Foley Catheter Research Articles

Risk factors for a failed trial without catheter following convective water vapor thermal therapy (CWVTT-Rezum).

Convective water vapor thermal therapy (CWVTT-Rezum) is a minimally invasive surgical therapy that is being increasingly utilized for bladder outlet obstruction. Most patients leave the site of care with a Foley catheter in place for a mean reported duration of 3-4 days. A minority of men will fail their trial without catheter (TWOC). We aim to identify the frequency of TWOC failure following CWVTT and its associated risk factors. Patients who underwent CWVTT at a single institution from October 2018 to May 2021 were retrospectively identified and pertinent data extracted. The primary endpoint was TWOC failure. Descriptive statistics were performed, and rate of TWOC failure was determined. Potential risk factors for failed TWOC were assessed through univariate and multivariate logistic regression. A total of 119 patients were analyzed. Seventeen percent (20/119) had a failed TWOC on their first attempt. Of those, 60% (12/20) failed in a delayed fashion. In patients who failed, the median number of total TWOC attempts required for success was two (interquartile range [IQR] = 2-3). All patients eventually had a successful TWOC. The median preoperative postvoid residual for successful and failed TWOC was 56 mL (IQR = 15-125) and 87 mL (IQR = 25-367), respectively. Preoperative elevated postvoid residual (unadjusted odds ratio [OR] 1.02, 95% CI: 1.01-1.04; adjusted OR 1.02, 95% CI: 1.01-1.04) was associated with TWOC failure. Seventeen percent of patients failed their initial TWOC after CWVTT. Elevated postvoid residual was associated with TWOC failure.

(089) Regional Vestibulectomy and Buccal Mucosal Graft Reconstruction for Refractory Neuroproliferative Vestibulodynia

Abstract Introduction Buccal mucosal grafts (BGM) are widely used in male urethral reconstruction and have more recently been reported for female urethral reconstruction. We report the first case of using a buccal mucosa graft (BMG) to cover the excised 12:00 vestibule in a 19 year old woman with lifelong persistent genital arousal disorder (PGAD) presumed secondary to congenital neuro-proliferative vestibulodynia. She presented to our clinic at 17 and underwent lysis of clitoral adhesions, excision of the core 12:00 region with primary closure, and complete vestibulectomy with vaginal advancement flap. Her vestibular specimen positively stained for CD117 and PGP9.5 consistent with excess mast cells and nerves, respectively. Post-operatively, there was marked reduction of vestibular pain in the 1:00 to 11:00 region posteriorly, however she had persistent PGAD and significant residual tenderness to cotton-tipped swab testing at the 12:00 region. Her PGAD was medically managed successfully with tramadol, clonazepam and low dose zolpidem. Desiring to eliminate the need for systemic medications, the patient returned to the clinic at age 19. Again, local anesthesia applied to the clitoris and 12:00 vestibule region resulted in clinically significant PGAD symptom reduction and 12:00 vestibulodynia. We discussed repeat clitoral lysis and re-excision of the 12:00 region with BMG reconstruction. Objective To report on a novel technique using BMG for 12:00 region vestibular reconstruction in one woman with distressing vestibulodynia and PGAD. Methods Pre-operative counseling included discussion of routine surgical risks, benefits, alternatives, with additional possible complications including failure of the procedure to relieve PGAD or vestibulodynia, graft contracture, buccal harvest site contracture, sexual dysfunction, and genital disfigurement. The patient gave consent for the procedure and underwent a repeat lysis of clitoral adhesions and 12:00 regional subepithelial vestibulectomy. The defect measured 2.5 cm x 2.5 cm. A non-tubularized onlay patch of buccal mucosa was harvested and used for vestibular reconstruction. The procedures were performed by a single surgeon. The patient was discharged the same day. Results The patient’s post-operative course was notable for acute urinary retention in the recovery room. She was discharged with a foley catheter and passed a voiding trial on post-op day 1. Her pain was well-controlled with non-opioid medications and she was able to resume a soft food diet immediately after surgery. At post-op week 5, the clitoral area, buccal harvest site, and graft site were healed without complication. The patient reports that her 12:00 pain to touch has resolved. Her PGAD has decreased slightly, although she has not yet attempted to discontinue oral medications. Conclusions For this patient, regional vestibulectomy with BMG to the 12:00 region of the vestibule appears to have been a safe and feasible technique for refractory neuroproliferative vestibulodynia. Given that the vestibule is of endodermal origin derived from the urogenital sinus, and neuroproliferation may represent a congenital anomaly, there is a rationale to replace urogenital sinus endoderm with a non-urogenital sinus endoderm such as buccal mucosa. Pre-operative counseling should include surgery specific adverse events like mouth opening restriction and genital disfigurement. Longer follow up and larger studies are needed. Disclosure No

