Urinalysis Findings Research Articles

ACUTE CONFUSIONAL STATES IN OLDER ADULTS WITH MAJOR NEUROCOGNITIVE DISORDER AND BACTERIURIA: IS ANTIBIOTIC TREATMENT WARRANTED?

Introduction Uncomplicated urinary tract infection (UTI)/acute simple cystitis (ASC) is defined as an infection confined to the bladder/lower urinary tract with the absence of signs and symptoms that would suggest an upper tract or systemic infection (such as fever, chills, rigors, significant fatigue or malaise beyond baseline, flank pain, costovertebral angle tenderness, pelvic or perineal pain in men). Presence of systemic symptoms suggests a complicated UTI. Symptoms of ASC include dysuria, urinary frequency or urgency, and/or suprapubic pain. The term asymptomatic bacteriuria refers to isolation of bacteria in an appropriately collected urine specimen from an individual without symptoms of UTI. Asymptomatic bacteriuria generally is not treated unless the patient is pregnant, undergoing urological procedure or has a history of recent renal transplant. However, it is recommended that ASC be treated empirically with antibiotics. Minimum criteria for the initiation of antibiotics for urinary tract infection in long-term care residents without indwelling catheter include acute dysuria or fever and at least one of the following: new or worsening urgency, frequency, suprapubic pain, gross hematuria, CVA tenderness, urinary incontinence. Acute change in mental status is not considered as a criterion to diagnose and treat UTI. However, it is known that infection in older patients may be associated with nonspecific symptoms such as increased confusion, falling, and anorexia besides other classic symptoms of infection. Diagnosis of ASC is based solely on the subjective complaints of patients. Cognitive impairment with reduced capacity to specifically communicate symptoms makes it challenging to rule out the diagnosis of ASC in older patients with major neurocognitive disorder (MNCD). Such patients may communicate the pain and discomfort from ASC by having increased confusion and behavioral disturbances. Under these circumstances, is bacteriuria a clinically significant condition that warrants antibiotic therapy? Guidelines to relate urinalysis findings to the diagnosis of ASC in older adults with MNCD with behavioral disturbance are not currently available. Establishing the diagnosis in older patients is further complicated due to the higher prevalence in this group, of asymptomatic bacteriuria and chronic urinary symptoms (such as chronic urinary nocturia, incontinence, and general sense of lack of well-being). The Infectious Diseases Society of American (IDSA) Guidelines of 2019 recommend against antibiotic “trials” as these may cause drug toxicity, drug-drug interactions, and antimicrobial resistance. Recommendation is not to routinely test urine in elderly or debilitated patients with nonspecific changes in mental or functional status in the absence of focal urinary tract symptoms, and instead hydrate, carefully observe, and assess other potential contributing factors.However, as a part of work-up for delirium/acute change in mental status ruling out UTI with UA is still standard practice despite the recommendation not to do so in the absence of specific genitourinary symptoms. This is possibly due to the failure of current guidelines to convince clinicians of its adequacy to rule out possibility of UTI in cognitively impaired patients. This diagnostic challenge often leads to dilemma in the treatment approach of these patients. Methods Case series, systematic literature review Results Case identification: Six cases of elderly patients with MNCD who presented to the emergency department with acute change in mental status and behavioral disturbance were identified. Initial work-up included abnormal urinanalysis results. In the absence of patients reporting genitourinary symptoms, a diagnosis of UTI was not considered and they were admitted to a geriatric psychiatric unit for evaluation and behavioral management.. Variation in the treatment approach for each case was evaluated which included either considering the mental status change to be a result of UTI and treating with antibiotics or managing them with psychotherapeutic interventions and psychotropic medications for behavioral stabilization if safety and well-being were concerns. Discrepancies were noted in the recommendations made by the consulting internist and geriatric psychiatrist regarding whether or not antibiotic therapy vs. psychotropic medication treatment was most appropriate for older adults with MNCD and acute confusional states who had bacteriuria >100,000?CFU/?ml. While internists were concerned about adding load of antibiotic resistance to the community, psychiatrists were worried about the adverse effects of antipsychotics including thromboembolic events and sudden deaths in elderly patients. Conclusions The cases described here illustrate the need for concrete specialized diagnostic criteria for early and accurate identification of uncomplicated UTI/ ACS in elderly population with MNCD along with an appropriate management protocol. This research was funded by: Not applicable

Biochemical recovery from exertional heat stroke follows a 16-day time course.

