Qualitative Analysis of Patient Experiences Reaching Urethroplasty for Recurrent Urethral Stricture Disease.

PURPOSE: Despite the inferior outcomes, urethral stricture patients often undergo multiple endoscopic procedures prior to undergoing definitive urethroplasty. We sought to qualitatively evaluate the patient experience of obtaining urethroplasty to better understand the impact of this experience on quality of life. MATERIALS AND METHODS: Patients treated with urethroplasty between September 2019 and July 2021 were identified and invited to participate in our study if they had undergone ≥ 2 endoscopic procedures prior to urethroplasty. Semistructured telephone interviews were conducted, coded, and analyzed using an iterative inductive-deductive approach. RESULTS: Of the 105 urethroplasty patients during the study period, 50 (47.6%) had undergone ≥ 2 endoscopic procedures prior (IQR 3-5), of whom 20 participated in the study. Qualitative themes related to repeat endoscopic procedures included unmet treatment expectations, dissatisfaction with catheterization and repeat procedures, and negative impacts of recurrent stricture symptoms and treatments on quality of life. External factors associated with a delay to urethroplasty included financial constraints, surgeon access, and time off work. CONCLUSIONS: A trajectory of declining quality of life and unmet treatment expectations are the primary factors driving the decision to proceed with urethroplasty. However, external factors such as recovery costs and access to specialists play important roles in delaying surgery. These findings illustrate the need for improved community provider education and patient counseling to better inform expectations of both patients and providers with various treatment outcomes. Furthermore, these data highlight the need to improve access to specialized care for urethral stricture patients.

Unlocking Peer Review: Elevating Scholarly Writing and Research Competence in Urology Residency.

PURPOSE OF REVIEW: It is incumbent upon training programs to set the foundation for evidence-based practices and to create opportunities for trainees to develop into academic leaders. As dedicated resident research time and funding have declined in recent years, residency programs and the field at large will need to create new ways to incorporate scholarly activity into residency curricula. RECENT FINDINGS: Literature across specialties demonstrates barriers to resident involvement including lack of time, cost, and absent scholarly mentorship. Peer review stands as a ready-made solution that can be formalized into a collaborative relationship with journals. A formal relationship between professional societies, academic journals, and residencies can facilitate the use of peer review as a teaching tool for residency programs.

Isotopic labeling of metabolic water with 18 O2.

RATIONALE: Water is the medium of life, is involved in biochemical reactions, and is exchanged among internal pools and with the water in the external environment of organisms. Understanding these processes can be improved by isotopically labeling the metabolic water that is produced inside the cells of organisms during aerobic respiration. METHODS: Here we describe a new method for isotopically labeling cellular water by incubating microbes and plant tissues in air enriched in 18 O2 . As oxygen gas is reduced during respiration, H2 18 O is produced. The rate of H2 18 O production and the synthesis of biomolecules that incorporate 18 O from H2 18 O can be quantified using cavity ringdown spectrometry and isotope ratio mass spectrometry. RESULTS: For Escherichia coli in solution culture, soil microbial communities, and respiring tissues of plants, the amount of H2 18 O produced was strongly correlated with that of 18 O2 consumed during incubations. Measurements of 18 O in DNA, microbial biomass, and CO2 showed that metabolic water was an important substrate in biosynthesis reactions. CONCLUSIONS: Any organism with aerobic respiration is amenable to labeling with 18 O2 , and the method described here enables a new approach to investigate questions regarding plant and microbial physiology. In plants, 18 O introduced as metabolic water could be tracked as it moves between living cells and exchanges with external water. For probing soil microbial physiology, the method described here has the advantage over the application of exogenous H2 18 O of not increasing the soil moisture, a disturbance that can affect microbial metabolism.

Global patterns of drought recovery.