Liver-specific metastases as an independent prognostic factor in cancer patients receiving hospice care in hospital

BackgroundSurvival prediction is important in cancer patients receiving hospice care. Palliative prognostic index (PPI) and palliative prognostic (PaP) scores have been used to predict survival in cancer patients. However, cancer primary site with metastatic status, enteral feeding tubes, Foley catheter, tracheostomy, and treatment interventions are not considered in aforementioned tools. The study aimed to investigate the cancer features and potential clinical factors other than PPI and PaP to predict patient survival.MethodsWe conducted a retrospective study for cancer patients admitted to a hospice ward between January 2021 and December 2021. We examined the correlation of PPI and PaP scores with survival time since hospice ward admission. Multiple linear regression was used to test the potential clinical factors other than PPI and PaP for predicting survival.ResultsA total of 160 patients were enrolled. The correlation coefficients for PPI and PaP scores with survival time were -0.305 and -0.352 (both p < 0.001), but the predictabilities were only marginal at 0.087 and 0.118, respectively. In multiple regression, liver metastasis was an independent poor prognostic factor as adjusted by PPI (β = -8.495, p = 0.013) or PaP score (β = -7.139, p = 0.034), while feeding gastrostomy or jejunostomy were found to prolong survival as adjusted by PPI (β = 24.461, p < 0.001) or PaP score (β = 27.419, p < 0.001).ConclusionsAssociation between PPI and PaP with patient survival in cancer patients at their terminal stages is low. The presence of liver metastases is a poor survival factor independent of PPI and PaP score.

The spine intra-abdominal pressure (SIAP) trial. A prospective, observational, single arm, monocenter study looking at the evolutions of the IAP prior, during and after spine surgery

Background and aimsBoth anaesthesiologists and spine surgeons consider the intra-abdominal pressure (IAP) as an important peri-operative factor affected by patient positioning.We assessed the change in IAP caused by using a thoraco pelvic support (inflatable prone support, IPS) with the subject under general anesthesia. The IAP was measured before, during and immediately after surgery. MethodsThe Spine Intra-Abdominal Pressure study (SIAP trial) is a prospective, single-arm, monocenter, observational study looking at changes in IAP prior, during and after spine surgery. The objective is to assess the change in IAP, measured via an indwelling urinary catheter, using the inflatable prone support (IPS) device during prone positioning of patients in spinal surgery. ResultsForty (40) subjects requiring elective lumbar spine surgery in prone position were enrolled after providing informed consent. The inflation of the IPS results in a significant decrease of IAP (from a median of 9.2 mmHg to 6.46 mmHg (p < 0.001)) in patients undergoing spine surgery in prone position. This decrease in IAP was maintained throughout the procedure despite the discontinuation of muscle relaxants. No serious adverse events or unexpected adverse events occurred. ConclusionThe use of the thoraco-pelvic support IPS device was able to significantly lower the IAP during spine surgery.

(214) Female bmg Urethroplasty and 2nd Degree Vaginal Tear Repair

Abstract Introduction Pregnancy and childbirth bring biological, psychological, and social changes which may influence women's health. Objective Second degree tears are the most common type of tear. A female urethral stricture is a less common condition. Buccal mucosa graft (BMG) is widely used tissue for urethral stricture repair. Methods We present a 38-year old female who suffered a 9-year long history of urethral stricture disease and dyspareunia after two vaginal child births. The patient (pt) had urethral injury and 2nd degree tear in vaginal wall and pelvic muscle. Despite repeated attempts of urethral dilations, the stricture and the obstructive complaints persisted. Additionally, lack of sexual arousal and painful intercourses, affected the patient’s quality of life. The pt was treated with a dorsal onlay urethroplasty using a buccal mucosa graft, excision of vaginal wall scar, pelvic floor muscle repair, and repair of vaginal opening The surgery was carried out with a suprameatal approach. A semicircular incision was performed and the urethra was dissected from the ventral aspect of the clitoris with a sharp and blunt dissection up to the proximal part of stricture. Then, a dorsal sagittal incision is performed over the stricture and the BMG is sutured dorsally for the edges and quilted with 4.0 polyglactin sutures. A 16Fr Foley catheter was left in place for two weeks. Then, we performed hydrodissection of posterior vaginal wall, scar excision from episiotomy and 2nd degree tear, approximation of levator ani muscle, vaginal wall and opening repair. Results Two weeks after surgery the patient urinates without strain and with no post voiding residual urine. Uroflow 6 weeks after surgery showed Qmax of 28ml/sec and urethra was easily passable for 20Fr Nelaton catheter. Eight weeks after surgery the patient reported having a normal sexual life without pain and lack of sexual satisfaction Conclusions Female dorsal onlay urethroplasty and vaginal wall tear repair are feasible and give great functional and aesthetical results Disclosure No

