Incidence and predictors of delays in starting fellowship training in urology.

INTRODUCTION: The completion of residency and start of fellowship training marks a critical transition for urologists in the pursuit of subspeciality training. Most graduating urology residents are under contract until June 30, and most fellowships are scheduled to begin on July 1. There has been no investigation into the practical implications of fellowship delays in urology from a trainee perspective. Our research study aimed to investigate the incidence and predictors of delays in fellowship starts. METHODS: Pediatric urology fellows that began their fellowship training between 2019 and 2023 and endourologic fellows that began their fellowship training between 2017 and 2022 were surveyed using SurveyMonkey®. A total of 250 endourology (EU) fellows and 90 pediatric urology (PU) fellows were contacted. RESULTS: A total of 26.0% and 14.3% of EU and PU fellows, respectively, experienced a delay in their training, despite many leaving their residency positions early (33.8% vs. 44.9%, p=0.2097); 11.7% and 8.2% of EU and PU fellows, respectively, experienced delays they reported to be "very stressful" and 9.1% and 4.1%, respectively, found them "somewhat stressful." Delays of 2-4 weeks were experienced by 5.2% and 6.1%, 4-6-week delays by 7.8% and 4.1%, and delays >6 weeks by 2.6% and 0% of EU and PU fellows, respectively (p=0.0007). CONCLUSIONS: Delays in fellowship training do occur at a notable rate, despite nearly half of urology fellows leaving their residency training positions early, with unclear impacts on patient care and resident colleague well-being. This research highlights the importance of fellowship programs considering delaying fellowship starts to mid-July or August, with support of the prior fellow cohorts.

Nephrolithiasis in two patients on iron chelation therapy: A case report.

Drug-induced nephrolithiasis can arise from insoluble components within medications or crystallization of metabolites due to changes in metabolism and urinary pH. The connection between drugs utilized for iron chelation therapy (ICT) and nephrolithiasis is not well understood. In this report, we describe two pediatric patients diagnosed with nephrolithiasis while undergoing treatment with the chelating agents deferasirox, deferiprone, and deferoxamine for iron overload secondary to repeat blood transfusion.

Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021.

OBJECTIVES: Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care. METHODS: Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables. RESULTS: Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79-0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8-96.3%), specificity of 20.0% (19.0-21.0%), negative likelihood ratio of 0.22 (0.19-0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points). CONCLUSION: Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.

A survey and panel discussion of the effects of the COVID-19 pandemic on paediatric urological productivity, guideline adherence and provider stress.

INTRODUCTION: The COVID-19 pandemic has led to an unprecedented need to re-organise and re-align priorities for all surgical specialties. Despite the current declining numbers globally, the direct effects of the pandemic on institutional practices and on personal stress and coping mechanisms remains unknown. The aims of this study were to assess the effect of the pandemic on daily scheduling and work balances, its effects on stress, and to determine compliance with guidelines and to assess whether quarantining has led to other areas of increased productivity. METHODS: A trans-Atlantic convenience sample of paediatric urologists was created in which panellists (Zoom) discussed the direct effects of the COVID-19 pandemic on individual units, as well as creating a questionnaire using a mini-Delphi method to provide current semi-quantitative data regarding practice, and adherence levels to recently published risk stratification guidelines. They also filled out a Perceived Stress Scale (PSS) questionnaire to assess contemporary pandemic stress levels. RESULTS: There was an 86% response rate from paediatric urologists. The majority of respondents reported near complete disruption to planned operations (70%), and trainee education (70%). They were also worried about the effects of altered home-lives on productivity (≤90%), as well as a lack of personal protective equipment (57%). The baseline stress rate was measured at a very high level (PSS) during the pandemic. Adherence to recent operative guidelines for urgent cases was 100%. CONCLUSION: This study represents a panel discussion of a number of practical implications for paediatric urologists, and is one of the few papers to assess more pragmatic effects and combines opinions from both sides of the Atlantic. The impact of the pandemic has been very significant for paediatric urologists and includes a decrease in the number of patients seen and operated on, decreased salary, increased self-reported stress levels, substantially increased telemedicine usage, increased free time for various activities, and good compliance with guidelines and hospital management decisions.

Early identification of an atypical case of type A dissection by transthoracic echocardiography by the emergency physician.

Thoracic aortic dissection is a lethal disease, and emergency department diagnosis is limited by imperfect diagnostic testing and limited resources;however, this case report illustrates the nonspecific presentation of thoracic aortic dissection and the use of emergency physician use of transthoracic echocardiography with the addition of suprasternal notch views to help differentiate all-cause chest pain and aid in accurate diagnosis,as well as earlier surgical correction for best patient outcomes in cases of thoracic aortic dissection.

