Urinary pH and antibiotics, choose carefully. A systematic review.

Uncomplicated urinary tract infection (UTI) is the most common bacterial infection in women. Since 1948, the relationship between urinary pH and antibiotics (ABs) has been established. We aimed to search for the best urinary pH for each family of antibiotics and to assess whether pH changes bacterial susceptibility to them. We included in vitro research and in vivo studies including one or more bacterial species and tested the effect of one or more ABs at different pH values. We also included randomized controlled clinical trials (RCTs) in uncomplicated UTI (EAU guidelines 2019 definition), choosing the ABs based on urinary pH or using an antibiotic plus urinary pH modifiers (L-methionine, vitamin C…) vs. an antibiotic and a placebo. Quadas-2 tool was used as a quality assessment of the studies and PRISMA set of items for systematic reviews. Two authors independently screened and evaluated the papers, while two additional authors individually repeated the search. A fifth researcher acted as an arbiter, and another author collaborated as a hospital pharmaceutical consultant. Alkaline-friendly antibiotics are most fluoroquinolones, aminoglycosides, trimethoprim. Acidic-friendly antibiotics are fosfomycin, tetracycline, nitrofurantoin and some ß-lactams. We suggest performing urine cultures with antibiogram tests, in both acidic and alkaline media, to define the bacterial susceptibility profile. There is insufficient in vivo evidence to support whether choosing an antibiotic based on a patient's urinary pH or adding urinary pH modifiers will lead to a higher cure rate.

Application of Lean Healthcare methodology in a urology department of a tertiary hospital as a tool for improving efficiency. / Aplicación de la metodología Lean healthcare en un servicio de urología de un hospital terciario como herramienta de mejora de la eficiencia.

OBJECTIVE: To describe the application of the Lean methodology as a method for continuously improving the efficiency of a urology department in a tertiary hospital. MATERIAL AND METHODS: The implementation of the Lean Healthcare methodology in a urology department was conducted in 3 phases: 1) team training and improvement of feedback among the practitioners, 2) management by process and superspecialisation and 3) improvement of indicators (continuous improvement). The indicators were obtained from the Hospital's information systems. The main source of information was the Balanced Scorecard for health systems management (CUIDISS). The comparison with other autonomous and national urology departments was performed through the same platform with the help of the Hospital's records department (IASIST). A baseline was established with the indicators obtained in 2011 for the comparative analysis of the results after implementing the Lean Healthcare methodology. RESULTS: The implementation of this methodology translated into high practitioner satisfaction, improved quality indicators reaching a risk-adjusted complication index (RACI) of 0.59 and a risk-adjusted mortality rate (RAMR) of 0.24 in 4 years. A value of 0.61 was reached with the efficiency indicator (risk-adjusted length of stay [RALOS] index), with a savings of 2869 stays compared with national Benchmarking (IASIST). The risk-adjusted readmissions index (RARI) was the only indicator above the standard, with a value of 1.36 but with progressive annual improvement of the same. CONCLUSIONS: The Lean methodology can be effectively applied to a urology department of a tertiary hospital to improve efficiency, obtaining significant and continuous improvements in all its indicators, as well as practitioner satisfaction. Team training, management by process, continuous improvement and delegation of responsibilities has been shown to be the fundamental pillars of this methodology.

Costs and hospital procedures in an urology department of a tertiary hospital. Analysis of groups related by their diagnosis. / Costes y procesos hospitalarios en un servicio de urología de un hospital terciario. Análisis de los grupos relacionados por el diagnóstico.

