Prone vs supine percutaneous nephrolithotomy: does position affect renal pelvic pressures?

The purpose of this study was to measure and compare renal pelvic pressure (RPP) between prone and supine percutaneous nephrolithotomy (PCNL) in a benchtop model. Six identical silicone kidney models were placed into anatomically correct prone or supine torsos constructed from patient CT scans in the corresponding positions. A 30-Fr renal access sheath was placed in either the upper, middle, or lower pole calyx for both prone and supine positions. Two 9-mm BegoStones were placed in the respective calyx and RPPs were measured at baseline, irrigating with a rigid nephroscope, and irrigating with a flexible nephroscope. Five trials were conducted for each access in both prone and supine positions. The average baseline RPP in the prone position was significantly higher than the supine position (9.1 vs 2.7 mmHg; p < 0.001). Similarly, the average RPP in prone was significantly higher than supine when using both the rigid and flexible nephroscopes. When comparing RPPs for upper, middle, and lower pole access sites, there was no significant difference in pressures in either prone or supine positions (p > 0.05 for all). Overall, when combining all pressures at baseline and with irrigation, with all access sites and types of scopes, the mean RPP was significantly higher in the prone position compared to the supine position (14.0 vs 3.2 mmHg; p < 0.001). RPPs were significantly higher in the prone position compared to the supine position in all conditions tested. These differences in RPPs between prone and supine PCNL could in part explain the different clinical outcomes, including postoperative fever and stone-free rates.

Do Flat Panel Detector C-Arms Decrease Radiation Exposure Compared to Conventional Image Intensifiers?

OBJECTIVE: To compare the radiation dose and image quality between flat panel detector (FPD) and traditional image intensifier (II) C-arms at their lowest radiation settings. METHODS: In a ureteroscopy simulation using a cadaver model, the radiation exposure was compared between FPD and II at 4 pulses-per-second (pps) using both low dose and automatic exposure control (AEC) settings. Additionally, the lowest dose settings for each machine were compared (4 pps with low dose in the FPD and 1 pps with low dose in the II). Five trials of 5 minutes were conducted for each setting. Four new optically stimulated luminescent dosimeters were used in each trial to record radiation exposure. Ten blinded urologists completed a survey rating image quality for each setting. RESULTS: When comparing the FPD and II at their lowest possible settings, the FPD produced significantly more radiation (P <.05). Using both machines at 4 pps in low dose mode resulted in no significant difference between C-arms (P >.05). Conversely, operating the C-arms at 4 pps and AEC resulted in significantly higher radiation exposure from the FPD compared to the II (P <.05). There was no significant difference in image quality at each setting. CONCLUSION: FPDs produce significantly more radiation at the lowest settings compared to IIs. Surgeons should employ IIs when reducing radiation exposure as low as possible is imperative, such as when operating on pediatric and pregnant patients.

Ultrasound-based quantitative tools in predicting renal involvement in asymptomatic primary hyperparathyroidism.

PURPOSE: Asymptomatic primary hyperparathyroidism (aPHPT) has been recognized as a condition that can lead to renal complications. Timely identification of prognostic indicators for renal impairment holds the potential to facilitate proactive monitoring and treatment strategies in these patients. This study aims to investigate the utility of acoustic radiation force impulse (ARFI) imaging and renal resistive index (RRI), in identifying renal parenchymal and vascular changes in patients with aPHPT. METHODS: Forty-two patients with aPHPT and 42 controls matched for age, sex, and body mass index were included in the study. The presence of renovascular changes was evaluated by RRI measurement with Doppler ultrasonography, and the presence of renal parenchymal involvement was evaluated by ARFI quantification, given as shear wave velocity (SWV). RESULTS: In aPHPT patients, both the mean RRI and mean SWV values exhibited substantial elevation compared to the control group (P < 0.001 for both). Significant associations were observed between SWV values and serum calcium, parathyroid hormone (PTH), and adenoma size within the patient group (P < 0.001, P < 0.001, P = 0.016, respectively). Similarly, the mean RRI demonstrated positive correlations with serum calcium and PTH levels in the patient group (P< 0.001, P = 0.011, respectively). Multivariate linear regression analysis underscored the connection between mean RRI and mean SWV values with serum calcium levels within the patient group. In addition, serum PTH levels affected mean SWV positively and significantly. CONCLUSION: The use of ARFI imaging and RRI measurements appears to hold potential in identifying renal involvement in patients with aPHPT.

