Bladder instillations vs onabotulinumtoxinA injection for interstitial cystitis/bladder pain syndrome: a randomized clinical trial.

BACKGROUND: Interstitial cystitis (IC)/bladder pain syndrome (BPS) is an unpleasant sensation related to the bladder with lower urinary tract symptoms lasting more than 6 weeks, unrelated to an otherwise identifiable cause. The etiology is likely multifactorial including urothelial abnormalities, neurogenic pain upregulation, and potentially bladder and vaginal microbiome alterations. Despite treatment effectiveness of both bladder instillations and intradetrusor onabotulinumtoxinA injection for this condition, a head-to-head comparison has not been performed. OBJECTIVE: To compare the efficacy of bladder instillations and intradetrusor onabotulinumtoxinA injection for treatment of IC/BPS. STUDY DESIGN: Patients with O'Leary-Sant (OLS) questionnaire scores of ≥6, meeting clinical criteria for IC/BPS, and desiring procedural management were randomized to bladder instillations or intradetrusor onabotulinumtoxinA injection. The primary outcome was the difference in OLS scores at 2 months posttreatment between groups. Secondary outcomes included evaluation of sexual function, physical/mental health status, pain, patient satisfaction, treatment perception, retreatment, and adverse event rates. RESULTS: Forty-seven patients were analyzed with 22 randomized to bladder instillations and 25 to onabotulinumtoxinA injection. There were no differences in demographic and clinical characteristics between groups. From baseline to 2 months posttreatment, there was a decrease in OLS subscales in all patients (Interstitial Cystitis Symptom Index [ICSI] -6.3 (confidence interval [CI] -8.54, -3.95), P<.0001; Interstitial Cystitis Problem Index [ICPI] -5.9 (CI -8.18, -3.57), P<.0001). At 2 months posttreatment, patients in the onabotulinumtoxinA group had significantly lower OLS scores compared to those in the bladder instillation group (ICSI 6.3±4.5 [onabotulinumtoxinA] vs 9.6±4.2 [instillation], P=.008; ICPI 5.9±5.1 [onabotulinumtoxinA] vs 8.3±4.0 [instillation], P=.048). The difference in OLS scores between groups did not persist at 6 to 9 months posttreatment. There were no statistically significant differences between baseline and posttreatment time points for the remaining questionnaires. Eight percent of patients who received onabotulinumtoxinA injection experienced urinary retention requiring self-catheterization. Patients who underwent onabotulinumtoxinA injection were significantly less likely to receive retreatment within 6 to 9 months compared to patients who received bladder instillations (relative risk 13.6; 95% CI, 1.92-96.6; P=.0002). There were no differences between groups regarding patient satisfaction, perception of treatment convenience, or willingness to undergo retreatment. CONCLUSION: Both onabotulinumtoxinA injection and bladder instillations are safe, effective treatments for patients with IC/BPS, with significant clinical improvement demonstrated at 2 months posttreatment. Our findings suggest that intradetrusor onabotulinumtoxinA injection is a more effective procedural treatment for this condition than bladder instillation therapy and associated with decreased rates of retreatment.

Upper Airway Stimulation Therapy Effect on Blood Pressure.

OBJECTIVE: Upper airway stimulation (UAS) therapy has become increasingly utilized to treat obstructive sleep apnea, which is an independent risk factor for the development of hypertension. This study examines the impact of this therapy on blood pressure (BP). STUDY DESIGN: Retrospective cross-sectional cohort study. SETTING: Tertiary center, Military Health System. METHODS: Patients who underwent UAS implantation at Brooke Army Medical Center between July 2015 and July 2020 were included if they used their device for at least 25 h/wk. Pre- and postoperative systolic BP, diastolic blood pressure (DBP), calculated mean arterial pressure (MAP), and the apnea-hypopnea index (AHI) were compared using paired t test or Wilcoxon's signed-rank test. RESULTS: Thirty patients met the inclusion criteria. The median age was 60, and the median body mass index was 29.9 kg/m2 . The mean time between pre- and postoperative BP measurements was 11.6 months. AHI decreased from 35.1 to 16.5 events/h (p < .001). DBP decreased from 78.5 (73.8, 85.0) to 74.5 mm Hg (68.8, 81.3), with a mean difference of -3.7 mm Hg (p = .002). MAP decreased from 94.8 (89.6, 100.6) to 90.2 mm Hg (84.3, 100.0), with a mean difference of -3.7 mm Hg (p = .004). CONCLUSION: UAS therapy was associated with a significant reduction in DBP, MAP, and AHI. These reductions in BP could potentially lead to favorable decreases in cardiovascular morbidity.

