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Objective: To evaluate the viability of robot-assisted appendiceal ureteroplasty as an innovative surgical approach for the reconstruction of ureteral strictures in cases where traditional methods are unsuitable., Methods: We conducted a retrospective review of 14 patients who underwent robot-assisted appendiceal ureteroplasty for right-sided ureteral stricture disease at three academic centers between March 2018 and November 2022. Patients were selected based on stricture characteristics, tissue quality, and the need for tissue transfer techniques. Surgical outcomes, including stricture-free rates, renal function, and complication rates, were analyzed., Results: The median patient age was 63years, with a balanced gender distribution. The median stricture length was 4.75 cm. The majority of strictures were located in the proximal ureter (50%). Surgical approaches included appendiceal onlay flaps (71.4%) and interposition flaps (28.6%). The median operative time was 268 minutes, with an average estimated blood loss of 75 mL. Postoperatively, ureteral patency was achieved in 92.9% of patients. Two patients (14.3%) experienced urinary tract infections requiring readmission. There was no significant change in serum creatinine levels postoperatively. Hydronephrosis grade significantly improved following surgery (P = .025)., Conclusion: Robot-assisted appendiceal ureteroplasty is a safe and effective technique for managing ureteral strictures. It offers a high success rate with minimal complications, making it a valuable addition to the urologic surgeon's armamentarium for complex ureteral reconstructions., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Penile prosthesis implantation offers a durable, safe, and effective treatment option for male erectile dysfunction; however, many urologists feel apprehensive and uncomfortable placing penile prostheses due to limited training, low surgical experience, and intra- and postoperative complication management., Aim: To compare a previously validated hydrogel inflatable penile prosthesis (IPP) training model with cadaver simulations across 4 main categories: anatomic replication and realism, procedural replication and realism, educational effectiveness, and efficacy and safety., Methods: An overall 88 participants (15 attendings, 18 fellows, and 55 residents) performed guided IPP placements on a cadaver and a hydrogel model. Based on a 5-point Likert scale, postsurveys were used to assess the participants' opinions regarding anatomic replication and realism, procedural replication and realism, educational effectiveness, and safety between the hydrogel model and cadavers., Outcomes: A direct head-to-head scenario was created, allowing participants to fully utilize the hydrogel model and cadaver, which ensured the most accurate comparison possible., Results: A total of 84% agreed that the hydrogel model replicates the relevant human cadaveric anatomy for the procedure, whereas 69% agreed that the hydrogel tissue resembles the appearance of cadaveric tissue. Regarding the pubic bone, outer skin, corporal bodies, dartos layer, and scrotum, 79%, 74%, 82%, 46%, and 30% respectively agreed that the hydrogel tissue resembled the texture/behavior of cadavers. Furthermore, 66% of participants agreed that the hydrogel model replicates all the procedural steps. Specifically, participants agreed that the model replicates the skin incision/dartos dissection (74%), placement of stay suture and corporotomy (92%), corporal dilation (81%), measurement of prosthetic size (98%), reservoir placement (43%), IPP placement (91%), scrotal pump placement (48%), and skin closure (51%). Finally, 86%, 93%, and 78% agreed that the hydrogel model is useful for improving technical skills, as a teaching/practicing tool, and as an evaluation tool, respectively. To conclude, 81% of participants stated that they would include the hydrogel model platform in their current training., Clinical Implications: By replicating the IPP procedure, the hydrogel model offers an additional