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The application of turmeric powder as a natural product-based material for removing Hg2+ from water was demonstrated. In this study, carbon disulfide-modified turmeric (MT) was synthesized and incorporated into silica gel to create a selective sorbent (SiO2-MT). Infrared spectroscopy and energy-dispersive X-ray spectroscopy confirmed that MT was successfully incorporated into the silica gel matrix. Morphological studies revealed that SiO2-MT was porous with a pore size of 1.87 nm. SiO2-MT exhibited selectivity for the adsorption of Hg2+. The overall performance of SiO2-MT in adsorbing Hg2+ significantly improved with increasing SiO2-MT dosage, ranging from 5 to 20 mg. After reaching a dosage of 20 mg of SiO2-MT, no further significant improvement was observed. The optimal pH for Hg2+ removal ranged from four to five, with approximately 90% Hg2+ removal, and the adsorption process reached equilibrium at 180 min. The adsorption data were well-fitted to the Langmuir isotherm and pseudo-second-order kinetics models, indicating that SiO2-MT adsorbed Hg2+ through monolayer adsorption and chemisorption. The maximum adsorption capacity of the synthesized SiO2-MT was 37.6 mg g−1, which is higher than that of other reported biomasses, including bamboo leaves and garlic powder. In conclusion, this study demonstrates the potential use of turmeric powder, a natural product, for effective Hg2+ removal during water treatment. [ABSTRACT FROM AUTHOR]

Rubber producers, consumers, traders, and those who are involved in the rubber industry face major risks of rubber price fluctuations. As a result, decision-makers are required to make an accurate estimation of the price of rubber. This paper aims to propose hybrid intelligent models, which can be utilized to forecast the price of rubber in Malaysia by employing monthly Malaysia's rubber pricing data, spanning from January 2016 to March 2021. The projected hybrid model consists of different algorithms with the symbolic Radial Basis Functions Neural Network k-Satisfiability Logic Mining (RBFNN-kSAT). These algorithms, including GreyWolf Optimization Algorithm, Artificial Bee Colony Algorithm, and Particle Swarm Optimization Algorithm were utilized in the forecasting data analysis. Several factors, which affect the monthly price of rubber, such as rubber production, total exports of rubber, total imports of rubber, stocks of rubber, currency exchange rate, and crude oil prices were also considered in the analysis. To evaluate the results of the introduced model, a comparison has been conducted for each model to identify the most optimum model for forecasting the price of rubber. The findings showed that GWO with RBFNN-kSAT represents the most accurate and efficient model compared with ABC with RBFNNkSAT and PSO with RBFNN-kSAT in forecasting the price of rubber. The GWOwithRBFNN-kSAT obtained the greatest average accuracy (92%), with a better correlation coefficient R = 0.983871 than ABC with RBFNN-kSAT and PSO with RBFNN-kSAT. Furthermore, the empirical results of this study provided several directions for policymakers to make the right decision in terms of devising proper measures in the industry to address frequent price changes so that the Malaysian rubber industry maintains dominance in the international markets. [ABSTRACT FROM AUTHOR]

Neuroprotective factors are essential to successful ageing. As such, digital device use was proposed as an easily accessible and stimulating available cognitive activity to enhance brain function. Nonetheless, there was a lack of studies inspecting the connection between digital device use and cognitive reserve, the risk of cognitive impairment, and cognition. This study aims to investigate the potential mediator and moderator of the association between digital device use, cognitive reserve, the risk of cognitive impairment, and cognition among healthy older adults. A quantitative cross-sectional study was conducted to investigate the relationship between digital device use and cognitive reserve, the risk of cognitive impairment, and cognition. A total of 210 healthy older adults were recruited through purposive sampling. The results obtained from this study revealed that there was a significant difference in cognitive reserve and cognition between healthy older adults who use a digital device for communication purpose only and who use a digital device for multiple purposes. A significant relationship was also found between cognitive reserve, the risk of cognitive impairment, and cognition. Although digital device use was found to be significantly associated with cognitive reserve and cognition, it was not significantly associated with the risk of cognitive impairment. Cognitive reserve partially mediated the relationship between digital device use and cognition, supporting the notion that cognitive reserve acts as an underlying mechanism in the relationship between digital device use and cognition. Hence, digital device use was suggested to be a good daily intervention for healthy older adults to build on their cognitive reserve and potentially protect their cognition from declining. Nevertheless, relying on digital device use alone is not sufficient, and other activities should be explored to enhance cognitive reserve among healthy older adults.

Remote vehicle operators (RVO) work in a sensory-deprived environment. A reduction or absence of sensory cueing like auditory feedback, combined with variable workload, has been attributed to a number of remotely piloted aircraft (RPA) accidents. Therefore, this research sought to understand the relationship between workload and dynamic auditory feedback on RVO task performance. Twenty-four participants completed a counterbalanced series of decision-making (spatial orientation accuracy) and perception (spotting accuracy) tasks in an automated beyond visual line of sight environment, under varying workload and auditory volume levels. The management style employed by participants in dealing with the auditory information was also measured and compared with decision-making performance. A relative decline in spatial orientation accuracy was evident when auditory feedback was considered “soft” or “loud” (±10 dBA) compared with a participant-defined comfortable volume level, but contingent on an adequate level of workload experienced concurrently. From an applied perspective, these findings support the inclusion of adaptive auditory systems in future Remotely Piloted Aircraft Systems (RPAS) designs.

