Bridging Inequity Gaps in Healthcare Systems While Educating Future Healthcare Professionals-The Social Health Bridge-Building Programme.

Social inequity in healthcare persists even in countries with universal healthcare. The Social Health Bridge-Building Programme aims to reduce healthcare inequities. This paper provides a detailed description of the programme. The Template for Intervention Description and Replication (TIDieR) was used to structure the description. The programme theory was outlined using elements from the British Medical Research Council's framework, including identifying barriers to healthcare, synthesising evidence, describing the theoretical framework, creating a logic model, and engaging stakeholders. In the Social Health Bridge-Building Programme, student volunteers accompany individuals to healthcare appointments and provide social support before, during, and after the visit. The programme is rooted in a recovery-oriented approach, emphasising personal resources and hope. The programme finds support in constructs within the health literacy framework. Student volunteers serve as health literacy mediators, supporting individuals in navigating the healthcare system while gaining knowledge and skills. This equips students for their forthcoming roles as healthcare professionals, and potentially empowers them to develop and implement egalitarian initiatives within the healthcare system, including initiatives that promote organisational health literacy responsiveness. The Social Health Bridge-Building Programme is a promising initiative that aims to improve equity in healthcare by addressing individual, social, and systemic barriers to healthcare. The programme's description will guide forthcoming evaluations of its impact.

Multidisciplinary interventions increase weekly working hours and quality of life in persons with post-concussion syndrome.

OBJECTIVES: To improve labor market attachment, general health and quality of life in persons suffering from post-concussion syndrome. Labor market attachment often changes after mTBI, and especially in persons suffering from post-concussion syndrome, and constitutes a huge societal burden. METHODS: Eighty-two adults with persistent post-concussion syndrome participated in this single-center and uncontrolled interventional efficacy open-label investigation. The primary endpoint was to increase weekly working hours. Outcome measures ranged from self-reported cognitive symptoms to objective performance testing. Multidisciplinary interventions were used to reduce symptoms of fatigue, stress, pain, oculomotor malfunction, and sensitivity to both sound and light. RESULTS: Workhours improved from median 0 to 6 hours (p = 0.00002). Several significant improvements were observed in quality of life measured by the SF-36. General fatigue measured by the MFI-20 was reduced (p < 0.0001), and symptoms of depression were reduced (p < 0.0001). The COPM results were improved for task completion satisfaction and for ability to perform a task (p < 0.0001). Reading speed, and performances in the Groffman Visual Tracing Test and the King-Devick Test, all improved (p < 0.01). The intervention did not reduce perception of pain intensity (p = 0.11). CONCLUSION: After the intervention, participants increased weekly workhours and improved in many aspects of life - including quality of life, performance in everyday activities, fatigue and depression. Perception of pain intensity was not improved.

Calcium Electroporation for Management of Cutaneous Metastases in HER2-Positive Breast Cancer: A Case Report.

We report a case of successful treatment of cutaneous metastases in HER2-positive breast cancer with calcium electroporation (CaEP), in addition to trastuzumab, over a period of 5 years. CaEP is performed in local or general anesthesia, by injecting calcium chloride intratumorally and then electroporating cells in the area. Using a handheld needle electrode, a series of short, high-voltage electric pulses are delivered, which transiently permeabilizes cell membranes, causing toxic intracellular calcium levels. The treatment causes cancer cell death, while normal cells are less affected, making the treatment useful for local management of cutaneous lesions. This case presents a 66-year-old female, who had mastectomy surgery followed by adjuvant chemo- and radiotherapy for an ER-negative, HER2-positive breast cancer on her right side in 2003, and a mastectomy followed by endocrine therapy for an ER-positive, HER2 normal breast cancer on her left side in 2006. In 2015, the patient presented local cutaneous recurrence of the ER-negative, HER2-positive breast cancer. The patient was treated with trastuzumab alone, trastuzumab emtansine (TDM1), and a combination of trastuzumab and CaEP. TDM1 was found to have a slightly better effect on the cutaneous metastases than trastuzumab, but the side effects of TDM1 were not acceptable to the patient. The combination of continuous HER2-inhibition and intermittent CaEP, when needed, has been effective in keeping the cutaneous metastases under control for 5 years, and presumably more tolerable for the patient than chemotherapy. An interesting finding was local sparing of calcium electroporated skin from new recurrences, otherwise seen in the general area, which could be a sign of local immunity. This warrants further studies investigating local immunomodulation following CaEP. The patient reported appreciation of a treatment option without chemotherapy, and satisfaction with the outcome of the combination of HER2 inhibition and CaEP treatment. CaEP treatment is currently phase II treatment, and mechanisms and possible applications still need investigation. This novel anticancer treatment could potentially benefit many patients, due to its efficacy, low cost, and accessibility. This case provides observations, which may inspire future trials with CaEP for skin metastases of HER2-positive breast cancer.

