The impact of COVID-19 in medical practice. A review focused on Urology

ABSTRACT COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties nondirectly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.

The impact of COVID-19 in medical practice. A review focused on Urology.

COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties non-directly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.

Impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists

ABSTRACT Objectives To evaluate the impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists during the month of April 2020. Materials and Methods A 39-question, web-based survey was sent to all urologist members of the Brazilian Society of Urology. We assessed socio-demographic, professional, health and behavior parameters. The primary goal was to evaluate changes in urologists' clinical practice and income after two months of COVID-19. We also looked at geographical differences based on the incidence rates of COVID-19 in different states. Results Among 766 urologists who completed the survey, a reduction ≥ 50% of patient visits, elective and emergency surgeries was reported by 83.2%, 89.6% and 54.8%, respectively. An income reduction of ≥ 50% was reported by 54.3%. Measures to reduce costs were implemented by most. Video consultations were performed by 38.7%. Modifications in health and lifestyle included weight gain (32.9%), reduced physical activity (60.0%), increased alcoholic intake (39.9%) and reduced sexual activity (34.9%). Finally, 13.5% of Brazilian urologists were infected with SARS-CoV-2 and about one third required hospitalization. Urologists from the highest COVID-19 incidence states were at a higher risk to have a reduction of patient visits and non-essential surgeries (OR=2.95, 95% CI 1.86 - 4.75; p< 0.0001) and of being infected with SARS-CoV-2 (OR=4.36 95%CI 1.74-10.54, p=0.012). Conclusions COVID-19 produced massive disturbances in Brazilian urologists' practice, with major reductions in patient visits and surgical procedures. Distressing consequences were also observed on physicians' income, health and personal lives. These findings are probably applicable to other medical specialties.

Special strategies and management of urological diseases during the COVID-19 pandemic: initial experiences from a Medical Center of China

ABSTRACT Although urological diseases are not directly related to coronavirus disease 2019 (COVID-19), urologists need to make comprehensive plans for this disease. Urological conditions such as benign prostatic hyperplasia and tumors are very common in elderly patients. This group of patients is often accompanied by underlying comorbidities or immune dysfunction. They are at higher risk of COVID-19 infection and they tend to have severe manifestations. Although fever can occur along with urological infections, it is actually one of the commonest symptoms of COVID-19; urologists must always maintain a high index of suspicion in their clinical practices. As a urological surgeon, how we can protect medical staff during surgery is a major concern. Our hospital had early adoption of a series of strict protective and control measures, and was able to avoid cross-infection and outbreak of COVID-19. This paper discusses the effective measures that can be useful when dealing with urological patients with COVID-19.

Special strategies and management of urological diseases during the COVID-19 pandemic: initial experiences from a Medical Center of China.

Although urological diseases are not directly related to coronavirus disease 2019 (COVID-19), urologists need to make comprehensive plans for this disease. Urological conditions such as benign prostatic hyperplasia and tumors are very common in elderly patients. This group of patients is often accompanied by underlying comorbidities or immune dysfunction. They are at higher risk of COVID-19 infection and they tend to have severe manifestations. Although fever can occur along with urological infections, it is actually one of the commonest symptoms of COVID-19; urologists must always maintain a high index of suspicion in their clinical practices. As a urological surgeon, how we can protect medical staff during surgery is a major concern. Our hospital had early adoption of a series of strict protective and control measures, and was able to avoid cross-infection and outbreak of COVID-19. This paper discusses the effective measures that can be useful when dealing with urological patients with COVID-19.

Impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists.

