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Ahmad Haffar,1 Alexander Hirsch,1 Christian Morrill,1 Adelaide Garcia,1 Zachary Werner,2 John P Gearhart,1 Chad Crigger1 1Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children’s Hospital, Baltimore, MD, USA; 2West Virginia University School of Medicine, Department of Urology, Division of Pediatric Urology, Morgantown, WV, USACorrespondence: Ahmad Haffar, The Johns Hopkins University School of Medicine, The James Buchanan Brady Urological Institute, Robert D. Jeffs Division of Pediatric Urology, Charlotte Bloomberg Children’s Center, Baltimore, MD, 21287, USA, Tel +1 (304) 993-2237, Email ahaffar1@jh.eduPurpose: This study examines the readability of online medical information regarding cloacal exstrophy (CE). We hypothesize that inappropriate levels of comprehension are required in these resources, leading to poor understanding and confusion amongst caregivers.Methods: The Google and Bing search engines were used to search the terms “cloacal exstrophy” and “cloacal exstrophy treatment”. The first 100 results for each were collected. Each webpage was analyzed for readability using four independent validated scoring systems: the Gunning-Fog index (GFI), SMOG grade (Simple Measure of Gobbledygook), Dale-Chall index (DCI), and the Flesch-Kincaid grade (FKG).Results: Forty-seven unique webpages fit the inclusion criteria. Mean readability scores across all websites were GFI, 14.6; SMOG score, 10.8; DCI, 9.3; and FKG, 11.8, correlating to adjusted grade levels of college sophomore, 11th grade, college, and 11th grade, respectively. There were significant differences across all readability formulas. Non-profit websites were significantly less readable than institutional and commercial webpages (GFI p = 0.012, SMOG p = 0.018, DCI p = 0.021, FKG p = 0.0093).Conclusion: Caregiver-directed health information regarding CE and its treatment available online is written at the 11th grade reading level or above. Online resources pertaining to CE must be simplified to be effective.Plain Language Summary: Cloacal exstrophy is a rare severe birth defect that does not always show up in prenatal screening. Parents are often unfamiliar with this disease and must learn about the disease, procedures, and outcomes their child may have in a short amount of time. Online medical information has been recommended to be written at a 6th grade reading level so that the general public may understand. The authors of this study wanted to investigate if average websites that parents might find using common search engines would be easily understood. The authors used different search phrases on Google and Bing search engines, and used them to look at the top 100 search results for each. The text from each page was graded based on 4 different readability scoring systems. The authors found 47 unique webpages that matched the criteria and found that most pages had reading levels of about 11th grade-college level. Due to its rarity, the information available about cloacal exstrophy are similar and would likely be poorly understood by most parents. Hospital institutions and non-profit exstrophy programs need to make a concerted effort to work together to develop simple yet helpful information regarding this disease.Keywords: cloacal exstrophy, readability, online health information, exstrophy treatment

Zachary Werner,1 Ahmad Haffar,2 Emma Bacharach,1 Jennifer Knight-Davis,3 Ali Hajiran,1 Adam Luchey1 1Department of Urology, West Virginia University, Morgantown, WV, USA; 2School of Medicine, West Virginia University, Morgantown, WV, USA; 3Department of Surgery, West Virginia University, Morgantown, WV, USACorrespondence: Ahmad Haffar, School of Medicine, West Virginia University, Suite 6300 Health Sciences Center Morgantown, Morgantown, WV, 26505, USA, Tel +304 993-2237, Fax +304 293-2807, Email aihaffar@mix.wvu.eduObjective: Current urologic renal trauma guidelines favor conservative management. In 2012, we implemented an institution-wide renal trauma protocol to standardize management. This protocol details initiation of DVT (deep vein thrombosis) prophylaxis, cessation of bed rest, and frequency of laboratory studies. We hypothesized that low-grade injuries (grade I–III) could be managed without urologic consultation and that our chemical DVT prophylaxis regimen would not pose an increased risk of hemorrhage requiring transfusion.Methods: We performed a cross-sectional analysis of a prospectively maintained database containing all renal trauma at our institution from 2009 to 2019. We segregated injuries based on grade, presence of multi-organ trauma, and evaluated the presence and types of intervention, initiation of chemical DVT prophylaxis, and post-DVT prophylaxis hemorrhage requiring transfusion.Results: We identified 295 cases of renal trauma, of which 62 were isolated injuries. Forty-three of the isolated renal injuries were transferred from outside facilities, 70% of which were classified as low-grade injuries. There were 220 low-grade lacerations and 75 high-grade lacerations. No grade I or II lacerations required any interventions. Two (2.5%) grade III lacerations required IR embolization. Twenty-five (41%) grade IV lacerations required intervention, of which five were nephrectomy. Seven (54%) grade V lacerations required intervention, of which 5 were nephrectomies. Upon review of our protocol with early ambulation and DVT prophylaxis, there were no cases of isolated renal injury where initiation of either treatment resulted in delayed hemorrhage requiring transfusion or surgical intervention.Conclusion: Only 2/220 low-grade renal lacerations required intervention. Our data suggest that grade I and II renal lacerations can be managed safely without urologic consultation. Consultation is warranted for grade III injuries given the possibility of initial understaging. Furthermore, we believe our renal laceration protocol in our admittedly small, isolated sample has shown our DVT prophylaxis initiation to not pose increased risk.Keywords: renal, trauma, review, protocol, thromboembolic

