ABSTRACT
Natural antibodies (Abs) can target host glycans on the surface of pathogens. We studied the evolution of glycan-reactive B cells of rhesus macaques and humans using glycosylated HIV-1 envelope (Env) as a model antigen. 2G12 is a broadly neutralizing Ab (bnAb) that targets a conserved glycan patch on Env of geographically diverse HIV-1 strains using a unique heavy-chain (VH) domain-swapped architecture that results in fragment antigen-binding (Fab) dimerization. Here, we describe HIV-1 Env Fab-dimerized glycan (FDG)-reactive bnAbs without VH-swapped domains from simian-human immunodeficiency virus (SHIV)-infected macaques. FDG Abs also recognized cell-surface glycans on diverse pathogens, including yeast and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike. FDG precursors were expanded by glycan-bearing immunogens in macaques and were abundant in HIV-1-naive humans. Moreover, FDG precursors were predominately mutated IgM+IgD+CD27+, thus suggesting that they originated from a pool of antigen-experienced IgM+ or marginal zone B cells.
Subject(s)
Antibodies, Neutralizing/immunology , HIV-1/immunology , Immunoglobulin Fab Fragments/immunology , Polysaccharides/immunology , SARS-CoV-2/immunology , Simian Immunodeficiency Virus/immunology , Spike Glycoprotein, Coronavirus/immunology , env Gene Products, Human Immunodeficiency Virus/immunology , Animals , B-Lymphocytes/immunology , Broadly Neutralizing Antibodies/immunology , COVID-19/immunology , Dimerization , Epitopes/immunology , Glycosylation , HIV Antibodies/immunology , HIV Infections/immunology , Humans , Immunoglobulin Fab Fragments/chemistry , Macaca mulatta , Polysaccharides/chemistry , Receptors, Antigen, B-Cell/chemistry , Simian Immunodeficiency Virus/genetics , Vaccines/immunology , env Gene Products, Human Immunodeficiency Virus/chemistry , env Gene Products, Human Immunodeficiency Virus/geneticsABSTRACT
BACKGROUND: To evaluate contemporary preoperative risk factors and subsequent postoperative management of incidental prostate cancer (iPCa) and incidental clinically significant prostate cancer (icsPCa, Grade Group [GG] ≥ 2 PCa). METHODS: A retrospective cohort of 811 men undergoing Holmium enucleation of the prostate (HoLEP) (January 2021-July 2022) were identified. Advanced preoperative testing was defined as prostate health index (PHI), prostate MRI, and/or negative preoperative biopsy. Descriptive statistics (Whitney-Mann U test, Chi-squared test) and multivariable logistic regression were performed. RESULTS: iPCa and icsPCa detection rates were 12.8% (104/811) and 4.4% (36/811), respectively. Advanced preoperative testing (406/811, 50%) was associated with younger age and higher (prostate specific antigen) PSA, prostate volume, and PSA density. On multivariable analysis, PHI ≥ 55 was associated with iPCa (OR 6.91, 95% CI 1.85-26.3, p = 0.004), and % free PSA (%fPSA) was associated with icsPCa (OR 0.83, 95% CI 0.67, 0.94, p = 0.01). GG1 disease comprised the majority of iPCa (65%, 68/104) with median 1% involvement. iPCa patients were followed with active surveillance (median follow up 9.3 months), with higher risk patients receiving prostate MRI and confirmatory biopsy. Three patients proceeded to radical prostatectomy or radiation. CONCLUSIONS: In the era of MRI and advanced biomarkers, the majority of iPCa following HoLEP is low volume GG1 suitable for active surveillance. A tentative follow-up strategy is proposed. Patients with PHI ≥ 55 or low %fPSA, even with negative prostate MRI, can consider preoperative prostate biopsy before HoLEP.
