Patient Satisfaction with Oral Testosterone Undecanoate in Men Who Received Prior Testosterone Therapy: An Open-Label, Single-Center Clinical Trial

PURPOSE

To evaluate patient satisfaction and symptom control in hypogonadal men transitioning from other testosterone therapies to oral testosterone undecanoate (TU).

MATERIALS AND METHODS

In this open-label clinical trial, men aged 18 to 75 years with hypogonadism were switched to oral TU after a sufficient washout of previous testosterone therapies. Treatment satisfaction and symptom control were primarily measured using the 9-item Treatment Satisfaction Questionnaire for Medication (TSQM-9) and quantitative androgen deficiency in aging males (qADAM) questionnaires, respectively. Secondary outcomes included changes in serum testosterone (T), estradiol (E2), hematocrit (HCT), and prostate-specific antigen (PSA) levels.

RESULTS

Forty-one men participated, with significant improvements in all TSQM-9 scores observed over 6 months. Symptom control as measured by qADAM remained consistent. There was a significant increase in serum T and E2 levels, but HCT and PSA levels remained stable.

CONCLUSIONS

Switching to oral TU from other testosterone therapies is associated with increased patient satisfaction and stable hypogonadal symptom control.

Risk factors for adverse outcomes following paraesophageal hernia repair among obese patients

BACKGROUND

Although obesity is an established risk factor for adverse outcomes after paraesophageal hernia repair (PEHR), many obese patients nonetheless receive PEHR. The purpose of this study was to explore risk factors for adverse outcomes of PEHR among this high-risk cohort. We hypothesized that obese patients may have other risk factors for adverse outcomes following PEHR.

METHODS

A retrospective study of adult obese patients who underwent minimally invasive PEHR from 2017 to 2019 was performed. Patients were excluded for BMI < 30 or if they had concomitant bariatric surgery at time of PEHR. The primary outcome of interest was a composite adverse outcome (CAO) defined as having any of the four following outcomes after PEHR: persistent GERD > 30 d, persistent dysphagia > 30 d, recurrence, or reoperation. Chi-square and t-test analysis was used to compare demographic and clinical characteristics. Multivariable logistic regression analysis was used to evaluate independent predictors of CAO.

RESULTS

In total, 139 patients met inclusion criteria with a median follow-up of 19.7 months (IQR 8.8-81). Among them, 51/139 (36.7%) patients had a CAO: 31/139 (22.4%) had persistent GERD, 20/139 (14.4%) had persistent dysphagia, 24/139 (17.3%) had recurrence, and 6/139 (4.3%) required reoperation. On unadjusted analysis, patients with a CAO were more likely to have a history of prior abdominal surgery (86.3% vs 70.5%, p = 0.04) and were less likely to have undergone a preoperative CT scan (27.5% vs 45.5%, p = 0.04). On multivariable analysis, previous abdominal surgery was independently associated with an increased likelihood of CAO whereas age and preoperative CT scan had a decreased likelihood of CAO.

CONCLUSIONS

Although there were adverse outcomes among obese patients, minimally invasive PEHR may be feasible in a subset of patients at specialized centers. These findings may help guide the appropriate selection of obese patients for PEHR.

Comparison of Hematocrit Change in Testosterone-deficient Men Treated With Intranasal Testosterone Gel vs Intramuscular Testosterone Cypionate: A Randomized Clinical Trial

PURPOSE

Our primary aim was to compare changes in hematocrit in testosterone-deficient men treated with intranasal testosterone gel vs intramuscular testosterone cypionate.

MATERIALS AND METHODS

This 2-arm, open-label, randomized trial recruited men with testosterone deficiency at the University of Miami between August 2020 and October 2022. Men with 2 total testosterone levels <350 ng/dL and hypogonadal symptoms, aged 18-75 years were randomly assigned to receive either intranasal testosterone gel 11 mg 3 times daily or intramuscular testosterone cypionate 200 mg every 2 weeks. The primary outcome was change in hematocrit after 4 months of treatment. Secondary outcomes were changes in serum testosterone, estradiol, prostate-specific antigen, 17-hydroxyprogesterone, and the 6-item International Index of Erectile Function.

