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Will you bury your Bentley for pleasures in your ‘after life’?

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Last year in September, a Brazilian multi-millionaire Count Scarpa, announced to his followers on Facebook that he would bury his most favorite car, a black Flying Spur Bentley costing half a million Dollars, in his backyard! He expressed his intention to be buried next to the Bentley when he died. He explained that this desire arose after he had watched a documentary on the Egyptian Pharaohs and how they buried themselves with their beloved items, so that they can be used during the afterlife. Count Scarpa had stared death in the face on two occasions. He was in a coma after over-whelming sepsis that nearly killed him following an operation to reduce weight. In fact, a priest gave him the last rites on two occasions. However, he recovered to continue with his business. As you would expect, the announcement of the Bentley burial caused uproar in the Brazilian national media and also caught the international media’s attention reported in the UK by Daily Mail and the Metro. His Facebook account was flooded with comments most of which were derogatory and questioning his intentions.

Count Scarpa even posted photos of him digging the grave and of his favourite Bentley waiting to be buried.

He invited the media for the D-day when the event would take place. The car was being driven into the grave, when Count Scarpa stopped the process and invited the entire media team inside his multi-million Dollar mansion. Once inside, he mentioned that he is not crazy to bury his Bentley but exclaimed ‘everyone thought it was absurd when I said I was going to do that.’ ‘Absurd is bury their organs, which could save many lives. Nothing is more valuable. Be a donor, tell your family.’ (See the video here). The publicity stunt certainly worked. A photo of the Count holding a sign reading “I am an organ donor. Are you?” had spread like wildfire over social media sites, being shared over 40,000 times in just 24 hours! The power of Social Media!

The reason for writing this blog stemmed from reading a very touching article in the UK’s Guardian newspaper. The article quotes that there has been a 30.5% increase in transplants in the past five years, there are still more than 7,000 on the transplant list, and last year more than 1,300 people either died while on the waiting list or became too sick to receive a transplant! There is an urgent need worldwide to raise awareness about organ donation. In the UK, there is a drive by the NHS for organ donation. The organ donations website has very interesting statistics regarding donation as well as that of the recipients. The “Did you Know?” page sheds light on some interesting facts including renal transplantation. It is estimated that 30% of people on the NHS Organ Donor Register are aged between 16-25 when they join. A further 24% are aged between 26-35. Only 9% are 65 or over when they join. More women (54%) than men (46%) have signed up on the NHS Organ Donor Register. There is also a need to raise awareness among the ethnic minorities in the Western World as Black people are three times as likely as the general population to develop kidney failure and the need for organs in the Asian community is three to four times higher than that of Caucasians. 

Government agencies of various countries should take note of the way Count Scarpa took the advantage of the power of Social Media such as Facebook to raise awareness. In fact, an initiative by John’s Hopkins along with Facebook to increase the organ donation was a huge success. The findings were published in the American Journal of Transplantation. On May 1, 2012, Facebook allowed members to specify their organ donor status on their profile. Members were then offered a link to their state registry to complete an official designation, and their “friends” in the network were made aware of the new status as a donor. Those considering the new organ donor status were provided educational links regarding donation. On the first day, astonishingly there were 13,054 new online registrations, representing a 21.1-fold increase over the baseline average of 616 registrations!

Just as BJUI has capitalized social media among the Urologists, we should encourage our respective Governments to use the various channels effectively to spread the word about Organ Donation.  

Amrith Raj Rao is a Consultant Urological and Robotic Surgeon at Wexham Park Hospital, Wexham, UK. Twitter: @urorao

 

Mind Your Language Please!

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Recently I came across a clinic letter that had the patient’s problem typed as “Balanitis EROTICA obliterans”. Reading the typo error and sharing it with the nursing staff instantly converted a serious clinic into one where everyone started to recall their funny typo encounters. Having come across similar typos in the past, I thought about sharing it with this blog. Examples such as abnormal lover (liver) function test, digital erectile (rectal) examination, examination of the penis revealed that he is circus sized (circumcised), testes were distended (descended), he does have a lot of flabulets (phleboliths), among many others are often found in the clinic letters. There are others who have also shared their experiences on the web that are worth a read for a hearty laugh.

