Mpox: The Reemergence of an Old Disease and Inequities.

Mpox, previously known as monkeypox, is caused by an Orthopoxvirus related to the variola virus that causes smallpox. Prior to 2022, mpox was considered a zoonotic disease endemic to central and west Africa. Since May 2022, more than 86,000 cases of mpox from 110 countries have been identified across the world, predominantly in men who have sex with men, most often acquired through close physical contact or during sexual activity. The classical clinical presentation of mpox is a prodrome including fever, lethargy, and lymphadenopathy followed by a characteristic vesiculopustular rash. The recent 2022 outbreak included novel presentations of mpox with a predominance of anogenital lesions, mucosal lesions, and other features such as anorectal pain, proctitis, oropharyngeal lesions, tonsillitis, and multiphasic skin lesions. We describe the demographics and clinical spectrum of classical and novel mpox, outlining the potential complications and management.

Tolerability of four-drug antiretroviral combination therapy in primary HIV-1 infection.

OBJECTIVES: Rapid initiation of antiretroviral therapy (ART) is important for individuals with high baseline viral loads, such as in primary HIV-1 infection (PHI). Four-drug regimens are sometimes considered; however, data are lacking on tolerability. We aimed to evaluate the tolerability of four-drug regimens used in the Research in Viral Eradication of HIV-1 Reservoirs (RIVER) study. METHODS: At enrolment, ART-naïve adult participants or those newly commenced on ART were initiated or intensified to four-drug regimens within 4 weeks of PHI. Rapid start was defined as pre-confirmation or ≤ 7 days of confirmed diagnosis. Primary and secondary outcomes were patient-reported adherence measured by 7-day recall and regimen switches between enrolment and randomization, respectively. RESULTS: Overall, 54 men were included: 72.2% were of white ethnicity, with a median age of 32 years old, 42.6% had a viral load of ≥ 100 000 HIV-1 RNA copies/mL, and in 92.6% sex with men was the mode of acquisition of HIV-1. Twenty (37%) started a four-drug regimen and 34 (63%) were intensified. Rapid ART initiation occurred in 28%, 100% started in ≤ 4 weeks. By weeks 4, 12, and 24, 37.0%, 69.0%, and 94.0% were undetectable (viral load < 50 copies/mL), respectively. Adherence rates of 100% at weeks 4, 12, 22 and 24 were reported in 88.9%, 87.0%, 82.4% and 94.1% of participants, respectively. Five individuals switched to three drugs, four changed their regimen constituents, and two switched post-randomization. CONCLUSIONS: Overall, four-drug regimens were well tolerated and had high levels of adherence. Whilst their benefit over three-drug regimens is lacking, our findings should provide reassurance if a temporarily intensified regimen is clinically indicated to help facilitate treatment.

CD4:CD8 ratio in children with perinatally acquired HIV-1 infection.

OBJECTIVES: In adults with horizontally acquired HIV infection, an inverted CD4:CD8 ratio is associated with persistent immune activation, size of HIV reservoir and predicts an increased risk of non-AIDS-defining adverse events. Normalization of this ratio with antiretroviral therapy (ART) is suboptimal in adults, despite viral suppression, and is less well described in paediatric populations. We investigated rates of CD4:CD8 ratio recovery in children with perinatally acquired HIV infection (PaHIV) on ART. METHODS: A cross-sectional, retrospective analysis of routine clinical data in children with PaHIV (5-18 years old) attending a single UK centre was carried out. RESULTS: CD4:CD8 normalization was seen in 62% of children on suppressive ART. A negative correlation was found between current CD4:CD8 ratio and age at start of ART. Positive correlations were found between current CD4:CD8 ratio and total time with suppressed HIV viral load and nadir CD4 counts. Multiple linear regression analysis showed that age at start of ART was significantly associated with current CD4:CD8 ratio (standardized ß = -0.680; P < 0.001). Patient sex, ethnicity and antiretroviral regimen did not affect ratio recovery. CONCLUSIONS: We found higher rates of CD4:CD8 ratio normalization compared with previous adult studies. Children who started ART at a younger age were more likely to recover a normal ratio. The current policy of universal treatment for all HIV-positive adults and children will enhance immunological normalization.

The Impact of pH and Ion Exchange on 133Cs Adsorption on Vermiculite.

