A traumatic enterorenal fistula.

Enterorenal fistulas can arise from various spontaneous and traumatic etiologies. While nephrectomy is frequently the treatment of choice, renal sparing techniques have been described. We report a case of an enterorenal fistula as a complication of penetrating trauma. The fistula was managed conservatively with only ureteral stenting.

The Treatment of Genitoperineal Hidradenitis Suppurativa: A Review of the Literature.

Hidradenitis suppurativa is a chronic inflammatory condition affecting the axilla, genitals, perineum, and perianal regions. The pathophysiology of hidradenitis suppurativa is complex and requires a multidisciplinary approach to treatment involving medical and surgical management when indicated. We describe our multidisciplinary protocol for treatment, which includes rheumatology-monitored immunotherapy, medical management, wide surgical resection, wound care, and reconstruction. The multidisciplinary care team includes rheumatology, wound care, and reconstructive urologic surgery. Surgical management includes wide local surgical resection, negative pressure dressing, delayed reconstruction, and perioperative immunotherapy. Multimodal treatment with surgical, medical, wound, and immunotherapy care is vital to successful treatment.

An update on urotrauma.

PURPOSE OF REVIEW: The subject of genitourinary trauma was recently reviewed as an American Urologic Association guideline as well as recently updated as a European Association of Urology guideline. These guidelines, while complete and authoritative, deserve review, amplification and clarification. Also, notably absent from the guidelines is a section on the management of renovascular injuries, which will be reviewed here. RECENT FINDINGS: In the 2014, the American Urologic Association and updated European Association of Urology guidelines were published with highlighted features or changes described here. SUMMARY: We report the updated features of the guidelines as well as sections of update from our own experiences in which the guidelines remain vague or are absent.

Associations between healthcare quality and use of electronic health record functions in ambulatory care.

OBJECTIVES: Contemporary electronic health records (EHRs) offer a wide variety of features, creating opportunities to influence healthcare quality in different ways. This study was designed to assess the relationship between physician use of individual EHR functions and healthcare quality. MATERIALS AND METHODS: Sixty-five providers eligible for "meaningful use" were included. Data were abstracted from office visit records during the study timeframe (183 095 visits with 61 977 patients). Three EHR functions were considered potential predictors: acceptance of best practice alerts, use of order sets, and viewing panel-level reports. Eighteen clinical quality measures from the "meaningful use" program were abstracted. RESULTS: Use of condition-specific best-practice alerts and order sets was associated with better scores on clinical quality measures capturing processes in diabetes, cancer screening, tobacco cessation, and pneumonia vaccination. For example, providers above the median in use of tobacco-related alerts had higher performance on tobacco cessation intervention metrics (median 80.6% vs. 66.7%; P < .001), and providers above the median in use of diabetes order sets had higher quality on diabetes low density lipoprotein (LDL) testing (68.2% vs. 59.5%; P == .001). Post hoc examination of the results showed that the positive associations were with measures of healthcare processes (such as rates of LDL testing), whereas there were no positive associations with measures of healthcare outcomes (such as LDL levels). DISCUSSION: Among primary care providers in the ambulatory setting using a single EHR, intensive use of certain EHR functions was associated with increased adherence to recommended care as measured by performance on electronically reported "meaningful use" quality measures. This study is relevant to current policy as it uses quality metrics constructed by contemporary certified EHR technology, and quantitative EHR use metrics rather than self-reported use. CONCLUSION: In the early stages of the "meaningful use" program, use of specific EHR functions was associated with higher performance on healthcare process metrics.

Smartphone Data in Rheumatoid Arthritis - What Do Rheumatologists Want?

OBJECTIVE: To create a relevant and clinically informative visualization of passively collected patient mobility data from smartphones of rheumatoid arthritis (RA) patients for rheumatologists. METHODS: (1) Pilot analysis of smartphone mobility data in RA; (2) Assessment of rheumatologists' needs for patient data through semi-structured interviews; and (3) Evaluation of the visual format of the RA data using scenario-based usability methods. RESULTS: We created a color-scale mobility index superimposed on a calendar to summarize the passive mobility measures from the smartphone that the rheumatologists confirmed would be clinically relevant. CONCLUSION: This assessment of clinician data needs and preferences demonstrates the potential value of passively collected smartphone data to resolve an important data question in RA. Efforts such as these are necessary to ensure that any smartphone data that patients share with their doctors will not exacerbate clinician information overload, but actually facilitate clinical decisions.

Pro: endoscopic realignment for pelvic fracture urethral injuries.

