Diverse manifestations of a sickle cell crisis.

We describe the case of a 21-year-old man with a background of sickle cell disease (SCD) who was on acute presentation in a sickle cell crisis required immediate intensive care admission with red blood cell exchange and ventilatory support. He had right frontal lobe infarcts and extensive bilateral deep white matter lesions most likely secondary to fat embolism. Inpatient investigations demonstrated a patent foramen ovale, explaining the route of spread of the fat embolus. He then had a transcatheter closure of the atrial defect. The patient needed prolonged inpatient rehabilitation. He was discharged from hospital in a wheelchair secondary to severe lower limb neurology and bilateral knee heterotopic ossification. He lives with the possibility of early onset dementia and cognitive decline, requiring constant care. The case highlights the multiple manifestations of SCD and their diverse and debilitating consequences.

Intravesical sodium hyaluronate reduces severity, frequency and improves quality of life in recurrent UTI.

PURPOSE: Urinary tract infections (UTI) occur in nearly half of all women at least once, with around 35% experiencing recurrences. Bladder mucosal glycosaminoglycan (GAG) layer damage is postulated to contribute. Sodium hyaluronate (SH) replenishes the GAG layer and is believed to be protective. However, there is limited literature on patient-reported outcomes and quality of life (QoL) after treatment. Our objective was to observe changes in UTI severity and QoL after treatment with intravesical SH. METHODS: In this retrospective, observational patient-reported outcome study, we examined outcomes in UTI patients treated with intravesical SH. SH was instilled weekly for 6 weeks. If symptoms persisted, patients received further instillations on demand. Patients were sent postal questionnaires to score symptoms before and after treatment. Patient-reported UTI occurrences before treatment were compared with recurrences after treatment collected from their primary care providers. RESULTS: There were 18 (58.1%) valid replies. The median age was 75. The median duration of illness before treatment was 4.5 (IQR 2.8-7) years. The median number of infections fell from ten per year (IQR 7-10) before treatment to two per year (IQR 0-5) after treatment. Pain improved by 34%, urgency 30%, nocturia 30%, frequency 32%, 'inability to carry out daily activities due to UTI related ill-health' 37% and 'loss of sleep' by 38%. Patients reported a 76% improvement in 'UTI-related QoL.' No adverse events were reported. CONCLUSION: SH is safe and useful for managing patients with recurrent UTI, with improvements in symptoms, QoL, a decrease in the number of UTI episodes and in the best interests of antimicrobial stewardship.

Correction to: Intravesical sodium hyaluronate reduces severity, frequency and improves quality of life in recurrent UTI.

The article "Intravesical sodium hyaluronate reduces severity, frequency and improves quality of life in recurrent UTI", written by Deepak Batura, Roisin Warden, Tumaj Hashemzehi, Malwina Julia Figaszewska was originally published electronically on the publisher's internet portal (currently SpringerLink) on October 15, 2019 without open access.

Should contrast CT urography replace non-contrast CT as an investigation for ureteric colic in the emergency department in those aged 65 and over?

PURPOSE: Elderly patients with upper tract urothelial cancer (UTUC) may present with colic and microscopic haematuria, mimicking urolithiasis. Patients presenting to emergency departments with acute ureteric colic are investigated with a CT KUB. CT urography (CTU) identifies UTUC better than a CT KUB. Thus, there is a possibility that a CT KUB may miss UTUC. METHODS: We studied patients aged 65 years or over presenting to the emergency department with ureteric colic and microscopic haematuria who had a CT KUB between January 2014 and October 2016. Patients who had both CT KUB and CTU were then compared to determine if CT KUB had missed a UTUC and if the diagnoses were concordant by the two tests. A radiologist independent from the reporting radiologists reviewed images as well as their reports. According to the Health Research Authority, England regulations, we did not obtain an ethical review on a voluntary basis for this retrospective study. RESULTS: Four hundred eighty-five patients [228 (47.01%) male and 257 (52.99%) female] had a CT KUB scan over the 34-month period. Their mean age was 74 (SD 6.97) [males 73 (SD 6.42), females 75 (SD 7.42)] years. One hundred eighty-seven scans were normal. Ureteric calculi (167), renal calculi (58) and renal cysts (28) were most frequent diagnoses. The diagnosis was uncertain in 33 patients (6.8%) [16 (48.49%) males and 17 (51.51%) females]. The mean age of this group of patients was 74 (SD 6.64) [males 73 (SD4.43), females 74 (SD7.64)] years. These patients had a CTU for clarity. CTU identified one UTUC not identified by CT KUB (0.2%), corroborated the diagnosis of a ureteric tumour in one patient and excluded UTUC in two others. CTU diagnosed two new bladder tumours and an endometrial tumour. Diagnoses were concordant between CT KUB and CTU in 17 of 33 patients (51.5%). CONCLUSIONS: CT KUB scans for patients 65 years and over presenting with ureteric colic is justified. Only a small proportion of patients will subsequently require the higher radiation dose CTU as the probability of missing UTUC is low.

