Assessing the Impact of Percutaneous Nephrostomy Presence on Neoadjuvant Treatment Quality in Patients With Muscle Invasive Bladder Cancer.

INTRODUCTION: Symptomatic hydronephrosis associated with muscle invasive bladder cancer (MIBC) necessitates percutaneous nephrostomy (PCN) insertion before neoadjuvant chemotherapy (NAC). This study assesses the impact of PCN presence on standard intended NAC quality, its related complications and outcome after radical cystectomy (RC). MATERIALS AND METHODS: The study comprises a retrospective, multicenter cohort of 193 consecutive RCs performed between 2016 and 2019. Eighty (42%) of these patients received NAC and were divided in 2 comparison groups by presence (n = 26; 33%) or absence (n = 54; 67%) of PCN. Endpoints included completion of adequate NAC treatment (cisplatin-based chemotherapy for at least 4 courses), complications during NAC, post-RC complications and hospital stay. RESULTS: Overall, patients with PCN (45/193; 23%) featured a higher referral rate to NAC (58% vs. 36%, P = .01), worse glomerular filtration rates (P < .001) and more adverse events (P = .04), in comparison to non-PCN patients. In the NAC cohort, PCN patients had less adequate treatment rates (54% vs. 85%, P = .005), and more infections (35% vs, 7%; P = .008) and hospitalizations (58% vs. 13%; P < .001) during chemotherapy. Post-RC outcome was similar for both comparison groups. PCN was an independent risk factor for inadequate NAC (OR = 3.9, P = .04), and infections (OR = 11.3, P = .01) and hospitalizations (OR = 7.5, P = .004) during NAC. CONCLUSIONS: PCN in MIBC patients is a significant risk factor for inadequate NAC and adverse events during treatment. This finding may quire the rationale of NAC, potentially leading to consideration of NAC avoidance and upfront RC in PCN patients. Further survival studies with long follow-up are needed for elucidating this issue.

11-item modified frailty index and outcomes after radical cystectomy.

INTRODUCTION: To investigate the association between modified frailty index (mFI) scores and radical cystectomy outcomes. MATERIALS AND METHODS: We conducted a multicenter retrospective analysis of 292 patients who underwent radical cystectomy between 2015 and 2019. The patients were stratified according to mFI scores (mFI 0-1 vs. mFI ≥2). Baseline characteristics were compared between groups. The primary endpoints were cancer-specific survival (CSS) and overall survival (OS), and the secondary endpoint was the 30-day postoperative complication rate. RESULTS: One group included 164 patients with mFI 0-1 and the other included 128 patients with mFI ≥2. The cohort's median age was 69 years, and median follow-up for survivors was 33 months. Thirty-day major postoperative complication rate was 19%. Ninety patients (31%) died during the study period, 70 of them (24%) from bladder cancer. Older age, male sex, lower kidney function, and diversion to an ileal conduit were significantly more common in the mFI ≥2 group. The postoperative complication rates were comparable between groups, but the CSS and OS were significantly lower in the frailer group (p = 0.007 and p = 0.03, respectively). An mFI score ≥ 2 emerged as an independent risk factor for cancer-specific death (hazard ratio [HR] = 1.7, p = 0.03) and overall-mortality (HR = 1.8, p = 0.008). DISCUSSION: High mFI scores are associated with shorter CSS and OS after radical cystectomy. Healthcare providers should be encouraged to calculate frailty preoperatively for judicious patient selection in light of the predicted outcomes.

The role of malnutrition universal screening tool in predicting outcomes after radical cystectomy.

