The Success and Evolution of a Urological "Boot Camp" for Newly Appointed UK Urology Registrars: Incorporating Simulation, Nontechnical Skills and Assessment

BACKGROUND

Urological training has dramatically changed in recent years. Training durations are shorter and a drive toward consultant led care has reduced trainees experience. Within the UK, approximately 50 registrars annually embark on a 5-year Urology training programme, with variable levels of basic urological experience.

OBJECTIVE

To describe a simulation programme aimed at delivering the knowledge and skills necessary to safely and effectively start working as a registrar in Urology by intensive training with a 1:1 faculty to delegate ratio.

DESIGN, SETTING, AND PARTICIPANTS

Our course content mirrors the UK training syllabus for junior Urology registrars. We delivered 8 modules over a 4-day programme with a fifth day of assessments. Delegates level of urological knowledge, operative competency and confidence pre-, immediately post-training and at 3-months postcourse were assessed. Objective delegate and faculty feedback was also collected. Technical skills modules include; inguinoscrotal surgery, ureteroscopy, transurethral resection, urodynamics, and Botox administration as well as basic reconstructive and laparoscopic operative skills. "Nontechnical" skills included simulated ward round, out-patient, and emergency scenarios.

RESULTS

Feedback from delegates and faculty members has been overwhelmingly positive. We have used this feedback to tailor the content of the course for following years. An increased knowledge level (based on mean examination scores [precourse 55.5%, postcourse 70.1%]) and operative competency was observed in all skills assessed (transurethral resection of the prostate, transurethral resection of bladder tumor, Ureteroscopy, laparoscopic skills, and instrument assembly). Operative confidence was increased immediately and at 3-months postcourse.

CONCLUSIONS

Our "boot camp" course provides a realistic introduction and foundation to begin Urological practice. Being delivered at the beginning of the training scheme, prior to intensive patient exposure, registrars are in an optimum position to develop their newly acquired knowledge and skills to enhance training and intends to improve patient safety and satisfaction.

Global Collaborations for Cervical Cancer: Can the East-West Alliance Facilitate Treatment for all?

Despite the advances in the primary prevention of cervical cancer, there is an absolute increase in the incidence of cervical cancer as a result of an increase in world population. A vast majority of patients in low and low-middle income countries continue to present at a locally advanced stage, necessitating treatment with chemoradiation and brachytherapy. There is a dearth of equipment and trained professionals for the treatment of cervical cancer, especially in low and low-middle income countries. There is an urgent need to improve treatment availability and develop better treatments. Worldwide trends, however, reveal a low number of therapeutic and innovative research trials in cervical cancer. The present article elucidates the existing challenges and provides solutions to improve outcomes. The proposed strategies hinge on strengthening collaborations for global advocacy.

A linear viscoelastic model to understand skin mechanical behaviour and for cosmetic formulation design

OBJECTIVES

Skin is arguably one of the most important organs that plays an active role in our everyday biological functions after brain. Owing to the wide range of applications in medicine, cosmetics industry and more recently robotics, skin research has gained tremendous attention with respect to its mechanical behaviour. Various macro modelling approaches are available for modelling skin's mechanical behaviour. The objective of this paper is to study skin's mechanical property change with age and demonstrate anti-ageing effects of cosmetic formulations from skin mechanical property change perspective.

METHODS

In this study, skin's mechanical behaviour was modelled using a 1D linear viscoelastic phenomenological model and the model was validated using two sets of experimentally observed skin data (strain, stress relaxation and cyclical loading). The model was further modified to study the effect of the presence of a thin layer of cosmetic polymer and to demonstrate anti-ageing effects of the cosmetic polymer from the perspective of change in the mechanical behaviour of skin with cosmetic layer.

RESULTS

The estimated values of skin mechanical properties from the model agree with those in literature. The extracted model features show good correlation with skin age (viscosity and time constant). The results from our model indicate that the cosmetic polymers enhance the mechanical properties of skin significantly.

CONCLUSIONS

This work will find its applications in designing and testing anti-ageing formulations. This model can be used to filter various combinations of cosmetic formulations by knowing the mechanical response of polymer on skin, thereby accelerating the product development.

