The challenges and opportunities for implementing group antenatal care ('Pregnancy Circles') as part of standard NHS maternity care: A co-designed qualitative study.

OBJECTIVE: To identify the challenges and opportunities for rolling out a bespoke model of group antenatal care called Pregnancy Circles (PC) within the National Health Service: what kind of support and training is needed and what adaptations are appropriate, including during a pandemic when face-to-face interaction is limited. DESIGN: Exploratory qualitative study (online focus group). Study co-designed with midwives. Data analysed thematically using an ecological model to synthesise. SETTING: Five maternity services within the National Health Service. PARTICIPANTS: Seven midwives who facilitated PCs. Three senior midwives with implementation experience participated in the co-design process. FINDINGS: Three themes operating across the ecological model were identified: 'Implementing innovation', 'Philosophy of care' and 'Resource management'. Tensions were identified between group care's focus on relationships and professional autonomy, and concepts of efficiency within the NHS's market model of care. Midwives found protected time, training and ongoing support essential for developing the skills and confidence needed to deliver this innovative model of care. Integrating Pregnancy Circles with continuity of carer models was seen as the most promising opportunity for long-term implementation. Midwives perceived continuity and peer support as the most effective elements of the model and there was some evidence that the model may be robust enough to withstand adaptation to online delivery. KEY CONCLUSIONS: Midwives facilitating group care enjoyed the relationships, autonomy and professional development the model offered. Harnessing this personal (micro-level) satisfaction is key to wider implementation. Group care is well aligned with current maternity policy but the challenges midwives face (temporal, practical and cultural) must be anticipated and addressed at macro and meso level for wider implementation to be sustainable. The PC model may be flexible enough to adapt to online delivery and extend continuity of care but further research is needed in these areas. IMPLICATIONS FOR PRACTICE: Implementation of group care in the NHS requires senior leadership and expertise in change management, protected time for training and delivery of the model, and funding for equipment. Training and ongoing support, are vital for sustainability and quality control. There is potential for online delivery and integrating group care with continuity models.

Efficacy and safety of the EMS Swiss LithoClast® Trilogy for PCNL: results of the European multicentre prospective study on behalf of European Section of UroTechnology.

PURPOSE: PCNL requires a lithotrite to efficiently break stones, and some devices include active suction to remove the fragments. We set out to determine the efficacy and safety of the Swiss LithoClast® Trilogy, in a prospective European multicentre evaluation and compared it to published stone clearance rates for Trilogy based on surface area (68.9 mm2/min) and using the 3D calculated stone volume (526.7 mm3/min). METHODS: Ten European centres participated in this prospective non-randomized study of Trilogy for PCNL. Objective measures of stone clearance rate, device malfunction, complications and stone-free rates were assessed. Each surgeon subjectively evaluated ergonomic and device effectiveness, on a 1-10 scale (10 = extremely ergonomic/effective) and compared to their usual lithotrite on a 1-10 scale (10 = extremely effective). RESULTS: One hundred and fifty seven PCNLs using Trilogy were included (53% male, 47% female; mean age 55 years, range 13-84 years). Mean stone clearance rate was 65.55 mm2/min or 945 mm3/min based on calculated 3D volume. Stone-free rate on fluoroscopy screening at the end of the procedure was 83%. Feedback for suction effectiveness was 9.0 with 9.1 for combination and 9.0 for overall effectiveness compared to lithotrite used previously. Ergonomic score was 8.1, the least satisfactory element. Complications included 13 (8.2%) Clavien-Dindo Grade II and 2 (1.3%) Grade III. Probe breakage was seen in 9 (5.7%), none required using a different lithotrite. CONCLUSIONS: We have demonstrated that Trilogy is highly effective at stone removal. From a user perspective, the device was perceived by surgeons to be highly effective overall and compared to the most commonly used previous lithotrite, with an excellent safety profile.

'Will you be doing my operation doctor?' Patient attitudes to informed consent.

