Open versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database.

BACKGROUND: It is generally perceived that minimally invasive nephroureterectomy (MINU), especially in the form of robotic-assisted laparoscopy, is gaining an increasing role in many institutions. OBJECTIVE: The aim of our study was to investigate contemporary trends in the adoption of MINU in the United States compared with open nephroureterectomy (ONU). METHODS: Patients who underwent ONU or MINU between 2011 and 2021 were retrospectively analyzed using PearlDiver Mariner, an all-payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patients' characteristics, social determinants of health (SDOH), and perioperative complications. The primary objective assessed different trends and costs in NU adoption, while secondary objectives analyzed factors influencing the postoperative complications, including SDOH. Outcomes were compared using multivariable regression models. RESULTS: Overall, 15,240 patients underwent ONU (n = 7675) and MINU (n = 7565). Utilization of ONU declined over the study period, whereas that of MINU increased from 29 to 72% (p = 0.01). The 60-day postoperative complication rate was 23% for ONU and 19% for MINU (p < 0.001). At multivariable analysis, ONU showed a significantly higher risk of postoperative complications (odds ratio 1.33, 95% CI 1.20-1.48). Approximately 5% and 9% of patients reported at least one SDOH at baseline for both ONU and MINU (p < 0.001). CONCLUSIONS: Contemporary trend analysis of a large national dataset confirms that there has been a significant shift towards MINU, which is gradually replacing ONU. A minimally invasive approach is associated with lower risk of complications. SDOH are non-clinical factors that currently do not have an impact on the outcomes of nephroureterectomy.

Prior smoking and nasoseptal flap usage adversely impact quality of life and healing after endoscopic pituitary surgery.

OBJECTIVE: Endoscopic pituitary surgery (EPS) via the endonasal transsphenoidal approach is well established as an effective treatment modality for sellar masses. The objective of this study was to determine the relationship between key patient and operative variables and rhinological outcomes as determined by the 22-item Sino-Nasal Outcome Test (SNOT-22) and endoscopic scores following EPS. METHODS: Prospectively collected SNOT-22 scores and objective endoscopic data were analyzed from a cohort of 109 patients who underwent EPS and had at least 90 days of postoperative follow-up. Trends in postoperative SNOT-22 scores were analyzed using linear mixed-effects models. Time to return to baseline endoscopic score was analyzed using Cox regression. RESULTS: After adjusting for age and sex, the authors found that prior smokers had higher total and rhinological subdomain SNOT-22 scores (p < 0.01, 95% CI 5.82-16.39; p = 0.01, 95% CI 1.38-5.09, respectively) following EPS. Nasoseptal flap use also showed higher total and rhinological subdomain SNOT-22 scores (p = 0.01, 95% CI 1.62-12.60; p = 0.02, 95% CI 0.42-4.30, respectively). Prior sinonasal surgery and concurrent septoplasty did not affect the change in SNOT-22 total scores over time (p = 0.08, 95% CI -0.40 to 0.02; p = 0.33, 95% CI -0.09 to 0.29). CONCLUSIONS: The findings suggest that the evolution of healing and patient-reported quality of life (QOL) measures are multifaceted with contributions from two key variables. Nasoseptal flap usage and prior smoking status may adversely impact postoperative QOL. No variables were found to be associated with objective postoperative endoscopic findings.

Pigmented Epithelioid Melanocytoma of the Penis: A Case Report.

Pigmented epithelioid melanocytoma is rare cutaneous melanocytic proliferation, characterized by heavily pigmented melanocytes, with a potential for regional node metastasis, but with an overall favorable clinical course. Here, we describe an uncommon case of pigmented epithelioid melanocytoma involving the penis in an adolescent patient.

Minimally Invasive Adrenalectomy: A Population-Based Analysis of Contemporary Trends, Outcomes, Costs, and Impact of Social Determinants of Health.