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BACKGROUND: Antimicrobial stewardship (AS) programs are required by Centers for Medicare and Medicaid Services and should ideally have infectious diseases (ID) physician involvement; however, only 50% of ID fellowship programs have formal AS curricula. The Infectious Diseases Society of America (IDSA) formed a workgroup to develop a core AS curriculum for ID fellows. Here we study its impact. METHODS: ID program directors and fellows in 56 fellowship programs were surveyed regarding the content and effectiveness of their AS training before and after implementation of the IDSA curriculum. Fellows' knowledge was assessed using multiple-choice questions. Fellows completing their first year of fellowship were surveyed before curriculum implementation ("pre-curriculum") and compared to first-year fellows who complete the curriculum the following year ("post-curriculum"). RESULTS: Forty-nine (88%) program directors and 105 (67%) fellows completed the pre-curriculum surveys; 35 (64%) program directors and 79 (50%) fellows completed the post-curriculum surveys. Prior to IDSA curriculum implementation, only 51% of programs had a "formal" curriculum. After implementation, satisfaction with AS training increased among program directors (16% to 68%) and fellows (51% to 68%). Fellows' confidence increased in 7/10 AS content areas. Knowledge scores improved from a mean of 4.6 to 5.1 correct answers of 9 questions (Pâ =â .028). The major hurdle to curriculum implementation was time, both for formal teaching and for e-learning. CONCLUSIONS: Effective AS training is a critical component of ID fellowship training. The IDSA Core AS Curriculum can enhance AS training, increase fellow confidence, and improve overall satisfaction of fellows and program directors.
Subject(s)
Antimicrobial Stewardship , Communicable Diseases , Aged , Communicable Diseases/drug therapy , Curriculum , Education, Medical, Graduate , Fellowships and Scholarships , Humans , Medicare , Surveys and Questionnaires , United StatesABSTRACT
PURPOSE: To identify a threshold for intrarenal pressure (IRP), that if exceeded, will result in renal parenchymal damage. Herein, we attempt to identify an IRP threshold by subjecting in vivo porcine kidneys to various levels of extreme pressurized irrigation. Our objective was not to simulate ureteroscopy treatment, but to attempt identify a threshold of IRP injury. METHODS: Ten female pigs were intubated and sedated. The abdomen was opened; the ureters were isolated and incised. A LithoVue™ (Boston Scientific) ureteroscope was inserted. A 0-silk tie was then used to tie the ureter around the scope to create a closed system (to achieve a constant level of pressure). Real-time IRPs were measured using the Comet™ Pressure guidewire (Boston Scientific). Kidneys were exposed to pressurized, saline for 36 min (at control, 50, 100, 150 mmHg and higher pressures). Kidneys were then immediately harvested. Two expert histologists independently analyzed kidney slides to identify areas of renal damage. RESULTS: The two kidneys exposed to IRPs > 185 mmHg resulted in forniceal rupture and large areas of hematoma. The other IRP groups (control, 50, 100, and 150 mmHg) had no identifiable gross or histologic renal parenchymal damage. CONCLUSIONS: No differences in renal parenchymal morphology were identified between pressure groups of control, 50, 100, or 150 mmHg. However, IRPs > 185 mmHg did result in forniceal rupture in this closed-system in vivo porcine model. Further study is required to elucidate the damage threshold.
Subject(s)
Ureteroscopes , Ureteroscopy , Female , Swine , Animals , Ureteroscopy/methods , Kidney Pelvis , Pressure , KidneyABSTRACT
PURPOSE: We sought to objectively compare laser fiber degradation for holmium laser enucleation of the prostate (HoLEP) cases performed with 550 µm standard fibers versus 550 µm Moses 2.0 fiber in BPH mode on a macroscopic and microscopic level. METHODS: We prospectively collected outcomes for 50 standardized HoLEP cases using 550 µm Moses fiber with 2.0 BPH mode compared to our historical cohort of 50 patients using 550 µm standard fibers on regular mode. Macroscopic degradation length was the difference in length of exposed fiber at the start and end of each case. Five consecutive 550 µm standard fibers, five 550 µm Moses fibers and their respective controls underwent novel utilization of three objective corroborating imaging techniques: Brightfield high resolution microscopy, high resolution 3-D microCT and Confocal Reflection Surface Analysis. Mann-Whitney U, 2-tailed T tests and Chi-squared tests were used. RESULTS: Standard fibers demonstrated greater degradation than the Moses fibers with 2.0 BPH mode [2.9 cm (IQR 1.7-4.3 cm) vs 0.2 cm (IQR 0.1-0.4 cm), p < 0.01]. This difference remained significant when comparing degradation per energy used, per minute enucleation and per gram enucleated (all p < 0.05). None of the cases with Moses fiber and 2.0 BPH mode required intraoperative interruption to re-strip the fiber. Objective fiber degradation by three microscopic techniques confirmed more damage to the standard fibers with regular mode. CONCLUSION: Overall, use of the 550 µm Moses fiber with 2.0 BPH mode resulted in less fiber degradation compared to a standard 550 µm fiber with regular mode as confirmed using 4 corroborating macroscopic and microscopic techniques.
