The Pull-through Anastomosis of Ureter to Enteric Conduit (PAUTEC): A Novel Technique for Urinary Diversion.

OBJECTIVE: To describe and illustrate a novel technique of uretero-ileal anastomosis for use in urinary diversion - the Pull-through Anastomosis of Ureter To Enteric Conduit (PAUTEC). A second objective was to evaluate the surgical outcomes of the PAUTEC anastomosis. MATERIALS AND METHODS: Our novel anastomotic technique was described step-by-step and visually depicted with illustrations and the accompanying narrated video. Additionally, to evaluate safety and efficacy, a retrospective review of a prospectively maintained database was performed. Patients who underwent radical cystectomy alone or during pelvic exenteration, with ileal conduit diversion incorporating PAUTEC, 2016-2020 with ≥6 months follow-up were included. Surgical outcomes and renal function were analysed. RESULTS: PAUTEC anastomosis was performed on 43 ureters in 23 patients. Mean age was 66 years [50-80] and 21 of 23 patients were male. One patient had a conservatively-managed small urine leak. No ureteric strictures have been identified to date. Mean serum creatinine was 1.15 mg/dL [0.69-2.08] (102umol/L, range 61-184 umol/L) preoperatively, and 1.09 mg/dL [0.61-2.59] (96.3 umol/L, range 54-229 umol/L) at follow-up, demonstrating no significant change (P= .26, paired t-test). Mean follow-up was 15 months [6-44]. CONCLUSION: A PAUTEC technique of uretero-ileal anastomosis is feasible and technically straightforward, with satisfactory outcomes observed to date.

Long-Term Surveillance and Laparoscopic Management of Zinner Syndrome.

Zinner syndrome was first described in 1914 and represents the triad of unilateral renal agenesis and ipsilateral seminal vesicle cyst and ipsilateral ejaculatory duct obstruction. Seminal vesicle cysts are often asymptomatic but can also present with pain, haematospermia, or other lower urinary tract symptoms. Treatment strategies include observation and surgical excision. We present the laparoscopic management of an enlarged seminal vesicle cyst, consistent with Zinner syndrome, 14 years after the initial diagnosis. A 58-year-old male patient was diagnosed with a left-sided seminal vesicle cyst while undergoing assessment for renal transplant due to progressively worsening renal function in his solitary right kidney. The otherwise asymptomatic cyst enlarged from the time of initial diagnosis in 2004 (11.3 cm × 9.7 cm × 13.1 cm) to nearly double the size in 2018 (12.8 cm × 11.9 cm × 14.2 cm). This cyst size ultimately precluded renal transplant, and the patient was referred for excision. Laparoscopic excision of the cyst was performed, histopathology confirmed seminal vesicle cyst tissue, and there has been no recurrence of the cyst to date. The patient remains active on the renal transplant waitlist. Zinner syndrome is a rare syndrome, with the seminal vesicle cysts being managed by observation or surgical excision. We report the longest documented observation of a seminal vesicle cyst, culminating in a safe and successful laparoscopic excision.

Ethics of Artificial Intelligence in Radiology: Summary of the Joint European and North American Multisociety Statement.

This is a condensed summary of an international multisociety statement on ethics of artificial intelligence (AI) in radiology produced by the ACR, European Society of Radiology, RSNA, Society for Imaging Informatics in Medicine, European Society of Medical Imaging Informatics, Canadian Association of Radiologists, and American Association of Physicists in Medicine. AI has great potential to increase efficiency and accuracy throughout radiology, but it also carries inherent pitfalls and biases. Widespread use of AI-based intelligent and autonomous systems in radiology can increase the risk of systemic errors with high consequence and highlights complex ethical and societal issues. Currently, there is little experience using AI for patient care in diverse clinical settings. Extensive research is needed to understand how to best deploy AI in clinical practice. This statement highlights our consensus that ethical use of AI in radiology should promote well-being, minimize harm, and ensure that the benefits and harms are distributed among stakeholders in a just manner. We believe AI should respect human rights and freedoms, including dignity and privacy. It should be designed for maximum transparency and dependability. Ultimate responsibility and accountability for AI remains with its human designers and operators for the foreseeable future. The radiology community should start now to develop codes of ethics and practice for AI that promote any use that helps patients and the common good and should block use of radiology data and algorithms for financial gain without those two attributes. This article is a simultaneous joint publication in Radiology, Journal of the American College of Radiology, Canadian Association of Radiologists Journal, and Insights into Imaging. Published under a CC BY-NC-ND 4.0 license. Online supplemental material is available for this article.

