Physicians are over optimistic in recognizing inpatients' survival and palliative care needs: a large-scale multi-center study in Taiwan.

BACKGROUND: Physicians' recognition of end of life (EOL) has key influences on patients' 'good death'. AIM: We aimed to study physicians' attitude toward EOL, and to analyze the relationship between physicians' assessment and patients' actual survival and the trigger effect on patient's access to palliative consultation and palliative care. DESIGN: This is a multi-center retrospective cohort study in seven community hospitals in Taiwan. METHODS: Inpatients admitted between 1 March 2016 and 31 December 2020, scored ≥4 points using Taiwan version-Palliative Care Screening Tool (TW-PCST), and expired before 31 December 2020 were enrolled. Physicians answered three questions regarding these inpatients: 'surprised of mortality within 6-12 months', 'EOL' and 'in need of palliative care'. We followed up patients' actual survival and access to palliative consultation and services. RESULTS: We enrolled 10 304 cases. There was high correlation among the three questions. The median survival of patients with 'not surprised of death within 6-12 months', 'EOL', and 'needing palliative care' were 68, 60 and 58 days, respectively. Those with opposite responses were 206, 166 and 186 days, respectively. Patients' main diagnosis, TW-PCST score, physicians' palliative care qualifications and reward measures were all associated with physicians' recognition of EOL. Physicians' assessment, physicians' training, disease characteristics and TW-PSCT scores were all associated with palliative consultation and palliative care. CONCLUSIONS: Physicians are still over optimistic in recognizing inpatients' survival and palliative care needs. EOL talks can be initiated when the TW-PCST score is high. Universal palliative care training can be integrated into medical education.

Preoperative Rehabilitation Is Feasible in the Weeks Prior to Surgery and Significantly Improves Functional Performance.

BACKGROUND: Frailty is a multidimensional state of increased vulnerability. Frail patients are at increased risk for poor surgical outcomes. Prior research demonstrates that rehabilitation strategies deployed after surgery improve outcomes by building strength. OBJECTIVES: Examine the feasibility and impact of a novel, multi-faceted prehabilitation intervention for frail patients before surgery. DESIGN: Single arm clinical trial. SETTING: Veterans Affairs hospital. PARTICIPANTS: Patients preparing for major abdominal, urological, thoracic, or cardiac surgery with frailty identified as a Risk Analysis Index≥30. INTERVENTION: Prehabilitation started in a supervised setting to establish safety and then transitioned to home-based exercise with weekly telephone coaching by exercise physiologists. Prehabilitation included (a)strength and coordination training; (b)respiratory muscle training (IMT); (c)aerobic conditioning; and (d)nutritional coaching and supplementation. Prehabilitation length was tailored to the 4-6 week time lag typically preceding each participant's normally scheduled surgery. MEASUREMENTS: Functional performance and patient surveys were assessed at baseline, every other week during prehabilitation, and then 30 and 90 days after surgery. Within-person changes were estimated using linear mixed models. RESULTS: 43 patients completed baseline assessments; 36(84%) completed a median 5(range 3-10) weeks of prehabilitation before surgery; 32(74%) were retained through 90-day follow-up. Baseline function was relatively low. Exercise logs show participants completed 94% of supervised exercise, 78% of prescribed IMT and 74% of home-based exercise. Between baseline and day of surgery, timed-up-and-go decreased 2.3 seconds, gait speed increased 0.1 meters/second, six-minute walk test increased 41.7 meters, and the time to complete 5 chair rises decreased 1.6 seconds(all P≤0.007). Maximum and mean inspiratory and expiratory pressures increased 4.5, 7.3, 14.1 and 13.5 centimeters of water, respectively(all P≤0.041). CONCLUSIONS: Prehabilitation is feasible before major surgery and achieves clinically meaningful improvements in functional performance that may impact postoperative outcomes and recovery. These data support rationale for a larger trial powered to detect differences in postoperative outcomes.

[Forsythiaside B inhibits cerebral ischemia/reperfusion-induced oxidative stress injury in mice via the AMPK/DAF-16/FOXO3 pathway].

