality to spare the urethra. This study presents a novel analytical approach to solving the corresponding HDR planning problem. The catheter and dual-energy source selection problem was formulated as a constrained optimization problem with a non-convex group sparsity regularization. The optimization problem was solved using the fast-iterative shrinkage-thresholding algorithm (FISTA). Two isotopes were considered. The dose rates for the HDR 4140 Ytterbium (Yb-169) source and the Elekta Iridium (Ir-192) HDR Flexisource were modeled according to the TG-43U1 formalism and benchmarked accordingly. Twenty-two retrospective HDR prostate brachytherapy patients treated with Ir-192 were considered. An Ir-192 only (IRO), Yb-169 only (YBO), and dual-source (DS) plan with optimized catheter location was created for each patient with N catheters, where N is the number of catheters used in the clinically delivered plans. The DS plans jointly optimized Yb-169 and Ir-192 dwell times. All plans and the clinical plans were normalized to deliver a 15Gy prescription (Rx) dose to 95% of the clinical treatment volume (CTV) and evaluated for the CTV D90%, V150%, and V200%, urethra D0.1cc and D1cc, bladder V75%, and rectum V75%. Dose-volume histograms (DVHs) were generated for each structure. The DS plans ubiquitously selected Ir-192 as the only treatment source. IRO outperformed YBO in organ at risk (OARs) OAR sparing, reducing the urethra D0.1cc and D1cc by 0.98% ( ) and 1.09% ( ) of the Rx dose, respectively, and reducing the bladder and rectum V75% by 0.09 ( ) and 0.13 cubic centimeters (cc) ( ), respectively. The YBO plans delivered a more homogenous dose to the CTV, with a smaller V150% and V200% by 3.20 ( ) and 1.91 cc ( ), respectively, and a lower CTV D90% by 0.49% ( ) of the prescription dose. The IRO plans reduce the urethral D1cc by 2.82% ( ) of the Rx dose compared to the clinical plans, at the cost of increased bladder and rectal V75% by 0.57 ( ) and 0.21 cc ( ), respectively, and increased CTV V150% by a mean of 1.46 cc ( ) and CTV D90% by an average of 1.40% of the Rx dose ( ). While these differences are statistically significant, the clinical differences between the plans are minimal. The proposed analytical HDR planning algorithm integrates catheter and isotope selection with dwell time optimization for varying clinical goals, including urethra sparing. The planning method can guide HDR implants and identify promising isotopes for specific HDR clinical goals, such as target conformality or OAR sparing.

Use of a Guide-wire as an Adjunct for the Safe Removal of a 'Stuck' Indwelling Central Venous Catheter at Risk for Breaking.

Port-based central venous catheters may remain indwelling for years with subsequent fibrosis resulting in a "stuck" catheter. At time of removal, this can lead to complications such as catheter fracture or require additional operative techniques for safe extraction. We present a case utilizing a protocol wherein a J-tip guidewire is placed to assist in removal. We believe this serves the following beneficial functions: Mechanically, as the catheter stretches and collapses upon retraction it distributes the force circumferentially along the length of the catheter as well as reduces angular kinking, mitigating stress points of fracture. Second, in case of fracture, the distal portion should remain intubated by the J-tip guidewire, reducing embolic potential. Third, it allows more facile percutaneous transvenous retrieval if indicated. Though this does not represent a perfect solution to the "stuck" catheter problem, this technique increases safety and efficacy of removal with easy application at minimal additional cost.

Role and effectiveness of an information guide in improving catheter confidence and knowledge in junior clinicians

Objective: Referrals to the on-call urology team for catheter-related problems are common. Experience and previous studies highlight that urology exposure and catheter skills are unsatisfactory in undergraduate training as well as in subsequent junior clinical practice. These deficiencies may compromise patient safety and delay appropriate treatment. This study aimed to assess catheter insertion confidence and associated knowledge in junior doctors and advanced nurse practitioners in a single teaching hospital and evaluate whether this could be improved by introducing a freely available catheter information and problem-solving guide. Methods: An online survey assessing confidence inserting two and three-way urethral catheters, changing suprapubic catheters and assessing knowledge related to common catheter problems was delivered to all non-registrar junior clinicians. Based on these results, an information guide was created and made freely available to these clinicians. The survey was then repeated to check for catheter-related knowledge and confidence. Results: A total of 58 junior clinicians responded to the initial survey and 61 to the repeat survey. Catheterisation confidence and knowledge was generally low in the first survey but improved in all areas and across all grades after the introduction of the information guide. Of the respondents, 100% thought the guide was helpful and 93.4% said they would use it in future. Conclusions: A catheter information guide is a simple and effective method of improving junior clinician confidence with catheter insertion and managing catheter-associated problems. Level of Evidence: This study does not directly correlate with a defined level of evidence.