Postoperative Venous Thromboembolism Following Hysterectomy in the Department of Defense.

INTRODUCTION: Hysterectomy is the most common major gynecologic procedure performed in the USA. Surgical complications, such as venous thromboembolism (VTE), are known risks that can be mitigated by preoperative risk stratification and perioperative prophylaxis. Based on recent data, the current post-hysterectomy VTE rate is found to be 0.5%. Postoperative VTE significantly impacts health care costs and patients' quality of life. Additionally, for active duty personnel, it can negatively impact military readiness. We hypothesize that the incidence of post-hysterectomy VTE rates will be lower within the military beneficiary population because of the benefits of universal health care coverage. MATERIALS AND METHODS: The Military Health System (MHS) Data Repository and Management Analysis and Reporting Tool was used to conduct a retrospective cohort study of postoperative VTE rates within 60 days of surgery among women who underwent a hysterectomy at a military treatment facility between October 1, 2013, and July 7, 2020. Patient demographics, Caprini risk assessment, preoperative VTE prophylaxis, and surgical details were obtained by chart review. Statistical analysis was performed using the chi-squared test and Student t-test. RESULTS: Among the 23,391 women who underwent a hysterectomy at a military treatment facility from October 2013 to July 2020, 79 (0.34%) women were diagnosed with VTE within 60 days of their surgery. This post-hysterectomy VTE incidence rate (0.34%) is significantly lower than the current national rate (0.5%, P < .0015). There were no significant differences in postoperative VTE rates with regard to race/ethnicity, active duty status, branch of service, or military rank. Most women with post-hysterectomy VTE had a moderate-to-high (4.29 ± 1.5) preoperative Caprini risk score; however, only 25% received preoperative VTE chemoprophylaxis. CONCLUSION: MHS beneficiaries (active duty personnel, dependents, and retirees) have full medical coverage with little to no personal financial burden for their health care. We hypothesized a lower VTE rate in the Department of Defense because of universal access to care and a presumed younger and healthier population. The postoperative VTE incidence was significantly lower in the military beneficiary population (0.34%) compared to the reported national incidence (0.5%). Additionally, despite all VTE cases having moderate-to-high preoperative Caprini risk scores, the majority (75%) received only sequential compression devices for preoperative VTE prophylaxis. Although post-hysterectomy VTE rates are low within the Department of Defense, additional prospective studies are needed to determine if stricter adherence to preoperative chemoprophylaxis can further reduce post-hysterectomy VTE rates within the MHS.

What is the relative risk of urologic malignancy in microscopic hematuria patients after negative evaluation? A long-term population-based retrospective analysis of 8465 patients.

OBJECTIVE: To evaluate whether microscopic hematuria (MH) patients with a negative initial evaluation have an elevated risk for urinary carcinoma. METHODS: This is a population-based retrospective study with a matched control identified 8465 adults with an MH ICD code, an initial negative urinary malignancy work-up of cystoscopy and CT urography, and at least 35 months of clinical care. 8465 hematuria naïve controls were age, gender, and smoking status matched. Subsequent coding of non-prostatic urinary cancer, or any following hematuria codes: additional microscopic unspecified or unspecified hematuria, and gross hematuria was obtained. Χ2 tests were performed. RESULTS: There was no statistically significant difference in urinary malignancy rates (p > 0.05). Any urinary cancer: cases 0.74% (63/8465; 95% CI 0.58-0.95%)/controls 0.83% (71/8465; 95% CI 0.66-1.04%%) (p = 0.54); bladder: 0.45%/0.47% (p = 0.82); renal: 0.31%/0.38% (p = 0.43); ureteral: 0.01%/0.02% (p = 0.56). Subsequent gross hematuria in both males and females increased the odds of cancer: males 2.35 (p = 0.001; CI 1.42-3.91); females 4.25 (p < 0.001; CI 1.94-9.34). Males without additional hematuria had decreased odds ratio: 0.32 (p = 0.001; CI 0.16-0.64). Females without additional hematuria 0.58 (p = 0.19; CI 0.26-1.30) and both genders with additional unspecified hematuria/microscopic hematuria males 1.02 (p = 0.97; CI 0.50-2.08) and females 1.00 (p = 0.99; CI 0.38-2.66) did not have increased odds ratios (p > 0.05). CONCLUSION: MH patients with initial negative evaluation have a subsequent urologic malignancy rate of less than 1% and likely do not need further urinary evaluation unless they develop gross hematuria.

