Within State Variability of Antimicrobial Susceptibility: Missouri as an Archetype to Assess Guidelines for Antimicrobial Prophylaxis for Transurethral Procedures.

OBJECTIVE: To evaluate variability among hospitals in susceptibility of common uropathogens to antimicrobial agents frequently used in transurethral procedures in order to examine whether state-based guidelines might be more appropriate than national prophylactic guidelines. METHODS: Hospital-level antibiograms were requested from all hospitals throughout the state of Missouri. We studied Escherichia coli, Klebsiella, and Proteus sensitivities to evaluate common guideline recommended antimicrobials including trimethoprim sulfamethoxazole (TMP-SMX), third-generation cephalosporins, cefazolin, penicillin combinations, gentamicin, and fluoroquinolones. We evaluated variability and association between hospital characteristics and antimicrobial sensitivities. RESULTS: Data was requested from 81 hospitals across the state and 38 provided the requested data (47% response rate). Susceptibility was highest for third-generation cephalosporins for E. coli (mean of 94%), Proteus (96%), and Klebsiella (96%). Gentamicin also had high susceptibility for the bacteria studied; 94% for E. coli and 96% for Klebsiella. Current first line recommended agents showed more modest coverage for E. coli (cefazolin 84%, TMP-SMX 78%), Proteus (cefazolin 82%, TMP-SMX 71%), and Klebsiella (cefazolin 90%, TMP-SMX 89%). CONCLUSION: Post transurethral procedure infections are common. Rates can be limited with appropriate prophylaxis. Deciding on empirical coverage must take into account local resistance patterns. There is substantial variability among and within states in antimicrobial susceptibility for common uropathogens. When selecting antimicrobial prophylaxis, urologists should consider local- rather than state- or nation-level antibiograms, given the considerable variability. Future studies should consider the merits of very-broad spectrum prophylaxis and the potential role of molecular urinary pathogen (and pathogen-resistance) testing when selecting an optimal regimen.

Healthcare Workers' Perceptions of On-Site Childcare.

GOAL: Measures taken by healthcare organizations to address COVID-19 highlighted the long-standing lack of childcare infrastructure required to support healthcare workers. This study, designed to provide evidence to support operations at an academic medical center, looked at the influence that in-house and emergency childcare could have on the retention, recruitment, and productivity of healthcare workers. This study also outlined the implications that childcare, or its lack, has for healthcare organizations during and after the COVID-19 pandemic. METHODS: We conducted a 35-question electronic employee survey (under institutional review board approval) during pandemic-induced public school closures, which included both quantitative and qualitative (write-in) questions. PRINCIPAL FINDINGS: The survey results showed that weekday on-site childcare was very or extremely important to more than half of survey respondents, the majority of whom were staff members (28%) or physicians (25%), followed by administrators (15%), researchers (12%), others (10%), nurses (5%), educators (2%), and residents (1%). Sixty percent of respondents reported that emergency on-site childcare was extremely important (34%) or very important (26%). Almost half (49%) reported that emergency childcare needs have disrupted their work in the past year, including canceling of clinics or surgical cases. Analysis of qualitative comments via a strategy based on coding and categorization showed that, when asked how childcare influences their work choices, employees responded that childcare availability has limited the hours or times they could work, that lack of childcare has prevented career growth, that they left a previous job or will leave their current job because of childcare needs, or that they stayed at a previous job or have remained in their current job longer because of the availability of childcare. PRACTICAL APPLICATIONS: Although data from this mixed-methods study support findings in the literature that there is a need for in-house and emergency childcare, the data suggest that current employees at this academic medical center do not currently expect it, likely because such childcare is not generally available at most academic institutions. With increased rates of burnout and healthcare workers leaving the field since COVID-19, offering in-house and emergency childcare provides hospital systems with new opportunities to retain and recruit physicians, nurses, and staff, as well as to improve their well-being and productivity.

Antimicrobial Selection for Transurethral Procedures Across the United States: A State-by-State Antibiogram Evaluation.