The aim of this study was to characterize the time-resolved progression of clinical laboratory disturbances days-following an exertional heat stroke (EHS). Currently, normalization of organ injury clinical biomarker values is the primary indicator of EHS recovery. However, an archetypical biochemical recovery profile following EHS has not been established. We performed a retrospective analysis of EHS patient records in US military personnel from 2008-2014 using the Military Health System Data Repository (MDR). We focused on commonly reported clinical laboratory analytes measured on the day of injury and all proceeding follow-up visits. Over the prescribed period, there were 2,529 EHS episodes treated at 250 unique treatment locations. Laboratory results, including a standardized set of blood, serum and urine assays, were analyzed from 0-340 days following the initial injury. Indicators of acute kidney injury, including serum electrolyte disturbances and abnormal urinalysis findings, were most prevalent on the day of the injury but normalized within 24-48hours (creatinine, blood urea nitrogen, and blood and protein in urine). Muscle damage and liver function-associated markers peaked 0-4 days after injury and persisted outside their respective reference ranges for 2-16 days (alanine aminotransferase, aspartate aminotransferase, creatine phosphokinase, myoglobin, prothrombin time). Biochemical recovery from EHS spans a 16-day time course, and markers of end-organ damage exhibit distinct patterns over this period. This analysis underscores the prognostic value of each clinical laboratory analyte and will assist in evaluating EHS patient presentation, injury severity and physiological recovery.

Incidence and prediction of checkpoint inhibitor immune-related nephrotoxicity.

91 Background: Immune checkpoint inhibitors (ICIs), through inhibition of self-tolerance, have the potential to cause immune-related adverse events that can affect any organ, including the kidneys. Our study aimed to better characterize the incidence of and predictive characteristics for immune-related nephrotoxicity. Methods: All patients at the University of North Carolina (UNC) who received ICIs between April 2014 and December 2018 for any malignancy were identified. Patients on dialysis or those who received concurrent platinum-based chemotherapy were excluded. Any patient who subsequently had a clinically significant acute kidney injury (AKI), defined as a doubling or more of baseline creatinine, was included for analysis. A retrospective chart review was performed to determine the cause of AKI. Any uncertain cases were reviewed by two nephrologists for expert consensus (R.R. and V.D.). Results: 1766 patients received an ICI during the study period. 123 (7%) patients had AKI within one year of the first ICI dose. 14 were due to immune-related nephrotoxicity (11% of patients with AKI and 0.8% of all ICI patients). Pre-existing autoimmune disease was more likely in patients with immune-related nephrotoxicity than in those with non-immune AKI (14% vs 3%, p = 0.04). Similarly, concurrent or prior other immune-related adverse events were more common in patients with immune-related AKI (57% vs 6%, p = 0.01). Patients with immune-related AKI were more likely to see a nephrologist (57% vs 23%, p = 0.007) and had a more profound increase in creatinine from baseline (median 2.6 vs 1.6, p = 0.02). Age, sex, urinalysis findings, and primary tumor type were not associated with increased risk. Conclusions: The true incidence of ICI related nephrotoxicity is difficult to ascertain due to the many confounders that contribute to AKI in this population. Severe immune-related nephrotoxicity is rare, but patients with preexisting autoimmune disease or history of immune-related adverse events are at increased risk.

Characteristics associated with bacterial growth in urine in 451 proteinuric dogs (2008-2018).

BackgroundUrine cultures are frequently recommended to rule out infection as a postrenal cause of proteinuria.ObjectiveIdentify characteristics associated with bacterial growth in urine in proteinuric dogs.AnimalsFour hundred and fifty‐one dogs admitted to a teaching hospital between January 2008 and January 2018 with urine protein‐to‐creatinine ratios (UPCs) >0.5.MethodsRetrospective study included dogs with a UPC, urinalysis, and quantitative urine culture (QUC) performed within a 72‐hour period by searching electronic records. Dogs with recent antimicrobial therapy, urine collected by methods other than cystocentesis, or UPC ≤0.5 were excluded. Signalment, comorbidities, serum BUN and creatinine concentrations, urinalysis findings, and QUC results were recorded. The association between these characteristics and presence of bacterial growth in urine was assessed by univariable and multivariable analysis.ResultsThirty of four hundred fifty‐one dogs (6.7%) had bacterial growth in urine. Of these, 18 (60.0%) had active urine sediment. Bacterial growth in urine was associated with pyuria (odd ratio [OR] 25.1, 95% confidence interval [CI] 7.9‐79.6, P < .001), bacteriuria (OR 11.1, 95% CI 3.2‐39.1, P < .001), and lower urinary tract disease (OR 6.7, 95% CI 1.9‐23.0; P = .0028). If QUC was prompted based on these criteria, 8/451 (1.8%) of proteinuric dogs would have had undetected bacterial growth.Conclusions and Clinical ImportanceThe proportion of proteinuric dogs with both inactive urine sediment and bacterial growth in urine was low, suggesting that QUC might not be necessary in the evaluation of all proteinuric dogs. An active urine sediment or lower urinary tract disease should prompt QUC for proteinuric dogs.

