This study evaluated a new single-visit adult male circumcision technique called Unicirc that uses a disposable plastic instrument and tissue adhesive. In a trial of 110 men across 3 sites in South Africa, the procedure took a median of 9 minutes with minimal blood loss and pain. There was a 6.3% rate of moderate complications like bleeding and infection but no serious adverse events. Nearly all wounds were fully healed by 4 weeks with high patient satisfaction and excellent cosmetic results, demonstrating the potential for this technique to safely scale up circumcision programs with one visit and without injections.
Outpatient surgery benefits patients and surgeons alike, as it is convenient, safe and cost-effective. We sought to assess the safety and feasibility of daycare thyroid surgery in a stand-alone Daycare Surgery Center in South India.
Fifteen Years Experience of Managing Penetrating Extra-Peritoneal Rectal Inju...Crimsonpublisherssmoaj
Fifteen Years Experience of Managing Penetrating Extra-peritoneal Rectal Injuries.Background: Although civilian injuries are generally less severe, they nevertheless remain a challenging problem for the surgeons. In isolated rectal injury patients, though proximal diversion, pre-sacral drainage, distal rectal wash-out and wound debridement are the various surgical options employed in various combinations, the optimum strategy especially for civilian injuries remains unknown. We reviewed our experience of managing penetrating extra peritoneal rectal injuries.Methods: We conducted a Retrospective review of Adult patients with penetrating extra-peritoneal rectal injuries. Follow-up information of at least one month was needed for early post-operative complications.Results: A total number of fifteen patients met inclusion criteria. Median age of our patients was 46 years with range being 20-80 years. All our patients were males. Thirteen of our patients (86%) suffered from gunshot injury while one was a blast victim and one had a stab injury to rectum. Nine patients (60%) had pelvic fracture associated with rectal injury.Diversion stoma was made in all of our patients. Overall post-operative morbidity was 40%. Two patients developed necrotizing fasciitis and required repeated debridements followed by graft placement and one patient developed intra-abdominal abscess which was treated by radiological guided drain placement and antibiotics. Conclusion: Drainage with fecal diversion is the most commonly employed management of extra-peritoneal rectal injuries. Delayed or inadequate drainage can lead to disastrous consequences including necrotizing fasciitis, intra-abdominal abscess
Intranasal adhesions formation was a troub-lesome complication following endoscopic sinus surgery. It can be advocated that silastic splints should be routinely used in endoscopic sinus surgery to reduce the occurrence of post-opera-tive adhesions with their associated morbidity regardless of patient’s age, gender and duration of symptoms.
WHO has undertaken a number of global and regional initiatives to address surgical safety. The Global Initiative for Emergency and Essential Surgical Care and the Guidelines for Essential Trauma Care focussed on access and quality. The Second Global Patient Safety Challenge: Safe Surgery Saves Lives addresses the safety of surgical care.
Outpatient surgery benefits patients and surgeons alike, as it is convenient, safe and cost-effective. We sought to assess the safety and feasibility of daycare thyroid surgery in a stand-alone Daycare Surgery Center in South India.
Fifteen Years Experience of Managing Penetrating Extra-Peritoneal Rectal Inju...Crimsonpublisherssmoaj
Fifteen Years Experience of Managing Penetrating Extra-peritoneal Rectal Injuries.Background: Although civilian injuries are generally less severe, they nevertheless remain a challenging problem for the surgeons. In isolated rectal injury patients, though proximal diversion, pre-sacral drainage, distal rectal wash-out and wound debridement are the various surgical options employed in various combinations, the optimum strategy especially for civilian injuries remains unknown. We reviewed our experience of managing penetrating extra peritoneal rectal injuries.Methods: We conducted a Retrospective review of Adult patients with penetrating extra-peritoneal rectal injuries. Follow-up information of at least one month was needed for early post-operative complications.Results: A total number of fifteen patients met inclusion criteria. Median age of our patients was 46 years with range being 20-80 years. All our patients were males. Thirteen of our patients (86%) suffered from gunshot injury while one was a blast victim and one had a stab injury to rectum. Nine patients (60%) had pelvic fracture associated with rectal injury.Diversion stoma was made in all of our patients. Overall post-operative morbidity was 40%. Two patients developed necrotizing fasciitis and required repeated debridements followed by graft placement and one patient developed intra-abdominal abscess which was treated by radiological guided drain placement and antibiotics. Conclusion: Drainage with fecal diversion is the most commonly employed management of extra-peritoneal rectal injuries. Delayed or inadequate drainage can lead to disastrous consequences including necrotizing fasciitis, intra-abdominal abscess
Intranasal adhesions formation was a troub-lesome complication following endoscopic sinus surgery. It can be advocated that silastic splints should be routinely used in endoscopic sinus surgery to reduce the occurrence of post-opera-tive adhesions with their associated morbidity regardless of patient’s age, gender and duration of symptoms.
