Urethral Injuries: Diagnostic and Management Strategies for Critical Care and Trauma Clinicians.

Urologic trauma is a well-known cause of urethral injury with a range of management recommendations. Retrograde urethrogram remains the preferred initial diagnostic modality to evaluate a suspected urethral injury. The management thereafter varies based on mechanism of injury. Iatrogenic urethral injury is often caused by traumatic catheterization and is best managed by an attempted catheterization performed by an experienced clinician or suprapubic catheter to maximize urinary drainage. Penetrating trauma, most commonly associated with gunshot wounds, can cause either an anterior and/or posterior urethral injury and is best treated with early operative repair. Blunt trauma, most commonly associated with straddle injuries and pelvic fractures, can be treated with either early primary endoscopic realignment or delayed urethroplasty after suprapubic cystostomy. With any of the above injury patterns and treatment options, a well thought out and regimented follow-up with a urologist is of utmost importance for accurate assessment of outcomes and appropriate management of complications.

Minimally Invasive Surgery (MIS) fellowship website content: are applicants receiving enough information?

BACKGROUND: Advanced GI/Minimally Invasive Surgery (MIS) fellowships are one of the largest non-ACGME post-residency training pathways. MIS programs are highly competitive, with only 68% of applicants in the 2021 cycle successfully matching into fellowship positions. An evaluation of MIS fellowship program websites is warranted to determine if applicants are receiving adequate information to meet their needs. METHODS: Using the Fellowship Council website, the authors identified 92 MIS fellowship programs that advertised open fellowships positions for general surgery residency graduates. These 92 fellowship websites were evaluated for 12 pre-identified variables based on published literature. RESULTS: 90% of websites included access to contact information for a program director/coordinator and 72% of websites displayed selection criteria; however, other recruitment information offered to applicants was limited. Only 25% of websites mentioned interview details, 34% of websites showcased current or past fellows, and 51% included a faculty directory. Regarding operative information, only 46% of MIS fellowship websites mentioned case volume, 23% mentioned locations of rotations, and 55% mentioned rotation schedule selection criteria. Didactic information was focused on research productivity with 80% of websites highlighting scholarly requirements; academic conferences were only mentioned in 40% of websites. Fellow wellness and career information was skipped on many websites, with 30% describing resident benefits and 16% dedicating a section to career development. Overall, the mean number of pre-identified variables present on a fellowship website was 6.57 ± 2.39 (54.75 ± 19.17%). CONCLUSIONS: General surgery residents turn to program websites when evaluating MIS fellowships. Although websites contain adequate information on several variables evaluated in the study, information on benefits and career development, fellow and faculty support, and case volume were limited. By including relevant information, MIS fellowship websites can align with ACGME requirements, strengthen existing frameworks, and help display data that are important to applicants.

Opiate Prescriptions Vary among Common Urologic Procedures: A Claims Dataset Analysis.

Objectives: This study aimed to better understand differences in the total days' supply and fills of common opiates following urologic procedures. Materials and Methods: The Truven Health MarketScan® database was used to extract CPT codes from adults 18 years or older who underwent a urologic procedure with 90-day follow-up from 2012−2015 within the Austin−Round Rock, Texas metropolitan service area. A multivariate analysis and first hurdle modeling with a logistic outcome for any opiates was used to (1) assess differences in opioid prescribing patterns, (2) investigate opioid prescription outcomes, and (3) explore variability among opiate prescription patterns across seven urologic procedure categories. Results: Among the 2312 patients who met the inclusion criteria, 23.7% received an opiate, with an average total day's supply of 6.20 (range 2.61−10.59). The proportion of patients receiving opiates varied significantly by procedure type (p = 0.028). Patients that had reconstructive procedures had the highest proportion of any opiates and the highest number of mean opiate prescriptions among the seven procedure categories (42% received opiates, p = 0.028, mean opiate prescriptions were 1.0 among all patients, p = 0.026). After adjustments, the multivariate analysis demonstrated that patients undergoing reconstructive procedures filled more opiate prescriptions (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.00−3.50, p = 0.05) compared to other subcategories. Of those that received opiates, reconstructive patients had a shorter time to fills (mean −18.4 days, CI −8.40 to −28.50, p < 0.001). Conclusion: Patients undergoing reconstructive procedures are prescribed and fill more opiates compared to other common urological procedures. The standardization and implementation of postoperative pain regimens may help curtail this variability.

The Perception and Impact of Relative Value Units (RVUs) and Quality-of-Care Compensation in Neurosurgery: A Literature Review.

The debate surrounding the integration of value in healthcare delivery and reimbursement reform has centered around integrating quality metrics into the current fee-for-service relative value units (RVU) payment model. Although a great amount of literature has been published on the creation and utilization of the RVU, there remains a dearth of information on how clinicians from various specialties view RVU and the quality-of-care metric in the compensation formula. The aim of this review is to analyze and consolidate existing theories on the RVU payment model in neurosurgery. Google and PubMed were searched for English-language literature describing opinions on the RVU in neurosurgery. Commentary was noted to be primary opinions if it was mentioned at least twice in the eight articles included in this review. Overall, seven primary opinions on the RVU were identified across the analyzed articles. Integration of quality into the RVU is viewed favorably by neurosurgeons with a few caveats and opportunities for further improvement.

