Thickened Endometrium: When to Intervene? A Clinical Conundrum.

The endometrium is a dynamic target organ in a woman's reproductive life. It undergoes cyclical change regulated by the fine balance between oestrogen and progesterone. The endometrial thickness (ET) varies according to the phases of the menstrual cycle. Endometrium contains both oestrogen and progesterone receptors, which respond to above hormones, irrespective of whether the woman is in reproductive or menopausal phase. Abundance of oestrogen leads to endometrial hyperplasia, and paucity causes endometrial atrophy. The initial best modality of assessing ET or aberration is high resolution transvaginal ultrasonogram. Thickened endometrium is always a clinical conundrum. Dilemma does remain as to the thickness of endometrium which requires intervention, mostly in symptomatic pre and perimenopausal women. In post-menopausal women with bleeding, the cut-off of ET that warrants investigation is almost defined. However, the cut-off value of ET in asymptomatic postmenopausal women; beyond which intervention is required, is still debated. Dilemma also exists about the cut-off of ET in both symptomatic and asymptomatic women on HRT and Tamoxifen. This article will discuss the above issues and reach at some consensus about the cut-off of ET after critical analysis of evidence and experience and will help clinicians in arriving at a proper decision in dealing with such clinically confounding situations.

Ayurvedic management of necrozoospermia - A case report.

Male factors are responsible for more than forty percent of the infertility cases. Necrozoospermia is one among the main cause for infertility in male. Necrospermia i.e. 100% immotile and 0% viable spermatozoa in ejaculate, is a rare and poorly documented cause of male infertility. A 56-year-old man was referred for reproductive counseling with secondary infertility and diagnosed as necrozoospermia (Shukra Dosha). He presented with complaints of having no issues since 7 years of married life with his second wife. The patient has a son from divorced first wife. After the thorough clinical examination and laboratory investigations, diagnosis was confirmed as necrozoospermia. The patient was administered Koshtha-Shuddhi (purgation) with Eranda Taila (castor oil) as per the guidelines of Ayurvedic treatment. After the proper purificatory procedures depending on dominance of deranged Dosha, the patient was given Arogyavardhini Vati, Chandraprabha Vati, Shilapravanga and Phala Ghrita (medicated ghee) as Sneha (internal oleation). At the end of 3½ month, semen analysis showed marked improvement in sperm count and increase in the sperm motility. The present finding and the effective management of necrozoospermia with Ayurvedic formulations with no adverse effect highlight the promising scope of traditional medicine in male infertility disorders.

Blunt testicular trauma - is surgical exploration necessary?

OBJECTIVES: EAU and AUA guidelines recommend urgent surgical exploration in cases of suspected testicular rupture. However, the management of rupture to other encapsulated organs (e.g. kidney) is primarily non-operative. The aim of this study was to evaluate the conservative management of blunt scrotal trauma. METHODS: Standard practice in our Level II trauma centre is to manage all blunt scrotal injuries conservatively with analgesia, antibiotics and scrotal support. Ultrasonography is performed where testicular injury or haematocoele is suspected clinically. All patients are offered a 3 month follow-up appointment. A retrospective chart review was performed on all patients who underwent ultrasonography for blunt scrotal trauma between 1998 and 2014. Each patient was contacted by telephone to assess for testicular atrophy. RESULTS: Thirty-seven consecutive patients were identified for inclusion in the study. Twenty-three patients (62%) were diagnosed with significant testicular injury (rupture of tunica albuginea or large haematocele). All were managed conservatively regardless of ultrasound findings. Four patients had evidence of testicular atrophy at their three month follow up appointment. None reported chronic pain or required delayed orchidectomy. Four patients later underwent repair of an asymptomatic post-traumatic hydrocoele. CONCLUSIONS: Our experience shows that blunt scrotal trauma can be safely managed conservatively and may reduce the risk of atrophy compared to case series where the testis was surgically explored.

Efficacy of vacuum erectile devices (VEDs) after radical prostatectomy: the initial Irish experience of a dedicated VED clinic.

