Urinary tract infection and patient satisfaction after flexible cystoscopy and urodynamic evaluation.

OBJECTIVES: To investigate the incidence of symptomatic and asymptomatic bacteriuria and to assess patient satisfaction after flexible cystoscopy (FC) and urodynamic (UD) evaluation in a prospective survey. The incidence of urinary tract infection after FC and UD studies and the use of prophylactic antibiotics are issues of debate. The tolerability and acceptance of FC and UD studies by patients have not been thoroughly documented. It would be helpful to be able to give such information to patients before performing these procedures. METHODS: A total of 215 nonconsecutive patients seen as outpatients for FC and UD studies to evaluate various indications were studied. A midstream urine sample was taken before and 48 hours after the procedures. Patients were given a questionnaire that inquired about the presence of lower urinary tract symptoms before and 48 hours after the procedures. The self-administered questionnaire included questions to assess patients' tolerance of the procedures and how it compared with their expectations. RESULTS: Of the 201 patients analyzed (FC 103, UD studies 98), 9 patients (4. 5%) developed significant bacteriuria within 48 hours of FC and UD studies. Only 2 patients with significant bacteriuria reported newly developed symptoms within 48 hours. In a subgroup of 25 patients who were given prophylactic antibiotics for various reasons, 6 (24%) reported new symptoms, although none developed significant bacteriuria. The association between patients who had preprocedure pyuria (n = 7) and the development of significant growth after the procedure (n = 6) was significant (P <0.01). In response to the patient-satisfaction questionnaire, 166 (82.5%) reported that the procedure was not as bad as they expected, and 200 (99.5%) said that they would undergo the test again if necessary. CONCLUSIONS: FC and UD studies are safe, well-tolerated procedures. The addition of prophylactic antibiotics in these procedures is unnecessary, unless specific indications are present.

The effect of diclofenac (voltarol) and pethidine on ureteric peristalsis and the isotope renogram.

Diclofenac (a non-steroidal anti-inflammatory drug) and pethidine (a synthetic opiate) are the two analgesics most commonly used to relieve the pain of ureteric colic. Fast frame renography is a non-invasive means of imaging ureteric peristalsis and renal drainage. The aim of this study was to determine the effects of each of these drugs on the drainage pattern of the upper tracts. Twelve normal male volunteers were studied. All underwent a standard fast frame renogram using 75 MBq of technetium-99m-mercaptoacetyltriglycine, and were then administered either 100 mg pethidine or 75 mg diclofenac by intramuscular injection. Fast frame renography was then repeated. Peristalsis was determined from the condensed image of each ureter and the renogram curves were analysed to obtain standard parameters and deconvolution analysis. Diclofenac caused a profound disruption to both ureteric peristalsis and the renogram curve. This effect was not seen after the administration of pethidine. Deconvolution analysis suggests the effects of diclofenac are mediated via a direct effect on drainage rather than by any alteration of blood flow to the kidney. This study suggests that pethidine is the analgesic of choice prior to renography and that inferences about alterations of drainage in the presence of diclofenac should be interpreted with care.

Breast disease and the general surgeon. I. Referral of patients with breast problems.

OBJECTIVES: To determine the proportion of all new and follow-up patients referred to general surgical outpatient clinics with breast problems. To ascertain how long these patients wait for an appointment and how many require investigation or admission for operation. To review our management of patients with breast problems in the clinic and to determine the ratio of benign breast disease to malignancy. DESIGN: A 3-month prospective outpatient survey with patient details recorded on questionnaires completed by the medical staff. SETTING: The general surgical outpatient clinics of this firm at Battle Hospital, Reading, and Newbury District Hospital, Berkshire. PATIENTS: Those patients attending the above clinics during the 3-month period 1 October to 31 December 1989. RESULTS: In all, 693 new patients and 554 follow-up patients were seen. Of the new patients, 119, and of the follow-up patients 140 were seen for a breast complaint. At Battle Hospital 16% of all new patients presented with a breast problem, while at Newbury Hospital the figure was 24%. Of the follow-up patients at Battle Hospital, 23% were seen for a breast problem, and 41% at Newbury. The overall median waiting time for a new outpatient appointment was 21 days. No investigations were needed in 22% of the patients. The remaining 93 patients had investigations and a total of 70 mammograms and 53 fine needle aspirations for cytology were performed. The mean cost of investigations per patient investigated was estimated at 27 pounds. Of new patients, 58% were discharged from the clinic after a single consultation, and investigations as necessary. In 79% of the patients admitted for an operation, the decision to admit was made on the basis of the initial history and examination alone. Of new patients, 84% did not need admission and were managed in the clinic. In all, 14 breast carcinomas were diagnosed--12% of new patients with breast problems. CONCLUSIONS: The figures suggest that 24% of new patients and 41% of follow-up patients attending a general surgical clinic are seen for a breast problem. The waiting time for new appointments is unacceptably long. Most new patients do not require admission for an operation. Only 12% of new patients referred with a breast problem were found to have a carcinoma.