Oral health promotion and labour market prospects of socially disadvantaged and unemployed people - a randomised controlled trial.

BACKGROUND: Previous studies indicate that poor oral health may constitute a barrier for labour market success. This study examines whether an oral health promotion intervention has an effect on economic self-support, and proximity to the labour market, among socially disadvantaged unemployed people. METHODS: From April-June 2018, we enrolled 273 vulnerable people on welfare benefits into a randomised controlled trial. Participants were allocated to either control (n=159), or intervention (n=114). Intervention consisted of individual support to improve individuals' oral health by reducing significant barriers to dental care. Ten participants were excluded, leaving 263 participants (intervention n=110, control n=153) for analyses. A national register was used to assess economic self-support and proximity to the labour market within 1.5 years post-intervention. Items of information on health and socio-demographics were obtained from a questionnaire and from national registers. Logistic and multiple linear regression modelling was performed. RESULTS: Overall, higher frequencies of economic self-support and proximity to the labour market were found in the intervention group, although no significant results were seen for economic self-support alone. Adjusted models revealed significantly higher odds (odds ratio=1.85, 95% confidence interval 1.08-3.17) among the intervention group of achieving proximity to the labour market after 12 months. After 18 months, the intervention group had on average obtained 5 more weeks (95% confidence interval 0.02-9.99) with proximity to the labour market. CONCLUSIONS: Overall, the oral health promotion intervention had a positive effect on proximity to the labour market in the intervention group, especially within the first year of the study. Our findings suggest that interventions promoting oral health among socially disadvantaged and unemployed groups may contribute to social rehabilitation.

Effects of shared mental models in teams performing video-assisted thoracoscopic surgery lobectomy.

BACKGROUND: Important non-technical skills enable operating teams to establish shared mental models (SMMs). The importance of SMMs in regards to surgical performance and peri-operative outcomes remains to be investigated. The aim of this study was to explore whether shared mental models (SMMs) of team resources and the current situation, respectively, were predictive of technical skills, duration of surgery, and amount of intra-operative bleeding in video-assisted thoracoscopic surgery (VATS). METHODS: A prospective multi-center observational study was conducted at four tertiary academic hospitals during VATS lobectomy procedures. Data included pre-operative and post-operative questionnaires answered by each of the six team members to measure the SMMs; thoracoscopic video recordings assessed using the previously validated VATS lobectomy Assessment Tool (VATSAT); surgery-related time stamps; and amount (volume) of intra-operative bleeding. Linear regression analyses were conducted to adjust for confounders. RESULTS: Fifty-eight lobectomy procedures were included. Median (interquartile range) VATSAT score was 33.3 (scale 8-40) duration of surgery 101 min (88-123), and amount of intra-operative bleeding 100 ml (20-150). The mean (± SD) of teams' SMMs of the current situation was 20 (± 5). They were not predictive of the surgeons' technical skills, but every one point increase in SMM score significantly predicted a 1 min 52 s decrease in duration of surgery and an 11% decrease in amount of bleeding. The SMMs of team resources were not predictive of any outcomes. CONCLUSION: VATS teams' superior SMMs of the current situation related to significantly shorter duration of surgery and decreased intra-operative bleeding, indicating an effect on team performance and patient care. TRIAL REGISTRATION: NCT02999113 at http://www. CLINICALTRIALS: gov .

