Marketing yourself in social media as a global health organization: lessons to be learned.

PURPOSE: To evaluate whether X, formerly known as Twitter, is being used effectively to advance the goals of International Volunteers in Urology (IVUmed). How is X activity associated with end-user engagement? METHODS: Monthly analytics of the X account @IVUmed were reviewed between September 2014 and November 2022 using https://analytics.twitter.com/ . Outcomes included tweets, mentions, impressions, engagements, interactions, followers, and profile visits. Statistical analysis using Mann-Whitney U test and Spearman's rank-order correlation was performed. Top tweet content between December 2020 and November 2022 was also analyzed and assigned one of seven different categories: research, workshops, mission statement, educational materials, fundraising, individual spotlight, and other. RESULTS: Of @IVUmed's 1668 followers, 1334 (80.0%) were individuals. One thousand one hundred twenty-six (84.4%) individuals listed their locations with the majority (79.8%) residing in high-income countries. Tweet impressions have increased over time; they were significantly higher (p < 0.01) on average after the onset of COVID-19 in March 2020. From December 2020 to November 2022, new followers were positively correlated with tweet impressions (p < 0.01), total mentions (p < 0.01), and profile visits (p < 0.01). Profile visits were positively correlated with total tweets (p < 0.01). The content categories for monthly top tweets that proportionally garnered the most engagements were workshops (50%) and individual spotlight (29%), despite not being the most tweeted about content categories. CONCLUSION: Non-profit organizations wishing to increase their web-based outreach can benefit from increased primary X activity. While not evaluated in this study, it may also improve fundraising capabilities. Nevertheless, periodic review of account activity is important to ensure engagement of the targeted audience.

First Series Using Ultrasonic Propulsion and Burst Wave Lithotripsy to Treat Ureteral Stones.

PURPOSE: Our goal was to test transcutaneous focused ultrasound in the form of ultrasonic propulsion and burst wave lithotripsy to reposition ureteral stones and facilitate passage in awake subjects. MATERIALS AND METHODS: Adult subjects with a diagnosed proximal or distal ureteral stone were prospectively recruited. Ultrasonic propulsion alone or with burst wave lithotripsy was administered by a handheld transducer to awake, unanesthetized subjects. Efficacy outcomes included stone motion, stone passage, and pain relief. Safety outcome was the reporting of associated anticipated or adverse events. RESULTS: Twenty-nine subjects received either ultrasonic propulsion alone (n = 16) or with burst wave lithotripsy bursts (n = 13), and stone motion was observed in 19 (66%). The stone passed in 18 (86%) of the 21 distal ureteral stone cases with at least 2 weeks follow-up in an average of 3.9±4.9 days post-procedure. Fragmentation was observed in 7 of the burst wave lithotripsy cases. All subjects tolerated the procedure with average pain scores (0-10) dropping from 2.1±2.3 to 1.6±2.0 (P = .03). Anticipated events were limited to hematuria on initial urination post-procedure and mild pain. In total, 7 subjects had associated discomfort with only 2.2% (18 of 820) propulsion bursts. CONCLUSIONS: This study supports the efficacy and safety of using ultrasonic propulsion and burst wave lithotripsy in awake subjects to reposition and break ureteral stones to relieve pain and facilitate passage.

Fragmentation of Stones by Burst Wave Lithotripsy in the First 19 Humans.

PURPOSE: We report stone comminution in the first 19 human subjects by burst wave lithotripsy (BWL), which is the transcutaneous application of focused, cyclic ultrasound pulses. MATERIALS AND METHODS: This was a prospective multi-institutional feasibility study recruiting subjects undergoing clinical ureteroscopy (URS) for at least 1 stone ≤12 mm as measured on computerized tomography. During the planned URS, either before or after ureteroscope insertion, BWL was administered with a handheld transducer, and any stone fragmentation and tissue injury were observed. Up to 3 stones per subject were targeted, each for a maximum of 10 minutes. The primary effectiveness outcome was the volume percent comminution of the stone into fragments ≤2 mm. The primary safety outcome was the independent, blinded visual scoring of tissue injury from the URS video. RESULTS: Overall, median stone comminution was 90% (IQR 20, 100) of stone volume with 21 of 23 (91%) stones fragmented. Complete fragmentation (all fragments ≤2 mm) within 10 minutes of BWL occurred in 9 of 23 stones (39%). Of the 6 least comminuted stones, likely causative factors for decreased effectiveness included stones that were larger than the BWL beamwidth, smaller than the BWL wavelength or the introduction of air bubbles from the ureteroscope. Mild reddening of the papilla and hematuria emanating from the papilla were observed ureteroscopically. CONCLUSIONS: The first study of BWL in human subjects resulted in a median of 90% comminution of the total stone volume into fragments ≤2 mm within 10 minutes of BWL exposure with only mild tissue injury.