Purpose/objective(s): The Anatomy and Radiology Contouring (ARC) Bootcamp was a three-day in-person course providing integrated radiology, anatomy, and contouring education for radiation oncology (RO) residents and medical physicists. The course consisted of didactic radiology and contouring lectures, small group anatomy sessions using cadaveric prosections, and real-time contouring using commercial software. Acknowledging the importance of increasing access to the Bootcamp, we launched an online (ONL) version of the ARC Bootcamp in November 2019. We evaluated the ONL course's impact on participants' knowledge acquisition, contouring skills, and self-confidence by comparing it to the face-to-face (F2F) course.Materials/methods: The F2F Bootcamp was adapted into an ONL version using the Teachable platform (teachable.com). The ONL course was structured in a linear progression of locked modules to offer similar content to the F2F comparator. Participants from the 2019 F2F and the 2019-2020 ONL Bootcamp provided consent for the study and completed pre-and post-intervention evaluations, which assessed anatomy/radiology knowledge, contouring skills, anatomy/radiology knowledge and contouring self-confidence, and course satisfaction.Results: Fifty-seven (F2F: n = 30; ONL: n = 27) participants completed both evaluations. The ONL course had a substantially wider geographic participation, with participants from 19 countries (vs. 4 countries in the F2F course) completing the pre-evaluation. F2F had primarily RO resident participation (80%) compared to ONL (41%). In the ONL course, most were from a different field (52%), including medical physics residents or medical students. Compared to baseline self-assessments, both cohorts demonstrated similar self-confidence improvements with their anatomy knowledge, contouring skills, and in interpreting radiology images (all P < 0.001). In the anatomy/radiology knowledge testing, the ONL group showed improvement (mean improvement ± SD: 4.6 ± 6.3 on a 40-point scale; P < 0.001) but the F2F group did not (1.6 ± 5.6; P = 0.159). The F2F group demonstrated improvement with the contouring assessment (mean ± SD: 0.10 ± 0.17 on a 1-point Dice scale; P = 0.004), whereas only a trend was found for the ONL group (0.07 ± 0.16; P = 0.076). Both cohorts perceived the course as a positive learning experience (F2F: 4.8 ± 0.4 on a 5-point scale; ONL: 4.5 ± 0.6) and stated it will improve their professional practice (F2F: 4.6 ± 0.5 on a 5-point scale; ONL: 4.2 ± 0.8). Both groups would recommend the course to others (F2F: 4.8 ± 0.4 on a 5-point scale; ONL: 4.4 ± 0.6).Conclusion: The ONL ARC Bootcamp achieved similar results as the F2F version, with improved self-confidence, knowledge scores, and high satisfaction levels among participants. The ONL course is more accessible to diverse geographic regions and disciplines, allows for ongoing education during the COVID-19 pandemic, and can be used as a framework to develop other online educational interventions in radiation oncology. [ABSTRACT FROM AUTHOR]

Introduction:  Primary preventative medicine lacks a consensus on effective concussion prevention strategies for collegiate athletes. Cervical strength has been identified as a potential factor in concussion risk reduction. This study evaluates the impact of a commercially available, portable cervical muscle stretching and strengthening device, NeckX®, on cervical strength, range of motion (ROM), and concussion incidence in collegiate athletes participating in high-concussion-risk sports., Methods:  A single-arm prospective cohort study was conducted with 162 collegiate athletes from various sports. Participants underwent a 12-week neck exercise protocol using the NeckX® device. Clinical data, including neck strength and ROM, were collected at weeks 0, 6, and 12. Concussion incidence was self-reported by participants and cross-referenced with records from the athletic department. Data were analyzed for significant neck strength and ROM changes throughout the 12-week study. A two-way analysis of variance multiple comparisons with the Tukey-Kramer significant difference test was utilized, using the Holm-Sidak method, with an alpha of 0.05., Results:  All athletic teams experienced a significant increase in cervical strength during the 12-week intervention (α = 0.05, p < 0.05). Increases in cervical flexion and extension force were most consistent between teams. Cervical ROM increased significantly in male and female soccer players (α = 0.05, p < 0.05). The overall incidence of head and neck injuries, including concussions, was reduced to 6.60% during the study period, the lowest recorded value in the university's athletic department history., Conclusion:  The use of the NeckX® device for 12 weeks was effective in enhancing pericervical muscle strength and ROM while reducing concussion incidence in collegiate athletes participating in high-concussion-risk sports. Interestingly, the positive outcomes were consistent for both males and females, indicating the universal advantages of neck training among collegiate athletes. These findings support existing research on the benefits of cervical strengthening exercises for reducing concussions in collegiate athletes and highlight the convenience and affordability of using this device., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Mercyhurst University Institutional Review Board issued approval 00018003. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Intellectual property info: Devices used in this research include the NeckX® device (NeckX® LLC, Aspen, CO), Activ5® dynamometer (Activbody, Inc., San Diego, CA), and Halo digital goniometer (Halo Medical Devices, LLC, Sydney, Australia). No financial compensation was provided for the use of any device. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Klein et al.)

