Metastatic Testicular Cancer Patterns and Predictors: A Contemporary Population-based SEER Analysis.

OBJECTIVE: To elucidate clinical and demographic predictors of metastatic testicular cancer (TC) at presentation and study the impact of these factors on prognosis. Patients with metastatic TC experience poorer outcomes than those with localized or locoregional disease. Social determinants of health may compound this trend. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried to identify 16,528 patients aged ≥18 with TC diagnosed from 2010 to 2016. Descriptive statistics were analyzed using Fisher exact test and Pearson chi-square test for continuous and categorical variables. Predictors of specific metastases and factors impacting cancer-specific mortality (CSM) were evaluated using multivariate logistic regression analysis and competing risks regression, respectively. RESULTS: Of 16,474 patients with complete data, 1877 (11.39%) had distant metastases at diagnosis. These patients more commonly featured disease-specific and demographic variables associated with worse health outcomes (all P < .001). Lung metastases were the predominant site of synchronous and solitary metastases. Disease-specific predictors of metastasis included T stage, histology, tumor size, lymphovascular invasion, and cryptorchidism. Patient-specific predictors included age, geography, ethnicity, race, marital status, and socioeconomic status. Nearly one-fourth of patients with metastases died. Poor CSM was predicted by histology, age, insurance status, and socioeconomic status. All metastatic sites except bone were associated with worse CSM, with lung metastases conferring the greatest risk. CONCLUSION: This cross-sectional study identifies variables associated with TC metastasis and survival, particularly highlighting the importance of social determinants of health in TC mortality. These findings can facilitate a risk-stratified approach to staging and management while supporting new approaches to target disparities.

Physician Burnout and Medical Errors: Exploring the Relationship, Cost, and Solutions.

Physician burnout has demonstrated risks to providers and patients through medical errors. This review aims to synthesize current data surrounding burnout and its impacts on quality to inform targeted interventions that benefit providers and patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review methodology was utilized to identify studies of quantitative metrics for burnout and medical errors. Three independent reviewers conducted screening, study selection, and data extraction. Of 1096 identified articles, 21 were analyzed. Overall, 80.9% used the Maslach Burnout Inventory to evaluate for burnout. Moreover, 71.4% used self-reported medical errors as their primary outcome measure. Other outcome measures included observed/identified clinical practice errors and medication errors. Ultimately, 14 of 21 studies found links between burnout and clinically significant errors. Significant associations exist between burnout and medical errors. Physician demographics, including psychological factors, well-being, and training level, modulate this relationship. Better metrics are necessary to quantify errors and their impacts on outcomes. These findings may inform novel interventions that target burnout and improve experiences.

Gender Diversity in Urology Residency Program Leadership Is Associated With Gender Diversity in Residency Cohort.

OBJECTIVE: To evaluate the association of program director (PD) gender on the proportion of female residents in urology residency programs. METHODS: Demographics for program faculty and current residents matched in the 2017-2022 cycles at United States' accredited urology residency programs were collected from institutional websites. Data verification was completed using the American Urological Association's (AUA) list of accredited programs and the programs' official social media channels. Proportion of female residents across cohorts was compared using two-tailed Student's t-tests. RESULTS: One hundred forty-three accredited programs were studied, and 6 were excluded for lack of data. Thirty (22%) of the 137 programs studied have female PDs. Of 1799 residents, 571 (32%) are women. There has been an upward trend in the proportion of females matched from 26% in 2018 to 30% in 2019, 33% in 2020, 32% in 2021, to 38% in 2022. When compared to programs with male PDs, those with female PDs had a significantly higher proportion of female residents (36.2% vs 28.8%, p = .02). CONCLUSION: Nearly one-quarter of urology residency PDs are female, and approximately one-third of current urology residents are women, a proportion that has been increasing. Programs with female PDs are more likely to match female residents, whether those programs with female leadership rank female applicants more favorably or female applicants rank those programs higher. Given the ongoing gender disparities in urology, these findings indicate notable benefit in supporting female urologists in academic leadership positions.

The Impact of COVID-19 on the Urology Residency Match and Geographic Proximity of Applicants.

