5 Improving Diagnosis and Management of Urinary Tract Infections for Elderly Patients

Introduction

Diagnosis of urinary tract infection (UTI) in the elderly population is challenging as they commonly present with atypical signs and symptoms. Prevalence of asymptomatic bacteriuria in the elderly population is high. Hence, urine dipstick and urine culture are no longer diagnostic tests. UTI is over-diagnosed and overtreated in the elderly, resulting in poor antimicrobial stewardship. This project was carried out to assess and improve the current practices in the diagnosis and treatment of UTI in the Department of Medicine of the Elderly.

Methods

We reviewed current Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for health and Care Excellence (NICE) guidelines on management of UTI and defined indications for performing urine dipstick and sending urine culture. We then collected and assessed data on all urine dipsticks performed, urine cultures sent, and use of antibiotics in treating UTI and asymptomatic bacteriuria in three Medicine of the Elderly wards in Aberdeen Royal Infirmary.

We carried out intervention by means of presenting and discussing findings of Plan-Do-Study-Act (PDSA) cycles in departmental multi-disciplinary Quality Improvement (QI) meetings followed by educational sessions.

Results

Our baseline data showed 77% of urine dipsticks were performed without clinical indication and 18% of patients had urine cultures sent without clinical indication. After presenting our initial findings and carrying out an educational intervention session, 25% of patients had urine dipstick done without clinical indication, and 0% of patients had urine cultures sent without clinical indication. However, over the course of four subsequent PDSA cycles, practices in investigation of UTI fluctuated but were overall consistently better than the initial practice with further interventions. In all PDSA cycles, no patients were treated for asymptomatic bacteriuria.

Conclusions

Multidisciplinary team involvement in discussion of this QI project findings and educational sessions proved to be an effective form of intervention for improving current practice.

Study of the mechanisms of killing of Mycobacterium bovis BCG by apoptosis in J774 murine macrophages

OBJECTIVE

To determine the relationship between the mechanism of apoptosis and intracellular killing of Mycobacterium bovis BCG. Apoptosis, "programmed cell death"--a physiologically beneficial and distinct form of cell death.

SETTING

In vitro study was carried out in murine macrophage cell line J774 that was infected with Mycobacterium bovis BCG in different set of conditions. Percentage of surviving BCG and apoptotic cells was determined.

METHODS

IFN-g and/or LPS-activated and non-activated J774 mouse macrophage cells were infected with BCG in a ratio of 1:5. The morphology of the host cells was studied after 4 hours, 24 hours and 48 hours of infection in cytospins stained with Jenner-Giemsa. Surviving bacteria were counted by incorporation of radiolabelled-uridine after cell lysis.

RESULTS

Both in the activated and non-activted J774 cultures some cells undergo apoptosis. In cells activated with IFN-g or LPS without BCG, less than 10% of cells were found to be apoptotic. More apoptosis was seen when LPS-activated cells were infected with BCG. In the cells activated with IFN-g or LPS-activated cells the percentage of apoptotic cells was much higher than in non-activated cells or cells activated with either INF-g or LPS alone. After 24 hours culture, without BCG, about 15% of the cells were found to be apoptotic and with BCG infection this increased to 23% (p < 0.01). The level further increased after 48 hours of infection. BCG growth inhibition was observed in both non-activated J774 cells and cells activated with LPS, INF-g or both and was sustained to 48 hours of co-culture.

CONCLUSION

It is evident that BCG-infected J774 cells undergo apoptosis in the presence of a high concentration of RNI and/or ROI. During this process the cells shrink considerably in volume with the removal of water that may concentrate toxic products in the cell. The increased concentration of toxic species and the disorganisation of the phagocytic vacuoles may account for the enhanced stasis and/or death of the intracellular micro-organisms. We conclude that host cell apoptosis may arrest the growth and account for the death of the intracellular mycobacterial pathogen.