Many studies have shown that the adsorption of ions like K and Cs on 2:1 clay minerals can prompt the collapse of their interlayers and render the adsorbing ions nonexchangeable. This study sought to better understand this unique adsorption mechanism through the generation of an adsorption envelope for Cs adsorption on vermiculite and the exploration of the kinetics of interlayer collapse. The collapse of the vermiculite interlayer was confirmed via X-ray diffraction (XRD), and the timing of interlayer collapse was determined by placing Cs in competition with K at different time intervals. The adsorption envelope for Cs on vermiculite showed that although H competition does affect the adsorption of Cs on vermiculite, the effect of this competition is quite limited, even at very low pH values. This hypothesis is supported by the fact that XRD demonstrated a significant decrease in interlayer dimension after Cs adsorption. Finally, kinetics experiments showed that the irreversible adsorption of K and the collapse of the interlayer may take place on a much longer time scale than previously considered.

Extramammary Paget 's disease Of Glans Penis: A Rare Case Report

We present the case of an 83-year-old man with Extramammary Paget's disease (EMPD) of the penis. He underwent a total penectomy and histopathology confirms the association of underlying invasive high grade urothelial carcinoma. Penile EMPD is rare and can be misinterpreted for benign skin conditions. A high index of suspicion is required for correct diagnosis and appropriate treatment.

Predictors of live birth after vasectomy reversal in a specialist fertility centre.

In a retrospective review of 106 consecutive vasectomy reversals (May 2002-April 2015) in our institution, patients were stratified according to post vasectomy obstructive interval (PVOI); less than 5 years, 5-10 years, 10-15 years and >15 years. Positive semen analysis and live birth rates were analysed. Logistic regression tested potential predictors for these outcomes. Overall patency rate (positive semen analysis) was 75% and live birth rate was 41%. Shorter PVOI was a significant predictor for positive semen analysis (p=0.028). Male smoking or male age at reversal had no significant correlation (p=0.99 and 0.95 respectively). For a live birth, PVOI and female age (threshold: 36 years) at reversal were significant predictors (p=0.007 and p=0.043 respectively). Outcomes compared favourably with international series yielding satisfactory pregnancy rates, particularly with a short obstructive interval and in females <36 years of age.

Incidence, Cost, Complications and Clinical Outcomes of Iatrogenic Urethral Catheterization Injuries: A Prospective Multi-Institutional Study.

PURPOSE: Data on urethral catheter related injuries are sparse. To highlight the dangers inherent in traumatic urethral catheterization we prospectively monitored the incidence, cost and clinical outcomes of urethral catheter related injuries. MATERIALS AND METHODS: This prospective study was performed during a 6-month period at 2 tertiary referral teaching hospitals. Recorded data included method and extent of urethral catheterization injury, setting and time of injury, number of catheterization attempts, urological management provided, additional bed days due to urethral injury and clinical outcomes after followup. The additional cost of managing urethral injuries was also calculated. RESULTS: A total of 37 iatrogenic urethral injuries were recorded during the 6-month period. The incidence of traumatic urethral catheterization was 6.7 per 1,000 catheters inserted. Thirty (81%) patients sustained a complication Clavien-Dindo grade 2 or greater. The additional length of inpatient hospital stay was 9.4 ± 10 days (range 2 to 53). Of these patients 9 (24%) required an indwelling suprapubic catheter and 8 (21%) have an indwelling transurethral catheter. In addition, 9 (24%) are performing self-urethral dilation once weekly and 4 (11%) have required at least 1 urethral dilation due to persistent urethral stricture disease. The additional cost of managing iatrogenic urethral injuries was €335,377 ($371,790). CONCLUSIONS: Iatrogenic urethral catheterization injuries represent a significant cost and cause of patient morbidity. Despite efforts to educate and train health care professionals on urethral catheterization insertion technique, iatrogenic urethral injuries will continue to occur unless urinary catheter safety mechanics are altered and improved.

Testicular Sperm Extraction and Intracytoplasmic Sperm Injection: Outcomes in a specialist fertility centre.

Assisted reproduction with testicular sperm extraction (TESE) and intra-cytoplasmic sperm injection (ICSI) are fertility treatment options for couples with severe oligospermia or azoospermia. A retrospective review was performed of 146 TESE procedures in a specialist fertility centre in Ireland. The indication for TESE was obstructive azoospermia (OA) in 59% (n = 80) and non-obstructive azoospermia (NOA) in 41% (n = 56). Sperm retrieval rates after TESE were determined and the pregnancy rates per ICSI cycle number were evaluated. Sperm retrieval rates were 99% (n = 79/80) and 32% (n = 18/56) for OA and NOA men respectively. Fifty-eight couples proceeded to ICSI. Overall 114 ICSI cycles were performed and 33 cycles resulted in fertilisation (29%). Our sperm retrieval and pregnancy rates are consistent with international studies and support the ongoing role for TESE and ICSI as successful assisted reproductive techniques for male factor infertility in Ireland.

Transurethral resection of the prostate--"now and then".

