Diagnostic imaging--the end of intravenous urography?

For diagnosing patients with acute flank pain, unenhanced helical computed tomography (CT) is the most accurate method. However, conventional diagnosis using sonography and intravenous urography yields comparable results. For proper assessment, the availability, radiation dose, and cost have to be considered as well. Although the availability of CT has increased, radiation dose and cost are in favour of conventional diagnosis. At this time, we recommend sonography as the primary method. Depending on availability, intravenous urography or CT is a possible alternative.     

Interferon alfa in the treatment paradigm for non–muscle-invasive bladder cancer

ObjectivesIn this article, we review the various options for and the potential role of interferon alfa (IFN-α) in the treatment of non–muscle-invasive bladder cancer (NMIBC).MethodsPubMed was searched for journal articles on IFN-α use in treating bladder cancer. The references listed in the National Comprehensive Cancer Network guidelines were used as a guide to identify relevant publications on treatments for NMIBC.ResultsTransurethral resection with adjuvant intravesical chemotherapy or immunotherapy is the standard treatment option for NMIBC. Adjuvant IFN-α therapy has limited efficacy in preventing recurrences in intermediate-risk and high-risk patients; bacillus Calmette-Guérin (BCG) monotherapy is the recommended first-line treatment in these patients. Unfortunately, cancer progression or recurrence is a common outcome; radical cystectomy, which is often the lifesaving approach in such a scenario, is associated with significant morbidity, mortality, and decreased quality of life. Current alternatives to cystectomy include repeat intravesical immunotherapy, conventional instillation chemotherapy, and device-assisted intravesical chemotherapy. The efficacy of any chemotherapy after BCG failure, either conventional or device assisted, has not been established. BCG and IFN-α combination intravesical therapy has not been investigated thoroughly; based on available data, combination therapy appears to be most effective in patients with carcinoma in situ and may be preferentially considered as an alternative to radical cystectomy for patients with intermediate-risk or high-risk NMIBC who do not tolerate the standard BCG dose or experience BCG failure after 1 year of therapy. However, this approach requires close follow-up and should only be chosen after careful consideration of all risk factors.ConclusionsThere is a lack of efficacious treatment options for patients with NMIBC recurrence or progression after initial BCG treatment. There is a need for well-designed clinical trials investigating the safety and efficacy of available therapies, including BCG and IFN-α2b combination therapy.     

Pre-prostatectomy intravenous urography — Is it a must?

The value of intravenous urography (IVU) as a pre-operative necessity in patients with enlarged prostate is discussed. 150 IVUs were studied retrospectively, and on the basis of the findings it was concluded that it is still an important investigation in patients with "prostatism": 13.3% showed impaired renal function and back pressure changes, 21.3% showed coexistence of abnormalities and pathology of the urinary tract and 59.3% suggested enlarged prostate.     

Can parturients distinguish between intravenous and epidural fentanyl?

We tested the hypothesis that the sedative, euphoric, and analgesic effects of intravenous fentanyl would distinguish intravenous from epidural administration. One hundred ASA I and II labouring parturients received 100 μg fentanyl either iv or via an epidural catheter in a double-blind, randomized, crossover fashion. Nineteen anaesthetists (8 staff and 11 residents) participated and correctly guessed the route of administration of the fentanyl in 61/66 intravenous doses and in 69/75 epidural doses yielding a sensitivity of 92.4%, a specificity of 92.0%, a positive predictive value of 91.0%, and a negative predictive value of 93.2%. Of the 41 patients that were crossed over, 38 (92.7%) were able to detect a difference between the routes of administration. Most patients experienced prompt, short-lived symptoms with iv fentanyl but no important differences in fetal heart rate pattern or in maternal desaturation were seen between the groups. This study suggests that subjective symptoms will accurately distinguish intravenous from epidural fentanyl administration in labouring parturients (P < 0.001), and should serve as a safe and reliable intravenous test dose for epidural anaesthesia in the obstetric population.     

Total intravenous or balanced anaesthesia in ambulatory surgery?

General anaesthesia is still the most common anaesthetic technique in the ambulatory surgery setting. With the introduction of propofol, total intravenous anaesthesia gained widespread acceptance. Recently, the combination with remifentanil, an ultra-short acting opioid analgesic, allowed even more control over the duration of the anaesthetic. In comparison to propofol, however, the new inhalational anaesthetics desflurane and sevoflurane possess a pharmacokinetic profile that is preferable to that of propofol. Initial studies show that these pharmacokinetic advantages lead to a faster short-term recovery, although both substances have been associated with a higher incidence of postoperative nausea and vomiting. No differences have so far been demonstrated in respect to long-term recovery, discharge from the post-anaesthesia care unit and discharge from the ambulatory care centre. Currently the anaesthesiologist has the possibility to choose his preferred anaesthetic technique based on individual patient needs, the surgery performed and the side-effects each technique may have. However, in contrast to the situation at the beginning of the 1990s total intravenous anaesthesia is not the technique that fits all needs but balanced anaesthesia presents an alternative.     

Is intravenous urography a prerequisite for renal shockwave lithotripsy?