A care bundle to improve perioperative mitomycin use in non-muscle-invasive bladder cancer.

PURPOSE: Intravesical chemotherapy administered within 24 h of the first resection of non-muscle-invasive bladder cancer (NMIBC) reduces recurrence rates and prolongs recurrence-free intervals. However, there is considerable variation in the use of intravesical chemotherapy amongst urologists. In our hospital, we use mitomycin C (MMC), and our usage was inconsistent. Therefore, we devised a care bundle to improve MMC usage. The objective of this study was to evaluate the effectiveness of the care bundle on postoperative MMC use. METHODS: We measured baseline postoperative MMC use during the first quarter of 2013. In 2014, we implemented a care bundle by changing MMC delivery, through computer-based clinical information systems and repeated training of key stakeholders. We studied the performance of the bundle through snapshot audits in the last quarter of 2014, a 6-month period in the middle of 2015 and again in the final quarter of 2016. RESULTS: We observed an increase in intravesical chemotherapy usage after implementing the care bundle. Instillation rates in our samples increased from 46% (6/13), in 2013 to 89% (8/9), in 2014, 90% (9/10), in 2015 and 100% (12/12), in 2016. CONCLUSION: Compliance rates of intravesical chemotherapy in NMIBC can improve by devising care bundles to modify team behaviour.

Beneath the tip of the iceberg: using electronic referrals to map the unquantified burden of clinical activity in a urology service.

INTRODUCTION: The aim of this study was to inform health policy by demonstrating the benefits of an electronic referral (e-referral) system to study inpatient referrals to urology departments. METHODS: London North West Healthcare NHS Trust has over 800 beds and several secondary and tertiary care services. In January 2014, we designed an e-referral form to requisition urology input for in-patients using the Integrated Clinical Environment™ (ICE) platform. We retrospectively reviewed e-referral records from February to December 2014 for patient demography, the referring service and disease groups triggering a referral. RESULTS: There were 1192 referrals. There was a median of 107 e-referrals per month (IQR 97-123, range 91-132) and 4 per day (IQR 2-6, range 0-12). Weekend e-referrals were 127 (median 1, IQR 0-2, range 0-5) with 1065 e-referrals on weekdays (median 4, IQR 3-6, range 0-12). A total of 848 (71.1 %) patients were male, and 344 (28.9 %) were female. Patients' mean age was 63 (SD 21) years. Almost half (550, 46 %) were acute referrals. Amongst the acute referrals, the majority (466, 84.7 %) arose from A&E. From the non-acute conditions, 381 (59.3 %) patients were from the medical specialities and 246 (38.3 %) from surgical disciplines. The three largest disease categories were urolithiasis (287, 24.1 %), haematuria (185, 15.5 %) and for ex-catheterisation (102, 8.6 %). A qualitative review showed the strengths and weaknesses of the system, enabling improvements in operational efficiency. CONCLUSION: An e-referral system monitors activity accurately. Systemic improvement in referral pathways would lead to better patient care and enable services to factor in the unseen component of workload and prompt realistic staffing.