Occupational traumatic injuries rarely affect genitourinary organs: a retrospective, comparative study.

PURPOSE: To determine the mechanisms of injury associated with occupational injuries (OI) to genitourinary (GU) organs and compare GU OIs with GU non-OIs. METHODS: A single institution, retrospective study was conducted at a level 1 trauma center between 2010 and 2016 of all patients with GU injuries. OI was defined as any traumatic event that occurred in the workplace requiring hospital admission. Types of occupations were recorded in addition to the location of injury, mechanisms of injury, concomitant injuries, operative interventions, total cost, and mortality. GU OI patients were then compared to GU non-OI patients. RESULTS: 623 patients suffered a GU injury, of which 39 (6.3%) had a GU OI. Fall (43%) was the most common mechanism of injury; followed by motor vehicle collision/motorcycle crash (31%), crush injury (18%), and pedestrian struck (8%). The adrenal gland (38%) and kidney (38%) were the most commonly injured organs. There was no difference in mortality (13% GU OI vs. 15% GU non-OI, p = 0.70) or total direct cost ($21,192 ± 28,543 GU OI vs. $28,215 ± 32,332 GU non-OI, p = 0.45). Total costs were decreased with mortality from a GU injury (odds ratio (OR) 0.3, CI 0.26-0.59; p = < 0.001) and increased with higher injury severity scores (OR 1.1, CI 1.09-1.2; p = < 0.0001). Total costs were not affected by OI status. CONCLUSIONS: Occupational GU trauma presents with similar patterns of injury, hospital course, and direct cost as GU trauma that occurs in non-occupational settings.

Desmopressin is a transfusion sparing option to reverse platelet dysfunction in patients with severe traumatic brain injury.

BACKGROUND: Platelet dysfunction (PD) is an independent predictor of mortality in patients with severe traumatic brain injury (sTBI). Platelet transfusions (PLTs) have been shown to be an effective treatment strategy to reverse platelet inhibition. Their use is contingent on availability and may be associated with increased cost and transfusion-related complications, making desmopressin (DDAVP) attractive. We hypothesized that DDAVP would correct PD similarly to PLTs in patients with sTBI. METHODS: This retrospective study evaluated all blunt trauma patients admitted to an urban, level 1 trauma center from July 2015 to October 2016 with sTBI (defined as head abbreviated injury scale [AIS] ≥3) and PD (defined as adenosine diphosphate [ADP] inhibition ≥60% on thromboelastography) and subsequently received treatment. Per our institutional practice, patients with sTBI and PD are transfused one unit of apheresis platelets to reverse inhibition. During a platelet shortage, we interchanged DDAVP for the initial treatment. Patients were classified as receiving DDAVP or PLT based on the initial treatment. RESULTS: A total of 57 patients were included (DDAVP, n = 23; PLT, n = 34). Patients who received DDAVP were more severely injured (injury severity score, 29 vs. 23; p = 0.045), but there was no difference in head AIS (4 vs. 4, p = 0.16). There was no difference between the two groups in admission platelet count (244 ± 68 × 10/µL vs. 265 ± 66 × 10/µL, p = 0.24) or other coagulation parameters such as prothrombin time, partial thromboplastin time, or international normalized ratio. Before treatment, both groups had similar ADP inhibition as measured by thromboelastography (ADP, 86% vs. 89%, p = 0.34). After treatment, both the DDAVP and PLT groups had similar correction of platelet ADP inhibition (p = 0.28). CONCLUSION: In patients with severe traumatic brain injury and PD, DDAVP may be an alternative to PLTs to correct PD. LEVEL OF EVIDENCE: Therapeutic, level IV.

Unifying Pathophysiological Explanations for Sports-Related Concussion and Concussion Protocol Management: Literature Review.

OBJECTIVE: There is a plethora of theories about the pathophysiology behind a sport-related concussion. In this review of the literature, the authors evaluated studies on the pathophysiology of sport-related concussion and professional athlete return-to-play guidelines. The goal of this article is to summarize the most common hypotheses for sport-related concussion, evaluate if there are common underlying mechanisms, and determine if correlations are seen between published mechanisms and the most current return-to-play recommendations. METHODS: Two authors selected papers from the past 5 years for literature review involving discussion of sport-related concussion and pathophysiology, pathology, or physiology of concussion using mutually agreed-upon search criteria. After the articles were filtered based on search criteria, pathophysiological explanations for concussion were organized into tables. Following analysis of pathophysiology, concussion protocols and return-to-play guidelines were obtained via a Google search for the major professional sports leagues and synthesized into a summary table. RESULTS: Out of 1112 initially identified publications, 53 met our criteria for qualitative analysis. The 53 studies revealed 5 primary neuropathological explanations for sport-related concussion, regardless of the many theories talked about in the different papers. These 5 explanations, in order of predominance in the articles analyzed, were (1) tauopathy, (2) white matter changes, (3) neural connectivity alterations, (4) reduction in cerebral perfusion, and (5) gray matter atrophy. Pathology may be sport specific: white matter changes are seen in 47% of football reports, tauopathy is seen in 50% of hockey reports, and soccer reports 50% tauopathy as well as 50% neural connectivity alterations. Analysis of the return-to-play guidelines across professional sports indicated commonalities in concussion management despite individual policies. CONCLUSIONS: Current evidence on pathophysiology for sport-related concussion does not yet support one unifying mechanism, but published hypotheses may potentially be simplified into 5 primary groups. The unification of the complex, likely multifactorial mechanisms for sport-related concussion to a few common explanations, combined with unique findings within individual sports presented in this report, may help filter and link concussion pathophysiology in sport. By doing so, the authors hope that this review will help guide future concussion research, treatment, and management.

