Disparities in job characteristics by race and sex in a Southern aluminum smelting facility.

BACKGROUND: Former workers at a Southern aluminum smelting facility raised concerns that the most hazardous jobs were assigned to Black workers, but the role of workplace segregation had not been quantified or examined in the company town. Prior studies discuss race and gender disparities in working conditions, but few have documented them in the aluminum industry. METHODS: We obtained workers' company records for 1985-2007 and characterized four job metrics: prestige (sociologic rankings), worker-defined danger (worker assessments), annual wage (1985 dollars), and estimated total particulate matter (TPM) exposure (job exposure matrix). Characteristics of job at hire and trajectories were compared by race and sex using linear binomial models. RESULTS: Non-White males had the highest percentage of workers in low prestige and high danger jobs at hire and up to 20 years after. After 20 years tenure, 100% of White workers were in higher prestige and lower danger jobs. Most female workers, regardless of race, entered and remained in low-wage jobs, while 50% of all male workers maintained their initial higher-wage jobs. Non-White females had the highest prevalence of workers in low-wage jobs at hire and after 20 years-increasing from 63% (95% CI: 59-67) to 100% (95% CI: 78-100). All female workers were less likely to be in high TPM exposure jobs. Non-White males were most likely to be hired into high TPM exposure jobs, and this exposure prevalence increased as time accrued, while staying constant for other race-sex groups. CONCLUSIONS: There is evidence of job segregation by race and sex in this cohort of aluminum smelting workers. Documentation of disparities in occupational hazards is important for informing health interventions and research.

Discovery and Toxicological Profiling of Aminopyridines as Orally Bioavailable Selective Inhibitors of PI3-Kinase γ.

Using a novel physiologically relevant in vitro human whole blood neutrophil shape change assay, an aminopyrazine series of selective PI3Kγ inhibitors was identified and prioritized for further optimization. Severe solubility limitations associated with the series leading to low oral bioavailability and poor exposures, especially at higher doses, were overcome by moving to an aminopyridine core. Compound 33, with the optimal balance of on-target activity, selectivity, and pharmacokinetic parameters, progressed into in vivo studies and demonstrated good efficacy (10 mg/kg) in a rat model of airway inflammation. Sufficient exposures were achieved at high doses to support toxicological studies, where unexpected inflammatory cell infiltrates in cardiovascular tissue prevented further compound development.

A framework for breast cancer classification using Multi-DCNNs.

BACKGROUND: Deep learning (DL) is the fastest-growing field of machine learning (ML). Deep convolutional neural networks (DCNN) are currently the main tool used for image analysis and classification purposes. There are several DCNN architectures among them AlexNet, GoogleNet, and residual networks (ResNet). METHOD: This paper presents a new computer-aided diagnosis (CAD) system based on feature extraction and classification using DL techniques to help radiologists to classify breast cancer lesions in mammograms. This is performed by four different experiments to determine the optimum approach. The first one consists of end-to-end pre-trained fine-tuned DCNN networks. In the second one, the deep features of the DCNNs are extracted and fed to a support vector machine (SVM) classifier with different kernel functions. The third experiment performs deep features fusion to demonstrate that combining deep features will enhance the accuracy of the SVM classifiers. Finally, in the fourth experiment, principal component analysis (PCA) is introduced to reduce the large feature vector produced in feature fusion and to decrease the computational cost. The experiments are performed on two datasets (1) the curated breast imaging subset of the digital database for screening mammography (CBIS-DDSM) and (2) the mammographic image analysis society digital mammogram database (MIAS). RESULTS: The accuracy achieved using deep features fusion for both datasets proved to be the highest compared to the state-of-the-art CAD systems. Conversely, when applying the PCA on the feature fusion sets, the accuracy did not improve; however, the computational cost decreased as the execution time decreased.

Trunk and Lower Extremity Movement Patterns, Stress Fracture Risk Factors, and Biomarkers of Bone Turnover in Military Trainees.

