Fluoroquinolone resistance in urinary tract infections: Epidemiology, mechanisms of action and management strategies.

Background: Fluoroquinolone resistance is an issue of concern amongst physicians worldwide. In urology, fluoroquinolones are often used in the treatment of acute pyelonephritis and prostatitis, as well as infections caused by multidrug-resistant pathogens. Aims: We aim to highlight the importance of antimicrobial stewardship and the need for ongoing biomedical research to discover novel agents in our losing battle against resistant pathogens. Materials and methods: In this review, we survey the literature and summarise fluoroquinolone resistance as it pertains to pyelonephritis and prostatitis, as well as alternative treatment strategies and prevention of multidrug resistance. Results: The rise of fluoroquinolone resistance in bacteria has reduced the available treatment options, often necessitating hospital admission for intravenous antibiotics, which places an additional burden on both patients and the healthcare system. Many countries such as Australia have attempted to limit fluoroquinolone resistance by imposing strict prescribing criteria, though these efforts have not been entirely successful. Solutions to overcome resistance include prevention, combination therapy and the development of novel antimicrobial agents. Conclusions: Prevention of the proliferation of resistant organisms by antimicrobial stewardship is paramount, and urologists are obliged to be aware of responsible prescribing practices such as referring to local guidelines when prescribing. By reserving fluoroquinolones for infections in which they are truly indicated and by prescribing based on both patient and local environmental factors, we can preserve this effective resource for future use.

The Tactical Athlete: Definitions, Cardiovascular Assessment, and Management, and "Fit for Duty" Standards.

Tactical athletes are individuals in the military, law enforcement, and other professions whose occupations have significant physical fitness requirements coupled with the potential for exposure to life-threatening situations. Such exposures can have varied hemodynamic effects on the cardiovascular system. It is crucial that their clinical evaluation is inclusive of specific occupational requirements. Safety protocols regarding medical clearance are relatively more stringent for this population than for competitive athletes due to the increased impact to the tactical athlete, their team, and the population they aim to serve and protect should they experience a cardiovascular event on the job.

Meds to Beds at Hospital Discharge Improves Medication Adherence and Readmission Rates in Select Populations.

OBJECTIVES: Medication nonadherence caused by difficulty obtaining and paying for medicines can increase hospital readmissions. This project implemented Medications to Beds ("Meds to Beds," M2B), a multidisciplinary predischarge medication delivery program, at a large urban academic hospital that provided subsidized medications for uninsured and underinsured patients to reduce readmissions. METHODS: This 1-year retrospective analysis of patients discharged from the hospitalist service after implementing M2B contained two groups: one with subsidized medications (M2B-S) and one with unsubsidized medications (M2B-U). Primary analysis was 30-day readmission rates for patients, stratified by Charlson Comorbidity indexes (CCIs) of 0, 1-3, ≥4 to represent low, medium, and high comorbidity burden. Secondary analysis included readmission rates by Medicare Hospital Readmission Reduction Program diagnoses. RESULTS: Compared with controls, the M2B-S and M2B-U programs had significantly reduced readmission rates among patients with CCIs of 0 (10.5% [controls] vs 9.4% [M2B-U] and 5.1% [M2B-S], P < 0.05). A nonsignificant reduction occurred in readmissions for patients with CCIs ≥4 (20.4% [controls] vs 19.4% [M2B-U] vs 14.7% [M2B-S], P < 0.07). Patients with CCIs of 1 to 3 showed a significant increase in readmission rates in the M2B-U, but a decrease in readmission rates among the M2B-S (15.4% [controls] vs 20% [M2B-U] vs 13.1% [M2B-S], P < 0.05). Secondary analyses found no significant differences in readmission rates when patients were stratified by Medicare Hospital Readmission Reduction Program diagnosis. Cost analyses demonstrated that subsidizing medicines cost less per patient for every 1% readmission reduction than delivery alone. CONCLUSIONS: Providing medicine to patients predischarge tends to lower readmission rates for populations with no comorbidities or with a high burden of disease. This effect is amplified when prescription costs are subsidized.

The Tactical Athlete: Definitions, Cardiovascular Assessment, and Management, and "Fit for Duty" Standards.