Objective: To evaluate plaintiff and defendant characteristics associated with iatrogenic genitourinary (GU) trauma litigation and outcomes of closed claims., Methods: LexisNexis was queried in April 2023 using terms related to GU organs and injury, and manually reviewed for iatrogenic cases. Case details including defendant, organ involvement, and legal outcome were obtained. Multinomial regression analysis was performed to identify factors associated with outcome., Results: Four hundred ten cases involving 611 defendants were identified, with the ureter the most commonly affected organ (202/410, 49.3%). Most cases involved adult plaintiffs (380, 92.7%) and resulted in favor of the defense (227, 55.4%). Injuries resulted most frequently from gynecologic surgeries (179, 43.7%). Defendants were most commonly obstetricians/gynecologists (243/611, 39.8%) and urologists (168, 27.5%). Penile (OR 6.3 [95% CI 2.5-16.1]) and urethral (OR 4.8 [2.0-11.7]) injuries were associated with greater odds of a plaintiff verdict relative to ureter injury. A plaintiff verdict was also more likely when defendants were academic hospitals compared to individual practitioners (OR 4.3 [1.9-9.9]). In cases ruling in favor of the plaintiff, indemnity payments were larger when the defendants were comprised of individual practitioners compared to a hospital or medical group (median $549,613 vs $250,000, P <.001)., Conclusion: Urologists may be involved in medical malpractice lawsuits for iatrogenic injury even when they are uninvolved in the index procedure. Most cases that reach litigation result in defense verdicts regardless of the GU organ injured. Defendant characteristics associated with plaintiff verdicts are more nuanced, and providers should be aware of potential downstream effects of litigation., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

The American Urological Association and Endocrine Society published guidelines for the management of testosterone deficiency in 2018. Testosterone prescription patterns have varied widely recently, owing to increased public interest and emerging data on the safety of testosterone therapy. The effect of guideline publication on testosterone prescribing is unknown. Thus, we aimed to assess testosterone prescription trends using Medicare prescriber data. Specialties with over 100 testosterone prescribers from 2016-2019 were analyzed. Nine specialties were included (in order of descending prescription frequency): family practice, internal medicine, urology, endocrinology, nurse practitioners, physician assistants, general practice, infectious disease, and emergency medicine. The number of prescribers grew by a mean of 8.8% annually. There was a significant increase in average claims per provider from 2016 to 2019 (26.4 to 28.7, p < 0.0001), with the steepest increase occurring between 2017 and 2018 when the guidelines were released (27.2 to 28.1, p = 0.015). The largest increase in claims per provider was among urologists. Advanced practice providers comprised 7.5% of Medicare testosterone claims in 2016 and 11.6% in 2019. While no causation can be established, these results suggest that professional society guidelines are associated with increasing numbers of testosterone claims per provider, especially among urologists. The changing demographics of prescribers justifies targeted education and further research., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

