Mpox: The Reemergence of an Old Disease and Inequities.

Mpox, previously known as monkeypox, is caused by an Orthopoxvirus related to the variola virus that causes smallpox. Prior to 2022, mpox was considered a zoonotic disease endemic to central and west Africa. Since May 2022, more than 86,000 cases of mpox from 110 countries have been identified across the world, predominantly in men who have sex with men, most often acquired through close physical contact or during sexual activity. The classical clinical presentation of mpox is a prodrome including fever, lethargy, and lymphadenopathy followed by a characteristic vesiculopustular rash. The recent 2022 outbreak included novel presentations of mpox with a predominance of anogenital lesions, mucosal lesions, and other features such as anorectal pain, proctitis, oropharyngeal lesions, tonsillitis, and multiphasic skin lesions. We describe the demographics and clinical spectrum of classical and novel mpox, outlining the potential complications and management.

Tolerability of four-drug antiretroviral combination therapy in primary HIV-1 infection.

OBJECTIVES: Rapid initiation of antiretroviral therapy (ART) is important for individuals with high baseline viral loads, such as in primary HIV-1 infection (PHI). Four-drug regimens are sometimes considered; however, data are lacking on tolerability. We aimed to evaluate the tolerability of four-drug regimens used in the Research in Viral Eradication of HIV-1 Reservoirs (RIVER) study. METHODS: At enrolment, ART-naïve adult participants or those newly commenced on ART were initiated or intensified to four-drug regimens within 4 weeks of PHI. Rapid start was defined as pre-confirmation or ≤ 7 days of confirmed diagnosis. Primary and secondary outcomes were patient-reported adherence measured by 7-day recall and regimen switches between enrolment and randomization, respectively. RESULTS: Overall, 54 men were included: 72.2% were of white ethnicity, with a median age of 32 years old, 42.6% had a viral load of ≥ 100 000 HIV-1 RNA copies/mL, and in 92.6% sex with men was the mode of acquisition of HIV-1. Twenty (37%) started a four-drug regimen and 34 (63%) were intensified. Rapid ART initiation occurred in 28%, 100% started in ≤ 4 weeks. By weeks 4, 12, and 24, 37.0%, 69.0%, and 94.0% were undetectable (viral load < 50 copies/mL), respectively. Adherence rates of 100% at weeks 4, 12, 22 and 24 were reported in 88.9%, 87.0%, 82.4% and 94.1% of participants, respectively. Five individuals switched to three drugs, four changed their regimen constituents, and two switched post-randomization. CONCLUSIONS: Overall, four-drug regimens were well tolerated and had high levels of adherence. Whilst their benefit over three-drug regimens is lacking, our findings should provide reassurance if a temporarily intensified regimen is clinically indicated to help facilitate treatment.

Extramammary Paget 's disease Of Glans Penis: A Rare Case Report

We present the case of an 83-year-old man with Extramammary Paget's disease (EMPD) of the penis. He underwent a total penectomy and histopathology confirms the association of underlying invasive high grade urothelial carcinoma. Penile EMPD is rare and can be misinterpreted for benign skin conditions. A high index of suspicion is required for correct diagnosis and appropriate treatment.

The Impact of pH and Ion Exchange on 133Cs Adsorption on Vermiculite.

Many studies have shown that the adsorption of ions like K and Cs on 2:1 clay minerals can prompt the collapse of their interlayers and render the adsorbing ions nonexchangeable. This study sought to better understand this unique adsorption mechanism through the generation of an adsorption envelope for Cs adsorption on vermiculite and the exploration of the kinetics of interlayer collapse. The collapse of the vermiculite interlayer was confirmed via X-ray diffraction (XRD), and the timing of interlayer collapse was determined by placing Cs in competition with K at different time intervals. The adsorption envelope for Cs on vermiculite showed that although H competition does affect the adsorption of Cs on vermiculite, the effect of this competition is quite limited, even at very low pH values. This hypothesis is supported by the fact that XRD demonstrated a significant decrease in interlayer dimension after Cs adsorption. Finally, kinetics experiments showed that the irreversible adsorption of K and the collapse of the interlayer may take place on a much longer time scale than previously considered.

