Women with Rheumatoid Arthritis have similar rates of postpartum maternal outcomes compared to women without autoimmune disease.

OBJECTIVE: Limited data exist on the effect of rheumatoid arthritis (RA) on maternal postpartum outcomes. Using a real-world, electronic health record (EHR) cohort, we assessed maternal postpartum outcomes in RA. METHODS: In a large, de-identified EHR, we identified possible RA deliveries using ≥1 delivery ICD-9 or ICD-10-CM codes and a validated RA algorithm. RA cases were required to be diagnosed by a rheumatologist on chart review. Maternal postpartum outcomes included rates of blood transfusion, rates of infection up to 6 weeks postpartum defined by a clinician, and length of hospital stay. We also identified deliveries to women without autoimmune diseases. RESULTS: We identified 202 deliveries occurring after RA diagnosis and 596 deliveries to controls without autoimmune diseases. Postpartum infection rates were similar among RA patients and controls (8% vs. 4%, p = 0.10), as were red blood cell transfusion rates (2% vs. 2%, p = 1.00). RA case status was not significantly associated with postpartum infection (OR = 2.10, 95% CI 0.88 - 4.98, p = 0.09) but was significantly associated with preterm birth (OR = 2.11, 95% CI 1.38 - 3.23, p = 0.001). Corticosteroid use during pregnancy was common at 41%, while tumor necrosis factor inhibitor use was 13%. After adjusting for age at delivery and race, corticosteroid use at delivery was not associated with postpartum maternal infections but was associated with a significantly lower birthweight in RA cases. CONCLUSION: Women with RA have an increased risk of adverse pregnancy outcomes, particularly preterm birth. Our study highlights, however, that maternal postpartum outcomes such as postpartum infection and blood transfusion are not significantly increased in RA patients.

Hybrid guidewires: Analysis and comparison of the mechanical properties and safety profiles.

INTRODUCTION: Hybrid guidewires are commonly used in urology due to the advantage of an atraumatic hydrophilic tip, which facilitates negotiating tight areas, coupled with an unkinkable nitinol core shaft that is easy to work over due to the Teflon coating. Our aim was to compare the physical and mechanical properties of five commercially available hybrid guidewires to assess their characteristics and functionality. METHODS: In vitro testing was performed on the following straight-tipped 0.035 inch guidewires: Sensor™ (Boston Scientific), Solo™ Plus (Bard), UltraTrack (Olympus), Rio Tracer™ (Rocamed), and Motion™ (Cook). We evaluated characteristics impacting function (tip flexibility, shaft stiffness, lubricity) and safety (perforation force). Measurements included tip flexibility, lubricity, shaft buckling, and force required to perforate a sheet of aluminum foil. RESULTS: The Motion had the highest tip-bending force (p<0.00001). The Rio Tracer had the stiffest shaft (p<0.00001), followed by the Solo Plus and the Motion, which were significantly stiffer than the Sensor and UltraTrack (p<0.00001). The Solo Plus and UltraTrack had the greatest perforation force (p=0.00023), and the Rio Tracer had the lowest perforation force (p=0.016) when compared to the Sensor. There was no significant difference in frictional force between the five guidewires (p=0.1516). CONCLUSIONS: The Solo Plus and UltraTrack required the greatest force to perforate, which conveys a higher safety margin. The RioTracer is the stiffest guidewire, which may be beneficial for instrument insertion with the tradeoff of having a lower perforation force. The clinical significance of higher tip-bending forces (unfavourable) and higher shaft-bending forces (favourable) deserve further investigation.

Can a Simplified 12-Hour Nighttime Urine Collection Predict Urinary Stone Risk?

OBJECTIVE: To determine if there is correlation between nighttime 12-hour and traditional 24-hour urine collection in regard to chemistry values and the supersaturations of calcium oxalate, calcium phosphate, and uric acid for the metabolic evaluation of nephrolithiasis. MATERIALS AND METHODS: Ninety-five patients were prospectively enrolled from 2013 to 2015. Patients >18 years of age who presented to a tertiary stone clinic and who would normally be counseled for 24-hour urine collection were eligible for the study. Participants completed 24-hour urine collections twice, with each divided into 2 separate 12-hour collections. Day-time collection began after the first morning void and continued for 12 hours. The night collection proceeded for the next 12 hours through the first morning void. RESULTS: Forty-nine 24-hour samples from 35 patients met inclusion criteria and were included in the analysis. Overall, there was strong correlation between the night 12-hour and the 24-hour urine collections with R2 ranging from 0.76 for pH to 0.96 for Citrate. In our analysis of variability, the nighttime 12-hour collection differed from the 24-hour collection by 30% in 1-9 patients (2.0%-18.4%) based on individual chemistry value. Diagnosis of underlying metabolic abnormalities was concordant in 92% of patients. CONCLUSION: A 12-hour nighttime collection has strong correlation with 24-hour urine collection. As such, simplifying the metabolic evaluation to a 12-hour overnight collection may be feasible-improving compliance and decreasing patient burden.

