Clovis organizational dynamics at a Late Glacial campsite in the central Great Lakes: Belson site excavations 2020-2021.

The Belson site is located on an outwash plain draining the Early Algonquin stage of the central Great Lakes (coinciding with the Older Dryas stadial period around 14,000 Cal B.P) southwest across Lower Michigan into the Ohio tributaries. By 13,000 Cal B.P the St. Joseph River had incised multiple channels into this plain. On a terrace just north of a now-abandoned channel, a detailed surface study by Talbot from 2005-2018 showed several flake clusters largely of Attica chert, procured about 235 km southwest of Belson. A study of the surface sample was published by the authors in 2021 and indicated that the points were made with the Clovis technological pattern. Excavations in 2020-21 revealed hundreds of buried flakes and multiple tools in the lower, less-disturbed terrace sediment. Plotting of this material indicates successive occupations below the ploughed deposit and covering more than 30 m2. The buried assemblages are similar to the published surface assemblage with the addition of more small scrapers and manufacturing debris. Several of the buried tools have traces of proteins from a range of mammals, suggesting a broad-spectrum subsistence strategy. The documentation of a succession of little disturbed deposits with precisely recorded micro-debris will allow for testing of models describing settlement choice and developing dynamics of internal site organization. Initial analysis of recovered data provides support for an 'outcrop centered' model where high-quality chert outcrops serve as central places on the landscape. Samples of sediment and charcoal for identification and dating await study.

Explicit and implicit locomotor learning in individuals with chronic hemiparetic stroke.

Motor learning involves both explicit and implicit processes that are fundamental for acquiring and adapting complex motor skills. However, stroke may damage the neural substrates underlying explicit and/or implicit learning, leading to deficits in overall motor performance. While both learning processes are typically used in concert in daily life and rehabilitation, no gait studies have determined how these processes function together after stroke when tested during a task that elicits dissociable contributions from both. Here, we compared explicit and implicit locomotor learning in individuals with chronic stroke to age- and sex-matched neurologically intact controls. We assessed implicit learning using split-belt adaptation (where two treadmill belts move at different speeds). We assessed explicit learning (i.e., strategy-use) using visual feedback during split-belt walking to help individuals explicitly correct for step length errors created by the split-belts. The removal of visual feedback after the first 40 strides of split-belt walking, combined with task instructions, minimized contributions from explicit learning for the remainder of the task. We utilized a multi-rate state-space model to characterize individual explicit and implicit process contributions to overall behavioral change. The computational and behavioral analyses revealed that, compared to controls, individuals with chronic stroke demonstrated deficits in both explicit and implicit contributions to locomotor learning, a result that runs counter to prior work testing each process individually during gait. Since post-stroke locomotor rehabilitation involves interventions that rely on both explicit and implicit motor learning, future work should determine how locomotor rehabilitation interventions can be structured to optimize overall motor learning.

Can Perioperative Antibiotic Choice Impact Rates of Infectious Complications After Percutaneous Nephrolithotomy? A Single-Blind, Prospective Randomized Trial.

Objective: National guidelines recommend periprocedural antibiotics before percutaneous nephrolithotomy (PCNL), yet it is not clear which is superior. We conducted a randomized trial to compare two guideline-recommended antibiotics: ciprofloxacin (cipro) vs cefazolin, on PCNL outcomes, focusing on the development of systemic inflammatory response syndrome (SIRS) criteria. Methods: Adult patients who were not considered high risk for surgical or infectious complications and undergoing PCNL were randomized to receive either cipro or cefazolin perioperatively. All had negative preoperative urine cultures. Demographic and perioperative data were collected, including SIRS criteria, intraoperative urine culture, duration of hospitalization, and need for intensive care. SIRS is defined by ≥2 of the following: body temperature <96.8°F or >100.4°F, heart rate >90 bpm, respiratory rate >20 per minute, and white blood cell count <4000 or >12,000 cells/mm3. Results: One hundred forty-seven patients were enrolled and randomized (79 cefazolin and 68 cipro). All preoperative characteristics were similar (p > 0.05), except for mean age, which was higher in the cipro group (64 vs 57 years, p = 0.03). Intra- and postoperative findings were similar, with no difference between groups (p > 0.05), except a longer mean hospital stay in the cefazolin group (2 hours longer, p = 0.02). There was no difference between SIRS episodes in both univariate and multivariate analyses. Conclusions: Despite the relatively broader coverage for urinary tract pathogens with ciprofloxacin, this prospective randomized trial did not show superiority over cefazolin. Our findings therefore support two appropriate options for perioperative antibiotic prophylaxis in patients undergoing PCNL who are nonhigh risk for infectious complications.