RESULTS

Of the 81 men randomized, 54 completed treatment (intranasal n=23; intramuscular n=31). The mean age was 47.5 vs 49.5 years, with mean baseline testosterone of 244.6 vs 240.7 ng/dL and mean hematocrit of 44.4% vs 42.7% in intranasal vs intramuscular groups, respectively. Men who received intramuscular injections had a significant increase after 4 months of treatment in mean hematocrit from 42.7% to 46.6% (P < .0001), but there was no significant change in men who received intranasal gel (P = .233). Men in both groups experienced significantly increased serum testosterone levels throughout the study period, though a larger increase was seen in men treated with intramuscular injections (mean change 511 vs 283, P = .025). Men who received injections also experienced an increase in estradiol (mean change 22.9, P < .001), decrease in 17-hydroxyprogesterone (mean change -39.8, P < .0001), and increase in the 6-item International Index of Erectile Function score (mean change 4.8, P = .015); men treated with intranasal gel experienced no such changes. Prostate-specific antigen levels were stable in both groups.

CONCLUSIONS

Intranasal testosterone gel does not appear to significantly affect hematocrit levels. Men who wish to avoid polycythemia or changes in estradiol or 17-hydroxyprogesterone levels may benefit from short-acting testosterone therapy formulations such as intranasal gel.

Telehealth Sterilization Consultation Does Not Impact Likelihood of Vasectomy: A Retrospective Institutional Analysis

OBJECTIVE

To evaluate if telehealth consultations would impact the likelihood of patients following through with vasectomies.

METHODS

We utilized electronic medical records from the past 5 years to retrospectively evaluate male patients undergoing a sterilization consult. Telehealth consultations have been offered since March 2020 due to the COVID-19 pandemic. Patients were stratified to in-office or telehealth consultation. We then utilized billing codes to determine if patients underwent a vasectomy. Percentages of patients who subsequently underwent vasectomy were compared using Chi-square analysis. Logistic regression was performed to identify factors associated with completing vasectomy.

RESULTS

There were a total of 369 patients who underwent a telehealth male sterilization consultation and 1664 patients who were seen in the office. We found that 66.9% of telehealth patients ultimately underwent a vasectomy (n.ß=.ß247) compared to 64.3% of patients who were seen via office assessment (n.ß=.ß1070) (X2 =.ß0.646, p.ß=.ß.724). Younger age was the only variable on univariate logistic regression that was associated with completing vasectomy (p.ß=.ß.002) via either an in-person or televisit, while body mass index, race, and ethnicity were not significant.

CONCLUSION

Only 2/3 of the men completing a vasectomy consult receive a subsequent vasectomy. Both in-office and telehealth consultations resulted in comparable rates of vasectomy. This is the first study to report on the likelihood of following through with a surgical procedure comparing in-office vs.ßtelehealth assessment in male sexual and reproductive medicine. As vasectomy consultations continue to rise, clinicians can be reassured by the effectiveness of telehealth consultations prior to vasectomy.

Evaluation and management of male genital tract infections in the setting of male infertility: an updated review

PURPOSE OF REVIEW

Male infertility may be secondary to male genital tract infection (MGTI) in an estimated 15% of cases. In the absence of overt clinical signs, evaluation for MGTI beyond semen analysis is not well established. Therefore, we review the literature on the evaluation and management of MGTI in the setting of male infertility.

RECENT FINDINGS

A set of international guidelines recommends semen culture and PCR testing, but the significance of positive results remains unclear. Clinical trials evaluating anti-inflammatory or antibiotic treatment report improvements in sperm parameters and leukocytospermia, but data on the effect on conception rates are lacking. Human papillomavirus (HPV) and the novel coronavirus (SARS-CoV-2) have been associated with poor semen parameters and decreased conception rates.

SUMMARY

The finding of leukocytospermia on semen analysis prompts further evaluation for MGTI, including focused physical examination. The role of routine semen culture is controversial. Treatment options include anti-inflammatories; frequent ejaculation; and antibiotics, which should not be used in the absence of symptoms or microbiological infection. SARS-CoV-2 represents a subacute threat to fertility that should be screened for in the reproductive history along with HPV and other viruses.

Integrating Radiomics With Clinicoradiological Scoring Can Predict High-Risk Patients Who Need Surgery in Crohn's Disease: A Pilot Study

BACKGROUND

Early identification of Crohn's disease (CD) patients at risk for complications could enable targeted surgical referral, but routine magnetic resonance enterography (MRE) has not been definitively correlated with need for surgery. Our objective was to identify computer-extracted image (radiomic) features from MRE associated with risk of surgery in CD and combine them with clinical and radiological assessments to predict time to intervention.

METHODS

This was a retrospective single-center pilot study of CD patients who had an MRE within 3 months prior to initiating medical therapy. Radiomic features were extracted from annotated terminal ileum regions on MRE and combined with clinical variables and radiological assessment (via Simplified Magnetic Resonance Index of Activity scoring for wall thickening, edema, fat stranding, ulcers) in a random forest classifier. The primary endpoint was high- and low-risk groups based on need for surgery within 1 year of MRE. The secondary endpoint was time to surgery after treatment.