Ethics of artificial intelligence in radiology: summary of the joint European and North American multisociety statement.

This is a condensed summary of an international multisociety statement on ethics of artificial intelligence (AI) in radiology produced by the ACR, European Society of Radiology, RSNA, Society for Imaging Informatics in Medicine, European Society of Medical Imaging Informatics, Canadian Association of Radiologists, and American Association of Physicists in Medicine.AI has great potential to increase efficiency and accuracy throughout radiology, but also carries inherent pitfalls and biases. Widespread use of AI-based intelligent and autonomous systems in radiology can increase the risk of systemic errors with high consequence, and highlights complex ethical and societal issues. Currently, there is little experience using AI for patient care in diverse clinical settings. Extensive research is needed to understand how to best deploy AI in clinical practice.This statement highlights our consensus that ethical use of AI in radiology should promote well-being, minimize harm, and ensure that the benefits and harms are distributed among stakeholders in a just manner. We believe AI should respect human rights and freedoms, including dignity and privacy. It should be designed for maximum transparency and dependability. Ultimate responsibility and accountability for AI remains with its human designers and operators for the foreseeable future.The radiology community should start now to develop codes of ethics and practice for AI which promote any use that helps patients and the common good and should block use of radiology data and algorithms for financial gain without those two attributes.

Ethics of Artificial Intelligence in Radiology: Summary of the Joint European and North American Multisociety Statement.

This is a condensed summary of an international multisociety statement on ethics of artificial intelligence (AI) in radiology produced by the ACR, European Society of Radiology, RSNA, Society for Imaging Informatics in Medicine, European Society of Medical Imaging Informatics, Canadian Association of Radiologists, and American Association of Physicists in Medicine. AI has great potential to increase efficiency and accuracy throughout radiology, but it also carries inherent pitfalls and biases. Widespread use of AI-based intelligent and autonomous systems in radiology can increase the risk of systemic errors with high consequence and highlights complex ethical and societal issues. Currently, there is little experience using AI for patient care in diverse clinical settings. Extensive research is needed to understand how to best deploy AI in clinical practice. This statement highlights our consensus that ethical use of AI in radiology should promote well-being, minimize harm, and ensure that the benefits and harms are distributed among stakeholders in a just manner. We believe AI should respect human rights and freedoms, including dignity and privacy. It should be designed for maximum transparency and dependability. Ultimate responsibility and accountability for AI remains with its human designers and operators for the foreseeable future. The radiology community should start now to develop codes of ethics and practice for AI that promote any use that helps patients and the common good and should block use of radiology data and algorithms for financial gain without those two attributes.

Ethics of Artificial Intelligence in Radiology: Summary of the Joint European and North American Multisociety Statement.

This is a condensed summary of an international multisociety statement on ethics of artificial intelligence (AI) in radiology produced by the ACR, European Society of Radiology, RSNA, Society for Imaging Informatics in Medicine, European Society of Medical Imaging Informatics, Canadian Association of Radiologists, and American Association of Physicists in Medicine. AI has great potential to increase efficiency and accuracy throughout radiology, but it also carries inherent pitfalls and biases. Widespread use of AI-based intelligent and autonomous systems in radiology can increase the risk of systemic errors with high consequence and highlights complex ethical and societal issues. Currently, there is little experience using AI for patient care in diverse clinical settings. Extensive research is needed to understand how to best deploy AI in clinical practice. This statement highlights our consensus that ethical use of AI in radiology should promote well-being, minimize harm, and ensure that the benefits and harms are distributed among stakeholders in a just manner. We believe AI should respect human rights and freedoms, including dignity and privacy. It should be designed for maximum transparency and dependability. Ultimate responsibility and accountability for AI remains with its human designers and operators for the foreseeable future. The radiology community should start now to develop codes of ethics and practice for AI that promote any use that helps patients and the common good and should block use of radiology data and algorithms for financial gain without those two attributes.

