INTRODUCTION Ureteric stenting is a common urological procedure. Forgotten stents have a well-documented morbidity and mortality. Therefore, we asked the question, is a stent register an important factor in reducing the number of lost or overdue stents? PATIENTS AND METHODS We conducted a retrospective review of 203 patients who had ureteric stents inserted in the operating theatre, for the 5-year period 1 December 1998 to 1 December 2003. We analysed all stent cards, patient notes and theatre logs; where no record of stent removal was found, we contacted the patient, their GP or their local hospital. RESULTS A total of 191 patients were identified from the stent card register. An additional 12 patients were found from the theatre logs, but with no record in the stent card register. Of the 203 patients, 8 had bilateral stents. The most common indication for stenting was stone disease. Of the 203 patients, 11 had overdue stents and 51 had no record of the stents ever being removed. The 51 presumed ‘forgotten’ stents were traced, and it was found that 42 patients had had their stents removed by other hospitals, and 9 patients died with stents in situ, but before they were due for removal. CONCLUSIONS Our current stent card tracking system is ineffective, because it was infrequently reviewed. However, despite overdue and ‘forgotten’ stents which were removed by other hospitals, no patients came to any real harm and we had no lost stents. Our stent register system did not appear to play any role in terms of preventing stent loss, and it seems likely that there are other more effective safeguards in place to prevent this from happening. However, if a stent register was required at all, a computerised system would be preferable. Alternatively, patients could share some of the responsibility of stent tracking with their clinicians.
• Newly diagnosed squamous cell carcinomas (SCC) of the penis, including squamous cell carcinoma in situ (CIS), from biopsy specimens were referred from 15 centres to the regional supra-network multidisciplinary team (Sn-MDT) between 1 January 2008 and 30 March 2011.• Biopsy histology reports and slides from the respective referring hospitals were reviewed by the Sn-MDT pathologists.• The biopsy specimens' histological type, grade and stage reported by the Sn-MDT pathologist were compared with those given in the referring hospital pathology report, as well as with definitive surgery histology.• Any changes in histological diagnosis were sub-divided into critical changes (i.e. those that could alter management) and non-critical changes (i.e. those that would not affect management). Results• A total of 155 cases of squamous cell carcinoma or CIS of the penis were referred from 15 different centres in North-West England.• After review by the Sn-MDT, the histological diagnosis was changed in 31% of cases and this difference was statistically significant. A total of 60.4% of the changes were deemed to be critical changes that resulted in a significant change in management.• When comparing the biopsy histology reported by the Sn-MDT with the final histology from the definitive surgical specimens, a good correlation was generally found. Conclusions• In the present study a significant proportion of penile cancer histology reports were revised after review by the Sn-MDT. Many of these changes altered patient management.• The present study shows that accurate pathological diagnosis plays a crucial role in determining the correct treatment and maximizing the potential for good clinical outcomes in penile cancer. • In the case of histopathology, centralization has increased exposure to penile cancer and thereby increased diagnostic accuracy, and should therefore be considered the 'gold standard' .
Retrospective review of 929 patients, with biopsy proven GS 3 + 3 and 3 + 4 PCa, undergoing upfront radical prostatectomy (RP) was performed. Suitability for AS was adapted from protocols by Royal Marsden Hospital, University of Toronto, and PRIAS by allowing Gleason 3 + 4 disease.The outcomes assessed were adverse pathology at RP (upgrading ≥GS 4 + 3 and/or upstaging ≥pT3) and biochemical recurrence (BCR) after RP. ResultsAdverse pathology at RP was compared between GS 3 + 3 vs 3 + 4 groups. When selecting patients using Royal Marsden (n = 714) or University of Toronto (n = 699) protocols, there was statistically significantly more adverse pathology at RP in GS 3 + 4 group (21% vs 31%, P = 0.0028 and 19% vs 33%, P=<0.001 respectively). Using the more stringent PRIAS protocol (n = 198), there was no statistical significant difference in groups.There was no difference in BCR survival between biopsy GS 3 + 3 and 3 + 4 groups, regardless of which AS protocol assessed. Pre-operative PSA and clinical staging were the predictors for BCR. ConclusionPresence of Gleason 3 + 4 at biopsy, when compared to 3 + 3, increases the risk of adverse pathology being present at radical prostatectomy for less stringent selection criteria. When considering AS, a stricter protocol such as PRIAS, limiting PSA density and number of positive cores to ≤2, appears to decrease the risk of adverse pathology. No differences in BCR were seen between biopsy 3 + 3 and 3 + 4 disease, regardless of AS selection criteria.
