The American Association for the Surgery of Trauma Renal Grading System-Should Segmental Kidney Infarction be Classified as a Grade IV Injury?

PURPOSE: In 2018 the American Association for the Surgery of Trauma revised renal injury grading. One change was inclusion of segmental kidney infarction under grade IV injuries. We aimed to assess how segmental kidney infarction will change the scope of grade IV injuries and compare bleeding control interventions in those with and without isolated segmental kidney infarction. METHODS: We used high grade renal trauma data from 7 level 1 trauma centers from 2013 to 2018 as part of the Multi-institutional Genito-Urinary Trauma Study. Initial computerized tomography scans were reviewed to regrade the injuries. Injuries were categorized as isolated segmental kidney infarction if segmental parenchymal infarction was the only reason for inclusion under grade IV injury. All other grade IV injuries (including combined injury patterns) were categorized as without isolated segmental kidney infarction. Bleeding interventions were compared between those with and without isolated segmental kidney infarction. RESULTS: From 550 patients with high grade renal trauma and available computerized tomography, 250 (45%) were grade IV according to the 2018 American Association for the Surgery of Trauma grading system. Of these, 121 (48%) had isolated segmental kidney infarction. The majority of patients with isolated segmental kidney infarction (88%) would have been assigned a lower grade using the original 1989 grading system. Rate of bleeding control interventions was lower in isolated segmental kidney infarction compared to other grade IV injuries (7% vs 21%, p=0.002). Downgrading all patients with isolated segmental kidney infarction to grade III did not change the grading system's associations with bleeding interventions. CONCLUSIONS: Approximately half of the 2018 American Association for the Surgery of Trauma grade IV injuries have isolated segmental kidney infarction. Including isolated segmental kidney infarction in grade IV injuries increases the heterogeneity of these injuries without increasing the grading system's ability to predict bleeding interventions. In future iterations of the American Association for the Surgery of Trauma renal trauma grading isolated segmental kidney infarction could be reclassified as grade III injury.

Stereotactic body radiation therapy with simultaneous integrated boost for prostate cancer: does MRI-targeted biopsy alter the boost field?

INTRODUCTION: We aim to investigate if the addition of MRI-US fusion biopsy (FB) can aid in radiation planning and alter the boost field in cases of stereotactic body radiation therapy (SBRT) for prostate cancer with a simultaneous integrated boost (SIB) to a magnetic resonance imaging (MRI)-defined intraprostatic lesion. MATERIALS AND METHODS: Patients undergoing SBRT with SIB for biopsy-proven prostatic adenocarcinoma and a pre-radiation MRI were retrospectively reviewed. 36.25 Gy in 5 fractions was delivered to entire prostate along with SIB of 40 Gy to an MRI-defined intraprostatic lesion. Demographic, radiation planning details, and post-procedural outcomes were compared between patients undergoing systematic transrectal ultrasound (TRUS) biopsy followed by MRI to those undergoing an MRI followed by a FB prior to radiation planning. RESULTS: Forty-three patients underwent systematic TRUS biopsy followed by MRI and 46 patients underwent FB prior to radiation planning. Patients undergoing systematic TRUS biopsy had a smaller prostate volume when compared to the FB cohort (37.58 ± 13.78 versus 50.28 ± 26.76 cc, p = 0.007). No differences in prostate planning target volume (PTVprostate) and boost volume (PTVboost) were noted, but those undergoing TRUS biopsy prior to MRI had a higher integrated boost volume density (IBVD = PTVboost/total prostate volume) (0.16 ± 0.09 versus 0.13 ± 0.06, p = 0.045). No differences were observed in genitourinary or gastrointestinal toxicity rates. CONCLUSIONS: Compared to systematic TRUS biopsy, implementation of prebiopsy prostate MRI and FB allows for safe and feasible SBRT in patients with significantly larger prostate volumes without increasing SIB cancer-directed treatment volumes, oncologic outcomes, quality of life measures, or treatment-related toxicities.

Current Management of Extraperitoneal Bladder Injuries: Results from the Multi-Institutional Genito-Urinary Trauma Study (MiGUTS).

