Newly modified 'pseudo flap' without compromising vascularity to enhance repair of long distal ureteral loss: A retrospective analysis of a prospective database.

Objective: To present an alternative technique called pseudo-flap for reconstructing long ureteral defects as an alternative to Boari flap. Despite being used for more than 70 years by urologists for tension-free reconstruction of distal and mid-ureteral defects, the Boari flap exhibits high complication rates, with an average of 27% (range 5.5%-30.4%). These complications arise from compromised blood supply, attributed to incisions made on all three sides of the flap and dependence on the flap base as the sole source of blood supply. Methods: We retrospectively reviewed patients who underwent our modified technique by a single surgeon between 2008 and 2021. We used a semi-oblique cystotomy on the lowest part of the anterior and contralateral aspects of the bladder after complete release from adhesions and sacrificing the superior vesical pedicle, if necessary. The innovative part of the technique involved making short relaxing incisions at different levels on both sides of a pseudo-flap while pushing the bladder dome upward to reach the healthy ureter in a tension-free manner, followed by anastomosis with a non-refluxing or refluxing technique. Results: Fifteen patients underwent the pseudo-flap technique with a mean follow-up of 16.9 months. Four had prior radiation, three had hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis, and one had a ureteral stricture in a transplanted kidney. Eight procedures were performed during intraoperative consultations.Only one patient (7%) developed a major complication (Clavien-Dindo grade ≥2). This patient developed postoperative leak, and none developed obstructive hydronephrosis, suggesting stricture or flap ischemia. The mean length of the flap was 9.3 cm. Conclusion: Our pseudo-flap technique has lower complication rates than the traditional Boari flap. It is not technically challenging, minimally compromises blood supply and is thus especially suitable for complex, highly morbid patients with decreased tissue vascularity, such as those with prior radiation and peritoneal carcinomatosis.

Injection site number and outcomes of intradetrusor onabotulinumtoxinA for refractory overactive bladder syndrome: a randomized clinical trial.

INTRODUCTION AND HYPOTHESIS: The optimal number of onabotulinumtoxinA injections for the treatment of refractory overactive bladder syndrome is unknown. Our primary objective was to determine whether 10-injections sites with 100 units of onabotulinumtoxinA each were associated with less pain than 20-injections sites. METHODS: In a single-blinded randomized trial, 100 units of onabotulinumtoxinA was administered, either as 10 × 1 ml or as 20 × 0.5 ml injections following the instillation of 30 ml of bupivacaine and 5 ml of NaHCO3 solution for 15 min. The primary outcome was procedural pain, as measured on an 11-point Numerical Pain Rating Scale (NPRS) immediately following the procedure. A power calculation estimated that 16 subjects in each arm were needed to detect a mean difference of 1 with a standard deviation of 1, on the NPRS score between the two treatment groups, with α 0.05 and power 80%. To adjust for an estimated 20% dropout rate, the final sample size was planned for 20 patients per group. RESULTS: From October 2020 to November 2022, a total of 56 patients were approached and 40 were enrolled and randomized to two groups (21 in the 10-injections group and 19 in 20-injections group). The difference in the median pain score between the group was not statistically significant (4 [1.5-5] for 10 injections vs 3 [1-4] for 20 injections, p=0.823). CONCLUSION: Patients' perception of pain, efficacy, and adverse events did not significantly differ between patients receiving 10 and those receiving 20 injections of 100 units of onabotulinumtoxinA.

Advancing the Role of the Doctor of Nursing Practice in Palliative Care.

Doctor of nursing practice-prepared nurses are well suited to provide high-quality palliative care to patients with serious illness and their caregivers. Their rigorous education and expertise prepare them for the complexity often associated with chronic disease and end of life. There are clear and strong recommendations from multiple national organizations supporting palliative care education for nurses and tools available for nurses to implement palliative care into practice. This article is from the perspective of the doctor of nursing practice nurse. It reviews the limited evidence on palliative care integration into the doctor of nursing practice role, the barriers to palliative care education and implementing palliative care into practice, and the potential roles that a doctor of nursing practice palliative care nurse may fill in health care.

