The transcription factor CREB1 is a mechanistic driver of immunogenicity and reduced HIV-1 acquisition following ALVAC vaccination.

Development of effective human immunodeficiency virus 1 (HIV-1) vaccines requires synergy between innate and adaptive immune cells. Here we show that induction of the transcription factor CREB1 and its target genes by the recombinant canarypox vector ALVAC + Alum augments immunogenicity in non-human primates (NHPs) and predicts reduced HIV-1 acquisition in the RV144 trial. These target genes include those encoding cytokines/chemokines associated with heightened protection from simian immunodeficiency virus challenge in NHPs. Expression of CREB1 target genes probably results from direct cGAMP (STING agonist)-modulated p-CREB1 activity that drives the recruitment of CD4+ T cells and B cells to the site of antigen presentation. Importantly, unlike NHPs immunized with ALVAC + Alum, those immunized with ALVAC + MF59, the regimen in the HVTN702 trial that showed no protection from HIV infection, exhibited significantly reduced CREB1 target gene expression. Our integrated systems biology approach has validated CREB1 as a critical driver of vaccine efficacy and highlights that adjuvants that trigger CREB1 signaling may be critical for efficacious HIV-1 vaccines.

Assessment of opioid use following septorhinoplasty and its association with pain catastrophizing.

PURPOSE: Anxiety towards pain is correlated with increased post-surgical pain and assessed with the "Pain Catastrophizing Scale" (PCS). We assess patient reported pain and opioid usage following septorhinoplasty and their association with the PCS. METHODS: This prospective cohort study enrolled patients over 18 years of age undergoing open septorhinoplasty on an outpatient basis at a single academic institution. Participants completed the PCS preoperatively and recorded post-operative pain and analgesic use with a daily online based survey through post-operative day 5. Total opioid use and highest pain rating are assessed. RESULTS: Postoperative pain was assessed in 34 patients with a median age of 37 years (Range: 22-62y). The average highest pain rating was 6.2/10 (σ = 2.03) and occurred on post-operative day 2. A median of 20 5-mg narcotic tablets (Range: 10-25) was prescribed to study participants though only an average of 7.25 (Range: 0-15) were reported as used. Medical comorbidities and surgical characteristics, including history of anxiety, cosmetic indication, surgical revision, use of osteotomies, Doyle splints, costal or conchal cartilage grafts, or inferior turbinate reduction, were not associated with increased pain or narcotic use. Those using >10 tablets scored higher on the PCS ([10.6] v. [4.8], p = 0.025). CONCLUSION: Most patients require <10, 5 mg opioid tablets following septorhinoplasty. Surgeons should attempt to decrease opioid prescriptions while considering that patients with significant anxiety towards pain may report higher narcotic needs.

Peri-Urethral and Anterior Vaginal Wall Masses: Does Radiological Imaging Change the Predicted Diagnosis?

INTRODUCTION: This study aims to determine the accuracy of radiological imaging compared with surgical pathology in patients with periurethral (PU) and anterior vaginal wall (AVW) lesions. METHODS: This study is a retrospective analysis of 126 women who underwent surgical treatment for PU and AVW masses between 2011 and 2020. Clinicopathological data were extracted along with radiological findings from medical records. The primary outcome was the diagnostic accuracy of preoperative imaging compared to the gold standard, pathological diagnosis. The secondary outcome was the rate of imaging correcting the clinical diagnosis. RESULTS: A total of 126 women with a median age of 42 underwent surgical treatment for PU and AVW masses. The most diagnoses were periurethral cysts (PUC) (52%) and urethral diverticulum (UD) (39%). Clinical diagnosis was accurate in 102 cases (81%) for the group of pathological diagnoses. Magnetic resonance imaging (MRI) and transvaginal ultrasound (TV US) were performed in 82 (65%) and 22 (17%) cases. The accuracy of MRI and TV US for the diagnosis of PU and AVW lesions was 76% and 82%, respectively. MRI and TV US corrected the clinical diagnosis in five (6%) and two (9%) cases, respectively. Voiding cystourethrography (VCUG) and double balloon urethrography (DBU), each performed in six (5%) cases, were accurate in four (67%) and three (50%) cases. No statistical difference was found for any imaging modality compared to clinical diagnosis. CONCLUSION: Clinical diagnosis based on pelvic and cystoscopy examinations was sufficient for diagnosing PU and AVW masses and was not significantly different from imaging diagnosis. Imaging may be helpful with preoperative surgical planning in selected cases.

