Publications by authors named "Kevin Chu"

132 Publications

Restorative Therapies for Erectile Dysfunction: Position Statement From the Sexual Medicine Society of North America (SMSNA).

Sex Med 2021 May 14;9(3):100343. Epub 2021 May 14.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address:

Introduction: Current non-invasive treatments for erectile dysfunction (ED) include oral medications, intracavernosal injections, and vacuum-assisted devices. Though these therapies work well for many, a subset of patients have contraindications or are unsatisfied with these options. Restorative therapies for ED are a new frontier of treatments focused on regenerating diseased tissue and providing a potential "cure" for ED.

Aim: The aim of this position statement is to examine existing clinical trial data for restorative therapies and identify elements that require further research before widespread adoption.

Methods: A literature review was performed to identify all clinical trials performed with regenerative therapy for ED. This includes treatments such as stem cell therapy (SCT), platelet rich plasma (PRP), and restorative related technologies like low-intensity shockwave therapy (LiSWT).

Main Outcome Measures: Most clinical trials in restorative therapies were assessed for safety, feasibility, or efficacy. This included recording adverse events, changes in sexual function and erectile function questionnaires, and diagnostics measures.

Results: To date there is an absence of robust clinical data supporting the efficacy of restorative therapies regarding ED, though technologies such as LiSWT have established relative safety.

Conclusions: Restorative therapies are a promising technology that represents a new frontier of treatment geared towards reversing disease pathology rather than just treating symptoms. However, current published clinical studies are limited. Future work needs to be adequately powered, multi-center, randomized, sham/placebo-controlled trials in well-characterized patient populations to ensure safety and demonstrate efficacy. Until these studies are done, restorative therapies should be reserved for clinical trials and not offered in routine clinical practice. Liu JL, Chu KY, Gabrielson AT, et al. Restorative Therapies for Erectile Dysfunction: Position Statement From the Sexual Medicine Society of North America (SMSNA). J Sex Med 2021;9:100343.
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http://dx.doi.org/10.1016/j.esxm.2021.100343DOI Listing
May 2021

Evaluating reliability and validity of the modified radiographic union scale for tibia (mRUST) among North American and Tanzanian surgeons.

OTA Int 2021 Mar 23;4(1):e093. Epub 2020 Dec 23.

University of California, San Francisco, San Francisco, CA, USA.

Objectives: To determine the international reliability and validity of the modified Radiographic Union Scale for Tibial fracture (mRUST) scoring method for open tibial shaft fractures based on ratings of radiographs by separate groups of North American and Tanzanian surgeons.

Methods: Seven North American and 9 Tanzanian surgeons viewed 100 pairs of AP and lateral radiographs of open tibial shaft fractures obtained in Dar Es Salaam, Tanzania. The radiographs showed 25 patients' fractures at 4 time points postfracture after treatment with either external fixation or intramedullary nailing. Surgeons evaluated each fracture using the mRUST scoring method and indicated their confidence that the fracture was healed on a scale from 1 to 10. Reliability of mRUST was determined using inter-rater agreement among North American and Tanzanian surgeons. Validity was determined via analysis of correlation between mRUST scores and EQ-5D-3L index scores at each time point postfracture.

Results: mRUST scores demonstrated strong reliability overall (ICC = 0.64) as well as within each group of North American (ICC = 0.72) and Tanzanian (ICC = 0.69) surgeons. Reliability was stronger for external fixation than for intramedullary nailing cases. mRUST scores were significantly correlated with overall healing confidence at all time points and with quality of life at 6 months and 1 year postfracture. mRUST scores also correlated significantly with patients' quality of life scores (EQ-5D index) at 6 months and 1 year postfracture.

Conclusion: North American and Tanzanian surgeons exhibited strong agreement in rating open tibial shaft fractures. Using mRUST scores is a valid means of assessing radiographic healing of tibial fractures in austere environments like Tanzania.
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http://dx.doi.org/10.1097/OI9.0000000000000093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016608PMC
March 2021

Temporal changes in metabolism late in seed development affect biomass composition.

Plant Physiol 2021 Mar 9. Epub 2021 Mar 9.

Donald Danforth Plant Science Center, St. Louis, Missouri 63132, USA.

The negative association between protein and oil production in soybean (Glycine max) seed is well-documented. However, this inverse relationship is based primarily on the composition of mature seed, which reflects the cumulative result of events over the course of soybean seed development and therefore does not convey information specific to metabolic fluctuations during developmental growth regimes. In this study, we assessed maternal nutrient supply via measurement of seed coat exudates and metabolite levels within the cotyledon throughout development to identify trends in the accumulation of central carbon and nitrogen metabolic intermediates. Active metabolic activity during late seed development was probed through transient labeling with 13C substrates. The results indicated: i) a drop in lipid contents during seed maturation with a concomitant increase in carbohydrates, ii) a transition from seed filling to maturation phases characterized by quantitatively balanced changes in carbon use and CO2 release, iii) changes in measured carbon and nitrogen resources supplied maternally throughout development, iv) 13C metabolite production through gluconeogenic stepsfor sustained carbohydrate accumulation as the maternal nutrient supply diminishes, and v) oligosaccharide biosynthesis within the seed coat during the maturation phase. These results highlight temporal engineering targets for altering final biomass composition to increase the value of soybeans and a path to breaking the inverse correlation between seed protein and oil content.
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http://dx.doi.org/10.1093/plphys/kiab116DOI Listing
March 2021

An initial psychometric evaluation of the APS-POQ-R in acute pain presenting to the emergency department.

