Urologist-perceived barriers and perspectives on the underuse of sacral neuromodulation for overactive bladder in Canada.

INTRODUCTION: An estimated 18% of Canadians have overactive bladder (OAB), with approximately 24% of those reporting difficulty adhering to pharmacotherapy. To date, there has been no investigation into barriers facing sacral neuromodulation (SNM) as treatment for OAB in Canada. METHODS: Current Canadian Urological Association members were invited to participate in an anonymous survey. Data collected included open-ended and Likert scale responses addressing barriers to referral for SNM. Qualitative analysis used a Theoretical Domains Framework (TDF), while quantitative responses are reported using descriptive statistics. RESULTS: A response rate of 20.4% (n=142) was obtained. Most respondents believed SNM was underused (n=82, 57.7%) compared to only 6.3% (n=9) who believed it was used adequately. The most commonly cited reasons for not offering SNM were lack of availability (n=85, 59.9%), expertise (n=49, 34.5%), and funding (n=26, 18.3%). Participants were neutral regarding confidence to appropriately recommend SNM to patients (median 3, interquartile range [IQR] 2-4) and were not confident to manage patient care and issues related to SNM devices (median 2, IQR 1-3). On thematic analysis using the TDF, the most prevalent barriers to SNM care were related to infrastructure and resources. A lack of trained experts and lack of knowledge related to SNM use were also commonly identified barriers. CONCLUSIONS: In this first study exploring urologist-perceived barriers to SNM referral for medically refractory OAB in Canada, urologists acknowledge that SNM implantation is underused but did not feel confident in recommending SNM appropriately. A lack of trained experts and poor funding were also identified as major barriers to SNM referral.

Conservatism Gets Funded? A Field Experiment on the Role of Negative Information in Novel Project Evaluation.

The evaluation and selection of novel projects lies at the heart of scientific and technological innovation, and yet there are persistent concerns about bias, such as conservatism. This paper investigates the role that the format of evaluation, specifically information sharing among expert evaluators, plays in generating conservative decisions. We executed two field experiments in two separate grant-funding opportunities at a leading research university, mobilizing 369 evaluators from seven universities to evaluate 97 projects, resulting in 761 proposal-evaluation pairs and more than $250,000 in awards. We exogenously varied the relative valence (positive and negative) of others' scores and measured how exposures to higher and lower scores affect the focal evaluator's propensity to change their initial score. We found causal evidence of a negativity bias, where evaluators lower their scores by more points after seeing scores more critical than their own rather than raise them after seeing more favorable scores. Qualitative coding of the evaluators' justifications for score changes reveals that exposures to lower scores were associated with greater attention to uncovering weaknesses, whereas exposures to neutral or higher scores were associated with increased emphasis on nonevaluation criteria, such as confidence in one's judgment. The greater power of negative information suggests that information sharing among expert evaluators can lead to more conservative allocation decisions that favor protecting against failure rather than maximizing success.

Accuracy and safety of partial thickness femtosecond laser radial and arcuate keratotomy incisions in porcine eyes.

BACKGROUND: To evaluate the accuracy and safety of micro radial and arcuate keratotomy incisions constructed by a femtosecond laser system with a curved contact patient interface in porcine eyes. METHODS: Partial thickness micro radial and arcuate keratotomy incisions were constructed in porcine eyes with a femtosecond laser system and evaluated for precision of depth, quality, and consistency. Optical coherence tomography was used to determine the accuracy and precision of incision depth. Corneal endothelial safety was assessed by a fluorescent live/dead cell viability assay to demonstrate laser-induced endothelial cell loss. Quality was evaluated by ease of opening and examination of interfaces. RESULTS: In two micro radial incision groups, intended incision depths of 50% and 80% resulted in mean achieved depths of 50.01% and 77.69%, respectively. In three arcuate incision groups, intended incision depths of 80%, 600 µm or 100 µm residual uncut bed thickness resulted in mean achieved depths of 80.16%, 603.03 µm and residual bed of 115 µm, respectively. No loss of endothelial cell density occurred when the residual corneal bed was maintained at a minimum of 85-116 µm. The incisions were easy to open, and interfaces were smooth. CONCLUSIONS: A femtosecond laser system with curved contact interface created precise and reproducible micro radial and arcuate keratotomy incisions. Accuracy and precision of the incision depth and preservation of endothelial cell density demonstrated the effectiveness and safety of the system.

Permanent Medical Grounding in Royal Canadian Air Force Pilots (20082017).

