Search

As men age, the prostate continues to grow on average 2.5% per year. While the variable growth rate of the total prostate gland is recognized, the growth rate of different prostate zones remains largely unclear. We evaluated the growth patterns of the prostate zones and identified clinical parameters contributing to the zonal growth rates.Prostate magnetic resonance imaging (MRI) data and clinical information were obtained retrospectively on 156 patients who had at least 3 prostate MRIs between 2003 and 2018. Different prostate zonal volumes were measured and analyzed. The outcome was analyzed using linear regression.We observed that prostate growth rates vary depending on body mass index (BMI), transition zone index (TZI), the prostate zone and 5-alpha reductase inhibitor (5ARI) use. The peripheral zone volume growth rates increased with age and peaked at 60-70 years of age (p=0.047), while the transition zone volume demonstrates continuous growth without a peak through all ages. BMI and TZI are associated with the growth rate of the peripheral zone (p=0.026, p0.001, respectively) but not the transition zone growth rate. 5ARI use is significantly associated with the reduction in the transition zone growth rate (p=0.033), not the peripheral zone. In addition, patients with TZI greater than 60% had the most significant reduction in the transition zone growth rate while taking 5ARI (p0.001).Transition and peripheral zones of the prostate grow at variable rates. BMI and TZI affect peripheral zone growth rate, while 5ARI use reduces the transition zone growth rate.

Context With the addition of active surveillance and thermal ablation (TA) to the urologist’s established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced. Objective To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process. Evidence acquisition A collaborative critical review of the medical literature was conducted. Evidence synthesis We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making. Conclusions Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care. Patient summary With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.

Prostate cancer presents a significant challenge and burden for health care centres across the world. In the UK and other parts of Europe, as well as areas of the USA, centralisation of services has been implemented. In the UK and Europe, hospital centres are split into a hub-and-spoke system. High-volume centres carry out treatment as hubs and local hospitals carry out diagnostics and referrals as spokes. In this narrative mini-review we evaluate whether centralisation of services has improved patient outcomes, streamlined the use of resources, and reduced costs. We also discuss the positive and negative impacts of centralisation of prostate cancer services. PATIENT SUMMARY: This mini-review discusses the current use of centralisation of prostate cancer services. We assess the evidence in favour of centralisation as well as the issues it can present to both health care systems and patients.

To (1) examine the contemporary incidence of occult inguinal LN metastases and (2) identify predictors of occult inguinal LN metastases to improve selection of cN0 patients for inguinal lymphadenectomy (ILND).We identified 590 men with cTany cN0 cM0 penile cancer who underwent partial/radical penectomy and ILND from 2006-2016 in the NCDB. Rates of pN+ disease were examined, and a multivariable regression model was constructed to identify features associated with pN+ disease.Tumors were ≤pT1 in 21%, pT2 in 43%, and pT3/pT4 in 24% of patients. A median of 15 (IQR 8-22) LNs were removed at ILND. The overall pN+ rate was 24% and did not vary over the study period. The pN+ rate, stratified by pT stage, varied from 18-33%. On multivariable analysis, only higher tumor grade (OR 2.16; P = 0.02 for grade 2; OR 2.81; P = 0.005 for grade 3-4, versus grade 1) and lymphovascular invasion (OR 3.12; P0.001) were independently associated with pN+ disease, whereas pT stage was not.The contemporary rate of occult LN metastases in men with cN0 penile cancer remains high at approximately 24%. Our results suggest that high tumor grade and/or lymphovascular invasion are better determinants of lymph node involvement than primary tumor stage.

Context In response to growing concerns over rising costs and major variation in quality, improving value for patients has been proposed as a fundamentally new strategy for how healthcare should be delivered, measured, and remunerated. Objective To systematically review the literature regarding the implementation and impact of value-based healthcare in urology. Evidence acquisition A systematic review was performed to identify studies that described the implementation of one or more elements of value-based healthcare in urologic settings and in which the associated change in healthcare value had been measured. Twenty-two publications were selected for inclusion. Evidence synthesis Reorganization of urologic care around medical conditions was associated with increased use of guidelines-compliant care for men with prostate cancer, and improved outcomes for patients with lower urinary tract symptoms. Measuring outcomes for every patient was associated with improved prostate cancer outcomes, while the measurement of costs using time-driven activity-based costing was associated with reduced resource utilization in a pediatric multidisciplinary clinic. Centralization of urologic cancer care in the UK, Denmark, and Canada was associated with overall improved outcomes, although systems integration in the USA yielded mixed results among urologic cancer patients. No studies have yet examined bundled payments for episodes of care, expanding the geographic reach for centers of excellence, or building enabling information technology platforms. Conclusions Few studies have critically assessed the actual or simulated implementation of value-based healthcare in urology, but the available literature suggests promising early results. In order to effectively redesign care, there is a need for further research to both evaluate the potential results of proposed value-based healthcare interventions and measure their effects where already implemented. Patient summary While few studies have evaluated the implementation of value-based healthcare in urology, the available literature suggests promising early results.

The ability to transfer knowledge across tasks and generalize to novel ones is an important hallmark of human intelligence. Yet not much is known about human multi-task reinforcement learning. We study participants’ behavior in a novel two-step decision making task with multiple features and changing reward functions. We compare their behavior to two state-of-the-art algorithms for multi-task reinforcement learning, one that maps previous policies and encountered features to new reward functions and one that approximates value functions across tasks, as well as to standard model-based and model-free algorithms. Across three exploratory experiments and a large preregistered experiment, our results provide strong evidence for a strategy that maps previously learned policies to novel scenarios. These results enrich our understanding of human reinforcement learning in complex environments with changing task demands.

