Factors associated with radiological misstaging of pancreatic ductal adenocarcinoma: A retrospective observational study.

PURPOSE: Accurate staging of disease is vital in determining appropriate care for patients with pancreatic ductal adenocarcinoma (PDAC). It has been shown that the quality of scans and the experience of a radiologist can impact computed tomography (CT) based assessment of disease. The aim of the current study was to evaluate the impact of the rereading of outside hospital (OH) CT by an expert radiologist and a repeat pancreatic protocol CT (PPCT) on staging of disease. METHODS: Patients evaluated at the our institute's pancreatic multidisciplinary clinic (2006 to 2014) with OH scan and repeat PPCT performed within 30 days were included. In-house radiologists staged disease using OH scans and repeat PPCT, and factors associated with misstaging were determined. RESULTS: The study included 100 patients, with a median time between OH scan and PPCT of 19 days (IQR: 13-23 days.) Stage migration was mostly accounted for by upstaging of disease (58.8 % to 83.3 %) in all comparison groups. When OH scans were rereviewed, 21.5 % of the misstaging was due to missed metastases, however, when rereads were compared to the PPCT, occult metastases accounted for the majority of misstaged patients (62.5 %). Potential factors associated with misstaging were primarily related to imaging technique. CONCLUSION: A repeat PPCT results in increased detection of metastatic disease that rereviews of OH scans may otherwise miss. Accessible insurance coverage for repeat PPCT imaging even within 30 days of an OH scan could help optimize delivery of care and alleviate burdens associated with misstaging.

Antibiotic resistance in patients undergoing serial prostate biopsies: risk factors and impact on clinical outcomes.

INTRODUCTION: We evaluate the rate of developing ciprofloxacin resistance in patients undergoing repeat prostate biopsies (PBx), associated risk factors, and impact on complications. MATERIALS AND METHODS: We retrospectively evaluated pre-procedural rectal culture (RCx) data in men undergoing PBx from 1/1/2016 to 1/15/2021. Univariate and multivariate logistic regression were utilized to identify risk factors associated with development of antibiotic resistance. Complication rates were compared between ciprofloxacin-sensitive and ciprofloxacin-resistant patients. RESULTS: A total of 743 men underwent initial RCx. Initial RCx detected ciprofloxacin resistance in 22% of patients. A history of diabetes (p = 0.01), > 2 prior prostate biopsies (p = 0.01), and ciprofloxacin use (p = 0.002) were significant risk factors for ciprofloxacin resistance on initial RCx. The rate of new ciprofloxacin resistance following biopsy with standard ciprofloxacin prophylaxis on 1st and 2nd exposure was 17.2% and 9.1% respectively. The number of biopsy cores, interval antibiotic exposure and interval procedures performed between first and second RCx were not significant predictors of developing ciprofloxacin resistance. Patients who received a non-ciprofloxacin antibiotic between first and second RCx did not develop ciprofloxacin resistance. Antibiotic resistance profile did not significantly affect the rate or type of complications after various prostate procedures. CONCLUSIONS: Serial exposure to standard antibiotic prophylaxis for PBx and associated procedures can lead to development of ciprofloxacin resistance after each subsequent exposure. This carries important implications for serial biopsy and highlights the role for RCx prior to repeat biopsy.

Attitudes, Perceptions, and Use of Cancer-based Genetic Testing Among Healthy U.S. Adults and Those With Prostate or Breast/Ovarian Cancer.

