Air Travel Rant - Annoying Passengers

Usually when there are complaints to be made about travel, it will be to do with a provider whether it is a tour operator, tourist venue, airline or hotel.  Some of you may have seen my periodic twitter rants on travel complaints – instead, mine is directed at fellow air passengers.  In order, here are the five of the things I particularly find annoying.

1. Bare feet – as far as I am aware, no airlines that I have flown with have a policy on bare feet during flight.  They do however, mandate that foot wear must be worn for boarding or disembarking (not ‘de-planing’  – if this was to be an appropriate term, then getting on a plane would be called ‘planing’ - which joker came up with that moronic term! – apologies for the extra little rant on the side here.)  Imagine you have just reclined back in your seat and have just closed your eyes – all of a sudden you become aware of the pungent smell of foot odour.  Just because they have boarded from exotic places such as Bangkok or Singapore does not make the fruitiness of the flavor any more tolerable!  You then look down and see the distorted looking nails from chronic fungal infection, not to mention the peeling skin from tinea.  Apart from the assault on our visual and olfactory senses, you see these people put their foot up on their knee and see it touching the seat in front and side of the cabin smearing the foot love on the internal plane surfaces.  You then see the love metastasise as they climb over the two seats to reach the aisle to go to the toilet.

Lovely tinea of the feet

Lovely fungal nails

2. Legs apart syndrome.  Yes, this is the man with the hydrocele.  These men have pathologic scrotal swelling that necessitate them to sit with their legs apart so that they invade your personal space.  There is an unwritten rule that the airspace immediately in front of your seat is for your personal use.  Of course there could not be any other reason why somebody would sit with their legs so widely, would there?  To remedy this, it sometimes takes an applied equal and opposite force but eventually your fight to reclaim your airspace will prevail – as gross as it is to have such a large surface area of contact with a total stranger, just close your eyes and chant “Newton”

Hydocele is a good reason to have to sit with legs apart

3. The super halogen light effect – the cabin lights have been dimmed and all the windows have been closed except for the jerk across the seat row next to the window who decides to open it so he or she can read.  It’s like a super powerful halogen light that is shone on to a stunned kangaroo and is about to be shot.  During a night flight when trying to get some sleep, you can forget it.  Flight attendants can ask them to close the window but if passengers do not wish to, they will not go as far as instructing them to do so as it is not against the rules (airline dependent of course).

4. People who won’t shut (shout) up.  When you have trouble hearing, there is that natural tendency to speak louder.  When they natter for hours like they’re speaking into a mobile phone with poor reception.

Almost enough to make you re-think your support of gun control

5. People hogging the flight attendant.  You are trying to get the attention of the flight attendant who has been quarantined by passengers who don’t want to stop telling him or her about every detail of their holiday. 

***

When there are no specific rules to say that something cannot be done, I have found flight attendants to often be reluctant to take action.  As much as you do not wish to have conflict, so do they.  For a growing number of airlines, they really don’t give a damn about your comfort, they just want to get to the end of their shift – another flight down before they reach their retirement work entitlements.

Generally, I can put up with crap from airlines, tour operators and hotels.  For the most part they either genuinely try to fix any problems that arise or are totally disingenuous about concern for your inconvenience and don’t give a damn (if you fly a budget airline, what do you expect?).  For selfish fellow passengers, I think it is time to make a stand and ask them to correct their behavior with the threat to shame them through social media – lets not put up with this crap anymore.  

What annoys you about fellow passengers?

***

Since posting this blog piece less than 24 hours ago, I received this tweeted comment which I just had to share with you.  It makes you sick thinking that some poor punter will pick up this magazine that has had a foot smeared all over it.

Superbugs and Prostate Biopsy

I am deeply concerned about the rising incidence of so called ‘superbug’ infections associated with prostate biopsy.  These bacteria are resistant to the great majority of antibiotics we have available for use and the only ones that work generally have to be given through the veins.  These bacteria have become particularly prevalent in Asia where the indiscriminant use of antibiotics in agriculture has lead to the breeding of antibiotic resistant bacteria in the community.  When you are well, they are of no risk and they live harmoniously within your body.  Should you be placed in circumstances where your own bacteria turn against you and you happen to have the ‘superbug’, this can lead to serious infection as conventional antibiotics are not effective.  For those who wish to get technical, with the term ‘superbug’, I am referring to the so called extended spectrum beta lactamase producing bacteria (ESBL). With increasing travel to Asia, growing numbers of Australians will carry these bacteria within their intestines.  Any procedure that carries ANY risk of infection, which happens to include prostate biopsies, will carry a risk of serious infection.

