Integrated Urology and Primary Care Model Improves Outcomes for Men With Testosterone Deficiency.

INTRODUCTION: Many men presenting with testosterone deficiency do not have access to a primary care provider. We sought to integrate primary care into initial urological evaluation to better identify and manage undertreated comorbidities. METHODS: New patients presenting with testosterone deficiency were offered primary care provider evaluation within a men's health center between October 2019 and 2022. Data collected from the electronic health record included age, race, BMI, access to prior primary care provider, new diagnoses, prescriptions, and referrals. RESULTS: Eighty-one men were evaluated over the 3-year study period. Thirty-three men (41%) did not have a preexisting primary care provider. Older men were significantly more likely to have a preexisting primary care provider (OR 1.06 [95% CI: 1.02-1.10], P < .001). Hispanic men were significantly less likely to have an existing primary care provider (OR 0.16 [95% CI: 0.03-0.84], P = .01). Forty-eight men (59%) established continuity of care. Newly diagnosed comorbidities included hypertension (41%), obesity (37%), hyperlipidemia (27%), obstructive sleep apnea (25%), depression (23%), and diabetes (14%). Forty-one patients (51%) were prescribed a new medication. Twenty-one patients (26%) were referred to nutrition, with mean BMI decrease of 1.75 kg/m2. Twenty-six patients (32%) underwent sleep medicine evaluation for obstructive sleep apnea. Twenty-seven (33%) and 37 patients (46%) received a flu vaccination and immunization updates. Eleven patients (14%) were referred for screening colonoscopy. CONCLUSIONS: This is the first report of integrated primary care and urology evaluation for testosterone deficiency. This comprehensive model results in improved outcomes including increased access to subspecialty referrals, objective weight loss, treatment of new diagnoses, updated immunizations, and cancer screening.

Prognostic Value of the Intermediate-risk Feature in Men with Favorable Intermediate-risk Prostate Cancer: Implications for Active Surveillance.

Background: Guidelines suggest that active surveillance (AS) may be considered for select patients with favorable intermediate-risk (fIR) prostate cancer. Objective: To compare the outcomes between fIR prostate cancer patients included by Gleason score (GS) or prostate-specific antigen (PSA). Most patients are classified with fIR disease due to either a 3 + 4 = 7 GS (fIR-GS) or a PSA level of 10-20 ng/ml (fIR-PSA). Previous research suggests that inclusion by GS 7 may be associated with worse outcomes. Design setting and participants: We conducted a retrospective cohort study of US veterans diagnosed with fIR prostate cancer from 2001 to 2015. Outcome measurements and statistical analysis: We compared the incidence of metastatic disease, prostate cancer-specific mortality (PCSM), all-cause mortality (ACM), and receipt of definitive treatment between fIR-PSA and fIR-GS patients managed with AS. Outcomes were compared with those of a previously published cohort of patients with unfavorable intermediate-risk disease using cumulative incidence function and Gray's test for statistical significance. Results and limitations: The cohort included 663 men; 404 had fIR-GS (61%) and 249 fIR-PSA (39%). There was no evidence of difference in the incidence of metastatic disease (8.6% vs 5.8%, p = 0.77), receipt of definitive treatment (77.6% vs 81.5%, p = 0.43), PCSM (5.7% vs 2.5%, p = 0.274), and ACM (16.8% vs 19.1%, p = 0.14) between the fIR-PSA and fIR-GS groups at 10 yr. On multivariate regression, unfavorable intermediate-risk disease was associated with higher rates of metastatic disease, PCSM, and ACM. Limitations included varying surveillance protocols. Conclusions: There is no evidence of difference in oncological and survival outcomes between men with fIR-PSA and fIR-GS prostate cancer undergoing AS. Thus, presence of GS 7 disease alone should not exclude patients from consideration of AS. Shared decision-making should be utilized to optimize management for each patient. Patient summary: In this report, we compared the outcomes of men with favorable intermediate-risk prostate cancer in the Veterans Health Administration. We found no significant difference between survival and oncological outcomes.

Short-term radiographic analysis of a stemless humeral component for anatomic total shoulder arthroplasty.

