Antibiotic utilization and symptom improvement in a retrospective cohort of women with urinary tract infection symptoms.

INTRODUCTION AND HYPOTHESIS: Urinary tract infections (UTIs) are one of the most common bacterial infections in women. We hypothesized that over half of those treated empirically would receive inappropriate antibiotics, those treated expectantly would have lower symptom improvement without antibiotics, and that overall progression to sequelae would be uncommon. METHODS: In this retrospective cohort study of women with UTI symptoms, we quantified the proportion who received inappropriate antibiotics in those treated empirically, defined as those with a negative urine culture or antibiotics that were changed according to culture sensitivities, and identified factors associated with symptom improvement during expectant management. Secondarily, we sought to determine the proportion of UTI sequelae in both groups. During the study time frame, a modified UTI Symptom Assessment (UTISA) questionnaire was administered at baseline and again, with a global rating for change instrument, when urine culture results were relayed. RESULTS: Analyses included 152 women, mean age 66.5 (SD 15.0) years, 30 (20%) received empiric antibiotics, and 122 (80%) expectant management. At baseline, the empiric group reported greater mean scores for dysuria (p < 0.01), urgency (p < 0.01), frequency (p < 0.01), and incomplete emptying (p < 0.01). Positive culture results were reported for 16 (53%) in the empiric group and 72 (59%) in the expectant group. Inappropriate antibiotics were prescribed to 18 (60%) of the empiric group. A negative urine culture was associated with improvement in symptoms in the expectant group. No subjects experienced UTI sequelae within 30 days of initial evaluation. CONCLUSION: In our cohort of older women with UTI symptoms, deferring antibiotics until urine culture  resulted appeared to be safe and decreased the use of inappropriate antibiotics.

Assessing academic productivity of U.S. otolaryngology departments using the h(5) index.

Objectives: We aim to examine the h(5) index of U.S. otolaryngology programs to help assess current academic productivity. Methods: A total of 116 otolaryngology departments with residency programs were included. Our primary outcome was the h(5) index, calculated cumulatively for faculty MDs, DOs, and PhDs within the department. Audiologists and clinical adjunct faculty were excluded. This was calculated over a 5-year period (2015-2019) using Elsevier's database SCOPUS. Faculty affiliation within SCOPUS was confirmed by cross-referencing department websites. The h(5) indices were calculated and then correlated with other publication metrics, including total publications by department and publications in major otolaryngology journals. Results: The h(5) index was highly correlated positively with other metrics of academic productivity, including total publications and publications in top 10 otolaryngology journals. Greater variability in data was noted as the h(5) index increased. Similar trends were observed when the h(5) was compared to the number of residents accepted per year. Rankings of departments by Doximity and US News and World Report were positively correlated with h(5) though they remained weaker when compared to other correlations. Conclusions: h(5) indices are a valuable tool to objectively assess academic productivity for otolaryngology residency departments. They are a better indicator of academic productivity than national rankings.

Surgical treatment of stress urinary incontinence: comparison of robotic-assisted Burch urethropexy with retropubic midurethral sling.

Synthetic retropubic midurethral slings (RMUS) and robotic-assisted Burch urethropexies (RA-Burch) are common surgical treatment options for stress urinary incontinence (SUI). Few data exist comparing the success of these two retropubic surgeries. This retrospective cohort study of RA-Burch and RMUS procedures compared the proportion of patients with subjective cure after RA-Burch compared to RMUS at our institution between 2016 and 2020. Subjective cure was defined as reporting no symptoms of SUI at longest follow-up. Chi-square, Fisher's exact, Mann-Whitney U tests, logistic regression, and Kaplan-Meier log-rank tests were used in analyses. The overall cohort of 235 subjects included 47 RA-Burch cases matched 1:4 with 188 RMUS cases. Patients who underwent RA-Burch were younger (p < .01), had lower BMIs (p = .04), and were more likely to have concomitant procedures, including hysterectomy (p < .01). There was no difference in subjective cure at longest follow-up (p = .76). Median follow-up was longer in the RA-Burch group (p < .01). There was no difference in early postoperative complications, EBL, treatment for persistent SUI, or new urge urinary incontinence at longest follow-up. Both groups experienced postoperative urinary retention at a similar rate, although 4 RMUS patients required sling lysis and one patient experienced a mesh exposure. Patients undergoing RA-Burch had significantly longer OR times when no concomitant procedure was performed (p < .01). There were no significant predictors of SUI recurrence when controlling for baseline variables. This study suggests that RA-Burch and RMUS may be equally efficacious for patients with symptoms of SUI desiring surgical management.