The article published in the The Age today is entitled “Prostate biopsy blamed for preventable superbug deaths”.  This headline will understandably place fear in every man who is about to be scheduled to undergo a prostate biopsy should they read this piece.  However, there needs to be some perspective on the calls for urgent rectification of the problem of superbugs by having all public hospitals purchase the equipment that will enable the risk of any prostate biopsy related infection to be eliminated.  The typical cost of such equipment is $150,000 and multiply this by the number of public hospitals, it poses a massive infrastructure cost and represents monies that have to be taken from somewhere else in the health budget.

Transperineal prostate biopsy (TPB) creates significant burdens on resource utilization. TPB require a general anaesthetic and day surgery admission to hospital as well as utilization of precious operating theatre time.  Almost all Transrectal ultrasound prostate biopsies (TRUSPB) are performed in an outpatient setting and typically take 15 to 30 minutes including turnover time.  A TPB can typically utilize as much as 45 to 60 minutes of operating time including turnover time.   More than 20,000 prostate biopsies are performed in Australia each year and if every one of these were to be immediately pushed into the hospital system, urological surgical resources would be pressed to cope.  Waiting lists would likely significantly increase and it is highly unlikely that there would be increased allocations of operating theatre sessions for urological procedures.

Figure 1. Transperineal biopsies performed in the operating theatre setting 

Even if a reliable mechanism was found to perform the procedure under local anaesthetic, the procedure would still need to be performed in the hospital setting as appropriate infrastructure such as physical floor space and the operating table which enables coupling to the transperineal biopsy equipment is simply not readily available in the outpatient setting.  

The majority of men would need to take the day off for the procedure and often the following day given that they have had a general anaesthetic.  If the procedure is performed as a TRUSPB under local anaesthesia, most are able to return to normal activities either the same or following day.

There are certainly issues with infections associated with TRUSPB.  These men can become very sick and a small number of cases may require admission to Intensive Care Units.  Men should however, be reassured that their risk of dying from a prostate biopsy infection is extremely small.  The Victorian data demonstrates a reported incidence of 2 deaths over the past five years. With over 7000 biopsies being performed in Victoria each year, this equates to an incidence of 2 out of over 35,000 prostate biopsy procedures (<0.006%) and in the article published in the Age today, these are attributed to the ‘superbugs’.  When we look at the mortality rates associated with infections, a recent paper found that the incidence of community acquired ESBL sepsis was around 10%.  In a mix of patients with healthcare related and community acquired ESBL sepsis, the mortality rate was as high as 20%.   The patients most likely to die were elderly or had significant medical co-morbidity and exactly the type of patient who perhaps prostate biopsy ought not be undertaken.

There are relatively few invasive procedures that do not carry a risk of infection although transperineal prostate biopsy is one where the risk is negligible if not zero.   This data has been repeatedly confirmed and provide a compelling argument to switch completely from TRUSPB to TPB.  But are there any medical reasons why we should reflect on this assertion?  A recent Australian study published this year, the risk of acute urinary retention was 4.2% whereas following TRUSPB, it is a very rare event.

Rather than see panic stations with public outcry and a call for all hospitals to be immediately armed with the expensive equipment, other processes should be enter into practice with a greater level of urgency.  We have to be pragmatic and recognize that hospitals are not about to be funded for this equipment in the immediate future and other strategies need to be sought in the meantime. 

With the recognition that too many men diagnosed with prostate cancer die with the disease rather than from it, we need to better select the men in whom prostate biopsies are recommended.  We also need better risk assess which men are more likely to carry the ESBL ‘superbug’ and a history of recent travel to Asia should be explored.  We also need to get smarter about either using or searching for simple strategies to minimize the risk of ESBL infection such as performing rectal microbial swabs in advance of the prostate biopsy, use of antiseptics such as betadine suppositories in the rectum or dipping the biopsy needle in chemicals such as formaldehyde before each pass.  These strategies need more work but represent that the profession recognizes more needs to be done. With growth in the use of MRI scans prior to prostate biopsy, it is also possible that fewer biopsies will need to be taken and there is the potential that fewer numbers of biopsies taken may ultimately be proven to be associated with less risk of infection.  We can also potentially improve the recovery from infection by having men appropriately counseled to attend for assistance immediately with the onset of infection rather than ‘sitting on it overnight and attending in the morning’ – when bacteria are capable of double in numbers as fast as 20 minutes for some, early presentation can make a huge difference to recovery.