high-fidelity training opportunity for urologists, allowing them to improve their skills and confidence in placing penile prostheses, with the goal of improving patient surgical outcomes., Strengths and Limitations: The hydrogel training model allows users to perform the entire IPP placement procedure with high anatomic realism and educational effectiveness, maintaining many of the high-fidelity benefits seen in cadavers while improving safety and accessibility., Conclusion: Ultimately, this high-fidelity nonbiohazardous training model can be used to supplement and bolster current IPP training curriculums., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The use of volume-rendered images is gaining popularity in the surgical planning for complex procedures. IRIS™ is an interactive software that delivers three-dimensional (3D) virtual anatomical models. We aimed to evaluate the preoperative clinical utility of IRIS for patients with ≤T2 localized renal tumors who underwent either partial nephrectomy (PN) or radical nephrectomy (RN). Patients and Methods: Six urologists (four faculty and two trainees) reviewed CT scans of 40 cases over 2 study phases, using conventional two-dimensional (2D) CT alone (Phase-I), followed by the CT + IRIS 3D model (Phase-II). After each review, surgeons reported their decision on performing a PN or an RN and rated (Likert scale) their confidence in completing the procedure as well as how the imaging modality influenced specific procedural decisions. Modifications to the choice of procedure and confidence in decisions between both phases were compared for the same surgeon. Concordance between surgeons was also evaluated. Results: A total of 462 reviews were included in the analysis (231 in each phase). In 64% (95% CI: 58-70%) of reviews, surgeons reported that IRIS achieved a better spatial orientation, understanding of the anatomy, and offered additional information compared with 2D CT alone. IRIS impacted the planned procedure in 20% of the reviews (3.5% changed decision from PN to RN and 16.5% changed from RN to PN). In the remaining 80% of reviews, surgeons' confidence increased from 78% (95% CI: 72-84%) with 2D CT, to 87% (95% CI: 82-92%) with IRIS ( p  = 0.02); this confidence change was more pronounced in cases with a high RENAL score ( p  = 0.009). In 99% of the reviews, surgeons rated that the IRIS accurately represented the anatomical details of all kidney components. Conclusion: Application of IRIS 3D models could influence the surgical decision-making process and improve surgeons' confidence, especially for robot-assisted management of complex renal tumors.

Evidence suggests that where people live, learn, work, and play affects a range of health outcomes for children and adults. Differential access to social, economic, and environmental supports puts some community members at greater risk, leading to disparities in health and well-being. The 2014 release of the For the Sake of All report highlighted persistent health disparities for African Americans in St. Louis, Missouri, and their social and economic impacts on the St. Louis region. This study extends this work by developing partnerships with community organizations and neighborhood residents to address health disparities. Community-based participatory research (CBPR) methods were utilized to engage partners in a 10-month research process to address community concerns that impact health. Seven community residents, neighborhood researchers, engaged in workshops to learn about the research process and used techniques to gather information to implement action strategies. Neighborhood researchers selected 14 vacant lots to implement their action plan, which included visions for repurposing the land into a community park, produced a report for dissemination, and organized a community action forum to communicate their findings. This study highlights a promising approach to promote healthy communities and health equity by empowering neighborhood residents using participatory methodologies., (© 2020 Society for Community Research and Action.)

