Patient Understanding and Perception of Urology Resident Training, Role, and Capabilities.

INTRODUCTION: We sought to identify patient understanding of urology residents and comfort with being cared for by residents. Through this pilot study, we aim to propose educational objectives to improve this knowledge gap and ultimately allow for an improved patient experience. METHODS: A prospective survey was distributed from September 2022 to October 2022. A patient knowledge about residents (KAR) score was calculated by combining correct responses to 5 questions (maximum = 5). Another score evaluating patient opinion of residents was calculated using Likert scale questions (range 3-19; higher scores correlate with positive opinion) denoting patient outlook on residents. RESULTS: A total of 88 surveys were completed. The average ± SD patient age was 62.7 ± 15.2 years. Patients previously seen by a resident had significantly higher KAR scores (3.591 ± 1.210) compared to patients never interacting with a resident or unsure (KAR = 2.381 ± 1.324; P < .0001). Additionally, those with higher levels of education had greater KAR scores (graduate-level KAR = 3.792 ± 1.179; P = .002). No variables were found to have a statistically significant impact on patients' average opinion of residents. CONCLUSIONS: Current patient understanding of the role of a urology resident is suboptimal. Given this knowledge gap, we hope to propose educational approaches to help aid in patient understanding of resident physicians, who play a critical role in their clinical care.

Disparities in insurance status negatively affect patients with infantile hypertrophic pyloric stenosis.

PURPOSE: Infantile hypertrophic pyloric stenosis (IHPS) is suspected to have worse outcomes when length of illness prior to presentation is prolonged. Our objective was to evaluate how social determinants of health influence medical care and outcomes for babies with IHPS. METHODS: A retrospective review was performed over 10 years. Census data were used as proxy for socioeconomic status via Geo-Identification codes and correlated with food access and social vulnerability variables. The cohort was subdivided to understand the impact of Medicaid Managed Care (MMC). RESULTS: The cohort (279 cases) was divided into two groups; early group from 2011 to 2015 and late from 2016 to 2021. Cases in the late group were older at the time of presentation (41.5 vs. 36.5 days; p = 0.022) and presented later in the disease course (12.8 vs. 8.9 days; p = 0.021). There was no difference in race (p = 0.282), gender (p = 0.874), or length of stay. CONCLUSIONS: Patients who presented with IHPS after implementation of phased MMC were older, had a longer symptomatic course, and shorter pylorus measurements. Patients with public insurance after the implementation of MMC were more likely to follow-up with an outpatient pediatrician within a month of hospitalization. These results suggest that MMC may have improved access to care for infants with IHPS.

Single port (SP) robotic pyeloplasty in a pediatric patient.

We began using the da Vinci single port (SP) robot for pediatric urologic surgeries at our institution due to limited access to the multiport robot. Availability of this technology has allowed us to schedule cases in a timelier fashion and increase access to minimally invasive urologic surgery for children in our area. Here, we report our technique for transperitoneal SP robotic pyeloplasty in the case of a 7 year-old boy with left ureteropelvic junction obstruction. Our technique was refined over a series of 10 patients under the age of 18. Highlights of the SP RALP technique include one 3 cm, concealed incision over the pubic tubercle, gentle frog leg positioning and burping of the boom to create optimal angle for robotic docking, and use of a "floating dock" to obtain 10 cm distance from target anatomy which is essential in smaller pediatric patients. SP pyeloplasty is safe and feasible in children and offers a concealed single incision alternative to the multiport approach.

Bilateral proximal ureteral and ureterovesical junction obstruction in a child.

The most common sites of ureteral obstruction in children are at the level of the ureteropelvic junction (UPJ) and ureterovesical junction (UVJ). Bilateral hydronephrosis or hydroureteronephrosis due to varying degrees of obstruction at the UPJ or UVJ is common in children and typically improves with time. Clinically significant obstruction at both locations in an ipsilateral ureter occurs less commonly and rarely requires both dismembered pyeloplasty and ureteral reimplantation. We believe this case report is the first description of bilateral proximal and distal ureteral obstruction requiring both dismembered pyeloplasty and ureteral reimplantation.

Clinical Considerations for Patients Experiencing Acute Kidney Injury Following Percutaneous Nephrolithotomy.

Acute kidney injury (AKI) is a common postoperative outcome in urology patients undergoing surgery for nephrolithiasis. The objective of this study was to determine the prevalence of postoperative AKI and its degrees of severity, identify risk factors, and understand the resultant outcomes of AKI in patients with nephrolithiasis undergoing percutaneous nephrolithotomy (PCNL). A cohort of patients admitted between 2012 and 2019 to a single tertiary-care institution who had undergone PCNL was retrospectively analyzed. Among 417 (n = 326 patients) encounters, 24.9% (n = 104) had AKI. Approximately one-quarter of AKI patients (n = 18) progressed to Stage 2 or higher AKI. Hypertension, peripheral vascular disease, chronic kidney disease, and chronic anemia were significant risk factors of post-PCNL AKI. Corticosteroids and antifungals were associated with increased odds of AKI. Cardiovascular, neurologic complications, sepsis, and prolonged intensive care unit (ICU) stay percentages were higher in AKI patients. Hospital and ICU length of stay was greater in the AKI group. Provided the limited literature regarding postoperative AKI following PCNL, and the detriment that AKI can have on clinical outcomes, it is important to continue studying this topic to better understand how to optimize patient care to address patient- and procedure-specific risk factors.

A Case Report of Culture-Negative Necrotizing Fasciitis With Low Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score: A Diagnostic Dilemma.