Quantifying the Severity of Metopic Craniosynostosis Using Unsupervised Machine Learning.

BACKGROUND: Quantifying the severity of head shape deformity and establishing a threshold for operative intervention remains challenging in patients with metopic craniosynostosis (MCS). This study combines three-dimensional skull shape analysis with an unsupervised machine-learning algorithm to generate a quantitative shape severity score (cranial morphology deviation) and provide an operative threshold score. METHODS: Head computed tomography scans from subjects with MCS and normal controls (5 to 15 months of age) were used for objective three-dimensional shape analysis using ShapeWorks software and in a survey for craniofacial surgeons to rate head-shape deformity and report whether they would offer surgical correction based on head shape alone. An unsupervised machine-learning algorithm was developed to quantify the degree of shape abnormality of MCS skulls compared to controls. RESULTS: One hundred twenty-four computed tomography scans were used to develop the model; 50 (24% MCS, 76% controls) were rated by 36 craniofacial surgeons, with an average of 20.8 ratings per skull. The interrater reliability was high (intraclass correlation coefficient, 0.988). The algorithm performed accurately and correlates closely with the surgeons assigned severity ratings (Spearman correlation coefficient, r = 0.817). The median cranial morphology deviation for affected skulls was 155.0 (interquartile range, 136.4 to 194.6; maximum, 231.3). Skulls with ratings of 150.2 or higher were very likely to be offered surgery by the experts in this study. CONCLUSIONS: This study describes a novel metric to quantify the head shape deformity associated with MCS and contextualizes the results using clinical assessments of head shapes by craniofacial experts. This metric may be useful in supporting clinical decision making around operative intervention and in describing outcomes and comparing patient population across centers.

National Survey Using CFIR to Assess Early Outpatient Specialty Palliative Care Implementation.

CONTEXT: The American Society of Clinical Oncology (ASCO) recommends that outpatient specialty palliative care (OSPC) be offered within eight weeks of an advanced cancer diagnosis. To meet the rising demand, there has been an increase in the availability of OSPC services at National Cancer Institute (NCI)-designated cancer centers; however, many OSPC referrals still occur late in the disease course. OBJECTIVES: Using the Consolidated Framework for Implementation Research (CFIR), we evaluated facilitators and barriers to early OSPC implementation and associated clinic characteristics. METHODS: We selected relevant CFIR constructs for inclusion in a survey that was distributed to the OSPC clinic leader at each NCI-designated cancer center. For each statement, respondents were instructed to rate the degree to which they agreed on a five-point Likert scale. We used descriptive statistics to summarize responses to survey items and explore differences in barriers based on OSPC clinic size and maturity. RESULTS: Of 60 eligible sites, 40 (67%) completed the survey. The most commonly agreed upon barriers to early OSPC included inadequate number of OSPC providers (73%), lack of performance metric goals (65%), insufficient space to deliver early OSPC (58%), logistical challenges created by early OSPC (55%), and absence of formal interdisciplinary communication systems (53%). The most frequently reported barriers differed according to clinic size and maturity. CONCLUSION: Most barriers were modifiable in nature and related to the "Inner Setting" domain of the CFIR, which highlights the need for careful strategic planning by leadership when implementing early OSPC.

Magnetic Resonance Elastography of the Liver: A Single-Institution Review of Cases Performed in a 5-Year Interval.

