Diseño y evaluación de un modelo de simulación de fractura de pene / Design and assessment of a penile fracture simulation model

Objetivo: Diseñar y evaluar un nuevo modelo de simulación de fractura de pene para la enseñanza de su reparación.MétodosHemos utilizado un simulador de circuncisión validado para crear un nuevo modelo. El prepucio para circuncisión se dividió en 2 mitades. Se creó un corte transversal («simulación de fractura») en una parte de la primera mitad del prepucio (imitando la «túnica») y se colocó sobre el modelo de pene. Se colocó una pastilla de gelatina roja («coágulo») debajo del corte. Se aplicó un segundo trozo para completar el prepucio por encima y cubrir el defecto. El modelo fue evaluado por los participantes y docentes expertos del boot camp de simulación de urología. La evaluación se realizó mediante un cuestionario con escala de Likert de 5 puntos. Los datos se analizaron mediante Microsoft Excel e IBM SPSS Statistics V25. La correlación intraclase se calculó mediante «un modelo aleatorio unidireccional».ResultadosVeintidós estudiantes de urología y 4 expertos participaron en la evaluación. La mayoría de los aprendices estuvieron muy de acuerdo (59%, n=13) en la utilidad del modelo para la formación, y los expertos también estuvieron de acuerdo en el 75% de los casos. Tanto alumnos (68%, n=14) como docentes (75%) consideraron correcta la apariencia de la fractura del pene. En general, la capacidad del modelo para representar una simulación realista de la tarea fue considerada excelente por el 23% de los participantes y buena por el 64%. Tras la simulación los alumnos afirmaron tener una mayor confianza en el manejo de este tipo de casos. Las principales dificultades señaladas estaban relacionadas con los planos fasciales y la uretra.ConclusiónEste es el primer modelo de simulación para la reparación de fracturas de pene y ha demostrado su validez en un boot camp de urología nacional. (AU)

Objective: To design and assess a novel penile fracture simulation model for teaching penile fracture repair.MethodsWe used a validated circumcision simulator to create a model. Foreskin for a circumcision was divided into two halves. A transverse slit (“simulated fracture”) was created on one part of the first half of the foreskin (mimicking “tunica”) and was applied over the penile model. A red jelly tablet (“clot”) was placed underneath the cut. A second full-length of foreskin was applied over it to cover the defect. The model was assessed by participants and expert faculty at the Urology Simulation Boot Camp. Evaluation was performed using a 5-point Likert Scale questionnaire. Data was analysed using Microsoft Excel and IBM SPSS Statistics V25. The intra-class correlation was calculated using a “One-way random model”.ResultsTwenty-two urology trainees and four experts participated in the evaluation. The majority of trainees strongly agreed (59%, n=13) the model is useful for training with experts similarly agreeing in 75% of cases. The appearance of penile fracture was considered good by both trainees (68%, n=14) and faculty (75%). Overall, the ability of the model to represent a realistic simulation of the task was considered excellent by 23% of participants and good by 64%. Personal confidence after simulation in managing a similar situation was considered high among trainees. The main difficulties reported were related to fascial planes and urethra.ConclusionThis is the first simulation model for penile fracture repair and has demonstrated face validity at a national urology bootcamp. (AU)

Design and assessment of a penile fracture simulation model.

OBJECTIVE: To design and assess a novel penile fracture simulation model for teaching penile fracture repair. METHODS: We used a validated circumcision simulator to create a model. Foreskin for a circumcision was divided into two halves. A transverse slit ("simulated fracture") was created on one part of the first half of the foreskin (mimicking "tunica") and was applied over the penile model. A red jelly tablet ("clot") was placed underneath the cut. A second full-length of foreskin was applied over it to cover the defect. The model was assessed by participants and expert faculty at the Urology Simulation Boot Camp. Evaluation was performed using a 5-point Likert Scale questionnaire. Data was analysed using Microsoft Excel and IBM SPSS Statistics V25. The intra-class correlation was calculated using a "One-way random model". RESULTS: Twenty-two urology trainees and four experts participated in the evaluation. The majority of trainees strongly agreed (59%, n = 13) the model is useful for training with experts similarly agreeing in 75% of cases. The appearance of penile fracture was considered good by both trainees (68%, n = 14) and faculty (75%). Overall, the ability of the model to represent a realistic simulation of the task was considered excellent by 23% of participants and good by 64%. Personal confidence after simulation in managing a similar situation was considered high among trainees. The main difficulties reported were related to fascial planes and urethra. CONCLUSION: This is the first simulation model for penile fracture repair and has demonstrated face validity at a national urology bootcamp.

