Regulation of medical care is something that has grown from humble roots in professional craft groups to huge establishment in well-resourced, high-income countries. Self-regulation was the preferred method of determining appropriate behaviour initially, but a lack of public trust in this, and the desire of patients to contribute to the establishment of the standard of care that they receive, has meant that most Anglophone countries have adopted some form of independent regulation. Regulators are responsible for the registration of doctor's qualifications, licensing them to practise, accrediting institutions to provide undergraduate and postgraduate education and certifying the attainment of accepted standards of achievement by some form of assessment process. Regulators also have powers to sanction individuals whose practice falls outside expected levels of competence. Both centralized and devolved models of regulation have evolved. Much of the accreditation for postgraduate education and training has been handed down to collegiate bodies, or non-governmental organizations, who can also certify completion of training. Evidence-based medicine and clinical practice guidelines have enforced an informal tier of regulation in high-income countries; guideline-derived practice is now widely regarded as an accepted standard of care. In low- and middle-income countries in sub-Saharan Africa the governmental and legislative structures and finance available to provide the regulation espoused in more privileged environments is rarely available. The workforce is structured in a completely different way and some care groups are totally unregulated. Medical councils in sub-Saharan Africa fulfil a registration and licensing function but surgical collegiate bodies provide the structure for postgraduate training. The East and West African Colleges of Surgeons have developed into robust organizations, who have verifiable, quality-assured, accreditation systems that have helped improve standards of care for the large populations for which their member surgeons are responsible. Formal regulation of continuing practice and sanctions are challenges that are, at present, largely unaddressed.
This study was designed to investigate non-invasively human ureteric function between individuals and with increasing diuresis, using the radioisotope compressed image technique. Five normal males underwent fast frame renography with ureteric spindle imaging in dehydrated and hydrated states, urine production being measured in each individual for each scan. Urine flow rates and renographic parameters demonstrated that each ureter carried more urine in the hydrated state. The velocity at which individual boluses passed down the ureter was constant for each ureter and did not change with diuresis. The ureteric peristaltic rate showed wide individual variation between ureters in the same subject, but fell within what is becoming accepted as the "normal range" of < 4 urine boluses per minute. Some ureters accommodated an increase in urine flow by an increased peristaltic frequency, some showed no change and others showed a decreased frequency. In those ureters in which there was no change, or a decrease in peristaltic frequency with diuresis, the increased urine flow must have been handled by increases in bolus volume. Thus increases in ureteric urine flow in man are accommodated by changes in both peristaltic frequency and bolus size. The results are discussed in relation to previous studies which used invasive techniques.
A retrospective study was undertaken of the results of vasography in 440 male partners of infertile marriages who had undergone scrotal exploration and in a group of 42 men with a variety of genital tract disorders. Abnormalities were observed in 10% of 265 azoospermic men and in 4% of 175 other men with infertility. There was no evidence that vasography caused damage to the vas deferens and no oligozoospermic man became azoospermic. A high incidence radiological of abnormalities was seen in haemospermia but the incidence of abnormalities in selected men with ejaculatory problems or testicular pain was low.
The dynamics of disease prevalence and healthcare systems continue to change dramatically in low- and middle-income countries (LMICs). This is a result of multiple factors including the demands of an ageing population in the context of increasing life expectancy and the rise of non-communicable diseases putting an additional burden on an already weak healthcare system. Further healthcare deficiency is attributable to additional factors such as low financial budgets, political conflicts and civil war, as well as continuing burden of communicable diseases, which are known to be the major risk to health in LMICs. Surgical needs largely remain unmet despite a Lancet report published in 2015. Various deficient aspects of healthcare systems need to be addressed immediately to provide any hope of creating a sustainable healthcare environment in the coming decades. These include developing strong primary and secondary care structures as well as strengthening tertiary care hospitals with an adequately trained healthcare workforce. The facilities required to improve patients' access to healthcare cannot be developed and sustained solely within the local budget allocation and require major input from international organizations such as the World Bank and the World Health Organization as well as a chain of donor networks. To create and retain a local healthcare workforce, improved training and living conditions and greater financial security need to be provided. Finally, healthcare economics need to be addressed with financial models that can provide insurance and security to the underprivileged population to achieve universal health coverage, which remains the goal of several global organizations promoting equity in high-standard healthcare provision.
Summary— Urothelial biopsies from ureters intubated with silicone (11) and other polymer (13) double J stents revealed features of mucous metaplasia in 12/24 cases. These changes were associated with encrustation of the stents and occurred principally in stone‐forming patients.
