Is traditional stone clinic the optimal use of NHS resources?

There is no clear guidance on the efficacy of stone follow-up. NICE have been unable to make recommendations with current published evidence. The aim of this study was to understand the patient journey resulting in surgical intervention, and whether traditional stone follow-up is effective. A retrospective review of patients undergoing ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) over a 3 year period identified 471 patients who underwent these procedures to treat stone disease. Records were interrogated for the following: symptoms, mechanism of booking, reason for intervention, stone size, stone location, risk factors and previous follow-up. Of 471 patients who underwent intervention, 168 were booked from stone clinic follow-up (36%). Of these, 96% were symptomatic and 4% were asymptomatic. When risk factors were removed, this figure was reduced to 1%. Sepsis rate for emergency admissions differs between those followed up (13%) versus new presentations (19)%. There was no statistically significant difference in the outpatient imaging frequency between patients booked from an emergency admission (80% having imaging every 6 months) and those from the clinic (82%). Our Hospital provides on average 650 stone clinic appointments a year with a cost of £93,000. Given the low rate of intervention in patients with asymptomatic renal stones, a symptomatic, direct-access emergency stone clinic could be a better model of care and use of NHS resources. Urgent research is required in this area to further assess if this is the case.

A Novel cause of abdominal pain presenting with anuria and renal failure

A girl in early adolescence with autism presented with 3 months of abdominal pain and 36 hours of anuria. She had recently received treatment for urinary tract infections, anxiety and menorrhagia (she had undergone menarche a few months earlier). Due to the pain, she had pulled out an incisor. Bladder scan showed 923 mL, creatinine was 829 mmol/L but urethral catheter insertion did not drain urine. An unenhanced CT scan revealed an absent left kidney, didelphys uterus and right-sided hydroureteronephrosis caused by haematocolpos in keeping with a diagnosis of OHVIRA syndrome and ureteric obstruction of a single kidney causing acute renal failure. She underwent vaginal septoplasty, drainage of the haematocolpos and right ureteric stent.

Malignant upper urinary tract obstruction: A prospective evaluation of patients presenting as an emergency to urology and their long-term real-life outcomes

Objective:

The objective of this study was to evaluate the management and survival outcomes of patients referred to urology as an emergency with malignant upper urinary tract obstruction (MUUTO).

Patients and Methods:

Between 2019 and 2020, the outcomes of all emergency referrals with MUUTO to the Urology team at a single institution were prospectively analysed.

Results:

In total, 119 patients, median age 77 years, were referred to the urology team with MUUTO. Of these, 59% (70/119) had bilateral and 41% (49/119) unilateral obstruction. The three commonest primary underlying malignancies were gladder (41% (49/119)), prostate (19% (23/119)), and colorectal (8% (10/119)) cancer. The commonest indication for referral was acute kidney injury (86% (103/119)), the remainder had sepsis (13% (15/119)), and pain (1% (1/119)). Median in-patient stay for the admission was 7 days. Median estimated glomerular filtration rate (eGFR/1.73 m2) measured on discharge improved irrespective of whether intervention for MUUTO was received. Overall survival of the cohort was 13% (16/119).

Conclusions:

Patients referred with MUUTO as an emergency have a poor prognosis. Renal function does not significantly deteriorate in the short term in this patient group with no intervention, and overall survival is not significantly improved after intervention unless further treatment is received. Multidisciplinary team discussion, including patients and oncologists, should be best practice before intervention in this challenging situation.

Level of evidence:

2b

Superinfection with a transmissible strain of Pseudomonas aeruginosa in adults with cystic fibrosis chronically colonised by P aeruginosa

Infection with transmissible strains of Pseudomonas aeruginosa can occur in uncolonised patients, but cross infection (superinfection) of patients already colonised withP aeruginosa has not been reported. With genotypic identification, we found superinfection by a multiresistant transmissible strain of P aeruginosa in four patients with cystic fibrosis (CF) who were already colonised by unique strains of P aeruginosa. No evidence of environmental contamination was found, but all patients became superinfected after contact with colonised individuals during inpatient stays. Inpatients with CF who are colonised with P aeruginosa should be separated by strain type. Such strain typing can only be reliably done by genomic methods, but this has resource implications.

Multi-drug resistant non-typhi salmonellae in Kenya

Two methods of plasmid characterization, restriction digest patterns and incompatibility grouping, were used to study self-transmissible multi-drug resistance among non-typhi salmonellae (NTS). Resistance to ampicillin and other commonly applied beta-lactams was evaluated by iso-electric focusing and disc inactivation. Of the NTS isolated from blood, 75% were Salmonella typhimurium but those included several different phage types. Over 47% of isolates were resistant to three or more of the readily available drugs including ampicillin, cefuroxime, chloramphenicol, co-trimoxazole, streptomycin and tetracycline. Self-transferable resistance plasmids (c. 100 kb) were essentially of incompatibility group incFIIA, but their restriction fragment patterns revealed a diversity in relatedness. More than half of parent strains and their transconjugants produced beta-lactamases which co-electrophoresed with TEM-1 and OXA-1. This study has observed a disturbingly high prevalence of transmissible multi-drug resistance among NTS which are an important cause of morbidity in HIV-1 seropositive individuals.

Detection of beta lactamase in sputum

AIMS

To develop a rapid, sensitive, and reproducible test for the detection of beta lactamase in sputum, and to relate these findings to bacteriological culture results.

METHODS

One hundred and twenty sputum samples from inpatients were investigated for beta lactamase activity using the chromogenic cephalosporin nitrocefin. Sputum samples were sonicated and incubated aerobically at 37 degrees C with nitrocefin for up to two hours. Positive results (production of a red colour) were treated with blue sepharose beads to remove albumin (which can cause non-specific hydrolysis of nitrocefin) and retested. Samples were also cultured for both aerobic and anaerobic bacteria, with all isolates being tested for beta lactamase production using nitrocefin. All positive sputum samples and beta lactamase producing isolates were further examined by isoelectric focusing (IEF) to determine isoelectric point(s) (pIs).

RESULTS

The process of sonication and albumin removal had no demonstrable effect on beta lactamase activity. Forty seven of the 120 sputum samples were positive on initial testing, and of these, 16 remained positive following removal of albumin. These 16 subsequently yielded 19 beta lactamase producing bacteria. All sputum samples yielding beta lactamase producing bacteria were also positive on direct nitrocefin testing. On no occasion were sputum samples positive in the absence of enzyme producing bacteria--that is, the test was both 100% specific and 100% sensitive. The presence of beta lactamase activity in the sputum samples was also confirmed using a microbiological method. In 11 sputum samples the beta lactamases detected had similar pI values to the beta lactamases obtained from their bacterial isolates.

CONCLUSION

Detection of beta lactamase activity in sputum using nitrocefin, after treatment with blue sepharose beads, is a rapid, reproducible test with high specificity and sensitivity. Analytical isoelectric focusing showed that for 11 of the 16 positive sputa, the source of the beta lactamases could be traced to their concurrent bacterial isolates.