Clinical and Pathologic Characterization of 94 Radiation-Associated Sarcomas: Our Institutional Experience.

Radiation-associated sarcomas are an uncommon complication of therapeutic radiation. However, their prevalence has increased with the more widespread use of this treatment modality. The clinical, pathologic and genetic characteristics of radiation-associated sarcomas are not fully understood. In this study we describe the features of 94 radiation-associated sarcomas reviewed at our institution between 1993 and 2018, evaluate their overall survival (OS) and progression-free survival (PFS) outcomes, and compare them with their sporadic counterparts reviewed within the same time period. Histologic subtypes of all radiation-associated sarcomas included 31 (33%) undifferentiated sarcomas, 20 (21%) osteosarcomas, 17 (18%) angiosarcomas, 10 (11%) malignant peripheral nerve sheath tumor (MPNST), 9 (10%) leiomyosarcomas, 4 (4%) myxofibrosarcomas, and 3 (3%) rhabdomyosarcomas. Six patients had a documented cancer predisposition syndrome. The most common preceding neoplasms included adenocarcinoma (47%) and squamous cell carcinoma (19%), with a mean latency of 13 years. Multivariable Cox survival analysis demonstrated that advanced stage at diagnosis based on pT category (AJCC eighth edition) and fragmented resection were associated with worse survival outcomes. In addition, there was a statistically significant difference in PFS between radiation-associated undifferentiated sarcomas and MPNST when compared to their sporadic counterparts using the Kaplan-Meier method and Log-rank analysis. Overall, our study shows that radiation-associated sarcomas comprise a wide clinico-pathologic spectrum of disease, with a tendency for aggressive clinical behavior. This study further delineates the understanding of these uncommon diseases. Future studies are necessary to better understand the genetic and epigenetic changes that drive the differences in behavior between these tumors and their sporadic counterparts, and to offer better treatment options.

The Role of Routine Ureteral Stenting Following Uncomplicated Ureteroscopic Treatment for Upper Ureteral and Renal Stones: A Randomized Control Trial.

Purpose: Ureteral stenting following uncomplicated ureteroscopy (URS) is common practice. Several studies have proven the safety of omitting routine stent placement following distal ureteral stone treatment. However, there is a paucity of data regarding the utility of stent placement for proximal URS. We designed a prospective, randomized controlled trial to evaluate the role of ureteral stent placement following URS for proximal ureteral and renal stones. Methods: Seventy-two patients with proximal ureteral or renal stones measuring as much as 1.5 cm were prospectively randomized into stented (37) or unstented (35) groups. The surgeon was blinded to the treatment group until after stone treatment. Patients tracked postoperative pain medications and completed validated pain questionnaires on postoperative days 0, 3, 7, and 28. Stents were removed on postoperative day 7. Postoperative follow-up imaging was obtained at 4 weeks. Results: No statistical differences were observed between the two groups in terms of demographics or stone characteristics. The operative time was longer in the stented group (p < 0.03). Patients in the stented group had more irritative urinary symptoms (p < 0.0001) and pain (p < 0.0001), missed more days of work (p < 0.01), and used more narcotics (p < 0.0005) during the first week, but no differences were observed at 30 days. Emergency room visits and overall complication rates were similar between the two groups. Three nonstented patients required stent placement. Two stented patients required early stent removal. Urinary tract infections developed in three stented patients, but not in unstented patients. Postoperative imaging did not reveal any hydronephrosis in either group, and the total stone-free rate was 94%. Conclusions: For most patients undergoing uncomplicated ureteroscopic treatment for proximal ureteral and kidney stones, it may be safe to omit ureteral stents to potentially decrease urinary symptoms and pain while improving short-term quality of life. Further studies with larger patient cohorts may be warranted to confirm our results.