PURPOSE: The Malnutrition Universal Screening Tool integrates body mass index, unintentional weight loss and present illness to assess risk for malnutrition. The predictive role of 'MUST' among patients undergoing radical cystectomy is unknown. We investigated the role of 'MUST' in predicting postoperative outcomes and prognosis among patients after RC. MATERIALS AND METHODS: We conducted a multicenter retrospective analysis of 291 patients who underwent radical cystectomy in 6 medical centers between 2015 and 2019. Patients were stratified to risk groups according to the 'MUST' score [low risk (n = 242) vs. medium-to-high risk (n = 49)]. Baseline characteristics were compared between groups. Endpoints were 30-day postoperative complications rate, cancer-specific-survival and overall survival. Kaplan-Meier curves and Cox-regression analyses were used to evaluate survival and identify predictors of outcomes. RESULTS: Median age of the study cohort was 69 years (IQR 63-74). Median duration of follow up for survivors was 33 months (IQR 20-43). Thirty-day major postoperative complications rate was 17%. Baseline characteristics were not different between the 'MUST' groups, and there was no difference in early post-operative complication rates. CSS and OS were significantly lower (p ≤ 0.02) in the medium-to-high-risk group ('MUST' score≥1) with estimated 3-year CSS and OS rates of 60% and 50% compared to 76% and 71% in the low-risk group, respectively. On multivariable analysis, 'MUST'≥1 was an independent predictor of overall- (HR = 1.95, p = 0.006) and cancer-specific-mortality (HR = 1.74, p = 0.05). CONCLUSIONS: High 'MUST' scores are associated with decreased survival in patients after radical cystectomy. Thus, the 'MUST' score may serve as a preoperative tool for patient selection and nutritional intervention.

Post-refractive surgery of Israeli Defense Forces recruits in 2005-2018-prevalence, combat unit drop-out rates and utilization of eye-care services.

PURPOSE: To assess the number of recruits for military service in the Israeli Defense Force (IDF) who underwent refractive surgery prior to enlistment and examine whether the procedure affected their ability to accomplish combat training. SETTING: Medical records of IDF recruits. DESIGN: Retrospective analysis of medical records of recruits with ametropia who underwent or did not undergo refractive surgery prior to enlistment. METHODS: Recruits were categorized into ametropes and recruits who underwent refractive surgery. Fitness and assignment to combat units and completion status of combat training were compared between the two groups. RESULTS: The study included 334,688 (182,969 males, 151,719 females) ametropes of which 5231 (4753 males, 478 females) underwent refractive surgery prior to recruitment. Refractive surgery prevalence increased from 9/1000 ametropes in 2005 to 18.5/1000 ametropes in 2018 (r = 0.912, p < 0.001); 2643 of the operated recruits (50.5%) had their surgery at the age of 17-18. Dropout rates from combat training were significantly lower in the refractive surgery group during the study period (1.68% vs. 6.14%, respectively, p < 0.001). Soldiers in the operated group were more frequently referred to ophthalmologists than those in the ametropes group and less frequently referred to optometrists. CONCLUSIONS: The prevalence of refractive surgery in IDF recruits has increased substantially during the last decade with more of them applying to combat units. Refractive surgery opened new possibilities for recruits who were unfit for combat duty prior to surgery and did not appear to impair the chances of successfully completing combat training.

Lessons from outbreaks of COVID-19 at Israeli military bases.

BACKGROUND: To mitigate the spread of coronavirus disease 2019 (COVID-19), national guidelines, in accordance with international health authorities, mandated 14 days of quarantine for every close contact of a confirmed COVID-19 patient. Although health benefits are obvious, consequences are profound, especially for organizations required to maintain operational preparedness. OBJECTIVES: To present the Israel Defense Force (IDF) experience with outbreaks regarding quarantined individuals. To weigh the consequences of quarantined individuals needed for workforce and operation. METHODS: All positive COVID-19 cases in the IDF, as measured by a positive rRT-PCR test result, between 29 February and 18 May 2020 were evaluated. Numbers of positive individuals, quarantined individuals, and confirmatory exams conducted were collected. We compared the events in four units with the largest outbreaks and assessed the impact of confirmed cases, tests conducted, and workforce loss due to quarantine. RESULTS: Of the 187 soldiers who tested positive for COVID-19, source of infection was traced to 140 soldiers (75%). Almost no medical treatment was delivered, and hospitalization was rare. We found a median of 15.2% (interquartile range 5.3-34) for decline in unit workforce due to quarantine measures. Maximum reduction reached 47% of the workforce in one unit. CONCLUSIONS: Despite a relatively small number of confirmed cases, units underwent a substantial change in mode of operation due to the toll of quarantined individuals. In certain populations and organizations, perhaps a more liberal application of isolation and contact tracing is suitable due to the heavy economic burden and consequences in term of operational readiness.