Reducing hand radiation during renal access for percutaneous nephrolithotomy: a comparison of radiation reduction techniques.

Percutaneous nephrolithotomy confers the highest radiation to the urologist's hands compared to other urologic procedures. This study compares radiation exposure to the surgeon's hand and patient's body when utilizing three different techniques for needle insertion during renal access. Simulated percutaneous renal access was performed using a cadaveric patient and separate cadaveric forearm representing the surgeon's hand. Three different needle-holding techniques were compared: conventional glove (control), a radiation-attenuating glove, and a novel needle holder. Five 300-s fluoroscopy trials were performed per treatment arm. The primary outcome was radiation dose (mSv) to the surgeon's hand. The secondary outcome was radiation dose to the patient. One-way ANOVA and Tukey's B post-hoc tests were performed with p < 0.05 considered significant. Compared to the control (3.92 mSv), both the radiation-attenuating glove (2.48 mSv) and the needle holder (1.37 mSv) reduced hand radiation exposure (p < 0.001). The needle holder reduced hand radiation compared to the radiation-attenuating glove (p < 0.001). The radiation-attenuating glove resulted in greater radiation produced by the C-arm compared to the needle holder (83.49 vs 69.22 mGy; p = 0.019). Patient radiation exposure was significantly higher with the radiation-attenuating glove compared to the needle holder (8.43 vs 7.03 mSv; p = 0.027). Though radiation-attenuating gloves decreased hand radiation dose by 37%, this came at the price of a 3% increase in patient exposure. In contrast, the needle holder reduced exposure to both the surgeon's hand by 65% and the patient by 14%. Thus, a well-designed low-density needle holder could optimize radiation safety for both surgeon and patient.

Not All Flat-Panel C-Arms Are Created Equal: A Comparison of Three Major Manufacturers.

Introduction: Flat-panel detector C-arms (FCs) are reported to reduce radiation exposure and improve image quality compared with conventional image intensifier C-arms (CCs). The purpose of this study was to compare radiation exposure and image quality between three commonly used FCs. Materials and Methods: A cadaver model was placed in the prone position to simulate percutaneous nephrolithotomy. We compared the following three FCs: OEC Elite CFD from GE HealthCare, Zenition 70 from Philips, and Ziehm Vision RFD from Ziehm Imaging. To measure the radiation dose, optically stimulated luminescence dosimeters (OSLDs) were utilized during five 300-second trials, conducted under three settings: automatic exposure control (AEC), AEC with low dose (LD), and LD with the lowest pulse rate (LDLP). Ten blinded urologists evaluated the image quality. Data were statistically analyzed using the analysis of variance (ANOVA) and Tukey's B post hoc tests. Results: In the AEC setting, the Philips C-arm demonstrated lower ventral OSLD exposure (42,446 mrad) compared with both the GE (51,076 mrad) and Ziehm (83,178 mrad; p < 0.001) C-arms. Similarly, in the LD setting, the Philips C-arm resulted in less ventral OSLD exposure (25,926 mrad) than both the Ziehm (30,956 mrad) and GE (38,209 mrad; p < 0.001) C-arms. Meanwhile, in the LDLP setting, the Ziehm C-arm showed less ventral OSLD exposure (4019 mrad) than both the GE (7418 mrad) and Philips (8229 mrad; p < 0.001) C-arms. All three manufacturers received adequate image quality ratings at the AEC and LD settings. However, at LDLP, the Ziehm C-arm received inadequate ratings in 8% of images, whereas both the GE and Philips C-arms received 100% adequate ratings (p = 0.016). Conclusions: Radiation produced by flat-panel C-arms varies dramatically, with the highest exposure (Ziehm) being almost double the lowest (Philips) in AEC. Improved picture quality at the lowest settings may come at the cost of increased radiation dose. Surgeons should carefully select the machine and settings to minimize radiation exposure while still preserving the image quality.