Circulating microvesicles and exosomes in small cell lung cancer by quantitative proteomics.

BACKGROUND: Early detection of small cell lung cancer (SCLC) crucially demands highly reliable markers. Growing evidence suggests that extracellular vesicles carry tumor cell-specific cargo suitable as protein markers in cancer. Quantitative proteomic profiling of circulating microvesicles and exosomes can be a high-throughput platform for discovery of novel molecular insights and putative markers. Hence, this study aimed to investigate proteome dynamics of plasma-derived microvesicles and exosomes in newly diagnosed SCLC patients to improve early detection. METHODS: Plasma-derived microvesicles and exosomes from 24 healthy controls and 24 SCLC patients were isolated from plasma by either high-speed- or ultracentrifugation. Proteins derived from these extracellular vesicles were quantified using label-free mass spectrometry and statistical analysis was carried out aiming at identifying significantly altered protein expressions between SCLC patients and healthy controls. Furthermore, significantly expressed proteins were subjected to functional enrichment analysis to identify biological pathways implicated in SCLC pathogenesis. RESULTS: Based on fold change (FC) ≥ 2 or ≤ 0.5 and AUC ≥ 0.70 (p < 0.05), we identified 10 common and 16 and 17 unique proteins for microvesicles and exosomes, respectively. Among these proteins, we found dysregulation of coagulation factor XIII A (Log2 FC = - 1.1, p = 0.0003, AUC = 0.82, 95% CI: 0.69-0.96) and complement factor H-related protein 4 (Log2 FC = 1.2, p = 0.0005, AUC = 0.82, 95% CI; 0.67-0.97) in SCLC patients compared to healthy individuals. Our data may indicate a novel tumor-suppressing role of blood coagulation and involvement of complement activation in SCLC pathogenesis. CONCLUSIONS: In comparing SCLC patients and healthy individuals, several differentially expressed proteins were identified. This is the first study showing that circulating extracellular vesicles may encompass specific proteins with potential diagnostic attributes for SCLC, thereby opening new opportunities as novel non-invasive markers.

[Pregnant woman with renal cancer treated with simultaneous section and partial nephrectomy].

This is a case report of a 43-year-old pregnant woman, who in 26+0 was referred to a department of urology on suspicion of a kidney tumor. A CT scan of chest and abdomen showed a 7 cm tumor in the right kidney without signs of metastases. Biopsy revealed a clear cell renal cell carcinoma. The patient was treated in week 32+0 by a joint venture between a department of urology and a department of obstetrics with a midline incision caesarean followed by a right-sided open partial nephrectomy. The delivery of the baby was uncomplicated. The patient showed no signs of relapse in her control regiment after 1,5 years of observation.

[Tumour of the ureter surprisingly turned out to be localised amyloidosis].

Localised amyloidosis in the urinary tract is a rare and often benign condition, which is usually clinically mistaken for malignancy. I this case report, a 48-year-old man was referred to the hospital with left flank pain, and CT-urography showed a tumour with calcification in the distal ureter. During transurethral procedure, the tumour was resected macroscopically. Histology revealed the diagnosis of amyloidosis. Follow-up was without signs of systemic involvement or recurrence. This case underlines the significance of preoperative diagnostic biopsy, thus saving the patient from unnecessary major surgery.

Hyperparasitism in caves: Bats, bat flies and ectoparasitic fungus interaction.