OBJECTIVE: To evaluate optimal regimens for perioperative antimicrobial prophylaxis in transurethral procedures by examining antimicrobial susceptibility patterns in the United States. MATERIALS AND METHODS: Through several methods, we attempted to attain an antibiogram for each state. We focused on microbes known to cause infections after transurethral surgeries and antibiotics referred to in current or prior recommendations and compared susceptibility rates across states using Kruskal Walis tests and the Dwass, Steel, Critchlow-Fligner tests. We also examined susceptibility to (non-ceftazidime) third generation cephalosporins. RESULTS: Data is included from 40 states. For each microbe studied, there was significant variability in sensitivity to antibiotics studied. Current first line recommendations for antimicrobial prophylaxis include first generation cephalosporins with 82%, 80%, and 87% mean coverage for E coli, Proteus, and Klebsiella respectively and trimethoprim-sulfamethoxazole with 74%, 80%, and 93% coverage, respectively. Susceptibility to aminoglycosides is 91%, 92%, and 96%, respectively and to third generation cephalosporin, it is 92%, 99%, and 94%. CONCLUSION: Current first line recommended antimicrobials for prophylaxis in transurethral procedures provide overall poor predicted coverage based on our database of antibiograms. Alternatives exist that have higher predicted susceptibility, though clinical significance of this and risk of resultant antimicrobial resistance is unknown. Urologists should consider local patterns when selecting antimicrobial prophylaxis for their patients.

Patient and Provider Satisfaction With Pediatric Urology Telemedicine Clinic.

The use of telemedicine continues to grow as more patients are receptive to this innovative way of providing health care. Multiple publications in telemedicine indicated high satisfaction for this service. This study focuses on the use of telemedicine in a pediatric urology clinic and examines 3 research questions: (1) How did patients' parents/guardians feel about their video appointments? (2) What were the experiences of novice telemedicine providers conducting postsurgical appointments via video? and (3) How did novice telemedicine providers' experiences compare to those of expert telemedicine providers?

A qualitative study of parental preferences for postcircumcision care education.

INTRODUCTIONR/BACKGROUND: Although uncommon, complications associated with newborn male circumcision may require costly and emotionally upsetting surgical revisions. Improvements in parental education regarding postcircumcision care may reduce preventable complications; however, little is known about parents' preferences for education of this type. OBJECTIVE: The authors sought to describe parents' preferences regarding the content and delivery of education on postcircumcision care as a first step toward improving parental education and ultimately reducing the need for surgical revisions. STUDY DESIGN: The authors conducted a qualitative, descriptive study, collecting data from 14 parents during two separate focus group discussions. The authors applied thematic analysis techniques to analyze the transcribed content of both groups. RESULTS: Parents indicated that postcircumcision care instructions should be detailed and include clear images and/or an actual demonstration of care processes. Despite being aware of the low likelihood of complications, parents expressed a preference for providers who took education seriously rather than those approaching it with a 'cavalier attitude.' There was widespread support for delivering education at a time that met each family's unique circumstances and needs. DISCUSSION: Consistent with prior research, parents in this study identified gaps in understanding postprocedure care instructions. However, this study adds to the literature in highlighting the specific concerns and preferences of parents with regard to the content and delivery of postcircumcision care education. Based on these findings, the authors conclude that healthcare teams should ensure that parents have access to detailed instructions for postcircumcision care. Education of parents should occur at times when they are able to pay attention and should be supplemented with materials that they can easily access from home. Pediatric urologists can play a leading role in the development and dissemination of high-quality, family-centered educational materials to both parents and providers in other specialty areas that perform high volumes of newborn circumcision. Future research would benefit from larger, more diverse samples. In addition, future studies investigating the effect of parental education on potentially avoidable complications are needed to maximize clinical impact. CONCLUSION: Parents readily provided detailed input into what they perceived as much-needed improvements in postcircumcision care education. Future research is needed to determine what effect, if any, such changes would have on the incidence of preventable complications, particularly those requiring surgical intervention.

Propranolol as an effective therapy for infantile haemangioma of the urinary bladder.