Subject(s)
Laser Therapy , Lasers, Solid-State , Prostatic Hyperplasia , Transurethral Resection of Prostate , Holmium , Humans , Laser Therapy/methods , Lasers, Solid-State/therapeutic use , Male , Prostate/surgery , Prostatic Hyperplasia/surgery , Technology , Treatment OutcomeABSTRACT
BACKGROUND: Laboratory parameters and the associated clinical outcomes have been an area of focus in COVID-19 research globally. PURPOSE: We performed a scoping review to synthesize laboratory values described in the literature and their associations with mortality and disease severity. METHODS: We identified all primary studies involving laboratory values with clinical outcomes as a primary endpoint by performing data searches in various systematic review databases until 10th August, 2020. Two reviewers independently reviewed all abstracts (13,568 articles) and full text (1126 articles) data. A total of 529 studies involving 165,020 patients from 28 different countries were included. Investigation of the number of studies and patients from a geographical perspective showed that the majority of published literature from January-March 2020 to April-June 2020 was from Asia, though there was a temporal shift in published studies to Europe and the Americas. For each laboratory value, the proportion of studies that noted a statistically significant (p < 0.05) correlation with adverse clinical outcomes (e.g., mortality, disease severity) was tabulated. RESULTS AND CONCLUSION: Among frequently reported laboratory values, blood urea nitrogen was the most often reported predictor of mortality (91%); neutrophil-to-lymphocyte ratio was the most frequent statistically significant laboratory parameter in predicting disease severity (96%). This review highlights the temporal progression of laboratory value frequencies, as well as potentially distinct utilities of different markers for clinical outcomes of COVID-19. Future research pathways include using this collected data for focused quantitative meta-analyses of particular laboratory values correlated with clinical outcomes of mortality and disease severity.
Subject(s)
COVID-19 , Adult , Hospitalization , Humans , Laboratories , Lymphocytes , SARS-CoV-2ABSTRACT
Cornelia de Lange Syndrome (CdLS) and associated spectrum disorders are characterized by one or more congenital anomalies including distinctive facial features, upper limb abnormalities, intellectual disability, and other symptoms. The molecular genetic basis of CdLS is linked to defects in cohesin, a protein complex that functions in sister chromatid cohesion, chromatin organization, and transcriptional regulation. Histone deacetylase 8 (HDAC8) plays an important role in cohesin function by catalyzing the deacetylation of SMC3, which is required for efficient recycling of the cohesin complex. Missense mutations in HDAC8 have been identified in children diagnosed with CdLS spectrum disorders, and here we outline structure-function relationships for four of these mutations. Specifically, we report the 1.50 Å-resolution structure of the I45T HDAC8-suberoylanilide hydroxamic acid complex, the 1.84 Å-resolution structure of E66D/Y306F HDAC8 complexed with a peptide assay substrate, and the 2.40 Å-resolution structure of G320R HDAC8 complexed with the inhibitor M344. Additionally, we present a computationally generated model of D176G HDAC8. These structures illuminate new structure-function relationships for HDAC8 and highlight the importance of long-range interactions in the protein scaffold that can influence catalytic function.