Background: Standard stemmed humeral implants have traditionally been utilized for total shoulder arthroplasty (TSA) with a recent trend to implant smaller stems including short and stemless humeral designs. However, the rate of stress shielding after stemless TSA has not been primarily studied. Therefore, the objective of this study is to report the short-term survivorship and radiographic analysis of a stemless humeral implant. Methods: A retrospective cohort review of a prospectively collected, multicenter database for patients undergoing total shoulder arthroplasty with a stemless humeral design (Equinoxe Stemless; Exactech, Inc., Gainesville, FL, USA) with a minimum of 2 years clinical and radiographic follow-up was performed. The primary outcomes were to report the location and rate of stress shielding from a radiographic analysis of the humeral stem. Additionally, the revision rate of the humeral stem is reported. The secondary outcomes included ASES scores, visual analog scale (VAS) pain scores, and range of motion (ROM). Radiographs (anterior-posterior/Grashey and axillary) were reviewed blindly by two fellowship trained shoulder surgeons. Radiographic analysis included stress shielding (partial or complete cortical resorption) and subsidence or shift in component position. Results: Fifty four patients were included in this study with an average follow-up of 27 months (range 24-32 months). The average age of this cohort was 65 years (range 57-73 years) with 23 patients (43%) being female. Stress shielding was observed in 4 patients (7%) with the medial calcar being the most common location of stress shielding. Three of the 4 patients (75%) had evidence of partial resorption while 1 patient (25%) had evidence of complete resorption. No humeral component shift or subsidence was observed. There were no revisions due to humeral component complications. There was 1 revision surgery for aseptic glenoid loosening. A significant improvement for all clinical outcome measures was seen including with respect to VAS pain, which improved from 6.2 to 1.8 (P < .05), ASES, which improved from 38.2 to 81.8 (P < .05), and ROM which forward flexion improved from 120 degrees to 153 degrees (P < .05) and external rotation improved from 29 degrees to 49 degrees (P < .05). Discussion: This ongoing study demonstrates a low rate of stress shielding for a stemless design humeral implant at short-term follow-up without any revision surgery due to humeral component complications. Longer term radiographic and clinical analysis with this cohort will be needed to confirm these findings and theoretical benefits for future revision surgeries.

Association Between Acute Kidney Injury During Invasive Mechanical Ventilation and ICU Outcomes and Respiratory System Mechanics.

Compare ICU outcomes and respiratory system mechanics in patients with and without acute kidney injury during invasive mechanical ventilation. DESIGNS: Retrospective cohort study. SETTINGS: ICUs of the University of California, San Diego, from January 1, 2014, to November 30, 2016. PATIENTS: Five groups of patients were compared based on the need for invasive mechanical ventilation, presence or absence of acute kidney injury per the Kidney Disease: Improving Global Outcomes criteria, and the temporal relationship between the development of acute kidney injury and initiation of invasive mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 9,704 patients were included and 4,484 (46%) required invasive mechanical ventilation; 2,009 patients (45%) had acute kidney injury while being treated with invasive mechanical ventilation, and the mortality rate for these patients was 22.4% compared with 5% in those treated with invasive mechanical ventilation without acute kidney injury (p < 0.01). Adjusted hazard of mortality accounting for baseline disease severity was 1.58 (95% CI, 1.22-2.03; p < 0.001]. Patients with acute kidney injury during invasive mechanical ventilation had a significant increase in total ventilator days and length of ICU stay with the same comparison (both p < 0.01). Acute kidney injury during mechanical ventilation was also associated with significantly higher plateau pressures, lower respiratory system compliance, and higher driving pressures (all p < 0.01). These differences remained significant in patients with net negative cumulative fluid balance. CONCLUSIONS: Acute kidney injury during invasive mechanical ventilation is associated with increased ICU mortality, increased ventilator days, increased length of ICU stay, and impaired respiratory system mechanics. These results emphasize the need for investigations of ventilatory strategies in the setting of acute kidney injury, as well as mechanistic studies of crosstalk between the lung and kidney in the critically ill.