Persistent storage symptoms following Y-V plasty reconstruction for the treatment of refractory bladder neck contracture.

PURPOSE: Refractory bladder neck contracture (BNC) following transurethral prostatectomy is rare and difficult to manage. Success rate of endoscopic treatment decline considerably after repeated treatments. Bladder neck reconstruction are often the last resort to treat refractory BNC failing endoscopic treatments. In general, experience is limited with this type of bladder neck reconstruction, particularly in adult patients. This study aims to determine the success rate, functional and patient-reported outcomes (PRO) of open Y-V plasty in treatment of refractory BNC after transurethral prostatectomy. The study also aims to determine the rate, and potential predictors of persistent storage symptoms after Y-V plasty. MATERIALS AND METHODS: Between January 2016 and February 2021, 18 consecutive patients with refractory BNC who underwent open Y-V plasty were included in this study. All patients presented with voiding dysfunction after two or more failed attempts of endoscopic treatments followed by a 3-month period of outpatient serial dilation program. Clinicopathological data were extracted from medical records including baseline demographics, aetiology of BNC, previous endoscopic treatment, operative time, length of stay, complications, uroflow findings, International Prostate Symptom Score (IPSS) and OAB-V8. Primary outcome was the success of open YV plasty, defined as no need for further instrumentation such as indwelling catheterization, urethral dilatation, urethrotomy, or open surgery. Simple linear regression analysis was performed to determine predictor factors for postoperative OAB-V8. Variables that showed p < 0.25 were included in the multiple linear regression analysis. RESULTS: Most common aetiology of BNC was transurethral resection of prostate gland (n = 18, 100%). Mean age at surgery age (SD) was 65.5 (7.3) years. Mean follow-up was 14.8 (7) months. Success rate was 100%. Postoperative Qmax improved significantly [pre-OP 6.7 (8.1) ml/s vs. post-OP was 14.8 (7.3) ml/s, p < 0.001]. Mean postvoid residual decreased significantly [pre-OP 223.3 (254.3) ml vs. post-OP 45.1 (71.0) ml, p < 0.01)]. Persistent storage symptoms were reported in 61% of patients. BMI and baseline IPSS score are significant predictors for the postoperative OAB V8 change (adjusted b (95% confidence interval) = 1.037 (0.2-1.9), 0.64 (0.28-0.99), respectively, R2 = 0.59). CONCLUSION: Y-V plasty reconstruction for refractory BNC represents a feasible and successful option with high success rate and favorable outcomes. While functional and patient-reported outcomes had significantly improved post-operatively, persistent storage symptoms after this procedure still exist. BMI and baseline IPSS score are significant predictors for persistent storage symptoms after bladder neck reconstruction.

The use of onabotulinumtoxinA to treat idiopathic overactive bladder in elderly patients is in need of study.

BACKGROUND: Injecting onabotulinumtoxinA (BoTN-A) into the bladder has been established as an effective treatment of overactive bladder (OAB) and well-tolerated by patients. However, there evidence suggests the efficacy and safety of this treatment may decrease with age due to increased comorbidities and frailty. This study's objective was to establish empirical evidence regarding age-related differences in outcomes related to BoTN-A for the treatment of idiopathic OAB. METHODS: MEDLINE, EMBASE, and the Cochrane Central Registry for Controlled Trials were systematically searched. Results were restricted to randomized control trials of BoTN-A bladder injections for the treatment of idiopathic OAB. The resulting articles' abstracts were screened independently by two reviewers. Those passing the screen were reviewed in full. Articles were excluded if participants were <18 years old, diagnosed with neurogenic overactivity, or treated with both oral medications and BoTN-A; if the frequency and severity of OAB symptoms were not specified; or, if symptoms were not stratified by age. RESULTS: The initial search resulted in 1572 articles; 166 were reviewed in full. None met all inclusion/exclusion criteria. However, 21 studies met all criteria except age stratification. Authors were contacted to obtain raw data to perform an independent age-based analysis, but sufficient data was not received. CONCLUSION: While the initial systematic review did not generate the expected results, it did reveal that age-related outcomes of BoTN-A for the treatment of OAB are significantly under-studied. Given that the prevalence of OAB increases with age, this is an important knowledge gap. Our article explains the rationale for further study in this area.