BACKGROUND: Magnetic resonance imaging (MRI) of the prostate (MRI-prostate) facilitates better detection of clinically significant prostate cancer (PCa). Yet, the national trends of MRI at the time of prostate biopsy and its ability to increase the detection of PCa in a biopsy-naïve population remain unknown. OBJECTIVE: To elucidate the contemporary trends of MRI and prostate biopsy, and whether it improved PCa diagnosis among privately insured patients. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of a large private health insurance database in the USA—the OptumLabs Data Warehouse. We identified all men [notdef]40 yr of age who underwent index prostate biopsies from 2010 through 2016. INTERVENTION: MRI-prostate at the time of index biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Utilization of the MRI at the time of biopsy and incident PCa diagnosis constituted the primary outcomes. We enumerated unadjusted and age-specific annual rates of MRI over time to elucidate trends using regression models (trend analysis). Bivariate and multivariable regression analyses identified patient characteristics associated with MRI-prostate, and the association between the use of MRI and PCa diagnosis. RESULTS AND LIMITATIONS: Overall, 119 202 men underwent index prostate biopsies. Unadjusted annual rates of MRI at the time of biopsy significantly increased from 7 per 1000 biopsies in 2010 to 83 per 1000 biopsies in 2016 (p < 0.001 for trend). Age-specific rates increased across all age groups (40–49, 50–59, 60–65, 66–74, and 75 +yr; all p < 0.001). On multivariable analysis, black patients had a lower likelihood of MRI compared with white patients (odds ratio [OR]: 0.6; p < 0.01). MRI at the time of biopsy was not associated with a higher likelihood of incident PCa compared with traditional systematic biopsy (OR: 1.0; p = 0.7). The retrospective design and the inability to detect clinically significant PCa (Gleason 7+) constitute the limitations of this study. CONCLUSIONS: While the use of MRI at the time of biopsy rose markedly, it was not associated with a higher detection rate of PCa. Further research is needed to address effective dissemination of MRI and targeted biopsies, and racial disparities. PATIENT SUMMARY: From 2010 to 2016, our study found a significant rise in the utilization of magnetic resonance imaging of the prostate (MRI-prostate) at the time of index biopsy, although only a minority of patients undergo MRI-prostate. The use of MRI-prostate was not associated with a higher likelihood of diagnosing incident prostate cancer.

Background Central airway obstruction and fistula are treated with a tracheobronchial Y stent. In the currently used self‐expandable metal Y stents, the delivery system is 8 mm in diameter and requires either a 9 mm tracheal tube or rigid bronchoscope to enable airway control during insertion. In this study we present a novel technique of laryngeal mask airway (LMA) assisted Y stent insertion, enabling airway control during deployment of the Y stent. Methods All procedures using LMA in assisting Y stent insertions between 2014–2020 were reviewed. Data collected included demographics, clinical diagnosis and disease characteristics, indication, procedural success rates, clinical outcome and survival. Results A total of 10 patients with a median age of 61.5 years (range 37–73) underwent LMA assisted Y stent insertion. Indications for stent insertion were malignant disease with central airway obstruction or fistula. In all cases airway patency was achieved leading to improvement of symptoms and performance status. No procedural complications were reported. The median survival was 4.5 weeks (range: 2–26). Conclusions LMA assisted Y stent insertion enables airway control during the procedure. In comparison to silicone Y stent insertion, the procedure is less cumbersome, shorter in duration and does not require the use of general anesthesia or rigid bronchoscopy. Key points Significant findings of the study LMA assisted Y stent insertion enables airway control during the implantation of metallic self‐expanding Y stent. The procedure does not require the use of general anesthesia or rigid bronchoscopy. What this study adds In this study we present the technique and outcomes of LMA assisted Y stent insertion. This method of Y stent insertion provides an additional treatment option for patients with central airway obstruction and fistula., LMA assisted Y stent insertion enables airway control during the implantation of metallic self‐expanding Y stent. The procedure does not require the use of general anaesthesia or rigid bronchoscopy.

PURPOSE: Investigate the relationship between history of cancer and adverse pregnancy outcomes according to subfertility/fertility treatment. METHODS: Deliveries(2004–2013) from Massachusetts(MA) Registry of Vital Records and Statistics were linked to MA assisted reproductive technology data, hospital discharge records, and Cancer Registry. The relative risks(RR) and 95% confidence intervals of adverse outcomes(gestational diabetes(GDM), gestational hypertension(GHTN), cesarean section(CS), low birth weight(LBW), small for gestational age(SGA), preterm birth(PTB), neonatal mortality, and prolonged neonatal hospital stay) were modeled with log-link and Poisson distribution generalized estimating equations. Differences by history of subfertility/fertility treatment were investigated with likelihood ratio tests. RESULTS: Among 662,630 deliveries, 2,983 had a history of cancer. Women with cancer history were not at greater risk of GDM, GHTN, or CS. However, infants born to women with prior cancer had higher risk of LBW(RR:1.19 [1.07–1.32]), prolonged neonatal hospital stay(RR:1.16[1.01–1.34]), and PTB(RR:1.19[1.07–1.32]). We found clinically and statistically significant differences in the relationship between cancer history and SGA by subfertility/fertility treatment(p-value, test for heterogeneity=0.02); among deliveries with subfertility or fertility treatment, those with history of cancer experienced greater risk of SGA(RRsubfertile:1.36[1.02–1.83]). CONCLUSIONS: Women with a history of cancer had greater risk of some adverse pregnancy outcomes; this relationship varied by subfertility and fertility treatment.

