Search

Introduction and hypothesis Evidence-based care pathways improve care standardization and patient outcomes. We created pelvic organ prolapse (POP) and stress urinary incontinence (SUI) care pathways as decision aids for our multidisciplinary team to use when counseling patients. Methods Using a modified Delphi process, an expert team reviewed existing guidelines and literature to reach consensus on pathway definitions and components. Results Entry to the care pathways occurs via an advanced practice provider visit. Symptom and quality-of-life questionnaires as well as open-ended patient goals are used to guide patient–provider shared decision making. All treatment choices, including surgical and nonsurgical management, are presented to patients by advanced practice providers. Patients electing nonsurgical management follow-up by telehealth (preferred) or in-person visits as determined by the care pathway. Surgeon consultations are scheduled for patients desiring surgery. Surgical patients undergo urodynamics, simple cystometrics or deferred bladder testing according to the urodynamics clinical pathway. Postoperative follow-up includes telehealth visits and minimizes in-person visits for women with uncomplicated postoperative courses. Patients with resolution of symptoms are graduated from clinic and return to their referring physician. The pathways are revised following publication of new compelling evidence. Conclusions We developed POP and SUI care pathways to standardize care across a diverse provider group. Advanced practice providers use care pathways with patients as shared decision-making tools for initial evaluation of patients with prolapse and incontinence. These pathways serve as components of value-based care and encourage team members to function independently while utilizing the full scope of their training.

A fiber-type heterostructured scintillator based on bismuth germanate (Bi4Ge3O12) functionalized with the 2D-perovskite butylammonium lead bromide ((BA)2PbBr4) has been fabricated, and its scintillation performance analyzed toward its use for fast timing applications such as time-of-flight Positron Emission Tomography. The pixel shows energy sharing between the matrix and filler component, confirming that the two components are in synergy.

The principal nature-based solution for offsetting relative sea-level rise in the Ganges-Brahmaputra delta is the unabated delivery, dispersal, and deposition of the rivers’ ~1 billion-tonne annual sediment load. Recent hydrological transport modeling suggests that strengthening monsoon precipitation in the 21st century could increase this sediment delivery 34-60%; yet other studies demonstrate that sediment could decline 15-80% if planned dams and river diversions are fully implemented. We validate these modeled ranges by developing a comprehensive field-based sediment budget that quantifies the supply of Ganges-Brahmaputra river sediment under varying Holocene climate conditions. Our data reveal natural responses in sediment supply comparable to previously modeled results and suggest that increased sediment delivery may be capable of offsetting accelerated sea-level rise. This prospect for a naturally sustained Ganges-Brahmaputra delta presents possibilities beyond the dystopian future often posed for this system, but the implementation of currently proposed dams and diversions would preclude such opportunities.

Background Renal mass biopsy (RMB) has had limited and varied utilization to guide management of renal masses (RM). Objective To evaluate utilization of RMB for newly diagnosed cT1 RMs across diverse practice types and assess associations of outcomes with RMB. Design, setting, and participants MUSIC-KIDNEY commenced data collection in September 2017 for all newly presenting patients with a cT1 RM at 14 diverse practices. Patients were assessed at ≥120 d after initial evaluation. Outcome measurements and statistical analysis Demographics and outcomes were compared for patients undergoing RMB versus no RMB. Clinical and demographic characteristics were summarized by RMB status using a χ2 test for categorical variables and Student t test for continuous variables. A mixed-effects logistic regression model was constructed to identify associations with RMB receipt. Results and limitations RMB was performed in 15.5% (n = 282) of 1808 patients with a cT1 RM. Practice level rates varied from 0% to 100% (p = 0.001), with only five of 14 practices using RMB in >20% of patients. On multivariate analysis, predictors of RMB included greater comorbidity (Charlson comorbidity index ≥2 vs 0: odds ratio [OR] 1.44; p = 0.025) and solid lesion type (cystic vs solid: OR 0.17; p = 0.001; indeterminate vs solid: OR 0.58; p = 0.01). RMB patients were less likely to have benign pathology at intervention (5.0% vs 13.5%; p = 0.01). No radical nephrectomies were performed for patients with benign histology at RMB. The limitations include short follow-up and inclusion of practices with low numbers of RMBs. Conclusions Utilization of RMB varied widely across practices. Factors associated with RMB include comorbidities and lesion type. Patients undergoing RMB were less likely to have benign histology at intervention. Patient summary Current use of biopsy for kidney tumors is low and varies across our collaborative. Biopsy was performed in patients with greater comorbidity (more additional medical conditions) and for solid kidney tumors. Pretreatment biopsy is associated with lower nonmalignant pathology detected at treatment., Take Home Message Utilization of renal mass biopsy (RMB) within a statewide quality improvement collaborative (MUSIC-KIDNEY) was low overall, with wide practice variation. Predictors of RMB utilization included greater comorbidity and solid lesion type. The results of RMB performed before treatment greatly impacted management, particularly when a benign histological diagnosis was made. More widespread use of RMB could further reduce the number of radical nephrectomies with findings of only benign pathology.