Surgical Trends in Nephrolithiasis: Increasing De Novo Renal Access by Urologists for Percutaneous Nephrolithotomy.

Purpose: Percutaneous nephrolithotomy (PCNL) has wide variability in the methods of renal access. In many centers, this is done as a separate nephrostomy procedure by interventional radiology, while other urologists gain initial access themselves during the PCNL. We aimed to characterize these trends to confirm the need for continued training in this aspect of PCNL. Methods: Using MarketScan insurance claims, we examined surgical volume for ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL), and PCNL during 2007-2017. For PCNL, current procedural terminology (CPT) codes were used to identify the provider performing the de novo renal access over time. We stratified postoperative outcomes for PCNL by provider type. Results: From 2007 to 2017, the annual proportion of PCNL procedures peaked at 4.5%, with a recent decline in 2016 and 2017 to 3.2%. URS steadily increased from 46.3% to 60.0% of procedures, and SWL mirrored that change with a decrease from 50.0% to 36.7%. Within 19,743 PCNLs, there was a notable increase from 12.8% to 32.3% in the number of procedures with urologists performing de novo renal access. Most cases (40.0%) still had a de novo access code assigned to a radiologist. Length-of-stay, readmission, transfusion, and secondary stone procedure rates were higher in the radiologist-gained access PCNLs. Conclusions: URS has surpassed SWL as the most common stone procedure. While the proportion of PCNLs has remained fairly stable over the last decade, urologists obtaining their own de novo access have increased substantially. Continued outreach efforts focused on urologist-obtained access may further increase this proportion and improve outcomes for PCNL.

Ultrasound-guided Morcellation During Difficult Holmium Laser Enucleation of the Prostate.

OBJECTIVE: To demonstrate how bladder ultrasound can be useful in completing morcellation during difficult Holmium Laser Enucleation of the Prostate (HoLEP). As HoLEP has emerged as a standard of care for the treatment of benign prostatic hyperplasia, multiple studies have reported the potentially catastrophic complication of bladder injury during morcellation. This video aims to assist any urologist performing HoLEP by providing step-by-step instruction for using ultrasound to complete morcellation safely. METHODS: Enucleation is performed using a 26-French continuous flow scope, off-set laser bridge with a laser stabilization catheter, and a 550 µm holmium laser fiber. Once the median and lateral lobes have been enucleated, the outer sheath is removed and the nephroscope is inserted to facilitate morcellation. Under dual inflow irrigation, the Piranha morcellator (Richard Wolf, Knittlingen, Germany) is introduced and set to the manufacturer's recommended settings of 1500 rpm. A 3.5-MHz convex abdominal ultrasound transducer (Hitachi Prosound Alpha 7; Hitachi Aloka Medical America, Wallingford, CT) under B-mode is used to visualize the bladder, predominantly in the sagittal orientation. Morcellation proceeds under simultaneous ultrasound and direct cystoscopic guidance. RESULTS: The distended bladder is visualized concurrently with the ultrasound and via the nephroscope as the Piranha engages the adenoma and begins morcellation. Once the adenoma is engaged, the operator then drops their hands to place the morcellator in the center of the bladder. Ultrasound provides real-time feedback as to the location of the morcellator in relation to the adenoma and bladder. CONCLUSION: This video highlights the use of intraoperative bladder ultrasound as a visual aid to assist during the morcellation portion of HoLEP. This proof of concept demonstrates that ultrasound can be an additional tool to utilize during difficult cases when cystoscopic visualization during morcellation is limited.

Ultrasound-guided Access and Dilation for Percutaneous Nephrolithotomy in the Supine Position: A Step-by-Step Approach.

INTRODUCTION: Ultrasound guidance for percutaneous nephrolithotomy (PCNL) has gained acceptance amongst urologists given its numerous advantages over fluoroscopy. While traditionally performed in the prone position, this video demonstrates a step-by-step approach to performing PCNL in the supine position, solely under ultrasound guidance. MATERIALS AND METHODS: Once in the modified supine (Galdakao-modified Valdivia) position, important anatomic landmarks are identified. It is important to first orient the ultrasound probe such that its cranial side corresponds to the left of the ultrasound screen. After optimizing a target calyx, keeping the needle in the imaging plane of the probe facilitates renal access. Tract dilation under ultrasound guidance is then achieved by keeping the wire and dilators in the same imaging plane. RESULTS: The 11th and 12th ribs, paraspinous muscle, iliac crest, midaxillary line, and costal margin are the anatomic landmarks that orient the probe to the location of the kidney. Placing the ultrasound probe in the midaxillary line, parallel to the 11th rib allows the operator to identify key renal landmarks: the renal cortex, peri-pelvic fat, collecting system, kidney stone with its associated postacoustic shadow, and the intended target calyx. Controlling the needle is easiest in the longitudinal view, as the needle can be visualized from skin to target. Dilation under ultrasound relies on keeping the wire in view. The tip of the 10-French dilator is based on the location where the wire image disappears as the dilator advances. The balloon dilator tip is visualized on ultrasound reaching the appropriate depth just inside the collecting system, at which time balloon inflation results in complete dilation of the tract. CONCLUSIONS: This video provides a step-by-step approach demonstrating that PCNL can be performed in the supine position using only ultrasound-guidance. This approach facilitates renal access in this position and obviates the need for radiation exposure.