INTRODUCTION: Differences in public awareness and uptake of genetic testing among patients with inheritable cancers are not well understood. The purpose of this study is to examine self-reported rates of undergoing cancer-specific genetic testing in patients with breast/ovarian cancer vs prostate cancer from a nationally representative sample of U.S. PATIENTS: Secondary objectives include examining sources of genetic testing information and perceptions of genetic testing for both patient populations as well as the general public. METHODS: Data from the National Cancer Institute's Health Information National Trends Survey 5, Cycle 4 were used to generate nationally representative estimates of adults living in the U.S. Our exposure of interest was patient reported cancer history categorized as having: (1) either breast or ovarian cancer, (2) prostate cancer, or (3) no history of cancer. χ2 testing was used to compare differences among categorical variables. RESULTS: In a nationally representative sample of 231.7 million adults, 3.7 million adults reported a history of breast/ovarian cancer while 1.5 million patients reported a history of prostate cancer; 52.3% of patients with breast/ovarian cancer vs 1.0% with prostate cancer reported undergoing cancer-specific genetic testing (P = .001). Patients with prostate cancer were less aware of cancer-specific genetic testing than either individuals with breast/ovarian cancer or adults without a cancer history (19.7% vs 64.7% vs 35.8%, respectively; P = .003). Health care professionals were the most common source of genetic testing information for patients with breast/ovarian cancer whereas the Internet was the most common source for patients with prostate cancer. CONCLUSIONS: Our results suggest a lack of awareness and limited utilization of genetic testing among patients with prostate cancer relative to breast/ovarian cancer. Patients with prostate cancer cite the Internet and social media as sources of information, which may be an avenue for more optimal dissemination of evidence-based information.

Sleep disturbances are underappreciated in prostate cancer survivorship.

BACKGROUND: The prevalence of sleep disturbances among prostate cancer (PCa) survivors, and extent of urologist involvement in sleep care are not well-studied. METHODS: PCa survivors (n = 167) and urologists (n = 145) were surveyed about sleep disturbances and survivorship care practices. RESULTS: Most PCa survivors had sleep disturbances, including 50.9% with poor sleep quality, 18.0% with clinical/severe insomnia, and 36.5% at high-risk for sleep apnea. Few urologists routinely screened for sleep disturbances, as recommended in national cancer survivorship guidelines. CONCLUSIONS: Optimal PCa survivorship care should incorporate screening for sleep disturbances, addressing comorbid factors affecting sleep and referring to sleep medicine when appropriate.

Two Year Functional Outcomes Stratified According to Baseline Erectile Function Following Partial Gland Cryo-Ablation.

OBJECTIVE: To critically evaluate time dependent sexual function following primary partial gland cryo-ablation (PGCA) stratified according to baseline erectile function. METHODS: Between March 2017 and March 2022, all men undergoing primary PGCA by 2 surgeons were enrolled in an IRB approved outcomes registry. All subjects with PIRADS 2-5 lesion concordant with unilateral GGG 1-3 disease, no gross extra-prostatic extension on mpMRI, GGG >1 contralateral to the ROI, or distal apical disease on mpMRI were enrolled. Patients completed the Sexual Health Inventory for Men (SHIM) scale at baseline, 6, and 24 months. Men were stratified by baseline erectile function. Men with SHIM Score < 8 were excluded. Ability to sustain erection (aka "potency") was defined as a score of 3 or greater on question 2 of the SHIM index. Median SHIM scores and the proportion of men reporting "potency" at baseline, 6, and 24 months was recorded with comparisons between each timepoint. A univariate analysis was used to determine if clinical factors were associated with loss of "potency" at 24 months. RESULTS: 106 men met the inclusion criteria. There was a statistically significant decrease in the mean SHIM scores for the entire cohort between baseline to 6 months and baseline to 24 months. SHIM scores increased significantly for the total cohort between 6 and 24 months. "Potency" was preserved in 70% at 24 months. CONCLUSION: Those patients most likely to exhibit a decrease in sexual function have moderate ED at baseline. Only baseline ED was shown to predict preservation of "potency".

Early functional outcomes following partial gland cryo-ablation.

INTRODUCTION: Given the increasing interest in partial gland cryo-ablation as a treatment modality and the lack of data surrounding urinary and sexual outcomes after the procedure, the goal of this analysis was to assess functional outcomes following partial gland cryo-ablation (PGCA) stratified according to baseline severity of lower urinary tract symptoms (LUTS) and erectile function (EF). A secondary goal was to also determine if there were any clinical factors associated with significant change in LUTS and EF. MATERIALS AND METHODS: Since 3/2017, all men undergoing primary PGCA were offered enrollment into an IRB-approved prospective outcomes registry. Men were given International Prostate Symptom Score (IPSS) and Sexual Health Inventory for Men (SHIM) surveys prior to and 6 months post treatment. Differences in IPSS and SHIM scores are described, and factors associated with clinically significant change were assessed using univariate and multivariate analysis. RESULTS: A total of 100 men completed 6 month follow up. The mean IPSS for the overall cohort decreased 2.1 units (p > 0.05). The mean changes in IPSS for men with baseline mild, moderate, and severe LUTS were 0.9 (p = 0.06), -4.2 (p = 0.001), and -11.1(p = 0.001) units, respectively. The mean changes in the SHIM score for all men were - 5.1 units (p = 0.001). The mean changes in SHIM score for baseline none, mild/mild-to-moderate, moderate-severe ED were -7.6 (p = 0.001), -6.5 (p = 0.001) and -1.1 units (p = 0.27), respectively. No variables of interest were significantly associated with changes in IPSS or SHIM scores. CONCLUSION: Stratifying functional outcomes according to baseline IPSS and SHIM is imperative to assess the true impact of PGCA on functional outcomes.

