Whole-body magnetic resonance imaging for staging patients with high-risk prostate cancer.

BACKGROUND: Staging patients with high-risk prostate cancer (HRPCa) with conventional imaging of computed tomography (CT) and bone scintigraphy (BS) is suboptimal. Therefore, we aimed to compare the accuracy of whole-body magnetic resonance imaging (WBMRI) with conventional imaging to stage patients with HRPCa. METHODS: We prospectively enrolled patients with newly diagnosed HRPCa (prostate-specific antigen ≥20 ng/ml and/or Grade Group ≥4). Patients underwent BS, CT of the abdomen and pelvis, and WBMRI within 30 days of evaluation. The primary endpoint was the diagnostic performances of detecting metastatic disease to the lymph nodes and bone for WBMRI and conventional imaging. The reference standard was defined by histopathology or by all available clinical information at 6 months of follow-up. To compare diagnostic tests, Exact McNemar's test and area under the curve (AUC) of the receiver operating characteristics curves were utilized. RESULTS: Among 92 patients enrolled, 15 (16.3%) and 8 (8.7%) patients were found to have lymphatic and bone metastases, respectively. The sensitivity, specificity, and accuracy of WBMRI in detecting lymphatic metastases were 0.60 (95% confidence interval 0.32-0.84), 0.84 (0.74-0.92), and 0.80 (0.71-0.88), respectively, while CT were 0.20 (0.04-0.48), 0.92 (0.84-0.97), and 0.80 (0.71-0.88). The sensitivity, specificity, and accuracy of WBMRI to detect bone metastases were 0.25 (0.03-0.65), 0.94 (0.87-0.98), and 0.88 (0.80-0.94), respectively, while CT and BS were 0.12 (0-0.53), 0.94 (0.87-0.98), and 0.87 (0.78-0.93). For evaluating lymphatic metastases, WBMRI demonstrated a higher sensitivity (p = 0.031) and discrimination compared to CT (0.72 versus 0.56, p = 0.019). CONCLUSIONS: For staging patients with HRPCa, WBMRI outperforms CT in the detection of lymphatic metastases and performs as well as CT and BS in the detection of bone metastases. Further studies are needed to assess the cost effectiveness of WBMRI and the utility of combined PSMA PET and WBMRI.

Whole-body MRI for staging prostate cancer: a narrative review.

OBJECTIVE: To present a narrative review regarding the diagnostic accuracy of whole-body magnetic resonance imaging (WBMRI) in staging patients with high-risk prostate cancer (HRPCa) and compare it to established imaging modalities. METHODS: A narrative review was carried out using PubMed using the following keywords: 'whole body', 'magnetic resonance imaging', 'MRI', 'prostate cancer', 'risk stratification', and 'staging'. Articles that evaluated WBMRI as the imaging modality to stage patients with HRPCa were included, while studies that solely assessed for biochemical recurrence or metastatic disease progression were excluded. RESULTS: In the evaluation of lymphatic metastases, WBMRI has demonstrated a comparable, if not improved, sensitivity and specificity compared to conventional imaging of computed tomography (CT). Furthermore, WBMRI demonstrates improved sensitivity and specificity in detecting bone metastases compared to bone scintigraphy (BS). However, with advent of prostate-specific membrane antigen (PSMA) radioligands for positron emission tomography (PET), the diagnostic performance of WBMRI to detect metastatic disease appears inferior. CONCLUSIONS: The diagnostic capabilities of WBMRI exceed that of conventional imaging of CT and BS in detecting metastatic disease in patients with HRPCa. However, WBMRI does not perform as well as PSMA PET/CT. Further study on cost comparisons between WBMRI and PSMA PET/CT are needed, as well as evaluations of combined PSMA PET/MRI are needed.

Rational design of structure-based vaccines targeting misfolded alpha-synuclein conformers of Parkinson's disease and related disorders.