Objectives There is interest in doxycycline as prophylaxis against sexually transmitted infections (STIs), but concern about antimicrobial resistance (AMR). We conducted a systematic review (CRD42021273301) of the impact of oral tetracycline-class antibiotics on AMR in normal flora. Methods We searched MEDLINE, EMBASE, the Cochrane Library (1940–2021) and conference proceedings (2014–21) for randomized controlled trials in adults comparing daily oral tetracycline-class antibiotics to non-tetracycline controls. The primary outcome was AMR to tetracyclines; secondary outcomes included resistance to non-tetracyclines. Data were inappropriate for meta-analysis, so we analysed findings descriptively. Results Our search yielded 6265 abstracts of which 7 articles fulfilled inclusion criteria. Most were at moderate/high risk of bias, generally due to inadequate methodologic reporting. Studies used doxycycline, tetracycline, oxytetracycline or minocycline for 2–18 weeks. Most observed an increased burden of tetracycline resistance, including in subgingival (n = 3 studies), gastrointestinal (n = 2) and upper respiratory tract (n = 1) flora; one study of skin flora found no change in tetracycline-resistant Propionibacterium species after 18 weeks of oxytetracycline/minocycline. Four studies reassessed AMR at 2–50 weeks post-intervention and reported varying degrees of resistance. Three articles reported on the prevalence of non-tetracycline AMR after doxycycline prophylaxis, of which one found a transient increase among gastrointestinal Escherichia coli; the other two showed no difference from control. Conclusions Although the effects are modest and transient, limited data from small prospective studies may suggest that oral tetracyclines for 2–18 weeks increase resistance in subgingival, gastrointestinal and upper respiratory tract flora. STI prophylaxis trials should include AMR in commensal bacteria as study outcomes.
Introduction The fluid balance chart is used as a non-invasive tool to assess the surgical patient's hydration status. Surgical trainees prescribe fluids on a daily basis, an essential part of patient fluid management. A good understanding of these charts is important, as inaccurate interpretation can have a detrimental effect on patient outcome. Therefore, we asked the question: can surgical trainees interpret and calculate fluid balance charts correctly? Method We prospectively asked 25 surgical trainees including 12 at Specialty Training (ST) level and 13 at Foundation Year (FY) level, to calculate the total input and output of 13 fluid balance charts, and rate how difficult these charts were to interpret. Results Clinical experience does not appear to influence the correct calculation of the total input and output values of the fluid balance charts. However, out of the 13 charts, there is a statistically significant difference from the original documented values in eight of the ST group and nine of the FY group for the total input values, and three of the ST group and four of the FY group for the total output values, with some by a large magnitude. Conclusion This study shows alarming results with cause for concern where there is a huge variation in surgical trainee calculated and original documented values, as well as variations between trainees irrespective of training grades, which is a potential risk management issue. It highlights that inaccurate interpretation of these charts are not due to lack of clinical experience, but the fundamental problem lies within the lack of education and inconsistent poor documentation of these charts.
Levy and Charkin described the longitudinal cut at the tip of the catheter to allow the guide-wire to pass through for rail-roading into the bladder. This method maintains the manufactured conical shape of the catheter tip, hence the ease of advancement. However, the longitudinal cut to the tip of the catheter can potentially cause the catheter to bivalve and split, which can lead to urethral trauma.An alternative technique, using a 14-gauge (Brown) intravenous cannula needle threads through the side drainage hole of the urethral catheter and then punctures the centre of the tip of the catheter to form a track; the guide-wire is subsequently passed retrograde through the intravenous cannula needle. The needle is removed which allows the guide-wire to pass into the central catheter drainage lumen. After lubricating the guidewire and the urethral catheter with lignocaine gel, the catheter is passed into the bladder over the guide-wire. From our experience, this method is easy to use, and also maintains the integrity of the shape of the catheter with no risk of the above complication. We have never experienced the theoretical problem of the catheter splitting. We believe this is because the slit made in the catheter is small as it only needs to allow a guide-wire to pass through. We do agree though that a long slit could potentially cause the catheter to bivalve and, hence, cause further trauma. Therefore, the slit should be kept as short as possible to allow the guide-wire to pass through. AUTHORS' RESPONSEThe technique described involving the guide-wire being passed through the side drainage hole and then through the tip of the catheter using a 14-G intravenous cannula is an alternative technique. The problem we have had with this approach is the difficulty in advancing the catheter over the guide-wire. As the authors state, the guide-wire and catheter must be well lubricated: if not, the catheter catches on the guide-wire due to the oblique angle that it runs through the distal catheter. Advancement is then very difficult and one is uncertain whether the resistance is due to the guide-wire or due to urethral narrowing.
End stage renal failure patients requiring long term total parenteral nutrition (TPN) often have multiple central line placements due to line infection or occlusion. Sometimes this can cause central venous stenosis or even occlusion. We present three cases in this consecutive series, in which we have successfully used arteriovenous fistulae for both hemodialysis and long term TPN administration as an alternative route without any complications. We therefore think that native AVF and grafts can be used as dual access for hemodialysis and TPN administration provided careful case selection, counselling and follow-up.
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