Sociodemographic differences in utilization of fertility services among reproductive age women diagnosed with cancer in the USA.

PURPOSE: To determine whether sociodemographic differences exist among female patients accessing fertility services post-cancer diagnosis in a representative sample of the United States population. METHODS: All women ages 15-45 with a history of cancer who responded to the National Survey for Family Growth (NSFG) from 2011 to 2017 were included. The population was then stratified into 2 groups, defined as those who did and did not seek infertility services. The demographic characteristics of age, legal marital status, education, race, religion, insurance status, access to healthcare, and self-perceived health were compared between the two groups. The primary outcome measure was the utilization of fertility services. The complex sample analysis using the provided sample weights required by the NSFG survey design was used. RESULTS: Five hundred forty-five women reported a history of cancer and were included in this study. Forty-three (7.89%) pursued fertility services after their cancer diagnosis. Using the NSFG sample weights, this equates to a population of 161,500.7 female cancer survivors in the USA who did utilize fertility services and 1,811,955.3 women who did not. Using multivariable analysis, household income, marital status, and race were significantly associated with women utilizing fertility services following a cancer diagnosis. CONCLUSIONS: In this nationally representative cohort of reproductive age women diagnosed with cancer, there are marital, socioeconomic, and racial differences between those who utilized fertility services and those who did not. This difference did not appear to be due to insurance coverage, access to healthcare, or perceived health status.

Gaps in Public Awareness About BRCA and Genetic Testing in Prostate Cancer: Social Media Landscape Analysis.

BACKGROUND: Genetic testing, particularly for BRCA1/2, is increasingly important in prostate cancer (PCa) care, with impact on PCa management and hereditary cancer risk. However, the extent of public awareness and online discourse on social media is unknown, and presents opportunities to identify gaps and enhance population awareness and uptake of advances in PCa precision medicine. OBJECTIVE: The objective of this study was to characterize activity and engagement across multiple social media platforms (Twitter, Facebook, and YouTube) regarding BRCA and genetic testing for PCa compared with breast cancer, which has a long history of public awareness, advocacy, and prominent social media presence. METHODS: The Symplur Signals online analytics platform was used to obtain metrics for tweets about (1) #BRCA and #breastcancer, (2) #BRCA and #prostatecancer, (3) #genetictesting and #breastcancer, and (4) #genetictesting and #prostatecancer from 2016 to 2020. We examined the total number of tweets, users, and reach for each hashtag, and performed content analysis for a subset of tweets. Facebook and YouTube were queried using analogous search terms, and engagement metrics were calculated. RESULTS: During a 5-year period, there were 10,005 tweets for #BRCA and #breastcancer, versus 1008 tweets about #BRCA and #prostatecancer. There were also more tweets about #genetictesting and #breastcancer (n=1748), compared with #genetic testing and #prostatecancer (n=328). Tweets about genetic testing (12,921,954) and BRCA (75,724,795) in breast cancer also had substantially greater reach than those about PCa (1,463,777 and 4,849,905, respectively). Facebook groups and pages regarding PCa and BRCA/genetic testing had fewer average members, new members, and new posts, as well as fewer likes and followers, compared with breast cancer. Facebook videos had more engagement than YouTube videos across both PCa and breast cancer content. CONCLUSIONS: There is substantially less social media engagement about BRCA and genetic testing in PCa compared with breast cancer. This landscape analysis provides insights into strategies for leveraging social media platforms to increase public awareness about PCa germline testing, including use of Facebook to share video content and Twitter for discussions with health professionals.