Australas Emerg Care 2021 Jan 12. Epub 2021 Jan 12.

Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia.

Aim: The purpose of this study was to examine the psychometric properties of a modified version of the American Pain Societies - Patient Outcome Questionnaire - Revised edition in adult patients presenting with acute pain to the emergency department.

Background: There is a lack of validation and use of patient-reported outcome measures of pain care in the adult emergency setting.

Design: Prospective psychometric evaluation.

Methods: Adult patients who had presented with acute pain were invited to participate in the study after their emergency department care. The Questionnaire was administered by one of the investigators. Exploratory factor analysis (principal axis factoring) was used to explore items mapping to constructs. The number of constructs with an Eigenvalue closest to 1 was considered the correct fit for the data. Assessment of the analysis was conducted using the Kaiser-Meier-Olkin test of sampling adequacy, and the fit was assessed using Bartlett's test of sphericity.

Results: The Questionnaire demonstrated construct validity in these patients. Exploratory factor analysis demonstrated five constructs. The tool demonstrated discriminatory ability based on patient urgency, and subscale measurement was associated with patient satisfaction with care CONCLUSIONS: The Questionnaire has demonstrable construct validity in adult patients presenting with acute pain to the ED.
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http://dx.doi.org/10.1016/j.auec.2020.12.001DOI Listing
January 2021

Mechanical Stiffness Controls Dendritic Cell Metabolism and Function.

Cell Rep 2021 Jan;34(2):108609

Division of Cellular and Molecular Biology, Diabetes Research Group, Toronto General Hospital Research Institute (TGHRI), University Health Network, Toronto, ON M5G 1L7, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Immunology, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Pathology, University Health Network, Toronto, ON M5G 2C4, Canada; Buck Institute for Research on Aging, 8001 Redwood Boulevard, Novato, CA 94945, USA. Electronic address:

Stiffness in the tissue microenvironment changes in most diseases and immunological conditions, but its direct influence on the immune system is poorly understood. Here, we show that static tension impacts immune cell function, maturation, and metabolism. Bone-marrow-derived and/or splenic dendritic cells (DCs) grown in vitro at physiological resting stiffness have reduced proliferation, activation, and cytokine production compared with cells grown under higher stiffness, mimicking fibro-inflammatory disease. Consistently, DCs grown under higher stiffness show increased activation and flux of major glucose metabolic pathways. In DC models of autoimmune diabetes and tumor immunotherapy, tension primes DCs to elicit an adaptive immune response. Mechanistic workup identifies the Hippo-signaling molecule, TAZ, as well as Ca-related ion channels, including potentially PIEZO1, as important effectors impacting DC metabolism and function under tension. Tension also directs the phenotypes of monocyte-derived DCs in humans. Thus, mechanical stiffness is a critical environmental cue of DCs and innate immunity.
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http://dx.doi.org/10.1016/j.celrep.2020.108609DOI Listing
January 2021

Patient-Reported outcomes of pain care research in the adult emergency department: A scoping review.

Australas Emerg Care 2021 Jun 10;24(2):127-134. Epub 2020 Nov 10.

Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia; School of Nursing, Queensland University of Technology, Kelvin Grove, Australia. Electronic address:

Despite more than 30 years of research, pain in the emergency department (ED) setting is frequently undertreated. EDs prioritise process measures that often have tenuous links to patient-reported outcomes. However, process measures, such as time to the administration of first analgesic medication, are neither direct objective measures of analgesia nor appropriate surrogate markers of pain relief. Since pain is a subjective symptom that lacks an objective measure, pain research in any clinical environment, including EDs, should rely upon patient-reported outcomes. This scoping review examined patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs) of pain care in the adult emergency department at the micro, meso and macro-level over the last ten years. We reviewed pain care research conducted on adults in EDs over the last ten years and identified 57 articles using 14 patient-reported outcomes of pain care falling into five broad areas, most without validation or adaption to the ED setting. Despite efforts made to incorporate PROs and PROMs into acute pain care research in the ED over the last ten years, there is still no gold-standard PROM in widespread use. We recommend the adaptation of existing tools with rigorous validation in ED populations.
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http://dx.doi.org/10.1016/j.auec.2020.10.003DOI Listing
June 2021

Histopathology and Ultrastructural Findings of Fatal COVID-19 Infections on Testis.

World J Mens Health 2021 Jan 3;39(1):65-74. Epub 2020 Nov 3.

Department of Urology, Miller School of Medicine, University of Miami, Miami, FL, USA.

Purpose: To evaluate the presence and analyze the pathological changes within the testes of patients who died or recovered from severe acute respiratory syndrome coronavirus 2 (COVID-19) complications.

Materials And Methods: Testis tissue was collected from autopsies of COVID-19 positive (n=6) and negative men (n=3). Formalin-fixed paraffin-embedded tissues were stained with hematoxylin and eosin (H&E) and subjected to immunofluorescence for angiotensin-converting enzyme 2 (ACE-2) expression. Fluorescent-labeled tissue slides were imaged on a quantitative pathology scope with various zoom levels allowing for qualitative and quantitative interpretation. Tissue from four COVID-19 positive autopsy cases and a live seroconverted patient was imaged with transmission electron microscopy (TEM).