BACKGROUND: As part of the consent process, it is part of a doctor's duty of care to reveal any material risk. Depending upon the level of supervision, whether the operating surgeon is a trainee may be such a risk, but in our experience this is not routinely discussed with patients pre-operatively. We set out to discover patients' attitudes to being operated on by trainee urological surgeons. PATIENTS AND METHODS: A total of 101 completed questionnaires were received from patients (90 male, 11 female, mean age 72 years) undergoing transurethral resection of the prostate (TURP), transurethral resection of a bladder tumour (TURBT) or cystodiathermy on various aspects of their attitudes to being operated on by junior doctors as part of training. RESULTS: The response rate was 77%. Of the respondents, 94 patients (91%) thought that junior doctors should perform surgery as part of their training. Only 11 of 73 (15%) said they would be happy for a junior doctor, competent to perform the procedure, to operate unsupervised. Of 98 patients, 80 (82%) thought they should be told if the operation was going to be performed by a junior doctor, and 85 (87%) that they should be told their name and designation. CONCLUSIONS: For consent to be 'informed', the experience and identity of the surgeon should be made known to patients. Most patients are happy to be operated on by a junior doctor under consultant supervision, but would want to be told and know their name and status.

An open-label pilot study of cannabis-based extracts for bladder dysfunction in advanced multiple sclerosis.

The majority of patients with multiple sclerosis (MS) develop troublesome lower urinary tract symptoms (LUTS). Anecdotal reports suggest that cannabis may alleviate LUTS, and cannabinoid receptors in the bladder and nervous system are potential pharmacological targets. In an open trial we evaluated the safety, tolerability, dose range, and efficacy of two whole-plant extracts of Cannabis sativa in patients with advanced MS and refractory LUTS. Patients took extracts containing delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD; 2.5 mg of each per spray) for eight weeks followed by THC-only (2.5 mg THC per spray) for a further eight weeks, and then into a long-term extension. Assessments included urinary frequency and volume charts, incontinence pad weights, cystometry and visual analogue scales for secondary troublesome symptoms. Twenty-one patients were recruited and data from 15 were evaluated. Urinary urgency, the number and volume of incontinence episodes, frequency and nocturia all decreased significantly following treatment (P <0.05, Wilcoxon's signed rank test). However, daily total voided, catheterized and urinary incontinence pad weights also decreased significantly on both extracts. Patient self-assessment of pain, spasticity and quality of sleep improved significantly (P <0.05, Wilcoxon's signed rank test) with pain improvement continuing up to median of 35 weeks. There were few troublesome side effects, suggesting that cannabis-based medicinal extracts are a safe and effective treatment for urinary and other problems in patients with advanced MS.

The role of the human bladder lamina propria myofibroblast.

OBJECTIVES: To describe the ultrastructure and relationship to nerves of the myofibroblast in the human bladder lamina propria, and discuss its possible role in bladder function, including sensing stretch, as the response of the bladder to stretch has been thoroughly investigated by afferent nerve recordings, but specialized stretch sensing organs have yet to be identified. MATERIALS AND METHODS: Flexible cystoscopic bladder biopsies were obtained from patients with detrusor hyper-reflexia and from controls. Systematic electron micrographs were obtained throughout the lamina propria, and the presence and location of cells with ultrastructural characteristics of myofibroblasts noted, together with their relation to surrounding nerves. RESULTS: Within the lamina propria there was a layer of cells with the cytological characteristics of both fibroblasts and smooth muscle cells, that included bundles of fine cytoplasmic filaments, dense bodies, linear arrays of subsurface vacuoles, and the presence of an interrupted basal lamina. This combination of features is characteristic of the myofibroblast. These cells had close contacts with unmyelinated axonal varicosities containing a mixture of clear and large dense-cored vesicles, or clear vesicles alone. CONCLUSIONS: There is a layer of cells with the ultrastructural characteristics of myofibroblasts within the human bladder lamina propria. Their close contacts with nerves containing both small clear, and small clear with dense-cored, vesicles implies they have both an efferent and an afferent nerve supply, possibly functioning as a bladder stretch receptor. Furthermore, because of their similarities with the interstitial cells of Cajal in the gut, which are claimed to modulate small intestinal function, we discuss other possible roles for bladder lamina propria myofibroblasts.