Are Infertile Men Less Healthy Than Fertile Men? An Analysis of the National Survey for Family Growth.

OBJECTIVE: To characterize the general health status of infertile men in the United States using a nationally representative sample of men. METHODS: Using the National Survey for Family Growth from 2011 to 2017, infertile subgroups were created using a range of inclusion criteria. Univariate and multivariate analyses were conducted comparing these men to fertile men. RESULTS: Using population estimates, 6.5 million men with reduced fertility potential were compared to 26 million fertile men. After controlling for demographic and healthcare utilization factors, these groups did not have significantly different rates of key medical co-morbidities, including cancer, obesity, and overall disability. Looking at the subset of men who had received a specific infertility diagnosis, estimated as a population of nearly 600,000 men, this pattern held, in that there were no significant differences in the rates of medical co-morbidities. Notably, the rate of male infertility evaluation among potentially infertile men was only 50%. These findings also persisted after a propensity-matched analysis. CONCLUSION: In this cohort, there was no significant relationship between infertility and specific medical co-morbidities. We must consider the influence of sample selection as we continue to investigate the relationship between medical co-morbidities and reduced fertility potential. Given the persistent low rates of infertility evaluation, even among men who seek medical advice to conceive, we must continue to search for ways to characterize the infertile male population while simultaneously working to improve access.

The Effect of Symptomatic Stress Urinary Incontinence on Catheterization Rates After Intradetrusor OnabotulinumtoxinA Injections.

OBJECTIVES: To determine whether catheterization rates after intradetrusor onabotulinumtoxinA injection for nonneurogenic overactive bladder and urgency incontinence differ between women with urgency urinary incontinence only and women with urgency-predominant mixed urinary incontinence. METHODS: This was a retrospective cohort study of patients that underwent intradetrusor onabotulinumtoxinA injection of 100 U for nonneurogenic urgency urinary incontinence. The primary outcome was the difference in catheterization rates between women with urgency urinary incontinence alone compared with women with urgency-predominant mixed urinary incontinence. Descriptive statistics and multivariate logistic regression analysis were performed. RESULTS: Of the 177 women included in the final analysis, 105 had urgency urinary incontinence and 72 had urgency-predominant mixed urinary incontinence. The overall catheterization rate after onabotulinumtoxinA injection was 11.3%, with significantly fewer women with mixed urinary incontinence requiring catheterization when compared with women with urgency urinary incontinence alone (4.2% vs 16.2%; P = 0.03), despite an older population (P = 0.02). Patient-reported improvement (P = 0.37) and decision to continue onabotulinumtoxinA treatments (P = 0.89) were similar between groups. Multivariate logistic regression analysis revealed that women with mixed urinary incontinence had significantly lower odds of requiring catheterization after onabotulinumtoxinA injections than women with urgency urinary incontinence alone (odds ratio, 0.16; 95% confidence interval, 0.04-0.67; P = 0.01). CONCLUSIONS: Findings suggest that the presence of symptomatic stress urinary incontinence is associated with lower rates of catheterization after intradetrusor onabotulinumtoxinA, but does not compromise efficacy of treatment for urgency-predominant mixed urinary incontinence.

Evaluating the unevaluated: a secondary analysis of the National Survey for Family Growth (NSFG) examining infertile women who did not access care.