Hepatic hydrothorax is the formation of transudative pleural effusion as a consequence of portal hypertension. Only a minority of cases resolve after sodium restriction and diuretics. Despite the relatively low incidence of 5-15% among patients with cirrhotic portal hypertension, the high morbidity and serious clinical implications associated with hepatic hydrothorax necessitate a well-defined treatment strategy to guide patient care. Management is typically multidisciplinary, involving hepatologists, interventional pulmonologists, interventional radiologists, surgeons, and other specialties. In this manuscript, we assemble a multidisciplinary team to critically review the available literature and provide an evidence-based guidance for management of hepatic hydrothorax.

The role of lymph node dissection (LND) in the management of renal cell carcinoma (RCC) is controversial. LND serves an indisputable staging role by providing pathologic nodal stage. However, while earlier observational studies had suggested a survival benefit to LND, more recent observational evidence and a randomized trial do not support a survival benefit. The majority of patients with isolated lymph node involvement appear to harbor occult metastatic disease. Still, LND is not associated with increased perioperative morbidity when performed in experienced centers. LND may therefore play a predominantly staging role in patients at increased risk of lymph node metastases.

Humans spontaneously organize a continuous experience into discrete events and use the learned structure of these events to generalize and organize memory. We introduce theStructured Event Memory(SEM) model of event cognition, which accounts for human abilities in event segmentation, memory, and generalization. SEM is derived from a probabilistic generative model of event dynamics defined over structured symbolic scenes. By embedding symbolic scene representations in a vector space and parametrizing the scene dynamics in this continuous space, SEM combines the advantages of structured and neural network approaches to high-level cognition. Using probabilistic reasoning over this generative model, SEM can infer event boundaries, learn event schemata, and use event knowledge to reconstruct past experience. We show that SEM can scale up to high-dimensional input spaces, producing human-like event segmentation for naturalistic video data, and accounts for a wide array of memory phenomena.

Although robot assistance can facilitate the advantages of minimally invasive surgery, it is unclear whether it offers benefits in settings in which laparoscopic surgery has been established as the standard of care.To examine the comparative effectiveness of robot-assisted laparoscopic radical nephrectomy (RALRN) and laparoscopic radical nephrectomy (LRN) using a nationwide data set.8316 adults who underwent RALRN or LRN for non-urothelial renal cancer from the Nationwide Inpatient Sample from 2010 to 2013.RALRN and LRN.The associations of surgical approach with perioperative outcomes and total hospital costs were evaluated using multivariable logistic regression.Over the study period, utilization of RALRN increased from 46% to 69%. Compared to LRN, RALRN was associated with lower rates of intraoperative (0.9% vs 1.8%; p0.001) and postoperative complications (20.4% vs 27.2%; p0.001), but there were no differences in perioperative blood transfusion (5.6% vs 6.2%; p=0.27) and prolonged hospitalization (7.2% vs 7.1%; p=0.81). RALRN was also significantly associated with higher total hospital costs (median $16 207 vs $15 037; p0.001). In multivariable analyses, RALRN remained independently associated with a lower risk of intraoperative (odds ratio [OR] 0.50; p=0.001) and postoperative complications (OR 0.72; p0.001) but not perioperative blood transfusion (OR 1.10; p=0.34), and with a higher risk of prolonged hospitalization (OR 1.29; p=0.007) and higher mean total hospital costs (+$1468; p0.001). There was no effect modification by hospital volume.Although RALRN was independently associated with a reduction in perioperative complications compared to LRN, it was associated with prolonged hospitalization and higher total hospital costs. These relationships must be interpreted in light of potential differences in case mix.Although robot-assisted laparoscopic radical nephrectomy was independently associated with a reduction in perioperative complications compared to laparoscopic radical nephrectomy, it was associated with prolonged hospitalization and higher total hospital costs.

Lymph node dissection may benefit patients at increased risk for lymph node metastases from renal cell carcinoma. Therefore, we evaluated the association of lymph node dissection with survival in patients at high risk undergoing radical nephrectomy for renal cell carcinoma.We identified 2,722 patients with M0 renal cell carcinoma who underwent radical nephrectomy with or without lymph node dissection at 2 international centers from 1990 to 2010. The associations of lymph node dissection with the development of distant metastases, and cancer specific and all cause mortality were evaluated using propensity score techniques and traditional multivariable Cox regression. Subset analyses were done to examine patients at increased risk of lymph node metastases.Overall 171 patients (6.3%) had pN1 disease. Median followup was 9.6 years. Clinicopathological features were well balanced after propensity score adjustment. Lymph node dissection was not significantly associated with a reduced risk of distant metastases, or cancer specific or all cause mortality in the overall cohort, among patients with preoperative radiographic lymphadenopathy (cN1), or across an increasing probability of pN1 disease from 0.10 or greater to 0.50 or greater. Neither extended lymph node dissection nor the extent of lymph node dissection was associated with improved oncologic outcomes.The current analysis of a large, international cohort indicates that lymph node dissection is not associated with improved oncologic outcomes among patients at high risk who undergo radical nephrectomy for M0 renal cell carcinoma. This includes patients with radiographic lymphadenopathy (cN1) and across increasing probability thresholds of pN1 disease.