Design and assessment of a penile fracture simulation model. / Diseño y evaluación de un modelo de simulación de fractura de pene.

OBJECTIVE: To design and assess a novel penile fracture simulation model for teaching penile fracture repair. METHODS: We used a validated circumcision simulator to create a model. Foreskin for a circumcision was divided into two halves. A transverse slit ("simulated fracture") was created on one part of the first half of the foreskin (mimicking "tunica") and was applied over the penile model. A red jelly tablet ("clot") was placed underneath the cut. A second full-length of foreskin was applied over it to cover the defect. The model was assessed by participants and expert faculty at the Urology Simulation Boot Camp. Evaluation was performed using a 5-point Likert Scale questionnaire. Data was analysed using Microsoft Excel and IBM SPSS Statistics V25. The intra-class correlation was calculated using a "One-way random model". RESULTS: Twenty-two urology trainees and four experts participated in the evaluation. The majority of trainees strongly agreed (59%, n=13) the model is useful for training with experts similarly agreeing in 75% of cases. The appearance of penile fracture was considered good by both trainees (68%, n=14) and faculty (75%). Overall, the ability of the model to represent a realistic simulation of the task was considered excellent by 23% of participants and good by 64%. Personal confidence after simulation in managing a similar situation was considered high among trainees. The main difficulties reported were related to fascial planes and urethra. CONCLUSION: This is the first simulation model for penile fracture repair and has demonstrated face validity at a national urology bootcamp.

[Urethral centralization and pseudo-glans formation after partial penectomy]. / Zentralisierung der Harnröhre und Pseudoglansbildung nach partieller Penektomie.

The management of penile cancer has altered dramatically over the last decade. Confidence to excise lesions safely with smaller margins has led to the adoption of penile-preserving techniques and in turn improved the functional and cosmetic results. Patients undergoing partial penectomy (PP) find that the urethral meatus is located in an abnormal ventral position. In addition, there is a high risk of meatal stenosis. We describe our novel technique that allows the urethral meatus to be centralised after PP and creation of a pseudo-glans and wide meatus and therefore maintain the cosmetic appearance of the penis after split thickness skin grafting. The UCAPP technique allows the restoration of the normal meatal location and creation of a pseudo-glans in case of partial penectomy and therefore can improve the overall cosmetic appearance and reduce the psychological morbidity.

Atypical haemolytic uraemic syndrome treated with the complement inhibitor eculizumab: the experience of the Australian compassionate access cohort.

BACKGROUND/AIM: This study aimed to report the clinical characteristics and outcomes of Australian patients treated with eculizumab for atypical haemolytic uraemic syndrome (aHUS). METHODS: A retrospective cohort study was undertaken of all patients in Australia treated with eculizumab provided in a compassionate access programme for a clinical diagnosis of aHUS using prospectively collected clinical data. RESULTS: A total of 10 patients with a median age of 23.5 years (interquartile range (IQR) 24.83 years) received compassionate access eculizumab for aHUS in Australia. Eight patients were female, and three had a family history of aHUS. Three received eculizumab for an initial acute aHUS presentation, three for relapsing and refractory acute aHUS, two for de novo aHUS post-renal transplantation, and one each for aHUS recurrence post-transplantation and facilitation of transplantation with a history of aHUS. The median duration of eculizumab therapy has been 911.5 days (IQR 569 days) with a cumulative exposure of 9184 days. At baseline all patients had renal and extra-renal aHUS involvement, with up to three non-renal organs affected. All but one patient, who died from uncontrollable gastrointestinal aHUS manifestations, have continued. The nine continuing patients achieved remission of aHUS. Two of the four patients requiring renal replacement therapy (RRT) at eculizumab commencement subsequently ceased RRT. Clinical events occurring in this cohort while on eculizumab treatment included neutropenia (two), posterior reversible encephalopathy syndrome (one), cardiomyopathy (one), pulmonary embolus (one), antibody-mediated rejection resulting in renal graft failure (one), iron deficiency (one), gastrointestinal haemorrhage (one) and death (one). CONCLUSION: Eculizumab has been an effective therapy for aHUS in this cohort, including when other therapies have failed.

Innovation in tissue viability documentation for acute services.

This paper discusses the developmental process, outcome and delivery of an innovative approach to standardising tissue viability documentation across two sites within Nottingham University Hospitals NHS Trust, following the results of benchmarking pressure ulcer preventive care strategies and recommendations from pressure ulcer root cause analysis. It reflects upon the process, highlighting the lessons learnt.