Increasing Activity After Stroke: A Randomized Controlled Trial of High-Intensity Walking and Step Activity Intervention.

BACKGROUND: Physical inactivity in people with chronic stroke profoundly affects daily function and increases recurrent stroke risk and mortality, making physical activity improvements an important target of intervention. We compared the effects of a high-intensity walking intervention (FAST), a step activity monitoring behavioral intervention (SAM), or a combined intervention (FAST+SAM) on physical activity (ie, steps/day). We hypothesized the combined intervention would yield the greatest increase in steps/day. METHODS: This assessor-blinded multisite randomized controlled trial was conducted at 4 university/hospital-based laboratories. Participants were 21 to 85 years old, walking without physical assistance following a single, unilateral noncerebellar stroke of ≥6 months duration, and randomly assigned to FAST, SAM, or FAST+SAM for 12 weeks (2-3 sessions/week). FAST training consisted of walking-related activities at 70% to 80% heart rate reserve, while SAM received daily feedback and goal setting of walking activity (steps/day). Assessors and study statistician were masked to group assignment. The a priori-determined primary outcome and end point was a comparison of the change in steps/day between the 3 intervention groups from pre- to post-intervention. Adverse events were tracked after randomization. All randomized participants were included in the intent-to-treat analysis. RESULTS: Participants were enrolled from July 18, 2016, to November 16, 2021. Of 2385 participants initially screened, 250 participants were randomized (mean [SE] age, 63 [0.80] years; 116 females/134 males), with 89 assigned to FAST, 81 to SAM, and 80 to FAST+SAM. Steps/day significantly increased in both the SAM (mean [SE], 1542 [267; 95% CI, 1014-2069] P<0.001) and FAST+SAM group (1307 [280; 95% CI, 752-1861] P<0.001) but not in the FAST group (406 [238; 95% CI, -63 to 876] P=0.09). There were no deaths or serious study-related adverse events. CONCLUSIONS: Only individuals with chronic stroke who completed a step activity monitoring behavioral intervention with skilled coaching and goal progression demonstrated improvements in physical activity (steps/day). REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02835313.

Increasing activity after stroke: a randomized controlled trial of highintensity walking and step activity intervention.

Background: Physical inactivity in people with chronic stroke profoundly affects daily function and increases recurrent stroke risk and mortality, making physical activity improvements an important target of intervention. We compared the effects of a highintensity walking intervention (FAST), a step activity monitoring behavioral intervention (SAM), or a combined intervention (FAST+SAM) on physical activity (i.e., steps per day). We hypothesized the combined intervention would yield the greatest increase in steps per day. Methods: This assessor-blinded multi-site randomized controlled trial was conducted at four university/hospital-based laboratories. Participants were 21-85 years old, walking without physical assistance following a single, unilateral non-cerebellar stroke of ≥6 months duration, and randomly assigned to FAST, SAM, or FAST+SAM for 12 weeks (2-3 sessions/week). FAST training consisted of walking-related activities for 40 minutes/session at 70-80% heart rate reserve, while SAM received daily feedback and goal-setting of walking activity (steps per day). Assessors and study statistician were masked to group assignment.The a priori-determined primary outcome and primary endpoint was change in steps per day from pre- to post-intervention. Adverse events (AEs) were tracked after randomization. All randomized participants were included in the intent-to-treat analysis.This study is registered at ClinicalTrials.gov, NCT02835313. Findings: Participants were enrolled from July 18, 2016-November 16, 2021. Of 250 randomized participants (mean[SE] age 63[0.80], 116F/134M), 89 were assigned to FAST, 81 to SAM, and 80 to FAST+SAM. Steps per day significantly increased in both the SAM (mean[SE] 1542[267], 95%CI:1014-2069, p<0.001) and FAST+SAM groups (1307[280], 752-1861, p<0.001), but not in the FAST group (406[238], 63-876, p=0.09). There were no deaths or serious study-related AEs and all other minor AEs were similar between groups. Interpretation: Only individuals with chronic stroke who completed a step activity monitoring behavioral intervention with skilled coaching and goal progression demonstrated improvements in physical activity (steps per day).