Genotoxicity and repeated-dose toxicity evaluation of dried Wolffia globosa Mankai

Wolffia is a genus of protein-rich aquatic plants. Mankai, a cultivated strain of Wolffia globosa, contains more than 40 % protein based on dry matter evaluation. Furthermore, Mankai is nutritionally excellent as a food material, and is expected to be applicable to various products as a substitute for animal protein. A battery of toxicological studies was conducted on the dried product of Mankai (Dry Mankai), with the expectation to utilize it as a raw material for food applications. Dry Mankai was not genotoxic in a bacterial reverse mutation test and in vitro micronucleus assay. In the subchronic toxicity study, rats were provided Dry Mankai in the diet at levels of 0 %, 5 %, 10 %, or 20 % (w/w), equivalent to 0, 3.18, 6.49, and 13.16 g/kg/day for males and 0, 3.58, 7.42, and 15.03 g/kg/day for females, respectively. No adverse effects that could be attributable to treatment were observed in clinical observations, body weight, food consumption, ophthalmology, hematology and blood chemistry, urinalysis, and macroscopic and microscopic findings. According to the repeated-dose study in rats, the no observed adverse effect level of Dry Mankai was 20 % (w/w) for both sexes (13.16 and 15.03 g/kg/day for males and females, respectively).

Preclinical safety evaluation of triacylglycerol lipase QLM from Burkholderia ubonensis

Triacylglycerol lipases are well characterized enzymes that catalyze the hydrolysis of fats. They are biotechnologically relevant enzymes and are used in a wide range of practical applications in industry. Lipase produced from Burkholderia ubonensis (strain PL266-QLM) (Lipase QLM) is being investigated for use as a processing aid in multiple food applications and may therefore be present at trace levels in finished food products. A battery of toxicological studies was therefore conducted on Lipase QLM to support its safe use in food. Lipase QLM was not genotoxic or mutagenic in an in vitro bacterial reverse mutation test and chromosome aberration test. Additionally, no test article-related adverse effects were observed in clinical observations, body weight, food consumption, ophthalmology, hematology, blood chemistry, urinalysis, and macroscopic and microscopic findings in a subchronic toxicity study in rats administered Lipase QLM in the diet at levels of 0%, 0.8%, 2%, and 5% Lipase QLM. The no-observed-adverse-effect level was therefore considered to be 5% Lipase QLM in both sexes [3357.2 and 3777.6 mg/kg body weight/day (2756.3 and 3101.4 mg total organic solids/kg body weight/day) in males and females, respectively] under the test conditions, which supports the safety of this ingredient for use in food for human consumption.

A 26-week 20(S)-ginsenoside Rg3 oral toxicity study in Beagle dogs

20(s)-ginsenoside Rg3 is a red ginseng-derived compound with the formula C42H72O13 that has been increasingly used by humans, leading to safety concerns regarding this use. In the current study, we conducted a 26-week study during which 20(S)-ginsenoside Rg3 (0, 7, 20, or 60 mg/kg) was continuously administered orally to Beagle dogs in order to explore its toxicity in these animals, with control dogs receiving a vehicle capsule. In total, 10 dogs received each dose of this compound (n = 5 male, n = 5 female per dose). Animals were continuously monitored for a 26-week administration period and a subsequent 4-week follow-up recovery period. At the end of study, we observed no evidence of 20(S)-ginsenoside Rg3 toxicity in clinical indications, body weight, food intake, ophthalmoscopy, electrocardiogram, urinalysis, hematology, serum biochemistry, gross and histopathology findings. However, the kidney relative weight of animals receiving 60 mg/kg of compound was significantly elevated relative to control animals (5.15 ± 0.88‰ vs. 4.11 ± 0.59‰. P < 0.05), and this effect was reversed after 4-week recovery period. Based on these results, the NOAEL value for orally administered 20(S)-ginsenoside Rg3 in dogs is 20 mg/kg.

Association of Clinical Signs and Symptoms with Abnormal Urinalysis Findings of Blunt Trauma Patients; a Cross-Sectional Study.

