The Gender Gap in Promotions: Inhibitors and Catalysts, Strategies to Close the Gap.

The gender gap is an amalgam of gender disparity issues in the workplace ranging from fewer opportunities to network, decreased funding for research, microaggressions, nebulous promotional criteria and difficulty achieving the perception of professionalism because of inherent gender bias. Contributing home factors include more substantial household duties for women typically, spouses who also have a career, and the inherent delay associated with maternity leave for those who choose to have children. This article subdivides gender disparity that impedes promotion into experiences inside and outside the workplace. Disparities within the workplace are divided into directly quantified versus qualitative differences.

Medical Assistance in Dying and Palliative Care: Shared Trajectories.

Medical Assistance in Dying (MAID) and palliative care often have an antagonistic relationship in jurisdictions where both are legal, but the early ethical and legal history of palliative care closely mirrors that of MAID in important ways. Palliative practices that are commonplace today were considered homicide or "medically assisted death" in most jurisdictions until quite recently. Moreover, while many patients request MAID today for reasons that are criticized as "ableist," the same rationale is accepted without comment or judgment when used to justify withdrawal of life support or a discontinuation of life-prolonging therapies. Concerns about factors that undermine autonomous decisions for MAID would apply equally to routine palliative care practices. By the same token, palliative care exists because no field in medicine is able to fix every problem it encounters. It is ironic, therefore, that some palliative care providers oppose MAID with the hubristic argument that we can relieve all forms of suffering. Palliative care providers may choose not to participate in MAID, but palliative care and MAID do not have to be mutually exclusive and are often complementary and synergistic for patients and families.

Medical Assistance in Dying, Palliative Care, Safety, and Structural Vulnerability.

As more jurisdictions consider legalizing medical assistance in dying or assisted death (AD), there is an ongoing debate about whether AD is driven by socioeconomic deprivation or inadequate supportive services. Attention has shifted away from population studies that refute this narrative, and focused on individual cases reported in the media that would appear to support these concerns. In this editorial, the authors address these concerns using recent experience in Canada, and argue that even if we accept these stories at face value, the logical policy response would be to address the root causes of structural vulnerability rather than attempt to restrict access to AD. In terms of concerns about safety, the authors go on to point out the parallels between media reports about the misuse of AD and reports of wrongful deaths due to the misuse of palliative care (PC) in jurisdictions where AD was not legal. Ultimately, we cannot justify having a different response to these reports when they apply to AD instead of PC, and nobody has argued that PC should be criminalized in response to such reports. If we are skeptical of the oversight mechanisms used for AD in Canada, we must be equally skeptical of the oversight mechanisms used for end-of-life care in every jurisdiction where AD is not legal, and ask whether prohibiting AD protects the lives of the vulnerable any better than legalization of AD with safeguards.

Male infertility and the human microbiome.

The historical belief in urology was that the genitourinary system should be sterile in a normal, healthy, asymptomatic adult. This idea was perpetuated for decades until research revealed a diverse microbiota existing in human anatomical niches that contributed to both human health and disease processes. In recent years, the search for an etiology and modifiable risk factors in infertility has turned to the human microbiome as well. Changes in the human gut microbiome have been associated with changes in systemic sex hormones and spermatogenesis. Certain microbial species are associated with higher levels of oxidative stress, which may contribute to an environment higher in oxidative reactive potential. Studies have demonstrated a link between increased oxidative reactive potential and abnormal semen parameters in infertile men. It has also been hypothesized that antioxidant probiotics may be able to correct an imbalance in the oxidative environment and improve male fertility, with promising results in small studies. Further, the sexual partner's microbiome may play a role as well; studies have demonstrated an overlap in the genitourinary microbiomes in sexually active couples that become more similar after intercourse. While the potential applications of the microbiome to male fertility is exciting, there is a need for larger studies with uniform microbial sequencing procedures to further expand this topic.

Emerging Issues on Tropane Alkaloid Contamination of Food in Europe.

The occurrence of tropane alkaloids (TAs), toxic plant metabolites, in food in Europe was studied to identify those TAs in food most relevant for human health. Information was extracted from the literature and the 2016 study from the European Food Safety Authority. Calystegines were identified as being inherent TAs in foods common in Europe, such as Solanum tuberosum (potato), S. melongena (eggplant, aubergine), Capsicum annuum (bell pepper) and Brassica oleracea (broccoli, Brussels sprouts). In addition, some low-molecular-weight tropanes and Convolvulaceae-type TAs were found inherent to bell pepper. On the other hand, atropine, scopolamine, convolvine, pseudotropine and tropine were identified as emerging TAs resulting from the presence of associated weeds in food. The most relevant food products in this respect are unprocessed and processed cereal-based foods for infants, young children or adults, dry (herbal) teas and canned or frozen vegetables. Overall, the occurrence data on both inherent as well as on associated TAs in foods are still scarce, highlighting the need for monitoring data. It also indicates the urge for food safety authorities to work with farmers, plant breeders and food business operators to prevent the spreading of invasive weeds and to increase awareness.