Holmium Laser Enucleation of the Prostate vs Transvesical Single-port Robotic Simple Prostatectomy for Large Prostatic Glands.

OBJECTIVE: To compare the perioperative outcomes of transvesical single-port robotic simple prostatectomy (SP-RASP) and holmium laser enucleation of the prostate (HoLEP). MATERIALS AND METHODS: A retrospective review was performed of patients undergoing SP-RASP and HoLEP from 2019 to 2022 with preoperative prostatic volume (PPV) >80 cm3. Percent of prostate adenoma removed (%PAR) was estimated by specimen weight normalized by PPV. Univariate analysis was performed using chi-square, Fisher exact, and Wilcoxon rank-sum tests. A subgroup analysis with 1:1 matching for PPV was also performed. RESULTS: A total of 50 SP-RASP and 90 HoLEP cases were analyzed. The median (interquartile range) PPV was 169 (128-244)cm3 for SP-RASP and 129 (100-150)cm3 for HoLEP, (P < .01). The median (interquartile range) %PAR was 57(44-68) for SP-RASP vs 51(42-62) for HoLEP (P = .10). Overall, 11(12%) HoLEP and 5(10%) SP-RASP patients experienced complications (P = .51). Same-day discharge occurred in 24(48%) SP-RASP vs 7(8%) HoLEP patients (P < .01). Median foley catheter duration was longer in SP-RASP (6 vs 1 day, P < .01) and trial of void was successful at first attempt in >94% (P = .68). Transient de novo incontinence was reported in 24(28%) HoLEP vs 2(5%) SP-RASP (P < .01). No differences in voiding parameters were observed at latest follow up. Subgroup postmatched analysis revealed analogous findings. CONCLUSION: SP-RASP and HoLEP have similar favorable perioperative outcomes for management of large prostatic adenomas. SP-RASP may be considered in patients unwilling to accept the risk of transient incontinence and in those with unfavorable urethral access, large bladder stone burden, or diverticula.

Optimal Intensity and Duration of Walking Rehabilitation in Patients With Chronic Stroke: A Randomized Clinical Trial.

Importance: For walking rehabilitation after stroke, training intensity and duration are critical dosing parameters that lack optimization. Objective: To assess the optimal training intensity (vigorous vs moderate) and minimum training duration (4, 8, or 12 weeks) needed to maximize immediate improvement in walking capacity in patients with chronic stroke. Design, Setting, and Participants: This multicenter randomized clinical trial using an intent-to-treat analysis was conducted from January 2019 to April 2022 at rehabilitation and exercise research laboratories. Survivors of a single stroke who were aged 40 to 80 years and had persistent walking limitations 6 months or more after the stroke were enrolled. Interventions: Participants were randomized 1:1 to high-intensity interval training (HIIT) or moderate-intensity aerobic training (MAT), each involving 45 minutes of walking practice 3 times per week for 12 weeks. The HIIT protocol used repeated 30-second bursts of walking at maximum safe speed, alternated with 30- to 60-second rest periods, targeting a mean aerobic intensity above 60% of the heart rate reserve (HRR). The MAT protocol used continuous walking with speed adjusted to maintain an initial target of 40% of the HRR, progressing up to 60% of the HRR as tolerated. Main Outcomes and Measures: The main outcome was 6-minute walk test distance. Outcomes were assessed by blinded raters after 4, 8, and 12 weeks of training. Results: Of 55 participants (mean [SD] age, 63 [10] years; 36 male [65.5%]), 27 were randomized to HIIT and 28 to MAT. The mean (SD) time since stroke was 2.5 (1.3) years, and mean (SD) 6-minute walk test distance at baseline was 239 (132) m. Participants attended 1675 of 1980 planned treatment visits (84.6%) and 197 of 220 planned testing visits (89.5%). No serious adverse events related to study procedures occurred. Groups had similar 6-minute walk test distance changes after 4 weeks (HIIT, 27 m [95% CI, 6-48 m]; MAT, 12 m [95% CI, -9 to 33 m]; mean difference, 15 m [95% CI, -13 to 42 m]; P = .28), but HIIT elicited greater gains after 8 weeks (58 m [95% CI, 39-76 m] vs 29 m [95% CI, 9-48 m]; mean difference, 29 m [95% CI, 5-54 m]; P = .02) and 12 weeks (71 m [95% CI, 49-94 m] vs 27 m [95% CI, 3-50 m]; mean difference, 44 m [95% CI, 14-74 m]; P = .005) of training; HIIT also showed greater improvements than MAT on some secondary measures of gait speed and fatigue. Conclusions and Relevance: These findings show proof of concept that vigorous training intensity is a critical dosing parameter for walking rehabilitation. In patients with chronic stroke, vigorous walking exercise produced significant and meaningful gains in walking capacity with only 4 weeks of training, but at least 12 weeks were needed to maximize immediate gains. Trial Registration: ClinicalTrials.gov Identifier: NCT03760016.

