Saturday, February 21, 2015

Penile Reduction Surgery - What's the Truth Behind This Story?

Over week gone by, the Murdoch press were at it again with absolute rubbish click bait articles which effectively ridiculed a teenager who needed to have surgery to reduce the girth of his penis.  The article shows an image of an American football with the caption “An American football ... not usually used as a simile when describing the size and shape of a man’s manhood.”   Well, they aren’t attributing that comment to anybody because it is they who are saying it to draw attention to the article.  I won’t give the URL for the link to various Murdoch news outlet articles as I am not in the business of giving them anymore weblink clicks than they deserve. 

For a change, it is actually a true story about an American teenager who did need surgery to reduce the girth of a significantly large penis. The details of the case were published on line ahead of print by the prestigious journal called the Journal of Sexual Medicine. It was actually up on line in mid November 2014 so it has taken a while before news outlets got hold of story.

The case is about a 17 year teenager who was born with sickle cell anaemia. Individuals with this condition have a tendency for blood to congeal in vessels and therefore affecting the flow of blood to various organs.  One of the organs that can be affected is the penis and the most problematic complication for the penis is that of priapism. Priapism is a prolonged erection of the penis.  It is unpleasant, unwanted and not uncommonly associated with pain.  This teenager had experienced three such episodes of priapism since he was 10 years of age for which emergency treatment was required on each occasion.  A complication of priapism is damage to spongy tissue that fill the corpora cavernosa of the penis.  The copora cavernosa are the paired structures in the shaft of the penis that distend with blood to become erect.  Damage to the spongy tissue of the corpora lead to ballooning of the spongy tissue also known as aneurysmal dilatation.  With the integrity of the spongy tissue damaged, the corpora became distended and so much so that its girth was creating both physical and functional disability.

The surgery to reduce the girth of the penis involves excising segments of the coverings of the corpora cavernosa and suturing closed the defect.  The end result is reduced calibre corpora cavernosa.

Image from

Forget the talk of football sized penises, this unfortunate teenager has been unlucky enough to have an inherited disease that lead to the complication of priapism which in turn was complicated by aneurysmal dilatation.  This is obviously a very rare condition and it is unlikely that a similar case will reported any time soon.

Given that the real story behind this case lies behind a pay wall, the junk press finds it easy to stray from the truth and hence my reasons for summarizing the principal details of this case in this blog piece.

Wednesday, February 11, 2015

If You Pay, OMICS will Play. All Abstracts Accepted to Predatory Publisher Organised Conferences.

Many of my colleagues are aware of my thoughts about predatory journals and their associated conferences.  They often update me with articles they have seen on the subject or interesting spamming emails that they have received. 

Of particular note at this present point in time is the OMICS run conference called UROLOGY 2015.  I have already mentioned on Twitter several times on how they relentlessly spam me about this conference. 

In one of their emails, it almost sounds like they are getting a bit short with me for not getting on with accepting their invitation to pay high registration fees for the privilege of presenting at their meeting. “With due respect we had asked you…….” 

Hmmm, I am so sorry

Its associated journal, Medical and Surgical Urology has recently changed it’s Editor in Chief. The outgoing Editor in Chief claims that he did not even know that he was holding that position and has never seen or read a manuscript associated with the journal. Once alerted to the fact that his image and bio was up on the journal website (appears to have been taken from his university website), he immediately requested that it be removed.  They have since installed a new Editor in Chief.  I hope that the real guy knows he is there. 

Now back to this conference.  A colleague (I presume this to be the case) has anonymously sent me some correspondence between him or herself with the UROLOGY 2015 conference organisers.  They have taken the abstract from an article that I published in the Australian and New Zealand Journal of Surgery (Yes, this is a real journal which is indexed on Medline/Pubmed). Some additional text has been added and I think it is hilarious.  

Firstly, the authors names sound a bit dodgy, especially the last name. What’s haemorrhoids got to do with prostate biopsy apart from the fact that they might make the procedure a little more uncomfortable.  

Now for the additional sentences:- The last sentence of the Background is “We're sure this conference is BS”.   Under Objectives is “This abstract was especially plagiarized from original author who is known to be critical of predatory publishers and conference organisers.” I guess that they are talking about me.
Under Conclusion, the last sentence now reads “No idea how this got accepted”.

Not sure how to feel about having my work taken and modified and then submitted to an OMICS conference. Rather than feel outraged, I guess it is an honour that my unknown colleague chose my work above others to copy.  Clearly, nobody has really read the abstract.  It is clearly case of submit and if you are prepared to pay, your abstract will be accepted. I suspect that the urologists of the organising committee have nothing to do with the abstracts but the quality of the meeting is associated with their names. 

I think this exercise confirms what we expect from an OMICS run conference.

Related blog posts on Predatory Publishing

Predatory Journals. Academics Are as Much a Part of the Problem
Photon Journal is a clear nominee for the worst predatory journal
OMICS Publishing - pseudo-academia? predatory?