Drought, a recurring phenomenon with major impacts on both human and natural systems, is the most widespread climatic extreme that negatively affects the land carbon sink. Although twentieth-century trends in drought regimes are ambiguous, across many regions more frequent and severe droughts are expected in the twenty-first century. Recovery time-how long an ecosystem requires to revert to its pre-drought functional state-is a critical metric of drought impact. Yet the factors influencing drought recovery and its spatiotemporal patterns at the global scale are largely unknown. Here we analyse three independent datasets of gross primary productivity and show that, across diverse ecosystems, drought recovery times are strongly associated with climate and carbon cycle dynamics, with biodiversity and CO2 fertilization as secondary factors. Our analysis also provides two key insights into the spatiotemporal patterns of drought recovery time: first, that recovery is longest in the tropics and high northern latitudes (both vulnerable areas of Earth's climate system) and second, that drought impacts (assessed using the area of ecosystems actively recovering and time to recovery) have increased over the twentieth century. If droughts become more frequent, as expected, the time between droughts may become shorter than drought recovery time, leading to permanently damaged ecosystems and widespread degradation of the land carbon sink.

The Impact of Delayed-Phase Imaging at Admission on the Management of Urinary Extravasation in High-Grade Renal Trauma.

PURPOSE: American Urological Association Urotrauma guidelines recommend delayed-phase imaging on presentation for all renal injuries, although data to support it are anecdotal. Forgoing delays risks unrecognized collecting system injuries. We hypothesized that renal trauma patients without admission delays have more complications from urinary extravasation. MATERIALS AND METHODS: From 2005 through 2020, 1,751 renal trauma patients were identified from our institutional trauma registry. Included patients had an estimated American Association for the Surgery of Trauma renal injury grade of III-V and a perinephric fluid collection. Propensity scores for receipt of delayed-phase imaging were calculated based on Injury Severity Score, arrival condition, admission systolic blood pressure, sex and renal injury grade. Propensity score-adjusted logistic regression was used to compare clinical outcomes between those with and without admission delays. RESULTS: Ninety (28.6%) of 315 included patients had delays on presentation. Patients without delays had higher Injury Severity Scores (29 vs 23, p=0.002), fewer isolated renal injuries (27.6% vs 38.9%, p=0.05) and lower grade renal injuries (56.9% vs 41.1% grade 3, p=0.03). After propensity score adjustment, patients with delays were more likely to undergo immediate interventions (OR 11.75, 95% CI 2.99-78.10) and interval stent placement for urinary extravasation (OR 6.86, 95% CI 1.56-47.64) without a difference in urological complications (OR 5.07, 95% CI 0.25-766.16). CONCLUSIONS: Delayed-phase imaging was associated with an increased odds of undergoing immediate and asymptomatic interval urological interventions without a difference in the odds of a complication after high-grade renal trauma. Post-trauma urinary extravasation requires further research to determine which patients require imaging and intervention.

Temporal shifts in iso/anisohydry revealed from daily observations of plant water potential in a dominant desert shrub.

Plant species are characterized along a spectrum of isohydry to anisohydry depending on their regulation of water potential (Ψ), but the plasticity of hydraulic strategies is largely unknown. The role of environmental drivers was evaluated in the hydraulic behavior of Larrea tridentata, a drought-tolerant desert shrub that withstands a wide range of environmental conditions. With a 1.5 yr time-series of 2324 in situ measurements of daily predawn and midday Ψ, the temporal variability of hydraulic behavior was explored in relation to soil water supply, atmospheric demand and temperature. Hydraulic behavior in Larrea was highly dynamic, ranging from partial isohydry to extreme anisohydry. Larrea exhibited extreme anisohydry under wet soil conditions corresponding to periods of high productivity, whereas partial isohydry was exhibited after prolonged dry or cold conditions, when productivity was low. Environmental conditions can strongly influence plant hydraulic behavior at relatively fast timescales, which enhances our understanding of plant drought responses. Although species may exhibit a dominant hydraulic behavior, variable environmental conditions can prompt plasticity in Ψ regulation, particularly for species in seasonally dry climates.

Non-structural carbohydrate dynamics associated with antecedent stem water potential and air temperature in a dominant desert shrub.

