Cost-effectiveness and budget impact analysis of enzalutamide in comparison to abiraterone in treatment of metastatic prostate cancer resistant to castration in Iran.

INTRODUCTION: In recent years, enzalutamide and abiraterone have been widely used as treatments for metastatic castration-resistant prostate cancer (mCRPC). However, the cost-effectiveness of these drugs in Iran is unknown. This study evaluated the cost-effectiveness of enzalutamide for the treatment of metastatic prostate cancer resistant to castration in Iran. METHODS: A 3-state Markov model was developed to evaluate the cost-effectiveness of enzalutamide and abiraterone from a social perspective over 10 years. The clinical inputs were obtained from the meta-analysis studies. The direct medical costs were obtained from the tariffs of the healthcare system, while the direct non-medical and indirect costs were collected from the patients. The data of utilities were derived from the literature. In addition, sensitivity analyses were conducted to assess the uncertainties. RESULTS: Compared with Abiraterone, enzalutamide was associated with a high incremental cost-effectiveness ratio (ICER) of $6,260 per QALY gained. According to the one-way sensitivity analysis, ICER was most heavily influenced by the prices of enzalutamide and Abiraterone, non-medical costs, and indirect costs. Regardless of the variation, enzalutamide remained cost-effective. The budget impact analysis of enzalutamide in the health system during 5 years was estimated at $6,362,127. CONCLUSIONS: At current prices, adding enzalutamide to pharmaceutical lists represents the cost-effective use of the healthcare resources in Iran for the treatment of metastatic castration-resistant prostate cancer.

Cost and utilization analysis of concurrent versus staged testicular prosthesis implantation for radical orchiectomy.

PURPOSE: American Urological Association guidelines recommend testicular prosthesis discussion prior to orchiectomy. Utilization may be low. We compared outcomes and care utilization between concurrent implant (CI) and staged implant (SI) insertion after radical orchiectomy. MATERIALS & METHODS: The MarketScan Commercial claims database (2008-2017) was queried for men ages >18 years who underwent radical orchiectomy for testicular mass, stratified as orchiectomy with no implant, CI, or SI. 90-day outcomes included rate of reoperation, readmission, emergency department (ED) presentation, and outpatient visits. Regression models provided rate ratio comparison. RESULTS: 8803 patients (8564 no implant, 190 CI, 49 SI; 2.7% implant rate) were identified with no difference in age, Charlson Comorbidity Index, insurance plan, additional cancer treatment, or metastasis. Median perioperative cost at orchiectomy (+/- implant) for no implant, CI, and SI were $5682 (3648-8554), $7823 (5403-10973), and $5380 (4130-10521), respectively (p<0.001). Median perioperative cost for SI at implantation was $8180 (4920-14591) for a total cost (orchiectomy + implant) of $13650 (5380 + 8180). CI patients were more likely to have follow-up (p = 0.006) with more visits (p = 0.030) compared to the SI group post-implantation but had similar follow-up (p = 0.065) and less visits (p = 0.025) compared to the SI patients' post-orchiectomy period. Overall explant rates were 4.7% for CI and 14.3% for SI (p = 0.04) with a median time to explant of 166 (IQR: 135-210) and 40 days (IQR: 9.5-141.5; p = 0.06). Median cost of removal was $2060 (IQR: 967-2880). CONCLUSIONS: CI placement has less total perioperative cost, lower explant rate, and similar postoperative utilization to SI.

Simplified assessment of castration-induced pain in pigs using lower complexity algorithms.

Pigs are raised on a global scale for commercial or research purposes and often experience pain as a by product of management practices and procedures performed. Therefore, ensuring pain can be effectively identified and monitored in these settings is critical to ensure appropriate pig welfare. The Unesp-Botucatu Pig Composite Acute Pain Scale (UPAPS) was validated to diagnose pain in pre-weaned and weaned pigs using a combination of six behavioral items. To date, statistical weighting of supervised and unsupervised algorithms was not compared in ranking pain-altered behaviors in swine has not been performed. Therefore, the aim of this study was to verify if supervised and unsupervised algorithms with different levels of complexity can improve UPAPS pain diagnosis in pigs undergoing castration. The predictive capacity of the algorithms was evaluated by the area under the curve (AUC). Lower complexity algorithms containing fewer pain-altered behaviors had similar AUC (90.1-90.6) than algorithms containing five (89.18-91.24) and UPAPS (90.58). In conclusion, utilizing a short version of the UPAPS did not influence the predictive capacity of the scale, and therefore it may be easier to apply and be implemented consistently to monitor pain in commercial and experimental settings.

