Visible haematuria-an unusual presentation of metastatic testicular mixed germ cell tumour

A 29-year-old male patient presented to the emergency department with haematuria and flank pain. Ten months agopreviously, he had undergone orchidectomy and adjuvant chemotherapy for a testicular mixed germ cell tumour. Cystoscopy revealed a large bladder wall mass. The final diagnosis of yolk sac tumour was established after transurethral resection of the lesion. The patient was treated with salvage chemotherapy and placed on short-interval biochemical and radiological surveillance to assess treatment response.

Precision Assessment of COVID-19 Phenotypes Using Large-Scale Clinic Visit Audio Recordings: Harnessing the Power of Patient Voice

COVID-19 cases are exponentially increasing worldwide; however, its clinical phenotype remains unclear. Natural language processing (NLP) and machine learning approaches may yield key methods to rapidly identify individuals at a high risk of COVID-19 and to understand key symptoms upon clinical manifestation and presentation. Data on such symptoms may not be accurately synthesized into patient records owing to the pressing need to treat patients in overburdened health care settings. In this scenario, clinicians may focus on documenting widely reported symptoms that indicate a confirmed diagnosis of COVID-19, albeit at the expense of infrequently reported symptoms. While NLP solutions can play a key role in generating clinical phenotypes of COVID-19, they are limited by the resulting limitations in data from electronic health records (EHRs). A comprehensive record of clinic visits is required—audio recordings may be the answer. A recording of clinic visits represents a more comprehensive record of patient-reported symptoms. If done at scale, a combination of data from the EHR and recordings of clinic visits can be used to power NLP and machine learning models, thus rapidly generating a clinical phenotype of COVID-19. We propose the generation of a pipeline extending from audio or video recordings of clinic visits to establish a model that factors in clinical symptoms and predict COVID-19 incidence. With vast amounts of available data, we believe that a prediction model can be rapidly developed to promote the accurate screening of individuals at a high risk of COVID-19 and to identify patient characteristics that predict a greater risk of a more severe infection. If clinical encounters are recorded and our NLP model is adequately refined, benchtop virologic findings would be better informed. While clinic visit recordings are not the panacea for this pandemic, they are a low-cost option with many potential benefits, which have recently begun to be explored.

Prostate cancer detection with magnetic resonance imaging (MRI)/cognitive fusion biopsy: Comparing standard and targeted prostate biopsy with final prostatectomy histology

INTRODUCTION

The use of multiparametric magnetic resonance imaging (MRI) with targeted biopsies of the prostate improves the diagnosis of clinically significant prostate cancer. Recent studies have shown that targeted prostate biopsies also more accurately predict final histopathology after radical prostatectomy (RP). There are three broad techniques for performing MRI-targeted prostate biopsy: cognitive MRI/ultrasound (US) fusion, software MRI/US fusion, and in-bore MRI-guided. Current practices recommend that a standard systematic 12-core prostate biopsy be performed, as well as targeted biopsies in patients with positive MRI findings. This study aimed to evaluate the accuracy of histological grading of cognitive MRI/US fusion prostate biopsy by comparing the histology from the targeted biopsy specimens (TB), standard systematic specimens (SB), and the combination of both (CB) specimens with the final histological grade from subsequent prostatectomy.

METHODS

A retrospective, single-center review of 115 patients who underwent standard systematic and cognitive MRI/US-targeted biopsy of the prostate before undergoing a RP between 2016 and 2019 was performed. MRI findings, biopsy, final histology International Society of Urological Pathology (ISUP) grades, and patient demographics were collected. Cochran's Q test and McNemar test were used to compare the differences in upgrading, downgrading, and concordance between each biopsy group.

RESULTS

The concordance between SB, TB, and CB biopsy were 28.7%, 49.6%, and 50.4%, respectively. There was no significant difference in concordance between TB and CB. Patients were more likely to be downgraded on the final histology when comparing CB with TB alone (26.1% vs. 16.5%, p<0.05). In cases where an ISUP grade 1 cancer was diagnosed on TB (n=24), there was a 62.5% chance that the final histology would be upgraded. In the same sample, when combined with a SB, the risk of upgrading on final histology reduced to 37.5%.

CONCLUSIONS

Although grading concordance between TB and CB were similar, the concomitant use of a SB significantly reduced the rate of upgrading in the final RP histopathology. CB may result in better decision-making regarding treatment options and also have implications for intraoperative planning.

Natural growth pattern of sporadic renal angiomyolipoma

BACKGROUND

Surveillance of sporadic renal angiomyolipomas is a growing issue for physicians and radiologists. Current treatment recommendations favor active surveillance. However, the evidence underlying these is based on small case series, which also typically include angiomyolipomas associated with tuberous sclerosis.