Predictors and outcomes of peritoneal dialysis-related infections due to filamentous molds (MycoPDICS).

We sought to evaluate the predictors and outcomes of mold peritonitis in patients with peritoneal dialysis (PD). This cohort study included PD patients from the MycoPDICS database who had fungal peritonitis between July 2015-June 2020. Patient outcomes were analyzed by Kaplan Meier curves and the Log-rank test. Multivariable Cox proportional hazards model regression was used to estimating associations between fungal types and patients' outcomes. The study included 304 fungal peritonitis episodes (yeasts n = 129, hyaline molds n = 122, non-hyaline molds n = 44, and mixed fungi n = 9) in 303 patients. Fungal infections were common during the wet season (p <0.001). Mold peritonitis was significantly more frequent in patients with higher hemoglobin levels, presentations with catheter problems, and positive galactomannan (a fungal cell wall component) tests. Patient survival rates were lowest for non-hyaline mold peritonitis. A higher hazard of death was significantly associated with leaving the catheter in-situ (adjusted hazard ratio [HR] = 6.15, 95%confidence interval [CI]: 2.86-13.23) or delaying catheter removal after the diagnosis of fungal peritonitis (HR = 1.56, 95%CI: 1.00-2.44), as well as not receiving antifungal treatment (HR = 2.23, 95%CI: 1.25-4.01) or receiving it for less than 2 weeks (HR = 2.13, 95%CI: 1.33-3.43). Each additional day of antifungal therapy beyond the minimum 14-day duration was associated with a 2% lower risk of death (HR = 0.98, 95%CI: 0.95-0.999). Non-hyaline-mold peritonitis had worse survival. Longer duration and higher daily dosage of antifungal treatment were associated with better survival. Deviations from the 2016 ISPD Peritonitis Guideline recommendations concerning treatment duration and catheter removal timing were independently associated with higher mortality.

MP29-16 SAME-DAY HOME RECOVERY TRANSURETHRAL RESECTION OF THE PROSTATE IS NOT ASSOCIATED WITH INCREASED URGENT CARE OR EMERGENCY DEPARTMENT RETURN RATES IN AN INTEGRATED HEALTH CARE DELIVERY SYSTEM

You have accessJournal of UrologyCME1 May 2022MP29-16 SAME-DAY HOME RECOVERY TRANSURETHRAL RESECTION OF THE PROSTATE IS NOT ASSOCIATED WITH INCREASED URGENT CARE OR EMERGENCY DEPARTMENT RETURN RATES IN AN INTEGRATED HEALTH CARE DELIVERY SYSTEM Krystal DePorto, Trevor Cesar, Eugene Rhee, Steven Crain, Gary Chien, Polina Reyblat, and Christopher Tenggardjaja Krystal DePortoKrystal DePorto More articles by this author , Trevor CesarTrevor Cesar More articles by this author , Eugene RheeEugene Rhee More articles by this author , Steven CrainSteven Crain More articles by this author , Gary ChienGary Chien More articles by this author , Polina ReyblatPolina Reyblat More articles by this author , and Christopher TenggardjajaChristopher Tenggardjaja More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002572.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) represent one of the most common medical problems in adult men. Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment for BPH with excellent outcomes [1]. Referencing publicly accessible Medicare data, the cost of an outpatient TURP is approximately $1667 compared to $4367 when done as an inpatient procedure. Prior research demonstrates a return to urgent care (UC)/ emergency department (ED) rate and readmission rate after TURP of 21.4% and 7.4%, respectively. Risk factors include age >75 years [OR 1.61, p < 0.001], urgent surgical status [OR 1.34, p = 0.0095], and Charlson Comorbidity Index > 1 [OR 5.31, p = 0.001] [2,3]. The primary objective of this study is determining the efficacy of same-day home recovery (SHR) TURP. METHODS: This study was a retrospective chart review of all TURPs done in integrated health care delivery system between June 2019 and August 2021. Patient variables including age, comorbidities, and perioperative factors were included for analysis. Appropriate statistical analyses were completed for categorical and continuous variables. RESULTS: 2559 TURPs were performed across seven medical centers in Southern California. Of these, 2138 were SHR versus 421 were admitted inpatient (length of stay (LOS) > 24 hours). The average age in both cohorts was 72 years old (31 - 101 years). The average LOS for inpatients was 28.8 hours (24.1 - 39.9 hours). Indication for TURP and anticoagulation status were not significantly different between the two groups. SHR patients returned to UC/ED within 30 days of their surgical date at a lower rate than those who were admitted inpatient, 12% versus 17%, respectively [OR 0.68, p = 0.00886]. Patients who were on anticoagulation returned at a higher rate than those who were not, 29% vs 11% [OR 3.38, p < 0.00001]. Inpatient admission of patients on anticoagulation did not reduce the rate of return to UC/ED when compared to SHR, 92.6% vs 13.7% [OR 78.62, p < 0.00001]. The most common reasons for return to UC/ED were catheter problems (25%), hematuria (12%), and LUTS (11%). The readmission rate was 0.2%. CONCLUSIONS: Appropriately selected patients can be safely discharged home the same day after TURP. Admission to inpatient status and use of anticoagulation were found to be associated with statistically significant higher return to UC/ED rates. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e475 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Krystal DePorto More articles by this author Trevor Cesar More articles by this author Eugene Rhee More articles by this author Steven Crain More articles by this author Gary Chien More articles by this author Polina Reyblat More articles by this author Christopher Tenggardjaja More articles by this author Expand All Advertisement PDF DownloadLoading ...