CD4:CD8 ratio in children with perinatally acquired HIV-1 infection.

OBJECTIVES: In adults with horizontally acquired HIV infection, an inverted CD4:CD8 ratio is associated with persistent immune activation, size of HIV reservoir and predicts an increased risk of non-AIDS-defining adverse events. Normalization of this ratio with antiretroviral therapy (ART) is suboptimal in adults, despite viral suppression, and is less well described in paediatric populations. We investigated rates of CD4:CD8 ratio recovery in children with perinatally acquired HIV infection (PaHIV) on ART. METHODS: A cross-sectional, retrospective analysis of routine clinical data in children with PaHIV (5-18 years old) attending a single UK centre was carried out. RESULTS: CD4:CD8 normalization was seen in 62% of children on suppressive ART. A negative correlation was found between current CD4:CD8 ratio and age at start of ART. Positive correlations were found between current CD4:CD8 ratio and total time with suppressed HIV viral load and nadir CD4 counts. Multiple linear regression analysis showed that age at start of ART was significantly associated with current CD4:CD8 ratio (standardized ß = -0.680; P < 0.001). Patient sex, ethnicity and antiretroviral regimen did not affect ratio recovery. CONCLUSIONS: We found higher rates of CD4:CD8 ratio normalization compared with previous adult studies. Children who started ART at a younger age were more likely to recover a normal ratio. The current policy of universal treatment for all HIV-positive adults and children will enhance immunological normalization.

Predictors of live birth after vasectomy reversal in a specialist fertility centre.

In a retrospective review of 106 consecutive vasectomy reversals (May 2002-April 2015) in our institution, patients were stratified according to post vasectomy obstructive interval (PVOI); less than 5 years, 5-10 years, 10-15 years and >15 years. Positive semen analysis and live birth rates were analysed. Logistic regression tested potential predictors for these outcomes. Overall patency rate (positive semen analysis) was 75% and live birth rate was 41%. Shorter PVOI was a significant predictor for positive semen analysis (p=0.028). Male smoking or male age at reversal had no significant correlation (p=0.99 and 0.95 respectively). For a live birth, PVOI and female age (threshold: 36 years) at reversal were significant predictors (p=0.007 and p=0.043 respectively). Outcomes compared favourably with international series yielding satisfactory pregnancy rates, particularly with a short obstructive interval and in females <36 years of age.

Evaluating the cost of iatrogenic urethral catheterisation injuries.

INTRODUCTION: Technique is vital to prevent urethral trauma during urethral catheterisation (UC). Education programmes are helpful but are not compulsory and safe UC remains operator dependent. Traumatic UC is associated with increased morbidity, length of stay, resource utilisation and surgical intervention. AIM: To determine the cost of iatrogenic urethral injuries managed in a tertiary referral centre over a 6-month period. METHODS: A 6-month prospective study monitored iatrogenic urethral injuries secondary to traumatic UC. Included were referrals from district hospitals and inpatient consultations relating to urethral injury caused by traumatic UC. The added cost of management was estimated. RESULTS: Thirteen iatrogenic urethral injuries were recorded in 6 months. Management included open surgery for a ruptured bladder (n = 1), flexible cystourethroscopy (n = 10), suprapubic catherisation (n = 4), 3-way catheterisation (n = 4) and catheter re-insertion under direct vision (n = 6). The cost of acute management of these injuries was approximately €50,000 including theatre costs, ambulance transfer, hospital stay, procedural and equipment costs and short-term follow-up care. CONCLUSION: Iatrogenic injuries during UC represent a significant cost burden to the healthcare system. Training programmes should be compulsory for all healthcare professionals routinely involved in catheterisation procedures.