Patient Compliance With Surveillance of Thyroid Nodules Classified as Atypia of Undetermined Significance.

OBJECTIVE: To determine whether thyroid nodule surveillance compliance is influenced by patient demographics or plan type. STUDY DESIGN: Retrospective case series from 2010 to 2018. SETTING: United States Military Health System. METHODS: There were 481 patients with a thyroid nodule fine-needle aspiration classified as atypia of undetermined significance for whom treatment and follow-up information were available. Demographic information and surveillance plan type were extracted from the medical record and statistical analysis was performed to determine whether these characteristics influenced compliance rates. RESULTS: A total of 289 nodules were surveilled and 192 diagnostic lobectomies were performed. An initial surveillance plan was documented in 93% (268/289) and 86% (231/268) complied. The most common plans were repeat biopsy in 78% (210/268) or ultrasound in 20% (53/268). A second plan was documented in 88% (204/231) of those who complied with the first. The most common second plans were ultrasound in 87% (178/204) or repeat biopsy in 8% (17/204). Compliance with the second plan was 64% (130/204), significantly lower than with the first (OR 3.6, 95% CI: [2.3, 5.6], P < .0001). Only 45% (130/289) were surveilled twice. Age and gender did not significantly affect compliance rates. Compliance with primary care ultrasound surveillance was 40% (21/52), significantly lower than with a specialist (77% [137/179]; OR 4.8, 95% CI: [2.5, 9.3, P < .0001). CONCLUSION: Compliance with surveillance of thyroid nodules classified as atypia of undetermined significance was poor in this military cohort. Ultrasound surveillance by a specialist may be more reliable than with primary care.

Use of a Chemotherapy Toxicity Prediction Tool to Decrease Risks for Hospitalization in Older Patients.

Objectives Performance status (PS) scales such as the Eastern Cooperative Oncology Group (ECOG) PS and the Karnofsky Performance Index have limited utility in selecting therapies and predicting related adverse events in older patients with cancer. In July 2016, medical oncologists at our institution adopted the Cancer and Aging Research Group toxicity prediction score (CARG), a toxicity prediction tool, to identify patients who are "fit" for chemotherapy versus those who are "frail" and may experience severe complications. Methods Our retrospective review included referrals of beneficiaries 75 years of age and older who received standard systemic therapy and patients of the same age whose treatment was modified due to CARG. We compared the score's utilization six months before and after its incorporation and then assessed how its application impacted admissions, emergency department (ED) visits, and medical management. Results Thirty-eight patients with a mean age of 81 years met the inclusion criteria. Their diagnoses included gastrointestinal (37%), lung (21%), hematologic (18%), breast (10.5%), genitourinary (3%), and other (10.5%) malignancies. CARG was documented for 12.5% of systemic therapy recipients before its adoption and 41% of recipients after adoption. Its use was limited by the reliance on physicians to perform scoring during time-constrained patient encounters. Patients had fewer mean inpatient admissions (0.7 versus 2.3), admission days (4.3 versus 8), and ED visits (1.1 versus 2.5) when management was modified based on the score. Conclusion CARG assessment may facilitate a safer and more tailored approach to cancer care in older patients than conventional PS scales alone. Its integration into patient screening would increase its application and better define its potential predictive capacity to decrease risks for hospitalization.

Comparing outcomes among outpatients treated for pyelonephritis with oral cephalosporins versus first-line agents.