CONTEXT: Military service members commonly sustain lower extremity stress fractures (SFx). How SFx risk factors influence bone metabolism is unknown. Understanding how SFx risk factors influence bone metabolism may help to optimize risk-mitigation strategies. OBJECTIVE: To determine how SFx risk factors influence bone metabolism. DESIGN: Cross-sectional study. SETTING: Military service academy. PATIENTS OR OTHER PARTICIPANTS: Forty-five men (agepre = 18.56 ± 1.39 years, heightpre = 176.95 ± 7.29 cm, masspre = 77.20 ± 9.40 kg; body mass indexpre = 24.68 ± 2.87) who completed Cadet Basic Training (CBT). Individuals with neurologic or metabolic disorders were excluded. INTERVENTION(S): We assessed SFx risk factors (independent variables) with (1) the Landing Error Scoring System (LESS), (2) self-reported injury and physical activity questionnaires, and (3) physical fitness tests. We assessed bone biomarkers (dependent variables; procollagen type I amino-terminal propeptide [PINP] and cross-linked collagen telopeptide [CTx-1]) via serum. MAIN OUTCOME MEASURE(S): A markerless motion-capture system was used to analyze trunk and lower extremity biomechanics via the LESS. Serum samples were collected post-CBT; enzyme-linked immunosorbent assays determined PINP and CTx-1 concentrations, and PINP : CTx-1 ratios were calculated. Linear regression models demonstrated associations between SFx risk factors and PINP and CTx-1 concentrations and PINP : CTx-1 ratio. Biomarker concentration mean differences with 95% confidence intervals were calculated. Significance was set a priori using α ≤ .10 for simple and α ≤ .05 for multiple regression analyses. RESULTS: The multiple regression models incorporating LESS and SFx risk factor data predicted the PINP concentration (R2 = 0.47, P = .02) and PINP : CTx-1 ratio (R2 = 0.66, P = .01). The PINP concentration was increased by foot internal rotation, trunk flexion, CBT injury, sit-up score, and pre- to post-CBT mass changes. The CTx-1 concentration was increased by heel-to-toe landing and post-CBT mass. The PINP : CTx-1 ratio was increased by foot internal rotation, lower extremity sagittal-plane displacement (inversely), CBT injury, sit-up score, and pre- to post-CBT mass changes. CONCLUSIONS: Stress fracture risk factors accounted for 66% of the PINP : CTx-1 ratio variability, a potential surrogate for bone health. Our findings provide insight into how SFx risk factors influence bone health. This information can help guide SFx risk-mitigation strategies.

Cancer and noncancer mortality among aluminum smelting workers in Badin, North Carolina.

BACKGROUND: Badin, North Carolina, hosted an aluminum smelting plant from 1917 to 2007. The Concerned Citizens of West Badin reported suspected excess cancer mortality among former employees. This study aimed to investigate these concerns. METHODS: The study cohort was enumerated from United Steel Workers' records of workers employed from 1980 to 2007. Cause-specific mortality rates in the cohort were compared with North Carolina population mortality rates using standardized mortality ratios (SMRs), standardized by age, sex, race, and calendar period. We estimated cause-specific adjusted standardized mortality ratios (aSMRs) using negative controls to mitigate healthy worker survivor bias (HWSB). Standardized rate ratios (SRRs) were calculated to compare mortality rates between workers ever employed vs never employed in the pot room. RESULTS: All-cause mortality among Badin workers was lower than in the general population (SMR: 0.81, 95% confidence interval [CI]: 0.71-0.92). After adjusting for HWSB, excesses for all cancers (aSMR: 1.55, 95% CI: 1.10-2.21), bladder cancer (3.47, 95% CI: 1.25-9.62), mesothelioma (17.33, 95% CI: 5.40-55.59), and respiratory cancer (1.24, 95% CI: 0.77-1.99) were observed. Black males worked the highest proportion of their employed years in the pot room. Potroom workers experienced higher respiratory cancer (SRR: 2.99, 95% CI: 1.23-7.26), bladder cancer (SRR: 1.58, 95% CI: 0.15-15.28), and mesothelioma (SRR: 3.36, 95% CI: 0.21-53.78) mortality rates than never workers in the pot room. CONCLUSIONS: This study responds to concerns of a group of former aluminum workers. The results, while imprecise, suggest excess respiratory and bladder cancers among pot room workers in a contemporary cohort of union employees at a US smelter.

Osteoarthritis Prevalence in Retired National Football League Players With a History of Ankle Injuries and Surgery.