Incidence, Cost, Complications and Clinical Outcomes of Iatrogenic Urethral Catheterization Injuries: A Prospective Multi-Institutional Study.

PURPOSE: Data on urethral catheter related injuries are sparse. To highlight the dangers inherent in traumatic urethral catheterization we prospectively monitored the incidence, cost and clinical outcomes of urethral catheter related injuries. MATERIALS AND METHODS: This prospective study was performed during a 6-month period at 2 tertiary referral teaching hospitals. Recorded data included method and extent of urethral catheterization injury, setting and time of injury, number of catheterization attempts, urological management provided, additional bed days due to urethral injury and clinical outcomes after followup. The additional cost of managing urethral injuries was also calculated. RESULTS: A total of 37 iatrogenic urethral injuries were recorded during the 6-month period. The incidence of traumatic urethral catheterization was 6.7 per 1,000 catheters inserted. Thirty (81%) patients sustained a complication Clavien-Dindo grade 2 or greater. The additional length of inpatient hospital stay was 9.4 ± 10 days (range 2 to 53). Of these patients 9 (24%) required an indwelling suprapubic catheter and 8 (21%) have an indwelling transurethral catheter. In addition, 9 (24%) are performing self-urethral dilation once weekly and 4 (11%) have required at least 1 urethral dilation due to persistent urethral stricture disease. The additional cost of managing iatrogenic urethral injuries was €335,377 ($371,790). CONCLUSIONS: Iatrogenic urethral catheterization injuries represent a significant cost and cause of patient morbidity. Despite efforts to educate and train health care professionals on urethral catheterization insertion technique, iatrogenic urethral injuries will continue to occur unless urinary catheter safety mechanics are altered and improved.

Post-chemotherapy retroperitoneal lymph node dissection in the management of metastatic testis cancer: the 16-year experience in an Irish setting.

INTRODUCTION: Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an important tool in the management of advanced germ cell testis cancer, particularly non-seminoma. AIM: We present the 16-year experience with PC-RPLND in a single Irish tertiary referral centre, and compare our results to the major speciality centres worldwide. METHODOLOGY: All 78 patients undergoing PC-RPLND for the treatment of metastatic testis cancer between January 1996 and December 2011 were included. Medical records were reviewed and up to date follow-up obtained from primary referral centres, patient's GPs and individual patient interview. RESULTS: The mean age at diagnosis was 28.5 ± 7 years. Initial pathology included non-seminoma 62.8 %, seminoma 6.4 % and combined 19.2 %. All patients underwent pre-operative chemotherapy. The resection template utilised was bilateral infra-hilar in 29.5 %, unilateral infra-hilar in 46.2 % and supra-hilar in 20.5 %. Complete abdominal remission was achieved in all but one patient. Additional procedures were required in 38.5 % of patients (n = 30). Clavien Dindo grade three or four complications were seen in 8.9 %, including five patients who required early reoperation. Histology of RPLND specimen showed mature teratoma (41 %) and active cancer (11.5 %). Follow-up data were available for 66 patients (85 %). Median follow-up was 101 (11-207) months. Nine patients relapsed with median time to relapse 15 (8-60) months. Overall 5-year survival rate was 95.2 % (four deaths). CONCLUSION: In this relatively small series due to small population and low disease incidence, we have shown acceptable peri-operative course, morbidity and oncological outcomes with PC-RPLND compared to major international centres.

The improved accuracy of planar bone scintigraphy by adding single photon emission computed tomography (SPECT-CT) to detect skeletal metastases from prostate cancer.