Foley catheter (80 vs 60 mL) and misoprostol for labor induction in nulliparous women: a randomized controlled trial

Induction of labor is a common intervention in obstetrics worldwide. Foley catheter is a commonly used mechanical method for labor induction in nulliparous women with an unfavorable cervix at term. We hypothesize that a higher volume of Foley catheter (80 mL vs 60 mL) will shorten the induction-delivery interval for labor induction in nulliparous women at term with an unfavorable cervix with simultaneous use of vaginal misoprostol. This study aimed to evaluate the effect of transcervical Foley catheter (80 mL vs 60 mL) with simultaneous use of vaginal misoprostol on the induction-delivery interval in nulliparous women at term with an unfavorable cervix for induction of labor. In this double-blind, single-center, randomized controlled trial, nulliparous women with a term singleton gestation with unfavorable cervix were randomized to either group 1 (Foley catheter [80 mL] simultaneously with vaginal misoprostol 25 µg every 4h) or group 2 (Foley catheter [60 mL] with vaginal misoprostol 25 µg every 4h). The primary outcome was induction-delivery interval. Secondary outcomes were duration of the latent phase of labor, number of doses of vaginal misoprostol required, mode of delivery, as well as maternal and neonatal morbidity. Analyses were based on the intention-to-treat method. A sample size of 100 women per group (N=200) was selected. Between September 2021 to September 2022, 200 nulliparous women at term with an unfavorable cervix were randomized to labor induction with either FC (80 mL vs 60 mL) and vaginal misoprostol. Induction delivery interval (in minutes) was statistically significantly shorter in Foley catheter (80 mL) (median [interquartile range], 604 [524-719] vs 846 [596-990]; [P<.001]). Median time to labor onset (in minutes) (240 [120-300] vs 360 [180-600]; P<.001) was also shorter in group 1 (80 mL). The number of doses of misoprostol required for labor induction was statistically significantly less than with 80 mL (mean±standard deviation, 1.4±0.7 vs 2.4±1.3; P<.001). There was no statistically significant difference in the mode of delivery (vaginal delivery: 69 vs 80; odds ratio, 0.55 [1.1-0.3]; P=.104 and cesarean delivery: 29 vs 17; odds ratio, 0.99 [0.9-1.1]; P=.063, respectively). The relative risk of delivery within 12 hours with 80 mL was 2.4 [95% confidence interval, 1.68-3.43], P<.001. Maternal and neonatal morbidity were similar across the 2 groups. FC (80 mL) simultaneously with vaginal misoprostol significantly shortens the induction-delivery interval (P<.001) in nulliparous women at term with an unfavorable cervix, as compared with Foley catheter 60 mL and vaginal misoprostol.

Omitting Foley Catheter Use in Mastectomy Patients With or Without Immediate Reconstruction.

Foley catheter placement is often advised in surgeries anticipated to exceed 3 hours; however, this time cutoff does not take into account the type of surgery. Complications from Foley catheter placement include urinary tract infections and genitourinary trauma that may be costly to healthcare systems. Our objective was to determine whether mastectomy with or without reconstruction can be done without Foley use, without an increase in urinary retention risk. One hundred eighty-seven patients who underwent unilateral or bilateral mastectomies with or without reconstruction in 2020 and 2021 were reviewed. Chart review included intraoperative fluids given, estimated blood loss, lymph node dissection, and duration of procedure. After excluding patients with case duration under 180 minutes, 145 remained. Ninety-four patients did not have a Foley and 51 patients had an intraoperative Foley. None of the patients without a Foley experienced postoperative urinary retention, including 3 patients who also underwent lymphatic microsurgical preventive healing approach. Eighty-six percent of patients were discharged on the day of surgery. Patients with or without a Foley did not differ significantly in terms of race, rate of axillary lymph node dissection, body mass index, rate of same-day discharge, presence of hypertension or diabetes, estimated blood loss, or age. Patients undergoing unilateral and bilateral mastectomies with or without reconstruction or lymphatic microsurgical preventive healing approach may avoid Foley catheter placement without increased risk of urinary retention, even if the case is anticipated to exceed 3 hours. Advantages include elimination of catheter-associated urinary tract infections and their associated hospital costs, as well as avoiding genitourinary trauma.

Epistaxis Treatment Options: Literature Review.