INTRODUCTION: The health care system has management tools available in hospitals that facilitate the assessment of efficiency through the study of costs and management control in order to make a better use of the resources. OBJECTIVE: The aim of the study was the calculation and analysis of the total cost of a urology department, including ambulatory, hospitalization and surgery activity and the drafting of an income statement where service costs are compared with income earned from the Government fees during 2014. MATERIAL AND METHODS: From the information recorded by the Economic Information System of the Department of Health, ABC and top-down method of cost calculation was applied by process care activity. The cost results obtained were compared with the rates established for ambulatory and hospital production in the Tax Law of the Generalitat Valenciana. The production was structured into outpatient (external and technical consultations) and hospital stays and surgeries (inpatient). RESULTS: A total of 32,510 outpatient consultations, 7,527 techniques, 2,860 interventions and 4,855 hospital stays were made during 2014. The total cost was 7,579,327€; the cost for outpatient consultations was 1,748,145€, 1,229,836 Euros for technical consultations, 2,621,036€ for surgery procedures and 1,980,310€ for hospital admissions. Considered as income the current rates applied in 2014 (a total of 15,035,843€), the difference between income and expenditure was 7,456,516€. CONCLUSIONS: The economic balance was positive with savings over 50% and a mean adjusted hospitalization stay rate (IEMAC) rate of 0.67 (33% better than the standard). CMA had a favorable impact on cost control.

The role of IGF-1 and the distribution of body fat in decreasing the number of prostate rebiopsies. / Papel del IGF-1 y la distribución de la grasa corporal para disminuir el número de rebiopsias prostáticas.

OBJECTIVE: To assess the usefulness of IGF-1 and internal organ fat measured by bioelectrical impedance audiometry to avoid rebiopsies in patients with persistently high prostate-specific antigen (PSA) levels. MATERIAL AND METHOD: A prospective study was conducted with 92 patients who underwent prostate rebiopsy due to high PSA levels with negative results in the rectal examination and a lack of preneoplastic lesions. The patients previously had their IGF-1 levels measured and had undergone an impedance audiometry test using the abdominal Fat Analyser AB-140 TANITA system. We calculated the receiver operating characteristic (ROC) curves for the PSA levels, %PSA, internal organ fat and IGF-1 and PSA density. RESULTS: Twenty-five patients were diagnosed with prostate cancer. These patients had significantly higher PSA, PSAd and IGF-1 values and a tendency towards higher internal organ fat levels and lower %PSA readings (p=.001, p=.003, p=.001, p=.24 and P=0.28, respectively). The ROC curve showed an area under the curve for IGF-1 and PSA of .82 and .81, respectively. Using the cutoff points for 95% sensitivity and using the 3 criteria as an indication of rebiopsy, 74% of the biopsies would have been spared, leaving undiagnosed only 1 patient with clinically significant cancer -Gleason score>7 (4+3)-. The positive and negative predictive values for the set of variables were higher than for each one separately (PPV: 66/NPV: 63). The cost of both determinations was 82 euros. CONCLUSIONS: Our results suggest that measuring IGF-1 could significantly decrease the number of unnecessary rebiopsies in an inexpensive and safe manner.

Multicenter study on costs associated with two surgical procedures: GreenLight XPS 180 W versus the gold standard transurethral resection of the prostate.

OBJECTIVE: To analyze the costs associated with two surgical procedures for lower urinary tract symptoms secondary to benign prostatic hyperplasia: GreenLight XPS 180¦W versus the gold standard transurethral resection of the prostate. METHODS: A multicenter, retrospective cost study was carried out from the National Health Service perspective, over a 3-month time period. Costs were broken down into pre-surgical, surgical and post-surgical phases. Data were extracted from records of patients operated sequentially, with IPSS=15, Qmax=15 mL/seg and a prostate volume of 40-80mL, adding only direct healthcare costs (€, 2013) associated with the procedure and management of complications. RESULTS: A total of 79 patients sequentially underwent GL XPS (n: 39) or TURP (n: 40) between July and October, 2013. Clinical outcomes were similar (94.9% and 92.5%, GL XPS and TURP, respectively) without significant differences (P=.67). The average direct cost per patient was reduced by €114 in GL XPS versus TURP patients; the cost was higher in the surgical phase with GL XPS (difference: €1,209; P<.001) but was lower in the post-surgical phase (difference: €-1,351; P<.001). CONCLUSIONS: The GreenLight XPS 180-W laser system is associated with a reduction in costs with respect to transurethral resection of prostate in the surgical treatment of LUTS secondary to PBH. This reduction is due to a shorter inpatient length of stay that offsets the cost of the new technology.