BACKGROUND: The aim of this retrospective registry study was to review the medical causes of RCAF pilot permanent grounding during the period 20082017 and to compare our findings to the previous study of 19781987 to determine if disease patterns had changed.METHODS: Material was obtained from the RCAF 1 Canadian Air Division Surgeons' medical registry of military pilots. Anonymized data for permanently grounded pilots were classified by medical diagnosis, age, and training status.RESULTS: During the period 20082017, there were a total of 162 pilots permanently grounded, of which 110 were trained and 52 untrained.DISCUSSION: In comparison to the 1991 study, there has been a decrease in permanent groundings due cardiovascular disease, but an increase due to mental health conditions, musculoskeletal issues, and motion sickness.Haworth D, Gray G, Zoltenko R, Bashirzadeh AJ. Permanent medical grounding in Royal Canadian Air Force pilots (20082017). Aerosp Med Hum Perform. 2021; 92(11): 913-918.

Robot-assisted artificial urinary sphincter implantation.

PURPOSE OF REVIEW: The aim of the present manuscript was to provide an overview on the current state of robotic artificial urinary sphincter (AUS) implantation in male and female patients. RECENT FINDINGS: Over the past few years, several series have been reported, with promising outcomes for the most part. This has contributed to expand the use of bladder neck AUS, especially in female patients, which was, until then, hampered by its perioperative morbidity. SUMMARY: Robotic AUS has been developed to overcome the technical challenge of bladder neck implantation in female patients and in specific male subgroups, especially self-catheterizing neurological patients. All the series of robotic AUS implantation published in the past few years reported much lower rates of cuff erosion and AUS explantation than the historical open cohorts suggesting that the robotic approach might become the standard for female AUS implantation. This less morbid approach along with technological improvement of the AUS device may contribute to make it a more popular option in the treatment of female stress urinary incontinence due to intrinsic sphincter deficiency. There are much less data available on robotic bladder neck AUS implantation in male patients.

Current Use of the Artificial Urinary Sphincter in Adult Females.

PURPOSE OF REVIEW: The aim of the present report was to review the recent evidences regarding the use of artificial urinary sphincter (AUS) in adult females. RECENT FINDINGS: While the excellent functional outcomes of AUS in female patients with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) have been reported for decades, its use has remained confidential in most countries likely due to its challenging implantation and inherent morbidity. Over the past few years, laparoscopic and, more recently, robotic techniques of AUS implantation in female patients have been described with promising perioperative outcomes. As a result, the use of AUS has increased in several countries. The indications are mostly recurrent or persistent SUI after previous anti-incontinence procedures and neurogenic SUI. Owing to its unique potential to restore continence while maintaining low outlet resistance during the voiding phase, AUS may be of special interest in female patients with detrusor underactivity. High level of evidence data from trials which are underway, along with developments in robotic surgery and technological refinements of the device, may well, almost 50 years after its introduction, give to the AUS its momentum as a major contributor in the female SUI armamentarium. While the use of AUS in female patients has been restricted to some countries and a few high-volume centers, it has started spreading again over the past few years, thanks to the rise of minimally invasive approaches which facilitate its implantation, and this is yielding promising outcomes.

The history of sacral neuromodulation in Canada.

Sacral neuromodulation (SNM) has been used for the past 30 years, with significant improvements in the implantation technique and technology over the last several years. Canadian centers were involved with this technique from the very beginning by participating in several multicenter clinical trials and engaging in basic and clinical research. Presently, six Canadian centers continue to have SNM implantation programs.

Femtosecond laser-assisted capsulotomy with capsular marks for toric IOL alignment: Comparison of tensile strength with standard femtosecond laser capsulotomy.

PURPOSE: To compare the capsulotomy rim strength with capsular marks (CMs) to the rim strength without CMs in porcine eyes, and to demonstrate the practicality of CMs for intraoperative toric intraocular lens (IOL) alignment. SETTING: LENSAR facility, Orlando, Florida, USA. DESIGN: Laboratory study. METHODS: The biomechanical strength of the capsulotomy with CMs was tested under two different load orientations (orthogonal to or in-line with CMs). Thirty-six porcine eyes were randomly assigned to three treatment cohorts: (1) standard capsulotomy with no CMs, (2) capsulotomy with CMs for in-line tensile testing and (3) capsulotomy with CMs for orthogonal tensile testing. Study parameters were capsulotomy break force and maximum extensibility. The ease of using CMs for toric IOL alignment was also evaluated. RESULTS: There was no significant difference between the mean break force for standard capsulotomy (180.57 mN ± 22 [SD]), capsulotomy with CMs with orthogonal load (178.04 ± 20 mN, P = 1.000), and with in-line load (181.05 ± 15 mN, P = 1.000). Likewise, the mean extensibility at the break point for standard capsulotomy (6.47 ± 0.33 mm) was equivalent to the mean extensibility with CMs with orthogonal load (6.49 ± 0.45 mm, P = 1.000) and with in-line load (6.3 ± 0.47 mm, P = .960). In the implanted eyes, toric IOLs were found to be easily aligned with the CMs. CONCLUSION: The femtosecond laser capsulotomies with CMs were equivalent in tensile strength and extensibility to standard femtosecond laser capsulotomies and showed high potential for effective alignment of toric IOLs.