Synucleinopathies, including Parkinson's disease (PD), multiple system atrophy (MSA), and dementia with Lewy bodies (DLB), are neurodegenerative disorders caused by the accumulation of misfolded alpha-synuclein protein. Developing effective vaccines against synucleinopathies is challenging due to the difficulty of stimulating an immune-specific response against alpha-synuclein without causing harmful autoimmune reactions, selectively targeting only pathological forms of alpha-synuclein. Previous attempts using linear peptides and epitopes without control of the antigen structure failed in clinical trials. The immune system was unable to distinguish between native alpha-synuclein and its amyloid form. The prion domain of the fungal HET-s protein was selected as a scaffold to introduce select epitopes from the surface of alpha-synuclein fibrils. Four vaccine candidates were generated by introducing specific amino acid substitutions onto the surface of the scaffold protein. The approach successfully mimicked the stacking of the parallel in-register beta-sheet structure seen in alpha-synuclein fibrils. All vaccine candidates induced substantial levels of IgG antibodies that recognized pathological alpha-synuclein fibrils derived from a synucleinopathy mouse model. Furthermore, the antisera recognized pathological alpha-synuclein aggregates in brain lysates from patients who died from DLB, MSA, or PD, but did not recognize linear alpha-synuclein peptides. Our approach, based on the rational design of vaccines using the structure of alpha-synuclein amyloid fibrils and strict control over the exposed antigen structure used for immunization, as well as the ability to mimic aggregated alpha-synuclein, provides a promising avenue toward developing effective vaccines against alpha-synuclein fibrils.

Comparison of Magnetic Resonance Imaging-Based Risk Calculators to Predict Prostate Cancer Risk.

Importance: Magnetic resonance imaging (MRI)-based risk calculators can replace or augment traditional prostate cancer (PCa) risk prediction tools. However, few data are available comparing performance of different MRI-based risk calculators in external cohorts across different countries or screening paradigms. Objective: To externally validate and compare MRI-based PCa risk calculators (Prospective Loyola University Multiparametric MRI [PLUM], UCLA [University of California, Los Angeles]-Cornell, Van Leeuwen, and Rotterdam Prostate Cancer Risk Calculator-MRI [RPCRC-MRI]) in cohorts from Europe and North America. Design, Setting, and Participants: This multi-institutional, external validation diagnostic study of 3 unique cohorts was performed from January 1, 2015, to December 31, 2022. Two cohorts from Europe and North America used MRI before biopsy, while a third cohort used an advanced serum biomarker, the Prostate Health Index (PHI), before MRI or biopsy. Participants included adult men without a PCa diagnosis receiving MRI before prostate biopsy. Interventions: Prostate MRI followed by prostate biopsy. Main Outcomes and Measures: The primary outcome was diagnosis of clinically significant PCa (grade group ≥2). Receiver operating characteristics for area under the curve (AUC) estimates, calibration plots, and decision curve analysis were evaluated. Results: A total of 2181 patients across the 3 cohorts were included, with a median age of 65 (IQR, 58-70) years and a median prostate-specific antigen level of 5.92 (IQR, 4.32-8.94) ng/mL. All models had good diagnostic discrimination in the European cohort, with AUCs of 0.90 for the PLUM (95% CI, 0.86-0.93), UCLA-Cornell (95% CI, 0.86-0.93), Van Leeuwen (95% CI, 0.87-0.93), and RPCRC-MRI (95% CI, 0.86-0.93) models. All models had good discrimination in the North American cohort, with an AUC of 0.85 (95% CI, 0.80-0.89) for PLUM and AUCs of 0.83 for the UCLA-Cornell (95% CI, 0.80-0.88), Van Leeuwen (95% CI, 0.79-0.88), and RPCRC-MRI (95% CI, 0.78-0.87) models, with somewhat better calibration for the RPCRC-MRI and PLUM models. In the PHI cohort, all models were prone to underestimate clinically significant PCa risk, with best calibration and discrimination for the UCLA-Cornell (AUC, 0.83 [95% CI, 0.81-0.85]) model, followed by the PLUM model (AUC, 0.82 [95% CI, 0.80-0.84]). The Van Leeuwen model was poorly calibrated in all 3 cohorts. On decision curve analysis, all models provided similar net benefit in the European cohort, with higher benefit for the PLUM and RPCRC-MRI models at a threshold greater than 22% in the North American cohort. The UCLA-Cornell model demonstrated highest net benefit in the PHI cohort. Conclusions and Relevance: In this external validation study of patients receiving MRI and prostate biopsy, the results support the use of the PLUM or RPCRC-MRI models in MRI-based screening pathways regardless of European or North American setting. However, tools specific to screening pathways incorporating advanced biomarkers as reflex tests are needed due to underprediction.

