Improvement of antibiotic prescription in outpatient care: a cluster-randomized intervention study using a sentinel surveillance network of physicians.

OBJECTIVES: To assess the effectiveness of implementing guidelines, coupled with individual feedback, on antibiotic prescribing behaviour of primary care physicians in Switzerland. METHODS: One hundred and forty general practices from a representative Swiss sentinel network of primary care physicians participated in this cluster-randomized prospective intervention study. The intervention consisted of providing guidelines on treatment of respiratory tract infections (RTIs) and uncomplicated lower urinary tract infections (UTIs), coupled with sustained, regular feedback on individual antibiotic prescription behaviour during 2 years. The main aims were: (i) to increase the percentage of prescriptions of penicillins for all RTIs treated with antibiotics; (ii) to increase the percentage of trimethoprim/sulfamethoxazole prescriptions for all uncomplicated lower UTIs treated with antibiotics; (iii) to decrease the percentage of quinolone prescriptions for all cases of exacerbated COPD (eCOPD) treated with antibiotics; and (iv) to decrease the proportion of sinusitis and other upper RTIs treated with antibiotics. The study was registered at ClinicalTrials.gov (NCT01358916). RESULTS: While the percentage of antibiotics prescribed for sinusitis or other upper RTIs and the percentage of quinolones prescribed for eCOPD did not differ between the intervention group and the control group, there was a significant increase in the percentage of prescriptions of penicillins for all RTIs treated with antibiotics [57% versus 49%, OR=1.42 (95% CI 1.08-1.89), P=0.01] and in the percentage of trimethoprim/sulfamethoxazole prescriptions for all uncomplicated lower UTIs treated with antibiotics [35% versus 19%, OR=2.16 (95% CI 1.19-3.91), P=0.01] in the intervention group. CONCLUSIONS: In our setting, implementing guidelines, coupled with sustained individual feedback, was not able to reduce the proportion of sinusitis and other upper RTIs treated with antibiotics, but increased the use of recommended antibiotics for RTIs and UTIs, as defined by the guidelines.

Pandemic 2009 A(H1N1) infection requiring hospitalization of elderly Spanish adults.

To describe the clinical presentation and prognosis of elderly adults hospitalized with pandemic 2009 A(H1N1) influenza infection and to compare these data with those of younger patients. DESIGN: Prospective, observational, multicenter study. SETTING: Thirteen hospitals in Spain. PARTICIPANTS: Adults admitted to the hospital with confirmed pandemic 2009 A(H1N1) influenza infection. MEASUREMENTS: Demographic, clinical, laboratory, radiological, and outcome variables. RESULTS: Between June 12 and November 10, 2009, 585 adults with confirmed 2009 A(H1N1) influenza were hospitalized, of whom 50 (8.5%) were aged 65 and older (median age 72, range 65-87). Older adults (≥ 65) were more likely to have associated comorbidities (88.0% vs 51.2%; P < .001), primarily chronic pulmonary diseases (46.0% vs 27.3%; P < .001). Lower respiratory tract symptoms and signs such as dyspnea (60.0% vs 45.6%) and wheezing (46.0% vs 27.8%; P = .007) were also more common in these elderly adults, although pulmonary infiltrates were present in just 14 (28.0%) of the older adults, compared with 221 (41.3%) of the younger adults (P = .06). Multilobar involvement was less frequent in elderly adults with pulmonary infiltrates than younger adults with pulmonary infiltrates (21.4% vs 60.0%; P = .05). Rhinorrhea (4.0% vs 21.9%; P = .003), myalgias (42.0% vs 59.1%; P = .01), and sore throat (14.0% vs 29.2%; P = .02) were more frequent in younger adults. Early antiviral therapy (<48 hours) was similar in the two groups (34.0% vs 37.9%; P = .58). Two older adults (4.0%) died during hospitalization, compared with 11 (2.1%) younger adults (P = .30). CONCLUSION: Elderly adults with 2009 A(H1N1) influenza had fewer viral-like upper respiratory symptoms than did younger adults. Pneumonia was more frequent in younger adults. No significant differences were observed in hospital mortality.

Forced diuresis improves the diagnostic accuracy of 18F-FDG PET in abdominopelvic malignancies.