Controversy exists regarding optimal penile rehabilitation program following radical prostatectomy (RP). Vacuum erectile devices (VEDs) have become an important component of penile rehabilitation protocols. The aim of this study was to assess the efficacy and patient satisfaction of a dedicated VED clinic. A voluntary telephone questionnaire was performed of all patients who attended a VED clinic to date in two university teaching hospitals. Patient demographics, histopathological characteristics and functional status (International Index of Erectile Function (IIEF) scores) were obtained from a retrospective review of a prospectively maintained database. Sixty-five men attended the dedicated VED clinic in the two university teaching hospitals. Forty-men (76.3%) men purchased a VED following the dedicated clinic. There was significant differences noted between the mean preoperative and the 3-month postoperative IIEF scores (22.08±3.16 vs 11.3±3.08, P=0.0001) and between the 3-month postoperative IIEF score and the post-VED use IIEF score (11.3±3.08 vs 16.74±2.62, P=0.0001). Despite VED use, there was a significant reduction in erectile function from presurgery status (22.08±3.16 vs 16.74±2.62, P=0.0001). All patients reported that the dedicated VED was helpful and would recommend it to other patients. Our study demonstrates that, despite a reduction in erectile function after RP, successful erections are attainable with a VED. There is potential and need for the development of a standard penile rehabilitation program and treatment of ED after RP internationally.

Attitudes of GP trainees towards the training received in urology on the GP training scheme.

INTRODUCTION: The majority of patients with scrotal problems or urinary symptoms will first present to their general practitioner (GP). The importance of the initial examination performed by the GP is often underestimated; however, it frequently determines the course of investigation and ultimately treatment. Unfortunately, medical schools have devoted increasingly less time to teaching urology over the past decade. The impact of this decline in teaching on a GP trainee's assessment of urological complaints remains unclear. The aim of this study was to investigate the self-reported competency of GP trainees in assessing urological presentations. METHODS: A questionnaire was circulated to 101 GP trainees from five separate training programmes. Respondents rated their confidence in evaluating four different urological presentations. They were also invited to give their opinion regarding the teaching of urology on their current scheme and whether they would be in favour of the addition of urology as an optional rotation. RESULTS: Only 18 trainees (19 %) felt urology was adequately covered on their curriculum. A small yet significant number of respondents felt uncomfortable in their assessment of testicular (28 %, 28/101) or prostate (35 %, 35/101) pathology and male (17 %, 17/101) or female (10 %, 10/101) urinary symptoms. Twenty-six trainees (26 %) would choose a rotation in urology if available. Another ten trainees felt that attending urology outpatient clinics would benefit training. CONCLUSION: This study highlights a number of concerns among GP trainees in relation to their training in urology. These issues should be addressed to ensure that the training scheme sufficiently prepares GPs to manage common urological conditions.

Homemade laparoscopic surgical simulator: a cost-effective solution to the challenge of acquiring laparoscopic skills?

BACKGROUND: Laparoscopic surgery is well known to have a long and variable learning curve and there is a potential benefit from earlier integration of laparoscopic skills in medical education. AIMS: The aim of this study was to assess the challenges facing surgical trainees regarding the acquisition of laparoscopic skills and second to assess their opinion regarding the use of a homemade laparoscopic surgical simulator. METHODS: A homemade laparoscopic surgical simulator (HLSS) was constructed. An online survey using Survey Monkey® of surgical trainees at a tertiary referral university teaching hospital was conducted assessing their experience with laparoscopic surgery. Surgical trainees were voluntarily enrolled to assess the self-designed laparoscopic trainer. Each trainee was asked to perform simple exercises without supervision. RESULTS: All trainees (n = 34) responded to the survey. No trainee had full-time access to a laparoscopic box trainer. The mean time spent per week using the simulator was 0.38 h (range 0-3 h), with 61.8 % (n = 21) reporting not using the simulator at all. 94.1 % (n = 32) enrolled in our study. 90.6 % (n = 29) found the HLSS easy to use compared to 93.8 % (n = 30) with the CLS (p = 1.00). 96.9 % (n = 31) reported an overall satisfaction with the HLSS. There was no difference with regard to the completing the tasks: peg transfer (78.1 vs 78.1 %, p = 1.00), cutting patterns (65.6 vs 71.9 %, p = 0.788) or knot tying (12.5 vs 18.8 %, p = 0.732) whether using HLSS and the CLS. CONCLUSION: Homemade laparoscopic surgical simulators are easy to construct, affordable, usable and of interest to trainees.