PURPOSE

To evaluate the natural growth pattern of sporadic renal angiomyolipomas in patients without tuberous sclerosis.

MATERIAL AND METHODS

A retrospective review was performed in three separate tertiary referral centers. A keyword search of each institutions PACS history was performed. Inclusion criteria were angiomyolipomas > 1 cm in size, three years of follow-up, and lesions requiring treatment before reaching three years of follow-up. Exclusion criteria included a diagnosis of tuberous sclerosis, pregnancy, prior treatment with embolization without any prior imaging, and lesions which were treated on presentation. Growth of the angiomyolipomas was evaluated on the basis of maximum dimension on initial and follow-up images.

RESULTS

Sixty-three patients were identified in total, with 64 lesions eligible for inclusion. The majority of patients were women (55/63). The mean age at which the angiomyolipomas discovered was 56.4 years. Mean total growth was 0.085 mm and mean follow-up was 65.5 months. At initial measurement, the mean maximum dimension of the lesions in our cohort was 2.08 cm. After follow-up, this was 2.16 cm. The average rate of growth was 0.015 cm per year.

CONCLUSION

Sporadic angiomyolipomas exhibit minimal, if any, natural growth. Current surveillance strategies could be relaxed.

An in vitro–in vivo sequential cascade for the synthesis of iminosugars from aldoses

Here, we report a chemoenzymatic approach for the preparation of a small panel of biologically important iminosugars from readily available aldoses, employing a transaminase in combination with Gluconobacter oxydans whole cells.

Solvent-free manufacture of methacrylate polymers from biomass pyrolysis products

Biomass pyrolysis liquid is functionalised into a potential replacement for petrochemical derived methacrylates used in resins, adhesives and binders.

Total Knee Arthroplasty Design and Kinematics: Past, Present, and Future

Total knee arthroplasty has undergone significant improvement in design and clinical application over the past 45 years. Unfortunately, 15-20% of patients are not satisfied with their result. While the explanation for this discrepancy is multifactorial, prosthetic design and the motion of the knee in space has come under greater scrutiny. The early designs attempted to copy the anatomic appearance of the knee joint without considering how the knee would move. Kinematics is now considered to be of paramount importance and may be the key to the future of knee arthroplasty.

Building Your Own Neuroscience Equipment: A Precision Micromanipulator and an Epi-fluorescence Microscope for Calcium Imaging

A faculty member's ability to develop meaningful research-oriented laboratories in neurobiology is often hampered by the rapid pace of new technologies and the increasing cost of equipment. To help undergraduate neuroscience faculty meet these challenges, we introduce two important neuroscience research tools we designed and built. The first is a precision micromanipulator for neurophysiology applications costing less than $40 USD. We compare data generated using the DIY manipulator with commercial micromanipulators costing over $1000. The second tool is our newly designed 3D printed epi-fluorescence microscope. Commercial fluorescence imaging devices often cost over $20,000, but our 3D printed version is constructed for less than $1200. This epi-fluorescence microscope uses interchangeable LED light sources and filter sets to image static fluorescence in prepared slides and calcium imaging of neuronal activity in living Drosophila brains. This later technique uses transgenic flies with a genetically encoded calcium indicator, GCaMP, linked to green fluorescent protein (GFP). During an action potential, calcium ions (Ca2+) enter neurons and are observed as an increase in fluorescence intensity from a series of video images. These neuronal firing patterns can be assessed qualitatively and quantitatively to understand neural circuits leading to specific behaviors. We plan to develop curricula around the use of the epi-fluorescence microscope for calcium imaging in the next year, and to provide detailed parts sources and construction guides for the student and faculty DIY experience.

Estimating the rate and reasons of clinical trial failure in urologic oncology

OBJECTIVES

Clinical trials are pillars of modern clinical evidence generation. However, the clinical trial enterprise can be inefficient, and trials often fail before their planned endpoint is reached. We sought to estimate how often urologic oncology trials fail, why trials fail, and associations with trial failure.

METHODS

We queried phase 2/3 urologic clinical trial data from ClinicalTrials.gov registered between 2007 and 2019, with status marked as active, completed, or terminated. We extracted relevant trial data, including anticipated and actual accrual, from trial records and ClinicalTrials.gov archives. We manually coded reasons given in the "why stopped" free text field for trial failure into categories (poor accrual, interim results, toxicity/adverse events, study agent unavailable, canceled by the sponsor, inadequate budget, logistics, trial no longer needed, principal investigator left, no reason given, or other). We considered trials terminated for safety or efficacy to be completed trials. Trials marked as terminated for other reasons were considered failed trials. We then estimated the rate of trial failure using competing risks methods. Finally, we assessed associations with trial failure using a Cox proportional hazards model.