WHO has undertaken a number of global and regional initiatives to address surgical safety. The Global Initiative for Emergency and Essential Surgical Care and the Guidelines for Essential Trauma Care focussed on access and quality. The Second Global Patient Safety Challenge: Safe Surgery Saves Lives addresses the safety of surgical care.
IVF is stressful and expensive and there is a continued need to improve outcome using all information technology available to improve outcomes , meet expectations and review management.
Effects of Intralesional Triamcinalone injection following Internal Urethroto...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
A comparative study of fine needle aspiration cytology, trucut biopsy and his...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Prehospital rapid sequence intubation improves functional outcome for patient...Emergency Live
In adults with severe TBI, prehospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital.
My slides for a presentation to some surgeons in Scotland on the WHO Surgical Safety Checklist, built with Lego. Based on Atul Gawande's book/research.
Iatrogenic Ureteral Injuries in Non – Urological Surgeries: An Institutional ...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
IVF is stressful and expensive and there is a continued need to improve outcome using all information technology available to improve outcomes , meet expectations and review management.
Effects of Intralesional Triamcinalone injection following Internal Urethroto...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
A comparative study of fine needle aspiration cytology, trucut biopsy and his...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Prehospital rapid sequence intubation improves functional outcome for patient...Emergency Live
In adults with severe TBI, prehospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital.
My slides for a presentation to some surgeons in Scotland on the WHO Surgical Safety Checklist, built with Lego. Based on Atul Gawande's book/research.
Iatrogenic Ureteral Injuries in Non – Urological Surgeries: An Institutional ...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The final protocol (v5.3). Notable changes include:
1) Confirmation of audit standard (Page 6).
2) Refinement of inclusion and exclusion criteria (Page 7)
3) Confirmation of audit status (Appendix C)
4) Refinement of required data fields (Page 19) including definitions (Pages 20-25)
Day care surgery was started as money saving modality. It has picked up momentum even in India. In last one decade due to innovations in surgical techniques and advances in anaesthesia, the positive feedback from the patients and their relations has enhanced the popularity of day care surgery. There is an immense opportunity for expansion of day care surgery in India to ensure faster, safer, cost-effective and patient turnover. Retrospective and Prospective day care surgery is being performed on general surgery patients at National Institute of Medical Science and Hospital (NIMS), Jaipur from 2014 to 2017. During this period, 4547 day care surgical procedures and 2757 OPD procedures were performed. Only 212 day care surgery patients (2.9%) were transferred to day care unit as in-patient admission. We found the day care surgery as safe and effective means of fast track surgery, which was economical also. In-patient admission following day surgery can be reduced by improved out-patient selection of cases by introducing a pre-admission assessment form filled in at the out-patient clinic, operating early on day care by using separate day care theatre. Anaesthetic complications were reduced by increased use of local anaesthetic techniques.
Key-words: Day care surgery, Ambulatory surgery, Anaesthesia, Early Ambulation, Post-Operative, Laparoscopy
Background: The transition from resident physician to independent practitioner is an important period for young physicians.Optimally, they would feel well prepared to independently care for all patients presenting to them for anesthesia, however, this is unlikely Methods: A survey was emailed to all accredited anesthesiology residency program coordinators in April 2018 for further distribution to their CA3 residents. The survey collected data on the resident’s perception of his or her preparedness to manage a variety of anesthesia cases, patients with comorbid conditions, and ethical issues as well as perform various procedures.
Video Vs direct laryngoscopy for tracheal intubation of critically ill adults...Ahmed Lotfy
In this trial (The DEVICE Trial), among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope.
