Nosocomial SARS-CoV-2 infection in urology departments: Results of a prospective multicentric study

OBJECTIVE

To evaluate the coronavirus disease 2019 perioperative infection rate and mortality rate of patients undergoing urological surgeries during the early pandemic period in Spain.

METHODS

This was a non-interventional multicenter prospective study carried out from 9 March to 3 May 2020 in two urology departments in Madrid, Spain. Clinical, microbiological and radiological data of patients who underwent surgery were collected from computerized medical records.

RESULTS

A total of 148 patients were included in the study, and 141 were analyzed for nosocomial infection risk, after excluding previous and concomitant severe acute respiratory syndrome coronavirus type 2 infections. Elective surgeries represented 76.6% of the procedures, whereas emergent surgeries represented 23.4%. Preoperative screening was carried out with polymerase chain reaction test in 34 patients, all were negative. A total of 14 patients also had chest X-ray (not suspicious in all cases). Three patients (2.1%) developed severe acute respiratory syndrome coronavirus type 2 nosocomial infection (symptoms developed between the third day after surgery to the 14th day after hospital discharge). Time from admission to a compatible clinical case was 5.5 days (4-12 days). Two patients underwent surgery with concomitant diagnosis of coronavirus disease. The mortality rate due to severe acute respiratory syndrome coronavirus type 2 infection is 0.7%, and the specific mortality rate in patients undergoing surgery with community-acquired coronavirus disease 2019 infection was 50% (1/2).

CONCLUSIONS

The nosocomial severe acute respiratory syndrome coronavirus type 2 infection rate was low in patients undergoing urological surgical procedures during the peak of the pandemic in Madrid. With appropriate perioperative screening, urological surgical activity can be carried out in safety conditions.

Impact of the COVID-19 pandemic on the surgical activity of Pediatric Urology: analysis of postoperative complications according to the Clavien-Dindo classification

Introducción y objetivo

La coronavirus disease 2019 (COVID-19) ha ocasionado una pandemia de repercusión mundial que obligó a tomar medidas sociopolíticas, como la declaración del estado de alarma en España. Paralelamente se llevó a cabo la reestructuración de las actividades e infraestructuras médico-quirúrgicas pediátricas, con la consecuente suspensión de la actividad quirúrgica no urgente de Urología Pediátrica. Analizamos la repercusión de la pandemia COVID-19 sobre la actividad quirúrgica en una sección de Urología Pediátrica, así como las complicaciones quirúrgicas, según la clasificación de Clavien-Dindo.

Materiales y métodos

Se procedió a la revisión sistemática de los datos epidemiológicos, clínicos y quirúrgicos, incluyendo las complicaciones y reingresos de todos los pacientes intervenidos en la sección de Urología Pediátrica desde la declaración del estado de alarma hasta el levantamiento del mismo. Para su estudio se procedió a la división en cinco bloques temporales acorde a las fases de desescalada.

Resultados

Se realizaron 49 intervenciones quirúrgicas en 45 pacientes (ocho previos a la implantación de las fases de desescalada). La patología con prioridad alta fue la más frecuente en las primeras fases, siendo la estenosis de la unión pieloureteral (EPU) la más prevalente. Se registraron cuatro complicaciones (8,8%), ninguna de ellas de origen respiratorio.

Conclusiones

Las recomendaciones de la EAU para la reanudación de la actividad quirúrgica han permitido una correcta, segura y gradual transición al ritmo quirúrgico habitual en Urología Pediátrica. La clasificación de Clavien-Dindo es útil y válida para su aplicación en esta sección. No se han registrados complicaciones respiratorias que pudiesen ser atribuibles a la situación pandémica.

Guess Who's Coming to Dinner: COVID-19 in a COVID-free Unit

Objective

To assess the impact of the pandemic on surgical activity and the occurrence and features of Covid-19 in a Covid-free urologic unit in a regional hospital in Northern Italy.

Materials and Methods

Our Department is the only urologic service in the Trento Province, near Lombardy, the epicenter of Covid-19 in our Country. We reviewed the surgical and ward activities during the 4 weeks following the national lockdown (March 9 to April 5, 2020). The following outcomes were investigated: surgical load, rate of admissions and bed occupation, and the rate and characteristics of unrecognized Covid-positive patients. Data were compared with that of the same period of 2019 (March 11 to April 7).

Results and Conclusion

About 63%, 70%, 64%, and 71%, decline in surgery, endoscopy, bed occupation, and admission, respectively, occurred during the 4 weeks after the lockdown, as compared to 2019. Urgent procedures also declined by 32%. Three (8%) of 39 admissions regarded unrecognized Covid-19 overlapping or misinterpreted with urgent urologic conditions such as fever-associated urinary stones or hematuria. In spite of a significant reduction of activity, a non-negligible portion of admissions to our Covid-free unit regarded unrecognized Covid-19. In order to preserve its integrity, we propose an enhanced triage prior to the admission to a Covid-free unit including not only routine questions on fever and respiratory symptoms but also nonrespiratory symptoms, history of exposure, and a survey about the social and geographic origin of the patient.

Considerations for Bedside Urologic Procedures in Patients With Severe Acute Respiratory Syndrome Coronavirus-2

Objective

To provide guidance when performing bedside urologic procedures on severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) positive patients and offer considerations to maximize the safety of the patients and providers, conserve supplies, and provide optimal management of urologic issues.

Methods

Urologic trainees and attending physicians at our institution, who are familiar with existing safety recommendations and guidelines regarding the care of infected patients, were queried regarding their experiences to determine an expert consensus on best practices for bedside procedures for SARS-CoV-2 positive patients.

Results

Our team developed the following general recommendations for urologic interventions on SARS-CoV-2 positive patients: maximize use of telehealth (even for inpatient consults), minimize in-room time, use personal protective equipment appropriately, enlist a colleague to assist, and acquire all supplies that may be needed and maintain them outside the room. Detailed recommendations were also developed for difficult urethral catheterization, bedside cystoscopy, incision and drainage of abscesses, and gross hematuria/clot irrigations.

Conclusion

As patients hospitalized with SARS-CoV-2 infection are predominantly men over 50 years old, there are significant urologic challenges common in this population that have emerged with this pandemic. While there is tremendous variation in how different regions have been affected, the demographics of SARS-CoV-2 mean that urologists will continue to have a unique role in helping to manage these patients. Here, we summarize recommendations for bedside urologic interventions specific to SARS-CoV-2 positive patients based on experiences from a large metropolitan hospital system. Regulations and requirements may differ on an institutional basis, so these guidelines are intended to augment specific local protocols.