RESULTS

A total of 1,869 urologic oncology trials were included. Of these, 225 (12.0%) failed, and 51 (2.7%) were terminated for "good" reasons (e.g., toxicity, efficacy). Of the 225 failed trials, 122 (54%) failed due to poor accrual. Failed trials had a lower anticipated accrual than successfully completed trials (55 vs. 63 patients, P<0.001). A total of 6,832 patients were actually accrued to failed trials. The 10-year estimated risk of trial failure was 17% (95% CI 15%-22%). Single center trials, phase 3 trials, drug trials, and trials with exclusively USA sites were more likely to fail.

CONCLUSION

We estimate that 17%, or roughly 1 in 6, of urologic oncology trials fail, most frequently for poor accrual. Further investigations are needed into systemic, trial, and site-specific factors that may impact accrual and successful trial completion.

A functional ecological network based on metaproteomics responses of individual gut microbiomes to resistant starches

Resistant starches (RS) are dietary compounds processed by the gut microbiota into metabolites, such as butyrate, that are beneficial to the host. The production of butyrate by the microbiome appears to be affected by the plant source and type of RS as well as the individual's microbiota. In this study, we used in vitro culture and metaproteomic methods to explore individual microbiome's functional responses to RS2 (enzymatically-resistant starch), RS3 (retrograded starch) and RS4 (chemically-modified starch). Results showed that RS2 and RS3 significantly altered the protein expressions in the individual gut microbiomes, while RS4 did not result in significant protein changes. Significantly elevated protein groups were enriched in carbohydrate metabolism and transport functions of families Eubacteriaceae, Lachnospiraceae and Ruminococcaceae. In addition, Bifidobacteriaceae was significantly increased in response to RS3. We also observed taxon-specific enrichments of starch metabolism and pentose phosphate pathways corresponding to this family. Functions related to starch utilization, ABC transporters and pyruvate metabolism pathways were consistently increased in the individual microbiomes in response to RS2 and RS3. Given that these taxon-specific responses depended on the type of carbohydrate sources, we constructed a functional ecological network to gain a system-level insight of functional organization. Our results suggest that while some microbes tend to be functionally independent, there are subsets of microbes that are functionally co-regulated by environmental changes, potentially by alterations of trophic interactions.

Cosmic-ray antinuclei as messengers of new physics: status and outlook for the new decade

The precise measurement of cosmic-ray antinuclei serves as an important means for identifying the nature of dark matter and other new astrophysical phenomena, and could be used with other cosmic-ray species to understand cosmic-ray production and propagation in the Galaxy. For instance, low-energy antideuterons would provide a "smoking gun" signature of dark matter annihilation or decay, essentially free of astrophysical background. Studies in recent years have emphasized that models for cosmic-ray antideuterons must be considered together with the abundant cosmic antiprotons and any potential observation of antihelium. Therefore, a second dedicated Antideuteron Workshop was organized at UCLA in March 2019, bringing together a community of theorists and experimentalists to review the status of current observations of cosmic-ray antinuclei, the theoretical work towards understanding these signatures, and the potential of upcoming measurements to illuminate ongoing controversies. This review aims to synthesize this recent work and present implications for the upcoming decade of antinuclei observations and searches. This includes discussion of a possible dark matter signature in the AMS-02 antiproton spectrum, the most recent limits from BESS Polar-II on the cosmic antideuteron flux, and reports of candidate antihelium events by AMS-02; recent collider and cosmic-ray measurements relevant for antinuclei production models; the state of cosmic-ray transport models in light of AMS-02 and Voyager data; and the prospects for upcoming experiments, such as GAPS. This provides a roadmap for progress on cosmic antinuclei signatures of dark matter in the coming years.

Predictors of emergency department attendance following ureterorenoscopy for urolithiasis

BACKGROUND

We sought to determine the rate of emergency department (ED) attendance for complications after ureterorenoscopy (URS) for stone disease and to identify risk factors for ED attendance after URS.

METHODS

An analysis of all patients undergoing URS over 12 months at a single institution was performed. Patient demographics, preoperative and intraoperative variables associated with postoperative complications and subsequent ED attendance were collected. Logistic regression analyses were performed to determine predictors of URS complications presenting to ED.