Gastroesophageal reflux disease: 2021 guideline updates and clinical pearls.

ABSTRACT: In 2021, the American College of Gastroenterology updated its diagnosis and treatment guideline for gastroesophageal reflux disease (GERD). This article provides a summary of noteworthy changes to the guideline and describes clinical pearls that are pertinent to the diagnosis and treatment of GERD in primary care.

Establishing interprofessional clinical learning experiences in primary care safety-net sites.

This paper describes an interprofessional clinical learning experience for students within two primary care safety-net sites. An interprofessional team of faculty at one university partnered with two safety-net systems to provide students opportunities to work in an interprofessional team providing care for socially and medically complex patients. Our evaluation outcomes are student-centered, focusing on students' perceptions of caring for medically underserved populations and satisfaction with the clinical experience. Students reported positive perceptions of the interprofessional team, clinical experience, primary care, and caring for underserved populations. Strategic development of partnerships between academic and safety-net systems to offer learning opportunities can increase future healthcare providers' exposure and appreciation for interprofessional care of underserved populations.

An Innovative Approach to a Multitrack Advance Practice Registered Nurse Program: The Integration of Psychiatric Mental Health and Primary Care Cohorts.

ABSTRACT: We describe how an online graduate nurse practitioner program combined psychiatric mental health nurse practitioner and primary care advanced practice registered nurse (AGNP/FNP/PNP) tracks into an integrated curriculum. Student evaluations and assessments, along with board certification scores, demonstrated improvement in identifying and managing behavioral health problems, as well as increased competence and collaboration with other nurse practitioner students. Details of the integrated curriculum are provided.

Patient Satisfaction, Provider Productivity, and Efficacy of a Standardized Preparatory Toolkit With Broad Telemedicine Adaptation in an Outpatient Urology Clinic.

IMPORTANCE: The COVID-19 pandemic prompted telemedicine adoption. In March 2020, we developed an implementation toolkit with a nursing protocol for patient preparation before tertiary care urology clinic visits. OBJECTIVES: Our primary objective was to determine patient satisfaction after implementation of a telemedicine toolkit. Our secondary objective was to assess downstream productivity generated from telehealth visits. STUDY DESIGN: We prospectively conducted a postvisit survey that included the Telehealth Usability Questionnaire, a validated survey assessing patient satisfaction, for all patients with documented completion of the nursing protocol to assess patient experience and satisfaction. We then performed a retrospective chart review of all telemedicine visits to determine downstream outcomes, including imaging and procedure scheduling. RESULTS: Between April and May 2020, 1,422 visits were completed, of which 265 had complete nursing protocol documentation. Eighteen of 265 (6.8%) reported setup assistance. Four (1.8%) were unsuccessful and converted to a nonvisual phone visit. Overall, 186 (70.1%) completed the Telehealth Usability Questionnaire with a mean score of 118.31 ± 23.44. High satisfaction was reported regardless of race, marital status, income, education, employment status, or travel distance. Younger age ( P = 0.017) and female sex ( P = 0.017) were associated with greater satisfaction. Of 1,422 total visits, imaging was ordered in 29%, office procedures scheduled in 14%, and surgery scheduled in 14%. New visits were more likely to result in procedure and surgery scheduling than returns ( P < 0.0001). CONCLUSIONS: Our telemedicine toolkit designed to maximize patient engagement was successful in achieving patient-provider connectivity in 98% of patients with high satisfaction. Telemedicine visits are effective to provide comprehensive urologic care with implications beyond the pandemic.

Rare germline heterozygous missense variants in BRCA1-associated protein 1, BAP1, cause a syndromic neurodevelopmental disorder.

