Reduction in Rates of Symptomatic Urinary Tract Infection After Pelvic Reconstructive Surgery: A Quality Improvement Analysis.

IMPORTANCE: Urinary tract infections contribute to high health care costs. OBJECTIVE: This study aimed to determine if a combination of interventions was successful at reducing the rate of postoperative symptomatic urinary tract infections (SUTIs) in a female pelvic medicine and reconstructive surgery (FPMRS) practice. STUDY DESIGN: Observational, retrospective quality improvement analysis looking at the rate of postoperative SUTI within 30 days of surgery in women who underwent gynecologic surgery performed by an FPMRS surgeon from October 2015 to October 2019. Symptomatic urinary tract infection was defined by symptoms and urinalysis, positive urine culture, or treatment for cystitis or urethritis within 30 days of surgery. Interventions were implemented between 2015 and 2016: perioperative cranberry use, intraoperative protocols for catheterization, and postoperative protocols for urinary retention management. In 2018, we added metronidazole to cefazolin for antibiotic prophylaxis. We developed a multivariable logistic regression to determine if postoperative SUTI rates decreased over the study period with adjustment for clustering by surgeons, patient factors, and surgery type. RESULTS: Of 2,389 procedures performed, 284 (11.8%) involved patients who had an SUTI within 30 days of surgery. The annual infection rate decreased 50% (year 1, 14.7%; year 4, 7.3%). Adjusting for age, race, body mass index, length of stay, surgery type, and surgeon, the odds of SUTI decreased 19% each year (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.72-0.91; P < 0.001). Compared with women who had other gynecologic procedures, those who underwent vaginal prolapse surgery with or without incontinence procedures (OR, 2.75; 95% CI, 1.35-5.54; P = 0.01) or incontinence surgery alone (OR, 2.65; 95% CI, 1.25-5.62; P = 0.01) were more likely to have an SUTI. CONCLUSION: Combining interventions can be highly effective in reducing postoperative SUTI rates.

Creating a Composite Index to Target Recruitment of UK Students from Areas of Low Participation in Higher Education.

This research presents a framework through which a new Higher Education Access and Deprivation (HEAD) composite index was created to assist UK universities in efficiently recruiting and supporting students from areas with traditionally low engagement rates in higher education. The index was designed to be easily adaptable by university staff to suit their own work priorities and/or an institution's strategic requirements by utilising open socio-demographic data and construction techniques that require minimal technical statistical skills. Although Cornwall was used as the study area in this research, this index has been designed such that it can be readily applied elsewhere. Two differently weighted models were created using the framework - one with equal weights and the other based on the frequency the constituent indicators appeared in the reviewed academic literature. Both models were mapped across Cornwall, identifying areas of deprivation at a finer resolution than under the current widely used Participation of Local Areas (POLAR) methodology. The weighted model performed marginally better than both the equal weighted model and the current POLAR methodology when validated against external data, and additionally it worked well in both rural and urban environments leading to it being selected as the new HEAD index. The HEAD index maps smaller scale areas of deprivation than previously available, and by enabling users to investigate the underlying socio-demographic characteristics of an area, it also allows universities to create interventions, support, and policies that best targets the students they aim to recruit and teach.

Improving Pediatric Neuro-Oncology Survival Disparities in the United States-Mexico Border Region: A Cross-Border Initiative Between San Diego, California, and Tijuana, Mexico.

PURPOSE: Treatment of children with CNS tumors (CNSTs) demands a complex, interdisciplinary approach that is rarely available in low- and middle-income countries. We established the Cross-Border Neuro-Oncology Program (CBNP) between Rady Children's Hospital, San Diego (RCHSD), and Hospital General, Tijuana (HGT), Mexico, to provide access to neuro-oncology care, including neurosurgic services, for children with CNSTs diagnosed at HGT. Our purpose was to assess the feasibility of the CBNP across the United States-Mexico border and improve survival for children with CNSTs at HGT by implementing the CBNP. PATIENTS AND METHODS: We prospectively assessed clinicopathologic profiles, the extent of resection, progression-free survival, and overall survival (OS) in children with CNSTs at HGT from 2010 to 2017. RESULTS: Sixty patients with CNSTs participated in the CBNP during the study period. The most common diagnoses were low-grade glioma (24.5%) and medulloblastoma (22.4%). Of patients who were eligible for surgery, 49 underwent resection at RCHSD and returned to HGT for collaborative management. Gross total resection was achieved in 78% of cases at RCHSD compared with 0% at HGT (P < .001) and was a predictor of 5-year OS (hazard ratio, 0.250; 95% CI, 0.067 to 0.934; P = .024). Five-year OS improved from 0% before 2010 to 52% in 2017. CONCLUSION: The CBNP facilitated access to complex neuro-oncology care for underserved children in Mexico through binational exchanges of resources and expertise. Survival for patients in the CBNP dramatically improved. Gross total resection at RCHSD was associated with higher OS, highlighting the critical role of experienced neurosurgeons in the treatment of CNSTs. The CBNP model offers an attractive alternative for children with CNSTs in low- and middle-income countries who require complex neuro-oncology care, particularly those in close proximity to institutions in high-income countries with extensive neuro-oncology expertise.

