Sensorimotor conflict tests in an immersive virtual environment reveal subclinical impairments in mild traumatic brain injury.

Current clinical tests lack the sensitivity needed for detecting subtle balance impairments associated with mild traumatic brain injury (mTBI). Patient-reported symptoms can be significant and have a huge impact on daily life, but impairments may remain undetected or poorly quantified using clinical measures. Our central hypothesis was that provocative sensorimotor perturbations, delivered in a highly instrumented, immersive virtual environment, would challenge sensory subsystems recruited for balance through conflicting multi-sensory evidence, and therefore reveal that not all subsystems are performing optimally. The results show that, as compared to standard clinical tests, the provocative perturbations illuminate balance impairments in subjects who have had mild traumatic brain injuries. Perturbations delivered while subjects were walking provided greater discriminability (average accuracy ≈ 0.90) than those delivered during standing (average accuracy ≈ 0.65) between mTBI subjects and healthy controls. Of the categories of features extracted to characterize balance, the lower limb accelerometry-based metrics proved to be most informative. Further, in response to perturbations, subjects with an mTBI utilized hip strategies more than ankle strategies to prevent loss of balance and also showed less variability in gait patterns. We have shown that sensorimotor conflicts illuminate otherwise-hidden balance impairments, which can be used to increase the sensitivity of current clinical procedures. This augmentation is vital in order to robustly detect the presence of balance impairments after mTBI and potentially define a phenotype of balance dysfunction that enhances risk of injury.

The use of Alloderm® for correction of severe chordee in children: An initial experience.

INTRODUCTION: Correction of chordee remains a prerequisite prior to urethroplasty in children with severe hypospadias. The use of an interposition graft is indicated when significant chordee (>300) persists after division of the urethral plate. The use of free dermis or tunica vaginalis are most often used, but the use of a pre-packaged graft material is attractive with regards to efficiency. The success with small intestine submucosa (SIS) has been variable and experience with Alloderm® has not been published. OBJECTIVE: To determine if Alloderm®, an acellular dermal matrix with regenerative properties, can effectively, safely, and efficiently be used for corporal grafting in cases of severe chordee in children associated with hypospadias or intersex STUDY DESIGN: All boys underwent planned staged repair of severe hypospadias (penoscrotal or more proximal). If artificial erection (AE) demonstrated chordee >450 after penile degloving and removal of fibrotic tissue, and again after urethral plate division, the ventral tunica albuginea was incised 1800 transversely and the oval defect measured in both axes. Alloderm® was trimmed to size and sewn into the defect. AE confirmed chordee correction. At the second stage repair (>6 months later), AE was performed to confirm continued absence of chordee. CONCLUSION: Alloderm®is safe, effective and simple to use graft material for correcting severe chordee. The benefits include performance efficiency without need for separate harvesting and donor site closure, and redundancy of material, if needed. Additional series and longer follow up must confirm these results and better assess durability.

A Framework for Biomarkers of COVID-19 Based on Coordination of Speech-Production Subsystems.

Goal: We propose a speech modeling and signal-processing framework to detect and track COVID-19 through asymptomatic and symptomatic stages. Methods: The approach is based on complexity of neuromotor coordination across speech subsystems involved in respiration, phonation and articulation, motivated by the distinct nature of COVID-19 involving lower (i.e., bronchial, diaphragm, lower tracheal) versus upper (i.e., laryngeal, pharyngeal, oral and nasal) respiratory tract inflammation, as well as by the growing evidence of the virus' neurological manifestations. Preliminary results: An exploratory study with audio interviews of five subjects provides Cohen's d effect sizes between pre-COVID-19 (pre-exposure) and post-COVID-19 (after positive diagnosis but presumed asymptomatic) using: coordination of respiration (as measured through acoustic waveform amplitude) and laryngeal motion (fundamental frequency and cepstral peak prominence), and coordination of laryngeal and articulatory (formant center frequencies) motion. Conclusions: While there is a strong subject-dependence, the group-level morphology of effect sizes indicates a reduced complexity of subsystem coordination. Validation is needed with larger more controlled datasets and to address confounding influences such as different recording conditions, unbalanced data quantities, and changes in underlying vocal status from pre-to-post time recordings.