Epistaxis means bleeding from nostrils, nasal cavity or nasopharynx. To summarize the available epistaxis treatment options. Methods: 61 articles published in the last 20years were included. Duplicate records, irrelevant and inaccessible ones were excluded. Epistaxis can be treated with first aid measures such as external pressure and ice packing and applying topical agents, e.g. oxymetazoline that stops 65-75% of nosebleeds in A&E. Also, with electrocautery which is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization and applying tranexamic acid that promotes hemostasis in 78% of patients, versus 35% and 31% respectively in patients treated with oxymetazoline and nasal packing. Furthermore, nasal packing can be applied with non-absorbable materials, e.g. petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino), absorbable materials, e.g. nasal tampon (Nasopore), and with newer hemostatic materials which are more effective and with fewer complications, e.g. hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) and fibrin glue. Moreover, epistaxis can be achieved with endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing (97% vs. 62%), and with endoscopic cauterizationwhich is more effective than ligation. Finally, for intractable cases embolization can be applied using gelatin sponge, foam, PVA and coils with 80% success rate and comparable efficacy and complications to surgical methods. Epistaxis can be dealt with various methods depending on patient's history and available resources. Newer hemostatic agents in combination with endoscopic methods have advantages over traditional methods.

P-003 ASSESSMENT OF UROSTOMY PARASTOMAL HERNIATION FORCES

Abstract Introduction Approximately 10,000 patients undergo cystectomy with ileal conduit diversion annually in the USA, of which ∼ 50% will subsequently develop a parastomal hernia (PSH) at 2 years. Due to the knowledge gap between urostomy surgical factors and abdominal wall forces, we developed a silicone and ex-vivo human cadaver fascia-based model for study. Our objective was to measure the relationship between incision size/type/material and axial tension force (ATF) as a surrogate for herniation force. Methods Using incisions (linear, cruciate, circular) ranging 1 to 3 cm (0.5cm increments) in clamped 3″x3″x0.020″ silicone or cadaveric sheets, a dynamometer was hooked to a Foley catheter at the drainage aperture and pulled using a motorized positioning system at 20 millimeters/minute. Balloons were hydrated to 125% incision dimension. Upward ATF was recorded until balloon herniation and repeated up to N=5 membranes/size. As limited cadaveric fascia was available, a single incision size was used. Results Controlling for silicone incision size, linear incision ATF was highest. With an average 3cm incision herniation force of 18.58, 8.48, and 2.36 Newtons (linear, cruciate, and circular respectively), linear was greater than cruciate herniation force (p&amp;lt;0.0001), and cruciate was greater than circular (p=0.0039). This was true in cadaveric fascia for linear vs cruciate (p=0.0001) and cruciate vs circular (p=0.0024). Conclusion This ex-vivo study suggests incision type/size have predictable influences on ATF for herniation. En-bloc human studies are underway to assess these factors in more clinically optimized models. If confirmed, these data can help to standardize urostomy creation, reducing PSH risk.

Early Removal of Foleys Catheter within 48 Hours of Transurethral Resection of the Prostate

Objectives: To study outcomes of early removal of foley’s catheter after transurethral resection of prostate (TURP). Study Design and Duration: This is a cross sectional study completed in six months duration from May to October 2022. Setting: study was conducted in the department of urology Shaheed Mohtarma Benazir Bhutto Medical College. Methodology: All male patients above 50 years of age with prostate more than 30 gm and less than 60 grams with definitive indication of TURP were included in this study. Those with age less than 50 years, prostate less than30 gram, more than 60, patient with cerebrovascular disease or psychiatric disorder and history of stricture urethra were not included in this study. Results: Total 60 patients were included in this study with maximum age 70 years and minimum age was 55 years. Average size of prostate determined by trans-abdominal ultrasound was 52 grams, maximum size was76 grams and minimum size was 30 grams. Foleys catheter was removed in all patients on the second postoperative day within 48 hours after TURP. Patient voided with good stream after Foley’s removal. Out of sixty patients one patient (1.7%) developed urinary retention immediately after Foley’s removal who was recatheterized and Foley’s was kept for further three days and trial of catheter was given which was successful. One patient (1.7%) developed mild hematuria and Foley’s was kept for 2 days and trial was successful. Conclusion: Early removal of Foley’s reduces hospital stay, early return to work, prevents catheter related side effects and reduces patients anxiety due to catheter. Keywords: Foleys Catheter, TURP, Catheterization, BPH

Outcome, risk factors and therapeutic strategies in carbapenem-resistant Gram-negative bacteraemia from Pakistan.

