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For nursing home residents with severe dementia, high-intensity medical treatment offers little possibility of benefit but has the potential to cause significant distress. Nevertheless, mechanical ventilation and intensive care unit (ICU) transfers have increased in this population. We sought to understand how and why such care is occurring. Mixed methods study, with retrospective collection of qualitative and quantitative data. Department of Veterans Affairs (VA) hospitals. Using the Minimum Data Set, we identified veterans aged ≥65 years who had severe dementia, lived in nursing homes, and died in 2013. We selected those who underwent mechanical ventilation or ICU transfer in the last 30 days of life. We restricted our sample to patients receiving care at VA hospitals because these hospitals share an electronic medical record, from which we collected structured information and constructed detailed narratives of how medical decisions were made. We used qualitative content analysis to identify distinct paths to high-intensity treatment in these narratives. Among 163 veterans, 41 (25.2%) underwent mechanical ventilation or ICU transfer. Their median age was 85 (IQR, 80–94), 97.6% were male, and 67.5% were non-Hispanic white. More than a quarter had living wills declining some or all treatment. There were 5 paths to high-intensity care. The most common (18 of 41 patients) involved families who struggled with decisions. Other patients (15 of 41) received high-intensity care reflexively, before discussion with a surrogate. Four patients had families who advocated repeatedly for aggressive treatment, against clinical recommendations. In 2 cases, information about the patient's preferences was erroneous or unavailable. In 2 cases, there was difficulty identifying a surrogate. Our findings highlight the role of surrogates' difficulty with decision making and of health system–level factors in end-of-life ICU transfers and mechanical ventilation among nursing home residents with severe dementia. [ABSTRACT FROM AUTHOR]

We describe the common presenting signs and symptoms, treatment modalities, and outcomes of acutely presenting scrotal pyoceles. We conducted a retrospective chart review of all adult patients treated for ultrasound-confirmed scrotal pyoceles between 2010 and 2020 at two sites within the [redacted]. Vitals at presentation, microbiology, and inpatient courses including antibiotic treatment and surgical procedures were collected. A total of 360 scrotal ultrasounds were reviewed identifying 15 patients with pyoceles, 11 patients presenting to the emergency department and 4 hospitalized patients. The most common chief complaint was testicular pain (67%). Only seven patients (47%) met SIRS criteria upon presentation. All patients were initially treated with broad-spectrum antibiotics and observation; 11 (73%) responded to this management alone, while four patients (27%) required surgical drainage due to persistent infection. No patients contracted Fournier's gangrene. This study reports the largest published database of scrotal pyoceles to date and describes our clinical approach to management. While pyoceles have traditionally been treated aggressively with surgical drainage, this case series suggests that most patients improve with broad-spectrum antibiotic treatment and observation alone, requiring surgical drainage if infection persists. Future investigations including multi-institutional data will be necessary to validate our institution's approach. [ABSTRACT FROM AUTHOR]

Purpose: The primary study objective was to describe the incidence of osteochondral damage (OD) in our cohort of patients with patellar instability (PI). The secondary objective was to assess for associations between patient demographic characteristics, duration of PI, and quantitative radiographic measurements of anatomic risk factors for PI and OD in this cohort.Methods: A retrospective chart review identified patients treated for PI at a tertiary referral center between 2013 and 2018. Patients were evaluated for osteochondral injury with either magnetic resonance imaging if treated nonoperatively or operative reports if treated surgically. The Caton-Deschamps ratio, proximal tibial tubercle-to-trochlear groove (pTT-TG) distance, distal tibial tubercle-to-trochlear groove (dTT-TG) distance, lateral trochlear inclination (LTI) angle, lateral patellar inclination (LPI) angle, and sulcus angle were calculated from magnetic resonance imaging scans. Trochlear dysplasia is an important risk factor for PI that can be reliability quantified by the pTT-TG distance, dTT-TG distance, LTI angle, sulcus angle, and LPI angle. Demographic data including age at first instability event, sex, body mass index, symptom duration, and number of dislocations were documented.Results: A total of 125 knees in 118 patients (average age, 13.9 ± 3.4 years; 48% female patients) with PI were identified. Within this cohort, 67% were treated surgically and 53% had OD. No association was identified between osteochondral injury and age, sex, body mass index, symptom duration, LTI angle, LPI angle, dTT-TG distance, pTT-TG distance, or number of dislocations. An increased sulcus angle (more dysplasia) showed a statistically significant association with osteochondral pathology (P = .021), and higher sulcus angles were statistically significantly associated with acute osteochondral fracture compared with chondral injury (P = .001).Conclusions: Using quantitative analysis of trochlear dysplasia, this study identified a significant association between trochlear dysplasia (sulcus angle) and the incidence of OD in our cohort of patients with PI. The frequency of dislocation or subluxation and patient demographic characteristics were not significantly associated with OD.Level Of Evidence: Level III, retrospective prognostic study. [ABSTRACT FROM AUTHOR]