Effects of assessment method (real-time versus video-recorded) on a validated pain-altered behavior scale used in castrated piglets.

We aimed to compare two assessment methodologies (real-time vs. video-recorded) using the Unesp-Botucatu Pig Composite Acute Pain Scale (UPAPS) in piglets before and after castration. Twenty-nine male piglets were castrated. Four observers scored the UPAPS over three perioperative timepoints of castration following two assessment methodologies. In real-time assessments, the observers were in-person observing the piglets in front of the pen. After two weeks, the observers did video-recorded assessments randomizing piglets and timepoints. Modeling was conducted to compare the UPAPS and each pain-altered behavior between methodologies. Intraclass correlation coefficient (ICC), Bland-Altman, and Lin's concordance correlation coefficient (CCC) were conducted to investigate agreement between methodologies. UPAPS was statistically equivalent between methodologies (P = 0.4371). The ICC for each method was very good (0.85 to 0.91). The agreement of the UPAPS assessed between methodologies had minimal bias (- 0.04), no proportion bias, and 53% of the assessments presented a perfect agreement. However, CCC of the UPAPS was moderate (0.65), and only one pain-altered behavior ("presents difficulty in overcoming obstacles or other animals") occurred more in real-time assessments (P = 0.0444). In conclusion, piglet pain assessment by UPAPS can be conducted in real-time based on a suitable agreement between the real-time and video-recorded assessment methods.

Pain Assessment and Acute Phase Response in Donkeys Submitted to Inguinal Orchiectomy.

In most animals, pain can compromise physiological functions and delay healing so, rapid detection of pain through behavior and inflammatory reaction with biomarkers are necessary. This study aimed to evaluate pain, physiological variations and Acute Phase Proteins (APP) in donkeys undergoing orchiectomy technique by inguinal access. For this research, 15 male northeastern donkeys kept in extensive management were selected, with a mean age of 4.5±3.1 years. All animals had the same anesthetic protocol, using dissociative anesthesia and local block with lidocaine, followed by orchiectomy by inguinal access. Due to their predisposition to complications, the inguinal technique is the most indicated to minimize complications and excessive inflammation in donkeys' orchiectomy, the donkeys were evaluated regarding behavioral assessment of pain, hematological parameters, APP and the surgical wound, during 0 hour, 24 hours, 48 hours and 72 hours. As for the physiological parameters and APP, no significant differences were observed between times, due to the use of nonsteroidal antiinflammatory drugs. In the macroscopic evaluation of the surgical wound, it was observed that there were no significant differences between the times, with animals presenting mean scores of 1.8±0.414, in 48 hours 1.6 ± 0.507, and in 72 hours 1.6 ± 0.507. Most animals had mild to moderate edema in the scrotum and foreskin regions. As for pain assessment, the average scores were between 2 and 3, representing mild and moderate pain, not requiring intervention. However, further research is needed to elucidate the behavior of PFAs in the face of variables and the creation of new pain scales for animals raised in an extensive system.

Retrospective histological evaluation of orchiectomy specimens following testicular torsion reveals a 10% incidence of reversible injury. Is it time for a change of strategy?

