Consistencies in Follow-up After Radical Cystectomy for Bladder Cancer: A Framework Based on Expert Practices Collaboratively Developed by the European Association of Urology Bladder Cancer Guideline Panels.

BACKGROUND AND OBJECTIVE: There is no standardized regimen for follow-up after radical cystectomy (RC) for bladder cancer (BC). To address this gap, we conducted a multicenter study involving urologist members from the European Association of Urology (EAU) bladder cancer guideline panels. Our objective was to identify consistent post-RC follow-up strategies and develop a practice-based framework based on expert opinion. METHODS: We surveyed 27 urologist members of the EAU guideline panels for non-muscle-invasive bladder cancer and muscle-invasive and metastatic bladder cancer using a pre-tested questionnaire with dichotomous responses. The survey inquired about follow-up strategies after RC and the use of risk-adapted strategies. Consistency was defined as >75% affirmative responses for follow-up practices commencing 3 mo after RC. Descriptive statistics were used for analysis. KEY FINDINGS AND LIMITATIONS: We received responses from 96% of the panel members, who provided data from 21 European hospitals. Risk-adapted follow-up is used in 53% of hospitals, with uniform criteria for high-risk (at least ≥pT3 or pN+) and low-risk ([y]pT0/a/1N0) cases. In the absence of agreement for risk-based follow up, a non-risk-adapted framework for follow-up was developed. Higher conformity was observed within the initial 3 yr, followed by a decline in subsequent follow-up. Follow-up was most frequent during the first year, including patient assessments, physical examinations, and laboratory tests. Computed tomography of the chest and abdomen/pelvis was the most common imaging modality, initially at least biannually, and then annually from years 2 to 5. There was a lack of consistency for continuing follow-up beyond 10 yr after RC. CONCLUSIONS AND CLINICAL IMPLICATIONS: This practice-based post-RC follow-up framework developed by EAU bladder cancer experts may serve as a valuable guide for urologists in the absence of prospective randomized studies. PATIENT SUMMARY: We asked urologists from the EAU bladder cancer guideline panels about their patient follow-up after surgical removal of the bladder for bladder cancer. We found that although urologists have varying approaches, there are also common follow-up practices across the panel. We created a practical follow-up framework that could be useful for urologists in their day-to-day practice.

Roles of the tubulin-based cytoskeleton in the Toxoplasma gondii apical complex.

Microtubules (MTs) play a vital role as key components of the eukaryotic cytoskeleton. The phylum Apicomplexa comprises eukaryotic unicellular parasitic organisms defined by the presence of an apical complex which consists of specialized secretory organelles and tubulin-based cytoskeletal elements. One apicomplexan parasite, Toxoplasma gondii, is an omnipresent opportunistic pathogen with significant medical and veterinary implications. To ensure successful infection and widespread dissemination, T. gondii heavily relies on the tubulin structures present in the apical complex. Recent advances in high-resolution imaging, coupled with reverse genetics, have offered deeper insights into the composition, functionality, and dynamics of these tubulin-based structures. The apicomplexan tubulins differ from those of their mammalian hosts, endowing them with unique attributes and susceptibility to specific classes of inhibitory compounds.

Sustained rhoptry docking and discharge requires Toxoplasma gondii intraconoidal microtubule-associated proteins.

In Apicomplexa, rhoptry discharge is essential for invasion and involves an apical vesicle (AV) docking one or two rhoptries to a macromolecular secretory apparatus. Toxoplasma gondii is armed with 10-12 rhoptries and 5-6 microtubule-associated vesicles (MVs) presumably for iterative rhoptry discharge. Here, we have addressed the localization and functional significance of two intraconoidal microtubule (ICMT)-associated proteins instrumental for invasion. Mechanistically, depletion of ICMAP2 leads to a dissociation of the ICMTs, their detachment from the conoid and dispersion of MVs and rhoptries. ICMAP3 exists in two isoforms that contribute to the control of the ICMTs length and the docking of the two rhoptries at the AV, respectively. This study illuminates the central role ICMTs play in scaffolding the discharge of multiple rhoptries. This process is instrumental for virulence in the mouse model of infection and in addition promotes sterile protection against T. gondii via the release of key effectors inducing immunity.

Diagnostic Accuracy of Adrenal Iodine-131 6-Beta-Iodomethyl-19-Norcholesterol Scintigraphy for the Subtyping of Primary Aldosteronism.

