United States

Background
Chronic pain is now the number one reason for medical visits and a major driver of the opioid epidemic. Oftentimes, patients with chronic pain exhaust standard treatment options with little symptomatic relief due to our inability to precisely identify pain generators. 18F-FDG PET/MRI provides a highly sensitive method to identify sites of active inflammation. Our overarching goal is to determine whether 18F-FDG PET/MRI can improve outcomes in patients with challenging pain conditions.

Methods
Twenty-two patients, whose source of chronic pain was unclear, were referred for 18F-FDG PET/MR imaging by their physicians. Potential pain generators were identified as increased FDG uptake on PET and/or T2 abnormalities on MRI. The patients were then followed to determine if their referring physicians altered their management based on the imaging findings.

Results
All twenty-two cases had 18F-FDG PET/MRI results that directly impacted management after the results were reviewed with referring clinicians. Based on the findings, either a diagnostic injection at a new site was attempted/recommended or surgery was recommended. One patient had endured a proximal fifth metatarsal fracture and subsequently underwent surgical fixation. However, the patient suffered from chronic right lateral foot pain despite an adequate healing period, negative radiographic findings, and eventual removal of the bone screw. 18F-FDG
PET/MRI revealed increased FDG uptake at the site of the previous fracture, suggesting fracture instability and chronic osteitis. Additionally, MRI showed an inflamed and swollen sural nerve entering an area of scarring near the fracture site. This patient has been referred for anesthetic block of the sural nerve and possible surgical correction of the bone inflammation. Another patient had lower back pain initially attributed to Bertolotti’s disease. However, 18F-FDG PET/MRI demonstrated increased FDG uptake in both sacroiliac joints consistent with
sacroiliitis and a lack of uptake at the pseudo-articulation. Bilateral SI joint injections were performed with excellent symptomatic relief.

Conclusion
Chronic pain is a debilitating condition affecting millions worldwide and is difficult to diagnose due to our inability to target pain generators. 18F-FDG PET/MRI has shown groundbreaking promise in identifying pain sources and in preliminarily altering clinical management, leading to improved quality of life for individuals suffering from chronic pain.

AMA Research Challenge 2024 

Light ‘Em Up! Early Experience Utilizing 18F-FDG PET/MRI to Pinpoint Pain Generators in Patients with Diagnostically Challenging Chronic Pain

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Background: Subdural hematoma (SDH) is a common finding in patients with acute traumatic brain injury (TBI). Traumatic meningeal enhancement (TME) of the subdural space is visible on post-contrast MRI following administration of gadolinium. TME has since been described in patients with SDH, suggesting overlapping pathophysiology. It is unclear if TME is in the continuum of a SDH, or if it is a distinct injury. Given the current debate, we explored the relationship of SDH and TME to determine whether TME is a marker of a SDH, or whether TME is a distinct entity. 

Methods: This retrospective analysis included a subset of consented patients (n=151) that were identified to have post-contrast MRI scans within 48 hours of injury who were selected from the Traumatic Head Injury Neuroimaging Classification (THINC) study. One rater reviewed Gradient Echo (GRE), pre-contrast fluid-attenuated inversion recovery (FLAIR) and post-contrast FLAIR axial brain MRI. Cohen’s kappa was performed. Discordant pairs found during the intra-rater agreement analysis were reviewed by a second independent rater. Areas where SDH was present were inspected for TME. SDH presence outside of TME areas was also noted. Following the rating, study data was reviewed to verify accuracy of interpretation. Contingency tables (2x2) were constructed to analyze reading results. 

Results: Cohen’s kappa demonstrated intrareader and interreader agreement for SDH and TME was substantial (Kappa of 0.9, Kappa of 0.8). Initially, 91 SDH were identified. After reviewing radiologist and prior image interpretations, 20 cases were discordant. Of those, 17 were reclassified as SDH absent, 2 were reclassified SDH present, and 1 did not receive contrast and was excluded from analysis. Of the 150 included patients (99 Males, 51 Females, median age 49 [30-63.8]), 107 (71.3%) had TME, 77 (51.3%) had SDH, and 76 (50.7%) had both. 98.7% of patients with SDH also had TME present (p<0.001). Of these, 72 (94.7%) had SDH and TME overlapping in at least one area. Inversely, only 71% of patients with TME also had SDH present (p<0.001). Only 15.9% of patients with TME had no evidence of brain hemorrhage, and 1 showed SDH with no TME (p<0.001). 