Fluoroquinolones and trimethoprim/sulfamethoxazole (TMP-SMX) are first-line agents for acute pyelonephritis. Oral ß-lactams are second-line agents owing to reported lower efficacy rates, primarily seen with aminopenicillins rather than cephalosporins. The increase in resistance rates and adverse effects associated with first-line agents provides justification to reconsider oral cephalosporins for pyelonephritis. Therefore, the objective of this study was to determine whether there is a difference in urinary tract infection (UTI) recurrence rates between oral cephalosporins and first-line agents in the treatment of acute pyelonephritis. This was a retrospective, single-centre, observational cohort study from 1 December 2018 to 31 May 2020. The study population was adult TRICARE beneficiaries with a diagnosis of acute pyelonephritis who were treated with oral antibiotics. The two cohorts compared were first-line antibiotics (ciprofloxacin, levofloxacin and TMP-SMX) and oral cephalosporins. The primary outcome was UTI recurrence rate at 30 days, which was defined as a repeat clinic visit, emergency department visit or hospital admission for a UTI (cystitis or pyelonephritis). The secondary outcome was to determine independent risk factors for UTI recurrence. A total of 268 cephalosporin and 211 first-line cases were included. The primary composite outcome of UTI recurrence within 30 days occurred in 44 (16%) cephalosporin and 36 (17%) first-line cases (P = 0.851). Independent risk factors for UTI recurrence were chronic kidney disease and Klebsiella spp. isolation. In conclusion, there was no significant difference in UTI recurrence rates between oral cephalosporins and first-line agents in the treatment of acute pyelonephritis in the outpatient setting.

Implementation of a Traumatic Brain Injury Guideline at A Department of Defense Level 1 Trauma Center.

BACKGROUND: Traumatic brain injury (TBI) is one of the most prevalent diagnoses among trauma populations and places significant strain on valuable rural hospital resources. Limited studies show safety and efficacy of implementation of a Brain Injury Guideline (BIG) protocol at a Department of Defense (DoD) Level 1 trauma center. MATERIALS AND METHODS: Data from patients diagnosed with traumatic brain injury during the study period were collected from our institutional trauma database. A retrospective review was performed on patients identified in the database to collect demographic and injury related data. All primary and secondary outcome data were analyzed using two-tailed Fischer's exact tests, Pearson Chi-square tests, and non-parametric Mann Whitney U tests. RESULTS: A total of 354 patients were included in the study, 189 pre-implementation and 165 post-implementation. Demographics, head injury severity, initial HCT findings, and BIG classification distributions were well-matched. There was a significant reduction in neurosurgical consultations (NSC) (98.4% pre- to 77.0% post-implementation, P<0.001) and ICU admissions (84.1% pre-, 74.5% post-implementation, P=0.025) following protocol implementation. There were no differences between groups in ICU LOS (P=0.239), incidence of worsening findings on RHCT (P=0.894), or in-hospital mortality (P=0.814). There was a slight reduction in hospital LOS from 4.0d pre-implementation to 3.0d post-implementation (P=0.043). CONCLUSIONS: Implementation of a BIG protocol at our Level 1 trauma center suggested at a relationship with fewer NSCs and ICU admissions. Management of mild and moderate TBI by acute care and trauma surgeons without direct neurosurgical oversight is safe and implies a reduction in utilization of hospital resources.

Osteophyte-Sparing Treatment of Mucous Cysts: Case Analysis and Surgical Technique.

OBJECTIVE: The purpose of this study was to examine patient outcomes and the risk of recurrence of mucous cysts affecting the distal interphalangeal (DIP) joint in the absence of osteophytectomy using the described flap technique. METHODS: A retrospective review of 143 records of patients who were treated for mucous cysts of the DIP joint by a single surgeon. Inclusion criteria included the absence of an osteophytectomy during treatment using the described dorsally based flap technique and a minimum of 12 months of follow-up. RESULTS: A total of 143 mucous cysts affecting the DIP joint of 131 patients with an average age of 65.3 years were included. The average follow-up was 21.9 months (12 to 139). Postoperative DIP joint extension was less in the surgical digit compared with the same digit of the contralateral hand with a significant change from the preoperative motion (1.5° versus 0.3°; P = 0.05). No significant change in the postoperative flexion of the DIP joint was observed compared with that of the contralateral side (-1.4° versus -0.9°; P = 0.57). Recurrence occurred in 2 patients (1.4%). No infections or wound complications were identified. CONCLUSIONS: Using the described technique without an osteophytectomy seemed to be an effective treatment of mucous cysts originating from the DIP joint.