[Phytotherapy in urology. Current scientific evidence of its application in urolithiasis, chronic pelvic pain, erectile dysfunction and urinary tract infections]. / Fitoterapia en Urología. Evidencia científica actual de su aplicación en urolitiasis, dolor pélvico crónico, disfunción eréctil e infecciones urinarias.

OBJECTIVE: To assess the usefulness of phytotherapy in urolitiasis, urinary tract infections, erectile dysfunction (ED) and chronic prostatitis/chronic pelvic pain (CP/CPP). ACQUISITION OF THE EVIDENCE: Systematic review of the evidence published until January 2011 using the following scientific terms:phytotherapy, urinary lithiasis, Chronic prostatitis, chronic pelvic pain, erectile dysfunction, urinary tract infection, cystitis and the scientific names of compounds following the rules of the International Code of Botanical Nomenclature. The databases used were Medline and The Cochrane Library.We included articles published until January 2011 written in English and Spanish. We included studies in Vitro/in vivo on animal models or human beings. Exclusion criteria were literature not in English and Spanish or articles with serious methodological flaws. SYNTHESIS OF THE EVIDENCE: We included 86 articles selecting 40 that met the inclusion criteria. In Urolitiasis there are few works in humans. The phytate has its main use as prevention and in reducing the growth of residual fragments after extracorporeal shock wave lithotripsy (ESWL). In CP/CPP the only compound that has shown effectiveness was the extract of pollen in a field of multimodal treatment. In DE ther is no evidence for the use of herbal medicine.Most of the works have limitations in the design or low sample size. In urinary tract infections most of the products are diuretics .There is only evidence for the cranberry as prevention in young or pregnant women. It must not be used as a treatment for urinary tract infections. CONCLUSIONS: Phytotherapy is usefull in repeat urinary tract infections and the CP/CPP. It has some role in the urolitiasis and lacks useful in the DE.

[Phytotherapy in urology. Current scientific evidence of its application in benign prostatic hyperplasia and prostate adenocarcinoma]. / Fitoterapia en Urología. Evidencia científica actual de su aplicación en hiperplasia benigna de próstata y adenocarcinoma de próstata.

OBJECTIVE: To evaluate the usefulness of phytotherapy in the treatment of the benign prostatic hyperplasia (BPH) and prostatic adenocarcinoma (ADCP). ACQUISITION OF EVIDENCE: Systematic review of the evidence published until January 2011 using the following scientific terms: phytotherapy, benign prostate hyperplasia, prostatic adenocarcinoma, prostate cancer and the scientific names of compounds following the rules of the International Code of Botanical Nomenclature. The databases used were Medline and The Cochrane Library. We included articles published until January 2011 written in English and Spanish. We included studies in vitro/in vivo on animal models or human beings. Exclusion criteria were literature not in English and Spanish or articles with serious methodological flaws. SYNTHESIS OF THE EVIDENCE: We included 65 articles of which 40 met the inclusion criteria. BPH: the most studied products are serenoa repens and pygeum africanum. There are many studies in favour of the use of phytotherapy but its conclusions are inconsistent due to the small number of patients, the lack of control with placebo or short follow-up. However the use of these products is common in our environment. ADCP: there is no evidence to recommend phytotherapy in the treatment of the ADCP. There are works on prevention but only at experimental level so there is no evidence for its recommendation. CONCLUSIONS: The scientific evidence on the use of phytotherapy in prostatic pathology is conclusive not recommend ing the use of it for BPH or the ADCP.

Prognostic nomogram for disease-free survival in patients with renal adenocarcinoma.