CONTEXT: Ankle injuries are common at all levels of American football, and retired National Football League (NFL) players have a high prevalence of osteoarthritis (OA), but little is known about how ankle injuries influence OA prevalence and daily activities in this population or how surgical interventions for such injuries alter the risk of OA. OBJECTIVE: To examine (1) the association of ankle-injury history with OA prevalence, (2) the association of surgical intervention after ankle injury with OA prevalence, and (3) the relationships among ankle injuries, reported OA, and daily activities in retired NFL players. DESIGN: Case-control study. SETTING: Survey. PATIENTS OR OTHER PARTICIPANTS: Data from the Retired NFL Players General Health Survey. MAIN OUTCOME MEASURE(S): We created a 7-category main exposure variable that differentiated respondents by football-related ankle injury and surgical intervention. Multivariable binomial regression models were used to estimate prevalence ratios and 95% confidence intervals. Among those reporting OA, we examined the distribution of responses regarding whether OA affected daily activities. RESULTS: Among the 2446 respondents, 920 participants experienced OA in any joint during their lifetime. Compared with those reporting no ankle injuries, the prevalence of OA was higher among those with a history of ankle injury. Also, the prevalence of OA was higher among those who had undergone surgery versus those who had not. The number of retired NFL players who reported that OA often affected their daily activities increased with the number of ankle injuries. CONCLUSIONS: Among former NFL players, a history of ankle injury increased the prevalence of OA. More ankle injuries increased the probability that OA negatively affected daily activities. Future prospective research is needed to better determine the influence of surgical intervention at the ankle or foot on OA.

Employment characteristics and cause-specific mortality at automotive electronics manufacturing plants in Huntsville, Alabama.

BACKGROUND: This study was carried out in response to worker concerns over their exposure to lead solder and chlorinated solvents at automotive electronics manufacturing plants in Huntsville, Alabama. METHODS: A study of 4396 United Autoworkers members ever-employed at the plants between 1972 and 1993 was conducted with mortality follow-up through 2016. Poisson regression was used to estimate mortality rate ratios (RR) according to employment characteristics, including calendar period of employment. RESULTS: Pre-1977 hires exhibited elevated adjusted rates of all-cause (RR, 1.29; 95% confidence interval [CI], 1.09-1.52), cardiovascular (RR, 1.38; 95% CI, 1.03-1.86), and digestive system (RR, 2.31; 95% CI, 1.04-5.10) disease mortality relative to the most recent hire group (1984-1993). Never- versus ever-employment in a skilled trade job was associated with elevated adjusted rates of all-cause, all-cancer, and cardiovascular disease mortality. Nervous system disorder mortality was greatest among 1977-1983 hires. CONCLUSIONS: Elevated mortality among pre-1977 hires is consistent with worker concerns over greater exposure to hazards at the original plant building.

Breast cancer detection using deep convolutional neural networks and support vector machines.

It is important to detect breast cancer as early as possible. In this manuscript, a new methodology for classifying breast cancer using deep learning and some segmentation techniques are introduced. A new computer aided detection (CAD) system is proposed for classifying benign and malignant mass tumors in breast mammography images. In this CAD system, two segmentation approaches are used. The first approach involves determining the region of interest (ROI) manually, while the second approach uses the technique of threshold and region based. The deep convolutional neural network (DCNN) is used for feature extraction. A well-known DCNN architecture named AlexNet is used and is fine-tuned to classify two classes instead of 1,000 classes. The last fully connected (fc) layer is connected to the support vector machine (SVM) classifier to obtain better accuracy. The results are obtained using the following publicly available datasets (1) the digital database for screening mammography (DDSM); and (2) the Curated Breast Imaging Subset of DDSM (CBIS-DDSM). Training on a large number of data gives high accuracy rate. Nevertheless, the biomedical datasets contain a relatively small number of samples due to limited patient volume. Accordingly, data augmentation is a method for increasing the size of the input data by generating new data from the original input data. There are many forms for the data augmentation; the one used here is the rotation. The accuracy of the new-trained DCNN architecture is 71.01% when cropping the ROI manually from the mammogram. The highest area under the curve (AUC) achieved was 0.88 (88%) for the samples obtained from both segmentation techniques. Moreover, when using the samples obtained from the CBIS-DDSM, the accuracy of the DCNN is increased to 73.6%. Consequently, the SVM accuracy becomes 87.2% with an AUC equaling to 0.94 (94%). This is the highest AUC value compared to previous work using the same conditions.