Urinalysis (UA) is performed routinely as a diagnostic screening test for trauma patients in most centers. This study aimed to examine the relationship between patients' clinical signs and symptoms with UA findings. This cross-sectional study was carried out on multiple trauma patients between 18 to 65 years old, who were referred to the Emergency Department. UA was performed for all patients and its association with clinical signs and symptoms (pain, tenderness, abrasion, ecchymosis, hematoma, etc.) in abdomen, back, flank, and inferior hemi-thorax was evaluated. 640 patients with the mean age of 39.8 ± 11.2 years were studied (65.0% males). 271 (42.4%) cases had associated injuries and 554 (86.6%) cases had at least one sign or symptom of trauma in abdomen, back, flank or inferior hemi-thorax. 146 (22.8%) patients had negative UA. Among cases with positive UA, 364 (56.9%) cases had microscopic hematuria with RBC < 25/HPF, 60 (9.4%) had microscopic hematuria with RBC ≥ 25/HPF and 70 (10.9%) had gross hematuria. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria (p <0.001). Symptomatic patients who had signs in the abdomen, back or inferior hemi-thorax mainly had microscopic hematuria with RBC < 25/HPF, but those with signs in the flank, mainly had microscopic hematuria with RBC ≥ 25/HPF (p<0.001). Patients with pain, tenderness, abrasion, and ecchymosis in flank had a higher risk of positive UA findings (figure 2; p <0.001). Based on the findings of the present study, patients with any findings of pain, tenderness, abrasion, or ecchymosis in flank had higher risk of abnormal UA and perhaps urogenital injuries. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria.

Relationship between urinalysis findings and responsible pathogens in children with urinary tract infections

Pyuria, presence of bacteria, leukocyte esterase, and nitrite positivity in urinalysis should be considered together, and simultaneous urine culture test should be performed in the diagnostic evaluation of urinary tract infection (UTI). The absence of pyuria in urinalysis cannot exclude UTI in patients with suggestive clinical findings. It was aimed to assess relationship between urinalysis tests and uropathogen and to evaluate antibiotic resistance in children. The study included patients (aged 0-18 years) with significant uropathogen growth in urine culture tests. The patients' data regarding age, gender, results of urine microscopy, urine culture, and antibiogram were recorded retrospectively. Overall, 705 patients (562 girls, 143 boys) with significant growth in urine culture test were included. Median age was 72 months among girls and 12 months among boys. Most common uropathogens were Escherichia coli (79.6%) and Klebsiella pneumoniae (8.2%). E. coli was more commonly among girls (87%) and Klebsiella spp. among boys (53.3%). Pyuria was positive in urinalysis in 75% of patients. Pyuria presence was more common in patients with E.coli or Proteus spp. (80.6% and 71.4%, respectively) than those with Enterococcus spp. and Klebsiella spp. (52.0% and 53.3%, respectively). In culture antibiogram tests, ampicillin resistance was 100% in Klebsiella oxytoca and Enterobacter spp. and 72% in E. coli strains. No ceftriaxone resistance was observed in K. oxytoca, Citrobacter spp., Pseudomonas aeruginosa, and Enterobacter spp. Most UTIs were seen in older girls. Pyuria might be lacking in UTIs associated to Klebsiella spp. and Enterococcus spp., and absence of pyuria may not exclude UTI in patients with compatible clinical findings. Ceftriaxone is still an option in empirical treatment; unnecessary use of third-generation cephalosporins should be avoided, particularly in infections other than UTI. It was found that E. coli more commonly caused leukocyturia, leukocyte esterase positivity, and pyuria; that pyuria might be lacking in UTIs associated to Klebsiella spp. and Enterococcus spp. and that pyuria was more prevalent among girls. It is though that urine culture tests should be performed in children with suspected UTI even in the absence of pyuria because lack of pyuria may lead delay in diagnosis and treatment as well as renal scar formation.

Is Dipstick Urinalysis Screening Beneficial in Men with Lower Urinary Tract Symptoms?

IntroductionDipstick urinalysis is a widely used screening tool in the evaluation of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). As limited data support the use of dipstick urinalysis, we have used data from three recently published studies to assess clinical outcomes in those who had dipstick urinalysis findings for blood, glucose, and/or leukocytes.MethodsWe analyzed data from three observational studies involving men interested in using over-the-counter tamsulosin: a self-selection study (SSS) and two actual-use studies of 8-week (AUS8) and 24-week (AUS24) durations. Subgroup analyses focused on pooled data from participants not using α-blockers or other prescription medication for LUTS suggestive of BPH (nonRx users) and who had urine dipstick findings. Data from participants using α-blockers (AUS8) or any prescription BPH medications (SSS and AUS24) are presented as reference.ResultsOverall, 2488 nonRx users underwent dipstick urinalysis and 680 (27.3%) had positive findings including traces of blood (332; 13.3%), glucose (259; 10.4%), and/or leukocytes (245; 9.8%). Among users of prescription medicines, 21.6% (37/171) in SSS, 27.4% (23/84) in AUS8, and 31.1% (47/151) in AUS24 had urine dipstick findings. The 200 dipstick-positive nonRx users in SSS underwent per protocol urological assessment: 26 (13.0%) had a newly diagnosed condition causing/contributing to urinary symptoms of which 2.9% were identified as medically important conditions. Among nonRx users with or without a dipstick finding, medically important conditions reported included prostate cancer (1.0% vs. 1.0%, respectively) and urolithiasis (1.0% vs. 0.3%, respectively). The proportion of men with dipstick urinalysis findings was similar between men who regularly visited their physician and those who did not.ConclusionDipstick urinalysis did not markedly increase the detection of undiagnosed medically important conditions that cause/contribute to urinary symptoms, suggesting that this test may not be a very effective screening tool for men with LUTS.FundingBoehringer Ingelheim Pharmaceuticals, Inc.Electronic Supplementary MaterialThe online version of this article (10.1007/s12325-019-01042-0) contains supplementary material, which is available to authorized users.