Non-structural carbohydrates (NSCs) are necessary for plant growth and affected by plant water status, but the temporal dynamics of water stress impacts on NSC are not well understood. We evaluated how seasonal NSC concentrations varied with plant water status (predawn xylem water potential, Ψ) and air temperature (T) in the evergreen desert shrub Larrea tridentata. Aboveground sugar and starch concentrations were measured weekly or monthly for ~1.5 years on 6-12 shrubs simultaneously instrumented with automated stem psychrometers; leaf photosynthesis (Anet ) was measured monthly for 1 year. Leaf sugar increased during the dry, premonsoon period, associated with lower Ψ (greater water stress) and high T. Leaf sugar accumulation coincided with declines in leaf starch and stem sugar, suggesting the prioritization of leaf sugar during low photosynthetic uptake. Leaf starch was strongly correlated with Anet and peaked during the spring and monsoon seasons, while stem starch remained relatively constant except for depletion during the monsoon. Recent photosynthate appeared sufficient to support spring growth, while monsoon growth required the remobilization of stem starch reserves. The coordinated responses of different NSC fractions to water status, photosynthesis, and growth demands suggest that NSCs serve multiple functions under extreme environmental conditions, including severe drought.

Linking tree genetics and stream consumers: isotopic tracers elucidate controls on carbon and nitrogen assimilation.

Leaf litter provides an important nutrient subsidy to headwater streams, but little is known about how tree genetics influence energy pathways from litter to higher trophic levels. Despite the charge to quantify carbon (C) and nitrogen (N) pathways from decomposing litter, the relationship between litter decomposition and aquatic consumers remains unresolved. We measured litter preference (attachments to litter), C and N assimilation rates, and growth rates of a shredding caddisfly (Hesperophylax magnus, Limnephilidae) in response to leaf litter of different chemical and physical phenotypes using Populus cross types (P. fremontii, P. angustifolia, and F1 hybrids) and genotypes within P. angustifolia. We combined laboratory mesocosm studies using litter from a common garden with a field study using doubly labeled litter (13 C and 15 N) grown in a greenhouse and incubated in Oak Creek, Arizona, USA. We found that, in the lab, shredders initially chose relatively labile (low lignin and condensed tannin concentrations, rapidly decomposing) cross type litter, but preference changed within 4 d to relatively recalcitrant (high lignin and condensed tannin concentrations, slowly decomposing) litter types. Additionally, in the lab, shredder growth rates were higher on relatively recalcitrant compared to labile cross type litter. Over the course of a three-week field experiment, shredders also assimilated more C and N from relatively recalcitrant compared to labile cross type litter. Finally, among P. angustifolia genotypes, N assimilation by shredders was positively related to litter lignin and C:N, but negatively related to condensed tannins and decomposition rate. C assimilation was likewise positively related to litter C:N, and also to litter %N. C assimilation was not associated with condensed tannins or lignin. Collectively, these findings suggest that relatively recalcitrant litter of Populus cross types provides more nutritional benefit, in terms of N fluxes and growth, than labile litter, but among P. angustifolia genotypes the specific trait of litter recalcitrance (lignin or tannins) determines effects on C or N assimilation. As shredders provide nutrients and energy to higher trophic levels, the influence of these genetically based plant decomposition pathways on shredder preference and performance may affect community and food web structure.

Developing climate-smart restoration: Can plant microbiomes be hardened against heat waves?

Heat waves are increasing in frequency and intensity, presenting a challenge for the already difficult practice of ecological restoration. We investigated whether pre-heating locally sourced rhizosphere soil (inoculum) could acclimatize plants to a field-imposed heat wave in a restoration setting. Soil heating in the laboratory caused a marked shift in rhizosphere bacterial community composition, accompanied by an increase in species evenness. Furthermore, pre-heated rhizosphere soil reduced plant height, number of leaves, and shoot mass of the C4 grass, blue grama (Bouteloua gracilis), and it reduced the shoot mass of the C3 grass, Arizona fescue (Festuca arizonica) in the glasshouse. Following transplantation and the application of a field heat wave, pre-heated inoculum did not influence heat wave survival for either plant species. However, there were strong species-level responses to the field heat wave. For instance, heat wave survivorship was over four times higher in blue grama (92%) than in Arizona fescue (22%). These results suggest that the use of C4 seeds may be preferable for sites exhibiting high heat wave risk. Further research is needed to understand whether inocula are more effective in highly degraded soil in comparison with partially degraded soils.

Transobturator sling for post-prostatectomy incontinence: radiation's effect on efficacy/satisfaction.