Patients with pelvic fracture urethral distraction injuries may benefit from early endoscopic realignment. Realignment is associated with a low risk of immediate complications and has a high success rate for achieving catheter placement. Review of over thirty studies assessing for subsequent urethral stenosis, including at least a dozen that directly compare realignment to suprapubic diversion along, conclude that there is a benefit averaging at least 35% in favor of realignment. Furthermore, realignment may result in easier subsequent urethroplasty and possibly shorter stenoses.

Concurrent Testicular and Bladder Cancer in a 57-year-old Man.

We present a rare finding of concurrent right testis non-seminomatous mixed germ cell tumor and muscle invasive urothelial carcinoma of the bladder in a 57-year-old homeless man. The socioeconomic factors and the disease presentation caused a treatment dilemma in terms of the appropriate type of neoadjuvant chemotherapy. The patient ultimately underwent upfront surgery with retroperitoneal lymph node dissection and radical cystoprostatectomy followed by adjuvant cisplatin-based chemotherapy.

Fertility Preservation Preferences and Perspectives Among Adult Male Survivors of Pediatric Cancer and Their Parents.

Purpose: In this study, we set out to determine the preferences, concerns, and attitudes toward fertility preservation of adult male survivors of pediatric cancer and their parents. Methods: We conducted 3 focus groups with a total of 15 male survivors of pediatric cancer (age at diagnosis: mean=14, range: 10-20; age at study: mean=35, range: 25-47) and 2 groups with a total of 7 parents of survivors. Grounded theory methodology was used for the identification and analysis of recurrent themes expressed by survivors and their parents in the course of focus group discussions. Results: Themes most frequently expressed by survivors included concern regarding long-term treatment effects and a retrospective desire for fertility impairment to have been discussed when they were originally diagnosed with cancer. Parental themes included the same hindsight desire, as well as reliance upon the treating oncologist for direction in selecting the course of treatment, and an acknowledgment that input from a specialist in fertility preservation would have been beneficial. Conclusions: Although future reproductive potential was not consistently reported as a source of apprehension when diagnosed with cancer, both survivors and their parents noted it to be a paramount concern later in life. Parents and survivors both reported that fertility preservation discussions should be routinely incorporated in the clinical context of a pediatric cancer diagnosis.

How is the electronic health record being used? Use of EHR data to assess physician-level variability in technology use.

BACKGROUND: Studies of the effects of electronic health records (EHRs) have had mixed findings, which may be attributable to unmeasured confounders such as individual variability in use of EHR features. OBJECTIVE: To capture physician-level variations in use of EHR features, associations with other predictors, and usage intensity over time. METHODS: Retrospective cohort study of primary care providers eligible for meaningful use at a network of federally qualified health centers, using commercial EHR data from January 2010 through June 2013, a period during which the organization was preparing for and in the early stages of meaningful use. RESULTS: Data were analyzed for 112 physicians and nurse practitioners, consisting of 430,803 encounters with 99,649 patients. EHR usage metrics were developed to capture how providers accessed and added to patient data (eg, problem list updates), used clinical decision support (eg, responses to alerts), communicated (eg, printing after-visit summaries), and used panel management options (eg, viewed panel reports). Provider-level variability was high: for example, the annual average proportion of encounters with problem lists updated ranged from 5% to 60% per provider. Some metrics were associated with provider, patient, or encounter characteristics. For example, problem list updates were more likely for new patients than established ones, and alert acceptance was negatively correlated with alert frequency. CONCLUSIONS: Providers using the same EHR developed personalized patterns of use of EHR features. We conclude that physician-level usage of EHR features may be a valuable additional predictor in research on the effects of EHRs on healthcare quality and costs.

Erectile function in men with failed hypospadias repair.