PURPOSE: We studied the current management trends for extraperitoneal bladder injuries and evaluated the use of operative repair versus catheter drainage, and the associated complications with each approach. MATERIALS AND METHODS: We prospectively collected data on bladder trauma from 20 level 1 trauma centers across the United States from 2013 to 2018. We excluded patients with intraperitoneal bladder injury and those who died within 24 hours of hospital arrival. We separated patients with extraperitoneal bladder injuries into 2 groups (catheter drainage vs operative repair) based on their initial management within the first 4 days and compared the rates of bladder injury related complications among them. Regression analyses were used to identify potential predictors of complications. RESULTS: From 323 bladder injuries we included 157 patients with extraperitoneal bladder injuries. Concomitant injuries occurred in 139 (88%) patients with pelvic fracture seen in 79%. Sixty-seven patients (43%) initially underwent operative repair for their extraperitoneal bladder injuries. The 3 most common reasons for operative repair were severity of injury or bladder neck injury (40%), injury found during laparotomy (39%) and concern for pelvic hardware contamination (28%). Significant complications were identified in 23% and 19% of the catheter drainage and operative repair groups, respectively (p=0.55). The only statistically significant predictor for complications was bladder neck or urethral injury (RR 2.69, 95% 1.21-5.97, p=0.01). CONCLUSIONS: In this large multi-institutional cohort, 43% of patients underwent surgical repair for initial management of extraperitoneal bladder injuries. We found no significant difference in complications between the initial management strategies of catheter drainage and operative repair. The most significant predictor for complications was concomitant urethral or bladder neck injury.

Correlation Between H-Index, M-Index, and Academic Rank in Urology.

OBJECTIVE: To evaluate the h- and m-indices of academic urologists across all U.S. accredited urology residency programs to determine the relationship between these metrics and an author's academic rank, academic degrees, and gender. METHODS: A total of 136 urology residency programs with available faculty information on their websites were evaluated. The academic rank, academic degrees, and gender were recorded for each clinical and research faculty member. Each author's h-index was determined using the Scopus database. The m-indices for each author were then calculated. Statistical analysis was performed using the Wilcoxon rank-sum test. RESULTS: This study demonstrated that the h- and m-indices positively correlate with an author's academic rank. Among the 2253 academic urologists evaluated, chairs/chiefs and professors had the highest median h- and m-indices (h-index 26, m-index 1.046 for chairs/chiefs; h-index 30, m-index 1.094 for professors). This was followed by associate professors (h-index 14, m-index 0.750), assistant professors (h-index 6, m-index 0.667), and clinical instructors (h-index 6, m-index 0.511). The median h- and m-indices were overall statistically higher for males than females. Faculty members with only a PhD were found to have the highest h- and m-indices followed by MD PhD, MD MBA, MD MPH, MD only, and DO only in descending order of index value. CONCLUSION: The h- and m-indices of academic urologists positively correlate with their academic rank. These metrics may serve as an additional tool in measuring an individual's academic productivity in consideration of job hirings, positional promotions, societal memberships, achievement awards, research grants, and more.

#ENT: Otolaryngology Residency Programs Create Social Media Platforms to Connect With Applicants During COVID-19 Pandemic.

OBJECTIVE: To determine which otolaryngology residency programs have social media platforms and to review which programs are utilizing platforms to advertise virtual open houses and virtual subinternships for residency applicants. STUDY DESIGN: Cross-sectional study. SETTING: The study was conducted online by reviewing all accredited otolaryngology residency programs in the United States participating in the Electronic Residency Application Service. METHODS: Otolaryngology residency programs were reviewed for social media presence on Instagram, Twitter, and Facebook. Social media posts were evaluated for virtual open houses and virtual subinternships. Residency websites and the Visiting Student Application Service were evaluated for the presence of virtual subinternships. All data were collected between September 5, 2020, and September 9, 2020. This study did not require approval from the University of Alabama at Birmingham Institutional Review Board for Human Use. RESULTS: Among 118 otolaryngology residency programs, 74 (62.7%) participate on Instagram, 52 (44.1%) participate on Twitter, and 44 (37.3%) participate on Facebook. Fifty-one Instagram accounts, 20 Twitter accounts, and 4 Facebook accounts have been created during 2020. Forty-two (36%), 30 (25.4%), and 15 (13%) programs are promoting virtual open houses on Instagram, Twitter, and Facebook, respectively. Two programs on the Visiting Student Application Service offered virtual subinternships. Seven residency program websites offered virtual subinternships. Nine, 6, and 1 program offered virtual subinternships on Instagram, Twitter, and Facebook, respectively. CONCLUSION: This study demonstrates that social media presence on Instagram and Twitter among otolaryngology residency programs has substantially grown in 2020 at a higher rate compared to previous years. These data suggest that otolaryngology residency programs are finding new ways to reach out to applicants amid an unprecedented type of application cycle due to the challenges presented by COVID-19. Many programs are advertising virtual open houses via social media platforms to connect with applicants, and a few programs are offering virtual subinternships to replace traditional subinternships.

Evaluation of the accessibility and content of urology residency websites.