Histologic Analysis of Buccal Graft Quality Stratified by Tobacco Use in Patients Undergoing Substitution Urethroplasty.

OBJECTIVE: To determine if there are histologic differences relative to tobacco exposure in buccal mucosa. Substitution urethroplasty outcomes may be worse in tobacco users and we investigate if the buccal graft is inherently damaged due to chronic tobacco exposure. METHODS: Subjects undergoing substitution urethroplasty with buccal graft harvest were prospectively consented in this IRB approved study. Subjects with poor dentition were excluded. A detailed tobacco use history was obtained. Cotinine testing was performed day of surgery to confirm or exclude active tobacco use. Trimmed portions of harvested graft were sent for tissue processing. Standard hematoxylin and eosin staining was performed. A single blinded pathologist performed analysis of the slides. Using a scale of none, mild, moderate, or severe slides were analyzed for cytologic atypia, architectural complexity, inflammation, and keratinization. Evidence of vascular damage was noted and the type of inflammation if present was classified. RESULTS: Twenty-five buccal grafts were analyzed. No evidence of vascular damage or cytologic atypia were noted in any grafts. While mild architectural complexity and mild inflammation, typically lymphocytic, were noted in several of the buccal mucosa sections, this did not appear to correlate with tobacco exposure. The majority of grafts demonstrating increased keratinization correlated with significant tobacco exposure, but this was not consistently noted in all those with tobacco use. CONCLUSIONS: Buccal mucosa in patients with tobacco exposure did not show significant histologic alterations. Outcomes of substitution urethroplasty may be more impacted by persistent systemic exposure causing local ischemia as opposed to the graft tissue itself.

The pandemic and the delivery of palliative care and MAiD: What was the impact?

COVID-19 changed healthcare forever. But behind the headlines and news coverage of the emergency rooms and intensive care units, another quieter battle raged on. Within the field of palliative care, the ill and vulnerable were suffering greater distress and their clinicians were struggling to provide care.

Women in Academic Urology: A Qualitative Analysis of the Relationship Between Pregnancy, Parenting, and Delayed Promotion.

OBJECTIVE: To determine the role that the burden of childbearing, including pregnancy and maternity leave, plays in academic promotion for women in urology, which has been shown to be delayed as compared to their male counterparts. METHODS: Female academic urologists of varying academic rank who have children were invited to participate in a semistructured interview. A representative sample from multiple subspecialties and geographic locations were targeted. Topics addressed included pregnancy, maternity leave, parenting, and promotion in academic urology. Transcripts of the interview were analyzed using grounded theory methodology. RESULTS: Eleven participants were interviewed, including 3 assistant, 5 associate, and 3 full professors. The majority of participants chose to time pregnancy with training either during less strenuous portions or avoiding residency altogether. Nearly half endorsed self-inflicted hardships during pregnancy or early postpartum to prevent inconveniencing colleagues or to "pull their weight" in accordance with surgical culture. Outsourcing of childcare and household duties, along with spousal support, were discussed as contributing to success. Lack of transparency for promotional criteria was identified as a significant obstacle to promotion. Sponsorship and self-motivated information gathering were identified as critical components to success in promotion. CONCLUSION: A culture of support created by administration and colleagues is critical for a positive experience with childbearing, and return to clinical practice or training postpartum. Explicit promotional criteria that are accessible in early career development and sponsorship from members of the academic department or subspecialty community are crucial for all urologists, but for women in particular.

Development of learning objectives for a medical assistance in dying curriculum for Family Medicine Residency.

BACKGROUND: Medical assistance in dying (MAID) became legal across Canada when Bill C-14 was passed in 2016. Currently, little is known about the most effective strategies for providing MAID education, and the importance of integrating MAID into existing curricula. In this study, a set of learning objectives (LOs) was developed to inform a foundational MAID curriculum in Canadian Family Medicine (FM) residency training programs. METHODS: Mixed methods were used to develop LOs based on a published needs assessment from a large, four-site family medicine residency program in southeastern Ontario. Draft LOs were evaluated and revised by faculty and resident leaders using a modified Delphi process and a focus group. LOs were mapped to the existing family medicine residency curriculum, as well as the College of Family Physicians of Canada's Priority Topics. RESULTS: Nine LOs were developed to provide a foundational education regarding MAID. While all LOs could be mapped to the Domains of Clinical Care within the departmental curriculum, they mapped inconsistently to departmental Entrustable Professional Activities and the Priority Topics. LOs focused on patient education and identification of patient goals were most readily mapped to existing curricular framework, while LOs with MAID-exclusive content revealed gaps in the current curriculum. CONCLUSIONS: The developed LOs provide a guide to ensure family medicine residents obtain generalist-level knowledge to counsel their patients about MAID. These LOs can serve as a model for developing LOs for both family medicine and specialist residency programs in Canada and in countries where MAID is legal.