Conclusion: In our population TME was seen without SDH in 31 of 107 cases, SDH and TME were seen together in 76 of 77 cases, but seldom is SDH seen without TME. They likely represent very similar pathophysiology, and the discordance may reflect a spectrum of severity of injury.

Subdural Hematoma and Traumatic Meningeal Enhancement in Patients with Acute Traumatic Brain Injury

Background
RTOG 1205 is the only randomized study to evaluate the safety and efficacy of reirradiation (reRT) in recurrent glioblastoma (GBM). While this study showed reRT was safe and improves progression-free survival (PFS), an improved approach for reRT is needed. Here, we report on patterns of failure and outcomes of a cohort of patients with recurrent GBM who underwent reRT. We hypothesize that patients at high risk of leptomeningeal spread (LMS) are not good candidates for reRT due to the risk of treatment-related toxicity without clinical benefit.

Methods
In this retrospective study, patients with recurrent GBM who underwent reRT at a single institution from 2015-2023 were included. Sociodemographic, treatment, and outcomes data were collected via chart review. Response assessment in neuro-oncology criteria (RANO) was used to evaluate treatment response. PFS and overall survival (OS) were estimated using the Kaplan-Meier method.

Results
Thirteen patients with recurrent GBM who underwent reRT were identified. Median age at diagnosis was 58. Six patients (46.2%) had tumors that were MGMT methylated, four (30.8%) were MGMT unmethylated, and three (23.11%) had unknown MGMT status. Eight patients underwent repeat resection after recurrence and prior to reRT. Most patients (n=7) received 35 Gy in 10 fractions with concurrent bevacizumab, while other patients were treated with 25-40 Gy in 5-15 fractions with grade 1 or less acute toxicity. Three patients were treated with tumor-treating fields. Median follow up was five months. Median PFS was three months (95% confidence interval [95% CI], 1-4 months) and median OS was five months (95% CI, 1-8 months) as compared to 7.1 months and 10.1 months, respectively, on RTOG 1205. Five patients developed LMS after reRT, one patient died prior to progression, and the remaining seven patients all developed progression within one centimeter of the recurrent tumor. Of the patients who developed LMS, all had tumors abutting the ventricles and three underwent resection 2-17 months prior to reRT.

Conclusion
Patterns of failure suggest a potential treatment selection approach for patients with recurrent GBM, in which patients at high risk of LMS (tumor abutting ventricles with or without recent surgery) should not undergo reRT, while patients at low risk of LMS are good candidates for reRT. Furthermore, reRT could be administered with reduced margins given that all non-LMS recurrences were within 1cm of the original tumor. Additional studies are needed to validate this approach.

The Patterns of Failure and Prognostic Impact of Tumor Location in Patients Undergoing Reirradiation for Glioblastoma

Background
Pulmonary arterial hypertension (PAH) is a life-limiting complication of systemic sclerosis (SSc), with median survival of 3 years. Within PAH therapy, a notable heterogeneity of response exists, leading to identification of a subset of patients termed ‘super-responders’. Although lacking a universally accepted definition, super-responders experience significantly greater benefits compared to the average population. Here, we define super-responders as patients demonstrating a 2-point improvement in their NYHA functional class. In this study, we aim to explore the impact of prostacyclin therapy on SSc-PAH and review the potential clinical and molecular markers that could predict super-responder status.

Methods
This is a retrospective case series with a collection of data of four patients seen at Albany Medical Center between 2010 to 2024 with a diagnosis of SSc and PAH, who were treated with prostacyclin and showed an improvement in their functional status and pulmonary hemodynamics. After obtaining IRB approval, data was extracted that included patient demographics, time of onset of PAH, functional class, and right heart catheterization findings before and after treatment with prostacyclin.

Results
Our study included 3 females and 1 male patient with a median age of 46 years. All patients received prostacyclin therapy: two subcutaneous Treprostinil, one inhaled Treprostinil, and one started subcutaneously before transitioning to oral medication. Clinically, all patients experienced a 2-point improvement in NYHA functional class within approximately a year of prostacyclin therapy. Additionally, all patients had improvements in pulmonary hemodynamics, evidenced by reductions in the mean pulmonary artery pressures (mPAP) and pulmonary vascular resistance (PVR), following prostacyclin therapy as observed via right heart catheterization (table 1). Median survival to date is 9 years.