OBJECTIVES: To evaluate the impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists during the month of April 2020. MATERIALS AND METHODS: A 39-question, web-based survey was sent to all urologist members of the Brazilian Society of Urology. We assessed socio-demographic, professional, health and behavior parameters. The primary goal was to evaluate changes in urologists' clinical practice and income after two months of COVID-19. We also looked at geographical differences based on the incidence rates of COVID-19 in different states. RESULTS: Among 766 urologists who completed the survey, a reduction ≥ 50% of patient visits, elective and emergency surgeries was reported by 83.2%, 89.6% and 54.8%, respectively. An income reduction of ≥ 50% was reported by 54.3%. Measures to reduce costs were implemented by most. Video consultations were performed by 38.7%. Modifications in health and lifestyle included weight gain (32.9%), reduced physical activity (60.0%), increased alcoholic intake (39.9%) and reduced sexual activity (34.9%). Finally, 13.5% of Brazilian urologists were infected with SARS-CoV-2 and about one third required hospitalization. Urologists from the highest COVID-19 incidence states were at a higher risk to have a reduction of patient visits and non-essential surgeries (OR=2.95, 95% CI 1.86 - 4.75; p< 0.0001) and of being infected with SARS-CoV-2 (OR=4.36 95%CI 1.74-10.54, p=0.012). CONCLUSIONS: COVID-19 produced massive disturbances in Brazilian urologists' practice, with major reductions in patient visits and surgical procedures. Distressing consequences were also observed on physicians' income, health and personal lives. These findings are probably applicable to other medical specialties.

Guía práctica clínica para el manejo de la infección del tracto urinario no complicada / Clinical practice guideline for the management of uncomplicated urinary tract infection

Las Infecciones del Tracto Urinario (ITU) son unas de las más frecuentes y con mayor morbilidad a nivel mundial. La mayoría de veces son de origen bacteriano (alrededor del 80%)(1, 2). En un estudio realizado en el Hospital Nacional Cayetano Heredia (Lima) se encontró que en pacientes no hospitalizados los gérmenes más comunes eran Escherichia coli (76%) y Klebsiella spp. (5%), en cambio en pacientes hospitalizados se encontró que los gérmenes más comunes eran Escherichia coli (49%), Enterococcus spp (11.4%) y Klebsiella spp (8.4%)(3). Las Infecciones del Tracto Urinario suelen dividirse en Infecciones del Tracto Urinario bajo (ITU baja y/o uretritis) y las Infecciones de Tracto Urinario alto (ITU alta)(4). Asimismo, se consideran complicadas si se presenta en pacientes con alteraciones funcionales, metabólicas, inmunológicas o anatómicas, como pacientes con diabetes, cáncer, usuarios de catéter urinario, litiasis, entre otras(5, 6). El manejo de las ITUs no complicadas es importante, ya que debido a su alta frecuencia(1, 7), hay un potencial riesgo de un uso no racional de antibióticos, lo cual puede llevar a un incremento de resistencia bacteriana, lo cual ya se está reportando con Escherichia coli(8, 9). Otro problema del manejo de las ITUs es el sobrediagnóstico, en gran parte debido a que los profesionales de salud no siguen las guías de práctica (GPC) (10-12). Debido a estas consideraciones, el Seguro Social de Salud EsSalud apunta estandarizar el manejo de Infección de Tracto Urinario (ITU), contribuyendo a mejorar la calidad de la atención y a la eficiencia en el uso de recursos en estas condiciones clínicas. Para alcanzar este cometido, el Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) de EsSalud plantea la elaboración de una guía de práctica clínica para el manejo de ITU no complicada.

Antibacterial activity of 3, 3', 4'-Trihydroxyflavone from Justicia wynaadensis against diabetic wound and urinary tract infection

The present investigation was designed to study the effect of an active compound isolated from Justicia wynaadensis against multi drug resistant organisms (MDRO's) associated with diabetic patients. The drug resistant pathogens implicated in wound and urinary tract infection of diabetic patients were isolated and identified by molecular sequencing. Solvent-solvent fractionation of crude methanol extract produced hexane, chloroform, ethyl acetate and methanol-water fraction, among which chloroform fraction was found to be potent when compared with other three fractions. Further, chloroform fraction was subjected to preparatory HPLC (High-Performance Liquid Chromatography), that produced four sub-fractions; chloroform HPLC fraction 1 (CHF1) through CHF4. Among the sub-fractions, CHF1 inhibited the pathogens effectively in comparison to other three sub-fractions. The purity of CHF1 was found to be >95%. Therefore, CHF1 was further characterized by NMR and FTIR analysis and based on the structure elucidated, the compound was found to be 3,3',4'-Trihydroxyflavone. The effective dose of this bioactive compound ranged from 32 µg/mL to 1.2 mg/mL. Thus, the present study shows that 3,3',4'-Trihydroxyflavone isolated from J. wynaadensis is an interesting biopharmaceutical agent and could be considered as a source of antimicrobial agent for the treatment of various infections and used as a template molecule for future drug development.(AU)