Nuclear deubiquitinase BAP1 (BRCA1-associated protein 1) is a core component of multiprotein complexes that promote transcription by reversing the ubiquitination of histone 2A (H2A). BAP1 is a tumor suppressor whose germline loss-of-function variants predispose to cancer. To our knowledge, there are very rare examples of different germline variants in the same gene causing either a neurodevelopmental disorder (NDD) or a tumor predisposition syndrome. Here, we report a series of 11 de novo germline heterozygous missense BAP1 variants associated with a rare syndromic NDD. Functional analysis showed that most of the variants cannot rescue the consequences of BAP1 inactivation, suggesting a loss-of-function mechanism. In T cells isolated from two affected children, H2A deubiquitination was impaired. In matching peripheral blood mononuclear cells, histone H3 K27 acetylation ChIP-seq indicated that these BAP1 variants induced genome-wide chromatin state alterations, with enrichment for regulatory regions surrounding genes of the ubiquitin-proteasome system (UPS). Altogether, these results define a clinical syndrome caused by rare germline missense BAP1 variants that alter chromatin remodeling through abnormal histone ubiquitination and lead to transcriptional dysregulation of developmental genes.

Gluteal and Posterior Thigh Pain From a Suture Compared With an Anchor-Based Device in Patients Undergoing Sacrospinous Ligament Fixation: A Randomized Controlled Trial.

OBJECTIVE: To compare postoperative gluteal and posterior thigh pain, device performance, and perioperative complications in women undergoing sacrospinous ligament fixation with an anchor-based compared with a suture-capturing device. METHODS: This was a single-center, patient-blinded, parallel, superiority trial of patients undergoing native-tissue pelvic organ prolapse repair through sacrospinous ligament fixation with an anchor-based compared with suture-capturing device using randomized-block randomization. The primary outcome was the increase in gluteal and posterior thigh pain from baseline to 1-week postoperation using the numerical rating scale. Pain was also assessed at postoperative day 1, week 6, and a summarized assessment for the first postoperative week. Intraoperative device performance, home opioid pain medication use, and changes in prolapse symptom scores were also analyzed. To provide 80% power to detect a pain difference of 2.5 points between the groups with an SD of 2.8 and a 15% dropout estimate using a two-sided 5% significance level, 24 patients were required per group. Analysis with Student's t test, Wilcoxon rank-sum tests, and Fisher exact tests were performed as well as an analysis of covariance for the primary outcome. RESULTS: Between September 2018 and June 2020, 47 patients (24 anchor-based and 23 suture-capturing) were included in the study. There was no significant difference between the anchor-based and suture-capture groups in mean change in gluteal and posterior thigh pain from baseline to 1-week postoperation (-0.4, 95% CI -1.6 to 2.3). The highest pain increase from baseline during the first postoperative week was also similar between the two groups (up 4.00 and up 4.74, respectively) with no significant difference between the anchor-based and suture-capture groups (-0.7, 95% CI -1.4 to 2.8). There were no differences in changes in pain at any of the other timepoints, in opioid pain medication utilization, device performance, or in prolapse symptom scores. CONCLUSION: An anchor-based device did not reduce postoperative gluteal and posterior thigh pain compared with a suture-based device after sacrospinous ligament fixation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03565640. FUNDING SOURCE: Supported by Neomedic via Adler Instruments. Neomedic provided funding for this principal investigator-initiated study. Funding went to providing small value gift cards to patients for study completion, office supplies for the study, and funding the data analysis collaboration with the Wake Forest Baptist Health CTSI Biostatistics Department. Neomedic did not have any direct role in study design, patient recruitment, study execution, data analysis, or manuscript writing or editing.

Promoting Physical Activity in Rural Settings: Effectiveness and Potential Strategies.