BACKGROUND: Planar bone scintigraphy (PBS) is a standard radiological technique to detect skeletal metastases from prostate cancer (PC), the addition of SPECT-CT to PBS improves its diagnostic accuracy. The aim of this study was to assess the additional value of targeted SPECT-CT with PBS in detecting skeletal metastasis form prostate cancer, considering resource implications in an Irish hospital setting. METHODS: 54 PC patients with increased radiotracer uptake on PBS were retrospectively recruited from 2012 to 2013. All underwent targeted evaluation with SPECT-CT. PBS and SPECT-CT images were reviewed by two nuclear medicine radiologists and reported independently. The final diagnosis was made based on the CT finding corresponding to the area of radiotracer uptake. RESULTS: The mean age was 70.9 years (48-88 years) and median PSA at presentation was 13.9 ng/ml (4.2-215 ng/ml). 68.5 % (n = 37) men received treatment for PC while 31.5 % (n = 17) patients had not received treatment prior to PBS. 164 areas of increased radiotracer uptake were identified on PBS; 13 areas were characterised as metastatic on SPECT-CT; iliac bone (n = 3), ribs (n = 1), skull (n = 2), sacrum (n = 1), ischium (n = 1), femur (n = 3), thoracic spine (n = 1) and cervical spine (n = 1). 151 areas were characterised as benign on SPECT-CT. One area of increased radiotracer uptake in the ribs was subsequently described as indeterminate after evaluation with SPECT-CT. CONCLUSION: SPECT-CT improves the diagnostic accuracy of PBS in detecting skeletal metastasis from PC and is superior to PBS alone in differentiating benign from malignant lesions. Notwithstanding resource implications of increased cost, specialist equipment and specialist manpower hours; we recommend the use of SPECT-CT in conjunction with PBS for targeted evaluation of suspicious bony lesions in this cohort of patients.

Dilemmas in diagnosis and natural history of renal oncocytoma and implications for management.

INTRODUCTION: Oncocytomas have traditionally been treated with surgical excision; however, their excellent long-term prognosis has popularized conservative and minimally invasive ablative techniques. We evaluated the evolving management and natural history of renal oncocytomas and investigated the relationship between radiological and histopathological diagnosis. METHODS: We performed a 17-year retrospective cohort study on all patients with a confirmed histopathological diagnosis of renal oncocytoma. The primary outcome variables were long-term outcomes, coexistence with renal cell carcinoma, and development of metastatic disease. RESULTS: A total of 38 oncocytomas were reported in 36 patients. Of the 36 patients, 29 (81%) were diagnosed incidentally. Oncocytoma was considered in the differential diagnosis in 4 oncocytomas (10.5%). In total, 34 patients underwent early surgical intervention; of these, 27 (79.4%) underwent radical nephrectomy and 7 underwent partial nephrectomy (20.6%). Four patients (11.1%) were managed conservatively with surveillance. No patients developed recurrence or metastatic disease after a median follow-up of 84 months (range: 4-178). CONCLUSIONS: The diagnostic accuracy for imaging modalities in renal oncocytoma is poor. Surveillance or minimally invasive ablative techniques are appropriate in selected patients with biopsy-proven oncocytoma that are not increasing in size.

Testicular Sperm Extraction and Intracytoplasmic Sperm Injection: Outcomes in a specialist fertility centre.

Assisted reproduction with testicular sperm extraction (TESE) and intra-cytoplasmic sperm injection (ICSI) are fertility treatment options for couples with severe oligospermia or azoospermia. A retrospective review was performed of 146 TESE procedures in a specialist fertility centre in Ireland. The indication for TESE was obstructive azoospermia (OA) in 59% (n = 80) and non-obstructive azoospermia (NOA) in 41% (n = 56). Sperm retrieval rates after TESE were determined and the pregnancy rates per ICSI cycle number were evaluated. Sperm retrieval rates were 99% (n = 79/80) and 32% (n = 18/56) for OA and NOA men respectively. Fifty-eight couples proceeded to ICSI. Overall 114 ICSI cycles were performed and 33 cycles resulted in fertilisation (29%). Our sperm retrieval and pregnancy rates are consistent with international studies and support the ongoing role for TESE and ICSI as successful assisted reproductive techniques for male factor infertility in Ireland.

Transurethral resection of the prostate--"now and then".