Combined laparoscopic-assisted nephrectomy and complete mesocolic excision for synchronous renal and colon cancers.

Cancers of the colon and kidney are common malignancies, however, the occurrence of primary synchronous neoplasms of these two organs is uncommon. To the best of our knowledge, this is the first case report of a laparoscopic radical left nephrectomy and extended right complete mesocolic excision (CME) for a patient with synchronous renal and colon cancers. While a radical nephrectomy has long been the standard of care for a renal malignancy, CME has only recently been used. Combined surgeries provide the patient with various benefits such as decreased hospital stay, less postoperative pain and morbidity, early return to work and better cosmoses.

The use of smartphone applications by urology trainees.

OBJECTIVE: Mobile phone technology is continuously advancing- the smartphone allows users instant access to information via the internet. Downloadable applications (apps) are becoming widespread across medical specialities. The aim of this study was to assess the use of smartphone apps among urology trainees in Ireland. METHODS: An anonymous electronic survey was distributed via Survey Monkey(®) to all urology trainees in Ireland assessing their ownership and use of smartphones and downloadable apps. A search of urology apps was performed using the Apple App Store and the Android Market. RESULTS: 36 (81.8%) of trainees responded with 100% ownership of smartphones. 28 (77%) report downloading apps with 11 (30.6%) reporting paying for them. The mean number of apps downloaded was 4 (Range 1-12). 16 (44.4%) trainees think apps for smartphones are very useful in clinical practice, 14 (42.4%) think they are useful. A total of 126 urology apps were available. 76 (60.3%) were designed for physicians, 46 (36.5%) for patients, 2 (1.6%) for students and 2 (1.6%) for urological nurses. CONCLUSION: There are an ever increasing number of urology apps available. Urology trainees are using smartphones as an educational and reference tool and find them a useful aide in clinical practice.

Paediatric orchidopexy: a need for dedicated paediatric surgical training among urologists?

BACKGROUND: Undescended testis (UDT) is one of the most common congenital abnormalities with a prevalence of about 1% at the age of 1 year. UDT is associated with an increased risk of testicular tumours and infertility. AIMS: The aim of this study was to assess who is carrying out paediatric orchidopexy in Ireland. METHODS: A survey was distributed via Survey Monkey to all Consultant Paediatric Surgeons and Urologists in Ireland. RESULTS: Twenty-seven (64.3%) urologists and five (71.4%) paediatric surgeons responded to our online survey. Of the urologists, 100% reported formal training in paediatric orchidopexy. Eight (29.6%) underwent a dedicated paediatric fellowship. 13 (48.1%) currently perform paediatric orchidopexy. Nine (33%) think it should be carried out by a urologist, whereas eight (29.6%) think it should be carried out by paediatric surgeon. The mean age at which urologists think an orchidopexy for UDT should be performed by was 18 months (range 1-4 years). Approximately 400 orchidopexies are performed per year by the surveyed urologists. Of the paediatric surgeons, three (60%) feel it should be carried out by a paediatric surgeon whereas two (40%) feel it does not matter. All paediatric surgeons feel it should be performed by 1 year of age. Approximately 700 orchidopexies are performed per year by the surveyed paediatric surgeons. CONCLUSION: UDT is a concerning condition which requires intervention at an early stage. Dedicated training in core paediatric procedures is required to continue to meet this need for the future to prevent delayed orchidopexy and resultant increased risk of testicular tumours.

A prospective audit of emergency urology activity in a university teaching hospital.