Sacral neuromodulation and pregnancy.

PURPOSE: Sacral neuromodulation is effective for lower urinary tract dysfunction. However, despite its increasing use and a preponderance of female patients treated to our knowledge its effect in pregnant women and developing fetuses remains unknown. Therefore, we obtained information on patients on sacral neuromodulation who then achieved pregnancy. MATERIALS AND METHODS: Data were obtained using a standard questionnaire from 4 physicians with a total of 6 eligible patients. We recorded patient urological history, indication for neuromodulation, pregnancy course, the mode of delivery and neonatal health. We also noted the timing of implant deactivation and reactivation. RESULTS: In 5 patients the stimulator was deactivated between weeks 3 and 9 of gestation, after which 2 with a history of urinary retention had urinary tract infection. In another case, stimulation was discontinued 2 weeks before conception. The only noted complication developed in a pregnancy in which birth was premature at 34 weeks. Three patients underwent normal vaginal delivery, including 1 in whom subsequent implant reactivation did not resolve voiding dysfunction. In 3 cases elective cesarean section was performed. All neonates were healthy. CONCLUSIONS: When a patient on neuromodulation achieves pregnancy, the stimulation should be deactivated. If implant deactivation leads to urinary related complications that threaten the pregnancy, reactivation should be considered. Elective cesarean section should be discussed since it is possible for sacral lead damage or displacement to occur during vaginal delivery.

Capsaicin receptor VR1 and ATP-gated ion channel P2X3 in human urinary bladder.

OBJECTIVES: To determine the presence, distribution and molecular forms of the vanilloid receptor VR1, and confirm the presence and distribution of the ATP-gated ion channel P2X3 in the human urinary bladder. Materials and methods Normal urinary bladder tissues were obtained at postmortem from four subjects. Eight urinary bladder biopsies were also taken from patients with detrusor hyper-reflexia treated with intravesical resiniferatoxin. The specimens were studied using affinity-purified specific antibodies to VR1 and P2X3 by Western blotting and immunocytochemistry, and compared with immunostaining using antibodies to the pan-neuronal marker PGP 9.5 and Schwann cell marker S-100. RESULTS: VR1- and P2X3-immunoreactive fine nerve fibres were scattered throughout the suburothelium of the normal bladder and cystoscopic biopsies, and traversed the muscle layer. They had a similar distribution to PGP 9.5-immunoreactive fibres, but there were fewer, suggesting localization in subsets of axons. Western blot studies showed an expected 100-kDa VR1 protein and a P2X3-immunoreactive 66-kDa protein. Conclusion VR1 and P2X3 are present in the human urinary bladder and may contribute to distinct pathophysiological states of bladder overactivity, in accord with their differential expression in sensory neurones. Intravesical vanilloids act via VR1 and are effective in the treatment of detrusor hyper-reflexia. P2X3 may represent a selective therapeutic target for other causes of overactive bladder.

A Pacinian corpuscle in the human bladder lamina propria.

The fortuitous finding of a complex Pacinian corpuscle within the lamina propria of the human urinary bladder is described. It consisted of a complex of encapsulated nerve endings within the areolar connective tissue of the lamina propria immediately adjacent to the inner aspect of the detrusor muscle. It showed no structural evidence of directional sensitivity and was associated on its outer aspect with small unmyelinated axons containing small clear and dense-cored vesicles. This appears to be the first report of an encapsulated nerve ending within the lining of the adult human urinary bladder.

Presentation of thyroid carcinoma as a thrombosed external jugular vein, with intraluminal tumour thrombus in the great veins.

