Investigation of bacteremia following nasotracheal intubation

BACKGROUND: The aim of this study was to detect the risk of bacteremia from nasotracheal intubation in children undergoing dental treatment under general anesthesia. METHODS: Two 10 ml blood samples were taken, the first as a baseline and the second within 30 s following the nasotracheal intubation. The samples were inoculated into 5 ml aerobic and 5 ml anaerobic blood culture bottles. Following incubation in an automated blood culture system, bacteria were identified by using conventional biochemical methods and commercial identification systems. Mc Nemar's test was used to assess the findings statistically. RESULTS: Of 74 patients only nine (12.3%) had positive blood cultures after the intubation and seven of these had been intubated without trauma. The incidence of bacteremia was significantly higher after atraumatic intubation (7/9) compared with traumatic intubation (2/9) (P < 0.05). The most common bacteria in positive cultures were Streptococcus viridans, four of 74 (5.4%). CONCLUSIONS: Since the occurrence of bacteremia after nasotracheal intubation is hazardous for patients at risk for developing infective endocarditis, to prevent further complications prophylactic antibiotic treatment is recommended.     

Two centuries of cystoscopy: the development of imaging,instrumentation and synergistic technologies

The cystoscope used today is the product of centuries of development. The desire to view the cavities of the body was first described several centuries ago. The earliest true prototype was Bozinni’s 1805 urethral viewing tube, on which many others were based. These primitive instruments were challenging to use for the operator, uncomfortable for the patient, and dangerous for both. Patient positioning was based on the method of bladder distension and the goal of the operation, rather than comfort. Images visualized by early models were inverted and backwards, and required the operator to be skilled in correcting this image. Reflected candlelight was used for illumination, and objects appeared small and distant. With the advent of lenses, prisms and the incandescent light, cystoscopy advanced to Nitze’s prototype, a forerunner of the current cystoscope. Once the image quality was improved, instrumentation through the cystoscope was introduced, broadening the scope of urology, from the management of venereal disease to a premier surgical speciality. Finally, the invention of fibre optics and digital imaging provided the cystoscope used by urologists worldwide, giving unparalleled image quality, allowing for educational opportunities and a quality of patient care unimaginable to the early pioneers. An understanding of this past brings not only an appreciation of the technology currently available, but also a glimpse into what the cystoscope has the potential to become. From this past, it is clear that today’s cystoscope is merely a forerunner of that which the future will bring.     

A comparison of white-light cystoscopy and narrow-band imaging cystoscopy to detect bladder tumour recurrences

OBJECTIVE

To determine whether narrow‐band imaging (NBI) cystoscopy enhances the detection of non‐muscle‐invasive bladder tumours over standard white‐light imaging (WLI) cystoscopy, as surveillance WLI is the standard method used to diagnose patients with recurrent bladder tumours, but they can be missed by WLI cystoscopy, possibly accounting for early recurrences.

PATIENTS AND METHODS

We evaluated 427 patients for recurrent bladder tumours by WLI cystoscopy, followed by NBI cystoscopy as a further procedure, using the same video‐cystoscope. Recurrent tumours visualized by WLI or NBI cystoscopy were mapped, imaged, biopsied and subsequently treated by transurethral resection (TUR) or fulguration. Biopsies or TUR specimens obtained by WLI and NBI were examined separately for presence of tumour.

RESULTS

In all, 103 patients (24%) had tumour recurrences; 90 (87%) were detected by both WLI and NBI and another 13 (100%) only by NBI cystoscopy. NBI detected extra papillary tumours or more extensive carcinoma in situ in 58 (56%) patients found to have recurrences. The mean number of recurrent tumours visualized on WLI cystoscopy was 2.3, vs to 3.4 seen on NBI cystoscopy (P = 0.01).

CONCLUSION

NBI cystoscopy improved the detection of recurrent non‐muscle‐invasive bladder tumours over standard WLI cystoscopy.     