Early Adverse Events Following Pediatric Mandibular Advancement: Analysis of the ACS NSQIP-Pediatric Database.

OBJECTIVE: This study aims to assess early adverse events and patient factors associated with complications following mandible distraction osteogenesis (MDO). MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) database, years 2012 to 2019, was queried for patients undergoing mandible advancement via relevant Current Procedural Terminology and postoperative diagnosis codes. Thirty-day adverse events and co-morbidities are assessed. RESULTS: A total of 208 patients were identified with 17.3% (n = 36) experiencing an adverse event, reoperation (n = 14), and readmission (n = 11) being most common. Patients < 365 days old at the time of operation were more likely to experience an adverse event (26.1% vs 10.8%; P = .005). However, among patients less than 1 year of age, differences in the complication rates between patients ≤ 28 days and >28 days (30.2% vs 22.2%; P = .47) and those weighing ≤ 4 kg and >4 kg (31.7% vs 11.5%; P = .063) did not reach statistical significance. CONCLUSIONS: Adverse events following mandible advancement are relatively common, though often minor. In our analysis of the NSQIP-Pediatric database, neonatal age ( ≤ 28 days) or weight ≤ 4 kg did not result in a statistically significant increase in complications among patients less than 1 year of age. Providers should consider early intervention in patients who may benefit from MDO.

Incidence and predictors of early and late hospital readmission after transurethral resection of the prostate: a population-based cohort study.

OBJECTIVES: To evaluate the incidence and predictors of hospital readmission and emergency department (ED) visits in patients with benign prostatic hyperplasia treated by transurethral resection of the prostate (TURP). PATIENTS AND METHODS: We conducted a retrospective cohort study using a linked administrative dataset from Calgary, Canada. Participants were men who underwent their first TURP procedure between 2015 and 2017. We examined patient demographics, and type of surgery (elective or urgent). Comorbidities were scored using the Charlson comorbidity index (CCI). The primary outcomes were unplanned hospital readmissions and ED visits at 30, 60 and 90 days after TURP. The secondary aim was to identify potential predictors across these groups. RESULTS: We identified 3059 men, most of whom underwent elective TURP (83%). The mean (sd) patient age was 71.0 (10.0) years. A total of 224 patients (7.4%) were readmitted to the hospital within 30 days, 290 (9.5%) within 60 days, and 339 (11.1%) within 90 days of discharge. The frequency of return visits within 30, 60 and 90 days of TURP were 21.4%, 26% and 28.6%, respectively. The most responsible diagnoses for ED visit within 90 days were haematuria (15.4%) and retention of urine (12.8%). Multivariable analysis showed that age (odds ratio [OR] 1.61, P < 0.001), surgery type (OR 2.20, P < 0.001), and CCI score (OR 2.03, P < 0.001) were independently associated with odds of readmission and ED visits at all time points. CONCLUSION: Older age, poorer health and urgent surgery predicted return to ED or readmission after TURP; efforts should be made to improve selection, counselling and preoperative optimization based on these risks.

Impact of radical prostatectomy on bladder function as demonstrated on urodynamics study-A systematic review.

AIMS: This study aims to describe the effects of radical prostatectomy (RP) on bladder function by performing a systematic review of urodynamics study findings before and after RP. METHODS: This systematic review was conducted in accordance with the PRISMA guideline and registered on PROSPERO (CRD42020206844). A systematic search was conducted using PubMed, Cochrane, and Embase. Studies were included if they involved men who underwent RP and had urodynamics study performed preoperatively, postoperatively, or both. Studies that included only subgroups of patients based on symptoms were excluded. Three hundred and four articles were screened, with 20 articles included. A qualitative analysis was performed. RESULTS: The rate of baseline bladder outlet obstruction (BOO) pre-RP was 19%-67%. All six studies with comparative data pre- and postoperatively demonstrated a decrease in the rate of patients with equivocal or clear obstruction. The baseline rates of detrusor overactivity (DO) varied widely from 11% to 61.2%. Six of eight studies with 6 months or more follow-up showed an improvement in the rates of DO ranging from 3.0% to 12.5%. The rate of de novo DO ranged from 0% to 54.5%. Four studies reported an increased rate of impaired bladder contractility and two of three studies showed a worsening rate of impaired bladder compliance following RP. This review is limited by the absence of level I/II studies. CONCLUSIONS: Urodynamics study shows that BOO is improved following RP in most patients. RP resolves DO in some patients and cause de novo DO in others. The net effect is a reduced overall rate of DO in most studies. Bladder compliance and contractility may be impaired after RP.

