Innovative training modality for sacral neuromodulation (SNM): Patient-specific computerized tomography (CT) reconstructed 3D-printed training system: ICS School of Modern Technology novel training modality.

INTRODUCTION: Sacral neuromodulation (SNM) is an effective treatment of urinary and bowel dysfunction, including secondary to neurological disorders. The learning curve for the optimal electrode placement for SNM is steep, expensive, and limited by patient factors such as obesity and previous injuries. We aim to create a patient specific 3-dimensional (3D) model for successful SNM training. MATERIALS AND METHODS: A total of 26 urology residents who had different level of knowledge and experience were enrolled to the 3D SNM training program. The creation of 3D sacrum model has been started with evaluation of real patient computerized tomography images and creation of Digital Imaging and Communications in Medicine files. The segmented anatomic structures from the files then edited and stereolithographic files were generated for 3D-model prints via Mimics© software. The 3D-printed models were used for training and evaluation of participants during the SNM intervention was performed. The evaluation of 3D SNM model training was led by one mentor who is expert on SNM. RESULTS: On the preprinted 3D sacrum model all 26 participants were requested to perform the essential steps to complete a SNM procedure and individual procedure time was recorded. The mean and median scores were 18.8 and 19, respectively according to Likert scores (min 11 max 28). CONCLUSIONS: SNM is increasing in popularity as a treatment option with physicians and patients with refractory symptoms. Few experienced specialists exist, and more effective training methods are needed to tackle the increasing demand, and individual patient anatomy.

Urogynaecology and Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) can lead to a presentation to urogynaecology services with multiple symptoms including vaginal prolapse, overactive bladder symptoms, voiding dysfunction, bladder pain syndrome, recurrent urinary tracts infections, stress urinary incontinence, recurring bladder diverticula, vesicoureteral reflux, pelvic floor pain or spasms, and complicated postnatal perineal wounds. This article explores the pathophysiology of these conditions in causing urinary urgency, incontinence, and infections; highlighting the key investigations and management considerations for women with EDS including conservative, pharmacological, and surgical.

Mental health among clinicians: what do we know and what can we do?

Mental health and mental health disorders among clinicians remain a taboo, despite increasing evidence showing the direct impact on medical teams and patient care. This editorial is aimed at increasing awareness of mental issues amongst healthcare professionals, identifying perceived barriers to seeking help, and suggesting ways in which to seek help. Mental health disorders, including anxiety and depression, are prevalent from medical school, leading to increased burnout and suicide risks at later stages of a clinician's career. There is often a reluctance to seek help, particularly amongst the surgical specialties, caused by self-criticism, lack of convenient access and the potential negative impact on medical licensure. This editorial has been written in loving memory of our colleague, friend and board member Dr. Nikolaus Veit-Rubin, who sadly passed away at the beginning of the year. It is written in the hope of highlighting the importance of maintaining mental wellbeing amongst the medical team, supporting help-seeking behaviour and changing attitudes toward mental health disorders amongst clinicians.

Delayed Diagnosis and Complications of Predominantly Antibody Deficiencies in a Cohort of Australian Adults.

Background: Predominantly antibody deficiencies (PADs) are the most common type of primary immunodeficiency in adults. PADs frequently pass undetected leading to delayed diagnosis, delayed treatment, and the potential for end-organ damage including bronchiectasis. In addition, PADs are frequently accompanied by comorbid autoimmune disease, and an increased risk of malignancy. Objectives: To characterize the diagnostic and clinical features of adult PAD patients in Victoria, Australia. Methods: We identified adult patients receiving, or having previously received immunoglobulin replacement therapy for a PAD at four hospitals in metropolitan Melbourne, and retrospectively characterized their clinical and diagnostic features. Results: 179 patients from The Royal Melbourne, Alfred and Austin Hospitals, and Monash Medical Centre were included in the study with a median age of 49.7 years (range: 16-87 years), of whom 98 (54.7%) were female. The majority of patients (116; 64.8%) met diagnostic criteria for common variable immunodeficiency (CVID), and 21 (11.7%) were diagnosed with X-linked agammaglobulinemia (XLA). Unclassified hypogammaglobulinemia (HGG) was described in 22 patients (12.3%), IgG subclass deficiency (IGSCD) in 12 (6.7%), and specific antibody deficiency (SpAD) in 4 individuals (2.2%). The remaining four patients had a diagnosis of Good syndrome (thymoma with immunodeficiency). There was no significant difference between the age at diagnosis of the disorders, with the exception of XLA, with a median age at diagnosis of less than 1 year. The median age of reported symptom onset was 20 years for those with a diagnosis of CVID, with a median age at diagnosis of 35 years. CVID patients experienced significantly more non-infectious complications, such as autoimmune cytopenias and lymphoproliferative disease, than the other antibody deficiency disorders. The presence of non-infectious complications was associated with significantly reduced survival in the cohort. Conclusion: Our data are largely consistent with the experience of other centers internationally, with clear areas for improvement, including reducing diagnostic delay for patients with PADs. It is likely that these challenges will be in part overcome by continued advances in implementation of genomic sequencing for diagnosis of PADs, and with that opportunities for targeted treatment of non-infectious complications.