Early Cardiac Dysfunction in Biopsy-proven Nonalcoholic Fatty Liver Disease.

BACKGROUNDS/AIMS: Nonalcoholic fatty liver disease (NAFLD) encompasses a range of diseases from nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH) and has been linked to cardiovascular disease and sub-clinical cardiac remodeling. This paper presents a retrospective study of biopsy-proven NAFL and NASH to examine the differences in subclinical cardiac remodeling. METHODS: Patients were recruited from an institutional repository of patients with liver-biopsy-confirmed NAFLD. Patients with a transthoracic echocardiogram (TTE) within 12 months of the liver biopsy were included. The parameters of the diastolic dysfunction were reviewed for the differences between NAFL and NASH as well as between the stages and grades of NASH. RESULTS: Thirty-three patients were included in the study, 17 with NAFL and 16 with NASH. The NASH patients were more likely to have lower platelets, higher AST, higher ALT, and higher rates of type 2 diabetes mellitus, coronary artery disease, and hypertension than the NAFL patients. The E/e' ratio on transthoracic echocardiogram was significantly higher in NASH compared to NAFL, advanced-stage NASH compared to early stage, and high-grade NASH compared to low-grade. The E/e' ratio was also significantly higher in NASH than NAFL in patients without diabetes mellitus. The presence of diastolic dysfunction trended toward significance. The other markers of diastolic dysfunction were similar. Logistic regression revealed a statistical association with E/e' and NASH. CONCLUSIONS: NASH patients had evidence of a higher E/e' ratio than NAFL, and there was a trend towards a significant diastolic dysfunction. Patients with NASH compared to NAFL should be closely monitored for signs and symptoms of cardiac dysfunction.

Intraoperative blood transfusions in burn patients.

BACKGROUND: Donated blood is a valuable and limited resource. Excision of burn wounds often leads to significant blood loss requiring transfusion. Accurately estimating blood loss is difficult, so examining the amount of blood products given intraoperatively is a clinically relevant way to measure utilization of this valuable resource. In this study, we examined the factors that influenced the amount of blood given intraoperatively during burn wound excisions. STUDY DESIGN AND METHODS: A retrospective analysis of patients admitted to a single burn center over 5 years who underwent excision of their burn wounds and received intraoperative blood products was performed. Patient and burn characteristics as well as pertinent surgical data and laboratory values on the day of surgery and postoperatively were gathered. A linear regression analysis examined factors influencing the number of units of products given and a predictive model was generated. RESULTS: A total of 563 operations performed on 166 patients were included. The amount of burn excised was the most influential variable on the amount of blood products given. Hemoglobin level, international normalized ratio, and platelet count on the day of surgery were associated with transfusion of different blood products. A predictive model was generated to aid in preoperative ordering of blood products. CONCLUSION: The amount of burn excised and common hematology and coagulation lab values were associated with the amount of different blood products administered during burn surgery. The predictive model generated needs to be validated prospectively to aid in preoperative planning for burn excisions.

Diagnostic Lobectomy for Bethesda III Thyroid Nodules: Pathological Outcomes and Risk Factors for Malignancy.

OBJECTIVE: An indeterminate thyroid nodule fine-needle aspiration (FNA) presents a unique dilemma. We evaluated our institution's experience with Bethesda III thyroid nodules, including the risk of malignancy (ROM) of these nodules removed for diagnostic lobectomy and radiologic and clinical risk factors for malignancy. STUDY DESIGN: Retrospective chart review. SETTING: San Antonio Military Medical Center (SAMMC; 483 bed Military Treatment Facility and Level 1 Trauma Center). METHODS: We identified all patients with a Bethesda III thyroid FNA at our institution from 2010 to 2018 and determined which nodules were removed. The final histological diagnosis was recorded. Whether or not age, gender, body mass index (BMI), race, nodule size, margin regularity, rate of nodule growth, vascularity, internal calcifications, family history of thyroid cancer, personal history of radiation, and history of repeated AUS/FLUS on FNA had a significant impact on malignancy risk was evaluated with chi square and rank sum Wilcoxon tests. RESULTS: 492 patients had 1 or more AUS result. 52% (258/492) underwent repeat FNA. This resulted in Bethesda II or III in 90% (232/258). In 10% (26/258), the repeat FNA resulted in a higher Bethesda grade. 183 lobectomies were performed on the side containing an AUS nodule. The malignancy percentage was 38.3% (70/183). Age less than 30 was the only variable showing statistical significance for increased risk of malignancy (P = .04). CONCLUSION: The ROM of nodules characterized as AUS/FLUS on FNA may be higher than expected. Age may be a better predictor of malignancy than repeat FNA.