Time Efficiency and Performance of Single-Use vs Reusable Cystoscopes: A Randomized Benchtop and Simulated Clinical Assessment.

Introduction: A flexible cystoscope is an indispensable tool for urologists, facilitating a variety of procedures in both the operating room and at bedside. Single-use cystoscopes offer benefits including accessibility and decreased burden for reprocessing. The aims of this study were to compare time efficiency and performance of single-use and reusable cystoscopes. Methods: Ten new Ambu® aScope™ 4 Cysto single-use and two Olympus CYF-5 reusable cystoscopes were compared in simulated bedside cystoscopy and benchtop testing. Ten urologists performed simulated cystoscopy using both cystoscopes in a randomized order. Times for supply-gathering, setup, cystoscopy, cleanup, and cumulative time were recorded, followed by a Likert feedback survey. For benchtop assessment, physical, optical, and functional specifications were assessed and compared between cystoscopes. Results: The single-use cystoscope demonstrated shorter supply-gathering, setup, cleanup, and cumulative times (824 vs 1231 seconds; p < 0.05) but a comparable cystoscopy time to the reusable cystoscope (202 vs 212 seconds; p = 0.32). The single-use cystoscope had a higher image resolution, but a narrower field of view. Upward deflection was greater for the single-use cystoscope (214.50° vs 199.45°; p < 0.01) but required greater force (2.5 × ). The working channel diameter and irrigation rate were greater in the reusable cystoscope. While the single-use cystoscope lacked tumor enhancing optical features, it had higher Likert scale scores for Time Efficiency and Overall Satisfaction. Conclusion: The single-use cystoscope demonstrates comparable benchtop performance and superior time efficiency compared to reusable cystoscopes. However, the reusable cystoscope has superior optical versatility and flow rate. Knowledge of these differences allows for optimal cystoscope selection based on procedure indication.

Effect of Low pH Dietary Supplements on Discoloration of Resin Composites.

AIM: This study aimed to evaluate the impact of the consumption of low pH dietary supplements on the color stability of different resin composites. MATERIALS AND METHODS: Three different restorative materials were used for this in vitro study: Filtek One Bulk-Fill (FOB), Filtek Z550 (Z550), and Fill-Up (FUP). Samples fabricated from each composite group were divided into four subgroups, and color measurements were performed at baseline. The control subgroup was stored in distilled water, and the other three subgroups were immersed in acidic dietary supplement solutions (Redoxon, Supradyn, and Voonka Collagen Shake) for 2 minutes daily for 28 days. Color measurements were obtained using a digital spectrophotometer. Color change values (ΔE1) were calculated after each color measurement. Next, all samples were immersed in a coffee solution for 7 days and repeat color measurements were taken to determine ΔE2 values. The study groups were compared using the Kruskal-Wallis test (α =0.05). RESULTS: ΔE1 values were significantly different among the groups (P < 0.05). While Voonka Collagen Shake produced the greatest discoloration in FOB (1.67 ± 1.08) and Filtek Z550 (3.59 ± 1.90) materials, Fill-Up showed the highest discoloration (3.14 ± 0.37) with Supradyn. Analysis of ΔE2 values demonstrated a significant difference only for the Filtek Z550-Redoxon group versus the control group (P < 0.05). CONCLUSION: Acidic dietary supplements not only produce color alterations in resin composites but also reduce the staining resistance of the composite further, depending on the type of composite and dietary supplement. Consumption of staining food after taking Redoxon effervescent tablets produces greater discoloration in Filtek Z550 restorations compared with other restorative materials.

The relationship between oral health and sleep quality in community-dwelling older adults.

