Case 267: Cecureterocoele Manifesting in a Man with Infertility.

History A 28-year-old man presented with lifelong anejaculation, which had become an issue because of family planning. The patient had a history of normal erections and experienced the sensation of orgasm without ever ejaculating. On physical examination, both testes were present in the scrotum, with normal dimensions and a normal epididymis bilaterally. The patient had a slightly tender left testicle, and digital rectal examination findings were normal. The patient underwent further investigation for the possibility of retrograde ejaculation with urine cytology, the results of which were negative. Genetic testing was performed to exclude Y chromosome microdeletions. Serum-luteinizing and follicle-stimulating hormone levels were normal, with a borderline low level of testosterone (7.6 nmol/L; normal range, 8.0-29.0 nmol/L). All other pertinent laboratory results were noncontributory. Pelvic MRI was requested to exclude an anatomic cause of anejaculation. MRI was performed in accordance with the standard clinical prostate protocol, with a dynamic contrast material-enhanced study. CT of the upper abdomen was also performed. The patient subsequently underwent cystoscopy, which revealed an intravesicular fluid-filled mass near the left ureteric orifice

Accuracy of urine pH testing in a regional metabolic renal clinic: is the dipstick accurate enough?

Urine pH is a useful marker for assessing treatment need and efficacy in patients with nephrolithiasis. Though the gold standard of measurement is with a pH electrode, dipsticks offer the convenience of cost, ease of use, and the possibility of patients measuring their own values outside the clinic. The aim of this study was to determine whether dipsticks offer the same accuracy as the electrode. Paired measurements of freshly voided urine pH with both electrode and dipstick were analysed in a multidisciplinary renal clinic. We found that although there was a high Pearson correlation between the samples (0.89, p = 0.001), urine dipstick measurements carried an approximately 1 in 4 risk of producing clinically significant differences (pH differences  > 0.5 pH unit) from meter values. We also found that at high and low urine pH, the dipstick tended to over- and underestimate true pH readings, respectively. Examining the values in the 98 patients where a need for pharmacological urinary pH manipulation was indicated by the true pH, we found 14 who would not have been appropriately treated, and 5 who would have been unnecessarily medicated, if the stick pH value had been used. We conclude that dipstick pH measurement is insufficiently reliable for guiding clinical decision-making

Experimental demonstration of Gaussian protocols for one-sided device-independent quantum key distribution

Nonlocal correlations, a longstanding foundational topic in quantum information, have recently found application as a resource for cryptographic tasks where not all devices are trusted, for example in settings with a highly secure central hub, such as a bank or government department, and less secure satellite stations which are inherently more vulnerable to hardware "hacking" attacks. The asymmetric phenomena of Einstein-Podolsky-Rosen steering plays a key role in one-sided device-independent quantum key distribution (1sDI-QKD) protocols. In the context of continuous-variable (CV) QKD schemes utilizing Gaussian states and measurements, we identify all protocols that can be 1sDI and their maximum loss tolerance. Surprisingly, this includes a protocol that uses only coherent states. We also establish a direct link between the relevant EPR steering inequality and the secret key rate, further strengthening the relationship between these asymmetric notions of nonlocality and device independence. We experimentally implement both entanglement-based and coherent-state protocols, and measure the correlations necessary for 1sDI key distribution up to an applied loss equivalent to 7.5 km and 3.5 km of optical fiber transmission respectively. We also engage in detailed modelling to understand the limits of our current experiment and the potential for further improvements. The new protocols we uncover apply the cheap and efficient hardware of CVQKD systems in a significantly more secure setting.Comment: Addition of experimental results and (several) new author

Case 267.

History A 28-year-old man presented with lifelong anejaculation, which had become an issue because of family planning. The patient had a history of normal erections and experienced the sensation of orgasm without ever ejaculating. On physical examination, both testes were present in the scrotum, with normal dimensions and a normal epididymis bilaterally. The patient had a slightly tender left testicle, and digital rectal examination findings were normal. The patient underwent further investigation for the possibility of retrograde ejaculation with urine cytology, the results of which were negative. Genetic testing was performed to exclude Y chromosome microdeletions. Serum-luteinizing and follicle-stimulating hormone levels were normal, with a borderline low level of testosterone (7.6 nmol/L; normal range, 8.0-29.0 nmol/L). All other pertinent laboratory results were noncontributory. Pelvic MRI was requested to exclude an anatomic cause of anejaculation. MRI was performed in accordance with the standard clinical prostate protocol, with a dynamic contrast material-enhanced study ( Figs 1 - 3 ). CT of the upper abdomen was also performed ( Fig 4 ). The patient subsequently underwent cystoscopy, which revealed an intravesicular fluid-filled mass near the left ureteric orifice ( Fig 5 ). Figure 1a: (a) Coronal and (b, c) axial fast spin-echo T2-weighted MR images of the pelvis, with b being superior to c. Figure 1b: (a) Coronal and (b, c) axial fast spin-echo T2-weighted MR images of the pelvis, with b being superior to c. Figure 1c: (a) Coronal and (b, c) axial fast spin-echo T2-weighted MR images of the pelvis, with b being superior to c. Figure 2a: (a) Coronal T2-weighted (repetition time msec/echo time msec, 4574/86.5) MR image of the pelvis. (b) Axial T2-weighted (3000/85.4) MR image of the pelvis. Figure 2b: (a) Coronal T2-weighted (repetition time msec/echo time msec, 4574/86.5) MR image of the pelvis. (b) Axial T2-weighted (3000/85.4) MR image of the pelvis. Figure 3: Unenhanced axial fat-saturated T1-weighted (6.2/3.1) MR images. Figure 4: Coronal CT urogram. Figure 5: Image obtained at cystoscopy