BACKGROUND: According to standard medical practice, immediate orchiectomy is advised in the case of a non-viable testis following testicular torsion. Because of the lack of objective criteria in the evaluation of testicular viability, the fate of the testis solely depends on the discretion and experience of the surgeon. OBJECTIVE: In this study, we retrospectively reassess the management of patients with testicular torsion in our center, and we ask the question, from a retrospective point of view, of whether the decision to perform orchiectomy has always been correct. MATERIALS AND METHODS: We retrospectively reviewed all cases of patients with testicular torsion who underwent surgery in our center between 2001 and 2021. All orchiectomy specimens were reevaluated and graded by an experienced pathologist using the Mikuz grading system. RESULTS: Immediate orchiectomy was performed in 48 of the 136 patients (35%). Five (10.4%) of the 48 orchiectomy specimens were categorized as "grade 1," and 17 (35.4%) were categorized as "grade 2." The time between the onset of symptoms and surgical exploration exceeded 12 h in three of the five patients with a "grade 1" testicular injury, and in one case, it even exceeded 24 h. DISCUSSION: "Grade 1" testicular injury is potentially reversible, whereas the fate of a testis with a "grade 2" testicular injury remains unknown. Whether and to what extent partial testicular tissue salvage in a "grade 2" injury is still possible remain unclear. CONCLUSIONS: Our results indicate that at least 10% of the testicles removed in our center could, from a retrospective point of view, have been salvaged. Our study further demonstrated that the duration of symptoms is not an absolute indicator of testicular damage and that the decision of whether orchiectomy should be performed, based simply on the subjective macroscopic image of the affected testis, is not always correct.

Butler e a psicanálise: do fracasso das normas à estranheza do gozo / Butler and psychoanalysis: from the failure of norms to the uncanniness of jouissance / Butler y el psicoanálisis: del fracaso de las normas a la rareza del goce

O objetivo deste artigo é fazer avançar o debate entre a psicanálise e os estudos queer, em especial a partir da interlocução traçada por Judith Butler com os trabalhos de Freud e Lacan. Retomando o modo como Butler articula Foucault, Derrida e a psicanálise para pensar os problemas de gênero, evidenciamos que a teoria psicanalítica permite à filósofa situar, a partir de sua concepção da melancolia de gênero, os pontos de fracasso da norma em função da vida psíquica do poder. Ainda que a cisheterossexualidade normativa imponha um roteiro de identificações e escolhas de objeto a seus sujeitos, há uma imprevisibilidade na maneira pela qual cada um responderá às injunções normativas da cultura, o que aponta para uma falha das normas em determinar completamente a subjetividade. A melancolia de gênero se torna, assim, uma marca da importância da psicanálise no percurso de Butler. Em seguida, discutimos as interpelações da filósofa ao simbólico lacaniano, bem como as nuances progressivamente introduzidas em sua leitura da diferença sexual. Ao longo do percurso de Butler, a diferença sexual deixa de ser considerada uma teoria da heterossexualidade e passa a ser apresentada como um conceito-borda, uma fronteira vacilante, que tomamos aqui como um convite para produzirmos uma releitura não normativa da diferença sexual na psicanálise a partir da teoria lacaniana da sexuação. Finalmente, localizamos a estranheza do gozo e o caráter irredutível da sexualidade às normas sociais como um importante eixo partilhado entre Butler e a psicanálise.(AU)

The aim of this article is to branch out the debate between psychoanalysis and queer studies, focusing on the interlocution drawn by Judith Butler with the works of Freud and Lacan. Returning to the way Butler articulates Foucault, Derrida and psychoanalysis to think about gender trouble, we show that psychoanalytic theory allows the philosopher to situate, from her conception of gender melancholy, the points of failure of the norm in function of the psychic life of power. After all, even though normative cis-heterosexuality imposes a script of identifications and object-choices on its subjects, there is an unpredictability to the way in which each one will respond to the normative injunctions of culture, so that norms fail to fully determine subjectivity. Gender melancholy thus becomes a mark of the importance of psychoanalysis in Butler's path. Then, we discuss the philosopher's interpellations to the Lacanian symbolic order, as well as the nuances progressively introduced in her reading of sexual difference. Along Butler's path, sexual difference is no longer considered a theory of heterosexuality and is presented as a border-concept, a vacillating frontier, which we take here as an invitation to produce a non-normative rereading of sexual difference in psychoanalysis, resorting to the Lacanian theory of sexuation. Finally, we locate the uncanniness of jouissance and the irreducible character of sexuality to social norms as an important shared axis between Butler and psychoanalysis.(AU)