Assessing mechanical catheter dysfunction in automated tidal peritoneal dialysis using cycler software: a case control, proof-of-concept study

New recommendations on evaluation of peritoneal membrane function suggest ruling out catheter dysfunction when evaluating patients with low ultrafiltration capacity. We introduce the use of a combination of parameters obtained from the cycler software PD Link with HomeChoicePro (Baxter International Inc., Illinois, United States) cyclers for predicting catheter dysfunction in automated peritoneal dialysis patients (APD). Out of 117 patients treated at the Medical University of Vienna between 2015 and 2021, we retrospectively identified all patients with verified catheter dysfunction (n = 14) and compared them to controls without clinical evidence of mechanical catheter problems and a recent X-ray confirming PD catheter tip in the rectovesical/rectouterine space (n = 19). All patients had a coiled single-cuff PD catheter, performed tidal PD, and received neutral pH bicarbonate/lactate-buffered PD fluids with low-glucose degradation products on APD. Icodextrin-containing PD fluids were used for daytime dwells. We retrieved cycler data for seven days each and tested parameters' predictive capability of catheter dysfunction. Total number of alarms/week > 7 as single predictive parameter of catheter dislocation identified 85.7% (sensitivity) of patients with dislocated catheter, whereas 31.6% (1-specificity) of control patients were false positive. A combination of parameters (number of alarms/week > 7, total drain time > 22 min, ultrafiltration of last fill < 150 mL) where at least two of three parameters appeared identified the same proportion of patients with catheter dislocation, but was more accurate in identifying controls (21.1% false positive). In contrast to yearly PET measurements, an easily applicable combination of daily cycler readout parameters, also available in new APD systems connected to remote monitoring platforms shows potential for diagnosis of catheter dysfunction during routine follow-up.

Technique failure in peritoneal dialysis: Modifiable causes and patient-specific risk factors.

Technique survival is a core outcome for peritoneal dialysis (PD), according to Standardized Outcomes in Nephrology-Peritoneal Dialysis. This study aimed to identify modifiable causes and risk factors of technique failure in a large Dutch cohort using standardised definitions. Patients who participated in the retrospective Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes cohort study and started PD between 2012 and 2016 were included and followed until 1 January 2017. The primary outcome was technique failure, defined as transfer to in-centre haemodialysis for ≥ 30 days or death. Death-censored technique failure was analysed as secondary outcome. Cox regression models and competing risk models were used to assess the association between potential risk factors and technique failure. A total of 695 patients were included, of whom 318 experienced technique failure during follow-up. Technique failure rate in the first year was 29%, while the death-censored technique failure rate was 23%. Infections were the most common modifiable cause for technique failure, accounting for 20% of all causes during the entire follow-up. Leakage and catheter problems were important causes within the first 6 months of PD treatment (both accounting for 15%). APD use was associated with a lower risk of technique failure (hazard ratio 0.66, 95% confidence interval 0.53-0.83). Infections, leakage and catheter problems were important modifiable causes for technique failure. As the first-year death-censored technique failure rate remains high, future studies should focus on infection prevention and catheter access to improve technique survival.