RESULTS

Eight radiomic features capturing localized texture heterogeneity within the terminal ileum were significantly associated with risk of surgery within 1 year of treatment (P < .05); yielding a discovery cohort area under the receiver-operating characteristic curve of 0.67 (n = 50) and validation cohort area under the receiver-operating characteristic curve of 0.74 (n = 23). Kaplan-Meier analysis of radiomic features together with clinical variables and Simplified Magnetic Resonance Index of Activity scores yielded the best hazard ratio of 4.13 (P = (7.6 × 10-6) and concordance index of 0.71 in predicting time to surgery after MRE.

CONCLUSIONS

Radiomic features on MRE may be associated with risk of surgery in CD, and in combination with clinicoradiological scoring can yield an accurate prognostic model for time to surgery.

Comparing Rates of Polycythemia in Hypogonadal Men Using Nasal Testosterone Gel Versus Intramuscular Testosterone: Update of a Randomized Clinical Trial

Men with hypogonadism who use intranasal testosterone are less likely to develop polycythemia than men using intramuscular testosterone cypionate.

Practice Comparison and Cost Analysis of Direct-to-Consumer Telemedicine Platforms Offering Testosterone Therapy

BACKGROUND

Direct-to-consumer telemedicine platforms have expanded their reach to include services for the evaluation and treatment of testosterone deficiency.

AIM

We aim to (i) evaluate the treatment practices and costs associated with receiving testosterone therapy through direct-to-consumer telemedicine platforms; (ii) compare these practices to the American Urological Association guidelines; and (iii) compare the cost of receiving similar care at a tertiary center.

METHODS

Google was queried to identify telemedicine platforms offing testosterone therapy. Websites were analyzed for information regarding the initial consultation, initial laboratory evaluation, follow up, treatment monitoring regimen, and associated costs of receiving testosterone therapy. The costs for similar services at a tertiary care center were estimated using a single institution's online cost estimator for a patient with no insurance, private insurance, or Medicare.

OUTCOMES

Evaluation and treatment practices of each platform were compared to the American Urological Association guidelines, and a cost analysis was completed for the cost of (i) undergoing an initial evaluation, and (ii) receiving 12 months of treatment through each platform and at a tertiary center.

RESULTS

Three online platforms met inclusion criteria: Hone, Regenex Health, and TRT Nation. The initial evaluation and follow up of patients on TTh were similar between the online platforms and practice guidelines. The costs of the initial consultation were lowest for the patient with Medicare at a tertiary center and via the telemedicine platforms. Conversely, the cost of 12 months of intramuscular testosterone treatment was highest via the telemedicine platforms, ranging from $1,586 to $4,200, as compared to the tertiary center, which ranged from $134.01 to $1,333.04 with varying insurance models. Costs of ongoing treatment with transdermal testosterone are similarly higher via DTC platforms.

CLINICAL IMPLICATIONS

Patients with private insurance or Medicare should be counseled that ongoing treatment through telemedicine platforms will likely incur a greater cost than receiving such care at a tertiary center that can utilize insurance coverage.

STRENGTHS & LIMITATIONS

Practice and cost comparisons include accurate, up-to-date information based on each platform's website. Limitations include the analysis of only three telemedicine platforms, and the ability to describe only the information provided on each website. In addition, cost estimates for the tertiary center only include a single type of private and public insurance, limiting generalizability.

CONCLUSION

This observational study indicates that direct-to-consumer telemedicine platforms are largely following practice guidelines in the evaluation and treatment of testosterone, however, there is a high cost associated with ongoing treatment.