Impact of Ureteral Stent Material on Stent-related Symptoms: A Systematic Review of the Literature

CONTEXT Ureteral stents are essential implants that are used on a daily basis. Since their invention, advances in stent design have been directed towards alleviating stent-related symptoms. It remains unclear how the material composition of the stent affects stent-related symptoms. OBJECTIVE To review the literature and define the clinical impact of ureteral stent material on stent-related symptoms. EVIDENCE ACQUISITION A literature search of the Embase, MEDLINE (PubMed), and Web of Science databases was conducted on December 17, 2021 to collect articles comparing stent composition materials regarding stent-related symptoms. Thirteen publications met the inclusion criteria, of which only one met the high-quality requirements of the Cochrane Collaboration tool for assessing the risk of bias in randomized trials. EVIDENCE SYNTHESIS Most trials, including the highest quality trial, seem to support that silicone double-J (DJ) stents reduce stent-related symptoms compared to nonsilicone DJ stents. Regarding physical properties, it seems that "soft" or "flexible" DJ stents reduce stent-related symptoms. However, since there was only one high-quality study with a low risk of bias, it is impossible to draw a definitive conclusion owing to the lack of quality data. CONCLUSIONS Silicone DJ stents, and by extension "soft" DJ stents, appear to reduce stent-related symptoms compared to nonsilicone polymers and "hard" DJ stents. No definitive conclusion can be drawn owing to a lack of quality evidence. Creating a standard for measuring and reporting physical stent properties should be the first step for further research. PATIENT SUMMARY A ureteral stent is a small hollow tube placed inside the ureter to help urine drain from the kidney. We reviewed the literature on the impact of stent material on stent-related symptoms. We found that silicone may reduce stent-related symptoms, but no definitive conclusion can be drawn and further studies are needed

Investigating upper urinary tract urothelial carcinomas: a single-centre 10-year experience.

OBJECTIVES: Evidence of the accuracy of predictive tests in confirming the presence and grade of upper urinary tract urothelial carcinomas (UUTUC) is limited. We present the largest series evaluating the diagnostic value of pre- and intra-operative parameters in the detection of UUTUC. MATERIALS AND METHODS: We retrospectively analysed records of patients who underwent diagnostic ureteroscopy between 2005 and 2014 for suspected UUTUC. Pre-operative workup included voided urine cytology and CT imaging. Intra-operative assessments involved ureteroscopy to directly visualise suspicious lesions, and where possible selective cytology and biopsy. Primary outcomes were the visualisation of UUTUC and histopathological confirmation of tumour. RESULTS: Hundred out of 160 (63 %) patients presenting with suspected upper tract malignancy had UUTUC. Voided and selective urine cytology and CT individually predicted UUTUC with a sensitivity/specificity of 63/67, 76/73, and 95/26 %, respectively. Forty out of 48 (83 %) patients who had abnormal CT and abnormal voided urine cytology had UUTUC, while 100 % of those with normal CT and normal voided cytology (investigated for ongoing symptoms) were normal. Comparing endoscopic biopsy to nephroureterectomy specimen grade, 19 (46 %), 18 (44 %), and 4 (10 %) were identical, upgraded, and downgraded, respectively. CONCLUSION: Pre-operative investigations can predict UUTUCs. When these investigations were normal, the risk of UUTUC is negligible. In selective patients with abnormal investigations, ureteroscopy should be performed to confirm and predict the grade of UUTUC, in order to guide future management. Selective cytology is unlikely to significantly contribute to the diagnostic workup of UUTUC.This is the author accepted manuscript. It is currently under an indefinite embargo pending publication by Springer

The clinical and cost effectiveness of surgical interventions for stones in the lower pole of the kidney : the percutaneous nephrolithotomy, flexible ureterorenoscopy and extracorporeal shockwave lithotripsy for lower pole kidney stones randomised controlled trial (PUrE RCT) protocol

PUrE is a UK Collaborative Trial funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project no. 13/152/02). The Health Services Research Unit is funded by the Chief Scientists Office of the Scottish Government Health Directorates. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the Health Technology Assessment Programme, the National Institute of Health Research, the National Health Service or the Department of Health. The funder (through their peer-review and funding board review process) approved the study proposal but had no role in the collection, analysis or interpretation of data or writing of the report.Peer reviewedPublisher PD

Impact of COVID-19 on the management and outcomes of ureteric stones in the UK: a multicentre retrospective study