We study the nature of pressure-strain interaction at reconnection sites, detected by NASA's Magnetospheric Multiscale (MMS) Mission. We employ data from a series of published case studies, including a large-scale reconnection event at the magnetopause, three small-scale reconnection events at the magnetosheath current sheets, and one example of the recently discovered electron-only reconnection. In all instances, we find that the pressure-strain shows signature of conversion into (or from) internal energy at the reconnection site. The electron heating rate is larger than the ion heating rate and the compressive heating is dominant over the incompressive heating rate in all cases considered. The magnitude of thermal energy conversion rate is close to the electromagnetic energy conversion rate in the reconnection region. Although in most cases the pressure-strain interaction indicates that the particle internal energy is increasing, in one case the internal energy is decreasing. These observations indicate that the pressure-strain interaction can be used as an independent measure of energy conversion and dynamics in reconnection regions, in particular independent of measures based on the electromagnetic work. Finally, we explore a selected reconnection site in a turbulent Particle-in-Cell (PIC) simulation which further supports the observational results., The following article has been accepted by Physics of Plasmas

Identifying the structure of motion relations in the environment is critical for navigation, tracking, prediction, and pursuit. Yet, little is known about the mental and neural computations that allow the visual system to infer this structure online from a volatile stream of visual information. We propose online hierarchical Bayesian inference as a principled solution for how the brain might solve this complex perceptual task. We derive an online Expectation-Maximization algorithm that explains human percepts qualitatively and quantitatively for a diverse set of stimuli, covering classical psychophysics experiments, ambiguous motion scenes, and illusory motion displays. We thereby identify normative explanations for the origin of human motion structure perception and make testable predictions for new psychophysics experiments. The proposed online hierarchical inference model furthermore affords a neural network implementation which shares properties with motion-sensitive cortical areas and motivates a novel class of experiments to reveal the neural representations of latent structure.

Objectives Data are limited regarding the clinical significance of nontuberculous mycobacteria pulmonary infections among lung transplant recipients. We investigated the incidence and characteristics of pulmonary nontuberculous mycobacteria infection in ourlung transplant patient population. Materials and methods We obtaineddata of the patients who underwent lung transplant in our center from January 1997 to March 2019. Results Of 690 patients, nontuberculous mycobacteria were identified in 58 patients (8.4%) over a median follow-up of 3 years. Types of species were as follows: Mycobacterium simiae (n = 24), avium complex (n = 12), abscessus (n = 9), fortuitum (n = 6), chelonae (n = 2), szulgai (n = 1), kansasii (n = 1), lentiflavum (n = 1), and undefined mycobacteria (n = 2). When we compared infections in the early versus late period posttransplant (before and after 6 months), infections with Mycobacterium simiae (16 vs 8 incidents) and Mycobacterium fortuitum (5 vs 1 incident) were more often observed within the early period, whereas most Mycobacterium abscessus (7 vs 1 incident) and Mycobacterium avium complex (9 vs 3 incidents) were observed in the later period. The median forced expiratory volume in 1 second overtime did not differ significantly between patients with and without nontuberculous mycobacteria infection (P = .29). Nontuberculous mycobacteria acquisition was significantly associated with decreased survival (relative risk of 2.41, 95% CI, 1.70-3.43; P ⟨ .001). Conclusions The nontuberculous mycobacteria species isolated varied according to the time elapsed since transplant. Among lung transplant recipients, nontuberculous mycobacteria infection was associated with increased mortality but not with lung dysfunction.

We present observations in Earth’s magnetotail by the Magnetospheric Multiscale spacecraft that are consistent with magnetic field annihilation, rather than magnetic topology change, causing fast m...

INTRODUCTION AND OBJECTIVE:Massachusetts (MA) is a northeastern state with universally mandated health insurance since 2006. Although Black men have generally worse prostate cancer outcomes, emergi...

INTRODUCTION AND OBJECTIVE:MRI-targeted biopsy has emerged as a standard of care in the management of men with elevated PSA and prostate cancer on active surveillance. Although two main biopsy tech...

INTRODUCTION AND OBJECTIVE:Clinical practice guidelines recommend antibiotic prophylaxis for transrectal prostate biopsy. However, infectious complications following biopsy have been an emerging co...

INTRODUCTION AND OBJECTIVE:Benign prostatic hyperplasia (BPH) is highly prevalent in elderly men and is a major cause of lower urinary tract symptoms (LUTS). The zonal growth rate of the prostate a...

Background Bone marrow mononuclear cells have been successfully utilized for numerous regenerative purposes. In the current study, patients suffering from erectile dysfunction (ED) unresponsive to phosphodiesterase 5 inhibitors were administered autologous bone marrow concentrate delivered intracavernously utilizing a point of care FDA cleared medical device. Methods A total of 40 patients were treated in the primary trial and 100 in the clinical registry, with the longest follow up of 12 months. Results Minimal treatment associated adverse effects where observed related to short term bruising at the site of harvest or injection. No long-term adverse events were noted related to the intervention. Mean improvements in IIEF-5 score were 2 in the Caverstem 1.0 low dose group, 3 in the high dose Caverstem 1.0 group and 9 in the Caverstem 2.0 group. Furthermore, improvements peaked by 3 months and maintained at 6 months follow-up. Conclusion These data support the safety and efficacy of point of care, minimally to non-manipulated, non-expanded bone marrow concentrate for the treatment of ED. Trial registration Funded by Creative Medical Health, Inc.; Clinicaltrials.gov number: NCT03699943; https://clinicaltrials.gov/ct2/show/NCT03699943?term=caverstem&rank=1; initially registered December 12, 2015.