A low cost, high fidelity nerve block model.

BACKGROUND: We have constructed a simple, inexpensive simulation model for ultrasound guided nerve blocks. To date there are no low cost, high fidelity models for nerve block simulations. The models that do exist are expensive and vaguely resemble actual anatomy. As ultrasound guided nerve blocks become more common in medical education it is essential to develop better training models to help increase the comfort level of the individual provider and increase the chances for success during live-patient procedures [Anaesth Intensive Care 37: 824-829, 2009]. METHODS: The nerve block model was produced with a single pork loin with pressure-injected ultrasound gel through both CAT 5 cable and IV tubing inserted length-wise into the pork loin. RESULTS: Our nerve block model had a realistic, life-like feel simulating human tissue. CONCLUSION: This ultrasound nerve block model was inexpensive with life-like feel allowing resident trainees to develop more confidence and tactile skill to increase the chance for success.

Acute pediatric stroke-what's the hurry? A case for emergency physician-performed echocardiography.

Acute ischemic stroke in a pediatric population is uncommon and has a different etiology from the adult population. We describe a case of acute ischemic stroke for which emergent, physician-sonographer­performed transthoracic echocardiography (TTE) changed his outcome.The patient in this case presented with left-sided hemiparesis,with subsequent CT Angiography (CTA) imaging and follow-on neurosurgical embolectomy for a proximal middle cerebral artery occlusion after which showed early recovery of muscular deficit. The cause ultimately was from an atrialmyxoma that was identified early by emergency physician-performed TTE and led to early resection possibly preventing recurrence of stroke.

Spontaneous retroperitoneal hemorrhage in a dialysis patient.

BACKGROUND: Patients with end-stage renal disease (ESRD) often present to the Emergency Department with a multitude of complaints. Abnormal vital signs and a chief complaint of pain can produce a diagnosis ranging from a cardiac etiology to an infectious source. OBJECTIVES: Our goal is to discuss a case in which an ESRD dialysis patient presented with a rare, life-threatening emergency. CASE REPORT: A 55-year-old man with ESRD presented with acute abdominal pain and hypotension caused by a spontaneous retroperitoneal hemorrhage. CONCLUSION: This case report demonstrates the necessity of having broad differential diagnoses when evaluating patients with ESRD.

Urologic findings on computed tomography of the abdomen and pelvis in a pediatric population.

OBJECTIVES: (1) Determine the number of urologic conditions diagnosed by computed tomography (CT) in children in the emergency department setting. (2) Identify which diagnoses were incidental. (3) Determine how often there was urologic follow-up by a local pediatric urologist. PATIENTS AND METHODS: We reviewed the charts and radiologist interpretations of all CT scans of the abdomen and pelvis performed within 2 days of admission via our emergency department from July 2007 to June 2009. Patients were included if the diagnosis was new. If a urologic finding was noted on final read, the CT was re-examined by one of our urologists to verify the finding. RESULTS: Among 2991 CT scans (one CT scan per patient), there were 213 (7%) new urologic findings: 124 were incidental; 144 patients (68% of patients with urologic findings) did not receive follow-up. Renal abnormalities were present in 127. The most common finding was renal cyst (69 patients). Ureteral abnormalities were present in 47. The most common ureteral finding was hydroureteronephrosis (40). Other anomalies identified included bladder (7) and scrotal (14) abnormalities, stones (13), and adrenal lesions (5). CONCLUSION: Many urologic diagnoses are revealed during CT scans of the abdomen and pelvis. The majority are cysts, hydroureteronephrosis, and pyelonephritis. Many incidental findings have also been revealed in the emergency department setting.

Evaluation of differential renal function and renographic patterns in patients with dietl crisis.

PURPOSE: We analyzed preoperative and postoperative differential renal function and characterized the renographic findings in patients with ureteropelvic junction obstruction associated with Dietl crisis. MATERIALS AND METHODS: Patients with Dietl crisis who underwent pyeloplasty between January 2004 and December 2010 were classified by renographic presentation. Patients in group 1 were diagnosed with cortical retention, those in group 2 had an initial obstructed scan (T1/2 of 20 minutes or more and no cortical retention) and those in group 3 had an initial nondiagnostic scan (T1/2 of less than 20 minutes and no cortical retention). Renographic parameters were used to analyze each group. RESULTS: A total of 59 patients met criteria for study inclusion. The 13 patients in group 1 demonstrated the most significant recovery of function after pyeloplasty (mean differential renal function change 13.59%). The 38 patients in group 2 exhibited a mean differential renal function change of 43.06% (range 20% to 54.6%) and mean preoperative T1/2 of 64.31 minutes. Pyeloplasty was performed in all 8 patients in group 3 based on subsequent diagnostic scan (4 patients) or increased hydronephrosis on other imaging associated with further symptomatic episodes (4). Initial renographic patterns noted in group 3 included biphasic curves, diminished clearance after 15 minutes upright or symptoms despite nonobstructive drainage. CONCLUSIONS: Interpretation of diuretic renography requires the assimilation of multiple parameters since patients with Dietl crisis can exhibit variability in renographic patterns due to the intermittent nature of ureteropelvic junction obstruction. Cortical retention represents a specific and pathognomic finding of acute ureteropelvic junction obstruction. With appropriate evaluation of these parameters, obstruction can be reliably diagnosed and appropriate surgical candidates chosen.