Effect of Norplant on liver function

Combined pills have known adverse effects on liver function. Progesterone based contraceptives are thought to be safer in this regard. The effect of Norplant, a levonorgestrel contraceptive implant, on liver function was evaluated in 149 Bangladeshi women of reproductive age in this study. Liver function tests and ultrasonography of hepato-biliary system were done before and after the implantation. The patients were followed upto two years. There were non-significant transient rise of serum bilirubin and slight enlargement of liver during the first year. There was no significant change in the levels of AST, ALT, alkaline phosphatase, total protein, albumin-globulin ratio and prothrombin time. The results suggest that Norplant has no adverse effect on liver function.

[Intranasal skin grafting for Osler's disease (author's transl)]

Between 1965-1972, 12 patients with Osler's disease of the nose were treated surgically by a modification of the method suggested by Saunders. The mucosa of the entire nasal septum and entire floor of the nose up to the insertion of the inferior turbinate was removed without interference to the perichondrium or periosteum. The denuded area was covered with split thickness skin graft taken from the thigh. Haemorrhage, which was never severe, occassionally occurred. In all patients, there occurred crusting and foetor, which was controlled by nasal douching. Patients with Osler's disease should be treated as early as possible in order to curtail the work disability.

Comparison between ultrasound and plain X-ray in evaluating the cause of shoulder pain

Painful shoulder is a common painful condition among patients. Apart from acute traumatic lesions such as fractures, dislocations, contusions, sprains and ruptured tendons, 85 to 90% of painful shoulders are due to adhesive capsulitis, acute or chronic calcific tendinitis, bursitis, bicipital tendinitis and lesions of the musculotendinous cuff. Arthritis is the cause of less than 5% of painful shoulders. For evaluating conditions of shoulder joint, X-ray has been regarded as only method of choice for long time. Magnetic resonance imaging (MRI) is an alternative procedure but the cost limits its utilization especially in Bangladesh. Ultrasonography is an effective imaging modality in the evaluation of both rotator and non-rotator cuff disorders. Because of low cost and availability, it can be an alternative procedure for the diagnosis of painful shoulder. The present study was conducted to assess ultrasonography as a useful modality in evaluating cases of shoulder pain and to compare the findings with X-ray findings. Thirty two patients with shoulder pain were evaluated by X-ray and Ultrasonography (USG). Clinical diagnosis was done for correlation. To identify the cause of shoulder pain, 100% patients were found normal in plain X-ray. On Ultrasonography (USG) 12.5% patients had displaced long head of biceps, 21.9% had biceps tendinitis, and 3.1% had bursitis. In the assessment of shoulder pathology, USG had a sensitivity of 73.3%, specificity of 88.2%, Positive predictive value (PPV) of 84.6%, Negative predictive value (NPV) of 78.9% and an accuracy of 81.3%. USG is a useful modality for evaluation the shoulder joint in case of painful shoulder even plain X-ray is non conclusive.

Body Mass Index (BMI) at Time of Diagnosis as a Prognostic Indicator in Patients with Newly Diagnosed Glioblastoma (GBM)

PURPOSE/OBJECTIVE(S)

Glioblastoma (GBM) is the most common primary brain cancer in adults with very poor prognosis. Metabolic drivers of tumorigenesis are highly relevant within the central nervous system, where glucose is the sole source of energy. The impact of obesity on survival outcomes in patients with GBM has not been well reported and some initial results are inconsistent. This study investigates the factor of body mass index (BMI) in patients diagnosed with GBM. This study evaluated the prognostic association of BMI with survival outcomes in patients with newly diagnosed GBM.

MATERIALS/METHODS

Patientswith newly diagnosed GBM at our institution from 2015-2022 were included in this study. All patients were >18 years of age and received 60 Gy of radiation therapy with concurrent and adjuvant temozolomide following maximal safe resection. Through retrospective chart review, patient BMI at the time of diagnosis and overall survival (OS) were recorded. Analysis was done between patient groups of underweight/normal weight (BMI <25) and overweight/obese (BMI ≥ 25.00). The subgroup of overweight patients was also divided into subgroups of overweight (BMI 25.00-29.99) and obese (BMI≥30.00). A difference in clinical outcomes of overall survival was evaluated between the groups using Gehan-Breslow-Wilcoxon and log-rank tests.