Carbapenem-resistant Gram-negative (CRGN) bacteraemia has high mortality and limited therapeutic options. We assessed the risk factors and outcome of CRGN bacteraemia treated with limited options. A prospective cohort study done at a tertiary care hospital in Pakistan, from October 2021 to August 2022. All patients >18 years with CRGN bacteraemia were assessed for demographics, source, risk factors and treatment received. Outcome was assessed as bacterial clearance and all-cause mortality at Day 14 of bacteraemia. We included 175 patients. Median age was 45 years (IQR 30-58) and the majority of our patients were on haemodialysis (75%). We found 14 day mortality in 26.8% of our patients; in addition, microbiological clearance was achieved in 95%. The central line (49.7%) was the most common source and Klebsiella spp. (47%) the most common organism. On multivariate analysis, risk factors for mortality were Foley's catheter [aOR 2.7 (95% CI 1.1-6.5)], mechanical ventilation [aOR 5.1 (95% CI 1.6-15.8)] and Pitt bacteraemia score >4 [aOR 3.48 (95% CI 1.1-10.5)]. Source control was a significant protective factor [aOR 0.251 (95% CI 0.09-0.6)]. The majority received a colistin-based regimen with no difference in mortality between monotherapy and combination therapy. Our cohort of CRGN bacteraemia is unique, comprising younger patients mostly on haemodialysis with a central line as the source of bacteraemia and we have found 14 day mortality of 27%. Colistin with various combinations can be an effective option in patients with renal failure having prompt source control.

Using urine output tending to manage fluid balance among patients with acute decompensated heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background Positive fluid balance has been associated with adverse outcomes in patients admitted to intensive care units (ICU). Urine output (UO) is used both to assess deterioration of renal function as well as for management of fluid balance in patients admitted to the general ICU. In the cardiac ICU, patients admitted for acute decompensated heart failure (ADHF) are at high risk for type I cardio-renal syndrome and increased morbidity and mortality. Studies have shown that poor fluid management in these patients contributes to worse outcomes in this patient population (1). Aim To investigate the possible effect of real-time monitoring of UO trends on the individualized pharmacologic management, fluid balance, and clinical outcomes of patients admitted to the cardiac ICU with ADHF. Methods We performed a case series of 35 patients admitted to the cardiac ICU from July 2021 and January 2022 with ADHF. Their standard Foley catheter was connected to an electronic monitoring system (Clarity-RMS sensor kit) that continuously monitors UO in real-time. Its technology is described elsewhere (2). The UO monitoring system displays UO trends on the consoles that are updated in real-time. UO trends were utilized to detect dynamic changes in urine output and guide an individualized approach for the pharmacologic management of each patient, based on blood pressure, hourly UO and total fluid balance. Daily and accumulated fluid balance was registered at up to 72 hours following admission. Patient outcomes included incidence of acute kidney injury (AKI), as defined by the KDIGO criteria for changes in serum creatinine (SCr), and 30-day mortality. The case series group was than compared to a historical group of 35 matched controlled patients admitted between 2018-2019. Patients were matched according to cause of admission, age and glomerular filtration rate. Results Mean age was 71 ± 11 years and 49 (70%) were men. Patients in the electronic urinary monitoring cohort demonstrated significantly more negative daily and cumulative fluid balance as compared to the historical cohort, (P&amp;lt;0.001 for all, Figure 1). Incidence of AKI and AKI combined with 30-day mortality was significantly lower in the electronic UO monitoring cohort (23% vs. 57%, p&amp;lt;0.001, and 34% vs. 63%, p&amp;lt;0.001, respectively). These changes were more prominent in the subgroup of patients with chronic kidney disease (CKD) (Figure 2). Conclusion We demonstrated that real time monitoring of UO trends may be used for goal-directed care for the prevention of fluid overload and adverse outcomes in patients with ADHF. Further studies on larger populations are required to validate the potential utility of UO trending in the management of critically ill patients with ADHF.

Microbiological Characterization and Clinical Facets of Elizabethkingia Bloodstream Infections in a Tertiary Care Hospital of Eastern India.

