The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder

PURPOSE

The purpose of this guideline is to provide evidence-based guidance to clinicians of all specialties on the evaluation, management, and treatment of idiopathic overactive bladder (OAB). The guideline informs the reader on valid diagnostic processes and provides an approach to selecting treatment options for patients with OAB through the shared decision-making process that will maximize symptom control and quality of life, while minimizing adverse events and burden of disease.

METHODS

An electronic search employing OVID was used to systematically search the MEDLINE and EMBASE databases, as well as the Cochrane Library, for systematic reviews and primary studies evaluating diagnosis and treatment of OAB from January 2013 to November 2023. Criteria for inclusion and exclusion of studies were based on the Key Questions and the populations, interventions, comparators, outcomes, timing, types of studies and settings (PICOTS) of interest. Following the study selection process, 159 studies were included and were used to inform evidence-based recommendation statements.

RESULTS

This guideline produced 33 statements that cover the evaluation and diagnosis of the patient with symptoms suggestive of OAB; the treatment options for patients with OAB, including non-invasive therapies, pharmacotherapy, minimally invasive therapies, invasive therapies, and indwelling catheters; and the management of patients with BPH and OAB.

CONCLUSION

Once the diagnosis of OAB is made, the clinician and the patient with OAB have a variety of treatment options to choose from and should, through shared decision-making, formulate a personalized treatment approach taking into account evidence-based recommendations as well as patient values and preferences.

Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study

OBJECTIVES

Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose.

METHODS

Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0.

RESULTS

A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05).

CONCLUSIONS

There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

Evaluation of ChatGPT for Pelvic Floor Surgery Counseling

IMPORTANCE

Large language models are artificial intelligence applications that can comprehend and produce human-like text and language. ChatGPT is one such model. Recent advances have increased interest in the utility of large language models in medicine. Urogynecology counseling is complex and time-consuming. Therefore, we evaluated ChatGPT as a potential adjunct for patient counseling.

OBJECTIVE

Our primary objective was to compare the accuracy and completeness of ChatGPT responses to information in standard patient counseling leaflets regarding common urogynecological procedures.

STUDY DESIGN

Seven urogynecologists compared the accuracy and completeness of ChatGPT responses to standard patient leaflets using 5-point Likert scales with a score of 3 being "equally accurate" and "equally complete," and a score of 5 being "much more accurate" and much more complete, respectively. This was repeated 3 months later to evaluate the consistency of ChatGPT. Additional analysis of the understandability and actionability was completed by 2 authors using the Patient Education Materials Assessment Tool. Analysis was primarily descriptive. First and second ChatGPT queries were compared with the Wilcoxon signed rank test.

RESULTS

The median (interquartile range) accuracy was 3 (2-3) and completeness 3 (2-4) for the first ChatGPT query and 3 (3-3) and 4 (3-4), respectively, for the second query. Accuracy and completeness were significantly higher in the second query (P < 0.01). Understandability and actionability of ChatGPT responses were lower than the standard leaflets.

CONCLUSIONS

ChatGPT is similarly accurate and complete when compared with standard patient information leaflets for common urogynecological procedures. Large language models may be a helpful adjunct to direct patient-provider counseling. Further research to determine the efficacy and patient satisfaction of ChatGPT for patient counseling is needed.

The Impact of the Virtual Interview on Candidate Experience and Outcomes: Society of Academic Urologists National Survey of Interns Who Participated in the 2020-2021 Urology Match

OBJECTIVE

To examine retrospective experiences with the virtual interview (VI) process among postgraduate year 1 (PGY1) urology residents who participated in the 2020-2021 American Urologic Association (AUA) Match cycle.

METHODS

A 27-question survey created by a Society of Academic Urologists Taskforce on VI was distributed to PGY1 residents from 105 institutions between February 1, 2022 and March 7, 2022. The survey asked respondents to reflect on the VI process, cost concerns, and how experiences at their current program aligned with prior VI representation.