Introduction: Students applying for urology residency often have limited resources for obtaining information on prospective programs. Applicants commonly rely on institutional websites to compare program elements. The information on these websites can attract or deter applicants and can have a major impact on application costs, rank lists, and career goals. The objective of this study was to determine the accessibility and content of urology residency program websites. Materials and Methods: A list of accredited urology residency programs was obtained from the American Urological Association residency directory in 2020. A total of 141 program websites were evaluated for the presence of 53 criteria, which were categorized into five groups: Personnel information, applicant information, program information, training/research, and resident benefits. Residencies lacking an available website or functional links were excluded from the study. Results: Of the 53 criteria analyzed, only 24 were featured on more than 50% of the websites. Less than 10% of the programs had available information regarding resident contact information (5.67%), alumni contact information (2.84%), frequently asked questions (9.22%), electives (9.93%), night float (5.67%), and board pass rates (5.67%). The three factors most commonly available included program description (100%), coordinator contact information (88.65%), and clinical sites (87.94%). None of the 141 programs had all 53 criteria available on their website. Conclusions: The majority of current urology residency websites may lack the accessibility and content necessary for candidates to make application decisions for desired programs. Residency programs should consider revising their websites to enhance resident recruitment and facilitate applicants' decision-making process.

External validation of a nomogram predicting risk of bleeding control interventions after high-grade renal trauma: The Multi-institutional Genito-Urinary Trauma Study.

BACKGROUND: Renal trauma grading has a limited ability to distinguish patients who will need intervention after high-grade renal trauma (HGRT). A nomogram incorporating both clinical and radiologic factors has been previously developed to predict bleeding control interventions after HGRT. We aimed to externally validate this nomogram using multicenter data from level 1 trauma centers. METHODS: We gathered data from seven level 1 trauma centers. Patients with available initial computed tomography (CT) scans were included. Each CT scan was reviewed by two radiologists blinded to the intervention data. Nomogram variables included trauma mechanism, hypotension/shock, concomitant injuries, vascular contrast extravasation (VCE), pararenal hematoma extension, and hematoma rim distance (HRD). Mixed-effect logistic regression was used to assess the associations between the predictors and bleeding intervention. The prediction accuracy of the nomogram was assessed using the area under the receiver operating characteristic curve and its 95% confidence interval (CI). RESULTS: Overall, 569 HGRT patients were included for external validation. Injury mechanism was blunt in 89%. Using initial CT scans, 14% had VCE and median HRD was 1.7 (0.9-2.6) cm. Overall, 12% underwent bleeding control interventions including 34 angioembolizations and 24 nephrectomies. In the multivariable analysis, presence of VCE was associated with a threefold increase in the odds of bleeding interventions (odds ratio, 3.06; 95% CI, 1.44-6.50). Every centimeter increase in HRD was associated with 66% increase in odds of bleeding interventions. External validation of the model provided excellent discrimination in predicting bleeding interventions with an area under the curve of 0.88 (95% CI, 0.84-0.92). CONCLUSION: Our results reinforce the importance of radiologic findings such as VCE and hematoma characteristics in predicting bleeding control interventions after renal trauma. The prediction accuracy of the proposed nomogram remains high using external data. These variables can help to better risk stratify high-grade renal injuries. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Nephrectomy After High-Grade Renal Trauma is Associated With Higher Mortality: Results From the Multi-Institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates. METHODS: We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS). RESULTS: A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P <.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55). CONCLUSION: Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage.

Examining the Correlation Between Altmetric Score and Citations in the Urology Literature.

OBJECTIVE: To determine if article Altmetric scores correlate with journal impact factor and citation count in the urologic literature. METHODS: We identified the top 10 most-cited articles for the 15 urology journals with the highest impact factor in 2013 and 2016. Citation count and Altmetric scores were recorded for each of the articles. The journal impact factor and date of Twitter account development were recorded for each of the journals. The variables were analyzed in Microsoft excel using Pearson's correlation testing. RESULTS: A total of 300 articles were analyzed. In 2013, Altmetric scores and citation number showed a significant positive correlation (r = 0.164, P = .045), although Altmetric scores did not correlate with journal impact factor (r = 0.005, P = .957). In 2016, there was significant positive correlation between Altmetric scores and citation number (r = 0.268, P = .0009), as well as between Altmetric scores and journal impact factor (r = 0.201, P = .014). The total citation count decreased from 15,235 in 2013 to 8622 in 2016 while the total Altmetric score increased from 1135 in 2013 to 2563 in 2016. Older Twitter accounts were not associated with increasing correlations between Altmetric score and bibliometrics in either 2013 (r = 0.221, P = .54) or 2016 (r = 0.083, P = .819). CONCLUSION: At this point in time, Altmetric score is only weakly correlated with citation counts in the urology literature. Altmetrics and traditional bibliometrics should be viewed as complements to one another rather than surrogates when determining research dissemination and impact.