Methodologic limitations of prescription opioid safety research and recommendations for improving the evidence base.

PURPOSE: The ongoing opioid epidemic has claimed more than a quarter million Americans' lives over the past 15 years. The epidemic began with an escalation of prescription opioid deaths and has now evolved to include secondary waves of illicit heroin and fentanyl deaths, while the deaths due to prescription opioid overdoses are still increasing. In response, the Centers for Disease Control and Prevention (CDC) moved to limit opioid prescribing with the release of opioid prescribing guidelines for chronic noncancer pain in March 2016. The guidelines represent a logical and timely federal response to this growing crisis. However, CDC acknowledged that the evidence base linking opioid prescribing to opioid use disorders and overdose was grades 3 and 4. METHODS: Motivated by the need to strengthen the evidence base, this review details limitations of the opioid safety studies cited in the CDC guidelines with a focus on methodological limitations related to internal and external validity. RESULTS: Internal validity concerns were related to poor confounding control, variable misclassification, selection bias, competing risks, and potential competing interventions. External validity concerns arose from the use of limited source populations, historical data (in a fast-changing epidemic), and issues with handling of cancer and acute pain patients' data. We provide a nonexhaustive list of 7 recommendations to address these limitations in future opioid safety studies. CONCLUSION: Strengthening the opioid safety evidence base will aid any future revisions of the CDC guidelines and enhance their prevention impact.

Mortality among autoworkers manufacturing electronics in Huntsville, Alabama.

BACKGROUND: Workers raised concerns over suspected excesses of mortality at automotive electronics manufacturing facilities in Huntsville, Alabama. METHODS: A study of 4396 UAW members ever-employed at Huntsville facilities between 1972 and 1993 was conducted with mortality follow-up through 2016. Standardized Mortality Ratios (SMRs) were estimated using U.S. and Alabama reference rates. RESULTS: Relative to U.S. rates, there was a modest excess of all-cause mortality among White female workers (SMR 1.08, 95%CI: 0.99-1.18) and among all workers hired <1977 at the original plant building (SMR 1.10, 95%CI: 0.99-1.22). There was excess nervous system disorder (SMR 1.24, 95%CI: 0.91-1.65) and brain and nervous system cancer (SMR 1.31, 95%CI: 0.67-2.28) mortality. Estimates for several causes of interest were imprecise. CONCLUSIONS: All-cause mortality estimates were greater than anticipated based on results from other UAW cohorts. The excess of nervous system disease mortality is consistent with other studies of electronics workers exposed to lead-solder and chlorinated solvents.

Trends in Incidence of ACL Reconstruction and Concomitant Procedures Among Commercially Insured Individuals in the United States, 2002-2014.

BACKGROUND:: Few population-based descriptive studies on the incidence of anterior cruciate ligament (ACL) reconstruction and concomitant pathology exist. HYPOTHESIS:: Incidence of ACL reconstruction has increased from 2002 to 2014. STUDY DESIGN:: Descriptive clinical epidemiology study. LEVEL OF EVIDENCE:: Level 3. METHODS:: The Truven Health Analytics MarketScan Commercial Claims and Encounters database, which contains insurance enrollment and health care utilization data for approximately 158 million privately insured individuals younger than 65 years, was used to obtain records of ACL reconstructions performed between 2002 and 2014 and any concomitant pathology using Current Procedures Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes. The denominator population was defined as the total number of person-years (PYs) for all individuals in the database. Annual rates were computed overall and stratified by age, sex, and concomitant procedure. RESULTS:: There were 283,810 ACL reconstructions and 385,384,623 PYs from 2002 to 2014. The overall rate of ACL reconstruction increased 22%, from 61.4 per 100,000 PYs in 2002 to 74.6 per 100,000 PYs in 2014. Rates of isolated ACL reconstruction were relatively stable over the study period. However, among children and adolescents, rates of both isolated ACL reconstruction and ACL reconstruction with concomitant meniscal surgery increased substantially. Adolescents aged 13 to 17 years had the highest absolute rates of ACL reconstruction, and their rates increased dramatically over the 13-year study period (isolated, +37%; ACL + meniscal repair, +107%; ACL + meniscectomy, +63%). Rates of isolated ACL reconstruction were similar for males and females (26.1 vs 25.6 per 100,000 PYs, respectively, in 2014), but males had higher rates of ACL reconstruction with concomitant meniscal surgery than females. CONCLUSION:: Incidence rates of isolated ACL reconstruction and rates of concomitant meniscal surgery have increased, particularly among children and adolescents. CLINICAL RELEVANCE:: A renewed focus on adoption of injury prevention programs is needed to mitigate these trends. In addition, more research is needed on long-term patient outcomes and postoperative health care utilization after ACL reconstruction, with a focus on understanding the sex-based disparity in concomitant meniscal surgery.

