Atypical Presentation Delays Treatment of Pediatric Testicular Torsion

OBJECTIVE

The aim of the study is to identify patient- and care-related factors associated with time to treatment for acute testicular torsion and the likelihood of testicular loss.

METHODS

Data were retrospectively collected for patients 18 years and younger who had surgery for acute testicular torsion between April 1, 2005, and September 1, 2021. Atypical symptoms and history were defined as having abdominal, leg, or flank pain, dysuria, urinary frequency, local trauma, or not having testicular pain. The primary outcome was testicular loss. The primary process measure was time from emergency department (ED) triage to surgery.

RESULTS

One hundred eleven patients were included in descriptive analysis. The rate of testicular loss was 35%. Forty-one percent of all patients reported atypical symptoms or history. Eighty-four patients had adequate data to calculate time from symptom onset to surgery and time from triage to surgery and were included in analyses of factors affecting risk of testicular loss. Sixty-eight patients had adequate data to evaluate all care-related time points and were included in analyses to determine factors affecting time from ED triage to surgery. On multivariable regression analyses, increased risk of testicular loss was associated with younger age and longer time from symptom onset to ED triage, while longer time from triage to surgery was associated with reporting atypical symptoms or history.The most frequently reported atypical symptom was abdominal pain, in 26% of patients. These patients were more likely to have nausea and/or vomiting and abdominal tenderness but equally likely to report testicular pain and swelling and have testicular findings on examination.

CONCLUSIONS

Patients presenting to the ED with acute testicular torsion reporting atypical symptoms or history experience slower transit from arrival in the ED to operative management and may be at greater risk of testicular loss. Increased awareness of atypical presentations of pediatric acute testicular torsion may improve time to treatment.

Comparative Analyses and Ablation Efficiency of Thulium Fiber Laser by Stone Composition

PURPOSE

There are limited data on ablation effects of thulium fiber laser (TFL) settings with varying stone composition. Similarly, little is known surrounding the photothermal effects of TFL lithotripsy regarding the chemical and structural changes after visible char formation. We aim to understand the TFL's ablative efficiency across various stone types and laser settings, while simultaneously investigating the photothermal effects of TFL lithotripsy.

MATERIALS AND METHODS

Human specimens of calcium oxalate monohydrate, calcium oxalate dihydrate, uric acid, struvite, cystine, carbonate apatite, and brushite stones were ablated using 13 prespecified settings with the Coloplast TFL Drive. Pre- and postablation mass, ablation time, and total energy were recorded. Qualitative ablative observations were recorded at 1-minute intervals with photographs and gross description. Samples were analyzed with Fourier-transform infrared spectroscopy pre- and postablation and electron microscopy postablation to assess the photothermal effects of TFL.

RESULTS

Across all settings and stone types, 0.05 J × 1000 Hz was the best numerically efficient ablation setting. When selected for more clinically relevant laser settings (ie, 10-20 W), 0.2 J × 100 Hz, short pulse was the most numerically efficient setting for calcium oxalate dihydrate, cystine, and struvite stones. Calcium oxalate monohydrate ablated with the best numerical efficiency at 0.4 J × 40 Hz, short pulse. Uric acid and carbonate apatite stones ablated with the best numerical efficiency at 0.3 J × 60 Hz, short pulse. Brushite stones ablated with the best numerical efficiency at 0.5 J × 30 Hz, short pulse. Pulse duration impacted ablation effectiveness greatly with 6/8 (75%) of inadequate ablations occurring in medium or long pulse settings. The average percent of mass lost during ablation was 57%; cystine stones averaged the highest percent mass lost at 71%. Charring was observed in 36/91 (40%) specimens. Charring was most often seen in uric acid, cystine, and brushite stones across all laser settings. Electron microscopy of char demonstrated a porous melting effect different to that of brittle fracture. Fourier-transform infrared spectroscopy of brushite char demonstrated a chemical composition change to amorphous calcium phosphate.