BACKGROUND: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. Such delays can lead to disease progression. OBJECTIVE: We aimed to develop guidance on criteria for prioritization for surgery and reconfiguring management pathways for non-metastatic stage of prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve low likelihood of COVID-19 hazard if radical prostatectomy was to be carried out during the outbreak and whilst the disease is endemic. DESIGN, SETTING AND PARTICIPANTS: An accelerated consensus process and systematic review. We conducted a systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n=34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. OUTCOME MEASURES: Consensus opinion was defined as ≥80% agreement, which were used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and develop measures to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritization criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as "COVID-19 cold sites". CONCLUSION: Re-configuring management pathways for prostate cancer patients is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing radical prostatectomy within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

When robots operate in real-world off-road environments with unstructured terrains, the ability to adapt their navigational policy is critical for effective and safe navigation. However, off-road terrains introduce several challenges to robot navigation, including dynamic obstacles and terrain uncertainty, leading to inefficient traversal or navigation failures. To address these challenges, we introduce a novel approach for adaptation by negotiation that enables a ground robot to adjust its navigational behaviors through a negotiation process. Our approach first learns prediction models for various navigational policies to function as a terrain-aware joint local controller and planner. Then, through a new negotiation process, our approach learns from various policies' interactions with the environment to agree on the optimal combination of policies in an online fashion to adapt robot navigation to unstructured off-road terrains on the fly. Additionally, we implement a new optimization algorithm that offers the optimal solution for robot negotiation in real-time during execution. Experimental results have validated that our method for adaptation by negotiation outperforms previous methods for robot navigation, especially over unseen and uncertain dynamic terrains., 10 pages : 8 pages main + 2 pages supplemental

Imagery collected from outdoor visual environments is often degraded due to the presence of dense smoke or haze. A key challenge for research in scene understanding in these degraded visual environments (DVE) is the lack of representative benchmark datasets. These datasets are required to evaluate state-of-the-art vision algorithms (e.g., detection and tracking) in degraded settings. In this paper, we address some of these limitations by introducing the first realistic hazy image benchmark, from both aerial and ground view, with paired haze-free images, and in-situ haze density measurements. This dataset was produced in a controlled environment with professional smoke generating machines that covered the entire scene, and consists of images captured from the perspective of both an unmanned aerial vehicle (UAV) and an unmanned ground vehicle (UGV). We also evaluate a set of representative state-of-the-art dehazing approaches as well as object detectors on the dataset. The full dataset presented in this paper, including the ground truth object classification bounding boxes and haze density measurements, is provided for the community to evaluate their algorithms at: https://a2i2-archangel.vision. A subset of this dataset has been used for the ``Object Detection in Haze'' Track of CVPR UG2 2022 challenge at http://cvpr2022.ug2challenge.org/track1.html., This paper has been ACCEPTED for publication as a REGULAR paper in the IEEE Transactions on Image Processing (TIP)