Objective: To determine the degree of contemporary practice variation for the treatment of urethral stricture disease (USD) given repeated endoscopic management yields poor long-term success.Materials and Methods: The AUA Quality (AQUA) Registry collects data from participating urologists across practice settings by direct interface with local electronic health record systems. We identified procedures used for USD using Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9/-10) codes. We assessed the association between patient and provider factors and repeated endoscopic treatment using generalized linear models. Provider details were derived from AUA Census.Results: We identified 20,640 male patients with USD treated surgically in AQUA from 2014-2018. The patients were cared for by 1343 providers at 171 practices, 95% of these community-based. Among patients with USD who had treatment, 20,101(97.9%) underwent endoscopic management. 6218(31%) underwent repeated endoscopic treatment during the study period. Urethroplasty was performed in 539(2.6%) patients.  Median patient age at first procedure for endoscopic surgery vs. urethroplasty was 73 vs. 39 years old, respectively (p<0.001). At the practice level, significant variation in rates of repeated endoscopic management was noted. Patients of older age (OR=1.08, 95%CI: 1.06-1.11 for ages ≥80) and patients with a bladder cancer diagnosis (OR=1.17, 95%CI: 1.15-1.20) had higher odds of receiving repeated endoscopic management. Increasing practitioner age was also associated with increased odds of repeated endoscopic management. (OR=1.13, 95%CI: 1.11- 1.16, for practitioners ≥64).Conclusions: Repeated endoscopic management for USD is overused. The utilization of endoscopic management is variable across practices and frequently guideline-discordant, presenting an opportunity for quality improvement. [ABSTRACT FROM AUTHOR]

Objective: To demonstrate our hypothesis that the presence of extravasation on postoperative urethrogram is inconsequential for disease recurrence in urethroplasty postoperative follow-up.Materials and Methods: We utilized the Trauma and Urologic Reconstructive Network of Surgeons database to assess 1691 patients who underwent urethroplasty and post-operative urethrogram. Anatomic and functional recurrence were defined as <17 Fr stricture documented at 12-month cystoscopy and need for a secondary procedure during 1 year of follow-up, respectively. Our primary outcomes were the sensitivity and positive predictive value of post-operative urethrogram for predicting anatomic and functional recurrence of urethral stricture disease.Results: Among 1101 patients with cystoscopy follow-up, 54 (4.9%) had extravasation on initial postoperative urethrogram. Among those 54, 74.1% developed an anatomic recurrence vs 13% without extravasation (P <.001). Similarly, functional recurrence was 9.3% with extravasation vs 3.2 % without extravasation (P = .04). Patients with extravasation more often reported a postoperative urinary tract infection (12.9% vs 2.7%; P <.01) or wound infection (7.4% vs 2.6%; P = .04). Sensitivity of postoperative urethrogram in predicting any recurrence was 27.3%, specificity 98.7%, positive predictive value 77.8%, and negative predictive value 89.3%. Fourty-five of 54 patients with extravasation had a recurrence of some kind, equating to a 22.2% urethroplasty success rate at 1 year.Conclusion: Postoperative urethrogram has a high specificity but low sensitivity for anatomic and functional recurrence during short term follow-up. The positive predictive value of urinary extravasation is high: patients with extravasation incur a high risk of anatomic recurrence within 1 year and such patients may warrant increased monitoring. [ABSTRACT FROM AUTHOR]