Elizabethkingia is an emerging non-fermenting Gram-negative bacillus (NFGNB) causing bloodstream infections (BSI) associated with high mortality. It demonstrates a unique antimicrobial profile in showing susceptibility to antimicrobials effective against Gram-positive bacteria. This study was undertaken to determine the overall frequency of Elizabethkingia BSI, associated risk factors, microbiological susceptibility, and clonal relationship of Elizabethkingia isolates using Enterobacterial Repetitive Intergenic ConsensusPolymerase Chain Reaction (ERIC-PCR). Elizabethkingia isolates obtained from the blood culture of admitted patients (August 2020-December 2021) were identified by the VITEK 2 system and subjected to an antimicrobial susceptibility test by standard procedures. Demographics, co-morbidities, risk factors for survival, and outcome were summarized and analyzed by Chi-square test, Kaplan-Meier curve, and Cox regression. Clonal relatedness between Elizabethkingia isolates was analyzed using ERIC‑PCR fingerprinting with the "PAST: Paleontological statistics software package". Of 13,747 blood samples received during the study period, 13.59% were culture positive, and 14.60% were NFGNBs. The frequency of Elizabethkingia spp. among all NFGNBs in BSI was 29.30%, and the overall prevalence in BSI was 4.21%. In patients with Elizabethkingia BSI, Foley's catheter was present in 81.25% of the cases. 100% susceptibility was observed to linezolid, followed by vancomycin (98.75%) and chloramphenicol (89.5%). The 30-day mortality rate in the patients of Elizabethkingia BSI was 26.25%. The Presence of COVID-19, pneumonia, diabetes mellitus (DM), mechanical ventilation (MV), and prior antibiotics were significantly different (p<0.05) between the survival and death groups. ERIC-PCR profile dendrogram of Elizabethkingia isolates showed ten major clusters indicating high genetic diversity. Elizabethkingia was responsible for one-third of NFGNB BSI in a single-center study, with approximately 26% of 30-day all-cause mortality. Most isolates were susceptible to linezolid, vancomycin, and chloramphenicol. COVID-19 was the most significant risk factor associated with mortality. ERIC-PCR of Elizabethkingia isolates exhibited high genetic diversity.

Abstract #1392363: Copeptin Role in the Diabetes Insipidus Work Up, a Case of Nephrogenic DI Diagnosed by Copeptin Levels After Indeterminate Results on Water Deprivation Test

The indirect water-deprivation test (WDT) is the gold standard for the diagnosis of diabetes insipidus (DI). This test can be technically cumbersome and inaccurate. Because Copeptin and Argine Vasopressin (AVP) are derived from the same precursor protein, pre-provasopressin, copeptin provides the advantage of a better diagnostic marker. We present a case of DI where copeptin elucidated the diagnosis. A 66 y/o male with past medical history of bipolar disorder (20 years taking lithium, last use 2 years prior), hypertension, chronic kidney disease stage 3, head trauma 10 years prior. He was sent to the ER from a psychiatry facility for urinary and fecal incontinence. History is significant for polyuria, and polydipsia (∼3 liters of water/day). No headaches, or vision changes. Unremarkable physical exam including mental status. Labs showed sodium of 152; urine osm 260; serum osm 309, and urinary sodium 68; baseline creatinine 1.5 with GFR 55. CT head w/o contrast was negative. Hypernatremia improved with D5W solution. Urine output was difficult to calculate given urinary incontinence. Endocrinology was consulted for DI work-up. The patient was transferred to the ICU for a WDT. Foley catheter was placed. The starting sodium level was 145. One hour later, sodium went up to 147 with plasma osm of 304. A copeptin level was sent. He received 2 mcg of DDAVP IV. The urine osm was checked every 30 min for 2 hours. Results showed urine osmolarity levels of 304, 320, 346 and 346 post-DDAVP. Sodium remained unchanged at a level of 148 pointing to nephrogenic DI. He was started on HCTZ 25 mg PO daily with normal sodium levels at 24 hours without IV fluids. Copeptin resulted at 26 pmol/L confirming a diagnosis of complete nephrogenic DI. Our patient had risk factors for central and nephrogenic DI. WDT was performed with an increase of < 15% in uOsm with persistently high sodium despite DDAVP ruling out central DI. This minimal response pointed to complete Nephrogenic DI; however, persistent urine osm >300 left partial central DI possible. The copeptin level of 26 confirmed the diagnosis of complete nephrogenic DI. Diagnostic accuracy of the classical WDT is only around 70%. Multiple studies have evaluated the accuracy of copeptin in the differential diagnosis of polyuria-polydipsia syndrome showing a single baseline copeptin level >21.4 pmol/L differentiated nephrogenic DI from other etiologies with a 100% sensitivity and specificity (1). The superiority of copeptin has also been confirmed when applies to hypertonic saline-stimulated testing (2). Copeptin is a more stable, reliable, and rapidly measurable blood biomarker of AVP. The use of copeptin should become standard of care for all DI work-up.

Carbapenemase-producing uropathogens in real life: epidemiology and treatment at a County Emergency Hospital from Eastern Romania.