Results: H&E histomorphology showed three of the six COVID-19 biopsies had normal spermatogenesis while the remaining three had impaired spermatogenesis. TEM showed the COVID-19 virus in testis tissue of one COVID-19 positive autopsy case and the live biopsy, H&E stain on the same autopsy case demonstrated interstitial macrophage and leukocyte infiltration. Immunofluorescent stained slides from six COVID-19 positive men demonstrated a direct association between increased quantitative ACE-2 levels and impairment of spermatogenesis.

Conclusions: The novel COVID-19 has an affinity for ACE-2 receptors. Since ACE-2 receptor expression is high in the testes, we hypothesized that COVID-19 is prevalent in testes tissue of infected patients. This study suggests the male reproductive tract, specifically the testes, may be targets of COVID-19 infection. We found an inverse association between ACE-2 receptor levels and spermatogenesis, suggesting a possible mechanism of how COVID-19 can cause infertility.
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http://dx.doi.org/10.5534/wjmh.200170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752514PMC
January 2021

Strategies to increase testosterone in men seeking fertility.

Turk J Urol 2020 Oct 19. Epub 2020 Oct 19.

Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA.

Prevalence of testosterone deficiency is increasing in the adolescent and young adult male population. As the average paternal age rises, there is a significant population of men with hypogonadism seeking testosterone therapy wishing to achieve or maintain fertility potential. Identification of potential lifestyle modifications that may improve the testosterone deficiency is one of the initial interventions of the holistic strategy in treatment. This is followed by drug therapy; however, traditional testosterone therapy acts as a contraceptive by suppressing the hypothalamus-pituitary-gonadal (HPG) axis and therefore cannot be used as a treatment strategy. A solution has been the off-label use of selective estrogen receptor modulators, human chorionic gonadotropin (hCG), and anastrozole inhibitors to treat hypogonadal symptoms while increasing intratesticular testosterone, a necessity for spermatogenesis. Recently, a novel therapy, Natesto intranasal testosterone gel, has been shown to increase serum testosterone levels while maintaining semen parameters. This is hypothesized to be because of its short-acting properties having lesser effect on the HPG axis, in contrast to the long-acting properties of traditional testosterone therapy. It is important to differentiate hypogonadal men between those seeking to achieve or maintain fertility status because the drug therapy of choice differs. This can be accomplished by determining the levels of 17-hydroxyprogesterone (17-OHP), because it is a biomarker for intratesticular testosterone. Those with low 17-OHP may wish to initiate treatment with alternative therapies, whereas those with high 17-OHP may trial short-acting testosterone therapies. As the urologist's armamentarium continues to increase, better strategies to increase testosterone levels in men seeking fertility can be achieved.
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http://dx.doi.org/10.5152/tud.2020.20436DOI Listing
October 2020

USING AUTOMATIC SPEECH RECOGNITION AND SPEECH SYNTHESIS TO IMPROVE THE INTELLIGIBILITY OF COCHLEAR IMPLANT USERS IN REVERBERANT LISTENING ENVIRONMENTS.

Proc IEEE Int Conf Acoust Speech Signal Process 2020 May 14;2020:6929-6933. Epub 2020 May 14.

Department of Electrical and Computer Engineering, Duke University, Durham, NC, USA.

Cochlear implant (CI) users experience substantial difficulties in understanding reverberant speech. A previous study proposed a strategy that leverages automatic speech recognition (ASR) to recognize reverberant speech and speech synthesis to translate the recognized text into anechoic speech. However, the strategy was trained and tested on the same reverberant environment, so it is unknown whether the strategy is robust to unseen environments. Thus, the current study investigated the performance of the previously proposed algorithm in multiple unseen environments. First, an ASR system was trained on anechoic and reverberant speech using different room types. Next, a speech synthesizer was trained to generate speech from the text predicted by the ASR system. Experiments were conducted in normal hearing listeners using vocoded speech, and the results showed that the strategy improved speech intelligibility in previously unseen conditions. These results suggest that the ASR-synthesis strategy can potentially benefit CI users in everyday reverberant environments.
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http://dx.doi.org/10.1109/icassp40776.2020.9054450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568341PMC
May 2020

Short-acting testosterone appears to have lesser effect on male reproductive potential compared to long-acting testosterone in mice.

F S Sci 2020 Aug 14;1(1):46-52. Epub 2020 Apr 14.

Department of Urology, University of Miami Miller School of Medicine, Miami, FL 33136.

Objective: To compare the effect of exogenous short-acting and long-acting testosterone on male reproductive potential in mice.

Design: mouse model.

Setting: University-based basic science research laboratory.

Animals: A total of 30 wild-type C57BL/6 male and female mice were used for this experimentation. The male mice were used for control group and testosterone supplementation, while both male and female mice were used for the breeding portion of the study.

Interventions: Exogenous testosterone was administered either in short-acting formulation (Monday-Wednesday-Friday dosing schedule, testosterone propionate 0.2 mg/kg), or long-acting formulation (3-month dosing schedule - testosterone pellets 150 mg) to male mice.

Main Outcome Measures: Time to pregnancy, Luteinizing hormone (LH) levels, and testicular weight.

