Circumstances of the ambulatory prescription of quinolones in Urology and opportunities for intervention.

INTRODUCTION AND OBJECTIVES: Antimicrobial stewardship programmes (AMSP) seldom focus on ambulatory prescribing. Our AMSP primarily supervises in-hospital prescribing, but as we aim to include the ambulatory setting, we sought opportunities for intervention on ambulatory quinolone prescription. MATERIALS AND METHODS: We selected the prescriptions made by urologists during 2018 for analysis, and manually checked them for adequacy. RESULTS: We analyzed 237 prescriptions. Of 136 therapeutic prescriptions, 18.4% had no reported diagnosis and 31.6% had no reported symptoms. Most patients (60.3%) did not have any urinalysis or urine culture; among those who had, 27.7% had a urinalysis not suggestive of urinary tract infection and 67.4% had a positive culture, 83.9% of which had a suitable oral alternative to quinolones. Antimicrobial therapy was not indicated in 13.9% of cases; when it was, quinolones were considered inadequate in 67.8% of cases. Incorrect duration was found in 51.1% of cases. Forty-six prescriptions were made for prophylaxis; all of these were considered inadequate. CONCLUSION: We found a high prevalence of inadequate ambulatory quinolone prescriptions in Urology. Many followed incomplete recordings, lack of laboratory use, or inattention to alternatives. Treatment duration and quinolone choice were frequently inadequate. Quinolone prescribing for prophylaxis was always considered inadequate. These prescribing errors could serve as a starting point for future interventions.

Recurrence of vulvar carcinoma: A multidisciplinary approach.

Although oncogynaecological management of bulky vulvar tumors tends to minimally-invasive approaches preceded by neoadjuvant therapies, ultra-radical surgery with curative intent may still have an important role. These procedures remain associated with significant short and long-term complications, imposing the need for novel reconstructive techniques [Brown et al., 2017, Di Donato et al., 2017, Moreno-Palacios et al., 2015, Oonk et al., 2017]. We present a video highlighting the crucial surgical steps of a successful pelvic exenterative procedure followed by perineal reconstruction with a muscle-sparing flap technique. A 72-year woman with history of stage II vulvar epidermoid carcinoma, treated with radical surgery and adjuvant radiotherapy. At two-year follow-up local recurrence was diagnosed, handled with large excisional surgical treatment. Within four years a second local recurrence occurred, with infiltrative and bulky dimensions extending to perianal region and vaginal wall. A multidisciplinary surgical approach with curative intent was performed, involving gynecologists, colorectal and plastic surgeons: radical bilateral vulvectomy with distal colpectomy, abdominoperineal resection with colostomy, perineal reconstruction with deep inferior epigastric perforators (DIEP) flap. No major intraoperative or postoperative complications occurred, and the patient was discharged within two weeks with no readmissions for wound care. At two-year follow up she remains in complete remission of the disease. No flap complications occurred during this period. In highly selected patients with recurrent vulvar cancer previously submitted to multiple surgeries and radiotherapy, pelvic exenterative procedures followed by reconstructive techniques allow free surgical margins minimizing morbidity and pelvic disfiguring surgery. Association of reconstructive techniques to radical vulvo-vaginal surgery can shift the paradigm of oncological treatment approach, improving outcomes and quality-of-life.

Neurological damage arising from intrapartum hypoxia/acidosis.

Complications occurring at any level of foetal oxygen supply will result in hypoxaemia, and this may ultimately lead to hypoxia/acidosis and neurological damage. Hypoxic-ischaemic encephalopathy (HIE) is the short-term neurological dysfunction caused by intrapartum hypoxia/acidosis, and this diagnosis requires the presence of a number of findings, including the confirmation of newborn metabolic acidosis, low Apgar scores, early imaging evidence of cerebral oedema and the appearance of clinical signs of neurological dysfunction in the first 48 h of life. Cerebral palsy (CP) consists of a heterogeneous group of nonprogressive movement and posture disorders, frequently accompanied by cognitive and sensory impairments, epilepsy, nutritional deficiencies and secondary musculoskeletal lesions. Although CP is the most common long-term neurological complication associated with intrapartum hypoxia/acidosis, >80% of cases are caused by other phenomena. Data on minor long-term neurological deficits are scarce, but they suggest that less serious intellectual and motor impairments may result from intrapartum hypoxia/acidosis. This chapter focuses on the existing evidence of neurological damage associated with poor foetal oxygenation during labour.