The use of adipose tissue transfer in plastic and reconstructive surgery is not new and has been studied for more than a century but problems such as unpredictability in results and a low rate of graft survival due to partial necrosis were always among major concerns. However, emerging information regarding the potential of adipose derived stem cells, new methods of cell extraction, graft preparation and injection techniques have increased the popularity of fat transfer and the efforts toward development of cell based therapies for various diseases from Adipose Derived Stem Cells (ADSC’s) and Stromal Vascular Fraction (SVF) of the adipose tissue. Although the mechanism of action of those stem cells is not fully known, their paracrine activities and transformation to various cell types can be responsible for reported clinical outcomes [1,2]. Many clinicians and researchers report better outcomes in fat grafting upon addition of SVF cells [1,2]. This study aims to investigate the long-term (3 years) safety of Antria’s cell preparation process utilizing a digestive enzyme in SVF assisted fat grafting. The outcomes of this study was utilized to conduct further safety and efficacy studies to obtain regulatory and marketing approval for a novel SVF extraction method in the US.
Methods: Retrospectively, the file records of the patients who underwent sleeve gastrectomy were examined. Demographic features, Body Mass Index (BMI), the mouth opening, Mallampati score, thyromental distance, sternomental distance, neck circumference measurements and videolaryngoscopic examination results were recorded Results: In a total of 140 consecutive patients (58 male, 82 female) were included in the study. The mean age of the study participants was 35.40 ± 9.78 and the mean BMI of the patients was 44.33 ± 7.52 kg/m2
. The mean mouth opening of the patients was 4.82 ± 0.54 cm
and the mean neck circumference was 43.52 ± 4.66 cm. The mean thyromental distance was 8.02 ± 1.00 cm and the mean sternomental distance was16.58 ± 1.53 cm. Difficult intubation was determined in 8 (5.7%) patients. In logistic regression analysis, age (p : 0.446), gender (p : 0.371), BMI (p : 0.947), snoring (p : 0.567), sleep apnea (p : 0.218), mouth opening (p : 0.687), thyromental distance (p :0.557), sternomental (p : 0.596) and neck circumference (p : 0.838) were not the independent predictors of difficult intubation. However, Mallampati score (p : 0.001) and preoperative direct laryngoscopy findings (p : 0.037) performed in outpatient clinic were the significant
predictors of difficult intubation. Interestingly, all patients with grade 4 laryngoscopy findings had difficult intubation.
The correct application of the safety check steps in our routine theatre operations and procedures will greatly reduce surgically related mortality and morbidity.
Reliability of Med-El Cochlear Implants in children. The Romania Experience.IJERA Editor
Introduction: Early detection of hearing loss significantly lowered the age of cochlear implantation. A failed CI
is a very problematic issue for the child and family and seems to be, for the moment, inevitable. This is a
retrospective review aimed to evaluate the reliability of Med-El devices implanted in children in Romania.
Materials and Methods: We designed a questionnaire to assess the incidence, the time elapsed and the reason
of total device failure. Medical-surgical data were collected from children who received Med-El cochlear
implants since the start of the National Cochlear Implant Program in 2001.
Results: There were 256 patients included. Failure Rate (6,64%) and Cumulative Survival Rate (95,31%) at 5
years were calculated. The majority of the hard and soft failures were encountered in Pulsar devices. Flap
necrosis was the most frequent medical/surgical reason for re-plantation. There was only one case of
posttraumatic device failure. Time elapsed to device failure was short – 22 months on average.
Conclusion: Cochlear implant reliability data should be considered during the choice of an implant for each
individual patient. This study confirms the safety and efficacy of Med-El cochlear implants in children for both
ceramic and non-ceramic devices.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
2. Introduction
Voluntary medical male circumcision (VMMC) reduces female-to-male transmission of HIV
by 38% to 66% over 24 months.[1] Almost 6 million men have been circumcised in 14 priority
African countries of Eastern and Southern Africa, with a goal of 20 million by 2016.[2] If this
goal is met, more than 3.4 million new HIV infections can be prevented in Southern and East-
ern Africa with an estimated net savings of US$16.5 billion between 2011 and 2025.[3]
We have shown in a previous randomized controlled trial that VMMC, under local in-
jectable anaesthetic, using the Unicirc instrument to excise the foreskin and sealing the wound
with cyanoacrylate tissue adhesive is faster, easier, and has superior cosmetic results compared
to open surgical circumcision.[4–5] A subsequent case series of 50 Unicirc circumcisions con-
firmed the rapidity, safety, and excellent cosmetic results of Unicirc circumcision under local
anaesthesia.[6]
This study reports on a field trial of needle-free VMMC using topical lidocaine/prilocaine
anesthetic, excising the foreskin with the Unicirc instrument, and sealing the wound with
tissue adhesive.