Results: Mice treated with long-acting testosterone appear to have longer time to pregnancy when compared to wild-type (33 ± 11 vs 23 ± 2.6 days, p ≤ 0.05) and mice that received short-acting testosterone propionate (26 ± 5.9 days). Mice treated with long-acting testosterone had smaller testes weight when compared to control (0.08 ± 0.01 vs 0.11 ± 0.01g; p ≤ 0.01), while the short-acting testosterone treated mice had similar testis weight when compared to control (0.09 ± 0.02 vs 0.11 ± 0.01g; ns). The serum testosterone level was elevated in mice that received testosterone pellets (285.78 ng/dL) and testosterone propionate (122.16 ng/dL) versus control (68.4 ng/dL). In mice that received long-acting testosterone pellets, LH levels at 3 months were almost undetectable while those that received short-acting testosterone remained similar to control (0.017 ± 0.058 vs 0.348 ± 0.232 IU/L; p ≤ 0.01). Female reproductive potential parameters including litter size and pup weight were collected and observed to have no difference between groups.

Conclusion: Through a mouse breeding study, mice that received short-acting testosterone were shown to have fertility potential similar to wild-type male mice. Long-acting exogenous testosterone appeared to impair male reproductive capacity and LH levels when compared to short-acting testosterone. Short-acting testosterone appeared to cause less LH suppression. Identifying strategies to increase testosterone while simultaneously preserving male fertility is important for treating young men with hypogonadism.
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http://dx.doi.org/10.1016/j.xfss.2020.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480784PMC
August 2020

A Nurse's Advocacy: Finding Meaning Behind the Action.

Authors:
Kevin Chu

Creat Nurs 2020 Aug;26(3):213-214

Through the lens of a nursing student at the very end of his schooling, this article depicts the lengths to which his nursing preceptor will go to care for her patient. The lesson learned serves as a reminder that, while nurses may care for many patients in the course of their careers, each patient brings new knowledge and motivation to care for the next one.
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http://dx.doi.org/10.1891/CRNR-D-19-00046DOI Listing
August 2020

Tailoring the Venous Outflow for a Modified Right Posterior Section Graft in Living Donor Liver Transplantation.

Liver Transpl 2021 02 7;27(2):305-306. Epub 2020 Oct 7.

Division of Liver Transplantation, Department of Surgery, The University of Hong Kong, Hong Kong SAR, China.

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http://dx.doi.org/10.1002/lt.25876DOI Listing
February 2021

Influence of Overcrowding in the Emergency Department on Return Visit within 72 Hours.

J Clin Med 2020 May 9;9(5). Epub 2020 May 9.

Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea.

This study was conducted to determine whether overcrowding in the emergency department (ED) affects the occurrence of a return visit (RV) within 72 hours. The crowding indicator of index visit was the average number of total patients, patients under observation, and boarding patients during the first 1 and 4 hours from ED arrival time and the last 1 h before ED departure. Logistic regression analysis was conducted to determine whether each indicator affects the occurrence of RV and post-RV admission. Of the 87,360 discharged patients, 3743 (4.3%) returned to the ED within 72 hours. Of the crowding indicators pertaining to total patients, the last 1 h significantly affected decrease in RV ( = 0.0046). Boarding patients were found to increase RV occurrence during the first 1 h ( = 0.0146) and 4 hours ( = 0.0326). Crowding indicators that increased the likelihood of admission post-RV were total number of patients during the first 1 h ( = 0.0166) and 4 hours ( = 0.0335) and evaluating patients during the first 1 h ( = 0.0059). Overcrowding in the ED increased the incidence of RV and likelihood of post-RV admission. However, overcrowding at the time of ED departure was related to reduced RV.
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http://dx.doi.org/10.3390/jcm9051406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7290478PMC
May 2020

The pediatric patient and future fertility: optimizing long-term male reproductive health outcomes.

Fertil Steril 2020 03;113(3):489-499

Department of Urology, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Globally, male factor infertility accounts for 20%-70% of couples struggling to conceive. Certain male pediatric developmental conditions, such as cryptorchidism, hypospadias, testicular and other childhood cancers, infections, and pediatric varicocele have been associated with future infertility. Early fertility preservation, especially in those with pending chemotherapy or genetic conditions such as Klinefelter syndrome, should be strongly considered in patients expected to experience testicular loss. Although optimal treatment timing may be unknown owing to a paucity of long-term prospective studies, early diagnosis and targeted treatment may optimize fertility potential in adulthood.
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http://dx.doi.org/10.1016/j.fertnstert.2020.01.003DOI Listing
March 2020

Expanding Indications for Liver Transplant: Tumor and Patient Factors.

Gut Liver 2021 Jan;15(1):19-30

Department of Surgery and State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China.

During the past few decades, liver transplant has developed from a high-mortality procedure to an almost routine procedure with good survival outcomes. The development of living donor liver transplant has increased the availability of liver grafts, and the scope of indications for liver transplant has been expanding ever since. The aim of this review is to provide an overview of such an expansion of scope. Various criteria have been proposed to expand the eligibility of patients with hepatocellular carcinoma exceeding the Milan criteria for liver transplant. Furthermore, liver transplant is increasingly performed as a treatment modality for cholangiocarcinoma, neuroendocrine liver metastasis and colorectal liver metastasis. The number of elderly patients receiving liver transplant is on the rise. Combined organ transplantation has also been adopted to treat patients with multiple organ failure. Going forward, further development of preoperative noninvasive predictors in tumor, patient and even donor factors is needed to identify patients at risk of poor outcomes and hence optimize patient management.
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http://dx.doi.org/10.5009/gnl19265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817931PMC
January 2021

Optical density-based image analysis method for the evaluation of hematoxylin and eosin staining precision.

J Histotechnol 2020 03 23;43(1):29-37. Epub 2020 Jan 23.