Background: Depression is associated with receipt of opioids in non-cancer pain., Objectives: To determine whether the receipt of opioid therapy modifies the relationship of depression and use of multiple non-opioid pain treatments., Methods: Patients (n = 320) with chronic low back pain (CLBP) were recruited from family medicine clinics and completed questionnaires that measured use of home remedies, physical treatments requiring a provider and non-opioid medication treatments. A binary variable defined use (yes/no) of all three non-opioid treatment categories. Depression (yes/no) was measured with the PHQ-2. The use of opioids (yes/no) was determined by medical record abstraction. Unadjusted and adjusted logistic regression models, stratified on opioid use, estimated the association between depression and use of all three non-opioid treatments., Results: Participants were mostly female (71.3%), non-white (57.5%) and 69.4% were aged 18 to 59 years. In adjusted analyses stratified by opioid use, depression was not significantly associated with using three non-opioid treatments (OR = 2.20; 95% CI = 0.80-6.07) among non-opioid users; but among opioid users, depression was significantly associated with using three non-opioid treatments (OR = 3.21; 95% CI: 1.14-8.99). These odds ratios were not significantly different between opioid users and non-users (P = 0.609)., Conclusion: There is modest evidence to conclude that patients with CLBP and comorbid depression, compared with those without depression, were more likely to try both opioid and non-opioid pain treatments. Non-response to other pain treatments may partly explain why depression is associated with greater prescription opioid use., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Background: The literature on results from primary care-based opioid-prescribing protocols is small and results have been mixed. To advance this field, we evaluated whether opioid prescribing changed after a comprehensive protocol was implemented and whether change was associated with the number and type of risk reduction tools adopted., Methods: Electronic medical record data were obtained for 2607 patients. Demographics, Patient Health Questionnaire-9 scores, body mass index, and utilization levels of protocol elements were measured for 24 months prior and 18 months post implementation of an opioid-prescribing protocol within a federally qualified health center. χ 2 and t -tests were computed to estimate change in opioid prescribing, morphine-equivalent dose, comedication prescribing, and number and type of protocol elements utilized., Results: The opioid protocol was associated with an increase in urine drug screens from 18.3% to 26.8% from pre to postimplementation ( P < .0001). There was no significant increase in opioid treatment agreements. Tramadol (21.4% to 16.8%, P = .0006) and antidepressant (56.0% to 51.6%, P = .012) prescribing significantly decreased. Total opioid prescriptions and maximum morphine-equivalent doses were similar from pre to postimplementation. Protocol elements were more often used when patients had a higher opioid dose and were receiving benzodiazepines., Conclusions: Implementing a multi-faceted opioid-prescribing protocol was not associated with change in number or dose of opioid prescriptions but was associated with greater use of urine drug screens, and risk reduction tools were used more often in high-risk patients. Implementation research is needed to identify barriers to maximizing adherence to opioid protocols., Competing Interests: Conflict of interest: none declared., (© Copyright 2020 by the American Board of Family Medicine.)

Background: The prevalence of sexual dysfunction (SDx) diagnoses in primary care settings is not well known, which is a concern because of the high prevalence of comorbid chronic health conditions in patients diagnosed with SDx., Aim: To explore the relation of SDx diagnosis, chronic health conditions, and prescription medications commonly associated with SDx for men and women in primary care using medical records diagnoses., Methods: Exploratory descriptive analyses were used to interpret secondary data from a primary care patient database. The database included patient data from 3 family and internal medicine clinics in the St Louis metropolitan area from July 1, 2008 to June 30, 2015. Analysis included key demographic variables, chronic illness, and health conditions of hypertension, pain, prostate disorder, menopause, substance abuse, depression, anxiety, and associated medications. Analysis of the database yielded 30,627 adult patients (men: n = 12,097, mean age = 46.8 years, 65.6% white race; women: n = 18,530, mean age = 46.6 years, 59.2% white race) with significant comorbid associations between SDx and other chronic illness, health conditions, and medication prescription., Results: Depression, anxiety, pain, hypertension, diabetes, and psychotropic medication use were significantly associated with SDx for men and