Wiskott Aldrich syndrome: healthcare utilizations and disparities in transplant care.

Wiskott Aldrich syndrome (WAS) is a rare disease and hematopoietic stem cell transplant (HCT) is considered the treatment modality of choice for WAS. We conducted a cross-sectional analysis on the KIDS' pediatric inpatient database and compared hospitalization rates, complications and healthcare utilizations in the transplant and non-transplant arms. Of the 383 pediatric admissions with diagnosis of WAS between 2006-2012, 114 underwent transplant and 269 did not. The non-transplant arm included older children, female patients and more African Americans. Death rates, income and payer source were similar in both arms, however the total charge for each admission was higher in the transplant arm. Emergency room visits were similar but non-elective admissions were more in the non-transplant arm. Length of stay was prolonged in the transplant arm. When comparing morbidities, lymphomas, ulcerative colitis and autoimmune complications of WAS were seen only in the non-transplant arm. Our study shows that transplant is the largest contributor to healthcare utilization in WAS patients. We identified healthcare disparities based on race and socioeconomic status and found that this rare disease is being appropriately directed to centers with HCT expertise. We noted a change in practice moving away from splenectomy in WAS patients.

Gender Disparity in Cystectomy Postoperative Outcomes: Propensity Score Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: While female gender is considered a protective determinant in the majority of cancers, outcomes in women diagnosed with bladder cancer have continued to show disproportional mortality when compared with men. OBJECTIVE: The aim of this retrospective propensity score-matched analysis was to evaluate the intra- and postoperative differences among genders, as well as to evaluate reproductive organ-preserving radical cystectomy (ROPRC) as compared with radical cystectomy (RC) as a potential confounder in female cystectomy patients. DESIGN, SETTING, AND PARTICIPANTS: Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), men and women undergoing a cystectomy between 2011 and 2017 were analyzed. In addition, females undergoing ROPRC and RC were analyzed for immediate postoperative outcomes. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Men and women undergoing a cystectomy were evaluated through propensity score matching (PSM) for baseline differences using a 1:1 caliper width of 0.2 to the nearest neighbor. Using multivariable logistic regression analysis, we evaluated differences in the risk of readmission, complications, and reoperation in the immediate postsurgical period in males and females. Similarly, differences were assessed in ROPRC and RC groups. RESULTS AND LIMITATIONS: We achieved a balance between males and females after PSM: 1263 males and 1263 females treated with cystectomy. The risks of readmission (adjusted odds ratio [aOR] 1.228 [1.005-1.510], p=0.045), superficial surgical site infection (aOR 1.507 [1.095-2.086], p=0.012), and transfusion (aOR 2.031 [1.713-2.411], p<0.001) were increased in females undergoing a cystectomy compared with males. No differences were observed in surgical outcomes in ovarian sparing/RC cohort. CONCLUSIONS: Using the 2011-2017 NSQIP database, we were able to demonstrate an increased rate of postoperative transfusion, readmission rate, and surgical site infection in females who underwent cystectomy. Our findings suggest that females experience an increased rate of complications in the immediate postoperative period. This may ultimately lead to worse oncologic outcomes in females after an RC. Lastly, we did not find any increased rate of complications in ROPRC as compared with RC. PATIENT SUMMARY: This study highlights differences in immediate postoperative outcomes between males and females undergoing cystectomy for bladder cancer. Some of these potential differences include higher risk of infection, transfusion, and readmission. These differences may predispose females to worse long-term outcomes. In addition, due to potential benefits of ovarian preservation in the recent literature, we also evaluated the risks and complications of ovarian sparing cystectomy. We found ovarian preservation to be a safe and feasible procedure in a highly selected group of patients.

Epidural Anesthesia is Associated With Increased Complications in Cystectomy Patients: A NSQIP Analysis.

OBJECTIVE: To identify differences in short-term outcomes and readmission rates in cystectomy patients managed with general anesthesia compared to those undergoing general anesthesia and adjuvant epidural anesthesia. METHODS: Utilizing the National Surgical Quality Inpatient Program database, patients who underwent a cystectomy with ileal conduit between 2014 and 2017 were included. Patients were further subdivided based on additional anesthesia modality; general anesthesia vs general anesthesia plus epidural anesthesia. Propensity score-matching was used to adjust for baseline differences between cohorts using 1:1 caliper width of 0.15 for the propensity score through the nearest neighbor. Stepwise multivariable logistic regression was used to identify preoperative and intraoperative predictors associated with 30-day procedure related readmission, complications, and length of stay. RESULTS: About 2956 patients met our inclusion and exclusion criteria and eligible for propensity score matching. Compared to general anesthesia, adjuvant epidural anesthesia showed an increased odds of procedure related complications (adjusted Odds Ratio (aOR): 1.264, 95% CI: 1.019-1.567, P = .033). There was an increased trend for development of pulmonary emboli (13 [1.8%] vs 4 [0.5%], P = .051) in the adjuvant epidural cohort. Combined general with epidural anesthesia demonstrated no difference in length of stay, readmission, or reoperation rate in comparison to general anesthesia alone. CONCLUSION: Cystectomy patients who underwent general anesthesia plus epidural anesthesia demonstrated a higher percentage of any procedural related complication without change in postoperative stay, reoperation rate, or readmission rate compared to patients undergoing general anesthesia alone.

