Resident physicians physical activity during on-call shifts: smartphone-based assessment.

BACKGROUND: Physical activity of resident physicians (RPs) during on-call shifts is difficult to objectively evaluate. The integration of smartphones in our daily routines may allow quantitative assessment, employing pedometric assessment. AIMS: To evaluate the number of steps that RPs walk during on-call shifts as a marker of physical activity by using smartphone-based pedometers. METHODS: Step counts were collected from 100 RPs' smartphones who volunteered to participate in the study between January 2018 and May 2019. The conversion rate was 1400 steps = 1 km (application's default). A shift was defined as regular morning work followed by an in-house on-call stay, totalling 26 hours. Statistical analyses included univariate and multivariate linear mixed models, and Fisher exact test. A P-value < 0.05 was considered statistically significant. RESULTS: The average walking distance was 12 118 steps (8.6 km/RP/shift). Paediatric intensive care unit and neurosurgery residents recorded the longest walking distances 16 347 and 15 630 steps (11.67 and 11.16 km/shift), respectively. Radiology residents walked the shortest distances 4718 steps (3.37 km/shift). Physically active RPs walked significantly longer distances during their shifts than non-physically active RPs: 12 527 steps versus 11 384 steps (8.95 versus 8.13 km/shift, P < 0.05), respectively. Distances covered during weekday shifts were longer than weekend shifts: 12 092 steps versus 11 570 steps (8.63 versus 8.26 km/shift, P < 0.05), respectively. CONCLUSIONS: Smartphone-based pedometers can aid in analysing physical activity and workload during on-call shifts; such information can be valuable for human resource department, occupational health authorities and medical students with impaired physical mobility when choosing a speciality.

Scrotal injuries during neonatal circumcision.

OBJECTIVE: To report very rarely encountered scrotal injuries during neonatal circumcision. Hospitals and physicians in the authors' country are mandated to report circumcision complications to the Ministry of Health. Those reports include the discharge summary from the emergency room or the admitting department. This is believed to be the first case series describing scrotal injuries during ritual circumcision. PATIENTS AND METHODS: Reports of all circumcision complications between 2007 and 2014 were evaluated. Retrieved data on cases of scrotal injuries included patient's age, time between injury and hospital admission, nature of the injury, and administered treatment. RESULTS: Twelve of a total of 489 reports of circumcision injuries involved the scrotum (2.5%). All circumcisions were performed during the neonatal period, and the infants were admitted on the day of injury. The only related genital injury was significant shortage of penile skin reported in six patients. Scrotal exploration and skin closure in the operating room was undertaken in six cases, five under general anesthesia. Suture closure in the emergency department was performed in three patients, and the scrotal skin was left to heal with secondary intention in three other patients. Scrotal content injury that extended to the tunica vaginalis of the testis was noted in one exploration. DISCUSSION: The injuries sustained by the 12 study infants were mostly superficial and are not expected to cause long-term damage, although half of the patients required treatment under general anesthesia in the operating room or under sedation in the emergency department. While all reported patients emerged unscathed from the anesthetic procedures, the possible immediate complications of anesthesia as well as its long-term effects are not to be taken lightly, especially when treating a newborn. Further education of medical providers as well as performers of ritual circumcisions may help lower the risk of this rare injury as well as other more severe complications. CONCLUSION: Scrotal injury during neonatal circumcision is rare. While half of the 12 reported patients required exploration in the operating room, the injuries were mostly superficial and did not involve scrotal content, although they often involved extensive resection of penile skin.

Variables Associated with Severity of Bacterial Canker and Wilt Caused by Clavibacter michiganensis subsp. michiganensis in Tomato Greenhouses.

