The 50 Year Evolution of the William P. Didusch Museum of the American Urological Association.

OBJECTIVES: To explore the history and evolution of the William P. Didusch Museum. METHODS: We reviewed the literature and personal accounts regarding the founding of the museum and changes to the museum over its history. RESULTS: William P. Didusch was a world-renowned medical artist and was the staff artist for the Brady Urological Institute under Hugh Hampton Young. The William P. Didusch Museum was founded in 1971 and comprised the collection of Didusch's drawings and instruments, which were housed at the AUA headquarters. In 1972 Didusch became the museum's first curator. At the time of Didusch's death, the AUA purchased a new building and began extensive renovations. In 1987, Dr. William W. Scott, the museum's third curator, catalogued the items housed in the museum prior to it being reopened in 1989. Dr. Rainer Engel took over as curator in 1993 and supervised renovations to the exhibit area. In 2003 the museum moved to the new AUA Headquarters in Linthicum, Maryland and the central exhibit on the history of the cystoscope was finalized. Under Dr. Ronald Rabinowitz as Historian, the museum history committee and leadership was restructured and included a website with a virtual museum tour, links to history exhibits and a newsletter. CONCLUSION: The William P. Didusch Center for Urologic History continues to evolve in pursuit of its mission to document, preserve, and present the history of urology and to educate and engage the medical community and the public.

The birth of pediatric urology in the United States: From pioneers to subcertification.

INTRODUCTION: Pediatric urology is a subspecialty of urology that emerged from a culture in which children with urological disorders were cared for by general urologists and general pediatric surgeons. The development of pediatric urology as a subspecialty was years in the making, highlighted by individuals who recognized that children with urological conditions were not just "small adults," but required special experience and training. Subspecialization was initiated by persistent visionaries who recognized the need for a trained cadre of experts to provide better care for children. It took the coordinated effort of all subgroups and leaderships in pediatric urology to push these efforts over the goal line. The focus of this review is to highlight certain individuals who played major roles in this vision and to document the efforts of many to coordinate the pathways to sub-specialization. METHODS: The careers of Meredith F. Campbell and Frank B. Bicknell were researched to identify their rationale and roles in developing pediatric urology as a distinct medical specialty in the United States. In addition, the minutes of the meetings of the Pediatric Urology Advisory Council (PUAC) with the American Board of Urology (ABU) were reviewed. The origins of the Society for Pediatric Urology (SPU) and the American Academy of Pediatrics Section of Urology (AAP-SOU) were researched. The contributions of each to the certification of pediatric urology as a distinct subspecialty was delineated. RESULTS: Campbell was Chair of Urology at the New York University (NYU) School of Medicine and wrote prolifically about pediatric urology. He published one of the first practical textbooks in pediatric urology, almost completely self-written, in 1937. Bicknell, a general urologist in Michigan on the faculty at Wayne State University School of Medicine, led the initiative to create the Society for Pediatric Urology (SPU) that first met at the 1951 annual American Urological Association (AUA) meeting in Chicago and included nine attendees. Subsequently, John Lattimer (College of Physicians and Surgeons at Columbia University) organized a well-attended meeting of urologists interested in pediatrics at the 1964 annual AAP meeting in New York City. This led to the formation of the AAP Section on Urology. Integral to the justification for the development of a subspecialty was evidence of a published corpus of content. In addition to published textbooks devoted exclusively to pediatric urology, this was further fulfilled by the AAP Section on Urology Pediatric Supplement to the Journal of Urology, first published in 1986, and later with the Journal of Pediatric Urology in 2005. The SPU and the AAP Section on Urology came together to form the Pediatric Urology Advisory Council (PUAC) in 2000, which worked with the ABU to create subspecialty certification in pediatric urology with an independent exam, first administered in 2008 to 176 applicants. CONCLUSION: The metaphor "We have stood on the shoulders of giants" is apt for pediatric urology: Meredith Campbell, Frank Bicknell, David Innes Williams (Hospital for Sick Children, London), and J. Herbert Johnston (Alder Hay Hospital, Liverpool) come to mind among the first generation of pediatric urology pioneers, and others among their colleagues also had significant impact. Clearly this is a story of persistence and attention to detail on the part of those giants and those who followed. Pediatric urology became a distinct discipline after the SPU and AAP-SOU came together to create a robust cohort of pediatric urologists who through education and negotiation were able to help the ABU and the American Board of Medical Specialties (ABMS) recognize that subspecialization would lead to better care for children with urologic disorders. This benchmark set a high bar for future subspecialization in urology and other fields.