Bat flies (Diptera: Nycteribiinae) are highly specialized bloodsucking bat ectoparasites. Some of the ectoparasitic bat flies are themselves parasitized with an ectoparasitic fungus of the genus Arthrorhynchus (Laboulbeniales). Ascospores of the fungus attach to the cuticle of a bat fly and develop a haustorium that penetrates the host cuticle. This interaction defines the fungus as a hyperparasite. Both the fly and the fungus are obligate parasites and this peculiar case of hyperparasitism has remained largely unstudied. We studied the prevalence of Laboulbeniales, genus Arthrorhynchus, in natural populations of bat flies infesting the bat species Miniopterus schreibersii, Myotis bechsteinii, My. blythii, My. daubentonii, My. escalerai and My. myotis in Portuguese caves. Laboulbeniales were found infecting 10 of the 428 screened bat flies (2.3%) in natural populations, with fewer infections in winter. Images obtained with transmission electron microscopy show the fungal haustorium within the bat fly host tissue, from where it extracts nutrition.

Quality of life of prosthetic and orthotic users in South India: a cross-sectional study.

BACKGROUND: The aim of this study was to compare QOL among people in India using lower-limb prostheses or orthoses with people without disability. A further aim was to compare subgroups and investigate whether QOL was associated with physical disability, gender, income, living area, and education. METHODS: A cross-sectional questionnaire study in which the World Health Organization Quality of Life-Bref was used to collect self-reported data. A total of 277 participants from India were included, 155 with disability and 122 without. Group comparisons were conducted using the Mann-Whitney U and the Kruskal-Wallis tests and associations were explored using regression analyses of the four QOL domains: physical health, psychological, social relationships, and environment. RESULTS: Participants with physical disability scored significantly lower than did participants without disability in three of the four QOL domains, i.e., physical health, (Median 14.29 vs 16.29; p < .001) psychological, (Median 14.67 vs. 15.33; p = .017) and environment (Median13.00 vs 14.00; p = .006). For people with disability those with no or irregular income and those not attending school having the lowest QOL scores in all four domains. Education was associated with all four QOL domains and income was associated with psychological and environment. Living in urban slums was associated with a higher risk of lower QOL in three QOL domains, i.e., physical health, psychology, and environment. CONCLUSIONS: Despite rehabilitation services, people with physical disability experienced lower QOL in terms of the physical health, psychological, and environmental domains than did people without disability. Community-based rehabilitation programmes for prosthetic and orthotic users need to increase and improve their rehabilitation services to increase income and improve access to education. Priority could be given to those who have no or irregular income, live in urban slums, and have not attended school to further improve their QOL.

Left sided flank pain due to Bochdalek hernia with intrathoracic kidney.

A 40 year old woman had undergone surgery as a newborn due to a left sided congenital Bochdalek hernia with the ventricle, spleen, left kidney and adrenal gland located intrathoracically. After three pregnancies, she developed left sided flank pain and dyspnea. A CT scan showed a diaphragmatic hernia with a malrotated intrathoracic placed left kidney with minimal hydronephrosis. The spleen was located caudally in the left iliac fossa; there were no other abnormalities. The patient underwent a thoracotomy with a small resection of the diaphragm in order to replace the kidney in the abdominal cavity and closure of the diaphragmatic defect with a Gore-Tex patch.

Evaluating competency in video-assisted thoracoscopic surgery (VATS) lobectomy performance using a novel assessment tool and virtual reality simulation.