Application of TG-100 risk analysis methods to the acceptance testing and commissioning process of a Halcyon linear accelerator.

PURPOSE: A new type of linear accelerator (linac) was recently introduced into the market by a major manufacturer. Our institution is one of the early users of this preassembled and preconfigured dual-layer multileaf collimator (MLC), ring-gantry linac - Halcyon™ (1st version). We performed a set of full acceptance testing and commissioning (ATC) measurements for three Halcyon machines and compared the measured data with the standard beam model provided by the manufacturer. The ATC measurements were performed following the guidelines given in different AAPM protocols as well as guidelines provided by the manufacturer. The purpose of the present work was to perform a risk assessment of the ATC process for this new type of linac and investigate whether the results obtained from this analysis could potentially be used as a guideline for improving the design features of this type of linac. METHODS: AAPM's TG100 risk assessment methodology was applied to the ATC process. The acceptance testing process relied heavily on the use of a manufacturer-supplied phantom and the automated analysis of electronic portal imaging device (EPID) images. For the commissioning process, a conventional measurement setup and process (e.g., use of water tank for scanning) was largely used. ATC was performed using guidelines recommended in various AAPM protocols (e.g., TG-106, TG-51) as well as guidelines provided by the manufacturer. Six medical physicists were involved in this study. Process maps, process steps, and failure modes (FMs) were generated for the ATC procedures. Failure modes and effects analysis (FMEA) were performed following the guidelines given in AAPM TG-100 protocol. The top 5 and top 10 highest-ranked FMs were identified for the acceptance and commissioning procedures, respectively. Quality control measures were suggested to mitigate these FMs. RESULTS: A total of 38 steps and 88 FMs were identified for the entire ATC process. Fourteen steps and 34 FMs arose from acceptance testing. The top 5 FMs that were identified could potentially be mitigated by the manufacturer. For commissioning, a total of 24 steps and 54 potential FMs were identified. The use of separate measurement tools that are not machine-integrated has been identified as a cause for the higher number of steps and FMs generated from the conventional ATC approach. More than half of the quality control measures recommended for both acceptance and commissioning could potentially be incorporated by the manufacturer in the design of the Halcyon machine. CONCLUSION: This paper presents the results of FMEA and quality control measures to mitigate the FMs for the ATC process for Halcyon machine. Unique FMs that result from the differences in the ATC guidelines provided by the vendor and current conventional protocols, and the challenges of performing the ATC due to the new linac features and ring-gantry design were highlighted for the first time. The FMs identified in the present work along with the suggested quality control measures, could potentially be used to improve the design features of future ring-gantry type of linacs that are likely to be preassembled, preconfigured, and heavily reliant on automation and image guidance.

Comparison of Prostate Biopsy with or without Prebiopsy Multiparametric Magnetic Resonance Imaging for Prostate Cancer Detection: An Observational Cohort Study.