Urinary tract infections are a public health problem exacerbated by the rising concern of antibiotic resistance. Carbapenem-resistant Enterobacterales (CRE), mostly isolated from urine samples, represent an immediate public health threat, often associated with healthcare settings. This study investigated 27 cases of carbapenemase-producing organisms (CPO) detected in urinalysis over one year. There was a significant association between the presence of chronic indwelling urinary catheters and the temporary use of urinary catheters, with both groups accounting for 66.7% of all cases. We identified two modes of transmission for extended drug-resistant microorganisms: inter-hospital spread, covering wide geographical distances (involving four healthcare units across two other counties), and intra-hospital transmission (12 departments within our institution). Medium-size hospitals should thoroughly investigate their specific carbapenemase-producing strains. Their laboratories must be well-supplied to handle this situation and perform the necessary testing accurately. Treatment options should be available based on presumed susceptibility and antimicrobial susceptibility testing, with a range of antibiotics available, including novel agents such as Ceftazidime-avibactam, as well as established options like Aminoglycosides and Colistin. Adherence to rigorous catheter handling protocols, as emphasized by national and international guidelines, is essential and should be implemented consistently across all hospital departments.

Efficacy of Transcervical Balloon Catheter Versus Hygroscopic Dilator for Outpatient Prelabor Cervical Ripening [ID: 1382587

INTRODUCTION: Outpatient preinduction cervical ripening with mechanical agents has been associated with reduced length of stay and cesarean delivery rates. This study aimed to demonstrate equivalence in efficacy and patient satisfaction between balloon catheter and hygroscopic dilators for outpatient cervical ripening. METHODS: This randomized control equivalence trial compared the 30-cc silicone Foley catheter (off-label) to Dilapan-S. Inclusion criteria were elective induction, low risk, group B streptococcus negative, and Bishop score of less than 6. The primary outcome was time from admission to delivery. Secondary outcomes included cesarean delivery rates, pain scores, and patient satisfaction. A power calculation determined 150 patients per arm were needed. Ochsner Health IRB approved CR00003326. RESULTS: Between March 1, 2019, and May 31, 2021, 8,150 deliveries occurred, with 1,605 patients meeting screening criteria and 175 completing the study. Time from admission to delivery for balloon was 17.7 hours versus 17.9 hours for dilators. The mean time difference was −0.1524 hours (90% CI –2.4617 to 2.1569), which was statistically significantly equivalent within the specified symmetrical 3-hour equivalence margin (P=.0215). Pain scores with insertion were 3.52 with balloon versus 3.87 with dilators. Satisfaction with outpatient cervical ripening was 91.7% with balloon versus 97.4% with dilators. Cesarean delivery rate of primiparous patients was 31% with balloon versus 25.3% with dilators. CONCLUSION: Although the enrollment goal was unmet, metrics suggested outpatient cervical ripening with balloon catheter and hygroscopic dilators were equivalent in time from admission to delivery and patient-reported pain scores. Further research is needed to assess a potential trend toward improved satisfaction and cesarean delivery rate with dilators.

Effect of an Obstetric Enhanced Recovery After Surgery (ERAS) Protocol on Maternal and Neonatal Outcomes [ID: 1375461

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) is a protocol initiated in many specialties with the goal of reducing health care costs, postoperative complications, and patient morbidity. METHODS: We undertook a retrospective cohort study of pregnant women undergoing nonlaboring, nonurgent cesarean delivery between October 2020 and October 2021. Data pertaining to demographic characteristics, pregnancy comorbidities, and maternal and neonatal outcome measures pertaining to operative and postoperative complications, readmission, length of stay, breastfeeding, neonatal cord gases, and neonatal intensive care unit admission were abstracted from electronic health records and compared across two groups, preimplementation and postimplementation, using Student t-test, Pearson’s χ2, Mann-Whitney U, and/or Fisher’s exact test, as indicated. Statistical significance was set at P&lt;.05. Institutional review board approval was obtained. RESULTS: Demographic characteristics and rates of pregnancy comorbidities, including chronic hypertension, hypertensive disorders of pregnancy, and pregestational/gestational diabetes, were similar across pregnant women undergoing cesarean delivery in the preimplementation (N=168) and postimplementation (N=123) groups. Cesarean procedure duration, overall intraoperative and/or postoperative complication rates, readmission, breastfeeding rates, and postoperative length of stay did not change after ERAS implementation and were comparable to the pre-ERAS cohort. Postoperative Foley catheter replacement was more common after ERAS implementation (P=.03). Neonatal outcomes were comparable across both study groups. CONCLUSION: Implementation of an ERAS protocol did not significantly alter maternal and neonatal clinical outcomes in our study cohort with the exception of a small increase in Foley catheter replacement rates, which may be attributable to the protocol workflow requiring Foley removal within 6 hours postoperatively.