BACKGROUND: Competency-based training has gained ground in surgical training and with it assessment tools to ensure that training objectives are met. Very few assessment tools are available for evaluating performance in thoracoscopic procedures. Video recordings would provide the possibility of blinded assessment and limited rater bias. This study aimed to provide validity evidence for a newly developed and dedicated tool for assessing competency in Video-Assisted Thoracoscopic Surgery (VATS) lobectomy. METHODS: Participants with varying experience with VATS lobectomy were included from different countries. Video recordings from participants' performance of a VATS right upper lobe lobectomy on a virtual reality simulator were rated by three raters using a modified version of a newly developed VATS lobectomy assessment tool (the VATSAT) and analyzed in relation to the unitary framework (content, response process, internal structure, relation to other variables, and consequences of testing). RESULTS: Fifty-three participants performed two consecutive simulated VATS lobectomies on the virtual reality simulator, leaving a total of 106 videos. Content established in previously published studies. Response process Standardized data collection was ensured by using an instructional element, uniform data collection, a special rating program, and automatic generation of the results to a database. Raters were carefully instructed in using the VATSAT, and tryout ratings were carried out. Internal structure Inter-rater reliability was calculated as intra-class correlation coefficients, to 0.91 for average measures (p < 0.001). Test/re-test reliability was calculated as Pearson's r of 0.70 (p < 0.001). G-coefficient was calculated to be 0.79 with two procedures and three raters. By performing D-theory was found that either three procedures rated by two raters or five procedures rated by one rater were enough to reach an acceptable G-coefficient of ≥ 0.8. Relation to other variables Significant differences between groups were found (p < 0.001). The participants' VATS lobectomy experience correlated significantly to their VATSAT score (p = 0.016). Consequences of testing The pass/fail score was found to be 14.9 points by the contrasting groups' method, leaving five false positive (29%) and six false negatives (43%). CONCLUSION: Validity evidence was provided for the VATSAT according to the unitary framework. The VATSAT provides supervisors and assessors with a procedure-specific assessment tool for evaluating VATS lobectomy performance and aids with the decision of when the trainee is ready for unsupervised performance.

Assessment of competence in video-assisted thoracoscopic surgery lobectomy: A Danish nationwide study.

BACKGROUND: Competence in video-assisted thoracoscopic surgery lobectomy has previously been established on the basis of numbers of procedures performed, but this approach does not ensure competence. Specific assessment tools, such as the newly developed video-assisted thoracoscopic surgery lobectomy assessment tool, allow for structured and objective assessment of competence. Our aim was to provide validity evidence for the video-assisted thoracoscopic surgery lobectomy assessment tool. METHODS: Video recordings of 60 video-assisted thoracoscopic surgery lobectomies performed by 18 thoracic surgeons were rated using the video-assisted thoracoscopic surgery lobectomy assessment tool. All 4 centers of thoracic surgery in Denmark participated in the study. Two video-assisted thoracoscopic surgery experts rated the videos. They were blinded to surgeon and center. RESULTS: The total internal consistency reliability Cronbach's alpha was 0.93. Inter-rater reliability between the 2 raters was Pearson's r = 0.71 (P < .001). The mean video-assisted thoracoscopic surgery lobectomy assessment tool scores for the 10 procedures performed by beginners were 22.1 (standard deviation [SD], 8.6) for the 28 procedures performed by the intermediate surgeons, 31.2 (SD, 4.4), and for the 20 procedures performed by experts 35.9 (SD, 2.9) (P < .001). Bonferroni post hoc tests showed that experts were significantly better than intermediates (P < .008) and beginners (P < .001). Intermediates' mean scores were significantly better than beginners (P < .001). The pass/fail standard calculated using the contrasting group's method was 31 points. One of the beginners passed, and 2 experts failed the test. CONCLUSIONS: Validity evidence was provided for a newly developed assessment tool for video-assisted thoracoscopic surgery lobectomy (video-assisted thoracoscopic surgery lobectomy assessment tool) in a clinical setting. The discriminatory ability among expert surgeons, intermediate surgeons, and beginners proved highly significant. The video-assisted thoracoscopic surgery lobectomy assessment tool could be an important aid in the future training and certification of thoracic surgeons.

The use of molecular descriptors in the development of co-amorphous formulations.