The number of transurethral resections of the prostate (TURP) performed each year is decreasing. The aim of this study was to assess a cohort of patients undergoing TURP and compare this to one twenty years earlier in terms of procedure, complications and outcomes. A retrospective comparative analysis of one hundred consecutive TURPs performed in 2010 was compared to one hundred cases performed in 1990. Fifty-five (55%) had a urinary catheter (UC) in situ pre-operatively in 2010 compared to 22 (22%) in 1990. The length of catheterisation time was significantly longer in 2010 compared with 1990 (average 65 days vs 20 days). Infective complications occurred in six (6%) patients in 2010 and three (3%) in the 1990 cohort. Patients who had UCs in situ preoperatively for longer periods had a higher rate of infective complications and more serious complications. This highlights the importance of early specialist referral for patients diaqnosed with urinary retention.

A comparative bibliometric analysis of the top 150 cited papers in hypospadiology (1945-2013).

INTRODUCTION: Hypospadias, the most common congenital malformation of the penis, is characterized by an abnormal ventral opening of the urethral meatus, abnormal ventral curvature of the penis, and an abnormal distribution of the foreskin around the glans, with a ventrally-deficient hooded foreskin, and has been described in modern peer-reviewed literature since Noble's description in 1853. A dramatic increase in the literature on hypospadiology has focused on two main topics: The aetiology of the condition including molecular mechanisms and environmental influences, as well as surgical techniques to repair the defect, however there have been a number of facets of research stemming from this poorly understood condition in a developing subspecialty (Figure). The majority of these publications focus on the evolution of surgical technique and management. Urethral reconstruction should offer the ability to stand to urinate and combine a satisfactory cosmetic result. The tubularized incised plate repair, popularized by Snodgrass et al., and the Mathieu repair, have been the mainstay for distal hypospadias, however, there have still been a large number of well-described techniques, with no consensus as to the ideal method of repair, some of which is attributed to non-uniform standards of reporting outcomes. There is also no standard objective means to qualitatively assess the importance of each of these contributions. OBJECTIVE: The objective of this study was to determine the top 150 peer-reviewed articles in the field of hypospadiology by way of citation analysis as a means to determine the importance/relevance of each contribution throughout 8 decades of research. STUDY DESIGN: A cited reference search was carried out for indexed citations within Web of Science™ Core Collection. The top 150 indexed cited articles containing the topic "hypospadias" in specific subject categories were compiled using a component of Science Citation Index command. References were then evaluated, and analysed across a number of indices, and over time. RESULTS: The mean number of citations was 76 for each article. The top 150 articles were published across 21 countries, with the majority originating from the USA. The lead research institution was the University of Texas (Southwestern) Medical Center. In total, the top 3 centers represented 33 publications within the top 150 citations. The most commonly utilized journal was the Journal of Urology. The most cited author was W.T. Snodgrass. 39% papers in the top 150 cited articles were published prior to 1990. Three out of the five papers cited in the 1940s dealt with operative technique to repair hypospadias. The period 2000-2010 in contrast, demonstrated a significant inverse correlation between molecular biology citations, and those for operative techniques, with the incidence of the latter dropping to 6% of all cited papers. DISCUSSION: This is the first study of its kind to analyse the most influential articles in hypospadiology, and their characteristics assessed for authorship, content and impact factor. Furthermore it allows data analysis by topic and between time points. This not only de-clutters the wealth of accumulated data on this subject, but also provides an important adjunct to education and training. As with this study, other citation analytical studies in urology found a significant preponderance in cited studies originating from the USA. The prevalence of the US in cited papers doesn't reflect any inherent bias, just a greater number of publications. CONCLUSION: Although there are inherent potential elements of bias in citation analysis, this study demonstrates that citation analysis in a complicated topic can provide a high-throughput, uncomplicated method of quickly deciphering important contributions of authors and institutions to the field of hypospadias research.

Evaluation of the Brix refractometer as an on-farm tool for the detection of passive transfer of immunity in dairy calves.