OBJECTIVE: To study the protective effect of forsythiaside B (FB) against cerebral oxidative stress injury induced by cerebral ischemia/reperfusion (I/R) in mice and explore the underlying mechanism. METHODS: Ninety C57BL/6 mice were randomized into sham-operated group, middle cerebral artery occlusion (MCAO) model group, and low-, medium and highdose (10, 20, and 40 mg/kg, respectively) FB groups. The expression levels of MDA, ROS, PCO, 8-OHdG, SOD, GSTα4, CAT and GPx in the brain tissue of the mice were detected using commercial kits, and those of AMPK, P-AMPK, DAF-16, FOXO3 and P-FOXO3 were detected with Western blotting. Compound C (CC), an AMPK inhibitor, was used to verify the role of the AMPK pathway in mediating the therapeutic effect of FB. In another 36 C57BL/6 mice randomized into 4 sham-operated group, MCAO model group, FB (40 mg/kg) treatment group, FB+CC (10 mg/kg) treatment group, TTC staining was used to examine the volume of cerebral infarcts, and the levels of ROS and SOD in the brain were detected; the changes in the protein expressions of AMPK, P-AMPK, DAF-16, FOXO3 and P-FOXO3 in the brain tissue were detected using Western blotting. RESULTS: In mice with cerebral IR injury, treatment with FB significantly reduced the levels of ROS, MDA, PCO and 8-OHdG, increased the activities of antioxidant enzymes SOD, GSTα4, CAT and GPx, and enhanced phosphorylation of AMPK and FOXO3 and DAF-16 protein expression in the brain tissue (P < 0.01). Compared with FB treatment alone, the combined treatment with FB and CC significantly reduced phosphorylation of AMPK and FOXO3, lowered expression of DAF-16 and SOD activity, and increased cerebral infarction volume and ROS level in the brain tissue of the mice (P < 0.01). CONCLUSION: FB inhibits oxidative stress injury caused by cerebral I/R in mice possibly by enhancing AMPK phosphorylation, promoting the downstream DAF-16 protein expression and FOXO3 phosphorylation, increasing the expression of antioxidant enzymes, and reducing ROS level in the brain tissue.

Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study.

Government and nongovernmental organizations need national and global estimates on the descriptive epidemiology of common oral conditions for policy planning and evaluation. The aim of this component of the Global Burden of Disease study was to produce estimates on prevalence, incidence, and years lived with disability for oral conditions from 1990 to 2017 by sex, age, and countries. In addition, this study reports the global socioeconomic pattern in burden of oral conditions by the standard World Bank classification of economies as well as the Global Burden of Disease Socio-demographic Index. The findings show that oral conditions remain a substantial population health challenge. Globally, there were 3.5 billion cases (95% uncertainty interval [95% UI], 3.2 to 3.7 billion) of oral conditions, of which 2.3 billion (95% UI, 2.1 to 2.5 billion) had untreated caries in permanent teeth, 796 million (95% UI, 671 to 930 million) had severe periodontitis, 532 million (95% UI, 443 to 622 million) had untreated caries in deciduous teeth, 267 million (95% UI, 235 to 300 million) had total tooth loss, and 139 million (95% UI, 133 to 146 million) had other oral conditions in 2017. Several patterns emerged when the World Bank's classification of economies and the Socio-demographic Index were used as indicators of economic development. In general, more economically developed countries have the lowest burden of untreated dental caries and severe periodontitis and the highest burden of total tooth loss. The findings offer an opportunity for policy makers to identify successful oral health strategies and strengthen them; introduce and monitor different approaches where oral diseases are increasing; plan integration of oral health in the agenda for prevention of noncommunicable diseases; and estimate the cost of providing universal coverage for dental care.

Early removal of catheters in an Enhanced Recovery Pathway (ERP) with intrathecal opioid injection does not affect postoperative urinary outcomes.