Clavibacter michiganensis subsp. michiganensis, the causal agent of bacterial canker and wilt of tomato, is considered to be one of the most important bacterial pathogens worldwide. In the year 2000 there was an increase in the number of infected greenhouses and in the severity of the disease in Israel. As part of the effort to cope with the disease, a comprehensive survey was conducted. Scouts recorded disease severity monthly in 681 production units. At the end of the season the scouts met with the growers and together recorded relevant details about the crop and cultural practices employed. The results suggested an absence of anisotropy pattern in the study region. Global Moran's I analysis showed that disease severity had significant spatial autocorrelation. The strongest spatial autocorrelation occurred within a 1,500 m neighborhood, which is comparable to the distance between production units maintained by one grower (Farm). Next, we tested three groups of variables including or excluding the Farm as a variable. When the Farm was included the explained variation increased in all the studied models. Overall, results of this study demonstrate that the most influential factor on bacterial canker severity was the Farm. This variable probably encompasses variation in experience, differences in agricultural practices between growers, and the quality of implementation of management practices.

Resonance(®) metallic stent in patients with ureterocutaneostomies.

PURPOSE: To evaluate the effectiveness and the safety of Resonance(®) stents in patients with ureterocutaneostomies (UCS). MATERIALS AND METHODS: We retrospectively enrolled all patients with UCS who presented with impaired ureteral drainage with traditional polymeric ureteral prosthesis. Preoperative and follow-up (1, 3, 6, 12 months) workup, after Resonance(®) placement, included: medical history, physical examination, serum laboratory tests, urinalysis, urine culture and urinary tract imaging by ultrasound, administration of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 (QLQ-C30) and an evaluation of patients' satisfaction rate. In addition, the number of emergency department patient admissions and hospitalizations occurred 1 year before and after the stent Resonance(®) placement was noted. RESULTS: Twenty-five renal units in 14 patients with UCS were included. Statistically significant improvements in creatinine serum levels, patients' satisfaction rate, hydronephrosis and number of urinary tract infections (UTI) were found at 1-, 3-, 6-, and 12-month follow-up compared to baseline. Statistically significant differences in EORTC QLQ-C30 were detected only in Emotional, Social and Global QoL domains before and after Resonance(®) placement (p < 0.0001). At inclusion, a total of 39 referrals to ED were recorded; at 1-year follow-up, only five cases of ED presentations have been recorded (p < 0.01). At the same endpoints, the number of hospitalizations was 18 and 2, respectively (p < 0.05). Failure rate was 8.3%. CONCLUSION: At 1-year follow-up, Resonance(®) stents are effective and safe in patients with UCS refractory to polymeric ureteral prosthesis, reporting evidence for significant improvements in hydronephrosis rate, renal function, UTI, and patients' satisfaction rate and QoL.

NF-kappaB regulates the response of embryonic cells to heat shock.

NF-kappaB was shown previously to regulate apoptotic cell death processes in various experimental systems. However, its role in controlling teratogen-induced cell death has not been established yet. Therefore, the objective of the present study was to explore the involvement of the p65 subunit of NF-kappaB in the response of mouse embryonic fibroblasts (MEFs) to heat shock, using p65 knockout (p65-/-) cells. Indeed, we found p65-/- MEFs to be more susceptible to the exposure to heat shock, as compared with wild-type (WT) MEFs, as they demonstrated a more prominent decrease in cell survival and proliferation as well as the appearance of cells undergoing apoptotic cell death. These heat-shock-induced effects were preceded by a decrease in p65 expression in WT cells, which was accompanied by a decrease in IkappaBalpha expression in WT MEFs, while disappearing completely in p65-/- MEFs and accordingly, by an increase in p-IkappaBalpha expression in both cell lines, which was found to be more prominent in p65-/- MEFs. Interestingly, the heat shock-induced decrease in p65 expression was accompanied by an increase in HSP70 expression in both cell lines. However, it was again found to be more prominent in p65-/- MEFs. Taken together, our results suggest a protective role for the p65 subunit of NF-kappaB in mechanisms underlying the response of embryonic cells to heat shock.

Are consecutive nightly recordings required for valid evaluation of sleep-associated erections?