El objetivo de este artículo es hacer avanzar el debate entre el psicoanálisis y los estudios queer, enfatizando la interlocución trazada por Judith Butler con los trabajos de Freud y Lacan. Volviendo a la forma en que Butler articula a Foucault, Derrida y el psicoanálisis para pensar los problemas de género, mostramos que la teoría psicoanalítica permite a la filósofa ubicar, desde su concepción de la melancolía de género, los puntos de falla de la norma en función de la vida psíquica del poder. Aunque la cis-heterosexualidad normativa imponga identificaciones y elecciones de objeto a sus sujetos, hay una imprevisibilidad en la forma en que cada uno responderá a los mandatos normativos de la cultura, lo que apunta a un fracaso de las normas para determinar completamente la subjetividad. La melancolía de género se convierte, entonces, en una marca de la importancia del psicoanálisis en la trayectoria de Butler. En seguida, discutimos las interpelaciones de la filósofa a lo simbólico lacaniano, así como los matices progresivamente introducidos en su lectura de la diferencia sexual. A lo largo de la trayectoria de Butler, la diferencia sexual deja de ser considerada una teoría de la heterosexualidad y pasa a ser presentada como un concepto-borde, um límite vacilante, que tomamos aquí como una invitación para producirmos una relectura no normativa de la diferencia sexual en psicoanálisis a partir de la teoría lacaniana de la sexuación. Finalmente, ubicamos la rareza del goce y el carácter irreductible de la sexualidad a las normas sociales como un importante eje compartido entre Butler y el psicoanálisis.(AU)

Testicular torsion disparities in the pediatric population.

BACKGROUND: There are disparate findings in the literature on the impact of race and insurance status on gonadal loss in testicular torsion. We sought to determine if race or levels of social vulnerability influence the rate of torsion or gonadal loss. METHODS: Retrospective cross-sectional review between December 2017 and September 2019. Social vulnerability index was dichotomized using the 75th percentile. Primary outcome was the diagnosis of testicular torsion. RESULTS: 515 patients were included. There was no difference in median age, torsion diagnosis, and orchiectomy rate between the two institutions. Black/African American patients were >3 times more likely than Caucasian patients to be diagnosed with TT when controlled for dichotomized SVI, insurance, and age (OR 3.39, 95% CI 1.74 - 6.61, p < 0.01). CONCLUSION: Black/African American children have an increased risk of testicular torsion. Despite these patients having higher levels of social vulnerability, it was not associated.

Do healthcare disparities play a role in pediatric testicular torsion? - Analysis of a single large pediatric center.

INTRODUCTION: Healthcare disparities have been shown to impact outcomes of various acute pediatric conditions. We sought to examine the impact of race, ethnicity and insurance status on the presentation, management and outcome of testicular torsion. MATERIALS AND METHODS: A retrospective review of a prospectively maintained testicular torsion database was performed. Patients ≤18 years of age evaluated in our pediatric institution's emergency room between April 2016-April 2020 with US diagnosed and OR confirmed testicular torsion were included. Basic demographics, timing of presentation, referral rate, time to OR and orchiectomy rate were extracted and compared. P < 0.05 was considered statistically significant. RESULTS: A total of 206 patients were included. 114 (56.2%) were Black or African American (Black/AA), 43 were (21.2%) Hispanic/Latino, 22 (10.8%) were Caucasian, and 24 (11.8%) were designated as Other races. Ninety-eight (48.3%) patients had Medicaid, 90 (44.3%) had private insurance, and 15 (7.4%) patients were uninsured. Sixty-eight (33.0%) presented in a delayed fashion (>24 h). Compared to the Caucasian patients, Black/AA patients were 2.1 years (95% CI: 0.5, 3.8; P = 0.010) older at the time of presentation. When compared to those with Medicaid insurance, uninsured patients had 6.26 times (95% CI: 1.58, 41.88; P = 0.021) higher odds to be referred from an outside hospital for management. In those patients presenting acutely (<24 h, N = 138), there were no significant differences in the odds of orchiectomy for Black/AA or Hispanic/Latino patients when compared to Caucasian patients, however, the odds of orchiectomy in Other races (non-Caucasian, non-Black/AA, non-Hispanic/Latino) was significantly higher (OR: 10.38; 95% CI: 1.13, 246.96; P = 0.049). While the mean time in minutes from ED to OR was longer in those with Medicaid insurance (141 vs 125.4 private vs 115 uninsured, p = 0.042), this did not impact orchiectomy rate (39.8% vs 40.9% vs 46.7%, p = 0.88). CONCLUSIONS: We found no differences in the orchiectomy rates by race with the exception of a higher rate in the diverse and heterogeneous Other race (non-Caucasian, non-Black/AA, non-Hispanic/Latino) group. Those uninsured had a higher referral rate highlighting the potential existence of disparities for those uninsured and the need for further investigation.