An introduction to aviation cardiology.

The management of cardiovascular disease (CVD) has evolved significantly in the last 20 years; however, the last major publication to address a consensus on the management of CVD in aircrew was published in 1999, following the second European Society of Cardiology conference of aviation cardiology experts. This article outlines an introduction to aviation cardiology and focuses on the broad aviation medicine considerations that are required to manage aircrew appropriately and optimally (both pilots and non-pilot aviation professionals). This and the other articles in this series are born out of a 3 year collaborative working group between international military aviation cardiologists and aviation medicine specialists, many of whom also work with and advise civil aviation authorities, as part of a North Atlantic Treaty Organization (NATO) led initiative to address the occupational ramifications of CVD in aircrew (HFM-251). This article describes the types of aircrew employed in the civil and military aviation profession in the 21st century; the types of aircraft and aviation environment that must be understood when managing aircrew with CVD; the regulatory bodies involved in aircrew licensing and the risk assessment processes that are used in aviation medicine to determine the suitability of aircrew to fly with medical (and specifically cardiovascular) disease; and the ethical, occupational and clinical tensions that exist when managing patients with CVD who are also professional aircrew.

Assessing aeromedical risk: a three-dimensional risk matrix approach.

Early aeromedical risk i was based on aeromedical standards designed to eliminate individuals ii from air operations with any identifiable medical risk, and led to frequent medical disqualification. The concept of considering aeromedical risk as part of the spectrum of risks that could lead to aircraft accidents (including mechanical risks and human factors) was first proposed in the 1980s and led to the development of the 1% rule which defines the maximum acceptable risk for an incapacitating medical event as 1% per year (or 1 in 100 person-years) to align with acceptable overall risk in aviation operations. Risk management has subsequently evolved as a formal discipline, incorporating risk assessment as an integral part of the process. Risk assessment is often visualised as a risk matrix, with the level of risk, urgency or action required defined for each cell, and colour-coded as red, amber or green depending on the overall combination of risk and consequence. This manuscript describes an approach to aeromedical risk management which incorporates risk matrices and how they can be used in aeromedical decision-making, while highlighting some of their shortcomings.

Management of established coronary artery disease in aircrew without myocardial infarction or revascularisation.

This paper is part of a series of expert consensus documents covering all aspects of aviation cardiology. In this manuscript, we focus on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease in those without myocardial infarction or revascularisation (both pilots and non-pilot aviation professionals). We present expert consensus opinion and associated recommendations. It is recommended that in aircrew with non-obstructive coronary artery disease or obstructive coronary artery disease not deemed haemodynamically significant, nor meeting the criteria for excessive burden (based on plaque morphology and aggregate stenosis), a return to flying duties may be possible, although with restrictions. It is recommended that aircrew with haemodynamically significant coronary artery disease (defined by a decrease in fractional flow reserve) or a total burden of disease that exceeds an aggregated stenosis of 120% are grounded. With aggressive cardiac risk factor modification and, at a minimum, annual follow-up with routine non-invasive cardiac evaluation, the majority of aircrew with coronary artery disease can safely return to flight duties.

The challenge of asymptomatic coronary artery disease in aircrew; detecting plaque before the accident.

Coronary events remain a major cause of sudden incapacitation, including death, in both the general population and among aviation personnel, and are an ongoing threat to flight safety and operations. The presentation is often unheralded, especially in younger adults, and is often due to rupture of a previously non-obstructive coronary atheromatous plaque. The challenge for aeromedical practitioners is to identify individuals at increased risk for such events. This paper presents the NATO Cardiology Working Group (HFM 251) consensus approach for screening and investigation of aircrew for asymptomatic coronary disease.A three-phased approach to coronary artery disease (CAD) risk assessment is recommended, beginning with initial risk-stratification using a population-appropriate risk calculator and resting ECG. For aircrew identified as being at increased risk, enhanced screening is recommended by means of Coronary Artery Calcium Score alone or combined with a CT coronary angiography investigation. Additional screening may include exercise testing, and vascular ultrasound imaging. Aircrew identified as being at high risk based on enhanced screening require secondary investigations, which may include functional ischaemia, and potentially invasive coronary angiography. Functional stress testing as a stand-alone investigation for significant CAD is not recommended in aircrew. Aircrew identified with coronary disease require further clinical and aeromedical evaluation before being reconsidered for flying status.

Management of established coronary artery disease in aircrew with previous myocardial infarction or revascularisation.