GEMpath, Inc, Longmont, CO, USA.

Staining quality and reproducibility are essential factors to monitor laboratory quality assurance. In the last decade, there has been an increase in the use of digital pathology and image analysis. While the adoption of these tools provides a potential means to track staining precision by optical density (OD), it also presents challenges. Results from image analysis are more sensitive to variations in staining than microscopic evaluation by a pathologist. There are two goals with this study. The first was to track the precision of hematoxylin and eosin (H&E) staining, in both nuclear and cytoplasmic components by OD. The second was to determine the impact of different pre-analytical and analytical variables on the OD results. Specifically, the endpoints investigated were quality parameters including impacts of section thickness, protocol manipulation, expired hematoxylin on staining precision and reproducibility of staining over time. Our results show that image analysis of H&E-stained tissue sections is a viable tool for assessing and verifying staining quality. We also show that OD analysis results for H&E-stained sections are affected by changing pre-analytical and/or reagent variables. These authors chose a graphical rather than fully statistical analysis of the results to highlight the utility of visual aids in demonstrating H&E staining reproducibility.
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http://dx.doi.org/10.1080/01478885.2019.1708611DOI Listing
March 2020

General practitioner-type patients in emergency departments in metro North Brisbane, Queensland: A multisite study.

Emerg Med Australas 2020 06 17;32(3):481-488. Epub 2019 Dec 17.

Emergency Department, Redcliffe Hospital, Redcliffe, Queensland, Australia.

Objective: To estimate the proportion of ED patients in urban Queensland who are potentially suitable for general practitioner (GP) care.

Methods: A retrospective analysis was conducted using ED Information System data from Metro North Hospital and Health Service in Brisbane, Australia for three consecutive financial years (2014-2015 to 2016-2017). The hospitals included two Principal Referral and two Public Acute hospitals. GP-type patients were calculated using the Australian Institute of Health and Welfare (AIHW), Australasian College for Emergency Medicine (ACEM) and the validated Sprivulis methods.

Results: Of the 822 841 ED presentations, 219 567 (27%) were potentially GP-type patients by AIHW, 49 307 (6%) by ACEM and 61 836 (8%) by Sprivulis methods. The higher proportion of GP-type presentations were during 08.00 to 17.00 hours by AIHW and ACEM methods. Of the lower-acuity triage categories of 4 (286 154 presentations) and 5 (5658 presentations), AIHW estimated that 62% and 80% of the patients were GP-type patients, as compared to 9% and 22% by ACEM, and 9% and 0.3% by Sprivulis method. The mean costs of adult GP-type patients is $345 by the AIHW and $406 by the ACEM method, lower than non-GP type patients ($706 and $622, respectively).

Conclusions: There is considerable variation in what is considered GP-type ED presentations based on the three methods employed and this variation may have fuelled the debate surrounding what is 'avoidable' ED utilisation. Regardless, the study findings provide an interesting addition to defining and addressing appropriate utilisation of ED services.
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http://dx.doi.org/10.1111/1742-6723.13447DOI Listing
June 2020

Toxin-Triggered Interleukin-1 Receptor Signaling Enables Early-Life Discrimination of Pathogenic versus Commensal Skin Bacteria.

Cell Host Microbe 2019 12 26;26(6):795-809.e5. Epub 2019 Nov 26.

Department of Dermatology, University of California, San Francisco, San Francisco, CA, USA. Electronic address:

The host must develop tolerance to commensal microbes and protective responses to infectious pathogens, yet the mechanisms enabling a privileged relationship with commensals remain largely unknown. Skin colonization by commensal Staphylococcus epidermidis facilitates immune tolerance preferentially in neonates via induction of antigen-specific regulatory T cells (Tregs). Here, we demonstrate that this tolerance is not indiscriminately extended to all bacteria encountered in this early window. Rather, neonatal colonization by Staphylococcus aureus minimally enriches for antigen-specific Tregs and does not prevent skin inflammation upon later-life exposure. S. aureus α-toxin contributes to this response by stimulating myeloid cell production of IL-1β, which limits S. aureus-specific Tregs. Loss of α-toxin or the IL-1 receptor increases Treg enrichment, whereas topical application of IL-1β or α-toxin diminishes tolerogenic responses to S. epidermidis. Thus, the preferential activation of a key alarmin pathway facilitates early discrimination of microbial "foe" from "friend," thereby preventing tolerance to a common skin pathogen.
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http://dx.doi.org/10.1016/j.chom.2019.10.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989301PMC
December 2019

A robotic system for telementoring and training in laparoscopic surgery.

Int J Med Robot 2020 Apr 25;16(2):e2040. Epub 2019 Dec 25.

Mechanical and Aerospace Engineering Department, University of California, Los Angeles, California.

A laparoscopic surgical training system, the LapaRobot, is introduced. The system is composed of an expert station and a trainee station connected through the Internet. Embedded actuators allow the trainee station to be driven by an expert surgeon so that a trainee learns proper technique through physical feedback. The surgical-tool trajectory and video feed can be recorded and later "played back" to a trainee to hone operative skills through guided repetition without the need for expert supervision. The system is designed to create a high-fidelity approximation of the intracorporeal workspace, incorporate commercially available surgical instruments, and provide a wealth of high-resolution data for quantitative analysis and feedback. Experimental evaluation demonstrated a 55% improvement in surgical performance with use of our system. In this paper, we introduce the details of the design and fabrication of the LapaRobot, illustrate the mechatronics and software-control schemes, and evaluate the system in a study.
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http://dx.doi.org/10.1002/rcs.2040DOI Listing
April 2020

The relationship between time to analgesic administration and emergency department length of stay: A retrospective review.