OBJECTIVE: To determine the impacts of COVID-19 pandemic-related changes and program-specific characteristics on the geographic diversity of the 2021 and 2022 urology match classes. METHODS: We gathered publicly available information to compare match outcomes in 2021 and 2022 to the previous 5 application cycles (2016-2020). Variables included residency program class size, program and resident AUA section, and program and resident medical school. Univariate comparisons were made with Fisher's t-tests. Odds ratios were calculated following multivariable analysis. RESULTS: Comparing the previous 5 application cycles to the 2 pandemic years individually and together showed no significant changes in home or in-section matches. However, when comparisons were stratified by small (1-2 residents) vs large (3+ residents) programs, a significant increase in at-home and in-section matches was observed for small programs in 2021. Large programs did not experience significant changes in match patterns. Multivariate analysis showed that small programs had significantly lower odds of matching applicants from home institutions and within AUA sections. Additionally, certain AUA sections demonstrated significantly increased likelihood of accepting in-section applicants. CONCLUSION: The changes from in-person to virtual application cycles during the pandemic particularly affected small residency programs in 2021. With easing restrictions and logistical improvements in the 2022 cycle, locoregional match rates partially shifted back to prepandemic patterns, though not completely. Although the pandemic did not affect geographic diversity in urology as much as in other surgical subspecialties, these findings and further study should be considered to optimize upcoming cycles.

In Layman's Terms: The Power and Problem of Science Communication.

Improved policies for science communication are needed to ensure scientific progress in coming decades. The COVID-19 pandemic illustrated massive gaps in science communication, ranging from masking and social distancing mandates to vaccination requirements. These obstacles compounded the pandemic's tremendous inherent clinical and public health challenges. Although science made immense progress in understanding the virus and designing infection control solutions, society still remains within the pandemic due to flawed understanding, low responsiveness, and widespread misinformation on behalf of the public. Flawed communication plagues national responses not only to the pandemic, but also other long-standing issues such as climate change or nutrition. This Letter proposes a new protocol and framework for effective science communication, designed to educate experts in evidence-based communication, improve public partnership through relatability and modern relevance, and increase empathy and trustworthiness to increase public cooperation. A defined protocol for science communication can ensure that evolving knowledge can tangibly benefit society.

The predictive value of PNH clones, 6p CN-LOH, and clonal TCR gene rearrangement for aplastic anemia diagnosis.

Acquired aplastic anemia (AA) is a life-threatening bone marrow aplasia caused by the autoimmune destruction of hematopoietic stem and progenitor cells. There are no existing diagnostic tests that definitively establish AA, and diagnosis is currently made via systematic exclusion of various alternative etiologies, including inherited bone marrow failure syndromes (IBMFSs). The exclusion of IBMFSs, which requires syndrome-specific functional and genetic testing, can substantially delay treatment. AA and IBMFSs can have mimicking clinical presentations, and their distinction has significant implications for treatment and family planning, making accurate and prompt diagnosis imperative to optimal patient outcomes. We hypothesized that AA could be distinguished from IBMFSs using 3 laboratory findings specific to the autoimmune pathogenesis of AA: paroxysmal nocturnal hemoglobinuria (PNH) clones, copy-number-neutral loss of heterozygosity in chromosome arm 6p (6p CN-LOH), and clonal T-cell receptor (TCR) γ gene (TRG) rearrangement. To test our hypothesis, we determined the prevalence of PNH, acquired 6p CN-LOH, and clonal TRG rearrangement in 454 consecutive pediatric and adult patients diagnosed with AA, IBMFSs, and other hematologic diseases. Our results indicated that PNH and acquired 6p CN-LOH clones encompassing HLA genes have ∽100% positive predictive value for AA, and they can facilitate diagnosis in approximately one-half of AA patients. In contrast, clonal TRG rearrangement is not specific for AA. Our analysis demonstrates that PNH and 6p CN-LOH clones effectively distinguish AA from IBMFSs, and both measures should be incorporated early in the diagnostic evaluation of suspected AA using the included Bayesian nomogram to inform clinical application.

Overlap Between Medicare's Comprehensive Care for Joint Replacement Program and Accountable Care Organizations.