With the budding interest in testosterone therapy (TTh), online health information plays a significant role in patients' health care decisions. Therefore, we evaluated the source and readability of web-based information available to patients regarding TTh on Google. From Google search terms "Testosterone Therapy" and "Testosterone Replacement", 77 unique sources were identified. Sources were categorized as Academic, Commercial, Institutional, or Patient Support, then evaluated using validated readability and English language text assessment tools: the Flesch Reading Ease score, Flesch Kincade, Gunning Fog, Simple Measure of Gobbledygook (SMOG), Coleman-Liau Index and Automated Readability index. The average grade level for understanding academic sources was 16 (college senior); commercial, institutional, and patient support sources were 13 (college freshman); 8 and 5 grade levels, respectively, above the average U.S. adult. Patient support sources were most prevalent, while commercial sources were the least at 35 and 14%, respectively. The average reading ease score was 36.8, indicative of difficult-to-read material overall. These results indicate that the most immediate online sources for TTh information exceed the average reading level of most adults within the U.S., hence more effort should be taken to publish accessible and readable material to improve patient health literacy., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Objective: To assess efficacy, comfort, and symptoms of a novel ureteral stent (RELIEF) substituting the distal semirigid coil of a traditional double-J for a floating, monofilament tether allowing coaptation of the ureteral orifice. Ureteral instrumentation notoriously cause discomfort, urgency, frequency, dysuria, and hematuria; prolonged morbidity is likely related to stent-associated vesicoureteral reflux (VUR). We hypothesized this design would eliminate VUR, be safe and provide comfort following intervention., Methods: Twenty-eight patients within a single institution were enrolled. Passive cystography was performed pre- and post-stent placement assessing VUR. Patients completed Ureteric Stent Symptoms Questionnaires (USSQ) before placement (baseline), postop day 1, and day of removal., Results: Twenty RELIEF stents were placed (11 female and 9 male). 95% demonstrated no VUR following placement. No unexpected adverse complications occurred; 1 patient opted for early stent removal for significant discomfort. Average total USSQ scores demonstrated statistically significant improvement between first and third surveys (P < .001). Statistically significant improvement in body pain, general health, and work performance scores were noted as well (P < .05)., Conclusion: The RELIEF stent eliminates VUR with similar stent-related morbidity and overall well-tolerance. RELIEF-associated USSQ scores were below published mean symptom scores for standard double-J stents and appear safe in this preliminary clinical trial., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The objective of this study was to explore the frequency of occurrence of extra-renal manifestations associated with monogenic nephrolithiasis., Methods: A literature review was conducted to identify genes that are monogenic causes of nephrolithiasis. The Online Mendelian Inheritance in Man (OMIM) database was used to identify associated diseases and their properties. Disease phenotypes were ascertained using OMIM clinical synopses and sorted into 24 different phenotype categories as classified in OMIM. Disease phenotypes caused by the same gene were merged into a phenotypic profile of a gene (PPG) such that one PPG encompasses all related disease phenotypes for a specific gene. The total number of PPGs involving each phenotype category was measured, and the median phenotype category was determined. Phenotype categories were classified as overrepresented or underrepresented if the number of PPGs involving them was higher or lower than the median, respectively. Chi-square test was conducted to determine whether the number of PPGs affecting a given category significantly deviated from the median., Results: Fifty-five genes were identified as monogenic causes of nephrolithiasis. A total of six significantly overrepresented and three significantly underrepresented phenotype categories were identified (p < 0.05). Four phenotypic categories (growth, neurological, skeletal, and abdomen/gastrointestinal) are significantly overrepresented after Bonferroni correction for multiple comparisons (p < 0.002). Among all phenotypes, impaired growth is the most common manifestation., Conclusion: Recognizing the extra-renal manifestations associated with monogenic causes of kidney stones is critical for earlier diagnosis and optimal care in patients., (© 2023. The Author(s), under exclusive licence to International Pediatric Nephrology Association.)

Aim: To compare the effectiveness and safety of pharmacological thrombolysis and mechanical thrombectomy., Material and Methods: This review was conducted in accordance with the PRISMA guidelines. Pooled proportions and subgroup analysis were calculated for primary and secondary patency rates, technical success, clinical success, major and minor complications rates., Results: This systematic review identified a total of 6,492 studies of which 17 studies were included for analysis. A total of 1,089 patients comprising 451 (41.4 %) and 638 (58.6 %) patients who underwent thrombolysis and mechanical thrombectomy procedures, respectively, were analysed. No significant differences were observed between thrombolysis and mechanical thrombectomy procedures in terms of technical success, clinical success, major and minor complications rates, primary and secondary patency rates; however, subgroup analysis of overall arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) demonstrated a significantly higher rate of major complications within the AVF group (p=0.0248)., Conclusion: The present meta-analysis suggests that pharmacological thrombolysis and mechanical thrombectomy procedures are similarly effective and safe; however, AVFs are subject to higher major complications compared to AVGs., (Copyright © 2024 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Introduction: Chronic refractory breathlessness is a debilitating symptom which negatively affects quality of life with profound impact on physical and psychosocial functioning of patients and/or carers. Multidisciplinary based interventions which focus on non-pharmacological approach have shown to be effective. We developed a breathlessness intervention service called breathlessness supportive therapy (BST) in a palliative care unit with limited resources. The aim is to evaluate the feasibility of developing a BST service and to study the characteristics and outcome of patients with chronic refractory breathlessness., Materials and Methods: This is a retrospective study of patients with chronic refractory breathlessness and Modified Medical Research Council (mMRC) dyspnoea scale grade ≥ 2 who attended the BST clinic over 1 year period. BST consists of two clinic sessions 2 weeks apart. Data was retrieved from patients' medical notes and analysis done using Microsoft Excel., Results: A total of 21 patients were identified. Median age was 69 years with 52% of females. 72% had non-malignant diagnoses. Median Charlson's Comorbidity Index score was 6.5. Median mMRC dyspnoea scale was 3. 47.6% had long term oxygen usage. Median Australian Karnofsky Performance Scale (AKPS) was 65 and the median baseline breathlessness visual analogue scale (VAS) was 2. 62% completed two sessions, the remaining 38% completed only one session. Mean time from BST intervention to death was 18.26 weeks, median was 22 weeks. 72% died at home, whilst 28% died in the hospital. All the patients scored 4 (somewhat agree) and 5 (strongly agree) on the overall feedback score., Conclusions: Development of a breathlessness intervention service is feasible in a resource limited setting and generally accepted by most patients. More research and prospective studies are needed to evaluate the effectiveness of BST in the future.