PURPOSE: To characterize the demographic differences between infertile/sub-fertile women who utilized infertility services vs. those that do not. METHODS: A retrospective analysis of cross-sectional data obtained during the 2011-2013, 2013-2015, and 2015-2017 cycles of National Survey for Family Growth from interviews administered in home for randomly selected participants by a National Center of Health Statistics (NCHS) surveyor was used to analyze married, divorced, or women with long-term partners who reported difficulty having biological children (sub-fertile/infertile women). Demographic differences such as formal marital status, education, race, and religion were compared between women who presented for infertility care vs. those that did not. The primary outcome measure was presenting for infertility evaluation and subsequently utilizing infertility services. Healthcare utilization trends such as having a usual place of care and insurance status were also included as exposures of interest in the analysis. RESULTS: Of the 12,456 women included in the analysis 1770 (15.3%) had used infertility services and 1011 (8.3%) said it would be difficult for them to have a child but had not accessed infertility services. On univariate analysis, compared to women who used infertility services, untreated women had lower average household incomes (295.3 vs. 229.8% of the federal poverty line respectively). Untreated women also had lower levels of education and were more likely to be divorced or never have married. In terms of health status, unevaluated women were less likely to have a usual place for healthcare (87.3%) as compared to women presenting for fertility care (91.9%) (p = 0.004). When examining insurance status, 23.3% of unevaluated women were uninsured as compared to 8.3% of evaluated women. On multivariate analysis, infertile women without insurance were at 0.37 odds of utilizing infertility care compared to women with insurance. CONCLUSIONS: Demographic factors are associated with the utilization of infertility care. Insurance status is a significant predictor of whether or not infertile women will access treatment. Data from the three most recent NSFG surveys along with prior analyses demonstrate the need for expanded insurance coverage in order to address the socioeconomic disparities between infertile women who are accessing services vs. those that are not.

#ILookLikeAUrologist: Using Twitter to Discuss Diversity and Inclusion in Urology.

According to the 2018 American Urological Association census, only 9.2% of practicing urologists are female and 16% are non-Caucasian. Social media have been used in other medical disciplines to promote diversity and form networks for gender and racial minorities. We studied the hashtag #ILookLikeAUrologist, started to promote diversity and inclusion in urology, to determine if it had any signs of a community of practice. Over the 4 yr since its inception, there have been 3694 tweets using the hashtag #ILookLikeAUrologist. The discussion had 1348 unique contributors, hailing from 35 countries on six continents. There were 8,156,051 impressions, highlighting a wide potential reach for the discussion. In a random 25% sample of original tweets, the main themes were gender representation, followed by personal narratives and camaraderie. Most contributors were practicing urologists, followed by urology trainees, other physicians, and professional organizations. Although most posts were authored by women, men represented nearly a quarter of individual contributors. The #ILookLikeAUrologist hashtag has been widely used by a large global audience in urology. Future research is warranted to examine the impact of digital communities of practice on outcomes such as fostering collaboration, providing mentorship, and reducing burnout. PATIENT SUMMARY: The #ILookLikeAUrologist hashtag has been widely used on Twitter by a large global audience to promote diversity and inclusion in urology.

Men Who Have Undergone Vasectomy are Healthier Than Non-sterilized Fertile Men: An Analysis of the Nation Survey for Family Growth.

OBJECTIVE: To evaluate the health status of men who have undergone vasectomy versus nonsterilized fertile men. METHODS: Using the National Survey for Family Growth from 2002 to 2017, univariate and multivariate analyses were performed on demographic and health data, including health status and health care utilization. RESULTS: Men who have undergone vasectomy are more likely to be older, healthier, have more children, identify as non-Hispanic white, be married, have a higher level of education, earn a higher mean household income, and were more likely to be privately insured than non-sterilized fertile men. On multivariate analysis, men who underwent vasectomy had a better health status despite being older. CONCLUSION: There are significant socioeconomic and health differences between men who elect vasectomy and non-sterilized fertile men. These differences should be considered when considering using sterilized men as a proxy for proven fertile men in epidemiological studies.

Kallman syndrome and central non-obstructive azoospermia.

The understanding of male factors of infertility has grown exponentially in the past ten years. While clear guidelines for obstructive azoospermia have been developed, management of non-obstructive azoospermia has lagged. Specifically, management of Kallmann Syndrome and central non-obstructive azoospermia has been limited by a lack of understanding of the molecular pathogenesis and investigational trials exploring the best option for management and fertility in these patients. This review aims to summarize our current understanding of the causes of central hypogonadotropic hypogonadism with a focus on genetic etiologies while also discussing options that endocrinologists and urologists can utilize to successfully treat this group of infertile men.

Outpatient Parenteral Therapy for Complicated Staphylococcus aureus Infections: A Snapshot of Processes and Outcomes in the Real World.

