Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea.

BACKGROUND: The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking. AIM: To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards. METHODS: A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively. FINDINGS: Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset. CONCLUSION: HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

Randomised prospective single-blinded study comparing 'inside-out' versus 'outside-in' transobturator tapes in the management of urodynamic stress incontinence: 1-year outcomes from the E-TOT study.

OBJECTIVE: To compare the 'inside-out' versus 'outside-in' routes for transobturator tape insertion for urodynamic stress incontinence, and to identify independent risk factors for failure at 1 year. DESIGN: Prospective single-blinded randomised trial. SETTING: Tertiary urogynaecology centre. POPULATION: A cohort of 341 women undergoing transobturator tape procedures between April 2005 and April 2007. METHODS: Women were randomised to tension-free vaginal tape-obturator (TVT)-O for the 'inside-out' route (n = 170) and transobturator tape (TOT)-ARIS for the 'outside-in' route (n = 171). Participants completed validated symptom-severity, quality-of-life and sexual-function questionnaires before and after surgery. In addition, they completed the patient global impression of improvement questionnaire (PGI-I) and standard 1-hour pad test postoperatively. MAIN OUTCOME MEASURES: The primary outcome was the patient-reported success rate reported on the PGI-I scale. Secondary outcomes included objective cure rate and improvement in King's Health Questionnaire scores. RESULTS: A total of 341 women were recruited: 171 women to the 'outside-in' (TOT-ARIS) group and 170 to the 'inside-out' (TVT-O) group; 299 completed the 1-year follow up. The patient-reported success rate was 80% with no statistically significant differences between the groups ('outside-in' 77.6% versus 'inside-out' 81.2%; OR 1.25; 95% CI 0.71, 2.20; P = 0.54). The objective cure rate was 91% with no statistically significant difference between the groups ('outside-in' 88% versus 'inside-out' 94%; OR 2.21; 95% CI 0.85, 5.75; P = 0.157). Previous incontinence surgery (OR 1.41; 95% CI 1.18, 1.91; P = 0.029) and preoperative urgency incontinence (OR 1.78; 95% CI 1.21, 3.91, P = 0.048) were significant risk factors for failure of transobturator tape at the 1-year follow up. CONCLUSIONS: There are no significant differences in patient reported and objective cure rates between 'inside-out' and 'outside-in' transobturator tapes. Quality of life and sexual function significantly improved following surgery. Both previous incontinence surgery and preoperative urgency incontinence are associated with significantly lower patient-reported cure rates.

Effect of abdominal hysterectomy on developing urinary and faecal incontinence later in life.

The objective of this retrospective longitudinal study was to investigate the incidence and severity of urinary and faecal incontinence in women after either total abdominal hysterectomy or comparable abdominal surgery. Age-matched and postoperative time-matched control groups were drawn from women attending for operation at a Scottish District General Hospital, during the early 1990s (59 women in the hysterectomy group and 33 women in the control group, with a mean preoperative age 40.4 years and 38.1 years, respectively). Within-group and between-group analyses were conducted using t and Fisher's exact tests. Within each group, changes in all urinary and faecal variables during the 10-year period were extremely significant (p < 0003). With the exception of urinary urgency (p = 0.028), there was no statistical difference between the groups.

Retrospective multicentre study of the new minimally invasive mesh repair devices for pelvic organ prolapse.

OBJECTIVES: To assess the complications and short-term outcomes of prolapse repair mesh devices used in the management of female pelvic organ prolapse (POP). DESIGN: Retrospective cohort study. SETTING: Multicentre study involving a tertiary referral urogynaecology unit and two district general hospitals. POPULATION: 329 women who underwent surgical management of prolapse with various prolapse repair mesh devices in the period between January 2005 and December 2006. METHODS: Women were identified from theatre records. An independent clinician performed a case notes review during the period March to May 2007. MAIN OUTCOME MEASURES: Complication rates and the short-term cure at 3-month follow-up (defined as

Transobturator tension free vaginal tapes: are they the way forward in the surgical treatment of urodynamic stress incontinence?