Co-amorphous systems consisting of a drug and an amino acid have been investigated extensively for the enhancement of drug solubility and amorphous stability. The purpose of this study is to investigate which molecular descriptors are important for predicting the likelihood of a successful co-amorphisation between amino acid and drug. The predictions are thought to be used in an early screening phase to identify potential drug-amino acid combinations for further studies. A large variety of molecular descriptors was calculated for six drugs (carvedilol, mebendazole, carbamazepine, furosemide, indomethacin and simvastatin) and the twenty naturally occurring amino acids. The descriptor differences for all drug-amino acid combinations were calculated and used as input in the X-matrix of a Partial Least Square Discriminant Analysis (PLS-DA). The Y-matrix of the PLS-DA consisted of the X-ray powder diffraction response ("co-amorphous" or "not co-amorphous") obtained by ball milling all combinations for 60 min. The PLS-DA model showed a clear separation of the not co-amorphous and the co-amorphous samples and was successfully predicting the class membership of 19 out of the 20 completely left out drug-amino acid combinations of mebendazole. The approach seems to be promising for predicting the ability of new drug-amino acids combinations to become co-amorphous.

A novel assessment tool for evaluating competence in video-assisted thoracoscopic surgery lobectomy.

BACKGROUND: Specific assessment tools can accelerate trainees' learning through structured feedback and ensure that trainees attain the knowledge and skills required to practice as competent, independent surgeons (competency-based surgical education). The objective was to develop an assessment tool for video-assisted thoracoscopic surgery (VATS) lobectomy by achieving consensus within an international group of VATS experts. METHOD: The Delphi method was used as a structured process for collecting and distilling knowledge from a group of internationally recognized VATS experts. Opinions were obtained in an iterative process involving answering repeated rounds of questionnaires. Responses to one round were summarized and integrated into the next round of questionnaires until consensus was reached. RESULTS: Thirty-one VATS experts were included and four Delphi rounds were conducted. The response rate for each round were 68.9% (31/45), 100% (31/31), 96.8% (30/31), and 93.3% (28/30) for the final round where consensus was reached. The first Delphi round contained 44 items and the final VATS lobectomy Assessment Tool (VATSAT) comprised eight items with rating anchors: (1) localization of tumor and other pathological tissue, (2) dissection of the hilum and veins, (3) dissection of the arteries, (4) dissection of the bronchus, (5) dissection of lymph nodes, (6) retrieval of lobe in bag, (7) respect for tissue and structures, and (8) technical skills in general. CONCLUSION: A novel and dedicated assessment tool for VATS lobectomy was developed based on VATS experts' consensus. The VATSAT can support the learning of VATS lobectomy by providing structured feedback and help supervisors make the important decision of when trainees have acquired VATS lobectomy competencies for independent performance.

Ensuring basic competency in chest tube insertion using a simulated scenario: an international validation study.

INTRODUCTION: Chest tube insertion can be associated with serious complications. A structured training programme is needed to minimise complications and enhance patient safety. Novices should pass a reliable test with solid evidence of validity before performing the procedure supervised on patients. The aim of this study was to establish a credible pass/fail standard. METHODS: We used an established assessment tool the Chest Tube Insertion Competency Test (TUBE-iCOMPT). Validity evidence was explored according to Messick's five sources of validity. Two methods were used to establish a credible pass/fail standard. Contrasting groups' method: 34 doctors (23 novices and 11 experienced surgeons) performed the procedure twice and all procedures were video recorded, edited, blinded and rated by two independent, international raters. Modified Angoff method: seven thoracic surgeons individually determined the scores that defined the pass/fail criteria. The data was gathered in Copenhagen, Denmark and Riyadh, Saudi Arabia. RESULTS: Internal consistency reliability was calculated as Cronbach's alpha to 0.94. The generalisability coefficient with two raters and two procedures was 0.91. Mean scores were 50.7 (SD±13.2) and 74.7 (SD±4.8) for novices and experienced surgeons, respectively (p<0.001). The pass/fail score of 62 points resulted in zero false negatives and only three false positives. DISCUSSION: We have gathered valuable additional validity evidence for the assessment tool TUBE-iCOMPT including establishment of a credible pass/fail score. The TUBE-iCOMPT can now be integrated in mastery learning programmes to ensure competency before independent practice.

Reduced Serotonin Transporter Levels and Inflammation in the Midbrain Raphe of 12 Month Old APPswe/PSEN1dE9 Mice.