Introduction: The assessment of the sleep status of older adults and its relationship to oral health can help determine their well-being and quality of life. In accordance with this purpose, we aimed to evaluate the relationship between oral health and sleep quality in community-dwelling older adults in an urban area. Materials and Methods: The data of this study were taken from the Kayseri Elderly Health Study. The study group was administered a questionnaire form and the Pittsburgh Sleep Quality Index. A specialist dentist examined the oral health conditions (dentures use; caries; deficient, filled, natural teeth numbers; periodontal health) using the Community Periodontal Index and the Oral Health Impact Profile-14 (OHIP-14-TR). Results: One hundred forty (38.1%) of the study group were female, and 227 (61.9%) were male. When evaluated in terms of oral hygiene, there was a statistically significant difference between those with good sleep quality and poor sleep quality in terms of mechanical interventions such as using toothpaste and an inter-dental brush, and also, OHIP-14-TR was significant. In the binary logistic regression analysis, OHIP-14-TR was found to be a significant risk factor, reflecting only the subjective interpretation of the older adults in terms of oral health-related quality of life (odds ratio: 1.069, 95.0% confidence interval: 1.043-1.096). Conclusion: This is the first epidemiologic study to examine the relationship between oral health status and sleep quality, in which many oral health indicators are evaluated together in Turkish community-dwelling older adults. OHIP-14-TR may be a useful tool to employ in sleep disorder clinics for older people.

Liposomal versus plain bupivacaine for pain control following vaginal reconstruction.

INTRODUCTION: Liposomal bupivacaine (LB) is a depot formulation of bupivacaine, which releases the drug over 72 hours to prolong local pain control. This retrospective study compares the effect of using LB versus plain bupivacaine on postoperative pain control, length of hospital stay and cost among patients undergoing vaginal reconstructive surgery. MATERIALS AND METHODS: Patients who underwent vaginal reconstructive surgery with levatorplasty and received an injection of 20 cc of either plain bupivacaine or LB for pudendal nerve block were included. The primary outcomes included postoperative narcotic use and subjective pain score. The secondary outcome was postoperative length of stay. Comparisons between groups were performed using the T test, Mann Whitney U and Chi-square tests with p < 0.05 considered significant. RESULTS: Between June 2016 and December 2021, 25 patients had received LB as a pudendal nerve block and 25 had received plain bupivacaine. Demographics between groups were similar. There was no difference between postoperative morphine equivalent dose (MED) for plain bupivacaine versus LB (25.3 ± 65.8 vs. 24.9 ± 31.7 MED; p = 0.159) or length of hospital stay (15.8 ± 12.0 hours vs. 23.8 ± 20.0; p = 0.094). Furthermore, subjective pain was also similar between groups (0 vs. 1.6 ± 2.6, p = 0.68), (4.6 ± 2.3 vs. 4.9 ± 2.0 average POD 1 pain, p = 0.534) and (4.3 ± 2.1 for vs. 4.9 ± 2.1 average POD 2 pain, p = 0.373). CONCLUSION: LB is not superior to plain bupivacaine for controlling pain following vaginal reconstructive surgery, and justification for the exponentially greater cost of LB is not supported. Prospective investigations with larger sample sizes are needed to determine the optimal pain management for levatorplasty in vaginal reconstructive surgery.

Which Laser System Is Optimal for Cystolithotripsy of Large Bladder Calculi?

