Variability of Pediatric Cervical Spine Clearance Protocols: A Systematic Review.

OBJECTIVE: The objective of this study was to better understand the variability that exists in the contemporary pediatric cervical spine (c-spine) clearance protocols and how this variability affects clinical practice and outcomes. BACKGROUND DATA: Pediatric c-spine injury is a rare but potentially devastating event. In the adult population, validated tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule, are available to aid in safely clearing the c-spine clinically while reducing the utilization of radiography. In the pediatric population, no standardized, validated tool exists, leading to variability in protocols that are put to use. METHODS: A systematic literature search was conducted in Cochrane, Embase, PubMed/MEDLINE, and Web of Science electronic databases from January 1, 2009 until April 30, 2021. Data were extracted from studies that met inclusion criteria. Quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: There were 19 studies included in this systematic review. From these 19 studies, there were 16 unique protocols, 12 of which (75%) utilized some or all NEXUS criteria. Of the protocols that provided a detailed imaging algorithm (N=14), 12 (85.7%) utilized x-rays as the initial imaging modality. Indications for computed tomography and magnetic resonance imaging varied widely across the protocols. The rate of x-rays, computed tomography, and magnetic resonance imaging utilization ranged from 16.7% to 97.8%, 5.4% to 100%, and 0% to 100%, respectively. Ten studies evaluated the efficacy of protocol implementation, with 9 (90%) of these studies showing an overall reduction of imaging rates in the postprotocol period. No clinically significant missed injuries were reported in the included studies. CONCLUSIONS: Details of c-spine clearance protocols differed significantly across the included studies, but many applied some or all NEXUS criteria. Overall, while variable, protocols served to safely treat pediatric patients without missing any clinically significant c-spine injuries, while reducing radiation exposure.

Does Shared Decision-Making for Prostate Cancer Screening Among African American Men Happen? It Depends on Who You Ask.

BACKGROUND: Shared decision-making (SDM) is recommended for prostate cancer screening, but little is known about how this process is perceived by patients and providers. SDM is especially important for African American men, who are at high risk for the disease. OBJECTIVE: To evaluate agreement in SDM ratings among patients, providers, and objective observers. METHOD: African American men ages 45-70 were recruited from primary care practices to participate in a study evaluating a decision aid (DA). Immediately after using the DA, patients proceeded to primary care appointments. Afterwards, patients and physicians completed surveys assessing perceptions about SDM. Clinical visits were also audio-recorded and coded to assess SDM. RESULTS: Mean scores on SDM measures among patients were 73.2 (SD = 27.5, 95% CI 55.71-90.62), 83.1 among physicians (SD = 7.8 95% CI 78.14-88.06), and 67.1 among objective raters (SD = 36.8 95% CI 43.72-90.45). Among patient-provider dyads, mean agreement was 49.9%. CONCLUSION: Patients, physicians, and objective observers perceived SDM differently. Understanding discordant experiences of SDM is vital for improving clinical guidance about SDM especially among African Americans who have historically faced healthcare discrimination and mistrust. DAs, particularly for African American men, should incorporate strategies to empower patients to advocate for their communication needs and preferences. TRIAL REGISTRATION: Clinical trials identifier number: NCT02787434.

Factors Mediating Type 2 Diabetes Remission and Relapse after Gastric Bypass Surgery.