Use of continuous ambulatory peritoneal dialysis (CAPD) in the treatment of children with END-stage renal disease

Continuous ambulatory peritoneal dialysis is a form of treatment for end-stage renal disease. This mini-review discusses the use of CAPD as a treatment for ESRD in children. It also discusses the knowledge of the complications of this technique on the effectiveness of the treatment as well as the knowledge of its therapeutic effects. Studies have been collected from electronic rulers (Google scholar /PubMed...) where 30 studies have been studied and analyzed so that these studies included experimenting with CAPD on many children of different age groups. Results of these studies have shown that CAPD is considered an advanced technique for the treatment of ESRD in children, despite many complications such as peritonitis and catheter problems, which are among the most important, but several studies have indicated that the position of the catheter in a surgically controlled manner by specialized physicians mitigates its problems. However, this treatment has many advantages over dialysis. Especially in children, they are freer, more energetic, and more easily able to carry out their activities, especially children who live in remote areas and far from health centers. But we need to think about how to relieve the complications of peritonitis that were common in all the studies that have been done analyzed in this mini-review.

Hemodialysis and Peritoneal Dialysis Patients’ Problems: Patients’ Perspective

Background: End-stage renal disease (ESRD) can be fatal without hemodialysis, peritoneal dialysis, or kidney transplantation. Hemodialysis and peritoneal dialysis participants confront many adverse effects due to both the disease course and the treatment program. Objectives: This study was done to analyze hemodialysis and peritoneal dialysis patients’ problems. Methods: A qualitative exploratory study was used, and a purposeful sample of 55 hemodialysis and 47 peritoneal dialysis patients were interviewed. The data were collected through interviews. Initially, 12 open-ended questions were developed and used to stimulate discussions in interview sessions. Directed content analysis was used for the analysis of the transcribed data. After giving a code to each line or incidence, codes were then compared for similarity and differences, merged, and categorized. Results: Themes of fatigue, diminished ability, sleeplessness, wasting time, body impairments, travel, and free-time activities limitations, low blood pressure, displeasure and gratification with hemodialysis if peritoneal dialysis patients compliant of peritoneal catheter problems, peritoneal dialysis difficulties and limitations, and gratification with peritoneal dialysis emerged. Conclusions: Hemodialysis problems and patients' dependency on the hemodialysis machine and ward are at a high level, and patients’ gratification is at a low level. Peritoneal dialysis patients, who do not get the infection, are satisfied with the dialysis method, and the patients' limitations and problems are fewer, and they are relaxed and have more freedom.

Is there a relationship between body mass index and postoperative pain scores in thoracotomy patients with thoracic epidural analgesia?

Postoperative efficacy of thoracic epidural analgesia (TEA) following thoracic surgery may vary in patients with different body mass index (BMI) values, regardless of the success of the method. This study aimed to investigate the effects of BMI on postoperative pain scores in patients who underwent thoracotomy with TEA.After obtaining the ethical committee approval (Date: May 11, 2021, Number: 2012-KEAK-15/2305) the data of 1326 patients, who underwent elective thoracic surgery in high volume tertiary thoracic surgery center between January 2017 and January 2021, were analyzed retrospectively. Patients between the age of 18 and 80 years, who underwent thoracotomy and thoracic epidural catheterization (TEC), and who were assigned American Society of Anesthesiologists I to III physical status were included to the study. Of the 406 patients, who underwent a successful TEC, 378 received postoperative analgesia for 72 hours. Visual analog scale (VAS) scores of these patients were evaluated statistically. Based on BMI, patients were categorized into the following 5 groups: Group I: BMI < 20 kg/m2, Group II: BMI = 20 to 24.9 kg/m2, Group III: BMI = 25 to 29.9 kg/m2, Group IV: BMI = 30 to 34.9 kg/m2, and Group V: BMI ≥ 35 kg/m2.There were no statistically significant differences in TEC success across different BMI groups (P > .05). Catheter problems and VAS scores significantly increased with higher BMI values in the postoperative 72-hours period (P < .05). Rates of rescue analgesic use were higher in BMI groups of 30 toto 34.9 kg/m2 and ≥35 kg/m2 compared to the other BMI groups.This study revealed that higher BMI in patients may increase VAS scores, who administered TEA for pain management following thoracotomy. This correlation was supported by the increased need for additional analgesics in patients with high BMI. Therefore, patients with high BMI values would require close monitoring and follow-up.

