Improving continuing medical education by enhancing interactivity: lessons from Iran

Introduction: Continuing Medical Education [CME] has been considered as a lifelong commitment for doctors to provide the optimal care for patients. Despite a long history of creating CME programs, outcomes are far from ideal. The present qualitative study aims to clarify the barriers affecting effectiveness of the CME programs in Iran based on the experiences of general practitioners

Methods: Sixteen general practitioners were recruited to participate in in-depth interviews and field observations concerning experiences with CME. The study was performed using a qualitative content analysis method. The codes, categories and themes were explored through an inductive process in which the researchers moved from specific to general

Results: The participants' experiences identified a number of barriers, particularly insufficient interaction with the instructors; additional problems included the teachers' use of an undifferentiated approach; unreal and abstract CME; and ignorance of the diverse reasons to participate in CME

Conclusion: Based on the study results, there are multiple barriers to effective implementation of CME in Iran. The key barriers include insufficient interaction between the trainees and providers, which must be considered by other stakeholders and program designers. Such interactions would facilitate improved program design, invite more specific tailoring of the education to the participants, allow for more effective educational methods and set the stage for outcome evaluation from the learners actually applying their new knowledge in practice. Replication of these findings with another sample would improve confidence in these recommendations, but these findings are broadly consistent with findings in the educational literature on improving the efficacy of CME

Expression of glycogen synthase kinase 3-beta [GSK3-beta] gene in azoospermic men

The Wnt/beta- The Wnt/beta-catenin signaling pathway is involved in many developmental processes in both fetal and adult life; its abnormalities can lead to disorders including several types of cancers and malfunction of specific cells and tissues in both animals and humans. Its role in reproductive processes has been proven. This study was designed to evaluate the expression of the key regulator of this signaling pathway GSK3-beta and its presumed role in azoospermia. WNT3[a] protein concentration and GSK3-beta gene expression levels were measured and compared between two groups of infertile men. The test groups consisted of 10 patients with obstructive and 10 non-obstructive azoospermia. The control group was selected among healthy men after vasectomies that were willing to conceive a child using a testicular biopsy technique. Samples were obtained by testicular biopsy and screened for the most common mutations [84, 86 and 255] in the SRY region before analyzing. GSK3-beta gene expression was assessed quantitatively by real time-PCR. The WNT3[a] protein concentration had no significant difference between the two test groups and controls. Expression of GSK3-beta was down-regulated in non-obstructive azoospermia [3.10 +/- 0.19] compared with normal [7.12 +/- 0.39] and obstructive azoospermia [6.32 +/- 0.42] groups [p=0.001]. Down-regulation of GSK-3beta may cause to non-obstructive azoospermia. Regulation and modification of GSK-3beta gene expression by drugs could be used as a therapeutic solution

Urethroscopic holmium: YAG laser ablation of large urethral stone after two-stage urethroplasty

Hairball in a urethral diverticulum has rarely been reported. These hairballs are usually formed in the diverticulum coated with a hair bearing epithelium and can lead to urinary obstruction or infection. Using laser is a safe way to ablate such stones

Value of prostate-specific antigen and prostate-specific antigen density in detection of prostate cancer in an Iranian population of men

The objective of this study was to evaluate the value of serum prostate-specific antigen [PSA] and prostate-specific antigen density [PSAD] in the diagnosis of prostate cancer. A total of 330 consecutive patients suspected of having prostate cancer due to either abnormal digital rectal examination or elevated serum PSA levels underwent transrectal ultrasonography-guided sextant biopsy of the prostate. The PSA and PSAD values were assessed based on the biopsy results. One hundred and twenty-one patients [36.7%] had prostate cancer. In this group, the mean PSA was 31.60 +/- 30.85 ng/mL [range, 1.9 ng/mL to 166.0 ng/mL] and the mean PSAD was 0.83 +/- 1.01 [range, 0.04 ng/mL/ cm[3] to 6.38 ng/mL/cm[3]]. In those without prostate cancer the mean PSA and PSAD levels were 13.80 +/- 18.72 ng/mL [range, 0.4 ng/mL to 130.0 ng/mL; P < .001] and 0.24 +/- 0.32 [range of 0.01 ng/mL/cm[3] to 2.29 ng/mL/ cm[3] P < .001]. The receiver operating characteristic curve analysis revealed that the discriminating power of serum PSA for detecting prostate cancer, as estimated by the area under the curve, was 0.74 while that for PSAD was 0.81 [P < .001]. For the PSA range of 3.5 ng/mL to 41 ng/mL [gray zone] the areas under the curve was 0.68 for PSA, while it was 0.78 for PSAD [P < .001]. The use of PSAD instead of PSA in the diagnosis of prostatic cancer improves the diagnostic accuracy