Objectives: To determine if management of ureteric stones in the UK changed during the coronavirus disease 2019 (COVID-19) pandemic and whether this affected patient outcomes. Patients and methods: We conducted a multicentre retrospective study of adults with computed tomography-confirmed ureteric stone disease at 39 UK hospitals during a pre-pandemic period (23/3/2019–22/6/2019) and a period during the pandemic (the 3-month period after the first severe acute respiratory syndrome coronavirus-2 case at individual sites). The primary outcome was success of primary treatment modality, defined as no further treatment required for the index ureteric stone. Our study protocol was published prior to data collection. Results: A total of 3735 patients were included (pre-pandemic 1956 patients; pandemic 1779 patients). Stone size was similar between groups (P > 0.05). During the pandemic, patients had lower hospital admission rates (pre-pandemic 54.0% vs pandemic 46.5%, P < 0.001), shorter mean length of stay (4.1 vs 3.3 days, P = 0.02), and higher rates of use of medical expulsive therapy (17.4% vs 25.4%, P < 0.001). In patients who received interventional management (pre-pandemic 787 vs pandemic 685), rates of extracorporeal shockwave lithotripsy (22.7% vs 34.1%, P < 0.001) and nephrostomy were higher (7.1% vs 10.5%, P = 0.03); and rates of ureteroscopy (57.2% vs 47.5%, P < 0.001), stent insertion (68.4% vs 54.6%, P < 0.001), and general anaesthetic (92.2% vs 76.2%, P < 0.001) were lower. There was no difference in success of primary treatment modality between patient cohorts (pre-pandemic 73.8% vs pandemic 76.1%, P = 0.11), nor when patients were stratified by treatment modality or stone size. Rates of operative complications, 30-day mortality, and re-admission and renal function at 6 months did not differ between the data collection periods. Conclusions: During the COVID-19 pandemic, there were lower admission rates and fewer invasive procedures performed. Despite this, there were no differences in treatment success or outcomes. Our findings indicate that clinicians can safely adopt management strategies developed during the pandemic to treat more patients conservatively and in the community

Musculoskeletal modelling of the Nile crocodile (Crocodylus niloticus) hindlimb: Effects of limb posture on leverage during terrestrial locomotion.

We developed a three-dimensional, computational biomechanical model of a juvenile Nile crocodile (Crocodylus niloticus) pelvis and hindlimb, composed of 47 pelvic limb muscles, to investigate muscle function. We tested whether crocodiles, which are known to use a variety of limb postures during movement, use limb orientations (joint angles) that optimise the moment arms (leverages) or moment-generating capacities of their muscles during different limb postures ranging from a high walk to a sprawling motion. We also describe the three-dimensional (3D) kinematics of the crocodylian hindlimb during terrestrial locomotion across an instrumented walkway and a treadmill captured via X-ray Reconstruction of Moving Morphology (biplanar fluoroscopy; 'XROMM'). We reconstructed the 3D positions and orientations of each of the hindlimb bones and used dissection data for muscle lines of action to reconstruct a focal, subject-specific 3D musculoskeletal model. Motion data for different styles of walking (a high, crouched, bended and two types of sprawling motion) were fed into the 3D model to identify whether any joints adopted near-optimal poses for leverage across each of the behaviours. We found that (1) the hip adductors and knee extensors had their largest leverages during sprawling postures and (2) more erect postures typically involved greater peak moment arms about the hip (flexion-extension), knee (flexion) and metatarsophalangeal (flexion) joints. The results did not fully support the hypothesis that optimal poses are present during different locomotory behaviours because the peak capacities were not always reached around mid-stance phase. Furthermore, we obtained few clear trends for isometric moment-generating capacities. Therefore, perhaps peak muscular leverage in Nile crocodiles is instead reached either in early/late stance or possibly during swing phase or other locomotory behaviours that were not studied here, such as non-terrestrial movement. Alternatively, our findings could reflect a trade-off between having to execute different postures, meaning that hindlimb muscle leverage is not optimised for any singular posture or behaviour. Our model, however, provides a comprehensive set of 3D estimates of muscle actions in extant crocodiles which can form a basis for investigating muscle function in extinct archosaurs

Embedded Research::a promising way to create evidence-informed impact in public health?

Background Embedded research (ER) is recognized as one way to strengthen the integration of evidence into public health (PH) practice. In this paper, we outline a promising example of the co-production of research evidence between Fuse, the UKCRC Centre for Translational Research in Public Health and a local authority (LA) in north east England. Methods We critically examine attempts to share and use research findings to influence decision-making in a LA setting, drawing on insights from PH practitioners, managers, commissioners and academic partners involved in this organizational case study. We highlight what can be achieved as a co-located embedded researcher. Results The benefits and risks of ER are explored, alongside our reflections on the added value of this approach and the institutional prerequisites necessary for it to work. We argue that while this is not a new methodological approach, its application in PH as a way to facilitate evidence use is novel, and raises pragmatic and theoretical questions about the nature of impact and the extent to which it can be engineered. Conclusion With increased situated understanding of organizational culture and norms and greater awareness of the socio-political realities of PH, ER enables new co-produced solutions to become possible