OBJECTIVES: While efforts have been made to study erectile function in patients with urethral stricture, very few prior investigations have specifically assessed erectile function in men with failed hypospadias surgery. We set forth to assess the baseline erectile function of men with hypospadias failure presenting for urethroplasty as adults. METHODS: Retrospective data was analyzed on 163 adult patients with prior failed hypospadias repair who presented for urethroplasty from 2002-2007 at two sites in the United States and Italy. All patients had completed the International Index of Erectile Function (IIEF) pre-operatively. Standard IIEF-6 categories were used to assess baseline level of erectile dysfunction (ED) defined as none (≥ 26), minimal (18-25) ,moderate (11-17), and severe (≤ 10). A subset of 13 hypospadias patients prospectively completed the IIEF questionnaire pre and post- operatively. RESULTS: The mean age at presentation for urethroplasty was 39.7 years. Based on IIEF-6 scores, 54% of patients presented with some degree of ED with 22.1%, 3.7%, and 28.2% reporting severe, moderate and mild ED respectively. While the oldest patient population (>50) had the highest incidence of severe ED (38.9%), the youngest age group (=30) had a 60% rate of ED with 18% classified as severe (Table I). Subset analysis of 13 failed hypospadias patients following urethroplasty revealed that 11 (85%) patients had the same or improved erectile function following surgery. CONCLUSIONS: Patients presenting for repair after hypospadias failure often require complex penile reconstruction impacting both urinary as well as sexual quality of life. Among these patients there appears to be a high baseline prevalence of ED. Older patients had a higher incidence of more severe ED; however, the majority of younger patients still presented with some form of ED and a significant number with severe ED. Urethroplasty does not appear to negatively impact erectile function in men with previous hypospadias failure; however a disease specific questionnaire is needed to fully address this issue.

Admission rates and costs associated with emergency presentation of urolithiasis: analysis of the Nationwide Emergency Department Sample 2006-2009.

BACKGROUND AND PURPOSE: We sought to examine a large nationwide (United States) sample of emergency department (ED) visits to determine data related to utilization and costs of care for urolithiasis in this setting. METHODS: Nationwide Emergency Department Sample was analyzed from 2006 to 2009. All patients presenting to the ED with a diagnosis of upper tract urolithiasis were analyzed. Admission rates and total cost were compared by region, hospital type, and payer type. Numbers are weighted estimates that are designed to approximate the total national rate. RESULTS: An average of 1.2 million patients per year were identified with the diagnosis of urolithiasis out of 120 million visits to the ED annually. Overall average rate of admission was 19.21%. Admission rates were highest in the Northeast (24.88%), among teaching hospitals (22.27%), and among Medicare patients (42.04%). The lowest admission rates were noted for self-pay patients (9.76%) and nonmetropolitan hospitals (13.49%). The smallest increases in costs over time were noted in the Northeast. Total costs were least in nonmetropolitan hospitals; however, more patients were transferred to other hospitals. When assessing hospital ownership status, private for-profit hospitals had similar admission rates compared with private not-for-profit hospitals (16.6% vs 15.9%); however, costs were 64% and 48% higher for ED and inpatient admission costs, respectively. CONCLUSIONS: Presentation of urolithiasis to the ED is common, and is associated with significant costs to the medical system, which are increasing over time. Costs and rates of admission differ by region, payer type, and hospital type, which may allow us to identify the causes for cost discrepancies and areas to improve efficiency of care delivery.

Nationwide emergency department visits for priapism in the United States.

INTRODUCTION: The epidemiology of priapism is not well characterized. A small number of studies based on inpatient data or small population samples have estimated the incidence to range from 0.34 to 1.5 cases per 100,000 males. AIM: To estimate the current epidemiology and impact on resource utilization of priapism in the United States (US). MAIN OUTCOME MEASURES: Rate of emergency department encounters for priapism in the US. METHODS: Emergency department (ED) visits for priapism were analyzed using discharge data from the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP). Priapism encounters were identified by ICD9 code. Priapism encounters were analyzed for patient and hospital characteristics, associated diagnoses, and hospital charge. Established weighting in the sample was used to calculate nationwide estimates. RESULTS: A total of 8,738 ED encounters for priapism were identified between 2006 and 2009 in the NEDS. This translated to an estimated 39,964 encounters out of a total of 496,195,793 ED visits, or 8.05 per 100,000 ED visits (95% confidence interval [CI] 7.59-8.51). 21.1% of patients had a concurrent diagnosis of sickle cell disease (SCD). 72.1% of all patients were discharged home from the ED, while only 49.6% of patients with SCD were discharged home. A concurrent diagnosis of SCD was associated with an odds ratio (OR) of 3.84 (95% CI 3.65-4.05) for admission to the hospital when controlling for age, region, hospital and payer type. The mean hospital charge was $1,778 per encounter if discharged home and $41,909 per encounter if admitted. The estimated mean total annual charge for priapism was $123,860,432 with 86.8% of charges attributed to inpatient admissions. CONCLUSIONS: Our estimate of the rate of ED visits for priapism was significantly higher than prior estimates with a SCD concurrence rate lower than previously estimated.