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is a diagnostic tool used to help clinicians identify necrotizing fasciitis (NF) in its early stages. This tool uses six laboratory values including the patient's white blood cell count, C-reactive protein level, serum sodium level, creatinine level, and hemoglobin level to help with risk stratification. Each of these laboratory values is assigned a point value and the total score is used to determine the likelihood that a patient has NF, with a score of 6 or higher considered to be strongly indicative. The LRINEC score has gained popularity in recent years, having been included in guidelines and society recommendations for the management of NF. However, some studies have challenged the validity of the LRINEC score. Prompt and accurate diagnosis of NF is imperative given the associated mortality rate, which can be as high as 30%-40%, especially if the diagnosis is delayed. We present a case of a patient with a delayed diagnosis of NF that was initially missed in the early stages in the setting of a low LRINEC, however, growing clinical suspicion eventually led to an accurate diagnosis and management.

Acute Bacterial Sinusitis With Epidural and Subdural Involvement.

Sinusitis is a common childhood infection with potential for rare intracranial complications. These neurologic sequelae can lead to serious morbidity and mortality if not addressed promptly. We describe a case of suspected sinusitis in a 13-year-old male complicated by a superior sagittal sinus thrombosis along with subdural and epidural empyemas.

Autonomic development in preterm infants is associated with morbidity of prematurity.

BACKGROUND: Previous studies have described an association between preterm birth and maturation of the autonomic nervous system (ANS); however, this may be impacted by multiple factors, including prematurity-related complications. Our aim was to evaluate for the effect of prematurity-related morbidity on ANS development in preterm infants in the NICU. METHODS: We compared time and frequency domains of heart rate variability (HRV) as a measure of ANS tone in 56 preterm infants from 2 NICUs (28 from each). One cohort was from a high-morbidity regional referral NICU, the other from a community-based inborn NICU with low prematurity-related morbidity. Propensity score matching was used to balance the groups by a 1:1 nearest neighbor design. ANS tone was analyzed. RESULTS: The two cohorts showed parallel maturational trajectory of the alpha 1 time-domain metric, with the cohort from the high-morbidity NICU having lower autonomic tone. The maturational trajectories between the two cohorts differed in all other time-domain metrics (alpha 2, RMS1, RMS2). There was no difference between groups by frequency-domain metrics. CONCLUSIONS: Prematurity-associated morbidities correlate with autonomic development in premature infants and may have a greater impact on the extrauterine maturation of this system than birth gestational age. IMPACT: Autonomic nervous system development measured by time-domain metrics of heart rate variability correlate with morbidities associated with premature birth. This study builds upon our previously published work that showed that development of autonomic tone was not impacted by gestational age at birth. This study adds to our understanding of autonomic nervous system development in a preterm extrauterine environment. Our study suggests that gestational age at birth may have less impact on autonomic nervous system development than previously thought.

The effect of unilateral stroke on autonomic function in the term newborn.

BACKGROUND: The mature cerebral cortex has a topographically organized influence on reflex autonomic centers of the brainstem and diencephalon and sympathetic activation coming primarily from the right hemisphere and parasympathetic activation from the left. In the term newborn, the maturational status of this central autonomic system remains poorly understood. METHODS: Sixteen term newborns admitted to Children's National with unilateral middle cerebral artery (MCA) strokes (n = 8 left, n = 8 right) had archived continuous electrocardiograph (EKG) signals available. We compared stroke laterality and severity with indices of autonomic function, as measured by heart rate variability. We performed both time- and frequency-domain analyses on the R-R interval (RRi) over 24h of continuous EKG data at around 7 days of age. RESULTS: Right MCA stroke significantly increased sympathetic tone, while left MCA stroke increased parasympathetic tone. Regardless of laterality, stroke severity was associated inversely with sympathetic tone and positively with parasympathetic tone. Surprisingly, injury to either insular region had no significant autonomic effect. Phenobarbital blood levels were positively associated with sympathetic tone and inversely related to parasympathetic tone. CONCLUSION: Based on these findings, it is difficult to reconcile the functional topography of the central autonomic system in term newborns with that currently proposed for the normal mature brain. Further investigation is clearly needed.

The recent evolution of the breadth of practice for pediatric surgeons in the United States, 2005-2014.

PURPOSE: Our objective was to determine if there was an association between subspecialist supply and a specific sub-set of procedures performed by pediatric surgeons over a 10-year period. METHODS: Data source was the Pediatric Health Information Systems database. Included were patients < 12 years who underwent one of nine outpatient surgical procedures between 1/1/2005 and 12/31/2014. Procedures were grouped into categories: pediatric surgery cases (PS), overlapping otolaryngology cases (OO), and overlapping urology cases (OU). Outcomes were number of cases performed by pediatric surgeons per pediatric surgeon, and proportion of cases performed by pediatric surgeons. Linear regression was used to test for association and temporal trends. RESULTS: Included were 193,695 procedures, 18.9% PS, 4.8% OO, and 76.3% OU. There was a strong association between specialty supply and number of cases performed by pediatric surgeons. Temporally, there was no change in proportion of pediatric surgeons who performed PS cases (R2 = 0.08, p = 0.08), but a downward trend in proportion of OO (R2 = 0.82, p < 0.001) and OU cases. (R2 = 0.79; p < 0.001.) CONCLUSION: We found an association between physician supply and pediatric surgeon case type, and a reduction in OO and OU cases performed by pediatric surgeons. These findings suggest a narrowing of case-mix for pediatric surgeons.