Professional Burnout and Career Choice Regret in Urology Residents.

PURPOSE OF REVIEW: High rates of professional burnout and career choice regret among urology residents may increase professional dissatisfaction, shorten career longevity, and exacerbate urology workforce shortages. Understanding the prevalence of and risk factors for burnout may help develop interventions. RECENT FINDINGS: Up to 48% of contemporary U.S. urology residents experience burnout symptoms, including up to 70% of second-year residents. Among overlapping personal, professional, institutional, and lifestyle risk factors, barriers to accessing medical and mental health care are frequently cited as an important association in residents. Limited intervention studies suggest that providing basic needs, such as on-call meals, and facilitating physical wellness and social engagement among residents may result in sustained reductions in burnout. Urology residents continue to experience high rates of burnout and career choice regret among medical specialties. Evidence-based interventions and sustainable policies that address primary risk factors are urgently needed.

Insights from First Nations, Government and Industry Leaders on Criteria for Successful Impact Benefit Agreements.

Over the past decade, British Columbia, Canada's westernmost province, has begun developing liquified natural gas (LNG) mega projects that can transport Canadian resources to foreign markets across the Pacific region. These projects have gained significant profile due to high-level debates over their environmental, social and economic impacts. While LNG projects are required to undergo environmental impact assessment procedures, there is growing recognition of the need to ensure that positive social, economic and environmental impacts are fairly distributed to local communities. Similar to other extractive industries, many corporations leading the development of these projects engage in negotiations over so-called "impact benefit agreements (IBAs)"-legal agreements between a corporation, a government and/or a community that details how projects can benefit the local community and on what timeline so as to build social license to operate and investor confidence. This contribution details the findings of a qualitative study highlighting the perspectives of First Nations, provincial and federal government, and industry leaders to examine what makes an IBA successful and from whose perspective. The paper provides an introduction to IBA structures and processes, a brief review of the legal context, a qualitative methodology co-developed between academic researchers and Indigenous community leaders, and describes key criteria to inform future successful IBA agreements that create equitable multi-party benefits in an era of Indigenous reconciliation.

Initial Experience and Clinical Assessment of the Karl Storz FLEX-XC1 Single-Use Flexible Ureteroscope.

INTRODUCTION: The Karl Storz FLEX-XC1 is a novel single-use flexible ureteroscope that uses the same videographics platform as its reusable digital counterpart. We evaluated the technical performance of the FLEX-XC1 in its initial clinical use. METHODS: We reviewed a series of consecutive ureteroscopy procedures performed by 2 endourologists using the FLEX-XC1 for indications for which we typically use a single-use device: total stone burden > 15 mm or > 10 mm in the lower pole, anticipated case duration > 60 minutes, bilateral procedure, or upper tract urothelial cancer procedures. We assessed device tip deflection, intraoperative mechanical failure, and clinical outcomes for each case. Surgeons rated visual clarity, image quality, and maneuverability on a 1 to 5 Likert scale. RESULTS: Of 29 procedures using FLEX-XC1, 27 (93%) were successfully completed. Preoperative upward deflection was < 270° in 6 (21%) cases, and downward deflection was < 270° in 9 (31%) cases. Three types of intraoperative malfunctions occurred: rotational twisting of deflectable tip (4 cases, 13%), device not advancing through distal ureter (1 case, 3%), and working channel not accommodating a 365-µm laser (1 case, 3%). Visual clarity, image quality, and maneuverability were rated as 5 "very good" or 4 "good" in 100%, 100%, and 97% of cases, respectively. No device-specific or general 30-day complications were observed. CONCLUSIONS: The FLEX-XC1 showed comparable image quality and maneuverability to reusable digital devices. We observed incomplete deflection in up to 31% of cases and mechanical failure in 2 cases. The FLEX-XC1 may be advantageous in prolonged cases where maintaining visual clarity is paramount.

OECD Case Studies of Integrated Regional and Strategic Impact Assessment: What Does 'Integration' Look Like in Practice?

Increasingly, protocols for assessing the impacts of land-uses and major resource development projects focus not only on environmental impacts, but also social and human health impacts. Regional and Strategic Environmental Assessment (RSEAs) are one innovation that hold promise at better integrating these diverse land-use values into planning, assessment, and decision-making. In this contribution, a realist review methodology is utilized to identify case studies of "integrated RSEA"-those which are strategic, have a regional assessment approach, and seek to integrate environmental, community and health impacts into a singular assessment architecture. The results of a systematic literature review are described and six RSEA-like case studies are identified: Kimberly Browse LNG SEA; HS2 Appraisal of Sustainability; Lisbon International Airport SEA; Beaufort Regional Environmental Assessment; Nordstream 2 Transboundary EIA; and the Portland Harbour Sustainability Project. The case studies are examined according to their unique contexts, mechanisms and outcomes of their assessment protocols to determine the degree to which they consider more than environmental valued components, and the means by which they were included. Findings suggest that RSEA has a contentious relationship with the integration of more than environmental values, but that there are significant lessons to be learned to support project planning, especially for assessment contexts characterized by large, transboundary projects.