RESULTS

A total of 116 PGY-1 residents completed the survey. The majority felt the VI represented the following domains well: (1) institution/program culture and strengths (74%), (2) representation of all faculty/disciplines (74%), (3) resident quality of life (62%), (4) personal fit (66%), (5) quality of surgical training and volume (63%), and (6) opportunities to meet residents (60%). Approximately 71% of respondents did not match at their home program or a program they visited in-person. Within this cohort, 13% agreed important aspects of their current program were not translated virtually, and they would not have prioritized the program had they been able to visit in-person. In total, 61% ranked programs they ordinarily might not have listed during an in-person interview season. Overall, 25% deemed financial costs a "very important" consideration during the VI process.

CONCLUSION

The majority of PGY1 urology residents reported key components of their current program translated well from the VI process. This platform offers a method of overcoming conventional geographic and financial barriers associated with the in-person interview process.

Understanding the Urology Program Directors Perspective on the Current Resident Selection Process: The Society of Academic Urologists National Survey of Urology Program Directors

OBJECTIVE

The traditional residency selection process was altered dramatically by the SARS CoV-2 (COVID-19) pandemic. For the 2020-2021 application cycle in-person interviews were transitioned to the virtual format. What was thought to be a temporary transition has now become the new standard with continued endorsement from the Association of American Medical Colleges (AAMC) and the Society of Academic Urologists (SAU) for virtual interviews (VI). We sought to assess the perceived efficacy and satisfaction of the VI format from the urology residency program director's (PDs) perspective.

DESIGN

A designated SAU Taskforce on "Optimizing the Applicant Experience in the Virtual Interview Era" developed and refined a survey composed of 69 questions on VI and was distributed to all urology program directors (PD) of member institutions of the SAU. The survey focused on candidate selection, faculty preparation, and interview day logistics. PDs were also asked to reflect on the impact of VI on their match results, recruitment of underrepresented minorities and female gender, and what their preference would be for future applications cycles.

PARTICIPANTS

Urology residency PDs (84.7% response rate) between January 13, 2022 - February 10, 2022 were included in the study.

RESULTS

Most programs interviewed a total of 36 to 50 applicants (80%), with an average of 10 to 20 applicants per interview day. The top 3 ranked criteria for interview selection reported by urology PDs surveyed included letters of recommendation, clerkship grades, and USMLE Step 1 score. The most common areas of formal training for faculty interviewers were diversity, equity and inclusion (55%), implicit bias (66%), and review of the SAU guidelines on illegal questions (83%). Over half (61.4%) of PDs believed that they were able to accurately represent their training program through the virtual platform, while 51% felt that VI did not afford similar assessments of applicant as in-person interviews. Two-thirds of PDs believed the VI platform improve access for all applicants to attend interviews. Focusing on the impact of the VI platform for recruitment of underrepresented minorities (URM) and female gender applicants, 15% and 24% reported improved visibility respectively for their program, and 24% and 11% reported increased ability to interview URM and female gender applicants respectively. Overall, in-person interviews were reported to be preferred by 42%, and 51% of PDs desired VIs to be included in future years.

CONCLUSIONS

PDs opinion and role of the VIs into the future is variable. Despite uniform agreement of cost savings and belief that VI platform improves access for all, only half of PDs expressed interest of the VI format being continued in some form. PDs note limitation of VI in the ability to comprehensively assess applicants as well as the in-person format. Many programs have begun to incorporate vital training in the areas of diversity equity and inclusion bias, and illegal questions. There is a role for continued development and research on ways to optimize virtual interviews.

Outcome of patients with tetralogy of Fallot repair over 50 years of age

Purpose

To report the outcomes of patients with repaired tetralogy of Fallot (TOF) above 50 years of age.

Methods

We reviewed records of TOF patients who were followed in our institution since 2000. Demographic data, surgical reports and long-term outcomes were analyzed retrospectively.