Caries risk in children of Udaipur City, India using genetic taste sensitivity to 6-n-propylthiouracil.

AIMS AND OBJECTIVES: Dental caries still remains the single most common disease of childhood. The present study was conducted to test the hypothesis that a higher prevalence of dental caries would be observed among nontaster children compared to medium tasters or supertasters of 6n propylthiouracil impregnated filter papers. MATERIALS AND METHODS: The present study was conducted on a random sample of 600 school children aged 6-12 years in Udaipur city. 6-n-propylthiouracil strips were prepared. The food preference questionnaire was filled by the participants, and their decayed missing filled status as well as taste sensitivity to the propylthiouracil impregnated filter papers were noted. The data obtained was then used for statistical analysis using chi square, analysis of variance, and Students t-tests with the consult of a statistician using the Statistical Package for the Social Sciences version 17 software. RESULTS: Nontasters had a greater caries experience than the supertasters and medium tasters. Females were found to be more tasters than nontasters. It was also found that nontasters belonged to caries active group more than the tasters. CONCLUSION: The caries status was higher among the nontaster children with more sweet preference than in taster children and they belonged more to the caries active group.

Evaluation of preparedness for medical emergencies at dental offices: A survey.

BACKGROUND: The best way to handle an emergency is to be prepared in advance. The purpose of this study was to assess the availability of medical emergency drugs at dental offices and to determine the level of knowledge and preparedness of dentists to manage medical emergencies at their dental offices. MATERIALS AND METHODS: A descriptive cross-sectional study was conducted from January to June 2014 with 250 dental graduates to determine their knowledge and ability in the management of medical emergencies and assess availability of emergency drugs and equipments in dental offices in the Ahmedabad and Udaipur areas of India. The questionnaire consisted of mainly objective questions, requiring a simple yes or no reply. Mann-Whitney test was used for the analysis. A 95% confidence level was used and a P value of less than or equal to 0.05 was considered statistically significant. RESULTS: The results of our study showed that almost all the surveyed dentists (98%) enquired about medical history, but only 12% obtained filled health history proforma from patients regarding the above. Only 38.4% participants recorded the vital signs of patients before commencing any treatment. Also, 7.6% reported about having attended any workshops on emergency training or management programs. Emergency kits were available with only 24% participants and the available kits were assessed for the availability of emergency drugs. Also, 34% were confident about giving intramuscular injection and only 6.6% were sure about giving intravenous injections. The P value was found to be highly statistically significant. CONCLUSION: The results of our study reflect an alarming situation about the capability of dentists to deal with such conditions.

Colorectal cancer risk information presented by a nonphysician assistant does not increase screening rates.

OBJECTIVE: To determine the effectiveness of presenting individualized colorectal cancer (CRC) risk information for increasing CRC screening rates in primary care patients at above-average risk of CRC. DESIGN: Randomized controlled trial. SETTING: Georgia Regents University in Augusta-an academic family medicine clinic in the southeastern United States. PARTICIPANTS: Outpatients (50 to 70 years of age) scheduled for routine visits in the family medicine clinic who were determined to be at above-average risk of CRC. INTERVENTIONS: Individualized CRC risk information calculated from the Your Disease Risk tool compared with a standard CRC screening handout. MAIN OUTCOME MEASURES: Intention to complete CRC screening. Secondary measures included the proportions of subjects completing fecal occult blood tests, flexible sigmoidoscopy, and colonoscopy. RESULTS: A total of 1147 consecutive records were reviewed to determine eligibility. Overall, 210 (37.7%) of 557 eligible participants were randomized to receive either individualized CRC risk information (prepared by a research assistant) or a standard CRC screening handout. The intervention group had a mean (SD) age of 55.7 (4.8) years and the control group had a mean (SD) age of 55.6 (4.6) years. Two-thirds of the participants in each group were female. The intervention group and the control group were matched by race (P = .40). There was no significant difference between groups for intention to complete CRC screening (P = .58). Overall, 26.7% of the intervention participants and 27.7% of the control participants completed 1 or more CRC screening tests (P = .66). CONCLUSION: Presentation of individualized CRC risk information by a nonphysician assistant as a decision aid did not result in higher CRC screening rates in primary care patients compared with presentation of general CRC screening information. Future research is needed to determine if physician presentation of CRC risk information would result in increased screening rates compared with research assistant presentation.