INTRODUCTION: We sought to analyze temporal trends in the utilization of minimally invasive vs open adrenalectomy in the United States; to assess costs, perioperative outcomes, and the determining factors influencing these variables. METHODS: A retrospective analysis of claims data obtained from PearlDiver Mariner, a Health Insurance Portability and Accountability Act-compliant deidentified nationwide database of insurance billing records, was performed. Per-population utilization rates and trends were analyzed using negative binomial regression and trends tests respectively. Continuous and categorical variables were compared using 2-sided t tests and χ2 tests. Multivariable logistic regression analysis was conducted to identify predictors of perioperative complication. RESULTS: A total of 10,753 patients were identified (mean age 53.3 ± 16.1 years). Using the 2011 to 2014 time frame as reference, utilization of adrenalectomy decreased over time (incidence rate ratio for 2015-2018: 0.65 [95% CI 0.62-0.68, P < .001]; incidence rate ratio for 2019-2021: 0.39 [95% CI 0.37-0.41, P < .001]). Minimally invasive adrenalectomies increased significantly over time (P < .001). A greater number of adrenalectomies were performed by general surgeons compared with urologists (70.4% vs 29.5%). Complications were not significantly predicted by any surgical specialty. Significant predictors for complication rates were Charlson comorbidity index > 1 (odds ratio [OR] 1.11, 95% CI 1.09-1.13), presence of social determinants of health (OR 1.5, 95% CI 1.18-1.88) and open approach (OR 1.54, 95% CI 1.34-1.77). CONCLUSIONS: The number of adrenalectomies in the United States decreased over the past decade, with a shift towards minimally invasive approach. No difference in outcomes for general surgeons vs urologists can be observed. Social determinants of health are independent predictors of increased rate of complications.

Trends and Costs of Minimally Invasive Surgery for Kidney Cancer in the US: A Population-based Study.

OBJECTIVE: To analyze temporal trends and costs associated with the use of minimally invasive surgery (MIS) for kidney cancer in the US over the past decade. To examine the impact of social determinants of health (SDOH) on perioperative outcomes. METHODS: The PearlDiver Mariner, a national database of insurance billing records, was queried for this retrospective observational cohort analysis. The MIS population was identified and stratified according to treatment modality, using International Classification of Diseases and current procedural terminology codes. SDOH were assessed using International Classification of Diseases codes. Negative binomial regression was used to evaluate the overall number of renal MIS and Cochran-Armitage tests to compare the utilization of different treatment modalities, over the study period. Multivariable logistic regression analysis identified predictors of perioperative complications. RESULTS: A total of 80,821 MIS for kidney cancer were included. Minimally invasive partial nephrectomy adoption as a fraction of total MIS increased significantly (slope of regression line, reg. = 0.026, P <.001). Minimally invasive radical nephrectomy ($26.9k ± 40.9k) and renal ablation ($18.9k ± 31.6k) were the most expensive and cheapest procedures, respectively. No statistically significant difference was observed in terms of number of complications (P = .06) and presence of SDOH (P = .07) among the treatment groups. At multivariable analysis, patients with SDOH undergoing minimally invasive radical nephrectomy had higher odds of perioperative complications, while renal ablation had a significantly lower probability of perioperative complications. CONCLUSION: This study describes the current management of kidney cancer in the US, offering a socioeconomic perspective on the impact of this disease in everyday clinical practice.

Utility of Neonatal Findings in Early Diagnosis of a Case of Haberland Syndrome.

Haberland syndrome or encephalocraniocutaneous lipomatosis (ECCL) is a rare, congenital syndrome characterized by lipomas and noncancerous tumors of the scalp, skin, and eyes, in addition to intellectual disability, early onset seizures, and ectomesodermal dysgenesis. The diagnosis of ECCL is classically made by clinical presentation, imaging, and histopathological findings, but due to the spectrum of clinical presentation and symptom severity, diagnosis is often delayed until adolescence or adulthood. Here we present a newborn male infant, one of the earliest case diagnoses to our knowledge, with a unique constellation of physical exam and neuroimaging findings consistent with this diagnosis. We aim to address important neonatal findings to aid in early detection and diagnosis of this unique disease, which is thought to improve clinical outcomes and patient quality of life.

Is Academic Medicine Prepared to Teach About the Intersection of Childhood Experiences and Health? An Exploratory Survey of Faculty.