Introduction and Objective: A variety of laser sources are available to treat bladder stones. The aim of this study was to compare time and cost efficiency of the thulium fiber laser (TFL) to four holmium lasers (HLs) with different powers or technologies, including MOSES™ during simulated cystolithotripsy. Materials and Methods: In a benchtop simulation of laser cystolithotripsy, 25 identical 4-cm BegoStones (calcium oxalate monohydrate consistency) were placed on a grid within a 3D-printed bladder model. Lasers were operated at maximal energy, using a 550 µm fiber. Lasers compared were as follows: 60 W TFL, 120 W HL with MOSES, and conventional 120, 100, and 30 W HLs. Five trials were performed for each laser with endpoints of laser time, total time, number of fiber strippings, and total energy. Cost-effectiveness was modeled using laser purchase price, fiber, and operating room (OR) time cost. ANOVA with Tukey's B post hoc was performed to compare outcomes. Spearman's test was used to assess correlation between laser power and procedure time. Results: The laser and total operating times were significantly different between the five systems (p < 0.001). The 120 W HL with MOSES was the fastest with 60.9 minutes of laser and 68.3 minutes of procedure times, while the 30 W HL was the slowest with 281.2 minutes of laser and 297.5 minutes of procedure times. The 60 W TFL was faster than the 30 W HL, but slower than the higher power HLs. Higher laser power was associated with shorter procedure time (Rs = -0.98; p = 0.002). When estimating cost per procedure, the MOSES HL was the cheapest, but had the highest purchase cost. The TFL was not cost-effective for large bladder stones compared with the 100 W HL. Conclusions: When treating large bladder stones, total laser power was highly correlated with laser and procedure times and the TFL was limited by its total power. The most cost-effective laser for use will depend on the case volume.

Multimodal Pain Control Utilizing Buprenorphine for Robotic-assisted Laparoscopic Prostatectomy: A Quality Improvement Comparison to Conventional Opioid Management.

INTRODUCTION: This study investigated the effectiveness of buprenorphine as an alternative to the use of conventional opioids perioperatively in an effort to help mitigate the impact of the use of perioperative conventional opioids for patients undergoing robotic-assisted laparoscopic prostatectomy. METHODS: Outcomes of patients with localized prostate cancer undergoing robotic-assisted laparoscopic prostatectomy were examined before and after implementation of novel quality improvement study that included receiving buprenorphine compared to conventional opioids for pain control intraoperatively and postoperatively. The primary end point was adequate pain control with secondary end points being analgesic consumption at home, opioid-related side effects, and patient satisfaction. RESULTS: When analyzing the secondary end point of oral morphine milligram equivalents, the buprenorphine group received significantly less morphine milligram equivalent compared to the conventional opioid group (15.19 vs 47.91, P = .006). The buprenorphine group also had lower reported pain scores at discharge (4.3; scale 1-10) compared to the conventional opioid group (5.4), though this did not reach significance (P = .069). In the buprenorphine group, 76.9% strongly agreed that their pain was adequately controlled in the hospital compared to 57.5% of the conventional opioid group (P = .223). There was no difference in overall satisfaction at postoperative day 5 (P = .358). CONCLUSIONS: Our study demonstrates buprenorphine's analgesic capabilities to maintain adequate pain control and patient satisfaction compared to conventional opioids during robotic-assisted laparoscopic prostatectomy, while decreasing perioperative opioid use.

Does renal failure worsen radiation cystitis following radical prostatectomy?

OBJECTIVE: To investigate the impact of renal function on the risk, severity, and management of radiation cystitis in patients who underwent postoperative radiation therapy for prostate cancer. METHODS: Retrospective data was assessed from patients treated with adjuvant/salvage radiation therapy at a single academic institution between 2006 and 2020. The incidence, severity, and management of radiation cystitis were compared between three groups: CKD 0-2, CKD 3-4, and CKD 5. Associations of clinicopathologic factors with radiation cystitis were assessed in univariate and multivariate Cox regression models. RESULTS: A total of 110 patients who underwent radiation therapy following robot-assisted laparoscopic radical prostatectomy were included. The incidence of radiation cystitis following postoperative radiation therapy was 17% with a median presentation time of 34 months (interquartile range 16-65 months). The incidence of radiation cystitis was 100% in CKD 5 patients compared to 15% in CKD 0-2 and 17% in CKD 3-4 patients (p < 0.001). CKD 5 patients required more treatments, emergency department visits, and longer hospitalization times than CKD 0-4 patients (all p < 0.001). Multivariate analyses identified CKD 5 as the only significant factor associated with radiation cystitis (HR = 10.39, p = 0.026). CONCLUSION: End-stage renal failure is associated with the risk and severity of radiation cystitis in patients receiving postoperative radiation therapy. Knowledge of the potential morbidity of this complication in this population could guide physicians and patients as they evaluate risks and benefits prior to selecting adjuvant or salvage radiation therapy.