BACKGROUND: Postoperative urinary retention (POUR) and catheter-associated urinary tract infections (CAUTI) are associated with significantly longer hospital length-of-stay and increased costs.1 This study investigates the effect of early removal of urinary catheters on POUR and CAUTI in patients undergoing an ERP with a preoperative intrathecal injection. METHODS: Retrospective cohort study of a prospectively maintained database of patients who underwent elective colorectal surgery in an Enhanced Recovery pathway was compared to historical National Surgical Quality Improvement Program cohort of patients. Primary outcomes measured are 30-day POUR and postoperative CAUTI rates. RESULTS: The overall POUR rate of ERP patients compared to non-ERP patients was significantly less (8% vs. 13%, p < 0.05). CAUTI rates were not significantly different between pre-ERP and ERP patients (1.2 vs 2.3%, p = 0.19). CONCLUSIONS: For patients undergoing ERP with a preoperative intrathecal opioid injection, early removal of urinary catheter significantly decreased POUR and did not significantly affect CAUTI rates. SUMMARY: The effect of early removal of urinary catheters on postoperative urinary retention and catheter-associated UTI rates in patients undergoing an ERP with a single preoperative intrathecal opioid injection was studied. Early urinary catheter removal after intrathecal injection was associated with decreased rates of POUR and equivalent CAUTI rates.

Encoding and Multiplexing of 2D Images with Orbital Angular Momentum Beams and the Use for Multiview Color Displays.

The orthogonal nature of different orbital angular momentum modes enables information transmission in optical communications with increased bandwidth through mode division multiplexing. So far the related works have been focused on using orbital angular momentum modes to encode/decode and multiplex point-based on-axis signals for maximum data channel numbers and capacity. Whether orbital angular momentum modes can be utilized to encode/decode off-axis signals for multiplexing in two-dimensional space is of significant importance both fundamentally and practically for its enormous potential in increasing the channel information capacity. In this work, a direct use of orbital angular momentum modes to encode/decode and multiplex two-dimensional images is realized in a scalable multiview display architecture, which can be utilized for viewing three-dimensional images from different angles. The effect of off-axis encoding/decoding and the resultant crosstalk between multiplexed different two-dimensional views are studied. Based on which, a color display of good image quality with four independent views is demonstrated. The resolution of the decoded images is analyzed and the limitation of this approach discussed. Moreover, a spatially multiplexed data communication scheme is also proposed with such a two-dimensional encoding/decoding approach to significantly enhance the data transmission capacity in free space for future data communication needs.

Phase flicker optimisation in digital liquid crystal on silicon devices.

Phase flickers in the digital liquid crystal on silicon (LCOS) devices employing the pulse width modulation (PWM) driving scheme have a detrimental effect on optical performances, especially in the non-display applications. This paper investigated the relationship between the PWM waveform and the corresponding phase flicker in digital LCOS devices. It has been identified that the magnitude of the phase flicker depends on the pulse patterns in the driving waveform as well as the dynamic response of the liquid crystal molecules at different tilting angles. A simple but generic method has been developed based on these findings, which is able to accurately predict the temporal phase response of the liquid crystal to any PWM waveforms. This method is further used for rapid identifications of low-flicker PWM waveforms, without the need for increasing the complexity of the driving circuitry. The peak-to-peak phase flicker in the LCOS device under our investigation has been reduced by >80% from ∼0.16pi to ∼0.03pi when operating at 30°C.

Laparoscopic living donor right nephrectomy: Assessment of outcome and association of BMI to length of right renal vein. / Nefrectomía laparoscópica derecha de donante vivo: evaluación del resultado y asociación del IMC con la longitud de la vena renal derecha.

AIMS: The aim of this study was to describe outcomes of laparoscopic living donor right nephrectomy (LLDRN) and study factors affecting the length of right renal vein from the donors. MATERIAL AND METHODS: This study was conducted in 60 donors (48 males and 12 females) from January 2016 to December 2017. We performed a retrospective review of consecutive patients who underwent transperitoneal right laparoscopic living donor nephrectomy at our unit. RESULTS: LLDRN was successfully performed in all subjects by the same surgeons. Among 60 cases, 47 donors had single renal artery and vein, 2 cases had one artery and 2 veins, and 5 donors had 2 arteries and one vein, and the rest had 2-3 arteries with 1-3 veins. Operative time was 142.60±33.73min. Warm ischemic time was 2.64±0.76min. The mean hospital stay was 6.69±0.63 days. The median length of right renal vein was 1.92±0.41cm. All transplanted kidneys showed immediate function. No graft losses were recorded. Almost no gender differences were found in study variables except BMI and warm ischemic time, that was higher BMI but shorter warm ischemic time in female versus male donors. Further analysis showed a negative correlation between BMI and right renal vein (r=-0.282, P<0.05), but a positive correlation between operative time and estimate blood loss (r=0.37, P<0.01). CONCLUSIONS: LLDRN is a feasible safe procedure, less traumatic approach, and provides good outcomes kidney for recipients. Notably, in the study group the higher BMI was associated with resulting more difficult LLDRN and kidney transplantation.