Reply to Veerman et al. Comment on "Rosenzweig et al. Very Low Prostate PET/CT PSMA Uptake May Be Misleading in Staging Radical Prostatectomy Candidates. J. Pers. Med. 2022, 12, 410".

We thank the commenters for their important insights [...].

Very Low Prostate PET/CT PSMA Uptake May Be Misleading in Staging Radical Prostatectomy Candidates.

Purpose: to evaluate a unique subpopulation of radical prostatectomy (RP) candidates with "negative" prostate 68Ga-labeled prostate-specific membrane antigen (PSMA) positron emission tomography (PET) computed tomography (CT) imaging scans and to characterize the clinical implications of misleading findings. Materials and Methods: This case-control retrospective study compared the final histological outcomes of patients with "negative" pre-RP PSMA PET/CT prostate scans (with a prostate maximal standardized uptake value [SUVmax] below the physiologic uptake) to those with an "intense" prostatic tracer uptake (with a SUVmax above the physiologic uptake). The patients underwent an RP between March 2015 and July 2019 in five academic centers. Data on the demographics, comorbidities, prostate-specific antigen (PSA) and rectal exam findings, prior biopsies, imaging results, biopsies, and RP histology results were collected. Results: Ninety-seven of the 392 patients who underwent an RP had PSMA PET/CT imaging preoperatively. Fifty-two (54%) had a "negative" uptake (in the study group), and 45 (46%) had a "positive" uptake (in the control group). Only the lesion size and SUVmax values on the PSMA PET/CT differed between the groups preoperatively. On the histological analysis, only the ISUP score, seminal vesicles invasion, T stage, and positive margin rates differed between the groups (p < 0.05), while 50 (96%) study group patients harbored clinically significant disease (ISUP ≥ 2), with an extra-prostatic disease in 24 (46%), perineural invasion in 35 (67%), and positive lymph nodes in 4 (8%). Conclusions: Disease aggressiveness generally correlated with an intense PSMA uptake on the preoperative PSMA PET/CT, but a subpopulation of patients with clinically significant cancer and aggressive characteristics showed a deceptively weak PSMA uptake. These data raise a concern about the unqualified application of PSMA PET/CT for staging RP candidates.

Data Empowerment of Decision-Makers in an Era of a Pandemic: Intersection of "Classic" and Artificial Intelligence in the Service of Medicine.

BACKGROUND: The COVID-19 outbreak required prompt action by health authorities around the world in response to a novel threat. With enormous amounts of information originating in sources with uncertain degree of validation and accuracy, it is essential to provide executive-level decision-makers with the most actionable, pertinent, and updated data analysis to enable them to adapt their strategy swiftly and competently. OBJECTIVE: We report here the origination of a COVID-19 dedicated response in the Israel Defense Forces with the assembly of an operational Data Center for the Campaign against Coronavirus. METHODS: Spearheaded by directors with clinical, operational, and data analytics orientation, a multidisciplinary team utilized existing and newly developed platforms to collect and analyze large amounts of information on an individual level in the context of SARS-CoV-2 contraction and infection. RESULTS: Nearly 300,000 responses to daily questionnaires were recorded and were merged with other data sets to form a unified data lake. By using basic as well as advanced analytic tools ranging from simple aggregation and display of trends to data science application, we provided commanders and clinicians with access to trusted, accurate, and personalized information and tools that were designed to foster operational changes and mitigate the propagation of the pandemic. The developed tools aided in the in the identification of high-risk individuals for severe disease and resulted in a 30% decline in their attendance to their units. Moreover, the queue for laboratory examination for COVID-19 was optimized using a predictive model and resulted in a high true-positive rate of 20%, which is more than twice as high as the baseline rate (2.28%, 95% CI 1.63%-3.19%). CONCLUSIONS: In times of ambiguity and uncertainty, along with an unprecedented flux of information, health organizations may find multidisciplinary teams working to provide intelligence from diverse and rich data a key factor in providing executives relevant and actionable support for decision-making.