Pain assessment in horses using automatic facial expression recognition through deep learning-based modeling.

The aim of this study was to develop and evaluate a machine vision algorithm to assess the pain level in horses, using an automatic computational classifier based on the Horse Grimace Scale (HGS) and trained by machine learning method. The use of the Horse Grimace Scale is dependent on a human observer, who most of the time does not have availability to evaluate the animal for long periods and must also be well trained in order to apply the evaluation system correctly. In addition, even with adequate training, the presence of an unknown person near an animal in pain can result in behavioral changes, making the evaluation more complex. As a possible solution, the automatic video-imaging system will be able to monitor pain responses in horses more accurately and in real-time, and thus allow an earlier diagnosis and more efficient treatment for the affected animals. This study is based on assessment of facial expressions of 7 horses that underwent castration, collected through a video system positioned on the top of the feeder station, capturing images at 4 distinct timepoints daily for two days before and four days after surgical castration. A labeling process was applied to build a pain facial image database and machine learning methods were used to train the computational pain classifier. The machine vision algorithm was developed through the training of a Convolutional Neural Network (CNN) that resulted in an overall accuracy of 75.8% while classifying pain on three levels: not present, moderately present, and obviously present. While classifying between two categories (pain not present and pain present) the overall accuracy reached 88.3%. Although there are some improvements to be made in order to use the system in a daily routine, the model appears promising and capable of measuring pain on images of horses automatically through facial expressions, collected from video images.

When is a Seminoma not a Seminoma? The Incidence, Risk Factors and Management of Patients With Testicular Seminoma With Discordant Elevated Serum Alpha-fetoprotein.

OBJECTIVE: To describe the incidence, clinical and demographic factors, and treatment patterns associated with discordant elevated alpha-fetoprotein (AFP) findings in patients with pure seminomatous histology. METHODS: We queried the National Cancer Database to identify patients with testicular germ cell tumors (GCT) diagnosed in 2011-2015. Patients were grouped based on histologic diagnosis and pre-operative serum AFP level. RESULTS: Of 18,616 patients diagnosed with testicular GCT, 53% (N = 9,849) had pure seminomatous histology, of whom 8.3% (N = 821) had an elevated serum AFP pre-operatively. Non-white patients with seminoma were more likely to have a pre-op elevated AFP (OR 1.42; 95% CI: 1.10-1.83); patients treated at higher volume centers were less likely to have a pre-op elevated AFP (0.66, 95% CI: 0.53-0.83). Patients with seminoma with elevated AFP received adjuvant radiation more frequently than those with NSGCT (Stage I: 15% vs 0.2%, P <.01; Stage II: 21.9% vs 0.1%, P <.01) and less frequently underwent retroperitoneal lymph node dissection (RPLND) (Stage 1: 1.9% vs 11.1% P <.01; Stage II: 8.8% vs 17.4%, P <.01). CONCLUSION: The detection of elevated serum alpha-fetoprotein (AFP) in patients with pure seminomatous testicular germ cell tumors (GCT) is a discordant finding that implies the presence of occult non-seminomatous GCT (NSGCT) elements. 8% of patients with pure seminomatous GCTs had diagnostically discordant elevated pre-operative AFP levels. Despite recommendations to manage these patients as NSGCT, patients with seminoma and elevated AFP were managed in a fashion comparable to those with seminoma and normal AFP levels.

X-ray micro-computed tomography in the assessment of penile cavernous fibrosis in a rabbit castration model.

