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Article of the week: Early and rapid prediction of postoperative infections following PCNL in patients with complex kidney stones

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial  and a visual abstract prepared by prominent members of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, it should be this one.

Early and rapid prediction of postoperative infections following percutaneous nephrolithotomy in patients with complex kidney stones

Dong Chen*, Chonghe Jiang, Xiongfa Liang*, Fangling Zhong*, Jian Huang*, Yongping Lin, Zhijian Zhao*, Xiaolu Duan*, Guohua Zeng* and Wenqi Wu*

 

*Department of Urology, Guangdong Key Laboratory of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Department of Urology, The Peoples Hospital of Qingyuan City, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan, and Department of Laboratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China

 

Read the full article

Abstract

Objectives

To obtain more accurate and rapid predictors of postoperative infections following percutaneous nephrolithotomy (PCNL) in patients with complex kidney stones, and provide evidence for early prevention and treatment of postoperative infections.

Patients and Methods

A total of 802 patients with complex kidney stones who underwent PCNL, from September 2016 to September 2017, were recruited. Urine tests, urine cultures (UCs) and stone cultures (SCs) were performed, and the perioperative data were prospectively recorded.

Results

In all, 19 (2.4%) patients developed postoperative urosepsis. A multivariate logistic regression analysis revealed that an operating time of ≥100 min, urine test results with both positive urine white blood cells (WBC+) and positive urine nitrite (WBC+NIT+), positive UCs (UC+), and positive SCs (SC+) were independent risk factors of urosepsis. The incidence of postoperative urosepsis was higher in patients with WBC+NIT+ (10%) or patients with both UC+ and SC+ (UC+SC+; 8.3%) than in patients with negative urine test results or negative cultures (P < 0.01). Preoperative WBC+NIT+ was predictive of UC+SC+, with an accuracy of >90%. The main pathogens found in kidney stones were Escherichia coli (44%), Proteus mirabilis (14%) and Staphylococcus (7.4%); whilst the main pathogens found in urine were E. coli (54%), Enterococcus (9.4%) and P. mirabilis (7.6%). The incidence of E. coli was more frequent in the group with urosepsis than in the group without urosepsis (P < 0.05).

Conclusions

WBC+NIT+ in preoperative urine tests could be considered as an early and rapid predictor of UC+SC+ and postoperative urosepsis. Urosepsis following PCNL was strongly associated with E. coli infections in patients with complex kidney stones.

 

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Editorial: Predicting sepsis after percutaneous nephrolithotomy

In this month’s BJUI, Chen et al. [1] report on a large series of percutaneous nephrolithotomy (PCNL) procedures from Guangzhou in China. The authors studied patients who developed postoperative urosepsis and looked for any predictive factors that would herald impending sepsis.

In this latest report, the authors analysed 802 patients with complex kidney stones undergoing PCNL in a single centre. ‘Complex’ was defined as complete staghorn, partial staghorn or pelvic stone with at least two calyceal stones. Midstream urines (MSU) were collected and analysed for white blood cells (WBC) and nitrites (NIT). Antibiotics were given preoperatively if the urine culture (UC) was positive for WBC (WBC+) or NIT (NIT+). Standard single‐dose antibiotic was given on induction of anaesthesia and only continued for 48 h if the culture was positive. Stone cultures (SCs) were routinely collected. Of the 802 patients, UCs were positive (UC+) in 171 (21%) and SCs subsequently positive (SC+) in 30%. Postoperatively, 98 (12%) developed a fever, 62 (7.7%) developed systemic inflammatory response syndrome (SIRS), and 19 (2.4%) developed sepsis as defined by the quick Sequential (sepsis‐related) Organ Failure Assessment (qSOFA).

Multiple factors were significantly associated with sepsis: female sex (79% vs 40%), infection stone (47% vs 21%), long operating time ≥100 min (74% vs 45%), multiple accesses (32% vs 10%), UC+ (63% vs 20%), SC+ (89% vs 29%), fever (74% vs 11%), as well as being both WBC+ and NIT+ (63% vs 13%). Conversely, if WBC and NIT were negative (WBC–NIT–) the risk of sepsis was only 5.3%. On multivariate analysis SC+ (odds ratio [OR] 8.0), operating time ≥100 min (OR 4.4), WBC+ and NIT+ (OR 3.9), UC+ (OR 3.2), were independent risk factors for sepsis. Not surprisingly having UC+, SC+ or both showed a statistically higher incidence of fever, SIRS, and sepsis. Being WBC+ and NIT+ was the best predictor of having both UC+ and SC+ with an impressive 92% sensitivity and 98% specificity.* Similarly, WBC+ and NIT+ was the best predictor of sepsis with 92% sensitivity and 82% specificity. The absolute risk of sepsis was only 0.2% if WBC–NIT–, 2.8% if only one was positive, and 10% if WBC+NIT+.