BACKGROUND: Overlap between Medicare's Comprehensive Care for Joint Replacement (CJR) model and accountable care organizations (ACOs) may result in positive or negative synergies. In this study, we describe the overlap between the programs at the beneficiary and hospital levels. METHODS: We conducted a retrospective study of patient and hospital characteristics using data from 2016 Medicare claims, the US Census Bureau, the American Hospital Association annual survey, Hospital Compare, and the Centers for Medicare & Medicaid Services Improving Medicare Post-Acute Care Transformation file. On the beneficiary level, we conducted 2 comparisons: (1) among patients who received joint replacement at CJR hospitals, ACO patients (overlap) vs not (CJR-only) and 2) among patients who received joint replacement elsewhere, ACO patients (ACO-only) vs not (neither). On the hospital level, we compared hospitals in the top quartile of overlap rate (high overlap) vs those in the bottom 3 (low overlap). RESULTS: We studied 14,519 overlap, 38,972 CJR-only, 26,872 ACO-only, and 68,945 neither beneficiaries. Compared with CJR-only patients, the overlap group was less likely to be older than 85, of black race, of low socioeconomic status, and burdened with clinical complications. Similar results were observed when the ACO-only group was compared with the neither group. Compared with low overlap hospitals, high overlap ones were more likely to be of nonprofit and less likely to be of safety net. CONCLUSION: CJR-ACO overlap is associated with differences in beneficiary and hospital characteristics, which raises key issues for providers and policymakers.

The Severity of Herpes Zoster in Inflammatory Bowel Disease Patients Treated With Anti-TNF Agents.

Aim: There is a paucity of data on the clinical course and the factors affecting the clinical course of herpes zoster (HZ) in inflammatory bowel disease (IBD). Our aim was to determine the impact of anti-TNF therapy and other factors on the clinical course of HZ in IBD patients. Methods: We conducted a retrospective cohort study among a cohort of nation-wide Veterans Affairs patients with IBD who developed incident HZ. The exposed group consisted of eligible study patients who were actively exposed to anti-TNF alone or anti-TNF plus thiopurines at the time of HZ onset. The unexposed group consisted of patients who were only exposed to 5-ASA agents before the onset of HZ without any exposure to anti-TNF medications. The outcome of interest was the development of severe HZ that was defined by including various HZ complications. Results: A total of 295 patients were identified with an incident HZ flare during follow- up duration, and among them 69 met the definition of having a severe flare. In multivariable logistic regression analysis adjusting for sex, age at HZ flare onset, race, Charlson comorbidity score, and receipt of oral anti-HZ treatment, exposure to anti-TNF agent was not associated with an increased risk of severe HZ flare compared to exposure to mesalamine alone (adjusted relative risk (RR) 1.1, 95% confidence intervals (CI): 0.75-1.55). Among the covariates, receipt of oral anti-HZ treatment (adjusted RR 0.42, 95% CI: 0.29-0.61), advancing age at HZ onset (adjusted RR for each year increase in age 1.02, 95% CI: 1.00-1.04), and African-American race (adjusted RR with whites as reference 1.58, 95% CI: 1.02-2.44) were significantly associated with the risk of having severe HZ flare. Conclusion: Our study showed that among IBD patients who developed HZ, treatment with anti-TNF agents was not associated with increased risk of developing severe HZ as compared to patients treated with 5-ASA therapy only. 10.1093/ibd/izx115_video1izx115_Video_15786486963001.

Frequency of Surveillance and Impact of Surveillance Colonoscopies in Patients With Ulcerative Colitis Who Developed Colorectal Cancer.

BACKGROUND: The risk of developing colorectal cancer (CRC) in patients with chronic ulcerative colitis (UC) is increased. The aim of this study was to evaluate if patients who developed CRC in the setting of UC were undergoing guideline-recommended surveillance colonoscopies and to determine the impact of surveillance on the staging of CRC. PATIENTS AND METHODS: Data was obtained from the Veterans Affairs healthcare system to identify patients with UC and CRC. Stage 0 and I were considered early-stage CRC, whereas stage ≥ II were considered advanced-stage CRC. Patients were considered to have adequate surveillance if they had a colonoscopy within 2 years before developing CRC. We conducted a case-case analysis using multivariable logistic regression to estimate the odds ratio for presenting with advanced-stage CRC associated with lack of adequate surveillance. RESULTS: Of the 48 patients, the majority were white (70.8%) and male (100%). Sixty-nine percent of patients had inadequate surveillance. In multivariable analysis, prior adherence to CRC surveillance was associated with a decreased risk of presenting with advanced-stage CRC (vs. early-stage CRC) (adjusted odds ratio, 0.20; 95% confidence interval, 0.05-0.85; P = .029). CONCLUSION: The majority of patients who developed CRC in the setting of UC underwent inadequate surveillance, and they were more likely to present with advanced-stage CRC.