PURPOSE: Implementing efficacious physical activity interventions in real-world rural settings is needed because rural cancer survivors are more physically inactive and experience poorer health. To address this gap, this study evaluated effectiveness of an evidenced-based physical activity program (Better Exercise Adherence after Treatment for Cancer [BEAT Cancer]) for rural women cancer survivors when implemented by community-based, non-research staff. METHODS: 16 rural women cancer survivors received BEAT Cancer implemented by a rural, community organization and non-research staff; physical activity, patient-reported outcomes, and social cognitive constructs were measured at baseline and post-program. Cancer survivors and interventionists completed program evaluations post-program. RESULTS: Cancer survivor mean age was 58±12 years; 62% were White. Mean months since diagnosis was 54±72; 69% had breast cancer. Significant improvements from pre- to post-program occurred for self-report weekly minutes of moderate-to-vigorous physical activity (mean change [M] = 146±186, p = 0.009), anxiety (M = -1.3±1.8, p = 0.016), depression (M = -2.1±2.0, p = 0.001), self-efficacy (M = 20.9±30.5, p = 0.019), barriers interference (M = -15.0±14.1, p = 0.001), and social support (M = 5.0±7.4, p = 0.02). Cancer survivors ranked the program highly, identified strategies that were helpful (e.g., group activities, personalized exercise plan, etc.), and suggested additional implementation strategies (e.g., guide for home-based phase, etc.). Interventionists identified strategies (e.g., logistics, staff training and certification, cost, etc.) for enhancing organizational readiness for program delivery. CONCLUSION: Evidence-based physical activity programs can be effective when implemented by non-research staff in rural settings. Further research testing strategies that improve implementation is needed. PRACTICAL IMPLICATIONS: Effectiveness and identified strategies supporting delivery when implemented by a rural organization can improve physical activity promotion for rural, at-risk populations.

Pulmonary function testing for the primary care nurse practitioner.

ABSTRACT: Knowledge of which pulmonary function tests are commonly performed in primary care and interpretation of their results is integral for the diagnosis, care, and management of those with pulmonary symptoms. This article provides an overview of the most common pulmonary function tests and interpretation of their results.

Robotic-assisted ureteral reimplantation and psoas hitch after ureteral injury during cesarean section.

INTRODUCTION AND HYPOTHESIS: Ureteral injury during gynecological surgery can be managed in a variety of ways, from endoscopic stent placement to ureteroneocystotomy with accompanying psoas hitch and/or Boari flap. The majority of these occur during hysterectomy; therefore, gynecologic surgeons may not be as familiar with repair in women with intact uteri. Herein we present our technique for delayed robotic-assisted ureteral reimplant and psoas hitch in a woman with a ureteral injury sustained during cesarean section, which initially presented as a uretero-cervical fistula. METHODS: In this video, we describe the evaluation and surgical management of a patient with delayed recognition of a left distal ureteral injury sustained during cesarean section. We present necessary modifications to robotic-assisted laparoscopic ureteroneocystostomy and psoas hitch to accommodate an intact uterus including the need for uterine manipulation, division of the round ligament, bladder mobilization from the lower uterine segment and development of the retropubic space, reimplantation steps, and psoas hitch. CONCLUSIONS: Simple modifications to a traditional technique of robotic-assisted ureteroneocystotomy effectively compensate for the presence of a uterus. Obstetricians should maintain a high index of suspicion for ureteral injury in women with new-onset severe urinary leakage post-cesarean section.

Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program During the COVID-19 Pandemic.

BACKGROUND: In the novel coronavirus disease 2019 (COVID-19) pandemic, social distancing has been necessary to help prevent disease transmission. As a result, medical practices have limited access to in-person visits. This poses a challenge to maintain appropriate patient care while preventing a substantial backlog of patients once stay-at-home restrictions are lifted. In practices that are naïve to telehealth as an alternative option, providers and staff are experiencing challenges with telemedicine implementation. We aim to provide a comprehensive guide on how to rapidly integrate telemedicine into practice during a pandemic. METHODS: We built a toolkit that details the following 8 essential components to successful implementation of a telemedicine platform: provider and staff training, patient education, an existing electronic medical record system, patient and provider investment in hardware, billing and coding integration, information technology support, audiovisual platforms, and patient and caregiver participation. RESULTS: Rapid integration of telemedicine in our practice was required to be compliant with our institution's COVID-19 task force. Within 3 days of this declaration, our large specialty-care clinic converted to a telemedicine platform and we completed 638 visits within the first month of implementation. CONCLUSIONS: Effective and efficient integration of a telemedicine program requires extensive staff and patient education, accessory platforms to facilitate video and audio communication, and adoption of new billing codes that are outlined in this toolkit.