OBJECTIVE: This study aimed to assess the diagnostic accuracy of magnetic resonance elastography (MRE) in detecting hepatic fibrosis and determining clinically relevant stiffness cutoff values per stage of fibrosis. METHODS: This retrospective study assessed 1488 hepatic MRE evaluations performed at a single institution for 5 years. Mean liver stiffness measurements were collected from 282 patients who had an MRE study within 1 year of histopathologic analysis. Areas under receiver operating characteristic curves were calculated for each stage of fibrosis with nonparametric ordinal measures of accuracy, and Youden Index was determined. RESULTS: Mean liver stiffness measurement values were as follows: F0, 2.5± 0.55 kPa; F1, 3.1± 0.80 kPa; F2, 3.4±0.95 kPa; F3, 4.7±1.44 kPa; and F4, 7.9± 2.64 kPa. Nonparametric ordinal measures of accuracy per fibrosis stage were as follows: F0: 0.934, P < 0.001; F0-F1: 0.917, P < 0.001; F0-F2: 0.944, P < 0.001; and F0-F3: 0.941, P < 0.001. Youden Index values for fibrosis stages F2, F3, and F4 were 3.9, 4.0, and 4.5 kPa, respectively. CONCLUSIONS: Magnetic resonance elastography is an accurate diagnostic tool in assessing liver fibrosis.

Patient Preparedness for Pelvic Organ Prolapse Surgery: A Randomized Equivalence Trial of Preoperative Counseling.

OBJECTIVE: Preoperative counseling can affect postoperative outcomes and satisfaction. We hypothesized that patient preparedness would be equivalent after preoperative counseling phone calls versus preoperative counseling office visits before prolapse surgery. METHODS: This was an equivalence randomized controlled trial of women undergoing pelvic organ prolapse surgery. Participants were randomized to receive standardized counseling via a preoperative phone call or office visit. The primary outcome was patient preparedness measured on a 5-point Likert scale by the Patient Preparedness Questionnaire at the postoperative visit. A predetermined equivalence margin of 20% was used. Two 1-sided tests for equivalence were used for the primary outcome. RESULTS: We randomized 120 women. The study was concluded early because of COVID-19 and subsequent surgery cancellations. There were 85 participants with primary outcome data (43 offices, 42 phones). Mean age was 62.0 years (±1.0) and 64 (75.3%) had stage III or stage IV prolapse. The primary outcome, patient preparedness measured at the postoperative visit, was equivalent between groups (office, n = 43 [97.7%]; phone, n = 42 [97.6%], P < 0.001). Most women reported they would have preferred a phone call (n = 66, 65.5%) with more women in the phone group expressing this preference than the office group (office 40.5% vs phone 90.5%, P < 0.001). Ultimately, nearly all women (96.5%) were satisfied with their method of counseling. CONCLUSIONS: Preoperative counseling phone calls were equivalent to office visits for patient preparedness for pelvic organ prolapse surgery. This study demonstrates patient acceptance of phone calls for preoperative counseling. Telehealth modalities should be considered as an option for preoperative patient counseling.

Preoperative Counseling Method and Postoperative Opioid Usage: A Secondary Analysis of the PREOP Study.

OBJECTIVE: The purpose of this analysis is to determine if postoperative opioid usage differs among women randomized to office or phone preoperative counseling for pelvic organ prolapse surgery. METHODS: This was a planned exploratory analysis of the Patient Preparedness for Pelvic Organ Prolapse Surgery study, which randomized women to standardized preoperative counseling by office visit or phone call before prolapse surgery. Inclusion criteria were the completion of the assigned counseling intervention and submission of a 7-day postoperative pain and medication diary. Multivariable logistic regression was done to assess the association between counseling method and total opioid use while controlling for variables significant on univariate analysis (surgery type and county of residence). RESULTS: There were 84 participants with postoperative data (41 office, 43 phone). Median total number of 5-mg oxycodone tablets used was higher for the office group (5 [interquartile range, 0-10]) than the phone group (0 [interquartile range, 0-2], P = 0.002). On multivariable logistic regression, women who underwent phone counseling were less likely to be in the highest third of opioid use when controlling for surgery type and county of residence (odds ratio, 0.23; P = 0.012; 95% confidence interval, 0.07-0.72). Daily pain scores and nonopioid medication use (nonsteroidal anti-inflammatory medications and acetaminophen) were similar between groups (P > 0.05). CONCLUSIONS: Despite similar pain scores, women who received preoperative phone counseling before pelvic organ prolapse surgery had lower opioid utilization than those with office counseling. Further research is needed to determine the optimal method of preoperative counseling and its role in postoperative pain management.