Metabolic syndrome and the urinary microbiome of patients undergoing percutaneous nephrolithotomy

Objective

To identify possible stone-promoting microbes, we compared the profiles of microbes grown from stones of patients with and without metabolic syndrome (MetS). The association between MetS and urinary stone disease is well established, but the exact pathophysiologic relationship remains unknown. Recent evidence suggests urinary tract dysbiosis may lead to increased nephrolithiasis risk.

Methods

At the time of percutaneous nephrolithotomy, bladder urine and stone fragments were collected from patients with and without MetS. Both sample types were subjected to expanded quantitative urine culture (EQUC) and 16 S ribosomal RNA gene sequencing.

Results

Fifty-seven patients included 12 controls (21.1%) and 45 MetS patients (78.9%). Both cohorts were similar with respect to demographics and non-MetS comorbidities. No controls had uric acid stone composition. By EQUC, bacteria were detected more frequently in MetS stones (42.2%) compared to controls (8.3%) (p=0.041). Bacteria also were more abundant in stones of MetS patients compared to controls. To validate our EQUC results, we performed 16 S ribosomal RNA gene sequencing. In 12/16 (75.0%) sequence-positive stones, EQUC reliably isolated at least one species of the sequenced genera. Bacteria were detected in both "infectious" and "non-infectious" stone compositions.

Conclusion

Bacteria are more common and more abundant in MetS stones than control stones. Our findings support a role for bacteria in urinary stone disease for patients with MetS regardless of stone composition.

Impact of intravesical Bacillus Calmette-Guérin and chemotherapy on the bladder microbiome in patients with non-muscle invasive bladder cancer

Introduction

Intravesical therapy (IVT), including Bacillus Calmette-Guérin (BCG), is the standard of care for high grade (HG) non-muscle invasive bladder cancer (NMIBC). Despite the use of IVT, many patients recur after treatment. The bladder microbiome and its role in disease processes has recently risen to prominence. We aim to characterize changes that occur in the bladder microbiome over the course of intravesical therapy and assess whether these changes correlate with outcomes in patients with NMIBC.

Methods

Patients with NMIBC undergoing induction BCG or intravesical therapy were prospectively enrolled from January 2019 to March 2020. Patients with clinical T2 or greater pathology or active urinary tract infection at enrollment were excluded. Twenty-nine patients had catheterized (bladder) urine samples collected prior to induction intravesical therapy and prior to each IVT instillation. Twenty-seven received BCG while 2 received intravesical gemcitabine. Bacteria were identified using 16S ribosomal RNA gene sequencing. Bladder microbiome changes were evaluated and differences between patients who recurred and patients who did not recur after IVT were investigated.

Results

Across the 29 patients analyzed, bacterial richness decreased significantly following intravesical therapy (Richness, P=0.01). Evenness and overall diversity did not change significantly (Pielou, P=0.62; Shannon, P=0.13). Patients who experienced recurrence had a higher relative abundance of Aerococcus in their urine (P<0.01), while those who did not recur had significantly more Ureaplasma (P=0.01) and Escherichia/Shigella species (P=0.05). Patients with decreased levels of alpha diversity were more likely to fall within the non-recurrence cohort.

Conclusion

IVT for NMIBC appears to change the urinary microbiome by decreasing richness while not altering evenness or overall diversity. The presence of Aerococcus species may be predictive of a poor cancer response to IVT, while the presence of Ureaplasma and Escherichia/Shigella may predict a favorable response to IVT. Further studies are warranted to elucidate and confirm the significance of changes in the bladder microbiome.

Global, regional, and national mortality among young people aged 10-24 years, 1950-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10-24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10-24 years by age group (10-14 years, 15-19 years, and 20-24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10-24 years with that in children aged 0-9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10-24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017).