Ergonomics in the OR: An Electromyographic Evaluation of Common Muscle Groups Used During Simulated Flexible Ureteroscopy - a Pilot Study.

OBJECTIVE: To assess the effects of different surgeon positions and ureteroscope types on muscle activation as measured by surface electromyography (sEMG) during simulated ureteroscopy in an endourology box-trainer model and the kidney phantom. METHODS: For this exploratory study, sEMG was used to quantify muscle activation of 3 endourology fellows during various ureteroscopic tasks. Electrodes were placed on the ureteroscope-holding side of the following muscles: thenar, forearm flexor, forearm extensor, biceps, triceps, deltoid, and trapezius. Subjects wore fitted lead aprons in an operating room and used a cystoscopy table with surgical drapes and an endoscopic video tower. Trials were completed with a disposable and reusable ureteroscope, both in the standing and sitting positions. Each subject performed an identical set of tasks in a phantom silicone kidney and ureteroscopy box trainer to recreate the procedural components of basketing, navigating a renal collecting system, and dusting. Raw EMG data for each task was processed and normalized as a percent of each subject's maximum voluntary contraction to allow comparison. RESULTS: The forearm extensor was the most heavily utilized muscle. The trapezius and deltoid muscles were activated more during sitting whereas the forearm flexors had increased activity during standing. The heavier reusable ureteroscope had increased forearm extensor activation compared to the disposable ureteroscope. CONCLUSION: Preliminary data show measurable differences in muscle activation based on both surgical posture and type of ureteroscope used. This highlights the need for more extensive EMG studies to identify techniques and equipment to optimize ergonomics and potentially minimize injury during flexible ureteroscopy.

The impact of smart technology on adherence rates and fluid management in the prevention of kidney stones.

Smart technology (ST) can enhance chronic disease management, yet little is known about the benefits of ST on kidney stone prevention. Our aim was to prospectively evaluate the impact of ST on follow-up adherence rates and urine output (UOP) in patients with nephrolithiasis. Kidney stone patients with low UOP (< 2.5 L/24 h) were randomized into three intervention groups: (1) standard dietary/medical counseling alone (control), (2) control + smartphone fluid management application (app), and (3) control + smart water bottle (bottle). Demographics, adherence rates, kidney stone events, and 24 h urine data were collected and analyzed at baseline, 3-6, and 12 months. We randomized 111 patients (37 per group), of which 20 (55%), 8 (26%), and 10 (33%) patients completed the 12 month follow-up in the control, app, and bottle groups respectively. Control group patients were the most likely to adhere to follow-up (p = 0.004). Overall mean UOP increased by 0.4 L in each group (p < 0.05), with no difference in mean baseline 24 h UOP (1.6 L) and 12 month 24 h UOP (2.0 L) between groups (p > 0.05). Twenty-nine percent of patients achieved a daily UOP goal of > 2.5 L across the treatment groups (p < 0.001). In this prospective study, the 24 h UOP improved across all groups compared to baseline, although adherence to follow-up remained low. Furthermore, the use of ST did not further augment UOP, underscoring the importance of dietary/medical counseling for kidney stone prevention.

Acute kidney injury and percutaneous nephrolithotomy: incidence and predictive factors.

