Surgical Approach to Urethral Diverticulum and Urethrovaginal Fistula With Mesh Erosion.

INTRODUCTION AND HYPOTHESIS: This video illustrates a rare surgical case involving a urethral diverticulum, urethrovaginal fistula, and mesh erosion. METHODS: We present a 58-year-old patient attending a tertiary care center with a suspected urethrovaginal fistula. Her concerns included stress urinary incontinence (SUI), recurrent urinary tract infection, and vaginal pain. The surgical history was notable for the placement of two different mesh slings during the same procedure to treat SUI. Preoperative evaluation and findings are illustrated in detail. The video uses a high-definition surgical camera to emphasize the initial intraoperative evaluation with localization of the fistula and diverticulum. We then demonstrate the approach to the dissection with the goal of ensuring complete resection of the diverticulum, fistula, and mesh, while preserving healthy tissue for subsequent closure. The utilization of unique and specialized tools for each portion of the procedure is also illustrated. A layered vaginal closure, including a Martius flap, is created to prevent recurrence. RESULTS: The surgery was accomplished without complications. CONCLUSIONS: To our knowledge, concomitant findings of a urethral diverticulum, urethrovaginal fistula, and mesh erosion are unique in the literature. We postulate that this triad could have resulted from the mesh burden in this particular patient.

Use of Wearable and Wireless Technology in Real-World Clinical Settings to Improve Patient Outcomes in Chronic Kidney Disease: A Mixed Methods Pilot Prospective Trial.

Background: During the 30-day period prior to initiating dialysis, there is a 10-fold rise in emergency department visits and hospitalizations related to kidney failure. Objective: The Virtual Ward Incorporating Electronic Wearables (VIEWER) trial implemented a home telemonitoring system to track changes in patients' vitals and assess their adherence and the acceptability of telemonitoring in a chronic kidney disease (CKD) population. Design: A pilot prospective clinical trial using a mixed methods approach was performed. Setting: The research was conducted in Winnipeg, Manitoba. Participants: There were 2 phases: Phase 1 was a 2-week-long pilot trial consisting of 10 participants. Phase 2 was a 3-month-long trial with a total of 26 participants. Patients with an estimated glomerular filtration rate <15 and a >40% risk of beginning dialysis in the next 2 years according to the kidney failure risk equation were eligible to participate in the study. Methods: The primary quantitative outcome was adherence, defined as the proportion of daily self-assessments completed using VIEWER over the follow-up period. The usability and acceptability of VIEWER was assessed qualitatively at the end of the trial through structured questionnaires and focus groups. Results: Phase 1 participants (n = 10) had a median adherence of 77.17% for the 2-week observation period. Phase 2 participants (n = 26) showed a lower median adherence of 36% for the 3-month period. Focus group participants (n = 11) identified many positive aspects of VIEWER, including increased awareness and empowerment over health, simplicity of the data platform, and the ability to show clinical staff their health trends. Some challenges identified with VIEWER were connectivity issues with the Bluetooth, perceived inconvenience, and negative thoughts toward their health. Limitations: Limitations of the study include a small sample size, which limited our ability to measure quantitative outcomes. In addition, patients agreeing to participate in any trial are generally more highly motivated and engaged in their care than those declining participation. Therefore, our results may not be generalizable to individuals who are not interested in self-management of their health. Conclusion: Our results suggest that home telemonitoring in patients with advanced CKD is feasible using a CKD-specific platform like VIEWER. We anticipate that improved functionality with incorporation of feedback from this study will result in greater long-term adherence. A future randomized clinical trial is planned.

