Examining the utility of routine perioperative hemoglobin monitoring in patients undergoing radical nephrectomy.

INTRODUCTION: Patients undergoing radical nephrectomy (RN) are often admitted with protocolized bloodwork for several days following their operation, yet the clinical value of serial hemoglobin (Hgb) measurements has not been established. This can lead to unnecessary costs and can prolong patient stay, despite the absence of an intervention based on these lab values. This study sought to examine perioperative Hgb values and identify those patients at high risk of bleeding requiring intervention, as well as those patients who are unlikely to require further monitoring. METHODS: Patient and perioperative factors were retrospectively examined for a cohort of 259 radical nephrectomy patients from 2015-2021 in Atlantic Canada. Postoperative Hgb values and transfusion rates were recorded. A multivariate logistic regression analysis was performed to identify variables associated with requiring a blood transfusion. RESULTS: Overall, 31 (12%) patients required a blood transfusion in the postoperative period. Median estimated blood loss (EBL) was 150 ml (interquartile range [IQR] 100-300), with a median Hgb change of 15 g/L (IQR 9-22 g/L) from preoperative to postoperative day 1 (POD1). In patients with a Hgb loss of ≤15 g/L (n=131), transfusion was only required in four of these patients (3.1%). Among those with a POD1 Hgb >100 g/L (n=199), only four (2%) required transfusion. These patients were identified to be having complications based on hemodynamic instability. Factors found to be associated on multivariate regression analysis with higher transfusion risk were age and intraoperative EBL, while higher preoperative Hgb was found to be associated with a lower transfusion risk. CONCLUSIONS: In patients who have a reassuring POD1 Hgb value, with a drop of <15 g/L or an absolute value of >100 g/L, consideration can be made towards discontinuing routine Hgb testing in the absence of a clinical indication. Age, blood loss, and preoperative Hgb are factors that may affect a patient's overall risk of transfusion.

Complications of non-medical assisted circumcision in Burkina Faso. Clinical presentation, management, and outcomes - about 23 cases and literature review.

OBJECTIVE: To report the clinical presentation of circumcision complications encountered at our center and evaluate their management and outcomes. PATIENTS AND METHODS: A retrospective and descriptive study was conducted at Souro Sanou University Hospital between January 1, 2014, and December 31, 2018. All patients presenting with circumcision complications were included. Parameters related to clinical aspects of circumcision complication, their management and outcomes were studied. RESULTS: During the study period, 23 cases of circumcision complications were reported. The average age of patients with circumcision complications was 8.3 years ± 3.5 years, with ages ranging from 18 months to 65 years old. Circumcision was performed by nurses in 12 cases and traditional practitioners in 11 cases. Observed complications included post-circumcision bleeding and hematoma (n = 8), leading to surgical exploration and hemostasis; total or partial amputation of the glans (n = 4), requiring regularization and meatoplasty; infectious complications (n = 3), managed with combined resuscitation, antibiotic administration, and penile debridement; penile urethra-cutaneous fistulas (n = 2), which were repaired; and stenosis of the external urethral meatus (n = 2), treated by meatoplasty. No deaths were reported. CONCLUSIONS: Circumcision complications presented various clinical manifestations, including hemorrhagic complications, glans amputation, infection, penile fistulas, and meatal stenosis. These complications were effectively managed from a functional perspective; however, aesthetic issues may persist. Emphasis should be placed on preventing these complications by ensuring circumcisions are performed by appropriately trained medical professionals.

Retrospective analysis of intra-patient laboratory variation demonstrates that the BD Vacutainer® Barricor™ blood collection tube reduces troponin variation.