Thulium versus holmium for in situ lower pole laser lithotripsy.

INTRODUCTION: During in situ lower pole laser lithotripsy, the dependent location may result in increased challenge fragmenting stones and a risk for stone regrowth if residual fragments remain. The purpose of this study was to compare the thulium fiber laser (TFL) with the holmium laser (HL) for in situ lower pole lithotripsy. MATERIALS AND METHODS: In a 3D printed kidney benchtop model, sixty 1 cm BegoStones were placed in the lower pole and fragmented in situ until fragments passed through a 2 x 2 mm mesh. Laser lithotripsy was performed using twelve energy, frequency and fiber size combinations and residual fragments were compared. In addition, laser fiber diameters and subsequent ureteroscope deflections and flow rates were compared between fibers. RESULTS: The TFL resulted in decreased residual fragments compared to the HL (11% vs. 17%, p < 0.001) and the three settings with least residual fragments were all TFL. Compared to the 150 µm TFL (265° deflection), there was a loss of 9° and 34° in the 200 µm TFL and 272 µm HL fibers, respectively. The measured fiber sizes were greater than manufacturer specified fiber size in every instance. Irrigation rates inversely correlated with fiber size. CONCLUSION: The TFL resulted in 35% less residual stone fragments, up to 34° additional deflection, and an increased irrigation rate when compared to the HL. Optimal fragmentation settings are identified to further improve lower pole lithotripsy. The combination of reduced residual fragments, improved deflection, and better flow rates make the TFL advantageous for in situ lower pole lithotripsy.

A COVID-19 infection incidentally detected during hyperbaric oxygen treatment and preventive measures for COVID-19 transmission in a multiplace hyperbaric chamber.

INTRODUCTION: SARS-CoV-2 (COVID-19) was declared a global pandemic on 11 March 2020 and has become a serious threat to public health. As it can easily be transmitted through droplets and aerosols, there is an increased risk of transmission in enclosed environments such as hyperbaric oxygen treatment (HBOT) units if preventive measures are not taken. CASE REPORT: A 16-year-old female tested positive for SARS-CoV-2 during HBOT for idiopathic sudden sensorineural hearing loss. The other patients and the inside attendant who attended the sessions with her were regarded as contacts, tested for SARS-CoV-2, and quarantined until the test results were available. Ultimately, none of them tested positive. DISCUSSION: As HBOT in multiplace chambers entails a high risk of SARS-CoV-2 transmission, we strictly adapted our practice to consider that every patient could be a potential asymptomatic carrier. Therefore, the negative results of all contacts in this case and the fact that no confirmed cases of COVID-19 were reported suggests that these measures successfully prevented SARS-CoV-2 transmission in our HBOT clinic. SARS-CoV-2 transmission can be prevented if sufficient protective measures are taken.

Does the Novel Thulium Fiber Laser Have a Higher Risk of Urothelial Thermal Injury than the Conventional Holmium Laser in an In Vitro Study?