OBJECTIVES: Acceptance and Commitment Therapy (ACT) is a third-wave behavioral and cognitive therapy that increases psychological flexibility through mindfulness, acceptance, and value-driven behavior change. ACT has been successfully used to inform a variety of health interventions. Using non-therapists to deliver ACT-based behavioral health interventions offers an opportunity to provide cost efficient and integrated care, particularly among underserved populations experiencing barriers to mental health care, such as inadequate insurance, mental health stigma, and provider shortages. This systematic review aims to: 1) identify ACT-informed behavioral health interventions delivered by laypeople and 2) review the specific characteristics of each intervention including number and duration of sessions, delivery modality, interventionist training, and intervention outcomes. METHODS: Two databases (PubMed and PsycINFO) were systematically searched for relevant literature. To further identify relevant studies, references of included manuscripts were checked, the Association for Contextual Behavioral Science’s webpage was examined, and an email was sent to the ACBS Health Special Interest Group listserv. Study abstracts and full texts (in English) were screened, resulting in 23 eligible articles describing 19 different interventions. RESULTS: A total of 1,781 abstracts were screened, 76 were eligible for full-text review, and 23 were included in a narrative synthesis. There were 19 unique interventions identified and delivered by the following: general healthcare workers (n= 7), trained researchers (n = 5), women/mothers (n= 2), municipal workers (n= 2), and teachers (n = 3). Eleven studies were RCTs and eight utilized alternative study designs. Study quality varied, with two rated as high risk for bias and eight rated to have some concerns. Target populations included clinical and non-clinical samples. There was some consistency in the effects reported in the studies: increases in pain tolerance, acceptance, and identifying and engaging in value driven behavior, improvements in cognitive flexibility, and reductions in psychological distress. CONCLUSIONS: Findings suggest that ACT interventions can be successfully delivered by a variety of laypeople and effectively address psychological distress and increase health behaviors.

Background Racial and ethnic disparities contribute to differences in access and outcomes for patients undergoing heart transplantation. We evaluated contemporary outcomes for heart transplantation stratified by race and ethnicity as well as the new 2018 allocation system. Methods and Results Adult heart recipients from 2011 to 2020 were identified in the United Network for Organ Sharing database and stratified into 3 groups: Black, Hispanic, and White. We analyzed recipient and donor characteristics, and outcomes. Among 32 353 patients (25% Black, 9% Hispanic, 66% White), Black and Hispanic patients were younger, more likely to be women and have diabetes mellitus or renal disease (all, P P =0.003) and 7.7% to 9.0% ( P =0.002), respectively. Compared with White patients, Black patients were less likely to undergo transplantation (adjusted hazard ratio [aHR], 0.87; CI, 0.84–0.90; P P =0.004). There were no differences in transplantation likelihood or post‐transplant mortality between Hispanic and White patients. Following the allocation system change, transplantation rates increased for all groups ( P P =0.024). Conclusions Although the proportion of Black and Hispanic patients listed for cardiac transplantation have increased, significant disparities remain. Compared with White patients, Black patients were less likely to be transplanted, even with the new allocation system, and had a higher risk of post‐transplantation death.

Aims The impact of mechanical ventilation (MV) at the time of heart transplantation is not well understood. In addition, MV was recently removed as a criterion from the new US heart transplantation allocation system. We sought to assess for the association between MV at transplantation and 1-year mortality. Methods and results We utilized the United Network for Organ Sharing database and included all adult, single organ heart transplantations from 1990 to 2019. We utilized multivariable logistic regression adjusting for demographics, comorbidities, and markers of clinical acuity. We identified 60 980 patients who underwent heart transplantation, 2.4% (n = 1431) of which required MV at transplantation. Ventilated patients were more likely to require temporary mechanical support, previous dialysis, and had a shorter median waitlist time (21 vs. 95 days, P Conclusion We found a strong association between the presence of MV at heart transplantation and 90-day and 1-year mortality. Future studies are needed to identify which patients requiring MV have reasonable outcomes, and which are associated with substantially poorer outcomes.