Gone are those good old days when you had your own secretary who would type your clinic and theatre dictations. Nowadays, the dictation is electronically transferred to a Medical Transcription service across the globe to somewhere in Asia or South Africa. The letter gets typed and medically qualified personnel correct any obvious mistakes and the Word document is electronically sent across to your secretary.

These kinds of typo errors have also emerged in the modern day smartphones. These ‘extra’ smart phones have an application wherein auto-correction takes place simultaneously as you type. On many occasions these changes go unnoticed and can lead to messages that can be hilarious. Indeed, there is a collection of mishaps due to auto-correction at this site.

On a serious note, typographical errors can be dangerous and detrimental to patients. Common examples quoted by this news article include “known malignant” instead of “non-malignant” and “urological” instead of “neurological”. Indeed, a patient’s death in the US due to wrong insulin dosage typed on the clinic letter led to a successful claim by the plaintiff.

If you have come across any funny transcription errors or anything more serious, please share it in the discussion.

Amrith Rao is a Consultant Urological Surgeon at Wexham Park Hospital, Wexham, UK.
Twitter: @urorao

A benedictory ode to urological live surgery

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This blog was originally published as a comment article in BJU International, 112: 11–12. doi: 10.1111/j.1464-410X.2012.11780.x

 

With the explosion and expansion of information technology, instantaneous dissemination of medical knowledge across the globe is a reality and here to stay. Performing live surgery to an audience, whether to the medical community or to the general public, has raised much controversy and continues to be hotly debated even today. While a recent article by a very senior urologist concentrated on the drawbacks of live surgery, little was written about the benefits [1]. We begin our debate with this ‘Benedictory Ode’ to live surgery:

Came the news about cancer of the prostate
Surgery, radiation or I had to be castrate
I was won over by the argument of the daVinci Robot
Surgical smile assured me protection of the lover’s knot
I was asked to be a patient for live surgery
I thought to myself, is it a circus or butchery?
Should I be scared, Should I be excited?
But was convinced many will be benefitted
My choice was voluntary and informed
Consent on the dotted line was performed
The day came and the day went
Surgery was smooth without a dent
Some might argue that I was a damn fool
But I am proud to have been an educational tool

Anonymous Patient

When did ‘live surgery’ really begin? Probably the answer would be as early as the birth of medicine itself. Medicine and surgery as we know them today have been based upon the ‘teacher–apprentice’ model for centuries. Whenever the ‘teacher’ became famous, apprentices from surrounding towns, and subsequently from surrounding countries, would flock to watch the way a diagnosis was made or indeed how the surgery was performed. In historical documents from the Middle Ages through to the Renaissance, we are reminded of the amphitheatre that was built especially to demonstrate anatomical dissections and surgeries. Indeed the very origin of the term ‘operating theatre’ probably stems from the fact that operations were carried out to an audience in a theatrical manner, as beautifully portrayed in many medical paintings across the world.

The birth of the first transmission of surgical procedures can be traced back to the famous British Broadcasting Corporation (BBC) series ‘Your Life in Their Hands’. This was first aired in 1958 and eight episodes were then broadcast over the next two months. This innovative series was conceived with three goals: to investigate new medical techniques; to applaud the medical profession; and to provide ‘reassurance’ for citizens at home. At the end of that period, the BBC had received 909 letters from viewers praising the programme and only 37 letters from viewers who were against it [2].

Professor Arthur Smith rightly points out the death of a patient that occurred in 2006 during live surgery organised by The Japanese Society of Thoracic Surgeons [1]; however, we should highlight that the very next year, the Japanese Society for Cardiovascular Surgery, the Japanese Association for Thoracic Surgery and the Japanese Society for Vascular Surgery collaborated in the development of guidelines for performing live surgeries [3]. In their guidelines, they rightly emphasize the need for feedback on the outcome of a patient who has undergone live surgery:

‘When a fixed interval has elapsed after live surgery, the surgeon must report on the postoperative course followed by the patient at an organized Society or research meeting. By this means, the body organizing such a meeting can investigate each of the cases in which live surgery has been conducted, and assesses the appropriateness of the use of live surgery in each.’