Ultrasound-Guided Morcellation During Holmium Laser Enucleation of the Prostate.

Background: Holmium laser enucleation of the prostate (HoLEP) has emerged as an accepted standard of care for the treatment of benign prostatic hyperplasia. This surgery relies on morcellation of the prostate adenoma once enucleation of the transition zone has been completed. Caution is required during this portion of the operation, as engaging bladder mucosa within the morcellator can result in bladder injury, a rare but potentially catastrophic complication of HoLEP. Morcellation of the prostatic tissue can be additionally challenging if visualization is poor from either equipment failure or increased bleeding from a highly vascularized prostate. Case Presentation: We report the case of a 66-year-old Caucasian man with an estimated 158 g prostate who underwent HoLEP at our institution. Enucleation was uneventful; however, upon placement of the nephroscope to begin morcellation, it was immediately evident that the lens of the nephroscope was damaged as there was extremely poor visualization. Without a replacement nephroscope available, this would have normally resulted in aborting the case and returning another day to complete the morcellation. Concurrent bladder ultrasonography was performed and allowed for additional visual feedback to the operator, helping guide the morcellator to safely engage the enucleated adenoma and complete the operation. Conclusion: This case report demonstrates the ability of performing the morcellation portion of HoLEP mainly with the visualization provided by concurrent bladder ultrasonography. By providing additional imaging feedback to the operator, ultrasound can be a complementary tool to assist in safely performing morcellation in situations of suboptimal cystoscopic visualization during HoLEP.

Emergency Department Imaging Modality Effect on Surgical Management of Nephrolithiasis: A Multicenter, Randomized Clinical Trial.

PURPOSE: In the emergency department ultrasonography is emerging as an alternative to computerized tomography for diagnosing patients with nephrolithiasis. In this multicenter randomized clinical trial we examined rates of urological referral and intervention to elucidate whether the initial diagnostic imaging modality affected the management of nephrolithiasis. MATERIALS AND METHODS: Patients 18 to 76 years old who presented to the emergency department with renal colic across 15 diverse treatment centers were randomized to receive abdominal ultrasonography by an emergency department physician or a radiologist, or abdominal computerized tomography. We analyzed the 90-day followup for patients diagnosed with nephrolithiasis to assess subsequent urological evaluation, procedure type and time to intervention. RESULTS: Of 1,666 patients diagnosed with nephrolithiasis in the emergency department 241 (14.5%) had a consultation with urology at initial presentation, 503 (30%) saw a urologist in followup and 192 (12%) underwent at least 1 urological procedure. Median time to outpatient procedure and type of procedure performed did not vary significantly among imaging groups. Most patients (78%) had computerized tomography performed before elective intervention. Patients with ultrasonography performed by an emergency department physician were 2.6 times more likely to undergo computerized tomography before intervention than those who had ultrasonography performed by a radiologist. CONCLUSIONS: Patients undergoing a urological intervention who had ultrasonography as initial imaging do not experience a significant delay to intervention or different procedure types, but the majority ultimately undergoes computerized tomography before surgery. Formal ultrasonography by a radiologist may encourage less computerized tomography preoperatively.

Surgical outcomes and cultural perceptions in international hypospadias care.

PURPOSE: This study was designed to assess perceptions of untreated hypospadias and quality of life in culturally disparate low or middle income countries, to highlight the demographic and care differences of patient groups treated for hypospadias in the surgical workshop context, and to evaluate the long-term outcomes achieved by these workshop groups. MATERIALS AND METHODS: Family member perceptions of hypospadias, perioperative process measures and urethrocutaneous fistula rates were compared between 60 patients from Vietnam and Senegal treated for hypospadias through training workshops by local surgeons and pediatric urologists from the U.S. between 2009 and 2012, of whom approximately 42% had previously undergone repair attempts. RESULTS: More than 90% of respondents surveyed believed that untreated hypospadias would affect the future of their child at least to some degree. Patient cohorts between the 2 sites differed from each other and published high income country cohorts regarding age, weight for age and frequency of reoperation. Telephone based outcomes assessment achieved an 80% response rate. Urethrocutaneous fistula was reported in 39% and 47% of patients in Vietnam and Senegal, respectively. CONCLUSIONS: Family members perceived that the social consequences of untreated hypospadias would be severe. Relative to patient cohorts reported in practices of high income countries, our patients were older, presented with more severe defects, required more reoperations and were often undernourished. Urethrocutaneous fistula rates were higher in cohorts from low or middle income countries relative to published rates for cohorts from high income countries. Our study suggests that outcomes measurement is a feasible and essential component of ethical international health care delivery and improvement.