The number of transurethral resections of the prostate (TURP) performed each year is decreasing. The aim of this study was to assess a cohort of patients undergoing TURP and compare this to one twenty years earlier in terms of procedure, complications and outcomes. A retrospective comparative analysis of one hundred consecutive TURPs performed in 2010 was compared to one hundred cases performed in 1990. Fifty-five (55%) had a urinary catheter (UC) in situ pre-operatively in 2010 compared to 22 (22%) in 1990. The length of catheterisation time was significantly longer in 2010 compared with 1990 (average 65 days vs 20 days). Infective complications occurred in six (6%) patients in 2010 and three (3%) in the 1990 cohort. Patients who had UCs in situ preoperatively for longer periods had a higher rate of infective complications and more serious complications. This highlights the importance of early specialist referral for patients diaqnosed with urinary retention.

Short communication: Validation of genomic breeding value predictions for feed intake and feed efficiency traits.

Validating genomic prediction equations in independent populations is an important part of evaluating genomic selection. Published genomic predictions from 2 studies on (1) residual feed intake and (2) dry matter intake (DMI) were validated in a cohort of 78 multiparous Holsteins from Australia. The mean realized accuracy of genomic prediction for residual feed intake was 0.27 when the reference population included phenotypes from 939 New Zealand and 843 Australian growing heifers (aged 5-8 mo) genotyped on high density (770k) single nucleotide polymorphism chips. The 90% bootstrapped confidence interval of this estimate was between 0.16 and 0.36. The mean realized accuracy was slightly lower (0.25) when the reference population comprised only Australian growing heifers. Higher realized accuracies were achieved for DMI in the same validation population and using a multicountry model that included 958 lactating cows from the Netherlands and United Kingdom in addition to 843 growing heifers from Australia. The multicountry analysis for DMI generated 3 sets of genomic predictions for validation animals, one on each country scale. The highest mean accuracy (0.72) was obtained when the genomic breeding values were expressed on the Dutch scale. Although the validation population used in this study was small (n=78), the results illustrate that genomic selection for DMI and residual feed intake is feasible. Multicountry collaboration in the area of dairy cow feed efficiency is the evident pathway to achieving reasonable genomic prediction accuracies for these valuable traits.

Mountain bikers priapism: a rare phenomenon.

Soft tissue and bony injuries are well described risks of the increasingly popular sport of mountain biking. Priapism, a persisting unwanted penile erection, as a result of perineal straddle injury due to a fall astride bicycle handlebar, is rare. We present a case of a competitive mountain biker with high flow priapism after such an injury who presented late but was successfully treated by non-invasive selective arterial embolization.

A patient reported outcome measure (PROM) assessing quality of care in the urology hospital outpatient setting.

A prospective blind PROM (patient reported outcome measure) study performed in our urology department examined the outpatient-clinic experience. 104 questionnaires were completed. 23 patients (22%) felt the waiting times for appointments was excessive. 13 patients (13%) experienced difficulty in contacting administrative staff. 98 patients (94%) considered the waiting areas good but 31 patients (31%) considered lack of privacy an issue. Consultants saw 65 patients (63%). 62 patients (60%) expected to be seen by a consultant. 32 patients (31%) felt consultation with a different doctor on return visits was unsatisfactory. 76 patients (73%) "fully trusted" their doctors. 78 patients (75%) rated their visit excellent, 10 patients (10%) added comments. Despite frustration with waiting times, the experience of patients reflects a positive rapport and trust between patient and doctor.

Prostate cancer knowledge in Irish men.

Men require prostate cancer (Pca) knowledge to practice health-seeking behaviours. Nine hundred seventy-nine men participated in a Pca screening programme comprising IPSS, bother score and health belief questionnaire. Men with private insurance had greater knowledge. Forty-nine percent (481) assessed their health status as average. Seventy-five percent (735) visited the GP at least once per year. The majority (576) felt well informed about health matters. Fifty-five percent (542) knew the prostate location but only 319 (33%) could identify it on a diagram. Forty-one percent (401) could not name a symptom. Few knew risk factors but 98% would attend a Pca screening clinic and sought more information. Men lack knowledge to pursue healthier behaviours and should be targeted possibly through a men's health initiative.

The pitfalls of treating anorectal conditions after radiotherapy for prostate cancer.

We present a salutary lesson learned from three cases with significant complications that followed anorectal intervention in the presence of radiation proctitis due to prior radiotherapy for adenocarcinoma of the prostate. After apparent routine rubber band ligation for painful haemorrhoids, one patient developed a colo-cutaneous fistula. Following laser coagulation for radiation proctitis, one patient required a pelvic exenteration for a fistula, while another developed a rectal stenosis. Those diagnosing and treating colonic conditions should be mindful of the increased prevalence of patients who have had radiotherapy for prostate cancer and the potential for complications in treating these patients.