OBJECTIVES: To investigate the accuracy of both the optical and digital Brix refractometers compared with radial immunodiffusion (RID) for determining the immunoglobulin G (IgG) concentrations in dairy calf serum. DESIGN: The experiment design was a cross-sectional survey of four dairy farms. Serum was sampled from 12 calves from each farm at approximately 48 hours of age. METHODS: Serum IgG concentrations of 48 calves were measured using RID and both types of Brix refractometer. RESULTS: IgG concentrations measured by Brix refractometer scores correlated with RID results: 0.74 and 0.71 for the digital and optical devices, respectively. The minimum Brix score that identified calf serum with success of passive immunity (>1000 mg/dL RID IgG) with 100% accuracy was 10% for both devices. The optical and digital devices performed similarly at identifying IgG concentrations in calf serum, with a concordance of 87%. CONCLUSION: Brix refractometer score ≥10% can be used to classify calves with successful transfer of passive immunity and the devices are sufficiently accurate for use as a simple, inexpensive on-farm tool for the monitoring of neonatal dairy calf immunity levels.

A 30-year experience of Millin's retropubic prostatectomy: Has this classic operation derived by a President of the College in Ireland stood the test of time?

INTRODUCTION: In patients with large gland volume, open prostatectomy/adenoma enucleation remains a valuable surgical option in treating large obstructing prostates. We report our series of open prostatectomies spanning 32 years from a single institution. PATIENTS AND METHODS: We retrospectively reviewed all patients who underwent open prostatectomy between 1980 and 2012. Patient demographical, clinical, pre- and postoperative data and final histology were retrieved from hospital in-patient enquiry system and chart review. RESULTS: A total of 161 patients underwent Millin's prostatectomy by seven surgeons between 1980 and 2012. The mean blood loss was 1,381 mls (range 300-3,675 mls). One-third (34%) of patients (n = 55) received a blood transfusion. The mean weight of prostate tissue removed was 119 g (median 112 g, range 17-372 g). 6.6 % of pathological specimens revealed incidental prostate cancer, of which 78% were well differentiated (Gleason score ≤ 6). The mean weight of prostate tissue removed in patients who received a transfusion was 124 g. Trial of micturition (TOM) was performed at a mean of 9 days (median 9 days, range 5-25 days) with 94% of patients having a successful trial of voiding. 6% of cases early in the series failed to void initially, but did so at later removal of catheter while still in hospital. 45 patients (28%) of patients developed peri- or postoperative complications. There were three deaths (1.9%). CONCLUSION: Open Millin's prostatectomy popularized over half a century ago continues to be a valuable option for the surgical treatment of high-volume prostate glands with excellent outcomes for patients.

A patient reported outcome measure (PROM) assessing quality of care in the urology hospital outpatient setting.

A prospective blind PROM (patient reported outcome measure) study performed in our urology department examined the outpatient-clinic experience. 104 questionnaires were completed. 23 patients (22%) felt the waiting times for appointments was excessive. 13 patients (13%) experienced difficulty in contacting administrative staff. 98 patients (94%) considered the waiting areas good but 31 patients (31%) considered lack of privacy an issue. Consultants saw 65 patients (63%). 62 patients (60%) expected to be seen by a consultant. 32 patients (31%) felt consultation with a different doctor on return visits was unsatisfactory. 76 patients (73%) "fully trusted" their doctors. 78 patients (75%) rated their visit excellent, 10 patients (10%) added comments. Despite frustration with waiting times, the experience of patients reflects a positive rapport and trust between patient and doctor.

Mountain bikers priapism: a rare phenomenon.

Soft tissue and bony injuries are well described risks of the increasingly popular sport of mountain biking. Priapism, a persisting unwanted penile erection, as a result of perineal straddle injury due to a fall astride bicycle handlebar, is rare. We present a case of a competitive mountain biker with high flow priapism after such an injury who presented late but was successfully treated by non-invasive selective arterial embolization.