A geographic analysis of male urethral stricture aetiology and location.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The incidence of specific aetiologies of urethral stricture disease has been reported from a variety of series throughout the world. Most reported urethral stricture series are from single institutions or from a specific region of the world. We provide a multi-centred series to compare aetiologic incidence between differing regional populations. OBJECTIVE: To better understand distinct regional patterns in urethral stricture aetiology and location among distinct regional populations. PATIENTS AND METHODS: Data on 2589 patients who underwent urethroplasty from 2000 to 2011 were collected retrospectively from three clinical sites, including 1646 patients from Italy, 715 from India and 228 from the USA. Data from all sites were single-surgeon series. As the data from the Italian and US cohorts were similar in aetiology, location and demographics, we combined these data to form group 1, and compared this group with men in the Indian cohort, group 2. Age, stricture site and primary stricture aetiology were identified for each patient. Stricture site and primary aetiology were determined by the treating surgeon. Primary aetiology was defined as iatrogenic, trauma including pelvic-fracture-related urethral injury (PFUI), lichen sclerosus (LS), infectious, congenital, or unknown. RESULTS: There were more penile strictures (27 vs 5%) and fewer posterior urethral stenoses (9 vs 34%) in group 1. There were more iatrogenic strictures identified in group 1 (35 vs 16%). When comparing the aetiology of iatrogenic strictures alone, more strictures in group 1 were attributable to failed hypospadias repair (49 vs 16%). More patients presented with LS (22 vs 7%) and external trauma (36 vs 16%) in group 2. Prevalence of strictures of infectious aetiology was low (1%) with similar proportions between the two groups. CONCLUSIONS: We have shown that significant regional differences in stricture aetiology exist in a large multicentre cohort study. Group 1 had a higher proportion of penile strictures, largely owing to more iatrogenic strictures and, in particular, failed hypospadias repair. Group 2 had a higher proportion of PFUI and LS-associated urethal stricture. Identified infection-related urethral stricture was rare in all cohorts. Significant regional differences in stricture aetiology exist and should be considered when analysing international outcomes after urethroplasty. These data may also help the development of international disease prevention and treatment strategies.

Implementation of a computerized patient handoff application.

For hospitalized patients, handoffs between providers affect continuity of care and increase the risk of medical errors. Most commercial electronic health record (EHR) systems lack dedicated tools to support patient handoff activities. We developed a collaborative application supporting patient handoff that is fully integrated with our commercial EHR. The application creates user-customizable printed reports with automatic inclusion of a variety of EHR data, including: allergies, medications, 24-hour vital signs, recent common laboratory test results, isolation requirements, and code status. It has achieved widespread voluntary use at our institution (6,100 monthly users; 700 daily reports generated), and we have distributed the application to several other institutions using the same EHR. Though originally designed for resident physicians, today about 50% of the application users are nurses, 40% are physicians/physician assistants/nurse practitioners, and 10% are pharmacists, social workers, and other allied health providers.

Commentary: time to sign off on signout.

The physician signout note is a widely used clinical document that supports patient safety and care continuity during patient handoff in the hospital. Despite its centrality to patient care, the signout note is not considered an official document, and it is, therefore, not generally standardized or taught to medical trainees, nor is it usually integrated into electronic health records (EHRs). This commentary outlines several of the potential advantages to establishing the physician signout note as an official part of the medical record, such as the facilitation of information flow between signout notes and other parts of the patient chart and the possibility of integrating decision support tools into this important aspect of the clinical workflow. The authors address frequently encountered concerns regarding the establishment of the signout note as an official part of the medical record. They conclude by making recommendations for integrating signout notes into EHRs and using modern, social Web technologies in such an implementation.

Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: a systematic review.

PURPOSE: The aims of this systematic review were: (1) to analyze the content overlap between nurse and physician hospital-based handoff documentation for the purpose of developing a list of interdisciplinary handoff information for use in the future development of shared and tailored computer-based handoff tools, and (2) to evaluate the utility of the Continuity of Care Document (CCD) standard as a framework for organizing hospital-based handoff information for use in electronic health records (EHRs). METHODS: We searched PubMed for studies published through July 2010 containing the indexed terms: handoff(s), hand-off, handover(s), shift-report, shift report, signout, and sign-out. Original, hospital-based studies of acute care nursing or physician handoff were included. Handoff information content was organized into lists of nursing, physician, and interdisciplinary handoff information elements. These information element lists were organized using CCD sections, with additional sections being added as needed. RESULTS: Analysis of 36 studies resulted in a total of 95 handoff information elements. Forty-six percent (44/95) of the information overlapped between the nurse and physician handoff lists. Thirty-six percent (34/95) were specific to the nursing list and 18% (17/95) were specific to the physician list. The CCD standard was useful for categorizing 80% of the terms in the lists and 12 category names were developed for the remaining 20%. CONCLUSION: Standardized interdisciplinary, nursing-specific, and physician-specific handoff information elements that are organized around the CCD standard and incorporated into EHRs in a structured narrative format may increase the consistency of data shared across all handoffs, facilitate the establishment of common ground, and increase interdisciplinary communication.