PURPOSE: To evaluate the diagnostic accuracy of the 131I-6ß-iodomethyl-19-norcholesterol (NP-59) adrenal scintigraphy for the subtyping diagnosis of primary aldosteronism (PA), considering as gold standard for the diagnosis of unilateral PA (UPA), either the results of the adrenal venous sampling (AVS) or the outcome after adrenalectomy. METHODS: A retrospective multicenter study was performed on PA patients from 14 Spanish tertiary hospitals who underwent NP-59 scintigraphy with an available subtyping diagnosis. Patients were classified as UPA if biochemical cure was achieved after adrenalectomy or/and if an AVS lateralization index > 4 with ACTH stimulation or >2 without ACTH stimulation was observed. Patients were classified as having bilateral PA (BPA) if the AVS lateralization index was ≤4 with ACTH or ≤2 without ACTH stimulation or if there was evidence of bilateral adrenal nodules >1 cm in each adrenal gland detected by CT/MRI. RESULTS: A total of 86 patients with PA were included (70.9% (n = 61) with UPA and 29.1% (n = 25) with BPA). Based on the NP-59 scintigraphy results, 16 patients showed normal suppressed adrenal gland uptake, and in the other 70 cases, PA was considered unilateral in 49 patients (70%) and bilateral in 21 (30%). Based on 59-scintigraphy results, 10.4% of the patients with unilateral uptake had BPA, and 27.3% of the cases with bilateral uptake had UPA. The AUC of the ROC curve of the NP-59 scintigraphy for PA subtyping was 0.812 [0.707-0.916]. Based on the results of the CT/MRI and NP-59 scintigraphy, only 6.7% of the patients with unilateral uptake had BPA, and 24% of the cases with bilateral uptake had UPA. The AUC of the ROC curve of the model combining CT/MRI and 59-scintigraphy results for subtyping PA was 0.869 [0.782-0.957]. CONCLUSION: The results of NP-59 scintigraphy in association with the information provided by the CT/MRI may be useful for PA subtyping. However, their diagnostic accuracy is only moderate. Therefore, it should be considered a second-line diagnostic tool when AVS is not an option.

Toxoplasma gondii HOOK-FTS-HIP Complex is Critical for Secretory Organelle Discharge during Motility, Invasion, and Egress.

Members of the Apicomplexa phylum possess specialized secretory organelles that discharge, apically and in a timely regulated manner, key factors implicated in parasite motility, host cell invasion, egress and subversion of host cellular functions. The mechanisms regulating trafficking and apical docking of these secretory organelles are only partially elucidated. Here, we characterized two conserved endosomal trafficking regulators known to promote vesicle transport and/or fusion, HOOK and Fused Toes (FTS), in the context of organelle discharge in Toxoplasma gondii. TgHOOK and TgFTS form a complex with a coccidian-specific partner, named HOOK interacting partner (HIP). TgHOOK displays an apically enriched vesicular pattern and concentrates at the parasite apical tip where it colocalizes with TgFTS and TgHIP. Functional investigations revealed that TgHOOK is dispensable but fitness conferring. The protein regulates the apical positioning and secretion of micronemes and contributes to egress, motility, host cell attachment, and invasion. Conditional depletion of TgFTS or TgHIP impacted on the same processes but led to more severe phenotypes. This study provides evidence of endosomal trafficking regulators involved in the apical exocytosis of micronemes and possibly as a consequence or directly on the discharge of the rhoptries. IMPORTANCE Toxoplasma gondii affects between 30 and 80% of the human population, poses a life-threatening risk to immunocompromised individuals, and is a cause of abortion and birth defects following congenital transmission. T. gondii belongs to the phylum of Apicomplexa characterized by a set of unique apical secretory organelles called the micronemes and rhoptries. Upon host cell recognition, this obligatory intracellular parasite secretes specific effectors contained in micronemes and rhoptries to promote parasite invasion of host cells and subsequent persistence. Here, we identified novel T. gondii endosomal trafficking regulators and demonstrated that they regulate microneme organelle apical positioning and exocytosis, thereby strongly contributing to host cell invasion and parasite virulence.

Is Tumor Budding a New Predictor for Early Cystectomy in pT1 High-Grade Bladder Cancer?

