Epidemics of COVID-19 in student populations at universities were a key concern for the 2020-2021 school year. The University of California (UC) System developed a set of recommendations to reduce ...campus infection rates. SARS-CoV-2 test results are summarized for the ten UC campuses during the Fall 2020 term.
UC mitigation efforts included protocols for the arrival of students living on-campus students, non-pharmaceutical interventions, daily symptom monitoring, symptomatic testing, asymptomatic surveillance testing, isolation and quarantine protocols, student ambassador programs for health education, campus health and safety pledges, and lowered density of on-campus student housing. We used data from UC campuses, the UC Health-California Department of Public Health Data Modeling Consortium, and the U.S. Census to estimate the proportion of each campus' student populations that tested positive for SARS-CoV-2 and compared it to the fraction individuals aged 20-29 years who tested positive in their respective counties.
SARS-CoV-2 cases in campus populations were generally low in September and October 2020, but increased in November and especially December, and were highest in early to mid-January 2021, mirroring case trajectories in their respective counties. Many students were infected during the Thanksgiving and winter holiday recesses and were detected as cases upon returning to campus. The proportion of students who tested positive for SARS-CoV-2 during Fall 2020 ranged from 1.2% to 5.2% for students living on campus and was similar to students living off campus. For most UC campuses the proportion of students testing positive was lower than that for the 20-29-year-old population in which campuses were located.
The layered mitigation approach used on UC campuses, informed by public health science and augmented perhaps by a more compliant population, likely minimized campus transmission and outbreaks and limited transmission to surrounding communities. University policies that include these mitigation efforts in Fall 2020 along with SARS-CoV-2 vaccination, may alleviate some local concerns about college students returning to communities and facilitate resumption of normal campus operations and in-person instruction.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Background To counsel patients adequately, it is important to understand the variables influencing satisfaction and regret following prostatectomy. Objective To identify independent ...predictors for satisfaction and regret after radical prostatectomy. Design, setting, and participants Patients who had undergone retropubic radical prostatectomy (RRP) or robot-assisted laparoscopic radical prostatectomy (RALP) between 2000 and 2007 were mailed cross-sectional surveys composed of sociodemographic information, the Expanded Prostate Cancer Index Composite (EPIC), and questions regarding satisfaction and regret. Measurements Sociodemographic variables, perioperative complications, type of procedure, length of follow-up, and EPIC scores were evaluated as independent predictors of satisfaction and regret in multivariate logistic regression analysis. Results and limitations A total of 400 patients responded (response rate 61%) of whom 84% were satisfied and 19% regretted their treatment choice. In multivariate analysis, lower income (odds ratio OR, 0.08; 95% confidence interval CI, 0.03–0.23), shorter follow-up (OR, 0.63; 95% CI, 0.41–0.98), having undergone RRP versus RALP (OR, 4.45; 95% CI, 1.90–10.4), urinary domain scores (OR, 2.70; 95% CI, 1.60–4.54), and hormonal domain scores (OR, 2.01; 95% CI, 1.30–3.12) were independently associated with satisfaction ( p ≤ 0.039). In terms of regret, RALP versus RRP (OR, 3.02; 95% CI, 1.50–6.07), lower urinary domain scores (OR, 0.58; 95% CI, 0.37–0.91) and hormonal domain scores (OR, 0.67; 95% CI, 0.45–0.98), and years since surgery (OR, 1.63; 95% CI, 1.13–2.36) were again predictive ( p ≤ 0.041). African American race (OR, 3.58; 95% CI, 1.52–8.43) and lower bowel domain scores (OR, 0.73; 95% CI, 0.55–0.97) were also independently associated with regret ( p ≤ 0.028). Conclusions Sociodemographic variables and quality of life were important variables associated with satisfaction and regret. Patients who underwent RALP were more likely to be regretful and dissatisfied, possibly because of higher expectation of an “innovative” procedure. We suggest that urologists carefully portray the risks and benefits of new technologies during preoperative counseling to minimize regret and maximize satisfaction.
Since ancient times we have attempted to facilitate hemostasis by application of topical agents. In the last decade, the number of different effective hemostatic agents has increased drastically. In ...order for the modern surgeon to successfully choose the right agent at the right time, it is essential to understand the mechanism of action, efficacy and possible adverse events as they relate to each agent. In this article we provide a comprehensive review of the most commonly used hemostatic agents, subcategorized as physical agents, absorbable agents, biologic agents, and synthetic agents. We also evaluate novel hemostatic dressings and their application in the current era. Furthermore, wholesale acquisition prices for hospitals in the United States are provided to aid in cost analysis. We conclude with an expert opinion on which agent to use under different scenarios.