Subject(s)
De Lange Syndrome/genetics , Histone Deacetylases/genetics , Mutation, Missense/genetics , Repressor Proteins/genetics , Cell Cycle Proteins/genetics , Chromosomal Proteins, Non-Histone/genetics , Humans , Phenotype , CohesinsABSTRACT
Professional societies serve many functions that benefit constituents; however, few professional societies have undertaken the development and dissemination of formal, national curricula to train the future workforce while simultaneously addressing significant healthcare needs. The Infectious Diseases Society of America (IDSA) has developed 2 curricula for the specific purpose of training the next generation of clinicians to ensure the future infectious diseases (ID) workforce is optimally trained to lead antimicrobial stewardship programs and equipped to meet the challenges of multidrug resistance, patient safety, and healthcare quality improvement. A core curriculum was developed to provide a foundation in antimicrobial stewardship for all ID fellows, regardless of career path. An advanced curriculum was developed for ID fellows specifically pursuing a career in antimicrobial stewardship. Both curricula will be broadly available in the summer of 2021 through the IDSA website.
Subject(s)
Antimicrobial Stewardship , Communicable Diseases , Curriculum , Delivery of Health Care , Humans , SocietiesABSTRACT
PURPOSE: To perform a global survey to identify contemporary practice patterns of transurethral therapies for benign prostatic hypertrophy. METHODS: A REDCap survey was distributed to the ~ 3500 members of the Endourological Society. Surgeons completed demographic information and then selected the BPH therapies they perform 10 cases/year. There were four categories of BPH therapies: ablation, enucleation, resection/vaporization, and MIST (minimally invasive surgical technique). Within each category, there were subcategories to account for different energy modalities. All statistical analyses were performed using SAS 9.4. RESULTS: A total of 175 surgeons responded to our survey. Prostate resection/vaporization remained the most commonly utilized technique (51.9%, n = 147/283) followed by enucleation (22.6%, n = 64/283). Bipolar TURP (bTURP) was the most common modality for prostate resection (69.4%, n = 102/147). Holmium laser enucleation (HoLEP) was the most common modality for enucleation (46.9%, n = 30/64). Urolift® was performed more often than Rezum™ (55.9% vs. 44.1%, n = 19/34 vs. 15/34, respectively). Among surgeons performing ablation, country of practice was a significantly associated with length of stay (LOS), p < 0.0001. For surgeons performing enucleation, academic institution and completion of a fellowship were associated with postoperative day (POD) 1 catheter removal (p = 0.0240 and p = 0.020, respectively). CONCLUSIONS: In this contemporary, global survey of the Endourology Society, resection/vaporization techniques were the most commonly performed. Rates of MISTs remained relatively low at 12.1%. Academic institution and fellowship status were associated with shorter catheterization times and LOS for certain surgical categories.
Subject(s)
Practice Patterns, Physicians' , Prostatectomy/methods , Prostatic Hyperplasia/surgery , Adult , Female , Health Care Surveys , Humans , Internationality , Male , Middle AgedABSTRACT
We present a patient with acute myeloid leukemia and prolonged, severe neutropenia who developed fulminant Clostridioides difficile infection refractory to medical therapy and was high-risk for surgical intervention. He was treated with fecal microbiota transplantation (FMT) for life-saving cure. The patient had subsequent clinical improvement, however, developed multidrug-resistant Pseudomonas aeruginosa bacteremia 2 days post-procedure. We describe subsequent investigation of this event that found this bacteremia was not related to the donor stool administered during FMT. This case adds to the literature that FMT could be considered in heavily immunocompromised patients with fulminant Clostridioides difficile infection where maximal medical therapy has been ineffective and surgery may carry an excessively high mortality risk.