Assessing the Cumulative Social Effects of Projects: Lessons from Canadian Hydroelectric Development.

Cumulative effects assessments are often expected to include an analysis of cumulative social effects to people, their communities, and livelihoods caused by resource development projects and land use activities. Understanding cumulative social effects is important for decisions about prospective resource development projects, but there has been limited attention devoted to how to complete such an assessment. This paper critically examines how cumulative effects frameworks are applied to social impacts during environmental assessments. We do this by analyzing semi-structured interviews exploring practitioner experience in environmental assessments for hydroelectric development in British Columbia and Manitoba, Canada. The results provide a conceptual framework for cumulative social effects and illustrate how identified challenges for cumulative effects assessment are exacerbated by social impacts that introduce additional complexities in impact identification, assessment, and decision-making. The paper concludes with a discussion of how these challenges can be addressed and recommendations for improving environmental assessment practice.

From Project Impacts to Strategic Decisions: Recurring Issues and Concerns in Wind Energy Environmental Assessments.

Wind energy is among the fastest-growing renewable energy source. Although not as controversial as fossil fuel-based energy projects, wind energy projects can be contested. Understanding common environmental assessment issues surrounding wind energy projects is important for addressing the transaction costs for renewable energy projects. This research examined 16 environmental assessments (EAs) for wind energy projects in Western Canada to identify the recurring issues and concerns raised by government reviewers, project interveners, and other affected interests. Fifty different issues were identified. Although variability existed among the number and diversity of issues by jurisdiction and by project, depending on location and size, concerns about land use, impacts on human well-being, impacts on natural ecosystems, and economic opportunity, represented nearly 80% of all issues and concerns. The majority of issues reflect project-specific impacts and concerns, but many issues including impacts to other land tenure holders or licensees (such as other utilities and industries) are issues that are beyond the scope and scale of what can be resolved at the time wind energy projects are proposed. Understanding and addressing recurrent issues and concerns and shifting the bigger issues to the planning and strategic process, are important conditions for the energy transition.

Successful application of pharmacogenomic testing in the evaluation and management of a patient with human immunodeficiency virus and disseminated histoplasmosis.

OBJECTIVES: To demonstrate the successful use of pharmacogenomic testing to specifically tailor antifungal treatment to the phenotype of a patient with human immunodeficiency virus (HIV) and disseminated histoplasmosis who had clinical progression while on itraconazole and subsequently had insufficient therapeutic drug levels of voriconazole. CASE SUMMARY: We present the case of a patient with HIV and disseminated histoplasmosis with a persistently elevated serum Histoplasma capsulatum antigen and subtherapeutic levels of voriconazole. Pharmacogenomic testing revealed he was a CYP2C19 rapid metabolizer, thus explaining his persistent, subtherapeutic levels of voriconazole and prompting a change in therapy. PRACTICE IMPLICATIONS: Our case illustrates the importance of pharmacogenomic testing as a tool to evaluate subtherapeutic itraconazole or voriconazole levels, especially in patients with failed clinical or Histoplasmosis Ag response despite reporting full adherence to prescribed therapy.

A case of traumatic penile fracture with simultaneous rupture of both corpora cavernosa and complete urethral transection.

Penile fracture is a rare injury to the penis caused by blunt trauma. The presence of urethral injuries sustained during fracture is less than 10%, but very few cases involve complete circumferential urethral transection. We present a case of a patient who presented with traumatic penile fracture involving bilateral corporal cavernosa injury and complete urethral transection.

Primary prostatic squamous cell carcinoma.

Primary prostate squamous cell malignancies are rare and very aggressive. A 65-year-old man presented to our institution with clinical and radiographic findings concerning for advanced prostatic malignancy. Surgical pathology of the tumor revealed poorly differentiated carcinoma with squamous differentiation, and histopathological markers were positive for markers of squamous differentiation negative for all urothelial and prostatic markers.

Incidental Findings on Brain MRI in People with HIV Infection.