We questioned the need for more than one RigiScan recording for accurate assessment of sleep-associated penile erections and determine the necessity of consecutive nightly recordings for valid evaluation of sleep-associated erections. Men complaining of erectile dysfunction (ED) and referred to RigiScan evaluation for the first time participated. Recordings were performed at the patient's home during two consecutive nights, and data on test time, number of erections, erection duration, minimal and maximal base and tip tumescence and rigidity were retrieved for both nights. Normal erectile function was defined with the recording of at least one erection (70 out of 100% tip rigidity lasting for at least 10 min during either night). The main outcome measures were RigiScan recordings. Group 1 consisted of 29 men (mean age 42.4+/-13.8 years, range 22-71) who had normal erections, all during the first night. Group 2 consisted of 26 men (mean age 48.6+/-13.5 years, range 25-70) who failed to fulfill both criteria for normal erection. In Group 2, only the values for penile base rigidity and erection duration were normal during the first night: the parameters of maximal base tumescence, tip rigidity, number of effective erections and duration of effective erections that were impaired during the first night were significantly worse (P<0.01) during the second night. The required information for the diagnosis of psychogenic ED was obtained during the first night in >50% of the participants. Men with normal erections during the first night can be spared the inconvenience and cost of re-testing. Consecutive night recording should be reserved for patients whose recorded data during the first night did not fulfill the criteria for normal erection.

Augmentation ureterocystoplasty: is it the preferred choice?

BACKGROUND: Various methods of urinary bladder augmentation have been attempted in order to try and achieve adequate bladder capacity, urinary continence, control urinary tract infection and preserve the upper urinary tract; however, long-term complications have been unavoidable. OBJECTIVE: To evaluate our experience with ureterocystoplasty as to whether it is the preferred method for bladder augmentation to achieve continence and preserve the upper urinary tract. DESIGN: Retrospective study. SETTING: Paediatric urology unit, Dana Children's hospital, Tel Aviv Medical Center (affiliated to the Sackler School of Medicine), Tel Aviv University. SUBJECTS: Four children; three girls, one boy, mean age 7.3, range (3-14) years. Two had neurogenic bladder due to occult spinal dysrraphism, the other two had non-neurogenic neurogenic bladder. The indications for surgery were urinary incontinence with recurrent urinary tract infections in all patients, one also had upper tract dilatation. INTERVENTIONS: All underwent augmentation ureteroplasty, two required nephrectomy due to non-functioning kidney, two required clean intermittent catheterizatiom postoperatively. MAIN OUTCOME MEASURES: Urinary continence, bladder capacity, vesicoureteral reflux, renal function tests, urinary tract infection rate and surgical complications encountered. RESULTS: In a mean follow-up period of 24 (6-46) months, all of the patients achieved urinary continence, two of the patients who have a normal bladder outlet are continent and void spontaneously with no residual urine. The other two patients are continent on clean intermittent catheterization. Only one episode of urinary tract infection was seen, none of the patients are currently on prophylactic antibiotics. The urinary bladder in all patients is spherical with good capacity and no vesicoureteral reflux was demonstrated. The upper urinary tracts are stable and the renal function tests are normal. CONCLUSION: Ureterocystoplasty is our preferred choice of bladder augmentation in patients with small, inelastic, poor compliant bladder with at least a moderately dilated ureter. Complications normally seen with enterocystoplasties are minimal.

Per urethra insertion of a through-and-through safety guide wire using a dual-lumen ureteral catheter during percutaneous nephrolithotripsy.

BACKGROUND: The second ("safety") of two guide wires is commonly inserted antegradely in percutaneous nephrolithotripsy (PCNL). We describe the retrograde insertion of a through-and-through safety guide wire during PCNL. METHODS: After inserting a percutaneous nephrostomy 1 day earlier, a guide wire was introduced through the nephrostomy tube to the bladder and pulled out through the urethral meatus via a cystoscope and grasper. The tube was removed, leaving the wire positioned from the flank to the meatus. A dual-lumen catheter was introduced retrogradely through the urethra over the wire, up to the nephrostomy incision. The safety guide wire was introduced retrogradely through the catheter's other port. RESULTS: This procedure succeeded in 9 of 10 patients: the exception was very obese and the catheter was too short to reach the incision in the flank. CONCLUSION: Using a dual-lumen catheter allows quick and simple retrograde insertion of a safety guide wire during PCNL.