Salvage ureteral reimplantation after failure of dextranomer/hyaluronic acid injection.

PURPOSE: Ureteroneocystostomy after dextranomer/hyaluronic acid injection is reportedly associated with significantly more morbidity, and increased operative time, length of stay and postoperative obstruction. To evaluate our experience, we reviewed results of patients who underwent salvage ureteral reimplantation following failed dextranomer/hyaluronic acid injection. MATERIALS AND METHODS: We retrospectively reviewed charts of patients at a single institution who underwent intravesical ureteral reimplantation as salvage treatment following failed dextranomer/hyaluronic acid injection. Data points such as operative time, blood loss and length of stay were compared to those of controls undergoing de novo reimplantation by the same surgeons. Statistical analysis was performed using Student's t test and chi-square test. RESULTS: We identified 18 patients who underwent salvage reimplant. We compared data to an equal number of controls. Mean age (4.28 years in patients vs 3.34 years in controls, p = 0.62) and mean reflux grade at reimplant (3.15 vs 3.40, p = 0.97) were comparable between the groups. Operative time (128 vs 141.9 minutes, p = 0.14), blood loss (12.9 vs 11.9 ml, p = 0.71) and length of hospital stay (1.68 vs 1.3 days, p = 0.25) were not significantly different. No statistically significant differences were found regarding any of the compared variables. CONCLUSIONS: Ureteral reimplantation after dextranomer/hyaluronic acid injection is no more difficult than primary ureteral reimplantation regarding operative time, blood loss and length of hospital stay. These results support dextranomer/hyaluronic acid as initial operative treatment of vesicoureteral reflux when deemed appropriate and may further shift the paradigm of treatment away from prolonged medical management.

Testicular lymphoma: a case report.

This case report describes a 67-year-old man with testicular lymphoma. The typical symptom in patients when first seen with testicular lymphoma is a painless enlargement of the testicle. However, this patient had a long history of progressively worsening weakness in his right arm and leg, as well as a sudden onset of chest pain and dyspnea. Upon initial examination of this patient, a large mass was discovered in the scrotal and inguinal region on the right side. The patient subsequently underwent a right radical orchiectomy. When the diagnosis of lymphoma was confirmed, a proper chemotherapy regimen was initiated. This case report reviews the case, diagnosis, and management of testicular lymphoma.

Pentosan polysulfate (Elmiron): in vitro effects on prostate cancer cells regarding cell growth and vascular endothelial growth factor production.

BACKGROUND: Elmiron (ALZA Corp, Mountain View, CA) is the only Food and Drug Administration-approved oral therapy for interstitial cystitis. We hypothesized that Elmiron would affect the growth of prostate cancer in vitro. METHODS: Prostate cancer cell lines (LnCaP, PC3, and DU145) were treated with Elmiron. Cell viability was measured by MTT (3-4, 5-dimethylthiazol-2-yl-2,5-diphenyltetrazolium bromide), whereas vascular endothelial growth factor (VEGF) was measured by a commercial enzyme-linked immunosorbent assay. RESULTS: Inhibition of cell growth was observed in all cell lines tested. LnCaP exhibited a mean inhibition of 12% +/- 7% at 24 hours (P = .025) and 20% +/- 15% at 72 hours (P < .001). PC3 exhibited a mean inhibition of 26% +/- 13% at 24 hours (P < .001) and 44% +/- 5% at 72 hours (P < .001). DU145 exhibited a mean inhibition of 9% +/- 6% at 24 hours (P < .015) and 30% +/- 5% at 72 hours (P < .001). PC3 cells exhibited a significant reduction in VEGF levels (P < .001). CONCLUSIONS: The reductions in cell growth and VEGF indicate that Elmiron may act as an antiangiogenic agent and may have application in the treatment of prostate cancer.