A study to determine the minimum volume of blood necessary to be discarded from a central venous catheter before a valid sample is obtained in children with cancer.

BACKGROUND: The objective of this study was to determine the minimum volume of blood that should be discarded from a range of different types of central venous catheter (CVC), such that the subsequent blood sample was not diluted or contaminated by the residual intra-luminal fluid. PROCEDURE: Seventy children aged 1-19 years with central venous access inserted as part of their standard clinical treatment were recruited to this prospective study. Statistical comparison of the extent of variation in biochemical and haematological parameters observed between two blood samples taken following routine 5 ml discard blood volumes, as compared to the extent of variation between samples drawn following a 5 ml discard volume and <5 ml volumes, was carried out. RESULTS: Data indicate that the measurement error in a clinical sample obtained following a 3 ml discard volume is no different to the measurement error obtained when using a standard 5 ml discard volume. Comparable results were obtained from patients with various different types of CVC or portacath access. CONCLUSIONS: The withdrawal of a 3 ml discard volume is sufficient to ensure that the subsequent blood sample is not diluted or contaminated by residual intra-luminal fluid. This may have a significant clinical impact in paediatric oncology, where patients frequently require blood transfusions due to the haematological toxicities associated with chemotherapy. It is hoped that these results will impact on hospital policies concerning specified discard volumes taken from CVCs prior to the withdrawal of blood samples for research purposes and routine clinical analysis.

Evaluation of two point-of-care analysers for measurement of fructosamine or haemoglobin A1c in dogs.

Measurement of glycosylated proteins such as fructosamine and haemoglobin A1c (HbA1c) can be used to assess glycaemic control in canine diabetic patients. Two point-of-care analysers, designed for human diabetics, were evaluated for use in dogs. Blood samples were collected from 50 normoglycaemic dogs, 100 diabetic patients and five dogs with insulinoma and tested using the In Charge fructosamine meter and the Haemaquant/Glycosal HbA1c meter. Readings were obtained in all cases except for 21 of 50 diabetics, which were above the upper limit of the In Charge meter. Diabetic dogs had higher fructosamine and HbA1c concentrations compared to controls. However, there was poor agreement between the In Charge meter readings and serum fructosamine concentrations, suggesting that there are problems associated with the use of this device in dogs. HbA1c concentrations showed a high degree of correlation with glycosylated haemoglobin measured at an external laboratory, suggesting that the Haemaquant/Glycosal meter warrants further evaluation for veterinary use.

Moist wound healing: does the theory apply to chronic wounds?

Winter's research on moist wound healing continues to exert a strong influence on tissue viability practice. But does this theory, which is based on porcine acute wounds, apply to human chronic wounds. This review explores the evidence.

Multicenter evaluation of Tosoh glycohemoglobin analyzer.

BACKGROUND: We describe an Anglo-French evaluation of a new analyzer. METHODS: The Tosoh HLC-723 GHb V, A1c2.2 glycohemoglobin analyzer is an HPLC instrument with primary blood tube sampling, bar-code reading, cap piercing, and the ability to chromatographically separate labile hemoglobin A1c (HbA1c). We evaluated two analytical protocols, 2.2 and 3.0 min, and compared results for blood samples collected from diabetic and nondiabetic subjects with those obtained with Bio-Rad Diamat and Variant analyzers. RESULTS: Within- and between batch-imprecision (CVs) was <2% with linearity to at least 15.9% HbA1c. Although some hemoglobinopathies were detected in the 2. 2-min chromatography, clearer evidence of abnormality was visible in the 3.0-min version. Comparison with established methods showed good correlation (r = 0.993; n = 316 with Diamat; and r = 0.995; n = 133 with Variant) but highlighted calibration differences. CONCLUSIONS: The problems of manual blood sample preparation, labile HbA1c, and carbamylated hemoglobin interference associated with the older instruments have been eliminated in the new Tosoh analyzer. The 3. 0-min protocol is preferred for routine use.

Interleukin-4 and interleukin-4 receptor polymorphisms in minimal change nephropathy.