INTRODUCTION: We review our experience with the AdVance sling in patients with post- prostatectomy incontinence, comparing the role that adjuvant radiation therapy plays in sling success and patient satisfaction at short and long term follow ups. MATERIALS AND METHODS: Men who underwent AdVance sling placement for post-prostatectomy incontinence from 2007 to present were identified using Current Procedural Terminology (CPT) codes. Manual chart review was performed. Level of incontinence was assessed using Expanded Prostate Cancer Index Composite (EPIC) and pads per day (PPD) use. Satisfaction was assessed by willingness to recommend the procedure to a friend. Outcomes in men who received radiation were compared to radiation-naïve men. RESULTS: Fifty-two men underwent AdVance sling placement. Eighteen men received adjuvant radiation. Thirty-six men were available for short term (19.4 months) and 16 men for long term (61.5 months) follow up. Overall, significant improvement was seen in post-sling EPIC score (24.6, p < 0.001), EPIC incontinence score (39.1, p < .001), and pad use (3.2 PPD to 1.4 PPD, p < .001). Greater improvement in EPIC scores and PPD use was seen in radiation-free men. Irradiated men were less satisfied with the procedure at both short and long term follow up. Diminished efficacy and satisfaction occurred at extended follow up for both groups but was more pronounced with radiation. CONCLUSIONS: The majority of patients undergoing the AdVance sling procedure for post-prostatectomy urinary incontinence saw a significant reduction in pad use, and were overall satisfied in both radiated and non-radiated groups at short and long term follow up. However, improvements were greater in the non-radiated groups and diminished with time.

Plant hydraulics as a central hub integrating plant and ecosystem function: meeting report for 'Emerging Frontiers in Plant Hydraulics' (Washington, DC, May 2015).

Water plays a central role in plant biology and the efficiency of water transport throughout the plant affects both photosynthetic rate and growth, an influence that scales up deterministically to the productivity of terrestrial ecosystems. Moreover, hydraulic traits mediate the ways in which plants interact with their abiotic and biotic environment. At landscape to global scale, plant hydraulic traits are important in describing the function of ecological communities and ecosystems. Plant hydraulics is increasingly recognized as a central hub within a network by which plant biology is connected to palaeobiology, agronomy, climatology, forestry, community and ecosystem ecology and earth-system science. Such grand challenges as anticipating and mitigating the impacts of climate change, and improving the security and sustainability of our food supply rely on our fundamental knowledge of how water behaves in the cells, tissues, organs, bodies and diverse communities of plants. A workshop, 'Emerging Frontiers in Plant Hydraulics' supported by the National Science Foundation, was held in Washington DC, 2015 to promote open discussion of new ideas, controversies regarding measurements and analyses, and especially, the potential for expansion of up-scaled and down-scaled inter-disciplinary research, and the strengthening of connections between plant hydraulic research, allied fields and global modelling efforts.

Restoring forest structure and process stabilizes forest carbon in wildfire-prone southwestern ponderosa pine forests.

Changing climate and a legacy of fire-exclusion have increased the probability of high-severity wildfire, leading to an increased risk of forest carbon loss in ponderosa pine forests in the southwestern USA. Efforts to reduce high-severity fire risk through forest thinning and prescribed burning require both the removal and emission of carbon from these forests, and any potential carbon benefits from treatment may depend on the occurrence of wildfire. We sought to determine how forest treatments alter the effects of stochastic wildfire events on the forest carbon balance. We modeled three treatments (control, thin-only, and thin and burn) with and without the occurrence of wildfire. We evaluated how two different probabilities of wildfire occurrence, 1% and 2% per year, might alter the carbon balance of treatments. In the absence of wildfire, we found that thinning and burning treatments initially reduced total ecosystem carbon (TEC) and increased net ecosystem carbon balance (NECB). In the presence of wildfire, the thin and burn treatment TEC surpassed that of the control in year 40 at 2%/yr wildfire probability, and in year 51 at 1%/yr wildfire probability. NECB in the presence of wildfire showed a similar response to the no-wildfire scenarios: both thin-only and thin and burn treatments increased the C sink. Treatments increased TEC by reducing both mean wildfire severity and its variability. While the carbon balance of treatments may differ in more productive forest types, the carbon balance benefits from restoring forest structure and fire in southwestern ponderosa pine forests are clear.