INTRODUCTION: Childhood experiences affect health across the lifespan. Evidence-based strategies targeting early-life stress are emerging. Nevertheless, faculty physicians' preparation to incorporate this science into practice has not been well studied. This study explores medical faculty knowledge and beliefs, timing and route of knowledge acquisition, perceived relevance and application of study topics, and characteristics associated with concept mastery. METHODS: The authors developed and administered an exploratory survey to faculty from six departments at two medical schools. The team analyzed responses using quantitative and qualitative methods. RESULTS: Eighty-one (8.8%) eligible faculty completed the survey. Of respondents, 53 (65.4%) achieved high knowledge, 34 (42.0%) high beliefs, and 42 (59.1%) high concept exposure question scores, but only 6 (7.4%) through a formal route. Although 78 (96.8%) respondents indicated that survey concepts are relevant, only 18 (22.2%) reported fully incorporating them in their work, and 48 (59.2%) identified the need for additional coaching. Respondents reporting full incorporation were significantly more likely to attain high concept exposure scores (17 respondents, 94.4%, versus 25 respondents, 39.7%, P < .001). Quantitative and qualitative analysis highlighted limited respondent awareness of trauma prevalence among health care workers, lack of familiarity with interventions, and time and resource challenges addressing childhood adversity. DISCUSSION: Although survey respondents had some familiarity with study concepts and perceived their relevance, most are not fully applying them. Results suggest that exposure to study concepts is associated with full incorporation. Therefore, intentional faculty development is essential to prepare faculty to include this science in practice.

Minimally Invasive Radical Nephroureterectomy: 5-Year Update of Techniques and Outcomes.

The gold standard treatment for non-metastatic upper tract urothelial cancer (UTUC) is represented by radical nephroureterectomy (RNU). The choice of surgical technique in performing UTUC surgery continues to depend on several factors, including the location and extent of the tumor, the patient's overall health, and very importantly, the surgeon's skill, experience, and preference. Although open and laparoscopic approaches are well-established treatments, evidence regarding robot-assisted radical nephroureterectomy (RANU) is growing. Aim of our study was to perform a critical review on the evidence of the last 5 years regarding surgical techniques and outcomes of minimally invasive RNU, mostly focusing on RANU. Reported oncological and function outcomes suggest that minimally invasive RNU is safe and effective, showing similar survival rates compared to the open approach.

Disparities in patient and system factors explain racial/ethnic disparities in delayed time to treatment in muscle invasive bladder cancer.

PURPOSE: Treatment delays in muscle invasive bladder cancer (MIBC) have been shown to be associated with worse outcomes. While every attempt is made to provide adequate treatment expeditiously, Black and Hispanic patients often experience delays at a higher rate than their White counterparts. This study aims to quantify the mechanisms that contribute to this disparity in treatment delay. METHODS: Retrospective analysis of clinical T-stages II-IVa MIBC patients who underwent surgical resection from 2004 to 2017 in the National Cancer Database. A causal inference mediation analysis using the counterfactual framework was implemented to estimate the extent to which racial/ethnic disparities in patient and system factors explain the racial/ethnic disparities in time to treatment. Mediators included income, education, comorbidities, insurance, and hospital type. RESULTS: Among 22,864 patients who met inclusion criteria, 7%, 3%, 2% were of Black, Hispanic, and Other race/ethnicity, respectively. In multivariable models, compared to White patients, Black, and Hispanic patients were associated with 26% (odds ratio = 1.26, 95% confidence interval = 1.12-1.42) and 29% (odds ratio = 1.29, 95% confidence interval = 1.07-1.55) increased odds of having a treatment delay relative to White patients. Mediation analyses suggested that 49% and 26% the treatment delay among Black and Hispanic patients, respectively, could be removed if an intervention equalized the distribution of academic treatment, education, and insurance status to that of White patients. Treatment at an academic hospital and education were the mediators that explained the largest portion of the racial/ethnic disparity in treatment delay. CONCLUSION: Black and Hispanic MIBC patients experience treatment delays when compared to White patients. Intervening upon patient and system factors could reduce substantial treatment delays. Future research is needed to identify other causes of disparities in treatment delays and may help population health initiatives to address racial/ethnic disparities in clinical settings.

Contemporary Assessment of the Economic Burden of Upper Urinary Tract Stone Disease in the United States: Analysis of One-Year Health Care Costs, 2011-2018.