Overlapping Physiologic Signs of Sepsis and Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury: Exploring A Clinical Conundrum.

BACKGROUND: Paroxysmal sympathetic hyperactivity (PSH) occurs in a subset of patients with traumatic brain injury (TBI) and is associated with worse outcomes. Sepsis is also associated with worse outcomes after TBI and shares several physiologic features with PSH, potentially creating diagnostic confusion and suboptimal management of each. This is the first study to directly investigate the interaction between PSH and infection using robust diagnostic criteria. METHODS: We performed a retrospective cohort study of patients with TBI admitted to a level I trauma center intensive care unit with hospital length of stay of at least 2 weeks. From January 2016 to July 2018, 77 patients diagnosed with PSH were 1:1 matched by age and Glasgow Coma Scale to 77 patients without PSH. Trauma infectious diseases subspecialists prospectively documented assessments corroborating diagnoses of infection. Extracted data including incidence, timing, classification, and anatomical source of infections were compared according to PSH diagnosis. We also evaluated daily PSH clinical feature severity scores and systemic inflammatory response syndrome (SIRS) criteria and compared values for patients with and without confirmed infection, stratified by PSH diagnosis. RESULTS: During the first 2 weeks of hospitalization, there were no differences in rates of suspected (62%) nor confirmed (48%) infection between patients with PSH and controls. Specific treatments for PSH were initiated on median hospital day 7 and for confirmed infections on median hospital day 8. SIRS criteria could identify infection only in patients who were not diagnosed with PSH. CONCLUSIONS: In the presence of brain injury-induced autonomic nervous system dysregulation, the initiation and continuation of antimicrobial therapy is a challenging clinical decision, as standard physiologic markers of sepsis do not distinguish infected from noninfected patients with PSH, and these entities often present around the same time. Clinicians should be aware that PSH is a potential driver of SIRS, and familiarity with its diagnostic criteria as proposed by the PSH assessment measure is important. Management by a multidisciplinary team attentive to these issues may reduce rates of inappropriate antibiotic usage and misdiagnoses.

Testicular Compartment Syndrome After Trauma Managed With a Tunica Vaginalis Flap.

Testicular compartment syndrome requires timely diagnosis and intervention but may be challenging. We present a case discussing the presentation and management of testicular compartment syndrome following testicular trauma in an 11-year-old male. The patient presented 24 hours after testicular trauma from a kick with testicular enlargement and sharp pain. Ultrasound showed markedly decreased blood flow and a reactive hydrocele. Testis-sparing intervention included emergent tunica albuginea incision, debridement, and tunica vaginalis flap.

COVID-19 outcomes of venovenous extracorporeal membrane oxygenation for acute respiratory failure vs historical cohort of non-COVID-19 viral infections.