PURPOSE: We hypothesized that 1) introducing prebiopsy multiparametric magnetic resonance imaging would increase the diagnostic yield of transrectal prostate biopsy and 2) this would inform recommendations regarding systematic transrectal prostate biopsy in the setting of negative prebiopsy multiparametric magnetic resonance imaging. MATERIALS AND METHODS: A total of 997 biopsy naïve patients underwent transrectal prostate biopsy alone to June 2016 (cohort 1) and thereafter 792 underwent transrectal prostate biopsy following prebiopsy multiparametric magnetic resonance imaging (cohort 2). Patients with lesions on prebiopsy multiparametric magnetic resonance imaging underwent cognitive targeted plus systematic transrectal prostate biopsy. Patients without lesions underwent systematic transrectal prostate biopsy. RESULTS: Cohort 2 comprised younger men (age 68 vs 69 years, p = 0.01) with lower prostate specific antigen (7.6 vs 7.9 ng/ml, p = 0.024) and smaller prostate volume (56.1 vs 62 cc, p = 0.006). In cohort 2 vs cohort 1 there was no increase in overall prostate cancer detection (57.6% vs 56.7%, p = 0.701), the Gleason Grade Group or the number of positive cores (each p >0.05). Increased multifocal prostatic intraepithelial neoplasia, maximum prostate cancer core length (5 mm or greater vs less than 5 mm) and radical surgery/high intensity focused ultrasound (each p <0.05) were observed in cohort 2. For Gleason Grade Group 2-5 prostate cancer negative prebiopsy multiparametric magnetic resonance imaging had 88.1% sensitivity, 59.8% specificity, 67.8% positive predictive value and 84% negative predictive value. For negative prebiopsy multiparametric magnetic resonance images a prostate specific antigen density cutoff of 0.15 ng/ml2 or greater increased clinically significant prostate cancer detection only if the latter was defined as Gleason Grade Group 3-5 disease and/or tumor length 6 mm or greater. CONCLUSIONS: Introducing prebiopsy multiparametric magnetic resonance imaging in our clinical setting increased the diagnostic yield of prostate cancer per biopsy core. Not performing a systematic transrectal prostate biopsy when prebiopsy multiparametric magnetic resonance imaging was negative would have led to under detection of 15.1% of Gleason Grade Group 2 or greater prostate cancer cases (approximately 1 in 6).

Association of Anthropogenic Disturbances and Intestinal Parasitism in Ecuadorian Mantled Howler Monkeys, Alouatta palliata aequatorialis.

Forest disturbance and human encroachment have the potential to influence intestinal parasite communities in animal hosts by modifying nutritional health, physiological stress, host densities, contact rates, and ranging patterns. Anthropogenic disturbances also have the ability to affect the ecological landscape of parasitic disease, potentially impacting the health of both wildlife and people. Our research investigated the association of forest disturbance and human encroachment on intestinal parasite communities in mantled howler monkeys, Alouatta palliata aequatorialis. We found that individual parasite species prevalence was associated with group size and forest disturbance. Proximity to people was not a direct factor influencing intestinal parasitism; rather, several human proximity indices were related to group size, which was in turn related to overall species richness and the presence of specific parasite species. These results, coupled with previous findings, suggest that anthropogenic disturbances are likely influencing intestinal parasite communities. Though no single study has definitively explained all relationships between anthropogenic disturbances and intestinal parasitism, we propose that our models are appropriate for meta-analysis testing across other species and environments.

Characterization of Blastocystis species infection in humans and mantled howler monkeys, Alouatta palliata aequatorialis, living in close proximity to one another.

This study characterizes Blastocystis species infections in humans and mantled howler monkeys, Alouatta palliata aequatorialis, living in close proximity to one another in northwestern Ecuador. Blastocystis species were identified from 58 of 96 (60.4 %) mantled howler monkey fecal samples, and 44 of 55 human fecal samples (81.5 %) by polymerase chain reaction. Using single-stranded conformation polymorphism, we were able to efficiently separate and sequence subtypes (STs) within mixed samples without the need for cloning. Blastocystis ST1, ST2, and ST3 were found in people, and two individuals were infected with more than one subtype. All monkey samples were ST8. The lack of shared subtypes between humans and monkeys suggests that no Blastocystis transmission occurs between these species in spite of close proximity in some instances. Based on analysis of demographic data from a questionnaire given to human participants, individuals who boiled their water before consumption were significantly less likely to be infected with Blastocystis (44.4 %) compared to those who did not (93.8 %) (p = 0.002). No other risk factors were significant, although hunters, females, individuals living in large families, and those living closer to forested habitat tended to have a higher proportion of Blastocystis infections.

Gastrointestinal Parasites of Ecuadorian Mantled Howler Monkeys (Alouatta palliata aequatorialis) Based on Fecal Analysis.