Infantile haemangiomas are one of the most common tumours in infancy, but typically present as cutaneous lesions; haemangiomas of the urinary bladder are incredibly rare. Although benign, these can sometimes ulcerate and bleed, causing haematuria in the case of bladder lesions. Propranolol is a well-documented medical therapy for cutaneous lesions, but surgical treatment dominates the literature on bladder haemangiomas. We present the case of a child with infantile haemangiomas of the urinary bladder, as well as internal and cutaneous lesions, treated with propranolol. At 6-week follow-up cystoscopy and MRI, there was a significant improvement in both bladder and internal lesions, respectively. Follow-up with dermatology 9 months after initiation of propranolol demonstrated excellent regression of the cutaneous lesions with a marked decrease in both size and prominence. This case demonstrates the potential role of propranolol in the treatment of bladder haemangiomas in lieu of more invasive surgical techniques.

The Effect of Handcycle Ergometer Exercise on Glucose Tolerance in Ambulatory and Non-Ambulatory Adolescents.

PURPOSE: Whole body or leg exercise before a meal can increase insulin sensitivity, but it is unclear whether the same can occur with upper body exercise since a smaller muscle mass is activated. We measured the impact of a single session of handcycle exercise on glucose tolerance and insulin sensitivity. METHODS: Nonambulatory (Non-Amb) adolescents with spina bifida or cerebral palsy (4F/3M), or ambulatory peers (Control, 4F/7M) completed 2 glucose tolerance tests on separate days, preceded by either rest or a 35-min bout of moderate-to-vigorous intermittent handcycle exercise. RESULTS: The Non-Amb group had higher body fat (mean ± SD: 38 ± 12%, Control: 24 ± 9, p = .041) but similar VO2peak (17.7 ± 6.1 ml/kg/min, Control: 21.1 ± 7.9). Fasting glucose and insulin were normal for all participants. Compared with the rest trial, exercise resulted in a reduction in glucose area under the curve (11%, p = .008) without a significant group x trial interaction and no difference in the magnitude of change between groups. Insulin sensitivity was increased 16% (p = .028) by exercise in the Control group but was not significantly changed in the Non-Amb group. CONCLUSION: A single bout of handcycle exercise improves glucose tolerance in adolescents with and without mobility limitations and could therefore help maintain or improve metabolic health.

Reliance of preoperative scrotal examination versus final operative findings in the evaluation of non-palpable testes.

OBJECTIVE: The current study evaluates whether the preoperative scrotal examination in children with non-palpable testes is sufficient in all cases or if laparoscopy is necessary to confirm the examination findings. Are the findings different amongst physicians depending on their level of experience? MATERIALS AND METHODS: This retrospective study was done between October 2009 and May 2013. Children with non-palpable testes underwent an examination under anesthesia prior to surgery to feel for a testis or nubbin, followed by a diagnostic laparoscopy to validate the scrotal examination. The test was considered correct if the laparoscopic findings supported the scrotal examination. It was considered incorrect if laparoscopy revealed a different finding. RESULTS: A total of 74 testes were evaluated. All patients underwent examination under anesthesia by the surgeon and senior resident. The findings were recorded separately. Despite careful examination by experienced surgeons under anesthesia, the scrotal examination was incorrect in 14 patients. Four viable testes would have been missed if laparoscopy had not been performed. CONCLUSION: Laparoscopy should be considered in case of palpable scrotal nubbins to ensure no testis is left within the abdominal cavity.

Mental health and parenting characteristics of caregivers of children with spina bifida.