INTRODUCTION: Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become a support modality for patients with acute respiratory failure refractory to standard therapies. VV ECMO has been increasingly used during the current COVID-19 pandemic for patients with refractory respiratory failure. The object of this study was to evaluate the outcomes of VV ECMO in patients with COVID-19 compared to patients with non-COVID-19 viral infections. METHODS: We retrospectively reviewed all patients supported with VV ECMO between 8/2014 and 8/2020 whose etiology of illness was a viral pulmonary infection. The primary outcome of this study was to evaluate in-hospital mortality. The secondary outcomes included length of ECMO course, ventilator duration, hospital length of stay, incidence of adverse events through ECMO course. RESULTS: Eighty-nine patients were included (35 COVID-19 vs 54 non-COVID-19). Forty (74%) of the non-COVID-19 patients had influenza virus. Prior to cannulation, COVID-19 patients had longer ventilator duration (3 vs 1 day, p = .003), higher PaCO2 (64 vs 53 mmHg, p = .012), and white blood cell count (14 vs 9 ×103/µL, p = .004). Overall in-hospital mortality was 33.7% (n = 30). COVID-19 patients had a higher mortality (49% vs. 24%, p = .017) when compared to non-COVID-19 patients. COVID-19 survivors had longer median time on ECMO than non-COVID-19 survivors (24.4 vs 16.5 days p = .03) but had a similar hospital length of stay (HLOS) (41 vs 48 Extracorporeal Membrane Oxygenationdays p = .33). CONCLUSION: COVID-19 patients supported with VV ECMO have a higher mortality than non-COVID-19 patients. While COVID-19 survivors had significantly longer VV ECMO runs than non-COVID-19 survivors, HLOS was similar. This data add to a growing body of literature supporting the use of ECMO for potentially reversible causes of respiratory failure.

The Wales Endoscope: The First American Cystoscope.

INTRODUCTION: Philipp Bozzini, a German army surgeon, in 1807 invented the Lichtleiter, the predecessor of the modern cystoscope. By the mid-1800s, several new instruments were created including one, a variation on Bozzini's instrument by Antoine Desormeaux in Paris. The William P. Didusch Museum of Urologic History acquired the Wales endoscope, a rare and unique cystoscope that was invented around the same time in the United States. METHODS: We researched the life of Philip Wales and the description of his cystoscope as well as Horatio Kern, the instrument maker that produced Wales' instrument. We examined the Wales cystoscope acquired by the William P. Didusch Museum. RESULTS: Philip Skinner Wales (1837-1906) was a surgeon who entered the United States Navy in 1856 and served throughout the Civil War. He organized and held charge of the Naval Hospital at New Orleans during the operations of Admiral Farragut's fleet in the Mississippi River. He was one of the first surgeons to attend President Garfield when he was shot. He was Surgeon General of the Navy (1879-1884) and founded the Museum of Naval Hygiene in Washington D.C. which later, combined with the naval laboratory and Department of Instruction, became the prototype of the Naval Medical School. In 1868 he published a series of papers in the Philadelphia Medical and Surgical Reporter on "Instrumental Diagnosis," with a paper entitled "Description of a New Endoscope." The instrument contained a metal shaft with an acute beak and used an ophthalmologic mirror to reflect light down the channel. The surgeon peered through the center hole to look into the bladder. Wales used his instrument multiple times in his private practice. Wales writes that the advantages of his cystoscope were that it was simple to produce and cheap compared to Desormeaux's endoscope. Furthermore it was light, weighing approximately 2 pounds. The main drawbacks of Wales' cystoscope were the inadequate illumination, as the light source was external and projected from the outside through a narrow channel into the bladder, and that without an optical system the image appeared relatively small. Horatio Kern, a well-known instrument maker in Philadelphia, that also supplied surgical sets and instruments for the U.S. Army during the Civil War, produced Wales' cystoscope. While he was Chief of the Bureau of Medicine, a subordinate embezzled Navy funds and Dr, Wales was court-martialed. Though he was eventually exonerated, he lived the rest of his life in disgrace in France. CONCLUSION: The Wales endoscope is unique in that it had an American inventor, was simple in design and cheap to produce. It is an important historical artifact and is one of the earliest and rarest cystoscopes developed.

Rapid Spread and Control of Multidrug-Resistant Gram-Negative Bacteria in COVID-19 Patient Care Units.

We describe rapid spread of multidrug-resistant gram-negative bacteria among patients in dedicated coronavirus disease care units in a hospital in Maryland, USA, during May-June 2020. Critical illness, high antibiotic use, double occupancy of single rooms, and modified infection prevention practices were key contributing factors. Surveillance culturing aided in outbreak recognition and control.