Recognizing the need for guidance for physicians and institutions with regard to live surgery, organisations such as the General Medical Council, AUA and the Royal College of Surgeons have published relevant guidelines. In their paper, Challacombe et al. [4] elegantly discuss the various aspects of the ethics of live surgery and highlight the important issues of patient consent and disclosures. We have followed the above guidelines for live robotic surgery to an audience and also to conduct the first live webcast in the UK of a robotic prostatectomy. Contrary to the norm, extra care is taken during live surgeries. Indeed, this may be an advantage for the patient as shown in Table 1. The operating surgeon is always an expert and, in our case, the surgeon was well trained to listen, respond to questions and operate without any hesitation. It is safe to assume that not all surgeons will achieve this high standard in their career. It is also vital to have a moderator who can manage the questions appropriately and convey them to the operating surgeon at the appropriate time.

In the era of evidence-based medicine, no debate can be complete without presenting supporting data from the literature. Several studies across different specialties have looked at the outcomes of patients who have undergone live surgeries. None of the studies showed any adverse outcome in the cohort of patients who subjected themselves to live surgery. Recently, a study analysed the outcomes of patients undergoing robotic partial nephrectomy as a live broadcast as compared with a cohort treated without observers [5]. The authors concluded that live robotic surgery is associated with excellent patient outcomes that compare favourably with cases performed under normal operating procedures. There is further evidence that live surgery as part of a course has a powerful impact on the practice patterns of a urologist [6]. Surprisingly, there is no published evidence in the literature that these patients come to any harm. There are several surveys of surgeons across specialties in the literature with contradictory views on live surgery, but there is no denying that transmission of live surgeries is becoming more and more popular, as evidenced by the packed rooms at all major urological meetings.

Conclusion

Performing live surgery on a patient is here to stay and will be an integral part of the dissemination of medical knowledge. The obligation that the medical society has towards the field of live surgery is to ensure that the operation is performed by the ‘right surgeon on the right patient in a right environment and with the right intentions’.

 

Amrith R. Rao and Omer Karim
Department of Urology, Wexham Park Hospital, Wexham, Berkshire, UK

References

1    Smith A. Urological live surgery – an anathema. BJU Int 2012; 110: 299–300 Full Article (HTML)

2    van Lingen A. Your life in their hands. Published online 27 November 2006. Accessed at https://www.birth-of-tv.org/birth/assetView.do?asset=1413260435_1164637516. Accessed 28 August 2012

3    Misaki T, Takamoto S, Matsuda H, Shigematsu H. Joint Committee for the Establishment of Guidelines for the Live Session of Thoracic and Cardiovascular Surgery. Published August 2007. Available at https://jscvs.umin.ac.jp/eng/live.html. Accessed 28 August 2012

4    Challacombe B, Weston R, Coughlin G, Murphy D, Dasgupta P. Live surgical demonstrations in urology: valuable educational tool or putting patients at risk? BJU Int 2010; 106: 1571–1574 Full Article (HTML)

5    Mullins JK, Borofsky MS, Allaf ME et al. Live Robotic Surgery: are outcomes compromised? Urology 2012; 80: 602–607 Web of Science®

6    Altunrende F, Autorino R, Haber GP et al. Immediate impact of a robotic kidney surgery course on attendees practice patterns. Int J Med Robot. 2011; 7: 165–169. doi: 10.1002/rcs.384 Full Article (HTML)

 

 

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Who let the Dogs Out?

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Or

Let’s Paws for a Second!

Or

Lets paws for a second before we all start howling about nothing!

 

Recently while driving to a Day Surgery list at Heatherwood hospital in Ascot, I happened to listen to BBC Radio 4. There was a report regarding high accuracy for the detection of stomach cancer by a simple breath test. This reminded me of a study published some time ago in European Urology on the ability of a dog to detect prostate cancer by smelling a sample of urine. For a skeptic like me, reading that article in the platinum journal had indeed brought a sarcastic chuckle. Pondering over the paper and the report on the radio, it just dawned on to me as to why I would instantly believe a high-tech nanosensor detecting stomach cancer but not a mortal Belgian Malinois shepherd! This formed my basis of my blog.