An analysis of gastrointestinal parasites of Ecuadorian mantled howler monkeys, Alouatta palliata aequatorialis, was conducted based on examination of fecal smears, flotations, and sedimentations. At least 1 type of parasite was detected in 97% of the 96 fecal samples screened across 19 howler monkey groups using these techniques. Samples averaged 3.6 parasite species per individual (±1.4 SD). Parasites included species representing genera of 2 apicomplexans: Cyclospora sp. (18% of individual samples) and Isospora sp. (3%); 6 other protozoa: Balantidium sp. (9%), Blastocystis sp. (60%), Chilomastix sp. (4%), Dientamoeba sp. (3%), Entamoeba species (56%), Iodamoeba sp. (5%); 4 nematodes: Enterobius sp. (3%), Capillaria sp. (78%), Strongyloides spp. (88%) which included 2 morphotypes, Trypanoxyuris sp. (12%); and the platyhelminth Controrchis sp. (15%). A statistically significant positive correlation was found between group size and each of 3 different estimators of parasite species richness adjusted for sampling effort (ICE: r(2) = 0.24, P = 0.05; Chao2: r(2) = 0.25, P = 0.05, and Jackknife: r(2) = 0.31, P = 0.03). Two significant associations between co-infecting parasites were identified. Based on the prevalence data, individuals infected with Balantidium sp. were more likely to also be infected with Isospora sp. (χ(2) = 6.02, P = 0.01), while individuals harboring Chilomastix sp. were less likely to have Capillaria sp. present (χ(2) = 4.03, P = 0.04).

Predictors of 10-year pancreas allograft survival after simultaneous pancreas and kidney transplantation.

OBJECTIVE: This study aimed to identify the preoperative, perioperative, and postoperative factors affecting 10-year pancreas allograft survival after simultaneous pancreas and kidney (SPK) transplantation. METHODS: Analysis was performed on a prospectively maintained database of 56 SPK transplants consecutively performed between January 1992 and October 2002. The definition cutoff points of specific variables were obtained by the receiver operating characteristic curve and multiple logistic regression analyses that were performed to determine the predictors of pancreas allograft survival after 10 years. RESULTS: In total, 44 (79%) patients had an overall survival of more than 10 years, and the overall 10-year pancreas allograft survival rate was 57% (n = 32/56). The significant predictors for pancreas allograft failure in 10 years and above were kidney allograft failure (P = 0.04), serum creatinine 1 year postoperatively (P = 0.002), and serum hemoglobin A1c (HbA1c) level 2 years postoperatively (P = 0.003). A serum creatinine cutoff value of more than 129 µmol/L at 1 year was 87.5% sensitive and 70% specific for predicting pancreas allograft failure at 10 years. Serum HbA1c of more than 5.6% at 2 years was 85.7% sensitive and 62.5% specific for predicting pancreas allograft failure at 10 years. On multivariate analysis, 129 µmol/L and above of serum creatinine and more than 5.6% of serum HbA1c were the independent predictors of pancreas allograft failure at 10 years. CONCLUSIONS: These findings may provide important information for identifying patients at risk for long-term pancreas allograft failure after SPK transplantation.

Cholestatic liver injury associated with dietary supplements: a report of five cases in active duty service members.

The use of dietary supplements (DS) is common in the active duty population, often without physician knowledge or approval. DS have been associated with drug-induced liver injury, with rare cases resulting in liver failure or death. We report five cases of transient drug-induced liver injury temporally associated with the use of a total of six DS in active duty service members. All patients presented with elevated serum bilirubin and liver-associated enzymes: three patients had a cholestatic liver enzyme pattern, one had a hepatocellular pattern, and one had a mixed pattern. In all cases, percutaneous needle core biopsies of the liver were obtained and demonstrated a cholestatic pattern of injury with variable periportal fibrosis. Causality was considered highly probable for three cases, probable for one case, and possible for one case. Hepatotoxicity has been previously associated with four of the supplements in our cases. For the two remaining supplements, C4 Extreme and Animal Stak, we are unaware of any previous reports of hepatotoxicity. Health care professionals, in particular military physicians, should be aware of the potential risk of these supplements and be prepared to discuss these risks with their patients.

Necrophobic behavior in small mammals.