INTRODUCTION: Urology cover is commonly available out-of-hours in most teaching hospitals. However, increased pressure to reduce hospital expenditure has forced many institutions to consider removing middle grade cover outside of normal working hours. The aim of this study was to audit the emergency urology activity in our institution over a 12-month period. METHODS: A prospective logbook was maintained for all urology referrals from the emergency department between August 2012 and March 2013. The diagnosis and patient outcome was recorded for each referral. The emergency theatre logbook was retrospectively evaluated for all emergency urology procedures carried out over the same time period. A basic cost analysis was performed to calculate the cost of providing the on-call service. RESULTS: A total of 752 patients were referred to the urology service over a 12-month period. The most common reasons for referral were renal colic and scrotal pain. Approximately 41 % of referrals were discharged directly from the emergency department. There were 167 emergency operations performed in total. The majority of emergency operations and referrals from the emergency department took place outside of normal working hours. A basic cost analysis revealed an associated cost saving of €58,120. CONCLUSION: Emergency urology activity constitutes a large proportion of the workload at our institution. Restricting emergency urology cover would limit essential training opportunities for urology trainees, increases length of stay and delay treatment of urological emergencies. Urology "out of hours" cover is a cost-efficient method of service provision.

Paediatric urology training: what does the future hold?

BACKGROUND: Paediatric urology training is not a mandatory part of higher surgical training in urology in Ireland. It is predicted there will be a shortfall of surgeons trained in paediatric surgery in the coming years leading to a reliance on specialist paediatric surgical centres. AIM: The aim of this study was to assess the attitudes of urological trainees regarding the current state of paediatric urology training and to address the potential future changes to training structures. METHODS: A voluntary anonymous internet-based survey was emailed to all urological trainees. Parameters assessed included sex, level of training, attitudes towards paediatric urology training and levels of competence regarding core paediatric urological procedures. RESULTS: 69.2 % (n = 18) responded to the survey. 94.4 % (n = 17) would favour mandatory paediatric training-of these, 52.9 % (n = 9) would favour this in a dedicated paediatric hospital with a paediatric urologist. 66.7 % (n = 12) would like to provide a paediatric urology service as a consultant. 55.6 % (n = 10) felt they were competent to perform circumcision or scrotal exploration independently and manage all associated complications. No trainee felt themselves to be competent to perform orchidopexy independently and manage all complications. CONCLUSION: Our study demonstrates a promising desire to provide paediatric services in the future. A greater emphasis on structured paediatric urology training is required to maintain the standard currently offered by adult urologists.

Design and development of modified atmosphere packaging system for guava (cv. Baruipur).

Modified atmosphere packaging (MAP) is a dynamic system during which respiration and permeation occur simultaneously. Hence factors affecting both respiration and permeation were considered for designing a package. In the design of MA packages for guava (cv. Baruipur) a total of 13 variables were considered. The independent variables includes: weight of fruits, surface area of packaging film, free volume of the package, thickness of the film and permeabilities of film to O2 and CO2 gas. The fixed variables considered were: the surrounding gas composition and temperature, the respiration rates for O2 consumption and CO2 evolution, and the equilibrium gas compositions to be attained in the package so that the fruit's shelf-life is extended. Two types of MA packages, having package size of 19 cm × 19 cm for a fill weight of 1,000 ± 100 g were developed. Packages were designed to accommodate a fill weight range of 0.90-1.10 kg. Various package parameters were optimized to facilitate establishment of dynamic equilibrium at target levels of O2 and CO2 concentration in the package. The storage study of MA packages was performed at 10, 15, 20 and 25 °C temperatures. The performance of film packages was evaluated for their ability to establish equilibrium at target levels and to extend the shelf life of the packaged fruit. The MA packaging system increased the shelf life of guava by 128-200 % compared to the unpacked fruits at various storage temperatures with a quality comparable with the freshly harvested commodity.

Evaluation of endoscopic laser excision of polypropylene mesh/sutures following anti-incontinence procedures.