OBJECTIVE: The BD Vacutainer® Barricor™ plasma blood collection tube uses a mechanical separator during centrifugation to separate plasma from the cellular elements of blood. Compared to use of plasma separator tubes (PST™) with gel, Barricor™ produces a cleaner sample with less residual cellular content. We sought to determine if Barricor™ reduces pre-analytical error compared to PST™. DESIGN & METHODS: We used a model previously published that utilizes serial differences between intra-patient measurements transformed into a Taylor series of variation vs time with the y-intercept equal to the sum of short-term analytic variation, preanalytic variation and biologic variation. The intra-patient variation of chloride, sodium, potassium, and troponin-T (hs-TnT) obtained from the Emergency Department of a large tertiary care center sampled with PST™ (May 2015-April 2018, n = 59,762 specimens) or Barricor™ (May 2018-May 2021, n = 61,512 specimens) was evaluated. All specimens were analyzed on either Roche Modular or Cobas® instruments. For each analyte, pairs of intra-patient results were tabulated and separated by 1 h intervals. The average between-pair variations were then regressed against time. We also determined the number of intra-patient outliers using the reference change value for each analyte. RESULTS: The Barricor™ hs-TnT y-intercept (-0.0132) was significantly lower than the PST™ intercept (0.9109; p = 0.022). This was also true for chloride (y-intercept = 1.0067 in Barricor™ and 1.3431 in PST™, p = 0.037). The percentage of hs-TnT outliers was significantly lower in Barricor™ (8.32 %) vs PST™ (12.2 %; p < 0.001). CONCLUSION: The analytical and biological variations are assumed to be steady over the study periods; we ascribe the difference in the y-intercept to the preanalytical effect of the Barricor™ tube reducing platelets and other cellular debris.

Comprehensive analysis of the performance of GPT-3.5 and GPT-4 on the American Urological Association self-assessment study program exams from 2012-2023.

INTRODUCTION: Artificial intelligence (AI) applications, specifically generative pre-trained transformers, have shown potential in medical education and board-style examinations. To assess this capability, we conducted a study comparing the performance of GPT-3.5 and GPT-4 on the American Urological Association (AUA) 2022 self-assessment study program (SASP) exams from 2012-2023. METHODS: We used a standardized prompt to administer questions from the AUA SASP exams spanning 2012-2023, totalling 1679 questions. The performance of the two AI models, GPT-3.5 and GPT-4, was evaluated based on the number of questions answered correctly. Statistical analysis was performed using Fisher's exact test and independent sample t-tests to compare the performance of GPT-4 to that of GPT-3.5 among test years and urology topic areas. Percentile scores were not calculable, however, a score of 50% is required to acquire CME credits on AUA SASP exams. RESULTS: The analysis showed significantly superior performance by GPT-4, which scored above 50% across all exam years except 2018, with scores ranging from 48-64%. In contrast, GPT-3.5 consistently scored below this threshold, with scores ranging from 26-38%. The total combined score for GPT-4 was 55%, significantly higher than the 33% achieved by GPT-3.5 (odds ratio [OR] 2.5, 95% confidence interval [CI] 2.2-2.9, p<0.001). GPT-4 significantly outperformed GPT-3.5 among AUA SASP test years from 2012-2023 (mean difference 23, t(22) 14, 95% CI 19-26, p<0.001), as well as among urology topic areas (mean difference 21, t(52)=5.5, 95% CI 13-29, p<0.001). CONCLUSIONS: GPT-4 scored significantly higher than GPT-3.5 on the AUA SASP exams in overall performance, across all test years, and in various urology topic areas. This suggests improvement in evolving AI language models in answering clinical urology questions; however, certain aspects of medical knowledge and clinical reasoning remain challenging for AI language models.

Identification of cannabinoids in post-mortem blood samples from the province of New Brunswick before and after recreational cannabis legalization.