Due to the historic lack of transparency in healthcare pricing in the United States, the degree of price variation for vasectomy is largely unknown. Our study aims to assess characteristics of hospitals reporting prices for vasectomy as well as price variation associated with hospital factors and insurance status. A cross-sectional analysis was performed in October, 2022 using the Turquoise Database which compiles publicly available hospital pricing data. The database was queried for vasectomy prices to identify the cash (paid by patients not using insurance), commercial (negotiated by private insurers) and Medicare and Medicaid prices for vasectomies. Hospital characteristics of those that reported a price for vasectomy and those that did not were compared and pricing differences based on hospital ownership and reimbursement source were determined using multivariable linear regression analysis. Overall, only 24.7% (1657/6700) of hospitals reported a price for vasectomy. Those that reported a price had more beds (median 117 vs 80, p < 0.001), more physicians (median 1745 vs 1275, p < 0.001). They were also more likely to be nonprofit hospitals (77% vs 14%, p < 0.001) and to be in well-resourced areas (ADI 91.7 vs 94.4, p < 0.001). Both commercial prices and cash prices for vasectomy were lower at nonprofit hospitals than at for-profit hospitals (commercial: $1959.47 vs $2861.56, p < 0.001; cash: $1429.74 vs $3185.37, p < 0.001). Our study highlights the current state of pricing transparency for vasectomy in the United States. Patients may be counseled to consider seeking vasectomy at a nonprofit hospital to reduce their costs, especially when paying with cash. These findings also suggest a need for new policies to target areas with decreased price transparency to reduce price disparities., (© 2024. The Author(s).)

Objective: Current literature demonstrates low rates of compliance with postvasectomy semen analysis (PVSA). This study sought to determine factors that correlate with noncompliance with PVSA., Methods: A retrospective chart review was conducted for patients who underwent vasectomy within our institution. ArcGIS was used to securely calculate the shortest driving time from each patient's home to the single PVSA drop-off site. Kruskal-Wallis and chi-square tests analyzed characteristics of patients who did and did not submit PVSA samples, and odds ratios were calculated via multivariable logistic regression., Results: Overall, 515 of 850 patients met inclusion criteria and 219 (42.5%) of these had no recorded PVSA. Of those with a PVSA, 59% were completed within 16 weeks. Compliance with PVSA was associated with a shorter median driving time (30.6 minutes vs 34.2 minutes), more vasectomy in the operating room (19% vs 10%), and attending a follow-up appointment (40% vs 17%) (P < .005 for all). Age at vasectomy, race, ethnicity, BMI, paternity, and location of preoperative consultation did not significantly differ between the groups. Each 30 minutes of driving time was associated with a 48% reduction in the odds of a patient submitting PVSA at any time (OR 0.52 [0.37, 0.73])., Conclusion: As driving time to a drop-off center appears to be a significant barrier to PVSA compliance, providers should consider alternative collection methods such as at-home or in-office semen analysis., Competing Interests: Declaration of Competing Interest The authors have no relevant conflicts of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Context: Whole-gland ablation is a feasible and effective minimally invasive treatment for localized prostate cancer (PCa). Previous systematic reviews supported evidence for favorable functional outcomes, but oncological outcomes were inconclusive owing to limited follow-up., Objective: To evaluate the real-world data on the mid- to long-term oncological and functional outcomes of whole-gland cryoablation and high-intensity focused ultrasound (HIFU) in patients with clinically localized PCa, and to provide expert recommendations and commentary on these findings., Evidence Acquisition: We performed a systematic review of PubMed, Embase, and Cochrane Library publications through February 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. As endpoints, baseline clinical characteristics, and oncological and functional outcomes were assessed. To estimate the pooled prevalence of oncological, functional, and toxicity outcomes, and to quantify and explain the heterogeneity, random-effect meta-analyses and meta-regression analyses were performed., Evidence Synthesis: Twenty-nine studies were identified, including 14 on cryoablation and 15 on HIFU with a median follow-up of 72 mo. Most of the studies were retrospective (n = 23), with IDEAL (idea, development, exploration, assessment, and long-term study) stage 2b (n = 20) being most common. Biochemical recurrence-free survival, cancer-specific survival, overall survival, recurrence-free survival, and metastasis-free survival rates at 10 yr were 58%, 96%, 63%, 71-79%, and 84%, respectively. Erectile function was preserved in 37% of cases, and overall pad-free continence was achieved in 96% of cases, with a 1-yr rate of 97.4-98.8%. The rates of stricture, urinary retention, urinary tract infection, rectourethral fistula, and sepsis were observed to be 11%, 9.5%, 8%, 0.7%, and 0.8%, respectively., Conclusions: The mid- to long-term real-world data, and the safety profiles of cryoablation and HIFU are sound to support and be offered as primary treatment for appropriate patients with localized PCa. When compared with other existing treatment modalities for PCa, these ablative therapies provide nearly equivalent intermediate- to long-term oncological and toxicity outcomes, as well as excellent pad-free continence rates in the primary setting. This real-world clinical evidence provides long-term oncological and functional outcomes that enhance shared decision-making when balancing risks and expected outcomes that reflect patient preferences and values., Patient Summary: Cryoablation and high-intensity focused ultrasound are minimally invasive treatments available to selectively treat localized prostate cancer, considering their nearly comparable intermediate- to long term cancer control and preservation of urinary continence to other radical treatments in the primary setting. However, a well-informed decision should be made based on one's values and preferences., (Published by Elsevier B.V.)