Subject(s)
Clostridium Infections/therapy , Fecal Microbiota Transplantation , Immunocompromised Host , Leukemia, Myeloid, Acute/complications , Neutropenia/complications , Adult , Anti-Bacterial Agents/therapeutic use , Clostridioides difficile , Diarrhea/therapy , Humans , Leukemia, Myeloid, Acute/microbiology , Male , Neutropenia/microbiology , Pseudomonas Infections/drug therapy , Treatment OutcomeABSTRACT
Histone deacetylases (HDACs) regulate cellular processes such as differentiation and apoptosis and are targeted by anticancer therapeutics in development and in the clinic. HDAC8 is a metal-dependent class I HDAC and is proposed to use a general acid-base catalytic pair in the mechanism of amide bond hydrolysis. Here, we report site-directed mutagenesis and enzymological measurements to elucidate the catalytic mechanism of HDAC8. Specifically, we focus on the catalytic function of Y306 and the histidine-aspartate dyads H142-D176 and H143-D183. Additionally, we report X-ray crystal structures of four representative HDAC8 mutants: D176N, D176N/Y306F, D176A/Y306F, and H142A/Y306F. These structures provide a useful framework for understanding enzymological measurements. The pH dependence of kcat/KM for wild-type Co(II)-HDAC8 is bell-shaped with two pKa values of 7.4 and 10.0. The upper pKa reflects the ionization of the metal-bound water molecule and shifts to 9.1 in Zn(II)-HDAC8. The H142A mutant has activity 230-fold lower than that of wild-type HDAC8, but the pKa1 value is not altered. Y306F HDAC8 is 150-fold less active than the wild-type enzyme; crystal structures show that Y306 hydrogen bonds with the zinc-bound substrate carbonyl, poised for transition state stabilization. The H143A and H142A/H143A mutants exhibit activity that is >80000-fold lower than that of wild-type HDAC8; the buried D176N and D176A mutants have significant catalytic effects, with more subtle effects caused by D183N and D183A. These enzymological and structural studies strongly suggest that H143 functions as a single general base-general acid catalyst, while H142 remains positively charged and serves as an electrostatic catalyst for transition state stabilization.
Subject(s)
Acids/chemistry , Alkalies/chemistry , Histone Deacetylases/chemistry , Repressor Proteins/chemistry , Catalysis , Crystallography, X-Ray , Histone Deacetylases/genetics , Humans , Hydrogen Bonding , Hydrogen-Ion Concentration , Mutagenesis, Site-Directed , Repressor Proteins/geneticsSubject(s)
HIV Infections/drug therapy , Sweating/physiology , Adenine/analogs & derivatives , Adenine/therapeutic use , Adult , Alanine , Anti-HIV Agents/therapeutic use , Asia, Southeastern , Cobicistat/therapeutic use , Emtricitabine/therapeutic use , Humans , Laos , Male , Quinolones/therapeutic use , Tenofovir/analogs & derivatives , Thailand , Travel , United StatesABSTRACT
OBJECTIVE: To compare anesthetic parameters using a novel prone single transverse chest roll technique (STR) to the standard thoraco-pelvic dual transverse roll technique (DTR). METHODS: A retrospective review of 441 patients who underwent PCNL between 2018 to 2022 was performed. A total of 4 surgeons were included-surgeon 1 utilized the STR technique while surgeons 2, 3, and 4 used the DTR technique. Anesthetic parameters including end tidal CO2 (ETCO2), mean arterial pressure (MAP), peak airway pressure (Ppeak), plateau airway pressure (Pplat), positive end expiratory pressure (PEEP), oxygen saturation (SpO2), and tidal volume (TV) were compared between both groups at 0 (supine), 15, 30, and 60 minutes post-intubation intervals. Mixed effects regression models with interaction and pairwise comparisons were made between both groups (p<0.05). RESULTS: A total of 581 PCNLs were performed with 199 using STR and 382 using DTR. Surgery duration, ASA class, and age were similar amongst the STR and DTR groups. Estimated blood loss (59cc vs 83cc, p=0.007) and length of stay (77 hrs vs 163 hrs, p=<0.001) was significantly lower in the STR group. There was a significantly lower Ppeak, Pplat and TV in the STR compared to DTR group at 0, 15, 30, and 60 minutes (p<0.001). CONCLUSION: Usage of a single transverse chest roll during prone PCNL appears to be a safe positioning method. STR patients had lower Ppeak and Pplat at all timepoints, which has been shown to be predictive of lower blood loss.
