Barriers to women entering surgical careers: a global study into medical student perceptions

Background Barriers to female surgeons entering the field are well documented in Australia, the USA and the UK, but how generalizable these problems are to other regions remains unknown. Methods A cross-sectional survey was developed by the International Federation of Medical Students' Associations (IFMSA)'s Global Surgery Working Group assessing medical students' desire to pursue a surgical career at different stages of their medical degree. The questionnaire also included questions on students' perceptions of their education, resources and professional life. The survey was distributed via IFMSA mailing lists, conferences and social media. Univariate analysis was performed, and statistically significant exposures were added to a multivariate model. This model was then tested in male and female medical students, before a further subset analysis by country World Bank income strata. Results 639 medical students from 75 countries completed the survey. Mentorship [OR 3.42 (CI 2.29–5.12) p = 0.00], the acute element of the surgical specialties [OR 2.22 (CI 1.49–3.29) p = 0.00], academic competitiveness [OR 1.61 (CI 1.07–2.42) p = 0.02] and being from a high or upper-middle-income country (HIC and UMIC) [OR 1.56 (CI 1.021–2.369) p = 0.04] all increased likelihood to be considering a surgical career, whereas perceived access to postgraduate training [OR 0.63 (CI 0.417–0.943) p = 0.03], increased year of study [OR 0.68 (CI 0.57–0.81) p = 0.00] and perceived heavy workload [OR 0.47 (CI 0.31–0.73) p = 0.00] all decreased likelihood to consider a surgical career. Perceived quality of surgical teaching and quality of surgical services in country overall did not affect students' decision to pursue surgery. On subset analysis, perceived poor access to postgraduate training made women 60% less likely to consider a surgical career [OR 0.381 (CI 0.217–0.671) p = 0.00], whilst not showing an effect in the men [OR 1.13 (CI 0.61–2.12) p = 0.70. Concerns about high cost of training halve the likelihood of students from low and low-middle-income countries (LICs and LMICs) considering a surgical career [OR 0.45 (CI 0.25–0.82) p = 0.00] whilst not demonstrating a significant relationship in HIC or UMIC countries. Women from LICs and LMICs were 40% less likely to consider surgical careers than men, when controlling for other factors [OR 0.59 CI (0.342–1.01 p = 0.053]. Conclusion Perceived poor access to postgraduate training and heavy workload dissuade students worldwide from considering surgical careers. Postgraduate training in particular appears to be most significant for women and cost of training an additional factor in both women and men from LMICs and LICs. Mentorship remains an important and modifiable factor in influencing student's decision to pursue surgery. Quality of surgical education showed no effect on student decision-making

The South African guidelines on enuresis-2017

Introduction: Enuresis (or Nocturnal Enuresis) is defined as discreet episodes of urinary incontinence during sleep in children over 5 years of age in the absence of congenital or acquired neurological disorders. Recommendations: Suggestions and recommendations are made on the various therapeutic options available within a South African context. These therapeutic options include; behavioural modification, pharmaceutical therapy [Desmospressin (DDAVP), Anticholinergic (ACh) Agents, Mirabegron (beta 3-adrenoreceptor agonists), and Tricyclic Antidepressants (TCA)], alternative treatments, complementary therapies, urotherapy, alarm therapy, psychological therapy and biofeedback. The role of the Bladder Diary, additional investigations and Mobile Phone Applications (Apps) in enuresis is also explored. Standardised definitions are also outlined within this document. Conclusion: An independent, unbiased, national evaluation and treatment guideline based on the pathophysiological subcategory is proposed using an updated, evidence based approach. This Guideline has received endorsement from the South African Urological Association, Enuresis Academy of South Africa and further input from international experts within the field

Global, regional and national burden of bladder cancer and its attributable risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease study 2019