It is well known that when someone is afflicted by a disease or cancer, there is a change that occurs in the internal milieu. In the vast majority, before this change can be manifested clinically, there is definite change seen biochemically.  There is emerging evidence that volatile organic compounds (VOC) that are exhaled either in the breath or in bodily fluids can indicate these changes reflecting the underlying pathology.  This is where the humble mongrel comes into play. Olfactory bulb in dogs is forty times bigger than of humans relative to total brain size. Having 125 to 220 million smell-sensitive receptors, their olfactory sense is up to one hundred thousand to one million times more sensitive than a human’s. So, there may be some sense and science in the paper that I had initially chuckled at. The earliest report is a letter to the Lancet reporting the diagnosis of melanoma made after the dog sniffed at a suspicious mole of its owner. Since then, there have been several reports on the ability for the trained dogs to detect various cancers and chronic illness, urological diseases. One of the earliest attempts to detect prostate cancer can be dated back to 2002. Further attempts were made to initiate trials in 2003 but no published results on Medline were found. Earliest published paper can be traced back to 2008, wherein the study did not support the concept of dogs being able to detect prostate cancer. This was recently challenged by the article by Cornu J et al that revealed a sensitivity and specificity of 91% for biopsy proven prostate cancer! In fact, one of the three patients who was wrongly classified as prostate cancer, was found to have cancer on a re-biopsy! The potential VOC that may be found in the urine of a patient with prostate cancer can be found in this letter to the editor. Indeed, to carry out more research, “Medical Detection Dogs” is aiming to recruit prostate cancer patients within the UK!

One would obviously think that if we can diagnose prostate cancer, why not bladder cancer? This is precisely what led to a “proof of principle” study headed by Carolyn Willis and findings were published in the BMJ. The dogs had a mean success rate of 41%, compared with 14% expected by chance alone. Multivariate analysis suggested that the dogs’ capacity to recognise a characteristic bladder cancer odour was independent of other chemical aspects of the urine detectable by urinalysis. What was astonishing about this study was on one occasion during training, all dogs unequivocally indicated as positive a sample from a participant recruited as a control on the basis of negative cystoscopy and ultrasonography. The consultant responsible for the patient was sufficiently concerned to bring forward further tests, and transitional cell carcinoma of the right kidney was discovered! The same group further reported specificity that ranged from 92% for urine samples obtained from healthy, young volunteers down to 56% for those taken from older patients with non-cancerous urological disease.

More trials are being carried out for detection of cancers affecting the lung, breast, ovary, bowel and others, a review of which can be found in this article. We may need to wait for a few more years to find out whether we are dealing with real science or we are going in circles like the dog chasing its own tail!

On the lighter note, if you hear an old male dog bark for no apparent reason, think prostate cancer!! Dog is the only other mammal that can be afflicted by prostate cancer and fortunately the doggie world will not be affected by the USPSTF recommendations, as canine prostate cancers do not secrete PSA!

Amrith Rao is a Consultant Urological Surgeon at Wexham Park Hospital, Wexham, UK

Tweet: @urorao

 

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Does Michelangelo’s David have an increased risk of prostate cancer?

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Recently when researching on the Italian Renaissance master Michelangelo and his suffering with kidney stones, I stumbled upon a project on his famous masterpiece David. At the precise time, I was browsing BJUI and came across the article by Motofei et al, on the sexual side effects of finasteride as related to hand preference (right-handed or left-handed) for men undergoing treatment of male pattern baldness. This manuscript reminded me of several articles that measured different parts of the male body and correlated with the risk of prostate cancer. With this paper on my mind and at the same time looking at David, it just occurred to me whether I could predict the possibility him getting prostate cancer!

Let’s start from the beginning. Being born as a male, he had acquired a 1 in 6 chance of being diagnosed with prostate cancer and 1 in 36 chance that he would have died from it. The moment David stood erect as a toddler; the risk of getting prostate cancer became a reality. Indeed, the authors of the study go on to claim the link of erect posture of humans with BPH and infertility. For those interested, the theoretical aspects of erect posture and its effects on the male reproductive tract can be found in this review.