OBJECTIVES: The transobturator approach for sub-urethral tension free vaginal tapes had gained wide popularity in surgical treatment of urodynamic stress incontinence over the last few years. This study aims to survey the practice and preferences of urogynaecologists and urologists worldwide as regards the transobturator tapes. MATERIAL AND METHODS: Seven hundred and twenty surgeons worldwide were surveyed via postal/email questionnaire about their views and practice regarding the transobturator tape procedures (TOTs). They were asked about their technique and tape material preference and their reasons for choosing them. They were also asked about every detail of the procedure. RESULTS: Adjusted response rate was 68%. Of the responding surgeons, 97% were well aware of the TOTs and only 44.3% undertake them. While 34.16% of the surgeons thought that TOTs are the way forward in the treatment of USI, 14.84% surgeons disagreed and the majority (51%) are yet to decide. With regards to technique of TOTs, most surgeons (38%) would prefer to use both techniques, while 34% use "In-Out" technique only and 28% use "Out-In" technique only. The vast majority (72%) use polypropylene mesh tapes due to better tissue incorporation and proven safety records. A few surgeons deviate from the originally described TOTs; 13.6% use a catheter guide to deviate the bladder and urethra during the trochar insertion and 31.41% use routine cystoscopy as part of the procedure. CONCLUSION: Whilst one-third of the responding surgeons think that the transobturator approach for tension free vaginal tapes is the way forward for the management of USI, the majority are awaiting studies with longer-term results. The variation from the originally described TOT procedures seems to be inherited from the TVT procedure.

A simple visual analogue scale to assess the quality of life in women with urinary incontinence.

AIM: The objective of this study is to determine whether a simple visual analogue scale; "incontinence bothersome scale (IBS)" can reliably assess the quality of life in women with urinary incontinence. DESIGN: A prospective cohort study in a UK district general hospital. METHODS: Two hundreds women with urinary incontinence participated in the study over 1-year period. They completed Kings health questionnaire version 7 (KHQ) and the incontinence bothersome scale (IBS). The results of the IBS were then compared to the total KHQ score and to each domain separately, using the Pearson correlation test. Women in the study were then classified into two main groups according to their urodynamics diagnosis (urodynamic stress incontinence group/detrusor overactivity group) and the total KHQ scores were compared with the IBS scores in each group. RESULTS: The IBS scores had poor correlation with the total KHQ scores (r=0.656) and the difference between both arms was not statistically significant (p=0.084). Further analysis of KHQ domains showed that except for the impact of incontinence domain (r=0.728) all other domains correlated poorly to the IBS. This poor correlation pertained in sub-analysis of women with DO and USI (r=0.65 and 0.48, respectively). CONCLUSION: This study has shown that a simple visual scale is not a reliable tool in assessing the QoL in women with urinary incontinence. A formal, validated and reliable QoL questionnaire is still the method of choice for QoL assessment, even if it takes longer to complete.

Lower urinary tract injuries after transobturator tape insertion by different routes: a large retrospective study.

OBJECTIVES: To identify the rate of, and risk factors for, lower urinary tract (LUT) injuries associated with the transobturator tension-free vaginal tape (TOT) procedure. DESIGN: Retrospective cohort study. SETTING: Tertiary referral urogynaecology centre. POPULATION: 390 women who underwent transobturator suburethral tapes for management of urodynamic stress incontinence between July 2002 and January 2006. METHODS: Early cases were identified from theatre records and a case note review performed. From May 2005 (n = 94), data from an ongoing prospective audit were reviewed. Data for LUT injuries with TOT procedures were examined and routes of insertion were compared using Fischer's exact test. MAIN OUTCOME MEASURES: Rate of LUT injuries associated with the TOT procedures. Assessment of factors increasing risk of LUT injury, and comparison of the 'outside-in' and 'inside-out' techniques. RESULTS: 241 women underwent TOT outside-in technique and 148 of them underwent inside-out technique. Four LUT injuries occurred (1%): two urethral injuries (0.5%) and two bladder injuries (0.5%). All LUT injuries occurred in the outside-in group, although this difference did not reach significance (P = 0.146). Bladder injuries occurred in women who underwent concomitant vaginal surgery, while urethral injuries occurred in women undergoing secondary procedures. CONCLUSION: LUT injury is an uncommon complication of the TOT procedures, and in our hands only occurred with the outside-in technique. Intraoperative cystoscopy should be considered only in selected cases.

Test method for measuring non-visible set-off from inks and lacquers on the food-contact surface of printed packaging materials.