Necrophobic behaviors, defined as the avoidance of dead or injured conspecifics, have been formally documented in insects and aquatic organisms. It is plausible that such avoidance has been selected for by the risks of predation and disease that are associated with the presence of cadavers, and that necrophobic behaviors may be present across a variety of taxa. We demonstrate the avoidance of a house mouse (Mus musculus) cadaver by small mammals visiting experimental food trays, and by male and female house mice in a Y-maze exploration paradigm. In addition, we present individual differences in the responses of house mice to a house mouse cadaver. Further, we propose potential applications for the study of necrophobic behavior in improving wildlife management practices and models in disease ecology.

Mycophenolate mofetil in low-risk renal transplantation in patients receiving no cyclosporine: a single-centre experience.

BACKGROUND: We assess our long-term experience with regards the safety and efficacy of Mycophenolate Mofetil (MMF) in our low risk renal transplant population and compared it retrospectively to Azathioprine (AZA) immunosuppressive regimen. Patients and methods. Between January 1999 and December 2005, 240 renal transplants received MMF as part of their immunosuppressive protocol (MMF group). AZA group of 135 renal transplants was included for comparative analysis (AZA group). Patients received Cyclosporine was excluded from this study. RESULTS: The incidence of biopsy proven 3-month acute rejections was 30 (12.5%) in MMF group and 22 (16%) in AZA group respectively (P = 0.307). Patient survival rates at 1 and 5 years for the MMF group were 97 and 94%, respectively, compared to 100% and 91% at 1 and 5 years respectively for the AZA group (P = 0.61). Graft survival rates at 1 and 5 years for the MMF group were 95 and 83%, respectively, compared to 97 and 84% at 1 and 5 years, respectively for the AZA group (P = 0.62). CONCLUSION: There was no difference in acute rejection episodes between MMF and AZA based immunotherapy. Additionally, we observed no significant difference concerning graft survival in the MMF group when compared to AZA group.

Upper gastrointestinal bleeding: predictors of risk in a mixed patient group including variceal and nonvariceal haemorrhage.

BACKGROUND AND STUDY AIMS: Effective management of upper gastrointestinal bleeding (UGIB) relies on the application of clinical risk scores. The validation of risk scores has to date focused mainly on nonvariceal UGIB groups. We aimed to evaluate our clinical and endoscopic management of UGIB, and to validate existing risk scores for a mixed patient population with a high percentage of variceal bleeds. STUDY DESIGN AND METHODS: Analysis included UGIB patients presenting consecutively to a tertiary referral university hospital. All patients had been admitted by our emergency department and had undergone upper gastrointestinal endoscopy. Clinical, biochemical and endoscopic data were recorded. Clinical and complete Rockall and Blatchford risk scores were calculated for all patients and statistical analysis was carried out by a multiple logistical regression model. RESULTS: A total of 21% of patients had variceal bleeds. There was considerable heterogeneity between groups with the variceal group having more comorbidities (P=0.003), lower haemoglobin (P=0.003) and lower systolic blood pressure (P=0.013) at presentation. This translated to higher risk scores (P<0.0001) and worse clinical outcomes (rebleeding P=0.004). Only complete Rockall score was predictive of outcome (rebleeding P=0.004, AUC 0.8). Blatchford score did not predict bleeding or mortality. However, no patient with a Blatchford score of 0 had an adverse clinical outcome. CONCLUSION: Postendoscopic Rockall score can be used as a predictor of outcome for mixed UGIB groups. Although Blatchford score did not predict outcome in our study, at a 0 level it does appear to be a safe triage tool for pre-endoscopic identification of patients with variceal bleeds, even where there is no known history of liver disease.

Magnitude-dependent variation in peak height balance at heterozygous STR loci.

When the smaller of two peaks at an STR locus is less than 70% the magnitude of the larger peak at that locus, the disparity is typically taken to be an indication that there is more than one contributor of template DNA to the sample being tested. An analysis of 1,763 heterozygous allele pairs suggests that a peak height imbalance threshold that varies with the magnitude of the peaks being evaluated at a locus is superior to a fixed threshold. Identifying samples that are likely to be mixtures and those that are likely to have arisen from a single source is accomplished more reliably when a statistically based, magnitude-dependent peak height imbalance threshold is used. The amelogenin locus was found to behave in a similar fashion and was also found to have no systematic bias that favored the amplification of Y or X alleles.