Promises and challenges of fluorescence cystoscopy

IntroductionFluorescence based photodynamic diagnostic (PDD) techniques have been developed to improve detection and treatment of non-muscle invasive bladder cancer. The goal of this article is to evaluate the promises and challenges of blue light cystoscopy.MethodsThe literature was reviewed regarding articles pertaining to fluorescent cystoscopy and blue light cystoscopy (BLC).ResultsBlue light cystoscopy improves detection of bladder cancer tumors especially CIS. Randomized trials have demonstrated a reduction of recurrences. BLC has been demonstrated to be safe and effective in treatment of NMIBC of varying risk. The main obstacle to BLC will be adoption by urologists. Purchase cost of capital equipment may impact usage especially if adopted for outpatient clinics.ConclusionsBLC has been demonstrated to be safe and effective in treatment of NMIBC of varying risk. The reduction of recurrences and yet unproven but potential reduction in progression should be viewed favorably by urologists and patients. The main obstacle to BLC will be adoption by urologists who can put pressure on hospitals to acquire the capital equipment and who will seek the training to become proficient in using the technology. Patient demand for the technology may also help increase availability. Finally, the companies involved with BLC need to support trials that will demonstrate reduction in progression and that will answer the practical issues regarding usage in proximity to BCG and repeated usage.     

The use of blue-light cystoscopy in the detection and surveillance of nonmuscle invasive bladder cancer

Nonmuscle invasive bladder cancer is associated with a high risk of recurrence as well as progression to muscle-invasive disease. Therefore, adequate visualization and identification of malignant lesions as well as complete resection are critical. Traditional white-light cystoscopy is limited in its ability to detect bladder cancer, specifically carcinoma in situ. Blue-light cystoscopy makes use of the intravesical instillation of a heme precursor to differentiate areas of malignancy from normal tissue. A narrative review of the literature on the use of blue-light cystoscopy in bladder cancer was conducted. Blue-light cystoscopy has been shown in several randomized clinical trials to increase detection of Ta, T1, and carcinoma in situ, as well as reduce risk of recurrence at 12 months as compared with traditional white-light cystoscopy. Research into the effects of blue-light cystoscopy on risk of disease progression has produced mixed results, in part due to changing definitions of progression. However, more recent research suggests a correlation with decreased risk of progression. Whereas the use of blue-light was initially limited to rigid cystoscopy in the operating room, results from a recent randomized clinical trial showing enhanced detection of recurrent disease using blue-light in-office surveillance flexible cystoscopy have led to expanded Food and Drug Administration approval. Overall, blue-light cystoscopy offers promise as an enhancement to white-light cystoscopy for the detection of nonmuscle invasive bladder cancer and may yield additional benefits in reducing disease recurrence and progression. Further prospective research is needed to evaluate the true benefit of blue-light cystoscopy in terms of disease progression as well as the cost-effectiveness of this technique.     

Prospective trial comparing intraoperative flexible,rigid, and no cystoscopy after ultrasound-guided transperineal permanent seed prostate brachytherapy

