Extracorporeal shock wave lithotripsy

After circumcision the first operations done on man were for bladder stone. Done by charlatans the operation often resulted in loss of life and caused the early lithotomists to maintain a peri­patetic existence, vanishing from the town the night after surgery was performed. About two centuries ago stones became a common disease amongst kings: surgeons took over from the charlatans and commenced blind skilful mechanical lithotripsy where a curved instrument was introduced per urethram, its jaws opened to engage the stone which was then crushed by a mechanical (screw driven) closure of the jaws. Now-a-days urinary bladder lithotripsy is done under vision and aided by ultrasound drilling, or electrohydraulic shock wave produced by a direct contact probe. Renal stones can be safely operated on or removed percutaneously

The training of a \u27stone doctor\u27

Objective: To propose alternative models of training for doctors treating patients with stones, and to identify their relative value, as such doctors are trained through urology programmes which sometimes cannot be expanded to meet the need, are short of teachers, too comprehensive and lengthy. This review explores new pathways for training to provide competence in the care of patients with stones. Methods: Previous reports were identified and existing training models collectively categorised as Model 1. Three alternative models were constructed and compared in the context of advantages, acceptability, feasibility, educational impact and applicability in different geosocio-political contexts. Results: In Model 2, urological and stone training diverge as options after common basic courses and experience. In Model 3, individuals access training through a common educational matrix (EM) for nurses, physicians, etc., according to the match between their capacities, entry requirements, personal desires and willingness for further responsibility. Stone doctors with no urological background cannot fulfil other service and educational commitments, and might create unwelcome dependence on other colleagues for complex situations. Programmes involving a common EM affect professional boundaries and are not easily acceptable. There is a lack of clarity on methods for medical certification and re-certification. However, the lack of technically competent stone experts in developing worlds requires an exploration of alternative models of training and practice. Conclusions: The ability to provide exemplary care after abbreviated training makes alternative models attractive. Worldwide debate, further exploration and pilot implementation are required, perhaps first in the developing world, in which much of the \u27stone belt\u27 exists

Lifelong learning: Established concepts and evolving values

Objective: To summarise the concepts critical for understanding the content and value of lifelong learning (LL).Methods: Ideas generated by personal experience were combined with those of philosophers, social scientists, educational institutions, governments and UNESCO, to facilitate an understanding of the importance of the basic concepts of LL.Results: Autopoietic, continuous, self-determined, informal, vicarious, biographical, lifelong reflexive learning, from and for society, when supported by self-chosen formal courses, can build capacities and portable skills that allow useful responses to challenges and society’s new structures of governance. The need for LL is driven by challenges. LL flows continuously in pursuit of one agenda, which could either be citizenship, as is conventional, or as this article proposes, health. LL cannot be wholly centred on vocation. Continuous medical education and continuous professional development, important in their own right, cannot supply all that is needed. LL aids society with its learning, and it requires an awareness of the environment and structures of society. It is heavily vicarious, draws on formal learning and relies for effectiveness on reflection, self-assessment and personal shaping of views of the world from different perspectives.Conclusion: Health is critical to rational thought and peace, and determines society’s capacity to govern itself, and improve its health. LL should be reshaped to focus on health not citizenship. Therefore, embedding learning in society and environment is critical. Each urologist must develop an understanding of the numerous concepts in LL, of which ‘biographicisation’ is the seed that will promote innovative strategies

Assessment, surgeon, and society

An increasing public demand to monitor and assure the quality of care provided by physicians and surgeons has been accompanied by a deepening appreciation within the profession of the demands of self-regulation and the need for accountability. To respond to these developments, the public and the profession have turned increasingly to assessment, both to establish initial competence and to ensure that it is maintained throughout a career. Fortunately, this comes at a time when there have been significant advances in the breadth and quality of the assessment tools available. This article provides an overview of the drivers of change in assessment which includes the educational outcomes movement, the development of technology, and advances in assessment. It then outlines the factors that are important in selecting assessment devices as well as a system for classifying the methods that are available. Finally, the drivers of change have spawned a number of trends in the assessment of competence as a surgeon. Three of them are of particular note, simulation, workplace-based assessment, and the assessment of new competences, and each is reviewed with a focus on its potential