Infections related to healthcare in patients hospitalized in a Urology service: resistance patterns and adequacy of empirical antibiotic treatment as a prognostic factor

OBJECTIVES

To evaluate the suitability of empirical antibiotic therapy in HAIs and the antibiotic resistance patterns of the responsible microorganisms, as well as the incidence of mortality and risk factors involved.

METHOD

A prospective observational study was carried out on patients of both sexes older than 16years, admitted by any urological process during a period of 4years. The incidence and characteristics of HAIs, as well as the causative organism and its resistance, the initial empirical antibiotic therapy and its modification, if required, and mortality rates are analysed.

RESULTS

Out of 6,546 patients, 6.3% suffered HAIs, 70.5% corresponding to urinary tract infection and 22.1% to infection of the surgical wound. E.coli, Enterococcus spp., Klebsiella spp. y P.aeruginosa were the most frequently implicated (25.1%, 17.5%, 13.5% and 12.3%, respectively). E.coli and Klebsiella spp. were producers of extended-spectrum beta-lactamases (ESBL) in 24.7% and 47.8%, respectively. 4.3% of Klebsiella and 33.3% of Pseudomonas were carbapenems-resistant. The overall resistance to quinolones was approximately 50%. The most commonly used antibiotics for empirical therapy were cephalosporins of 3rd and 4th generation (33.6%) and carbapenems (28.2%). An overall rate of adequacy of empirical antibiotic therapy of 82.9% was obtained. The mortality rate in patients with HAIs was 2.2%, compared with 0.3% in patients without infection. In a multivariate analysis, the variables associated with the highest mortality risk were the isolation of ESBL-producing enterobacteria and the inadequate empirical antibiotic treatment.

CONCLUSIONS

The selection of empirical antibiotic therapy was quite accurate. An increase in HAIs by multiresistant microorganisms, such as ESBL Enterobacteria or multiresistant P.aeruginosa is being observed. The mortality risk increases with inadequate initial empirical antibiotic therapy or when the responsible microorganism is an ESBL enterobacteria.

Analysis of drug-related problems in three departments of a German University hospital

BACKGROUND

During the last decades, pharmaceutical care services have been developed and implemented to optimize drug therapies and ensure medication safety. To investigate the need for pharmaceutical care services, drug-related problems can be measured.

OBJECTIVE

Thus, the aim of this study was to analyse number, type and occurrence of drug-related problems in different clinical departments.

SETTING

A pharmaceutical care service was established on general wards in Urology, Neurology and Gastroenterology at the University Hospital RWTH Aachen, Germany.

METHOD

For each of a total of 306 patients, a pharmacist conducted an extended medication history, performed medication reconciliation, conducted medication safety checks and if drug-related problems were discovered, gave valid recommendations to the attending healthcare team. Drug-related problems were classified using the APS-Doc system. For statistical analyses, SAS(®) 9.1.3, SAS Institute, Cary NC, USA was applied. The project was approved by the local ethics committee.

MAIN OUTCOME MEASURE

Type, occurrence and frequency of DRP in different medical departments.

RESULTS

On average, 2.3 drug-related problems per patient were documented for all three departments. Drug-related problems were found in each category of the APS-Doc system. The most pronounced drug-related problems found were drug-drug interactions (34.6 %). 37 % of the identified drug-related problems occurred before hospital admission, 27 % during transitional care, and 36 % on the ward. Subgroup analysis revealed specific drug-related problem patterns for each clinical department. The number of drug-related problems was found to be associated with the number of drugs and age.

CONCLUSION

Drug-related problems frequently occur in all investigated clinical departments. A holistic pharmaceutical care service could be an option to address this issue. In case of limited resources, individual drug-related problem patterns can be used as a basis for a tailored pharmaceutical care service. As number of drugs and age have been shown to be significant risk factors, it is crucial that the healthcare team including the pharmacist pays special attention to elderly patients and those with polymedication.

[Value of a multidisciplinary team for patients with a urological malignancy]

OBJECTIVE

To evaluate degree of agreement between treatment proposals from urologist and a multidisciplinary team (MDT) for patients with an urological malignancy.

DESIGN

Retrospective cohort study.

METHOD

All letters from patients with an urological malignancy of prostate, bladder, kidney or testicle who were discussed at the MDT in Ziekenhuisgroep Twente from January 2011 until January 2013 were collected. This study studied the level and frequency of agreement between treatment proposals from urologist and MDT. Level of agreement was expressed by using Cohen's Kappa. Also treatments proposed by the MDT were compared to the final treatment choice of the patient.

RESULTS

A total of 788 letters were analysed. For 9%, the MDT disagreed with the treatment recommended by the urologist. This disagreement was most often observed in patients with malignancy of kidney (κ: 0.507; p < 0.001). Agreement for patients with malignancy of bladder, testicle and prostate were substantial (respectively κ: 0.719; p < 0.001, κ: 0.803; p < 0.001, κ: 0.634; p < 0.001). Treatment proposals "brachytherapy" and "external radiotherapy" for prostate malignancy showed only moderate agreement (κ: 0.564 and κ: 0.568; p < 0.001 respectively). 93% of all patients elected to take (one of) the treatment proposals made by the MDT.

CONCLUSION

A multidisciplinary approach seems particularly useful for patients with malignancy of kidney. The additative value of MDT was less visible for patients with malignancy of prostate, which could be due to less consistent guidelines. Final treatment decision might be influenced by explanation and guidance of the treating urologist.

Where, when and what? A time study of surgeons' work in urology

Introduction

Staff time is a relevant resource in the delivery of health care interventions. Its measurement is a prerequisite for unit costing but usually complex. The aim of this study was to analyse the distribution of surgeons' work time among types and places of activities. A second aim was to use these data to calculate costs per unit of output.

Methods

A self-reporting work sampling study was carried out at a department of Urology. All of twelve surgeons involved in clinical care participated in a two-week analysis of their work time.

Results

A total of 2,485 data-points were collected, representing about 1,242 hours of work time. Surgeons spent the greater part of their work time in direct patient care, but substantial shares were required for documentation and organisation. Assistants were mainly required at the wards and consultants at the operating theatre and the outpatient unit. Staff costs of surgeons were 32 € and 29 € per patient day at the wards, respectively, 1.30 € per minute at the operating theatre and 32 € per visit at the outpatient unit.