BACKGROUND: Incidental findings are a well-known complication of imaging studies done for both diagnostic and research purposes. Little is known about the rates and types of incidental findings found on brain MRI in patients with HIV infection, who may be at risk for HIV-Associated Neurocognitive Disorders (HAND). METHODS: The parent study included 108 adults with HIV infection and 125 demographically-matched uninfected controls who completed MRI and neuropsychological testing. Incidental findings were classified by the study team as vascular, neoplastic, congenital, other neurologic, or non-neurologic. Categorical measures were compared using Pearson chi-square tests; continuous measures were compared using t-tests. RESULTS: Among participants with HIV infection, 36/108 (33%) had incidental findings compared to 33/125 (26%) controls (p = 0.248). Rates of incidental findings were significantly correlated with increasing age in both participants with HIV infection (p = 0.013) and controls (p = 0.022). We found no correlation between presence of incidental findings and sex or race/ethnicity among either cohort, and no correlation with CD4 count or HAND status for the HIV-infected cohort. CONCLUSIONS: Incidental findings were common in both participants with HIV infection and controls, at higher rates than previously reported in healthy populations. There was no significant difference in prevalence between the groups.

Water Quality Monitoring to Support Cumulative Effects Assessment and Decision Making in the Mackenzie Valley, Northwest Territories, Canada.

Project proponent- and government-led environmental monitoring are required to identify, understand, and manage cumulative effects (CE), yet such monitoring initiatives are rarely mutually supportive. Notwithstanding the need for a more integrated and complementary approach to monitoring, monitoring efforts are often less effective than intended for addressing CE. This paper examines current monitoring programs in the Mackenzie Valley, Northwest Territories, Canada, based on 7 attributes: consistency, compatibility, observability, detectability, adaptability, accessibility, and usability. Results indicate a tenuous link between and across proponent-led monitoring requirements under project-specific water licenses and government-led monitoring of regional baseline conditions. There is some consistency in what is monitored, but data are often incompatible, insufficient to understand baseline change, not transferable across projects or scales, inaccessible to end users, and ultimately unsuitable to understanding CE. Lessons from the Mackenzie Valley highlight the need for improved alignment of monitoring efforts across programs and scales, characterized by a set of common parameters that are most useful for early detection of cumulative change and supporting regulatory decisions at the project scale. This alignment must be accompanied by more open and accessible data for both proponents and regulators, while protecting the sensitivity of proprietary information. Importantly, there must be conceptual guidance for CE, such that the role of monitoring is clear, providing the types of CE questions to be asked, identifying the hypotheses to be tested, and ensuring timely and meaningful results to support regulatory decisions. © 2019 SETAC.

A precise measurement of the magnetic field in the corona of the black hole binary V404 Cygni.

Observations of binary stars containing an accreting black hole or neutron star often show x-ray emission extending to high energies (>10 kilo--electron volts), which is ascribed to an accretion disk corona of energetic particles akin to those seen in the solar corona. Despite their ubiquity, the physical conditions in accretion disk coronae remain poorly constrained. Using simultaneous infrared, optical, x-ray, and radio observations of the Galactic black hole system V404 Cygni, showing a rapid synchrotron cooling event in its 2015 outburst, we present a precise 461 ± 12 gauss magnetic field measurement in the corona. This measurement is substantially lower than previous estimates for such systems, providing constraints on physical models of accretion physics in black hole and neutron star binary systems.

A template for integrated community sustainability planning.

This article describes a template for implementing an integrated community sustainability plan. The template emphasizes community engagement and outlines the components of a basic framework for integrating ecological, social and economic dynamics into a community plan. The framework is a series of steps that support a sustainable community development process. While it reflects the Canadian experience, the tools and techniques have applied value for a range of environmental planning contexts around the world. The research is case study based and draws from a diverse range of communities representing many types of infrastructure, demographics and ecological and geographical contexts. A critical path for moving local governments to sustainable community development is the creation and implementation of integrated planning approaches. To be effective and to be implemented, a requisite shift to sustainability requires active community engagement processes, political will, and a commitment to political and administrative accountability, and measurement.

Integrated ecological and regional planning in a rapid-growth setting.

Toronto is among the fastest-growing urban regions in North America. Regional efforts to preserve rural landscapes and remnant habitat have had variable success. In the 1990s, significant conflict emerged over proposals to build large housing developments on portions of the Oak Ridges Moraine, a 160-km stretch of environmentally sensitive land along the city's northern edge. After years of planning conflict, Ontario's provincial government created the Oak Ridges Moraine Conservation Plan, an Act of the Ontario Legislature. The Plan represents a dramatic change in Ontario's approach to conservation planning. We examine the development and implementation of the Conservation Plan as an example of environmental planning policy in a complex urban setting. Data from interviews with policy actors, planning agency documents, and geospatial sources are used to construct an analysis and discussion of the Plan and its implementation. From a policy research perspective, the evolution and implementation of the Plan require analysis and monitoring to better understand how such approaches can best be implemented. The Conservation Plan marks a change in policy in Ontario, and the implementation process highlights challenges in putting conservation plans into practice.