Results

Thirty-five of 297 (12%) patients who underwent TOF repair were above 50 years of age (25 men [60%]) at the last follow-up. Eighteen patients (48%) had prior palliative surgery. The mean age at the first repair was 18±13 years (5 patients after 40 years of age). Reoperation with pulmonary valve replacement was performed in 10 (28%) patients, and a second redo surgery in 6 (17%) patients. During a mean 17± 2 years follow-up 7 (8.5%) patients died (n=6 end-stage heart failure, n=1 infective endocarditis). At the last follow-up 21/35 patients (60%) were treated with tachyarrhythmia, 19/35 (54%) with chronic heart failure and 17/35 (48%) with comorbidities (hypertension, coronary artery disease/peripherial artery disease, diabetes mellitus, renal failure). Using multivariate analysis the only predictor of death was heart failure (OR: 6.8). Furthermore atrial tachycardia (OR: 8.8) and at least grade II tricuspid regurgitation (OR: 5.0) were identified as predictors of heart failure.

Conclusion

This historical cohort of TOF patients with late repair has a high morbidity rate later in life. Approximately half of the patients require treatment for chronic heart failure, arrhythmias and cardiovascular related comorbidities. Atrial tachycardia and tricuspid regurgitation are strong predictors for heart failure. In this population the strongest predictor for death is heart failure.

Funding Acknowledgement

Type of funding source: None

A transition-edge sensor-based x-ray spectrometer for the study of highly charged ions at the National Institute of Standards and Technology electron beam ion trap

We report on the design, commissioning, and initial measurements of a Transition-Edge Sensor (TES) x-ray spectrometer for the Electron Beam Ion Trap (EBIT) at the National Institute of Standards and Technology (NIST). Over the past few decades, the NIST EBIT has produced numerous studies of highly charged ions in diverse fields such as atomic physics, plasma spectroscopy, and laboratory astrophysics. The newly commissioned NIST EBIT TES Spectrometer (NETS) improves the measurement capabilities of the EBIT through a combination of high x-ray collection efficiency and resolving power. NETS utilizes 192 individual TES x-ray microcalorimeters (166/192 yield) to improve upon the collection area by a factor of ∼30 over the 4-pixel neutron transmutation doped germanium-based microcalorimeter spectrometer previously used at the NIST EBIT. The NETS microcalorimeters are optimized for the x-ray energies from roughly 500 eV to 8000 eV and achieve an energy resolution of 3.7 eV-5.0 eV over this range, a more modest (<2×) improvement over the previous microcalorimeters. Beyond this energy range, NETS can operate with various trade-offs, the most significant of which are reduced efficiency at lower energies and being limited to a subset of the pixels at higher energies. As an initial demonstration of the capabilities of NETS, we measured transitions in He-like and H-like O, Ne, and Ar as well as Ni-like W. We detail the energy calibration and data analysis techniques used to transform detector counts into x-ray spectra, a process that will be the basis for analyzing future data.

Measuring the difference in nuclear charge radius of Xe isotopes by EUV spectroscopy of highly charged Na-like ions

The difference in the mean-square nuclear charge radius of xenon isotopes was measured utilizing a method based on extreme ultraviolet spectroscopy of highly charged Na-like ions. The isotope shift of the Na-like D1 (3s 2 S 1/2 - 3p 2 P 1/2) transition between the 124Xe and 136Xe isotopes was experimentally determined using the electron-beam ion-trap facility at the National Institute of Standards and Technology. The mass-shift and the field-shift coefficients were calculated with enhanced precision by the relativistic many-body perturbation theory and multiconfiguration Dirac-Hartree-Fock method. The mean-square nuclear charge radius difference was found to be δ〈r 2〉136,124 = 0.269(42) fm2. Our result has smaller uncertainty than previous experimental results and agrees with the literature values.

Successful use of cyclosporine as treatment for eosinophilic cystitis: a case report

Background

Eosinophilic cystitis is a rare inflammatory disorder characterized by eosinophilic infiltration of all layers of the urinary bladder wall. Due to lack of consensus and potential for side effect from various therapeutic options, treatment of the disease is often challenging.