Our aim was to evaluate the role of forced diuresis in improving the diagnostic accuracy of abdominopelvic (18)F-FDG PET. METHODS: Thirty-two patients were enrolled. Besides the presence of known intravesical tumors or undefined renal lesions on the initial PET scan, the inclusion criterion was the appearance of indeterminate or equivocal (18)F-FDG foci that extended along the course of the urinary tract and could not confidently be separated from urinary activity. For each patient, a second abdominopelvic PET study was performed after intravenous injection of 0.5 mg of furosemide per kilogram of body weight (maximum, 40 mg) coupled with parenteral infusion of physiologic saline. RESULTS: Forced diuresis coupled with parenteral hydration eliminated any significant (18)F-FDG activity from the lower urinary tract in 31 (97%) of 32 patients after the bladder had been voided 3 successive times. Twelve intravesical lesions were visualized with outstanding clarity, whereas radiologic suspicion of locally recurrent bladder tumors was ruled out in 3 patients. Among 14 indeterminate or equivocal extravesical foci, 7 were deemed of no clinical value because they disappeared after furosemide challenge, whereas 7 persisting foci were proven to be true-positive PET findings. The performance of (18)F-FDG PET in characterizing 3 renal-space-occupying lesions could not be improved by our protocol. CONCLUSION: Furosemide challenge has the potential to noninvasively resolve the inherent (18)F-FDG contrast handicap in the lower urinary tract.

Occupational asthma in workers exposed to Mesalazine powder inhalation

Background: Due to complains of respiratory symptoms of some employees a pharmaceutical company asked in 2008 the occupational medical department of the Institute for Work and Health in Lausanne to evaluate the health status of their workers exposed to Mesalazine powder, which is the active agent of a drug used for the treatment of bowels inflammation. Therefore we examined the 21 workers exposed to Mesalazine powder. Method: After a visit of the pharmaceutical company in order to investigate the Mesalazine powder production, we performed an individual medical evaluation of the 21 workers. Our medical protocol was based on the safety data sheet of Mesalazine, the data found in the scientific literature and the «Compendium Suisse des Médicaments» and covered upper and lower respiratory tract as well as skin and eyes. Results: Sixty two percent (62%) of the exposed employees had symptoms of skin, eyes and throat irritation. Three employees reported respiratory symptoms such as dyspnoea, cough and expiratory wheezing, which appeared during the working hours. The Peak Flow series performed at the workplace was lowered in the three employees with lower respiratory tract symptoms. None of the three had consulted a physician, even though the symptoms had been present since some months. The pneumological evaluation confirmed for all three cases the asthma diagnoses. Conclusion: It is known that patients who are treated with drugs including Mesalazine can develop adverse health effect such as asthma. However occupational asthma in workers exposed to Mesalazine powder inhalation is until now not described in the literature. Immunologic investigations in order to know if the occupational asthma caused by Mesalazine is of allergic or mechanical irritation nature are still ongoing. Concerning the three workers with asthma, inability to work with Mesalazine was pronounced. Furthermore, the SUVA recognized the three patients with asthma as occupational respiratory diseases. Following our results and recommendations, the company undertook some measures to reduce the exposure to Mesalazine. A new health evaluation of the employees in the Mesalazine production is hence planned in 2009. As each year new causes of occupational asthma are described, the possible work relation of new asthma onset has to be carefully investigated as the consequences for the patient e.g. removal from exposure and for the exposed co-workers are of substantial importance.

Preoperative assessment of neurovesical function in children with anorectal malformation: association with vertebral and spinal malformations.