Introduction and Objective: The novel thulium fiber laser (TFL) has been shown to break stones more rapidly than the holmium:YAG laser (HL). However, some evidence suggests that the TFL generates more heat. The purpose of this study is to compare ureteral temperatures generated by these lasers during ureteroscopic laser lithotripsy in a benchtop model. Methods: A 1-cm BegoStone was manually impacted in the proximal ureter of a three-dimensional printed kidney-ureter model and submerged in 35.5°C saline. Lithotripsy was performed using a 7.6F flexible ureteroscope and a 200 µm laser fiber without a ureteral access sheath. The Dornier 30 W HL, Olympus 100 W HL, and Olympus 60 W TFL were compared. A needle thermocouple to measure temperature was inserted 2 mm from the laser tip. Irrigation was maintained at 35 cc/minute at room temperature using the Thermedx FluidSmart System. Intraluminal temperature was continuously recorded for 60 seconds of laser activation. Five trials were performed for each of four different power settings: 3.6, 10, 20, and 30 W. Analysis of variance and Mann-Whitney U tests were performed with p < 0.05 considered significant. Results: Intraureteral fluid temperature increased as laser power settings increased for all lasers (p < 0.05). The TFL generated higher average ureteral fluid temperatures than the Dornier and Empower HL at all power settings tested (p < 0.001). The maximum temperature for the TFL was higher than the Dornier and Empower HL at all power settings tested (p < 0.001), except at 20 W with the Empower HL. At 30 W, the TFL exceeded 43°C, the threshold for tissue damage. Conclusions: The TFL generated more heat at all settings tested. Supraphysiologic ureteral temperatures may be generated with extended use at high energy settings and low irrigation rates. Understanding the heat generation properties of both lasers could help improve the safety of ureteroscopic laser lithotripsy.

PILE: a candidate prognostic score in cancer patients treated with immunotherapy

Background Although the immune checkpoint inhibitors (ICIs) became a vital part of cancer care, many patients do not respond to treatment, indicating need for biomarkers. The Pan-Immune-Inflammation Value (PIV) is a recently developed peripheral blood count-based biomarker. Herein, we evaluated a PIV-based candidate scoring system as a prognostic biomarker in ICI-treated patients. Methods A total of 120 advanced cancer patients treated with anti-PD-1 or anti-PD-L1 inhibitors for any cancer type were included in this study. The PILE scoring system incorporating the PIV (< median vs. ≥ median), lactate dehydrogenase levels (normal vs. > normal) and Eastern Cooperative Oncology Group performance status (0 vs. ≥ 1) was constructed from the multivariate analyses and used for stratification. The association between overall survival (OS), progression-free survival and PILE risk category was evaluated with multivariate analysis. Results The median follow-up was 9.62 months and the median OS of all cohort were 12.42 ± 2.75 months. Patients with higher PIV had significantly decreased OS (7.75 ± 1.64 vs. 18.63 ± 4.26 months, p = 0.037). The patients in the PILE high-risk group (PILE score 2–3) had decreased OS (18.63 ± 4.02 vs. 5.09 ± 1.23 months, HR: 2.317, 95% CI: 1.450–3.700, p < 0.001) and PFS (7.69 ± 1.30 vs. 2.69 ± 0.65 months, HR: 1.931, 95% CI: 1.263–2.954, p = 0.002) compared to PILE low-risk group (PILE score 0–1). The Harrell C-Index values were 0.65 and 0.61 for OS and PFS prediction, respectively. Conclusion In this study, we demonstrated a decreased overall survival in ICI-treated patients with a higher PILE score. If prospective studies validate our results, PILE score could be a biomarker for immunotherapy. (AU)

PILE: a candidate prognostic score in cancer patients treated with immunotherapy.