Methods
The protocol for this trial and supporting TREND checklist are available as supporting infor-
mation; see S1 TREND Checklist and S1 Protocol.
Trial design
This was a multi-centre field trial with two sites in Cape Town and one site in Marikana, South
Africa. Men were recruited via posters and word of mouth in the respective primary care clin-
ics. We obtained written informed consent from each participant. The South African Medical
Association's Research Ethics Committee (SAMAREC) approved the study and the informed
consent. The ClinicalTrials.gov identifier is NCT02091726. The study took place between Janu-
ary 20 and July 4, 2014. There were no deviations from the study protocol.
Participants
WHO, in the Framework for Clinical Evaluation of Devices for Adult Male Circumcision
(2009)[7]
states: “Studies involving about 100 men (range 50 to 300) are suggested as a compro-
mise between assessing safety, documenting the presumed advantages of the new method, and
ensuring rapid progress through the different stages of clinical assessment. The exact choice of
endpoint will be determined by the expected advantages of the new device over conventional
surgery, but the total operation time is likely one key measure by which to compare the
approaches.”
We therefore aimed for a sample size of approximately 100.
Healthy uncircumcised men at least 18 years of age were eligible for the study. Exclusion cri-
teria were concurrent illness, history of bleeding disorder, past reaction to local anesthetic, in-
fection, or penile abnormality which could complicate circumcision.
Participants received HIV prevention counseling. We offered HIV testing, but we did not
request testing as a study prerequisite, per SAMAREC guidelines. Participants were advised to
abstain from sexual intercourse until the wound was completely healed and for at least 4 weeks
after the circumcision. Condoms were made freely available.
Minimally Invasive Adult Male Circumcision
PLOS ONE | DOI:10.1371/journal.pone.0121686 March 30, 2015 2 / 11
3. Intervention
Three generalist physicians (GPs) performed the circumcisions in individual consultation
rooms in their own primary health care clinic. Two of the GPs (SN, ZP) had previous experi-
ence with the Unicirc; SKN trained on the instrument for this case series.
Unicirc with cyanoacrylate skin adhesive. The Unicirc is a plastic and metal single-use-
only disposable instrument designed in South Africa. For this study, we used the same instru-
ment that we used in our prior case series,[6] which was a slight modification from the instru-
ment used in our randomized controlled trial.[4] Prior to use, the instruments were gas
sterilized in sealed packages. After applying a topical mixture of lidocaine/prilocaine (EMLA
cream) to the glans and foreskin, we waited approximately 30 minutes before applying the Uni-
circ instrument (Fig. 1). We left the instrument in place for 5 minutes before excising the fore-
skin with a surgical scalpel (Fig. 2). After removing the instrument, we sealed the apposed skin-
mucosal edges with cyanoacrylate skin adhesive (Fig. 3). We used four different Unicirc sizes
(diameters) in this study: 2.6 cm, 2.9 cm, 3.2 cm, and 3.5 cm.
We covered the wound with an adherent tape (Hypafix) and absorbent gauze. We asked the
volunteer to remove the absorbent gauze at day two, to keep the wound dry, and to leave the
adherent tape in place for two weeks.
All men were observed for 20 minutes after the procedure. Subjects were given written post-
operative instructions and cellular telephone contact information of the doctor.
Outcomes
Outcome definitions are shown in Table 1.
Primary Outcome Measure. Intraoperative time.
Secondary Outcome Measures. Intra-operative pain; complications (operative and post-
operative); time to healing; patient satisfaction; cosmetic result.