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease (CAD) without myocardial infarction (MI) or revascularisation (both pilots and non-pilot aviation professionals). It presents expert consensus opinion and associated recommendations and is part of a series of expert consensus documents covering all aspects of aviation cardiology.Aircrew may present with MI (both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI)) as the initial presenting symptom of obstructive CAD requiring revascularisation. Management of these individuals should be conducted according to published guidelines, ideally with consultation between the cardiologist, surgeon and aviation medical examiner. Return to restricted flight duties is possible in the majority of aircrew; however, they must have normal cardiac function, acceptable residual disease burden and no residual ischaemia. They must also be treated with aggressive cardiac risk factor modification. Aircrew should be restricted to dual pilot operations in non-high-performance aircraft, with return to flying no sooner than 6 months after the event. At minimum, annual follow-up with routine non-invasive cardiac evaluation is recommended.

Management of cardiac conduction abnormalities and arrhythmia in aircrew.

Cardiovascular diseases i are the most common cause of loss of flying licence globally, and cardiac arrhythmia is the main disqualifier in a substantial proportion of aircrew. Aircrew ii often operate within a demanding physiological environment, that potentially includes exposure to sustained acceleration (usually resulting in a positive gravitational force, from head to feet (+Gz)) in high performance aircraft. Aeromedical assessment is complicated further when trying to discriminate between benign and potentially significant rhythm abnormalities in aircrew, many of whom are young and fit, have a resultant high vagal tone, and among whom underlying cardiac disease has a low prevalence. In cases where a significant underlying aetiology is plausible, extensive investigation is often required and where appropriate should include review by an electrophysiologist. The decision regarding restriction of flying activity will be dependent on several factors including the underlying arrhythmia, associated pathology, risk of incapacitation and/or distraction, the type of aircraft operated, and the specific flight or mission criticality of the role performed by the individual aircrew.

Heart muscle disease management in aircrew.

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with suspected or confirmed heart muscle disease (both pilots and non-pilot aviation professionals). ECG abnormalities on aircrew periodic medical examination or presentation of a family member with a confirmed cardiomyopathy are the most common reason for investigation of heart muscle disease in aircrew. Holter monitoring and imaging, including cardiac MRI is recommended to confirm or exclude the presence of heart muscle disease and, if confirmed, management should be led by a subspecialist. Confirmed heart muscle disease often requires restriction toflying duties due to concerns regarding arrhythmia. Pericarditis and myocarditis usually require temporary restriction and return to flying duties is usually dependent on a lack of recurrent symptoms and acceptable imaging and electrophysiological investigations.

Contemporaneous management of valvular heart disease and aortopathy in aircrew.

Valvular heart disease (VHD) is highly relevant in the aircrew population as it may limit appropriate augmentation of cardiac output in high-performance flying and predispose to arrhythmia. Aircrew with VHD require careful long-term follow-up to ensure that they can fly if it is safe and appropriate for them to do so. Anything greater than mild stenotic valve disease and/or moderate or greater regurgitation is usually associated with flight restrictions. Associated features of arrhythmia, systolic dysfunction, thromboembolism and chamber dilatation indicate additional risk and will usually require more stringent restrictions. The use of appropriate cardiac imaging, along with routine ambulatory cardiac monitoring, is mandatory in aircrew with VHD.Aortopathy in aircrew may be found in isolation or, more commonly, associated with bicuspid aortic valve disease. Progression rates are unpredictable, but as the diameter of the vessel increases, the associated risk of dissection also increases. Restrictions on aircrew duties, particularly in the context of high-performance or solo flying, are usually required in those with progressive dilation of the aorta.

Congenital heart disease in aircrew.

This article focuses i on the broad aviation medicine considerations that are required to optimally manage aircrew ii with suspected or confirmed congenital heart disease (both pilots and non-pilot aviation professionals). It presents expert consensus opinion and associated recommendations and is part of a series of expert consensus documents covering all aspects of aviation cardiology. This expert opinion was born out of a 3 year collaborative working group between international military aviation cardiologists and aviation medicine specialists, as part of a North Atlantic Treaty Organization (NATO) led initiative to address the occupational ramifications of cardiovascular disease in aircrew (HFM-251) many of whom also work with and advise civil aviation authorities.

Non-coronary cardiac surgery and percutaneous cardiology procedures in aircrew.

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew following non-coronary surgery or percutaneous cardiology interventions (both pilots and non-pilot aviation professionals). Aircrew may have pathology identified earlier than non-aircrew due to occupational cardiovascular screening and while aircrew should be treated using international guidelines, if several interventional approaches exist, surgeons/interventional cardiologists should consider which alternative is most appropriate for the aircrew role being undertaken; liaison with the aircrew medical examiner is strongly recommended prior to intervention to fully understand this. This is especially important in aircrew of high-performance aircraft or in aircrew who undertake aerobatics. Many postoperative aircrew can return to restricted flying duties, although aircrew should normally not return to flying for a minimum period of 6 months to allow for appropriate postoperative recuperation and assessment of cardiac function and electrophysiology.