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Antibiotic use can lead to the expansion of multi-drug-resistant pathobionts within the gut microbiome that can cause life-threatening infections. Selective alternatives to conventional antibiotics are in dire need. Here, we describe a Klebsiella PhageBank for the tailored design of bacteriophage cocktails to treat multi-drug-resistant Klebsiella pneumoniae. Using a transposon library in carbapenem-resistant K. pneumoniae, we identify host factors required for phage infection in major Klebsiella phage families. Leveraging the diversity of the PhageBank, we formulate phage combinations that eliminate K. pneumoniae with minimal phage resistance. Optimized cocktails selectively suppress the burden of K. pneumoniae in the mouse gut and drive the loss of key virulence factors that act as phage receptors. Phage-mediated diversification of bacterial populations in the gut leads to co-evolution of phage variants with higher virulence and broader host range. Altogether, the Klebsiella PhageBank charts a roadmap for phage therapy against a critical multidrug-resistant human pathogen., Competing Interests: Declaration of interests A patent (63/370,XXX) related to this research has been filed by The University of Chicago, with M.M. and E.R. as inventors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Although uncommon, vaginal fibroepithelial polyps can present as prolapsing vaginal tissue, causing discomfort and anxiety. Surgical excision of the polyps can provide a minimally invasive solution. In this case, we describe a nulliparous female in late adolescence who presented for evaluation of tissue protruding through the vagina. On exam, a 5×4 cm fibroepithelial polyp was extending from the distal posterior vagina on a broad stalk. Successful transperineal surgical excision was performed. Fibroepithelial polyps, although uncommon, can be a cause for prolapsing vaginal tissue and should be part of the differential diagnosis, especially in patients who have no risk factors for pelvic organ prolapse. They can be excised vaginally, alleviating symptoms and distress. Because they sometimes recur, continued surveillance with gynaecological exams is recommended., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: We aimed to understand the reasons patients choose to pursue third-line overactive bladder (OAB) therapy., Materials and Methods: We conducted a mixed methods study that included patient interviews and survey data. Eligible patients were diagnosed by symptoms, had tried behavioral modifications, and OAB medications enrolled from October 2018 to August 2019. In addition to interviews, patients completed 4 surveys: the Pelvic Floor Distress Inventory, Overactive Bladder Questionnaire Short Form, Life Orientation Test-Revised, and a patient confidence in the health care system survey. Qualitative interview data were analyzed thematically. Logistic regression and chi-square analysis was used to analyze survey data., Results: A total of 69 patients were consented, 4 withdrew, and 51 completed both interview and survey data. Overall 55% of patients were Caucasian, 45% were African American, and their average age was 71 (SD=10.4); 75% intended to pursue third-line OAB therapy and 31 (61%) expressed interest in a specific third-line therapy. Major interview themes included a desire for a better quality of life, embarrassment with accidents, and problems with medication. Themes leading patients away from third-line OAB treatment included concern about invasiveness and side effects of treatments, and restrictions to accessing care., Conclusions: Most patients desired to progress to third-line OAB therapy, were motivated by embarrassment, but were concerned about treatment side effects. We found that economic burden of OAB treatment is associated with patient interest in and decision to receive third-line therapies to include onabotulinumtoxinA and percutaneous tibial nerve stimulation. Improved quality of life, medication frustration, and concerns about side effects of further therapy are themes patients identified when patients considered third-line overactive bladder therapy.

A number of medical specialties have recently developed their own specialty-specific charters. This proliferation of charters is representative of an unease about medical professionalism that has arisen not just from increasing medical specialization, but also from evolving needs as physicians progress through their careers. The development of such specialty-specific definitions of professionalism is undesirable: all specialties should adhere to the same basic principles. These charters and "definitions" should be incorporated into a formal developmental model, derived from needs assessments from the level of medical school through the level of specialization. Such a model would provide physicians with more concrete guidance regarding professional behavior at each stage of their careers, address unmet needs in neglected areas such as mid- and late career, and help alleviate the tension associated with expressing these ideas. Incorporating concepts derived from more classic models of development may create opportunities to address the teaching of values and identify barriers to success.

Many challenges face practicing surgeons in today's medical environment. Decreasing revenues create a need for increasing patient volume. Increasing costs of malpractice insurance not only provide financial burdens, but also cause many practitioners to relocate or change the focus of their practice. Technological advancements with the rapid emergence of new procedures and medical devices tax the practicing physician's ability to keep apace of changes. These changes, in combination with increased focus on patient safety and physician competence, place even greater demands on practicing in the surgical subspecialties. In this environment, finding time to improve skills and gain competence in new procedures is a daunting task. This article addresses the topic of surgical competence, provides insight into how to learn to do and prove competence to perform new surgical procedures, as well as reviews the opportunities available for self-evaluation currently available for the practicing surgeon.