Contexte: Les visites aux urgences et les hospitalisations en lien avec l'insuffisance rénale augmentent d'environ dix fois dans les 30 jours qui précèdent le début de la dialyse. Objectif: L'essai VIEWER a mis en œuvre un système de télésurveillance à domicile qui permet de suivre les changements dans les paramètres vitaux des patients atteints d'insuffisance rénale chronique (IRC). L'essai permet également d'évaluer l'observance et l'acceptabilité de la télésurveillance dans cette population. Conception: Un essai clinique pilote prospectif utilisant une approche par méthodes mixtes. Cadre: Les recherches ont été menées à Winnipeg, au Manitoba. Sujets: L'essai s'est déroulé en deux phases: un essai pilote de deux semaines avec 10 participants (phase 1) et un essai de trois mois avec un total de 26 participants (phase 2). Étaient admissibles à participer: les patients présentant un DFGe inférieur à 15 ml/kg/1,73 m2 et une probabilité d'au moins 40 % d'amorcer des traitements de dialyse dans les deux ans, selon l'équation KFRE (kidney failure risk equation). Méthodologie: Le principal critère d'évaluation quantitatif était l'observance, définie par la proportion d'auto-évaluations réalisées quotidiennement à l'aide VIEWER au cours de la période de suivi. La facilité d'utilisation et l'acceptabilité de VIEWER ont été évaluées qualitativement à la fin de l'essai au moyen de questionnaires structurés et de groupes de discussion. Résultats: Les participants à la phase 1 (n=10) ont montré une observance médiane de 77,17 % pendant les deux semaines d'observation. Les participants à la phase 2 (n=26) ont montré une observance médiane inférieure, soit de 36 %, pendant les trois mois du suivi. Les participants au groupe de discussion (n=11) ont identifié plusieurs aspects positifs de VIEWER, notamment: une sensibilisation et une responsabilisation accrues à l'égard de la santé, la simplicité de la plateforme de données, et le fait de pouvoir montrer leurs tendances de santé au personnel clinique. Parmi les défis identifiés figurent des problèmes de connectivité avec Bluetooth, des désagréments perçus à son utilisation et des pensées négatives à l'égard de la santé. Limites: La faible taille des échantillons a limité notre capacité à mesurer les résultats quantitatifs. En outre, les patients qui acceptent de participer à un essai clinique sont généralement plus motivés et impliqués dans leurs soins que ceux qui refusent de participer. Par conséquent, nos résultats pourraient ne pas être généralisables aux personnes qui ne sont pas intéressées par l'autogestion de leur santé. Conclusion: Nos résultats suggèrent que la télésurveillance des patients atteints d'IRC avancée est réalisable par le biais d'une plateforme spécifique à l'IRC comme VIEWER. Nous pensons que l'amélioration de sa fonctionnalité, découlant des résultats de cette étude, se traduira par une plus grande observance à long terme. Un futur essai clinique randomisé est prévu.

Researchers' responsibility to uphold Indigenous rights.

Too often research brings harm to Indigenous peoples.

A vision to advance gender equality within pharmacy leadership: Next steps to take the profession forward.

The United Nations Sustainable Development Goal 5 to 'achieve gender equality and empower all women and girls' aims to eliminate all forms of discrimination against women and girls and ensure their full and effective participation in all spheres of life. In alignment with this, several key international initiatives are making progress towards gender equality in the pharmacy profession. The pharmacy profession must support women and accelerate the progress of women in leadership positions in pharmacy. International and national pharmacy professional bodies can play a critical role in fostering the change required to improve gender equality in all regions and countries. The ongoing development, evaluation and implementation of policies and initiatives are critical to a profession that is increasingly becoming feminised. Furthermore, there is an imperative to deeply understand the gender-based barriers and develop evidence-based strategies and solutions to support women in pharmacy leadership. There is extensive literature and research on gender inequality and its impact on leadership outside pharmacy which could be used strategically for the profession to develop its own evidence based strategic position. Robust initiatives are needed to ensure that women at all levels including women in pharmacy leadership are empowered and encouraged to participate in their profession. This commentary seeks to generate and contribute to the debate to ensure the profession is proactive and deliberate in tackling the challenges that have traditionally impeded women reaching leadership positions and several critical actions as next steps are proposed. Action is needed to improve gender equality in pharmacy leadership and a profession-wide discussion on ways to progress the above proposed actions is critically needed.