BACKGROUND: Current assessment methods of penile cavernous fibrosis in animal models have limitations due to the inability to provide complex and volume analysis of fibrotic alterations. OBJECTIVE: The aim was to evaluate micro-computed tomography for assessment of cavernous fibrosis and compare it with histological, histochemical, immunohistochemical, and RT-PCR analysis. MATERIALS AND METHODS: A controlled trial was performed involving 25 New Zealand male rabbits with induced testosterone deficiency by orchidectomy. Penile samples were obtained before and after 7, 14, 21, and 84 days from orchidectomy. We consistently performed (a) gray value analysis of corpora cavernosa 3D models reconstructed after micro-computed tomography, (b) morphometry of smooth muscles/connective tissue ratio, collagen type I/III ratio, and area of TGF-beta-1 expression in corpora cavernosa, and (c) RT-PCR of TGF-beta-1 expression. RESULTS: Micro-computed tomography allowed visualization of penile structures at a resolution comparable to light microscopy. Gray values of corpora cavernosa decreased from 1673 (1512-1773) on the initial day to 1184 (1089-1232) on the 21st day (p < 0.005). However, on the 84th day, it increased to 1610 (1551-1768). On 21st and 84th days, there was observed a significant decrease in smooth muscle/connective tissue ratio and a significant increase in collagen type I/III ratio (p < 0.05). TGF-beta1 expression increased on the 84th day according to immunohistochemistry (p < 0.005). RT-PCR was impossible to conduct due to the absence of RNA in obtained samples after micro-CT. DISCUSSION AND CONCLUSIONS: Micro-computed tomography provided 3D visualization of entire corpora cavernosa and assessment of radiodensity alterations by gray value analysis in fibrosis progression. We speculate that gray value changes at early and late fibrosis stages could be related to tissue reorganization. RT-PCR is impossible to conduct on tissue samples studied by micro-CT due to RNA destruction. We also suggest that micro-computed tomography could negatively affect the immunohistochemical outcome, as a significant increase of TGF-beta-1 expression occurs later than histological fibrotic signs.

Towards an improved pain assessment in castrated horses using facial expressions (HGS) and circulating miRNAs.

BACKGROUND: Pain in horses is an emergent welfare concern, and its assessment represents a challenge for equine clinicians. This study aimed at improving pain assessment in horses through a convergent validation of existing tools: we investigated whether an effective analgesic treatment influences the horse grimace scale (HGS) and the concentration of specific circulating microRNAs (miRNAs). METHODS: Eleven stallions underwent routine surgical castration under general anaesthesia. They were divided into two analgesic treatment groups: castration with the administration of preoperative flunixin and castration with preoperative flunixin plus a local injection of mepivacaine into the spermatic cords. HGS and levels of seven circulating miRNAs were evaluated pre-, 8 and 20 hours post-procedure. RESULTS: Compared to pre-castration, HGS, miR-126-5p, miR-145 and miR-let7e increased significantly in horses receiving flunixin at 8 hours post-castration (Friedman test, p < 0.05). Both behavioural and molecular changes occurred in horses receiving flunixin only, confirming that the addition of local mepivacaine is an effective analgesic treatment. CONCLUSIONS: Combining the use of HGS and circulating miRNAs, particularly miR-145, could be meaningful to monitor acute pain conditions in horses. Our results further validate the HGS as a method to assess acute pain in horses and point out miR-145 as a promising biomarker to identify pain.

Non-destructive evaluation of carcass and ham traits and meat quality assessment applied to early and late immunocastrated Iberian pigs.