Time between anterior cruciate ligament injury and reconstruction and cartilage metabolism six-months following reconstruction.

BACKGROUND: To determine the association between time from injury to ACL reconstruction (TimeInjury-ACLR) and biochemical markers of cartilage metabolism and inflammation six months following ACL reconstruction (ACLR). METHODS: Individuals with a unilateral ACL injury were enrolled at initial presentation in the orthopedic clinic; blood was collected six months following ACLR. Enzyme-linked immunosorbent assays were used to analyze the ratio of serum concentrations of type-II collagen breakdown (C2C) to synthesis (CPII), plasma matrix metalloproteinase-3 (MMP-3), interleukin-6 (IL-6), and serum aggrecan neoepitope (ARGS). We used separate linear regressions to assess associations between biochemical markers and TimeInjury-ACLR. RESULTS: Twenty-two participants (50% females, mean [SD], age 21.9 [4.5] years old; BMI 23.8 [2.6] kg/m2) completed the study. TimeInjury-ACLR ranged from nine to 67days (31.0 [14.4days]). Greater TimeInjury-ACLR predicted greater serum C2C:CPII ratios six months following ACLR (C2C:CPII=0.15 [0.02], R2=0.213, P=0.030). Males (R2=0.733, P=0.001) but not females (R2=0.030, P=0.609) demonstrated a significant association between greater C2C:CPII and TimeInjury-ACLR at the six-month follow-up exam. TimeInjury-ACLR did not associate with IL-6, MMP-3, or ARGS at six months. CONCLUSIONS: Greater time between injury and ACL reconstruction was associated with greater serum C2C:CPII six months following ACLR in males but not females, and IL-6, MMP-3, and ARGS levels were not associated with TimeInjury-ACLR in males or females. The time between ACL injury and ACLR may affect collagen metabolism in males and should be further investigated in a larger study along with other patient-relevant outcomes.

Associations Between Slower Walking Speed and T1ρ Magnetic Resonance Imaging of Femoral Cartilage Following Anterior Cruciate Ligament Reconstruction.

OBJECTIVE: To determine whether walking speed, collected at 6 and 12 months following anterior cruciate ligament reconstruction (ACLR), is associated with inter-extremity differences in proteoglycan density, measured via T1ρ magnetic resonance imaging, in tibiofemoral articular cartilage 12 months following ACLR. METHODS: Twenty-one individuals with a unilateral patellar-tendon autograft ACLR (10 women and 11 men, mean ± SD age 23.9 ± 2.7 years, mean ± SD body mass index 23.9 ± 2.7 kg/m2 ) were recruited for participation in this study. Walking speed was collected using 3-dimensional motion capture at 6 and 12 months following ACLR. The articular cartilage of the medial femoral condyle (MFC) and lateral femoral condyle and medial and lateral tibial condyles was manually segmented and subsectioned into 3 regions of interest (anterior, central, and posterior) based on the location of the meniscus in the sagittal plane. Inter-extremity mean T1ρ relaxation time ratios (T1ρ ACLR extremity / T1ρ contralateral extremity) were calculated and used for analysis. Pearson product-moment correlations were used to determine associations between walking speed and inter-extremity differences in T1ρ relaxation time ratios. RESULTS: Slower walking speed 6 months post-ACLR was significantly associated with higher T1ρ relaxation time ratios in the MFC of the ACLR extremity 12 months following ACLR (posterior MFC, r = -0.51, P = 0.02; central MFC, r = -0.47, P = 0.04). Similarly, slower walking speed at 12 months post-ACLR was significantly associated with higher T1ρ relaxation time ratios in the posterior MFC ACLR extremity (r = -0.47, P = 0.04) 12 months following ACLR. CONCLUSION: Slower walking speed at 6 and 12 months following ACLR may be associated with early proteoglycan density changes in medial femoral compartment cartilage health in the first 12 months following ACLR.