Prostate cancer (PCa) risk assessment can incorporate clinical features, gene expression, protein ‘biomarkers’ or imaging. In this review the benefits of layering multiparametric magnetic resonance ...imaging (mpMRI) with other risk assessment methods is considered. mpMRI is an increasingly utilized risk assessment tool in prostate cancer. The European Association of Urology, National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) guidelines call for mpMRI utilization in the prostate cancer management pathway. As such, the NCCN Guidelines and AUA guidelines emphasize differing levels of reliance on mpMRI preceding prostate biopsy. However, like all risk assessment tools, mpMRI has strengths and limitations. This include dependencies on reader expertise and interpretation, equipment and process standardization, tumor size, tumor multifocality, tissue architecture, ethnic and racial disparity, and cost. Thus, layering complementary risk assessment methods to mitigate the limitations of each approach, enables the most informed clinical management. The goal of ongoing biomarker/mpMRI studies is to provide insight into the clinically helpful integration of the two approaches. For new technologies to be adapted or layered together synergistically, five specific competencies must be considered acceptable: (1) efficacy, (2) potential side effect levels, (3) ease of use of technology, (4) cost vs. clinical benefit, and (5) durability.
Background
For specific clinical indications, androgen deprivation therapy (ADT) will induce disease prostate cancer (PC) regression, relieve symptoms and prolong survival; however, ADT has a ...well‐described range of side effects, which may have a detrimental effect on the patient's quality of life, necessitating additional interventions or changes in PC treatment. The risk‐benefit analysis for initiating ADT in PC patients throughout the PC disease continuum warrants review.
Methods
A 14‐member panel comprised of urologic and medical oncologists were chosen for an expert review panel, to provide guidance on a more judicious use of ADT in advanced PC patients. Panel members were chosen based upon their academic and community experience and expertise in the management of PC patients. Four academic members of the panel served as group leaders; the remaining eight panel members were from Large Urology Group Practice Association practices with proven experience in leading their advanced PC clinics. The panel members were assigned to four separate working groups, and were tasked with addressing the role of ADT in specific PC settings.
Results
This article describes the practical recommendations of an expert panel for the use of ADT throughout the PC disease continuum, as well as an algorithm summarizing the key recommendations. The target for this publication is all providers (urologists, medical oncologists, radiation oncologists, or advanced practice providers) who evaluate and manage advanced PC patients, regardless of their practice setting.
Conclusion
The panel has provided recommendations for monitoring PC patients while on ADT, recognizing that PC patients will progress despite testosterone suppression and, therefore, early identification of conversion from castrate‐sensitive to castration resistance is critical. Also, the requirement to both identify and mitigate side effects of ADT as well as the importance of quality of life maintenance are essential to the optimization of patient care, especially as more combinatorial therapeutic strategies with ADT continue to emerge.
Purpose Positive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive ...surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies. Materials and Methods We analyzed the records of 8,418 patients who underwent robotic assisted radical prostatectomy at 7 institutions. Of the patients 323 had missing data on margin status. Positive surgical margins were categorized into 4 groups, including apex, bladder neck, posterolateral and multifocal. The records of 6,169 patients were available for multivariate analysis. The variables entered into the logistic regression models were age, body mass index, preoperative prostate specific antigen, biopsy Gleason score, prostate weight and pathological stage. A second model was built to identify predictive factors for positive surgical margins in the subset of patients with organ confined disease (pT2). Results The overall positive surgical margin rate was 15.7% (1,272 of 8,095 patients). The positive surgical margin rate for pT2 and pT3 disease was 9.45% and 37.2%, respectively. On multivariate analysis pathological stage (pT2 vs pT3 OR 4.588, p <0.001) and preoperative prostate specific antigen (4 or less vs greater than 10 ng/ml OR 2.918, p <0.001) were the most important independent predictive factors for positive surgical margins after robotic assisted radical prostatectomy. Increasing prostate weight was associated with a lower risk of positive surgical margins after robotic assisted radical prostatectomy (OR 0.984, p <0.001) and a higher body mass index was associated with a higher risk of positive surgical margins (OR 1.032, p <0.001). For organ confined disease preoperative prostate specific antigen was the most important factor that independently correlated with positive surgical margins (4 or less vs greater than 10 ng/ml OR 3.8, p <0.001). Conclusions The prostatic apex followed by a posterolateral site was the most common location of positive surgical margins after robotic assisted radical prostatectomy. Factors that correlated with cancer aggressiveness, such as pathological stage and preoperative prostate specific antigen, were the most important factors independently associated with an increased risk of positive surgical margins after robotic assisted radical prostatectomy.