The main objective was to develop a technique to expose spots of invisible set-off of inks and lacquers on the food-contact surface of food-packaging materials. Set-off is the unintentional transfer of components of printing inks from the outer printed surface onto the food-contact surfaces. The target sensitivity was 20 microg cm(-2) and the technique should be capable of examining large areas of printed substrate for no more than 4% coverage by set-off. These requirements equate to an ability to detect a worst-case migration potential of less than 50 microg kg(-1). Other objectives were the industrial requirements that the equipment should be inexpensive, should be easy to use by existing personnel and should preferably be non-destructive with a clear criterion for pass or fail. The approaches investigated included chemical analysis of solvent extracts, Fourier-transform infrared spectroscopy and microbeam analytical techniques, but these were found to be cumbersome and had only limited success. The objectives were achieved using an optical approach to excite and observe luminescence from invisible set-off. In model experiments, resins were applied to different substrates (plastic, paper and cartonboard). For a given resin on a given material, the key to success was to maximize the discrimination between the luminescence from the resin and that from the substrate by selecting the optimal combination of exciting wavelength and viewing goggles with selective wavelength filters. The required level of detection (20 microg cm(-2)) was achieved or exceeded for all ten resins tested on three different plastics. It was also achieved for two different papers and in all but four cases of the resins on three different cartonboards. Quantitation was achieved by the use of a calibration palette prepared using different quantities of resin spotted onto the relevant blank packaging material.

Protein degradation during anaerobic wastewater treatment: derivation of stoichiometry.

The stoichiometry of reactions that describe protein degradation in anaerobic treatment systems were investigated. A methodology was developed to describe protein degradation to organic acids using a single reaction step. The reactions for individual amino acid fermentation and their mediating organisms were reviewed. The dominant fermentation pathways were selected based on a number of assumptions. Using the amino acid content of a model protein, it was then possible to determine stoichiometric coefficients for each major organic acid product in the overall degradation of the protein. The theoretical coefficients were then compared to those determined from two experimental runs on a continuously-fed, well-mixed, laboratory-scale anaerobic wastewater treatment system. In general, the coefficients compared well thus validating the use of a single reaction step for the overall catabolic reaction of protein degradation to organic acids. Furthermore, even when the protein concentration in feed or the feed flow rate was doubled, the amino acid fermentation pathways were found to occur predominantly by only one pathway. Although the choice of Stickland reactions over uncoupled degradation provided good comparisons, an electron balance showed that only about 40% of the amino acids could have proceeded coupled to other amino acid reactions. Uncoupled degradation of the remaining amino acids must have relied on the uptake of hydrogen produced from these reactions by hydrogen-consuming methane bacteria.

The synergistic effect of excimer and low-pressure mercury lamps on the disinfection of flowing water.

Microorganisms in flowing water were disinfected by UV radiation from two excimer (excited dimer) lamps (emitting at 172 and 222 nm) in combination with two low-pressure mercury lamps (emitting at 254 nm). Synergies were investigated among the three types of radiation in the treatment of water spiked in turn with Escherichia coli, Listeria innocua, Shewanella putrefaciens, and spores of Bacillus subtilis and Bacillus cereus. Synergy was demonstrated between radiations at 222 and 254 nm in the treatment of E. coli, L. innocua, and S. putrefaciens, but little or no synergy was observed in the treatment of B. subtilis and B. cereus. At maximum flow rates (60 liters/min), 5-log reductions in E. coli were achieved at 254 nm, although at 222 nm, less than 1-log reductions were observed. No bacterial kill was observed with 172-nm radiation alone, despite increasing exposure time by reducing flow rates to less than 3 liters/min.

A prospective, randomized controlled trial of inpatient versus outpatient continence programs in the treatment of urinary incontinence in the female.

Seventy-four patients presenting with a mixed pattern of urinary symptoms were randomly allocated to undergo either inpatient or outpatient continence programs as initial treatment, without prior urodynamic investigation. Both programs consisted of physiotherapy, bladder retraining, fluid normalization, dietary advice and general support and advice. Nine out of 39 in the outpatient group and 8 out of the 35 of the inpatient group failed to complete the study. There was a significant decrease in frequency, nocturia, number of incontinent episodes and visual analog scores for both groups. In addition the outpatients had a significant reduction in loss on pad testing, and a significantly greater improvement in their visual analog score. In each group 63% were cured or improved to the extent that they did not require further treatment. Staff costs per outpatient were half those for an inpatient. We conclude that outpatient conservative treatment as detailed above is a successful first-line treatment of urinary incontinence in women. It is as successful and possibly better than inpatient treatment, and is significantly cheaper.