Objective: To assess the feasibility and safety of delayed primary closure (DPC) in Fournier's gangrene (FG) patients with large genital defects., Methods: A single institution retrospective review was performed from October 2020 to December 2022 of adult males that underwent DPC for FG. All patients underwent standard medical management and were assessed for DPC eligibility by the urology service. Clinical data on patient factors and outcomes were collected, and descriptive statistics were assessed., Results: Of 16 patients that underwent DPC, the average age was 61.1years and body mass index was 34.6 kg/m 2 . Median Charlson Comorbidity Index was 3.5 (IQR 2-5.3) and Fournier's Gangrene Severity Index was 6.5 (IQR 4.8-8). Median number of debridements was 2.5 (IQR 2-3), with a time to closure of 6.5days (IQR 3-11) and length of stay of 13days (IQR 9-16.3). Mean genital defect size was 119 cm 2 (range 44-346 cm 2 ). Eight patients (50%) were closed using scrotal flaps alone while other patients had advancement flaps using the inner thigh, lower abdomen, and perineum. The majority of patients were discharged home directly (63%). There were four Clavien-Dindo III complications: two partial flap necrosis, one wound dehiscence, and one instance of bleeding. Of patients with follow-up, 6/15 (40.0%) had no known complications., Conclusion: DPC is safe and effective for a range of patients presenting with FG. Patients with large defects may benefit from less complex wound management and direct discharge home., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS., Methods: The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated., Results: A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains., Conclusion: Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms., (© 2023 ARS-AAOA, LLC.)

Background: Current techniques to evaluate computed tomography (CT) foot perfusion in patients with critical limb ischemia use high contrast doses and cannot be used during endovascular procedures. CT perfusion of the foot with intra-arterial contrast injection during endovascular treatment in a hybrid angiography CT suite might solve these problems., Purpose: The main objective of this study was to evaluate whether intra-arterial CT foot perfusion using a hybrid CT angiosystem is feasible during endovascular treatment for critical limb ischemia., Material and Methods: This prospective pilot study investigated intraprocedural, intra-arterial CT perfusion of the foot using a hybrid CT angiosystem in 12 patients before and after endovascular treatment for critical limb ischemia. Time to peak (TTP) and arterial blood flow were measured before and after treatment and compared using a paired t test., Results: All 24 CT perfusion maps could be calculated adequately. The contrast volume used for one perfusion CT scan was 4.8 ml. The mean TTP before treatment was 12.8 seconds (standard deviation [SD] 2.8) and the mean TTP posttreatment was 8.4 seconds (SD 1.7), this difference being statistically significant ( p =.001). Tendency toward increased blood flow after treatment, 340 ml/min/100 ml (SD 174) vs 514 ml/min/100 ml (SD 366) was noticed ( p =.104). The mean effective radiation dose was 0.145 mSv per scan., Conclusion: Computed tomography perfusion of the foot with low contrast dose intra-arterial contrast injection during endovascular treatment in a hybrid angiography CT suite is a feasible technique., Clinical Impact: Intra-arterial CT foot perfusion using a hybrid CT-angiography system is a feasible new technique during endovascular therapy for critical limb ischemia to assess the results of the treament. Future research is necessary in defining endpoints of endovascular treatment and establishing its role in limb salvage prognostication.