CONCLUSIONS

We describe the optimal ablation settings based on stone composition, which may guide urologists towards more stone-specific care when using thulium laser for treating renal stones (lower energy settings would be safer for ureteral stones). For patients with unknown stone composition, lasers can be preset to target common stone types or adjusted based on visual cues. We recommend using short pulse for all TFL lithotripsy of calculi and altering the settings based on visual cues and efficiency to minimize the charring, an effect which can make the stone refractory to further dusting and fragmentation.

Antimicrobial Prophylaxis for Percutaneous Nephrolithotomy: Contemporary Practice Patterns

Background: Updated in 2019, the American Urological Association's (AUA) Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis outlines prophylaxis for percutaneous nephrolithotomy (PCNL). Recent studies have challenged these recommendations. We hypothesized that endourologists do not routinely follow the AUA's statement on antibiotic use during PCNL and assessed their prescribing patterns. Methods: A 24-question survey was distributed to members of the Endourological Society. The primary outcome was adherence to the AUA's recommendations. Two multiple logistic regression analyses were performed with demographics and antibiotic preference as predictors of following the AUA. Results: A total of 51.4% of endourologists follow the AUA Best Practice Statement for antimicrobial prophylaxis of uncomplicated PCNL. No demographic data were predictive of following the AUA. 90.9% and 83.6% reported they have "never" used the first-line recommendation options of metronidazole and aztreonam, respectively. Preferred antibiotics were cephalosporins (uncomplicated 60%, complicated 52.6%), fluoroquinolones (13.3%, 7.2%), aminoglycosides (12.7%, 17.8%), penicillins (7.9%, 11.2%), carbapenems (0.6%, 0.7%), trimethoprim-sulfamethoxazole (2.4%, 5.9%), fosfomycin (0.6%, 0.7%), nitrofurantoin (2.4%, 2.6%), aztreonam (0%, 0.7%), and clindamycin (0%, 0.7%). For uncomplicated PCNL, 63.1% prescribe ≤24 hours of perioperative antibiotics. For complicated PCNL, 16.2% prescribe ≤24 hours of perioperative antibiotics, while 20.4% begin antibiotics 7 or more days prior. Conclusions: Nearly half of respondents do not follow the AUA's recommendations for antibiotic choice for PCNL. Few endourologists prescribe 7 days of preoperative antibiotics for complicated PCNL despite supporting data. Metronidazole and aztreonam are rarely used as a first-line antibiotic choice for PCNL and their roles needs to be further evaluated as first-line prophylaxis recommendations. Updates on antibiotic recommendations for PCNL are needed based on current literature, antimicrobial stewardship, and contemporary practice patterns.

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.

Survival outcomes in patients with muscle invasive bladder cancer undergoing radical vs. partial cystectomy

PURPOSE

While radical cystectomy (RC) is the standard of care for muscle invasive bladder cancer (MIBC), partial cystectomy (PC) is an effective alternative in select patients. We sought to examine differences in survival for RC and PC in a hospital-based registry.

MATERIAL AND METHODS

We identified patients diagnosed with cT2-4 bladder cancer who underwent RC or PC from 2003 to 2015 in the National Cancer Database (NCDB). Using inverse probability treatment weighting (IPTW) to control for known confounders, we compared the primary outcome of overall survival (OS) in patients who underwent RC vs. PC. Kaplan-Meier survival analysis, univariable and multivariable Cox proportional hazards modeling were used. We performed a secondary survival analysis for a subcohort of patients with cT2, cN0, tumor size ≤5 cm, and no concurrent carcinoma in situ (CIS), who may be optimal candidates for PC.

RESULTS

A total of 22,534 patients met inclusion criteria, of which 6.9% (1,457) underwent PC. RC had longer median OS than PC (67.8 vs. 54.1 months) and on Cox regression analysis (HR 0.88, 95% CI, 0.80-0.95, P = 0.002). However, in our subcohort, there was no difference in OS between RC and PC (HR 1.02, 95% CI, 0.9-1.2, P = 0.74). PC was associated with increased time from surgery to any systemic therapy or death in the subcohort.