Absolute quantification of plasma mitochondrial DNA by droplet digital PCR marks COVID-19 severity over time during intensive care unit admissions.

Increased plasma mitochondrial DNA concentrations are associated with poor outcomes in multiple critical illnesses, including COVID-19. However, current methods of cell-free mitochondrial DNA quantification in plasma are time-consuming and lack reproducibility. Here, we used next-generation sequencing to characterize the size and genome location of circulating mitochondrial DNA in critically ill subjects with COVID-19 to develop a facile and optimal method of quantification by droplet digital PCR. Sequencing revealed a large percentage of small mitochondrial DNA fragments in plasma with wide variability in coverage by genome location. We identified probes for the mitochondrial DNA genes, cytochrome B and NADH dehydrogenase 1, in regions of relatively high coverage that target small sequences potentially missed by other methods. Serial assessments of absolute mitochondrial DNA concentrations were then determined in plasma from 20 critically ill subjects with COVID-19 without a DNA isolation step. Mitochondrial DNA concentrations on the day of enrollment were increased significantly in patients with moderate or severe acute respiratory distress syndrome (ARDS) compared with those with no or mild ARDS. Comparisons of mitochondrial DNA concentrations over time between patients with no/mild ARDS who survived, patients with moderate/severe ARDS who survived, and nonsurvivors showed the highest concentrations in patients with more severe disease. Absolute mitochondrial DNA quantification by droplet digital PCR is time-efficient and reproducible; thus, we provide a valuable tool and rationale for future studies evaluating mitochondrial DNA as a real-time biomarker to guide clinical decision-making in critically ill subjects with COVID-19.

Management of Testicular Germ Cell Tumor With Somatic-Type Malignancy.

A man, aged 21 years, presented with a 4-month history of progressive swelling of the right testicle. Ultrasound revealed a heterogenous solid mass in the right testicle suspicious for malignancy. Further work-up included CT scans, which identified a 2-cm retroperitoneal lymph node; there was no evidence of thoracic metastases. Serum tumor markers revealed a mildly elevated α-fetoprotein (AFP) and normal lactate dehydrogenase (LDH) and human chorionic gonadotropin (hCG). The patient underwent right radical inguinal orchiectomy. Pathology evaluation demonstrated 1% teratoma with extensive secondary somatic-type malignant components of embryonal rhabdomyosarcoma and chondrosarcoma. No lymphovascular invasion was identified. Repeat tumor markers showed normal AFP, LDH, and hCG. Follow-up short-interval CT scans confirmed a dominant 2-cm interaortocaval lymph node with no evidence of distant metastases. The patient underwent retroperitoneal lymph node dissection, which revealed 1 of 24 lymph nodes positive for similar somatic-type malignancy composed of rhabdomyosarcoma and chondrosarcoma as well as undifferentiated spindle cell sarcoma with extranodal extension. Immunohistochemistry revealed that tumor cells were positive for myogenin and desmin and negative for SALL4.

A conserved retromer-independent function for RAB-6.2 in C. elegans epidermis integrity.

Rab proteins are conserved small GTPases that coordinate intracellular trafficking essential to cellular function and homeostasis. RAB-6.2 is a highly conserved C. elegans ortholog of human RAB6 proteins. RAB-6.2 is expressed in most tissues in C. elegans and is known to function in neurons and in the intestine to mediate retrograde trafficking. Here, we show that RAB-6.2 is necessary for cuticle integrity and impermeability in C. elegans RAB-6.2 functions in the epidermis to instruct skin integrity. Significantly, we show that expression of a mouse RAB6A cDNA can rescue defects in C. elegans epidermis caused by lack of RAB-6.2, suggesting functional conservation across phyla. We also show that the novel function of RAB-6.2 in C. elegans cuticle development is distinct from its previously described function in neurons. Exocyst mutants partially phenocopy rab-6.2-null animals, and rab-6.2-null animals phenocopy mutants that have defective surface glycosylation. These results suggest that RAB-6.2 may mediate the trafficking of one or many secreted glycosylated cuticle proteins directly, or might act indirectly by trafficking glycosylation enzymes to their correct intracellular localization.