Previous studies have indicated that flux transfer events (FTEs) grow as they convect away from the reconnection site along the magnetopause. This increase in FTE diameter may occur via adiabatic expansion in response to decreasing external pressure away from the subsolar region or due to a continuous supply of magnetic flux and plasma to the FTEs' outer layers by magnetic reconnection. Here we investigate an ensemble of 55 FTEs at the subsolar magnetopause using Magnetospheric Multiscale (MMS) multi‐point measurements. The FTEs are initially modeled as quasi‐force‐free flux ropes in order to infer their geometry and the spacecraft trajectory relative to their central axis. The MMS observations reveal a radially‐inward net force at the outer layers of FTEs which can accelerate plasmas and fields toward the FTE's core region. Inside the FTEs, near the central axis, plasma density is found to decrease as the axial net force increases. It is interpreted that the axial net force accelerates plasmas along the axis in the region of compressing field lines. Statistical analysis of the MMS observations of the 55 FTEs indicates that plasma pressure, Pth, decreases with increasing FTE diameter, λ, as Pth,obsv ∝ λ−0.24. Assuming that all 55 FTEs started out with similar diameters, this rate of plasma pressure decrease with increasing FTE diameter is at least an order of magnitude slower than the theoretical rate for adiabatic expansion (i.e., Pth,adiab. ∝ λ−3.3), suggesting the presence of efficient plasma heating mechanisms, such as magnetic reconnection, to facilitate FTE growth.

Objectives To characterize the perioperative morbidity of transurethral resection of bladder tumor (TURBT) in order to identify important determinants of both quality and cost in the delivery bladder cancer care. Methods We identified 24,100 patients aged 18-89 years who underwent TURBT from 2010 to 2015 in the National Surgical Quality Improvement Program database. Multivariable logistic regression was performed to evaluate the associations of patient features and tumor size ( 5 cm) with 30-day perioperative outcomes. Results Thirty-day postoperative complications occurred in 5.1% of patients, perioperative blood transfusion in 1.5% of patients, hospital readmission in 3.7% of patients, reoperation in 1.5% of patients, and mortality in 0.8% of patients. The most common reasons for readmission were bleeding (29%) and infectious (21%) complications. Although several patient features were associated with increased perioperative morbidity on multivariable analysis, including congestive heart failure, renal failure, higher American Society of Anesthesiology class, and dependent functional status, only larger tumor size was independently associated with increased risks of all perioperative endpoints. Conclusion Perioperative morbidity following TURBT is substantial and represents an important target for quality improvement. Extent of resection, patient functional status, and specific comorbidities are independently associated with increased risks of perioperative morbidity and mortality. These results have implications for patient counseling, perioperative management, and quality improvement programs.

Rapid histologic assessment of fresh prostate biopsies may reduce patient anxiety, aid in biopsy sampling, and enable specimen triaging for molecular/genomic analyses and research that could benefit from fresh tissue analysis. Nonlinear microscopy (NLM) is a fluorescence microscopy technique that can produce high-resolution images of freshly excised tissue resembling formalin-fixed paraffin-embedded (FFPE) H&E. NLM enables evaluation of tissue up to ~100 µm below the surface, analogous to serial sectioning, but without requiring microtome sectioning. One hundred and seventy biopsies were collected from 63 patients who underwent in-bore MRI or MRI/ultrasound fusion biopsy procedures. Biopsies were stained in acridine orange and sulforhodamine 101, a nuclear and cytoplasmic/stromal fluorescent dye, for 45 s. Genitourinary pathologists evaluated the biopsies using NLM by translating the biopsies in real time to areas of interest and NLM images were recorded. After NLM evaluation, the biopsies were processed for standard FFPE H&E and similarities and differences between NLM and FFPE H&E were investigated. Accuracies of NLM diagnoses and Gleason scores were calculated using FFPE histology as the gold standard. Pathologists achieved a 92.4% sensitivity (85.0–96.9%, 95% confidence intervals) and 100.0% specificity (94.3–100.0%) for detecting carcinoma compared to FFPE histology. The agreement between the Grade Group determined by NLM versus FFPE histology had an unweighted Cohen’s Kappa of 0.588. The average NLM evaluation time was 2.10 min per biopsy (3.08 min for the first 20 patients, decreasing to 1.54 min in subsequent patients). Further studies with larger patient populations, larger number of pathologists, and multiple institutions are warranted. NLM is a promising method for future rapid evaluation of prostate needle core biopsies.

Background The LungVision system is a novel augmented‐fluoroscopy‐based real‐time navigation and guidance technology for bronchoscopy that can be integrated with any standard biopsy tool, including the cryoprobe, to enable real‐time visualization and localization of pulmonary nodules. Objectives To evaluate the diagnostic yield and safety among patients undergoing peripheral pulmonary nodule biopsy with the LungVision system. Methods This prospective, single‐center study was conducted at Rabin Medical Center in Israel. All patients that underwent peripheral pulmonary nodule biopsy with the LungVision system from January 2016 to August 2020 were included. All procedures were performed under moderate sedation. The primary outcome was tissue diagnosis by either identification of malignant cells or benign diagnosis. Secondary outcomes were safety and the added value of cryobiopsy. Results Sixty‐three procedures were performed during the study period. Median lesion size (interquartile range) was 25.0 mm (18–28 mm). The diagnostic yield overall was 27/33 (81.8%) and for lesions smaller than 20 mm was 13/18 (72.2%). In nine cases the transbronchial cryobiopsy showed tissue with malignant cells that were not found in any other biopsy material taken with other sampling tools. One patient was treated with a chest tube for a pneumothorax. No other major complications were reported. Conclusions The LungVision system showed good feasibility and safety for peripheral pulmonary nodule biopsy. The system is compatible with all biopsy tools, including the cryoprobe. Randomized controlled trials are needed to accurately ascertain its diagnostic yield., The LungVision fluoroscopy‐based navigation and guidance technology for bronchoscopic biopsy of peripheral pulmonary nodules is safe and effective.

