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Acute thrombotic thrombocytopenic purpura (TTP) is a life-threatening emergency and plasma exchange (PEX) is the initial treatment shown to reduce acute mortality.To compare current practice in the United Kingdom (UK) against the standards set out in the 2012 British Society of Haematology guideline, and to better understand the issues affecting prompt initiation of PEX.The trainee research network HaemSTAR conducted a retrospective nationwide review of adults presenting to UK hospitals with a first episode of acute TTP.Data on 148 patients treated at 80 UK hospitals between 2014 and 2019 demonstrated that 64.8% of patients received PEX within 24 h. Diagnostic uncertainty was the most commonly cited reason for delayed treatment. Conversely, a shorter time to PEX occurred in patients who had red cell fragments or severe thrombocytopenia identified on their first complete blood count. Availability of on-site PEX was associated with a greater proportion of patients receiving PEX within 8 h compared to patients transferred, but by 24 h there was no difference between the two groups and two-thirds of all patients had received their first PEX. The mortality rate for patients that received PEX was 9.2%, with 27.8% of deaths linked to delayed treatment initiation.This is the first multi-center evaluation of treatment delays in acute TTP and it will inform targeted pathways to improve prompt access to life-saving intervention.

Introduction:Consultations represent a significant workload for inpatient urology providers, yet consult patterns are poorly described. We report trends in billable urology consult activity...

The hepsin gene encodes a type II transmembrane serine protease. Previous studies have shown the overexpression of hepsin in prostate cancer, and the dysregulation of hepsin promotes cancer cell proliferation, migration, and metastasis in vitro and in vivo. The review incorporated with our work showed that hepsin expression levels were specifically increased in prostate cancer, and higher expression in metastatic tumors than in primary tumors was also observed. Moreover, increased expression was associated with poor outcomes for patients with prostate cancer. Using in silico protein–protein interaction prediction, mechanistic analysis showed that hepsin interacted with eight other oncogenic proteins, whose expression was significantly correlated with hepsin expression in prostate cancer. The oncogenic functions of hepsin are mainly linked to proteolytic activities that disrupt epithelial integrity and regulatorily interact with other genes to influence cell-proliferation, EMT/metastasis, inflammatory, and tyrosine-kinase-signaling pathways. Moreover, genomic amplifications of hepsin, not deletions or other alterations, were significantly associated with prostate cancer metastasis. Targeting hepsin using a specific inhibitor or antibodies significantly attenuates its oncogenic behaviors. Therefore, hepsin could be a novel biomarker and therapeutic target for prostate cancer.

INTRODUCTION AND OBJECTIVE:Multiple transperineal prostate (TP) biopsy templates exist but with uncertainty regarding the optimal sampling strategy. Prior work shows that anterior base cores from t...

IntroductionTo evaluate the impact of non-technical skills (NTS) on team performance, workload and clinical outcomes.MethodsThe operating room (OR) environment of 20 robot-assisted radical prostatectomies performed by three different surgeons was recorded. Trained observers assessed NTS utilising the Non-Technical Skills for Surgeons (NOTSS) questionnaire. Associations between NOTSS scores, teamwork attributes (anticipation and inconveniences), workload (measured by National Aeronautics and Space Administration-Task Load Index (NASA-TLX)) and clinical outcomes (operative time, blood loss and surgical complexity) were determined using logistic regression and Pearson correlation.Results1780 requests were observed, 703 (39%) were non-verbal. Utilisation of non-verbal requests differed significantly among surgeons (26%, 36% and 44%, pConclusionNTS in the OR were associated with team efficiency, fewer surgical flow disruptions and an improved self-perceived performance.