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INTRODUCTION: We aimed to compare holmium laser enucleation of the prostate (HoLEP) outcomes in patients with and without neurologic diseases (ND). METHODS: A prospectively maintained database of patients undergoing HoLEP from January 2021 to April 2022 was reviewed. The following ND s were included: diabetes-related neuropathy/neurogenic bladder, Parkinson's disease, dementia, cerebrovascular accident, multiple sclerosis, traumatic brain injury, transient ischemic attack, brain/spinal tumors, myasthenia gravis, spinal cord injury, and other. Statistical analysis was performed using t-tests, Chi-squared, and binomial tests (p<0.05). RESULTS: A total of 118 ND patients were identified with 135 different neurologic diseases. ND patients were more likely to have indwelling catheters (57% vs. 39%, p=0.012) and urinary tract infections (UTIs) preoperatively (32% vs. 19%, p=0.002). Postoperatively, ND patients were more likely to fail initial trial of void (20% vs. 8.1%, p<0.001) and experience an episode of acute urinary retention (16% vs. 8.5%, p=0.024). Within 90 days postoperative, the overall complication rate was higher in the ND group (26% vs. 13%, p=0.001). Within the ND group, 30/118 (25%) had ≥1 UTI within 90 days preoperative, which decreased to 10/118 (8.7%) 90 days postoperative (p<0.001). At last followup (mean 6.7 months [ND] vs. 5.4 months [non-ND], p=0.03), four patients (4.4%) in the ND group required persistent catheter/clean intermittent catheterization compared to none in the non-ND group (p=0.002). CONCLUSIONS: Patients with ND undergoing HoLEP are more likely to experience postoperative retention and higher complication rates compared to non-ND patients. While UTI rates are higher in this population, HoLEP significantly reduced three-month UTI and catheterization rates.
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Introduction: Tranexamic acid (TXA) is a clot promoting agent utilized during orthopedic procedures to decrease bleeding. Urologists have demonstrated the benefits of TXA in percutaneous surgery. Our objective was to assess the safety and efficacy of single-dose TXA on same-day holmium laser enucleation of the prostate (HoLEP) outcomes. Methods: From September 2021 to January 2022, we prospectively randomized 110 patients undergoing HoLEP to either 1 g of TXA after induction or no treatment. Institutional Review Board (IRB) approval (STU00215134) and registry with ClinicalTrials.gov (NCT05082142) were obtained before enrollment. Primary outcome was the rate of effective same-day discharge (SDD). Secondary outcomes included transfusion rate, same-day catheter removal, length of stay (LOS), and 90-day complications. Power analysis determined that 110 patients should be enrolled to detect a 25% difference in SDD rate. Results: There was no difference in patient demographic and prostate features between the control (n = 55) and TXA groups (n = 55; all p > 0.05). The overall rate of effective SDD was not different between the control and TXA groups (49/55 [89%] vs 51/55 [93%], p = 0.74). Median LOS (hh:mm) was not different between groups (03:07 vs 02:50, p = 0.23) with only 3/110 (2.7%) having an LOS >24 hours. Effective same-day catheter removal occurred in 99/110 (90%) patients with no difference between groups (49/55 vs 50/55, p = 0.99). There was no difference in operative parameters (time, energy, specimen weight) and postoperative complications between groups (all p > 0.05). No patients required transfusions and there were no major 90-day complications related to surgery (Clavien-Dindo ≥IIIb). Conclusion: TXA administration is safe but did not impact SDD after HoLEP.
