Treating teenage phimosis and paraphimosis
Introduction of evidence base practice
Evidence-based practice (EBP) was defined French (1999) as: ‘The systematic interconnecting of scientifically generated evidence with the tacit knowledge of the expert practitioner to achieve achange in a particular practice for the benefit of awell defined client/patient group.’
In his paper entitled The Development of Evidence-based Nursing, he argues for
the use of the broader concept of evidence-based practice and identifies some critical features of evidence-based practice. He suggests that it is acomplex process that encompasses a number of domains:
It is problem-based, located in the context of practitioners’current experience, integrates research with the ‘tacit’ knowledge of the practitioner, forms part of an organisation’s quality assurance processes.
According to French, therefore, the tacit knowledge of the practitioner – that is, knowledge not necessarily found in the scientific literature but well known among practitioners (Carroll 1998, cited inFrench 1999) – is an important component of what constitutes nursing’s body of evidence.
For a proper evidence based practiced, one need to understand the patient’s views, the clinical data and knowledge together with the research evidences. A simple mind map of evidence based practice can be used to illustriate such processes. An optimal decision achieved when the factors of such data combined together.
It has been shown that evidence based practice can provide better healthcare outcome to patient compare to practice that not using evidence based practiced.
– About 30-40% of patients do not received care according to scientific evidence.
– 20-25% of care has been medically unnecessary and potentially harmful
– Can take 17-20 years for evidence to be implemented into practice.
Steps to approach the evidence based practices are:
1. Questionares or inquiry
As shown in diagram above, that inquiry leading to the decision on evidence based practiced.
Background question example: What are the most safest methods for male child circumcision?
Foreground questions ask about specific choices among different action options that fit the context of available resources and the client’s characteristics
Foreground question example: In child male circumcision, would using device method better and safer, compared to traditional method circumcision?
Getting the evidence for the subject matter. The higher quality level the evidence, the more probability that the subject can be implemented with success. The level of evidence is shown below in the diagram.
3. Appraise or analysis
Analyse and appraise the evidence of the research matter by selecting only the relevant and appropriate evidence.
Getting it into practice.
The practice need to be evaluate again as whether it is answering the early question of the subject matter.
Distribute the practice or share it by writing articles or conference.
Many articles and studies have been done on male circumcision, especially for the purpose of preventing the spreading of HIV (Human invitro virus infection) over the African continents. Most of the studies agree that circumcision reduce the HIV infection and had been approved by the WHO (World Health Organization). Foad Ali Moosa 2010 concluded from his retrospective study that minimal adverse events from using Plastibell device on neonates and infants.
A study by P S Millard in 2013 using randomize control trial on 200 volunteer males in Mozambie, showed that Gomco clamp device produce better cosmetic outcome, faster surgery and less bleeding. Another propective study done by Moses Galukande et al 2013 over device circumcision in International Hospital Kampala, Uganda, provide evidence of minimal adverse events and no cases of glans amputation occur. Neonatal circumcision is generally safe when done by an experienced practitioner. Older age group have higher adverse events such as
infection, bleeding and pain. Charbel El Bcheraoui et al 2014, also conclude that male circumcision had a relatively low incidence of adverse events overall, especially if the procedure was performed during the first year of life, but rose 10- 20 fold when performed after infancy.No urethral injury or glans amputations were reported over the above studies.
Glans penis amputation is rare and uncommon. Witswell and Geschke reviewed the records of 136,086 circumcised boys and reported an overall complication rate of 0.19%. The fairly high rate (1.5-15%), with more serious complications, is reported when the procedure is often performed by an inexperienced individual without attention to basic surgical principles often in a traditional setting or when poor surgical technique is used. Partial glans removal has been reported to occur with the use of clamp techniques (guillotine-type). With this technique, amputation can occur if the operator inadvertently catches the glans in the clamp, as in our case. According to BouassidaKhaireddine et al, carrying out circumcision under local anesthesia or without anesthesia by unqualified village barbers like in many Muslim countries is very dangerous and can cause many serious complications such as penile amputation. A recent event occurred in Malaysian boys in December 2016, was the results of same mistake made by the operator or by inexperience operator. Both cases were performed by the clamp gullatine method. If they were using device method such as smartklamp circumcision, such adverse event may not occurred.
Circumcision performed in the neonatal period had better results with fewer complications in comparison to older infants. Circumcision using devices such as Gamco clamp, Plastiblee, smartklamp produce better cosmetic, faster surgery , minimal bleeding and most important of all is safer.
In our society, conventional method of circumcision has long been adopted with the use of bone
cutter for homeostasis. It is important to emphasize that trauma to glans results in a well-known and dangerous complication of partial amputation of the glans is more common with bone cutter circumcision and should be discouraged.
Research done by Helen A Weiss et al 2010 on prospective studies of frequency of complications in studies of child circumcision undertaken by medical providers, study shows that serious complications occurred when circumcision was done by manual dissection methods. The study also provide result of the sixteen prospective studies on neonatal and infant circumcision. Most studies reported no severe adverse events (SAE), but two studies reported SAE frequency of 2%. The median frequency of any complication was 1.5% (range 0-16%). Child circumcision by medical providers tended to be associated with more complications (median frequency 6%; range 2-14%) than for neonates and infants. Traditional circumcision as a rite of passage is associated with substantially greater risks, more severe complications than medical circumcision or traditional circumcision among neonates.
The usefulness of such device on male circumcision especially in Malaysia, have been well known since the introduction and invented Taraklamp by Malaysian doctor in 2008. Now many clinics in Malaysia adopting using circumcision device. However, sadly, the traditional method still being practiced by many both experience and non experience providers in Malaysia. The most important reason why they choose this type of circumcision is because it cost much less as compared to using device. One unit of device cost around RM35.00 to Rm60.00, depend on size and types of manufactured. While the traditional method is using a single suture which cost around RM5.00 – Rm10.00 Another reason why such tradional method still welcome by many is because some people want to follow tradition and believe such act provide better spirit or religious acceptance.
Circumcision has been widely studied, reported and presented by WHO (World Health Organization.) WHO provide detail guideline on male circumcision using device type to prevent HIV. The latest articles on 2013, defining the scope of the guidance , retrieving the evidence, rating the evidence, clinical evaluation of the device and recommendation.
The practice of using device for circumcision is an evidence based practice as discussed above. The device is certainly safe, less bleeding and cosmetically better than manual stich cut traditional method. Having this safer and better methods will help to improve the service and productivity of healthcare organization, and for private healthcare it may provide competitive advantage which improve the revenue.