Sertoli cell only syndrome (SECOS): Lessons from case studies

Between June 85 and December 87, 69 testicular biopsies were submitted for histopathological examination during investigation of infertility; ten (14%) patients had a Sertoli cell only syndrome. The history, clinical features, and hormonal profiles were analyzed in an attempt to categorize these patients on aetiological basis. Two followed treatment of malignancy--one by radiation for testicular cancer and one by cyclophosphamide for a lymphoma. One had unilateral cryptorchidism. Mumps was etiological factor in one patient. FSH levels determined in 6 patients were elevated in all suggesting a possible dependence of (sick) Sertoli cells on spermatogenic cells for production of inhibin. Alternative explanations include changes insertoli cell enzymes or FSH receptors. Testosterone levels are in the low normal range suggesting that Leydig cells may also be affected by the etiological factor producing the syndrome. Two patients who had earlier received a higher Johansen score were found to have a sertoli cell onlysyndrome on expert review of testicular biopsies. It is suggested that the condition is more common than hitherto reported and is often confused with maturation arrest. Testicular histopathology should be done by specialists in testicular pathology

Institutional Vacuum in Sardar-Sarovar Project: Framing ‘Rules-of-the-Game’

Few large irrigation projects in India have been as elaborately planned as the Sardar- Sarovar Project (SSP), incorporating as it did the lessons of decades of irrigation project design and management. The project was to blaze a new trail in farmer-participatory irrigation project design and management with water user associations (WUAs) building their own distribution systems. However, as it unfolds, the institutional reality of the project is seen to be vastly different from its plans. If SSP is to chart a different course from scores of earlier large irrigationprojects, it must invent and put into place new rules of the irrigation management game.Length: pp.95-106Irrigation programsRiver basinsGroundwater irrigationSurface irrigationWater users associationsWater allocation

Bone and renal stone disease in patients operated for primary hyperparathyroidism in Pakistan: Is the pattern of disease different from the West?

Objective: To document the clinical presentation of primary hyperparathyroidism (PHPT) in a developing country and note differences from the West. Setting: A tertiary care teaching hospital. Method: The records of 37 patients operated for PHPT between January 1986 and December 1997 were reviewed. Symptoms, laboratory parameters and histopathology results were analyzed. Results: Surgery for PHPT accounted for 0.055% of 67,566 operative procedures performed in the Department of Surgery during the 12 year period. The mean age of our patients was 38.4±13.2 years (range 17 to 73 years). Ninety percent of patients were less than 60 years old and 51% less than 40 years. At presentation, the mean serum parathyroid hormone (sPTH) level was 618±741% abvoe the upper limit of normal (range 0-2900% using a variety of assays). A solitary adenoma was present in 86.5%, hyperplasia in 5.4% and carcinoma in 5.4% of patients. There was one (2.7%) negative exploration. Thirty-five percent of patients had renal stone disease (StD), 32.4% had bone disease alone (BD) and 27% had both bone abnormality and stones (BStD). There were neither bone disease nor stones in 5.4% of patients. BD was associated with a statistically non-significantly (p=O.O8) higher alkaline phosphatase level (sALP) as compared to the StD and BStD groups. The mean urinary calcium (Ca) was higher in the BD group (482±340 mg/24 hours) as compared to StD group (265±89 mg/24 hours) (pO.Ol3). The post-operative hospital stay was longer in the BD group (14.4±16 days) as compared to the StD group (6.7±3.7 days) (p=0.001). Conclusion: As compared to reports from the Western world, PHPT is less commonly diagnosed in our country and occurs at a younger age. In the absence of a screening programme, symptomatic disease and bone involvement occur more frequently. The high levels of PTH may indicate long-standing disease in our population, which may account for higher proportion of patients with symptoms. Unexpectedly. patients with bone disease had higher levels of urinary calcium than patients with stone disease (JPM A 49:194, 1999)