Implementing Outcome-based Care in Pediatric Psychiatry: Early Results and Overcoming Barriers.

BACKGROUND: Poor utilization of standardized outcome measures for monitoring patient care and progress in mental health services is evident. The objective of this work was to implement computerized diagnostic and history assessments for outpatient mental health visits in the ambulatory psychiatric clinic of a large pediatric health system. METHODS: A computerized assessment system was created for the iPad to administer and score a series of validated diagnostics before new patient and follow-up appointments with a psychiatry provider. Outcome measures were a percentage of completed assessments, provider satisfaction, and patient satisfaction. RESULTS: Across all outpatient psychiatry clinics, screener completion rate for new patients increased from 0% to 90% within 1 year of implementation and sustained within 3σ process control limits for 2 years. Return visit assessment completion increased from 0% to 80%. The most substantial completion rate increase was related to scheduling assessment time as part of the visit. Assessment of provider and patient satisfaction through surveys before and after the implementation showed 94% of providers felt that visit efficiency had improved, and overall opinion of the system was highly positive. Patients also reported high satisfaction with the assessment process (4.1 on Likert scale 0-5, 5 = very positive). CONCLUSIONS: This quality improvement program demonstrates strategies for overcoming barriers to the use of standardized assessments in outpatient psychiatry. We show that a large pediatric mental health system can achieve systematic outcome data collection with minimal disruption to routine clinical care.

Learning speech-internal cues to pronoun interpretation from co-speech gesture: a training study.

This study explores whether children can learn a structural processing bias relevant to pronoun interpretation from brief training. Over three days, 42 five-year-olds were exposed to narratives exhibiting a first-mentioned tendency. Two characters were introduced, and the first-mentioned was later described engaging in a solo activity. In our primary condition of interest, the Gesture Training condition, the solo-activity sentence contained an ambiguous pronoun, but co-speech gesture clarified the referent. There were two comparison conditions. In the Gender Training condition the characters were different genders, thereby avoiding ambiguity. In the Name Training condition, the first-mentioned name was simply repeated. Ambiguous pronoun interpretation was tested pre- and post-training. Children in the Gesture condition were significantly more likely to interpret ambiguous pronouns as the first-mentioned character after training. Results from the comparison conditions were ambiguous: there was a small but non-significant effect of training, but also no significant differences between conditions.

Master of Science in Nursing and Doctor of Nursing Practice Clinical Curriculum Map.

BACKGROUND: The development of a comprehensive and structured clinical curriculum map can outline the specific content covered throughout a nurse practitioner program and provide a method for identifying redundancy and omissions in the didactic clinical content. METHOD: A curriculum map outlining the specific clinical content covered in each didactic course in a Master of Science in Nursing and Doctor of Nursing Practice advanced practice program was created. The curriculum map incorporated accreditation standards, certification testing domains, and common primary care diagnoses. RESULTS: A curriculum map supported the development of organized, consistent, and transparent clinical didactic content across courses and the program. The curriculum map allows for frequent curriculum and course review and updates to help meet program and accreditation standards. CONCLUSION: The development and implementation of the clinical didactic curriculum map facilitates the integration of core clinical content in an organized manner that builds learning and prepares future nurse practitioners. [J Nurs Educ. 2018;57(7):440-445.].

Population representation among anatomical donors and the implication for medical student education.