Obstructed labor and caesarean delivery: the cost and benefit of surgical intervention.

BACKGROUND: Although advances in the reduction of maternal mortality have been made, up to 273,000 women will die this year from obstetric etiologies. Obstructed labor (OL), most commonly treated with Caesarean delivery, has been identified as a major contributor to global maternal morbidity and mortality. We used economic and epidemiological modeling to estimate the cost per disability-adjusted life-year (DALY) averted and benefit-cost ratio of treating OL with Caesarean delivery for 49 countries identified as providing an insufficient number of Caesarean deliveries to meet demand. METHODS AND FINDINGS: Using publicly available data and explicit economic assumptions, we estimated that the cost per DALY (3,0,0) averted for providing Caesarean delivery for OL ranged widely, from $251 per DALY averted in Madagascar to $3,462 in Oman. The median cost per DALY averted was $304. Benefit-cost ratios also varied, from 0.6 in Zimbabwe to 69.9 in Gabon. The median benefit-cost ratio calculated was 6.0. The main limitation of this study is an assumption that lack of surgical capacity is the main factor responsible for DALYs from OL. CONCLUSIONS: Using the World Health Organization's cost-effectiveness standards, investing in Caesarean delivery can be considered "highly cost-effective" for 48 of the 49 countries included in this study. Furthermore, in 46 of the 49 included countries, the benefit-cost ratio was greater than 1.0, implying that investment in Caesarean delivery is a viable economic proposition. While Caesarean delivery alone is not sufficient for combating OL, it is necessary, cost-effective by WHO standards, and ultimately economically favorable in the vast majority of countries included in this study.

Minor viral and host genetic polymorphisms can dramatically impact the biologic outcome of an epitope-specific CD8 T-cell response.

Human immunodeficiency virus-1 subtypes A and C differ in the highly conserved Gag-TL9 epitope at a single amino acid position. Similarly, the TL9 presenting human leukocyte antigen (HLA) class I molecules B42 and B81 differ only at 6 amino acid positions. Here, we addressed the influence of such minor viral and host genetic variation on the TL9-specific CD8 T-cell response. The clonotypic characteristics of CD8 T-cell populations elicited by subtype A or subtype C were distinct, and these responses differed substantially with respect to the recognition and selection of TL9 variants. Irrespective of the presenting HLA class I molecule, CD8 T-cell responses elicited by subtype C exhibited largely comparable TL9 variant cross-recognition properties, expressed T-cell receptors that used almost exclusively the TRBV 12-3 gene, and selected for predictable patterns of viral variation within TL9. In contrast, subtype A elicited TL9-specific CD8 T-cell populations with completely different, more diverse TCRBV genes and did not select for viral variants. Moreover, TL9 variant cross-recognition properties were extensive in B81(+) subjects but limited in B42(+) subjects. Thus, minor viral and host genetic polymorphisms can dramatically alter the immunologic and virologic outcome of an epitope-specific CD8 T-cell response.

Public clonotype usage identifies protective Gag-specific CD8+ T cell responses in SIV infection.

Despite the pressing need for an AIDS vaccine, the determinants of protective immunity to HIV remain concealed within the complexity of adaptive immune responses. We dissected immunodominant virus-specific CD8(+) T cell populations in Mamu-A*01(+) rhesus macaques with primary SIV infection to elucidate the hallmarks of effective immunity at the level of individual constituent clonotypes, which were identified according to the expression of distinct T cell receptors (TCRs). The number of public clonotypes, defined as those that expressed identical TCR beta-chain amino acid sequences and recurred in multiple individuals, contained within the acute phase CD8(+) T cell population specific for the biologically constrained Gag CM9 (CTPYDINQM; residues 181-189) epitope correlated negatively with the virus load set point. This independent molecular signature of protection was confirmed in a prospective vaccine trial, in which clonotype engagement was governed by the nature of the antigen rather than the context of exposure and public clonotype usage was associated with enhanced recognition of epitope variants. Thus, the pattern of antigen-specific clonotype recruitment within a protective CD8(+) T cell population is a prognostic indicator of vaccine efficacy and biological outcome in an AIDS virus infection.