Urolithiasis and Frequent CT Scans: Does Chronic Pain Play a Role?

INTRODUCTION: Urolithiasis is among the top 10 causes of Emergency Department (ED) visits in the United States. Approximately 50% of these patients undergo abdominopelvic CT scan, many more than once. We hypothesized that chronic pain conditions may contribute to frequent CT scans in patients who are evaluated in ED for urolithiasis. METHODS: A retrospective review of patients presenting to our tertiary care and the associated satellite EDs for urolithiasis, during the period 12/2012-05/2013, was performed. Patients with multiple ED visits and two or more abdominopelvic CT scans in any 6-month period were labeled as the frequent CT group. Control group consisted of similar patients who had no more than one CT scan in any 6-month period. Background information, number of CT scans for urolithiasis and other reasons, and the presence of chronic pain (established pain clinic visits, chronic pain medication, known chronic pain syndromes) were captured from charts. Wilcoxon rank-sum test and Fisher's exact test were used to compare variables. Multivariable logistic regression was performed to identify predictors associated with frequent CT scans. RESULTS: We identified 185 patients with frequent CTs and 139 patients in the control arm. Frequent CT scans were independently associated with chronic pain (odds ratio [OR]: 2.67, confidence interval [95% CI]: 1.55, 4.50), age (OR: 0.73, 95% CI: 0.60, 0.89), history of prior urolithiasis (OR: 2.15, 95% CI: 1.11, 4.15), and Medicaid insurance status (OR: 3.94, 95% CI: 1.66, 9.35). CONCLUSION: Chronic pain is a significant contributing factor to frequent CT scans among patients presenting to ED with urolithiasis, leading to increased radiation exposure and healthcare costs.

Predictors of Reporting Success With Increased Fluid Intake Among Kidney Stone Patients.

OBJECTIVE: To determine how kidney stone patients' knowledge, behaviors, and preferences toward fluid intake differed from those reporting being successful or unsuccessful at increasing fluid intake for prevention. MATERIALS AND METHODS: Three hundred two kidney stone patients filled out a survey on stone history, fluid intake success, and knowledge, behaviors, and preferences toward fluid intake. Responses were compared between those reporting being very successful at fluid intake and those reporting being not successful or only somewhat successful. Self-reported fluid intake success was correlated in a subset of 41 subjects using 24-hour urine volumes. RESULTS: Self-reported fluid intake success correlated significantly with 24-hour urine volumes. Unsuccessful fluid drinkers were less likely to be aware of their future stone risk and were less likely to be counseled on prevention by a urologist. Successful fluid drinkers reported the fewest barriers per person, were more likely to prefer water for fluid intake, and were more likely to like the "taste" of water. Strategies used for remembering to drink varied significantly with those unsuccessful most often reporting "just tried to remember" and those successful at fluid intake most likely to carry a water bottle. All groups reported similar perceived severity from stones, perceived benefits of drinking fluids, and preference for using urine color to monitor hydration. CONCLUSION: Awareness of future stone risk, preference for water, counseling on stone prevention by a urologist, and specific strategies used for increasing fluid intake varied between patients who were successful or unsuccessful with fluid intake. Addressing these differences may help improve fluid intake success.

Shared decision making: why do patients choose ureteroscopy?

To evaluate patient's characteristics that affects their decision on the management of asymptomatic renal calculi, and to determine the impact of anesthetic on the selection of shockwave lithotripsy (SWL). A survey was distributed to 100 patients in our multi-disciplinary stone clinic. The patients were given a hypothetical scenario of an asymptomatic 8 mm lower pole stone and descriptions for managements options including active surveillance (annual radiography, 40% chance of growth >10 mm within 4 years, 20% chance of passage), SWL under conscious sedation (65% success rate), and URS (90% success rate, with stent placement for 1 week). Patients were asked what was the most important variable impacting the choice of treatment. Patients preferred SWL (45%) over URS (32%) and active surveillance (23%). Patients with a previous experience with URS were more likely to choose it again (p = 0.0433). Decisions were driven primarily by success rate (52%), followed by risk of complications (29%), postoperative pain (7%) and others (12%). Patients choosing URS had the highest magnitude of history of pain (p = 0.03) and were more likely to prioritize success (78%) and less likely to prioritize surgical risk (13%) or anticipated pain after surgery (0%) (p = 0.01). Most (85%) of the patients would rely on the physician's recommendation for the treatment modality. Patients place differing value on risk versus success. As they rely heavily on the physician's recommendation, it is important that their urologist determine whether risk or success is of highest priority for them to facilitate a shared medical decision.