INTRODUCTION: Within the chronic medical illness literature, associations exist between caring for an affected child and parent mental health. The few studies examining both mothers and fathers provide mixed results. The purpose of this study is to examine associations between caregiver anxiety, depression, and parenting variables in caregivers of youth with SB as these relate to marital status, age, education, household income, work status, and child's severity of SB. OBJECTIVE: The aim of this study is to examine associations between anxiety, depression, and parenting variables in caregivers of youth with spina bifida and how they relate to demographic and disease variables. Exploratory analyses examined the relationship between participation in support activities and depressive and anxious symptomatology and parenting characteristics. STUDY DESIGN: Eighty-four primary caregivers (49 mothers) of 51 youth with spina bifida completed measures of depressive and anxious symptomology, parenting stress, parent overprotection, and perceived child vulnerability. RESULTS: There were differences between mothers and fathers on several parenting characteristics; however, these were related more to marital status and employment than to gender of the caretaker per se. In the 33 married/remarried couples for whom both spouses participated, stress for the mothers was correlated with stress for the fathers. This correlation was strongest in the 12 married couples in which the mother works. Higher perceived vulnerability scores were reported in parents of SB patients in the younger age group, especially preschoolers (0-4 years). Parents of children with shunts reported more anxiety, depression and perceived child vulnerability. Both male and female caregivers of younger children reported significantly higher protectiveness scores. Involvement in recreational activities with other families affected by SB was associated with more positive parenting characteristics for mothers. DISCUSSION: Stress and protectiveness were found to be positively correlated (r > 0.6); depression, anxiety, and perceived vulnerability were not (0.3 < r < -0.3). Overall, mothers reported more stress and anxiety than fathers. Higher perceived vulnerability scores were reported in parents of SB patients in the younger age group, especially preschoolers (0-4 years). Parents of children with shunts reported more anxiety, depression and perceived child vulnerability. Both male and female caregivers of younger children reported significantly higher protectiveness scores compared to caregivers of older children. Involvement in recreational activities with other families affected by SB was associated with more positive parenting characteristics for mothers. There were differences between mothers and fathers on several parenting characteristics; however, these were related more to marital status and employment than to gender of the caretaker per se. Limitations to the current study qualify our results and conclusions. Associations do not prove causation. Our measure of parent protection had a lower Cronbach's alpha score for male caregivers (0.68) than female caregivers (0.83), consistent with an examination of the factor structure of the PPS that found the measure to have a poor factor structure and limited reliability in samples with a chronic medical condition. CONCLUSION: Anxiety, depression, and parenting characteristics were differentially impacted by variables such as caregiver and child age, shunt status, and employment status/income for parents of youth with SB. Interventions to improve parenting skills and mental health of these caregivers can be designed to target specific needs of parents. Groups such as the Greater Oklahoma Disabled Sports Association (GODSA) offer real-world support to improve the lives of caregivers of SB children, and should be studied further to optimize outcomes for children.

Efficacy of transcutaneous electrical nerve stimulation in children with overactive bladder refractory to pharmacotherapy.

OBJECTIVES: To examine the outcome of transcutaneous electrical nerve stimulation (TENS) use in children with overactive bladder refractory to behavioral and anticholinergic therapy. METHODS: We reviewed the data of 18 children (13 girls and 5 boys; mean age 9 years) with overactive bladder refractory to standard therapy who underwent at-home TENS treatment twice daily for 20 minutes. Symptoms and objective measures (noninvasive uroflowmetry and postvoid residual urine volume) were noted at baseline and after treatment. RESULTS: Of the 18 children, 15 had pretreatment incontinence and 3 had only increased urgency/frequency. The incontinence group averaged 3.2 +/- 2.1 daytime accidents. The mean length of TENS use was 8 +/- 7 months, and the mean follow-up after starting TENS was 13 +/- 9 months. Of the 15 patients with incontinence, 2 became dry (13%), 9 were significantly improved (60%), and 4 reported no improvement (27%). Of 12 children with marked urinary frequency, 8 had significant symptom improvement. Noninvasive uroflow and postvoid residual urine volume measurements were not significantly different statistically before and after treatment. Pretreatment patient sex, age, and frequency of wetting were not predictive of the outcome. A post-TENS parabolic uroflow curve showed a statistically significant correlation with patients who became dry or improved (P = 0.018). CONCLUSIONS: The results of our study have indicated that TENS use in children with incontinence refractory to pharmacotherapy is safe and well tolerated. The encouraging results of this treatment modality in the refractory patient population warrant additional study of the pediatric overactive bladder.