Prevalence, pattern and determinants of urine abnormalities among school pupils in a semi-urban community

Background: Dipstick urinalysis is a semi-quantitative examination of the urine, which can be utilized as a screening and diagnostic tool in children. It is rapid, sensitive, easy to perform and affordable for the resource-poor environment. Objectives: To describe the pattern of urinalysis findings using urinary dipsticks and the determinants of urine abnormality among pupils in primary schools in a semi-urban area. Methods: Apparently healthy 387 pupils were recruited from 10 public and 5 private primary schools in Ikenne Local Government Area of Ogun State, Nigeria using multi-stage and proportionate sampling techniques. Data on demography, nutritional status and urinary examination were obtained using Interviewer-administered questionnaires, clinical examination and dipstick urinalysis respectively. Results: Dipstick urinalysis revealed the following; urine pH and specific gravity were normal in 98.2% and 100.0% of the pupils respectively. Protein, leukocyte esterase, nitrite, bilirubin, urobilinogen, blood and ketones were detected in 18.1%, 15.8%, 14.2%, 3.3%, 2.1%, 0.8%, and 0.5% respectively. Glucose and ascorbic acid were generally absent in the urine samples. Female gender significantly contributed to the pattern of urinalysis (leukocyte esterase and nitrites). Proteinuria was most frequent among the underweight (38/70; 54.3%). Urine abnormalities were more prevalent among pupils in public schools compared with private schools though not statistically significant, and not influenced by gender. Conclusion: Asymptomatic proteinuria and urinary tract infection are not uncommon among children. Female gender and socio-economic status play a role in the incidence of the conditions.

PROFILE OF URINALYSIS IN KIDNEY, URETER AND BLADDER STONE PATIENTS

Objective: To evaluate the profiles of urinalysis in kidney, ureter, and bladder stone patients. Material &amp; Methods: We reviewed the medical records of kidney, ureter and bladder stone patients proved underwent operative managements and urinalysis in Arifin Achmad Regional General Hospital Pekanbaru Riau Province, Indonesia in 2011-2015. The sampling technique in this study was minimum sampling that meets the inclusion criteria. Univariate test was used for statistical analysis. Approval on the study was obtained from the Ethical Review Board for Medicine and Health Research, Medical Faculty, University of Riau. Results: There were 226 patients fulfilled the inclusion criteria. This study showed that in macroscopic urinalysis the mostly (94.7%) urine density was 1.003-1.030, urine color mostly (46%) was turbid yellow, all (100%) urine acidity showed normal results with mean acidity was 6, most (95.1%) erythrocytes &gt;1 in urine sediment, most (66.2%) leukocytes was &gt;5 hpf, mostly (99.1%) crystal was absent and most urinary epithelium &lt;15 (63.1%). In microscopic urinalysis showed mostly protein in urine was absent (56.4%), and mostly ketone (98.7%) was absent in urine and mostly (56.2%) was absent protein in urine. Conclusion: Urinalysis findings could be normal or abnormal in kidney, ureter and bladder stone patients.

Drug-induced Obstructive and Retrograde Nephropathy Associated with α2u-globulin in Male Rats.