Castration is a common practice in Iberian pigs due to their advanced age and high weight at slaughter. Immunocastration (IC) is an alternative to surgical castration that influences carcass and cut fatness. These traits need to be evaluated in vivo and postmortem. The aims of the present work were (a) to determine the relationship between ham composition measured with computed tomography (CT) and in vivo ultrasound (US) and carcass fat thickness measurements, (b) to apply these technologies to early (EIP) and late (LIP) immunocastrated Iberian pigs in order to evaluate carcass fatness and ham tissue composition and (c) to assess meat quality on these animals and to find the relationships between meat quality traits (namely, intramuscular fat (IMF)) and fat depot thicknesses. For this purpose, 20 purebred Iberian pigs were immunocastrated with three doses of Improvac ®, at either 4.5, 5.5 and 9 or 11, 12 and 14 months of age (EIP or LIP; respectively; n = 10 each) and slaughtered at 17 months of age. Fat depots were evaluated in vivo by US, in carcass with a ruler and in hams by CT. Carcass and cut yields, loin meat quality and loin acceptability by consumers were determined. Also, IMF was determined in the loin and three muscles of the ham. Carcass weight was 14.9 kg heavier in EIP vs LIP, and loin backfat thickness (US- and ruler-measured) was also greater in EIP. Similarly, CT-evaluated ham bone and fat contents were greater and smaller for EIP vs LIP, respectively. Loin and ham IMF were also greater in EIP, but the other meat quality parameters were similar. The acceptability of meat by consumers was high and it did not differ between IC protocols. Correlations between several fat depots measured with the different technologies were high. In conclusion, all these technologies allowed fat depot measurements, which were highly correlated despite being obtained at different anatomical locations.

Testicular torsion: epidemiological risk factors for orchiectomy in pediatric and adult patients.

Testicular torsion is a known cause of morbidity in pediatric patients, but the burden in the adult population is poorly understood. We sought to determine the incidence of testicular torsion and risk factors for orchiectomy in a population encompassing all ages. A cohort analysis of 1625 males undergoing surgery for torsion was performed using the 2011 and 2012 Healthcare Cost and Utilization Project Nationwide Emergency Departments Sample. Patient and hospital factors were examined for association with orchiectomy vs. testicular salvage. The estimated yearly incidence of testicular torsion was 5.9 per 100,000 males ages 1-17 years and 1.3 per 100,000 males ≥18 years. Among those undergoing surgical intervention, orchiectomy was performed in 33.6%. The risk of orchiectomy was highest in patients 1-11 years of age and patients over 50 years of age (46.0% and 69.7% of patients, respectively). Orchiectomy was also associated with public insurance (Medicaid/Medicare) or self-pay as primary payer. While testicular torsion is less common in the adult population, the rate of orchiectomy is high. Those with disadvantaged payer status are also at increased risk for testicular loss.

Comparative study of surgical orchidectomy and medical castration in treatment efficacy, adverse effects and cost based on a large prospective metastatic prostate cancer registry.

INTRODUCTION: Androgen deprivation therapy (ADT) remains the mainstay of treatment for metastatic prostate cancer (mPCa) but is associated with significant morbidities. Comparisons of medical castration (MC) and surgical orchidectomy (SO) have yielded varied results. We aimed to evaluate the oncological outcomes, adverse effect (AE) profiles and costs of MC and SO in patients with mPCa. METHODS AND MATERIALS: We reviewed 523 patients who presented with de novo mPCa from a prospectively maintained prostate cancer database over 15 years (2001-2015). All patients received ADT (either MC or SO) within 3 months of diagnosis. The data were analyzed with chi-square, binary and logistics regression models. RESULTS: One hundred and fifty one (28.9%) patients received SO while 372 (71.1%) patients had MC. The median age of presentation was 73 [67 -79] years old. The median prostate-specific antigen (PSA) was 280ng/ml [82.4-958]. Three hundred and thirty one patients (66.3%) had high volume bone metastasis and 57 patients (10.9%) had visceral metastasis. Clinical demographics and clinicopathological were similar across both groups. Similar oncological outcomes were observed in both groups. The proportion of PSA response (PSA <1ng/ml) was 65.6% for SO and 67.2% for MC (P = 0.212). Both therapies achieve >95% of effective androgen suppression (testosterone <50ng/dL). Time to castrate-resistance was similar (18 vs 16 months, P = 0.097), with comparative overall survival (42 vs. 38.5 months, P = 0.058) and prostate cancer mortality (80.1 vs. 75.9%, P = 0.328). Similarly, no difference was observed for the 4 AE profiles between SO and MC respectively; change in Haemoglobin (-0.75 vs. -1.0g/dL, P = 0.302), newly diagnosed Diabetes mellitus (4.6 vs. 2.9%, P = 0.281), control measured by HbA1c (0.2 vs. 0.25%, P = 0.769), coronary artery disease events (9.9 vs. 12.9%, P = 0.376) and skeletal-related fractures (9.3 vs. 7.3%, P = 0.476). After adjusting for varying governmental subsidies and inflation rates, the median cost of SO was $5275, compared to MC of $9185.80. CONCLUSION: Both SO and MC have similar oncological outcomes and AE profiles. However, SO remains a much more cost-effective form of ADT for the long-term treatment of mPCa patients.