Assessing rectal temperature with a novel non-invasive sensor.

Athletes, soldiers, and workers who perform intense physical activities under extreme hot conditions might encounter increased physiological thermal strain. Consequently, the increase in body core temperature (Tc) might result in heat exhaustion and heatstroke. Thus, continuously following changes in Tc is of utmost importance. Recently, the Tcore sensor (Dräger, Germany), which employs a unique dual-sensor heat flux technology, became commercially available to measure Tc, in a hospital-controlled environment. This study aimed to evaluate the possibility of using the Tcore sensor to accurately monitor rectal temperature (Tre), reflecting Tc, under exercise-heat stress. Thirteen healthy young males completed the study protocol, consisting of 90 min of moderate exercise (walking on a treadmill - 5 km/h, 4% elevation) under controlled hot/dry and hot/wet climatic conditions (30 °C/60% rh, 34 °C/40% rh, and 40 °C/40% rh). Tcore sensors were placed on the forehead and the left wrist. Temperatures from both Tcore sensors were recorded continuously together with Tre using a rectal thermistor. The original algorithm used by the company to estimate Tre from the Tcore sensor was found to be inadequate under the study's conditions and new models for the forehead and the wrist measurements were developed. Nearly 150,000 measurement sets (after filtering) were used to build independent MATLAB software algorithms and test their reliability according to the cross-validation algorithm. Bland-Altman analysis was used to compare between the results obtained by the new models to Tre. The database consisted of a large Tre range (36.5-38.9 °C). The mean errors of the models were close to zero, and the mean absolute errors were 0.20 ± 0.16 °C and 0.27 ± 0.20 °C for the forehead and wrist, respectively. 95% of the measurements from the forehead model and 86% from the wrist model were within ±0.5 °C of Tre, and 78% (forehead) and 64% (wrist) were within ±0.3 °C. Root Mean Square Deviation (RMSD) values were 0.29 °C and 0.40 °C for the forehead and wrist models, respectively. The developed models show the feasibility to use the Tcore sensor for assessing Tre under exercise-heat conditions. Furthermore, the sensor was found to be adequate for use on the wrist as well, which might be more practical for use in field conditions.

Outcomes of descemet stripping automated endothelial keratoplasty in patients with an anterior chamber versus posterior chamber intraocular lens.

PURPOSE: The aim of this study was to assess the implications of a retained anterior chamber intraocular lens (ACIOL) during Descemet stripping automated endothelial keratoplasty (DSAEK) and to compare the outcomes in this group with those in patients who underwent DSAEK and had a posterior chamber intraocular lens (PCIOL). METHODS: This is a retrospective cohort study conducted in a tertiary medical center, which compares patients who underwent DSAEK and had a retained ACIOL with patients who underwent DSAEK and had a PCIOL regarding operative and postoperative complications, visual acuity, endothelial cell density, and long-term graft survival. RESULTS: Eleven eyes with an ACIOL and 50 eyes with a PCIOL met the study criteria. No significant differences were found between the groups in terms of operative complications, change in visual acuity, graft survival, and endothelial cell loss. CONCLUSIONS: DSAEK in the setting of an ACIOL produced similar results to those of uncomplicated PCIOL cases. Although further studies are needed to gain more accurate information on this subject, it seems that DSAEK can be performed while retaining an ACIOL with favorable results.