The chemically induced accumulation of α2u-globulin protein in male rats causes specific renal lesions and subsequent nephropathy. Herein, we report additional parallel findings in the kidney of male rats consistent with obstructive and retrograde nephropathy. Kidney and urinary bladder samples were evaluated from Wistar rats treated with RG7129 for 2 week and 8 week and from an 8-week mechanistic study using females, intact and castrated males. Histopathological findings were present in intact males in all studies, including hyaline droplet accumulation and granular casts consistent with α2u-globulin nephropathy. In addition, tubular degeneration and regeneration, tubular changes extending from papilla to cortex, tubular dilation, and interstitial and luminal inflammation were observed consistent with retrograde and obstructive nephropathy. Renal and urinary lesions and their severity increased in a time- and dose-dependent manner. Urinalysis findings, including increases in leukocytes, protein, and in kidney biomarkers, kidney injury molecule 1 and clusterin, were present only in intact males. No treatment-related changes were observed in female rats or in castrated males. These results indicate that RG7129 induces α2u-globulin nephropathy, associated with retrograde and obstructive nephropathy secondary to precipitation in intact male rats only, constituting a species- and sex-specific syndrome that is not expected to occur in humans or other species.

Unusual Presentation of Solid Pseudopapillary Tumor of the Pancreas With Pyelonephritis and Weight Loss

Solid pseudopapillary tumor (SPT) is a rare exocrine pancreatic neoplasm that accounts for 2-3% of pancreatic neoplasms. We present a unique case of a 20-year-old female that presented with pyelonephritis plus weight loss and was found to have SPT of the pancreas. A 20-year-old Jordanian female with history of type I diabetes mellitus presented to the ED with nausea, vomiting, dysuria, left sided flank pain, and a subjective 20-pound weight loss over the past 3 months. On physical exam, left sided CVA tenderness was elicited, but no palpable abdominal masses were found. Urinalysis and laboratory findings were consistent with pyelonephritis. Patient underwent CT abdomen/pelvis to evaluate for possible nephrolithiasis. Imaging was negative for nephrolithiasis but revealed a 7.5 x 7 cm mass in the pancreatic head with mass effect; suggestive of SPT of the pancreas or GIST tumor. GI recommended outpatient follow-up after resolution of the infection. Upon follow-up, EUS-FNA was performed and revealed an epithelial neoplasm, consistent with SPT of the pancreas. The tumor was compressing the gastric antrum and duodenal bulb causing partial gastric outlet obstruction. Surgery then performed a pylorus preserving Whipple resection. Patient recovered well post-op and was discharged home. SPT of the pancreas is a rare tumor that accounts for less than 3% of all pancreatic tumors. There has been a 7-fold increase in the incidence of SPTs since the year 2000, likely attributed to improved imaging and access to EUS. SPT predominantly affects younger females and is typically found in the pancreatic head or tail. The most common presenting signs are upper abdominal pain, palpable abdominal mass, or no symptoms altogether. In our case, the only presenting sign associated with SPT was weight loss, which is extremely rare. Diagnosis of SPT is made through a combination of imaging and pathologic findings. CT scan is the most common initial imaging modality followed by confirmation with EUS guided FNA. Overall, patients have a favorable outcome with a 5-year survival of 94-97% following surgical resection and have a recurrence rate less than 5%.1417_A.tif Figure 1: Non-contrast abdominal CT scan identifying SPT and duodenal compression1417_B.tif Figure 2: EUS identifying portal vein confluence1417_C.tif Figure 3: EUS identifying SPT and pancreatic bodyThis case is a unique presentation of SPT involving a patient with pyelonephritis and weight loss secondary to gastric outlet obstruction. Physicians should consider this neoplasm as a differential among patients, specifically females 20-30 years old, that present with unexplained weight loss and abdominal pain.

Does Voiding Cystourethrogram Exclude Posterior Urethral Valves in Late Presenting Cases?

Delayed presentation of posterior urethral valves (PUVs) is a rare condition. Presentation and diagnosis of the patients with late PUVs are challenging. Voiding cystourethrogram (VCUG) is mainly practiced. In this study, we aimed to evaluate the children with late-presented PUVs, and the reliability of VCUG in this group. Between January 2003 and December 2017 records of patients who were diagnosed with late-presented PUVs were analyzed. Delayed presentation of PUV was defined as patients who were diagnosed and treated after infancy. Cases were examined in terms of age at diagnosis, presenting symptoms, urinalysis, urinary ultrasound, urodynamic studies, VCUG, and dimercaptosuccinic acid scintigraphy findings. Postoperative follow-up conditions were also assessed. Seventeen boys were diagnosed with late-presented PUVs (mean age was 7.35 years). The most common symptoms at presentation were frequency (58.8%), day and nighttime incontinence (47%), and febrile urinary infection (41%). PUV was noted by VCUG in 10 patients alone. The classical sign of dilated posterior urethra was detected in 9 patients. The 10th patient had posterior urethral irregularity. Urethra could not be evaluated due to unsuccessful voiding in one patient. Six patients had normally appearing urethra on VCUG. Reflux was detected in nine (52.9%) patients. Late-presented PUVs may be missed on VCUG. Whether a PUV might be present is crucial in boys with a history of recurrent urinary infection, persistent reflux, and repetitive daytime incontinence. Based on our results, we conclude that cystoscopic examination should be preferred for those cases to diagnose PUVs regardless of VCUG results.