Conclusion
Our SSc-PAH patients achieved long term survival, notable improvements in functional status and even near normalization of pulmonary hemodynamics after prostacyclin therapy, indicating sustained benefits beyond mere stabilization.

Current studies speculate that prostacyclin therapy not only causes pulmonary artery vasodilation, but also influences vascular remodeling process by potentially recruiting endothelial progenitor cells (EPCs) into the pulmonary vasculature, as well as reducing the number and procoagulant activity of platelet micro-vesicles (PMVs). It will be worthwhile to investigate EPC count and PMVs as surrogate markers for prostacyclin response to address treatment response heterogeneity.



Breaking Ground: Super-responders to Prostacyclin Therapy in Systemic Sclerosis-associated Pulmonary Arterial Hypertension

Purpose:
Racial disparities in post-operative mortality following coronary artery bypass grafting (CABG) have been investigated, although underlying causes have yet to be elucidated. This study aims to analyze historical trends in 30-day postoperative
mortality rates between black and white patients, as well as the accuracy and methods used to elicit them.

Methods:
Studies published between 1984 and 2023 were collected from a nonstructured review in PubMed. Article inclusion criteria were patients of all ages who underwent CABG and explicit reporting of 30-day post-operative mortality in black and white patients. Studies that focused on non-CABG cardiac surgeries and studies that did not report 30-day mortality rates stratified by race were excluded. Studies meeting inclusion criteria were evaluated using title and abstract review. Subsequent full-text screening and data extraction were performed.

Results:
Differences in 30-day post-operative mortality rates still exist following CABG between black and white patients. (Image 1) Several studies have analyzed 30-day mortality rates stratified by race following CABG, however, there is a paucity of large database studies.(Table 1) Angraal et al. recently utilized Medicare data from the Centers for Medicare & Medicaid Services (CMS) to report on CABG outcomes in patients over age 65 among different races between 1999-2014.(1) Between 2011 and 2020, the mean age of a patient undergoing primary isolated CABG was
66.0 years.(2) In our experience, 61.3% of patients who underwent CABG in the past five years at our academic inner-city hospital were below 65 years of age and exhibited a greater number of comorbid conditions compared with their older counterparts, and there may not be a database that accurately captures the scope of outcomes and disparities that exist in and between patients of different racial backgrounds.

Conclusion:
There is no standardized way to evaluate CABG outcomes between patients of different racial backgrounds, leading to potential discrepancies between true and reported 30-day mortality rates. However, previous studies show differences. Thus, a standardized system is necessary to accurately assess mortality between races and to define areas for quality improvement.

Racial Disparities in Mortality Rates Following Coronary Artery Bypass Grafting: An Evaluation of Reporting Methods and Trends

Background:

Lung adenocarcinoma is the most common lung cancer and has variable biology that affects outcomes and treatment. Numerous prognostic factors can be obtained from resected tumors, but a tool that could predict lung adenocarcinoma biology pre-operatively would help tailor decision-making. 

SILA is a radiomic tool that assigns scores to 9 groups of CT features which are collectively used to calculate a risk that a tumor recurs. While SILA recurrence risks have been validated, it is not yet known how the 9 groups of features themselves might relate to lung adenocarcinoma characteristics.

In this study, our aim was to elucidate novel associations between the 9 scores and known prognostic factors in lung adenocarcinoma. 

Methods:

We retrospectively reviewed resected lung adenocarcinoma cases with available preoperative CT images at our hospital between August 2016 and August 2022.

SILA analysis involved manual segmentation of lung lesions on CT scans. The software then generated scores for each of the 9 groups of features. The 9 features are referred to by color names, such as violet (V), indigo (I), etc. We reviewed the charts to record pertinent clinical-pathologic variables. 
Statistical tests used included chi square, Kruskal-Wallis to Dunn-Bonferroni-Tests post-hoc analysis, and Mann-Whitney U-Test.