ObjectiveThis is a prospective trial comparing the impact of intraoperative flexible, rigid, and no cystoscopy on dysuria immediately after permanent seed prostate brachytherapy (PB). It prospectively documents the time course and characteristics of dysuria, as well as the rates of urinary retention post-PB. Furthermore, this study attempts to establish the utility of routine, post-PB cystoscopy, by documenting the incidence of finding significant pathology on cystoscopy.Materials and methodsBetween January 2003 and January 2007, 225 patients deemed by their physician to be candidates for PB alone were recruited to the study. Patients who had external beam radiation therapy and/or androgen deprivation therapy were excluded. Preimplant International Prostate Symptom Score (IPSS), urinary quality of life score, urine leakage score, Sexual Health Inventory for Men score, and Radiation Therapy Oncology Group Bowel Health Inventory Scores were obtained. Patients were assigned to one of the following three groups: intraoperative rigid cystoscopy, flexible cystoscopy, or no cystoscopy following PB. Patient self-administered questionnaires were given to the patient in the recovery room after PB. These questionnaires evaluated the intensity, type, and duration of urinary symptoms associated with the first four urinations post-PB. All patients were seen on postoperative Day 1 when the surveys were retrieved. Patients were then followed up every 3 months. Acute urinary retention (AUR) was documented in the follow ups. Frequencies of significant pathology (defined as bladder tumor, urethral stricture, or large blood clots) were documented at the time of cystoscopy. AUR rates were also evaluated by the isotope used (I¹²⁵, Pd¹⁰³, or Cs¹³¹).ResultsA total of 225 patients were enrolled into this study, but only 194 patients could be analyzed for dysuria. Thirty-one patients were excluded from analysis (6, 13, and 12 patients from the rigid, flexible, and no cystoscopy groups, respectively). These patients did not return the questionnaire, or were in retention, and thus did not have dysuria scores to report. Baseline characteristics for the 194 patients in terms of preimplant IPSS, quality of life, prostate volume, and isotope used were well balanced between all three groups. There were no significant differences in dysuria between the three cystoscopy groups at any time point following PB. The mean dysuria score across all time points was 5.5 of 10, with 0 representing “no pain” and 10 representing “the worst possible pain.” Pain was most often characterized as “burning” (78%), whereas dysuria most commonly was “only during urination” (56%). AUR rates (6.8–9.5%) and duration of catheter dependence (10.5–19 days) were not found to be significantly different between the assigned groups. When results were stratified by isotope, patients treated with I¹²⁵, Pd¹⁰³, and Cs¹³¹ seeds experienced a 6%, 14%, and 0% retention rate, respectively. The I¹²⁵ and Pd¹⁰³ patients had similar pretreatment IPSS and prostate volumes. Seven percent of patients undergoing cystoscopy had significant findings. The most common finding was “clots thought too large to void” (3%). Seeds in the bladder/urethra occurred in 1% of cases. Only 0.7% of patients were found to harbor unsuspected bladder tumors.ConclusionThere was no significant difference in dysuria in the first four urinations post-PB between patients in the rigid, flexible, and no cystoscopy groups. Larger blood clots that may have been difficult to void, seeds in the bladder and/or urethra, and other abnormalities were found in 7% of patients who had cystoscopy. This may suggest that cystoscopy may be worthwhile post-PB. The incidence of AUR was not significantly different between the three cohorts.     

A model of Staphylococcus aureus bacteremia, septic arthritis, and osteomyelitis in chickens

We studied the occurrence, magnitude, and kinetics of bacteremia and the resultant osteomyelitis and septic arthritis in an avian model of Staphylococcus aureus infection. Thirty-day-old male broiler chicks were inoculated i.v. with 10(5), 10(6), or 10(7) cfu of strain Duntravis, a beta-hemolytic, coagulase-producing, capsular type 8 isolate from the synovial fluid of a 2-year-old black boy. Bacteremia occurred in 80%, 90%, and 100% of animals inoculated with 10(5), 10(6), or 10(7) cfu, respectively. The magnitude of bacteremia in surviving, bacteremic animals increased for 96 hours after inoculation and then decreased after a plateau phase. Osteomyelitis and septic arthritis occurred only in chicks that were continuously bacteremic. The occurrence of osteomyelitis was uniform among continuously bacteremic animals and developed 1 to 23 hours after inoculation. Chickens are susceptible to systemic infections with S. aureus. Bacteremia, osteomyelitis, and septic arthritis may be induced in healthy chickens without prior manipulations that depress their resistance.     

A phase III, multicenter comparison of hexaminolevulinate fluorescence cystoscopy and white light cystoscopy for the detection of superficial papillary lesions in patients with bladder cancer

PURPOSE: We compared hexaminolevulinate fluorescence cystoscopy with white light cystoscopy for detecting Ta and T1 papillary lesions in patients with bladder cancer. MATERIALS AND METHODS: A total of 311 patients with known or suspected bladder cancer underwent bladder instillation with 50 ml 8 mM HAL for 1 hour. The bladder was inspected using white light cystoscopy, followed by blue light (fluorescence) cystoscopy. Papillary lesions were mapped and resected for histological examination. RESULTS: Noninvasive pTa tumors were found in 108 of 196 evaluable patients (55.1%). In 31 patients (29%) at least 1 more tumor was detected by HAL than by white light cystoscopy (p<0.05). Six of these patients had no lesions detected by white light, 12 had 1 lesion detected by white light and more than 1 by HAL, and 13 had multiple Ta lesions detected by the 2 methods. Conversely at least 1 more tumor was detected by white light cystoscopy than by HAL cystoscopy in 10 patients (9%, 95% CI 5-16). Tumors invading the lamina propria (T1) were found in 20 patients (10.2%). At least 1 additional T1 tumor was detected by HAL but not by white light cystoscopy in 3 of these patients (15%), while at least 1 more T1 tumor was detected by white light cystoscopy than by HAL cystoscopy in 1 patient (5%, 95% CI 0-25). Detection rates for Ta tumors were 95% for HAL cystoscopy and 83% for white light cystoscopy (p=0.0001). Detection rates were 95% and 86%, respectively, for T1 tumors (p=0.3). HAL instillation was well tolerated with few local or systemic side effects. CONCLUSIONS: HAL fluorescence cystoscopy detected at least 1 more Ta and T1 papillary tumor than white light cystoscopy in approximately a third of the patients with such tumors. Whether this would translate to improved patient outcomes has yet to be determined.     

