Can the introduction of single-use flexible ureteroscopes increase the longevity of reusable flexible ureteroscopes at a high volume centre?

OBJECTIVES: To assess whether the introduction of single use flexibles ureteroscopes (su-fURS) at our high-volume centre had an advantageous impact on the turn-over and breakage rates of reusable fURS (re-fURS). METHODS: We analysed re-fURS number of usages and breakages at our centre between February 2015 and December 2018. We recorded the number of usages for analysed scope between the first usage until a breakage requiring reconditioning. Usage count was restarted following each reconditioning episode. Since su-fURS (Lithovue, Boston Scientific, USA) were introduced at our center in September 2016, we had the chance to compare different re-fURS life cycles according to both su-fURS availability and usage intensity (i.e., number of su-fURS used during each re-fURS life cycle). We then explored the relationship between su-fURS usage intensity and reusable scope survival (i.e., number of utilizations before any breakage requiring reconditioning) using locally weighted scatterplot smoothing (LOWESS) approach. RESULTS: Five different re-fURSs were employed at our centre, for a total of 1820 usages and 40 breakages requiring reconditioning. The overall mean (SD) number of usages before breaking was 40 (22). After su-fURS introduction, mean (SD) re-fURS number of usages increased from 35 (22) to 49 (20), (+ 40%, p = 0.02). The relationship between su-fURS usage intensity and reusable scopes survival showed a linear survival increase after 10 or more su-fURS scopes were used per life cycle. CONCLUSIONS: The life cycle of re-fURS increased by 40% after the introduction of su-fURS. Ten or more used su-fURS per life cycle were associated with increased re-fURS survival.

Operator-assisted vs self-achieved basketing during ureteroscopy: results from an in vitro preference study.

OBJECTIVES: A recently introduced device (LithoVue Empower™ or LE, Boston Scientifics, USA) allows the surgeon to directly control the stone-retrieving basket without the need of an assistant during flexible ureteroscopy. We aimed to evaluate the stone-retrieval performance of this device. METHODS: We used a bench-training model for flexible ureteroscopy, the Key-box (K-Box®, Porgès-Coloplast, France), to compare the LE configured with a 1.9F stone-retrieval tipless basket (ZeroTip™, Boston Scientific, USA) and a traditional assistant-maneuvered 1.9F stone-retrieval tipless basket. Seven experienced endo-urologists and seven residents-in-training retrieved a fake stone from three different renal cavities of the K-Box with increasing access complexity first with the traditional basket and then with the LE device. We recorded retrieval time and all the operators filled in the NASA Task Load Index (TLI) for the self-evaluation of their performance. We then compared the use of LE in terms of retrieval time, failure rates, and NASA-TLI scores. RESULTS: Stone retrieval times and failure rates were similar according to the retrieval technique, although residents had non-statistically significant shorter times with the LE. NASA-TLI scores revealed lower frustration (p = 0.03) when LE was used by experienced urologists as compared to the traditional basketing. When stratifying the analyses according to surgical experience, fully trained urologists performed faster stone retrieval and showed lower effort scores than residents-in-training (p < 0.05). CONCLUSIONS: The individually controlled retrieval system is an effective device assisting stone retrieval and does not necessitate specific training among experienced endo-urologists. Young residents might benefit from LE during their learning curve.

Single molecule sequencing and genome assembly of a clinical specimen of Loa loa, the causative agent of loiasis.