Introduction and Objectives: Management of recurrent ureteropelvic junction obstruction (UPJO) following pyeloplasty presents a challenging clinical problem. Failure of initial pyeloplasty is, in part, secondary to ureteral devascularization and subsequent fibrosis. In this video, we present a case of an anastomotic augmentation with cryopreserved placental tissue (CPT) to improve tissue healing and angiogenesis, and aid with the success of re-do robotic pyeloplasty. Materials and Methods: We present a 46-year-old female with history of recurrent left-sided UPJO treated by initial endopyelotomy and then open pyeloplasty. She underwent re-do robotic pyeloplasty (DaVinci Si™, Intuitive Surgical) with CPT. The patient was placed in the flank position; a 12mm camera port, three 8mm robotic ports, and a 12mm assistant port were used. The renal pelvis and upper ureter were mobilized to reveal a dense scar at the UPJ. A dismembered pyeloplasty was performed with barbed suture. After completion of the anastomosis, a section of CPT (Stravix™, Osiris Therapeutics) was wrapped around the anastomosis. CPT is composed of umbilical amnion and Wharton's jelly, which contains a mixture of extracellular matrix, and growth factors. The CPT is prepared and thawed on the bedside table, and placed into the peritoneum through the 12mm port in the correct orientation. The wrap is secured to the anastomosis with a fibrin sealant (EVICEL™, Johnson & Johnson). Results: The patient experienced resolution of flank pain. MAG3 renogram demonstrated resolution of obstruction at 6 months, with improvement of T½ time from 34 minutes to 7 minutes, with sustained improvement with repeat scan 18 months after surgery. Ureteroscopy demonstrated a patent UPJ. Strategies for successful robotic pyeloplasty after initial failed management include: (1) use of appropriate CPT agent to support the anastomosis - selection of thicker, more durable CPT to allow passage through laparoscopic port, (2) preparation on bedside table with enough time to allow thawing, (3) marking Wharton's jelly side of tissue for orientation, and (4) use of sealing agent to secure CPT to the anastomosis and prevent dislodgement. Conclusions: We demonstrate a novel approach to manage recurrent UPJ obstruction with robotic surgery using CPT. Placenta-derived products may have an increasing role in the performance of complex robotic urologic reconstructive surgery.

Pathology residency training is currently a time-intensive process, frequently extending up to 6 years in duration as residents complete 1 or 2 fellowships following graduation. Innovative training curricula may help address the impending changes in the health-care landscape, particularly future shortfalls in pathology staffing and changing health-care models that incorporate more work within interdisciplinary teams. Montefiore has created a novel residency training program aimed at accelerating the acquisition of competency in pathology, preparing residents for independent practice at the completion of residency training, and providing residents with the requisite adaptability and consultative skills to excel wherever they choose to practice. We describe the implementation of this novel pathology residency training curriculum at Montefiore Medical Center/Albert Einstein College of Medicine and the perception of residents in both the old curriculum and the new curriculum.

INTRODUCTION AND OBJECTIVES:Transrectal fusion biopsy (TRFBx) has become ubiquitous with multiple published series establishing its utility. Validation of transperineal fusion biopsy (TPFBx) is lim...

INTRODUCTION AND OBJECTIVES:Sepsis following transrectal ultrasound-guided biopsy (TRbx) for prostate cancer is rising, due to growing antibiotic usage and resistance. Transperineal prostate biopsy...

Introduction: There is paucity of literature about the validation of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) surgical risk calculator fo...

Hepsin, a type II transmembrane serine protease, is commonly overexpressed in a variety of epithelial cancers, where its overexpression and concurrent proteolytic activity correlate with tumor progression. Recent studies indicate that Hepsin undergoes activation via autocatalysis and subsequent ectodomain shedding, thus highlighting its potential as a serum-based biomarker. Using transgenic mouse models of prostate adenocarcinoma, Hepsin overexpression has previously been implicated in disease progression and, notably, metastases that are neuroendocrine in nature. Collectively, these findings led us to explore the potential diagnostic utility of Hepsin expression in prostate cancer progression, inclusive of metastatic variants. Here, we reanalyzed pre-existing, publicly available gene expression datasets (2 datasets, 326 patient samples), which revealed a significant upregulation of Hepsin gene expression in tumor tissue versus benign tissue and further pronounced upregulation in androgen-dependent and -independent metastatic lesions. To further examine the potential correlation of Hepsin overexpression to androgen-independence, we reanalyzed in vitro data comparing LNCaP parental versus androgen-independent LNCaP subclones. This analysis revealed a stepwise increase in Hepsin expression over the course of androgen deprivation, which was accompanied by a concomitant decrease in PSA expression. Lastly, to evaluate circulating hepsin protein levels as they occur in patient serum, a total of 424 subjects suspected of prostate cancer were analyzed for circulating Hepsin levels from 2015 to 2018 at the time of biopsy and followed for recurrence or survival until the end of the study. Serum Hepsin levels, as determined by enzyme-linked immunosorbent assay, rendered a specificity of 89% (Gleason < 6 (3+3); Hepsin positive, >100 ng/mL). Within this cohort, 18 patients presented with biochemical recurrence, of which 44% were Hepsin positive and exhibited a 22-month accelerated clinical path to recurrence versus Hepsin negative patients. Collectively, these results highlight the longitudinal diagnostic potential of circulating Hepsin levels in the prostate cancer setting. Citation Format: John Beard, Sam Eddington, Noah Bowman, Adam Cole, Timothy O'Brien, Blake P. Johnson. Circulating hepsin as a novel serum biomarker in prostate cancer patients [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 6450.