Postoperative Outcomes and Analgesic Requirements of Single-Port vs Multiport Robotic-Assisted Radical Cystectomy.

Objective: To compare outcomes in patients undergoing robotic-assisted radical cystectomy (RARC) with urinary diversion for bladder cancer with either the single-port (SP) or multiport (MP) robotic platform. Methods: All patients who underwent SP and MP RARC at our institution between January 2018 and January 2023 were retrospectively reviewed. Postoperative analgesia was administered by a departmentwide narcotic stewardship protocol, and inpatient and outpatient narcotic use was tracked. The available preoperative clinical, operative, and postoperative outcomes were analyzed using t-test, chi-square, and Fischer exact statistical measures. Kaplan-Meier analysis with log-rank testing was used to determine the freedom from high-grade (Clavien-Dindo grade ≥3) postoperative complications stratified by SP or MP robotic use. Results: Overall, 96 patients underwent RARC with urinary diversion at our institution, with 49 MP and 47 SP procedures performed. Preoperative clinical parameters including age, body mass index, prior abdominal surgery, and use of neoadjuvant chemotherapy were similar between the two groups. Patients undergoing SP RARC had a shorter operative time (386.0 ± 90.9 minutes vs 453.6 ± 94.8 minutes, p < 0.01) and faster return of bowel function (3.4 ± 1.4 days vs 4.5 ± 2.2 days, p < 0.01). However, both cohorts had similar length of hospitalization, postoperative narcotic use, pathologic staging, and rate of positive surgical margin. Within 3 months postoperatively, both cohorts had a similar high-grade complication, hospital readmission, and cancer recurrence rate. Conclusions: The SP robot allows a safe alternative surgical approach for RARC and offers similar postoperative outcomes compared to the MP robot.

The association of body mass index with tumor aggression among men undergoing radical prostatectomy.

OBJECTIVES: To evaluate the association of preoperative body mass index (BMI) on adverse pathology in peripheral (PZ) and transition zone (TZ) tumors at time of prostatectomy for localized prostate cancer. METHODS: Clinical and pathologic characteristics were obtained from up to 100 consecutive prostatectomy patients from 10 prostate surgeons. BMI groups included normal (18.5-24.9), overweight (25-29.9) and obese (> 29.9). "Aggressive" pathology was defined as the presence of Grade Group (GG) 3 or higher and/or pT3a or higher. Pathologic characteristics were evaluated for association with BMI using univariate analyses. Our primary outcome was the association of BMI with adverse pathology, which was assessed using logistic regression accounting for patient age. We hypothesized that obese BMI would be associated with aggressive TZ tumor. RESULTS: Among 923 patients, 140 (15%) were classified as "normal" BMI, 413 (45%) were "overweight", and 370 (40%) were "obese." 474 patients (51%) had aggressive PZ tumors while 102 (11%) had aggressive TZ tumors. "Obese" BMI was not associated with aggressive TZ tumor compared to normal weight. Increasing BMI group was associated with overall increased risk of aggressive PZ tumor (HR 1.56 [95CI 1.04-2.34]; P = 0.03). Among patients with GG1 or GG2, increasing BMI was associated with presence of pT3a or higher TZ tumor (P = 0.03). CONCLUSIONS: Increased BMI is associated with adverse pathology in PZ tumors. TZ adverse pathology risk may be increased among obese men with GG1 or GG2 disease, which has implications for future studies assessing behavioral change among men whose tumors are actively monitored.

Surgical Management and Considerations for Patients with Localized High-Risk Prostate Cancer.