The authors also report on the bacterial findings of the UCs and SCs. In the SCs, Escherichia coli (44%), Proteus mirabilis (14%) and Staphylococcus (7.4%) were the most common; whilst in the UCs, E. coli (54%), Enterococcus (9.4%) and P. mirabilis (7.6%) were predominant. It is important to remember the potential differences when interpreting UCs preoperatively and to ensure broad‐spectrum cover is given and this justifies the sending of SCs, particularly in high‐risk patients [1].

The recognition of early sepsis is paramount and has been recognised in previous studies leading to the ‘golden hour’, when early aggressive treatment of the infection has been shown to lead to better outcomes [2]. In a large study by Kumar et al. [2], early antimicrobial administration (within the first hour of hypotension from septic shock) led to a higher overall survival; but worryingly, only 50% of patients received appropriate antibiotics within 6 h. Thus, if high‐risk patients could be predicted then closer monitoring, aggressive fluid management, and early broad‐spectrum antibiotics with intensive care support could be targeted at those specific patients.

There are multiple definitions for infection, e.g., sepsis, severe sepsis, septic shock, and SIRS. The 2016 International Consensus attempted to clarify these and defined sepsis as ‘A life‐threatening organ dysfunction due to dysregulated host response to infection’ [3]. They found the term ‘severe sepsis’ to be obsolete. Septic shock is defined as ‘a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone’ [3]. The Consensus recommended organ dysfunction is assessed by a SOFA score increase of ≥2, as this is associated with a mortality of 10%. This then led to the bedside assessment clinical score called qSOFA. Poorer outcomes were associated with two or more of the qSOFA criteria: respiratory rate ≥22 breaths/min, altered mentation (as judged by the Glasgow Coma Scale), and systolic blood pressure ≤100 mmHg.

In this current study [1], many of the factors associated with postoperative sepsis are logical and have been demonstrated before, e.g., female sex, infection stone, prolonged operating times, and multiple accesses. This paper has shown that careful attention to the preoperative urine dipstick can provide important prediction of potential severe infective complications postoperatively. In an era of antibiotic stewardship this could help guide targeted preoperative and prolonged postoperative antibiotics for a small group of patients, whilst managing WBC–NIT– patients with standard prophylaxis only. The high‐risk group should also be observed very closely postoperatively and moved to a high‐dependence setting rapidly if clinical signs of sepsis develop. It would also suggest that in this high‐risk group, operating times and intra‐renal pressure should be minimised. It may be that in these patients it is better to use larger tract PCNL sizes to allow rapid fragmentation and evacuation of the stone and that consideration should be given to staged procedures in complicated stones where multiple access is being considered to minimise operating time and allow analysis of intraoperative SCs.

It should of course be remembered that antibiotic decisions should be based on local policies and sensitivities, which may be very different from this population. Rapid treatment of sepsis is paramount and the most recent ‘Hour‐1’ bundle provides the most up‐to‐date guidance for immediate resuscitation and management with lactate management, blood cultures, broad‐spectrum antibiotics, i.v. fluids, and early use of vasopressors if the blood pressure does not respond to fluid replacement [4].

by Matt Bultitude and Kay Thomas

References

  1. Chen, DJiang, CLiang, X et al. Early and rapid prediction for postoperative infections following percutaneous nephrolithotomy in patients with complex kidney stones. BJU Int 20191231041– 7
  2. Kumar, ARoberts, DWood, KE et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006341589– 96
  3. Singer, MDeutschman, CSSeymour, CW et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis‐3). JAMA 2016315801– 10
  4. Levy, MMEvans, LERhodes, AThe surviving sepsis campaign bundle: 2018 update. Crit Care Med 201846997– 1000

*FileS1FileS2

 

What’s the diagnosis?

This lady had an incidental finding of severe hydronephrosis on an ultrasound scan.

No such quiz/survey/poll

Resident’s podcast: Palliative care use amongst patients with bladder cancer

Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the Week:

Palliative care use amongst patients with bladder cancer

Read the full article

Abstract

Objectives

To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies.

Patients and methods

Using Surveillance, Epidemiology, and End Results‐Medicare data, we identified patients diagnosed with muscle‐invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist. We examined determinants of palliative care use using logistic regression analysis.