INTRODUCTION: Since recreational legalization of cannabis in Canada in 2018, self-reported use in New Brunswick (NB) has increased from 15.1% to 20.3%, the largest increase of any province. Current literature on the impact of recreational cannabis legislation in other jurisdictions is conflicting, though retail availability has often been delayed on enactment. Given the immediate availability of cannabis in NB after legalization, we sought to establish the effect this had on post-mortem cannabinoid detection. Furthermore, we wanted to investigate the impact that age, sex, and manner of death had on cannabis use. We also established if there were any increases in commonly detected drugs over the study period. METHODS: A retrospective chart review was conducted on all adult Coroner's cases with toxicology analysis in NB between January 2014 and May 2020 (n = 3060). Differences in the proportion of cannabinoid-positive samples pre- versus post-legalization in the overall cohort as well as within each demographic parameter were assessed using chi-square tests. The effects of demographic parameters on cannabis presence were further assessed by logistic regression. Lastly, chi-square tests for trend were performed to identify increasing trends in cannabis detection, as well as cocaine, ethanol, opiates/opioids, benzodiazepines, and amphetamines over the study period. RESULTS: After controlling for age, sex, and manner of death, participants that died after recreational legalization had higher odds of having cannabis present post-mortem than those that died pre-legalization. In addition, demographic sub-analysis identified a greater proportion of cannabinoid-positive samples post-legalization in 25- to 44-year-olds and in deaths classified as either suicide or accidental compared to pre-legalization. We also observed a significant increase in the presence of cocaine and amphetamines in post-mortem samples over the study period. CONCLUSION: This study demonstrates that cannabis use has increased post-legalization in NB, particularly within young adults and those dying by suicide or accidental means. It also highlights the need for future research into the impact that legalization has on cannabis use in other jurisdictions.

Evaluation of BD Barricor™ and PST™ blood collection tubes compared to serum for testing 11 therapeutic drugs on a Roche Cobas® 8000 platform.

INTRODUCTION: The type of blood collection tube used when obtaining samples for therapeutic drug monitoring (TDM) has important implications on the accuracy of results. Serum tubes without a gel separator are currently considered best practice. We sought to evaluate the performance of Barricor™, a novel plasma tube that utilizes an inert mechanical separator, as well as a gel-based tube (PST™) for testing acetaminophen, digoxin, gentamicin, methotrexate, phenobarbital, phenytoin, salicylate, vancomycin, valproic acid, carbamazepine, and theophylline on a Roche Cobas® 8000 platform. METHODS: Paired patient samples were collected from individuals taking at least one of the medications evaluated. These were supplemented with spiked specimens to ensure a minimum of 40 paired samples per drug. All drugs were measured within two hours of collection on Roche e602 or c502 instruments. Deming regression was used to assess bias between Barricor™ vs serum and PST™ vs serum. Seven-day refrigerated stability was also assessed in Barricor™, PST™, and serum tubes in a subset of samples (n = 10) for each drug. RESULTS: Drug concentrations in Barricor™ were similar to serum for each drug assessed. In contrast, a negative bias was observed in PST™ compared to serum tubes for carbamazepine (-7.6%) and phenytoin (-6.8%) although this did not surpass our total allowable error goal of 10%. All drugs recovered within ±10% of baseline value when samples were stored refrigerated for 7 days except for carbamazepine, phenytoin, and phenobarbital where significant analyte loss was observed within the first day in PST™ tubes. CONCLUSION: Barricor™ tubes are a suitable alternative to serum for TDM on the Roche Cobas® 8000 platform.

Rate of malignancy for thyroid nodules with AUS/FLUS cytopathology in a tertiary care center - a retrospective cohort study.

BACKGROUND: Thyroid nodules are stratified through fine-needle aspiration (FNA) and are often categorized using The Bethesda System for Reporting Thyroid Cytopathology, which estimates the risk of malignancy for six cytopathological categories. The atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS) categories have varying malignancy rates reported in the literature which can range from 6 to 72.9%. Due to this heterogeneity, we assessed the malignancy rate and effectiveness of repeat FNA (rFNA) for AUS/FLUS thyroid cytopathology at our institution. METHODS: Electronic health records of patients with AUS/FLUS thyroid cytopathology on FNA at our center since the implementation of the Bethesda System on May 1, 2014-December 31, 2019 were retrospectively reviewed. Patient demographics, treatment pathway, and pathology results were collected. The treatment pathway of the nodules, the rFNA results, and the malignant histopathology results were reported. Malignancy rates were calculated as an upper and lower limit estimate. RESULTS: This study described 182 AUS/FLUS thyroid nodules from 177 patients. In total, 24 thyroid nodules were deemed malignant upon histopathology, yielding a final malignancy rate of 13.2-25.3%. All of the malignancies were variants of papillary thyroid carcinoma. The malignancy rate of the nodules which underwent resection without rFNA (21.5%) was lower than the malignancy rate of the nodules which underwent resection after rFNA (43.8%). 45.5% of the rFNA results were re-classified into more definitive categories. CONCLUSION: The malignancy rate of AUS/FLUS thyroid cytopathology at our center is in line with the risk of malignancy stated by the 2017 Bethesda System. However, our malignancy rate is lower than some other Canadian centers and approximately half of our rFNAs were re-classified, highlighting the importance of establishing center-specific malignancy and rFNA re-classification rates to guide treatment decisions.