In conclusion, ‘superbug’ infections are a serious problem and we need to do more to minimize the risk to our patients on many fronts.  I believe that transperineal prostate biopsies are one way forward, but the practicalities and priority needs to be considered in the context of other health priorities. 

Disclosure - A/Prof Henry Woo has access to TPB equipment at his hospital and does perform this procedure in selected men. The vast majority of his patients undergo TRUSPB under a local anaesthetic prostate block in an ambulatory outpatient setting.

Urolift-off. The rewards associated with Doctors working together with Engineers.

Since 2005, I have in my spare time, been working on a project that I was invited to join by a start up company called Neotract Inc which is based in the Bay area of San Francisco.  The company was initially made up of a small group of engineers who had a great idea of how a minimally invasive device could be created to treat male lower urinary tract symptoms (LUTS).  Over the years, minimally invasive devices to treat LUTS as a consequence of benign prostatic hyperplasia involved destroying prostate tissue whether it be by freezing, cooking, steaming, lasering or even microwaving. Whilst less invasive than procedures that physically removed prostate tissue at the time of surgery, these still required a period of recovery and there was often a delay in deriving full benefit due to the need for tissues to recover after destructive energy or one sort or another had been applied to the prostate. The idea was to use a mechanical implant that would pull open the prostate urethra. 

(Screenshot taken from www.neotract.com)

Through my involvement with Neotract, I was able to provide clinical input as well as being part of the clinical trials. This has lead to a number of publications that can easily be found by searching under my name and the search term either prostate or urolift.  This month, we have seen this technology finally achieved US FDA approval. I wrote a piece about the benefits of clinicians and engineers working together for the BJUI Blogs.  I was deeply moved to receive the following letter from Josh Makower, Chair of the Board of Neotract, Inc.  I felt compelled to share this letter (with permission) which was addressed to myself and my co-investigator Dr Peter Chin.

Dear Henry and Peter –

This morning I opened my email and found this...  http://www.bjuinternational.com/bjui-blog/urolift-takes-off-from-down-under-the-potential-rewards-when-engineers-bring-you-into-their-inner-circle/

I must say, Henry’s words brought a small tear to my eye.   After 9 years of amazing struggle against many obstacles, our small team of passionate dedicated people have finally made it through a most significant hurdle towards bringing this technology to patients in the US.  It’s a milestone that for many years seemed almost un-attainable and there were many dark days,.. but perseverance, trust and a vision held us together. 

Henry and Peter – you were the first.  There are always those who go first and history thankfully will mark them as innovators and leaders. You went where no one had gone before and gave us your time, your ideas and your talent towards a dream.  That dream is one step closer to being realized and we would not be here if it were not for the two of you.  When procedures and technologies become mainstream medicine, people often forget what it took to get there.  They  forget, or do not even know, how much a toll such a process takes on our relationships as we invest our lives in bringing something like this to fruition.  But for those of us who were all in the trenches together; for those of us who hunkered down, re-grouped, re-engaged, re-energized and stood up again to regain ground when all appeared lost, we will never forget you and never forget the team that brought us here.

On behalf of all us, Henry and Peter, thank you for your leadership and your partnership.  Henry – you articulated something special that must be shared – the partnership between engineers, entrepreneurs and physicians needed to advance medical technology is an essential one that we must never lose.  Without it, medical innovation would not happen.  Thank you for sharing your thoughts and putting them to paper in such a special way.  I hope thoughts like these help preserve that special balance of talents, interests and shared goals that truly have the power to change the world and make it a better place.

From all of us at ExploraMed and NeoTract, and for all the patients who will benefit from all our collective efforts – thank you.

Sincerely -

Josh

A Personal Perspective on Testing for Prostate Cancer - 2013

As an urologist who has subspecialized in just the area of prostate disease, I see men with prostate cancer every working day.  Every single consulting session I will see a number of men with advanced prostate cancer who are enduring either the side effects of the palliative drug treatment for advanced prostate cancer or who are battling the complications associated with advanced prostate cancer. 