Results:
Study cohort included 276 patients with a median age of 69. There were 176 (63.4%) female patients and 197 (71.4%) stage I. There were 54 (19.6%) recurrences.

Our results showed positive and negative associations between certain color scores and markers of tumor aggression, including standardized reuptake value (SUV) on T1 scans (p-values ranging from <0.001 to 0.009) and tumor size on CT (p-values from <0.001 to 0.009). In addition, color scores had associations with known prognostic factors that can only be determined after resection, including visceral pleural invasion (p-values from <0.001 to .045) and lymphovascular invasion (p values from <0.001 to .037).

Color scores were also significantly different between certain pathologic stages. For example, violet values were significantly different between stage IB and IA2 tumors (adjusted p=0.001) and between stage IA2 and IIB tumors (adjusted p<0.001). 

Conclusion:

The associations between SILA color scores and validated markers of tumor aggression point to the exciting possibility that color scores may provide information about lung adenocarcinoma biology pre-operatively. Future work will explore additional correlations between color scores and other pre- and post-operative clinicopathologic data.

Score Indicative of Lung Cancer Aggression (SILA) color scores are correlated with aggressive features in lung adenocarcinoma


Background
Compared to traditional laparoscopic radical nephrectomy (LRN), robotic surgery offers potential advantages such as improved surgical dexterity and enhanced anatomical visualization during surgery, which can improve dissection, tumor identification, and control of renal vessels, aspects critical for reconstructive surgery. It is unclear whether these potential benefits would translate to improved post-operative outcomes for patients undergoing radical nephrectomy; thus, our objective was to compare perioperative complications

Methods
We conducted a retrospective study using data from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Nephrectomy-Targeted database from 2019 to 2021, restricted to localized RCC. We utilized propensity score matching (1:1 PSM) to balance patient characteristics between the two groups. The association between the outcomes of interest (Primary Outcome as major complications within 30 days of surgery, including 30-day mortality, return to the operating room, cardiac arrest, MI, and CVA; Secondary outcome as other perioperative complications) and the operative modality was assessed using logistic regression.

Results
Among the 1,545 patients in the study (mean age: 62.9±11.8 years), 722 underwent RARN and 823 underwent LRN. We did not observe any differences in major complications [OR 0.93 (95% CI 0.43-2.00), p=0.848], including 30-day mortality, return rate to the operating room, cardiac arrest, myocardial infarction, and stroke or cerebrovascular accident between the operative modalities. LRN was associated with a 128% increased risk of surgical site infection [OR 2.28 (95% CI 1.01-5.16), p=0.047] and 54% increased risk of prolonged LOS (defined as >3 days) [OR 1.54 (95% CI 1.15-2.06), p=0.004), compared to RARN group. In addition, the conversion rate of LRN to open RN was 4.3%, while the conversion rate of RARN was 1.16% [OR 3.70 (3.25-4.15), p<0.001]. RARN was associated with significantly longer operative time (minutes) than LRN [Estimated coefficient: 30.67 (95% CI 23.15-38.18), p<0.001].

Conclusion
We found no significant difference in major complications between RARN and LRN for patients undergoing surgery for localized kidney cancer. At the expense of somewhat longer operative time, RARN was associated with a lower risk of SSI and lower conversion rate to open RN. These data support the notion that LRN and RARN should both be considered and selected on an individualized basis using tumor, patient, and physician factors.

Comparison of Mortality and Morbidity of Robotic vs Laparoscopuc Radical Nephrectomy for the Treatment of Renal Cell Carcinoma – An Analysis of the National Surgery Quality Improvement Targeted Database

Abstract Title: Determining Best Treatments for Pediatric Bowel and Bladder Dysfunction

Introduction and objectives
Bowel and bladder dysfunction (BBD) describes a spectrum of symptoms including urinary and stool incontinence, urgency, frequency, painful urination, and constipation that accounts for over 40% of all pediatric urology clinic visits. Children with BBD may also suffer from recurrent UTIs, which can cause renal scarring and reduced kidney function. In addition to the urinary and gastrointestinal issues, BBD has a profound impact on a child’s mental health, self-esteem, and social development. Given the impact of these issues, it is important not only to properly diagnose BBD, but provide an effective treatment plan. Unfortunately, no defined criteria currently exist as to which therapies should be used by clinicians despite the wide range of treatment options including: urotherapy (timed voiding schedule), stool softeners, anticholinergics, desmopressin, electrical stimulation, surgical interventions, and pelvic floor physical therapy.