Conclusion

Results provided a basis for costing of health care interventions at the study site. However, future research should focus on the establishment of standardised terminology in order to increase transferability of results.

RECRUITMENT AND RETENTION AUDIT: TRAINING DOES MAKE A DIFFERENCE

The aim of this study was to find out if offering specialist renal training courses enhanced staff recruitment and retention. An audit of staff with specialist renal skills acquired through training was completed. Analysis of the records available in this Trust since 2003, reporting on staff retention and increased nurse satisfaction following renal course attendance, were used in this study. The research used semi-structured interviews gaining qualitative data. The participants were all staff who had undertaken renal courses provided by this Trust. The results showed that when the interviews were thematically analysed, key themes emerged, which displayed enhanced insight, confidence and increased skill base. The quantitative data concerning staff retention, staff movement and staff sickness, helped to identify that not only do staff actually stay longer but also appear to develop advanced skills and knowledge as well as more positive attitudes. In summary, it was shown that by offering specialist training there is an increased number of skilled renal nurses presenting for employment attracted by the opportunity of undertaking specialist renal courses. They in return, benefit from the advanced renal programme, which enables them to deliver better quality of care with increased job satisfaction.

[Frequency of hospital infections at Department of Urology]

INTRODUCTION

At departments of urology, as well as other hospital departments, hospital infections represent an important problem. The objective of this work was to determine the frequency and the most common localizations of hospital infections at the Department of urology.

MATERIAL AND METHODS

All the patients hospitalized for longer than 48 hours at the Department of Urology, General hospital, Sabac were included in a prospective study of incidence in the period of 12 months. The everyday epidemiological surveillance was carried out, as well as the inspection of the existing medical files. The diagnosis of hospital infections was made on the basis of known definitions.

RESULTS

Ninety-four out of 554 hospitalized patients included in the research had 122 hospital infections. One hospital infection was recorded in 64 of those included in the research, whereas two and three infections were recorded in 26 and 2 patients, respectively. The incidence rate of the patients with hospital infections was 17.3%, and the rate of the incidence of the infections 22.4%. The incidence rate by 1,000 patients-hospitalization days was 12.4. Out of the total number of infections, 69.7% were urinary tract infections, 27% surgical site infections and 3.3% sepses. The incidence rate of the patients with urinary infections was 14.7% and the incidence rate of urinary infections 15.6%. The rate of urinary infections in the patients with urinary catheter (19.6%) was significantly higher than in those patients without urinary catheter (p < 0.001). The rate of incidence of surgical site infections was 6.1% and the incidence rate of blood infections was 0.7%.

CONCLUSION

The most common hospital infections in our work were urinary infections and surgical site infections. The rates recorded in our study are similar to those in the hospitals that have only started the surveillance of hospital infections.

[Percutaneous approach in postureteroenterostomy ureteral stenosis. Experience of the Urological Department of Sf. Ioan Emergency Hospital, Bucharest]

INTRODUCTION

Uretero-enteric stenosis may raise some specific problems due to difficulties concerning the retrograde access. The aim of our study was to evaluate the effectiveness of antegrade flexible ureteroscopic approach for this specific pathology.

MATERIAL AND METHODS

Between January 2002 and June 2008, a number of 7 patients underwent antegrade flexible ureteroscopy for uretero-enteric stenosis: 3 patients with stenosis of the uretero-neobladder anastomosis (Group I), 2 patients with stenosis of the uretero-sigmoidian implantation (Group II) and 2 patients with stenosis of the ureteral implantation in an ileal conduit (Group III). In Group I, we performed antegrade Nd:YAG laser star incision in 2 cases and balloon dilation in 1 case. In Group II, the antegrade Nd:YAG laser star incision was applied in 1 case and balloon dilation was performed in the other one. In Group III, we performed antegrade insertion of the guidewire followed by retrograde cold-knife incision in one case, and bipolar ureteral approach (cut-to-the-light technique) in 1 case.

RESULTS

The mean operative time was 58 min. (range 25 to 120 min). We didn't describe major intraoperative complications. Ultrasonography, IVP and isotopic renogram (in selected cases) have been the follow-up evaluation methods. Postoperatively, 2 cases from Group I and all cases from Groups II and III had a good evolution, with significant reduction of the hydronephrosis degree at 6, 12 and 18 months. One patient from Group I, in which balloon dilation of the stenosis was performed, developed recurrence at 6 months.

CONCLUSIONS

According to our experience, antegrade flexible ureteroscopic approach may represent an efficient and safe technique in uretero-enteric stenosis treatment. Being a minimally invasive approach, this procedure has a reduced rate of complications and good anatomical and functional results.

[Percutaneous approach in the treatment of matrix lithiasis. Experience of the urological department of "Saint John" Emergency Clinical Hospital]

INTRODUCTION

Matrix lithiasis has been relatively rarely described. Our goal was to establish the value of percutaneous approach in this pathology.

MATERIAL AND METHODS

Between July 1995 and January 2008 in Department of Urology of "Saint John" Emergency Clinical Hospital in Bucharest, 11 patients with pyelocaliceal matrix lithiasis (seven females and four males) were treated by percutaneous approach. The mean age was 55 years old (between 41 and 83 years old). The rigid nephroscope was exclusively used in seven cases. The approach of caliceal fragments imposed the flexible nephroscopic approach in the other four cases. The mean follow-up period was 48 months (range two to 86).

RESULTS

10/11 patients (90,9%) were stone-free at the end of procedures. In the other case, the spontaneous passage of the remaining matrix lithiasis fragments was encountered. No major complications were recorded. Recurrences occurred in two cases (18.2%), despite the long-term antibiotic therapy.

CONCLUSIONS

Percutaneous approach may represent an effective and safe therapy of matrix lithiasis. The management of this pathology must associate the preoperative treatment and postoperative prophylaxis of the urinary tract infections.

Prospective assessment of the efficacy of the EAU guidelines for the prevention of nosocomial acquired infections after genitourinary surgery in a district hospital

OBJECTIVES

To evaluate incidence and risk factors for nosocomial acquired infections in an urology ward after the application of the European Association of Urology (EAU) guidelines for surgical prophylaxis after genitourinary surgery in a district hospital.