Supracrural rerouting as a technique urology for resolution of posterior urethral disruption defects

Selection of an acceptable method for the treatment of posterior urethral disruption defects would be highly desirable. We determined the efficacy and success rate of some techniques including supracrural rerouting for removing of these defects among our patients. Records of 200 consecutive men treated with anastomotic urethroplasty for traumatic posterior urethral strictures were reviewed at our teaching hospital. Prior treatment, surgical approach, and ancillary techniques required during reconstruction were evaluated. Success rate due to posterior urethral reconstruction was achieved in 78.0% of cases. Supracrural urethral rerouting was performed in 11 patients [5.5%], of whom 7 sustained recurrent stricture requiring intervention. The highest success rate of defect resolving was reported by urethral mobilization [92.4%]. Supracrural rerouting is not an acceptable technique and can result in postoperative complications such as recurrent stricture in most of the patients with posterior urethral disruption defects

Surgical repair of posterior urethral defects. Review of literature and presentation of experiences

The main objective of the present review article was to study the different aspects of reconstructive surgery for posterior urethral defects by reviewing the published articles and presentation of our experiences in the reconstructive urology division at Shohada-e-Tajrish hospital. The Medline was searched with the keywords of posterior urethroplasty, end-to-end anastomosis, excisional urethroplasty, anastomotic urethroplasty, pelvic fracture, bulboprostatic anastomosis, and urethral repair. The search was limited to papers published from 1980 to September 2008. We selected the relevant published articles in this database and also presented our experience at our reconstructive urology division. Of over 5000 search results, we selected 38 relevant articles with substantial contribution to the subject. Pelvic fracture due to accidents was the most common etiology of pelvic fracture urethral distraction defect that usually involved the membranous urethra. Surgical treatment of this disorder with perineal anastomotic urethroplasty was accompanied by a success rate of 82% to 95% in different studies. The most important complications of this surgery include urinary incontinence and impotence; however, the incidence of these complications has been reduced by using new surgical techniques. Complete preoperative assessment, the use of suitable reconstructive techniques, and in particular, the use of flexible cystoscopy can lead to acceptable outcomes of the surgical repair of pelvic fracture urethral distraction defects

Fournier Gangrene: a series of 12 patients

Fournier gangrene is a rare, rapidly progressive, necrotizing fasciitis of the external genitalia, the perineum, or the abdominal wall that is associated with high morbidity and mortality. In this series, we describe 12 patients with Fournier gangrene who had presented to our medical center. Twelve men had been diagnosed with Fournier gangrene in Shohada-e- Tajrish hospital between March 2002 and September 2005. Their medical records were reviewed and the Fournier Gangrene Severity Index scores before and after the treatment were determined. Fifty percent of the patients were diabetic and their mean age was 58.2 ' 17.8 years. The mean delay between the onset of the disease and the admission was 4.9 days and the mortality rate was 16.6%. The median Fournier Gangrene Severity Index scores before the admission and at the time of discharge were 4.5 [range, 0 to 11] and 0 [range, 0 to 9], respectively [P = .005]. One of the patients who died had the scores of 11 and 9, respectively. Split-thickness skin graft was performed for 5 patients [41.7%]. In Fournier gangrene, a rapid diagnosis and emergent surgical intervention is crucial. The Fournier Gangrene Severity Index seems to be an excellent tool for outcome prediction

Diagnostic application of flexible cystoscope in pelvic fracture urethral distraction defects

The aim of this study was to evaluate the diagnostic value of antegrade flexible cystoscopy in pelvic fracture urethral distraction defects [PFUDD]. Between 1999 and 2004, a total of 111 patients with PFUDD were evaluated by antegrade flexible cystoscopy. The flexible cystoscope was introduced into the posterior urethra and the area was evaluated for any probable fistula, false passages, or displacement of the posterior urethra. For preventing misalignment, flexible cystoscope was also used during the urethroplasty to open the posterior urethra at its exact distal point. Posterior urethra ended distal to the external sphincter in 16 patients [14.4%]. Five [4.5%] and 9 [8.1%] patients had severe displacement of the posterior end of the urethra and bladder neck false passage, respectively. Prostatic urethrorectal fistula was detected in 1 patient. Another 1 patient had bladder rhabdomyoma. Flexible cystoscopy is a valuable procedure in the evaluation of the bladder, the bladder neck, and the posterior urethra in patients with urethral distraction defects and complements voiding cystography before the surgery. It is also helpful for showing the exact distal point of the proximal urethra during urethroplasty in cases with displaced posterior urethra