Urologic care and progression to end-stage kidney disease: a Chronic Kidney Disease in Children (CKiD) nested case-control study.

INTRODUCTION: Children with chronic kidney disease (CKD) risk progressing to end-stage kidney disease (ESKD). The majority of CKD causes in children are related to congenital anomalies of the kidney and urinary tract, which may be treated by urologic care. OBJECTIVE: To examine the association of ESKD with urologic care in children with CKD. STUDY DESIGN: This was a nested case-control study within the Chronic Kidney Disease in Children (CKiD) prospective cohort study that included children aged 1-16 years with non-glomerular causes of CKD. The primary exposure was prior urologic referral with or without surgical intervention. Incidence density sampling matched each case of ESKD to up to three controls on duration of time from CKD onset, sex, race, age at baseline visit, and history of low birth weight. Conditional logistic regression analysis was performed to estimate rate ratios (RRs) for the incidence of ESKD. RESULTS: Sixty-six cases of ESKD were matched to 153 controls. Median age at baseline study visit was 12 years; 67% were male, and 7% were black. Median follow-up time from CKD onset was 14.9 years. Seventy percent received urologic care, including 100% of obstructive uropathy and 96% of reflux nephropathy diagnoses. Cases had worse renal function at their baseline visit and were less likely to have received prior urologic care. After adjusting for income, education, and insurance status, urology referral with surgery was associated with 50% lower risk of ESKD (RR 0.50 [95% confidence interval [CI] 0.26-0.997), compared to no prior urologic care (Figure). After excluding obstructive uropathy and reflux nephropathy diagnoses, which were highly correlated with urologic surgery, the association was attenuated (RR 0.72, 95% CI 0.24-2.18). DISCUSSION: In this study, urologic care was commonly but not uniformly provided to children with non-glomerular causes of CKD. Underlying specific diagnoses play an important role in both the risk of ESKD and potential benefits of urologic surgery. CONCLUSION: Within the CKiD cohort, children with non-glomerular causes of CKD often received urologic care. Urology referral with surgery was associated with lower risk of ESKD compared to no prior urologic care but depended on specific underlying diagnoses.

Federal research funding and academic productivity in pediatric urology: from early career to research independence.

INTRODUCTION: Federal grants from the National Institutes of Health (NIH) or Agency for Healthcare Research and Quality (AHRQ) are crucial for early career physician-scientists. Federal funding success has been explored in other surgical specialties, but has not been evaluated in pediatric urology. OBJECTIVE: To characterize factors associated with receipt of federal grants, hypothesizing that pediatric urologists who were have advanced research degree(s) were more likely to be federally funded. STUDY DESIGN: All pediatric fellowship graduates from 1985-2016 listed on the Societies for Pediatric Urology and institutional websites were queried using the NIH Research Portfolio Online Reporting Tools. Primary outcomes were successful receipt of federal grants and transition from mentor-based to independent funding. The secondary outcome was publication rate on PubMed as of November 2017. Covariables included advanced degree(s) (eg, PhD, MPH, MSc, etc), sex, and year of fellowship graduation (1985-2006 versus 2007-2016). RESULTS: Of 445 pediatric urologists (73% male), 36 (8%) were federal grant recipients. Of 18 mentor-based awardees, 9 (50%) transitioned to independent awards. After adjusting for sex and year of fellowship graduation, having an advanced degree(s) was associated with funding success for mentor-based awards (hazard ratio [HR] 3.83 [95% confidence interval, 1.21-12.14], p = 0.02; Summary Table) and independent awards (HR 3.11 [1.21-8.02], p = 0.02), and with higher publication rates (incident rate ratio [IRR] 2.03 [1.43-2.87], p < 0.001). Recent training (2007-2016) was also associated with higher publication rates (IRR 2.70 [2.16-3.37], p < 0.001). DISCUSSION: Among fellowship-trained pediatric urologists in North America between 1985 and 2016, the prevalence of federal grant recipients was 8%. Pediatric urologists who had an advanced educational degree were more likely to be a federally funded grant recipient and have a higher publication rate. CONCLUSIONS: Fellowship programs should consider adding opportunities for self-selected applicants to pursue additional research training and degrees.