Familial testicular torsion.

PURPOSE: Isolated reported cases of familial torsion yield modest information on incidence, genetics or clinical features. We present what is to our knowledge the largest series of familial torsion, including the first 3 generation case and a review of the literature. MATERIALS AND METHODS: Since 2006, we have questioned the presence of a positive family history in all patients with torsion at the initial consultation. We compiled data on familial relationship, laterality, age and outcomes of the proband and affected relatives. We collected previously published cases to better understand clinical features and genetics. RESULTS: Eight of 70 boys (11.4%) with torsion had affected family members. Another 2 families were included from a historical perspective. One relative was affected in 7 families, 2 were affected in 2 and 3 were affected in 1. First degree relatives were most commonly affected. In 1 family torsion occurred in 3 consecutive generations. Despite a family history 50% of patients experienced testicular loss. Brothers were affected in each of the 10 previously reported cases. In 3 families fathers were also affected. There were 3 sets of monozygotic twins. We noted laterality concordance 5 times and discordance 6 times. Age at torsion in probands was adolescence except in 2 with neonatal torsion. No clear inheritance mode was found. CONCLUSIONS: Familial torsion occurs in about 10% of probands and can affect multiple relatives and generations. A positive family history may be useful for torsion diagnosis and management. Relatives of affected patients need education on the signs and symptoms of torsion, and the importance of early presentation to improve outcome.

Retrograde ureteral access after cross-trigonal ureteral reimplantation: A straightforward technique.

PURPOSE: Retrograde ureteral access after cross-trigonal ureteral reimplantation can be challenging. We present our experience with percutaneous retrograde ureteral catheterization, status post cross-trigonal ureteral reimplantation. MATERIALS AND METHODS: We evaluated all patients who underwent attempted percutaneous retrograde ureteral catheterization after cross-trigonal ureteral reimplantation. All clinical data, radiographic images and operative reports were reviewed. Ureteral access was obtained by percutaneously entering the bladder with an intravenous needle/catheter under cystoscopic guidance. The needle was then removed leaving the catheter in place. The ureteral orifice was then accessed through the intravenous catheter by a ureteral access wire and/or ureteral catheter under cystoscopic guidance. RESULTS: From 1978 to 2008, 13 patients (11 boys and 2 girls) with a history of cross-trigonal ureteral reimplantation underwent percutaneous retrograde ureteral catheterization. The procedure was unilateral in 12 patients and bilateral in one. Indications for the procedure included: retrograde pyelography and double-J stent insertion for ureteropelvic junction or ureterovesical junction obstruction (10); removal of migrated stent (2); and treatment of a ureteral stone (1). The procedure was performed successfully in all patients and without complications. CONCLUSIONS: Percutaneous retrograde ureteral catheterization is a safe, straightforward, and effective modality for obtaining retrograde ureteral access in children, status post cross-trigonal ureteral reimplantation.

Complications of circumcision.

In the United States, circumcision is a commonly performed procedure. It is a relatively safe procedure with a low overall complication rate. Most complications are minor and can be managed easily. Though uncommon, complications of circumcision do represent a significant percentage of cases seen by pediatric urologists. Often they require surgical correction that results in a significant cost to the health care system. Severe complications are quite rare, but death has been reported as a result in some cases. A thorough and complete preoperative evaluation, focusing on bleeding history and birth history, is imperative. Proper selection of patients based on age and anatomic considerations as well as proper sterile surgical technique are critical to prevent future circumcision-related adverse events.

Inconspicuous penis.

Inconspicous penis refers to a constellation of conditions that make the penis look diminutive and small. This could be secondary to short penile shaft often termed as micropenis. But more commonly, this inconspicuous appearance is secondary to other causes ranging from congenital conditions such as penoscrotal webbing or megaprepuce, developmental conditions like prepubic adiposity that overhang the penis, and iatrogenic causes like trapped penis after adhesions secondary to circumcision. In this paper, we propose to define these entities and provide their descriptions and then to describe their management including surgical correction.

Urologic emergencies in pregnancy.