The urogenital microbiome is associated with urgency and mixed urinary incontinence symptoms and differential treatment responses to pharmacotherapy for urgency urinary incontinence.This study aimed to describe whether the preoperative urinary and vaginal microbiomes were associated with surgical treatment responses at 12 months after a midurethral sling operation in women with mixed urinary incontinence.This cohort study compared the preoperative microbiome compositions of urine and vaginal samples from a subset of women undergoing a midurethral sling operation in the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence trial (NCT01959347) and compared the microbiota in women who were surgical responders vs surgical nonresponders. Twelve-month objective response was defined as a ≥70% reduction from baseline urinary incontinence episodes on a 3-day diary. Subjective response was defined as a change from baseline in the Urogenital Distress Inventory scores. Bacterial abundance and beta diversity were assessed using 16S ribosomal RNA sequencing. The primary differential abundance analysis described predominant bacterial operational taxonomic units associated with responders vs nonresponders using unadjusted and age-adjusted linear models.Objective nonresponders (n=28) compared with responders (n=72) were older (58.5±10.7 vs 51.6±10.2 years) and more likely postmenopausal without hormone use (odds ratio, 6.4; 95% confidence interval, 1.8-22.6). Vaginal and urinary microbiota beta diversities were associated with age (P.05) for both responders and nonresponders. Overall, predominant operational taxonomic units (genera) were Lactobacillus, Gardnerella, Tepidimonas, Escherichia, Streptococcus, and Prevotella. Operational taxonomic units from baseline urine samples were not significantly associated (P threshold=.05) with surgical treatment responses. A greater abundance of baseline vaginal Lactobacillus was associated with an objective response (P=.04) and Prevotella with an objective nonresponse (P=.01). Adjusting for age, only a greater abundance of baseline vaginal Prevotella was associated with an objective nonresponse (P=.01). Moreover, less abundant vaginal operational taxonomic units were associated with objective and subjective responses and persistent urinary incontinence symptoms (P.05).Women meeting a 70% reduction of urinary incontinence treatment episodes (objective responders) had greater vaginal Lactobacillus at the time of the surgical procedure; however, controlling for age diminished this association. Women not meeting a 70% reduction of urinary incontinence episodes 1 year after a midurethral sling operation had greater vaginal Prevotella at the time of the midurethral sling operation. Further research is needed to determine whether therapy altering the vaginal microbiome may impact surgical treatment responses in women with mixed urinary incontinence.

Background Extracellular vesicles (EVs) from heart stromal/progenitor cells modulate innate immunity, with salutary effects in a variety of cardiac disease models. Little is known, however, about the effects of these EVs on adaptive immunity. Methods Ex vivo differentiation of naive CD4+ T cells was conducted to assess the effect of EVs on cytokine production and proliferation of Th1, Th2, Th17, and regulatory T (T reg) cells. These effects were further tested in vivo using the experimental autoimmune myocarditis (EAM) model. Results Using differentiated CD4+ T cells, we show that EVs secreted by human-derived heart stromal/progenitor cells selectively influence the phenotype, activity, and proliferation of regulatory T (Treg) cells. Exposure of Treg cells to EVs results in faster proliferation, augmented production of IL-10, and polarization toward an intermediate FOXP3+RORγt+ phenotype. In experimental autoimmune myocarditis, EVs attenuate cardiac inflammation and functional decline, in association with increased numbers of splenic IL10 +-Treg cells. Conclusions T cell modulation by EVs represents a novel therapeutic approach to inflammation, harnessing endogenous immunosuppressive mechanisms that may be applied in solid organ transplantation , graft-versus-host disease, and autoimmune disorders.

Psychosocial syndemic conditions have received more attention regarding their deleterious effects on HIV acquisition risk than for their potential impact on HIV treatment and viral suppression. To examine syndemic conditions' impact on the HIV care continuum, we analyzed data collected from people living with HIV (N = 14,261) receiving care through The Centers for AIDS Research Network of Integrated Clinical Systems at seven sites from 2007 to 2017 who provided patient-reported outcomes ∼4-6 months apart. Syndemic condition count (depression, anxiety, substance use, and hazardous drinking), sexual risk group, and time in care were modeled to predict antiretroviral therapy (ART) adherence and viral suppression (HIV RNA

We prove a strong maximum principle for Schrödinger operators defined on a class of postcritically finite fractal sets and their blowups without boundary. Our primary interest is in weaker regularity conditions than have previously appeared in the literature; in particular we permit both the fractal Laplacian and the potential to be Radon measures on the fractal. As a consequence of our results, we establish a Harnack inequality for solutions of these operators.