Small molecule modulators of σ2R/Tmem97 reduce alcohol withdrawal-induced behaviors.

Repeated cycles of intoxication and withdrawal enhance the negative reinforcing properties of alcohol and lead to neuroadaptations that underlie withdrawal symptoms driving alcohol dependence. Pharmacotherapies that target these neuroadaptations may help break the cycle of dependence. The sigma-1 receptor (σ1R) subtype has attracted interest as a possible modulator of the rewarding and reinforcing effects of alcohol. However, whether the sigma-2 receptor, recently cloned and identified as transmembrane protein 97 (σ2R/TMEM97), plays a role in alcohol-related behaviors is currently unknown. Using a Caenorhabditis elegans model, we identified two novel, selective σ2R/Tmem97 modulators that reduce alcohol withdrawal behavior via an ortholog of σ2R/TMEM97. We then show that one of these compounds blunted withdrawal-induced excessive alcohol drinking in a well-established rodent model of alcohol dependence. These discoveries provide the first evidence that σ2R/TMEM97 is involved in alcohol withdrawal behaviors and that this receptor is a potential new target for treating alcohol use disorder.

Thoracic, Lumbar, and Sacral Pedicle Screw Placement Using Stryker-Ziehm Virtual Screw Technology and Navigated Stryker Cordless Driver 3: Technical Note.

OBJECT: Utilization of pedicle screws (PS) for spine stabilization is common in spinal surgery. With reliance on visual inspection of anatomical landmarks prior to screw placement, the free-hand technique requires a high level of surgeon skill and precision. Three-dimensional (3D), computer-assisted virtual neuronavigation improves the precision of PS placement and minimization steps. METHODS: Twenty-three patients with degenerative, traumatic, or neoplastic pathologies received treatment via a novel three-step PS technique that utilizes a navigated power driver in combination with virtual screw technology. (1) Following visualization of neuroanatomy using intraoperative CT, a navigated 3-mm match stick drill bit was inserted at an anatomical entry point with a screen projection showing a virtual screw. (2) A Navigated Stryker Cordless Driver with an appropriate tap was used to access the vertebral body through a pedicle with a screen projection again showing a virtual screw. (3) A Navigated Stryker Cordless Driver with an actual screw was used with a screen projection showing the same virtual screw. One hundred and forty-four consecutive screws were inserted using this three-step, navigated driver, virtual screw technique. RESULTS: Only 1 screw needed intraoperative revision after insertion using the three-step, navigated driver, virtual PS technique. This amounts to a 0.69% revision rate. One hundred percent of patients had intraoperative CT reconstructed images taken to confirm hardware placement. CONCLUSIONS: Pedicle screw placement utilizing the Stryker-Ziehm neuronavigation virtual screw technology with a three step, navigated power drill technique is safe and effective.

High-Content Microfluidic Screening Platform Used To Identify σ2R/Tmem97 Binding Ligands that Reduce Age-Dependent Neurodegeneration in C. elegans SC_APP Model.

The nematode Caenorhabditis elegans, with tractable genetics and a well-defined nervous system, provides a unique whole-animal model system to identify novel drug targets and therapies for neurodegenerative diseases. Large-scale drug or target screens in models that recapitulate the subtle age- and cell-specific aspects of neurodegenerative diseases are limited by a technological requirement for high-throughput analysis of neuronal morphology. Recently, we developed a single-copy model of amyloid precursor protein (SC_APP) induced neurodegeneration that exhibits progressive degeneration of select cholinergic neurons. Our previous work with this model suggests that small molecule ligands of the sigma 2 receptor (σ2R), which was recently cloned and identified as transmembrane protein 97 (TMEM97), are neuroprotective. To determine structure-activity relationships for unexplored chemical space in our σ2R/Tmem97 ligand collection, we developed an in vivo high-content screening (HCS) assay to identify potential drug leads. The HCS assay uses our recently developed large-scale microfluidic immobilization chip and automated imaging platform. We discovered norbenzomorphans that reduced neurodegeneration in our C. elegans model, including two compounds that demonstrated significant neuroprotective activity at multiple doses. These findings provide further evidence that σ2R/Tmem97-binding norbenzomorphans may represent a new drug class for treating neurodegenerative diseases.