Objective: To describe the outcomes of Same-Day Discharge (SDD) following Holmium Laser Enucleation of the Prostate (HoLEP) in patients during the COVID-19 pandemic., Methods: A retrospective review of HoLEP surgeries at a single institution between January 2021 and March 2022 was performed. Patient demographic and operative data were collected, and postoperative outcomes were evaluated in terms of safety and efficacy and compared in both groups using a t-test and chi-square test. Logistic regression was also performed to identify factors that correlate with the failure of SDD., Results: A total of 155 patients were identified; 135 patients were successfully discharged on the same day and 20 were admitted (87% SDD rate). Admitted HoLEP patients had a significantly higher median prostate-specific antigen (5.7 vs 3.9 ng/dL, P < 0.001), prostate volume (152.3 vs 100.6 mL, P < 0.001), and enucleated tissue weight (90.3 vs 56.9 g, P = 0.04) compared to the SDD group. The SDD group had a 2.9% (n = 4) readmission rate and a 5.2% (n = 7) Emergency Department (ED) visit rate. There was no significant difference in the rate of postoperative ED visits (P = 0.64), readmissions (P = 0.98), complications, and catheterization time (P = 0.98) between both groups. Preoperative predictors of SDD failure included prostate gland volume > 150 mL (OR = 7.17; CI 2.01-25.67; P < 0.01) and history of antiplatelet/anticoagulation use (OR = 6.59; CI 2.00-21.67; P < 0.01)., Conclusion: Same-day discharge following HoLEP is a safe and effective approach that can be performed in most patients using a liberal discharge criteria and relying on postoperative findings only., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: The aim of this study was to report the incidence and clinical course of a series of patients who were misdiagnosed with Bell's palsy and were eventually proven to have occult neoplasms., Methods: Two hundred forty patients with unilateral facial paralysis who were assessed at the facial nerve reanimation clinic, Victoria Hospital, London Health Science Centre, from 2008 through 2017 were reviewed. Persistent paralysis without recovery was the presenting complaint., Results: Nine patients (3.8%) who were proven to have occult neoplasms initially presented with a diagnosis of Bell's palsy. The mean diagnostic delay was 43.5 months. Four patients were proven to have skin cancers, 3 patients had parotid cancers, and 2 patients had facial nerve schwannomas as a final diagnosis. Initial magnetic resonance imaging (MRI) was performed in all 9 patients and 8 underwent a follow-up MRI. An occult tumor was identified upon review of the original MRI in one patient and at follow-up MRI in 8 patients. The mean time interval between the initial and follow-up imaging was 30.8 months. The disease status at most recent follow-up were no evidence of disease in 2 patients (22%) and alive with disease in 7 patients (78%). An irreversible, progressive pattern of facial paralysis combined with pain, multiple cranial neuropathies or history of skin cancer were predictable risk factors for occult tumors. Seven out of the 9 patients (77.8%) underwent at least one type of facial reanimation surgery, and the final subjective results by the surgeon were available for 5 patients. Three out of the 5 (60%) patients who were available for final subjective analysis were reported as Grade III according to the modified House-Brackmann scale., Conclusion: Occult facial nerve neoplasm should be suspected in patients with progressive and irreversible facial paralysis but the diagnosis may only become evident with follow-up imaging. Facial reanimation surgery is a satisfactory option for these patients., (© 2022. The Author(s).)

Purpose: To evaluate the role of metformin on thyroid cancer risk in patients with acromegaly., Methods: Medical charts of 534 patients with acromegaly that were followed-up between 1983 and 2019 were reviewed. Patients with follow-up duration at least 6 months were included. Cohort entry was defined as first visit date. The date of each case's thyroid cancer diagnosis was defined as index date. Patients were followed until the index date, death, or last visit date, whichever came first. Nested case-control study design was selected to evaluate the association between metformin and the thyroid cancer risk in patients with acromegaly., Results: 291 patients with acromegaly were included into final analysis. The mean age at acromegaly diagnosis was 42.3 ± 1.3 years. The median follow-up duration was 76 [34-132] months. Among 291 patients, 13 patients (4.5%) had thyroid cancer. Thirty-one percent (n = 92) of the patients used metformin for 6 months or longer. One standard deviation (SD) increase in average growth hormone increased the odds of having thyroid cancer by 1.164 folds (p = 0.017). One SD increase of the average insulin-like growth factor 1 to upper limit of normal ratio increased the odds of having thyroid cancer by 1.201 folds (p = 0.004). If a patient used metformin for at least 6 months, the odds to have thyroid cancer was decreased, multiplied by 0.62 with a 95% confidence interval of [0.47, 0.83] (p = 0.0013). The risk of thyroid cancer decreased with increasing duration of metformin use., Conclusion: Metformin may decrease the thyroid cancer risk in patients with acromegaly., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction: COVID-19 has forever impacted health care in the U.S. Changes to health and hospital policies led to disruptions to both patient care and medical training. There is limited understanding of the impact on urology resident training across the U.S. Our aim was to examine trends in urological procedures, as captured by the Accreditation Council for Graduate Medical Education resident case logs, throughout the COVID-19 pandemic., Methods: Retrospective review of publicly available urology resident case logs between July 2015 and June 2021 was performed. Average case numbers were analyzed via linear regression with different models specifying different assumptions regarding the impact of COVID-19 on procedure in 2020 and onward. Statistical calculations utilized R (version 4.0.2)., Results: Analysis favored models which assumed the impact of COVID-related disruptions were specific to 2019-2020. Analysis of procedures performed indicate an average upward trend of urology cases nationally. An average annual increase of 26 procedures between 2016 and 2021 was noted, except for 2020 which saw an average drop of approximately 67 cases. However, in 2021 case volume dramatically increased to the same rate as projected had there not been a disruption in 2020. Stratifying by category of urology procedure revealed evidence for variability between categories in the magnitude of the 2020 decrease., Conclusions: Despite widespread pandemic-related disruptions in surgical care, urological volume has rebounded and increased, likely having minimal detriment to urological training over time. Urological care is essential and in high demand as evidenced by the uptick in volume across the U.S.