BACKGROUND: Although the immune checkpoint inhibitors (ICIs) became a vital part of cancer care, many patients do not respond to treatment, indicating need for biomarkers. The Pan-Immune-Inflammation Value (PIV) is a recently developed peripheral blood count-based biomarker. Herein, we evaluated a PIV-based candidate scoring system as a prognostic biomarker in ICI-treated patients. METHODS: A total of 120 advanced cancer patients treated with anti-PD-1 or anti-PD-L1 inhibitors for any cancer type were included in this study. The PILE scoring system incorporating the PIV (< median vs. ≥ median), lactate dehydrogenase levels (normal vs. > normal) and Eastern Cooperative Oncology Group performance status (0 vs. ≥ 1) was constructed from the multivariate analyses and used for stratification. The association between overall survival (OS), progression-free survival and PILE risk category was evaluated with multivariate analysis. RESULTS: The median follow-up was 9.62 months and the median OS of all cohort were 12.42 ± 2.75 months. Patients with higher PIV had significantly decreased OS (7.75 ± 1.64 vs. 18.63 ± 4.26 months, p = 0.037). The patients in the PILE high-risk group (PILE score 2-3) had decreased OS (18.63 ± 4.02 vs. 5.09 ± 1.23 months, HR: 2.317, 95% CI: 1.450-3.700, p < 0.001) and PFS (7.69 ± 1.30 vs. 2.69 ± 0.65 months, HR: 1.931, 95% CI: 1.263-2.954, p = 0.002) compared to PILE low-risk group (PILE score 0-1). The Harrell C-Index values were 0.65 and 0.61 for OS and PFS prediction, respectively. CONCLUSION: In this study, we demonstrated a decreased overall survival in ICI-treated patients with a higher PILE score. If prospective studies validate our results, PILE score could be a biomarker for immunotherapy.

Clinical variations between three different causes of thrombocytopenia.

BACKGROUND: Thrombocytopenia is defined as the platelet count of less than 150 × 109/L and is a prominent cause of bleeding. Aplastic anemia (AA), immune thrombocytopenic purpura (ITP), and thrombotic thrombocytopenic purpura (TTP) are some of the reasons of low platelet counts. AIMS: We aimed to interpret different laboratory and clinical findings in these different reasons of thrombocytopenia. METHODS: Among patients with these disorders we assessed the performance of the ITP Bleeding Scale Assessment (ITP-BSA), which is principally designed for ITP patients. RESULTS: A hundred patients were included in analysis. Median platelet count at presentation was similar in all three groups. Thrombosis was seen more common in patients with TTP (20.7%) than the others (ITP; 5.6%, AA; 2.9%). In patients with TTP, sepsis (41.4%) and neurological findings (89.7%) are also more common than in the patients with ITP or AA. Bleeding was determined in all patients with AA. However, 13 patients with ITP (%36.1) and 10 patients with TTP (%34.5) had no bleeding. The most common bleeding site was skin in all three groups. There was not any gastrointestinal, lung, genitourinary, and cranial bleeding in patients with ITP. Patients with AA obtained the highest scores from the ITP-BSA. There was a significant difference between AA and the other two groups. The scores were found similar in patients with ITP and TTP (P = 0.17). CONCLUSION: Clinical variations in thrombocytopenic patients may vary and assist to diagnose the cause of thrombocytopenia. The bleeding scoring systems might be helpful.

Evaluation of progression from first to second stage sacral neuromodulation and unplanned device removal.

OBJECTIVE: Sacral neuromodulation (SNM) is an advanced treatment option for patients with refractory overactive bladder (OAB) symptoms, urinary retention, and bowel disorders; it is usually performed in 2 separate procedures. This study aims to determine a cohort's progression rate from stage 1 to 2 and predict factors for progression and unplanned device removal or revision. MATERIAL AND METHODS: A retrospective review was conducted in patients who underwent SNM at a single institution between June 2012 and May 2019. Progression rates from stage 1 to 2, patient characteristics, and indications for unplanned SNM removal or revision were recorded. Chi-square, Mann-Whitney U, and Fisher's exact tests were used for data analysis. RESULTS: A total of 128 patients underwent SNM for 1 or more of the following diagnoses: OAB (n=103), urinary retention (n=15), neurogenic bladder dysfunction (n=4), fecal incontinence (n=2), and constipation (n=4). The progression rate to stage 2 was 92.2% (118/128). Patients who failed to progress to stage 2 had additional diagnoses other than OAB, such as urinary retention or bowel disorders (p=0.007). Fifteen patients (12.7%) required SNM removal or revision within 4 years of surgery. Among these patients, the body mass index was significantly lower (p=0.036). CONCLUSION: Most patients (92.2%) progressed to stage 2. Patients with only OAB symptoms had a higher progression rate to stage 2. Single full-stage procedures may be considered in select patients to reduce morbidity, time, and costs.