CONCLUSIONS

Among patients with clinically organ-confined MIBC, PC appears to afford similar survival outcomes to RC in a large national data set. The safety and tolerability of PC may warrant consideration in highly selected patients.

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.

Ergonomic Considerations in Urologic Surgery

PURPOSE OF REVIEW

This paper aims to discuss the various work-related musculoskeletal disorders (WRMDs) among urologists and provide an overview of the latest recommendations to improve awareness of ergonomic principles that can be applied in the operating room, with special consideration of challenges faced during pregnancy.

RECENT FINDINGS

Urologists suffer from a large burden of WRMDs. The main drivers of pain associated with the various surgical approaches include repetitive movements, static and awkward body positions, and the use of burdensome equipment. Pregnant surgeons are at an even greater risk of WRMDs and face high rates of pregnancy complications. Laparoscopy, endoscopy, robot-assisted surgeries, and open surgeries present unique ergonomic challenges for the practicing urologist. Proper posture and equipment use, optimal operating room setup, intraoperative stretching breaks, and an emphasis on teaching ergonomic principles can reduce the risk of WRMDs. Surgeons are also at increased risk of WRMDs during pregnancy but may continue to operate while taking measures to limit physical exertion and fatigue. Improving awareness of and incorporating ergonomic principles early in a urologist's career may reduce the risk of injury and improve operative performance and longevity.

Lewy Body Pathology and Alzheimer Disease in Down Syndrome

Introduction/Objective

Aging adults with Down syndrome (DS) develop Alzheimer disease neuropathology (AD) by the age of 40 years, primarily due to the overexpression of the amyloid precursor protein on chromosome 21. Lewy bodies (LBs), containing alpha-synuclein protein, are observed in 7-60% of AD patients in the amygdala and in cortex. Prior DS studies (n=20-56 cases) find the frequency of LB pathology to range between 8-50% of cases being affected. We hypothesized that LB pathology would also be present in DS brain with similar locations and prevalence to AD. Thus, we evaluated the frequency of LB in our UCI cohort of DS cases that we have collected over the past 25 years.

Methods/Case Report

Neuropathology reports from 55 cases with DS from the UCI-ADRC were included in this study. Cases were stained for beta-amyloid, phosphor-tau, alpha-synuclein and TDP-43 as per NACC protocols (one case each v7,8,9 and three v11).

Results (if a Case Study enter NA)

We identified 6 cases (10.9%), all male, with a mean age of 57 years (SD=3) that showed LB and/or Lewy neurites. LB pathology was classified as amygdala predominant in 3 cases, brainstem predominant in one, intermediate/transitional in one, and diffuse/neocortical in one. Five cases were BRAAK stage 6 and one was stage 5. Five cases had CERAD neuritic plaque score C and one case had a B score. Two of 3 cases were Thal phase 5, and one was phase 4. The case with diffuse/neocortical LB pathology demonstrated hippocampal sclerosis.

Conclusion

The observation that all our LB positive cases were male may reflect a sample bias. In our study, Lewy pathology was most common in amygdala but other sites of involvement are seen similar to a prior DS study and AD studies. Prior DS studies (n=20-56 cases) find the frequency of LB pathology to range between 8-50% of cases being affected. The prevalence of LB in our DS cohort (10.9%) is in the low end of the range seen in other DS and AD studies.

Rare case of an isolated scaphoid congenital megalourethra: before and after reconstruction

Congenital megalourethra, first described in 1955, is a rare urethral anomaly resulting from dysgenesis of the penile corpus spongiosum, with or without corpus cavernosum involvement, leading to dilatation of the penile urethra. Presentations come in two forms, scaphoid and fusiform, with the former being more common and resulting from deficient or absent corpus spongiosum. Fusiform types are much rarer, and consist of absence of both the corpus spongiosum and cavernosum.3 Here, we present a case involving the surgical correction of an isolated scaphoid-type congenital megalourethra with significantly improved postoperative cosmetic and functional outcomes.