PURPOSE: To determine whether intravenous urography (IVU) is a prerequisite for shockwave lithotripsy (SWL) of renal stones by addressing whether using non-contrast-enhanced CT (NCCT) instead of IVU for delineating urinary tract anatomy is associated with post-SWL complications. PATIENTS AND METHODS: Thirty-eight patients treated by SWL (Econolith 2000) for radiopaque renal stones underwent either IVU or NCCT. Twenty patients with normal urinary tracts or with mild hydronephrosis proximal to the stone on urography comprised the IVU group. Eighteen patients who underwent NCCT and plain abdominal (KUB) films and had urinary tract systems similar in appearance to the IVU group comprised the NCCT group. The two groups were of similar mean age (45.75 years, range 24-73 years; and 49.0 years, range 26-72 years, respectively) and had a similar mean stone size (10.1-10.2 mm). Patients with internal ureteral or nephrostomy catheters were excluded. Information on episodes of intractable renal colic, urinary tract infections, and hospitalization was recorded at follow-up 2 to 6 weeks post-SWL. RESULTS: The IVU and NCCT patients had similar mean stone fragmentation rates (80% and 74%, respectively) at 2 to 6 weeks post-SWL. Four IVU patients (20%) had intractable renal colic. One NCCT patient (5.5%) had a urinary infection. Complication and hospitalization rates in the two groups were not significantly different (P = 0.34; Fisher' exact test). CONCLUSIONS: Using only NCCT before SWL was not associated with higher complication rates. Thus, IVU is not a prerequisite for SWL of radiopaque renal stones in patients with a normal urinary tract anatomy as seen on NCCT.     

Sub-Tenon's block: are fasting and intravenous access necessary?

Editor—You recently published a thorough and informativereview of the sub-Tenon’s block by Canavan and colleagues.¹We applaud their fine effort, but were disappointed that theydid not discuss the issue of preoperative fasting. We wouldalso like to take issue with their assertion that lack of i.v.access is a     

EMLA® patch for intravenous cannulation in adult surgical outpatients

Purpose

The purpose of this study was to evaluate the effectiveness of a single-unt-dose package of the EMLA® Patch for dermal analgesia during intravenous cannulation in adult outpatients and in preventing vaso-vagal side effects.

Methods

After giving consent. 51 ASA I–III adult outpatients participated in a randomized, double-blind, placebo-controlled, parallel-group tnal to receive either an EMLA* or placebo patch applied to the intravenous cannula site for 60 to 90 mm. Following cannula insertion, patients and investigators rated the pain using a 100 mm VAS ruler. The incidence and seventy of vaso-vagal responses, local skin reactions, and willingness to pay for the patch were also evaluated.

Results

The median VAS pain score by patient assessment in the EMLA® patch group was lower (8 mm; range: 0–92) than in the placebo group (25 mm; range: 0–98, P < 0.05). The median VAS pain score by Investigator assessment was also lower in the EMLA® patch group (15 mm; range 1–79) than in the placebo group (23 mm; range 3–81. P < 0.05). There was a notable difference in the number of vaso-vagal reactions (17 placebo vs 4 EMLA®, P < 0.05). Eighty-eight percent of patients who received the EMLA® patch would be willing to pay for the patch in the future compared with 69% of the placebo patch patients.

Conclusion

This study showed that the EMLA® patch, applied for 60–90 min before venous cannulation reduced the pain of venepuncture and vaso-vagal side effects in adult outpatients.     

Oxytocin injection after Caesarean delivery: intravenous or intramyometrial?

Purpose

To determine, after Caesarean delivery, uterine contractility and blood pressure following intravenous (iv) and intramyometrial (imy) injection of oxytocin.

Methods

In a double-blind clinical trial 40 parturients scheduled for elective Caesarean section with spinal anaesthesia were randomized into two equal groups. One litre Ringer’s lactate was administerediv before intrathecal injection of 1.7 ml bupivacaine 0.75% and 0.3 mg morphine. All patients received simultaneous iv andimy injections after removal of the placenta. Patients in Group 1 received 5 IU (10 IU·ml^?1) oxytociniv and 2 ml salineimy; Group 2 patients received 0.5 ml saline iv and 20 IU oxytocin into the myometrium. Baseline systolic blood pressure (SBP) and heart rate were measured before delivery and at one minute intervals for 15 min after injection of study solutions. Uterine contractility was assessed at 1, 2, 4, 6, 8, 10 and 15 min after oxytocin injection. Haemoglobin concentration before surgery and on first post-operative day was also recorded.

Results

Mean decrease in systolic blood pressure (SBP) one minute after oxytocin was 8.4 mmHg in Group 1vs 14.6 mmHg in Group 2 (P < 0.001). Systolic blood pressure returned to baseline two minutes after oxytocin in Group 1 and after three minutes in Group 2. Uterine contractility and change in haemoglobin concentration were similar in both groups.

Conclusion

Intramyometrial administration of 20 IU oxytocin after Caesarean delivery is associated with more severe hypotension than is iv injection of 5 IU oxytocin. Route of oxytocin injection did not affect uterine tone.