INTRODUCTION AND OBJECTIVE: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for patients with large stones. The risk of acute kidney injury (AKI) has not been reported in the Western world. Our objective was to assess the frequency of AKI in patients undergoing PCNL and to identify independent predictors of AKI. METHODS: A retrospective review of PCNL cases performed between January 2014 and June 2019 was reformed. Demographic, laboratory, and intraoperative date were obtained. Perioperative AKI was defined as (1) Increase in serum creatinine by ≥ 0.3 mg/dL (≥ 26.5 micromol/L) within 48 h, or (2) increase in serum creatinine to ≥ 1.5 times baseline. Multivariable logistic regression analysis was performed to determine the factors influencing AKI. A p value of 0.05 was considered significant. RESULTS: A total of 566 patients were included. Mean age was 58 ± 14.4 years. The frequency of AKI was 4.4% (n = 25). The risk factors for AKI after PCNL were having a baseline creatinine > 1.54 mg/dl (p = 0.03, odds ratio [OR] = 2.66, confidence interval [CI] = 1.07-6.6), and a preoperative hemoglobin of less than 10.6 g/dL (p = 0.02, odds ratio [OR] = 2.47, confidence interval [CI] = 1.09-5.5). Patients without AKI had a median hospitalization of 2 days, while those with an AKI were hospitalized for a median of 3 days, and this difference was statistically significant (p < 0.001). CONCLUSIONS: Perioperative AKI occurs in 4.4% of patients undergoing PCNL. Preoperative hemoglobin and serum creatinine can identify those at increased risk, in whom it may be important to avoid nephrotoxic agents.

Aerobic Responses to FES-Assisted and Volitional Cycling in Children with Cerebral Palsy.

Recumbent stationary cycling is a potential exercise modality for individuals with cerebral palsy (CP) that lack the postural control needed for upright exercises. Functional electrical stimulation (FES) of lower extremity muscles can help such individuals reach the cycling intensities that are required for aerobic benefits. The aim of this study was to examine the effect of cycling with and without FES assistance to that of a no-intervention control group on the cardiorespiratory fitness of children with CP. Thirty-nine participants were randomized to a FES group that underwent an 8-week FES-assisted cycling program, the volitional group (VOL), who cycled without FES, or a no-intervention control group (CON) (15 FES, 11 VOL, 13 CON). Cadence, peak VO2, and net rise in heart rate were assessed at baseline, end of training, and washout (8-weeks after cessation of training). Latent growth curve modeling was used for analysis. The FES group showed significantly higher cycling cadences than the VOL and CON groups at POST and WO. There were no differences in improvements in the peak VO2 and peak net HR between groups. FES-assisted cycling may help children with CP attain higher cycling cadences and to retain these gains after training cessation. Higher training intensities may be necessary to obtain improvements in peak VO2 and heart rate.

Collagen fingerprinting traces the introduction of caprines to island Eastern Africa.

The human colonization of eastern Africa's near- and offshore islands was accompanied by the translocation of several domestic, wild and commensal fauna, many of which had long-term impacts on local environments. To better understand the timing and nature of the introduction of domesticated caprines (sheep and goat) to these islands, this study applied collagen peptide fingerprinting (Zooarchaeology by Mass Spectrometry or ZooMS) to archaeological remains from eight Iron Age sites, dating between ca 300 and 1000 CE, in the Zanzibar, Mafia and Comoros archipelagos. Where previous zooarchaeological analyses had identified caprine remains at four of these sites, this study identified goat at seven sites and sheep at three, demonstrating that caprines were more widespread than previously known. The ZooMS results support an introduction of goats to island eastern Africa from at least the seventh century CE, while sheep in our sample arrived one-two centuries later. Goats may have been preferred because, as browsers, they were better adapted to the islands' environments. The results allow for a more accurate understanding of early caprine husbandry in the study region and provide a critical archaeological baseline for examining the potential long-term impacts of translocated fauna on island ecologies.

Moderate-intensity exercise versus high-intensity interval training to recover walking post-stroke: protocol for a randomized controlled trial.