Are there predictors of flexible ureteroscopic aptitude among novice trainees? objective assessment using simulation-based trainer.

PURPOSE: Non-surgical skills involving hand-eye coordination and bimanual dexterity may have a transferable impact on the acquisition of ureteroscopy skills. In this study, we aim to investigate the predictors of initial flexible ureteroscopy skills among novice trainees. METHODS: This was a prospective study involving students with no prior ureteroscopy exposure. Non-surgical parameters were assessed with a detailed survey, including demographics, video game, and musical history. Musical ability was objectively evaluated with the mini-Profile of Music Perception Skills test. Ureteroscopic performance was evaluated using a Boston Scientific© flexible ureteroscope on a bench model. Each participant completed diagnostic ureteroscopy and stone extraction. Outcomes included both speed and quality of performance, based on an Objective Structured Assessment of Technical Skills rubric. RESULTS: A total of 28 pre-clerkship medical students and 10 urology residents were included. Age and musical background were not associated with ureteroscopic aptitude. Those with video game history tended to perform ureteroscopy tasks faster with a higher OSATS score, although no statistical significance was reached. Male gender was associated with faster task completion with statistically higher OSATS score independent of video game activities (p = 0.011), however, the absolute score difference was small. CONCLUSIONS: Among novice trainees, musical and video game experience was not predictive of ureteroscopy skills. Male gender was associated with slightly faster and higher ureteroscopy technique scores, however, the differences are small and unlikely to represent clinical significance. Nevertheless, the use of ureteroscopy trainer provides useful insights and should be adopted in training programs as a marker of skills progression.

Do children use logic to spell logician? Implicit versus explicit teaching of morphological spelling rules.

BACKGROUND: Intervention studies have reported the advantage of teaching children about morphemes for spelling, but direct comparisons between explicit and implicit teaching have been examined systematically in relation to only a few morphological rules. AIMS: This study compared explicit versus implicit teaching of the functional rule for the conservation of stem morphemes in derived words in English (e.g., logic is conserved in the derivative logician in spite of changes in pronunciation). SAMPLE: Participants (n = 90; 7- to 9-year-olds) were drawn from three schools with a diverse intake. METHODS: The design included a pre-test and two post-intervention tests. Participants were randomly assigned to one of three groups: an explicit group, taught about stems and their conservation in derived words; an implicit group, exposed to the same stems and derivatives without explicit teaching; and an unseen control group. At pre- and post-test, the children's spelling of stems in derivatives was assessed. The interventions involved practice games in which the children spelled derived words after seeing the base forms; the explicit group discussed the connection between the spellings, whereas the implicit group did not. RESULTS: Analyses of variance revealed that explicit teaching led to more significant spelling improvements than implicit or no teaching, and this effect held at both post-tests. CONCLUSIONS: It was concluded that explicit teaching of the stem conservation rule in derived forms combined with appropriate practice games shows a sustained effect on spelling. The evidence supports explicit teaching of this morphological rule in classroom practice.

Influence of musical background on surgical skills acquisition.

BACKGROUND: There is growing interest in identifying trainees with surgical aptitude predictive of eventual technical proficiency. Musical tasks involve complex, cerebral activity, and ambidextrousity, which may have a positive impact on the acquisition of surgical skill sets. The purpose of this study was to investigate the influence of prior musical experience on the performance of basic surgical skills. METHODS: This was a prospective cross-sectional study involving 51 novice undergraduate and medical school trainees with no prior surgical exposure. Musicality was assessed with a detailed survey and objectively with the Mini-Profile of Music Perception Skills test. Dexterity was assessed using the Purdue Pegboard test. Surgical skills were then evaluated by performing 2 timed suturing trials after observing tutorial video, followed by a timed laparoscopic peg transfer test. Outcomes included both speed and quality of performance. RESULTS: Participants with prior musical experience performed better than nonmusicians on the Mini-Profile of Music Perception Skills test (P = .015), dominant hand dexterity (P = .05), suture quality (P < .03), and laparoscopic peg transfer speed (P < .01). There was no significant difference in the suturing speed between musicians and nonmusicians. The dexterity and Mini-Profile of Music Perception Skills scores were predictive of suture quality (P < .01). Among musicians, duration of musical training, inactivity, instrument type, and certification levels did not correlate with differences in surgical task performance. CONCLUSION: Musical background is associated with better performance of fundamental surgical skills among surgical novices, particularly technique quality. Although this does not imply superior ultimate surgical ability, musicality may be a marker for basic surgical skill development useful in identifying suitable candidates for surgical training.