Robotic pyeloplasty is still a relatively novel procedure. Clinically, early studies have shown high success rates, decreased complication rates, decreased length of hospital stay, and better ...cosmetic results. This goal of this article is to argue for the use of robotic pyeloplasty as the gold standard of ureteropelvic junction obstruction (UPJO) treatment. Results of studies that have compared robotic pyeloplasty with other procedures currently used are reviewed.
Our study, a comprehensive review of published outcomes of robotic pyeloplasty and alternative therapies, consisted of 666 pediatric patients and 653 adult patients. Our review coincided with the previously established studies that robotic pyeloplasty shows equivalent surgical success rates as previous standard of care treatments. Open pyeloplasty has fallen out of favor as standard of care due to the increased length of hospital stay, increased adverse events, and the undesirable aesthetics.
The use of robotic pyeloplasty has shown to have clinical outcomes that are consistent with other intervention for UPJO, with a potential decrease in length of stay and morbidity. More work has to be done to develop ways to decrease cost of the robot to help establish it as the gold standard for UPJO treatment.
Robot assisted prostatectomy (RAP) is more costly than traditional radical retropubic prostatectomy (RRP) under the cost structures at certain hospitals. However, this finding may not be the case in ...all care settings. We investigated the sensitivity of RAP and RRP inpatient costs to variations in length of stay (LOS), local hospitalization costs and robotic case volume in the specialist and generalist settings.
We developed a model of RAP vs RRP costs in the specialist and generalist settings using published data on operative time and LOS, and cost data from our academic medical center. All inpatient cost centers were included, namely surgery costs, professional fees, postoperative care, robotic equipment and service. Extensive 1 and 2-way sensitivity analyses were performed.
Our base case model demonstrated a cost premium for RAP vs RRP of $783 and $195 in the specialist and generalist settings, respectively. Sensitivity analysis of our model assumptions demonstrated that RAP could achieve cost equivalence with RRP at a surgical volume of 10 cases weekly. If case volume increased to 14 cases weekly, RAP would be less expensive than RRP in some practice settings in which RAP LOS was less than 1.5 days.
The inpatient costs of robotic assisted prostatectomy are volume dependent and cost equivalence with generalist radical retropubic prostatectomy is possible at higher volume RAP specialty centers. While RAP may be cost competitive with RRP at high cost hospitals or high volume RAP specialist centers, this procedure would exist at a cost premium to RRP in other practice settings.
Purpose With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently ...no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy. Materials and Methods We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring and credentialing. Results Proctoring is an essential mechanism for robot assisted radical prostatectomy institutional credentialing and should be a prerequisite for granting unrestricted privileges on the robot. This should be differentiated from preceptoring, wherein the expert is directly involved in hands-on training. Advanced technology has opened new avenues for long-distance observation through teleproctoring. Although the medicolegal implications of an active surgical intervention by a proctor are not clearly defined, the role as an observer should grant immunity from malpractice liability. Conclusions The implementation of guidelines and proctoring recommendations is necessary to protect surgeons, proctors, institutions and, above all, the patients who are associated with the institutional introduction of a robot assisted radical prostatectomy program. With no current guidelines we anticipate this article will serve as a catalyst of interorganizational discussion to initiate regulatory oversight of surgeon certification and proctorship.
The optimal management of lower pole renal calculi is controversial. We compared shock wave lithotripsy (SWL) and ureteroscopy (URS) for the treatment of patients with small lower pole stones in a ...prospective, randomized, multicenter trial.
A total of 78 patients with 1 cm or less isolated lower pole stones were randomized to SWL or URS. The primary outcome measure was stone-free rate on noncontrast computerized tomography at 3 months. Secondary outcome parameters were length of stay, complication rates, need for secondary procedures and patient derived quality of life measures.
A total of 67 patients randomized to SWL (32) or URS (35) completed treatment. The 2 groups were comparable with respect to age, sex, body mass index, side treated and stone surface area. Operative time was significantly shorter for SWL than URS (66 vs 90 minutes). At 3 months of followup 26 and 32 patients who underwent SWL and URS had radiographic followup that demonstrated a stone-free rate of 35% and 50%, respectively (p not significant). Intraoperative complications occurred in 1 SWL case (unable to target stone) and in 7 URS cases (failed access in 5 and perforation in 2), while postoperative complications occurred in 7 SWL and 7 URS cases. Patient derived quality of life measures favored SWL.
This study failed to demonstrate a statistically significant difference in stone-free rates between SWL and URS for the treatment of small lower pole renal calculi. However, SWL was associated with greater patient acceptance and shorter convalescence.
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