Case presentation

A 64-year old woman with hypertensive nephropathy resulting in stage III chronic kidney disease, obstructive sleep apnea, and obstructive lung disease presented with a 4 month history of dysuria, urgency, frequency, and persistent hematuria. Based on eosinophilic infiltration on bladder wall biopsy in the absence of any evidence of infection, malignancy, or immune disorder, she was diagnosed with eosinophilic cystitis. Despite multiple medication regimens, her symptoms persisted, requiring high-dose prednisone with steroid-related side effects. After four months, she was started on cyclosporine, which led to symptomatic improvement and reduction in prednisone dosage. At that time, repeat urine cytology and cystoscopy did not reveal friable tissues or eosinophiluria.

Conclusion

This case illustrates the utility of using cyclosporine to treat eosinophilic cystitis in adult patient with multiple comorbid conditions.

Rheological Evaluation and Observations of Extrusion Instabilities of Biodegradable Polyesters

The rheological properties of two commercially available biodegradable polyesters – poly(lactic acid) (PLA) and aliphatic-aromatic co-polyester Ecoflex™ – have been investigated. The rheological study was focused on measuring the viscosity and examining sharkskin, melt fracture, and extrudate swell phenomena, which are crucial in industrial applications. The experiments show that the two biodegradable polyesters exhibit shear-thinning behavior similar to other polymers and the Cox-Merz rule is obeyed. It was observed that with increasing shear rate PLA exhibits sharkskin and gross melt fracture while Ecoflex™ exhibits only gross melt fracture. Experimental results indicate that both biodegradable polyesters exhibit small extrudate swell, up to 28% for PLA and up to 34% for Ecoflex™.

Testing three-body quantum electrodynamics with trapped Ti20+ ions: evidence for a Z-dependent divergence between experiment and calculation

We report a new test of quantum electrodynamics (QED) for the w (1s2p(1)P(1)→1s(2)(1)S(0)) x-ray resonance line transition energy in heliumlike titanium. This measurement is one of few sensitive to two-electron QED contributions. Systematic errors such as Doppler shifts are minimized in our experiment by trapping and stripping Ti atoms in an electron beam ion trap and by applying absolute wavelength standards to calibrate the dispersion function of a curved-crystal spectrometer. We also report a more general systematic discrepancy between QED theory and experiment for the w transition energy in heliumlike ions for Z>20. When all of the data available in the literature for Z=16-92 are taken into account, the divergence is seen to grow as approximately Z(3) with a statistical significance on the coefficient that rises to the level of 5 standard deviations. Our result for titanium alone, 4749.85(7) eV for the w line, deviates from the most recent ab initio prediction by 3 times our experimental uncertainty and by more than 10 times the currently estimated uncertainty in the theoretical prediction.

Rotational Foam Molding of Metallocene Catalyzed Polyethylene: CBA Screening and Process Characteristics

The objective of this work is to investigate the effects of different chemical blowing agents (CBAs) and processing conditions on the cellular structure of foamed metallocene polyethylene and characterize an appropriate blowing agent. An experimental study was conducted to produce metallocene polyethylene foams in dry-blending-based rotational foam molding. The critical processing parameters that optimize the foam structure have been identified through modifications of the molding conditions. The physical properties and cellular structure of the final foamed parts were also examined. The foaming performance of exothermic and endothermic CBAs was studied. It was revealed that selecting a suitable CBA is crucial as the foam structure depends significantly on the properties of the blowing agent. Exothermic blowing agents resulted in greater foam density reduction and exhibited a wider processing window compared to endothermic blowing agents. It was found that a balance between different properties of the blowing agent is required to achieve control over the foam structure.

Study of solvent-protein coupling effects by neutron scattering

The present work aims to characterize the dynamical behavior of proteins immersed in bio-preserving liquids and glasses. For this purpose, the protein dUTPase was chosen, while the selected solvents were glycerol, a triol, and some homologous disaccharides, i.e., trehalose, maltose, and sucrose, which are known to be very effective bio-preserving agents. The results highlight that the disaccharides show a slowing down effect on the water dynamics, which is stronger for trehalose than in the case of the other disaccharides. Furthermore, a characterization of the medium which hosts the protein is performed by using an operative definition of fragility based on the mean square displacement extracted by elastic incoherent neutron scattering, which is directly connected to Angell's kinetic fragility based on the viscosity. Finally, a study of the dynamics of the protein sequestered within the solvents is performed. The result shows that the protein dynamics is coupled with that of the surrounding matrix.

