Intradetrusor botox injection and augmentation cystoplasty trends among spina bifida patients at US freestanding children's hospitals.

INTRODUCTION: Intra-detrusor botulinum toxin (Botox) injection is a minimally invasive alternative to augmentation cystoplasty in patients with refractory neurogenic bladder. Botox was first used for neurogenic bladder children two decades ago. However, there are no existing guidelines on indications or use among patients with spina bifida. Furthermore, there are little data regarding its use relative to bladder augmentation and patient volume on a national scale. OBJECTIVE: We sought to investigate the contemporary trends of intra-detrusor Botox injection and augment cystoplasty in free-standing children's hospitals. STUDY DESIGN: We queried the Pediatric Health Information System database to identify spina bifida patients from 2016 to 2019 who underwent intra-detrusor Botox injection and augment cystoplasty based on CPT and ICD-10 codes. Total spina bifida population under care in the free-standing children's hospitals was estimated by all inpatient and ambulatory surgery encounters as denominators to calculate frequency by time for both intra-detrusor Botox injections and augmentation cystoplasty. RESULTS: In total, we included 1924 intra-detrusor Botox injections and 842 augmentation cystoplasties. 1413 (51.1%) patients were female. Median age at surgery was 10.0 (interquartile range 6.98-13.5) years. There was a significant increase in intra-detrusor Botox injection frequency (p < 0.001). While there was an overall decreasing, but not significant, trend for augmentation cystoplasty, there was a significant increase in this procedure during the summer months compared to the rest of the year (p < 0.001, Figure 1). Sensitivity analysis using only first intra-detrusor Botox injection per patient demonstrated similarly significant increasing trend. DISCUSSION: Use of intra-detrusor Botox injection for the management of neurogenic bladder has significantly increased among patients with spina bifida while augmentation cystoplasty has slightly decreased, but not significantly. CONCLUSIONS: Over time, practice patterns for the treatments of neurogenic bladder among spina bifida children have favored minimally invasive Botox injections while augmentation cystoplasty use has not significantly changed.

Novel phenotype characterization utilizing electrical impedance myography signatures in murine spinal cord injury neurogenic bladder models.

Neurogenic bladder (NB) affects people of all ages. Electric impedance myography (EIM) assesses localized muscle abnormalities. Here, we sought to investigate whether unique detrusor EIM signatures are present in NB due to spinal cord injury (SCI). Twenty-eight, 8-10 weeks old, C57BL/6J female mice were studied. Twenty underwent spinal cord transection; 8 served as controls. Cohorts were euthanized at 4 and 6 weeks after spinal cord transection. Each bladder was measured in-situ with EIM with applied frequencies of 1 kHz to 10 MHz, and then processed for molecular and histologic study. SCI mice had greater bladder-to-body weight ratio (p < 0.0001), greater collagen deposition (p = 0.009), and greater smooth-muscle-myosin-heavy-chain isoform A/B ratio (p < 0.0001). Compared with the control group, the SCI group was associated with lower phase, reactance, and resistance values (p < 0.01). Significant correlations (p < 0.001) between bladder-to-body weight ratios and EIM measurements were observed across the entire frequency spectrum. A severely hypertrophied phenotype was characterized by even greater bladder-to-body weight ratios and more depressed EIM values. Our study demonstrated distinct EIM alterations in the detrusor muscle of mice with NB due to SCI. With further refinement, EIM may offer a potential point-of-care tool for the assessment of NB and its response to treatment.

Dietary Risk Factors for Pediatric Kidney Stones: A Case-Control Study.