IgG1+ B-cell immunity predates IgE responses in epicutaneous sensitization to foods.

BACKGROUND: The generation of IgE-mediated food allergy in humans is silent and only diagnosed upon manifestation of clinical symptoms. While experimental models have been used to investigate some mechanisms of allergic sensitization, the generation of humoral immunity and memory remains to be elucidated. Here, we defined the evolution of allergen-specific B-cell responses during epicutaneous sensitization to foods. METHODS: Wild-type and genetic knockout animals, and drug or antibody strategies for cell depletion and immunoglobulin signaling blockade were used to investigate epicutaneous sensitization and disease progression; we analyzed allergen-specific germinal centers and IgG1+ memory B cells by flow cytometry, evaluated humoral responses, and determined clinical reactivity (anaphylaxis). RESULTS: Epicutaneous sensitization caused microscopic skin damage, inflammation, and recruitment of activated dendritic cells to the draining lymph nodes. This process generated allergen-specific IgG1+ germinal center B cells, serum IgG1, and anaphylaxis that was mediated by the alternative pathway. Whether we used peanut and/or ovalbumin from the egg white for sensitization, the allergen-specific IgG1+ memory compartment predominantly exhibited an immature, pro-germinal center phenotype (PDL-2- CD80- CD35+ CD73+ ). Subsequent subclinical exposures to the allergen induced IgE+ germinal center B cells, serum IgE, and likely activated the classical pathway of anaphylaxis. CONCLUSIONS: Our data demonstrate that IgG1+ B-cell immunity against food allergens in epicutaneous sensitization precedes the generation of IgE responses. Therefore, the assessment of allergen-specific cellular and humoral IgG1+ immunity may help to identify individuals at risk of developing IgE-mediated food allergy and hence provide a window for therapeutic interventions.

Ipsilateral ureteroureterostomy: does function of the obstructed moiety matter?

PURPOSE: Upper pole nephrectomy has been the traditional surgical management of children with poorly functioning upper pole moieties in duplex renal collecting systems having ureteral ectopia and ureterocele. However, ablative surgery confers a risk of functional loss to the remnant moiety due to vasospasm or vascular injury. It was hypothesized that ipsilateral ureteroureterostomy (IUU) is a safe and feasible approach for the management of these patients and that residual function in the obstructed upper pole does not affect surgical outcomes. MATERIALS AND METHODS: All patients with duplex systems who underwent IUU between 2010 and 2016 were retrospectively reviewed. Patients were sorted into two groups based on pre-operative imaging: those having <10% upper pole moiety function (UPMF) and those having ≥ 10% UPMF. Outcomes assessed were postoperative complications (Clavien-Dindo classification), need for secondary surgery, and radiological outcomes. RESULTS: The study cohort comprised 53 children with ectopia or ureterocele affecting the upper pole in a duplex system, 21 with UPMF <10% (median function 0% and median age 1.49 years) and 32 with UPMF ≥ 10% (median function 15% and median age 0.91 years). Median follow-up was 27.4 months and 27.6 months. In both the groups, prenatal hydronephrosis was the most common presentation (57% and 56%, respectively; p = 0.18) followed by urinary tract infection. Mann-Whitney U test comparing the two groups revealed no significant differences in any of the outcomes assessed. No patient required secondary surgery. CONCLUSION: Ipsilateral ureteroureterostomy is a safe, definitive surgical intervention that preserves the renal architecture in children with duplex collecting systems regardless of upper pole function.

Evidence of equine influenza A (H3N8) activity in horses from Eastern and Central Saudi Arabia: 2013-2015.