Comparison of Glenoid Version and Posterior Humeral Subluxation in Patients With and Without Posterior Shoulder Instability.

PURPOSE: To evaluate glenoid version and humeral subluxation on preoperative multiplanar imaging of patients who underwent surgery for posterior glenohumeral instability compared with a matched group of patients who had shoulder surgery for other pathology. METHODS: All patients over a 2-year period who underwent surgery for posterior instability had preoperative magnetic resonance (MR) imaging or MR arthrogram reviewed. Patients undergoing shoulder surgery for reasons other than instability were identified as a control group and matched by sex, laterality, and age. Measurement of glenoid version and percentage of humeral subluxation was performed by 2 reviewers after completing a tutorial. Reviewers were blinded to diagnosis and to whether or not the patients were in the experimental or control group. RESULTS: There were 41 patients in each group. The average glenoid version in the control group was 5.6° of retroversion (standard deviation [SD] 3.0), and the average humeral subluxation was 54% (SD 5.1%). In the experimental group, the average glenoid version was 8.1° of retroversion (SD 5.0). The average humeral subluxation in the experimental group was 56% (SD 6.8%). Student t test revealed a statistically significant difference in glenoid version (P = .009) but not humeral subluxation (P = .25). Intra- and inter-rater reliability was measured by the intraclass correlation coefficient and found to have an excellent Fleiss rating with regard to both measurements. CONCLUSIONS: Glenoid retroversion is significantly increased in patients with symptomatic posterior labral tears compared with a control group. However, there was no statistically significant difference between the groups with regard to posterior humeral subluxation and, therefore, is not a reliable indicator of the presence or absence of symptomatic posterior shoulder instability. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Assessment of painful total shoulder arthroplasty using computed tomography arthrography.

BACKGROUND: This study assessed the accuracy of computed tomography (CT) arthrography when evaluating glenoid component stability in the setting of postarthroplasty shoulder pain. METHODS: We retrospectively reviewed all patients presenting to the clinic during a 5.5-year period to identify those with a painful shoulder arthroplasty more than 1 year after the index procedure. We excluded reverse and hemiarthroplasty procedures, patients with a clearly identifiable cause for pain, such as rotator cuff insufficiency or gross component loosening as seen on plain radiographs, and those with culture-positive aspiration. There were 14 patients with suspected glenoid component loosening but inconclusive plain radiographs. Each of the 14 patients underwent a CT arthrogram that was evaluated by the senior author (J.J.P.W.) for the presence or absence of contrast material underneath the polyethylene component. Operative reports and surgical videos from subsequent arthroscopy were reviewed to assess glenoid component stability as determined by direct arthroscopic visualization. RESULTS: CT arthrography suggested glenoid component loosening in 8 of 14 patients (57.1%), and arthroscopic inspection identified loosening in 10 of 14 patients (71.4%). In 3 of 10 patients (30%), CTA suggested a well-fixed glenoid component, but gross loosening was identified during arthroscopy. In this study, CTA yielded a sensitivity of 70%, a specificity of 75%, a positive predictive value of 87.5%, and a negative predictive value of 50.0%. CONCLUSION: CTA had a low negative predictive value (50%), and therefore, the prediction of component stability based on the absence of contrast between the glenoid component and the bone-cement interface does not always reflect true stability.