BACKGROUND: Stroke results in neurologic impairments and aerobic deconditioning that contribute to limited walking capacity which is a major barrier post-stroke. Current exercise recommendations and stroke rehabilitation guidelines recommend moderate-intensity aerobic training post-stroke. Locomotor high-intensity interval training is a promising new strategy that has shown significantly greater improvements in aerobic fitness and motor performance than moderate-intensity aerobic training in other populations. However, the relative benefits and risks of high-intensity interval training and moderate-intensity aerobic training remain poorly understood following stroke. In this study, we hypothesize that locomotor high-intensity interval training will result in greater improvements in walking capacity than moderate-intensity aerobic training. METHODS: Using a single-blind, 3-site randomized controlled trial, 50 chronic (> 6 months) stroke survivors are randomly assigned to complete 36 locomotor training sessions of either high-intensity interval training or moderate-intensity aerobic training. Main eligibility criteria are age 40-80 years, single stroke for which the participant received treatment (experienced 6 months to 5 years prior to consent), walking speed ≤ 1.0 m/s, able to walk at least 3 min on the treadmill at ≥ 0.13 m/s (0.3 mph), stable cardiovascular condition (American Heart Association class B), and the ability to walk 10 m overground without continuous physical assistance. The primary outcome (walking capacity) and secondary outcomes (self-selected and fast gait speed, aerobic fitness, and fatigue) are assessed prior to initiating training and after 4 weeks, 8 weeks, and 12 weeks of training. DISCUSSION: This study will provide fundamental new knowledge to inform the selection of intensity and duration dosing parameters for gait recovery and optimization of aerobic training interventions in chronic stroke. Data needed to justify and design a subsequent definitive trial will also be obtained. Thus, the results of this study will inform future stroke rehabilitation guidelines on how to optimally improve walking capacity following stroke. TRIAL REGISTRATION: ClinicalTrials.gov NCT03760016 . Registered on November 30, 2018.

The construct and concurrent validity of brief standing sway assessments in children with and without cerebral palsy.

BACKGROUND: Standing postural sway is often quantified from center of pressure trajectories. During assessments of longer durations, children may fidget, thus limiting the feasibility and validity of sway recordings. RESEARCH QUESTION: Do postural sway sample durations less than 30 s maintain construct and concurrent validity? METHODS: In this case-control, observational study, we measured postural sway in 41 children (age 5-12 years, 23 typically developing (TD); 18 with spastic cerebral palsy (CP), 13 diplegic and 5 hemiplegic, 11 GMFCS level I and 7 level II) for 30-second eyes-opened and eyes-closed conditions. From a single recording, 5-second incremental durations of 5-30 s were considered in this analysis. We quantified anteroposterior, mediolateral, and transverse-plane sway using seven time-domain variables: root-mean-square error, total excursion, mean frequency, mean distance, sway area, and 95 % confidence circle and ellipse areas. Variables were calculated in eyes-opened and eyes-closed conditions, as well as the ratio of the two. Construct validity was evaluated by the persistence of large effect sizes (Glass's Δ ≥ 0.80) between CP and TD participants at shorter durations than 30 s. Concurrent validity was evaluated by the correlations of shorter duration measures to the 30 s measure. RESULTS: Seven sway measures had large between-group effects (Glass's Δ ≥ 1.02) for the 30 s measure that persisted (Glass's Δ ≥ 0.81) at shorter durations (5-25 s) and also maintained concurrent validity (r ≥ 0.83). Six of these seven measures were taken in the eyes-closed condition, and all seven measures were in the mediolateral direction or transverse plane. SIGNIFICANCE: Our analysis suggests that sway durations less than 30 s can uphold construct and concurrent validity. These measures were primarily in the eyes-closed conditions and mediolateral direction. These results are a promising indicator that shorter-duration sway measures may be of utility when fidgeting prevents longer recordings.

Learning From Those who Learned: A Survey of Fellowship Trained HoLEP Surgeons and Their Current Practice Patterns.