Effects of an Interprofessional Student-Led Sexual Education Program on Self-Efficacy and Attitudes About Sexual Violence in Youths in Juvenile Detention.

STUDY OBJECTIVE: We aim to explore the impact of an interprofessional graduate student-led sexual education curriculum on sexual self-efficacy, perceived importance of sexual consent, and willingness to intervene against sexual violence in the high-risk population of detained youths. DESIGN, SETTING, AND PARTICIPANTS: Medical, nursing, social work, and physician assistant students implemented a 3-session, comprehensive sexual health curriculum for detained youths (n = 253). INTERVENTIONS AND MAIN OUTCOME MEASURES: The curriculum from Son et al (2017) was adapted to include a more targeted curriculum on consent and safe relationships. Youths completed pre- and postintervention assessments that evaluated their sexual self-efficacy and violence-related beliefs and behaviors. RESULTS: Detained youths completing the curriculum showed statistically significant increases in the sexual self-efficacy (P < .001), view of the importance of consent (P < .001), and willingness to intervene (P = .0027). The subset of male individuals and adolescents aged 17-19 years achieved statistically significant improvement in each category; adolescents aged 12-14 years did not. Female participants showed statistically significant improvement in sexual self-efficacy scores only. CONCLUSIONS: The curriculum addressing topics of consent and sexual violence was effective in improving detained youths' belief in their ability to safely navigate a sexual encounter and their attitudes toward sexual assault. Additional research on gender- and age-specific programming and the long-term impact on sexual health risk behaviors is needed.

Acute Urinary Retention Due to Late Migration of a Retained Bullet to the Urethral Meatus.

Urethral obstruction due to retained bullets migrating into the genitourinary system has rarely been reported. The literature describes 2 main methods of retained bullet removal from the genitourinary system: (1) spontaneous expulsion during voiding and (2) manual extraction due to urethral obstruction causing acute urinary retention. We present a case in which a 21-year-old man presented with acute urinary retention 3 years after suffering a gunshot wound to the abdomen. A retained bullet eroded through the bladder wall, migrated through the bladder and urethra, and eventually became lodged in the external urethral meatus, causing obstruction and urinary retention.

Obesity misclassification and the metabolic syndrome in adults with functional mobility impairments: Nutrition Examination Survey 2003-2006.

OBJECTIVES: The purpose of this study was to estimate the degree of obesity misclassification between body mass index (BMI) and body fat percentage in adults with functional mobility impairment, and to determine cardiometabolic risk profiles. METHODS: Data from the combined 2003-2006 National Health and Nutrition Examination Survey (NHANES) were incorporated. The representative sample included 852 individuals, aged 20-85years, reporting at least one major physical limitation related to mobility or lower body function, and 4724 individuals reporting no impairments. Body mass index, percent body fat (%BF) as determined by dual energy X-ray absorptiometry (DXA), objectively measured sedentary behavior and activity, and markers of cardiometabolic risk were compared between adults with and without functional mobility impairments. Among functional mobility impaired individuals, sensitivity, specificity, and receiver operating characteristic curves were used to evaluate the performance of BMI as a continuous variable, as well as various BMI thresholds to detect obesity defined by sex-specific %BF cutoffs. RESULTS: Adults with functional mobility impairments were older, had larger waist circumferences (WC), had greater prevalence of obesity according to BMI and %BF, were more sedentary, had less physical activity, and had higher overall cardiometabolic risk. The standard BMI cutoff for obesity had excellent specificity in both men (100%) and women (98.4%) with functional mobility impairment, but sensitivity was poor (<55%). Whereas approximately 36% and 43% of impaired men and women fell into the obese BMI category, over 80% of men and women were obese according to %BF. Individuals with high %BF who were misclassified as not obese, according to BMI, had a significantly higher prevalence of the metabolic syndrome (17.6%) compared to subjects with normal BMI and low %BF (2.1%). CONCLUSIONS: Obesity misclassification and cardiometabolic risk are prevalent among individuals with functional mobility impairments, and thus diagnostic screening for obesity should be modified to account for %BF and/or waist circumference. Behavioral interventions to decrease sedentary behavior, increase activity, and reduce abdominal obesity are warranted.