Background & Objectives: We aimed to evaluate the risk of progression in high-grade T1 (HGT1) tumors using tumor budding (TB) and other standard clinical and histological features. TB is defined as an isolated cancer cell or a cluster composed of fewer than 5 cells scattered in the stroma and is usually used as a strong predictor of lymph node metastasis in T1 colorectal cancer. METHODS: This is an observational longitudinal cohort study involving 168 consecutive patients with HGT1 between 2013 and 2016. Cox regression was performed to analyze the relationship between the clinical and histological features and progression. All slides were blindly assessed by 2 genitourinary pathologists. Budding was determined to be positive when the number of buds was equal to or greater than 6. RESULTS: The median age was 75 years; 152 (90.5%) patients were men, and 49 (29.2%) were positive for TB. At a median follow-up time of 35 months, 33 patients (19.6%) showed progression. Progression was observed in 32.7% of the patients positive for TB and in only 14.3% of those who were negative (p = 0.006). TB was significantly associated with the endoscopic tumor pattern (TP) (papillary/solid) and lymphovascular invasion (LVI). Univariate analysis showed that TB, carcinoma in situ (CIS), TP, LVI, sub-staging, and BCG induction predict progression. The multivariate analysis showed that TB (p = 0.032, hazard ratio 2.1), CIS, TP, and lack of BCG induction were significant for progression. CONCLUSIONS: TB is a new and significant pathological variable for predicting progression in HGT1 tumors and can be easily introduced in clinical practice. Its inclusion in the TNM system should be carefully considered, as it may aid early cystectomy decisions.

Controls of soil organic matter on soil thermal dynamics in the northern high latitudes.

Permafrost warming and potential soil carbon (SOC) release after thawing may amplify climate change, yet model estimates of present-day and future permafrost extent vary widely, partly due to uncertainties in simulated soil temperature. Here, we derive thermal diffusivity, a key parameter in the soil thermal regime, from depth-specific measurements of monthly soil temperature at about 200 sites in the high latitude regions. We find that, among the tested soil properties including SOC, soil texture, bulk density, and soil moisture, SOC is the dominant factor controlling the variability of diffusivity among sites. Analysis of the CMIP5 model outputs reveals that the parameterization of thermal diffusivity drives the differences in simulated present-day permafrost extent among these models. The strong SOC-thermics coupling is crucial for projecting future permafrost dynamics, since the response of soil temperature and permafrost area to a rising air temperature would be impacted by potential changes in SOC.

Matrix-Based Sensitivity Assessment of Soil Organic Carbon Storage: A Case Study from the ORCHIDEE-MICT Model.

Modeling of global soil organic carbon (SOC) is accompanied by large uncertainties. The heavy computational requirement limits our flexibility in disentangling uncertainty sources especially in high latitudes. We build a structured sensitivity analyzing framework through reorganizing the Organizing Carbon and Hydrology in Dynamic Ecosystems (ORCHIDEE)-aMeliorated Interactions between Carbon and Temperature (MICT) model with vertically discretized SOC into one matrix equation, which brings flexibility in comprehensive sensitivity assessment. Through Sobol's method enabled by the matrix, we systematically rank 34 relevant parameters according to variance explained by each parameter and find a strong control of carbon input and turnover time on long-term SOC storages. From further analyses for each soil layer and regional assessment, we find that the active layer depth plays a critical role in the vertical distribution of SOC and SOC equilibrium stocks in northern high latitudes (>50°N). However, the impact of active layer depth on SOC is highly interactive and nonlinear, varying across soil layers and grid cells. The stronger impact of active layer depth on SOC comes from regions with shallow active layer depth (e.g., the northernmost part of America, Asia, and some Greenland regions). The model is sensitive to the parameter that controls vertical mixing (cryoturbation rate) but only when the vertical carbon input from vegetation is limited since the effect of vertical mixing is relatively small. And the current model structure may still lack mechanisms that effectively bury nonrecalcitrant SOC. We envision a future with more comprehensive model intercomparisons and assessments with an ensemble of land carbon models adopting the matrix-based sensitivity framework.

Higher sex hormone-binding globulin and lower bioavailable testosterone are related to prostate cancer detection on prostate biopsy.