METHODS

A three-month survey was performed according with the definitions and methods of the National Nosocomial Infections Surveillance System. The study was conducted at the Urology Unit of a district hospital of about 800 care beds. The unit has 24 beds with approximately 1000 patients admitted per year and 750 surgical procedures performed each year. During the study period antimicrobial prophylaxis was administered according to 2006 EAU Guidelines. The following events by CDC criteria were considered: site specific infection (SSI), symptomatic urinary tract infection (SUTI), other infection of urinary tract (OUTI) and blood stream infection (BSI).

RESULTS

SUTI incidence density was 31/1000 patients-days and 34/1000 urinary catheter days. SSI and BSI incidence density were respectively 44/1000 and 25/1000 patients day. A total of 177 patients (146 M, 32 F) underwent surgical procedures (17 renal surgeries, 12 retropubic radical prostatectomies, 11 prostatectomies for benign prostatic hyperplasia, 9 cystectomies (with ileal neobladder or external urinary diversion respectively in 3 and 6), 19 male genital surgeries, 21 ureterorenoscopies (with/without lithotripsy), 10 ureteral catheterizations or stenting, 6 nephrostomies, 17 TURP, 50 TURB and 5 other procedures). Perioperative antibiotic prophylaxis was administered as a single dose of cefazolin 2 gr i.v. (or as an association of gentamicin and ampicillin) in 92 patients (51%). Nine patients with positive urine culture were treated with antibiotics prior to treatment (5%) and 40 patients were treated postoperatively (22%). After surgery UTI was diagnosed in 6 patients, SSI in 3 and BSI in 11. Risk factors for infection were indwelling catheter in 22, previous history of UTI in 15, long pre operative hospital stay in 2, diabetes in 24 patients.

CONCLUSIONS

Antimicrobial prophylaxis according to EAU guidelines together with an active surveillance seems to be adequate to prevent symptomatic/febrile genito-urinary infections as well as serious wound infections in the majority of patients. A further effort should be made in order to identify sub-populations of patients for which the actual prophylactic regimen proved to be less efficacious.

[Kidney sicknesses associated with gene of the drepanocytose in the Department of Nephrology and Haemodialysis of the CHU of Point G]

PURPOSE

To assess renal features joint to gene of the drepanocytose.

PATIENTS AND METHODS

It concerned a descriptive transversal study from June 1995 to January 2004. Were included drepanocytose patients admitted hospital or seeing for consulting having one of the features: haematuria, proteinuria, leucocyturia, positive aeroculture, urea increasing and/ or of blood creatinine. The analysis and data capture were conducted on SPSS 11.0. The statistic text was the Khi square with a threshold of signification p<0.05.

RESULTS

The folders of 30 patients (18 m and 12 w) were collected. The average age was of 3104 years (5 and 64 years). The most hospitalization reasons encountered were the oedema syndrome (26.7%) and the overall haematuria (20%). The majority of the patients were heterozygote 93.33%. The kidney sicknesses encountered were: acute renal deficiency 40%, the macroscopic haematuria 20%, the nephritic syndrome 20%, chronic renal deficiency 13.4%, urinary infection 3.3% and microscopic haematuria 33%.

CONCLUSION

The sicklaneny's gene in Mali is associated to a renal morbidity. The increased frequency of drepanocytaria feature bearers must be confirmed by other studies in order to establish a strategic of treatment of this pathology.

[Minimally invasive surgery in pediatric patients within a general urology department]

OBJECTIVES

The advances of minimally invasive surgery in urology over the last years have enabled a progressive and constant implementation of endourology and laparoscopy in pediatric patients. We perform a review of our experience, as a general hospital, with minimally invasive surgery performed in pediatric patients over the last ten years.

METHODS

We retrospectively analyzed the endourological and laparoscopic operations performed between 1997 and 2007 in children up to the age of 16 years, collecting data about patient's age and gender, type of disease, techniques, anesthesia, and perioperative events.

RESULTS

seventy-two surgical operations were performed in patients with an age range between 28 days and 16 years, with a mean age of 6.8 years. 56% of the patients were boys and 44% girls. Indications for surgery was vesicoureteral reflux (VUR) in 28 cases (38.8%); lithiasis 17 cases (23.6%) which were distributed in 4 cystolithotripsies, 9 ureterorenoscopy with lithotripsy, one pure percutaneous nephrolithotomy and three mixed; ureterocele 9 cases (12.5%); urethral obstruction 7 cases (9.7%); 3 diagnostic laparoscopies for cryptorchidism (4. 1%), 2 laparoscopic procedures for cystic pathology (2.7%), another 2 laparoscopic renal biopsies (2.7%), and one laparoscopic repair of a ureteropyelic junction syndrome; 1 case of emergency percutaneous nephrostomy in the supine position after open pyeloplasty with subsequent reoperation with percutaneous resection of a granuloma; and 1 case of botulin toxin injection into the detrusor muscle.

CONCLUSIONS

The consolidation of pediatric endourology in our department, and more recently laparoscopy, has contributed to improve the quality of care in pediatric patients; it has been achieved thanks to our previous know-how in general endourological techniques and the existence of adequate technical and human resources.

[Surveillance for bacteremia related to vascular access in hemodialysis]

Infections occur frequently in chronic dialysis patients. An incidence study of 13 months' duration (December 2003-January 2004) on nosocomial bacterial infections was performed in a dialysis center (Rivoli Hospital) in the Piedmont region of northern Italy. Data were collected according to a modified CDC methodology (CDC Dialysis Surveillance Network). The total incidence of infections was 4.55/100 patients/month and was lower than that reported for other reference series (CDC 6.16/100 patients/month). The low incidence was associated with a greater use of low-risk vascular access (fistula) than in other countries such as the U.S. The infection rates were: vascular access 1.73% (1.55% local infections, 0.18% access-related bacteremia); 0.82% wound infections; 0.91% pneumonia; 1% urinary tract infections; 0.09% other bacteremias. The hospital utilization rate was 6.9/100 patients/month. Blood cultures were performed in only 28.4% of patients who had received a course of antibiotics. Antibiotics were widely used but the use of vancomycin was less than reported elsewhere (e.g., CDC surveillance). The prevalence of methicillin-resistant Staphylococcus aureus (28 strains isolated) was high (>50%), whereas no vancomycin-resistant enterococci were isolated. Preventing nosocomial bacterial infections in chronic dialysis patients is a top priority; therefore, a surveillance system along the lines of the CDC model should be adopted by all dialysis centers. The risk of nosocomial infection is strongly associated with the type of vascular access.