Autologous bone marrow clot as an alternative to autograft for bone defect healing

Objectives

Long bone defects often require surgical intervention for functional restoration. The ‘gold standard’ treatment is autologous bone graft (ABG), usually from the patient’s iliac crest. However, autograft is plagued by complications including limited supply, donor site morbidity, and the need for an additional surgery. Thus, alternative therapies are being actively investigated. Autologous bone marrow (BM) is considered as a candidate due to the presence of both endogenous reparative cells and growth factors. We aimed to compare the therapeutic potentials of autologous bone marrow aspirate (BMA) and ABG, which has not previously been done.

Methods

We compared the efficacy of coagulated autologous BMA and ABG for the repair of ulnar defects in New Zealand White rabbits. Segmental defects (14 mm) were filled with autologous clotted BM or morcellized autograft, and healing was assessed four and 12 weeks postoperatively. Harvested ulnas were subjected to radiological, micro-CT, histological, and mechanical analyses.

Results

Comparable results were obtained with autologous BMA clot and ABG, except for the quantification of new bone by micro-CT. Significantly more bone was found in the ABG-treated ulnar defects than in those treated with autologous BMA clot. This is possibly due to the remnants of necrotic autograft fragments that persisted within the healing defects at week 12 post-surgery.

Conclusion

As similar treatment outcomes were achieved by the two strategies, the preferred treatment would be one that is associated with a lower risk of complications. Hence, these results demonstrate that coagulated BMA can be considered as an alternative autogenous therapy for long bone healing.

Cite this article: Z. X. H. Lim, B. Rai, T. C. Tan, A. K. Ramruttun, J. H. Hui, V. Nurcombe, S. H. Teoh, S. M. Cool. Autologous bone marrow clot as an alternative to autograft for bone defect healing. Bone Joint Res 2019;8:107–117. DOI: 10.1302/2046-3758.83.BJR-2018-0096.R1.

Oral hygiene, prevalence of gingivitis, and associated risk factors among pregnant women in Sarlahi District, Nepal

BACKGROUND

The oral health status of pregnant women in low-resource communities such as Nepal has not been well characterized. This sub-population is also of specific interest given associations between poor oral health and adverse pregnancy outcomes previously documented in other settings. We explored relationships between gingivitis and risk factors among pregnant women in rural Nepal.

METHODS

The design was a community-based, cross-sectional study in a sub-area of Sarlahi District, Nepal. Pregnant women < 26 weeks gestation underwent clinical periodontal exams conducted by community-based oral health workers. Exams included a full mouth assessment measuring bleeding on probing (BOP), probing depth (PD) (six sites per tooth), and gingival recession, the distance from the cemento-enamel junction to the free gingival margin (two direct sites per tooth). Data on participant risk factors were collected through household surveys, including demographic characteristics, oral health behaviors, care seeking, and health attitudes. Multivariable logistic regression modeling was used to assess relationships between gingivitis and risk factors.

RESULTS

We enrolled 1452 participants, of which 40% (n = 582) had signs of clinical gingivitis and 60% (n = 870) clinical health. Average participant age was 23. Most participants (88%) had never received oral health care. Participants averaged 10% of sites with BOP with most (79%) having ≥1 site with BOP. Nine percent of participants had ≥1 site with PD ≥4 mm, although very few participants (0.7%) had sites with PD ≥5 mm. Few participants (13%) had any recession (≥1 mm). In the final adjusted model, odds of gingivitis increased by 3% for each year of age (aOR 1.03, 95% CI 1.00, 1.06) and were higher for women of short maternal stature (< 150 cm) (aOR 1.43, 95% CI: 1.14, 1.79) and among women reporting cost to be a barrier to seeking dental care (aOR 2.13, 95% CI: 1.09, 4.15).

CONCLUSIONS

Gingivitis was common and associated with age, maternal stature, self-reported high cost of dental care, and other risk factors among pregnant women in rural Nepal.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial).