Introduction The current study determined the level and trends associated with the incidence, death and disability rates for bladder cancer and its attributable risk factors in 204 countries and territories, from 1990 to 2019, by age, sex and sociodemographic index (SDI; a composite measure of sociodemographic factors). Methods Various data sources from different countries, including vital registration and cancer registries were used to generate estimates. Mortality data and incidence data transformed to mortality estimates using the mortality to incidence ratio (MIR) were used in a cause of death ensemble model to estimate mortality. Mortality estimates were divided by the MIR to produce incidence estimates. Prevalence was calculated using incidence and MIR-based survival estimates. Age-specific mortality and standardised life expectancy were used to estimate years of life lost (YLLs). Prevalence was multiplied by disability weights to estimate years lived with disability (YLDs), while disability-adjusted life years (DALYs) are the sum of the YLLs and YLDs. All estimates were presented as counts and age-standardised rates per 100 000 population. Results Globally, there were 524 000 bladder cancer incident cases (95% uncertainty interval 476 000 to 569 000) and 229 000 bladder cancer deaths (211 000 to 243 000) in 2019. Age-standardised death rate decreased by 15.7% (8.6 to 21.0), during the period 1990–2019. Bladder cancer accounted for 4.39 million (4.09 to 4.70) DALYs in 2019, and the age-standardised DALY rate decreased significantly by 18.6% (11.2 to 24.3) during the period 1990–2019. In 2019, Monaco had the highest age-standardised incidence rate (31.9 cases (23.3 to 56.9) per 100 000), while Lebanon had the highest age-standardised death rate (10.4 (8.1 to 13.7)). Cabo Verde had the highest increase in age-standardised incidence (284.2% (214.1 to 362.8)) and death rates (190.3% (139.3 to 251.1)) between 1990 and 2019. In 2019, the global age-standardised incidence and death rates were higher among males than females, across all age groups and peaked in the 95+ age group. Globally, 36.8% (28.5 to 44.0) of bladder cancer DALYs were attributable to smoking, more so in males than females (43.7% (34.0 to 51.8) vs 15.2% (10.9 to 19.4)). In addition, 9.1% (1.9 to 19.6) of the DALYs were attributable to elevated fasting plasma glucose (FPG) (males 9.3% (1.6 to 20.9); females 8.4% (1.6 to 19.1)). Conclusions There was considerable variation in the burden of bladder cancer between countries during the period 1990–2019. Although there was a clear global decrease in the age-standardised death, and DALY rates, some countries experienced an increase in these rates. National policy makers should learn from these differences, and allocate resources for preventative measures, based on their country-specific estimates. In addition, smoking and elevated FPG play an important role in the burden of bladder cancer and need to be addressed with prevention programmes.publishedVersio

بررسی اثرات تحريک الکتريکی در بهبودعملکرد ادراری در کودکان مبتلا به اختلالات غیرعصبی ادراری