INTRODUCTION AND OBJECTIVE:Infectious complications following prostate biopsy remain a significant cause of patient morbidity driven by increasing antibiotic resistance. Fusion biopsy and transperi...

Introduction: We sought to evaluate the Robotic Anastomosis Competency Evaluation (RACE) — a validated tool that objectively quantifies surgical skills specifically for urethrovesical anastomosis (UVA) — as a means to track progress of trainees, as well as to determine its predictive value. Methods: UVAs performed by trainees at our institution were evaluated using RACE over a period of two years. Trainees were supervised by an experienced robotic surgeon. Outcomes included traineerelated variables (RACE score, proportion of UVA performed by trainee, and suturing speed), and clinical outcomes (total UVA duration, postoperative urinary continence, and UVA-related complications). Significance was determined using linear regression analysis. Results: A total of 51 UVAs performed by six trainees were evaluated. Trainee RACE scores (19.8 to 22.3; p=0.01) and trainee proportion of UVA (67% to 80%; p=0.003) improved significantly over time. Trainee suture speed was significantly associated with RACE score (mean speed range 0.54–0.74 sutures/minute; p=0.03). Neither urinary continence at six weeks nor at six months was significantly associated with RACE score (p=0.17 and p=0.15, respectively), and only one UVA-related postoperative complication was reported. Conclusions: Trainee RACE scores improved and the proportion of UVA performed by trainees increased over time. RACE can be used as an objective measure of surgical performance during training. Strict mentor supervision allowed safe training without compromising patient outcomes.

Objectives. To measure undiagnosed HIV and HCV in a New York City emergency department (ED). Methods. We conducted a blinded cross-sectional serosurvey with remnant serum from specimens originally drawn for clinical indications in the ED. Serum was deduplicated and matched to (1) the hospital’s electronic medical record and (2) the New York City HIV and HCV surveillance registries for evidence of previous diagnosis before being deidentified and tested for HIV and HCV. Results. The overall prevalence of HIV was 5.0% (250/4990; 95% confidence interval [CI] = 4.4%, 5.7%); the prevalence of undiagnosed HIV was 0.2% (12/4990; 95% CI = 0.1%, 0.4%); and the proportion of undiagnosed HIV was 4.8% (12/250; 95% CI = 2.5%, 8.2%). The overall prevalence of HCV (HCV RNA ≥ 15 international units per milliliter) was 3.9% (196/4989; 95% CI = 2.8%, 5.1%); the prevalence of undiagnosed HCV was 0.8% (38/4989; 95% CI = 0.3%, 1.3%); and the proportion of undiagnosed HCV was 19.2% (38/196; 95% CI = 11.4%, 27.0%). Conclusions. Undiagnosed HCV was more prevalent than undiagnosed HIV in this population, suggesting that aggressive testing initiatives similar to those directed toward HIV should be mounted to improve HCV diagnosis.

OBJECTIVE To investigate and analyse the different ways surgeons communicate with bedside assistants during robot-assisted surgery (RAS). METHODS We retrospectively reviewed video and audio recordings of 26 RAS procedures (23 prostatectomies and three cystectomies). Three cameras and eight lapel microphones were used to record the operating theatre environment. We identified five common tasks and categorized them into 'specific', 'non-specific' and 'unclear' categories. We also determined the frequency, time to execute the task, inconveniences and acknowledgements associated with each category. The most efficient category was the one that took the shortest duration to accomplish and was associated with the fewest inconveniences. RESULTS A total of 1 000 requests were made by three surgeons for six bedside assistants by three surgeons. The five identified tasks were: instrument change; clipping; suction; irrigation; and retraction. For instrument change, non-specific requests were the most frequent compared with the other categories (77% vs 18% vs 5%; P < 0.001). For suction, specific requests were the most frequently used of the three categories (73% vs 27% vs 0%; P < 0.001) and this task was associated with the fewest inconveniences (38% vs 62%; P = 0.01). For clipping, irrigation and retraction, both specific and non-specific requests were similar in terms of their frequency, action time and inconveniences. Comparing complete vs incomplete requests, incomplete requests had significantly shorter median action time (5 vs 8 s; P < 0.001) but did not significantly differ in terms of inconveniences and acknowledgement. CONCLUSION To our knowledge, this is the first study to provide a detailed analysis of communication during RAS. It lays a foundation for standardized taxonomy to improve communication, surgical efficiency and patient safety.