OPINION STATEMENT: Localized high-risk (HR) prostate cancer (PCa) is a heterogenous disease state with a wide range of presentations and outcomes. Historically, non-surgical management with radiotherapy and androgen deprivation therapy was the treatment option of choice. However, surgical resection with radical prostatectomy (RP) and pelvic lymph node dissection (PLND) is increasingly utilized as a primary treatment modality for patients with HRPCa. Recent studies have demonstrated that surgery is an equivalent treatment option in select patients with the potential to avoid the side effects from androgen deprivation therapy and radiotherapy combined. Advances in imaging techniques and biomarkers have also improved staging and patient selection for surgical resection. Advances in robotic surgical technology grant surgeons various techniques to perform RP, even in patients with HR disease, which can reduce the morbidity of the procedure without sacrificing oncologic outcomes. Clinical trials are not only being performed to assess the safety and oncologic outcomes of these surgical techniques, but to also evaluate the role of surgical resection as a part of a multimodal treatment plan. Further research is needed to determine the ideal role of surgery to potentially provide a more personalized and tailored treatment plan for patients with localized HR PCa.

Are markers of survival associated with perioperative outcomes for tumor thrombectomy patients?

INTRODUCTION: Despite modern advances in surgical and perioperative technologies, management of renal cell carcinoma (RCC) with tumor thrombus (TT) is a morbid procedure that necessitates careful patient selection. It is not known whether established prognostic models for metastatic RCC are suitable prognostic tools for more immediate perioperative outcomes in patients with RCC with TT. We evaluated if established risk models for cytoreductive nephrectomy, as a potential extension of their purpose-built use, are associated with immediate perioperative outcomes in patients undergoing nephrectomy and tumor thrombectomy. METHODS: Perioperative outcomes of patients who underwent radical nephrectomy and tumor thrombectomy for RCC were compared to presences of established predictors of long-term outcomes from prior risk models individually and as stratified by risk grouping (International Metastatic Renal-Cell Carcinoma Database Consortium [IMDC], Memorial Sloan Kettering Cancer Center [MSKCC], M.D. Anderson Cancer Center [MDACC], and Moffitt Cancer Center [MCC]). Wilcoxon rank-sum test or the Kruskal-Wallis test compared continuous variables and the chi-square test or Fisher's exact test compared categorical variables. RESULTS: Fifty-five patients were analyzed with 17 (30.9%) being cytoreductive. Eighteen (32.7%) patients had a level III or higher TT. Individually, preoperative variables were inconsistently associated with perioperative outcomes. Poorer risk patients per the IMDC model had more major postoperative complications (Clavien-Dindo grade≥3, P = 0.008). For the MSKCC model, poorer risk patients had increased intraoperative estimated blood loss (EBL), longer length of stay (LOS), more major postoperative complications, and more likely to discharge to a rehabilitation facility (P < 0.05). Less favorable risk patients per MDACC model had increased LOS (P = 0.038). Poorer risk patients per the MCC model had increased EBL, LOS, major postoperative complications, and 30-day hospital readmissions (P < 0.05). CONCLUSION: Overall, cytoreductive risks models were heterogeneously associated with perioperative outcomes in patients undergoing nephrectomy and tumor thrombectomy. Of available models, the MCC model is associated with more perioperative outcomes including EBL, LOS, major postoperative complications, and readmissions within 30 days when compared to the IMDC, MSKCC, and MDACC models.

Natural language processing in urology: Automated extraction of clinical information from histopathology reports of uro-oncology procedures.

Objectives: We aimed to automate routine extraction of clinically relevant unstructured information from uro-oncological histopathology reports by applying rule-based and machine learning (ML)/deep learning (DL) methods to develop an oncology focused natural language processing (NLP) algorithm. Methods: Our algorithm employs a combination of a rule-based approach and support vector machines/neural networks (BioBert/Clinical BERT), and is optimised for accuracy. We randomly extracted 5772 uro-oncological histology reports from 2008 to 2018 from electronic health records (EHRs) and split the data into training and validation datasets in an 80:20 ratio. The training dataset was annotated by medical professionals and reviewed by cancer registrars. The validation dataset was annotated by cancer registrars and defined as the gold standard with which the algorithm outcomes were compared. The accuracy of NLP-parsed data was matched against these human annotation results. We defined an accuracy rate of >95% as "acceptable" by professional human extraction, as per our cancer registry definition. Results: There were 11 extraction variables in 268 free-text reports. We achieved an accuracy rate of between 61.2% and 99.0% using our algorithm. Of the 11 data fields, a total of 8 data fields met the acceptable accuracy standard, while another 3 data fields had an accuracy rate between 61.2% and 89.7%. Noticeably, the rule-based approach was shown to be more effective and robust in extracting variables of interest. On the other hand, ML/DL models had poorer predictive performances due to highly imbalanced data distribution and variable writing styles between different reports and data used for domain-specific pre-trained models. Conclusion: We designed an NLP algorithm that can automate clinical information extraction accurately from histopathology reports with an overall average micro accuracy of 93.3%.