The use of cell salvage during radical retropubic prostatectomy: does it influence cancer recurrence?

OBJECTIVE: To assess whether there is a difference in the biochemical recurrence rate in patients who had radical retropubic prostatectomy (RRP) with or without cell salvage transfusion. PATIENTS AND METHODS: The records of 769 consecutive patients undergoing RRP between 1992 and 1998 were retrospectively reviewed. Patients having adjuvant hormonal treatment, postoperative external beam radiotherapy, or a follow-up of < 1 year were excluded from the analysis. The remaining 408 patients were categorized into three groups: 87 who received cell-salvaged blood using a commercial cell saver; 264 receiving only autologous transfusion; and 57 with no transfusion. Disease recurrence was defined as a prostate-specific antigen (PSA) level of> 0.2 ng/mL. Bivariate and multivariate logistic regression analyses were used to assess and compare the risk of cancer recurrence in the three groups. Covariates used in the multivariate analyses included Gleason score, preoperative PSA level, seminal vesicle involvement and surgical margins. RESULTS: The mean (range) follow-up was 40.2 (12-104) months; there were no significant differences among the groups in initial PSA level and Gleason score. In the multivariate logistic regression analysis, the initial PSA, Gleason score, seminal vesicle involvement and surgical margins, but not transfusion group, were independent predictors of recurrence. CONCLUSION: Cell salvage during RRP does not influence the recurrence of prostate cancer. Cell salvage is a safe method of transfusion during RRP.

A prospective randomized controlled trial comparing nonstented versus stented ureteroscopic lithotripsy.

PURPOSE: A prospective randomized controlled trial was performed to determine whether stents may be eliminated after uncomplicated ureteroscopic lithotripsy for ureteral stones. MATERIALS AND METHODS: A total of 58 patients underwent uncomplicated ureteroscopic intracorporeal lithotripsy. After stone fragmentation patients were randomized to a nonstented (29) or a stented (29) treatment group. Intracorporeal lithotripsy was performed with the holmium laser in 57 cases and by electrohydraulic lithotripsy in 1 without balloon dilation or the extraction of stone fragments. Patients were followed 1, 6 and 12 weeks postoperatively. In stented cases the stent was removed at 1 week. Outcome measures included postoperative symptoms assessed with a visual analog scale, postoperative analgesic requirements, complications and the stone-free rate. RESULTS: At 1 week the symptoms of flank pain, abdominal pain, dysuria and frequency were significantly greater in the stented group (p <0.005). There were no differences in symptoms in the groups at subsequent followup visits. There was no difference in treatment groups in terms of the amount of analgesic required in the recovery room or during 1 week after ureteroscopy. Similarly there was no difference in the number of patients requiring antiemetics. One patient in the stented group required hospitalization for genitourinary sepsis and 1 patient in the nonstented group visited the emergency room for postoperative vomiting. The stone-free rate was 100% in each group. CONCLUSIONS: These results demonstrate that after ureteroscopic intracorporeal lithotripsy with the holmium laser patients with a stent have significantly greater irritative and painful symptoms than those without a stent in the early postoperative period. There was no difference in nonstented and stented ureteroscopy with respect to complications or stone-free status. Therefore, we believe that routine stenting after ureteroscopic intracorporeal lithotripsy with the holmium laser is not required as long as the procedure is uncomplicated and performed without balloon dilation of the ureteral orifice.

Stray radiofrequency current as a cause of urethral strictures after transurethral resection of the prostate.