A comparison of hexaminolevulinate fluorescence cystoscopy and white light cystoscopy for the detection of carcinoma in situ in patients with bladder cancer: a phase III, multicenter study

PURPOSE: We compared hexaminolevulinate (Hexvix) fluorescence cystoscopy with white light cystoscopy for detecting carcinoma in situ. MATERIALS AND METHODS: In this multicenter study 298 patients with known or suspected bladder cancer underwent bladder instillation with 50 ml 8 mM hexaminolevulinate for 1 hour. Cystoscopy was then performed, first using standard white light and then hexaminolevulinate fluorescence cystoscopy. Lesions or suspicious areas identified under the 2 illumination conditions were mapped and biopsied for histological examination. In addition, 1 directed biopsy was obtained from an area appearing to be normal. RESULTS: Of 196 evaluable patients 29.6% (58 of 196) had carcinoma in situ, including 18 with carcinoma in situ alone, and 35 with carcinoma in situ and concomitant papillary disease, which was only detected on random biopsy in 5. Of the 18 patients with no concomitant papillary disease carcinoma in situ was detected only by hexaminolevulinate fluorescence in 4 and only by white light in 4. In the group with concomitant papillary disease carcinoma in situ was found only by hexaminolevulinate fluorescence in 5 patients and only by white light in 3. The proportion of patients in whom 1 or more carcinoma in situ lesions were found only by hexaminolevulinate cystoscopy was greater than the hypothesized 5% (p=0.0022). Overall more carcinoma in situ lesions were found by hexaminolevulinate than by white light cystoscopy in 22 of 58 patients (41.5%), while the converse occurred in 8 of 58 (15.1%). Biopsy results confirmed cystoscopy findings. Of a total of 113 carcinoma in situ lesions in 58 patients 104 (92%) were detected by hexaminolevulinate cystoscopy and 77 (68%) were detected by white light cystoscopy, while 5 were detected only on directed visually normal mucosal biopsy. Hexaminolevulinate instillation was well tolerated with no local or systemic side effects. CONCLUSIONS: In patients with bladder cancer hexaminolevulinate fluorescence cystoscopy with blue light can diagnose carcinoma in situ that may be missed with white light cystoscopy. Hexaminolevulinate fluorescence cystoscopy can be used in conjunction with white light cystoscopy to aid in the diagnosis of this form of bladder cancer.     

超声电子膀胱软镜在泌尿系疾病诊疗中的动物模型研究

目的 探讨超声电子膀胱软镜应用于泌尿系疾病诊疗的可行性. 方法 采用1 ～2岁雌性巴马香猪4只为实验模型,以超声支气管镜为雏形,通过B超模式观察不同膀胱充盈量下膀胱各层结构声像图,通过彩色多普勒超声模式观察膀胱周围重要血管的声像图,初步总结超声电子膀胱软镜的操作技巧和难点.采用专用一次性抽吸式活检针进行内镜超声引导下分层定位穿刺活检,活检组织送病理以验证超声分层定位的准确性,探讨超声电子膀胱软镜下穿刺的有效性和安全性. 结果 超声膀胱镜可同步显示内镜图像和超声图像.香猪膀胱充盈90 ml时,超声内镜下膀胱壁黏膜及黏膜下层、肌层、浆膜层层次清晰可辨并有助于穿刺针的分层定位,多普勒超声模式下,膀胱周围血管血流信号明显,超声引导穿刺可避免发生血管及周嗣脏器误伤.16处穿刺点送检组织病理结果与超声分层定位吻合. 结论 超声电子膀胱软镜诊断治疗泌尿系疾病安全可行,配套器械有待进一步改进.     