Subject(s)
Laser Therapy , Lasers, Solid-State , Prostatic Hyperplasia , Tranexamic Acid , Male , Humans , Prostate/surgery , Tranexamic Acid/therapeutic use , Lasers, Solid-State/therapeutic use , Prospective Studies , Prostatic Hyperplasia/surgery , Holmium , Laser Therapy/methods , Treatment OutcomeABSTRACT
INTRODUCTION: Prostatic urethral lift (PUL) accounts for approximately one-quarter of all surgical benign prostatic hyperplasia (BPH) procedures performed in the U.S. Within five years of a patient's PUL procedure, approximately 1/7 patients will require surgical BPH retreatment. We aimed to highlight the evidence of surgical BPH retreatment modalities after PUL, with a focus on safety, short-term efficacy, durability, and relative costs. METHODS: A literature review was performed using PubMed, and an exhaustive review of miscellaneous online resources was completed. The search was limited to English, human studies. Citations of relevant studies were reviewed. RESULTS: No study has examined the efficacy, safety, or durability of transurethral resection of the prostate (TURP) or repeat PUL in the post-PUL setting. Recently, groups have examined laser enucleation (n=81), water vapor thermal therapy (WVTT) (n=5), robotic simple prostatectomy (SP) (n=2), and prostatic artery embolization (PAE) (n=1) in the post-PUL setting. Holmium enucleation of the prostate (HoLEP) after PUL appears to be safe and has similar functional outcomes to HoLEP controls. Other treatment modalities examined appear safe but have limited efficacy evidence supporting their use. Photo-selective vaporization of the prostate (PVP) and robotic waterjet treatment (RWT) have no safety or efficacy studies to support their use in the post-PUL setting. CONCLUSIONS: Despite increasing numbers of patients expected to require surgical retreatment after PUL in North America, there is currently limited evidence and a lack of recommendations guiding the evaluation and management of these patients. HoLEP is associated with the strongest evidence to support its use in the post-PUL setting.
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OBJECTIVE: To evaluate if implementation of a percutaneous nephrolithotomy (PCNL) equipment whiteboard can improve communication accuracy of surgical equipment, streamline operative efficiency, and decrease unnecessary case equipment costs. METHODS: A real-time editable equipment whiteboard was designed and implemented for all PCNL cases between October and December 2021. The relative difference in pre- and post-intervention surgical equipment accuracy as well as overall case costing was compared from 90 days prior to implementation to the period after intervention. RESULTS: Quality assessment surveys were completed prior to whiteboard implementation (N = 25) and cost implementation (n = 15). Pre- and postoperative assessment of equipment communication, assessed on a 10-point scale, improved after implementation of the communication whiteboard (Pre-op: 6.7/10 vs. 8.9/10, P < .001. Post-op: 7.0/10 vs. 9.3/10, P < .001). On average 64% (3.2/5) of items were accurate on preintervention cases. Postintervention accuracy improved to 88% (4.4/5 items) (P = .049). There was a significant relative case cost improvement after implementing the PCNL equipment whiteboard with an average of $436.81 USD savings per case (P = .001) and $488.22 USD per renal moiety (P = .002). CONCLUSION: Our baseline quality assessment of surgical team communication regarding PCNL equipment identified an area for improvement. Multidisciplinary feedback resulted in the development of a real-time editable PCNL equipment whiteboard which improved team perception of equipment communication, case item accuracy and resulted in a relative average cost savings for PCNL.
Subject(s)
Kidney Calculi , Nephrolithotomy, Percutaneous , Nephrostomy, Percutaneous , Humans , Nephrolithotomy, Percutaneous/methods , Quality Improvement , Kidney , Communication , Kidney Calculi/surgery , Treatment Outcome , Nephrostomy, Percutaneous/methodsABSTRACT
Advanced practice providers are a diverse and established group of antimicrobial prescribers in both ambulatory and inpatient settings. We outline important considerations for antimicrobial stewardship programs and stewards to consider when engaging this important group of providers.