OBJECTIVE: To gain insight from the experience of learning Holmium laser enucleation of the prostate (HoLEP), teaching HoLEP, and the current HoLEP practice patterns of fellowship-trained endourologists. METHODS: Surveys were electronically distributed to United States (U.S.) practicing urologists who completed American Endourology fellowships (that included HoLEP) within the past 6 years. Questions focused on HoLEP training and current practice patterns. RESULTS: As of September 2019, 12% (6/49) of U.S. endourology fellowships reported including HoLEP as a component of training. With a 73% response rate (16 of 22), 81% participated in over 20 cases during training, while 50% participated in over 50. A total of 25% independently completed over 50 cases from start to finish. At training completion, most (80%) felt comfortable/somewhat comfortable completing an entire HoLEP independently and managing post-op complications. Seventy-five percent practice HoLEP currently, and 25% teach to trainees. When asked "What is most challenging about HoLEP in current practice?" common responses were: efficiency/profitability concerns, poor reimbursement, educating OR/hospital staff, establishing case volume, minimizing sphincter trauma, and large glands (>200gm). CONCLUSION: With diverse exposure in fellowship, most incorporate HoLEP into their practice after training. Aspects of the procedure remain challenging after several years of experience. Profitability/reimbursement concerns should be further explored to increase HoLEP adoption.

Readiness to Change is Related to Real-World Walking and Depressive Symptoms in Chronic Stroke.

BACKGROUND AND PURPOSE: The transtheoretical model is a health behavior model used to understand an individual's readiness to change their behavior. This study aims to apply the transtheoretical model in understanding a person with stroke's readiness to change their activity level, as it relates to physical capacity, physical health, depressive symptoms, self-efficacy, and daily stepping activity. METHODS: This was a cross-sectional analysis of baseline data from a clinical trial. Participants' readiness to change their activity levels was measured via self-report and daily stepping activity was measured using a step activity monitor. Robust regression (M-estimation with robust standard errors) was used to test the relationship between readiness to change and measures of physical capacity (6-minute walk test, self-selected walking speed), physical health (body mass index, age-adjusted Charlson Comorbidity Index), depressive symptoms (Patient Health Questionnaire-9), self-efficacy (Activities-Specific Balance Confidence Scale), and daily stepping (steps per day). RESULTS: A total of 274 individuals were included in the analysis. Adjusted for age, readiness to change was positively related to daily stepping (ß = 0.29, P < 0.001) and negatively related to depressive symptoms (ß = -0.13, P = 0.01). Readiness to change was not significantly associated with measures of physical capacity, physical health, or self-efficacy. DISCUSSION: These results suggest that individuals with stroke in the later stages of change may demonstrate greater daily stepping activity and lower depressive symptoms compared with those in earlier stages. CONCLUSIONS: Understanding the relationship between readiness to change, daily stepping, and depressive symptoms will help clinicians implement appropriate stage-specific intervention strategies and facilitate greater improvement in activity levels.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A333).

The role of laser in percutaneous surgery. Is this the best option for this approach? / Papel del láser en cirugía percutánea. ¿Es ésta la mejor opción para este procedimiento?

Holmium laser has been established asthe gold-standard for the ureteroscopic management of urinary stone disease. However the role of laser inpercutaneous nephrolithotomy (PCNL) varies, as multiple energy sources and lithotripters are available. Currently, lasers are becoming more relevant with the development of several miniaturized PCNL techniques. The purpose of this article is to review the role of laser in percutaneous renal surgery, and whether or not it is the best option for this approach. Discussion points include: the history and background of lasers in urologic surgery, PCNL and its outcomes in the literature, the positives and negatives of lasers versus other lithotripters in several different PCNL techniques, emerging laser technology such as thulium fiber laser, the use of lasers in establishing percutaneous renal access, and laser's role in non-stone percutaneous renal surgery.

El láser holmium está establecido como gold-standard en el manejo de la litiasis con ureteroscopio. El papel del láser en la nefrolitotomía percutánea varía ya que existen varios tipos de láser. El objetivo de este artículo es revisar el papel del láser en la cirugía percutánea renal para determinar si es una buena opción terapéutica. Discutiremos la historia del láser en urología, nefrolitotomía percutánea y sus resultados en la literatura, los pros y contras de los láseres vs otros litotriptores como el tulio, el uso del láser para establecer el acceso percutáneo; el papel del láser en la cirugía percutánea no-litiásica.

The role of laser in percutaneous surgery. Is this the best option for this approach? / Papel del láser en cirugía percutánea. ¿Es ésta la mejor opción para este procedimiento?