Vertical stratification of the foliar fungal community in the world's tallest trees.

PREMISE OF THE STUDY: The aboveground tissues of plants host numerous, ecologically important fungi, yet patterns in the spatial distribution of these fungi remain little known. Forest canopies in particular are vast reservoirs of fungal diversity, but intracrown variation in fungal communities has rarely been explored. Knowledge of how fungi are distributed throughout tree crowns will contribute to our understanding of interactions between fungi and their host trees and is a first step toward investigating drivers of community assembly for plant-associated fungi. Here we describe spatial patterns in fungal diversity within crowns of the world's tallest trees, coast redwoods (Sequoia sempervirens). METHODS: We took a culture-independent approach, using the Illumina MiSeq platform, to characterize the fungal assemblage at multiple heights within the crown across the geographical range of the coast redwood. KEY RESULTS: Within each tree surveyed, we uncovered evidence for vertical stratification in the fungal community; different portions of the tree crown harbored different assemblages of fungi. We also report between-tree variation in the fungal community within redwoods. CONCLUSIONS: Our results suggest the potential for vertical stratification of fungal communities in the crowns of other tall tree species and should prompt future study of the factors giving rise to this stratification.

Hydraulic constraints modify optimal photosynthetic profiles in giant sequoia trees.

Optimality theory states that whole-tree carbon gain is maximized when leaf N and photosynthetic capacity profiles are distributed along vertical light gradients such that the marginal gain of nitrogen investment is identical among leaves. However, observed photosynthetic N gradients in trees do not follow this prediction, and the causes for this apparent discrepancy remain uncertain. Our objective was to evaluate how hydraulic limitations potentially modify crown-level optimization in Sequoiadendron giganteum (giant sequoia) trees up to 90 m tall. Leaf water potential (Ψ l ) and branch sap flow closely followed diurnal patterns of solar radiation throughout each tree crown. Minimum leaf water potential correlated negatively with height above ground, while leaf mass per area (LMA), shoot mass per area (SMA), leaf nitrogen content (%N), and bulk leaf stable carbon isotope ratios (δ(13)C) correlated positively with height. We found no significant vertical trends in maximum leaf photosynthesis (A), stomatal conductance (g s), and intrinsic water-use efficiency (A/g s), nor in branch-averaged transpiration (E L), stomatal conductance (G S), and hydraulic conductance (K L). Adjustments in hydraulic architecture appear to partially compensate for increasing hydraulic limitations with height in giant sequoia, allowing them to sustain global maximum summer water use rates exceeding 2000 kg day(-1). However, we found that leaf N and photosynthetic capacity do not follow the vertical light gradient, supporting the hypothesis that increasing limitations on water transport capacity with height modify photosynthetic optimization in tall trees.

Accuracy in the digital workflow: From data acquisition to the digitally milled cast.

STATEMENT OF PROBLEM: The accuracy of digital impressions and the milling of implant crowns greatly influence the clinical outcome of implant restorations. PURPOSE: The purpose of this in vitro study was to calculate the propagation of error in the process of milling an implant crown. MATERIAL AND METHODS: Thirty digitally milled casts made directly from a reference model were prepared. The casts were scanned with a laboratory scanner, and 30 standard tesselation language (STL) datasets from each group were imported to inspection software. In each analysis, STL datasets were aligned by a repeated best fit algorithm, and 18 specified contact locations of interest were measured in mean volumetric deviations. The master reference dataset was aligned 30 times to the master reference dataset to determine the software variation. The reference datasets were aligned to the master reference dataset to determine the scanner variation. The milled cast datasets were aligned to the master reference dataset to determine the milling variation. The 18 specified contact locations of interest were pooled by cusps, occlusal ridge/fossae, interproximal contacts, facial/lingual aspect, and implant position. The pooled areas were statistically analyzed by comparing each group with the reference model to investigate the mean volumetric deviations accounting for accuracy and standard deviations for precision. RESULTS: Software and scanner variation were negligible. Variations in the milled models resulting from software and scanner error exhibited statistical significance (P<.001). Software, scanner, and milling error were shown to propagate through the digital workflow to the milled model. CONCLUSIONS: The pooled locations may describe the reliability of the milling process as it applies to specific anatomic locations on the tooth.