Improved functional status in patients undergoing cement and rebar reconstruction with total hip arthroplasty for uncontained metastatic tumors of the acetabulum.

BACKGROUND AND OBJECTIVE: Metastatic cancer of the acetabulum can produce marked pain and disability for patients. Several reconstruction techniques for such lesions have been described, with variable outcomes. The purpose of this study was to determine functional outcomes and complication rate for patients undergoing cement rebar reconstruction using posterior column screws with total hip arthroplasty for large, uncontained lesions of the acetabulum. METHODS: Twenty-two consecutive patients who underwent cement rebar reconstruction with posterior column screws and total hip arthroplasty for metastatic tumors of the acetabulum between 2014 and 2017 were identified. All cases were reviewed for patient demographics, surgical parameters, implant survival, complications, and functional status following these procedures. RESULTS: There was a significant increase in the proportion of patients able to ambulate post-surgery (95.5%) compared with presurgery (22.7%) (p < 0.001). Mean musculoskeletal tumor society score postoperatively was 17.9 (60%). Average operative time was 174 min and average estimated blood loss was 689 mL. Seven patients required an intraoperative or postoperative blood transfusion. Three patients had postoperative complications (14%), two of whom required revision (9%). CONCLUSION: Reconstruction using cement rebar with posterior column screws and total hip arthroplasty is a safe, reproducible approach that may greatly improve functional outcomes with a low rate of intraoperative or postoperative complications.

Development of a real-world database for asthma and COPD: The SingHealth-Duke-NUS-GSK COPD and Asthma Real-World Evidence (SDG-CARE) collaboration.

PURPOSE: The SingHealth-Duke-GlaxoSmithKline COPD and Asthma Real-world Evidence (SDG-CARE) collaboration was formed to accelerate the use of Singaporean real-world evidence in research and clinical care. A centerpiece of the collaboration was to develop a near real-time database from clinical and operational data sources to inform healthcare decision making and research studies on asthma and chronic obstructive pulmonary disease (COPD). METHODS: Our multidisciplinary team, including clinicians, epidemiologists, data scientists, medical informaticians and IT engineers, adopted the hybrid waterfall-agile project management methodology to develop the SingHealth COPD and Asthma Data Mart (SCDM). The SCDM was developed within the organizational data warehouse. It pulls and maps data from various information systems using extract, transform and load (ETL) pipelines. Robust user testing and data verification was also performed to ensure that the business requirements were met and that the ETL pipelines were valid. RESULTS: The SCDM includes 199 data elements relevant to asthma and COPD. Data verification was performed and found the SCDM to be reliable. As of December 31, 2019, the SCDM contained 36,407 unique patients with asthma and COPD across the spectrum from primary to tertiary care in our healthcare system. The database updates weekly to add new data of existing patients and to include new patients who fulfil the inclusion criteria. CONCLUSIONS: The SCDM was systematically developed and tested to support the use RWD for clinical and health services research in asthma and COPD. This can serve as a platform to provide research and operational insights to improve the care delivered to our patients.

Comparison of Perioperative Outcomes Between Single-Port and Multi-Port Robotic Adrenalectomy.

BACKGROUND: Single-port (SP) robotic surgery has been utilized in several surgical procedures. We aim to describe our institution's approach and perioperative experience with SP robotic adrenalectomy and compare it to the traditional multi-port (MP) approach. METHODS: We retrospectively reviewed all patients who underwent robotic adrenalectomy by a single surgeon between March 2019 and March 2020. Patient demographic, perioperative factors, and pathologic outcomes were recorded and analyzed using t-tests, chi-square, or Fisher's exact tests. RESULTS: Thirty-six patients underwent SP (n = 11) and MP (n = 25) robotic adrenalectomy. Age, body mass index, gender, operative time, major Clavien-Dindo complications, and margin status showed no differences. Patients undergoing SP adrenalectomy had a lower estimated blood loss (18.1 ± 13.0 vs 65.6 ± 95.0 cc, P = .02) and smaller lesion size (2.8 ± 1.3 vs 4.1 ± 1.8 cm, P = .04) compared to those undergoing MP. CONCLUSIONS: SP adrenalectomy appears to be a feasible approach in select adrenal masses. Further studies are needed to establish its safety and cost effectiveness.