Patient Preference for Management of an Asymptomatic 15 mm Renal Calculus-Avoid Risk or Maximize Success?

INTRODUCTION: We evaluate patient preferences and the underlying factors determining decision making in the management of the asymptomatic 15 mm renal stone. METHODS: A survey was randomly distributed to 106 patients at our multidisciplinary stone clinic. Patients were given a hypothetical scenario of a 15 mm renal stone, and were asked to choose among the 3 treatment options of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy. The success rate, risk and morbidity associated with each treatment were provided to patients. Statistical analysis involved the Fisher exact and Wilcoxon signed rank tests. Analysis was performed using standard computer software with p <0.05 considered statistically significant. RESULTS: A total of 103 patients completed our survey, and 58 (56%) chose ureteroscopy, 26 (25%) chose percutaneous nephrolithotomy and 19 (19%) preferred shock wave lithotripsy as the treatment option. Patients who selected shock wave lithotripsy were increasingly concerned with risk rather than success rate (74% vs 16%, respectively). In contrast, patients who selected percutaneous nephrolithotomy were more concerned with the success rate rather than risk (81% vs 7.5%, respectively). Rates of success and risk were given approximately equal importance by patients selecting ureteroscopy (40% vs 48%, respectively). CONCLUSIONS: Patients who choose percutaneous nephrolithotomy are primarily motivated by a desire to maximize success while the choice of shock wave lithotripsy is primarily motivated by a desire to minimize risks. The majority of patients selected ureteroscopy as a procedure with a balance of moderate risk and moderate success. Understanding the factors driving patient decision making would allow urologists to more effectively manage expectations and provide counseling.

Nomogram to predict uric acid kidney stones based on patient's age, BMI and 24-hour urine profiles: A multicentre validation.

INTRODUCTION: We performed a multicentre validation of a nomogram to predict uric acid kidney stones in two populations. METHODS: We reviewed the kidney stone database of two institutions, searching for patients with kidney stones who had stone composition analysis and 24-hour urine collection from January 2010 to December 2013. A nomogram to predict uric acid kidneys stones based on patient age, body mass index (BMI), and 24-hour urine collection was tested. Receiver-operating curves (ROC) were performed. RESULTS: We identified 445 patients, 355 from Cleveland, United States, and 90 from Sao Paulo, Brazil. Uric acid stone formers were 7.9% and 8.9%, respectively. Uric acid patients had a significantly higher age and BMI, as well as significant lower urinary calcium than calcium stone formers in both populations. Uric acid had significantly higher total points when scored according to the nomogram. ROC curves showed an area under the curve of 0.8 for Cleveland and 0.92 for Sao Paulo. The cutoff value that provided the highest sensitivity and specificity was 179 points and 192 for Cleveland and Sao Paulo, respectively. Using 180 points as a cutoff provided a sensitivity and specificity of 87.5% and 68% for Cleveland, and 100% and 42% for Sao Paulo. Higher cutoffs were associated with higher specificity. The main limitation of this study is that only patients from high volume hospitals with uric acid or calcium stones were included. CONCLUSION: Predicting uric acid kidneys stone based on a nomogram, which includes only demographic data and 24-hour urine parameters, is feasible with a high degree of accuracy.

Stone formation and management after bariatric surgery.

Obesity is a significant health concern and is associated with an increased risk of nephrolithiasis, particularly in women. The underlying pathophysiology of stone formation in obese patients is thought to be related to insulin resistance, dietary factors, and a lithogenic urinary profile. Uric acid stones and calcium oxalate stones are common in these patients. Use of surgical procedures for obesity (bariatric surgery) has risen over the past two decades. Although such procedures effectively manage obesity-dependent comorbidities, several large, controlled studies have revealed that modern bariatric surgeries increase the risk of nephrolithiasis by approximately twofold. In patients who have undergone bariatric surgery, fat malabsorption leads to hyperabsorption of oxalate, which is exacerbated by an increased permeability of the gut to oxalate. Patients who have undergone bariatric surgery show characteristic 24 h urine parameters including low urine volume, low urinary pH, hypocitraturia, hyperoxaluria and hyperuricosuria. Prevention of stones with dietary limitation of oxalate and sodium and a high intake of fluids is critical, and calcium supplementation with calcium citrate is typically required. Potassium citrate is valuable for treating the common metabolic derangements as it raises urinary pH, enhances the activity of stone inhibitors, reduces the supersaturation of calcium oxalate, and corrects hypokalaemia. Both pyridoxine and probiotics have been shown in small studies to reduce hyperoxaluria, but further study is necessary to clarify their effects on stone morbidity in the bariatric surgery population.