Influence of arterial elasticity and vessel dilatation on arteriovenous fistula maturation: a prospective cohort study.

BACKGROUND: Arteriovenous fistula maturation requires dilatation of the anastomosed artery and vein. The factors that affect dilatation and the mechanisms by which dilatation promotes maturation are not understood. This pilot study tested two hypotheses: that low arterial elasticity is associated with maturation failure, and that vessel dilatation is required for adequate fistula blood flow during dialysis. METHODS: Thirty-two patients underwent preoperative measurement of small artery elasticity index, and pre-anastomosis measurement of artery and vein luminal diameters during fistula surgery. Fistulas were considered mature if they were used successfully in three consecutive treatments within 6 months. A mathematical model was used to determine whether vessel dilatation is needed for adequate fistula flow. RESULTS: Six fistulas were excluded from analysis of maturation because dialysis did not begin within 6 months. Twenty-one of the remaining 26 fistulas were located in the upper arm. Six of 26 failed to mature, and all 6 developed stenosis. The average small artery elasticity index was lower in failed than in matured fistulas (2.25 versus 3.71 ml/ mmHg x 100, P = 0.02). Artery and vein diameters of the 32 patients ranged from 2.5 to 5.0 and 3.5 to 7.0 mm, respectively. When the diameters were applied to the mathematical model, predicted fistula flows ranged from 412 to 1380 ml/min. CONCLUSIONS: Low arterial elasticity is associated with stenosis and fistula maturation failure. However, vessel dilatation is not needed for adequate blood flow except at the smaller diameters in this study. We speculate that low elasticity promotes development of stenosis. Larger studies are needed to confirm these promising results and to determine whether therapies directed at improving elasticity can improve maturation.

CpG oligodeoxynucleotide stimulates production of anti-neutrophil cytoplasmic antibodies in ANCA associated vasculitis.

BACKGROUND: Wegener's Granulomatosis and Microscopic Polyangiitis are life-threatening systemic necrotizing vasculitides of unknown aetiology. The appearance of circulating antibodies to neutrophil cytoplasmic antigens (ANCA) is strongly associated with the development of the disease. A link between infection and disease has long been suspected, and the appearance of ANCA antibodies has been reported following bacterial and viral infections. The depletion of circulating B cells with monoclonal antibody therapy can induce remission, and this observation suggests a pathogenic role for B cells in this disease. As bacterial DNA is known to induce B cell proliferation and antibody production via TLR-9 stimulation, we have explored the possibility that unmethylated CpG oligodeoxynucleotide, as found in bacterial and viral DNA, may play a role in stimulating circulating autoreactive B cells to produce ANCA in patients with vasculitis. RESULTS: We have confirmed that unmethylated CpG oligonucleotide is a potent stimulator of antibody production by PBMC in vitro. The stimulation of PBMC with CpG oligonucleutides resulted in the production of similar amounts of IgG in both ANCA+ patients and normal controls. In spite of this, PR3 ANCA+ patients synthesised significantly higher amount of IgG ANCA than normal controls. In MPO ANCA+ patients, there was a tendency for patients to produce higher amount of ANCA than controls, however, the difference did not reach significance. Furthermore, we were able to detect circulating MPO-reactive B cells by ELISpot assay from the peripheral blood of 2 MPO+ ANCA vasculitis patients. Together, this indicates that circulating anti-neutrophil autoreactive B cells are present in ANCA+ vasculitis patients, and they are capable of producing antibodies in response to CpG stimulation. Of note, CpG also induced the production of the relevant autoantibodies in patients with other types of autoimmune diseases. CONCLUSION: Circulating ANCA autoreactive B cells are present in patients with ANCA+ vasculitis. The production of ANCA from these cells in response to unmethylated CpG stimulation lead us to propose that stimulation of these cells by immunostimulatory DNA sequences such as CpG oligodeoxynucleotide during infection may provide a link between infection and ANCA associated vasculitis. This phenomenon may also apply to other antibody mediated autoimmune diseases.