Complete Annular Pancreas with Concurrent Entero-Pancreatico-Biliary Symptoms in Adult: A Case Report

Complete Annular pancreas (AP) is a rare congenital anomaly, often presented and operated at the early age of life. Adult presentation group usually presents with either biliary or duodenal or pancreatic symptoms. We report a case of 43 years old female presenting with concurrent enteric, biliary and pancreatic symptoms admitted on April 2016 in Hepatobiliary and Pancreatic Surgery Department of BSMMU, Dhaka, Bangladesh. A complete type of annular pancreas with partial duodenal stenosis and dilated common bile duct was observed during laparotomy. We performed gastrojejunostomy as well as hepaticojejunostomy (Roux-en-Y anastomosis). Patient was discharged in a good symptom free condition. Complete Annular Pancreas can present at any age, with any one or all of the biliary, pancreatic or duodenal symptoms. Surgery is the treatment of choice and has a good outcome.

Effect of management system and season on semen freezability in Jakhrana bucks

AIM

The objective of the study was to determine the effect of the management system (intensive and semi-intensive) and season (autumn and winter) on semen freezability in Jakhrana bucks.

MATERIALS AND METHODS

A total of 24 Jakhrana bucks of same body weight and age (BW=30 kg, age=1 year) were randomly allotted into two groups, viz., Group I (intensive system, 12 bucks) and Group II (semi-intensive system, 12 bucks). These two groups were statistically tested for their homogeneity with respect to age and BW. Semen was collected twice weekly using an artificial vagina during two seasons: autumn (September-November) and winter (December-February). A total of 240 semen samples (120 from each group and season) were evaluated for post-thaw motility (PTM), viability, abnormality, functional membrane integrity (hypo-osmotic swelling [HOS]) response and acrosomal integrity.

RESULTS

The mean values of PTM and acrosomal integrity of spermatozoa were significantly (p<0.01) higher in Group II as compared to Group I. The mean values of viability and abnormality were also differed significant (p<0.05) between groups. However, the mean values of HOS response were found non-significant (p>0.05) between groups. The season showed a significant effect on all parameters except viability and HOS response. The PTM and acrosomal integrity of spermatozoa were significantly (p<0.01) higher in winter as compared to autumn season. Abnormality of spermatozoa was significantly (p<0.05) lower in winter season.

CONCLUSIONS

This study indicates that both management system and season influence semen freezability. The semen collected from bucks reared under the semi-intensive system and winter season showed better semen freezability characteristics.

Dosimetric evaluation and clinical outcome in post-operative patients of carcinoma vulva treated with intensity-modulated radiotherapy

BACKGROUND

To compare dosimetric parameters of intensity-modulated radiation therapy (IMRT) with 3D conformal radiotherapy (3DCRT) in post-operative patients of vulvar cancer and to assess clinical outcome and toxicity with IMRT.

MATERIALS AND METHODS

A total of 8 post-operative patients of vulvar cancer were treated with IMRT. All patients were also planned by 3DCRT for comparison with IMRT. The two plans were compared in terms of conformity index, homogeneity index, tumor control probability (TCP) and normal tissue complication probability (NTCP) for the planning target volume and organs at risk (OAR).

RESULTS

IMRT resulted in significantly lesser doses to rectum, bladder, bowel and femoral head as compared with 3DCRT plans. Mean conformity and homogeneity indices were better and within range with IMRT. The TCP was comparable between the two treatment plans and NTCP for rectum, bladder, bowel and femoral head was significantly less with IMRT as compared with 3DCRT. Treatment was well-tolerated and none of the patients developed Grade 3 or higher toxicity.

CONCLUSION

IMRT yielded superior plans with respect to target coverage, homogeneity and conformality while lowering dose to adjacent OAR as compared with 3DCRT. Thus, IMRT offers a reduction in NTCP while maintaining TCP.

Bladder-Rectum Spacer Balloon versus Vaginal Gauze Packing in High Dose Rate Brachytherapy in Cervical Cancer: A Randomised Study. Part II

AIMS

To compare the inter-fraction dose variation for bladder and rectum using a bladder-rectum spacer balloon (BRSB) versus vaginal gauze packing (VGP) in patients treated with high dose rate intracavitary brachytherapy for carcinoma cervix.