The Association Between Obstructive Sleep Apnea and Cotton-Wool Spots in Nonproliferative Diabetic Retinopathy.

Purpose: This work reports the association of obstructive sleep apnea (OSA) and cotton-wool spots (CWS) seen in patients with nonproliferative diabetic retinopathy (DR). Methods: A random sample of patients diagnosed with DR between January 1, 2015 and December 31, 2018, were selected from medical-billing codes. Dilated funduscopic examination findings and medical history were analyzed by reviewing medical records. Results: CWS were present in 12 of 118 patients without OSA, compared with 11 of 32 patients with OSA (10.2% vs 34.4%, respectively; P = .002). OSA was more common in men (68.8%, P = .03) and associated with a higher body mass index (30.0 ± 5.0 without OSA vs 33.6 ± 5.5 with OSA, P < .001). When comparing those with and without OSA, there was no association with age; glycated hemoglobin A1c; stage of DR; insulin dependence; presence of diabetic macular edema; smoking status; or a history of hypertension, hyperlipidemia, cardiovascular disease, or other breathing disorder. Conclusions: The presence of OSA is associated with CWS in patients with DR, as well as male sex and a higher body mass index. Further research is needed to determine the ophthalmologist's role in the timely referral of patients with CWS for OSA evaluation.

Validation of an Endometrial Tumor Diameter Model for Risk Assessment in the Absence of Lymph Node Mapping.

PURPOSE: This study aimed to assess the optimal tumor diameter for predicting lymphatic metastasis and to determine intraoperatively the need for lymph node dissection in patients with endometrioid endometrial cancer. METHODS: Military beneficiaries diagnosed with stage I-III endometrioid endometrial cancer during 2003-2016 who had at least 7 pelvic and/or paraaortic lymph nodes removed during the time of hysterectomy were studied. Tumor diameter was compared against the presence of positive nodes, using the prior models of 20 mm (ie, Mayo model) and 50 mm (ie, Milwaukee model), to determine the false-negative rate of each threshold. A separate analysis was completed to determine the optimal diameter for our population. Receiver operating characteristic curve analysis models of tumor diameter were evaluated for model fit and predictive power of lymph node involvement. RESULTS: Of the 1224 patients with endometrioid endometrial cancer included, 13% (n=160) had positive lymph node involvement. Tumor sizes ranged from 1 mm to 100 mm. In contrast to Mayo and Milwaukee models (ie, Mayo, Milwaukee), the optimal tumor diameter independent of myometrial invasion and grade of tumor to predict lymph node metastasis was found to be 35 mm. CONCLUSIONS: Endometrioid endometrial cancer tumor diameter of 35 mm was found to be the optimal threshold for lymphadenectomy when the operating surgeon has no knowledge of tumor invasion.

Electronic trauma resuscitation documentation and decision support using T6 Health Systems Mobile Application: A combat trauma center pilot program.