BACKGROUND: More than 20% of the world's population is at risk for infection by filarial nematodes and >180 million people worldwide are already infected. Along with infection comes significant morbidity that has a socioeconomic impact. The eight filarial nematodes that infect humans are Wuchereria bancrofti, Brugia malayi, Brugia timori, Onchocerca volvulus, Loa loa, Mansonella perstans, Mansonella streptocerca, and Mansonella ozzardi, of which three have published draft genome sequences. Since all have humans as the definitive host, standard avenues of research that rely on culturing and genetics have often not been possible. Therefore, genome sequencing provides an important window into understanding the biology of these parasites. The need for large amounts of high quality genomic DNA from homozygous, inbred lines; the availability of only short sequence reads from next-generation sequencing platforms at a reasonable expense; and the lack of random large insert libraries has limited our ability to generate high quality genome sequences for these parasites. However, the Pacific Biosciences single molecule, real-time sequencing platform holds great promise in reducing input amounts and generating sufficiently long sequences that bypass the need for large insert paired libraries. RESULTS: Here, we report on efforts to generate a more complete genome assembly for L. loa using genetically heterogeneous DNA isolated from a single clinical sample and sequenced on the Pacific Biosciences platform. To obtain the best assembly, numerous assemblers and sequencing datasets were analyzed, combined, and compared. Quiver-informed trimming of an assembly of only Pacific Biosciences reads by HGAP2 was selected as the final assembly of 96.4 Mbp in 2,250 contigs. This results in ~9% more of the genome in ~85% fewer contigs from ~80% less starting material at a fraction of the cost of previous Roche 454-based sequencing efforts. CONCLUSIONS: The result is the most complete filarial nematode assembly produced thus far and demonstrates the utility of single molecule sequencing on the Pacific Biosciences platform for genetically heterogeneous metazoan genomes.

High- and Low-Power Laser Lithotripsy Achieves Similar Results: A Systematic Review and Meta-Analysis of Available Clinical Series.

Purpose: There is no clear evidence that high-power (HP) laser generators perform better than low-power (LP) ones in terms of lithotripsy outcomes. We aimed to perform a systematic review of literature to compare the efficacy outcomes of both HP and LP during ureteroscopic lithotripsy. Materials and Methods: A computerized bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting perioperative outcomes of HP and LP lithotripsy. Using the methodology recommended by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, we identified 22 nonrandomized noncomparative retrospective studies published between 2015 and 2019 that were eligible for inclusion in this systematic review. Because of the lack of comparative studies, we decided to perform two separate meta-analytic syntheses for LP and HP studies, then we compared them using a Wald-type test. Results: Overall, the selected studies included 6403 patients. Study design, exposure assessment, selection criteria, and outcome of interest were heterogeneous. LP studies were more common (n = 17, 77%), whereas HP studies were more common in the latest inclusion period. Faster lithotripsy (32.9 minutes vs 63.9 minutes, p < 0.01) was observed in HP studies. However, stone volume resulted twofold higher (2604 mm3vs 1217 mm3, p = 0.048) in LP studies. Pooled stone-free rate was similar in both LP and HP studies, 81% and 82%, respectively, p > 0.05. No difference in complication rate was observed between the two groups, p = 0.12. Conclusions: HP laser lithotripsy appears to require shorter operative time, with similar stone-free and complication rates as compared with LP traditional lithotripsy. However, when taking into account stone burden, this advantage seems to be lost, or at least not to be comparable with what observed in laboratory studies. Because of the lack of high-level comparative evidence, further clinical studies are needed to elucidate the benefits of using HP laser generators during ureteroscopic stone treatment.

Cost comparison of single-use versus reusable flexible ureteroscope: A systematic review.

Single-use flexible ureteroscopes (su-fURS) aim at overcoming the main limitations of conventional reusable flexible ureteroscopes (re-fURS) in terms of acquisition and maintenance costs, breakages, and reprocessing. We aimed to perform a literature review on available re-fURS and su-fURS performances with a focus on costs. A search of Medline, EMBASE, CINAHL, and Scopus databases was performed to identify articles published in English within the last 10 years addressing refURS and su-fURS characteristics, clinical, and cost data. Relevant studies were then screened, and the data were extracted, analyzed, and summarized. The Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria were applied. A narrative synthesis was performed. To date, few studies have properly investigated the issue of costs in ureteroscopy. An important local and international variation in costs exists for both re-fURS and su-fURS in terms of acquisition, maintenance, and repair costs. Reusable scopes have high acquisition and ancillary (e.g. repair, involved personnel) costs, which are not considered in a pure su-fURS activity. However, only recently su-fURS were shown to have a similar efficacy as compared with reusable devices. In high-volume centers, with proper training for reusable ureteroscopes management, the cost per case of reusable and single-use scopes are overlapping ($1,212-$1,743 versus $1,300-$3,180 per procedure). There is a partial overlap in the ranges of costs for single-use and reusable scopes, which makes it important to precisely know the caseload, repair bills, and added expenses when negotiating purchase prices, repair prices, and warranty conditions for scopes.