Holmium laser has been established as the gold-standard for the ureteroscopic management of urinary stone disease. However the role of laser in percutaneous nephrolithotomy (PCNL) varies, as multiple energy sources and lithotripters are available. Currently, lasers are becoming more relevant with the development of several miniaturized PCNL techniques. The purpose of this article is to review the role of laser in percutaneous renal surgery, and whether or not it is the best option for this approach. Discussion points include: the history and background of lasers in urologic surgery, PCNL and its outcomes in the literature, the positives and negatives of lasers versus other lithotripters in several different PCNL techniques, emerging laser technology such as thulium fiber laser, the use of lasers in establishing percutaneous renal access, and laser's role in non-stone percutaneous renal surgery

El láser holmium está establecido como gold-standard en el manejo de la litiasis con ureteroscopio. El papel del láser en la nefrolitotomía percutánea varía ya que existen varios tipos de láser. El objetivo de este artículo es revisar el papel del láser en la cirugía percutánea renal para determinar si es una buena opción terapéutica. Discutiremos la historia del láser en urología, nefrolitotomía percutánea y sus resultados en la literatura, los pros y contras de los láseres vs otros litotriptores como el tulio, el uso del láser para establecer el acceso percutáneo; el papel del láser en la cirugía percutánea no-litiásica

An Evaluation of Three Kinematic Methods for Gait Event Detection Compared to the Kinetic-Based 'Gold Standard'.

Video- and sensor-based gait analysis systems are rapidly emerging for use in 'real world' scenarios outside of typical instrumented motion analysis laboratories. Unlike laboratory systems, such systems do not use kinetic data from force plates, rather, gait events such as initial contact (IC) and terminal contact (TC) are estimated from video and sensor signals. There are, however, detection errors inherent in kinematic gait event detection methods (GEDM) and comparative study between classic laboratory and video/sensor-based systems is warranted. For this study, three kinematic methods: coordinate based treadmill algorithm (CBTA), shank angular velocity (SK), and foot velocity algorithm (FVA) were compared to 'gold standard' force plate methods (GS) for determining IC and TC in adults (n = 6), typically developing children (n = 5) and children with cerebral palsy (n = 6). The root mean square error (RMSE) values for CBTA, SK, and FVA were 27.22, 47.33, and 78.41 ms, respectively. On average, GED was detected earlier in CBTA and SK (CBTA: -9.54 ± 0.66 ms, SK: -33.41 ± 0.86 ms) and delayed in FVA (21.00 ± 1.96 ms). The statistical model demonstrated insensitivity to variations in group, side, and individuals. Out of three kinematic GEDMs, SK GEDM can best be used for sensor-based gait event detection.

Larger patients shouldn't have fewer options: urethroplasty is safe in the obese.

OBJECTIVE: To examine the impact of obesity on perioperative outcomes and urethral stricture recurrence after anterior urethroplasty. MATERIAL AND METHODS: We reviewed our prospectively maintained single-surgeon database to identify men with anterior urethral strictures who had undergone anastomotic or augmentation urethroplasty between October 2012 and March 2018. In all, 210 patients were included for primary analysis of perioperative outcomes, while 193 patients with at least 12 months follow-up were included for secondary analysis of stricture recurrence. Patients grouped by BMI were compared using univariate and multivariate analyses for perioperative outcomes and log rank testing for recurrence-free survival. RESULTS: Overall, 41% (n=86) of patients were obese and 58.6% (n=123) had bulbar urethral strictures. Obese patients had significantly longer urethral strictures (mean=6.7cm±4.7) than nonobese patients (p< 0.001). Though urethroplasty in obese patients was associated with increased estimated blood loss (EBL) relative to normal BMI patients on both univariate (p=0.003) and multivariate (p< 0.001) analyses, there was no difference in operative time, length of stay, or complication rate between BMI groups. At a mean follow-up interval of 36.7 months, 15% (n=29) of patients had stricture recurrence, yet recurrence-free survival was not significantly different between groups (log rank p=0.299). Dorsal augmentation urethroplasty resulted in significantly fewer recurrences in obese patients compared to nonobese patients (p=0.036). CONCLUSION: Despite the association with increased urethral stricture length and EBL, obesity is not predictive of adverse perioperative outcomes or stricture recurrence. Obese patients should be offered urethral reconstruction, but patient selection and preoperative counseling remain imperative.