Background: The U.S. health care landscape has witnessed numerous changes since implementation of the Affordable Care Act coupled with rising prevalence of upper urinary tract stone disease (SD). Data on the economic burden of SD during this period are lacking, providing the objective of our study. Materials and Methods: Adults diagnosed as having SD from 2011 to 2018 were identified from PearlDiver Mariner, a national all-payer database reporting reimbursements and prescription costs for all health care encounters. Patients undergoing operative and nonoperative care were identified. Time trends in annual expenditures were evaluated. Multivariable analysis evaluated determinants of spending. Results: A total of $10 billion were spent on SD management between 2011 and 2018 (median overall annual expenditure = $1.4 billion) among 786,756 patients. Inpatient, prescription, and outpatient costs accounted for 34.7%, 20.7%, and 44.6% of expenditures, respectively. Seventy-eight percent of patients were managed nonoperatively (total cost = $6.9 billion). The average overall cost per encounter was $13,587 ($17,102 for surgical vs $11,174 for nonsurgical care). Expenditures on inpatient care decreased significantly over time, while expenditures on prescriptions and outpatient care increased significantly. On multivariable analysis, a higher Charlson Comorbidity Index (CCI) was associated with higher spending, while associations for age, insurance, and region varied by treatment modality. Conclusions: The economic burden of SD management is substantial, dominated by expenditure on nonoperative management and outpatient care. Expenditures for prescription and outpatient care are rising, with the only consistent predictor of higher spending being CCI. Spending variation according to demographic, clinical, and geographic factors was evident.

Genital monkeypox superimposed on co-incident sexually transmitted infections in AIDS patient; a case report.

Monkeypox outbreaks were, until recently, mostly confined to Africa but a currently expanding worldwide outbreak has recently been designated a global emergency by the World Health Organization. Genital manifestation is common and can be confused with sexually transmitted infection (STI), posing a diagnostic challenge. We herein report a case of genital monkeypox superimposed on multiple co-incident STIs in a HIV patient and describe characteristic clinical findings and management.

The monetary costs of pediatric upper urinary tract stone disease: Analysis in a contemporary United States cohort.

INTRODUCTION: The prevalence of upper urinary tract stone disease (USD) in the United States is rising among both adults and children. Studies on the contemporary economic burden of USD management in the pediatric population are lacking. OBJECTIVE: To comprehensively analyze the economic impact of USD in a contemporary United States pediatric cohort, and to evaluate drivers of cost. STUDY DESIGN: A retrospective cohort study of pediatric patients (aged 0-17), diagnosed with USD between 2011 and 2018 were identified from PearlDiver-Mariner, an all-payer claims database containing diagnostic, treatment and prescription data provided in all treatment settings. Relevant International Classification of Disease (ICD-9 and ICD-10) and Current Procedural Terminology (CPT) codes were used for identification, and only patients with claims recorded for at least one year before and after entry of a diagnosis code for USD were selected (N = 10,045). Patients were stratified into those undergoing operative vs. non-operative management and for each patient, total 1-year healthcare costs following USD diagnosis, including same day and non-same day encounters, were analyzed. Factors associated with increased spending, as well as economic trends were analyzed. RESULTS: Overall, 8498 (85%) patients were managed non-operatively, while 1547 (15%) underwent a total of 1880 procedural interventions. Total overall cost was $117.1 million, while median annual expenditure was $15.8 million. Proportion of spending for outpatient, inpatient and prescription services was 52%, 32% and 16%, respectively (Table). Outpatient management accounted for 67% of overall spending. The proportion of patients managed non-operatively increased significantly over time, in parallel with spending for non-operative care. Comorbidity burden, treatment year and geographic region were among predictors of costs. DISCUSSION: Our study is the first to report actual insurance reimbursements for pediatric USD management using actual reimbursement data, examined across all treatment settings. We found that majority of the costs were for outpatient services and for non-operative management, with a rising tendency toward non-operative management over time. Regional variation in expenditures was evident. Specific reasons underlying these observed patterns could not directly be discerned from our dataset, but merit further investigation. CONCLUSION: Non-operative and outpatient management for pediatric USD are increasingly common, resulting in parallel shifts in spending. Notably, 52% of overall spending was for outpatient care. These insights into the contemporary economic burden of pediatric USD could provide value in shaping future healthcare policy.

Association Between Mental Health Conditions and Postoperative Complications After Gender-Affirming Surgery.

This cohort study assesses whether postoperative complications are associated with having been diagnosed with a mental health condition in patients who have undergone gender-affirming surgery.