Objective: To describe the use of Lean in urology at Zuckerberg San Francisco General, a community safety-net and trauma hospital that serves as a major teaching site for the University of California San Francisco.Methods: We examined our process improvement activities from 2016 to 2018. Our Lean Daily Management System (DMS) includes a 15-minute team huddle ("urology Lean work") of service residents, faculty, clinic and operating room nursing staff, and anesthesia liaisons. Our DMS also includes a 5-minute preoperative huddle. Besides team-building, urology Lean work surfaces logistics, safety or equipment improvement ideas, and ensures progress and completion of initiated projects.Results: Over a 2-year period we developed and completed 67 projects. Projects impacted the outpatient setting (57%), followed by the operating room (22%), the Urology service (12%), and inpatient setting (9%). We completed projects in the following domains: safety (26%), quality (22%), care experience (21%), workforce care and development (13%), equity (11%), and financial stewardship (7%). Urology Lean work reduced new patient clinic access time (119-21 days) and Bacillus Calmette-Guérin in clinic treatment time (180-105 minutes). The average proportion of urology on-time surgeries was better than the overall surgery on-time surgeries (71% v 61%).Conclusion: Urology Lean work successfully applied DMS in a service specific yet holistic approach. Urology Lean work improved resident engagement in quality and safety endeavors and served as a DMS model throughout perioperative and clinic areas. [ABSTRACT FROM AUTHOR]

To compare outcomes among patients undergoing first-time urethroplasty with buccal mucosa graft (BMG) who receive postoperative antibiotics vs those who do not. A retrospective cohort study was conducted using the TriNetX claims database between 2008-2022. Using CPT, ICD10, and LOINC codes, patients >18 years old undergoing primary urethroplasty with BMG who received an outpatient prescription for antibiotics between postoperative day 0-30 or did not were queried. Patients with positive preoperative urine culture or urinary tract infection (UTI) within 30 days preoperatively were excluded. Surgical outcomes included 5-year revision rates and revision-free survival. Safety outcomes included new UTI within 30 days, surgical site infection within 90 days, or Clostridium difficile infection within 30 days of urethroplasty. We identified 884 patients (81% antibiotic cohort, 19% nonantibiotic cohort) that met inclusion criteria. Age at time of urethroplasty, suprapubic tube presence, and pre-existing medical comorbidities were comparable between cohorts (Table 1A). There was no difference in 5-year rates and revision-free survival for endoscopic revision (11.5% vs 9.5%, relative risk (RR) 1.2, 95% CI [0.7, 2.0], recurrence-free survival (RFS) log-rank P =.6), re-do urethroplasty (12.9% vs 13.7%, RR 0.9, 95% CI [0.6, 1.5], RFS log-rank P =.7), or all-cause revision (19.8% vs 17.7%, RR 1.1, 95% CI [0.8, 1.6], P =.5) between groups. Postoperative rates of UTI, surgical site infection, and C difficile infection were similar between groups. In this large retrospective cohort study of patients undergoing urethroplasty with BMG, we observed no significant benefit from use of postoperative antibiotics on long-term revision rates or perioperative infectious complications. [ABSTRACT FROM AUTHOR]

Objective: To describe the patient experience and chief concerns with urethroplasty to improve physician understanding and patient education. Online discussion boards allow patients with urethral stricture disease (USD) to connect with other USD patients. It is unknown how men use these web resources and what information is available about urethroplasty.Methods: Three online forums featuring urethroplasty were identified by Google search. Thematic analysis categorized the content of posts using manually applied codes, with inter-rater reliability and descriptive statistics generated by Dedoose (Los Angeles, CA).Results: A total of 140 unique posters contributed 553 posts to the forums. Posts were categorized as information support (n = 651), issues posturethroplasty (n = 470), own experience preurethroplasty (n = 336), feelings towards other posters (n = 312), what to expect posturethroplasty (n = 265), feelings after urethroplasty (n = 228), and considerations before urethroplasty (n = 134). Experience navigating the healthcare system with USD (n = 141) and weak urine stream (n = 70) were the most frequent preurethroplasty complaints. Postoperative pain (n = 164) was the most frequent issue. Patients expressed more positivity (n = 126) and satisfaction (n = 120) than negativity (n = 33) with urethroplasty.Conclusion: Patients participated in online discussions to share experiences with USD and urethroplasty, receive emotional support, and find answers. Men were more often satisfied than not with their urethroplasty outcomes, with 88% of postoperative feelings coded as positive or satisfied compared to negative. This study provides physicians with insight into the experiences of patients and how to best educate them. [ABSTRACT FROM AUTHOR]