The implementation of quality management systems in hospitals: a comparison between three countries

Background

Is the implementation of Quality Management (QM) in health care proceeding satisfactorily and can national health care policies influence the implementation process? Policymakers and researchers in a country need to know the answer to this question. Cross country comparisons can reveal whether sufficient progress is being made and how this can be stimulated.

The objective of the study was to investigate agreement and disparities in the implementation of QMS between The Netherlands, Hungary and Finland with respect to the evaluation model used and the national policy strategy of the three countries.

Methods

The study has a cross sectional design, based on measurements in 2000. Empirical data about QM-activities in hospitals were gathered by a self-administered questionnaire. The questionnaires were answered by the directors of the hospitals or the quality coordinators. The analyses are based on data from 101 hospitals in the Netherlands, 116 hospitals in Hungary and 59 hospitals in Finland.

Outcome measures are the developmental stage of the Quality Management System (QMS), the development within five focal areas, and distinct QM-activities which were listed in the questionnaire.

Results

A mean of 22 QM-activities per hospital was found in the Netherlands and Finland versus 20 QM-activities in Hungarian hospitals. Only a small number of hospitals has already implemented a QMS (4% in The Netherlands,0% in Hungary and 3% in Finland). More hospitals in the Netherlands are concentrating on quality documents, whereas Finnish hospitals are concentrating on training in QM and guidelines. Cyclic quality improvement activities have been developed in the three countries, but in most hospitals the results were not used for improvements. All three countries pay hardly any attention to patient participation.

Conclusion

The study demonstrates that the implementation of QM-activities can be measured at national level and that differences between countries can be assessed. The hypothesis that governmental legislation or financial reimbursement can stimulate the implementation of QM-activities, more than voluntary recommendations, could not be confirmed. However, the results show that specific obligations can stimulate the implementation of QM-activities more than general, framework legislation.

Lymphatics in the aorta of rats treated with a soy-bean oil extract (lipofundin)

Lipofundin-S 20% (a soy-bean oil extract) when administered intravenously to rats resulted in dilation of aortic lymphatics at the media-adventitia junction. Increased endothelial permeability as demonstrated by intraaortic colloidal iron uptake with dynamic insufficiency of lymphatic drainage is suggested as the basis for dilatation of intraaortic adventitial lymphatics.

Lysergic Acid Diethylamide (LSD): No Teratogenicity in Rats

Lysergic acid diethylamide (LSD) in doses of 1.5 to 300 micrograms was given to 55 pregnant rats during periods of organogenesis and on the 4th or 5th day of pregnancy to 34 rats. Examination of the resultant 887 young for congenital defects showed no greater frequency than in controls. These experimtents failed to prove that LSD is teratogenic in rats.

Chromosome changes in embryos treated with various teratogens

The association of chromosome changes with certain syndromes of congenital malformations has raised new questions as to the possible role of abnormal chromosome complements in teratogenesis. For example, mosaics are thought to originate in the first divisions of the fertilized ovum, and one may ask how late in embryogenesis permanent chromosome changes can be induced. Investigations have been undertaken in this laboratory to ascertain whether teratogens administered to pregnant rats on the 11–13th days of gestation, when many malformations can be induced, will result in embryos with chromosomal aberrations as well as malformations.

In a previous report (Soukup, Takacs & Warkany, 1965) we have described experiments in which pregnant rats were treated with teratogenic doses of X-ray followed by examination of embryos for detectable chromosome abnormalities.

In embryos irradiated on the 13th day with 400 r and examined 6–12 h later, approximately 60 % of the countable metaphase figures revealed chromosome aberrations.