J Adv Nurs 2020 Jan 9;76(1):183-190. Epub 2019 Oct 9.

Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Qld., Australia.

Aim: To determine the association between time to first analgesic medication and emergency department length of stay (ED LOS).

Design: Retrospective cohort study.

Method: We conducted this study in a large, inner-city emergency department and included adult patients who presented with pain as a symptom and received analgesic medication(s). Study participants were identified from a random selection of 2,000 adult patients who presented between August-October 2018. The relationship between ED LOS and time to first analgesic medication was described using bivariate and multivariate linear regression.

Results: Of the 2,000 randomly selected patients presenting between August and October 2018, 727 (36.35%) had pain as a symptom on arrival, 423 (21.15%) had analgesic medication administered. The median time to first analgesic medication was in 62 (interquartile range: 36-105) minutes and median ED LOS was 218 (interquartile range: 160-317.5) minutes. After adjusting for the effects of sex, urgency of the presentation, emergency department location first seen by clinician, departure destination and workload metrics (average daily time to be seen and daily access block). Time to first analgesic medication was independently associated with ED LOS, contributing to 6.96% of the variance in the multivariate model.

Conclusion: Providing analgesic medication faster to patients presenting in pain, in addition to previously demonstrated positive patient outcomes, may decrease their ED LOS.

Impact: Reducing ED LOS through faster pain care, benefits the patient through faster pain relief and can benefit the department by reducing the total amount of care delivered in the emergency department. Reducing total care delivery frees up resources to improve the care to all emergency department patients.
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http://dx.doi.org/10.1111/jan.14216DOI Listing
January 2020

Gaze coordination with strides during walking in the cat.

J Physiol 2019 11 6;597(21):5195-5229. Epub 2019 Oct 6.

Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA.

Key Points: Vision plays a crucial role in guiding locomotion in complex environments, but the coordination between gaze and stride is not well understood. The coordination of gaze shifts, fixations, constant gaze and slow gaze with strides in cats walking on different surfaces were examined. It was found that gaze behaviours are coordinated with strides even when walking on a flat surface in the complete darkness, occurring in a sequential order during different phases of the stride. During walking on complex surfaces, gaze behaviours are typically more tightly coordinated with strides, particularly at faster speeds, only slightly shifting in phase. These findings indicate that the coordination of gaze behaviours with strides is not vision-driven, but is a part of the whole body locomotion synergy; the visual environment and locomotor task modulate it. The results may be relevant to developing diagnostic tools and rehabilitation approaches for patients with locomotor deficits.

Abstract: Vision plays a crucial role in guiding locomotion in complex environments. However, the coordination between the gaze and stride is not well understood. We investigated this coordination in cats walking on a flat surface in darkness or light, along a horizontal ladder and on a pathway with small stones. We recorded vertical and horizontal eye movements and 3-D head movement, and calculated where gaze intersected the walkway. The coordination of gaze shifts away from the animal, gaze shifts toward, fixations, constant gaze, and slow gaze with strides was investigated. We found that even during walking on the flat surface in the darkness, all gaze behaviours were coordinated with strides. Gaze shifts and slow gaze toward started in the beginning of each forelimb's swing and ended in its second half. Fixations peaked throughout the beginning and middle of swing. Gaze shifts away began throughout the second half of swing of each forelimb and ended when both forelimbs were in stance. Constant gaze and slow gaze away occurred in the beginning of stance. However, not every behaviour occurred during every stride. Light had a small effect. The ladder and stones typically increased the coordination and caused gaze behaviours to occur 3% earlier in the cycle. At faster speeds, the coordination was often tighter and some gaze behaviours occurred 2-16% later in the cycle. The findings indicate that the coordination of gaze with strides is not vision-driven, but is a part of the whole body locomotion synergy; the visual environment and locomotor task modulate it.
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http://dx.doi.org/10.1113/JP278108DOI Listing
November 2019

Is the treatment outcome of hepatocellular carcinoma inferior in elderly patients?

World J Gastroenterol 2019 Jul;25(27):3563-3571

Department of Surgery and State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China.

In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such, further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.
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http://dx.doi.org/10.3748/wjg.v25.i27.3563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6658391PMC
July 2019

Artificial Intelligence in Reproductive Urology.

Curr Urol Rep 2019 Jul 29;20(9):52. Epub 2019 Jul 29.

Department of Urology, University of Miami Miller School of Medicine, 1120 NW 14th Street, 15th floor, Miami, FL, 33136, USA.

Purpose Of Review: The promise of artificial intelligence (AI) in medicine has been widely theorized over the past couple of decades. It has only been with technological advances over the past few years that physicians and computer scientists have started discovering its true clinical potential. Reproductive urology is a sub-discipline that AI could be of great contribution, as current predictive models and subjectivity within the field have several limitations. We review the literature to summarize recent AI applications in reproductive urology.