Methods
A retrospective chart review was performed to analyze questionnaire and treatment data from patients who presented to our pediatric urology clinic for evaluation and treatment of BBD within the last 5 years. Results from a BBD questionnaire were recorded at each clinic visit as well as the treatment each patient received. A self-administered 5-point Likert scale was used to assess the severity of each patient's BBD symptoms and the results were compared from the patient’s first to final visit. The questionnaire classified BBD symptom severity and frequency into eight subscales. The mean change in each subscale demonstrated the efficacy of each intervention studied. 

Results
Data from 300 patients was reviewed and included in the study. The average patient age was 6.1 years and included 89 males (30%) and 211 females (70%). Stool softeners demonstrated statistically significant improvement in the subscales of regularity of bowel movements, decreased stool accidents, and decreased pain and straining associated with bowel movements. Urotherapy significantly reduced daytime urinary incontinence. Stool softeners and anticholinergics each independently reduced urinary holding and straining. The limitations of the study were the concurrent interventions and subjective nature of the questionnaire data.

Conclusion
In addition to effectively managing constipation symptoms, stool softeners reduced daytime urinary incontinence and improved urinary holding and straining, underscoring the efficacy of stool softeners across multiple domains of BBD and highlighting the interplay between bowel and bladder function. Finally, our study demonstrated that the behavioral intervention of urotherapy was more effective than the medical management of daytime urinary incontinence in pediatric BBD.

Determining Best Treatments for Pediatric Bowel and Bladder Dysfunction

Background 
The exponential growth of biomedical literature, especially in urology, with 1.3M new citations added to MEDLINE in 2023, makes it difficult for clinicians to stay updated and conduct literature reviews and meta-analyses. Artificial intelligence, specifically through a technique called sentiment analysis, can help by facilitating the rapid extraction and summarization of insights from study data. Sentiment analysis uses large language models (such as GPT-4) to classify texts based on sentiment (i.e. tone expressed). This study tests GPT-4 in conducting sentiment analysis of literature about a common urology topic — the utilization of radiotherapy versus prostatectomy as treatment for localized prostate cancer — by comparing GPT-classified sentiments of studies to human-classified sentiments. 

Methods 
A PubMed literature search using MeSH keywords for prostate cancer, prostatectomy, and radiotherapy, yielded 29 relevant studies. Abstracts were reviewed by the research team, with members independently assigning a sentiment of prostatectomy-preferred, radiotherapy-preferred, or neutral. 
GPT-4 was then provided three abstracts that were human-classified as prostatectomy-preferred, radiotherapy-preferred, and neutral. This provided GPT-4 a baseline for sentiment classification. The model subsequently classified the remaining 26 abstracts by sentiment. It was prompted five separate times to ensure consistency. 
GPT-4 sentiment classification results were compared to human-classified sentiments (reference, gold standard answers) through accuracy, precision, recall, and F1 score metrics to gauge model performance. 

Results 
GPT-4 had 80.8% (21/26) accuracy in classifying sentiments compared to manual, human classified sentiments, correctly categorizing 3 radiotherapy-preferred, 7 prostatectomy-preferred, and 11 neutral abstracts. GPT-4 had 76.5% recall, 82.8% precision, and an F1 score of 79.5% (F1 scores range between 0-1, with 75% being an approximate cutoff for “good”). 

Conclusion 
GPT-4 is capable of fairly accurate (80.8%) sentiment analysis, even for specialized domains like urology. Its mistakes were limited to differentiating between neutral and polarized (radiotherapy-preferred or prostatectomy-preferred) sentiments. Mis-categorization of neutrality can be due to lack of specific words deemed neutral, as opposed to positive and negative. Thus, GPT-4 has promise to rapidly parse through large numbers of studies and capture overall sentiment, which may be useful for clinicians. 


Leveraging AI in urologic literature: GPT-4 for sentiment analysis on the utilization of radiotherapy versus prostatectomy in prostate cancer as an upfront treatment

Background: Patients may seek gender-affirming orchiectomy and scrotectomy (GAOS) to alleviate dysphoria related to the scrotum and testes, while allowing for penetrative intercourse, if desired. However, techniques and outcomes of scrotectomy in this specific setting have not been described to date. Here we discuss our initial experience with GAOS as an option for patients who do not necessarily desire other gender-affirming genital surgeries.