Factors Associated With Pregnancy Duration up to 32 Weeks in Patients With Twin Gestations Who Underwent Cerclage Placement [ID: 1378167

INTRODUCTION: Historically, cerclages were not recommended in multiple-gestation pregnancies because of uncertain efficacy and concern for harm. However, a meta-analysis of twin pregnancies found cerclage was associated with reduction in preterm birth (PTB) less than 32 weeks with cervical length (CL) of 15 mm or lower. METHODS: We conducted a retrospective analysis of women who underwent cervical cerclage placement at a single tertiary academic center from 2008 to 2020. Data pertaining to maternal demographics, obstetric course, sonographic CL, and cerclage operative technique were abstracted for women with twin gestations. Factors with P value of .2 or lower on univariate analysis of spontaneous PTB (sPTB) less than 32 weeks were considered for incorporation along with history of sPTB into a Cox proportional-hazards model to assess factors associated with pregnancy duration up to 32 weeks. RESULTS: Seventy-five twin gestations were analyzed. On univariate analysis, neuraxial anesthesia during cerclage placement, preoperative cervical dilation, use of Foley catheter for membrane elevation, shorter postoperative CL, and twin B male sex were found to be significantly associated with sPTB less than 32 weeks. Cox proportional-hazards analysis demonstrated that use of Foley catheter for membrane elevation, neuraxial anesthesia, postoperative CL less than 25 mm recorded 24 weeks or earlier, and history of sPTB greater than 16 weeks had significantly higher adjusted hazard ratios. The bias-corrected bootstrapped (1,000 repetitions) AUROC for a logistic regression model with these four covariates predictive of sPTB less than 32 weeks was 0.83 (95% CI 0.69–0.89). CONCLUSION: A survival analysis approach offers valuable clinical insight into predictors of shorter pregnancy duration up to 32 weeks in twin gestations undergoing cervical cerclage placement.

A FOUR-YEAR FORGOTTEN URINARY CATHETER IN A SEXUALLY ACTIVE YOUNG MALE AND ITS MANAGEMENT: A CASE REPORT

The urinary catheters’ mean indwelled duration after PIUR (primary interventional urethral realignment) is 25 days. Only four cases of forgotten urinary catheter were reported in the literature. The objective of this clinical case report is to highlight the unusual finding of a four-years forgotten urinary catheter in a young sexually active 23-year-old man and its management, aspiring future similar endeavors. A 23-year-old man presented to the hospital exhibiting severe supra-pubic pain and inability to urinate for one day. He described undergoing PIUR for a traumatic urethral rupture four years ago. An indwelling urinary catheter was placed subsequently, that he claims being removed by his physician 21 days later. Urinary hesitancy and frequency were reported since then, maintaining normal sexual activity. Based on having a tender vesicular globe, and a disclosed rod inside his penis, he was diagnosed with urinary retention by a foreign body and admitted to the hospital for further investigations. Vesicular decompression by a supra-pubic catheter was performed. A non-contrast pelvic CT scan revealed a calcified elongated structure suspecting an encrusted retained urinary catheter. In the operating room, rigid ureteroscope with the assistance of lithotripsy were proficient in fragmenting only intra-urethral calcifications. Sequentially, an open cystolithotomy evacuated the remaining calcified vesicular balloon. Patient was asymptomatic on subsequent visits denying any urinary symptoms and stating normal sexual activity. Removing such a foreign body, especially when severely encrusted as well as avoiding trauma to the urethra while minimizing patient morbidity remain a clinical confront for the surgeon. Hence, minimally invasive procedures are always preferred. In this case, we had to assist the rigid ureteroscope and the lithotripsy by an open cystolithotomy for the large calcified balloon. Nevertheless, this method has proved to be safe and efficient. Thus, it is suggested to be used in future comparable cases.

Utero-Vesical Fistula Closure after 3 Weeks Treatment with Intravenous Mesenchymal Stem Cells Infusion: Case Report

Objective: To describe the evolution of Utero-Vesical Fistula (UVF) of one patient who received conservative treatment using intravenous (IV) infusion of 120x106 Adipose tissue Mesenchymal Stem Cells (ADMSCs). Clinical case report: A 36-year-old female presented with postcesarean hematuria 3 hours after an emergency c-section was performed consequently to placental abruption during labor. The primary measure was to use a transurethral Silastic 18F Foley catheter to prevent bladder expansion. The catheter remained for 21 days. Evaluation through Computerized Tomography Cystography (Cysto-CT) revealed failure to close the fistula. The decision to inject ADMSCs as an IV single dose was done. Three weeks after this intervention no blood was seen in the urine drainage bag. Complete resolution of UVF was confirmed with a control CT urogram. Result: Total closure of UVF. Conclusions: The IV infusion of ADMSCs proved to be a plausible and effective conservative treatment of UVF.