Introduction: Small cell carcinoma of the urinary tract (SCCUT) is a rare finding with poor clinical course. This study sheds light on the molecular subtype and identifies risk factors in patients diagnosed with SCCUT.Methods: Immunohistochemical expression of immunotherapy target programmed death ligand 1 (PD-L1) and luminal (GATA3), basal (p63), and p53 markers are assessed in patients diagnosed with SCCUT. Univariate analysis identified risk factors. Overall survival (OS) is computed using the Kaplan–Meier method.Results: Tissue was available for 70.2% (33/47). All showed a high PD-L1 expression phenotype. p53 is seen in 93.9% (31/33), mostly as overexpression, GATA3 in 45.5% (15/33), and p63 in 57.6% (19/33). For the entire cohort (n = 47), 1-year survival was 59.6%, and the median OS was 17 months. Univariate analysis shows that chemotherapy [hazard ratio (HR) = 0.29, 95% confidence interval (CI) = 0.14–0.61, p = 0.001], radical surgery (HR = 0.37, 95% CI = 0.18–0.76, p = 0.007), and diagnosis of non-pure SCCUT (HR = 0.44, 95% CI = 0.22–0.86, p = 0.02) are favorable prognostic features. Metastasis had negative associations with survival (HR = 2.1, 95% CI = 1.1–4.2, p = 0.03).Conclusions: In this series, pure and mixed SCCUT are characterized by p53 overexpression and a high PD-L1 phenotype. Histology of non-pure SCCUT is a positive prognosticator, and radical cystectomy or chemotherapy can improve OS. These findings demonstrate that SCCUT may be eligible for PD-L1 immunotherapy.

Background Massachusetts is a northeastern state with universally mandated health insurance since 2006. Although Black men have generally worse prostate cancer outcomes, emerging data suggest that they may experience equivalent outcomes within a fully insured system. In this setting, the authors analyzed treatments and outcomes of non-Hispanic White and Black men in Massachusetts. Methods White and Black men who were 20 years old or older and had been diagnosed with localized intermediate- or high-risk nonmetastatic prostate cancer in 2004-2015 were identified in the Massachusetts Cancer Registry. Adjusted logistic regression models were used to assess predictors of definitive therapy. Adjusted and unadjusted survival models compared cancer-specific mortality. Interaction terms were then used to assess whether the effect of race varied between counties. Results A total of 20,856 men were identified. Of these, 19,287 (92.5%) were White. There were significant county-level differences in the odds of receiving definitive therapy and survival. Survival was worse for those with high-risk cancer (adjusted hazard ratio [HR], 1.50; 95% CI, 1.4-1.60) and those with public insurance (adjusted HR for Medicaid, 1.69; 95% CI, 1.38-2.07; adjusted HR for Medicare, 1.2; 95% CI, 1.14-1.35). Black men were less likely to receive definitive therapy (adjusted odds ratio, 0.78; 95% CI, 0.74-0.83) but had a 17% lower cancer-specific mortality (adjusted HR, 0.83; 95% CI, 0.7-0.99). Conclusions Despite lower odds of definitive treatment, Black men experience decreased cancer-specific mortality in comparison with White men in Massachusetts. These data support the growing body of research showing that Black men may achieve outcomes equivalent to or even better than those of White men within the context of a well-insured population. Lay summary There is a growing body of evidence showing that the excess risk of death among Black men with prostate cancer may be caused by disparities in access to care, with few or no disparities seen in universally insured health systems such as the Veterans Affairs and US Military Health System. Therefore, the authors sought to assess racial disparities in prostate cancer in Massachusetts, which was the earliest US state to mandate universal insurance coverage (in 2006). Despite lower odds of definitive treatment, Black men with prostate cancer experience reduced cancer-specific mortality in comparison with White men in Massachusetts. These data support the growing body of research showing that Black men may achieve outcomes equivalent to or even better than those of White men within the context of a well-insured population.

BACKGROUND: The pathologic diagnosis and Gleason grading of prostate cancer are time-consuming, error-prone, and subject to interobserver variability. Machine learning offers opportunities to improve the diagnosis, risk stratification, and prognostication of prostate cancer. OBJECTIVE: To develop a state-of-the-art deep learning algorithm for the histopathologic diagnosis and Gleason grading of prostate biopsy specimens. DESIGN, SETTING, AND PARTICIPANTS: A total of 85 prostate core biopsy specimens from 25 patients were digitized at 20× magnification and annotated for Gleason 3, 4, and 5 prostate adenocarcinoma by a urologic pathologist. From these virtual slides, we sampled 14 803 image patches of 256 × 256 pixels, approximately balanced for malignancy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We trained and tested a deep residual convolutional neural network to classify each patch at two levels: (1) coarse (benign vs malignant) and (2) fine (benign vs Gleason 3 vs 4 vs 5). Model performance was evaluated using fivefold cross-validation. Randomization tests were used for hypothesis testing of the model performance versus chance. RESULTS AND LIMITATIONS: The model demonstrated 91.5% accuracy (p < 0.001) at coarse-level classification of image patches as benign versus malignant (0.93 sensitivity, 0.90 specificity, and 0.95 average precision). The model demonstrated 85.4% accuracy (p < 0.001) at fine-level classification of image patches as benign versus Gleason 3 versus Gleason 4 versus Gleason 5 (0.83 sensitivity, 0.94 specificity, and 0.83 average precision), with the greatest number of confusions in distinguishing between Gleason 3 and 4, and between Gleason 4 and 5. Limitations include the small sample size and the need for external validation. CONCLUSIONS: In this study, a deep learning-based computer vision algorithm demonstrated excellent performance for the histopathologic diagnosis and Gleason grading of prostate cancer. PATIENT SUMMARY: We developed a deep learning algorithm that demonstrated excellent performance for the diagnosis and grading of prostate cancer.