An outbreak of Pseudomonas aeruginosa because of inadequate disinfection procedures in a urology unit: a pulsed-field gel electrophoresis-based epidemiologic study

BACKGROUND

Pseudomonas aeruginosa is an opportunistic pathogen causing nosocomial infections in many hospitals. We aimed to investigate the source of urinary tract infections by determining clonal relationship of Pseudomonas aeruginosa strains with pulsed-field gel electrophoresis (PFGE).

METHODS

During a 2-month period, all postoperative infections because of P aeruginosa were investigated in the Urology Department. Patient data were collected from medical records. Surveillance samples were obtained from various places in urological operating rooms. PFGE typing was performed for all P aeruginosa isolates.

RESULTS

A total of 14 P aeruginosa strains (12 from patients and 2 from environmental samples) were isolated. PFGE typing of these 14 strains yielded 2 possibly related clones, which differed from each other by 4 major bands. Ten of the patient isolates were clonally identical with the strains of 2 forceps.

CONCLUSION

Typing results confirmed that inadequately disinfected surgical devices can be the source of outbreak. After institution of infection control measures and education, no further clusters of P aeruginosa infection were detected in the Urology Department.

Safety and efficacy of tubeless percutaneous nephrolithotomy

OBJECTIVE

To determine the safety and efficacy of tubeless percutaneous nephrolithotomy (PCNL).

METHODS

A quasi-experimental study conducted on 50 patients, at a specialized urology centre.

RESULTS

The primary success rate of the procedure in terms of stone clearance was 70%. Mean length of hospital stay was 2.44 days. There were no significant complications during or after the surgery.

CONCLUSION

Tubeless PCNL is a safe and effective modification of the conventional procedure. Absence of the nephrostomy tube may help in keeping the patient comfortable after the surgery and reduction in the length of hospital stay.

Clinical course and outcome of a nosocomial outbreak of hepatitis C in a urology ward

This paper describes a prospective study of the clinical course and outcome of a nosocomial outbreak of hepatitis C virus (HCV) infection in six male urology patients at a hospital in Stara Zagora, Bulgaria. These patients had been previously hospitalised in the urology ward, during which all had received intravenous therapy. Approximately three weeks later, all six were admitted to the infectious diseases unit with acute hepatitis, shown to be caused by HCV genotype 1b. The diagnosis was confirmed by polymerase chain reaction during the first week of their hospital stay. Infected patients were followed up for 30 months following diagnosis and 54 potential contacts for 6 months post-exposure. Four patients recovered completely; one developed chronic HCV infection and one died. The latter already had cirrhosis due to co-infection with hepatitis B virus. The investigation established the index case as a patient with chronic hepatitis C, who had been an in-patient on the same ward at the same time. The most likely route of transmission was intravenous heparin flushes administered with a common syringe. Contrary to the common assumption that acute HCV infection often leads to chronic disease, only one chronic case was observed during the 30-month period of investigation.

[A concept of nephrologic care at the end of life]

BACKGROUND

A care pathway for the end-of-life had been implemented onto the two renal wards. An audit was performed to highlight potential issues and areas for development.

METHOD

The audit consisted of a base review of documentation from the medical notes of 10 patients who had died an 'expected' death prior to commencing the renal Integrated Care Pathway (ICP) for the end of life and then 10 patients who had died whilst using the ICP documentation. A questionnaire was also given out to nursing staff who had used the ICP documentation. The results were collated and analysed.

RESULTS

In the base review 100% of the documentation looked at did not provide a regular documented assessment of symptoms that are common in the terminal phase of life. The ICP provided a documented assessment of all of these main symptoms. The base review indicated a good response by doctors to meet the potential needs of the patient, but the ICP improved on this. This was through the use of a pre-emptive prescription. 80% of all patients were pain free, not agitated, had no nausea or vomiting or respiratory secretions. The 2 patients that had pain received further analgesia and were then pain free at the next assessment. One of the most positive aspects of the audit was that 90% of relatives were aware that the patient was dying and 100% had the plan of care discussed with them.

CONCLUSION

Implementing the ICP has generated the opportunity to deliver a hospice model of care to a busy renal unit. It has allowed best practice, and a measurable standard of care, in the final stages of patients' lives. Staff find the documentation easy to use and also see it as enhancing patient care.

Prevalence of hospital-acquired urinary tract infections in urology departments

OBJECTIVES

The aim of our study was to register the prevalence of nosocomial urinary tract infections (NAUTIs) in urology sections in Europe and Asia.

METHODS

A total of 6033 hospitalised patients in 194 different urology departments were screened in two Internet-based studies. Detailed reports on 727 patients with NAUTI were provided.

RESULTS

The prevalence of NAUTI was 10% in the Pan European Prevalence (PEP) study, 14% in the Pan EuroAsian Prevalence (PEAP) study, and 11% in the combined analysis. The largest group was asymptomatic bacteriuria (29%) followed by cystitis (26%), pyelonephritis (21%), and urosepsis (12%). There were significant differences between regions and types of hospitals.

CONCLUSIONS

NAUTI is a large problem for urologic patients and causes huge extra costs for hospitals.

Hospital acquired urinary tract infections in urology departments: pathogens, susceptibility and use of antibiotics

Data from two internet-based studies on NAUTI in hospitalized urological patients are presented together: the Pan European Prevalence (PEP) study, which was a 1-day prevalence study in November 2003; and the Pan Euro-Asian Prevalence (PEAP) study, which was carried out in November 2004. Overall, 93 and 101 hospitals from the two studies, respectively, completed the hospital questionnaires and provided patient information for the present study. NAUTI was diagnosed according to the Centres for Disease Control and Prevention (CDC) criteria in 727 of the 6033 patients hospitalized on study days in urological departments. The most commonly reported pathogen was Escherichia coli (31%), followed by species of Pseudomonas (13%), Enterococcus (10%), Klebsiella (10%), Enterobacter (6%) and Proteus (6%). Candida spp. and Pseudomonas spp. occurred significantly more frequently as causative agents in urosepsis than in other types of infections. The resistance of E. coli, Klebsiella and Proteus spp. was below 45% for the most commonly used antibiotics. Enterococcus spp. and Pseudomonas spp. however, had resistance rates above 70% to most antibiotics. A total of 56% of the hospitalized urological patients were receiving antimicrobial therapy on the study day; 46% for prophylaxis, 26% for microbiologically proven UTI, 21% for only clinically suspected UTI and 7% for other infections. The most commonly used antibiotics were fluoroquinolones (35%), cephalosporins (27%), penicillins (16%), aminoglycosides (15%), and co-trimoxazole (9%). Differences between countries and regions were highly significant. There is an urgent need for continuous surveillance of NAUTI and improvement of antibiotic policy to counteract the widespread increase of antimicrobial resistance.