Predicting Sepsis in Patients with Ureteral Stones in the Emergency Department

BACKGROUND

In the absence of overt infectious signs, clinical criteria for early intervention in patients with ureteral stones are poorly defined. We aimed to develop a model that can identify patients who are at risk for developing sepsis if discharged home from the emergency department (ED).

MATERIALS AND METHODS

We retrospectively reviewed patients between January 2010 and December 2019 who were discharged from the ED after diagnosis of ureteral stones. The primary outcome was sepsis requiring urgent surgical decompression. We used multivariable logistic regression to identify predictors of sepsis. We refined the model using backwards stepwise regression with a threshold p-value 0.05.

RESULTS

We identified 1,331 patients who were discharged from the ED with ureteral stones. Of these patients, 22 (2%) subsequently developed sepsis requiring urgent decompression. In the initial multivariable model, female gender (OR 2.82, p=0.039) and urine white blood cells (WBC) (OR 1.02 per cell count, p<0.001) were predictive of sepsis. After performing backwards stepwise regression, female gender, urine WBC, and leukocytosis (WBC > 15,000/mm3) met criteria for inclusion in the model. A logistic model including these variables predicted sepsis with an internally cross-validated area under the curve of 0.79. Among patients with urine cultures completed in the ED, rates of sepsis were 9% in patients with positive cultures and 1% in patients with negative cultures (p<0.001). Antibiotic usage was not protective against developing sepsis.

CONCLUSIONS

Sepsis is a rare complication among patients with ureteral stones selected for conservative management. The presence of elevated urine WBC and female gender can help identify patients who are at risk of developing sepsis. Patients with risk factors should be managed with an increased index of suspicion for infection and may benefit from early intervention to reduce the risk of sepsis. Sepsis is more common in patients with positive urine cultures.

Pediatric Penile Non-Involuting Congenital Hemangioma With an Associated Pyogenic Granuloma: Surgical Management of a Rare Vascular Anomaly

Vascular anomalies include both tumors and malformations. Infantile hemangiomas are the most common benign vascular tumor of infancy that proliferate after birth and eventually involute. By contrast, congenital hemangiomas are formed at birth and are categorized into three groups: rapidly involuting, partially-involuting, and non-involuting congenital hemangiomas (NICH). NICH do not regress and grow with age. Pyogenic granulomas, another acquired vascular tumor, develop over vascular lesions and cause bleeding. Primary treatment options for NICH and pyogenic granulomas are surgical resection. Here, we report a case of a NICH with a co-existing pyogenic granuloma involving the penile shaft and scrotum treated surgically.

Overcoming Immune Resistance in Prostate Cancer: Challenges and Advances

Simple Summary

Immunotherapy has changed the landscape of treatment modalities available for many different types of malignancies. However, the factors that influence the success of immunotherapeutics have not been as clearly seen in advanced prostate cancer, likely due to immunosuppressive factors that exist within the prostate cancer tumor microenvironment. While there have been many immunotherapeutics used for prostate cancer, the majority have targeted a single immunosuppressive mechanism resulting in limited clinical efficacy. More recent research centered on elucidating the key mechanisms of immune resistance in the prostate tumor microenvironment has led to the discovery of a range of new treatment targets. With that in mind, many clinical trials have now set out to evaluate combination immunotherapeutic strategies in patients with advanced prostate cancer, in the hopes of circumventing the immunosuppressive mechanisms.