PURPOSE: We reviewed our experience with and outcome of the largest series to our knowledge of patients who underwent endoscopic laser excision of eroded polypropylene mesh or sutures as a complication of previous anti-incontinence procedures. MATERIALS AND METHODS: A total of 12 female patients underwent endoscopic laser excision of suture/mesh erosions at 1 center during a 10-year period. Primary outcome variables were the requirement of additional endoscopic or open surgery to remove mesh/sutures. Secondary outcome variables were persistence of urinary symptoms, postoperative complications, continence status and requirement of additional anti-incontinence procedures. RESULTS: The mean interval from previous surgery to erosion was 59 months (range 7 to 144) and the duration of presenting symptoms ranged from 3 to 84 months (mean 19). Ten patients underwent endoscopic excision of the mesh/suture with the holmium:YAG laser and 2 underwent excision with the thulium laser. Mean operative duration was 19 minutes (range 10 to 25) and followup was 65.5 months (range 6 to 134). Postoperatively 6 patients remain asymptomatic and 2 required a rectus fascial sling for recurrent stress urinary incontinence. Four patients underwent a second endoscopic excision due to minor persistence of erosion. Only 1 patient ultimately required open cystotomy to remove the eroded biomaterial. No intraoperative complications were recorded and all patients are currently asymptomatic. CONCLUSIONS: Endoscopic laser excision is an acceptable first line approach for the management of eroded biomaterials due to its high long-term success rate and minimally invasive nature.

Sign reversal of junction magnetoresistance in p-La0.7Ca0.3MnO3/SiO2/n-Si heterostructure: a possibility in spintronics application.

We have fabricated a p-La0.7Ca0.3MnO3/SiO2/n-Si heterostructure, consisting of a p-type manganite (La0.7Ca0.3MnO3) and n-type Si with a interfacial layer of SiO2 with typical thickness of about 9 nm using pulsed laser deposition technique. The junction exhibits rectifying behavior over the temperature range of 10-300 K with rectification factor 52 at room temperature. Investigation on the electrical properties of p-La0.7Ca0.3MnO3/SiO2/n-Si heterostructure exhibits nonlinear J-V characteristics in a wide temperature range. A crossover from negative to positive junction magnetoresistance (JMR) is observed in p-La0.7Ca0.3MnO3/SiO2/n-Si heterostructure in current perpendicular to film plane (CPP) geometry. The temperature dependent sign of junction magnetoresistance of the heterojunction has been investigated carefully in details. It is found that the junction exhibits the positive junction magnetoresistance when the temperature is greater than the ferromagnetic to paramagnetic transition temperature (Tc) of the top highly spin-polarized half-metallic ferromagnetic La0.7Ca0.3MnO3 manganite film layer. The relation between junction magnetoresistance and external magnetic field is found to be of (delta rho/rho approximately equal alphaHbeta) type having both alpha and beta temperature dependent. We attribute the emergence of negative JMR at lower temperature (< Tc) and positive JMR at higher temperature (> Tc) to the quantum mechanical tunneling transport mechanism across the heterojunction. Our results might be very useful to fabricate artificial devices using the manganite-based heterojunction grown on single crystalline n-Si (100) in spintronics device applications.

Derivation, characterization and differentiation of buffalo (Bubalus bubalis) amniotic fluid derived stem cells.

Amniotic fluid cells (AFCs) are obtained from amnion for pre-natal analysis and can be cultured in vitro. Heterogeneous amniotic fluid (AF) contains various cell types, and it is believed that some of these cells possess the stem cell properties. The aim of this study was to characterize these cells by phenotypical and genotypical means in buffalo. The differentiation potential of amniotic fluid stem (AFS) cells was carried out by converting these cells into neurons. The AFCs were cultured without feeder cells in DMEM containing 16% foetal bovine serum, 1% penicillin/streptomycin and 1%l-glutamine in 5% CO(2) at 38.5 ± 0.5 °C in a CO(2) incubator. After 6 days of culture, different types of cells viz., star shaped (62.7%), spherical without nucleus (1.9%), spherical with nucleus (26.4%), pentagonal (0.4%) and free floating/rounded cells (8.3%) were observed. Most of the cells started anchorage-dependent growth after day 7 of the culture. Expression of Oct-4, Sox-2, Nanog, alkaline phosphatase, 18s rRNA, stem cell factor, cyclin A, Nestin and FGF-5 was observed from the AFS cells in different passages with PCR amplicon of 314, 277, 317, 180, 162, 216, 421, 307 and 210 bp, respectively. During the differentiation step, at day 6, neuron-like cells could be clearly identified and confirmed with Nestin-specific RT-PCR. The cells were found to have a normal karyotype at different passages. These results may contribute towards establishing non-embryonic pluripotent stem cells for various therapeutic and reproductive biotechnological applications in the species.