Methods: All patients who had undergone GAOS procedures from 2021 to 2022 at our institution were reviewed. The World Professional Association for Transgender Health (WPATH) criteria for surgical treatment were met for all patients preoperatively. In addition, patients were counseled on the irreversibility of the procedure and its implications, including sterility and the impact on future surgical options such as vaginoplasty. Patients were offered a choice of two approaches depending on their surgical goals: excision of a majority of scrotal tissue and primary closure of the perineal wound, or excision of all rugated skin with mons and groin (Y-flap) advancement. Preoperative demographic data, baseline sexual function, intraoperative findings, and postoperative outcomes were collected. Patient-reported outcomes (PROs) derived from the PROMIS ® Sexual Function questionnaires were sent to all patients postoperatively and collected.

Results: Five patients underwent GAOS during the study period. Median age was 29 years and median preoperative duration on hormones was 16 months. All patients reported dysphoria related to the scrotum and testes, and wished to preserve the phallus. Three of the five patients elected for primary closure, while two desired Y-flap perineoplasty. Median operative time was 152 min and median resected scrotal area was 96 cm2; all patients were discharged home the same day. At median follow up of 97 days, all patients reported satisfaction with the surgical outcome. One patient who had Y-flap experienced wound dehiscence requiring operative revision. Three of five patients completed detailed questionnaires regarding resolution of dysphoria and preservation of sexual function. All patients who experienced postoperative complications reported being sexually active with the ability to achieve erection and orgasm within the last thirty days of the survey collection, and no change to their libido. Further patient follow-up is being collected.

Conclusion: GAOS is a well tolerated procedure that can reasonably address dysphoria related to the scrotum and testes. Further and longer-term study of this emerging procedure is warranted.

Scrotectomy as Genital Gender-Affirming Surgery: Novel Surgical Technique and Patient-Reported Outcomes

Objective: 
Varicocele thrombosis has historically been described as a rare phenomenon, and little is known about how COVID-19 and its thrombophilic effects manifest in the male reproductive tract. The purpose of this study is to examine the risk of thrombosis in varicocele patients with or without documented COVID-19 infection.

Design: 
This is a retrospective cohort study composed of patients from a large tertiary care institution. 

Subjects: 
The study cohort was composed of patients with a clinical or radiographic diagnosis of varicocele between 2013-2022. 

Exposure: 
The exposure of interest in this study was documented COVID-19 infection status.

Main Outcome Measures:
Patient data was collected including COVID-19 infection status, age, and BMI via retrospective chart review of the electronic medical record. Pampiniform plexus thrombosis was diagnosed by a staff radiologist and noted within scrotal ultrasonography reports. Scrotal ultrasound reports were analyzed by independent reviewers for diagnosis of varicocele thrombosis. Standard statistical analysis was performed using chi-squared and t-tests in addition to multivariate regression analysis. 

Results:
We identified 110 cases of varicocele thrombosis amongst 1,999 diagnoses of varicocele, representing at least a 5.5% overall incidence rate. There was a strong association between history of COVID-19 infection and varicocele thrombosis (p=<0.001). There was also a significant increase in thrombosis incidence in 2020, consistent with epidemiological data regarding acute COVID-19 infection in unvaccinated reproductive-aged males. 

Conclusion:
Our data suggests that in contrast to prior reports, varicocele thrombosis is a relatively common phenomenon and is present in up to 5.5% of men with varicocele. COVID-19 is a strong risk factor for the development of thrombosis, and more work is necessary to reveal the effect of this phenomenon on long-term testicular function in patients with varicocele. This diagnosis should be considered in men with subacute scrotal pain out of proportion of traditional varicocele discomfort, particularly if a recent COVID-19 infection is suspected or confirmed.

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Light ‘Em Up! Early Experience Utilizing 18F-FDG PET/MRI to Pinpoint Pain Generators in Patients with Diagnostically Challenging Chronic Pain

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Subdural Hematoma and Traumatic Meningeal Enhancement in Patients with Acute Traumatic Brain Injury

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