[Extracorporeal shock wave lithotripsy (ESWL) can be done for lithiasic patients with cardiac arrhythmias with a lithotriptor without ECG triggering system--the experience of Iaşi Urological Department]

The recommendations for spark gap lithotripters include that the shock waves must be delivered according to the ECG, avoiding the discharge during the refractory part of the heart activity. The lithotripters we have in our department does not have from the factory an ECG correlated triggering system. Observing that ESWL for patients without heart problems did not induced arrhythmias, we decide to perform this procedure under strict cardiologic supervision to the patients having arrhythmias (chronic fibrillation, chronic atrial fibrillation, supraventricular arrhythmias, supraventricular premature beats, ventricular premature beats, ventricular tachycardia). All the ESWIL sessions did not have any major incidents and all the patients return home safe, without any changes of the cardiac medication. Even we did not notice any aggravation of the cardiac arrhythmias during ESWL we consider that the careful monitoring of the patients by the cardiologist is necessary during the procedure, most of all when the spark gap lithotripter has not an ECG triggering system.

[Bacteriological characteristics of intrahospital infections in urological patients]

The etiological structure of hospital infection in 40 urological patients was analysed. Antibiotic resistance of the microflora was studied. Optimal antibacterial therapy is recommended.

[Study on clostridium difficile-associated diarrhea suspected as nosocomial infection in urology ward]

Between June 2000 and January 2001, 11 patients were diagnosed with Clostridium diffcile (C. difficile)-associated diarrhea in the ward of urology at the Kakegawa Municipal Hospital. Of these 11 patients, 10 had exposure to antimicrobial agents, before the onset of diarrhea. All patients' stools were positive for C. difficile toxin A. After discotinuing antimicrobial agents with or without administering Vancomycin, they recovered from C. difficile-associated diarrhea. Between January 2001 and September 2002, 17 patients who were diagnosed with C. difficile-associated diarrhea in our hospital were classified into two types by PCR ribotyping. Therefore, we suspected a nosocomial outbreak of diarrhea caused by C. difficile.

Testicular torsion: a perspective from the Middle East

OBJECTIVE

To report our experience in the management of testicular torsion with emphasis on seasonal variation, salvage rate and the status of the torted testis 3-6 months after orchidopexy.

SUBJECTS AND METHODS

Seventy-five patients with a presumptive diagnosis of testicular torsion, who presented to our hospital between January 1999 and December 2002, were included in the study. Following scrotal exploration, 63 patients were found to have testicular torsion. Of these, 11 with nonviable testes had orchiectomy while 52 with viable testes had orchidopexy. Both groups of patients had simultaneous contralateral orchidopexy. Patients who had orchidopexy were followed up 3-monthly by testicular ultrasound to assess the volume of the affected testis.

RESULTS

Sixty-three patients were confirmed to have testicular torsion. The average number of new cases in the winter was 6.7 compared to 4 in the summer. Fifty-two patients underwent orchidopexy to give an operative salvage rate of 82.5%. Of 51 patients in whom the duration of torsion was less than 24 h, 1 (2.0%) had a nonviable testis, whereas of 12 patients in whom the duration of torsion was more than 24 h, 10 (83.3%) had a nonviable testis. After a minimum follow-up of 3 months for patients who had orchidopexy, 7 (13.5%) developed testicular atrophy. The incidence rate was estimated to be 7.9 cases per 100,000 population.

CONCLUSION

The highest incidence was during the cold season. The outcome of surgical management of testicular torsion was dependent on the duration of torsion.

[The treatment of urolithiasis in the specialized urologic department]

The experience of urolithiasis treatment with the use of modern diagnostic methods (the computer tomography with concrement density detection, the DV-Med program which permits to obtain the calculus volumetric image and to study its physical characteristics), and therapy (distant lithotripsy with the use of different types of lithotriptors as well as retrograde contact lithotripsy with "Lithoclast") permits to minimize the percent of open surgical interventions. For the last 3 years 780 patients with different clinical disease forms were treated with favorable clinical outcome and only in 0.5% cases the open surgical intervention was conducted. These patients underwent the pyelolithotomy for the secondary nephrolithiasis conditioned by the pelvis-and-ureteral segment stricture when the endoscopic method failed to eliminate this problem.

The (fixed) urinary sediment, a simple and useful diagnostic tool in patients with haematuria

Examination of the urinary sediment is a simple and indispensable tool in the diagnostic approach to patients with asymptomatic haematuria. Various glomerular and nonglomerular diseases can cause haematuria. A well-trained expert can distinguish between these two forms of haematuria by examining the urinary sediment under a simple light microscope. In glomerular haematuria, dysmorphic erythrocytes and erythrocyte casts are found, whereas in nonglomerular haematuria the erythrocytes are monomorphic and erythrocyte casts are absent. However, few people have sufficient expertise in the examination of the urinary sediment, and consequently this investigation is performed far too seldom. A few years ago, a simple method of fixation of the urinary sediment became available. Fixed specimens can be stored at room temperature for at least two weeks, which enables the sending of a fixed specimen to an expert examiner by regular mail. In this way, the urinary sediment can more frequently be used as the initial investigation in the diagnostic route of patients with asymptomatic haematuria.

Implementing psychiatric interventions on a medical ward: effects on patients' quality of life and length of hospital stay

OBJECTIVE

The authors investigated the effects of implementing psychiatric interventions on a general medical ward by means of a stepped detection and treatment strategy conducted by a consultation-liaison (CL) nurse in terms of reducing length of hospital stay (LOS) and improving quality of life (QOL) at discharge.

MATERIALS AND METHODS

One hundred ninety-three patients participated in a controlled trial, in which patients were screened with COMPRI and INTERMED. A nurse under supervision of a CL psychiatrist conducted interventions, consisting of simple psychiatric interventions by herself, referral to auxiliary services, or initiation of postdischarge care. Intervention patients were compared with historic controls on LOS and QOL (SF36) at discharge.

RESULTS

In multivariate analysis of variance, a significant effect of the intervention on QOL (p = 0.037) was found, which diminished after controlling for confounders (p = 0.28). No significant effect on LOS was found for the whole sample (p = 0.72), but in patients age 65 years or older, a reduction in LOS (p = 0.05) was found. This effect remained after controlling for confounders (p = 0.06).