BACKGROUND: Equine influenza virus (EIV) is one of the main causes of viral respiratory affections in horses. Little is known about the prevalence of EIV in Saudi Arabia especially the H3N8 serotype. OBJECTIVES: To assess prevalence of equine influenza in horse populations in Eastern and Central Saudi Arabia. STUDY DESIGN: Cross-sectional study. METHODS: We collected 145 sera, 323 nasal and 323 rectal swabs from horses from six major cities in Eastern and Central regions. None of the horses were vaccinated against EIV. Sera were tested in ELISA assays for influenza A type-specific antibodies and by haemagglutination inhibition (HI) tests using equine H3N8. The swabs were tested by RT-qPCR assay targeting a conserved region of the influenza A matrix gene that detects influenza A viruses of all subtypes. RESULTS: None of the swabs had detectable influenza A virus RNA. Of the 145 serasamples tested by ELISA, 81 (55.9%) were positive and 98 (67.6%) of 145 sera tested by HI tests were positive for equine H3. MAIN LIMITATIONS: Our failure to detect and sequence any EIV prevents identification of the lineage of virus that circulates in the Kingdom of Saudi Arabia. CONCLUSIONS: These results confirm that EIV H3N8 is circulating in Saudi Arabia and should be considered as a possible cause when investigating horses with respiratory disease in Saudi Arabia.

[Clinical applications of transcrestal around detached sinus floor elevation technique using osteotomes and sequential drills with stops].

Sinus floor elevation was needed in 11 patients having 15 implant sites with the residual bone height (RBH) was less than 10 mm in the posterior maxillary region from Feb to May 2017. The RBH ranged from 3.10 to 8.34 mm [averaged (6.18±1.60) mm]. RBH<6 mm was observed in 40% implant sites (6 implant sites) and RBH≥6 mm was observed in 60% implant sites (9 implant sites). The thickness of the sinus floor membrane correspond to the implant site measured by cone beam CT (CBCT) ranged from 0.50 to 4.24 mm [averaged (1.21±0.92) mm]. Sequential drills with stops were used to perforate the cortical bone of the sinus floor firstly, then the transcrestal around detached sinus floor elevation technique (TADSFET) was carried with osteotomes. Anorganic bovine bone was used as the augmentation material.Fifteen implants were placed in 15 implant sites. CBCT pictures showed that there was a smooth and continuous tent-shaped apophysis on each lifted site and no air fluid level was observed in the sinus immediately after operation. The mean elevated height of the 15 implant sites was (7.83±1.57) mm (ranged from 5.94 to 11.01 mm). The mean follow-up time was 7.91 months (7-10 months). The survival rate was 100% during the follow up period.

Pediatric robotic-assisted laparoscopic pyeloplasty: Does age matter?

BACKGROUND: Although shown to be safe in infancy, robotic-assisted laparoscopic pyeloplasty (RALP) for ureteropelvic junction obstruction (UPJO) is most commonly performed in older children and adolescents. OBJECTIVE: This study examined a contemporary RALP experience at a single tertiary pediatric center and compared outcomes in infants aged ≤1 year with an older cohort. METHODS AND DESIGN: All RALP procedures were entered into an Institutional Review Board-approved data registry from 2012 to 2016. Patients were retrospectively grouped according to age. The primary outcome was success rate. Secondary outcomes included complications and length of hospital stay. Failure was defined as the need for secondary surgical intervention for UPJO or worsening urinary tract dilation on imaging. Statistical analysis was performed using SPSS version 20. Mann-Whitney U testing was used for comparison. RESULTS: A total of 138 patients underwent RALP during 2012-2016, with a median age of 6 years (IQR 1, 13.25) and a male:female ratio of approximately 2:1. Of these, 34 (24.6%) were aged ≤1 year. Of all patients, 60 (43.5%) presented with a history of prenatal hydronephrosis, and 32% had a crossing vessel causing obstruction. An indwelling stent was placed in antegrade fashion in 71% of cases, and 18% had a percutaneously placed externalized stent. There were six (4%) failures requiring reoperation. Multivariate and comparative analysis demonstrated that the infant cohort utilized less morphine equivalents and more often had a percutaneous stent placed compared to the older cohort. Of the complications that occurred, 60% were minor (Clavien grades 1 and 2) and 40% were Clavien grade 3 in the infant cohort, and 70.1% and 29.9% in the older cohort, respectively. No studied criteria predicted failure in either cohort. CONCLUSION: This study presented one of the largest contemporary series of consecutive pediatric RALPs, and showed an overall success rate of 96%. There were no significant differences in length of hospital stay, and complications or failure rates in infants compared to older children. This study substantiated the ongoing trend towards the adaptation of robotic-assisted surgery for the entire pediatric patient population.