Succinylcholine-Induced Rhabdomyolysis in Adults: Case Report and Review of the Literature

Purpose: A case of succinylcholine (SCh) and sevoflurane as a probable cause of rhabdomyolysis in an adult is presented, along with a review of the relevant literature and strategies for prevention. Summary: A nondiabetic, morbidly obese 32-year-old female developed rhabdomyolysis after administration of SCh and sevoflurane for diagnostic procedures of 30 minutes’ duration. Thirty-three hours following anesthesia, the patient developed diffuse muscle tenderness and progressive weakness with a creatinine kinase (CK) of 4319 U/L. Urinalysis findings indicated contamination, a white blood cells of 12.1 × 103/μL was stress induced, while all other labs were normal. Following 26 hours of intravenous fluids, the patient’s CK decreased to 1243 U/L, with pain responsive to acetaminophen and improved mobility, resulting in discharge. With a lack of reasonable alternative causes and a temporal association of symptoms, procedural medication–induced rhabdomyolysis was suspected. Based on Naranjo scale evaluation, SCh and sevoflurane were probable causes of rhabdomyolysis. We reviewed the literature for SCh-induced rhabdomyolysis among adults and found 10 cases. The majority of patients received halogenated anesthesia (HA) and prophylaxis for SCh myopathy, with no known personal or family history of neuromuscular disorders (NMD) reported. Conclusion: Rhabdomyolysis was observed in a woman following the administration of SCh and sevoflurane for diagnostic procedures lasting 30 minutes. While avoidance is possible in adults with histories of NMDs, a high index of suspicion for occurrence of rhabdomyolysis is needed whenever combining SCh with HA in all adults.

Evaluation for association between indwelling urethral catheter placement and risk of recurrent urethral obstruction in cats.

OBJECTIVE To test for an association between indwelling urethral catheter placement in cats with urethral obstruction (UO) and the short-term (30-day) risk of recurrent urethral obstruction (RUO). DESIGN Prospective cohort study. ANIMALS 107 client-owned male cats with UO. PROCEDURES Owners were offered standard care for their cats, including hospitalization, placement of an indwelling urethral catheter, IV fluid therapy, and other supportive treatments (inpatient group). One-time catheterization and outpatient care were offered (outpatient group) if standard care was declined. Data regarding signalment, measures of metabolic compromise and urinalysis findings at enrollment, catheterization-related variables, and supportive treatments of interest were collected. Risk of RUO ≤ 30 days after urethral catheter removal was determined for the outpatient vs inpatient group by OR and 95% confidence interval calculation. Other variables were compared between cats that did and did not develop RUO with Fisher exact and trend tests. RESULTS 91 cats completed the study; 19 (5/46 [11%] inpatients and 14/45 [31%] outpatients) developed RUO. Risk of RUO was significantly greater for cats of the outpatient group (OR, 3.7; 95% confidence interval, 1.2 to 11.4). Among inpatients, increasingly abnormal urine color at the time of catheter removal was significantly associated with RUO. No other significant associations were identified. CONCLUSIONS AND CLINICAL RELEVANCE Hospitalization and indwelling catheterization significantly reduced the risk for RUO ≤ 30 days after treatment for the population studied. Results suggested that removal of an indwelling catheter before urine appears grossly normal may be associated with development of RUO. One-time catheterization with outpatient care was inferior to the standard care protocol but was successful in many cats and may be a reasonable alternative when clients cannot pursue standard care.

Urinary type IV collagen excretion is involved in the decline in estimated glomerular filtration rate in the Japanese general population without diabetes: A 5-year observational study.

Urinary type IV collagen (U-Col4) and albumin excretion is evaluated to monitor the development of diabetic kidney disease. However, U-Col4 excretion in the general population without diabetes has not yet been fully elucidated. In this study, 1067 participants without diabetes and with urinary albumin-creatinine ratio <300 mg/gCr (normo- or microalbuminuria) who underwent an annual health examination in 2004 were enrolled and observed for 5 years. They were divided according to the amount of U-Col4 or urinary albumin excreted. The decline in estimated glomerular filtration rate (eGFR) was calculated. In participants with eGFR ≥80 mL/min, abnormal U-Col4 excretion was indicated as a significant independent risk factor for 10% eGFR change per year, which is one of the prognostic factors for the development of end-stage kidney disease. Moreover, in contrast to urinary albumin excretion, U-Col4 excretion was not related to age or kidney function, suggesting that some individuals with abnormal U-Col4 excretion can have an independent hidden risk for the development of kidney dysfunction. In conclusion, it is important to measure U-Col4 excretion in the general population without diabetes to determine changes in renal features in every individual and help detect future complications such as diabetic kidney disease. If U-Col4 excretion is abnormal, kidney manifestation should be carefully followed up, even if the kidney function and urinalysis findings are normal.