Evaluation of surgical approaches for vesicovaginal fistulae repair: the case for transvaginal repair as the gold standard.

INTRODUCTION AND HYPOTHESIS: To highlight the success rates of two approaches of transvaginal vs. transabdominal closures for the vesicovaginal fistula (VVF) repair and to investigate the patient, fistula, and surgical factors relevant to surgical characteristics and successful outcomes. METHODS: Retrospective analysis of 66 consecutive patients who underwent VVF repair between 2005 and 2020. Fistula profile, operative data, and postoperative outcomes were analyzed. Primary outcome was success rate with regard to surgical approach. Secondary outcomes were to compare patients' and surgical characteristics with regard to surgical approach and correlate these characteristics relevant to surgical outcomes. RESULTS: A total of 66 women with a median age of 47 (27-82) years were included. Most (93.9%) of the VVFs were secondary to gynecological procedures. Thirteen (19.7%) patients had previous VVF repair. The median time from onset of leakage to surgical repair was 120 days. Forty-nine patients underwent transvaginal repair, whereas 17 (25.7%) women had abdominal repair. The success rates of transvaginal and abdominal techniques were 98% and 82%, respectively. Transvaginal approach had a significantly shorter operative time, less intraoperative blood loss, reduced hospital stay, and lower complication rates (p < 0.005). Age and time to surgery were positively and significantly correlated with surgical time [r (p value): 0.392 (0.003), (0.0386 (0.01)] and estimated blood loss [0.388 (0.002 and 0.410 (0.001)], respectively. CONCLUSION: Transvaginal repair of VVF is a technically feasible and successful approach with significantly better operative parameters and lower complications. Despite varied etiology and different surgical approach, age and time to surgery are the main factors that correlate with operative time and blood loss.

Evaluating the 8-item overactive bladder questionnaire (OAB-v8) using item response theory.

AIMS: The OAB-v8 is a patient-reported outcome questionnaire used to screen for overactive bladder and measure symptom bother. This study uses modern validation methods to assess the item and test characteristics of the OAB-v8, and determine whether it should be scored differently for men and women. METHODS: A secondary analysis of data from patients with lower urinary tract symptoms prospectively recruited from a urology clinic in Calgary, Canada. Item-response theory (IRT) was used to evaluate the dimensionality, reliability, and validity of the OAB-v8, and differential functioning analysis (DIF) was used to determine whether the OAB-v8 should be scored differently for men and women. RESULTS: A total of 1128 patients were included for analysis, of which 28% were female. Mean OAB-v8 scores indicated meaningful levels of symptom bother, and women scored 2 points higher, on average, than men (P = 0.005). Reliability was high (Cronbach's alpha = 0.901) for a wide range of patients (between -2 and 2.5 standard deviations of the mean). Samejima's graded response model best fit the data, and the scale demonstrated essential unidimensionality. Items #5 and #6 were excessively correlated. There was no evidence of differential functioning. CONCLUSIONS: OAB-v8 demonstrated high reliability and would be appropriate for a wide range of patients. Items #5 and #6 may need to be re-worded. The OAB-v8 should not be scored differently for men and women, although women do appear to experience higher average levels of symptom bother from OAB than men.

Case distribution and complications of mid-urethral sling surgery in a Canadian city before and after the Health Canada advisory on pelvic floor mesh.

INTRODUCTION AND HYPOTHESIS: Increased incidences of complications related to the use of mid-urethral slings (MUS) for the treatment of stress urinary incontinence resulted in both the Food and Drug Administration (FDA) and Health Canada issuing advisories in 2008 and 2010 respectively. The purpose of this study was to assess the effect these advisories had on the number of surgeons performing MUS surgery and post-surgical complications in Calgary, Canada. METHODS: In this study, we conducted a retrospective analysis of administrative data between 2006 and 2011. Post-surgical complications were identified using diagnostic codes. All rates were adjusted for the increase in the female population in Calgary during the study period. An interrupted time series model was used to evaluate any changes in the number of surgeons performing MUS surgery and any post-surgical changes from the period before and that after the advisories. RESULTS: The number of surgeons performing MUS surgery and the number of surgeries performed decreased over the study period, although neither of these was significantly related to the advisories. In terms of complications, we did not observe a significant change in the rate of repeat MUS surgeries, inpatient admissions, emergency department visits, or ambulatory care visits within 2 years of initial surgery. CONCLUSION: The FDA and Health Canada advisories had no effect on the use of MUS in Calgary. This suggests either that they bear little influence on local surgeons' practices, or that safety was already at such a high level that improvements were not possible.