Robotic-assisted laparoscopic ureteral re-implant (RALUR): Can post-operative urinary retention be predicted?

OBJECTIVE: Urinary retention following robotic-assisted laparoscopic extravesical ureteral reimplantation (RALUR) is proposed to be due to traction or injury of the pelvic parasympathetic nerve plexus during distal ureteral dissection. Nerve-sparing techniques have been employed to avoid injury to the pelvic plexus, either directly or indirectly. This single-center study assessed postoperative urinary retention rates after extravesical RALUR and investigated whether demographic or operative factors could predict this occurrence. METHODS: All RALUR cases entered into an Institutional Review Board-approved registry were retrospectively reviewed, and the rate of postoperative retention was determined. Postoperative urinary retention was defined as the need for catheterization at any time in the postoperative period during hospital admission or within 1 week after the operation. This included acute urinary retention episodes (AUR) as well as high post-void residuals (>50% of expected bladder capacity). Univariate analysis was performed to analyze for predictors of postoperative retention. Factors assessed included age, gender, clinical presentation, bowel bladder dysfunction (BBD), pre-operative urinary tract infection (UTI), procedure length, grade of vesicoureteral reflux (VUR), and operative laterality. RESULTS: A total of 128 patients underwent extravesical RALUR in 179 ureters during the study period 2012-2016. Male:female ratio was 1:2.6. Median age at surgery was 4 years. Bilateral RALUR was performed in 52 cases (40.6%), and unilateral in 76 (59.4%). Urinary retention requiring catheterization occurred in 11 cases (8.59%). Of these, seven were post-bilateral RALUR, while the remaining four were unilateral. In seven cases, postoperative retention occurred within 24 h following RALUR. The remaining four instances occurred within 1 week, despite successful voiding in the immediate postoperative period. Univariate analysis revealed male gender (P = 0.009) and operating room time (P = 0.029) as predictors of retention. No association was found with age, weight, BBD, pre-operative UTI, grade of VUR, or laterality. CONCLUSION: Urinary retention after RALUR was an infrequent complication. When it did occur, urinary retention appeared to be secondary to covariates such as male gender and length of surgical time - possibly an indication of technical difficulty - rather than laterality of repair.

Outcomes of externalized pyeloureteral versus internal ureteral stent in pediatric robotic-assisted laparoscopic pyeloplasty.

INTRODUCTION: After pyeloplasty, urinary drainage options include internal double-J (DJ) ureteral stents or externalized pyeloureteral (EPU) stents, which can avoid bladder symptoms and additional anesthetic exposure from stent removal. Comparative outcome studies, however, are lacking following primary pediatric robotic-assisted laparoscopic pyeloplasty (RALP). OBJECTIVE: To compare operative success, operative time, hospitalization, and postoperative complications of EPU versus DJ stents following RALP. STUDY DESIGN: Consecutive children undergoing primary RALP from 10/2013 to 9/2015 were retrospectively identified. Data collected included patient demographics, stent type and duration, postoperative complications, and operative success. To control for confounding by indication for EPU stent, propensity score weighting was used to balance baseline covariates. Weighted regression analyses compared between-group differences in study outcomes. RESULTS: At median follow-up of 12.3 months, 44 and 17 patients underwent DJ and EPU stenting, respectively. At baseline, DJ stent patients were older than EPU stent patients (median 7.7 vs 1.2 years, P = 0.01) and were less likely to be on postoperative antibiotic prophylaxis (25 vs 76%, P < 0.001). After weighting, these differences disappeared. All EPU stents were removed in the outpatient clinic; all DJ stents were removed under anesthesia. On weighted regression analyses (Summary Fig.), EPU stents had no different associations than DJ stents with operative success (95 vs 94%, between-group difference 1%, 95% CI -11, 13; P = 0.86), complications, or operative time, but did have 0.6 of a day more hospitalization (95% CI 0.04, 1.2; P = 0.04). DISCUSSION: Patients receiving EPU stents were different at baseline from those receiving DJ stents. After propensity score weighting balanced these covariates, EPU stents were associated with similar operative success, complications, and operative time to DJ stents. Further study is warranted in larger prospective cohorts. CONCLUSION: Use of EPU stents provided a viable alternative, particularly in younger patients, to DJ stenting with comparable success and complications, while avoiding the need for an additional anesthetic.