Assessment of Age and Duration of Symptoms on Outcomes of Emergency Scrotal Exploration for Acute Scrotal Pain.

OBJECTIVE: To study the effects of age and duration of symptoms on the outcomes of scrotal explorations for acute scrotal pain at our institution. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Bradford Teaching Hospital NHS Trust, from January 2006 to December 2017. METHODOLOGY: Retrospective data was collected from electronic case records of the patients who required scrotal exploration for suspected torsion of the testis. Group difference between continuous variables (age and duration of symptoms) were assessed by Kruskal Wallis and independent samples Mann-Whitney U-tests. The Fisher Exact and Chisquare tests were used to analyse relationships between categorical data. RESULTS: In total, 502 patients required scrotal exploration. The median age (years) and duration of symptoms (hours) were 16.4 years (1.3 - 77) and 4 hours (1 - 336), respectively. Torsion of the testis was found in 231 (46%), torsion of the testicular appendix in 126 (25%), epididymal inflammation in 46 (9.2%), and no cause identified in 99 (19.7%). Immediate orchidectomy for non-viable testis performed in 34 (14.7% of TT group and 6.8% of the overall cohort). Duration of symptoms was significantly associated with risk of orchidectomy in torsion patients 4 vs. 27 hours (p <0.0001). Overall 47 (9.3%) patients presented after 12 hours, 22 (46.8%) had TT. There were 13 (2.6%) patients older than 40 years and 8 (61.5%) of these had torsion. CONCLUSION: The most commonest diagnosis for patients presenting with acute scrotal pain was torsion of the testis followed by torsion of appendix testis. Testicular salvage was inversely related to the duration of symptoms. Patient's age did not predict the need for orchidectomy. This data supports the practice of urgent scrotal exploration for acute scrotal pain with a clinical suspicion of torsion regardless of age and duration of symptoms.

Utilization and Outcomes of Surgical Castration in Comparison to Medical Castration in Metastatic Prostate Cancer.

BACKGROUND: Androgen deprivation therapy (ADT) is the gold standard for metastatic prostate cancer, which can be achieved either by surgical or medical castration. In this study, we evaluated the trends of utilization of surgical castration and also assess the survival differences of patients who underwent surgical castration when compared with those who underwent medical castration. MATERIALS AND METHODS: The National Cancer Database was used to identify patients with metastatic prostate cancer from 2004 to 2014. Cochran-Armitage tests were used to assess temporal trends in the proportion of patients receiving surgical castration relative to medical castration. Logistic and Cox regression models were utilized to estimate the odds of utilization of surgical castration and the effect of castration on overall survival (OS). RESULTS: A total of 33,585 patients with metastatic prostate cancer were identified; 31,600 (94.1%) had medical castration, and 1985 (5.9%) underwent surgical castration. There was significant decline in the trend of utilization of surgical castration from 8.6% in 2004 to 3.1% in 2014. On multivariable analysis, being of a non-Caucasian race, having lower median income levels, having non-private insurance, and earlier years of diagnosis were found to be associated with increased odds of choosing surgical castration over medical castration. Notably, the odds of surgical castration were lower at academic centers. On univariable analysis, a survival difference between castration modality was evidenced (P < .01); 5-year OS for medical castration and surgical castration were 24.3% and 18.2%, respectively. However, on multivariable analysis, there was no OS difference between surgical castration and medical castration (P = .13). CONCLUSIONS: In this large contemporary analysis, the utilization of surgical castration has declined over time, with no OS difference when compared with medical castration. Increasing the utilization of surgical castration could help reduce health care expenditures. With rising health care costs, patients and physicians need to be aware of treatment options and their financial implications.