Suspected testicular torsion - urological or general surgical emergency?

INTRODUCTION

Suspected testicular torsion (TT) is a surgical emergency, usually requiring urgent scrotal exploration. Provision of urology on-call cover varies widely between hospitals and often falls under the remit of the general surgical team. The purpose of this study was to investigate whether the management of suspected TT differed between urology (UT) and surgical (ST) trainees in the Severn and South West Peninsula Deaneries.

SUBJECTS AND METHODS

An on-line questionnaire (SurveyMonkey. com) was sent to all UT and ST within the Deaneries. Questions covered training, on-call cover, intra-operative management and knowledge of complications following testicular fixation. Responses were analysed using an Excel spreadsheet and GraphPad statistical package.

RESULTS

Responses were received from 26/31 UT and 43/52 ST throughout 17 hospitals. Only three hospitals had separate middle-grade specialist urology cover. Scrotal exploration was taught by urologists to 72% of UT compared with 40% of ST (P = 0.012, Fisher's exact test). Variability in the number of operations performed, supervision and management of true TT was insignificant. However, ST were more likely to fix a normal testicle either in the absence of other pathology (53% vs 28%) or with a twisted appendix testis (42% vs 15%) than UT (P = 0.045 and P = 0.032, respectively). UT were more aware of evidence regarding chronic pain (47% vs 14%) and infertility (53% vs 18%) following testicular fixation than ST (P = 0.005 and P = 0.003, respectively). Medicolegally, 76% of UT would inform the on-call consultant prior to operation compared with 45% of ST (P = 0.012).

DISCUSSION

ST are significantly more likely to fix a normal testicle than UT (and then usually only on the affected side), contrary to best-practice. This variation may be due to the different sources of training received by the two groups. Knowledge of possible chronic pain and infertility following testicular fixation may also affect management.

CONCLUSIONS

Due to the variation, we suggest urology departments should draw up guidelines for management; trainees should be encouraged to discuss the case pre-operatively with the consultant; core surgical training should include a urology placement.

A Bayesian approach to analysing the cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening

AIMS

To assess the cost-effectiveness of two primary care interventions, a letter and a flag, aimed at improving attendance for breast screening among (i) all women invited for breast screening and (ii) non-attenders.

METHODS

A probabilistic decision analytic model was developed using Markov chain Monte Carlo simulation implemented in WinBUGS. The model was populated using economic and effectiveness data collected alongside two randomised controlled trials.

RESULTS

For all women invited, the incremental cost-effectiveness ratio (ICER) for the letter compared with no intervention is 27 pounds per additional attendance, and the ICER for the combined letter and flag intervention compared to the letter alone is 171 pounds. The corresponding ICERs for non-attenders are 41 pounds and 90 pounds. The flag intervention is an inefficient option in both settings. A large proportion of the costs fall on the practices (25-67%), depending on the intervention and target population. The total costs incurred do not, however, seem prohibitive. Expected value of perfect information suggests that there is greater value in carrying out further research on the intervention implemented among all women invited for breast screening rather than on non-attenders.

CONCLUSIONS

The flag intervention alone does not appear to be an efficient option. The choice between the letter and both interventions combined is subjective, depending on the willingness to pay for an additional screening attendance.

Cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening

OBJECTIVES

To examine the effectiveness and cost-effectiveness of two interventions based in primary care aimed at increasing uptake of breast screening.

SETTING

24 General practices with low uptake in the second round of screening (below 60%) in north west London and the West Midlands, UK. Participants were all women registered with these practices and eligible for screening in the third round.

METHODS

Pragmatic factorial cluster randomised controlled trial, with practices randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after the practices had been screened and cost-effectiveness of the interventions.

RESULTS

6,133 Women were included: 1,721 control; 1,818 letter; 1,232 flag; 1,362 both interventions. Attendance data were obtained for 5,732 (93%) women. The two interventions independently increased breast screening uptake in a logistic regression model adjusted for clustering, with the flag (odds ratio (OR) 1.43, 95% confidence interval (95% CI) 1.14 to 1.79; p=0.0019) marginally more effective than the letter (OR 1.31, 95% CI 1.05 to 1.64; p=0.015). Health service costs per additional attendance were 26 pounds (letter) and 41 pounds (flag).

CONCLUSIONS

Although both interventions increased attendance for breast screening, the letter was the more cost-effective. Any decision to implement both interventions rather than just the letter will depend on whether the additional (41 pounds) costs are judged worthwhile in terms of the gains in breast screening uptake.

Improving attendance for breast screening among recent non-attenders: a randomised controlled trial of two interventions in primary care

OBJECTIVES

To examine the effectiveness and cost-effectiveness of two primary care based interventions aimed at increasing breast screening uptake for women who had recently failed to attend.

SETTING

13 General practices with low uptake in the second round of breast screening (below 60%) in north west London and the West Midlands, United Kingdom. Participants were women in these practices who were recent non-attenders for breast screening in the third round.

METHODS

Pragmatic factorial randomised controlled trial, with people randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after randomisation and cost-effectiveness of the interventions.

RESULTS

1,158 Women were individually randomised as follows: 289 control; 291 letter; 290 flag; 288 both interventions. Attendance was ascertained for 1,148 (99%) of the 1,158 women. Logistic regression adjusting for the other intervention and practice produced an odds ratio (OR) for attendance of 1.51 (95% confidence interval (95% CI 1.02 to 2.26; p=0.04) for the letter, and 1.39 (95% CI 0.93 to 2.07; p=0.10) for the flag. Health service costs/ additional attendance were 35 pounds (letter) and 65 pounds (flag).

CONCLUSIONS

Among recent non-attenders, the letter was effective in increasing breast screening attendance. The flag was of equivocal effectiveness and was considerably less cost-effective than the letter.

Grade predictions for school-leaving examinations: do they predict anything?

The attributes of 721 medical students admitted to the United Medical and Dental Schools (UMDS) of Guy's and St. Thomas' Hospitals, London, UK between the years 1991 and 1994 were examined to determine the relationship between A-level grade predictions (as completed on each student's UCAS form by their school/college at the time of their application to the school) and subsequent assessments of their academic ability and performance. Predicted A-level grades were found to be significantly, if weakly, correlated with the rating of academic ability made at interview by the UMDS interviewing panel. They were not however, related to the grades obtained by students in the A-level examination itself. Further, while success at pre-clinical examinations was predicted by obtained A-level grades, it showed no relationship with the predicted grades. In contrast, the interview-based rating of the applicant's academic potential was significantly predictive of subsequent A level and, to a lesser extent, pre-clinical examination performance. It is concluded that predicted A-level grades may not offer a valid method of assessing the academic potential of applicants for medical school.