Minimal change nephropathy (MCN) is an important cause of nephrotic syndrome, especially in children, that is strongly associated with atopy and IgE production. The immunogenetics of MCN are poorly understood. Interleukin-4 (IL-4) is the critical cytokine involved in the development of atopy. Polymorphic regions in the genes encoding IL-4 itself and the IL-4 receptor have been demonstrated that may predispose to increased activity. We have analysed these polymorphisms in 149 patients with MCN and 73 controls to test the hypothesis that these loci are involved in genetic predisposition to MCN. In our populations there were no polymorphisms in the IL-4 promoter. We did confirm allelic variation in a dinucleotide repeat in the second intron of the IL-4 gene, but there was no significant difference between allele distributions in MCN and controls. Similarly, allele frequencies for the IL-4 receptor alpha chain polymorphism were similar in patients and controls. Genetic loci which are believed to influence IL-4 responsiveness and to predispose to atopy do not appear to be associated with susceptibility to MCN.

Transcolonic retrograde ureteric catheterization assisted by 3-D computed tomography.

A 42-year-old woman had bladder exstrophy at birth, treated by ureterocolic anastomosis of her single kidney. She suffered recurrent hyperammonaemia, leading to comas, but refused an ileal conduit. During her most recent coma, it was decided to divert her urine to test whether this would reduce hyperammonaemia: this was accomplished by transcolonic retrograde catheterization of the ureter. This was only possible after computed tomography ureterography to show the ureterocolic anastomosis.

Interface pressure measurements during ambulance journeys.

This study investigated the risk of developing pressure damage associated with surfaces used in ambulances. One subject's journey in an ambulance was evaluated to identify the intensity of interface pressures (in mmHg) at particularly susceptible areas (the ischial tuberosities, sacrum and heels) while the vehicle was both stationary and moving. Interface pressures measured on a standard ambulance stretcher and a spinal board were also compared. Results indicate that the pressure readings obtained are likely to lead to capillary occlusion with the potential development of pressure damage. Manufacturers of ambulances therefore need to consider incorporating pressure-relieving surfaces in seats and stretchers in the future.

Potential for bilateral nephrectomy to reduce oxalate release after combined liver and kidney transplantation for primary hyperoxaluria type 1.

Primary hyperoxaluria type 1 (PH-1) is frequently associated with end stage renal failure due to urinary calculi, obstructive uropathy and interstitial deposits of calcium oxalate. The currently accepted treatment for PH-1 is liver transplantation to replace the deficient enzyme peroxisomal alanine glycoxylate aminotransferase (AGT) and a simultaneous renal transplant to restore renal function. The transplanted kidney may become significantly impaired or fail when systemic calcium oxalate is eliminated by renal excretion. The native kidneys are a major source of this oxalate. This study was undertaken to determine whether there is a difference in oxalate clearance following combined liver-kidney transplant in patients with PH-1 by comparing the effect of native kidney nephrectomy at the time of transplantation against leaving the native kidneys in situ. Regression analysis was used to compare daily urinary oxalate excretion corrected for body surface area. There was a significant reduction in urinary oxalate excretion (P < 0.05) in the patient who had undergone bilateral nephrectomy compared to the patient whose native kidneys remained in situ for the first 100 d following combined liver and kidney transplantation. No difference was observed in the serum oxalate levels between patients over the same period or in the renal function assessed by creatinine clearance corrected for body surface area. Total body oxalate load was not determined in this study. A larger study should be undertaken to examine the benefits of nephrectomy in reducing oxalate deposition in recently inserted allografts for patients with PH-1.

Standardization of glycated haemoglobin assays throughout the Northern region of England: a pilot study.

We describe a pilot study designed to assess the comparability of measurements of glycated haemoglobin among 15 laboratories in the North of England. We also evaluated a means of improving agreement and aligning results by referencing locally measured values to those obtained by the central biochemistry laboratory of the Diabetes Control and Complications Trial research group. Blood samples from 50 diabetic and non-diabetic subjects were analysed for glycated haemoglobin content in the participating and reference laboratories using a variety of routinely available methods. The mean CV for these results was 15.3% (95% confidence interval 14.0% to 16.5%). Using a regression equation relating a subset of seven of these results to their assigned reference values, a glycated haemoglobin index was calculated for all the other samples distributed. The mean inter-laboratory CV improved to 4.6% (95% confidence interval 4.0% to 5.1%), p<0.0001. The percentage bias of results from the reference method also improved from 15.1% (95% confidence interval 9.4 to 20.1) to 4.67% (95% confidence interval 4.05 to 5.25) after alignment, p<0.001. This study demonstrated that substantial method related differences between reported glycated haemoglobin results exist. These can be reduced using a simple calibration strategy in which data are correlated to an established method with associated extensive clinical interpretive value as established by the DCCT.