Recent Findings: Early AI applications in reproductive urology focused on predicting semen parameters based on questionnaires that identify potential environmental factors and/or lifestyle habits impacting male fertility. AI has shown success in predicting the patient subpopulation most likely to need a genetic workup for azoospermia. With recent advances in image processing, automated sperm detection is a reality. Semen analyses, once a laboratory-only diagnostic test, have moved into health consumer homes with the advent of AI. AI's prospects in medicine are considerable and there is strong potential for AI within reproductive urology. Research in identifying the factors that can affect reproductive success either naturally or with assisted reproduction is of paramount importance to move the field forward.
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http://dx.doi.org/10.1007/s11934-019-0914-4DOI Listing
July 2019

Clinical Document Classification Using Labeled and Unlabeled Data Across Hospitals.

AMIA Annu Symp Proc 2018 5;2018:545-554. Epub 2018 Dec 5.

Royal Brisbane andWomens Hospital, Brisbane, QLD, Australia.

Reviewing radiology reports in emergency departments is an essential but laborious task. Timely follow-up of patients with abnormal cases in their radiology reports may dramatically affect the patient's outcome, especially if they have been discharged with a different initial diagnosis. Machine learning approaches have been devised to expedite the process and detect the cases that demand instant follow up. However, these approaches require a large amount of labeled data to train reliable predictive models. Preparing such a large dataset, which needs to be manually annotated by health professionals, is costly and time-consuming. This paper investigates a semi-supervised transfer learning framework for radiology report classification across three hospitals. The main goal is to leverage both vastly available clinical unlabeled data and already learned knowledge in order to improve a learning model where limited labeled data is available. Our experimental findings show that (1) convolutional neural networks (CNNs), while being independent of any problem-specific feature engineering, achieve significantly higher effectiveness compared to conventional supervised learning approaches, (2) leveraging unlabeled data in training a CNN-based classifier reduces the dependency on labeled data by more than 50% to reach the same performance of a fully supervised CNN, and (3) transferring the knowledge gained from available labeled data in an external source hospital significantly improves the performance of a semi-supervised CNN model over their fully supervised counterparts in a target hospital.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371298PMC
October 2019

Consideration of gender differences in infertility evaluation.

Curr Opin Urol 2019 05;29(3):267-271

Department of Urology, University of Miami, Miami, Florida, USA.

Purpose Of Review: We aim to provide a review of the literature to summarize the potential causes that lead to a disparity in infertility evaluation and the implications of male factor infertility.

Recent Findings: Owing to current social constructs, women are more likely to seek medical attention and establish reproductive health evaluation at an earlier age. The male factor evaluation in infertility usually gets delayed and can contribute to a couple's inability to conceive. Furthermore, the cost of assisted reproductive technology is not inconsequential and identifying reversible causes of male infertility could lead to substantial cost-savings to the couple. Additionally, male infertility has been identified as a potential early surrogate for adverse health outcomes and an early identification could serve to counsel these patients on lifestyle modification.

Summary: Infertility is defined as the inability to conceive after 12 months of unprotected intercourse with 15% of couples reporting difficulties in conception. Traditionally, female factor evaluation has been the driver for the infertility workup. It is estimated that male factor is likely to play a role in 50% of infertile couples with sole contribution in 20% of cases. It is therefore crucial to ensure appropriate investigations of both partners to rule out potentially reversible causes of infertility to improve their chances of natural fecundity.
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http://dx.doi.org/10.1097/MOU.0000000000000590DOI Listing
May 2019

Factors influencing variation in investigations after a negative CT brain scan in suspected subarachnoid haemorrhage: a qualitative study.

Emerg Med J 2019 Feb 20;36(2):72-77. Epub 2018 Dec 20.

Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.

Introduction: Variation in the approach to the patient with a possible subarachnoid haemorrhage (SAH) has been previously documented. The purpose of this study was to identify factors that influence emergency physicians' decisions about diagnostic testing after a normal CT brain scan for ED patients with a headache suspicious of a SAH.

Methods: We conducted an interview-based qualitative study informed by social constructionist theory. Fifteen emergency physicians from six EDs across Queensland, Australia, underwent individual face-to-face or telephone interviews. Content analysis was performed whereby transcripts were examined and coded independently by two co-investigators, who then jointly agreed on the influencing factors.

Results: Six categories of influencing factors were identified. Patient interaction was at the forefront of the identified factors. This shared decision-making process incorporated 'what the patient wants' but may be biased by how the clinician communicates the benefits and harms of the diagnostic options to the patient. Patient risk profile, practice evidence and guidelines were also important. Other influencing factors included experiential factors of the clinician, consultation with colleagues and external influences where practice location and work processes impose constraints on test ordering external to the preferences of the clinician or patient. The six categories were organised within a conceptual framework comprising four components: the context, the evidence, the experience and the decision.

Conclusions: When clinicians are faced with a diagnostic challenge, such as the workup of a patient with suspected SAH, there are a number of influencing factors that can result in a variation in approach. These need to be considered in approaches to improve the appropriateness and consistency of medical care.
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http://dx.doi.org/10.1136/emermed-2018-207876DOI Listing
February 2019

Emergency ABO-incompatible living donor liver transplant for patients with ultrahigh MELD scores.

Hepatobiliary Pancreat Dis Int 2019 Feb 24;18(1):87-89. Epub 2018 Nov 24.

Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.

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http://dx.doi.org/10.1016/j.hbpd.2018.11.006DOI Listing
February 2019

Adult plant resistance in maize to northern leaf spot is a feature of partial loss-of-function alleles of Hm1.

PLoS Pathog 2018 10 17;14(10):e1007356. Epub 2018 Oct 17.

Department of Botany and Plant Pathology, Purdue University, West Lafayette, Indiana, United States of America.