High Prevalence of Sterile Pyuria in the Setting of Sexually Transmitted Infection in Women Presenting to an Emergency Department.

IntroductionThe clinical presentations for sexually transmitted infections (STI) and urinary tract infections (UTI) often overlap, and symptoms of dysuria and urinary frequency/urgency occur with both STIs and UTIs. Abnormal urinalysis (UA) findings and pyuria are common in both UTIs and STIs, and confirmatory urine cultures are not available to emergency clinicians to aid in decision-making regarding prescribing antibiotics for UTIs. The objective of this study was to determine the frequency of sterile pyuria in women with confirmed STIs, as well as whether the absolute number of leukocytes on microscopy or nitrite on urine dipstick correlated with positive urine cultures in patients with confirmed STIs. We also sought to determine how many patients with STIs were inappropriately prescribed a UTI antibiotic.MethodsWe performed a retrospective chart review of patients aged 18–50 who had a urinalysis and pelvic examination in the emergency department (including cervical cultures), and tested positive for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis. Descriptive statistics were obtained for all variables, and associations between various findings were sought using the Fisher’s exact test for categorical variables. We calculated comparison of proportions using the N-1 chi-squared analysis.ResultsA total of 1,052 female patients tested positive for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis and were entered into the database. The prevalence of pyuria in all cases was 394/1,052, 37% (95% confidence interval [CI] [0.34–0.40]). Of the cases with pyuria, 293/394, 74% (95% CI [0.70–0.78]) had sterile pyuria with negative urine cultures. The prevalence of positive urine cultures in our study population was 101/1,052, 9.6% (95% CI [0.08–0.11]). Culture positive urines had a mean of 34 leukocytes per high-power field, and culture negative urines had a mean of 24 leukocytes per high-power field, with a difference of 10, (95% CI [3.46–16.15]), which was statistically significant (p=0.003). Only 123 cases tested positive for nitrite on the urinalysis dipstick; 50/123, 41% (95% CI [0.32–0.49]) had positive urine cultures, and 73/123, 59% (95% CI [0.51–0.68]) had negative urine cultures. Nitrite-positive urines were actually 18% more likely to be associated with negative urine cultures in the setting of positive STI cases, (95% CI [4.95–30.42], p=0.0048). Antibiotics were prescribed for 295 patients with suspected UTI. Of these, 195/295, 66% (95% CI [0.61–0.71]) had negative urine cultures, and 100/295, 34% (0.33, 95% CI [0.28–0.39]) had positive urine cultures. Chi-square analysis yielded a difference of these proportions of 32% (95% CI [23.92–39.62], p<0.0001).ConclusionThis study demonstrated that in female patients with STIs who have pyuria, there is a high prevalence of sterile pyuria. Our results suggest that reliance on pyuria or positive nitrite for the decision to add antimicrobial therapy empirically for a presumed urinary tract infection in cases in which an STI is confirmed or highly suspected is likely to result in substantial over-treatment.

Safety evaluation of fructooligosaccharide (FOSSENCETM): Acute, 14-day, and subchronic oral toxicity study in Wistar rats

Fructooligosaccharide (FOS) has been used in infant formula and conventional foods as prebiotics. Short chain FOS (FOSSENCETM) is produced by a patented process of biotransformation of sucrose by the action of enzyme from live microbial cells, hence toxicology studies were initiated to assess its safety. The objective of the present study was to determine safety of FOSSENCETM in acute, 14-day, and subchronic (90-day) toxicity studies. In acute and 14-day studies, administration of the FOSSENCETM to Wistar rats did not cause any mortality or clinical signs and changes in body weights, feed consumption, and gross pathology at the doses of 2000, 5000, and 9000 mg/kg body weight. In the subchronic (90-day) toxicity study, FOSSENCETM was administered by oral gavage to Wistar rats at the doses of 0, 2000, 5000, and 9000 mg/kg/day for 90 days. No treatment-related clinical signs or mortalities were observed. Similarly, no treatment-related toxicologically or biologically significant changes in body weight, feed consumption, ophthalmological findings, neurological effects, hematology, clinical chemistry, urinalysis, and gross pathological findings were noticed. However, statistically significant increase in weight of cecum (without correlative microscopic change) was noted at all the test item-treated groups in males and females and was considered to be a trophic effect and not a toxic effect in rats.