Mapping the BH3 Binding Interface of Bcl-xL, Bcl-2, and Mcl-1 Using Split-Luciferase Reassembly.

The recognition of helical BH3 domains by Bcl-2 homology (BH) receptors plays a central role in apoptosis. The residues that determine specificity or promiscuity in this interactome are difficult to predict from structural and computational data. Using a cell free split-luciferase system, we have generated a 276 pairwise interaction map for 12 alanine mutations at the binding interface for three receptors, Bcl-xL, Bcl-2, and Mcl-1, and interrogated them against BH3 helices derived from Bad, Bak, Bid, Bik, Bim, Bmf, Hrk, and Puma. This panel, in conjunction with previous structural and functional studies, starts to provide a more comprehensive portrait of this interactome, explains promiscuity, and uncovers surprising details; for example, the Bcl-xL R139A mutation disrupts binding to all helices but the Bad-BH3 peptide, and Mcl-1 binding is particularly perturbed by only four mutations of the 12 tested (V220A, N260A, R263A, and F319A), while Bcl-xL and Bcl-2 have a more diverse set of important residues depending on the bound helix.

Urinary bladder xanthoma: a multi-institutional series of 17 cases.

AIMS: To present a series of urinary bladder xanthomas and characterize their clinical features and associated pathology. METHODS AND RESULTS: We retrieved the clinicopathological data of bladder xanthomas, with and without associated urothelial neoplasms. We identified six isolated bladder xanthomas and 11 arising within or adjacent to urothelial neoplasms. The biopsies showed lamina propria aggregates of foamy histiocytes, without an accompanying inflammation. Patients presented either incidentally or with microscopic haematuria or irritative symptoms. Patients with isolated xanthomas had a mean age of 65.3 years (range: 54-75 years) and an equal male to female ratio. Four of five patients with isolated xanthomas with available serum results had an abnormal lipid profile. Eleven patients had xanthomas associated with urothelial neoplasms [papilloma n = 4, papillary urothelial neoplasm of low malignant potential (PUNLMP) n = 2 and low-grade urothelial carcinoma n = 5]. Mean patient age was 62.5 years (range: 51-69 years) and all were male. Of the six patients with metabolic abnormalities, five had hypercholesterolaemia and one had a history of diabetes mellitus. CONCLUSION: Bladder xanthomas are rare lesions found in older patients who present either non-specifically or with microscopic haematuria or irritative symptoms. These lesions are often associated with underlying lipid abnormalities. A biopsy is recommended for an accurate diagnosis and to exclude neoplasia.

Patient educational technologies and their use by patients diagnosed with localized prostate cancer.

BACKGROUND: Two urology practices in Calgary, Canada use patient educational technology (PET) as a core component of their clinical practice. The purpose of this study was to determine how patients interact with PET designed to inform them about their treatment options for clinically localized prostate cancer. METHODS: A PET library was developed with 15 unique prostate-related educational modules relating to diagnosis, treatment options, and potential side effects. The PET collected data regarding its use, and those data were used to conduct a retrospective analysis. Descriptive analyses were conducted and comparisons made between patients' utilization of the PET library during first and subsequent access; Pearson's Chi-Square was used to test for statistical significance, where appropriate. RESULTS: Every patient (n = 394) diagnosed with localized prostate cancer was given access to the PET library using a unique identifier. Of those, 123 logged into the library and viewed at least one module and 94 patients logged into the library more than once. The average patient initially viewed modules pertaining to their diagnosis. Viewing behavior significantly changed in subsequent logins, moving towards modules pertaining to treatment options, decision making, and post-surgical information. DISCUSSION: As observed through the longitudinal utilization of the PET library, information technology offers clinicians an opportunity to provide an interactive platform to meet patients' dynamic educational needs. Understanding these needs will help inform the development of more useful PETs. CONCLUSION: The informational needs of patients diagnosed with clinically localized prostate cancer changed throughout the course of their diagnosis and treatment.