Tactical athletes are individuals in the military, law enforcement, and other professions whose occupations have significant physical fitness requirements coupled with the potential for exposure to life-threatening situations. Such exposures can have varied hemodynamic effects on the cardiovascular system. It is crucial that their clinical evaluation is inclusive of specific occupational requirements. Safety protocols regarding medical clearance are relatively more stringent for this population than for competitive athletes due to the increased impact to the tactical athlete, their team, and the population they aim to serve and protect should they experience a cardiovascular event on the job.

Safety, efficacy and cost of intra-operative cell salvage during open radical prostatectomy.

BACKGROUND: We aim to examine the safety and efficacy of intra-operative cell salvage (ICS) in radical prostatectomy. METHODS: A retrospective cohort study was performed, enrolling consecutive patients undergoing open radical prostatectomy at two institutions during 01/01/18-31/12/19. Patients were grouped by ICS use. Primary outcomes were allogeneic transfusion rates, and biochemical recurrence (prostate specific antigen >0.2 mg/mL). Secondary outcomes were use of adjuvant therapies, Clavien-Dindo complications and transfusion-related cost (allogeneic transfusion + ICS setup + ICS reinfusion). RESULTS: In total, 168 men were enrolled. Patients were grouped based on whether they received no blood conservation technique (126 men) or ICS (42 men). Groups were similar in median age, pre- and post-operative haemoglobin and length of stay. They also had similar post-operative tumour Gleason score, TNM-stage and positive surgical margin rates. Compared with controls, the ICS group had shorter follow up (336 vs. 225 days; P=0.003). The groups had similar rates of biochemical recurrence (17% vs. 14%; P=0.90), adjuvant therapy use (30% vs. 29%; P=0.85) and complications (14% vs. 19% patients; P=0.46). There was no metastatic progression or cancer-specific mortality in either group. Although a similar proportion of patients received allogenic transfusion (2.4% vs. 4.8%; P=0.33) and units of packed red blood cells (PRBC) (9 vs. 5 units), transfusion-related costs were higher amongst the ICS group (AUD $11,422 vs. $43,227). CONCLUSIONS: ICS use in radical prostatectomy was not associated with altered rates of allogeneic transfusion, complications, biochemical recurrence or adjuvant or salvage therapies. Transfusion related costs were higher in the ICS group.

Breast ultrasound in breast cancer surveillance; incremental cancers found at what cost?

PURPOSE: To determine the diagnostic parameters of breast ultrasound (US) in the setting of routine radiological surveillance after a diagnosis of breast cancer and evaluate costs of the inclusion of breast US as well as any survival benefit of US detected cases of recurrence in surveillance. METHODS: 622 patients underwent breast cancer surgery and follow up at Austin Health from July 2009 to December 2015. Retrospective data analysis was performed to determine; diagnostic parameters, financial costs of US and survival outcomes of US detected cases of recurrence. RESULTS: Patients underwent 1-9 years of breast cancer surveillance, with a median of 4.24 years. 390 (62.7%) patients underwent additional breast US surveillance to mammography. 232 (38.3%) fit criteria for use of additional breast US. 199 abnormal imaging episodes occurred, leading to 16 screen detected-cases of locoregional recurrence. US alone generated 107 abnormal images and found 9 cancers. US had a sensitivity of 44.1%, specificity of 95.2% and positive predictive value of 11.7% in comparison to mammography; 20.6%, 97.4% and 9.9% respectively. US had a biopsy rate of 4.0% and lead to an incremental cancer detection rate of 0.38%. The cost of incremental cancer found was $31,463.72 AUD. Survival outcomes based on method of detection of recurrence were insignificant (p value = 0.71). CONCLUSIONS: Breast US has a sensitivity of 44.1% and detected seven recurrences that were mammographically occult. Breast US has a similar PPV to mammography in surveillance. Breast US generated considerable biopsy rates and costs. Survival analysis was not able to detect any benefit of US detected cases of recurrence.

Technical assessment of a prototype cone-beam CT system for imaging of acute intracranial hemorrhage.