Mortality Risk Assessment in COVID-19 Venovenous Extracorporeal Membrane Oxygenation.

BACKGROUND: A life-threatening complication of coronavirus disease 2019 (COVID-19) is acute respiratory distress syndrome (ARDS) refractory to conventional management. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) (VV-ECMO) is used to support patients with ARDS in whom conventional management fails. Scoring systems to predict mortality in VV-ECMO remain unvalidated in COVID-19 ARDS. This report describes a large single-center experience with VV-ECMO in COVID-19 and assesses the utility of standard risk calculators. METHODS: A retrospective review of a prospective database of all patients with COVID-19 who underwent VV-ECMO cannulation between March 15 and June 27, 2020 at a single academic center was performed. Demographic, clinical, and ECMO characteristics were collected. The primary outcome was in-hospital mortality; survivor and nonsurvivor cohorts were compared by using univariate and bivariate analyses. RESULTS: Forty patients who had COVID-19 and underwent ECMO were identified. Of the 33 patients (82.5%) in whom ECMO had been discontinued at the time of analysis, 18 patients (54.5%) survived to hospital discharge, and 15 (45.5%) died during ECMO. Nonsurvivors presented with a statistically significant higher Prediction of Survival on ECMO Therapy (PRESET)-Score (mean ± SD, 8.33 ± 0.8 vs 6.17 ± 1.8; P = .001). The PRESET score demonstrated accurate mortality prediction. All patients with a PRESET-Score of 6 or lowers survived, and a score of 7 or higher was associated with a dramatic increase in mortality. CONCLUSIONS: These results suggest that favorable outcomes are possible in patients with COVID-19 who undergo ECMO at high-volume centers. This study demonstrated an association between the PRESET-Score and survival in patients with COVID-19 who underwent VV-ECMO. Standard risk calculators may aid in appropriate selection of patients with COVID-19 ARDS for ECMO.

Rice body formation due to Haemophilus parainfluenza-associated chronic arthropathy.

A 68-year-old woman with a medical history significant for psoriatic arthritis was found to have an enlarged, painful lump on her left hip 15 months after intramedullary rod placement for a left subtrochanteric femur fracture sustained in a fall. Histopathological findings showed rice body formation (RBF) with concurrent H. parainfluenza. RBF is a relatively rare arthropathy of a subset of chronic inflammatory disease such as rheumatoid arthritis or tuberculous arthropathy. RBF associated with psoriatic arthritis or orthopedic hardware placement has been reported in a handful of cases in the literature but there has not been any definitive evidence for RBF as a result of Haemophilus parainfluenza infections and is a rather unusual characteristic of this case.

Intoxication and overdose should not preclude veno-venous extracorporeal membrane oxygenation.

INTRODUCTION: Acute intoxication (AI) related morbidity and mortality are increasing in the United States. For patients with severe respiratory failure in the setting of an acute ingestion, veno-venous extracorporeal membrane oxygenation (VV ECMO) can provide salvage therapy. The purpose of this study was to evaluate outcomes in patients with overdose-related need for VV ECMO. METHODS: We performed a retrospective review of all patients admitted to a specialty VV ECMO unit between August 2014 and August 2018. Patients were stratified by those whose indication for VV ECMO was directly related to an acute ingestion (alcohol, illicit drug, or prescription drug overdose) and those with unrelated diagnoses. Demographics, pre-cannulation clinical characteristics, ECMO parameters, and outcomes data was collected and analyzed with parametric and non-parametric statistics as indicated. RESULTS: 189 patients were enrolled with 27 (14%) diagnosed with AI. Patients requiring VV ECMO for an AI were younger, had lower median BMI and PaO2/FiO2, and higher RESP scores than non-AI patients (p = 0.002, 0.01, 0.03 and 0.01). There was no difference in pre-cannulation pH, lactate, or SOFA scores between the two groups (p = 0.24, 0.5, 0.6). There was no difference in survival to discharge (p = 0.95). Among survivors, there was no difference in ECMO time or hospital stay (p = 0.24, 0.07). CONCLUSION: We demonstrate no survival difference for patients with and without an AI-related need for VV ECMO. AI patients should be supported with VV ECMO when traditional therapies fail despite potential stigma against acceptance on referral.