Objective: To determine the impact of concurrent inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) implantation on perioperative complications and long-term device survival, among men with postprostatectomy erectile dysfunction and urinary incontinence.Methods: We identified men older than 65 treated with radical prostatectomy in the Surveillance, Epidemiology, and End Results Medicare database between 2002 and 2016. IPP or AUS placement was determined by current procedural terminology (CPT) code, with dual implantation (DI) defined as IPP and AUS placement on the same date. Device survival was assessed using CPT codes for device removal, replacement, and/or repair. Complications were assessed within 90 days using ICD-9 codes. Statistical analysis was performed using SAS v9.3 (Cary, NC).Results: A total of 37,599 men underwent radical prostatectomy, with AUS placed in 793 (2.1%), IPP placed in 644 (1.7%), and DI in 62 (0.2%). Relative to AUS placement alone, men undergoing DI were younger (68.8 vs 70.2 years, P = 0.03), but had equivalent Charlson comorbidity index, tumor grades, and rates of prior radiotherapy. Relative to IPP placement alone, men were more likely to undergo DI if treated with adjuvant or salvage radiotherapy. The incidence of complications within 30 and 90 days of prosthetic implantation did not differ between groups. Long-term device survival on Kaplan-Meier analysis was not impacted by DI relative to single device implantation with median follow-up of 61 months.Conclusion: Combined AUS and IPP placement does not adversely affect perioperative complications or device survival relative to placement of either device alone. [ABSTRACT FROM AUTHOR]

Objective: To determine whether statin intake affects nephrolithiasis risk, and whether higher lipid levels correlate with stone risk. Dyslipidemia is a known independent risk factor for urolithiasis, and emerging evidence suggests common biological pathways. Previous work has suggested that statins protect against new stone formation, but these findings have not been verified by other investigators.Methods: We queried our Institution's Electronic Data Warehouse for all patients who were newly diagnosed with hyperlipidemia between 2009 and 2011, and had never taken a statin drug. These patients' clinical outcomes were followed until 2015, to assess whether they had been newly prescribed statins and whether they had developed symptomatic urolithiasis. Patient demographics, stone risk factors, prescription data, and serum lipid values were collected.Results: A total of 101,259 patients met inclusion criteria, 47.8% of whom received a statin prescription during the study period. Patients prescribed statins were significantly older, had a greater likelihood of osteoporosis, hemiplegia, immobility, and more likely to take a thiazide diuretic. Patients without a history of urolithiasis who were started on statin therapy were significantly less likely to develop new stones than patients not taking statins. This protective effect was even greater in patients with a history of stone disease. Lipid parameters (low-density lipoprotein, triglyceride, cholesterol) were lower in the statin-treated group, suggesting overall compliance with these medications.Conclusion: Our data confirm previous work that statins protect against urinary stone formation; however, the underlying mechanism seems to be distinct from statins' lipid-lowering effect. [ABSTRACT FROM AUTHOR]

Andrew D. Cohen has a long history with System. Drawn to the journal by its publication of research conducted internationally, he published his first article with System in 1980 and continues to publish and review for the journal today. In this article celebrating System 's 50th anniversary, Andrew is interviewed by editor Nathan Thomas. They discuss Andrew's pathway to academia, his experience as an academic, and his contributions to System spanning 43+ years. The article concludes with Andrew's vision for the type of studies he would like to see published in his two main areas of interest: language learner strategies and pragmatics. He also offers words of encouragement for authors navigating the road of manuscript review, revision, and rejection. [ABSTRACT FROM AUTHOR]