We investigated the prevalence of and variables associated with parastomal hernia and its outcomes after robot-assisted radical cystectomy and ileal conduit creation for bladder cancer.We retrospectively reviewed the records of patients who underwent robot-assisted radical cystectomy at our institution. Parastomal hernia was defined as the protrusion of abdominal contents through the stomal defect in the abdominal wall on cross-sectional imaging. Parastomal hernia was further described in terms of patient and hernia characteristics, symptoms, management and outcomes. The Kaplan-Meier method was used to determine time to parastomal hernia and time to surgery. Multivariate stepwise logistic regression was done to evaluate variables associated with parastomal hernia.A total of 383 patients underwent robot-assisted radical cystectomy and ileal conduit creation. Of the patients 75 (20%) had parastomal hernia, which was symptomatic in 23 (31%), and 11 (15%) underwent treatment. Median time to parastomal hernia was 13 months (IQR 9-22). Parastomal hernia developed in 9%, 23% and 32% of cases at 1, 2 and 3 years, respectively. Patients with parastomal hernia had a significantly higher body mass index (30 vs 28 kg/mSymptoms develop in approximately a third of patients with parastomal hernia and 15% will require surgery. The risk of parastomal hernia plateaued after postoperative year 3. Longer operative time, a larger fascial defect and lower postoperative kidney function were associated with parastomal hernia.

Objective To investigate the cognitive and physical workload experienced by each operating room team member for different types of urologic procedures. Methods Surgeons, anesthesiologists, surgical fellows, bedside assistants, circulating nurses, and scrub nurses completed the National Aeronautics and Space Administration Task Load Index questionnaire for various urologic robot-assisted surgery procedures. A total of 338 questionnaires from 55 unique individuals were collected. Workload differences by role, type of procedure, and surgery duration were analyzed using analysis of variance for each of the 6 domains of the National Aeronautics and Space Administration Task Load Index. The effects of trainees' participation on their perceived workload and the workloads of the lead surgeon and bedside assistant were analyzed with correlation. Results The role of the surgical team was significant for all the scales of workload, and there was a main effect type of surgery on temporal demand and frustration. Frustration was higher for prostatectomy in comparison to cystectomy for the trainee surgeon. On the other hand, it was lower for the anesthesiologist, bedside assistant, and the circulating nurse. There was no effect of procedural complexity on workload. Regardless of surgical complexity, the trainees performed approximately 40% of the procedure without significantly impacting their perceived workload. Conclusion This study provides an analysis of variations and contributors to workload parameters and serves as a platform to optimize team members' workload during robot-assisted surgery.

Patient: A 39-year-old Hispanic woman. History of Present Illness: The patient had swelling of the left side of her neck, which she had first noticed 3 to 4 months before consultation and which did not subside after 2 courses of antibiotics. She reported no tenderness, dysphagia, odynophagia, dysphonia, otalgia, fevers, chills, or weight changes. Past medical history: The patient had a past history of gastroesophageal reflux disease, arthritis (knee and cervical disease), and a prior abnormal Pap smear result (high grade squamous intraepithelial lesion). The cervical lesion was treated with a loop electrosurgical excision procedure (LEEP). Her past surgical history is remarkable for cholecystectomy and a left breast biopsy with benign results. Social history: Noncontributory. Family history: Noncontributory. Physical exam: The patient harbored a firm, nontender, fully mobile 2- to 3-cm left parotid tail mass without other abnormalities; her facial nerve function was intact in all branches. Principle Laboratory Findings: See [Image 1][1], [Image 2][2], [Image 3][3], [Image 4][4], [Image 5][5], and [Image 6][6]. * FNA : fine needle aspiration LEEP : loop electrosurgical excision procedure CT : computed tomography [1]: #F1 [2]: #F2 [3]: #F3 [4]: #F4 [5]: #F5 [6]: #F6

Major progress in the crystal growth of nanowires and related structures places new demands on our abilities to characterize optical and electronic properties with both an ease and a resolution commensurate with the materials of interest. In particular, transport properties, such as minority carrier diffusion length, are important for a range of applications in light emission, sensing and solar energy conversion. In this paper, a technique to “image transport” in nanostructures by monitoring the motion of charge via the recombination emission of light is reviewed. Transport imaging combines the resolution of near-field optics with the charge generation control of a scanning electron microscope. The technique is related to, but significantly different from standard cathodoluminescence, since it maintains the spatial information of the emitted light. Light is collected in the near-field from a scanning fiber in an atomic force microscope/near-field scanning optical microscope system. It is possible to determine minority carrier or exciton diffusion lengths from a single optical image, without any electrical contact to the sample. New results are presented for minority carrier hole transport in ZnO nanowires and nanobelts.