FINDINGS

In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39-1·59) worldwide in people aged 10-24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10-14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15-19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1-4 years (2·4%), and around a third less than in females aged 1-4 years (2·5%). The proportion of global deaths in people aged 0-24 years that occurred in people aged 10-24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%.

INTERPRETATION

Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10-24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group.

FUNDING

Bill & Melinda Gates Foundation.

Four versus 3 Cycles of Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer: Implications for Pathological Response and Survival

PURPOSE

The ideal number of neoadjuvant chemotherapy (NAC) cycles for muscle-invasive bladder cancer is uncertain with 3 to 4 representing the standard of care (SOC). We compared ypT0 rates and survival between patients receiving 4 versus 3 cycles of NAC with evaluation of chemotherapy-related toxicity for correlation with tumor chemosensitivity and pathological response.

MATERIALS AND METHODS

Patients receiving NAC followed by radical cystectomy for cT2-4N0M0 urothelial carcinoma from 2 institutions were included. Primary study groups included 4 cisplatin-based NAC cycles, 3 cisplatin-based NAC cycles, and nonSOC NAC (1-2 cycles or noncisplatin-based) to compare ypT0/≤ypT1 rates and survival. A cohort of patients not receiving NAC was included for pathological reference.

RESULTS

Of 693 total patients, 318 (45.9%) received NAC. ypT0 and ≤ypT1 rates were 42/157 (26.8%) and 86/157 (54.8%) for 4 cycles, 38/114 (33.3%) and 71/114 (62.3%) for 3 cycles, and 6/47 (12.8%) and 13/47 (27.7%) for nonSOC (p=0.03 and p <0.01, respectively). Pathological response appeared higher among patients receiving 3 cycles due to toxicity (ypT0: 29/77 [37.7%]; ≤ypT1: 51/77 [66.2%]) but did not reach statistical significance. Toxicities leading to treatment modifications were thrombocytopenia (32.1%), neutropenia (27.2%), renal insufficiency (22.2%), and constitutional symptoms (18.5%). NonSOC patients had lower Kaplan-Meier survival (cT2-cT4N0M0: log-rank p=0.07; cT2N0M0: log-rank p=0.02). There were no statistically significant differences in survival between 4 and 3 cycles (HR 1.00 [95% CI 0.57-1.74], p=0.99).

CONCLUSIONS

Patients completing 3 cycles of cisplatin-based NAC have similar pathologic response and short-term survival compared to 4 cycles. Further evaluation of patients experiencing toxicity as a potential marker of tumor chemosensitivity is needed.

African American Men have Increased Risk of Prostate Cancer Detection Despite Similar Rates of Anterior Prostatic Lesions and PI-RADS Grade on Multiparametric Magnetic Resonance Imaging

OBJECTIVE

To determine whether the frequency of anterior prostate lesions (APL) on multiparametric magnetic resonance imaging (mpMRI) prior to biopsy differed between African American (AA) and non-AA men and evaluate implications of race and tumor location for prostate cancer (PCa) detection.

METHODS

Patients from the Prospective Loyola University mpMRI (PLUM) Prostate Biopsy Cohort (January 2015-December 2020) without prior diagnosis of PCa were evaluated for APLs by race. Multivariable logistic regression models evaluated predictors of APLs and associations of APLs and race with detection of any PCa (grade group 1+) and clinically significant PCa (csPCa; grade group 2+). Additional stratified and propensity score matched analyses were conducted.

RESULTS

Of 1,239 men included, 190 (15.3%) were AA and 302 (24.4%) had at least one APL with no differences by race on multivariable analysis. While men with APLs were twice as likely to harbor PCa or csPCa, the unadjusted proportion of targeted biopsy-confirmed APL PCa (12.6% vs 12.0%) or csPCa (8.4% vs 8.9%) were similar for AA and non-AA men. AA men had higher risk of prostate cancer on targeted cores (OR 1.66 (95%CI 1.06 - 2.61), P = 0.026) which was independent of lesion location or PI-RADS.