Fig 1. Unicirc placement.
doi:10.1371/journal.pone.0121686.g001
Minimally Invasive Adult Male Circumcision
PLOS ONE | DOI:10.1371/journal.pone.0121686 March 30, 2015 3 / 11
4. Adverse events. Key adverse events considered were anaesthetic complications, bleeding,
haematoma, infection, wound disruption, problems with urination, subsequent procedures
conducted to correct complications, and occupational exposure to blood and body fluids. We
used standardized definitions to grade adverse events as mild, moderate, or severe, using the
WHO Framework.[7] In brief, adverse events were categorized as mild if they required little or
Fig 2. Excising the foreskin.
doi:10.1371/journal.pone.0121686.g002
Fig 3. Applying cyanoacrylate adhesive.
doi:10.1371/journal.pone.0121686.g003
Minimally Invasive Adult Male Circumcision
PLOS ONE | DOI:10.1371/journal.pone.0121686 March 30, 2015 4 / 11
5. no intervention (e.g. mild wound disruption or slight bleeding), moderate if they required ac-
tive treatment (e.g. antibiotics or suturing), or severe if they required transfusion or hospitaliza-
tion, or resulted in permanent damage.
Follow-up
Follow-up was at seven days and four weeks. For those men who were not completely healed
by four weeks, we conducted an additional six-week follow-up visit.
Outcome assessment
Complications and wound healing outcomes were assessed by the GPs.
Results
Participant flow
A total of 125 men volunteered to participate and 110 men underwent circumcision (Fig. 4).
One volunteer completed the informed consent but did not arrive for his circumcision. We ex-
cluded two men with hypospadias, one man with a scarred frenulum, and 12 men with phimo-
sis. All participants were circumcised using topical anaesthetic and Unicirc. Per WHO
guidelines, the doctors decided that 2 men with tight (but not scarred) frenulums could partici-
pate. Each of the 2 frenulectomies was done and sutured under topical anaesthetic as a separate
procedure immediately prior to the circumcision. The sutures remained in place, and did not
affect healing of the subsequent Unicirc circumcision, which was done without sutures and did
not result in bleeding.
Baseline data
The baseline characteristics of the participants are shown in Table 2. The median age was 29.5
(IQR 23.5, 37.5) years. The large majority of men gave improved hygiene as their motivation
for circumcision and few were motivated by HIV prevention.
Table 1. Outcome definitions.
Endpoint Definition
Operating time Time from first clamp on foreskin until dressing placed
Pain assessment using Visual
Analog Scale (0–10)
Self-reported pain during first 24 and 48 hours
Blood loss Quantity estimated by senior surgeon (ml)
Adverse Event Mild adverse events required no active intervention other than
wound pressure for bleeding; moderate events required medical
intervention (sutures, antibiotics); severe events required
transfusion, hospitalization, or resulted in permanent disfigurement
Wound infection Empirical diagnosis based on wound swelling, redness, and pain.
No bacterial cultures were available
Wound disruption Length of wound disruption or granulation tissue (< 2cm vs. > 2cm)
Wound fully healed Completely epithelialized; no superficial ulcerations or granulation
tissue present
Cosmetic appearance Regular: scar line straight without any irregularity
Irregular: Some irregularity to scar line
Scalloped: wavy appearane to scar line
Participant satisfaction (5 point
Likert scale)
Are you satisfied with your circumcision result? If not, why not?
Would you recommend circumcision to friends or relatives?
doi:10.1371/journal.pone.0121686.t001
Minimally Invasive Adult Male Circumcision
PLOS ONE | DOI:10.1371/journal.pone.0121686 March 30, 2015 5 / 11
6. Outcomes analyzed
Operative outcomes are shown in Table 3. Two of the participants felt burning when the in-
strument was tightened but none required injectable anaesthesia. One participant had a partial
phimosis and required a dorsal slit before applying the Unicirc. No participant required intrao-
perative suturing and there were no intraoperative complications. The median operative time
time was 9 minutes (range: 7–15 min) and blood loss was minimal (range: 0–3 ml).