CONCLUSIONS

These data suggest that screening for risk of increased health care might improve outcomes in general medical inpatients. Because of the design of the study, however, these findings should be considered preliminary and confirmed in a larger, multicenter, randomized controlled trial.

[Clinical statistics of the operations during a 10-year period at the Department of Urology, Kouga Public Hospital: 1993-2002]

A clinical statistical survey of the operations was performed at our urology department during a 10-year period from 1993 to 2002. The total number of operations was 2,909 including 806 sessions of extracorporeal shock-wave lithotripsy (ESWL) that started in 1999. Since a combination unit of ESWL, fluoroscopic apparatus and digital video-urodynamics system was built next to the outpatient department in 1999, the number of operations and examinations has dramatically increased. Operations for bladders made up the greatest portion of all the surgeries and especially transurethral resection of bladder tumor and hydrodistention have been increasing.

[Primary symptoms of 301 patients with prostate cancer: Nagoya Urology Hospital experience]

PURPOSE

Primary symptoms were reviewed retrospectively in patients with prostate cancer diagnosed in our hospital with the aim of promoting early detection.

MATERIALS AND METHODS

The subjects included 301 cases with prostate cancer diagnosed histologically in Nagoya Urology Hospital from August, 1988 to December, 2001. The mean age was 72.7 years, and the median PSA was 20.0 ng/ml. Primary symptoms were classified according to the General Rule for Clinical and Pathological Studies on Prostate Cancer (The 3rd Edition).

RESULTS

Out of 301 cases, 274 (91%) visited our hospital with clinical symptoms. Of them, 272 had primary urological symptoms. In these 272 cases, 250 (92%) and 19 (7%) had lower urinary tract symptoms (LUTS) and macroscopic or microscopic hematuria, respectively. The majority of patients (82%) referred from other urologists had already undergone PSA measurement, compared to 50% in those referred from physicians other than urologists (p < 0.0005).

CONCLUSION

The present data revealed that LUTS were important primary symptoms for the detection of prostate cancer, particularly in an area like Nagoya where the mass screening for prostate cancer is still unavailable. In terms of the early detection of prostate cancer, PSA has to be measured in patients with LUTS even when they visit physicians who are not urologists.

Antimicrobial resistance in Gram-negative bacteria from Intensive Care Units and Urology Services. A nationwide study in The Netherlands 1995-2000

A nationwide 6-year surveillance of resistance in Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis and Pseudomonas aeruginosa from clinical specimens of patients from ten Intensive Care Units and ten Urology Services was started in 1995. MICs of amoxycillin, amoxycillin/clavulanate, trimethoprim, cotrimoxazole, norfloxacin, ciprofloxacin, cefaclor, ceftazidime, imipenem and gentamicin were determined by broth microdilution. Intensive Care Units had higher resistance levels of amoxycillin/clavulanate, cefaclor and ceftazidime (P<0.005) and lower resistance levels of nitrofurantoin, trimethoprim, cotrimoxazole and quinolones (P<0.01) than Urology Services. Changes in MIC distributions in time and development of resistant clusters were observed for nitrofurantoin (E. coli), amoxycillin (E. coli, P. mirabilis), amoxycillin/clavulanate (E. coli) and for quinolones (E. coli). The overall resistance level of ceftazidime and gentamicin was <5%, but this fluctuated with the appearance and disappearance of resistant clones in some Intensive Care Units. Quinolone resistance among P. aeruginosa from Intensive Care Units fluctuated between 7 and 14%.

[Use in daily urological practice of an ultrasound device for measuring bladder volume]

INTRODUCTION

Bladder volume estimation is an everyday necessity in urology, especially for evaluation of the postvoid residual volume (PVR). The Bladder-Scan is a portable, noninvasive ultrasound device for bladder volume estimation. This study was designed to assess the value of the Bladder-Scan to measure PVR in routine hospital urological practice.

MATERIAL AND METHODS

A prospective study was conducted from 1/12/1999 to 30/4/2000 with systematic use of the Bladder-Scan to measure PVR. Four operators performed three consecutive measurements of PVR and noted the following data: age, gender, history, type of disease and place of examination. The main endpoint was the need to use a complementary investigation to confirm or invalidate the result obtained.

RESULTS

PVR was determined in 250 consecutive patients (167 males, 83 females): 191 patients admitted to the urology department, 36 patients seen in the emergency room and 23 patients seen in other departments of the hospital. PVR was estimated to be between 0 and 400 cc (median: 72 cc) for 181 patients (72%), between 400 cc and 750 cc (median: 521 cc) in 50 patients (20%) and between 750 cc and 1000 cc (median: 942 cc) for 19 patients (8%). A control of the measurement was required for 27% of patients (68/250) using catheterism (n = 53) or sonography (n = 15). In this sub-group, the value of the ICC (intra-class correlation coefficient) for the measurement of the bladder volume using the Bladder-Scan and measurement of the volume controlled by sonography or catheterism was of 0.9888 (significance < 0.0001/nil hypothesis ICC = 0).

CONCLUSION

The Bladder-Scan provides a "third hand" in the urologist's daily practice, by supplying a reliable and rapid assessment of bladder volume for volumes < 750 cc. It is a good tool for the evaluation of postvoid residual volume.

[The urology department]

The Department of Urology of Erasme Hspital, University of Brussels, has participated to the development and implementation of new technologies that have significantly transformed the specialty in the last 25 years. The minimally invasive treatment of benign prostatic hypertrophia was developed by the use of Trans-Urethral Needle Ablation (TUNA) and new pharmacological treatments. Treatment of urinary stones by extracorporeal shockwaves lithotripsy and Endourology has allowed to avoid operating hundred of patients each year. In the field of prostate cancer, an original laparoscopic prostatectomy technique by the extraperitoneal approach was developed in our unit. The prevention of prostate cancer and the influence of various nutritional factors and its early diagnosis by the use of different markers have been the subject of numerous publications and have contributed to improve our knowledge in this field. Different prognostic factors of bladder cancer have been evaluated and in particular their place with the use of intravesical BCG. A better understanding of the different mechanisms involved in erectile dysfunction has been the subject of numerous studies during the last 20 years and the department is internationally recognised as a reference centre in this field.