Aim: To examine the relationship between catheter tip location and catheter dysfunction in the context of tunnelled central venous catheters (CVCs) for haemodialysis., Materials and Methods: This was a retrospective study of 993 haemodialysis patients who underwent insertion of tunnelled CVCs of step-tip design via the right internal jugular vein (IJV). Based on intra-procedural radiographs, the catheter tip was characterised as being in the superior vena cava (SVC), cavo-atrial junction (CAJ), or deep right atrium (DRA). Patients were tracked for 90 days post-procedure for complications resulting in catheter replacement, and these were compared between cohorts. Statistical analysis was performed with Pearson's chi-square and Fisher's exact tests for categorical variables and two-sample t-test and one-way analysis of variance (ANOVA) for continuous variables., Results: Ninety-five patients (9.6%) experienced catheter dysfunction necessitating replacement within 90 days of insertion. Tip location in SVC was associated with lower occurrence of catheter dysfunction (1.9%) as compared with the CAJ (8%) and DRA (11%; p=0.049). Catheter replacement due to other complications (catheter-associated bacteraemia, cuff dislodgement, exit-site infection, external catheter damage) showed no statistically significant relation to location of the CVC tip., Conclusion: When utilising tunnelled CVCs with a step-tip design inserted via the right IJV, location of the catheter tip in the SVC is associated with reduced occurrence of catheter dysfunction as compared to either the CAJ or DRA., (Copyright © 2022 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Introduction: Procedural specialties are at higher risk for malpractice claims than non-procedural specialties. Previous studies have examined common damages and malpractice lawsuits resulting from specific procedures. Our goal was to analyze urological interventions that led to sexual dysfunction (SD) claims., Methods: The Casetext legal research platform was queried using search terms for medical malpractice and common men's health procedures between 1993 and 2020. In total, 236 cases were found, and 21 cases met the inclusion criteria: malpractice cases against a urologist or urology group, clearly stated legal outcome, and allegation of sexual dysfunction from an intervention that directly caused damages., Results: A total of 42 damages were cited in 21 lawsuits. The top three damages claimed were erectile dysfunction (ED) (14/42, 33.3%), genital pain syndrome (7/42, 16.7%), and urinary incontinence (5/42, 11.9%). The most commonly cited treatments were urinary catheter placement or removal (3/21, 14.3%), robotic-assisted laparoscopic radical prostatectomy (RALP) (3/21, 14.3%), circumcision (3/21, 14.3%), and penile implant (3/21, 14.3%). In 19 of 21 suits (90.4%), the outcome favored the defendant. Two cases favored the plaintiff: penile implant (failure to prove the patient was permanently, organically impotent prior to the procedure; missed urethral injury at time of surgery, $300 000) and vasectomy (damage to vasculature resulting in loss of testicle, $300 000)., Conclusions: Most suspected malpractice cases resulting in SD favored the defendant urologist. Interestingly, urinary catheter placement is as likely to result in litigation as other operative interventions, such as RALP, inflatable penile prosthesis, and circumcision. It is possible that thorough preoperative counselling and increased responsiveness to patients' postoperative concerns may have avoided litigation in several cases.

Background and Aims: Currently used endoscopic items for the assessment of pouchitis and cuffitis have deficiencies in reliability and validation. We assessed the reliability and accuracy of new endoscopic items for pouchitis and of the Ulcerative Colitis Endoscopic Index of Severity [UCEIS] for cuffitis., Methods: Three new endoscopic items were assessed and included in the Monash pouchitis endoscopic subscore: bleeding [absent/contact/spontaneous]; erosions [absent/<10/≥10]; and ulceration [absent/<10%/≥10%]. Three raters evaluated 44 pouchoscopy videos in duplicates, in random order. Intra- and inter-rater reliability of all endoscopic items and UCEIS were assessed. Clinical and histological pouchitis disease activity index [PDAI] subscores were also assessed and faecal calprotectin was measured., Results: All three Monash endoscopic items had substantial intra-rater reliability with intraclass correlation coefficients [ICCs] >0.61 [95% CI >0.61], compared with only ulcers from the currently used PDAI endoscopic subscore, but inter-rater reliability was only substantial for ulceration and no better than those of the currently used endoscopic items. The Monash endoscopic subscore had a strong positive correlation with the reference standard global endoscopic lesion severity r = 0.80 [95% CI 0.80-0.80] and the reference standard PDAI endoscopic subscore r = 0.70 [95% CI 0.67-0.73], which was higher than the correlation observed for the currently used PDAI endoscopic subscore. The UCEIS had substantial intra-rater reliability, but only fair inter-rater reliability and poor diagnostic performance for cuffitis., Conclusions: The Monash endoscopic items, and endoscopic subscore they generate, have enhanced overall performance compared with the currently used PDAI items and subscore. Further validation and responsiveness to change in disease state are indicated., (© The Author(s) 2021. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.)