It is worth analyzing the David’s anthropometric measurements and bodily features from head to toe and correlate them to the current available evidence. David’s height has been calculated at being 497 cm. This, in real life would probably make him around 5’ 8” to 6’. According to the findings of the PLCO trial, being tall increased his risk of developing more aggressive prostate cancer and at a younger age. This is supported also by the findings of the ProtecT trial, which demonstrated that for high-grade tumours, there was a 23% increase in risk per 10 cm increase in height. The study group’s meta-analysis of published literature also support the increased risk of prostate cancer with increasing height.

Let us start from his head. Fortunately, David is not bald. Recent evidence suggests a strong correlation between vertex pattern androgenic alopecia and significant risk of prostate cancer. Looking at the elegance of the face, it is quite obvious that he is a clean-shaven man. Fortunately, being white, the age at which he started shaving indicating early or delayed adolescence, does not seem make his chances of getting prostate cancer worse.

Going on to his chest, it is apparent that David did not suffer from Gynaecomastia. There is considerable controversy in the literature regarding the association of gynaecomastia and future risk of prostate cancer. A cohort study following men with histologically proven gynaecomastia did not find any increased risk of prostate cancer but surprisingly showed an increased risk of testicular cancer. David’s chest, abdomen and back lack excess dense body hair. A Japanese study has shown that dense body hair raises the risk of prostate cancer!

A lot of research has gone into determining whether David is a right-handed or a left-handed man. If you take a closer look at the statue, the sling is held by the left hand and a rock on the right, suggesting that he could indeed be left handed, like his creator Michelangelo! Although no specific research has been carried out in prostate cancer, it has been shown in a few studies that women who are left handed are more prone to get breast cancer as compared to those who are right handed. The authors claim the effect of prenatal hormones on the foetus that determines the dominance of the side can also have effects on the breast tissue. A study found that men who were exposed to DES in utero were more likely to be left-handed. Similarly mouse experiments have shown an increased risk of prostate cancer in those exposed to DES. So, there may be a connection between left-handedness and risk of prostate cancer!

Coming to his fingers: The ratio of second to fourth digit length (2D:4D) would allow us to further assess the risk. It is now understood that the 2D:4D ratio is determined by Homeobox (Hox) a and d genes that also regulate urogenital system. What is even more interesting is the study that showed the patients with a lower 2D:4D ratio have higher risks of undergoing prostate biopsy and prostate cancer. The same group indeed went on to prove that a lower digit ratio was related to high percentage core cancer volume and higher Gleason score!

Fortunately, David’s waist circumference (WC) is within reasonable limits, thereby reducing his risk of prostate cancer. A recent study has shown that increased WC seems to be associated with high-grade disease at the time of biopsy.

It is obvious looking at David that he was not circumcised. Although aesthetically pleasing for many, there is considerable debate in the medical as well as philosophical literature whether David was circumcised or not?! Not being circumcised unfortunately increases his risk for prostate cancer.

There is a huge controversy about the size of David’s flaccid penis. Penis size has not (yet) been shown to correlate with risk of prostate cancer. Although, indirectly you conclude that because the 2D:4D digit ratio has been correlated with penis size and as shown above 2D:4D ratio has been correlated with prostate cancer. Therefore, the smaller the penis, greater the risk of prostate cancer! With so many manuscripts being published on 2D:4D ratio, I decided to research more on it and landed up on the Wikipedia page. I was astonished to find the various conclusions that have been reached with the curious case of 2D:4D ratio, including a recent study in Germany that found its correlation with male to female transsexuals!

Although not possible, but of interest would have been to measure David’s anogenital distances from anus to upper penis and from anus to scrotum. A study published in BJUI showed that a higher measurement between the anus and the penis was associated with lower risk of prostate cancer. As you may have guessed, yes there is research going on finding a relationship between anogenital distance and the 2D:4D ratio!

My interest then turned to David’s feet. Looking at it, it does seem that he would have been wearing a shoe size of 10 or 11 at least. Does it matter? Comparing his shoe size and the length of his flaccid penis, I was just reminded of the seminal paper by Jyoti Shah et al, which disproved that shoe size has got to do anything with the size of the penis. However, contrary to this paper, a study confirmed significant evidence of older age at the maximal shoe size (20.1 versus 17.6 years, P <0.05) was associated with increased risk of prostate cancer. Yes, as you may have guessed by now, there is a relationship between the 2D:4D to your penis size!