Fig 4. Flow diagram.
doi:10.1371/journal.pone.0121686.g004
Minimally Invasive Adult Male Circumcision
PLOS ONE | DOI:10.1371/journal.pone.0121686 March 30, 2015 6 / 11
7. Adverse events are shown in Table 4. There were no serious complications. The overall rate
of moderate complications was 6.3%, (5 (4.5%) post-operative bleeds requiring suture and 2
(1.8%) post-operative infections) affecting 7 men. There was no association between the sur-
geon’s experience and complication rate. All bleeding episodes occurred after the dressing was
placed and were treated before the volunteers left the site with haemostatic suture of the bleed-
ing site and closure of the part of the wound that was disrupted by the haemostasis. After sutur-
ing, the wound was covered by a dry dressing. There was no clinically significant wound
dehiscence > 2 cm.
Wound healing at 4 weeks, participant satisfaction, and cosmetic results are shown in
Table 5. All wounds were completely healed by 6 weeks. The cosmetic result was excellent
(Fig. 5) in all but one patient who had required suturing for post-operative bleeding.
Table 2. Baseline characteristics.
Unicirc/adhesive
N = 110
Age (yrs), n (%)
18–25 38 (34.5)
26–35 41 (37.2)
36+ 31 (28.2)
Religion, n (%)
Christian 101 (92.0)
Muslim 7 (6.4)
No religion 2 (1.8)
Employment, n (%)
Employed 41 (37.3)
Self-employed 3 (2.7)
Student 1 (0.9)
Unemployed 65 (59.1)
Reason for circumcision, n (%)
Hygiene 86 (78.2)
Reduce HIV risk 9 (8.2)
Social/religious 10 (9.1)
Appearance 5 (4.6)
doi:10.1371/journal.pone.0121686.t002
Table 3. Intraoperative outcomes.
Unicirc
N = 110
Center
Cape Town site 1 (ZP), n (%) 12 (11)
Cape Town site 2 (SN), n (%) 80 (73)
Marikana (SKN), n (%) 18 (16)
Intraoperative suturing, n (%) 0
Frenulectomy performed, n (%) 2 (1.8)
Intraoperative time (min), median (IQR) 9 (9, 10)
Estimated blood loss (ml), median (IQR) 1 (1, 1)
Pain on crushing foreskin, n (%) 2 (1.8)
IQR = Interquartile range
doi:10.1371/journal.pone.0121686.t003
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PLOS ONE | DOI:10.1371/journal.pone.0121686 March 30, 2015 7 / 11
8. Discussion
VMMC is an essential intervention to prevent female-to-male HIV transmission. Interesting,
in a country with a great deal of publicity about reducing HIV infection through VMMC, only
8.2% of the volunteers in this study indicated that partial HIV protection was their main reason
for desiring circumcision. The challenge for areas with high HIV prevalence is to provide safe
and cost-effective VMMC. In order to more effectively scale-up services, we require surgical
techniques that are rapid, easy to learn, can be performed with standard instruments, are inex-
pensive, result in few complications, and provide excellent patient satisfaction and
cosmetic results.
The Unicirc method is safe, rapid, easy to perform, requires only one visit for completion,
and has excellent cosmetic results. We have now shown another considerable advantage: it re-
quires no injectable local anesthetic. Because it requires neither an injection nor suturing, Uni-
circ is potentially safer than other methods.[4]
Our first study,[4] was marred by the need for intra-operative suturing in 17% of partici-
pants. We attributed this to a defect in the manufacturing process and the device developer
Table 4. Adverse Events.
Unicirc
N = 110
Serious post-operative complication, n 0
Post-operative bleeding, n (%)
Mild (dressing only) 1 (0.9%)
Moderate (sutured) 5 (4.5%)
Haematoma, n 0
Post-operative infection (antibiotic required), n (%) 2 (1.8%)
Wound disruption at 1 wk, n (%)
< 2 cm length 5 (4.5%)
> 2 cm length 0
doi:10.1371/journal.pone.0121686.t004
Table 5. Outcomes at 4 weeks.