Urological approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a clinical care center.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is associated with significant manipulation of the urinary tract (UT). We aim to describe the urological events and their management in patients who underwent CRS-HIPEC. METHODS: Clinical records of patients who underwent treatment between 2007 and 2015 were reviewed. Urological events and their multidisciplinary management were analyzed. Descriptive statistics were calculated. RESULTS: A total of 103 patients were included. Mean age was 51 years (SD ± 11.8). Mean peritoneal cancer index (PCI) was 20.4 (SD ± 10.1). Primary tumors included appendicular (64%), gynecological (16%), colorectal (10%), and peritoneal mesotheliomas (9%). Ninety-three percent of patients had bilateral ureteral catheters inserted prior to surgery, without complications. Intraoperative UT injuries occurred in 7% of patients. In 5% of patients, tumor invasion of the bladder was evident at surgery and partial resection and primary repair of the bladder wall was performed. Urological complications included urinary tract infection (UTI) (21%) acute post-renal failure (4%), urinary fistulae (4%), and acute urinary retention (AUR) (1%). CONCLUSIONS: In our study, intraoperative UT events and postoperative complications, although not neglectable, were infrequent. Due to the high complexity of these cases, a multidisciplinary approach is mandatory. However, randomized clinical trials are necessary to clarify current data on the need and efficacy of prophylactic ureteral catheterization in patients undergoing CRS-HIPEC.

International Consultation on Urological Diseases: Congenital Anomalies of the Genitalia in Adolescence.

OBJECTIVE: To provide a comprehensive overview of genital anomalies encountered among adolescents, including late effects of problems addressed earlier in childhood. MATERIALS AND METHODS: The major congenital genital anomalies encountered in pediatric urology were identified. They include hypospadias, exstrophy-epispadias, cloacal malformations, disorders of sexual development, undescended testes, and some acquired penile anomalies seen in adolescence (priapism, adolescent varicocele). Recommendations of the International Consultation on Urological Diseases are provided on various aspects of these conditions, such as postpubertal cosmesis and function, fertility implications, and long-term nephrological considerations (when relevant). RESULTS: Specific recommendations for care, including strength of clinical recommendation, are provided in this paper. Whereas the basis of this paper is to discuss specific management recommendations as they relate to several heterogeneous conditions, general recommendations include patient-centered discussions regarding operative treatment be deferred until the patient is able to articulate goals and participate in shared decision-making and utilization of multidisciplinary teams for conditions where multiple organ systems may be involved. CONCLUSION: Congenital abnormalities of the genitalia are common and widely heterogeneous. Late effects and concerns often emerge after puberty, and patients should be followed throughout their adult lives to address such concerns.

Protocolos de encaminhamento da atenção básica para a atenção especializada: urologia / Primary care referral protocols for specialized care: urology

Este material tem como objetivo orientar as equipes que atuam na AB, qualificando o processo de referenciamento de usuários para outros serviços especializados. É uma ferramenta, ao mesmo tempo, de gestão e de cuidado, pois tanto guiam as decisões dos profissionais solicitantes quanto se constitui como referência que modula as avaliações apresentadas pelos médicos reguladores.

The Ochoa urofacial syndrome: recognize the peculiar smile and avoid severe urological and renal complications / Síndrome urofacial de Ochoa: reconheça o sorriso peculiar e evite complicações urológicas e renais graves

Ochoa syndrome is rare and its major clinical problems frequently unrecognized. We describe facial characteristics of six patients to help health professional recognize the inverted smile that these patients present and refer them to proper treatment. Patients’ medical records were reviewed and patients’ urological status clinically reassessed. At last evaluation patients’ mean age was 15.5 years, and age ranged from 12 to 32 years. Mean follow-up was 35 months (12 to 60). Initial symptoms were urinary tract infections in four patients (67%) associated with enuresis and incontinence in three of them (50%). One patient had only urinary tract infection and two lower urinary tract symptoms without infections. Initial treatment consisted of clean intermittent catheterization with anticholinergics for all patients. Four patients (67%) were submitted to bladder augmentation. Two patients had end-stage renal disease during follow-up, one received kidney transplantation and one patient remained on the waiting list for a renal transplantation. Familial consanguinity was present in only one case. This significant condition is rare, but it must be recognized by pediatricians, nephrologists and urologists in order to institute early aggressive urological treatment.