Changes in adult home parenteral nutrition practice over 25 years

Home Parenteral Nutrition (HPN) is the established treatment of intestinal failure. This study considers the changes in practice in a single UK centre over the past twenty-five years. Data was culled from a database used for clinical care and maintained prospectively. Two hundred and five patients were included from 1993 to 2018. Patient numbers increased from 22 during 1999-2003 to 158 during 2014-2018. The median age at discharge increased from 52 years during 1999-2003 to 59 years during 2014-2018. Thirty percent of patients discharged during 1999-2003 had Crohn's disease, reducing to 14% during 2014-2018. Fifteen percent of patients discharged during 1999-2003 had small bowel fistula or obstruction in comparison to 44% during 2014-2018. Only 18 patients were treated with palliative intent, the majority in recent years. An increasing number of patients required help with HPN care over the years. Survival in non-palliative patients was 85% at 1 year, 67% at 3 years, 53% at 5 years and 42% at 10 years. The majority of deaths were due to underlying disease and only 5 of 55 deaths were attributed to HPN alone. HPN dependence in non-palliative patients was 73% at 1 year, 59% at 3 years, 56% at 5 years and 43% at 10 years. Fifty eight patients stopped HPN after reconstructive surgery. Patients experienced 5.1 admissions/1000 HPN days (64.7 admission days/1000 HPN days). Admission rate did not change over the years though the percentage due to catheter problems fell from 52% to 40% while the percentage due to underlying disease or unrelated cause rose. The increase in numbers, age and dependency of HPN patients requires increasing resource and consideration of new models of service. Many patients with short bowel syndrome now survive to old age and the care needs of the HPN patient who has become elderly can be complex. A significant proportion of patients are being referred for HPN as a bridge to reconstructive surgery after surgical complication and this requires close involvement of gastrointestinal surgeons in HPN teams. The need for hospital admissions remains a burden for HPN patients and there is scope for changes in service provision to try to reduce hospital days.

Minimally invasive peritoneal dialysis catheter insertions with concomitant cholecystectomy or hernioplasty: Surgical technique and our experiences.

Peritoneal dialysis is a well-accepted replacement therapy in patients with end-stage renal disease. There are many different options adopted on how to insert a peritoneal dialysis catheter. In our institution, a laparoscopic insertion has become the method of choice for providing peritoneal dialysis access in adult patients. The aim of this study was to analyze surgical outcomes of patients after laparoscopically assisted placement of a PD catheter some of them after concomitant cholecystectomy or hernioplasty. We have evaluated 70 consecutive patients from 1st of October 2015 to 30th of April 2020 who underwent laparoscopic insertion of a peritoneal dialysis catheter. Demographic data, details about surgery and about peri- and postoperative complications were gathered. Out of 70 enrolled patients, 15 had gallstones (21%) and underwent concomitant laparoscopic cholecystectomy. Three patients (4%) had abdominal wall hernia and underwent concomitant hernioplasty. We observed no perioperative complications connected with any of the performed procedures. There was one early postoperative complication: an early leak of dialysate fluid. Late complications were observed in nine patients (13%): mechanical catheter problems (two patients), peritonitis (three patients), skin exit-site infections (two patients), peri-catheter leak (one patient), and port-site hernia (one patient). For all patients with concomitant gallbladder disease or abdominal wall hernias we suggest to perform synchronous surgeries, due to finding no more complications after concomitant procedures in comparison to patients in whom only a PD catheter was inserted. Concomitant procedures are done to spare patients two separate procedures and to avoid possible complications. We also suggest using the cholecystectomy first, PD catheter insertion second approach for having excellent peri- and postoperative results.

Catheters at home: managing urinary catheters in the home environment.

In England, there are some 90000 people with catheters in the community, and community nurses often have to manage catheter-related problems. This article looks at these common catheter problems found in the community, for example, blockage, infections and positioning problems. These problems were identified by a literature review and from the author's experience, from many years working in the community. It has been found that education, knowledge, empowerment and communication are vital factors affecting patients' ability to manager their catheters themselves. The article begins with a discussion about how patients can be involved in and manage many aspects of care for their own catheters. It goes on to talk about the common catheter-associated problems and how these can be avoided or addressed. It is hoped that better management of catheter-associated complications in the community settings can prevent unnecessary visits to the emergency department, which will save time and costs for the health service, as well as avoid the negative impact of these on patient lives.