Motion relations in visual scenes carry an abundance of behaviorally relevant information, but little is known about how humans identify the structure underlying a scene’s motion in the first place. We studied the computations governing human motion structure identification in two psychophysics experiments and found that perception of motion relations showed hallmarks of Bayesian structural inference. At the heart of our research lies a tractable task design that enabled us to reveal the signatures of probabilistic reasoning about latent structure. We found that a choice model based on the task’s Bayesian ideal observer accurately matched many facets of human structural inference, including task performance, perceptual error patterns, single-trial responses, participant-specific differences, and subjective decision confidence—especially, when motion scenes were ambiguous and when object motion was hierarchically nested within other moving reference frames. Our work can guide future neuroscience experiments to reveal the neural mechanisms underlying higher-level visual motion perception.

As space-based charged particle measurement pushes the technical envelope, resolution, both spatially and temporally, is ever improving. As such, the knowledge of the associated error must also improve. We present a method for correlating data collected from multiple sensors at different times in order to estimate the pointing error of each sensor. The method is demonstrated using flight data from the Dual Ion Spectrometer suite, part of the Fast Plasma Investigation on the NASA's Magnetospheric Multiscale mission. By looking at signals with sharp features in the direction of spacecraft spin, the relative error in look direction between sensors can be estimated with sub-degree precision, roughly 20 times better than the native resolution in the azimuthal (spin) direction. These sharp features appear in nature often enough that a sufficiently large sample size can be identified, using an automated filter of routine science data, to calibrate the system, or post correct measured data. The relative pointing error can then be trended over time to monitor the evolution/aging of the measurement system. These data inform calibration/correction methods, should the error grow to a point where science quality is adversely affected.

Clinically regional node-positive (cN+) urothelial carcinoma of the bladder requires a multi-modal management approach amidst growing recognition that it represents a spectrum of disease. Herein, we review the contemporary evidence for the natural history, evaluation, and management of clinically regional node-positive urothelial carcinoma of the bladder, highlighting recent changes in lymph node staging. Despite advances in techniques, cross-sectional imaging remains relatively insensitive for the detection of lymph node metastases. Recent changes to nodal staging that distinguish between cN1, cN2–3, and non-regional lymph node metastases reflect an increasing understanding that node-positive disease is heterogeneous and its management must be individualized according to nodal staging. Systemic therapy remains the initial management strategy, either alone or in conjunction with radiotherapy, with choice and sequencing of agents extrapolated from studies of metastatic disease. Consolidative radical cystectomy is an option for patients with disease response to upfront systemic therapy, and several series demonstrate a subset of patients with favorable oncologic outcomes. The comparative effectiveness of radiotherapy and radical cystectomy as local therapy remains an important evidence gap. Future studies that identify predictive biomarkers will help inform optimal choice of systemic therapy. The management of clinically regional node-positive disease requires a multimodal approach comprising both systemic and local therapy, tailored to the patient and to disease response. While choice of systemic therapy will be informed by ongoing studies in patients with metastatic disease, including the elucidation of predictive biomarkers, the comparative effectiveness of local therapies remains an important evidence gap.

With growing support of perioperative chemotherapy for upper tract urothelial carcinoma (UTUC), current biopsy methods are challenging, and little is known as to the degree to which patients would appropriately receive neoadjuvant chemotherapy (NAC) from biopsy alone. Herein, we sought to assess the rates of appropriate clinical use of NAC and identify clinicopathologic factors associated with aggressive UTUC amongst patients undergoing radical nephroureterectomy (RNU) for clinically localized disease.From 2004 to 2013, we identified all treatment naïve patients diagnosed with clinically localized, high grade UTUC (cTa-4Nx) who underwent RNU from the National Cancer Database (NCDB). Pathologic criteria for NAC (pT2-4N0,x; pTanyN1) from RNU represented the primary outcome. Bivariate and multivariable analyses were utilized to identify covariates associated with primary outcome to determine appropriate use of NAC.During the study interval, 5,362 patients were diagnosed with clinically localized UTUC and underwent RNU. Overall, 49.1% of patients presented with an unknown primary tumor stage (Tx) and 24.5% had invasive UTUC from biopsy. On multivariable analysis, upper tract tumor size was associated with invasive UTUC eligible for NAC (all P0.05). Amongst patients with cTx UTUC from biopsy, half of patients had pathologic noninvasive UTUC (pTa,is,1) from RNU and would be overtreated with NAC.Significant uncertainty persists in assigning primary upper tract tumor depth and represents a key barrier to widespread implementation of NAC for patients with high grade UTUC. Further research is needed to more accurately determine clinical criteria to identify patients for NAC.

International audience; In order to determine particle velocities and electric field in the frame of the magnetic structure, one first needs to determine the velocity of the magnetic structure in the frame of the spacecraft observations. Here, we demonstrate two methods to determine a two-dimensional magnetic structure velocity for the magnetic reconnection event observed in the magnetotail by the Magnetospheric Multiscale (MMS) spacecraft on July 11, 2017, Spatio-Temporal Difference (STD) and the recently developed polynomial reconstruction method. Both of these methods use the magnetic field measurements; the reconstruction technique also uses the current density measured by the particle instrument. We find rough agreement between the results of our methods and with other velocity determinations previously published. We also explain a number of features of STD and show that the polynomial reconstruction technique is most likely to be valid within a distance of 2 spacecraft spacings from the centroid of the MMS spacecraft. Both of these methods are susceptible to contamination by magnetometer calibration errors.