Associations between BMI Change and Cardiometabolic Risk in Retired Football Players.

PURPOSE: Elevated rates of cardiometabolic diseases have been observed in former American football players. The current study sought to determine whether change in body mass index (ΔBMI) after retirement influences the prevalence of CHD, diabetes, or high blood pressure (HBP) in former professional football players. METHODS: Retired professional football players (n = 3729) were sent a survey with questions regarding health status, playing history, and demographic information. Self-reported BMI at the time of retirement was subtracted from current self-reported BMI to calculate ΔBMI. Prevalence of CHD, diabetes, and HBP were determined by asking participants if they had ever been diagnosed by a health care professional. Binomial regression with a Poisson residual and robust variance estimation was used to compute crude prevalence ratios (PR) and 95% confidence intervals (CI) for each outcome. Adjusted PR values were calculated by adjusting for BMI at the time of retirement, age, years of football experience, race, exercise habits, alcohol use, steroid history, smoking history, and playing position. RESULTS: Complete data were available for 2062 respondents. Prevalence of CHD increased 25%-31% for each five-point increase in ΔBMI after retirement (crude PR = 1.25, 95% CI = 1.03-1.52, P = 0.026; adjusted PR = 1.31, 95% CI = 1.11-1.55, P = 0.001). Diabetes prevalence increased 69%-88% for each five-point ΔBMI increase (crude = 1.88, 95% CI = 1.45-2.44, P < 0.001; adjusted = 1.69, 95% CI = 1.32-2.15, P < 0.001). A five-point increase in ΔBMI was associated with a 35%-40% increase in HBP prevalence (crude = 1.40, 95% CI = 1.27-1.53, P < 0.001; adjusted = 1.35, 95% CI = 1.24-1.47, P < 0.001). CONCLUSIONS: After controlling for relevant covariates, postretirement ΔBMI was positively and independently associated with prevalence of CHD, diabetes, and HBP. Postretirement interventions using diet and/or exercise to influence body composition may improve long-term health in retired football players.

Cost of Outpatient Arthroscopic Anterior Cruciate Ligament Reconstruction Among Commercially Insured Patients in the United States, 2005-2013.

BACKGROUND: Despite the significance of anterior cruciate ligament (ACL) injuries, these conditions have been under-researched from a population-level perspective. It is important to determine the economic effect of these injuries in order to document the public health burden in the United States. PURPOSE: To describe the cost of outpatient arthroscopic ACL reconstruction and health care utilization among commercially insured beneficiaries in the United States. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: The study used the Truven Health Analytics MarketScan Commercial Claims and Encounters database, an administrative claims database that contains a large sample (approximately 148 million) of privately insured individuals aged <65 years and enrolled in employer-sponsored plans. All claims with Current Procedural Terminology (CPT) code 29888 (arthroscopically aided ACL reconstruction or augmentation) from 2005 to 2013 were included. "Immediate procedure" cost was computed assuming a 3-day window of care centered on date of surgery. "Total health care utilization" cost was computed using a 9-month window of care (3 months preoperative and 6 months postoperative). RESULTS: There were 229,446 outpatient arthroscopic ACL reconstructions performed over the 9-year study period. Median immediate procedure cost was $9399.49. Median total health care utilization cost was $13,403.38. Patients who underwent concomitant collateral ligament (medial [MCL], lateral [LCL]) repair or reconstruction had the highest costs for both immediate procedure ($12,473.24) and health care utilization ($17,006.34). For patients who had more than 1 reconstruction captured in the database, total health care utilization costs were higher for the second procedure than the first procedure ($16,238.43 vs $15,000.36), despite the fact that immediate procedure costs were lower for second procedures ($8685.73 vs $9445.26). CONCLUSION: These results provide a foundation for understanding the public health burden of ACL injuries in the United States. Our findings suggest that further research on the prevention and treatment of ACL injuries is necessary to reduce this burden.