PURPOSE: A cone-beam CT scanner has been developed for detection and monitoring of traumatic brain injury and acute intracranial hemorrhage (ICH) at the point of care. This work presents a technical assessment of imaging performance and dose for the scanner in phantom and cadaver studies as a prerequisite to clinical translation. METHODS: The scanner incorporates a compact, rotating-anode x-ray source and a flat-panel detector (43 × 43 cm2) on a mobile U-arm gantry with source-axis distance = 550 mm and source-detector distance = 1000 mm. Central and peripheral doses were measured in 16 cm diameter CTDI phantoms using a 0.6 cm3 Farmer ionization chamber for various scan techniques and as a function of longitudinal position, including out of field. Spatial resolution, contrast, noise, and image uniformity were assessed in quantitative and anthropomorphic head phantoms. Two reconstruction protocols were evaluated, including filtered backprojection (FBP) for high-resolution bone imaging and penalized weighted least squares (PWLS) reconstruction for low-contrast soft tissue (ICH) visualization. A fresh cadaver was imaged with and without simulated ICH using the scanner as well as a diagnostic multidetector CT (MDCT) scanner using a standard head protocol. Images were interpreted by a fellowship-trained neuroradiologist for imaging tasks of ICH detection, gray-white-CSF differentiation, detection of midline shift, and fracture detection. RESULTS: The nominal scan protocol involved 720 projections acquired over a 360° orbit at 100 kV and 216 mAs, giving a dose (weighted CTDI) of 22.8 mGy (∼1.2 mSv effective dose). Out-of-field dose decreased to <10% within 6 cm of the field edge (approximate to the thyroid position). Image uniformity demonstrated <1% variation between the edge of the field (near the cranium) and center of the image. The high-resolution FBP reconstruction protocol showed ∼0.9 mm point spread function (PSF) full-width at half-maximum (FWHM). The smooth PWLS reconstruction protocol yielded ∼1.2 mm PSF FWHM and contrast-to-noise ratio exceeding 5.7 in ∼50 HU spherical ICH, resulting in conspicuous depiction of ICH down to ∼2 mm (the smallest diameter investigated). Cadaver images demonstrated good differentiation of brain and CSF (sufficient, but inferior to MDCT, recognizing that the CBCT dose was one-third that of MDCT), excellent visualization of cranial sutures and fracture (potentially superior to MDCT), clear detection of midline shift, and conspicuous detection of ICH. CONCLUSIONS: Technical assessment of the prototype demonstrates dose characteristics and imaging performance consistent with point-of-care detection and monitoring of head injury-most notably, conspicuous detection of ICH-and supports translation of the system to clinical studies.

Evaluation of detector readout gain mode and bowtie filters for cone-beam CT imaging of the head.

The effects of detector readout gain mode and bowtie filters on cone-beam CT (CBCT) image quality and dose were characterized for a new CBCT system developed for point-of-care imaging of the head, with potential application to diagnosis of traumatic brain injury, intracranial hemorrhage (ICH), and stroke. A detector performance model was extended to include the effects of detector readout gain on electronic digitization noise. The noise performance for high-gain (HG), low-gain (LG), and dual-gain (DG) detector readout was evaluated, and the benefit associated with HG mode in regions free from detector saturation was quantified. Such benefit could be realized (without detector saturation) either via DG mode or by incorporation of a bowtie filter. Therefore, three bowtie filters were investigated that varied in thickness and curvature. A polyenergetic gain correction method was developed to equalize the detector response between the flood-field and projection data in the presence of a bowtie. The effect of bowtie filters on dose, scatter-to-primary ratio, contrast, and noise was quantified in phantom studies, and results were compared to a high-speed Monte Carlo (MC) simulation to characterize x-ray scatter and dose distributions in the head. Imaging in DG mode improved the contrast-to-noise ratio (CNR) by ~15% compared to LG mode at a dose (D 0, measured at the center of a 16 cm CTDI phantom) of 19 mGy. MC dose calculations agreed with CTDI measurements and showed that bowtie filters reduce peripheral dose by as much as 50% at the same central dose. Bowtie filters were found to increase the CNR per unit square-root dose near the center of the image by ~5-20% depending on bowtie thickness, but reduced CNR in the periphery by ~10-40%. Images acquired at equal CTDIw with and without a bowtie demonstrated a 24% increase in CNR at the center of an anthropomorphic head phantom. Combining a thick bowtie filter with a short arc (180° + fan angle) scan centered on the posterior of the head reduced dose to the eye lens by up to 90%. Acquisition in DG mode (without a bowtie filter) was beneficial to the detection of small, low contrast lesions (e.g. subtle ICH) in CBCT. While bowtie filters were found to reduce dose, mitigate sensor saturation at the periphery in HG mode, and improve CNR at the center of the image, the image quality at the periphery was slightly reduced compared to DG mode, and the use of a bowtie required careful implementation of the polyenergetic flood-field correction to avoid artifacts.