RESULTS

Atotal of 393 patients met inclusion criteria. Median age 57.3 years, range 18.8-92.7. 185 female and 208 were male. 120 patients had a BMI <25 and 273 had a BMI ≥ 25.00. Median survival in patients with BMI <25 was 24.90 months and in patients with BMI ≥ 25.00, 18.20 months (p = 0.0001; HR 0.6552, 95% CI 0.5299-0.8101). We further divided patients with BMI ≥ 25.00 to 25-29.99 (n = 152) and BMI≥30.00 (n = 121). Both groups' OS were significantly worse than patients with BMI < 25 (p = 0.006). There was no difference in survival outcomes between patients with a BMI 25.00-29.99 and BMI≥30.00, with median OS 19.0 months and 18.1 months, respectively.

CONCLUSION

Patient baseline BMI <25 appears to be a prognostic indicator and correlates to improves overall survival for patients with newly diagnosed GBM. This study adds to the existing literature supporting overweight/obesity is associated with worse survival for GBM patients. Additional studies are warranted for further analysis of BMI and survival outcomes in GBM patients across patient demographics.

Cox-2 inhibitors and the risk of cardiovascular thrombotic events

In 1971, Vane showed that the analgesic action of traditional NSAIDs relies on inhibition of the cyclo-oxygenase (COX) enzyme, which in turn results in reduced synthesis of proalgesic prostaglandins. Two decades later COX was shown to exist as two distinct isoforms. The constitutive isoform COX-1, supports the beneficial homeostatic functions whereas the inducible isoform, COX-2 becomes up regulated by inflammatory mediators and its products cause many of the symptoms of inflammatory diseases such as rheumatoid and osteoarthritis. Despite the benefits of NSAIDs for acute and chronic pain one of the most clinically significant and well characterized adverse effect is on GI mucosa. The search for NSAIDs with less gastrointestinal toxicity led to the introduction of the selective cyclo-oxygenase-2 (COX-2) inhibitors. The COX-2 selective (COX-1 sparing) inhibitors are associated with reduced GI mucosal damage as demonstrated in several trials. In light of the overwhelming and sometimes contradictory information for patients and physicians regarding the safety of COX-2 agents this article will summarize the available evidence regarding cardiovascular (CV) safety data and contemporary recommendations for prescribing of COX-2-selective NSAIDs.

Breast lumps in service women

INTRODUCTION

Breast cancer is uncommon in a young population but it does occur. 80% of breast cancer occurs after 50 yrs of age. This article uses current guidelines and evidence to advise military medical staff on how best to investigate and manage serving-age women presenting with breast symptoms. Male breast changes will be dealt with in a future article.

DIFFERENTIAL DIAGNOSIS

Young females presenting with breast lumps are unlikely to have cancer. In order of frequency the causes are likely to be benign breast change; fibroadenoma; abscesses in 20-30 year olds; cysts in 30-40 year olds, and lastly cancer. The UK sees 48,000 new cases of breast cancer in women every year; breast cancer can also occur in men but is very rare.

DIAGNOSIS AND MANAGEMENT

Management in the deployed, primary and secondary care settings are described. It may be reasonable in young women to wait and see if a lump resolves after the patient's next menstrual cycle before referring the patient. Once referred, current guidelines recommend that all patients are seen by a breast surgeon within two weeks. Within this group, a subgroup of patients with 'red-flag' lumps is identified who need to be referred urgently. The remaining patients have lumps that can be considered non-urgent: however, hospitals will still endeavour to see these patients within two weeks..

CONCLUSIONS

Breast cancer is more difficult to diagnose in the younger patient. In primary care, breast lumps are still simple to manage if the points in this article are followed. Anxious patients can be reassured that cancer is unlikely. However, cancer in this young age group is associated with worse outcomes than breast cancer in older patients.