In Australia, over 3,200 men die from prostate cancer each year.  This is a greater number than the women who succumb to breast cancer each year.  Irrespective of what the denominator is in terms of how many are diagnosed each year, as the second greatest cause of cancer specific deaths in men (after lung cancer), it is continues to astound me that anybody can sweep these facts under the carpet.  But to give the denominator, number of men who are diagnosed with prostate cancer in Australia each year currently sits at just under 20,000. 

It is well recognized that not all men diagnosed with prostate cancer will actually die from their cancer but will instead die from some other cause.  The majority of cancers will follow an indolent slow growing course and will never cause harm. This said, these statistics include men who in spite of dying with prostate cancer (and not from it) have significantly suffered from the effects or treatment for advanced prostate cancer or were successfully treated for prostate cancer that otherwise have lead to a prostate cancer related death.

The overzealous desire to fight prostate cancer has had significant consequences.  Many men who did not need treatment have been unnecessarily treated and of these, some have experienced complications associated with radical treatment.  This has been a huge problem and with its recognition, attempts are being made to rectify this problem.  Significant progress has been made in getting smarter about who needs treatment and also reducing the risks of complications associated with treatment.

Not all men diagnosed with prostate cancer need treatment.  There has been a major shift towards treating early stage prostate cancer conservatively by what we call active surveillance and watchful waiting.  Active surveillance differs from watchful waiting in that curative treatment has not been ruled out.  Active surveillance is a program of monitoring that attempts to strike the right balance between avoiding the overtreatment of prostate cancer yet at the same time attempting to minimize of missing any window of opportunity to deal with the cancer should it subsequently prove itself to be more aggressive than originally anticipated. Protocols for active surveillance vary but contemporary monitoring includes monitoring PSA blood test levels and periodically carrying out MRI scans of the prostate or progress biopsies.  If there is evidence that suggests that the cancer is more aggressive than originally thought or if the disease appears to have progressed, the option of treatment remains on the cards.  Watchful waiting implies that curative treatment has been ruled out and monitoring is carried out until such time that the disease progresses to justify the commencement of palliative drug treatment in the form of androgen deprivation therapy (commonly referred to as hormone therapy).

There has also been a significant improvement in side effects associated with treatment for prostate cancer.  The majority of men with very early stage prostate cancer are candidates for treatment that can spare both urinary and sexual function.  Commonly, detractors against prostate cancer testing attempt to connect urinary incontinence and erectile dysfunction as being consequential certainties associated with prostate cancer testing.

Now on the issue of PSA blood testing, there have been quite polarized views on whether it should be performed or not.   I have tried to avoid the word ‘screening’ because I think that most of us who have in the past supported this approach have moved very much towards selected testing on an individual basis where each man as an individual has the opportunity to participate in the decision to undergo testing or not.

I think that it is time that those who so vehemently oppose PSA testing should acknowledge that an entity that is the second greatest cause of cancer related death in men is a public health problem.  It is also time to stop assertions that if a PSA test is abnormal that it leads to a high risk of complications with the biopsy and that should cancer be confirmed that it some form of aggressive intervention will invariably follow.  Additionally, we have moved on from the outcomes of 20years ago in that treatment is NOT invariably associated with incontinence and erectile dysfunction.

The answer for PSA testing lies somewhere between widespread population screening and totally opposing any form of testing at all.  I am looking forward to those who have vehemently opposed any form of testing for prostate cancer to acknowledge this as well.

Concluding Comments

I am NOT in favor of indiscriminate population screening for prostate cancer.  Men should be risk assessed as to whether the benefits of making a diagnosis of prostate cancer individually outweighs the attendant risks.  Men should NOT be denied the right to participate in any discussion regarding a decision to undergo prostate cancer testing or not.  I completely disagree with any assertion that there should no discussion about prostate cancer testing unless raised by the patient.  When men are counseled on making a decision as to whether or not they wish to be tested, they should be given information that is relevant to their individual circumstances.  The Melbourne Consensus Statement on Prostate Cancer Testing is a good place to start. 