The management of urological emergencies during pregnancy presents unique clinical challenges for the treating physician. Clinical signs and symptoms are often subtle while diagnostic and therapeutic options are limited in treating patients to avoid fetal morbidity. A high index of suspicion with early diagnosis and treatment are essential for the management of genitourologic emergencies in pregnant women. It is essential for patients to be managed on an individual basis using a multidisciplinary approach.

Avagard hand antisepsis vs. traditional scrub in 3600 pediatric urologic procedures.

OBJECTIVES: Avagard is a waterless, scrubless, and brushless hand antiseptic approved by the Food and Drug Administration as a replacement for traditional presurgical brush hand scrubbing. We evaluated the use of Avagard compared with hand brush scrub preparation for inpatient and outpatient pediatric urological operations. METHODS: We evaluated the first 1800 patients for whom we used Avagard as a preoperative hand antiseptic and compared them with the last 1800 consecutive patients for whom we performed traditional antiseptic-impregnated hand-brush scrubbing. All patients underwent a variety of inpatient and outpatient open, endoscopic, and laparoscopic pediatric urological procedures. Patients were monitored postoperatively for wound infection, and patients and surgeon were monitored for side effects. A cost analysis was performed. RESULTS: The incidence of wound infection was 2/1800 (0.11%) in the Avagard group and 3/1800 (0.17%) in the hand-scrub group (P > .99 Fisher's exact test). All wound infections were successfully treated with a single course of oral antibiotics. No side effects for the patients or surgeon were noted, including skin irritations or allergic reactions in either group. The traditional hand scrub is nearly 2 times more expensive per application than Avagard. CONCLUSIONS: The incidence of wound infections in pediatric urological procedures is low (0.09%). We observe that Avagard provides comparable hand antisepsis to the traditional surgical scrub in a variety of pediatric urological procedures. Avagard is superior to the surgical hand scrub in cost-effectiveness and time efficiency. Urologists should consider using Avagard for hand antisepsis before surgery.

Ungated extracorporeal shock wave lithotripsy: safe and effective in the pediatric population.

PURPOSE: Ungated extracorporeal shock wave lithotripsy (SWL) is unsynchronized to the patient's electrocardiogram. Although ungated extracorporeal shock wave lithotripsy (SWL) is associated with cardiac arrhythmias in adults, the incidence of arrhythmias in children has not been established. We report on the safety and efficacy of ungated SWL of renal calculi in children. MATERIALS AND METHODS: We evaluated all children less than 18 years of age undergoing ungated SWL for renal calculi. Lithotripsy with gradual incremental energy increase was used to treat the stones. Patients were monitored for arrhythmias and other standard monitoring intraoperatively and postoperatively. RESULTS: Twenty-four consecutive children (10 boys and 14 girls) between 3.5 and 17 years of age underwent 32 ungated SWL procedures for renal calculi. The stone size ranged from 5 mm to 19 mm. No patient had cardiac arrhythmias or other intraoperative complications, required to have the procedure terminated prematurely, or conversion to gated SWL. The overall stone free rate was 87% based on radiographic imaging. CONCLUSIONS: This series supports our initial series that ungated SWL is safe and efficacious in children less than 18 years of age. The arrhythmias associated with adults do no appear to occur in children undergoing ungated SWL.

Prenatal and postnatal management of hydronephrosis.

The majority of pregnant women in the U.S. undergo prenatal ultrasonography and approximately 0.5% of these examinations will detect fetal malformations. Up to one-half of these abnormalities include the genitourinary system and the most common urological finding is hydronephrosis. Some conditions associated with prenatal hydronephrosis portend a poor prognosis, while others can follow a fairly benign course. This review focuses on the definition and prenatal assessment of hydronephrosis, fetal intervention, and postnatal management.

A critical pathway for successful outpatient ureteral reimplantation: a nursing perspective.

Vesicoureteral reflux is a common pediatric urologic condition. Traditionally, surgical treatment of this condition requires a hospital stay of 1 to 6 days. Our experience has shown that both unilateral and bilateral extravesical ureteral reimplantation can be performed safely in the ambulatory surgery setting. Our perianesthesia care revolves around the concept of family-centered care. We have found that the key to our critical pathway involves both the patient and the family in every part of perianesthesia care. This "team" approach can be adapted for any pediatric procedure.