PURPOSE: We preoperatively assessed neurovesical function and spinal cord function in children with anorectal malformations. In cases of neurovesical dysfunction we looked for an association with vertebral malformation or myelodysplasia. MATERIALS AND METHODS: We prospectively evaluated 80 children with anorectal malformations via preoperative urodynamics and magnetic resonance imaging of the spine. Bladder compliance and volume, detrusor activity and vesicosphincteric synergy during voiding allowed urodynamic evaluation. Results were reported according to Wingspread and Krickenbeck classifications of anorectal malformations. RESULTS: Urodynamic findings were pathological in 14 children (18%). Pathological evaluations did not seem related to type of fistula or level of anorectal malformation. Vertebral anomalies were seen in 34 patients (43%) and myelodysplasia in 16 (20%). Neither vertebral anomaly nor myelodysplasia seemed associated with type of fistula or severity of anorectal malformation. Of 14 children with pathological urodynamics no vertebral anomaly or myelodysplasia was found in 7. Of 66 children with normal urodynamics 40 presented with vertebral or spinal malformation. CONCLUSIONS: Lower urinary tract dysfunction is common in patients with anorectal malformations. Normal spine or spinal cord does not exclude neurovesical dysfunction. Myelodysplasia or vertebral anomaly does not determine lower urinary tract dysfunction. Thus, we recommend preoperative urodynamic assessment of the bladder and magnetic resonance imaging of the spine in children with anorectal malformations.

La mortalité par tumeur maligne chez les ouvriers d'une fabrique de caoutchouc en Suisse: étude épidémiologique, 1955-1975. [Cancer mortality among the workers of a Swiss rubber goods factory. Epidemiological study, 1955-75].

In an epidemiologic investigation of mortality among workers in a Swiss rubber-goods factory the cancer mortality in the period 1955-1975 has been studied in all male workers active on 1 January 1955 in (a) a rubber-goods factory and (b) a munitions factory, the latter as reference population. The two groups numbered some 1000 each. Both factories were located in the same Central Swiss village where no other industry was present. Mortality in each industry is compared with that in the Swiss population in general (SMR) and the mortalities of the two industries are compared with each other. The results tend to confirm that rubber workers are exposed to a higher risk of cancer mortality. Three particular types of cancer are briefly discussed: cancer of the stomach, of the lower urinary tract, and glioblastoma.

Fetal laser therapy: applications in the management of fetal pathologies.

Fetoscopic coagulation of placental anastomoses is the treatment of choice for severe twin-to-twin transfusion syndrome. In the present day, fetal laser therapy is also used to treat amniotic bands, chorioangiomas, sacrococcygeal teratomas, lower urinary tract obstructions and chest masses, all of which will be reviewed in this article. Amniotic band syndrome can cause limb amputation by impairing downstream blood flow. Large chorioangiomas (>4 cm), sacrococcygeal teratomas or fetal hyperechoic lung lesions can lead to fetal compromise and hydrops by vascular steal phenomenon or compression. Renal damage, bladder dysfunction and lastly death because of pulmonary hypolasia may be the result of megacystis caused by a posterior urethral valve. The prognosis of these pathologies can be dismal, and therapy options are limited, which has brought fetal laser therapy to the forefront. Management options discussed here are laser release of amniotic bands, laser coagulation of the placental or fetal tumor feeding vessels and laser therapy by fetal cystoscopy. This review, largely based on case reports, does not intend to provide a level of evidence supporting laser therapy over other treatment options. Centralized evaluation by specialists using strict selection criteria and long-term follow-up of these rare cases are now needed to prove the value of endoscopic or ultrasound-guided laser therapy.

Complicaciones postoperatorias tempranas de la colporrafia anterior por técnica tradicional versus técnica de sitio específico

El prolapso del piso pélvico es una entidad frecuente, especialmente en pacientes postmenopáusicas y en su gran mayoría requiere tratamiento quirúrgico. En este estudio comparamos la aparición de complicaciones postoperatorias tempranas entre la colporrafia anterior con técnica clásica (TC) versus la colporrafia anterior con técnica de sitio especifico (CSE). Se realizó un estudio observacional analítico, retrospectivo, de dos cohortes de pacientes que requirieron colporrafia anterior entre agosto de 2009 hasta junio de 2012. Las características de cada grupo fueron homogéneas y comparables. El desenlace de mayor frecuencia fue dehiscencia de la línea de sutura, sin embargo, no se encontraron diferencias estadísticamente significativas entre las dos técnicas. La aparición de reprolapso temprano y el diagnóstico de abscesos o hematomas presentaron frecuencias que carecen de diferencia significativa. No hubo complicaciones tempranas graves tales como sangrado intraoperatoria mayor o lesiones vesicouretrales. Los resultados sugieren que las dos técnicas tienen una incidencia baja de complicaciones postoperatorias tempranas y por lo tanto parecen ser seguros dentro del manejo quirúrgico del prolapso del componente anterior del piso pélvico.