MATERIALS AND METHODS

After the completion of external radiotherapy, 80 patients were randomised to receive intracavitary brachytherapy using either the BRSB or VGP. The procedure was carried out under general anaesthesia using tandem ovoid applicators. Computed tomography-based planning was carried out and the dose was prescribed to point A. Doses to 0.1, 1 and 2 cm(3) volumes were reported for bladder and rectum for each fraction. The absolute inter-fraction dose variation for each subvolume was compared using the independent sample t-test.

RESULT

The mean bladder and rectal volumes, as well as the inter-fraction volume variation, were comparable for the BRSB and VGP. The BRSB resulted in a significant reduction in absolute dose as well as the inter-fraction variation for dose to 2 cm(3) rectum volumes (BRSB 0.80 Gy, standard deviation 0.71 Gy versus VGP 1.16 Gy, standard deviation 0.83 Gy; P = 0.04). Cumulative bladder D2cm(3) doses of more than 90 Gy3 were observed in six patients in the BRSB arm versus four patients in the VGP arm (P = 0.73). In both the arms, the rectal D2cm(3) doses did not exceed 75 Gy3.

CONCLUSIONS

Use of a BRSB resulted in a significant reduction in inter-fraction variation in D2cm(3) rectal dose. However, no significant difference in the inter-fraction dose variation for the other subvolumes of bladder and rectum could be shown between the BRSB and VGP. The use of a BRSB may enable rectal dose reduction and inter-fraction variation where anaesthesia is not routinely used or where there is limited physician expertise. The modification suggested in the BRSB may facilitate its additional usage.

Affinity-selected heparan sulfate for bone repair

Bone morphogenetic protein (BMP)-2 is a potent bone healing compound produced at sites of bone trauma. Here we present a therapeutic strategy to harness the activity of endogenously produced BMP-2 by delivery of an affinity-matched heparan sulfate (HS) glycos aminoglycan biomaterial that increases the bioavailability, bioactivity and half-life of this growth factor. We have developed a robust, cost effective, peptide-based affinity platform to isolate a unique BMP-2 binding HS variant from commercially available preparations of HS, so removing the manufacturing bottleneck for their translation into the clinic. This affinity-matched HS enhanced BMP-2-induced osteogenesis through improved BMP-2 kinetics and receptor modulation, prolonged pSMAD signaling and reduced interactions with its antagonist noggin. When co-delivered with a collagen implant, the HS was as potent as exogenous BMP-2 for the healing of critical-sized bone defects in rabbits. This affinity platform can be readily tuned to isolate HS variants targeted ata range of clinically-relevant growth and adhesive factors.

Modification of polystyrene surface in aqueous solutions

Herein, we report our analysis of the surface modification of polystyrene (PS) when treated under ambient conditions with a common biological buffer such as phosphate buffered saline (PBS) or aqueous solutions of the ionic constituents of PBS. Attenuated total reflection Fourier transform infrared spectroscopy was used for the analysis because the resultant spectra are very sensitive to minor changes in the chemical and structural properties of PS films. In addition, ultraviolet-visible spectroscopy was applied to characterize the surface modifications of PS. Treatment with PBS resulted in the most significant chemical and structural surface modifications of the PS films, as compared with each of the solutions of the constituents of PBS, which were tested separately. A multistep mechanism for the wet modification of PS is discussed. We postulate that the observed surface modifications are the result of photo-oxidation/reduction, swelling, and conformational changes and re-arrangement of the polymer chain. The resultant surface modifications could be similar to those produced by commonly used dry processes such as plasma treatments and electron, ion or ultraviolet irradiation. We found that the modifications that occurred in PBS were more stable than those initiated by dry processes. The formation of active groups on the surface of PS can be controlled by adsorption of bovine serum albumin or thermal annealing of PS before PBS treatment. This approach provides a simple and efficient method for the surface modification of PS for biomedical applications.