Bacteriuria management and urological evaluation of patients with spina bifida and neurogenic bladder: a multicenter survey

PURPOSE: We assessed how groups at spina bifida clinics evaluate and manage the urinary tract in patients with spina bifida, neurogenic bladder and bacteriuria. MATERIALS AND METHODS: A survey was mailed to all 169 clinics listed by the Spina Bifida Association of America. Survey items addressed baseline and surveillance evaluation, criteria used to assess urinary tract health and approaches to treatment in patients with spina bifida and neurogenic bladder. RESULTS: Of the 169 clinics personnel at 59 (35%) responded to the survey. Almost half of the respondents had an established protocol or standard of care. At most clinics the use of ultrasound (93%), voiding cystourethrograms (85%) and urodynamic testing (76%) was supported but not renal isotopic studies (14%) or excretory urograms (2%) for baseline evaluation. At all clinics ultrasound was supported for routine surveillance but there was no consensus for other imaging modalities. Assessment of clinic approaches to the evaluation and management of bacteriuria demonstrated variable results, although at most clinics fever, flank pain, dysuria, and changes in urinary pattern were identified as being consistent with true infection. Groups at clinics following their protocol or standard of care showed no significant differences in their approach compared to those at clinics lacking a protocol or standard of care. CONCLUSIONS: No consensus exists for the evaluation and management of bacteriuria in patients with spina bifida and neurogenic bladder at clinics specializing in the care of such patients, even at those with established standards of care. A clear need exists for an established, national set of evidence based guidelines to assist medical decision making in this high risk population and, thus, improve care.     

Predictors and outcome of catheter-related bacteremia in children on chronic hemodialysis

Tunneled central venous catheters are often used in children on chronic hemodialysis. This study was done to evaluate the spectrum of catheter-related bacteremia (CRB) and to determine predictors of recurrent CRB in children on hemodialysis. Chart review was performed in 59 children from a pediatric dialysis unit with chronic, tunneled, cuffed hemodialysis catheters between January 1999 and December 2003. CRB was diagnosed in 48 of 59 (81%) patients. The incidence of CRB was 4.8/1,000 catheter days. Overall catheter survival (290±216 days) was significantly longer than infection-free catheter survival (210±167 days, p<0.05). Organisms isolated were gram-positive in 67%, gram-negative in 14%, and polymicrobial in 19%. Systemic antibiotics cleared CRB in 34% and an additional 23% cleared with the inclusion of antibiotic-heparin locks; 43% required catheter exchange. There was a significant likelihood of early catheter exchange with polymicrobial CRB (p<0.01). Catheter loss occurred from infection in 63%. Risk factors for CRB included young age (<10 years) and presence of human immunodeficiency virus (HIV) infection. Patients with >2 initial positive blood cultures (p<0.0001) had a significantly higher rate of recurrence after 6 weeks of initial treatment. In conclusion, CRB remains a major determinant of catheter loss. However, overall catheter survival is longer than infection-free catheter survival, suggesting that systemic antibiotics with antibiotic-heparin locks should be the initial step in the management of CRB and this approach may salvage some catheters.     

5-氨基乙酰丙酸荧光膀胱镜在膀胱肿瘤诊治中的应用评价(附56例报告)

目的 与普通膀胱镜相比较，评价5-氨基已酰丙酸荧光膀胱镜检查在膀胱肿瘤诊断和治疗中的价值。方法 术前1.5h，1．4％的碳酸氢钠溶液50mL溶解1．5g的5一氨基乙酰丙酸（5-ALA），膀胱灌注。术中对普通光下及蓝光下的可疑部位取活检，并对活检部位电切和电灼，活检组织送病理检查。结果 56例患者共取活检155处，平均2．8次／人。荧光膀胱镜的敏感性98．4％（63／64位点），特异性73．5%（61／83位点），两者有显著统计学差异（P〈0．01）。蓝光下发现普通光下未发现的肿瘤位点14处。未发现5-ALA的局部和全身毒副作用。结论 5-ALA荧光膀胱镜是一种高敏感的用于膀胱肿瘤诊断和治疗的有效方法，能够提高对膀胱原位癌的诊断敏感性及降低术中因未发现和切除不完全所带来的膀胱肿瘤复发危险性。