BACKGROUND: Defining factors associated with remission and relapse of type 2 diabetes (T2D) after Roux-en-Y gastric bypass (RYGB) can allow targeting modifiable factors. We investigated factors associated with T2D remission and relapse after RYGB. STUDY DESIGN: We conducted a retrospective review of consecutive patients with T2D who underwent RYGB between 1993 and 2017. T2D remission was defined as medication discontinuation and/or hemoglobin A1c <6.5%. Relapse was defined as recurrence medication use and/or hemoglobin A1c ≥6.5%. Independent correlates of T2D remission and relapse were identified using logistic regression. RESULTS: Six hundred and twenty-one patients (aged 46.7 ± 10.6 years; 30% on insulin; BMI 49.8 ± 8.3 kg/m2) had at least 1-year follow-up. Median follow-up was 4.9 years (range 1 to 23.6 years). Prevalence of T2D remission was 74% at 1 year, 73% from 1 to 3 years, 63% between 3 and 10 years, and 47% beyond 10 years. Ninety-three percent of remissions occurred within 3 years of RYGB, 25% relapsed. Median time to relapse was 5.3 years (interquartile range 3 to 7.8 years) after remission. Higher 1-year percentage total body weight loss, lack of preoperative insulin use, and younger age at operation were independently associated with T2D remission. Preoperative insulin use, lower percentage total body weight loss at 1 year, and greater percentage total body weight regain after 1 year were independently associated with T2D relapse. CONCLUSIONS: This longitudinal retrospective analysis shows that preoperative insulin use and age, 1-year weight loss, and regain after that influence T2D remission and relapse after RYGB. Referring patients at a younger age, before insulin is needed, and optimizing weight loss and preventing weight regain after RYGB can improve the rates and durability of T2D remission.

The Urology Match Process and the Limited Value of Post-Interview Communication for Program Directors.

OBJECTIVE: To understand the urology Match process from the perspective of residency program directors, with a particular focus on the role of postinterview communication. Recent surveys of urology applicants revealed that postinterview communication from programs often violates the rules of the American Urological Association Urology Residency Matching Program (the "Match"), and that such communication may influence applicant rank lists. METHODS: An anonymous, electronic survey seeking information regarding postinterview communication during the Match was sent to all program directors of urology residency programs participating in the 2017 AUA Match cycle. RESULTS: Of 138 surveys sent, 84 were completed for a 61% response rate. Among respondents, 97.6% percent of programs received postinterview communication from applicants, 76.2% of programs received an informal commitment from an applicant, and 38.3% failed to match an applicant who made an informal commitment. Most program directors (81.7%) responded that promises by applicants did not influence their rank list, and 57.1% state that participating in a second look does not have the potential to influence an applicant's rank order. Cumulatively, 76.2% of program directors felt that it was appropriate for applicants to cancel an interview if they provided 2 or more weeks' notice. CONCLUSION: The current study suggests that urology program directors do not ascribe significant value to continued contact with applicants after the interview, regardless of whether such contact is in the form of postinterview communication or in the form of second-look visits.

Contemporary practice patterns in the treatment of pediatric stone disease.

INTRODUCTION: To compare endourology versus pediatric urology exposure to pediatric stone cases during fellowship, comfortability in treating pediatric stone cases, and access to pediatric surgical equipment. MATERIALS AND METHODS: A survey was distributed to all pediatric urology fellowship programs and the Endourological Society. Age was stratified into < 12 months old, 12 months-4 years, 5-12 years, and 13-18 years. Exposure and comfortability performing extracorporeal shock wave lithotripsy (SWL), ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) were assessed across age groups. Exposure was assessed as 'yes/no' and comfortability was scaled from 1-5 ('would not do' to 'very comfortable'). RESULTS: Seventy-two surveys met inclusion criteria, with 23 (31.9%) from pediatric urologists and 49 (68.1%) by endourologists. During fellowship, pediatric urologists had more exposure to SWL in toddlers (p = 0.03) and school age children (p = 0.045), URS in toddlers (p = 0.012) and school age children (p = 0.002), and PCNL in infants (p = 0.031) and school age children (p = 0.025) compared to endourologists. Pediatric urologists were significantly more comfortable performing SWL in toddlers (p = 0.04), URS in toddlers (p = 0.04) and school age children (p = 0.04), and PCNL in school age children (p = 0.02) compared to endourologists. Endourologists were significantly more uncomfortable than pediatric urologists in performing URS in toddlers (p = 0.03) and PCNL in infants (p = 0.04) and school age children (p = 0.03). There were no differences in availability of pediatric equipment. CONCLUSIONS: Pediatric urologists, have significantly more exposure than endourologists during fellowship and are more comfortable performing surgical treatment for urolithiasis in most pediatric ages. Endourology fellowships may benefit from greater exposure to pediatric patients with stones.