Survival and failure modes of the Compress® spindle and expandable distal femur endoprosthesis among pediatric patients: A multi-institutional study.

BACKGROUND: Expandable endoprostheses can be used to equalize limb length for pediatric patients requiring reconstruction following large bony oncologic resections. Outcomes of the Compress® Compliant Pre-Stress (CPS) spindle paired with an Orthopedic Salvage System expandable distal femur endoprosthesis have not been reported. METHODS: We conducted a multi-institutional retrospective study of pediatric patients with distal femoral bone sarcomas reconstructed with the above endoprostheses. Statistical analysis utilized Kaplan-Meier survival technique and competing risk analysis. RESULTS: Thirty-six patients were included from five institutions. Spindle survivorship was 86.3% (95% confidence interval [CI], 67.7-93.5) at 10 years. Two patients had a failure of osseointegration (5.7%), both within 12 months. Twenty-two (59%) patients had 70 lengthening procedures, with mean expansions of 3.2 cm (range: 1-9) over 3.4 surgeries. The expandable mechanism failed in eight patients with a cumulative incidence of 16.1% (95% CI, 5.6-31.5) at 5 years. Twenty-nine patients sustained International Society of Limb Salvage failures requiring 63 unplanned surgeries. Periprosthetic joint infection occurred in six patients (16.7%). Limb preservation rate was 91% at 10 years. CONCLUSIONS: There is a high rate of osseointegration of the Compress® spindle among pediatric patients when coupled with an expandable implant. However, there is a high rate of expansion mechanism failure and prosthetic joint infections requiring revision surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study.

A prostate biopsy risk calculator based on MRI: development and comparison of the Prospective Loyola University multiparametric MRI (PLUM) and Prostate Biopsy Collaborative Group (PBCG) risk calculators.

OBJECTIVES: To develop and validate a prostate cancer (PCa) risk calculator (RC) incorporating multiparametric magnetic resonance imaging (mpMRI) and to compare its performance with that of the Prostate Biopsy Collaborative Group (PBCG) RC. PATIENTS AND METHODS: Men without a PCa diagnosis receiving mpMRI before biopsy in the Prospective Loyola University mpMRI (PLUM) Prostate Biopsy Cohort (2015-2020) were included. Data from a separate institution were used for external validation. The primary outcome was diagnosis of no cancer, grade group (GG)1 PCa, and clinically significant (cs)PCa (≥GG2). Binary logistic regression was used to explore standard clinical and mpMRI variables (prostate volume, Prostate Imaging-Reporting Data System [PI-RADS] version 2.0 lesions) with the final PLUM RC, based on a multinomial logistic regression model. Receiver-operating characteristic curve, calibration curves, and decision-curve analysis were evaluated in the training and validation cohorts. RESULTS: A total of 1010 patients were included for development (N = 674 training [47.8% PCa, 30.9% csPCa], N = 336 internal validation) and 371 for external validation. The PLUM RC outperformed the PBCG RC in the training (area under the curve [AUC] 85.9% vs 66.0%; P < 0.001), internal validation (AUC 88.2% vs 67.8%; P < 0.001) and external validation (AUC 83.9% vs 69.4%; P < 0.001) cohorts for csPCa detection. The PBCG RC was prone to overprediction while the PLUM RC was well calibrated. At a threshold probability of 15%, the PLUM RC vs the PBCG RC could avoid 13.8 vs 2.7 biopsies per 100 patients without missing any csPCa. At a cost level of missing 7.5% of csPCa, the PLUM RC could have avoided 41.0% (566/1381) of biopsies compared to 19.1% (264/1381) for the PBCG RC. The PLUM RC compared favourably with the Stanford Prostate Cancer Calculator (SPCC; AUC 84.1% vs 81.1%; P = 0.002) and the MRI-European Randomized Study of Screening for Prostate Cancer (ERSPC) RC (AUC 84.5% vs 82.6%; P = 0.05). CONCLUSIONS: The mpMRI-based PLUM RC significantly outperformed the PBCG RC and compared favourably with other mpMRI-based RCs. A large proportion of biopsies could be avoided using the PLUM RC in shared decision making while maintaining optimal detection of csPCa.