Results

Over the study period, 7303 patients were diagnosed with MIBC and 262 (3.6%) received palliative care. Of 2185 patients with advanced bladder cancer, defined as either T4, N+, or M+ disease, 90 (4.1%) received palliative care. Most patients that received palliative care (>80%, >210/262) did so within 24 months of diagnosis. On multivariable analysis, patients receiving palliative care were more likely to be younger, female, have greater comorbidity, live in the central USA, and have undergone radical cystectomy as opposed to a bladder‐sparing approach. The adjusted probability of receiving palliative care did not significantly change over time.

Conclusions

Palliative care provides a host of benefits for patients with cancer, including improved spirituality, decrease in disease‐specific symptoms, and better functional status. However, despite strong evidence for incorporating palliative care into standard oncological care, use in patients with bladder cancer is low at 4%. This study provides a conservative baseline estimate of current palliative care use and should serve as a foundation to further investigate physician‐, patient‐, and system‐level barriers to this care.

BJUI Podcasts now available on iTunes, subscribe here https://itunes.apple.com/gb/podcast/bju-international/id1309570262

Article of the week: Palliative care use amongst patients with bladder cancer

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community, a video produced by the authors and a visual abstract created by Charles Scott and Nurhan Abbud. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, it should be this one.

Palliative care use among patients with bladder cancer

Lee A. Hugar*, Samia H. Lopa*, Jonathan G. Yabes, Justin A. Yu, Robert M. Turner II*, Mina M. Fam*, Liam C. MacLeod*, Benjamin J. Davies*, Angela B. Smith§¶ and Bruce L. Jacobs*

 

*Department of Urology, Department of Medicine, Department of Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, PA, §Department of Urology and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

 

Read the full article

Abstract

Objectives

To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies.

Patients and methods

Using Surveillance, Epidemiology, and End Results‐Medicare data, we identified patients diagnosed with muscle‐invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist. We examined determinants of palliative care use using logistic regression analysis.

Fig. 1. Time from diagnosis to receipt of palliative care. The timing of palliative care receipt for those patients who received palliative care (n = 262). Strata with <11 patients were suppressed in accordance with SEER‐Medicare guidelines

Results

Over the study period, 7303 patients were diagnosed with MIBC and 262 (3.6%) received palliative care. Of 2185 patients with advanced bladder cancer, defined as either T4, N+, or M+ disease, 90 (4.1%) received palliative care. Most patients that received palliative care (>80%, >210/262) did so within 24 months of diagnosis. On multivariable analysis, patients receiving palliative care were more likely to be younger, female, have greater comorbidity, live in the central USA, and have undergone radical cystectomy as opposed to a bladder‐sparing approach. The adjusted probability of receiving palliative care did not significantly change over time.

Conclusions

Palliative care provides a host of benefits for patients with cancer, including improved spirituality, decrease in disease‐specific symptoms, and better functional status. However, despite strong evidence for incorporating palliative care into standard oncological care, use in patients with bladder cancer is low at 4%. This study provides a conservative baseline estimate of current palliative care use and should serve as a foundation to further investigate physician‐, patient‐, and system‐level barriers to this care.

 

Read more Articles of the week

 

 

Video: Palliative care use amongst patients with bladder cancer

Palliative care use amongst patients with bladder cancer

Read the full article

Abstract

Objectives

To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies.

Patients and methods

Using Surveillance, Epidemiology, and End Results‐Medicare data, we identified patients diagnosed with muscle‐invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist. We examined determinants of palliative care use using logistic regression analysis.

Results

Over the study period, 7303 patients were diagnosed with MIBC and 262 (3.6%) received palliative care. Of 2185 patients with advanced bladder cancer, defined as either T4, N+, or M+ disease, 90 (4.1%) received palliative care. Most patients that received palliative care (>80%, >210/262) did so within 24 months of diagnosis. On multivariable analysis, patients receiving palliative care were more likely to be younger, female, have greater comorbidity, live in the central USA, and have undergone radical cystectomy as opposed to a bladder‐sparing approach. The adjusted probability of receiving palliative care did not significantly change over time.

Conclusions

Palliative care provides a host of benefits for patients with cancer, including improved spirituality, decrease in disease‐specific symptoms, and better functional status. However, despite strong evidence for incorporating palliative care into standard oncological care, use in patients with bladder cancer is low at 4%. This study provides a conservative baseline estimate of current palliative care use and should serve as a foundation to further investigate physician‐, patient‐, and system‐level barriers to this care.