Breathing Life Back Into the Kidney-Continuous Renal Replacement Therapy and Veno-Venous Extracorporeal Membrane Oxygenation.

The purpose of this study was to evaluate the incidence of continuous renal replacement therapy (CRRT) in patients supported with veno-venous extracorporeal membrane oxygenation (VV ECMO). Secondary outcomes included mortality and the need for hemodialysis on hospital discharge. We performed a retrospective cohort study of all patients admitted to a specialty unit on VV ECMO between August 2014 and August 2018. Trauma and bridge to lung transplant patients were excluded. Demographics, comorbidities, pre-ECMO, ECMO, and renal replacement therapy outcome data were collected and analyzed with parametric and nonparametric statistics as appropriate. One hundred eighty-seven patients were enrolled. Median age was 45 (32, 55) years; precannulation pH, 7.21 (7.12, 7.30); PaO2/FiO2 ratio, 69 (56, 86); respiratory ECMO survival prediction score, 3 (0, 5); sequential organ failure assessment score, 12 (10, 14); and creatinine, 1.45 (0.93, 2.35) mg/dL. Overall survival to hospital discharge was 74.6%. Ninety-four (50.3%) patients had CRRT while on VV ECMO. Median time on CRRT was 14 (7, 21) days with 59 (61.4%) of these patients surviving to hospital discharge. Four (6.8%) patients, none with documented preexisting renal disease, required hemodialysis on discharge. CRRT patients had a statistically higher precannulation sequential organ failure assessment score, creatinine, total bilirubin and lower precannulation pH, respiratory ECMO survival prediction score, and platelet count compared with non-CRRT patients. Survival was 61.4% vs. 88.1% (p < 0.001). More than half of our patients received CRRT while on VV ECMO. CRRT was used in a more critically ill patient population and was associated with higher in-hospital mortality. However, for patients who survived to hospital discharge, the majority have full renal recovery.

Outcomes of Venovenous Extracorporeal Membrane Oxygenation When Stratified by Age: How Old Is Too Old?

The purpose of this study was to evaluate survival to hospital discharge for patients on venovenous extracorporeal membrane oxygenation (VV ECMO) when stratified by age. We performed a retrospective study at single, academic, tertiary care center intensive care unit for VV ECMO. All patients, older than 17 years of age, on VV ECMO admitted to a specialized intensive care unit for the management of VV ECMO between August 2014 and May 2018 were included in the study. Trauma and bridge-to-lung transplant patients were excluded for this analysis. Demographics, pre-ECMO and ECMO data were collected. Primary outcome was survival to hospital discharge when stratified by age. Secondary outcomes included time on VV ECMO and hospital length of stay (HLOS). One hundred eighty-two patients were included. Median P/F ratio at time of cannulation was 69 [56-85], and respiratory ECMO survival prediction (RESP) score was 3 [1-5]. Median time on ECMO was 319 [180-567] hours. Overall survival to hospital discharge was 75.8%. Lowess and cubic spline curves demonstrated an inflection point associated with increased mortality at age >45 years. Kaplan-Meier analysis demonstrated significantly greater survival in patients <45 years of age (p = 0.0001). Survival to hospital discharge for those

A history of urolithiasis risk in space.