PURPOSE: Data are scarce regarding dietary risk factors for pediatric nephrolithiasis. Our objective was to perform a case-control study (nonmatched) of the association of dietary nutrients with pediatric urolithiasis. MATERIALS AND METHODS: We obtained dietary information from pediatric urolithiasis patients (from stone clinic in 2013-2016) and healthy controls (well-child visit at primary care in 2011-2012). Survey results were converted to standard nutrient intakes. Children younger than 5 years of age and those with extreme calorie intake values (<500 or >5,000 kcal/day) were excluded. The association of individual nutrients with urolithiasis was assessed by bivariate analysis results and machine-learning methods. A multivariable logistic regression model was fitted using urolithiasis as the outcome. RESULTS: We included 285 patients (57 stones/228 controls). Mean±SD age was 8.9±3.6 years (range 5-20). Of the patients 47% were male. After adjusting for age, sex, body mass index (obese/overweight/normal), calorie intake and oxalate, urolithiasis was associated with higher dietary sodium (OR=2.43 [95% CI=1.40-4.84] per quintile increase, p=0.004), calcium (OR=1.73 [95% CI=1.07-3.00] per quintile increase, p=0.034) and beta carotene (OR=2.01 [95% CI=1.06-4.18] per quintile increase, p=0.042), and lower potassium (OR=0.31 [95% CI=0.13-0.63] per quintile increase, p=0.003). Sensitivity analysis was performed by removing oxalate from the model and limiting the sample to patients aged 5-13 years, with similar results. CONCLUSIONS: In our cohort, higher dietary intake of calcium, sodium and beta carotene, and lower potassium intake were associated with pediatric urolithiasis. This is the first study using a detailed dietary survey to identify dietary risk factors for pediatric urolithiasis. Further research is warranted to delineate the mechanisms and to generate a lower risk diet profile for pediatric urolithiasis.

A Machine Learning Model to Maximize Efficiency and Face Time in Ambulatory Clinics.

INTRODUCTION: Ambulatory appointments are typically scheduled in fixed increments, resulting in suboptimal time utilization. Advanced analytics are rarely applied to address operational challenges in health care. We sought to develop a machine learning model that predicts the time pediatric urologists require to create a more efficient clinic schedule. METHODS: We prospectively collected data from January to April 2018. Variables included demographics and visit level covariates. The primary outcome was defined as in-room doctor time spent. Univariate analysis was performed. Data were split into train/test in a 4:1 ratio. Separate models using random forest were created for new and return visits. Two out-of-sample clinic days were used to compare the patient wait time between fixed-time visits and machine learning model. Patient punctuality simulation was performed 1,000 times for each day. RESULTS: A total of 256 visits (113 new/143 return) were included. Mean age at visit was 6.47 years. In univariate analysis, longer visits were significantly associated with new patients (p <0.01), testing (p <0.01), older patients and diagnoses like voiding dysfunction and neurogenic bladder. Conversely, morning clinic, previous urological surgery (p <0.01), recent postoperation (p <0.01) and diagnoses like penile complaints and hydrocele were associated with shorter visits. On average, our machine learning model predicted doctor time accurately to 3.6 (new patients) and 5.0 minutes (returning patients). In 1,000 simulated days with random patient punctuality machine learning reduced the wait time by 24% to 54%. CONCLUSIONS: Pediatric urologists' clinic time can be accurately predicted with machine learning models. This insight can be incorporated into a robust scheduling model to minimize patient wait time, increase clinical efficiency and likely improve family satisfaction.

Pattern recognition algorithm to identify detrusor overactivity on urodynamics.