Awareness of the Care Team in Electronic Health Records.

OBJECTIVE: To support collaboration and clinician-targeted decision support, electronic health records (EHRs) must contain accurate information about patients' care providers. The objective of this study was to evaluate two approaches for care provider identification employed within a commercial EHR at a large academic medical center. METHODS: We performed a retrospective review of EHR data for 121 patients in two cardiology wards during a four-week period. System audit logs of chart accesses were analyzed to identify the clinicians who were likely participating in the patients' hospital care. The audit log data were compared with two functions in the EHR for documenting care team membership: 1) a vendor-supplied module called "Care Providers", and 2) a custom "Designate Provider" order that was created primarily to improve accuracy of the attending physician of record documentation. RESULTS: For patients with a 3-5 day hospital stay, an average of 30.8 clinicians accessed the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants. The Care Providers module identified 2.7 clinicians/patient (1.8 attending physicians and 0.9 nurses). The Designate Provider order identified 2.1 clinicians/patient (1.1 attending physicians, 0.2 resident physicians, and 0.8 physician assistants). Information about other members of patients' care teams (social workers, dietitians, pharmacists, etc.) was absent. CONCLUSIONS: The two methods for specifying care team information failed to identify numerous individuals involved in patients' care, suggesting that commercial EHRs may not provide adequate tools for care team designation. Improvements to EHR tools could foster greater collaboration among care teams and reduce communication-related risks to patient safety.

Quantifying clinical narrative redundancy in an electronic health record.

OBJECTIVE: Although electronic notes have advantages compared to handwritten notes, they take longer to write and promote information redundancy in electronic health records (EHRs). We sought to quantify redundancy in clinical documentation by studying collections of physician notes in an EHR. DESIGN AND METHODS: We implemented a retrospective design to gather all electronic admission, progress, resident signout and discharge summary notes written during 100 randomly selected patient admissions within a 6 month period. We modified and applied a Levenshtein edit-distance algorithm to align and compare the documents written for each of the 100 admissions. We then identified and measured the amount of text duplicated from previous notes. Finally, we manually reviewed the content that was conserved between note types in a subsample of notes. MEASUREMENTS: We measured the amount of new information in a document, which was calculated as the number of words that did not match with previous documents divided by the length, in words, of the document. Results are reported as the percentage of information in a document that had been duplicated from previously written documents. RESULTS: Signout and progress notes proved to be particularly redundant, with an average of 78% and 54% information duplicated from previous documents respectively. There was also significant information duplication between document types (eg, from an admission note to a progress note). CONCLUSION: The study established the feasibility of exploring redundancy in the narrative record with a known sequence alignment algorithm used frequently in the field of bioinformatics. The findings provide a foundation for studying the usefulness and risks of redundancy in the EHR.

An analysis of team checklists in physician signout notes.

Teams of physicians in the hospital collaboratively maintain checklists in informal "signout" documents to help organize, manage, and hand off critical patient-based tasks. We created an application within our commercial EHR that supports basic management of these checklists at two urban, academic medical centers. We collected and analyzed over 400,000 checklist tasks created in the application. We calculated the frequencies of terms and term-combinations (n-grams) in these lists, and compared these data with a previously described clinical task model. Our findings provide evidence for the generalizability of the original clinical task model, and provide the foundation for a more sophisticated physician checklist utility. This could contribute to improved efficiency and safety in patient care.

What "to-do" with physician task lists: clinical task model development and electronic health record design implications.

Clinical task, or "to-do" lists are a common element in the physician document known as signout. Such lists are used to capture and track patient care plan items, supporting daily workflow and collaborative patient management continuity across care transitions. While physician task lists have been shown to be important to patient safety, the tasks themselves have not been systematically examined for their subject matter, structure, or components. A manual sublanguage analysis of 500 signout tasks was conducted, and a hierarchical conceptual model for clinical tasks was inductively constructed. Tasks were classified by action type (Assess, Order, Communicate, Perform) and corresponding components. The most common task action types were Assess and Order. The most common task components were "What" type components such as Tests, including subtypes Laboratory and Imaging. This study yielded several important design considerations for future electronic health record systems that support collaborative clinical task management.