Fifty patients have been treated for upper tract urinary calculi by extracorporeal shock wave lithotripsy (ESWL) at the Devonshire Hospital lithotripter centre since November 1984. The average stay for an inpatient was 3 X 7 days. All patients suffered minimal postoperative discomfort and nearly all resumed normal activity within one day after discharge. Complications requiring auxiliary procedures were few. The procedure was found to be safe, cost effective, extremely well received by patients, and superior to all other methods of removing renal stones. This study confirms that treatment by ESWL is a specialised urological procedure that requires operators who are also trained in open, percutaneous, and ureteroscopic surgery and with a back up of a radiological team skilled in percutaneous renal puncture.
Objective: The aim of this study was to establish an evidence-based best clinical practice consensus for the management of urethral stricture disease in the UK. Methods: A systematic review of optimal management of urethral stricture generated a base document which was endorsed by the British Association of Urological Surgeons (BAUS) section of Andrology and Genito-Urinary Reconstructive Surgeons (AGUS). A two-round electronic mail modified Delphi survey of 43 consultant reconstructive urologists, members of the British Association of Genito-Urinary Reconstructive Surgeons (BAGURS), was then performed. The panel’s views about the base document was sought in seven domains: definition, diagnosis, investigation, conservative, endoscopic and reconstructive treatments, and follow up. Responses were collated and used to modify the base to achieve a consensus statement. Results: In round one of the Delphi process four panel members commented on the base document and seven in round two. Consensus was thereby reached on 38 statements regarding definition (one), diagnosis (three), investigation (two), conservative/endoscopic (five) and reconstructive (24) treatments and follow up (three) for the management of urethral stricture disease. Conclusion: This consensus statement will help standardise care, provide guidance on the management of urethral stricture disease, and assist in clinical decision-making for healthcare professionals of all grades.
OBJECTIVE To examine the urinary cytological changes caused by flexible cystoscopy and provide clinical guidelines for a reliable time interval for urinary cytological examination after flexible cystoscopy. PATIENTS AND METHODS Forty‐eight patients attending for flexible cystoscopy were recruited into the study. Each patient was asked to provide eight urine samples before, immediately after and at 1, 2, 7, 14 and 28 days after cystoscopy. Cytospin preparations of the urine samples were made and slides stained using the Papanicolaou stain. Cytology was analysed while unaware of sample origin, by three different cytopathologists. RESULTS The cytological changes were characterized by a striking increase in cellularity immediately after flexible cystoscopy, mostly accounted for by urothelial cells. Consistent morphological changes included the formation of ‘columnar’ cells, papillary clusters, increased nucleo‐cytoplasmic ratio and nuclear atypia. These changes were transient, with most disappearing within a day of flexible cystoscopy. CONCLUSIONS There are cytological changes, on voided urine cytology, after flexible cystoscopy but they were transient, and urine sent more than a day after flexible cystoscopy should be free from artefactual change caused by instrumentation. These results suggest that clinicians sending urine for cytological analysis should provide information about the nature and timing of any endoscopy so as to avoid false‐positive interpretations of urine cytology by the cytopathologist.
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)
'/%3e%3c/defs%3e%3cpath fill='%23012169' d='M0 0h10080v5040H0z'/%3e%3cpath stroke='%23fff' stroke-width='.6' d='m0 0 6 3m0-3L0 3' clip-path='url(%23b)' transform='scale(840)'/%3e%3cpath stroke='%23e4002b' stroke-width='.4' d='m0 0 6 3m0-3L0 3' clip-path='url(%23c)' transform='scale(840)'/%3e%3cpath stroke='%23fff' stroke-width='840' d='M2520 0v2520M0 1260h5040'/%3e%3cpath stroke='%23e4002b' stroke-width='504' d='M2520 0v2520M0 1260h5040'/%3e%3cg fill='%23fff'%3e%3cuse xlink:href='%23d' x='2520' y='3780'/%3e%3cuse xlink:href='%23a' x='7560' y='4200'/%3e%3cuse xlink:href='%23a' x='6300' y='2205'/%3e%3cuse xlink:href='%23a' x='7560' y='840'/%3e%3cuse xlink:href='%23a' x='8680' y='1869'/%3e%3cuse xlink:href='%23e' x='8064' y='2730'/%3e%3c/g%3e%3c/svg%3e)