RESULTS

In total, 202 ureteroscopies were performed on 142 patients for urolithiasis. The mean age was 50.73 ± 13.93 and 66% were male. The incidence of re-presentation to ED was 14.8% (n = 30). Patients presented with postoperative pain (n = 10; 4.95%), pyrexia (n = 9; 4.46%), urinary tract infection (UTI) (n = 7, 3.47%), haematuria (n = 3, 1.49%) and urosepsis (n = 1; 0.5%). Significant risk factors for ED attendance included preoperative stent dwell time > 30 days (P = 0.004), recently treated positive preoperative urine culture (P < 0.0001), stone size ≥ 13 mm (P = 0.043), stone location mid-ureter (P = 0.036) and female gender (P = 0.005). The following factors did not predict ED attendance, stent omission, access sheath utilization and operation duration.

CONCLUSION

Risk factors for ED attendance after URS include prolonged pre-stent dwell time, stone size ≥ 13 mm, treatment for a positive preoperative urine culture, mid-ureteric stone location and female gender. Urologists should be aware of these findings to decrease the risk of emergency re-presentation after elective URS surgery.

Asymmetric Construction of Alkaloids by Employing a Key ω-Transaminase Cascade

An ω-transaminase-triggered intramolecular aza-Michael reaction has been employed for the preparation of cyclic β-enaminones in good yield and excellent enantio- and diastereoselectivity, starting from easily accessible prochiral ketoynones and commercially available enzymes. The powerful thermodynamic driving force associated with the spontaneous aza-Michael reaction effectively displaces the transaminase reaction equilibrium towards product formation, using only two equivalents of isopropylamine. To demonstrate the potential of this methodology, this biocatalytic aza-Michael step was combined with annulation chemistry, affording unique stereo-defined fused alkaloid architectures.

Presentation, treatment and outcome of long-bone fractures in pet rabbits (Oryctolagus cuniculus)

OBJECTIVES

To describe the incidence, aetiology, characteristics, assessment, management and outcome of long-bone fractures in rabbits presenting to a single institution.

MATERIALS AND METHODS

Medical records of pet rabbits diagnosed with long-bone fractures over a 12-year period were analysed. Patient signalment, fracture aetiology, fracture location, fracture description, time from fracture occurrence to veterinary presentation, fixation method, postoperative complications, clinical outcome and follow-up were recorded.

RESULTS

Twenty-eight pet rabbits that sustained 30 fractures were included in the study [femoral (n=12), tibial (n=6), metacarpal/metatarsal/phalangeal (n=5), radial and ulnar (n=4) and tarsal (n=3)]. Twenty-one (75%) of the rabbits were less than 2 years of age, including seven (25%) under 6 months of age. Twenty-five fractures had no identifiable cause and five were traumatic. Only one fracture was open. Surgical stabilisation was performed in 22 fractures, four were non-surgically managed, two had the affected limb amputated, one underwent digital amputation and one was euthanased. Postoperative complications occurred in nine fractures [major (n=6), minor (n=3)]. The frequency of complications or attainment of a functional recovery was not notably different between the different methods of fixation. Overall, 24 rabbits recovered, two were euthanased and four underwent limb amputation.

CLINICAL SIGNIFICANCE

Fractures in rabbits typically occur in young animals and they usually lack an obvious aetiology. The majority of the rabbits treated achieved a functional recovery, although the postoperative complication rate was high in fractures treated surgically (41%).

The impact of increasing antimicrobial resistance in the treatment of urosepsis

BACKGROUND AND AIMS

Urosepsis accounts for up to 20-30% of all sepsis cases; however, increasing antimicrobial resistance is posing a significant threat to patient's outcomes. The aim of this study was to look at the prevalence of multi-drug resistant (MDR) organisms in patients admitted with urosepsis and their effect on the treatment and outcome of patients in our hospital.

METHODS

A total of 2679 urine cultures and 654 blood cultures performed in Connolly Hospital Emergency Department were reviewed between 2016 and 2018. Patients were included if they had a matching urine culture and blood culture performed within 24 h of admission. We compared patient demographics and underlying co-morbidities between patients admitted with urosepsis secondary to MDR organisms and non-MDR organisms.

RESULTS

Our study included 85 patients admitted with urosepsis. The most common causative pathogen was Escherichia coli, and 34.1% (n = 29) of pathogens were classified as an MDR organism. Patients admitted with urosepsis from long-term care facilities were 2.3 times more likely to have urosepsis due to a MDR organism compared with patients admitted from the community. Patients admitted with urosepsis secondary to a MDR organism were also more likely to have co-morbidities such as diabetes and dementia.

CONCLUSION

The high rate of antimicrobial resistance in patients admitted with urosepsis poses a challenge in prescribing the most appropriate antibiotics. It is crucial that prescribers follow local antibiotic guidelines for the treatment of urosepsis and are cognisant of the risk of specific patient groups presenting with urosepsis due to MDR organisms.