Adult plant resistance (APR) is an enigmatic phenomenon in which resistance genes are ineffective in protecting seedlings from disease but confer robust resistance at maturity. Maize has multiple cases in which genes confer APR to northern leaf spot, a lethal disease caused by Cochliobolus carbonum race 1 (CCR1). The first identified case of APR in maize is encoded by a hypomorphic allele, Hm1A, at the hm1 locus. In contrast, wild-type alleles of hm1 provide complete protection at all developmental stages and in every part of the maize plant. Hm1 encodes an NADPH-dependent reductase, which inactivates HC-toxin, a key virulence effector of CCR1. Cloning and characterization of Hm1A ruled out differential transcription or translation for its APR phenotype and identified an amino acid substitution that reduced HC-toxin reductase (HCTR) activity. The possibility of a causal relationship between the weak nature of Hm1A and its APR phenotype was confirmed by the generation of two new APR alleles of Hm1 by mutagenesis. The HCTRs encoded by these new APR alleles had undergone relatively conservative missense changes that partially reduced their enzymatic activity similar to HM1A. No difference in accumulation of HCTR was observed between adult and juvenile plants, suggesting that the susceptibility of seedlings derives from a greater need for HCTR activity, not reduced accumulation of the gene product. Conditions and treatments that altered the photosynthetic output of the host had a dramatic effect on resistance imparted by the APR alleles, demonstrating a link between the energetic or metabolic status of the host and disease resistance affected by HC-toxin catabolism by the APR alleles of HCTR.
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http://dx.doi.org/10.1371/journal.ppat.1007356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6205646PMC
October 2018

Incorporating sustainability in small health-care facilities: an integrated model.

Leadersh Health Serv (Bradf Engl) 2018 Oct 10;31(4):441-451. Epub 2018 Apr 10.

Institute of International Business and Governance and Lee Shau Kee School of Business and Administration , The Open University of Hong Kong, Kowloon, Hong Kong.

Purpose It is challenging for small health-care facilities to implement changes when human and financial resources are limited for day-to-day operations. This paper aims to propose an integrated model for small- and medium-sized health-care facilities to integrate sustainability in their day-to-day operations, which have been derived from the leadership and change theories. Design/methodology/approach Drawing on previous research on leadership and change theories, the paper first critically reviewed the approaches to implementing changes and how applicable they are in the context of small- and medium-sized health-care facilities. Next, it proposes an integrated model with an execution plan. Findings The first part of the paper discusses how either the planned approach or emergent approach for change may fail in facilitating the implementation of sustainable initiatives, as incorporating sustainability into operations require both leadership of change and open learning systems. The second part outlines the four-phase combined approach, which includes phases of "exploration", "planning", "action" and "integration", and discusses how change readiness is ensured through such approach. Practical implications The authors propose an integrated model as a framework for integrating sustainability into the operations of small health-care facilities. The clearest possible steps at various phases are proposed. Potential barriers and risks are highlighted and the coping strategies proposed to maximise the chance of successfully transforming organisations. Originality/value Applying the "how to" ideas based on the integrated model for change management will help leaders of health-care facilities gradually integrate sustainability into their day-to-day operations.
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http://dx.doi.org/10.1108/LHS-07-2017-0043DOI Listing
October 2018

Transferability of artificial neural networks for clinical document classification across hospitals: A case study on abnormality detection from radiology reports.

J Biomed Inform 2018 09 17;85:68-79. Epub 2018 Jul 17.

Royal Brisbane and Women's Hospital, Queensland Health, Brisbane, Australia. Electronic address:

Objective: Application of machine learning techniques for automatic and reliable classification of clinical documents have shown promising results. However, machine learning models require abundant training data specific to each target hospital and may not be able to benefit from available labeled data from each of the hospitals due to data variations. Such training data limitations have presented one of the major obstacles for maximising potential application of machine learning approaches in the healthcare domain. We investigated transferability of artificial neural network models across hospitals from different domains representing various age demographic groups (i.e., children, adults, and mixed) in order to cope with such limitations.

Materials And Methods: We explored the transferability of artificial neural networks for clinical document classification. Our case study was to detect abnormalities from limb X-ray reports obtained from the emergency department (ED) of three hospitals within different domains. Different transfer learning scenarios were investigated in order to employ a source hospital's trained model for addressing a target hospital's abnormality detection problem.

Results: A Convolutional Neural Network (CNN) model exhibited the best effectiveness compared to other networks when employing an embedding model trained on a large corpus of clinical documents. Furthermore, CNN models derived from a source hospital outperformed a conventional machine learning approach based on Support Vector Machines (SVM) when applied to a different (target) hospital. These models were further improved by leveraging available training data in target hospitals and outperformed the models that used only the target hospital data with F1-Score of 0.92-0.96 across three hospitals.

Discussion: Our transfer learning model used only simple vector representations of documents without any task-specific feature engineering. Transferring the CNN model significantly improved (approx.10% in F1-Score) the state-of-the-art approach for clinical document classification based on a trivial transferred model. In addition, the results showed that transfer learning techniques can further improve a CNN model that is trained only on either a source or target hospital's data.

Conclusion: Transferring a pre-trained CNN model generated in one hospital to another facilitates application of machine learning approaches that alleviate both hospital-specific feature engineering and training data.
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http://dx.doi.org/10.1016/j.jbi.2018.07.017DOI Listing
September 2018