Endoscopic Valves and Irrigation Devices for Flexible Ureteroscopy: Is There a Difference?

BACKGROUND AND PURPOSE: A variety of ureteroscopic irrigation systems are available, ranging from gravity-driven pressure bags to hand-operated pumps. Endoscopic valves maintain a watertight seal during ureteroscopy (URS) while facilitating passage of instruments. The clinical utility and ergonomics of such devices have not been established. We systematically compare the mechanical properties and usability of select valve devices and hand-operated irrigation systems in an in vitro setting. MATERIALS AND METHODS: In vitro testing of four different endoscopic valves: UroSeal adjustable endoscopic valve (US Urology), adjustable biopsy port seal (Gyrus ACMI), Blue Silicone Seal ACMI CS B612 (Gyrus ACMI), and REF ABP Biopsy Port Seal (ACMI Corporation) was performed. Usability was evaluated via insertion/extraction forces and insertion time for instruments, including a straight tip sensor wire, 0.035″, (Boston Scientific), a laser fiber (Flexiva 200, Boston Scientific), and an Ngage Nitinol Stone Extractor 1.7F (Cook Urological) through a flexible ureteroscope (Olympus URF P5, Olympus). Flow rate, flow time, and user fatigue were tested for two irrigation systems: The single action pumping system (SAP, Boston Scientific) and the Pathfinder Plus (PP, Utah Medical Products). RESULTS: The US needed the shortest time for both wire insertion and basket insertion (P=0.005, and P<0.001, respectively), while the BSS needed the greatest time for laser fiber insertion (P<0.005). The REF ABP needed the greatest force for withdrawal of the Ngage basket, the laser fiber, and the Captura stone grasper through a closed seal, while the US took the least amount of force for both laser fiber withdrawal and insertion via analysis of variance. Leak point pressure assessment demonstrated that the US was leak free at irrigation pressures up to 200 mm Hg, while the ABP, BSS, and the REF ABP devices demonstrated leaks ranging from 30 to 200 mm Hg. The average and peak flow of the SAP were significantly higher than that of the PP. Mean grip strength decreased significantly after operation of the SAP for 10 minutes, while no loss of grip strength was observed after use of the PP. CONCLUSIONS: The US valve has the advantage of facile manipulation of wires and baskets while maintaining a watertight seal, while other devices may be more cost-effective and secure. The PP has the advantage of less operator hand fatigue and ease of use, but the SAPS may allow for greater on-demand pressures. Further studies are needed to evaluate the effect of these irrigation systems on outcomes.

Fluid Bolus for Renal Colic: Current Practice.

INTRODUCTION: Historically the administration of intravenous fluid boluses in patients with urolithiasis and acute renal colic has been a standardized practice in the emergency department as a part of a conservative approach. In theory, an intravenous fluid bolus may promote ureteral fluid flow. However, randomized, controlled trials have shown no benefit of fluid boluses in this setting. We assessed current fluid bolus practices in community and tertiary care emergency departments. METHODS: We analyzed all emergency department visits in the Cleveland Clinic health care network with an ICD-9 diagnosis of 592.0 and computerized tomography of the abdomen/pelvis between December 7, 2010 and May 6, 2013. The incidence of intravenous fluid bolus administration was assessed, and patient demographics, serum laboratory values and urinalysis were collected. Cases with a blood urea nitrogen-to-creatinine ratio greater than 20 were considered hypovolemic and urine specific gravity values greater than 1.030 were considered suggestive of hypovolemia. RESULTS: Overall 60.2% (3,037 of 5,048) of patients with nephrolithiasis and computerized tomography received intravenous fluid boluses. The majority of patients who received a fluid bolus (79.12%) did not meet the criteria for volume depletion based on blood urea nitrogen-to-creatinine ratio or urine specific gravity. In addition, there was no statistically significant difference in the proportion of patients with a blood urea nitrogen-to-creatinine ratio greater than 20 among those who received fluid boluses (25.50%, 617 of 2,420) and those who did not (25.45%, 408 of 1,603; p=1.00). CONCLUSIONS: The use of forced fluids continues to be a common practice in emergency departments and they are frequently administered despite normal blood urea nitrogen-to-creatinine ratios. Thus, it is likely that fluids are not administered due to hypovolemia but rather due to practice approaches rooted in historical dogma and the lack of guidelines on this topic.