Characteristics of outpatient emergency department visits of nursing home residents: an analysis of discharge letters

BackgroundUnplanned emergency department (ED) visits of nursing home residents (NHR) are common, with many transfers not leading to hospitalization. However, there is little research on what diagnostic and therapeutic measures are performed during visits.AimsWe analyzed underlying diagnoses, characteristics and performed medical procedures of unplanned outpatient ED visits by NHR.MethodsWe conducted a multi-center study of 14 nursing homes (NHs) in northwestern Germany in 03/2018–07/2019. Hospital transfers were documented by nursing staff using a standardized questionnaire for 12 months. In addition, discharge letters were used to collect information about the respective transfer, its reasons and the extend of the medical services performed in the ED.ResultsA total of 161 unplanned ED visits were included (mean age: 84.2 years; 68.3% females). The main transfer reasons were trauma (59.0%), urinary catheter and nutritional probe problems (overall 10.6%; male NHR 25.5%) and altered mental state (9.9%). 32.9% where discharged without imaging or blood test prior. 67.4% of injured NHR (n = 95) required no or only basic wound care. Catheter-related problems (n = 17) were mainly treated by changing an existing suprapubic catheter (35.3%) and by flushing the pre-existing catheter (29.4%).DiscussionOur data suggest that the diagnostic and therapeutic interventions performed in ED, often do not exceed general practitioner (GP) care and many ED visits seem to be unnecessary.ConclusionBetter coordination and consultation with GPs as well as better training of nursing staff in handling catheter problems could help to reduce the number of ED visits.

Factors Associated with Short Term Outcomes of Hypospadias Repair at the University Teaching Hospitals-Lusaka, Zambia

The study aimed to establish whether age at the time of surgery, glans size, urethral plate width, suture material, urethral catheter blockage/dislodgement and haemoglobin level influence short term outcomes of hypospadias surgery at the University Teaching Hospitals (UTH), Lusaka Zambia. This was a consecutive (total enumerative) observational cohort study done at D-block and Clinic 7 at UTH Lusaka over nine months. A total of 41 patients were enrolled, and their demographic data, haemoglobin, maximum glans width size and urethral plate size before creating glans wing or midline plate incision were noted and measured. Logistic regression assessed urethroplasty complications on urethral plate size, glans size, haemoglobin, suture material and catheter problems. The average age of participants was 34 months. Distal hypospadias was the most common type at 61%, while middle hypospadias was 27% and proximal hypospadias 12%. The complication rate was 34%. The most common complication seen was urethrocutaneous fistula at 53%. The other complications seen included 11.8% glanular dehiscence, 11.8% infections, 6% persistent chordee and 6% penile torsion. The risk factors for postoperative complications included the location of the urethral opening. The more proximal the site of the hypospadias, the higher the complication rate. Complications were strongly associated with haemoglobin levels of less than 11.5g/dl (p=0.001) and catheter blockage or dislodgment (p=0.008). There was no association of complications with Socioeconomic status, age at the time of repair, glans width size or suture material. Contrary to the finding of many authors, a wider urethral plate in this study was associated with a higher complication rate.

A systematic review and meta-analysis of unplanned hospital visits and re-admissions following radical prostatectomy for prostate cancer.