Artificial Urinary Sphincters for Treatment of Urinary Incontinence in Elderly Males.

INTRODUCTION: We sought to examine the role of advanced age (defined as >70 years), impaired cognitive function, and decreased manual dexterity in the rates of re-operation (revision or replacement) of artificial urinary sphincters (AUS). METHODS: From 1988 to 2012, 213 men underwent virgin AUS placements. Failure was defined as a revision performed for stress incontinence and replacement/exploration performed for urethral erosion/infection or mechanical failure. Kaplan-Meier curves were constructed to compare failure rates with age and Cox proportional hazard models were used to test associations. RESULTS: Advanced age was not associated with overall failure (p = 0.48), erosion/infection failure (p = 0.65), recurrent/persistent incontinence failure (p = 0.08), or mechanical failure (p = 0.36). Controlling for age, patients with cognitive dysfunction or decreased manual dexterity showed a higher rate of overall failure (p = 0.01). CONCLUSIONS: AUS placement is an excellent option to treat stress urinary incontinence in elderly men with intact cognition and good manual dexterity. AUS placement should be performed with caution in patients with impaired cognitive function or decreased manual dexterity, and additional effort should be made to identify these conditions both before and after surgery.

Botulinum Toxin Type A Injections for the Treatment of Continent Catheterizable Ileal-colic Urinary Diversion Muscularis Overactivity.

INTRODUCTION: Continent catheterizable diversions can exhibit long-term complications such as high pressures and involuntary unit contractions within the urinary reservoir, rendering them similar to neurogenic bladders. Given the similarity of these issues to neurogenic detrusor overactivity, the use of Botox injections is a logical treatment option to explore. TECHNICAL CONSIDERATIONS: A patient with a contracted Indiana pouch continent catheterizable diversion was treated with intra-pouch Botox injections after failing maximal doses of oral anticholinergic medications. This patient underwent four consecutive percutaneous Botox pouch injections every 11-12 months under general anesthesia. Flexible cystoscope via the catch stoma was attempted first on the first two surgeries, but the scope could not reach the majority of the pouch. Thus, percutaneous access was obtained under fluoroscopic guidance, and the injections were performed through a suprapubic tube access sheath. Two hundred to four hundred units of Botox (stained with methylene blue) were visually injected in 20-40 separate injection sites. Of note, the initial dose used was 200 units and was increased to 300 units then 400 units on subsequent treatments to improve results and durability. After each round of Botox injections, the patient noted resolution of her symptoms. Postinjection urodynamic studies showed normal filling with no evidence of muscularis overactivity, even at high volumes of 600 cc. CONCLUSION: Botox injections may be an excellent long-term treatment option for contracted continent catheterizable diversions, or at least used as a temporizing measure before surgical augmentation. Further studies are needed to verify the durability, complications, and long-term outcomes of this procedure.

Testicular Leydig Cell Tumor with Metachronous Lesions: Outcomes after Metastasis Resection and Cryoablation.

Leydig cell tumors represent 3% of testicular masses and usually occur in prepubertal boys and men between 30 and 60 years of age. Leydig cell tumors are benign in children but can be malignant in 10% of adults. This case report describes a 41-year-old patient who was diagnosed with a Leydig cell tumor that originated in his right testicle that subsequently metastasized to his liver, lungs, and retroperitoneum. We discuss the patient's presentation and review the radiographic findings, surgical treatment, surgical pathology, chemotherapeutic treatment, and published literature on this rare pathology.

The Impact of Medicaid Expansion on Oral Health Equity for Older Adults: A Systems Perspective.

This paper uses a collaborative, interdisciplinary systems science inquiry to explore implications of Medicaid expansion on achieving oral health equity for older adults. Through an iterative modeling process oriented toward the experiences of both patients and oral health care providers, complex feedback mechanisms for promoting oral health equity are articulated that acknowledge the potential for stigma as well as disparities in oral health care accessibility. Multiple factors mediate the impact of Medicaid expansion on oral health equity.