Abstract

The use of immunotherapy has become a critical treatment modality in many advanced cancers. However, immunotherapy in prostate cancer has not been met with similar success. Multiple interrelated mechanisms, such as low tumor mutational burden, immunosuppressive cells, and impaired cellular immunity, appear to subvert the immune system, creating an immunosuppressive tumor microenvironment and leading to lower treatment efficacy in advanced prostate cancer. The lethality of metastatic castrate-resistant prostate cancer is driven by the lack of therapeutic regimens capable of generating durable responses. Multiple strategies are currently being tested to overcome immune resistance including combining various classes of treatment modalities. Several completed and ongoing trials have shown that combining vaccines or checkpoint inhibitors with hormonal therapy, radiotherapy, antibody–drug conjugates, chimeric antigen receptor T cell therapy, or chemotherapy may enhance immune responses and induce long-lasting clinical responses without significant toxicity. Here, we review the current state of immunotherapy for prostate cancer, as well as tumor-specific mechanisms underlying therapeutic resistance, with a comprehensive look at the current preclinical and clinical immunotherapeutic strategies aimed at overcoming the immunosuppressive tumor microenvironment and impaired cellular immunity that have largely limited the utility of immunotherapy in advanced prostate cancer.

Urology Virtual Education Programs During the COVID-19 Pandemic

Purpose of Review

This article aims to describe the impact of the COVID-19 pandemic on American urology trainees, with a focus on virtual learning initiatives.

Recent Findings

Urological education was forced to rapidly adapt to the COVID-19 pandemic in 2020. Significant challenges included quarantines, redeployment of residents and faculty, and suspension of regularly scheduled conferences. In response, urologists across the country adopted web-based platforms to develop virtual lecture series to fill the gap. Popular programs for residents included UCSF’s COViD (Collaborative Online Video Didactics) series and the New York Section of the American Urological Association’s EMPIRE (Educational Multi-institutional Program for Instructing REsidents) series.

Summary

Virtual education programs have enabled urology trainees to pursue their education during the pandemic. While the long-term impact of the pandemic on urology training remains unknown, some good may be found in the innovative solutions that have arisen in urology education.

Gastrointestinal Tract Pathology in a BALB/c Niemann-Pick Disease Type C1 Null Mouse Model

BACKGROUND

Niemann-Pick disease, type C (NPC) is a rare lysosomal storage disorder characterized by progressive neurodegeneration, splenomegaly, hepatomegaly, and early death. NPC is caused by mutations in either the NPC1 or NPC2 gene. Impaired NPC function leads to defective intracellular transport of unesterified cholesterol and its accumulation in late endosomes and lysosomes. A high frequency of Crohn disease has been reported in NPC1 patients, suggesting that gastrointestinal tract pathology may become a more prominent clinical issue if effective therapies are developed to slow the neurodegeneration. The Npc1 nih mouse model on a BALB/c background replicates the hepatic and neurological disease observed in NPC1 patients. Thus, we sought to characterize the gastrointestinal tract pathology in this model to determine whether it can serve as a model of Crohn disease in NPC1.

METHODS

We analyzed the gastrointestinal tract and isolated macrophages of BALB/cJ cNctr-Npc1m1N/J (Npc1-/-) mouse model to determine whether there was any Crohn-like pathology or inflammatory cell activation. We also evaluated temporal changes in the microbiota by 16S rRNA sequencing of fecal samples to determine whether there were changes consistent with Crohn disease.

RESULTS

Relative to controls, Npc1 mutant mice demonstrate increased inflammation and crypt abscesses in the gastrointestinal tract; however, the observed pathological changes are significantly less than those observed in other Crohn disease mouse models. Analysis of Npc1 mutant macrophages demonstrated an increased response to lipopolysaccharides and delayed bactericidal activity; both of which are pathological features of Crohn disease. Analysis of the bacterial microbiota does not mimic what is reported in Crohn disease in either human or mouse models. We did observe significant increases in cyanobacteria and epsilon-proteobacteria. The increase in epsilon-proteobacteria may be related to altered cholesterol homeostasis since cholesterol is known to promote growth of this bacterial subgroup.

CONCLUSIONS

Macrophage dysfunction in the BALB/c Npc1-/- mouse is similar to that observed in other Crohn disease models. However, neither the degree of pathology nor the microbiota changes are typical of Crohn disease. Thus, this mouse model is not a good model system for Crohn disease pathology reported in NPC1 patients.