Saturday, February 7, 2015

I thought my surgical career was over before it began

I have just read this piece by Dr Rinjana Srivastava and she identifies a problem within the medical profession that only one from within could express with such clarity.

It reminds me of being on the receiving end of bad behaviour from colleagues and I felt that it was about time that I put this down in writing.

When I was a junior doctor, surgical training programmes in Australia were all hospital based. You would be accepted onto a training programme at your hospital and you would work within that system for the duration of your training toward specialisation. You had to keep your head low but not so low that you would not be noticed.  If you upset any surgeon in any specialty, you ran a significant risk of automatic exclusion. The chances of getting onto a training programme outside of your hospital system was low as they tended to be parochial and would appoint from within.

I will never forget seeing the poor treatment of a colleague who was a year or so senior to me. He was an outstanding doctor and it was generally held within the hospital network literally being ‘pick of the draft’ and was going to essentially walk into the next available surgical training position. At about 6 months before the interviews, he inadvertently slept in on his first day of a new rotation, which also happened to be an operating session.  The surgeon took a vindictive dislike of that talented young doctor. He was blackballed from succeeding in his application for the next available training position. That doctor had little choice but to go to another hospital to re-establish himself and it was several years later that he would then enter surgical training. This sent shockwaves through the hospital system and sent a strong message that we needed to do everything within our power to avoid upsetting anybody. 

Now for my story. As a junior doctor, I thought I was going okay. I had been a ‘finalist’ for the best intern award and I had passed my surgical primary examination on first attempt and had not managed to offend anybody. The surgical registrar under whom I was working was particular self confident and very much a larrikin type of individual. His self confidence and decisiveness was something that I had initially felt was something to aspire to. On the morning ward round, we looked a patient who had been operated upon the day before.  The leg was very swollen and the registrar felt that it was within acceptable limits and felt reassured given that there was no blood in the drain. 

A few hours later, I did a further quick ward round of the patients I was most worried about. For the man with swollen leg, it was my impression that the swelling was worse. I called the operating room to speak with the registrar. The phone was placed on loudspeaker and he reiterated that he was happy that all was fine and besides ’the drain had nothing in it’. I went back to the ward with my tail between my legs. An hour later, I reviewed the patient again and felt that things had progressed further.  On this occasion, he came out of the operating theatre to have a look and was again satisfied that all was fine.  A further hour later, I thought things were again worse and I could no longer feel pulses in the foot. On this occasion, I walked over to the vascular ward and got hold of a portable doppler and confirmed that the pulses were barely if at all audible. Apart from becoming increasingly swollen, the leg was now starting to look blue. I called up theatres and was again placed on speaker phone. The eye rolling was palpable and he again affirmed that his assessment of the patient was that everything was fine. With given tone of voice, I felt humiliated.

What was I to do? Keep my head low with the knowledge that I had done what was expected of me or step it up? I then decided to call the consultant surgeon who was nominally in charge of this case - I had to hold the phone away from my ear as he yelled "How dare you call consultant surgeon? The patient is a public patient and is managed by the registrar."

That moment, my only thought was with the patient who was going to lose his leg. I found myself  wandering almost aimlessly in the ward corridors trying to work out what to do next. It just so happened that a consultant vascular surgeon walked around the corner and I dared to approach him.  He wasn't even on call for emergencies but given the gravity of the situation, I asked if he could please come and look at this patient - he agreed and the moment he set eyes on the patient, I could almost see him mouth the words "Oh F**K"

We had the patient in the operating room within an hour. I scrubbed in to give a hand. The moment the leg was cut into, blood burst out and splashed all over the theatre light and ceiling. The blood in the thigh was under such pressure that it was compressing the flow of blood to his leg. The registrar dropped by and in a cheerful voice said "Yeah, I thought that he had had a bleed into his thigh."

Once this man's leg had been saved, I thought to myself that on this day, my surgical career easily have come to an end. I could not help but to think what would have happened if I was wrong about the diagnosis.  Thankfully things have changed a lot since then.

Addendum 8 February

To respond to questions as to what happened afterwards?  Back then, morbidity and mortality review meetings essentially did not exist.  To this day, I am not even sure that the consultant surgeon in charge even knew of this complication.  The registrar went onto to become a consultant surgeon and I have had no contact with him since.

A week of so later after the event, I bumped into the consultant surgeon who had yelled at me over the phone. I took the diplomatic approach and apologised for calling him. He responded in a kind forgiving voice and and said to me "Well we all learn from our mistakes".  As for the vascular surgeon, we became friends and I am forever grateful for his assistance.  He was an example of how there are brilliant role models for human beings as surgeons out there and one who led by example. 

Thursday, February 5, 2015

Keep the Penile Cancer prevention argument out of the Neonatal Circumcision Debate

A commonly used argument to support the use of neonatal circumcision is the proven relative risk (not necessarily a significant absolute risk) benefit in preventing cancer of the penis.  The purpose of this discussion is not to argue over the role of circumcision to prevent infections such as HIV (that's for another day) but to discuss why making an argument that it prevents penile cancer to justify recommending routine neonatal circumcision is a misuse of statistics.