Current concepts in female stress urinary incontinence.

Urinary incontinence is a social burden for up to one-third of the adult female population. Careful assessment, a methodical approach and appropriate treatment can lead to long-term success in the management of these patients. This article gives an outline of current concepts in the evaluation and treatment of stress urinary incontinence.

Mini-open reduction and intramedullary interlocking nailing of fracture shaft of tibia without an image intensifier.

Intramedullary interlocking tibial nailing is usually performed using an image intensifier. But being expensive, it is not available in the most of the hospitals of resource-poor countries of the world. The purpose of this study is to analyze the results of interlocking nailing without the use of an image intensifier. This is the retrospective study of 55 diaphyseal tibial fractures treated with minimally open reduction and internal fixation with interlocked intramedullary nail fixation. The proximal locking of the nail with the screws was made using external jig and for the distal locking direct visualization of the hole was carried out. There were 15 females and 40 males. The average age in years was 32 with a range of 18 to 64 years. The surgical approach was medial parapatellar. The average follow up period was 4 months. This period ranged from 3 months to 14 months. The union time in an average was 4 months. The complication mainly was distal screw loosening leading to valgus deformity and shortening in 1 case. It is, therefore, concluded that interlocking intramedullary nailing can be performed with proximal and distal locking accurately without the use of an image intensifier.

Diagnostic accuracy of hand-held Doppler in the management of acute scrotal pain.

We evaluate the reliability of hand-held Doppler (HHD) in the management of acute scrotal pain of 24 h or less duration. Between October 2003 and December 2004, patients presenting with acute scrotal pain were enrolled in this prospective study. After clinical examination, all patients had a HHD assessment. Presence or absence of Doppler arterial signals and its intensity were recorded. A blinded assessor corroborated HHD findings with the clinical, ultrasound, operative findings and final diagnosis. Primary outcome measured were sensitivity and specificity of HHD in the diagnosis of testicular torsion. Twenty-five patients presented during the study period with acute scrotal pain. The final diagnosis was testicular torsion in nine, epididymitis in 13, twisted cyst of Morgagni in two and Henoch-Schoenlein purpura in one patient. The HHD predicted all patients of testicular torsion correctly, preoperatively. HHD is a reliable diagnostic tool in the management of patients with acute scrotal pain.

Achieving distal locking without an image intensifier.

The tibia is commonly fractured bone frequently caused by high energy trauma leading to the complications and major disabilities. Different types of intramedullary nails have been employed by surgeons over 500 years. Today, the intramedullary interlocking tibial nailing is the leading modality of treatment because of its biomechanical advantage over the other modalities. This procedure is done in the advanced centers under the C-arm image intensifier. Yet, there is no facility of C- arm image intensifier in the operation theatre at the tertiary level public hospitals in Nepal. Most of the peripheral hospitals do not have portable X- ray facility. The purpose of this study was to study the success rate of distal locking in the intramedullary nailing of tibial shaft fractures with the aid of distal aiming device (DAD). The distal locking were done in 65 tibial shaft fractures. In this technique the distal hole was directly visualized after proper drilling. All the distal locking could be done without image intensifier. So this technique can be useful where the imaging facilities are not available and even in the advanced centers to avoid radiation hazards.

Bullying of junior doctors prevails in Irish health system: a bitter reality.

Workplace bullying in health systems is a well known fact. It leads to not only breakdown in teamwork but also has significant affect on the individual's personal life. True prevalence of bullying in junior doctors working in Ireland is unknown. Our aim of study was to find out the prevalence of bullying in junior doctors working hospitals in south and western counties of Ireland and to assess its effects on the productivity of work and family life and to identify the common source of bullying. We carried out a questionnaire survey. A total of 950 questionnaires were sent. Response rate was 51%. Our sample is 15% of the target population of all the hospital junior doctors. 30% of the responders claimed to be subjected to one or more bullying behaviors. Doctors from European Union (EU) reported significantly less rate of bullying compares to non EU doctors. Our results are in line with the results of studies conducted in United Kingdom. This study shows the magnitude and source of the problem. We conclude that bullying is a common problem in Irish health system. Increased awareness and zero tolerance are required to eradicate bullying.