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Editorial: Palliative care in patients with bladder cancer: an opportunity for value improvement?

The concept of improving value in healthcare translates, in practical terms, to maximizing patient outcomes per dollar spent [1]. Palliative care has been shown to improve quality of life and possibly survival while reducing overall treatment costs amongst the seriously ill by as much as 33% per patient [2]. In this context, appropriate integration of palliative services within urological oncology care can serve as a mechanism for improving value in the field.

In this issue of BJUI, Hugar et al. [3] provide a valuable characterization of the current state of palliative care service utilization for patients with bladder cancer. Within a contemporary population of Medicare beneficiaries, the authors found receipt of palliative care services by only 4.1% of patients with advanced bladder cancer (defined as those with T4, N+, or M+ disease). Most interestingly, this value did not differ in a statistically significant manner from the rate of utilization amongst a broader cohort including all patients with muscle‐invasive (i.e. T2) bladder cancer collectively, nor did the rate of utilization vary by time.

These findings suggest that, generally, clinicians are not taking advantage of a high‐value service for patients with bladder cancer. Furthermore, the fact that utilization rates are not distinctly higher for those who meet criteria for early palliative care under American Society for Clinical Oncology guidelines (i.e. those with metastatic or locally advanced disease) indicates that barriers to adoption may be rooted in factors beyond simple recognition of advanced malignancy.  Considered in the context of this study showing no momentum towards increasing adoption, one must consider what clinical or policy interventions could alter current utilization trends. For more info follow grid-nigeria .

The authors appropriately identify that absence of physician buy‐in and a traditional lack of emphasis on cost‐conscious care are among the possible explanations for the low, flat utilization figures they observed. Indeed, fee‐for‐service reimbursement is generally oriented towards rewarding volume over quality and is known to encourage inefficiencies, high costs, service duplication, and a lack of care coordination. As such, a powerful corrective counterbalance to these forces could include restructuring reimbursement such that clinicians’ financial incentives become more closely aligned with patient outcomes and goals [4]. Palliative care is merely one of the high‐value services that stands to be more appropriately integrated into clinical practice under such reforms.

Value‐oriented alternative payment models, such as bundled payments, have been shown to improve coordination of care amongst providers [5]. And, in fact, there are already data suggesting that integration of palliative services into an improved care coordination environment yields improved outcomes. Check here at spiritofthesea  for more details. For example, a comprehensive care management plan known as the Aetna Compassionate Care Programme was shown to decrease lengths of inpatient hospitalization while resulting in overall end‐of‐life cost savings of 22% [6].

As the appropriate rate of palliative care utilization in muscle‐invasive bladder cancer remains open to debate, so too does the question of which interventions could assist in moving towards that level. In that sense, employing reimbursement incentives as a driver of more appropriate utilization of palliative care services should be viewed as but one of many potential approaches to improve the practice patterns illustrated in the present study. Future research will be necessary to better elucidate both the barriers to palliative care adoption as well as the most effective tactics to overcome them. The authors should be commended for providing the preliminary contextual data for these conversations, as urologists seek to integrate palliative services properly into high‐value care delivery for patients with advanced malignancy.

 

References

  1. Kaplan, RSPorter, MEHow to solve the cost crisis in health care. Harv Bus Rev 20118946– 52
  2. Brumley, REnguidanos, SJamison, P et al. Increased satisfaction with care and lower costs: results of a randomized trial of in‐home palliative care. J Am Geriatr Soc 200755993– 1000
  3. Hugar, LLopa, SYabes, J et al. Palliative care use among patients with bladder cancer. BJU Int 2019123968– 75
  4. Miller, HDFrom volume to value: better ways to pay for health care. Health Aff (Millwood) 2009;281418– 28
  5. Bakker, DHStruijs, JNBaan, CB et al. Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination. Health Aff (Millwood)201231426– 33
  6. Spettell, CMRawlins, WSKrakauer, R et al. A comprehensive case management program to improve palliative care. J Palliat Med 200912827– 32

 

June 2019 – About the cover

 

The Article of the Month for June (In‐hospital cost analysis of prostatic artery embolization compared with transurethral resection of the prostate: post hoc analysis of a randomized controlled trial) is on work carried out by urologists from St Gallen and Zurich in Switzerland.

The city of St Gallen is located in Eastern Switzerland, south of Lake Constance (Bodensee) and on the border of four countries. It is best know for its UNESCO World Heritage listed Abbey precinct and library, which contains an impressive collection of medieval books. In the past it was an important centre for textiles and embroidery; now it is a university town specialising in Economic Sciences.

 

 

 

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