BACKGROUND: Although mood and sleep disturbances are nearly universal among patients with Alzheimer's disease (AD), brain structures involved in non-cognitive processing remain under characterized in terms of AD pathology. OBJECTIVES: This study was designed to evaluate hallmarks of AD pathology in the brainstem of the APPswe/PS1dE9 mouse model of familial AD. METHODS: Fresh-frozen sections from female, 12 month old, transgenic and control B6C3 mice (n=6/genotype) were examined for amyloid burden and neurofibrillary alterations, by using 6E10 immunohistochemistry and the Gallyas silver stain, respectively. Serotonin transporter (SERT) densities in the dorsal and the median raphe were quantified by [3H]DASB autoradiography. SERT mRNA expression was measured by RT-PCR and visualized by in situ hybridization. Neuroinflammation was evaluated by immunohistochemical staining for microglia and astrocytes, and by measuring mRNA levels of the proinflammatory cytokines TNF-α, IL-1ß and IL-6. RESULTS: No amyloid- and tau-associated lesions were observed in the midbrain raphe of 12 month old APPswe/PS1dE9 mice. SERT binding levels were reduced in transgenic animals compared to age-matched controls, and SERT mRNA levels were decreased by at least 50% from control values. Intense microglial, but not astrocytic immunoreactivity was observed in APPswe/PS1dE9 vs. wild-type mice. Levels of TNF-α mRNA were two-fold higher than control and correlated positively with SERT mRNA expression levels in transgenic animals. CONCLUSIONS: There was no amyloid accumulation and tau-associated pathology in the midbrain raphe of 12 month old APPswe/PS1dE9 mice. However, there was a local neuroinflammatory response with loss of serotonergic markers, which may partially account for some of the behavioral symptoms of AD.

Using virtual reality simulation to assess competence in video-assisted thoracoscopic surgery (VATS) lobectomy.

BACKGROUND: The societies of thoracic surgery are working to incorporate simulation and competency-based assessment into specialty training. One challenge is the development of a simulation-based test, which can be used as an assessment tool. The study objective was to establish validity evidence for a virtual reality simulator test of a video-assisted thoracoscopic surgery (VATS) lobectomy of a right upper lobe. METHODS: Participants with varying experience in VATS lobectomy were included. They were familiarized with a virtual reality simulator (LapSim®) and introduced to the steps of the procedure for a VATS right upper lobe lobectomy. The participants performed two VATS lobectomies on the simulator with a 5-min break between attempts. Nineteen pre-defined simulator metrics were recorded. RESULTS: Fifty-three participants from nine different countries were included. High internal consistency was found for the metrics with Cronbach's alpha coefficient for standardized items of 0.91. Significant test-retest reliability was found for 15 of the metrics (p-values <0.05). Significant correlations between the metrics and the participants VATS lobectomy experience were identified for seven metrics (p-values <0.001), and 10 metrics showed significant differences between novices (0 VATS lobectomies performed) and experienced surgeons (>50 VATS lobectomies performed). A pass/fail level defined as approximately one standard deviation from the mean metric scores for experienced surgeons passed none of the novices (0 % false positives) and failed four of the experienced surgeons (29 % false negatives). CONCLUSION: This study is the first to establish validity evidence for a VATS right upper lobe lobectomy virtual reality simulator test. Several simulator metrics demonstrated significant differences between novices and experienced surgeons and pass/fail criteria for the test were set with acceptable consequences. This test can be used as a first step in assessing thoracic surgery trainees' VATS lobectomy competency.

[An ordinary condom can be used for removing encircling metallic objects around penis].

We describe a new method for removing encircling objects from penis. A 69-year-old male was admitted with a ratchet spanner stuck at the penile base. A condom was applied to the penile shaft and manoeuvred in between the ratchet spanner and the penis. A lot of lubrication was applied, and the ratchet spanner was removed. Later the same method was tried when a 66-year-old male had a tap aerator stuck under glans penis. However, the method was unsuccessful because of a very narrow diameter of the tap aerator. Instead, the tap aerator was cut in two by using an angle grinder.