Nutritional value of suckler beef from temperate pasture systems

The role of beef in human diets has been questioned over the last few decades, due largely to its typically high mass-based carbon footprint. However, recent advancements in sustainability literature challenge this paradigm based on the new theory that climate impacts of food commodities should be measured relative to their overall nutritional value rather than their nominal mass. This shift has opened a new opportunity for the global beef industry, and especially for pasture-based systems that can avoid food-feed competition for land and other resources, as beef is a nutritionally dense food. Nonetheless, the sector's true capability to supply a wide range of nutrients for humans, consistently across multiple systems under multiple weather patterns, has not been well-documented. Using whole-system datasets from the North Wyke Farm Platform in the South West of England, we investigated the nutritional value of beef produced from the three most common pasture systems in temperate regions: permanent pasture (PP), grass and white clover (GWC) and a short-term monoculture grass ley (MG). Beef produced from these three pasture systems was analysed for key nutrients (fatty acids, minerals and vitamin E) over three production cycles (2015-2017) to determine potential differences between systems. Fatty acid, mineral and vitamin E profiles of the pasture and silage fed to each group were also assessed, with subtle differences between pastures reported. For beef, subtle differences were also observed between systems, with GWC having higher omega-6 polyunsaturated fatty acid (PUFA) concentrations than PP and MG. However, the overall nutritional quality of beef was found to be largely comparable across all systems, suggesting that temperate pasture-based beef can be classified as a single commodity in future sustainability assessments, regardless of specific sward types. A 100 g serving of temperate pasture-based beef was found to be a high source (>20% recommended daily intake: RDI) of protein, monounsaturated fatty acids, saturated fatty acids, vitamins - B2, B3, B12 and minerals - Fe, P, Zn; a good source (10-19% RDI) of vitamin - B6 and mineral - K; and a complementary source (5-9% RDI) of omega-3 PUFA, vitamin - B9 and minerals - Cu, Mg, Se. The nutritional value of a food item should be used in defining its environmental cost (e.g. carbon footprint) to make fair comparisons across different food groups (e.g. protein sources). Here, we showed that pasture-based beef had a nutrient indexed carbon footprint of between 0.19 and 0.23 Kg CO2-eq/1% RDI of key nutrients.

Phosphorylation control of the ubiquitin ligase Cbl is conserved in choanoflagellates

Cbl proteins are E3 ubiquitin ligases specialized for the regulation of tyrosine kinases by ubiquitylation. Human Cbl proteins are activated by tyrosine phosphorylation, thus setting up a feedback loop whereby the activation of tyrosine kinases triggers their own degradation. Cbl proteins are targeted to their substrates by a phosphotyrosine-binding SH2 domain. Choanoflagellates, unicellular eukaryotes that are closely related to metazoans, also contain Cbl. The tyrosine kinase complement of choanoflagellates is distinct from that of metazoans, and it is unclear if choanoflagellate Cbl is regulated similarly to metazoan Cbl. Here, we performed structure-function studies on Cbl from the choanoflagellate species Salpingoeca rosetta and found that it undergoes phosphorylation-dependent activation. We show that S. rosetta Cbl can be phosphorylated by S. rosetta Src kinase, and that it can ubiquitylate S. rosetta Src. We also compared the substrate selectivity of human and S. rosetta Cbl by measuring ubiquitylation of Src constructs in which Cbl-recruitment sites are placed in different contexts with respect to the kinase domain. Our results indicate that for both human and S. rosetta Cbl, ubiquitylation depends on proximity and accessibility, rather than being targeted toward specific lysine residues. Our results point to an ancient interplay between phosphotyrosine and ubiquitin signaling in the metazoan lineage.

Roles of instrumented farm-scale trials in trade-off assessments of pasture-based ruminant production systems

For livestock production systems to play a positive role in global food security, the balance between their benefits and disbenefits to society must be appropriately managed. Based on the evidence provided by field-scale randomised controlled trials around the world, this debate has traditionally centred on the concept of economic-environmental trade-offs, of which existence is theoretically assured when resource allocation is perfect on the farm. Recent research conducted on commercial farms indicates, however, that the economic-environmental nexus is not nearly as straightforward in the real world, with environmental performances of enterprises often positively correlated with their economic profitability. Using high-resolution primary data from the North Wyke Farm Platform, an intensively instrumented farm-scale ruminant research facility located in southwest United Kingdom, this paper proposes a novel, information-driven approach to carry out comprehensive assessments of economic-environmental trade-offs inherent within pasture-based cattle and sheep production systems. The results of a data-mining exercise suggest that a potentially systematic interaction exists between 'soil health', ecological surroundings and livestock grazing, whereby a higher level of soil organic carbon (SOC) stock is associated with a better animal performance and less nutrient losses into watercourses, and a higher stocking density with greater botanical diversity and elevated SOC. We contend that a combination of farming system-wide trials and environmental instrumentation provides an ideal setting for enrolling scientifically sound and biologically informative metrics for agricultural sustainability, through which agricultural producers could obtain guidance to manage soils, water, pasture and livestock in an economically and environmentally acceptable manner. Priority areas for future farm-scale research to ensure long-term sustainability are also discussed.

