Implementing Change Through an Outpatient Antibiotic Stewardship Program.

PURPOSE: We sought to implement a multi-pronged behavioral intervention to reduce and tailor antibiotic use for two common urologic outpatient procedures. MATERIALS AND METHODS: This study was a non-blinded intervention study that consisted of a pre-intervention phase (11/2018-1/2019), an intervention phase (1/2020-12/2020) in which a multi-pronged behavioral intervention was implemented, and a post-intervention phase (1/2021-3/2021). We examined antibiotic use for cystoscopy and transrectal prostate biopsy at three separate urologic outpatient clinics. A multi-pronged behavioral intervention consisted of formal physician education, modification of the electronic health order sets, clinic staff education, literature review, development and introduction of patient questionnaires, and individual audit feedback. The primary outcome was 30-day infections. Secondary outcomes were adherence to the recommended antibiotic protocols, questionnaire completion, and Escherichia coli outpatient antibiograms. RESULTS: A total of 2374 patients underwent 3047 cystoscopies and 547 patients underwent 559 prostate biopsies. The proportions of cystoscopy patients receiving antibiotic prophylaxis and prostate biopsy patients receiving augmented antibiotic prophylaxis decreased 33% and 35%, respectively. The odds of post-cystoscopy infection were not different between the pre-intervention and intervention phases and were lower in the post-intervention phase. The odds of post-biopsy infection were not changed between the pre-intervention and intervention or between the pre-intervention and post-intervention phases. CONCLUSIONS: Implementing a multi-pronged behavioral intervention reduced and tailored antibiotic use without an increase in 30-day infections. These findings suggest that outpatient antibiotic stewardship and facilitating rapid adoption of guidelines can be accomplished via this approach.

Effect of Private Equity Ownership on Access to Outpatient Urologic Cancer Care in Medicare Recipients.

OBJECTIVE: To compare appointment availability and wait times between private equity-owned and non-private equity-owned urology clinics for 2 common urologic complaints. METHODS: We identified all PE-owned urology clinic locations as of June 2022 (n = 390). For each PE-owned location, a geographically matched, non-PE-owned clinic was identified. Each office was called using a "secret shopper" method with a standardized script, requesting an appointment on behalf of their Medicare-aged father for evaluation of gross hematuria or elevated prostate-specific antigen (PSA). The primary outcome was appointment availability, and the secondary outcome was wait time until soonest appointment. RESULTS: PE-owned and non-PE-owned clinics treated the presenting complaints with similar frequency (gross hematuria: 85% vs 88%, P = .3, elevated PSA: 93% vs 94%, P = .5). Wait time in days until the next available appointment was similar for PE-owned clinics compared to non-PE clinics for both complaints (gross hematuria: 16 vs 13, P = .06, elevated PSA: 18 vs 19, P = .7). If available, the time in days until the soonest next appointment with an advanced practice provider was also similar between PE-owned and non-PE clinics (gross hematuria: 13 vs 11, P = .07, elevated PSA: 13 vs 12, P = .6). CONCLUSION: Overall, there were no large-scale differences in access to outpatient urologic care between PE-owned clinics and non-PE-owned clinics. Access to care in PE-owned clinics is likely clinically similar to geographic-matched controls for Medicare patients with gross hematuria or elevated PSA.

Controversies in prostate cancer screening.

Prostate cancer is the second most diagnosed cancer and the fifth leading cause of cancer death among men worldwide. In the 1980s, the development and implementation of Prostate-Specific Antigen (PSA) testing for diagnosing prostate cancer led to a surge in the number of prostate cancer diagnoses. We explore the trends in recommendations and new innovations in adjunctive testing for prostate cancer screening.

Outcomes of Initial Transcorporal Versus Standard Placement of Artificial Urinary Sphincter in Patients With Prior Radiation.

OBJECTIVE: This study aimed to evaluate both device and functional outcomes of men who underwent initial artificial urinary sphincter (AUS) placement after pelvic radiation using the transcorporal versus the standard approach. METHODS: A retrospective review of patients who underwent first-time AUS placement after pelvic irradiation for prostate cancer was conducted between January 2008 and June 2020. Patients were grouped by transcorporal versus standard device placement. The primary outcomes of interest included major complications (revision or explant surgery) and functional outcomes (pads per day, International Prostate Symptom Score {IPSS}, quality of life {QOL} score). RESULTS: We identified 45 patients who underwent first-time AUS with a history of prior pelvic irradiation for prostate cancer, 27 underwent transcorporal placement and 18 underwent standard placement. Transcorporal AUS placement resulted in a significantly lower number of major complications (p=0.01), explants (p=0.02), and revisions (p=0.04) The transcorporal artificial urinary sphincter group had better postoperative pads per day (p=0.04), IPSS (p<0.01), and IPSS QOL score (p<0.01). CONCLUSIONS: Initial transcorporal artificial urinary sphincter placement is a promising technique with lower rates of major complications in patients with a history of prior pelvic radiation and had better functional urinary outcomes.

Hemopexin deficiency promotes acute kidney injury in sickle cell disease.

Acute kidney injury (AKI) is a major clinical concern in sickle cell disease (SCD). Clinical evidence suggests that red cell alarmins may cause AKI in SCD, however, the sterile inflammatory process involved has hitherto not been defined. We discovered that hemopexin deficiency in SCD is associated with a compensatory increase in α-1-microglobulin (A1M), resulting in an up to 10-fold higher A1M-to-hemopexin ratio in SCD compared with healthy controls. The A1M-to-hemopexin ratio is associated with markers of hemolysis and AKI in both humans and mice with SCD. Studies in mice showed that excess heme is directed to the kidneys in SCD in a process involving A1M causing AKI, whereas excess heme in controls is transported to the liver as expected. Using genetic and bone marrow chimeric tools, we confirmed that hemopexin deficiency promotes AKI in sickle mice under hemolytic stress. However, AKI was blocked when hemopexin deficiency in sickle mice was corrected with infusions of purified hemopexin prior to the induction of hemolytic stress. This study identifies acquired hemopexin deficiency as a risk factor of AKI in SCD and hemopexin replacement as a potential therapy.