OBJECTIVE: Recent studies show an inverse relationship between testosterone levels and prostate cancer (PCa). The usefulness of hormonal patterns in PCa diagnosis is controversial. This study aimed to determine the relationship between hormonal patterns and PCa, and to find a cut-off point of hormone levels to assess PCa risk. MATERIAL AND METHODS: A prospective analysis was undertaken of 279 patients referred for first or second prostate biopsy in the Hospital Clínic Barcelona from November 2006 to May 2009. The indication for prostate biopsy was suspicion of PCa based on the results of digital rectal examination (DRE) and/or elevation of serum prostate-specific antigen (PSA). Screening was carried out with a 5+5-core transrectal ultrasound-guided prostate biopsy. Age, prostate volume, DRE (normal or abnormal), biopsy findings (normal or report of PCa), PSA, free-to-total PSA, PSA density, testosterone and sex hormone-binding globulin (SHBG) were also prospectively recorded. Free and bioavailable testosterone were calculated using Vermeulen's formula. RESULTS: In the multivariate analysis, abnormal DRE [odds ratio (OR = 5.46, p < 0.001], SHBG levels ≥ 66.25 nmol/l [OR = 3.27; 95% confidence interval (CI) 1.52 to 7.04, p < 0.002] and bioavailable testosterone levels ≤ 104 ng/dl (OR = 4.92, 95% CI 1.78 to 13.59, p = 0.002) were related to the diagnosis of prostate adenocarcinoma. Age, free testosterone, PSA, testosterone, PSA/testosterone, PSA/free testosterone and PSA/bioavailable testosterone were not related to PCa diagnosis. CONCLUSIONS: Low bioavailable testosterone levels and high SHBG levels were related to a 4.9- and 3.2-fold risk of detection of PCa on prostate biopsy owing to PSA elevation or abnormal DRE. This fact may be useful in the clinical scenario in counselling patients at risk for PCa.

[Home blood pressure self-monitoring. Influence of the mean calculation used on the diagnosis of white-coat hypertension]. / Automedida de la presión arterial domiciliaria. Influencia del sistema de cálculo de la media en el diagnóstico de la hipertensión de bata blanca.

OBJECTIVE: To describe the variations in the diagnosis performance of home blood pressure self-monitoring (hBPSM) with different methods for mean calculation, in order to diagnose white-coat hypertension (WCH). DESIGN: Multi-centre, descriptive, and comparative study to assess the diagnosis performance of a test method. SETTING: Four primary health care centres. PARTICIPANTS: A total of 157 recently-diagnosed, untreated patients with mild-moderate hypertension took part in the study. METHODS: The results obtained with hBPSM (3 consecutive days with readings in triplicate, morning-night) were compared with a "gold standard" out-patient blood pressure reading (OutBP). RESULTS: Systolic and diastolic BP values of the first day and first reading (morning-night) were higher than the remaining days and readings (linear trend P< .001). Results in hBPSM diagnostic performance using all readings to calculate the mean were: sensitivity (S), 47.6%; specificity (Sp), 77.4%; positive and negative predictive values (PPV and NPV), 58.8% and 68.6%, with positive and negative probability coefficients (PPC and NPC), 2.10 and 0.67. When readings with greater patient alarm reaction (first day and first reading, morning-night) were removed, greater values of S (61.9%) were obtained, albeit at expense of an excessive loss in Sp (64.5%) and without improvement in PPC (1.74). CONCLUSIONS: The diagnostic performance of hBPSM in WCH was low and failed to improve with the use of different systems to calculate mean BP.

Automedida de la presión arterial domiciliaria. Influencia del sistema de cálculo de la media en el diagnóstico de la hipertensión de bata blanca / Home blood pressure self-monitoring. Influence of the mean calculation used on the diagnosis of white-coat hypertension

Objetivo. Describir las variaciones que se producen en el rendimiento de la automedida de la presión arterial domiciliaria (AMPAd) al emplear diferentes sistemas para calcular la media, en el diagnóstico de la hipertensión de bata blanca (HBB). Diseño. Estudio multicéntrico, descriptivo y comparativo para evaluar el rendimiento diagnóstico de una prueba. Emplazamiento. Cuatro centros de atención primaria. Participantes. Se seleccionó a 157 pacientes con hipertensión leve-moderada, recién diagnosticados y sin tratamiento farmacológico, que presentaron las 18 lecturas de AMPAd. Métodos. A cada paciente se le realizó una AMPAd (3 días consecutivos con lecturas por triplicado mañana-noche) y una monitorización ambulatoria de la presión arterial (MAPA) empleado, como prueba de referencia. Resultados. Los valores de presión arterial sistólica y diastólica del primer día y de la primera lectura (mañana-noche) eran mayores que los restantes días y lecturas (tendencia lineal p < 0,001). Al emplear todas las lecturas para calcular la media los parámetros de rendimiento diagnóstico obtenidos fueron: sensibilidad (S) 47,6%, especificidad (E) 77,4%, valores predictivos positivo y negativo 58,8 y 68,6%, coeficientes de probabilidad positivo y negativo (CPP y CPN) 2,10 y 0,67, respectivamente. Al eliminar las lecturas con mayor reacción de alerta (primer día y primera lectura mañana-noche) se incrementaba la S (61,9%) a expensas de un descenso excesivo de la E (64,5%), sin que mejorara el CPP (1,74). Conclusiones. La AMPAd en el diagnóstico de la HBB obtiene un bajo rendimiento que no mejora con el empleo de diferentes sistemas para calcular la media de presión arterial

