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Introduction: Vesico-vaginal fistula, is a known complication that can occur following damage to the bladder wall during pelvic surgery or prolonged birth. Prompt and accurate diagnosis and timely repair are essential for a quick solution to the problem, and a reduction in medico-legal claims. Successful treatment requires an accurate assessment of the size and the location of the fistula, determination of timing and the surgical technique. There is an approach that advocates postponing the surgery for several months until "tissue healing" subsides and some advocate immediate repair. In our department, the surgery is performed early, immediately upon diagnosis without delay. The aim of the work is to define the clinical manifestation of fistula after surgery, to analyze the factors, and to summarize the experience of an early intervention., Methods: We reviewed the records of consecutive patients undergoing repair of urogenital fistulas at our institution. Patients with only vesico-vaginal fistulas were included. We recorded demographic characteristics, as well as surgical data, and postoperative complications were also collected. The follow-up period was at least 3 months., Results: A total of 67 women with urogenital fistulas were identified, of whom 37 were only with vesico-vaginal fistulas. Iatrogenic injury, during hysterectomy was the main cause in 70.3%; 2 women were treated conservatively. A repair in the vaginal approach was performed in 31 women, and in 4 women the repair was performed in the abdominal approach, of them, two underwent urethral re-implantation simultaneously. Complications included sepsis in one case, and vaginal cuff dehiscence in another. The success rate of the repair was 92%. Recurrence occurred in 3 patients, of whom 2 had a history of previous radiation., Conclusions: A vesico-vaginal fistula can be successfully repaired by early repair, without delay, thus saving the patient considerable distress and discomfort.

Introduction: There are major challenges in teaching and assessing skills expected from practicing anesthesiologists and residents in anesthesia training programs. It is important to measure two separate aspects of skilled performance in managing crises: implementing appropriate technical actions (technical performance), manifesting appropriate crisis solving, and management of anesthesia non-technical behaviors. Anesthesia nontechnical skills (ANTS) can be divided into two subgroups: (1) cognitive or mental skills (decision-making, planning, strategy, risk assessment, situation awareness); and (2) social or interpersonal affective skills (teamwork, communication, leadership). Competency assessment of nontechnical (i.e. cognitive and affective) and technical (i.e. psychomotor) skills, is extremely hard to accomplish using only traditional examinations. The Accreditation Council for Graduate Medical Education (ACGME) has instituted an initiative that requires training programs to assess each resident's competence in several domains of medical practice. The ACGME toolbox for evaluation lists simulation training as the most effective evaluation strategy for medical procedures. Simulation scripts or scenarios can and should be aimed to evaluate and assess the technical and non-technical capabilities of residents in anesthesia. Lapsed or deficient non-technical (cognitive) skills, can easily lead to cognitive errors in anesthesia. Understanding and correcting cognitive errors cannot be overemphasized. Cognitive errors are thought-process errors which lead to incorrect diagnoses and/or treatments. To achieve error-free levels, learning objectives and curriculum/teaching should be adjusted to address the deficiencies identified in these learning skills. To reach this aim, educational training in cognitive errors, meta-cognition, and de-biasing strategies is needed. However, there are still many questions regarding which errors are most important to address and which "adjustment" learning strategies are the most appropriate and effective in anesthesiology. Sharing scenarios can provide an objective comparative view of trainees in different residencies, and the potential for universal applicability of such scenarios, and learning from the mistakes detected. Communication and collaboration among centers involved in simulation programs (including sharing of validated scenarios) is important to the future of this technology and approach. In summary, cognitive and non-cognitive simulation-based skills assessment that included the so-called ANTS can help to identify areas of strength and weakness that can be used to guide the residency curriculum, especially regarding deficiencies in tasks requiring higher order processing. Any such deficiencies need to be addressed in any training program.

The death of a 23-year-old Chinese construction worker in southern Israel from refractory metabolic acidosis after presenting symptoms of edema and loss of sensation in his legs raised the suspicion of Beriberi disease. As thiamine deficiency was suspected, two other Chinese workers from the same construction site, who also complained of pain and swelling in their legs were tested and found to have a significant deficiency. In addition 56.5% of 46 Chinese workers at the site were found to have a thiamine deficiency without any significant clinical symptoms. A nutritional evaluation demonstrated a lack of thiamine in the workers diet due to a limited variety of food, their dietary preferences, and cooking style. There was also a lack of attention given to providing essential nutrients including thiamine by their employees. Clinicians must be aware that thiamine deficiency and beriberi disease may be common in this apparently healthy population.

Acute flank pain is commonly encountered in the emergency department, and often requires imaging to establish its cause. For decades intravenous urography and sonography have been the primary media for evaluating flank pain. Recently, noncontrast spiral CT (NCSCT) has been shown to be accurate and highly successful in diagnosing cause in such cases. We evaluated its use in the diagnosis of acute flank pain. During a 7-month period, 147 such cases had NCSCT imaging immediately after initial evaluation in the emergency department. Using a spiral CT scan without oral or i.v. contrast media, 109 of 147 cases were found to have ureteral stones, and 34 others to have other urological conditions unrelated to the cause of pain; 38 CT scans were negative for ureterolithiasis and in 14 non-urological disease was diagnosed. NCSCT is a valuable diagnostic technique for patients in the emergency department with flank pain. It rapidly and accurately detects ureteral stones causing renal colic and also detects extra-urinary causes of acute flank pain.

Between 1970 and 1980 we operated on 10 patients with congenital extrophy of the bladder and attempted staged anatomical and functional closure in all cases. Currently two patients have a functioning closed bladder, four are in different stages of treatment, and four have undergone urinary diversion. The importance of functional bladder reconstruction is stressed. Though it requires long hospitalization, and complication may result, the procedure can be justified because the anomaly is so grotesque.