Time-series analysis of urethral electrical conductance measurements in the assessment of unstable urethral pressure: results in normal patients and in those with genuine stress incontinence.

It is well established that urethral pressure variations occur in patients with or without urinary incontinence, but to what extent they contribute to a patient's symptoms remains unclear. Previous work has suggested that in stress incontinent patients, a rise in bladder neck electrical conductance (BNEC) occurs simultaneously with a fall in urethral pressure, and that this represents bladder neck opening. Six patients with genuine stress incontinence (gsi), and six normal controls underwent simultaneous urethral pressure and BNEC measurements, the results being subjected to time-series analysis, to determine whether the previous finding could be confirmed statistically, and to establish whether a similar association was present in normal women. All six patients with gsi and five of the normal patients had unstable urethral pressure. Estimated cross-correlation of differenced data for the two parameters showed a significant negative correlation at zero time lag in three patients with gsi and two of the control group. There was no significant correlation between the two parameters in the other seven patients. We conclude that the previous finding of a correlation between urethral pressure variation and BNEC, suggesting bladder neck opening occurs as urethral pressure falls in patients with gsi is confirmed, but appeared to be present in only 50% of patients; the finding is just as likely in normal patients, and therefore whilst it may be of relevance to the severity of symptoms, could not be held to have any aetiological significance.

Uroflowmetry in the puerperium.

One hundred women underwent uroflowmetry once per day for the first 3 days after delivery, and the results compared to those of 53 nonpregnant controls in an effort to determine 1) whether urinary flow in the puerperium is different to that found without pregnancy, 2) whether uroflow parameters change as the puerperium progresses, and 3) which characteristics of a patient or her labour bear most influence upon the results of uroflowmetry. Urinary flow in the puerperium was seen to be different from that of the nonpregnant female in that mean flow rates were lower. In addition to this, voided volume, total flow time, and time to peak flow were all significantly increased on day 1, but were comparable on days 2 and 3. Other than for falling voided volumes, uroflow parameters did not alter significantly as the puerperium progressed. Correlation of the variables age, parity, baby weight, length of first and second stage, use of epidural and perineal suturing with the parameters of urinary flow failed to show any significant relationship.

Incidence of abnormal voiding parameters in the immediate postpartum period.

One hundred eighty-four patients were assessed prospectively by uroflowmetry and postmicturition ultrasonography on a daily basis in the immediate postpartum period to assess the incidence of abnormal voiding parameters, their predisposing factors, and whether the combination of two screening tests was more helpful than either alone as a screening test of abnormal voiding in the puerperium. The incidence of abnormal voiding parameters was 43%. The majority of these were asymptomatic. Of those patients who had an abnormality, 68% had normal voiding parameters by the time they went home, and all of those who returned for follow-up had normal parameters. Operative delivery, perineal trauma, and epidural anaesthesia all increased the incidence of abnormal voiding parameters. Residual urine was a feature in 70 of the 79 patients found to be abnormal, and the incidence of an abnormal flow rate was not significantly greater than in the nonpregnant population. This suggests that the addition of uroflowmetry does not confer any benefit over postmicturition assessment of residual urine by ultrasonography in the detection of patients with postpartum voiding dysfunction.

Subtrigonal phenol injections in the treatment of idiopathic detrusor instability in the female--a long-term urodynamic follow-up.

A total of 36 subtrigonal phenol injections were performed on 29 patients with detrusor instability. Long-term follow-up (mean 13.7 months) showed a subjective response rate of only 14%, and objectively there was no significant change in any urodynamic parameter in the group as a whole. There was, however, a significant improvement in cystometric capacity and volume at first contraction, in those under 55 years of age. One patient developed a vesicovaginal fistula following repeat injections. This suggests that subtrigonal phenol injections have little place in the treatment of detrusor instability, especially in the over 55s, and repeat injections should be abandoned because of the risk of major complications.