Tracheoesophageal Fistula as a Complication of Prolonged Ventilation in COVID-19: Description of Reconstruction and Review of the Literature.

Infection with COVID-19 pneumonia may necessitate intubation and mechanical ventilation. Viral inflammation and pressure necrosis may lead to scarring, stenosis, and in severe cases, fistula formation. Nonmalignant tracheoesophageal fistulas (TEF) represent a surgical challenge and may necessitate locoregional tissue transfer and tracheal resection to prevent recurrence and maintain airway patency. We present a case of TEF in a 63-year-old female secondary to prolonged mechanical ventilation in the setting of COVID pneumonia, detailing the clinical findings and surgical repair. Primary closure of the esophageal defect with pectoralis major muscle flap onlay and tracheal resection, with median sternotomy for access, provided successful intervention, allowing for subsequent tracheostomy decannulation and return to a complete oral diet. This case offers further evidence of the increased risk of airway complications in COVID-19 infection and provides otolaryngologists with an example of a rare surgical approach useful in management.

Canadian cost data associated with treating overactive bladder is lacking.

INTRODUCTION: Cost-effectiveness analysis forms an integral part of the approval process for new medical treatments in Canada, including drug and non-drug technologies. This study's primary objective was to identify peer-reviewed studies that report Canadian-specific cost data for treating overactive bladder (OAB) based on the Canadian Urological Association (CUA) guideline. A secondary objective was to identify studies that report cost data from other healthcare jurisdictions that could be generalizable to the Canadian context. METHODS: We conducted a systematic review of the published peer-reviewed literature. We included studies from Organization for Economic Cooperation and Development countries, excluding the U.S., published in English since January 2009. RESULTS: From 165 abstracts identified in our initial search, 18 studies were ultimately included for analysis. This included one Canadian-based study reporting costs in Canadian dollars, all related to second-line treatments. The other studies were primarily from Europe, reporting costs in Euros or British pounds. There were no studies reporting costs for first-line treatments. Gaps in costs for select second-line and third-line treatments recommended by the CUA were also identified. CONCLUSIONS: Canadian-specific cost data for OAB treatments published in the peer-reviewed literature is limited to a single study reporting costs for only a few second-line treatments sourced from a single province over 10 years ago. Cost data from other healthcare jurisdictions are available, but the generalizability of costs associated with third-line treatments is questionable.

Management of patients susceptible to malignant hyperthermia: A surgeon's perspective.

OBJECTIVES: Malignant hyperthermia (MH) susceptibility caries broad implications for the care of pediatric surgical patients. While precautions must often be taken for only a vague family history, two options exist to assess MH-susceptibility. We evaluate the use of MH precautions and susceptibility testing at a freestanding children's hospital. METHODS: This single institution retrospective cohort study identified patients of any age who received general anesthetics utilizing MH precautions over a five-year period. The electronic medical record was further queried for patients diagnosed with MH. The indication for MH precautions and uses of susceptibility testing are assessed. Secondary outcomes included a diagnosis of bona fide MH. RESULTS: A total of 125 patients received 174 anesthetics with MH precautions at a mean age of 114 months (0-363 months). Otolaryngology was the procedural service most frequently involved in the care of the cohort (n = 45; 26%). A reported personal or family history of MH (n = 102; 59%) was the most common indication for precautions, followed by muscular dystrophy (n = 29; 17%). No MH events occurred in the cohort and further review of ICD-9 and -10 diagnosis codes found no MH diagnoses. No study subjects received muscle biopsy and contracture testing and only 5 (4%) underwent genetic testing for genomic variants known to cause MH susceptibility. A case example is given to highlight the implications of a reported MH history. CONCLUSION: Otolaryngologists should maintain a familiarity with the precautions necessary to manage patients at risk for MH and MH-like reactions. Without an accessible test to rule out susceptibility, surgeons must rely on a careful history to appropriately utilize precautions. An inappropriate label of "MH-susceptible" may result in decreased access to care and treatment delays.

Periurethral and Anterior Vaginal Wall Masses: Etiology, Presentation, and Treatment Outcomes.