Unplanned visits (UPV) - re-admissions and emergency room (ER) visits - are markers of healthcare system quality. Radical prostatectomy (RP) is a commonly performed cancer procedure, where variation in UPV represents a gap in care for prostate cancer patients. Here, we systematically synthesize the rates, reasons, predictors, and interventions for UPV after RP to inform evidence-based quality improvement (QI) initiatives. A systematic review was performed for studies from 2000-2020 using keywords: "re-admission," "emergency room/department," "unplanned visit," and "prostatectomy." Studies that focused on UPV following RP and that reported rates, reasons, predictors, or interventions, were included. Data was extracted via a standardized form. Meta-analysis was completed. Sixty studies, with 406 107 RP patients, were eligible; 16 028 UPV events (approximately 5%) were analyzed from 317 050 RP patients. UPV rates after RP varied between studies (ER visit range 6-24%; re-admissions range 0-56%). The 30-day and 90-day ER visit rates were 12% and 14%, respectively; the 30-day and 90-day re-admission rates were 4% and 9%, respectively. A total of 55% of all re-admissions after RP are directly due to postoperative genitourinary (GU)-related complications, such as strictures, obstructions, fistula, bladder-related, incontinence, urine leak, renal problems, and other unspecified urinary complications. The next most common re-admission reasons were anastomosis-related, infection-related, cardiovascular/pulmonary events, and wound-related issues. Thirty-four percent of all ER visits after RP are directly due to urine-related issues, such as retention, urinoma, obstruction, leak, and catheter problems. The next most common ER visit reasons were abdominal/gastrointestinal issues, infection-related, venous thromboembolic events, and wound-related issues. Predictors for increased re-admission included: open RP, lymph node dissection, Charlson comorbidity index ≥2, low surgeon/hospital case volume, and socioeconomic determinants of health. Of the 10 interventions evaluated, a 3.4% average reduction in UPV rate was observed, highlighting an approximate two-fold decrease. Meta-analysis demonstrated a significant benefit of interventions over controls, with odds ratio 0.62 (95% confidence interval 0.46-0.84). Interventions that used multidisciplinary, nurse-centered, programs, with patient self-care/empowerment were more beneficial than algorithmic patient care pathways and preoperative patient education. Twenty years of international, retrospective experience suggests UPV after RP are often related to GU complications and infection- or wound-related factors. QI interventions to reduce UPV should target these factors. While many re-admissions after RP appear to be unavoidable, ER visits have more opportunity for volume reduction by QI. The interventions evaluated herein have the potential to reduce UPV after RP.

Shunt malfunction and endoscopy

Objective: &#x0D; Hydrocephalus is the most common neurological disease in pediatric neurosurgery.(1) The CSF shunts remains as the most common treatment choice for nonobstructive hydrocephalus worldwide, but shunt complications still the most common neurosurgical problem, especially in pediatric neurosurgery. Endoscopy and shunts are the way to treat hydrocephalus. Especially third ventriculostomy is the most effective treatment to obstructive hydrocephalus but shunt still the most important way to treat.(2, 3) Shunt malfunction is frequent and after so many years this is very important problem to the patients. Ventricular problem due to obstruction is responsible up to 72% of shunt problems.(4) The Shunt Trial Study showed that the overall shunt survival was 62% at 1 year, 52% at 2 years, 46% at 3 years, 41% at 4 years. The survival curves for the 3 differents valves were similar to those from the original trial and did not show a survival advantage for any particular valve.(5, 6) We still don´t have one perfect solution to hydrocephalus and shunt malfunction.&#x0D; The major author described his experience in use endoscopy to evaluate and treat shunt malfunction and one new approach and way to evaluate this problem.&#x0D; &#x0D; Results/Discussion:&#x0D; The literature review was performed, and we found 84 articles when we used the keywords. Endoscopy has been one important way to treat and solve shunt problems. In obstructive hydrocephalus third ventriculostomy is the best way to treat these patients.(1-3)&#x0D; The major author first described goals of endoscopy. First goal is safe catheter removal in surgical review, avoiding bleeding when removing catheter addressing all the adhesions on catheter. Second goal is put in optimal position the new catheter with pure endoscopy view or using neuronavigation systems that could help the endoscope system.(7, 8) &#x0D; Optimal new catheter placement and optimal long-term catheter survival are especially important because most of the problems are due to ventricular problems. These good placements could avoid loculations and ventricular collapse with ependymal problems. Avoid new catheter malpositiitioning, you can use the endoscope to follow the old tract to insert the new catheter in one good position avoiding choroid plexus. Another situation is when you have small ventricles especially in slit ventricle syndrome.&#x0D; &#x0D; The major author has been studied some causes to ventricular catheter obstruction. He noticed after some surgical reviews some ventricular ependymal inside catheter. Ventricular ependymal protrusions inside the catheter could cause intermittent occlusion.(8) Some endoscope views showed these protrusion and ependymal changes after intermittent increase and decrease of ventricular pressure. These protrusions correspond to catheter holes a secondary to suction. These protrusions could stuck in the holes in chronicle suction.(8) The major author reported one endoscopic evidence of overdrainage-related ventricular tissue protrusions that cause partial or complete obstruction of the ventricular catheter. He did a retrospective review in fifty patients underwent 83 endoscopic shunt revision procedures that revealed in-growth of ventricular wall tissue into the catheter tip orifices (ependymal bands), producing partial, complete, or intermittent shunt obstructions. Endoscopic ventricular explorations revealed ependymal bands at various stages of development, which appear to form secondarily to siphoning.(8)&#x0D; How to minimize this overshunting? Anti siphon systems could help and decrease proximal shunt malfunction in some complex patients. The other problem is ventricular bleeding. The use of endoscope has been important tool to remove ventricular catheters, when you could see the adhesions.(9)&#x0D; The use the endoscope could be particularly important to open loculations and cysts avoiding ventricular entrapment. Patients with ventricular cysts could need more than one catheter. The use of endoscopy to fenestrate the cyst could keep the patient with one catheter or without any shunt system.(10, 11)&#x0D; &#x0D; Conclusion:&#x0D; Shunt malfunction has a lot of possible causes, but a probably ventricular catheter problem is the most common situation. Choose appropriate endoscope rigid or flexible for each case could help to treat and avoid some of ventricular. Endoscopy could be one important tool to help the surgeon to understand and solve this dangerous situation to the patient. Ventricular wall protrusions are a significant cause of proximal shunt obstruction, and they appear to be caused by siphoning of surrounding tissue into the ventricular catheter orifices.