Magnetically recoverable TiO2-WO3 photocatalyst to oxidize bisphenol A from model wastewater under simulated solar light

A novel magnetically recoverable, visible light active TiO₂-WO₃ composite (Fe₃O₄@SiO₂@TiO₂-WO₃) was prepared to enable the photocatalyst recovery after the degradation of bisphenol A (BPA) under simulated solar light. For comparison, the photocatalytic activity of other materials such as non-magnetic TiO₂-WO₃, Fe₃O₄@SiO₂@TiO₂, TiO₂, and the commercial TiO₂ P25 was also evaluated under the studied experimental conditions. The structure and morphology of the synthesized materials were characterized by X-ray diffraction (XRD), scanning electron microscopy (SEM), high-resolution transmission electron microscopy (HR-TEM), and electron dispersion spectroscopy (EDS). Moreover, Brunauer-Emmett-Teller (BET) surface area and magnetic properties of the samples were determined. The Fe₃O₄@SiO₂@TiO₂-WO₃ and TiO₂-WO₃ led to a BPA degradation of 17.50 and 27.92 %, respectively, after 2 h of the simulated solar light irradiation. Even though their activity was lower than that of P25, which degraded completely BPA after 1 h, our catalysts were magnetically separable for their further reuse in the treatment. Furthermore, the influence of the water matrix in the photocatalytic activity of the samples was studied in municipal wastewater. Finally, the identification of reaction intermediates was performed and a possible BPA degradation pathway was proposed to provide a better understanding of the degradation process. Graphical abstract ᅟ.

Pasture dry matter consumption in European wild boars (Sus scrofa L.) as affected by herbage allowance

The objective of this study was to evaluate the effect of herbage allowance on pasture DM consumption by growing European wild boar. An additional objective was to evaluate the influence of pasture consumption on supplemental diet intake and BW gain. A previously sown grass-clover pasture was managed by cutting to obtain an herbage mass equivalent to 1,500 kg/ha DM. Areas of pasture were limited by fencing to obtain 3 different herbage allowances whereas the pasture was removed in other areas. Forty-eight purebred European wild boars (initial age of 120 d and initial BW of 14.4 kg) were grouped in pairs and each pair was randomly allotted to 1 of 4 treatments (6 pairs per treatment): no pasture (4 m(2); pasture removed), low (5.33 m(2); 400 g/d pasture DM available/wild boar), medium (8 m(2); 600 g/d pasture DM available/wild boar), and high (16 m(2); 1,200 g/d pasture DM available/wild boar). The treatment areas were moved daily with a 7-d rotation. For a 28-d period, wild boars entered their treatment areas from 0830 to 1630 h, after which they had free access to a supplemental diet for 1 h. Pasture consumption was estimated daily by cutting pasture samples pre- and postgrazing. Supplemental diet consumption was determined daily (feed offered minus remaining feed). Animals were weighed weekly. Pasture consumption differed (P < 0.001) among wild boars receiving different treatments, with cumulative consumptions of 3.0 and 3.9 kg DM/wild boar over 28 d for low and medium herbage allowances, respectively (P < 0.09), and 6.4 kg DM/wild boar over 28 d for high herbage allowance, with the latter consumption being greater (P < 0.001) than the consumption recorded with the decreased herbage allowance treatments. The supplemental diet consumption tended (P = 0.16) to be less in wild boars with greater herbage allowance. European wild boars with access to pasture had greater (8.48 vs. 6.27 kg; P = 0.002) BW gain than those without access to pasture. In conclusion, pasture consumption by European wild boars can be enhanced by increasing herbage allowance and greater BW gains can be achieved in wild boars with access to pasture compared with those with no pasture access.

Membrane chemical reactor (MCR) combining photocatalysis and microfiltration for grey water treatment

Urban water recycling is now becoming an important issue where water resources are becoming scarce. This paper looks at reusing grey water; the preference is treatment processes based on biological systems to remove the dissolved organic content. Here, an alternative process, photocatalysis is discussed as it is an attractive technology that could be well-suited for treating the recalcitrant organic compounds found in grey water. The photocatalytic process oxidises organic reactants at a catalyst surface in the presence of ultraviolet light. Given enough exposure time, organic compounds will be oxidized into CO2 and water. The best contact is achieved in a slurry reactor but a second step to separate and recover the catalyst is need. This paper discusses a new membrane chemical reactor (MCR) combining photocatalysis and microfiltration for grey water treatment.

[Caroli's syndrome. Report of a case beginning in childhood with favorable course]

Caroli's disease is a rare entity that is included in the fibropolycystic abnormalities of the bile ducts. Ultrasonographic patterns consist of evident dilatation of the bile ducts. Although it is thought to be a congenital disease, it usually presents in young adults and few cases have been reported in children. We present the case of a 10-year-old boy with Caroli's syndrome (Caroli's disease, congenital hepatic fibrosis and polycystic renal disease). Evolution was favorable.