women. Examination of specific SDx diagnoses showed erectile dysfunction to be significantly associated with all tested variables for men. For women, pain-related SDx diagnoses were associated more with chronic illness, health conditions, and medication use than were psychosexual SDx diagnoses (eg, orgasm), except for menopause. Prevalence varied by sex, with a higher prevalence rate of any SDx for men (13.5%) than for women (1.0%), although sex comparisons were not part of the analytics., Clinical Translation: This study suggests the diagnosis of SDx is closely associated with other common chronic illness and health conditions and could go underdiagnosed in women in primary care., Strengths and Limitations: The cross-sectional nature of the study limits the ability to draw causal conclusions related to the nature of the associated conditions with SDx diagnoses. The generalizability of the findings also might be limited given the specific demographic or health makeup of the St Louis area where the study was conducted., Conclusion: The high comorbidity of SDx with mental health, chronic pain and illnesses, and medication use adds to the growing evidence that sexual health and functioning are essential components of overall well-being and holistic care for men and women. Heiden-Rootes KM, Salas J, Gebauer S, et al. Sexual Dysfunction in Primary Care: An Exploratory Descriptive Analysis of Medical Record Diagnoses. J Sex Med 2017;14:1318-1326., (Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Ribavirin improves treatment response to pegylated-interferon (PEG-IFN) in chronic hepatitis C but the mechanism remains controversial. We studied correlates of response and mechanism of action of ribavirin in treatment of hepatitis C., Design: 70 treatment-naive patients were randomised to 4 weeks of ribavirin (1000-1200 mg/d) or none, followed by PEG-IFNα-2a and ribavirin at standard doses and durations. Patients were also randomised to a liver biopsy 24 h before or 6 h after starting PEG-IFN. Hepatic gene expression was assessed by microarray and interferon-stimulated gene (ISG) expression quantified by nCounter platform. Temporal changes in ISG expression were assessed by qPCR in peripheral-blood mononuclear cells (PBMC) and by serum levels of IP-10., Results: After 4 weeks of ribavirin monotherapy, hepatitis C virus (HCV) levels decreased by 0.5±0.5 log10 (p=0.009 vs controls) and ALT by 33% (p<0.001). Ribavirin pretreatment, while modestly augmenting ISG induction by PEG-IFN, did not modify the virological response to subsequent PEG-IFN and ribavirin treatment. However, biochemical, but not virological, response to ribavirin monotherapy predicted response to subsequent combination treatment (rapid virological response, 71% in biochemical responders vs 22% non-responders, p=0.01; early virological response, 100% vs 68%, p=0.03; sustained virological response 83% vs 41%, p=0.053). Ribavirin monotherapy lowered serum IP-10 levels but had no effect on ISG expression in PBMC., Conclusions: Ribavirin is a weak antiviral but its clinical effect seems to be mediated by a separate, indirect mechanism, which may act to reset IFN-responsiveness in HCV-infected liver.

Background & Aims: Interferon treatment for chronic hepatitis C is associated with non-specific symptoms including fever. We aimed to determine the association of temperature changes with interferon antiviral activity., Methods: 60 treatment-naïve patients with chronic hepatitis C (67% genotype 1/4/6, 33% genotype 2/3) were admitted to start peginterferon alfa-2a and ribavirin in a clinical trial. Temperature was measured at baseline and 3 times daily for the first 24h and the maximal increase from baseline during that time (ΔTmax) was determined. Serum HCV-RNA, interferon-gamma-inducible protein-10 (IP-10) and expression of interferon-stimulated genes (ISGs - CD274, ISG15, RSAD2, IRF7, CXCL10) in peripheral blood mononuclear cells (PBMCs) were measured at very early time points, and response kinetics calculated. The IL28B single nucleotide polymorphism, rs12979860, was genotyped., Results: Temperatures rose by 1.2±0.8°C, peaking after 12.5h. ΔTmax was strongly associated with 1st phase virological decline (r=0.59, p<0.0001) and was independent of gender, cirrhosis, viral genotype or baseline HCV-RNA. The association with 1st phase decline was seen in patients with rs12979860CC genotype (r = 0.65, p <0.0001) but not in CT/TT (r = 0.13, p = 0.53) and patients with CC genotype had a higher DTmax (1.4 ± 0.8 C vs. 0.8 ± 0.6 +C, p = 0.001). DTmax was associated with 6- and 24-h induction of serum IP-10 and of PBMC ISG expression, but only in patients with rs12979860CC [corrected].ΔTmax weakly predicted early virological response (AUC=0.68, CI 0.49-0.88)., Conclusions: Temperature rise following peginterferon injection is closely associated with virological response and is modulated by IL28B polymorphism, reflecting host interferon-responsiveness., (Published by Elsevier B.V.)