Clinical Characteristics and Outcomes of S. Aureus Bacteremia in Patients Receiving Total Parenteral Nutrition.

Background: Patients on total parenteral nutrition (TPN) are at risk of developing central line-associated infections. Specifically, Staphylococcus aureus bacteremia (SAB) is feared for its high complication rates. This prospective cohort study compares characteristics, clinical course and outcome of SAB in patients with and without TPN support. Methods: Clinical and microbiological data from all patients with positive blood cultures for S. aureus from two facilities, including our referral center for TPN support, were retrieved (period 2013–2020). Primary outcome was overall mortality, and included survival analysis using a multivariate Cox regression model. Secondary outcomes comprised a comparison of clinical characteristics and outcomes between both patient groups and analysis of factors associated with complicated outcome (e.g., endocarditis, deep-seated foci, relapse and death) in patients on TPN specifically. Results: A total of 620 SAB cases were analyzed, of which 53 cases received TPN at the moment the blood culture was taken. Patients in the TPN group were more frequently female, younger and had less comorbidity (p < 0.001). In-hospital death and overall mortality were significantly lower in TPN patients (4% vs. 18%, p = 0.004 and 10% vs. 34%, p < 0.001, respectively). Positive follow-up blood cultures, delayed onset of therapy and previous catheter problems were associated with a higher incidence of complicated SAB outcome in patients on TPN. Conclusion: Our data show that patients on TPN have a milder course of SAB with lower mortality rates compared to non-TPN SAB patients.

Optimized vs. Standard Automated Peritoneal Dialysis Regimens (OptiStAR): study protocol for a randomized controlled crossover trial

BackgroundIt has been estimated that automated peritoneal dialysis (APD) is currently the fastest growing renal replacement therapy in the world. However, in light of the growing number of diabetic patients on peritoneal dialysis (PD), the unwanted glucose absorption during APD remains problematic. Recent results, using an extended 3-pore model of APD, indicated that large reductions in glucose absorption are possible by using optimized bi-modal treatment regimens, having “UF cycles” using a higher glucose concentration, and “Clearance cycles” using a low concentration or, preferentially, no glucose. The present study is designed to test the theoretical prediction of a lower glucose absorption using these novel regimes.MethodsThis study is a randomized single-center, open-label, prospective study. Prevalent PD patients between 18 and 75 years old without known catheter problems or recent peritonitis are eligible for inclusion. Patients are allocated to a first treatment session of either standard APD (6 × 2 L 1.36% over 9 h) or optimized APD (7 × 2 L 2.27% + 5 × 2 L 0.1% over 8 h). A second treatment session using the other treatment will be performed in a crossover fashion. Samples of the dialysis fluid will be taken before and after the treatment, and the volume of the dialysate before and after the treatment will be carefully assessed. The primary endpoint is difference in glucose absorption between the optimized and standard treatment. Secondary endpoints are ultrafiltration, sodium removal, Kt/V urea, and Kt/V Creatinine. The study will be closed when a total of 20 patients have successfully completed the interventions or terminated according to interim analysis. A Monte Carlo power analysis shows that the study has 80% power to detect a difference of 10 g (in line with that of theoretical results) in glucose absorption between the two treatments in 10 patients.DiscussionThe present study is the first clinical investigation of optimized bi-modal treatments proposed by recent theoretical studies.Trial registrationClinicalTrials.gov identifier: NCT04017572. Registration date: July 12, 2019, retrospectively registered.