Unicirc
N = 104
Wound fully healed at 4 weeks, n (%) 94 (90.4%)
Satisfactiona
, n (%)
Very satisfied 103 (100%)
Not satisfied 0
Recommendationa
, n (%)
Recommend highly 103 (100%)
Not recommend 0
Cosmetic resultsb
, n (%)
Regular 101 (99%)
Irregular 0
Scalloped 1 (1%)
a
In one case, the interviewer did not ask either the question about satisfaction or recommendation
b
In 2 cases, the doctor failed to assess the cosmetic result
doi:10.1371/journal.pone.0121686.t005
Minimally Invasive Adult Male Circumcision
PLOS ONE | DOI:10.1371/journal.pone.0121686 March 30, 2015 8 / 11
9. subsequently corrected this problem. No participants required intraoperative suturing in our
second study,[6] nor in this, our third Unicirc study.
Healing is delayed using plastic ring devices such as Prepex and Shang Ring, because they
heal by secondary intention. As a consequence, a major drawback of plastic rings may be an in-
creased probability of HIV transmission during the healing period. Like the Gomco/adhesive
method,[8] Unicirc/adhesive heals by primary intention. This is the fourth study using one of
these two methods (N = 347 assessed for healing at 4 weeks) showing healing times virtually
identical to open surgical circumcision with suturing. This is to be expected, since the average
time to healing by primary intention is constant.
Compared to the approximately 20 minutes required for a surgical circumcision, the 9-min-
ute operating time includes 1–2 minutes to place the instrument, 5 minutes of waiting after the
Unicirc is applied for the crushing action to take place, and 2–3 minutes to excise the foreskin,
remove the instrument, and apply the adhesive. Using WHO’s MOVE model of task-sharing,
[9] the 5 minute waiting time could be utilized for placing (or removing) the instrument on
other patients. The actual time-savings using the Unicirc/adhesive technique are therefore like-
ly to be greater than reflected by these 9 minutes, and should substantially reduce overall cost
and assist in mass scale-up.
Unlike plastic ring methods, the Unicirc method doesn’t require a second visit for device re-
moval, saving time and staff resources that can be used to circumcise additional men.
The cost of expendable materials is similar to other methods. The cost of tissue adhesive ap-
proximates the cost of suture, and Unicirc requires fewer disposable instruments (only one
haemostat and one scalpel) than other techniques. The market price has not been set for
Fig 5. Four-week follow-up.
doi:10.1371/journal.pone.0121686.g005
Minimally Invasive Adult Male Circumcision
PLOS ONE | DOI:10.1371/journal.pone.0121686 March 30, 2015 9 / 11
10. Unicirc, but would probably be similar to that of plastic ring devices. Because no follow-up vis-
its are required, we expect there to be significant cost savings compared to plastic ring devices.
No one technique will be suitable for all settings. The Unicirc method is ideal for outpatient
settings where large numbers of circumcisions are performed by mid-level staff using the
MOVE model, or for use by private practitioners who have basic surgical skills and wish to add
circumcision services to their practice. It is not suitable for rural clinics without the ability
to suture.
This field study was performed by moderately experienced GPs in their own practices. It
shares the same advantages and disadvantages of other field studies: it is more indicative of
real-world conditions, but outcomes are not as tightly controlled as in a clinical trial. For exam-
ple, there was no independent, objective measure of wound healing outcomes, which were as-
sessed by the surgeons themselves. Given the high follow-up rates and the easy available of the
practitioners via cell phone, we think it unlikely that we missed any adverse events.
Conclusions
This study has important implications for the scale-up of VMMC services. Using topical anaes-
thesia, excising the foreskin after applying the the Unicirc instrument for 5 minutes and sealing
the wound with cyanoacrylate tissue adhesive in adults is rapid, easy to learn, heals rapidly by
primary intention with excellent cosmetic results, and is potentially cheaper and safer than
other methods. Use of this new method will greatly facilitate scale-up of mass
circumcision programs.
Supporting Information
S1 Protocol. Trial Protocol.
(PDF)
S1 TREND Checklist. TREND Checklist.
(PDF)
Acknowledgments
We thank Dr. Senzo Ntshalintshali (SN), Dr. Sikhumbuso Ngwenya (SKN), and Dr. Zainul
Parker (ZP) for performing the circumcisions, Simone Harris for data management, and Drs.
Cyril and Elisabeth Parker for their support.
Author Contributions
Conceived and designed the experiments: PSM NG. Performed the experiments: NG. Analyzed
the data: PSM. Contributed reagents/materials/analysis tools: NS. Wrote the paper: PSM NS.
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