Dissection provides a unique opportunity to integrate anatomical and clinical education. Commonly, cadavers are randomly assigned to courses, which may result in skewed representation of patient populations. The primary aim of this study was to determine if the anatomical donors studied by students at the University of Massachusetts Medical School (UMMS) accurately represent the disease burden of the local patient population. This cross-sectional study compared the University of Massachusetts Memorial Medical Center patient claims data and body donation data from the UMMS Anatomical Gift Program (AGP). This study examined age, race, sex, and morbidities within a 10-year timeframe in 401,258 patients and 859 anatomical donors who met inclusion criteria. An independent t test was conducted to compare the mean ages of the two populations. Chi square analysis was conducted on race, sex, and 10 morbidity categories. A Fischer's exact test was conducted for two morbidity categories with n < 10. Demographic analysis showed a significant difference in age, and racial representation between the populations. No statistical difference was found regarding sex. Morbidities were separated into 22 ICD-10 categories. Twelve categories were excluded and 10 were analyzed for population comparison. Two categories were over represented and seven were under-represented in the AGP population. One category showed no significant difference between populations. Targeted selection of cadavers in anatomy courses would improve morbidity variability in the anatomy lab. In addition, AGP acceptance guidelines should be evaluated to increase disease variation among the donor population. Clin. Anat. 31:250-258, 2018. © 2017 Wiley Periodicals, Inc.

Differential toxicity and venom gland gene expression in Centruroides vittatus.

Variation in venom toxicity and composition exists in many species. In this study, venom potency and venom gland gene expression was evaluated in Centruroides vittatus, size class I-II (immature) and size class IV (adults/penultimate instars) size classes. Venom toxicity was evaluated by probit analysis and returned ED50 values of 50.1 µg/g for class IV compared to 134.2 µg/g for class I-II 24 hours post injection, suggesting size class IV was 2.7 fold more potent. Next generation sequencing (NGS and qPCR were used to characterize venom gland gene expression. NGS data was assembled into 36,795 contigs, and annotated using BLASTx with UNIPROT. EdgeR analysis of the sequences showed statistically significant differential expression in transcripts associated with sodium and potassium channel modulation. Sodium channel modulator expression generally favored size class IV; in contrast, potassium channel modulators were favored in size class I-II expression. Real-time quantitative PCR of 14 venom toxin transcripts detected relative expression ratios that paralleled NGS data and identified potential family members or splice variants for several sodium channel modulators. Our data suggests ontogenetic differences in venom potency and venom related genes expression exist between size classes I-II and IV.

Moment-to-moment within-person associations between acts of discrimination and internalized stigma in people living with HIV: An experience sampling study.

Internalized stigma related to HIV is associated with poorer outcomes for people living with HIV (PLWH). However, little is known about the association between experiences of daily acts of discrimination by others and the activation of internalized stigma, including factors that may moderate this association. One hundred nine men living with HIV responded to experience sampling method (ESM) questions 3 times a day for 7 days via smart-phones. ESM questions included experiences of recent acts of discrimination, internalized HIV stigma, avoidance coping with HIV, and recent social support. We also administered several traditional questionnaire measures assessing psychosocial constructs. In Hierarchical Linear Modeling analyses controlling for age, race, socioeconomic status, and time on antiretroviral therapy, experiencing discrimination predicted internalized stigma within-persons. Individuals higher on attachment-related avoidance, attachment-related anxiety, avoidance coping, perceived community stigma, and helplessness, and individuals lower on social support, had stronger associations between discrimination and current internalized stigma. Similarly, results from two state moderator variables supported our trait analyses: State-level (ESM) social support and avoidance coping were significant moderators. Thus, when PLWH experience incidents of discrimination due to HIV, this may lead to increased feelings of internalized stigma. We extend the literature by demonstrating that the associations between experienced and internalized stigma are not just at the generalized trait level, but also occur at the state-level, accounting for within person variability. Results provide implications for interventions aiming to modify maladaptive interpersonal traits as well as interventions to increase social support to reduce the impact of discrimination on PLWH.