Tissue damage from ultrasonic, pneumatic, and combination lithotripsy.

PURPOSE: To conduct a comparative evaluation of ultrasonic, pneumatic, and dual ultrasonic (DUS) lithotripsy to predict the safety of probes on urinary tract tissue. MATERIALS AND METHODS: The Swiss Lithoclast Ultra (ultrasonic-only [US] and ultrasonic-pneumatic combination [US+P]) and the Gyrus ACMI Cyberwand (DUS) were evaluated. Fresh porcine ureter, bladder, and renal pelvis tissues were used with a hands-free setup to vertically apply 0, 400, or 700 g of force with each probe for a duration of 3 seconds, 5 seconds, or 3 minutes (or until perforation occurred). Data collection included whether perforation occurred and time to perforation. Histological analysis of nonperforated samples was used to compare the anatomical depth to which damage occurred. RESULTS: The total percentage of trials resulting in perforation for all tissue types, contact durations, and forces was found to be 8.5% (10/117) for US, 13.7% (16/117) for US+P, and 26.4% (31/117) for DUS. No perforations occurred with light contact (0 g) of probe force, regardless of tissue type, lithotripsy mode, or contact duration. Overall, the renal pelvis was most resistant to perforation (p=0.0004), while no difference was found between the bladder and ureter tissue (p=0.32). Force beyond 400 g and contact greater than 5 seconds increased risk for damage. CONCLUSIONS: Mode of lithotripsy, tissue type, probe force, and probe-tissue contact duration all significantly impacted the extent of damage and likelihood for perforation to occur. All devices and tissue types provided a reasonable margin of safety for probe-tissue contact times of 3 and 5 seconds with no more than 400 g of force.

Perivascular epithelioid cell tumour of the bladder.

A 39-year-old woman presented with a long history of pelvic pain and urinary urgency. Prior workup by her primary care doctor had been negative. The patient's gynaecologist ultimately referred her to a urologist following an ultrasound that revealed a possible bladder mass. MRI of the abdomen and pelvis demonstrated a 4 cm soft tissue lesion arising from the bladder. Cystoscopy showed an atypical mass on the anterior bladder wall, and pathological examination of the TURBT (transurethral resection of the bladder tumour) specimen revealed a perivascular epithelioid cell tumour (PEComa) with involvement of the detrusor muscle. The patient underwent a robotically assisted laparoscopic partial cystectomy. Final pathology confirmed a PEComa with negative margins. The patient had an uncomplicated postoperative course and is doing well following surgery. A surveillance cystoscopy at 6 months showed no evidence of recurrence. This case underscores the variability of clinical presentation of PEComas while proposing an appropriate method of surgical management.

Characterization of ductal and lobular breast carcinomas using novel prolactin receptor isoform specific antibodies.

BACKGROUND: Prolactin is a polypeptide hormone responsible for proliferation and differentiation of the mammary gland. More recently, prolactin's role in mammary carcinogenesis has been studied with greater interest. Studies from our laboratory and from others have demonstrated that three specific isoforms of the prolactin receptor (PRLR) are expressed in both normal and cancerous breast cells and tissues. Until now, reliable isoform specific antibodies have been lacking. We have prepared and characterized polyclonal antibodies against each of the human PRLR isoforms that can effectively be used to characterize human breast cancers. METHODS: Rabbits were immunized with synthetic peptides of isoform unique regions and immune sera affinity purified prior to validation by Western blot and immunohistochemical analyses. Sections of ductal and lobular carcinomas were stained with each affinity purified isoform specific antibody to determine expression patterns in breast cancer subclasses. RESULTS: We show that the rabbit antibodies have high titer and could specifically recognize each isoform of PRLR. Differences in PRLR isoform expression levels were observed and quantified using histosections from xenografts of established human breast cancer cells lines, and ductal and lobular carcinoma human biopsy specimens. In addition, these results were verified by real-time PCR with isoform specific primers. While nearly all tumors contained LF and SF1b, the majority (76%) of ductal carcinoma biopsies expressed SF1a while the majority of lobular carcinomas lacked SF1a staining (72%) and 27% had only low levels of expression. CONCLUSIONS: Differences in the receptor isoform expression profiles may be critical to understanding the role of PRL in mammary tumorigenesis. Since these antibodies are specifically directed against each PRLR isoform, they are valuable tools for the evaluation of breast cancer PRLR content and have potential clinical importance in treatment of this disease by providing new reagents to study the protein expression of the human PRLR.