We present Language-mediated, Object-centric Representation Learning (LORL), a paradigm for learning disentangled, object-centric scene representations from vision and language. LORL builds upon recent advances in unsupervised object discovery and segmentation, notably MONet and Slot Attention. While these algorithms learn an object-centric representation just by reconstructing the input image, LORL enables them to further learn to associate the learned representations to concepts, i.e., words for object categories, properties, and spatial relationships, from language input. These object-centric concepts derived from language facilitate the learning of object-centric representations. LORL can be integrated with various unsupervised object discovery algorithms that are language-agnostic. Experiments show that the integration of LORL consistently improves the performance of unsupervised object discovery methods on two datasets via the help of language. We also show that concepts learned by LORL, in conjunction with object discovery methods, aid downstream tasks such as referring expression comprehension., Comment: ACL 2021 Findings. First two authors contributed equally; last two authors contributed equally. Project page: https://lang-orl.github.io/

INTRODUCTION Radiation therapy (XRT) has been investigated as a possible treatment for high-risk non-muscle invasive bladder cancer (NMIBC) with the goal of bladder preservation, especially with the ongoing Bacillus Calmette-Guerin (BCG) shortage. Yet, little is known about the clinical efficacy and the quality of evidence supporting XRT for NMIBC. Herein, we performed a systematic review and meta-analysis to evaluate XRT in the treatment of patients with high-risk NMIBC. METHODS Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Web of Science were searched for high-risk NMIBC (high grade T1, T1/Ta with associated risk features: carcinoma in-situ (CIS), multifocality, > 5cm in diameter, and/or multiple recurrences) treated with primary XRT. Outcomes evaluated were recurrence-free survival (RFS), cancer-specific-survival (CSS), overall survival (OS), and salvage cystectomy and progression to metastatic disease rates. A meta-analysis was performed to assess outcomes for XRT in NMIBC. RESULTS Overall,13 studies including 746 patients met the search criteria. The 5-year rates of RFS, CSS and OS were 54% (95% CI = 38% – 70%), 86% (95% CI = 80% – 92%), and 72% (95% CI = 64% – 79%). Notably, 13% of patients proceeded to salvage radical cystectomy and 9% developed metastatic disease. All studies were of poor quality, comprising single institution and retrospective studies with only one clinical trial. CONCLUSION XRT for high-risk NMIBC provides some degree of oncologic control, although distant progression was noted. In the setting of the low-quality evidence, a prospective clinical trial is needed to clearly define the risks and benefits of this approach.

There are limited data to support the safety of active surveillance in men with favorable-intermediate risk prostate cancer due only to a prostate specific antigen (PSA) above 10 ng/ml. We therefore evaluated the impact of pretreatment PSA on risk-stratification in men with Gleason 6 prostate cancer.We identified men aged 18 to 75 with cT1-2cN0cM0, pre-treatment PSA20 ng/ml, Gleason 6 prostate cancer diagnosed from 2010 to 2016 in the National Cancer Database who underwent radical prostatectomy. The associations of patient and disease features with Gleason score upgrading or adverse pathologic features at prostatectomy were evaluated using logistic regression. To evaluate for non linear relationships between PSA and each outcome, we examined predicted marginal event rates standardized for baseline characteristics with PSA modeled using restricted cubic splines RESULTS: A total of 75,566 patients were included in the cohort. In unadjusted analyses, patients with pretreatment PSA ≥ 10 ng/ml had higher rates of Gleason core upgrading (58.8% vs. 47.9%; P0.001) and adverse pathologic features (19.7% vs. 10.0%; P0.001) compared to patients with PSA10 ng/ml. In multivariable analyses, PSA ≥ 10 ng/ml was associated with statistically significantly increased risks of Gleason score upgrading (OR 1.47;95%CI 1.39 - 1.55) and adverse pathologic features (OR 2.15;95%CI 2.01 - 2.30). When modeled as a non linear continuous covariate, PSA was associated with increased adjusted rates of Gleason score upgrading and adverse pathologic features without a clear dichotomization at a threshold of 10 ng/ml.Higher pretreatment PSA was independently associated with increased risks of Gleason score upgrading and adverse pathologic features at prostatectomy. Flexible modeling of the relationship between PSA and each outcome did not support dichotomization at a threshold of 10 ng/ml. These results can be used to improve patient risk-stratification for active surveillance.

Shock parameters at Earth's bow shock in rare instances can approach the Mach numbers predicted at supernova remnants. We present our analysis of a high Alfv\'en Mach number ($M_A= 27$) shock utilizing multipoint measurements from the Magnetospheric Multiscale (MMS) spacecraft during a crossing of Earth's quasi-perpendicular bow shock. We find that the shock dynamics are mostly driven by reflected ions, perturbations that they generate, and nonlinear amplification of the perturbations. Our analyses show that reflected ions create modest magnetic enhancements upstream of the shock which evolve in a nonlinear manner as they traverse the shock foot. They can transform into proto-shocks that propagate at small angles to the magnetic field and towards the bow shock. The nonstationary bow shock shows signatures of both reformation and surface ripples. Our observations indicate that although shock reformation occurs, the main shock layer never disappears. These observations are at high plasma $\beta$, a parameter regime which has not been well explored by numerical models., Comment: Accepted by the Astrophysical Journal