BACKGROUND: In the United States, patients discharged on outpatient parenteral antimicrobial therapy (OPAT) are often treated by home health companies (HHCs) or skilled nursing facilities (SNFs). Little is known about differences in processes and outcomes between these sites of care. METHODS: We performed a retrospective study of 107 patients with complicated Staphylococcus aureus infections discharged on OPAT from 2 academic medical centers. Clinical characteristics, site of posthospital care, process measures (lab test monitoring, clinic follow-up), adverse events (adverse drug events, Clostridium difficile infection, line events), and clinical outcomes at 90 days (cure, relapse, hospital readmission) were collected. Comparisons between HHCs and SNFs were conducted. RESULTS: Overall, 33% of patients experienced an adverse event during OPAT, and 64% were readmitted at 90 days. Labs were received for 44% of patients in SNFs and 56% of patients in HHCs. At 90 days after discharge, a higher proportion of patients discharged to an SNF were lost to follow-up (17% vs 3%; P = .03) and had line-related adverse events (18% vs 2%; P < .01). Patients discharged to both sites of care experienced similar clinical outcomes, with favorable outcomes occurring in 61% of SNF patients and 70% of HHC patients at 90 days. There were no differences in rates of relapse, readmission, or mortality. CONCLUSIONS: Patients discharged to SNFs may be at higher risk for line events than patients discharged to HHCs. Efforts should be made to strengthen basic OPAT processes, such as lab monitoring and clinic follow-up, at both sites of care.

Incidence and risk factors for abdominal occult metastatic disease in patients with pancreatic adenocarcinoma.

BACKGROUND: The incidence of occult metastatic disease (OMD) in pancreatic ductal adenocarcinoma (PDAC) and associated risk factors are largely unknown. METHODS: We identified all patients with PDAC, who had an aborted oncologic operation due to OMD within a 10-year period. The cases were matched to a cohort of resected PDAC patients on a 1:3 ratio, based on age and sex, for comparison of preoperative clinical characteristics and potential risk factors for OMD. RESULTS: In the studied period, 117 patients with OMD were identified in 1423 pancreatectomies performed for PDAC (8%). Liver metastases were the most common finding (79%) followed by peritoneal implants (16%). When compared with non-OMD cases, patients with OMD presented more often with abdominal pain (P < 0.001), and higher preoperative carbohydrate antigen 19-9 (CA 19-9) values ( P = 0.007). Additionally, indeterminate liver lesions on preoperative computed tomography (CT) were identified in 40% of OMD versus 17% of non-OMD patients ( P < 0.001). Multivariable analysis distinguished four independent predictors for OMD: indeterminate lesions on preoperative CT, tumor size > 30 mm, abdominal pain, and preoperative CA 19-9 > 192 U/mL. CONCLUSIONS: Occurrence of OMD in PDAC accounts for 8% of cases. Preoperative CA 19-9 > 192 U/mL, primary tumor size > 30 mm, and identification of indeterminate lesions in preoperative CT may indicate the need for diagnostic laparoscopy.

Lessons learned from 29 lymphoepithelial cysts of the pancreas: institutional experience and review of the literature.

BACKGROUND: Lymphoepithelial cysts (LECs) are rare pancreatic cystic lesions. Since LECs are benign, preoperative diagnosis is important to differentiate from a cystic neoplasm and avoid unnecessary surgery. The aim of this study was to identify clinical, radiographic and cytopathologic features associated with LECs. METHODS: A retrospective review was performed of patients diagnosed with LEC between 1995 and 2017 at our hospital. Clinicopathologic and radiographic imaging features were documented. RESULTS: Of 29 patients with pancreatic LEC, 22 underwent surgical resection. The majority were male (n = 24) with a median age of 55 years (range, 21-74). During the evaluation, all patients underwent a CT, with endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) biopsy (n = 22) and/or MRI/MRCP (n = 11) performed in a smaller number of patients. A combination of exophytic tumor growth on imaging and the presence of specific cytomorphologic features on the EUS-FNA cytology biopsy led to the correct diagnosis of LEC and prevention of unnecessary surgery in 7 patients. DISCUSSION: Differentiating LECs from premalignant pancreatic cystic neoplasms remains difficult. Findings of an exophytic growth pattern of the lesion on abdominal imaging and the presence of specific cytomorphologic features in the EUS-FNA biopsy could help clinicians diagnose LEC preoperatively.