PURPOSE: This study was designed to define the pattern and significance of stray currents induced by two electrosurgical generators (ESGs) in relation to urethral strictures forming after transurethral resection of the prostate (TURP). MATERIALS AND METHODS: A 24F resectoscope irrigated with glycine was activated at various power outputs in different modes, with intact loops and loops with faulty insulation, simulating TURP. The Valleylab and ERBE ESGs were compared for inducing capacitance. An ESG analyzer simulated tissue impedance and recorded the stray currents induced along the resectoscope sheath. A fresh pig liver was used for assessment of tissue damage caused by the currents. RESULTS: In the cutting mode, the ERBE ESG produced a mean stray current of 70 mA with an intact loop and 144 mA with a loop having faulty insulation. The Valleylab ESG produced 150 mA and 161 mA, respectively. In the coagulation mode, the ERBE ESG produced an average leakage current of 35 mA and, with a loop with faulty insulation, 40 mA. The Valleylab ESG produced 148 mA and 151 mA, respectively. CONCLUSIONS: Electrical injury may represent a significant cause of urethral stricture after transurethral electrosurgery. The critical power density of 7.5 W/cm2 (which is likely to cause a urethral burn) may be reached, especially with the use of loops with faulty insulation or nonconductive lubricating gel. The ERBE ESG produced significantly less capacitance, decreasing the risk of urethral electrical burn. Conductive gel prevents dangerous current concentration.

Flexible ureteroscopy and lithotripsy with the Holmium: YAG laser.

Extracorporeal shock wave lithotripsy (ESWL), Dornier Medical Systems, remains the main form of therapy for most urinary stones. The minimally invasive nature of ESWL makes it an attractive form of therapy to both patients and physicians. Many patients however may be most effectively managed by an endoscopic procedure either percutaneously or by transurethral ureteroscopy. Recent years have seen considerable advancement in endoscope technology such that flexible, actively deflectable ureteroscopes of 7.5 F or smaller in diameter have become available for performing upper tract endoscopy. When combined with new intracorporeal lithotripsy devices such as the Holmium:YAG laser, urologists have an effective alternative to ESWL for many stone problems. In this article we review our technique of flexible ureteroscopy combined with Holmium:YAG laser lithotripsy.

Advances in ureteral stent technology.

This review focuses on technological advances and relevant research related to ureteral stents. The importance of physical and chemical biomaterial type, biocompatibility, material coatings such as hydrogels, and infection related to indwelling ureteral stents are discussed. Recent in vitro and in vivo research has focused on materials that will reduce encrustation and bacterial biofilm formation. The adsorption of antimicrobials onto devices holds promise of reducing infection rates, but multidrug resistant bacteria, short leaching times and adverse side effects make it essential that alternative strategies be investigated. Just so, encrustation limits the long-term use of urinary materials, and a better understanding of factors involved in encrustation are needed to reduce the problem.

Encrustation of biomaterials in the urinary tract.

The present review focuses on technological advances and relevant research related to encrustation of biomaterials in the urinary tract. The importance of physical and chemical biomaterial type, biocompatibility, material coatings such as hydrogels, and infection related to alloplastic materials used in urological practice are discussed. Recent in-vitro and in-vivo research has focused on materials that will reduce encrustation and bacterial biofilm formation, complications that limit the long-term use of urinary materials. Coordinating scientific resources in a multidisciplinary manner for a better understanding of factors that are involved in encrustation and biofilm formation will offer the potential to modify or resolve the problem of encrustation of foreign materials in the urinary tract.

Effect of oral administration of high-dose nitric oxide donor L-arginine in men with organic erectile dysfunction: results of a double-blind, randomized, placebo-controlled study.