Coronaviruses in guano from Pteropus medius bats in Peradeniya, Sri Lanka.

Bats are a unique group of mammals well suited to be hosts for emerging viruses. With current rates of deforestation and urbanization, redistribution of bat habitats to urban and suburban areas may bring bats into closer contact with livestock and humans. Common flying fox, Pteropus medius (previously known as Pteropus giganteus), forms large communal roosts on treetops, often in close proximity to human habitation in Sri Lanka. This report describes the detection of coronavirus RNA in P. medius bat guano collected in Peradeniya, Sri Lanka. These viruses had >97% nucleotide identity with coronaviruses detected in Cynopterus sphinx, Scotophilus heathii and S. kuhlii bats in Thailand. Pteropus medius is widespread in Asia and appears to excrete group D coronaviruses, which are hitherto confined to bats; however, these findings may have public health implications in the future.

Tunica vaginalis flap for salvaging testicular torsion: A matched cohort analysis.

INTRODUCTION: In testicular torsion, ischemia time from pain onset impacts testicular salvage. A tunica albuginea fasciotomy to relieve compartment pressure followed by a tunica vaginalis flap (TVF) may enhance salvage. OBJECTIVE: To define the optimal window of ischemia time during which TVF may be most beneficial to avoid orchiectomy. STUDY DESIGN: A retrospective cohort study of males presenting with testicular torsion at a single tertiary-care institution from January, 2003 to March, 2017. Ischemia time was defined as duration of pain from onset to surgery. Because TVF would be an option to orchiectomy, and it was found that ischemia time was longer in testicles that underwent orchiectomy, matching was performed. Cases of torsion treated with TVF were matched 1:1 with cases treated with orchiectomy on age at surgery, and ischemia time. Outcomes included postoperative viability, defined as palpable testicular tissue with normal consistency, and atrophy, defined as palpable decrease in size relative to contralateral testicle. Sensitivity analyses were performed restricting to the subgroups with postoperative ultrasound, >6 months' follow-up, and additionally matching for degrees of twist. RESULTS: A total of 182 patients met eligibility criteria, of whom 49, 36, and 97 underwent orchiectomy, TVF, and septopexy alone, respectively. Median follow-up was 2.7 months; 26% of patients had postoperative ultrasound (61% of TVF group). In the orchiectomy, TVF, and septopexy groups, respectively, median ischemia times were 51, 11, and 8 h, postoperative viability rates were 0, 86, and 95%, and postoperative atrophy rates were 0, 68, and 24%. After matching, 32 patients with TVF were matched to 32 patients who underwent orchiectomy. In the TVF group, postoperative viability occurred in 95% (19/20) vs 67% (8/12) of patients with ischemia times ≤24 and >24 h, respectively. Atrophy occurred in 67% (12/18) vs 83% (10/12) of these same respective patients. Sensitivity analysis by ultrasound and longer follow-up found similar viability results, although atrophy rates were higher. Additional matching for degrees of twist showed lower viability and higher atrophy rates for increasing ischemia times. DISCUSSION: Patients who presented with testicular torsion with ischemia times ≤24 h and who were being considered for orchiectomy may have benefitted most from TVF, albeit at high risk of atrophy. However, for ischemia times >24 h, TVF may still have preserved testicular viability in two-thirds of cases. A limitation was short follow-up. CONCLUSION: A TVF was a valid alternative to orchiectomy for torsed testicles, albeit with high testicular atrophy rates.