Interdisciplinary Care and a Focus on Fertility Preservation When Multi-cystic Ovaries Cause Ovarian Torsion: A Case of a 9-year-old Girl with Severe, Undiagnosed Hypothyroidism.

BACKGROUND: Ovarian torsion can occur in Van Wyk Grumbach syndrome, a disorder characterized by severe primary hypothyroidism and ovarian enlargement. To date, all documented cases of torsion in this setting describe oophorectomy, which has significant hormonal and fertility implications. CASE: A 9-year-old pubertal girl presented to the emergency room with abdominal pain. Magnetic resonance imaging demonstrated bilateral, multi-cystic ovaries. Operative laparoscopy confirmed unilateral adnexal torsion, and detorsion without oophorectomy was accomplished. Postoperative laboratory tests revealed severe primary hypothyroidism. Ovarian size was reduced with hormone replacement therapy. SUMMARY AND CONCLUSION: This case demonstrates that prompt interdisciplinary intervention and awareness of severe hypothyroidism as a cause of ovarian torsion related to enlarged, multi-cystic ovaries may reduce the rate of oophorectomy, allowing preservation of pediatric patients' future fertility, and reducing morbidity postoperatively through prompt, long-term thyroid supplementation.

Intracranial Hypotension and Hypertension Associated With Reconstructive Cranioplasty After Decompressive Craniectomy: Report of a Lethal Complication With Recommended Strategies for Future Avoidance.

Reconstructive cranioplasty can be associated with many complications and add to the not insignificant potential risks associated with decompressive craniectomy. In the setting of post-traumatic hydrocephalus, treatment with a ventriculoperitoneal (VP) shunt prior to reconstructive cranioplasty likely increases these risks even further. The authors report a case of a 17-year-old male with a history of a severe closed head injury who initially suffered a life-threatening complication associated with intracranial hypotension after cranioplasty only to succumb to malignant intracranial hypertension following a second cranioplasty attempt. To our knowledge, this is the first description of a single patient developing both these disparate complications after reconstructive cranioplasty and emphasizes the likely synergistic hazards involved with decompressive craniectomy in the setting of a VP shunt in particular and the overall myriad potential complications that may be associated with reconstructive cranioplasty in general.

Devising a Composite Index to Analyze and Model Loneliness and Related Health Risks in the United Kingdom.

Objective:This research presents a framework through which a spatial composite index is devised to determine areas of potential loneliness and associated health risks. The research is evidenced on the London borough of Southwark in the United Kingdom but is designed such that it could be applied more widely. Method: The work adopts a quantitative approach through the combination of census and accessibility variables at a small area level. The output is a scoring system whereby each area is assigned a value indicating the likely presence of loneliness and potentially corresponding health risks. Results: Findings imply that loneliness is quantifiable and that this correlates with socioeconomic and accessibility measures. A strong clustering is evident in Southwark. Discussion: This research builds on previous attempts to locate and quantify loneliness with favorable results. The outcome provides a replicable solution to assist the public service with the targeting of areas deemed most at risk from loneliness and resultant mental and physical health conditions at a time when such issues are high on the political agenda.

Medulloblastoma With Extensive Nodularity: Tailored Therapy in a Low-resource Setting.

Treatment for medulloblastoma carries significant risks, particularly in resource-constrained settings. We report a case of a Mexican infant with desmoplastic/nodular medulloblastoma. Given the nature of her tumor, we developed a tailored regimen following subtotal resection to avoid both radiation therapy and the high-dose cisplatin therapy offered at most centers in the United States. The patient is in remission 4 years after the initial diagnosis. This case suggests an alternative treatment plan for this particular tumor variant that accommodates the limited resources of many centers around the world and avoids the risks associated with radiation therapy at a young age.