Percutaneous angioplasty in a district general hospital: impact and implications.

Over a 2-year period 147 angioplasties were performed for stenoses or occlusions above or below the inguinal ligament. Most patients had intermittent claudication. The stenosis or occlusion was successfully dilated in 88% of cases. Successful dilatation produced a good result, as determined by improvement in Doppler pressures (63%), an increase in walking distance (60%) or limb salvage (66%). There have been 15 complications. Of seven distal emboli, three required operation and four were successfully treated with intra-arterial streptokinase. In three patients, immediate occlusion of the femoral artery required urgent operation, and one patient died following intra-arterial streptokinase and subsequent angioplasty. There were three further major haematomas, one requiring suture of the puncture site. Had angioplasty not been available, about half of the patients in this series would not have had an angiogram. Many of the remainder, not being suitable for vascular reconstruction, would have been treated conservatively. Thus a new group of patients is being defined for whom interventional treatment is now appropriate, and this has important revenue implications. Percutaneous transluminal angioplasty is a safe and effective technique in carefully selected patients. Complications can occur, however, and the immediate availability of a vascular surgeon is essential.

Aneurysm of lateral circumflex femoral artery in association with multiple atherosclerotic aneurysms.

Femoral aneurysms are uncommon and are frequently associated with other aneurysms, particularly those of the aorta and popliteal arteries. Other peripheral aneurysms are even more rare. As far as we are aware, only one aneurysm of the lateral circumflex artery has been previously described. We describe such an aneurysm in association with a common femoral aneurysm on the same side, an abdominal aortic aneurysm and an iliac aneurysm on the contralateral side.

Intra-arterial thrombolytic therapy in the management of acute and chronic limb ischaemia.

A group of 54 patients with acute or chronic limb ischaemia were initially treated with low dose intra-arterial thrombolytic therapy using streptokinase (10,000 units h-1) or plasminogen activator (0.5 mg h-1). Complete thrombolysis was obtained in 90 per cent of patients with symptoms of less than 1 week duration, and in 50 per cent with symptoms of greater than 1 week (P less than 0.05). Successful lysis in 36 patients was followed by successful bypass surgery in seven, percutaneous angioplasty in 13, no further treatment in 13, repeat thrombolysis in two and amputation in one. Failed therapy was associated with major amputation in 40 per cent. One patient died of haemorrhage and another of stroke as a direct result of thrombolytic treatment. The most common complication was haematoma at the site of cannulation of the vessel. Intra-arterial thrombolytic therapy can be very useful for the management of acute and chronic limb ischaemia, but complications do occur and patients should be carefully selected.

Popliteal aneurysms identified by intra-arterial streptokinase: a changing pattern of presentation.

Five patients presenting with chronic or subacute leg ischaemia due to thrombosed popliteal artery aneurysm are described. Only one of these aneurysms was diagnosed before intra-arterial streptokinase infusion, which successfully lysed the thrombus in all cases. One aneurysm had been symptomatic for 5 years and another for 2 years. Popliteal aneurysm may well be underdiagnosed as a cause of chronic leg ischaemia.

Surgical aspects of international drug smuggling.

The internal concealment of cocaine and other drugs in packets by "body packers"--those who swallow packets of drugs or hide them in their vagina or rectum--to avoid detection by customs officials has been increasing in both the United States and Europe. The types of package and how they are concealed are changing as the traffickers become more sophisticated in their methods. The latest parcels are less likely to burst, but obstruction of the bowel may occur. Awareness of the problem is important for staff of emergency medical services near international ports of arrival.