Purpose Magnetic resonance imaging is playing an ever‐bigger role in the management of prostate cancer. This study investigated barriers to obtaining multi‐parametric MRI (mpMRI) in African‐American men on active surveillance for prostate cancer in comparison to white men affected by the same type of cancer. Materials and Methods Retrospective review of prostate mpMRI orders from August 2015 to October 2017 at a single health organization treating a diverse population was performed. Data was extracted from the electronic medical records and cancellations were examined based on the documented reason for mpMRI cancellation, race, median zip code household income, and distance from healthcare facility. Results Out of 793 prostate mpMRI orders, 201 (25%) went unscanned. Access to care issues accounted for 46% of unscanned orders. Patient cancellations were the most common, followed by difficulty contacting patients, and insurance denials. African‐American patients disproportionately went unscanned because institution staff were unable to contact patients (29% vs 10% in white men, P = 0.0015). Median zip code household income was significantly different between racial groups but did not vary between indication for cancellation. Conclusions African‐American prostate cancer patients' access to mpMRI is hindered more by barriers to care than White patients. Urology providers must consider these issues before using prostate mpMRI within their active surveillance pathways.

Objective Participation in physical activity and sports is known to have positive implications for physical health, and for social and emotional wellbeing of children. Following corrective spinal surgery for scoliosis, the timeline for the return to activities and sports varies from surgeon to surgeon and from location to location, and return to activities can be limited due to pain, fear, and decreased flexibility. It is critical that patients know best-practice guidelines, and it is equally critical that medical professionals know whether their patients are following those guidelines. This paper includes a summary of recommendations published in the literature, and a pilot study to address a gap in the literature on determining how long, post-surgery, adolescents with idiopathic scoliosis waited before returning to various self-care and physical activities, and what factors influenced return to activities. We used a mixed-method approach that involved two phases: a questionnaire (n = 8), and subsequent interviews of some participants (n = 3). Participants were ages 14–17 (M = 15.4) and had had posterior instrumentation and fusion for scoliosis in the past 2 years. Results Some patients were cautious about return to activities, either because of emotional or medical reasons. However, in many instances, participants returned to physical activities earlier than was recommended, primarily for emotional and social reasons.

Background Patients with restrictive or hypertrophic cardiomyopathy (RCM/HCM) and congenital heart disease (CHD) do not derive clinical benefit from inotropes and mechanical circulatory support. Concerns were expressed that the new heart allocation system implemented in October 2018 would disadvantage these patients. This paper aimed to examine the impact of the new adult heart allocation system on transplantation and outcomes among patients with RCM/HCM/CHD. Methods We identified adult patients with RCM/HCM/CHD in the United Network for Organ Sharing (UNOS) database who were listed for or received a cardiac transplant from April 2017-June 2020. The cohort was separated into those listed before and after allocation system changes. Demographics and recipient characteristics, donor characteristics, waitlist survival, and post-transplantation outcomes were analyzed. Results The number of patients listed for RCM/HCM/CHD increased after the allocation system change from 429 to 517. Prior to the change, the majority RCM/HCM/CHD patients were Status 1A at time of transplantation; afterwards, most were Status 2. Wait times decreased significantly for all: RCM (41 days vs 27 days; P Conclusions The new allocation system has had a positive impact on time to transplantation of patients with RCM, HCM, and CHD without negatively influencing survival.

To explain the prevalence and persistence of informal economic activity globally, scholars have recently advanced an institutional incongruence perspective. Institutional incongruence exists where there is a misalignment between what is considered legitimate by a society’s formal institutions (e.g. its laws and regulations) and its informal institutions (e.g. norms, values and beliefs). Reporting findings from a series of qualitative focus groups in Bulgaria, Croatia and the Former Yugoslav Republic of Macedonia, this article explores relationships between such institutional incongruence and informal economic activity. In particular, it sheds light on how informality and institutional incongruence are experienced by individuals in South-East Europe. It furthermore provides insights on the causes of such incongruence, and how it can lead to informal economic activity. Finally, it reports on individuals’ perceptions towards different measures to tackle institutional incongruence and informal economic activity, with implications for policymakers in South-East Europe and more widely.