INTRODUCTION: The development of renal stones in space would not only impact the health of an astronaut but could critically affect the success of the mission. MATERIALS AND METHODS: We reviewed the medical literature, texts and multimedia sources regarding the careers of Dr. Abraham Cockett and Dr. Peggy Whitson and their contributions to the study of urolithiasis in space, as well as the studies in between both of their careers that helped to further characterize the risks of stone formation in space. RESULTS: Dr. Abraham T. K. Cockett (1928-2011) was Professor and Chair of the Department of Urology at the University of Rochester and served as AUA President (1994-1995). In 1962, Dr. Cockett was one of the first to raise a concern regarding astronauts potentially forming renal stones in space and suggested multiple prophylactic measures to prevent stone formation. Many of the early studies in this field used immobilized patients as a surrogate to a micro-gravity environment to mimic the bone demineralization that could occur in space in order to measure changes in urinary parameters. Dr. Peggy A. Whitson (1960-), is a biochemistry researcher and former NASA astronaut. She carried out multiple studies examining renal stone risk during short term space shuttle flights and later during long-duration Shuttle-Mir missions. CONCLUSION: From the early vision of Dr. Cockett to the astronaut studies of Dr. Whitson, we have a better understanding of the risks of urolithiasis in space, resulting in preventive measures for urolithiasis in future long duration space exploration.

Annie, Annie! Are You Okay?: Faces Behind the Resusci Anne Cardiopulmonary Resuscitation Simulator.

We investigated the history of Resusci Anne, the well-known cardiopulmonary resuscitation (CPR) simulation trainer. The creation of Resusci Anne began with Peter J. Safar, an accomplished anesthesiologist who experimented with resuscitation of respiration and cardiac function. He collaborated with Asmund S. Laerdal, whose early experimentation with soft plastics allowed him to create a human simulator that could be used to teach the skills of resuscitation to both medical care practitioners and individuals of all walks of life. A special face was chosen for the simulation mannequin, one based on a mysterious death mask of a beautiful woman from the late 19th century. The success of Resusci Anne led to the widespread acceptance of CPR and simulation use in medical training.

Methylprednisolone may be associated with improved lung compliance in acute respiratory distress syndrome patients on veno-venous extracorporeal membrane oxygenation.

INTRODUCTION: Methylprednisolone has been used for acute respiratory distress syndrome with variable results. Veno-venous extracorporeal membrane oxygenation use in acute respiratory distress syndrome has increased. Occasionally, both are used. We hypothesized that methylprednisolone could improve lung compliance and ease weaning from extracorporeal membrane oxygenation in acute respiratory distress syndrome patients. METHODS: We retrospectively reviewed all patients in our veno-venous extracorporeal membrane oxygenation unit treated with methylprednisolone over a 20 month period. Methylprednisolone was initiated for inability to wean off veno-venous extracorporeal membrane oxygenation. Dynamic compliance (Cdyn) was calculated at cannulation, methylprednisolone initiation, and decannulation. Demographics, extracorporeal membrane oxygenation-specific data, and ventilator data were collected. Wilcoxon rank-sum test was used to test for differences in dynamic compliance. RESULTS: A total of 12 veno-venous extracorporeal membrane oxygenation patients received methylprednisolone. Mean age was 50 (±15) years. Seven had influenza. Methylprednisolone was started on median Day 16 (interquartile range: 11-22) of veno-venous extracorporeal membrane oxygenation. In total, 10 patients had veno-venous extracorporeal membrane oxygenation decannulation on median Day 12 (7-22) after methylprednisolone initiation. Two patients died before decannulation. The 10 decannulated patients had initial median dynamic compliance (mL × cm H2O-1) of 12 (7-23), then 16 (10-24) at methylprednisolone initiation, and then 44 (34-60) at decannulation. Dynamic compliance was higher at decannulation than methylprednisolone initiation (p = 0.002), and unchanged from cannulation to methylprednisolone initiation for all patients (p = 0.97). A total of 10 patients had significant infections. None had significant gastrointestinal bleed or wound healing issues. CONCLUSION: Methylprednisolone may be associated with improved compliance in acute respiratory distress syndrome allowing for decannulation from veno-venous extracorporeal membrane oxygenation. High rates of infection are associated with methylprednisolone use in veno-venous extracorporeal membrane oxygenation. Further studies are required to identify appropriate patient selection for methylprednisolone use in patients on veno-venous extracorporeal membrane oxygenation.