The association between increasing levels of O-GlcNAc and galectins in the liver tissue of hibernating thirteen-lined ground squirrels (Ictidomys tridecemlineatus).

Post-translational glycosylation of proteins with O-linked ß-N-acetylglucosamine (O-GlcNAcylation) and changes of galectin expression profiles are essential in many cellular stress responses. We examine this regulation in the liver tissue of hibernating thirteen-lined ground squirrels (Ictidomys tridecemlineatus) representing a biological model of hypometabolism and physiological stress resistance. The tissue levels of O-GlcNAcylated proteins as well as galectin-1 and galectin-3 proteins detected by immunodot blot assay were significantly lower by 4.6-5.4-, 2.2-2.3- and 2.5-2.9-fold, respectively, in the non-hibernating summer squirrels compared with those in winter, whether hibernating or aroused. However, there were no differences in the expression of genes encoding enzymes involved in O-GlcNAc cycle (O-GlcNAc transferase and O-GlcNAcase) and such galectins as LGALS1, LGALS2, LGALS3, LGALS4 and LGALS9. Only the expression of LGALS8 gene in the liver tissue was significantly decreased by 37.6 ± 0.1% in hibernating ground squirrels relative to summer animals. Considering that the expression of a proven genetic biomarker ELOVL6 encoding ELOVL fatty acid elongase 6 was readily upregulated in non-hibernating animals by 11.3-32.9-fold, marginal differential changes in the expression of galectin genes cannot be classified as biomarkers of hibernation. Thus, this study provides evidence that hibernation in Ictidomys tridecemlineatus is associated with increasing O-GlcNAcylation of liver proteins and suggests that the contribution of galectins deserves further studies at the protein level.

Effects of Global O-GlcNAcylation on Galectin Gene-expression Profiles in Human Cancer Cell Lines.

BACKGROUND/AIM: The effects of O-linked ß-N-acetyl-D-glucosamine (O-GlcNAc) transferase (OGT) and O-GlcNAcase (OGA) inhibitors on galectin gene expression profiles were examined in MCF7, HT-29, and HL-60 cancer cell lines. MATERIALS AND METHODS: Cell cultures were treated for 24 h with OGA inhibitor thiamet G or OGT inhibitor 2-acetamido-1,3,4,6-tetra-O-acetyl-2-deoxy-5-thio-α-D-glucopyranose, and global O-GlcNAc levels and expression of galectin genes were determined using an immunodot blot assay and real-time quantitative polymerase chain reaction. RESULTS: Two galectin genes, LGALS3 in MCF7 cells and LGALS12 in HL-60 cells, were up-regulated by O-GlcNAc, whereas other cell-specific galectins were unresponsive to changes in O-GlcNAc level. Of interest, basal levels of O-GlcNAc in resting HL-60 and HT-29 cells were significantly higher than those in cells differentiated into neutrophilic or enterocytic lineages, respectively. CONCLUSION: O-GlcNAc-mediated signaling pathways may be involved in regulating the expression of only a limited number of galectin genes. Additional O-GlcNAc-dependent mechanisms may work at the protein level (galectin secretion and intracellular localization) and warrant further investigation.