Let's first set the context correctly. I am writing this from the perspective of residents of Westernized countries.  Cancer of the penis in Westernized countries is very uncommon.  The figures vary depending on which publication you look at and when the data was collected but using the very worst figures, the incidence is around 1-2 per 100,000 population.   

Penile cancer is most commonly seen in men who are uncircumcised but there are often other factors additional to this.  These include poor hygiene, poverty, smoking, human papilloma virus infection, sexual promiscuity, sex with animals and others.  In my relatively limited experience of diagnosing and treating penile cancer, the majorities have been in uncircumcised men who were living in poverty and had poor hygiene.  When we look at this list of risk factors, it is clear that many of these are much less of an issue in Westernized countries than developing countries.  Before criticism is raised about sexual promiscuity and lack of condom protection still being a problem in Westernized countries, it pales into insignificance when compared to some developing countries.

Now let's compare the incidence of breast cancer. The incidence in Westernized countries is about 100-125 case per 100,000 population. Yes, this is a huge difference compared to penile cancer. Recommending circumcision to prevent penile cancer is like recommending bilateral mastectomy to prevent breast cancer. Okay, you might argue that bilateral mastectomy is a substantially more major operation that a circumcision? Fair enough. Why don’t we instead consider skin cancers involving the ear lobes which are not only far more common that penile cancers but to prophylactically remove the earlobes to prevent cancer in that location is not a major operation.

Another consideration is how many neonatal circumcisions would have to be performed to save one diagnosis of penile cancer? We do not have good data on this in the Western world because the incidence is so low. We cannot extrapolate data from developing countries where the incidence is relatively high.  Without having the necessary data to make a number needed to treat analysis, we can make an intuitive assessment of this. Lets take the incidence in Israel which is about 0.1 cases per 100,000 where almost all are circumcised.  Let’s take the incidence in Australia which is about 1 case per 100,000.  It is obvious that the NNT is going to be massive. Imagine having to carry out 10’s of thousands of circumcisions just to save one diagnosis?

If zealots are using the argument that circumcision significantly reduces the risk of penile cancer to justify a stance of routine neonatal circumcision, they might as well support a far stronger argument for performing routine bilateral mastectomy to prevent breast cancer.  

Remember that this blog piece is not an argument about whether circumcision can reduce the risk of penile cancer but the fanciful argument that this is why we can justify routine neonatal circumcision in Westernized countries.  Keep the penile cancer argument out of the circumcision debate in Westernized countries.

Sunday, February 1, 2015

My Brush with God

My favourite twitter account is God. I have followed it religiously. I had been one of the almost 1.8 million followers who eagerly awaited his witty one to two sentence tweets. Whilst they will undoubtedly offend any given large proportion of the population, they equally provide comic relief for an adulating audience. I love this account and it is one of the first accounts that I recommend all new twitter subscribers follow. Each day, I would look forward to God’s latest instalments and I would retweet my favourites to my own humble following.

This all changed when I saw the following tweet appear on the timeline. I often screenshot the ones that I like for possible future use in a presentation on social media where I would highlight the use of humour to gather an audience. 

I saw the following tweet:-

I screenshot it and then was trying to retweet it but discovered that it had been deleted. I then tweeted to God with the cheeky line as follows

He was clearly not impressed when he send me a private direct message as follows:-

Clearly God was not impressed.  You dare to take up a point with God, you run the risk of him unleashing his power over us.  I shamefully dared to do so.

Immediately following this I was placed into purgatory and blocked by the account.  This is the first time that I am aware of being blocked on twitter.  If others have blocked me, then I have not known about it.  

Anybody who follows God knows that the account is not for one who is sensitive.  He will unleash his fury and nobody is immune from the wrath of God.  I am now God-less but will now survive on screenshots of his best tweets sent to me by DM by friends. Yes, I could set up another twitter account but this be trying to escape from the purgatory that I have been banished to. I need to do my time and hopefully one day I will be released.  Please pray for me.  Please tell him that I am sorry.

(David Javerbaum is a well known comedy writer in the US. On social media, he is particularly known for his very popular account known as @TheTweetofGod.)

Addendum 2 February 2015

Last night I was messaged by God who essentially stated that he hoped that I had learned my lesson in purgatory and that I was being welcomed back into the promised land. I had been forgiven. I thank everybody for their prayers and on line appeals for forgiveness. Clearly he was listening.

Once again, this is my favourite Twitter account. I have seen him put followers into periods of time out in purgatory with the usual expletive laiden barrage but he is always forgives.  Whilst I knew my time out was temporary, it was for how long that I was unsure about. Do follow @TheTweetofGod but don't take it too seriously because it never is.

The 2nd Addendum 2 February 2015

I had a dream. Crazy dream. It was good whilst it lasted.
For those who know, God only ever follows one account. It used to be Ricky Gervais but he later dropped him for Justin Bieber.  This of course fits well with his book called the Book of Biebs.