Acknowledgement:  I wish to thank Katy Hanlon for creating the images that accompany this piece.  Katy can be contacted on Twitter @khanlon 

Update on Transitioning From Open to Robotic Assisted Radical Prostatectomy

Since I first blogged on robotic surgery in July last year, it has become the predominant manner by which I perform prostate cancer surgery.  I continue to offer open surgery and particularly for those who cannot afford the cost of robotic surgery - it is important to not make them feel inadequate and that there is a reasonable alternative approach available.  Robotic surgery for prostate cancer is rapidly moving towards being the predominant manner by which prostate cancer surgery is being performed in Australia.  

Sydney had the lowest concentration of robotic platforms per capita in any of the mainland capital cities and for many years there was only one hospital with the technology.  Subsequent to a second hospital acquiring the technology and the significant marketing that followed, the dominos fell rapidly.  In the space of less than two years, there are now 7 hospitals in Sydney which now gives it the highest concentration of robotic platforms in Australia.  The competition for men to undergo robotic assisted radical prostatectomy has never been more palpable.  Many surgeons feel they are being forced into the technology on the basis of marketing pressures rather than being able to transition into the technology on their own terms. There has been a sense of urgency for surgeons to enter into the robotics space and enthusiastically offer their services and there is this sense of urgency for surgeons to announce that they have reached a certain threshold of cases or are now the most experienced with the technology for a particular geographical part of Sydney.  The tenor of competitive marketing material has lowered to include accusations of how one hospital is much more expensive than another without any factual basis to make such statements.  

One surgeon's overzealous attempts to market his services went to the extremes of misleading readers of his training credentials and true level of experience.  His marketing was excessive to the extreme that he has been formally counselled by his university and reprimanded by our professional body, the Urological Society of Australia and New Zealand.  He has also been referred to the Royal Australasian College of Surgeons for investigation of breach of its Code of Practice and to the Australian Health Practitioners Regulatory Authority for investigation of breach of advertising regulations.  Others have provided more carefully crafted glossy brochures to referring general practitioners and it is becoming increasingly common to have the addition of the term "Robotic Surgeon" to their professional stationary.  I hope that I will continue to not have to resort to these measures in order to maintain my existing sub-specialised practice in prostate surgery.  

I digress for just a moment to recount how a mentor of mine once told me when I started practice that the best advertising you could do was to look after your patients well.  In other words, your patients would be your best advertisement. Maybe this is an old fashioned approach but for as long as this still works for me, then I will consider myself fortunate.  That said, back on topic.

I feel very grateful for the fact that I have been in the position to pick and choose which patients that I felt that I could safely offer robotic surgery instead of open surgery in my hands.  This enabled me to get comfortable with doing easier cases before taking on more complex cases.  I am now comfortable with offering robotic assisted radical prostatectomy for all men for whom surgery is an appropriate option.   I have been extremely fortunate to have undergone transitioning to this technology in an era where training tools (such as the virtual reality simulator), an established technique and surgical proctoring were so readily available to me.  I am particularly grateful for my friends and colleagues Damien Bolton (Melbourne) and Peter Swindle  (Brisbane) making an effort to come to Sydney to help train me without accepting any remuneration for my over and above minimum expected proctored cases.

Robotic surgery is clearly here to stay and to be fair, the advantages of  less pain and quicker recovery have turned out to be more profound than what I had anticipated.  It was very easy to be critical of such claims when I had no personal experience with the technology and given that I had thought that my patients undergoing open surgery were doing just fine with no need improve upon this.  It has also been gratifying to see that my cancer clearance rates and recovery of continence are unchanged although I have an impression that the latter is actually better.  It is too early to know for sure of my outcomes for recovery of erectile function but my impression at this early stage is that it may in fact be better.  In spite of great anxiety and trepidation in making this transition, it is pleasing to report that my personal experience with adopting robotic surgery has turned out to be a particularly positive and exciting period of my surgical career.   My only disappointment has been the aggressive marketing and collegial fragmentation seen in association with the rapid uptake of the technology.  As one very astute GP wrote to me regarding a second opinion referral that he had sent to me: "I am concerned that the joy of a new technology and one's desire to expand their series is impacting on clinical decision making" - I sincerely hope that the race to adopt robotic surgery does not become a prostate harvesting exercise after the huge leaps forward that have been made in embracing conservative approaches such as active surveillance for those with clinically insignificant disease.