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Introduction: Intradetrusor onabotulinumtoxinA (OTA) injection is a well-established treatment option for refractory overactive bladder; however, its use at the time of holmium laser enucleation of the prostate (HoLEP) for men with bladder outlet obstruction (BOO) and severe storage symptoms has not been previously reported. Materials and Methods: We retrospectively identified men with BOO and severe storage symptoms who underwent treatment with 200 U of intradetrusor OTA (Botox®) at the time of HoLEP. Patients were propensity score matched to a cohort of HoLEP-only patients based on age, Michigan Incontinence Symptom Index (M-ISI) score, preoperative urinary retention, urge incontinence, and prostate size. Perioperative, postoperative, and patient-reported outcomes were examined between groups. Results: We identified 82 men who underwent HoLEP, including 41 patients in the OTA group and 41 patients in the control group. There was no difference in operative times (59 minutes OTA vs 55 minutes control, p = 0.2), rates of same-day trial of void (TOV) (92% OTA vs 94% control, p = 0.7), or rates of same-day discharge (88% OTA vs 85% control, p = 0.6) between groups. There was no difference in temporary postoperative urinary retention (7% OTA vs 2% control, p = 0.3) between groups. Patients who received OTA injections had a significant reduction in their incontinence scores at 3-month follow-up (M-ISI -8, interquartile range [IQR]: -13 to 0, p < 0.001), whereas control patients did not (M-ISI -5, IQR: -8 to -1, p = 0.2). There was no difference in rates of 90-day complications between groups (OTA 10% vs control 5%, p = 0.7). Conclusions: Intradetrusor OTA at the time of HoLEP is safe and is associated with improved urinary incontinence scores and AUA Symptom Score. Rates of same-day discharge and same-day TOV after HoLEP were not affected by OTA. These findings support the role of OTA as an adjunct to surgical intervention in men with incontinence in the presence of BOO.
Subject(s)
Botulinum Toxins, Type A , Laser Therapy , Lasers, Solid-State , Prostatic Hyperplasia , Urinary Bladder Neck Obstruction , Urinary Incontinence , Urinary Retention , Male , Humans , Prostate/surgery , Botulinum Toxins, Type A/therapeutic use , Urinary Retention/surgery , Lasers, Solid-State/therapeutic use , Retrospective Studies , Prostatic Hyperplasia/complications , Prostatic Hyperplasia/drug therapy , Prostatic Hyperplasia/surgery , Treatment Outcome , Laser Therapy/adverse effects , Urinary Incontinence/surgery , Urinary Bladder Neck Obstruction/drug therapy , Urinary Bladder Neck Obstruction/etiology , Urinary Bladder Neck Obstruction/surgery , Holmium , Quality of LifeABSTRACT
Introduction: Holmium laser enucleation of the prostate (HoLEP) has evidenced-based advantages in treating benign prostatic hyperplasia (BPH) relative to other interventions. Unfortunately, the adoption of HoLEP has remained relatively low in Medicare and the National Surgical Quality Improvement Program populations. HoLEPs role as an inpatient surgical intervention is changing as advancements in the technique and systems have demonstrated the feasibility of same-day discharge. Thus, our objective was to evaluate national HoLEP trends in ambulatory surgery settings from 2016 to 2019. Materials and Methods: The Nationwide Ambulatory Surgery Sample (NASS) is the largest national all-payer database of ambulatory surgical encounters, managed by the Agency for Healthcare Research and Quality. A cross-sectional retrospective analysis of the 2016 and 2019 NASS was performed. Rates of BPH surgeries were calculated and stratified by age, census region, and primary payer to compare across time points for trends. Chi-squared tests and two-sample t-tests were completed for categorical and continuous variables, respectively. Results: The total number of ambulatory BPH surgeries fell 20% between 2016 (n = 124,538) and 2019 (n = 100,593). In 2016, HoLEP lagged behind photoselective vaporization of the prostate (PVP) and transurethral resection of prostate (TURP) with 4.7% of surgeries but rose to the second most common procedure in 2019 with 8.3% of total surgeries. TURP was the most common intervention (62.6% in 2016, 90.7% in 2019). Simple prostatectomy was the most expensive intervention. By U.S. census region, more HoLEPs were carried out in the South (43.1% in 2016, 37.5% in 2019) and Midwest (26.8% in 2016, 31.7% in 2019). Conclusions: Overall, HoLEP uptake is increasing. HoLEP has replaced greenlight PVP as the second most frequently used intervention. The rate of ambulatory HoLEPs has nearly doubled despite a general decrease in the number of surgeries.