A síndrome de Ochoa é rara, e seus principais problemas clínicos são frequentemente não reconhecidos. Descrevem-se aqui características faciais de seis pacientes para auxiliar profissionais de saúde a reconhecer o sorriso invertido que eles apresentam e encaminhá-los para o tratamento adequado. Os prontuários médicos foram revisados e a condição urológica dos pacientes foi reavaliada clinicamente. A média de idade na última avaliação foi de 15,5 anos, variando de 12 a 32 anos. O seguimento médio foi de 35 meses (12 a 60). Os sintomas iniciais foram infecções do trato urinário em quatro pacientes (67%) associadas com enurese e incontinência urinária em três deles (50%). Um paciente apresentou infecções do trato urinário isoladamente e dois apresentaram sintomas do trato urinário inferior, porém sem infecções. O tratamento inicial consistiu em cateterismo intermitente limpo, com anticolinérgicos em todos os pacientes. Reconstrução urinária foi realizada em quatro pacientes (67%) por meio de ampliação vesical. Dois pacientes apresentaram doença renal em estágio terminal no seguimento, um recebeu transplante renal e outro manteve-se em lista de espera para transplante renal. Consanguinidade familiar esteve presente em apenas um caso. Essa condição significativa é rara, porém deve ser reconhecida por pediatras, nefrologistas e urologistas, a fim de instituir tratamento urológico agressivo precoce.

The Ochoa urofacial syndrome: recognize the peculiar smile and avoid severe urological and renal complications.

Ochoa syndrome is rare and its major clinical problems frequently unrecognized. We describe facial characteristics of six patients to help health professional recognize the inverted smile that these patients present and refer them to proper treatment. Patients' medical records were reviewed and patients' urological status clinically reassessed. At last evaluation patients' mean age was 15.5 years, and age ranged from 12 to 32 years. Mean follow-up was 35 months (12 to 60). Initial symptoms were urinary tract infections in four patients (67%) associated with enuresis and incontinence in three of them (50%). One patient had only urinary tract infection and two lower urinary tract symptoms without infections. Initial treatment consisted of clean intermittent catheterization with anticholinergics for all patients. Four patients (67%) were submitted to bladder augmentation. Two patients had end-stage renal disease during follow-up, one received kidney transplantation and one patient remained on the waiting list for a renal transplantation. Familial consanguinity was present in only one case. This significant condition is rare, but it must be recognized by pediatricians, nephrologists and urologists in order to institute early aggressive urological treatment.

Adolescents and adults in pediatric urology clinics.

OBJECTIVE: Adolescents represent a significant proportion of the patients seen by pediatric urologists (PU). Adolescents that require long-term follow-up (FU) eventually need to be transferred to adult care. This research aims to describe the disease profile of adolescent and adult patients from a referral PU clinic, in order to allow future medical education and cost planning. PATIENTS AND METHODS: A retrospective review was made of cases seen in a PU referral clinic from January 1st to December 31st 2011. Patients were classified as child (≤12 years old), adolescent (12 < age ≤ 18 years old) or adult (>18 years old). Diagnoses and presentations were analyzed. RESULTS: 521 patients were seen: 404 children (77.5%), 103 adolescents (19.8%) and 14 adults (2.7%). Clinical profiles differed between the three groups. 43.7% of the adolescents and all adults were FU cases or patients with late sequelae of congenital diseases. Some diseases predominated largely in adolescents. CONCLUSIONS: Adolescents represent a significant proportion of our PU clinics. Half of them are FU cases or present sequelae from previous treatments/diseases. Some adolescents do not adapt to adult care, and persist being followed up by PU.