[Bacterial strains isolated in high nosocomial risk departments]

We collected 312 samples from hospitalized patients in two hospitals in Timişoara between September-December 2003. We isolated 83 strains with nosocomial potential. Identification of the germs was performed using the automatic API system, and the susceptibility tests were performed using disc-diffusion and the agar dilution test. By analyzing the extended antibiograms we categorized the germs considering their phenotypes of resistance and we remarked a high percentage of E. coli, Klebsiella pneumoniae pneumoniae and S. aureus with multiple resistance to antibiotics.

[Statistics on operations at the Department of Urology, Nippon Telegraph and Telephone West Osaka Hospital during a ten-year period from 1992 to 2001]

A 10-year clinical statistic survey was made on the operations performed at the department of urology, NTT West Osaka Hospital between 1992 and 2001. The total number of operations was 2,540, comprising 1,899 males and 641 females, and a total of 1,559 ESWL was performed. The number of operations per year was chronologically constant. Major operations were transurethral resection of prostate (299 cases). The number of operations for malignant tumors, for examples radical nephrectomy and enucleation for renal cancer, nephroureterectomy for upper urinary tract cancer and transurethral resection of bladder tumor, has increased since 1997 year after year. The number of ESWL has decreased since 1994. Renal transplantation was introduced in 1995, and laparoscopic adrenalectomy also in 1997.

Analysis of the drugs, applied for the treatment of the patients, hospitalized in a urological department, by pharmacological groups

The analysis of the drugs, applied for the treatment of the hospitalized patients in a urological department shows that the application of the drugs in a urological department gives the opportunity to stop the process of the development of the disease and to avoid the hospitalization of the patients. The research shows the different pharmacological groups of drugs that are applied and also the expenses that are made for the treatment of the patients.

Influence of a prophylactic single dose of ciprofloxacin on the level of resistance of Escherichia coli to fluoroquinolones in urology

During the years 1991-1996 an increase in fluoroquinolone-resistant Escherichia coli was observed at the Urological Department of the Municipal Hospital in Straubing, Germany. A prospective study was undertaken to investigate the influence of single-dose prophylaxis (SDP) using 500 mg ciprofloxacin orally on the level of resistance to ciprofloxacin of faecal E. coli. One hundred and five patients were recruited to the study: E. coli resistance to ciprofloxacin before prophylaxis was 3% (3/91) in contrast to 12% (5/42) after prophylaxis (P = 0.052). In 31 isolates no major change in the low MIC values before and after SDP was observed. PFGE showed clonal diversity in about half of the cases. Three isolates showed low-level resistance and three isolates high-level resistance to ciprofloxacin both before and after SDP. PFGE showed clonal identity in all cases. All patients had previously been treated with fluoroquinolones (FQ). In two isolates emergence of high-level resistance to ciprofloxacin after SDP occurred. PFGE showed clonal diversity in both cases. We conclude that after SDP with 500 mg ciprofloxacin there is a shift to gram-positive bacteria in the faeces and an increase in the rate of FQ resistance. Since selection of highly resistant E. coli is possible, a careful risk-benefit evaluation of prophylaxis with FQ is indicated.

[Clinical statistics on patients and operations during a 20-year period (1978-1997) at Department of Urology, Jikei University School of Medicine]

A statistical analysis was made of diseases, patients, and operations at our department in the four affiliated hospitals of Jikei University School of Medicine from 1978 through 1997. Our findings were as follows. Newly diagnosed urogenital malignancies, except testicular tumors, have been increasing in the last two decades among both outpatients and inpatients. Urogenital infections, including tuberculosis, have gradually been decreasing in the last two decades. The treatment of urinary stone diseases was markedly altered by the induction of extracorponeal shock wave lithotripsy.

[Clinical statistics on in-patients and operations during a 14-year period (1986-1999) at Department of Urology, Gunma Cancer Center]

The patients, diseases and operations experienced between 1986 and 1999 in our department were analyzed. The number of in-patients has been increasing since 1995. Renal cell carcinoma, urinary bladder cancer and testicular cancer have been gradually increasing recently, and in-patients with prostate cancer have increased markedly. Pelvic and ureteral cancers were almost constant during this period. Radical nephrectomy and prostatectomy have been increasing since 1994 and 1990, respectively. The examinations for malignancy, especially prostate biopsy, have been increasing.

[Statistics of the operations at the Department of Urology, Tone Chuo Hospital during a six-year period (June 1993-May 1999)]

A clinical statistic survey was made on the operations performed at the Department of Urology, Tone Chuo Hospital between June 1993 and May 1999. The total number of operations was 1296, consisting of 97 (7.5%) operations of the kidney, 67 (5.2%) operations of the ureter, 190 (14.7%) operations of the bladder, 454 (35.0%) operations of the prostate, 63 (4.9%) operations of the urethra, 92 (7.1%) operations of the penis, 149 (11.5%) operations of the scrotum and 184 (14.2%) other operations. With the aging society, the number of operations for those over 60 years old has exceeded 60%.

A review of food provision to a renal ward and the proposed appointment of feeding assistants

Malnutrition among renal patients has been widely documented and is associated with increased morbidity and mortality. Advances in dialysis technology and transplantation have helped to increase patient long-term survival, and as more elderly patients commence dialysis programs, the problem of malnutrition is escalating. Hospitalized renal patients are at a greater risk, as dietary intakes may be reduced for a number of reasons. A multidisciplinary team decided to review the existing cook-chill plated meal system and all food provision to the renal ward. The aim of this review was to assess the nutritional intake of renal inpatients and to gauge patients' and relatives' attitudes towards hospital food provision. From these results, we hoped to go on and implement some changes to help improve the situation. Results showed that 34% of the patients ate half or less of the hospital food provided, and 80% of patients surveyed relied on food brought in by relatives and friends. Actual dietary intakes were compared to Dietary Reference Values (DRVs; Department of Health [DoH], UK, 1995). One hundred percent of the patients did not achieve the DRVs for energy, iron, potassium, zinc, folate, B6, and riboflavin. Sixty-six percent of the patients did not achieve the DRV for protein. These results were discussed by the multidisciplinary group, and it was decided to trial a cook-chill bulk trolley to replace the existing plated meal system. Unfortunately, to implement a bulk trolley system, the ward needs someone to serve the food. This could be the job of a "feeding assistant" or "ward hostess." A bid has been put forward to the hospital Trust Board to obtain funding for these "feeding assistants, " and the bulk trolley can be acquired from existing funds. It is hoped that the creation of these new posts will go some of the way towards improving the patients' dietary intake while in the hospital.