چکیده هدف مطالعه: در این مطالعه اثر تحریک الکتریکی interferential روی اختلالات عملکردی و غیر عصبی ادراری کودکان بررسی شد. مواد و روش ها: 80 کودک با اختلالات عملکردی و غیر عصبی ادراری شامل 9 پسر و 71 دختر در رده ی سنی 5 تا 13 سال وارد این مطالعه شدند و به طور تصادفی به دو گروه مساوی case و کنترل تقسیم شدند. گروه کنترل تحت درمان دارویی آنتی کولینرژیک و یوروتراپی اولیه شامل آموزش رژیم غذایی صحیح و مصرف درست مایعات، آموزش روش صحیح ادرار کردن، داشتن دفعات ادرار منظم و آموزش نحوه ریلکس کردن عضلات کف لگن و اسفنکتر ادراری در حین ادرار کردن قرار گرفتند. گروه case علاوه بر موارد ذکر شده برای گروه کنترل، تحت درمان با تحریک الکتریکی interferential نیز قرار گرفتند که شامل 15 جلسه درمانی، هفته ای دومرتبه، هر بار به مدت 20 دقیقه بود. چارت ادراری کامل کودک توسط والدین قبل، بعد از اتمام دوره درمان و یکسال بعد برای تمام کودکان حاضر در مطالعه پر شد. تمامی کودکان قبل، بعد از اتمام دوره درمان و یکسال بعد تحت سونوگرافی کلیه ها و مجاری ادراری و یوروفلومتری- الکترومیوگرافی (EMG) قرار گرفتند. یافته ها: 40 درصد کودکان در گروه case و 41 درصد کودکان در گروه کنترل بی اختیاری ادراری در طول روز داشتند که بعد از اتمام دوره درمان و یکسال بعد به طور معنی داری در گروه case در مقایسه با کنترل کاهش پیدا کرد (P < 0.05). بی اختیاری ادراری طی شب (شب ادراری) نیز به طور معنی داری در گروه case در مقایسه با کنترل کاهش یافت (P < 0.05). در رابطه با پارامترهای یوروفلومتری، بعد از اتمام دوره درمان و یکسال بعد maximum urine flow به طور معنی داری در گروه case در مقایسه با گروه کنترل افزایش یافته و voiding time به طور معنی داری کاهش یافت (P < 0.05). در ابتدای مطالعه تمامی کودکان فرم ادرار (flow pattern) غیرنرمال داشتند که بعد از اتمام دوره ی درمان در 80 درصد از گروه case و 55 درصد از گروه کنترل اصلاح شد. بعد از یکسال اصلاح flow pattern غیرنرمال به نرمال در گروه case در مقایسه با کنترل بیشتر بود (P < 0.015). تغییر معنی داری در بهبود عفونت ادراری، بازگشت ادرار از مثانه به حالب و یبوست بین دو گروه case و کنترل وجود نداشت. نتیجه گیری: ترکیب روش درمانی تحریک الکتریکی interferential با درمان دارویی و یوروتراپی در درمان کودکان مبتلا به اختلالات عملکردی و غیرعصبی ادراری روشی موثر، ارزان و بدون عارضه جانبی است

Management of Urinary Incontinence in Complete Bladder Duplication by Injection of Bulking Agent at Bladder Neck Level into the Proximal Urethra

Bladder duplication is a rare entity in children. The term encompasses a wide spectrum of anomalies from isolated bladder duplication in coronal or sagittal planes to duplicated bladder exstrophy and associated musculoskeletal and visceral anomalies. Given this wide variability, the treatment of these patients is not standardized. We hereby present a female patient with chief complaint of long-standing urinary incontinence who had complete bladder and urethral duplication and pubic diastasis. The patient was treated with bulking agent injection at the incompetent bladder neck and proximal urethra with resolution of incontinence, obviating the need for extensive surgeries

Pelvic floor electromyography and urine flow patterns in children with vesicoureteral reflux and lower urinary tract symptoms

ABSTRACT Objective: To determine the different urine flow patterns and active pelvic floor electromyography (EMG) during voiding in children with vesicoureteral reflux (VUR) as well as presenting the prevalence of lower urinary tract symptoms in these patients. Materials and Methods: We retrospectively reviewed the charts of children diagnosed with VUR after toilet training from Sep 2013 to Jan 2016. 225 anatomically and neurologically normal children were included. The reflux was diagnosed with voiding cystourethrography. The study was comprised an interview by means of a symptom questionnaire, a voiding diary, uroflowmetry with EMG and kidney and bladder ultrasounds. Urine flow patterns were classified as bell shape, staccato, interrupted, tower and plateau based on the current International Children's Continence Society guidelines. Results: Of 225 children with VUR (175 girls, 50 boys), underwent uroflowmetry + EMG, 151 (67.1%) had an abnormal urine flow pattern. An active pelvic floor EMG during voiding was confirmed in 113 (50.2%) children. The flow patterns were staccato in 76 (33.7 %), interrupted in 41 (18.2%), Plateau in 26 (11.5%), tower in 12 (5.3%) and a bell shape or normal pattern in 70 (31.5%). Urinary tract infection, enuresis and constipation respectively, were more frequent symptoms in these patients. Conclusions: Bladder/bowel dysfunction is common in patients with VUR that increases the risk of breakthrough urinary tract infections in children receiving antibiotic prophylaxis and reduces the success rate for endoscopic injection therapy. Therefore investigation of voiding dysfunction with primary assessment tools can be used prior to treating VUR