Background and Aims: Roux-en-Y gastric bypass (RYGB) is associated with gastrojejunal (GJ) strictures in up to 20% of patients. Surgical revision of the GJ anastomosis is technically challenging and carries significant morbidity, making endoscopic therapies such as endoscopic balloon dilation (EBD) and stent placement the preferred approach. In addition, the angulation of GJ anastomosis relative to the Roux limb can cause obstructive symptoms, which are less amenable to EBD or stent placement. In patients with refractory strictures and/or angulation, we evaluate the safety and feasibility of a new anastomosis EUS-guided gastroenterostomy as an alternative to surgical revision. Methods: In patients with refractory GJ strictures and/or angulation, a new anastomosis EUS-guided gastroenterostomy between the gastric pouch and Roux limb is created. Results: Our case series includes 6 patients with a history of RYGB referred for management of obstructive symptoms. Upper endoscopy revealed severe GJ stenosis in 2 patients, complete obliteration of GJ anastomosis in 1 patient, stenosis with angulation in 1 patient, and angulation only in 2 patients. Four patients underwent previous unsuccessful attempts at balloon dilation. Lumen-apposing metal stent (LAMS) placement was initially performed in 4 patients, resulting in resolution of symptoms. However, their symptoms recurred after LAMS removal. EUS-guided anastomosis between the gastric pouch and Roux limb was created successfully in all patients, with no major adverse events. One patient experienced LAMS migration after 54 days. Patients had complete resolution of symptoms after the new anastomosis anastomosis was created. Conclusions: Our case series highlights the safety and feasibility of EUS-guided gastroenterostomy as an alternative to surgical revision in such patients. Large prospective studies with longer follow-up are needed to assess long-term outcomes of this intervention.

The study explores the impact of integrating blended learning (asynchronous/synchronous) on the learning of students in higher education programs in Jordan, such as sciences and humanities, from the perspective of the professors. The study also examines whether there is a statistically significant difference ([alpha] = 0.05) in the level of using blended learning for student learning concerning the sciences or humanities programs. In addition, the study also explores whether there is a statistically significant difference ([alpha] = 0.05) in the level of using blended learning on student learning concerning gender. The study also highlights the main challenges that higher education instructors face when applying blended learning to their programs. Data is collected by using the quantitative method. A questionnaire was answered by 380 instructors that teach in the sciences and humanities programs of higher institutions. Data was analyzed using the Statistical Package for the Social Sciences (SPSS). The instructors were asked to state their challenges during the implementation of blended learning in their courses. The findings show that instructors who teach humanities programs are more satisfied than instructors who teach science programs. The study contributes to the aim of the Ministry of Higher Education and Scientific Research in Jordan to increase the percentage of blended courses for all higher education programs.

Urologic patients with anatomic abnormalities can be particularly susceptible to urinary tract infections (UTI). UTI with urease-producing bacteria can promote struvite urinary calculi and pose unique treatment problems. There is potential for rapid stone growth and bacterial eradication can be difficult secondary to urothelial or stone colonization. Antibiotic resistance among urease-producing organisms further complicates treatment. In this report, we describe the use of intravesical vancomycin in the treatment of a patient with struvite bladder calculi secondary to urease-producing Corynebacterium urealyticum cystitis, resistant to enteral antibiotics. This highlights the potential of intravesical antibiotics for the treatment of UTI.

Cyanobacteria, also known as blue-green algae, are a diverse phylum of photosynthetic, Gram-negative bacteria and one of the largest microbial taxa. These organisms produce cyanotoxins, which are secondary metabolites that can have significant impacts on both human health and the environment. While toxins like Microcystins and Cylindrospermopsins are well-documented and have been extensively studied, other cyanotoxins, including those produced by Lyngbya and Nostoc, remain underexplored. These lesser-known toxins can cause various health issues in humans, including neurotoxicity, hepatotoxicity, and dermatotoxicity, each through distinct mechanisms. Moreover, recent studies have shown that cyanobacteria can be aerosolized and transmitted through the air over long distances, providing an additional route for human exposure to their harmful effects. However, it remains an area that requires much more investigation to accurately assess the health risks and develop appropriate public health guidelines. In addition to direct exposure to toxins, cyanobacteria can lead to harmful algal blooms, which pose further risks to human and wildlife health, and are a global concern. There is limited knowledge about these lesser-known cyanotoxins, highlighting the need for further research to understand their clinical manifestations and improve society’s preparedness for the associated health risks. This work aims to review the existing literature on these underexplored cyanotoxins, which are associated with human intoxication, elucidate their clinical relevance, address significant challenges in cyanobacterial research, and provide guidance on mitigating their adverse effects.