OBJECTIVE: The aim of this study was to develop a postoperative prognostic nomogram for disease-free survival in patients with renal adenocarcinoma. MATERIALS AND METHODS: A total of 224 patients with organ-confined or locally advanced renal adenocarcinoma were treated with radical or partial nephrectomy. The variables included in the model were age, histological type, pathological stage, Fuhrman grade and DNA ploidy. Tumor recurrence was defined as any clinical evidence of recurrence. The probability of progression-free survival was calculated using the Kaplan-Meier estimate, and multivariate analysis was performed using a Cox regression. The nomogram was created using the data obtained from the Cox regression. RESULTS: Tumor recurrence was detected in 89 patients (39.74%). The median progression-free time in these patients was 9.55 months (range 0-133). Of these patients, 70.9% relapsed during the first 2 years, and only 15 patients (6.9%) were alive but ill at the end of the study. The probability of progression-free survival at 5 and 10 years was 66.64 and 61.97%, respectively. We performed a statistical validation of the model with accurate predictions that were discriminated with a confidence interval of 0.75 (comparing the predicted and actual probability). According to the nomogram obtained, patients with low-grade, diploid, organ-confined tumors would be candidates for follow-up not exceeding 5 years due to the low probability of recurrence (<40 points). CONCLUSION: The nomogram we developed is clinically relevant and can provide prognostic information for both patients and researchers. In addition, it can be used by researchers during the monitoring protocols that categorize patients based on their relative risk of disease progression.

[Usefulness of new schemes to group Fuhrman grades in clinical practice for clear cell renal tumour]. / Utilidad de los nuevos esquemas de agrupación de los grados de Fuhrman en la práctica clínica para el tumor renal de células claras.

OBJECTIVE: To evaluate if re-grading renal cell carcinoma (CRCC) in two or three-tiered grading schemes versus the traditional Fuhrman classification maintains the same prognostic value. MATERIAL AND METHODS: A study of a cohort of 383 treated CRCC with radical or partial nephrectomy between 1990-2009 was made. We analyzed the demographic data, evolution and survival of these patients. An uropathologist reassigned the Fuhrman grades blindly to the first classification. In order to study if the prognostic value was maintained with the different classification, three Cox multivariate regression analysis were performed, classifying the variable of grade into four categories: (I-II-III-IV), into three (I+II-III-IV) and into two (I+II-III+IV). The explanatory variables were: age, gender, tumor size, study stage and grade. The response variables were progression-free survival (local-regional recurrence/metastasis) and cancer specific survival time. RESULTS: The median overall survival was 125 months (95% CI: 92-159). In the three multivariate analyses carried out, the Fuhrman classification showed independent predictive value (p=:0.0001) compared to progression-free survival and cancer specific survival. The predictive power was maintained in the new classifications. In the three categories, the changing from grade I+II to III meant RR: 2.31 (p=0.0001) and from grade III to IV RR: 2.47 (p=0.0001) and in two-tiered classification an RR: 2.8 (p=0.001) was found when changing from I+II to III+IV. CONCLUSIONS: Our results show that categorizing the Fuhrman grade into three or two-tiered grading schemes provide the same predictive accuracy on progressive free survival and cancer specific survival. Grades III and IV have different outcomes so that the three-tiered classification seems to be more appropriate to described the course of these patients.

[Should ureteral catheterization be systematically used in kidney transplants?]. / ¿Debe emplearse de manera sistemática el cateterismo ureteral en los implantes renales?