OBJECTIVE: To describe the etiology and presenting symptoms of periurethral and anterior vaginal wall masses in a large series of patients in an academic institution. METHODS: A retrospective chart review of 126 patients presenting and undergoing treatment for periurethral and anterior vaginal wall masses between November 2001 and July 2021 was completed. Clinicopathologic data were extracted. Ethics approval was obtained. The primary objective of this study was to determine the etiology of these masses; secondary objectives included determining the rates of presenting symptoms, complications, resolution of stress urinary incontinence (SUI), and de novo SUI. RESULTS: The median age of patients was 42 years. The most common etiology was urethral diverticula (39.7%), followed by Skene gland cysts or abscesses (30.2%). The rate of malignancy was 1.6%, and the rate of infection was 21.4%. The most common presenting symptoms were sensation of mass (78.6%), dyspareunia (52.4%), and discharge (46.0%). The rate of surgical complications was 9.5%. Three patients had recurrence on follow-up, but there were no recurrent urethral diverticula after excision. The rate of de novo SUI was 5.6%. The rate of resolution of SUI was 67.6%, and all patients who had slings reported resolution of SUI. CONCLUSION: Urethral diverticula and Skene gland cysts or abscesses accounted for 70% of periurethral and anterior vaginal wall masses in this series. Treatment by complete excision is usually successful.

Efficacy of botulinum toxin A injection for neurogenic detrusor overactivity and urinary incontinence: a randomized, double-blind trial.

PURPOSE: We determined the efficacy of onabotulinumtoxinA for neurogenic detrusor overactivity secondary to spinal cord injury or multiple sclerosis. MATERIALS AND METHODS: In a prospective, double-blind, multicenter study 57 patients 18 to 75 years old with neurogenic detrusor overactivity secondary to spinal cord injury or multiple sclerosis and urinary incontinence (defined as 1 or more occurrences daily) despite current antimuscarinic treatment were randomized to onabotulinumtoxinA 300 U (28) or placebo (29) via cystoscopic injection at 30 intradetrusor sites, sparing the trigone. Patients were offered open label onabotulinumtoxinA 300 U at week 36 and followed a further 6 months while 24 each in the treatment and placebo groups received open label therapy. The primary efficacy parameter was daily urinary incontinence frequency on 3-day voiding diary at week 6. Secondary parameters were changes in the International Consultation on Incontinence Questionnaire and the urinary incontinence quality of life scale at week 6. Diary and quality of life evaluations were also done after open label treatment. RESULTS: The mean daily frequency of urinary incontinence episodes was significantly lower for onabotulinumtoxinA than for placebo at week 6 (1.31 vs 4.76, p <0.0001), and for weeks 24 and 36. Improved urodynamic and quality of life parameters for treatment vs placebo were evident at week 6 and persisted to weeks 24 to 36. The most common adverse event in each group was urinary tract infection. CONCLUSIONS: In adults with antimuscarinic refractory neurogenic detrusor overactivity and multiple sclerosis onabotulinumtoxinA is well tolerated and provides clinically beneficial improvement for up to 9 months.

The Effect of Manual Therapy on Lower Extremity Joint Kinematics during Running: A single-subject case study.

BACKGROUND: While there is scarcity of current literature to support the effectiveness of muscle energy techniques (MET) with musculoskeletal injuries, the overall impact on gait kinematics necessitates investigation. This case study involved a 48-year-old male runner and aimed to determine the effect of manual therapy, including joint mobilization and MET, on lower extremity (LE) kinematics. The subject had a medical history that included: Achilles tendonitis, low back pain, and iliotibial band syndrome. METHODS: A clinical exam and Xsens motion capture were performed on the subject prior to treatment and at the conclusion of the 6 weeks of treatment. Motion capture was used to examine bilateral foot contact time, hip transverse plane motion and ankle sagittal plane motion. Pre-treatment and post-treatment ipsilateral and bilateral differences between groups were analyzed. RESULTS: Changes were noted between ipsilateral and bilateral pre- and post-treatment contact times; right foot sagittal plane joint angle at foot off; left hip transverse plane joint angle at foot contact and foot off, all bilateral pre- and post-treatment hip angles at foot contact and foot off, all bilateral pre- and post-treatment ankle angles at foot contact and foot off. CONCLUSIONS: Clinical exams paralleled the change in hip external rotation bringing the hips to a more neutral position. In addition, the final clinical exam noted a decrease in subtalar eversion bilaterally, which may relate to the improved pelvic symmetry and biomechanical compensation pattern. Clinically, these findings may coincide with improving proximal lumbopelvic symmetry assisting with normalizing distal mobility by using manual therapy.