To conclude on the observations, there are several factors that increased David’s risk and several others that are protective, as shown in Table 1. I would leave it to the reader’s judgment, whether you would recommend a PSA test for David or indeed climb on to him and measure the most important parameter, the 2D:4D ratio!

Amrith Rao is a Consultant Urological Surgeon at Wexham Park Hospital, Wexham, UK. His views are his own. @urorao

 

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Error Training: An emerging teaching tool not to be ignored!

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“To err is human, to cover up is unforgivable, to fail to learn is inexcusable”

Sir Liam Donaldson, Former Chief Medical Officer

As a specialist registrar, I recall operating on a large renal tumour along with my mentor Omer Karim (who is now my colleague). As the mobilization was difficult due to neovascularization, he took over and just as the kidney was about to be delivered out, the adrenal vein was avulsed and there was a gush of blood. A Satinsky clamp was placed and to my surprise, Omer asked me to come over and repair the tear, which was successfully done. I remember his wise words even today “Anyone can remove this kidney, what you need to learn is to fix the complications!”

The traditional apprenticeship model of training that exists even today involves the Boss taking over the case whenever there is a complication. This leads to a teaching model wherein the trainee fails to learn on ‘how to get out of the complication’. Indeed, a very wise piece of advice for a young surgeon in training is to work under a ‘not so good’ surgeon for a period of time, as you will then be exposed to many complications (some not mentioned in the books!), learn how to deal with them and try to avoid repeating those same mistakes. The very concept of learning from others’ errors goes into the heart of the very popular meeting held regularly by the Southern Laparoscopic Urology Group (SLUG). The group comprising of highly experienced laparoscopic urologists present their unusual complications and how they were dealt with and what others can learn from that particular complication.

Two recent blogs on bjui.org emphasize the importance of surgical simulation, especially training in the era of EWTD. However, most simulation exercises concentrate on how to perform a proper operation avoiding any errors. Although, this aspect is extremely important, less emphasis has been devoted to developing simulation modules on intra-operative complications and how to deal with them. This is where the concept of Error Training is fast becoming the buzzword among the education psychologists. A well-written article by DaRosa and Pugh on this interesting concept is well worth a read. The authors explore the reasons for the lack of integration of this important aspect into surgical training. There are only a few studies that have looked into the impact of error training on acquisition of skills. A study by Roger et al on the role for error training on surgical technical skill instruction and evaluation found that instruction about common errors, when combined with instruction about the correct performance enhanced the acquisition of the particular surgical skill. Their study suggested a role for the use of errors in surgical technical skill instruction. Similarly, in a study by Brannick et al, who evaluated an error-reduction training program for surgical residents, showed a reduction in the error during surgery. Natalie Bourgeois in her thesis on error training draws the attention for the need to develop error management training (EMT) as opposed to error avoidant training (EAT). EMT is a teaching method that promotes ‘trainee learning’ enabling them to make errors during their simulation exercises. EAT, however, dictates the trainee not to deviate from the prescribed steps and follow the instructions accurately avoiding any errors. Research has now shown that tasks, which involve making deliberate errors during the learning process, may decrease performance during that particular training session, but increases the performance in the ‘transfer environment’. Keith and Frese have shown that errors lead to more exploration during training, increased metacognition, increased emotional control and increased intrinsic motivation, which benefits transfer performance. Thus, there is emerging but limited scientific evidence about integrating error training into the surgical curriculum.

In the future, laparoscopic and robotic simulators should incorporate modules that would expose the trainee to scenarios of intra-operative complications and assess their ability to deal with it. Studies to validate the effectiveness of these modules would be difficult in a patient setting due to obvious ethical considerations. But there is no doubt that this kind of exposure would definitely prepare the trainee’s mind to manage any eventuality. I would end with the quote “First do no Harm. But if you do, have the knowledge to heal the harm”.

 

Amrith Rao is a Consultant Urological Surgeon at Wexham Park Hospital, Wexham, UK. @urorao

 

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