Scrotal signs and symptoms in the general population, the value of testis self-examination and the pitfalls of a scrotal screening programme: is the two-week rule relevant?

PURPOSE: Testicular symptoms/lumps are a cause of concern, anxiety and possible diagnostic dilemma for patient and general practitioner. The majority of scrotal pathology is benign in nature and results in a huge workload. The main aim of this study was to determine the relationship between scrotal symptoms, previous scrotal surgery, testicular self-examination and awareness of scrotal abnormalities. Secondarily, we sought to determine the scrotal findings in men enrolled in a consultant urologist-directed screening programme. METHODS: There were 677 men surveyed on their performance of TSE. They were also asked about scrotal symptoms and prior surgery, before undergoing blinded physical examination by one of four consultant urologists. RESULTS: Among the participants, 9.8% of men had scrotal symptoms with 55% of these having a normal scrotal examination and the rest having benign pathology. A number of men who had undergone previous scrotal surgery (13%) had no clinical findings detected on scrotal examination. No subject was found to have testis cancer; 20.9% had a benign scrotal or inguinal condition detected with the majority (65%) not aware of the abnormality. Men who demonstrate a superior awareness of their scrotal abnormalities were more likely to perform TSE. CONCLUSIONS: Increased awareness of scrotal abnormalities combined with TSE may have a role in improving detection of significant testicular pathology. However, the high prevalence of benign scrotal conditions, of which most men were unaware, may serve to raise anxiety in the patient and general practitioner. We believe there is no role for a one-stop scrotal anxiety clinic, as the costs do not justify the benefits.

Extended long term functional outcome of inflatable penile prosthesis in a single institution.

We sought to evaluate the extended long term functional outcome of the AMS700 three piece inflatable prosthesis in men with erectile dysfunction in a single urological department and assess our revision rates. Patients that underwent first-time insertion or revision of an AMS700 3 piece inflatable penile prosthesis between 1984-2007 were included. Data was obtained from medical records and long term follow up of patients was conducted by telephone interview. The medical records of 38 patients were available for review. Of these 38 men, 56 prostheses were inserted. The mean follow up was 8.4 years (101 months). The revision rate at 50 months postoperatively was 7/38 (18%). The overall revision rate was 18/38 (47%). The mean time to revision in these 18 patients was 72 months (12-156 months) after initial insertion of AMS700 penile prosthesis. This study highlights that with longer follow u revision rates markedly increase after 72 months.

Pathways for the influx of molecules into cercariae of Schistosoma mansoni during skin penetration.

It has been observed that fluorescent membrane-impermeant molecules can enter the cercariae as they penetrate mouse skin. The hypothesis to be tested was that such molecules, which included Lucifer Yellow and a variety of fluorescent dextrans, entered the parasite through the nephridiopore and excretory tubules as well as through the surface membrane. FITC-labelled poly-L-lysine (molecular weight 10 kDa), added at 4 degrees C during syringe transformation, was found to enter the nephridiopore and labelled the excretory bladder and sometimes the excretory tubules. This finding indicates that macromolecules (10 kDa) can enter the nephridiopore. It was found that linoleic acid (a normal constituent of skin) greatly stimulated uptake of Lucifer Yellow and dextrans into the excretory/subtegumental region of 2-h-old schistosomula. This correlated with an increased uptake of membrane-impermeant propidium iodide at 37 degrees C. Since increased uptake of propidium iodide occurs when membranes become permeable, the surface membrane could also be a pathway of transport of the membrane-impermeant molecules into the schistosomulum.

Schistosoma mansoni cercariae experience influx of macromolecules during skin penetration.

We have observed that when cercariae penetrate the skin of mice, there is influx into their tissues of Lucifer Yellow and certain labelled molecules of up to 20 kDa molecular weight. This observation was made using a variety of fluorescent membrane-impermeant compounds injected into the skin before the application of cercariae. This unexpected phenomenon was investigated further by transforming cercariae in vitro in the presence of the membrane-impermeant compounds and examining the distribution by microscopy. In schistosomula derived from this procedure, the nephridiopore and surface membrane were labelled while the pre- and post-acetabular glands were not labelled. The region associated with the oesophagus within the pharyngeal muscle clearly contained the fluorescent molecules, as did the region adjacent to the excretory tubules and the germinal mass. We used cercariae stained with carmine to aid identification of regions labelled with Lucifer Yellow. Although the mechanism of this influx is unclear, the observation is significant. From it, we can suggest an hypothesis that, during skin penetration, exposure of internal tissues of the parasite to external macromolecules represents a novel host-parasite interface.