Infecciones urinarias en gestantes y adherencia a guía de manejo en primer nivel – Colmedica. Bogotá D.C., 2007

Las Infecciones Urinarias son causa de frecuente morbilidad, afecta a amplios sectores de la población, conllevan la utilización de antibióticos, afectan más a las mujeres, siendo un significativo problema de salud debido a su incidencia durante el embarazo que es del l0%1, diagnosticándose en la primera visita del control prenatal. Aproximadamente el 15% de las mujeres, tendrán una infección urinaria en alguna época durante su vida, con riesgos a largo plazo y calidad de vida. Amerita la detección temprana, el tratamiento oportuno y eficaz, el estudio y seguimiento posteriores.

Evaluación de la disfunción sexual en mujeres con incontinencia urinaria antes y después de la cinta suburetral

Objetivo: Evaluar prospectivamente el grado de disfunción sexual en pacientes con incontinencia urinaria de esfuerzo antes y después de la cinta suburetral libre de tensión mediante el cuestionario PISQ-12 validado en español. Materiales y Métodos: Estudio observacional longitudinal de antes y después. Se seleccionaron 60 mujeres sexualmente activas con algún grado de disfunción sexual, entre abril del 2014 hasta marzo del 2015, diagnosticadas con incontinencia urinaria, programadas para colocación de cinta suburetral transobturadora en el Hospital Universitario Mayor Méderi. La mayoría de las pacientes presentaron algún grado de prolapso genital y requirieron corrección quirúrgica asociada a la cinta. Todas las pacientes respondieron el cuestionario PISQ-12 antes y 6 meses después del procedimiento. Resultados: La edad promedio fue 48 ± 4.58 años. El grado de prolapso con mayor frecuencia fue el estadío II del POP-Q 55% (n=33). El 96.7% (n=50) de las pacientes requirieron además de la colocación de la cinta suburetral corrección quirúrgica del prolapso genital. En la evaluación preoperatoria la disfunción sexual se distribuyó así: Severa: 70%, Moderada 18.3% y Leve 11.7%, después de 6 meses postoperatorios se encontró una diferencia estadísticamente significativa del cambio en el grado de disfunción sexual así: Moderada 41.5% y Leve 58.2% donde ninguna paciente quedó clasificada con disfunción severa. Discusión y Conclusión: Las pacientes que presentaron disfunción sexual severa obtuvieron mayor cambio en el grado de disfunción, luego de la colocación de la cinta suburetral.

Nocturia is not associated with falls among the elderly: a population study in the city of Sao Paulo

Introduction: the present study aims to evaluate the association between nocturia and falls in a group of community-living elderly men in the city of Sao Paulo (Brazil). Material and methods: under the coordination of the Pan American Health Organization and World Health Organization, a multicenter study named Health, Welfare and Aging (SABE Study) is being conducted to evaluate the living and health conditions of older people in Latin America and Caribbean. In Brazil, this study is evaluating the elderly population (60 years or more) in Sao Paulo since 2000. The presence of nocturia was taken as the response ""yes"" to the question ""Do you need to void three times or more at night?"". The presence of falls was also taken as the response ""yes"" to the question ""Did you have any fall during the last 12 months?"" The intergroup analysis used was the logistic regression. Results: total of 865 men was interviewed, mean age 68 years. It was observed high prevalence of nocturia and falls in all groups, with higher prevalence of both in the eldest group (p < 0.001), however, the association of nocturia and falls was not statistically significant in any of the groups (p = 0.45). Conclusion: this is one of the pioneering studies that assess only the male population, showing that nocturia was not significantly associated with falls. Nocturia and falls are highly prevalent conditions in the elderly, but no association was found between both, so that these variables may be correlated to age and other clinical conditions. (C) 2010 AEU. Published by Elsevier Espana, S.L. All rights reserved.