CONCLUSION

AA men were found to have similar rates of APLs on mpMRI to non-AA men indicating access to mpMRI may mitigate some of the historical racial disparity based on lesion location. AA men have increased risk of PCa detection compared to non-AA men independent of anterior location or lesion grade on mpMRI reinforcing the importance of identifying genetic, biologic, and socioeconomic drivers.

Bridging the Telemedicine Gap Among Seniors During the COVID-19 Pandemic

At the onset of the COVID-19 pandemic, many senior patients in the USC-Keck Family Medicine clinics were limited or lacking in telemedicine participation. Three factors contributed: lack of video-enabled devices, technological literacy, and/or absence of Wi-Fi connectivity. We addressed the first 2 of these factors. Via phone contact, 9 patients agreed to receive donated Android or Apple devices and to trial instruction manuals for use. Donated equipment and instructions were prepared and delivered in accordance with pandemic guidelines. Follow-up calls indicated that 4 participants were able to set up their devices and 3 of whom had connected with their providers. The remaining 5 participants had not set up their devices by the end of the follow-up period, had difficulty with device setup, accessing applications necessary for telemedicine, or had limited access to Wi-Fi. This project highlights some telemedicine barriers that senior patients may overcome with the additional support of care providers.

Optimal Cystectomy Outcome: A Composite Measurement Evaluating Quality of Care and Mortality Benefit

OBJECTIVES

To evaluate the incidence and impact of an "optimal cystectomy outcome" (OCO), a simplified performance metric that encompasses multiple patient-centered outcomes.

METHODS

We identified patients in the National Cancer Center Database undergoing radical cystectomy for stage cT2-cT3 urothelial carcinoma (2006-2014). OCO was defined as negative resection margin, adequate lymphadenectomy (>10 nodes), no prolonged length-of-stay (<75th percentile), no 30-day-readmission, and no 30-day-mortality. We used multivariable logistic regression and Cox proportional-hazards models to identify factors associated with OCO and overall survival (OS).

RESULTS

Among 12,997 patients who fit the inclusion criteria, individual OCO components were attained at a relatively high rate; however, only 37.6% of patients met all 5 OCO criteria. Patients who underwent surgery at a high-volume (OR 2.45) academic facility (OR 1.60) using a minimally-invasive approach (OR 1.32) were more likely to receive an OCO. Patients were less likely to receive an OCO if they were older (OR 0.98), African American (OR 0.71), had Medicaid insurance (OR 0.66), or more comorbidities (OR 0.48) (all P <0.05). Patients who received an OCO were found to have a significantly lower risk of overall mortality (HR 0.69, P <0.05).

CONCLUSION

Various patient- and hospital-specific factors affect a system's ability to achieve OCO in patients undergoing radical cystectomy. OCO is directly associated with improved OS and has the potential to function as a composite performance metric for the quality of care in bladder cancer.

Implications of the Genitourinary Microbiota in Prostatic Disease

PURPOSE OF REVIEW

To summarize recent investigation into associations between the genitourinary microbiota and prostatic disease.

RECENT FINDINGS

The genitourinary tract is not sterile. There are microbial communities (microbiota) in each niche of the genitourinary tract including the bladder, prostate, and urethra, which have been the subject of increasing scientific interest. Investigators have utilized several unique methods to study them, resulting in a highly heterogeneous body of literature. To characterize these genitourinary microbiota, diverse clinical specimens have been analyzed, including urine obtained by various techniques, seminal fluid, expressed prostatic secretions, and prostatic tissue. Recent studies have attempted to associate the microbiota detected from these samples with urologic disease and have implicated the genitourinary microbiota in many common conditions, including benign prostatic hyperplasia (BPH), prostate cancer, and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). In this review, we summarize the recent literature pertaining to the genitourinary microbiota and its relationship to the pathophysiology and management of three common prostatic conditions: BPH, prostate cancer, and CP/CPPS.