Objective. To describe the variations in the diagnosis performance of home blood pressure self-monitoring (hBPSM) with different methods for mean calculation, in order to diagnose white-coat hypertension (WCH). Design. Multi-centre, descriptive, and comparative study to assess the diagnosis performance of a test method. Setting. Four primary health care centres. Participants. A total of 157 recently-diagnosed, untreated patients with mild-moderate hypertension took part in the study. Methods. The results obtained with hBPSM (3 consecutive days with readings in triplicate, morning-night) were compared with a "gold standard" out-patient blood pressure reading (OutBP). Results. Systolic and diastolic BP values of the first day and first reading (morning-night) were higher than the remaining days and readings (linear trend P<.001). Results in hBPSM diagnostic performance using all readings to calculate the mean were: sensitivity (S), 47.6%; specificity (Sp), 77.4%; positive and negative predictive values (PPV and NPV), 58.8% and 68.6%, with positive and negative probability coefficients (PPC and NPC), 2.10 and 0.67. When readings with greater patient alarm reaction (first day and first reading, morning-night) were removed, greater values of S (61.9%) were obtained, albeit at expense of an excessive loss in Sp (64.5%) and without improvement in PPC (1.74). Conclusions. The diagnostic performance of hBPSM in WCH was low and failed to improve with the use of different systems to calculate mean BP

Púrpura de Schölein-Henoch:Estudio retrospectivo de los últimos 20 años / Henoch-Schonlein purpura: a 20-year retrospective study

Fundamento. La púrpura de Schónlein-Henoch (PSH) es una vasculitis sistémica por hipersensibilidad, mediada por Ig-A, que afecta casi exclusivamente a la edad pediátrica. Las afectaciones principales son a nivel cutáneo, gastrointestinal, renal y articular. La afectación nefrológica, que se puede presentar desde su inicio o bien días o semanas después, condiciona el pronóstico. Objetivo. Evaluar las características clínicas, epidemiológicas y evolutivas de la enfermedad de los niños con diagnóstico de PSH controlados en consultas externas de nefrología pediátrica. Método. Estudio retrospectivo y descriptivo realizado entre septiembre de 1980 i enero de 2001. Se han revisado las historias clínicas de los pacientes controlados en consulta externa por presentar una PSH. Resultado. Hemos estudiado 77 pacientes con una edad media de 4.7 años (2 -15 años). Encontramos antecedentes de infección aguda en 17 (22 por ciento) de los que 6 son amigdalitis. Todos han presentado afectación cutánea no siendo la forma de debut en dos (1 dolor abdominal, 1 artritis). Encontramos dolor abdominal en 22 (28.5 por ciento), 2 acompañados de hemorragia digestiva i 1 de invaginación que requirió intervención. La afectación articular se observa en 22 (28.5 por ciento). Hemos encontrado afectación renal en 17 (22 por ciento). De éstos, 3 han tenido síndrome nefrótico y a 2 se le ha realizado biopsia renal (2 nefropaties IgA con glomerulonefritis segmentaria y focal y 1 de éstos con 20 por ciento de semilunas). Han presentado rebrote 21 (29 por ciento). Han recibido tratamiento con corticoides 8 (11.2 por ciento). Conclusiones. 1. La afectación renal encontrada es similar a otras series publicadas (20-25 por ciento). 2. La posibilidad de una afectación renal, que ocasionalmente puede ser grave, obliga al seguimiento de los pacientes con PSH. 3. La determinación por tira reactiva de orina de proteinuria y/o hematuria es un buen instrumento para el cribado. (AU)