Long-term nitric oxide deficiency causes muscarinic supersensitivity and reduces beta(3)-adrenoceptor-mediated relaxation, causing rat detrusor overactivity

Background and purpose: Overactive bladder is a complex and widely prevalent condition, but little is known about its physiopathology. We have carried out morphological, biochemical and functional assays to investigate the effects of long-term nitric oxide (NO) deficiency on muscarinic receptor and beta-adrenoceptor modulation leading to overactivity of rat detrusor muscle. Experimental approach: Male Wistar rats received No-nitro-L-arginine methyl ester (L-NAME) in drinking water for 7-30 days. Functional responses to muscarinic and b-adrenoceptor agonists were measured in detrusor smooth muscle (DSM) strips in Krebs-Henseleit solution. Measurements of [H-3] inositol phosphate, NO synthase (NOS) activity, [H-3] quinuclidinyl benzilate ([H-3]QNB) binding and bladder morphology were also performed. Key results: Long-term L-NAME treatment significantly increased carbachol-induced DSM contractile responses after 15 and 30 days; relaxing responses to the beta(3)-adrenoceptor agonist BRL 37-344 were significantly reduced at 30 days. Constitutive NOS activity in bladder was reduced by 86% after 7 days and maintained up to 30 days of L-NAME treatment. Carbachol increased sixfold the [H-3] inositol phosphate in bladder tissue from rats treated with L-NAME. [H-3] QNB was bound with an apparent KD twofold higher in bladder membranes after L-NAME treatment compared with that in control. No morphological alterations in DSM were found. Conclusions and implications: Long-term NO deficiency increased rat DSM contractile responses to a muscarinic agonist, accompanied by significantly enhanced KD values for muscarinic receptors and [H-3] inositol phosphate accumulation in bladder. This supersensitivity for muscarinic agonists along with reductions of beta(3)-adrenoceptor-mediated relaxations indicated that overactive DSM resulted from chronic NO deficiency.

Uroflow studies in children: Correlation with age, weight and body surface area.

Peak flow rate data (Q(max)) are important for diagnosis of lower urinary tract obstruction. However, the lack of uroflowmetry studies in children, makes their interpretation difficult. With this aim, we studied 167 boys classified in four groups according to their age (G1 : n = 48, 6-7 years; G2 : n = 43, 8-9 years; G3 : n = 37, 10-11 years; G4: n = 39, 12-14 years). We studied in all children, weight, height, body surface area, peak flow rate (Q(max) and the correspondant urinary volume (Vol). Means and standard deviations of Q(max) (ml/sec) were : 15 +/- 5 (G1), 15 +/- 5 (G2), 17 +/- 5 (G3) and 22 +/- 7 (G4) respectively. Corresponding urinary volumes (Vol) (mean standard deviation - in ml) were : G1 = 123 +/- 75; G2 = 122 +/- 79; G3 = 158 +/- 96 and G4 = 162 +/- 101. We found a significant correlation (p < 0,01) between Q(max) and Vol in groups G2, G3 and G4; and between Q(max) and height in groups G1 and G4.The authors demonstrated a positive correlation between maximum flow and voided volume, and an increase of Q(max) with age.

Carcinoma de células transicionales en perros: Un informe de dos casos, madre e hija

The transitional cell carcinoma is usually located in the trigone region of the bladder, and shows nonspecific clinical signs of the lower urinary tract such as hematuria, strangury, pollakiuria and urinary incontinence. The urethral and ureteral obstructions occur in some cases. Etiological factors such as endogenous and iatrogenic have been listed as the cause of disease. The objective of this report is to describe the process and treatment of two cases of transitional cell carcinoma presented simultaneously in two dogs, mother and daughter, that showed hematuria and post-renal azotemia, both with tumor in the trigone of bladder. After partial cystectomy ureteroneocistostomia, the diagnosis of transitional cell carcinoma was confirmed by histopathological analysis of bladder tissue. Patients received firocoxib as adjuvant to surgery. It is concluded that the surgical procedure associated with the use of specific anti-inflammatory COX-2 provided a better quality of life in both patients.

Avaliação dos parâmetros espermáticos e caracterização do perfil bioquímico do plasma seminal de cães (Canis familiaris – LINNAEUS, 1758) com hiperplasia prostática benigna, tratados com toxina botulínica A

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)