Temporal Trends in Deep Surgical Site Infections After Six Orthopaedic Procedures Over a 12-year Period Within a US-based Healthcare System.

INTRODUCTION: Centers of excellence and bundled payment models have driven perioperative optimization and surgical site infection (SSI) prevention with decolonization protocols and antibiotic prophylaxis strategies. We sought to evaluate time trends in the incidence of deep SSI and its causative organisms after six orthopaedic procedures in a US-based integrated healthcare system. METHODS: We conducted a population-level time-trend study using data from Kaiser Permanente's orthopaedic registries. All patients who underwent primary anterior cruciate ligament reconstruction (ACLR), total knee arthroplasty (TKA), elective total hip arthroplasty (THA), hip fracture repair, shoulder arthroplasty, and spine surgery were identified (2009 to 2020). The annual incidence of 90-day deep SSI was identified according to the National Healthcare Safety Network/Centers for Disease Control and Prevention guidelines with manual chart validation for identified infections. Poisson regression was used to evaluate annual trends in SSI incidence with surgical year as the exposure of interest. Annual trends in overall incidence and organism-specific incidence were considered. RESULTS: The final study sample was composed of 465,797 primary orthopaedic procedures. Over the 12-year study period, a decreasing trend in deep SSI was observed for ACLR and hip fracture repair. Although there was variation in incidence rates for specific operative years for TKA, elective THA, shoulder arthroplasty, and spine surgery, no consistent decreasing trends over time were found. Decreasing rates of Staphylococcus aureus infections over time after hip fracture repair, shoulder arthroplasty, and spine surgery and decreasing trends in antibiotic resistance after elective THA and spine surgery were also observed. Increasing trends of polymicrobial infections were observed after TKA and Cutibacterium acnes after elective THA. CONCLUSIONS: The overall incidence of deep SSI after six orthopaedic procedures was rare. Decreasing SSI rates were observed for ACLR and hip fracture repair within our US-based healthcare system. Polymicrobial infections after TKA and Cutibacterium acnes after elective THA warrant closer surveillance. LEVEL OF EVIDENCE: IV.

Augmenting prostate magnetic resonance imaging reporting to incorporate diagnostic recommendations based upon clinical risk calculators.

Risk calculators have offered a viable tool for clinicians to stratify patients at risk of prostate cancer (PCa) and to mitigate the low sensitivity and specificity of screening prostate specific antigen (PSA). While initially based on clinical and demographic data, incorporation of multiparametric magnetic resonance imaging (MRI) and the validated prostate imaging reporting and data system suspicion scoring system has standardized and improved risk stratification beyond the use of PSA and patient parameters alone. Biopsy-naïve patients with lower risk profiles for harboring clinically significant PCa are often subjected to uncomfortable, invasive, and potentially unnecessary prostate biopsy procedures. Incorporating risk calculator data into prostate MRI reports can broaden the role of radiologists, improve communication with clinicians primarily managing these patients, and help guide clinical care in directing the screening, detection, and risk stratification of PCa.

Intravenous caval leiomyomatosis in the setting of renal cell carcinoma - A case report.

Uterine leiomyomas are common, benign neoplasms of the uterine smooth muscle. Leiomyomatosis is uncommon and causes development of multiple leiomyomas that can manifest as intravascular leiomyomatosis (IVL). We present the case of a 46-year-old female with IVL extending from the right gonadal vein to the right atrium and pulmonary arteries with an independent renal cell carcinoma of the right kidney. She underwent successful open right radical nephrectomy, inferior vena caval tumor thrombectomy and pulmonary embolectomy. While there was initial concern for hereditary renal cell carcinoma, final histologic testing did not support the diagnosis.