Carcinoma of the thyroid most commonly presents as an asymptomatic thyroid nodule. Some types of thyroid carcinoma show vascular invasion, but this is usually microscopic.(1,2)It is rare for such invasion to involve the great veins and be macroscopic. There are 18 such reports in the literature to date.(3-12)We report a case of a carcinoma of the thyroid that presented due to the presence of tumour thrombus within the external jugular vein, where thrombus was also seen within the great veins.

Results of holmium laser resection of the prostate for benign prostatic hyperplasia.

PURPOSE: To assess the results of holmium laser resection of the prostate (HoLRP) in the treatment of benign prostatic hyperplasia. PATIENTS AND METHODS: Since October 1996, 259 patients have undergone elective HoLRP. Peak urinary flow rates (Qax), IPSS scores, and duration of catheterization and hospital stay from admission to discharge catheter free were used as outcome measures. RESULTS: There were no perioperative deaths nor cases of transurethral resection syndrome. Two patients required blood transfusion. The mean duration of catheterization was 1.6 days and the mean hospital stay 2.9 days. The mean IPSS decreased from 21.0 preoperatively to 7.0 at 1 year, whilst the Qmax increased from 10.5 mL/sec to 20.5 mL/sec. CONCLUSION: The HoLRP technique is a safe and effective treatment for benign prostatic hyperplasia, allowing resection of the prostate at the level of the capsule with minimal bleeding or fluid absorption and with results equivalent to those of standard transurethral resection.

Lateral ligaments of the rectum: an anatomical study.

BACKGROUND: The lateral ligaments of the rectum are surrounded by confusion and misconception. Their identification before 'hooking them on the finger', clamping and ligating is considered in many surgical texts to be an essential step in mobilization of the rectum. By contrast, it is the experience of many colorectal surgeons that the mesorectum can be dissected out either by diathermy or sharp dissection alone. METHODS: Dissection in the mesorectal plane was performed on 28 cadaveric pelves. RESULTS: In ten of the pelves, no connective tissue structure crossed from the pelvic side wall to the rectum. The remaining 18 had only very insubstantial connective tissue strands crossing this space. A total of 17 middle rectal arteries were found, all of them unilateral. Fourteen of these vessels crossed the mesorectum independent of any structure, while the remainder were part of a neurovascular bundle with a connective tissue element. CONCLUSION: It is proposed that the 'lateral ligaments' of the rectum do not exist and that the term should be dropped from surgical texts. When present, the middle rectal artery is a small vessel, close to the pelvic floor. The entire rectum may be mobilized by sharp dissection without the need for clamping or ligation of any significant structure.

Management of the long-term urinary catheter in the asymptomatic patient in the Accident and Emergency department.

OBJECTIVE: To determine the management of long-term urinary catheters in the asymptomatic patient in the Accident and Emergency (A&E) Department. PATIENTS AND METHODS: Using data obtained from patient records, a retrospective study was undertaken of 41 patients who presented to the A&E department of a large district general hospital, on a total of 80 occasions in a 6-month period, with blocked or bypassing long-term urinary catheters, but who were otherwise asymptomatic. RESULTS: In 78% of presentations, patients had one or more investigations performed on their urine, which in 15% was on urine aspirated through an old, unchanged catheter. In 23% of presentations, patients were discharged only having had their catheters flushed, and in only 41% was the catheter changed as the first line of management. Finally, in 63% of episodes, patients were discharged with antibiotics, despite having no symptoms of a urinary tract infection. CONCLUSIONS: All patients with long-term urinary catheters will have bacteriuria and performing investigations on this urine if the patient is asymptomatic is a waste of resources. Long-term urinary catheters which become blocked usually do so by encrustation on the luminal surface of the catheter. Flushing these catheters may dislodge some of these encrustations, but ideally the catheter should be changed. The prescribing of antibiotics to asymptomatic patients with bacteriuria has no proven benefit, but on the contrary it may cause harmful side-effects and also selects for antibiotic-resistant bacteria. These patients should be managed in the A&E department with a simple catheter change.