Reconstructing past environmental variability at short (annual-decadal) time scales is critical for understanding ecosystem change and ecological drivers of evolution. One promising approach to reconstructing that variability is through the use of stable isotope geochemistry and sclerochronology, the study of growth banding in organisms that undergo accretionary growth. We used a combination of sclerochronology, conventional stable isotope ratios and clumped isotope paleotemperatures to improve our understanding of past seasonality and climate variability in the Turkana Basin (Kenya, Ethiopia), which experiences a highly seasonal (tropical semi-desert) climate. In this case study, we apply these approaches to both Early Pleistocene and Holocene bivalve shells (Etheria and Pseudobovaria) to develop a model using various proxies of seasonal-interannual temporal variability in lake temperature and isotope chemistry. We leverage this model to better understand how lakes in the Turkana Basin have changed over short time-scales in the past. One modern (1979) river oyster has exclusively negative δ18O values through ∼1.5 yrs of growth and clumped isotope temperature reconstructions (30.1–31.5 °C) consistent with a river delta provenance. Late Holocene shells show a wider range of isotopic variability within each shell's growth history than the modern sample (∼2‰ for the modern sample vs. 5–7‰ for the Late Holocene samples) and near modern paleotemperatures, suggesting growth under both seasonal Omo flood pulse and lacustrine conditions. Middle Holocene shells exhibit less δ18O variability, consistent with growth in fresher Lake Turkana water at the end of the African Humid Period (12-5 ka), and with both surface water temperatures and water column temperature range similar to the Late Holocene. The Early Pleistocene shells have large seasonal δ18O cycles (4–7‰), with δ18O values comparable to modern and Holocene deltaic shells, and a large range of paleotemperatures (21.8–31.3 °C, including temperatures notably cooler than those measured in the modern lake: 25–31 °C), reflecting growth under significant seasonality in paleo-Omo River runoff. Oxygen isotope cycles suggest high degrees of seasonality of the paleo-Omo River runoff (or that of other major influents) into paleolake Lorenyang at ∼1.6 Ma, which may be similar to modern hydroclimate conditions. Comparison to prior datasets from nearby outcrops in the same basin suggests an increase in hydroclimate seasonality between 1.9 and 1.6 Ma. The combination of clumped isotope paleotemperature estimates from shallow water species such as E. elliptica with TEX 86 measurements (derived here from previously published, contemporaneous sediment core studies from the south basin of Lake Turkana), which record temperatures near the oxycline, may provide a new approach to estimating past temperature variability along a vertical profile in lakes, thereby providing information on water column mixing regimes. Our approach greatly expands our toolkit for understanding coupled climate seasonality and variability in the Turkana Basin. • Stable isotope sclerochronology combined with clumped stable isotopes on bivalve shells from the Turkana Basin (Africa) show changes in catchment precipitation and runoff seasonality during the Quaternary • Oxygen isotopic records from Late Holocene bivalve shells are more variable than those in a modern bivalve, however reconstructed lake water temperatures are comparable to modern lake water. • Records from Middle Holocene shells suggest reduced lake water physicochemical seasonality, with fresher water than modern. • Early Pleistocene bivalve fossil isotope geochemistry indicates enhanced seasonality in riverine runoff in a deltaic setting, and cooler than modern water temperatures. • Methods developed in this study combining clumped isotopes from littoral carbonates with TEX86 measurements from contemporaneous sediments deposited in deeper waters provide a model for future reconstructions of variations in vertical temperature profiles in paleolakes. [ABSTRACT FROM AUTHOR]

Learners have difficulty with the pronunciation of both consonants, vowels, and tones in Mandarin Chinese. While there are numerous studies which describe these difficulties, there seem to be few studies looking at the strategies that these learners actually use in order to cope with them. This study focused exclusively on oral production and not auditory comprehension, with special emphasis on the strategies that learners reported using in attempting to master pronunciation of Chinese. The study examined reported and actual difficulties in Chinese pronunciation, along with reported and actual pronunciation strategies. The findings showed both consistencies and inconsistencies between students’ self-report of difficulties in pronunciation and the errors that they made. Likewise, there were found to be similarities and differences between what the students reported their strategies were for dealing with Chinese pronunciation and the strategies that were reportedly used in the read-aloud task. [ABSTRACT FROM AUTHOR]