Differential salivary gland transcript expression profile in Ixodes scapularis nymphs upon feeding or flavivirus infection.

Ixodid ticks are vectors of human diseases such as Lyme disease, babesiosis, anaplasmosis, and tick-borne encephalitis. These diseases cause significant morbidity and mortality worldwide and are transmitted to humans during tick feeding. The tick-host-pathogen interface is a complex environment where host responses are modulated by the molecules in tick saliva to enable the acquisition of a blood meal. Disruption of host responses at the site of the tick bite may also provide an advantage for pathogens to survive and replicate. Thus, the molecules in tick saliva not only aid the tick in securing a nutrient-rich blood meal, but can also enhance the transmission and acquisition of pathogens. To investigate the effect of feeding and flavivirus infection on the salivary gland transcript expression profile in ticks, a first-generation microarray was developed using ESTs from a cDNA library derived from Ixodes scapularis salivary glands. When the salivary gland transcript profile in ticks feeding over the course of 3 days was compared to that in unfed ticks, a dramatic increase in transcripts related to metabolism was observed. Specifically, 578 transcripts were up-regulated compared to 151 down-regulated transcripts in response to feeding. When specific time points post attachment were analyzed, a temporal pattern of gene expression was observed. When Langat virus-infected ticks were compared to mock-infected ticks, transcript expression changes were observed at all 3 days of feeding. Differentially regulated transcripts include putative secreted proteins, lipocalins, Kunitz domain-containing proteins, anti-microbial peptides, and transcripts of unknown function. These studies identify salivary gland transcripts that are differentially regulated during feeding or in the context of flavivirus infection in Ixodes scapularis nymphs, a medically important disease vector. Further analysis of these transcripts may identify salivary factors that affect the transmission or replication of tick-borne flaviviruses.

As the raven flies: using genetic data to infer the history of invasive common raven (Corvus corax) populations in the Mojave Desert.

Common raven (Corvus corax) populations in Mojave Desert regions of southern California and Nevada have increased dramatically over the past five decades. This growth has been attributed to increased human development in the region, as ravens have a commensal relationship with humans and feed extensively at landfills and on road-killed wildlife. Ravens, as a partially subsidized predator, also represent a problem for native desert wildlife, in particular threatened desert tortoises (Gopherus agassizii). However, it is unclear whether the more than 15-fold population increase is due to in situ population growth or to immigration from adjacent regions where ravens have been historically common. Ravens were sampled for genetic analysis at several local sites within five major areas: the West Mojave Desert (California), East Mojave Desert (southern Nevada), southern coastal California, northern coastal California (Bay Area), and northern Nevada (Great Basin). Analyses of mtDNA control region sequences reveal an increased frequency of raven 'Holarctic clade' haplotypes from south to north inland, with 'California clade' haplotypes nearly fixed in the California populations. There was significant structuring among regions for mtDNA, with high F(ST) values among sampling regions, especially between the Nevada and California samples. Analyses of eight microsatellite loci reveal a mostly similar pattern of regional population structure, with considerably smaller, but mostly significant, values. The greater mtDNA divergences may be due to lower female dispersal relative to males, lower N(e), or effects of high mutation rates on maximal values of F(ST). Analyses indicate recent population growth in the West Mojave Desert and a bottleneck in the northern California populations. While we cannot rule out in situ population growth as a factor, patterns of movement inferred from our data suggest that the increase in raven populations in the West Mojave Desert resulted from movements from southern California and the Central Valley. Ravens in the East Mojave Desert are more similar to ones from northern Nevada, indicating movement between those regions. If this interpretation of high gene flow into the Mojave Desert is correct, then efforts to manage raven numbers by local control may not be optimally effective.