Vitamin D levels in Smith-Lemli-Opitz syndrome

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive congenital malformation syndrome caused by mutations in the 7-dehydrocholesterol reductase gene. This inborn error of cholesterol synthesis leads to elevated concentrations of 7-dehydrocholesterol (7-DHC). 7-DHC also serves as the precursor for vitamin D synthesis. Limited data is available on vitamin D levels in individuals with SLOS. Due to elevated concentrations of 7-DHC, we hypothesized that vitamin D status would be abnormal and possibly reach toxic levels in patients with SLOS. Through a retrospective analysis of medical records between 1998 and 2006, we assessed markers of vitamin D and calcium metabolism from 53 pediatric SLOS patients and 867 pediatric patients who were admitted to the NIH Clinical Center (NIHCC) during the same time period. SLOS patients had significantly higher levels of 25(OH)D (48.06 ± 19.53 ng/ml, p < 0.01) across all seasons in comparison to the NIHCC pediatric patients (30.51 ± 16.14 ng/ml). Controlling for season and age of blood draw, 25(OH)D levels were, on average, 15.96 ng/ml (95%CI 13.95-17.90) higher in SLOS patients. Although, mean calcium values for both patient cohorts never exceeded the normal clinical reference range (8.6-10.2 mg/dl), the levels were higher in the SLOS cohort (9.49 ± 0.56 mg/dl, p < 0.01) compared to the NIHCC patients (9.25 ± 0.68 mg/dl). Overall, in comparison to the control cohort, individuals with SLOS have significantly higher concentrations of 25(OH)D that may be explained by elevated concentrations of serum 7-DHC. Despite the elevated vitamin D levels, there was no laboratory or clinical evidence of vitamin D toxicity.

EASTERN DODDER (CUSCUTA MONOGYNA VAHL.) SEED GERMINATION AFFECTED BY SOME HERBACEOUS DISTILLATES

Eastern dodder (Cuscuta monogyna Vahl.) is one of the noxious parasitic weeds that infected many ornamental trees in green spaces and gardens. Our purpose is to find natural inhibitors for prevention of its seed germination. In order to reach this aim, laboratory studies were conducted by using of herbaceous distillates of Dracocephalum moldavica, Nasturtium officinalis, Malva neglecta, Mentha piperita, Mentha pulegium, Rosa damascene, Ziziphora tenuior, and Urtica dioica on seed germination of C. monogyna. Z. tenuior distillate stimulated C. monogyna seed germination, whereas others reduced this parasitic weed's seed germination. D. moldavica caused maximum inhibition on weed seed germination. Seedling growth of C. monogyna was more affected than its seed germination. All of these herbaceous distillates reduced C. monogyna seedling length so that the latter decreased from 28.2 mm in distilled water to 4.5, 3.97, 3.85, 3.67, 3.1, 2.87, 2.57, 1.9, and 1.17 in M. pulegium, M. piperita, F. officinalis, Z. tenuior, N. officinalis, M. neglecta, R. damascene, U. dioica and D. moldavica, respectively. By using these medicinal plants distillates instead of herbicides, the parasitic weed seedling length and host plant infection will reduce.

Synthesis of C-protected alpha-amino aldehydes of high enantiomeric excess from highly epimerizable N-protected alpha-amino aldehydes

A new procedure for the preparation of C-protected alpha-amino aldehydes of high enantiomeric excess is illustrated using five differently substituted alpha-(N-Fmoc)amino aldehydes as starting materials. Highly epimerization-prone substrates were converted to the corresponding morpholino nitrile-protected alpha-amino aldehydes with minimal racemization (products >/= 89% ee). Morpholino nitrile derivatives of phenylglycinal were crystallized and subjected to X-ray structural analysis, allowing for definitive determination of the stereochemistry of amino nitrile formation. A rationale for the stereoselectivity of amino nitrile formation is presented.