OBJECTIVE: To assess if the systematic use of double J ureteral catheters in ureteroneocystostomies of kidney transplants reduces the rate of complications. MATERIALS AND METHODS: Non-randomized prospective, comparative study of parallel groups in 194 kidney transplants. We established two equal groups, 111 patients with double J catheter and another of 83 catheter-free patients. We studied the incidence of complications between both groups by means of a univariate comparative study (X2 test)and a multivariate analysis (logistic regression). RESULTS: In the catheter group, the overall complications appeared in 22.2% as opposed to 43.3% of the catheter-free group (p=0.04). Depending on the ureteral transplant, complications appeared in 38.12% of the Paquin type reimplantation as opposed to the 20.3% in Lich-Gregoir (p=0.09). There was evidence of 1 (0.9%) urinary fistula in the catheter group as opposed to 5 (6%) in the catheter-free group (p=0.08), and 3 (2.7%) ureterovesical anastomosis stricture in the group with catheter against 7 (8.4%) of the catheter-free group (p=0.13). The multivariate analysis showed that not using the catheter increases the risk of suffering complications related to reimplantation (OR: 2.55; IC 95%, 1.37-4.75). The risk of fistula increased significantly when a catheter was not placed (OR 9.19, IC 95%, 1.01-84.7). There were no differences between the two groups as regards urinary tract infections; there were 3 (2.7%) in the catheter group and 1 (1.2%) in the catheter-free group (p=0,63). CONCLUSIONS: The placement of a double J catheter reduces complications related to ureteral reimplantation without increasing the morbidity associated with their use.

[Factors associated to urgent referral in a mental health center]. / Factores asociados a la derivación urgente en un centro de salud mental.

INTRODUCTION: In this paper we analyze the factors related with the urgent referral. METHOD: We analyze a sample of 718 patients who were seen for an initial medical visit during a one year period in a community mental health center (418 of whom were urgent patients and 300 programmed patients). Variables associated to the referral process, clinical variables and social adjustment are studied. RESULTS AND CONCLUSIONS: The urgent medical visit is associated to clinical importance, to people previously seen in the health system, to initiative by others and not by the patient, to diseases that cause dysfunction in the sociofamiliar environment, and to the subjective loneliness feeling. The data show very little agreement between the clinician in the mental health center and referral doctor evaluation.

Mycobacterial infection in a series of 1261 renal transplant recipients.

OBJECTIVE: To describe the incidence and clinical characteristics of mycobacterial infection in renal transplant recipients. METHODS: We retrospectively analyzed the cases of mycobacterial infection in a series of 1261 renal transplants carried out in our Unit of Renal Transplantation from 1980 to 2000. Demographic parameters and clinical antecedents such as age, cause of end-stage renal disease, time of follow-up of the graft, previous renal function and type of immunosuppression were considered. Moreover, the clinical onset, diagnostic tools, treatment policy and evolution were studied. The pathogenesis of the different types of mycobacteria isolated was also analyzed. Diagnosis was made with the Ziehl-Neelsen staining method. Culture was performed by the conventional Löwenstein-Jensen method and the Bactec-460 radiometric method. RESULTS: We found mycobacterial infection in 27 patients (2.1%), due to Mycobacterium tuberculosis in 20 cases, M. kansasii in five patients, and M. fortuitum in two patients. The mean elapsed time from the renal transplant was 20.5 months; the infection appeared in 18 patients during the first eight months after transplantation. The clinical onset was pulmonary infection in 17 cases (12 M. tuberculosis and five M. kansasii); five had urinary symptoms (three M. tuberculosis and two M. fortuitum); three cases of M. tuberculosis infection had abdominal symptoms; another one began with a perineal tuberculous abscess; the rest of the patients were asymptomatic. The types of specimen on which microbiological identification was carried out were, in decreasing order: sputum and/or bronchial washing/pleural aspiration, urine, feces, gastric and peritoneal fluids, bone marrow and blood. The first-line drug isoniazid had the highest resistance index in the susceptibility test. Clinical dissemination was observed in eight patients, four of whom died. Another three patients had a significant impairment in renal function, and in one of these patients an allograft nephrectomy was necessary due to a severe septic syndrome. CONCLUSIONS: Mycobacterial infection, mainly by M. tuberculosis, has an important impact on kidney transplant recipients, particularly during the first year after surgery. Diagnosis often presents some difficulties, and a delay in treatment represents a determinant factor for the evolution, with a risk of death or permanent damage in renal function. Therefore, early diagnosis is mandatory. When the Mantoux reaction is positive, antituberculous prophylaxis seems advisable.