AIMS: Detrusor overactivity (DO) of the bladder is a finding on urodynamic studies (UDS) that often correlates with lower urinary tract symptoms and drives management. However, UDS interpretation remains nonstandardized. We sought to develop a mathematical model to reliably identify DO in UDS. METHODS: We utilized UDS archive files for studies performed at our institution between 2013 and 2019. Raw tracings of vesical pressure, abdominal pressure, detrusor pressure, infused volume, and all annotations during UDS were obtained. Patients less than 1 year old, studies with calibration issues, or those with significant artifacts were excluded. In the training set, five representative DO patterns were identified. Candidate Pdet signal segments were matched to representative DO patterns. Manifold learning and dynamic time warping algorithms were used. Five-fold cross validation (CV) was used to evaluate the performance. RESULTS: A total of 799 UDS studies were included. The median age was 9 years (range, 1-33). There were 1,742 DO events that did not overlap with annotated artifacts (cough, cry, valsalva, movements). The AUC of the training sets from the five-fold CV was 0.84 ± 0.01. The five-fold CV leads to an overall accuracy 81.35%, and sensitivity and specificity of detecting DO events are 76.92% and 81.41%, respectively, in the testing set. CONCLUSIONS: Our predictive model using machine learning algorithms provides promising performance to facilitate automated identification of DO in UDS. This would allow for standardization and potentially more reliable UDS interpretation. Signal processing and machine learning interpretation of the other components of UDS are forthcoming.

Trends in Sickle Cell Disease-related Priapism in U.S. Children's Hospitals.

OBJECTIVE: To define rates of priapism diagnosis and inpatient admission among males with sickle cell disease (SCD). PATIENTS AND METHODS: We retrospectively reviewed the Pediatric Health Information System database for males aged <21 years treated 2004-2012. We identified patients with SCD and priapism based on the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Logistic regression and generalized estimating equation models were used to control for confounding and to adjust for within-hospital clustering of similar patients. RESULTS: We identified 17,186 males who were admitted 137,710 times during the study period. Of these, 362 (2.1%) were diagnosed with priapism on 748 admissions. There was a significant decrease in the number of priapism admissions among patients with SCD over time (0.81% in 2004 to 0.44% in 2012, P < .001). The number of patients diagnosed with SCD-related priapism varied over time without a statistically significant trend (2.3% in 2004, 2.69% in 2008, 1.01% in 2012, P = .34). Rates of priapism admissions (0-4.4%) varied widely between hospitals. Older patient age was associated with an increased likelihood of a priapism admission in the multivariate logistic regression model after adjusting for treatment year, hospital region, and for hospital-level clustering of similar patients. CONCLUSION: From 2004 to 2012, the number of admissions for SCD-related priapism declined whereas the number of individual patients diagnosed with SCD-related priapism did not. Rates of priapism-related admissions in males with SCD vary widely among PHIS hospitals.

Shock wave lithotripsy vs ureteroscopy: variation in surgical management of kidney stones at freestanding children's hospitals.

PURPOSE: Although shock wave lithotripsy has long been considered the gold standard for treatment of kidney stones in children, ureteroscopy has become increasingly common. The factors determining procedure choice at individual centers are unclear. We sought to identify patient and hospital factors associated with the choice between shock wave lithotripsy and ureteroscopy. MATERIALS AND METHODS: We searched the Pediatric Health Information System hospital database to identify patients with renal calculi who underwent inpatient or outpatient shock wave lithotripsy or ureteroscopy between 2000 and 2008. We used multivariate regression to evaluate whether procedure type was associated with hospital level factors, including treating hospital, region, size and teaching status, or patient level factors, including age, race, gender and insurance type. RESULTS: We identified 3,377 children with renal stones, of whom 538 (16%) underwent surgery (shock wave lithotripsy in 48%, ureteroscopy in 52%). Procedures in 445 patients at hospitals performing both procedures were included. The relative proportion of ureteroscopy increased during the study period (24% from 2000 to 2002 vs 50% from 2006 to 2008, p=0.0001). Procedure choice was not significantly associated with patient age (p=0.2), gender (p=0.1), race (p=0.07), insurance (p=0.9), hospital size (p=0.6) or teaching status (p=0.99). Procedure choice varied significantly by geographical region (p=0.05), regional population (p=0.002) and stone location (p<0.0001). On multivariable analysis controlling for stone location, gender and treatment year the treating hospital was still highly associated with procedure choice. CONCLUSIONS: There is wide variation in procedure choice for children with kidney stones at freestanding children's hospitals in the United States. Treatment choice depends significantly on the hospital at which a patient undergoes treatment.