Multi-institutional review of non-hypospadiac penile urethral stricture management and outcomes.

OBJECTIVES: Penile urethral stricture disease not associated with hypospadias is rare, and there is a wide range of commonly used surgical repair techniques for this disease. We sought to compile a multi-institutional database of patients who had surgical correction of strictures in the penile urethra not limited to the meatus, and who had no history of hypospadias, for analysis using the Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology classification system. METHODS: A retrospective database from 13 institutions was compiled of patients who had undergone surgical correction of Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology urethral stricture segments S2b/S2c and excluding E5, with a minimum follow-up time of 4 months. Failure was defined as cystoscopically confirmed recurrence of a stricture measuring less than 16-Fr. RESULTS: We analyzed 222 patients with a median age of 57 years and a follow-up of 49 months. The overall surgical success rate was 80.2%. On multivariate analysis, the two variables identified that were predictive of surgical success were stricture length ≤2 cm as well as use of a buccal mucosa graft as compared to use of a fasciocutaneous flap, which had success rates of 83% and 52%, respectively (P = 0.0004). No statistically significant differences were found based on incisional approach or surgical technique, nor were outcomes different based on etiology or preoperative patient demographics. CONCLUSIONS: Surgical repair of penile urethral strictures of non-hypospadiac origin have a favorable overall success rate, at 80.2%. Regardless of incisional approach or surgical technique, all operations appear to have similar outcomes other than repairs using fasciocutaneous flap, which were statistically less successful than those using buccal mucosa graft.

Surgical Preparation by Urology Trainees in 2021: The Interplay of Video and Print Resources.

INTRODUCTION: We investigate urology trainee preparation for surgical procedures by querying type and degree of video sources used and combination with traditional print materials for preparation of surgical procedures. METHODS: An Institutional Review Board-approved 13-question REDCap® survey was distributed to 145 American College of Graduate Medical Education-accredited urology residency programs. Social media were also used to recruit participants. Results were collected anonymously and analyzed using Excel®. RESULTS: A total of 108 residents completed the survey. The majority (87%) reported using videos for surgical preparation including, YouTube (93%), American Urological Association (AUA) Core Curriculum videos (84%) and institutional or attending-specific videos (46%). Video selection was based on quality (81%), length (58%) and the site of video creation (37%). Video preparation was reported predominantly for minimally invasive surgery (95%), subspecialty procedures (81%) and open procedures (75%). The most common print sources reported include Hinman's Atlas of Urologic Surgery (90%), Campbell-Walsh-Wein Urology (75%) and the AUA Core Curriculum (70%). When asked to rank their overall top 3 sources, 25% of residents reported YouTube as their primary source and 58% included it in their top 3. Only 24% of residents reported being aware of the AUA YouTube channel, while 77% were aware of the video section of the AUA Core Curriculum. CONCLUSIONS: Urology residents use video resources to prepare for surgical cases, with a heavy reliance on YouTube. AUA-curated video sources should be highlighted in the resident curriculum as the quality and educational content of YouTube videos are variable.

Long-term Safety and Efficacy of Mexiletine in Myotonic Dystrophy Types 1 and 2.

BACKGROUND AND OBJECTIVE: Myotonic dystrophy types 1 and 2 are progressive multisystem genetic disorders whose core clinical feature is myotonia. Mexiletine, an antagonist of voltage-gated sodium channels, is a recommended antimyotonic agent in the nondystrophic myotonias, but its use in myotonic dystrophy is limited because of lack of data regarding its long-term efficacy and safety profile. METHODS: To address this issue, this study retrospectively evaluated patients with myotonic dystrophy receiving mexiletine over a mean time period of 32.9 months (range 0.1-216 months). RESULTS: This study demonstrated that 96% of patients reported some improvement in myotonia symptoms with mexiletine treatment. No clinically relevant cardiac adverse events were associated with the long-term use of mexiletine. CONCLUSIONS: These findings support that mexiletine is both safe and effective when used long-term in myotonic dystrophy. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that mexiletine is a well-tolerated and effective treatment for myotonic dystrophy types 1 and 2.

Physiology of Erection and Pathophysiology of Erectile Dysfunction.

The science of penile erection, including recent advances in its molecular physiology and neuroanatomic pathways, is described. The pathophysiology of erectile dysfunction is presented, acknowledging associated disease states, and accordingly follows a practical classification scheme: vasculogenic, neurogenic, endocrine, and psychogenic.