OBJECTIVES: To determine, in a prospective randomized, double-blind placebo-controlled study, the effect of 6 weeks of high-dose (5 g/day) orally administered nitric oxide (NO) donor L-arginine on men with organic erectile dysfunction (ED). PATIENTS AND METHODS: The study included 50 men with confirmed organic ED who were randomized after a 2-week placebo run-in period to receive L-arginine or placebo. A detailed medical and sexual history, O'Leary's questionnaire, a specially designed sexual function questionnaire and a sexual activity diary were obtained for each patient. All participants underwent a complete physical examination including an assessment of bulbocavernosus reflex and penile haemodynamics. Plasma and urine nitrite and nitrate (designated NOx), both stable metabolites of nitric oxide, were determined at the end of the placebo run-in period, and after 3 and 6 weeks. RESULTS: Nine of 29 (31%) patients taking L-arginine and two of 17 controls reported a significant subjective improvement in sexual function. All objective variables assessed remained unchanged. All nine patients treated with L-arginine and who had subjectively improved sexual performance had had an initially low urinary NOx, and this level had doubled at the end of the study. CONCLUSIONS: Oral administration of L-arginine in high doses seems to cause significant subjective improvement in sexual function in men with organic ED only if they have decreased NOx excretion or production. The haemodynamics of the corpus cavernosum were not affected by oral L-arginine at the dosage used.

Rigiscan versus snap gauge band measurements: is the extra cost justifiable?

Both RigiScan and the Snap Gauge band devices are used to objectively measure penile rigidity. The Snap Gauge band is the more simple and inexpensive of the two techniques. We investigated the correlation between the results obtained by both devices in order to evaluate whether the Snap Gauge band could be employed as the sole method of rigidity evaluation while not affecting the quality of diagnosis. Forty eight patients who were presented to our erectile dysfunction clinic used the two devices simultaneously, each according to the accepted protocols. Breakage of two and three strings of the Snap Gauge (good rigidity) correlated well with good tip and average rigidity as evaluated by the RigiScan. Snap gauge results also correlated with duration of erection, number of erections, the number of adequate erections, and the longest duration of erection measured by the RigiScan. Therefore, good rigidity according to the Snap Gauge test correlated well with the results of functional erections (number, rigidity, duration) as obtained by the RigiScan. The Snap Gauge band can be used to adequately evaluate penile rigidity. RigiScan measurements, which are more complicated and more expensive, should be reserved for selected patients in whom the results of the Snap Gauge band are inconclusive or when more detailed information is required.

Percutaneous drainage of subcapsular splenic hematoma: an experimental model in dogs.

Preservation of the spleen in patients with posttraumatic subcapsular hematoma is still controversial. To determine the best therapeutic approach for this type of splenic injury, we designed an experimental model of subcapsular hematoma of the spleen in dogs. A total of 23 subcapsular hematomas were caused in 19 dogs, which were followed both clinically and ultrasonographically for 12 weeks. Fifty-seven per cent of the hematomas resolved spontaneously; those that persisted (43%) were aspirated percutaneously with ultrasound guidance, after which they were all resolved. Our results support a conservative approach. When the hematoma does not resolve spontaneously, percutaneous ultrasound-guided aspiration may be considered.

Intraprostatic metal stents (Prostakath and Urospiral): more than 6 years' clinical experience with 110 patients.

We reviewed the long-term results of two different intraprostatic metal stents. Patients (N = 110) with either benign prostatic hyperplasia or prostatic cancer were included in a prospective study and treated by the insertion of one of two intraprostatic stents (Prostakath or Urospiral). The mean follow-up was 53 (range 36-80) months. Subjective and objective symptoms and signs were evaluated at each follow-up visit. The different complications and overall success rates were compared for the two intraurethral spirals. When considering both patient satisfaction and device functionality, the overall success rate was 65%. Stent migration, incrustation, failure to void, and clinical infections were the most common complications. Of 41 cases of late complications, removal of the stents was required in 35 patients. No difference in the rate of late complications was noted for the two stents. Intraurethral stents are well-tolerated by patients. The relatively low cost of spirals and the fact that they may be left in situ for long periods renders them highly cost efficient. There is a need for continued close follow-up when the stent is left in situ for prolonged periods. There was no significant difference between the two metal stents despite their different coating.