BACKGROUND: The care of trauma patients in combat operations is handwritten on a five-page flow sheet. The process requires the manual scanning and uploading of paper documents to bridge the gap between electronic and paper record management. There is an urgent operational need for an information technology solution that will enable medics to better capture patient treatment information, which will improve long-term health care without impacting short-term care responsibilities. METHODS: We conducted a process improvement project to evaluate the ability of T6 Health Systems Mobile Application to improve combat casualty care data collection at a deployed trauma hospital. We performed a head-to-head comparison of the completeness and accuracy of data capture of electronic versus handwritten records to determine noninferiority. RESULTS: During the 90-day pilot, there were 131 trauma evaluations of which 53 casualty resuscitations (40.5%) were also documented in the electronic application. We compared completeness and accuracy of admit, prehospital, primary survey, secondary survey, interventions, and trends data. We found an overall 13% increase in data capture at 96% accuracy compared with the written record, suggesting that the electronic record was superior. Completion of electronic documentation compared with paper by section was statistically significantly higher for admitting data, 119.7% (p < 0.0001); prehospital, 116.2% (p = 0.0039); primary, 109.6% (p < 0.001); and secondary, 125.5% (p < 0.001). We also had the medical evacuation teams document prehospital and en route care and then synchronize the record in the trauma bay, allowing the trauma teams there to continue documenting on the same casualty record, likely contributing to superiority because teams did not have to redocument based on an oral report. CONCLUSION: Our pilot program in the deployed environment demonstrated a mobile technology that actually enhanced the completeness and accuracy of paper trauma documentation that has the capability of providing patient-specific decision support and real-time data analysis. LEVEL OF EVIDENCE: Care Management, level IV.

Semi-rigid ureteroscope as a dilator in renal stone ureteroscopic treatment.

INTRODUCTION: To determine the efficacy and safety of using the semi-rigid ureteroscope as the only ureteral dilator for primary ureteroscopy (URS) in the treatment of renal stones. MATERIALS AND METHODS: A retrospective review of primary URS for renal stone disease was performed on consecutive patients treated by a single provider from 2013 to 2017. Utilizing wire placement under fluoroscopic guidance and direct visual ureteroscopic dilation with a semi-rigid ureteroscope, primary outcome was successful completion of stone treatment. In addition, perioperative safety was evaluated. RESULTS: A total of 126 consecutive cases of primary URS using the semi-rigid ureteroscope as the only ureteral dilator were attempted for renal stone treatment. The renal stones were treated in 124 (98.4%) patients without other forms of active ureteral dilation. Two (1.6%) patients required ureteral stent placement for passive dilation despite attempted other dilating techniques. No intraoperative ureteral perforations were identified. Postoperative radiographic follow up was available for 67% patients with a 91% stone free rate and no hydronephrosis or ureteral strictures were detected. CONCLUSION: Utilizing direct visual semi-rigid ureteroscopic dilation with a semi-ridged ureteroscope prior to flexible ureteroscopy leads to successful primary ureteroscopy for renal stone treatment in most patients. This technique is an effective, safe and possibly cost-effective method of obtaining ureteral access to facilitate primary URS for renal stone treatment.

Tranexamic acid in pediatric combat trauma requiring massive transfusions and mortality.

BACKGROUND: Tranexamic acid (TXA) has been demonstrated to decrease mortality in adult trauma, particularly in those with massive transfusions needs sustained in combat injury. Limited data are available for the efficacy of TXA in pediatric trauma patients outside of a single combat support hospital in Afghanistan. METHODS: The Department of Defense Trauma Registry was queried for trauma patients younger than 18 years from Iraq and Afghanistan requiring 40 mL/kg or greater of blood product within 24 hours of injury. Burns and fatal head traumas were excluded. Primary outcome was in-hospital mortality. Secondary outcomes were hospital, ventilator, and intensive care unit-free days, as well as total blood product volume. RESULTS: Among those pediatric patients receiving massive transfusions, those who received TXA were less likely to die in hospital (8.5% vs. 18.3%). Patients who received TXA and those who did not have similar hospital-free days (19 vs. 20), ventilator-free days (27 vs. 27), and intensive care unit-free days (25 vs. 24). Those who received TXA had higher 24-hour blood product administration (100 mL/kg vs. 75 mL/kg). None of our results rose to the level of statistical significance. The TXA administration significantly reduced odds of death on logistic regression (odds ratio, 0.35; 95% confidence interval, 0.123-0.995; p = 0.0488). CONCLUSION: Use of TXA in pediatric patients with combat trauma requiring massive transfusions trended toward a significant improvement in in-hospital mortality (p = 0.055). This mortality benefit is similar to that seen in adult studies and a less well characterized cohort in another pediatric study suggesting TXA administration confers mortality benefit in massively transfused pediatric combat trauma victims. LEVEL OF EVIDENCE: Evidence (retrospective cohort), Level IV.