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1.
World J Urol ; 41(4): 981-992, 2023 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-36856833

RESUMO

PURPOSE: The aim of this review is to highlight the unique factors that predispose geriatric patients to nephrolithiasis and to compare the utility and efficacy of surgical techniques in this specific patient population. METHODS: PubMed and EMBASE databases were reviewed, and studies were organized according to surgical treatments. RESULTS: Few prospective studies exist comparing kidney stone removal in the elderly to younger cohorts. In addition, various age cut-offs were used to determine who was considered elderly. Most studies which analyzed Percutaneous Nephrolithotomy (PCNL) found a slightly higher rate of minor complications but comparable stone free rate and operative time. For ureteroscopy (URS) and extracorporeal shockwave lithotripsy (ESWL), there were minimal complications observed and no difference in clinical success in the elderly. All surgical techniques were presumed to be safe in the elderly and most found no difference in stone-free rates. CONCLUSIONS: Unique attributes of the geriatric population contribute to stone formation and must be considered when determining appropriate management modalities. This review provides an overview of the utility and efficacy of PCNL, URS and ESWL in the elderly, as well as a porposed algorithm for management in this population.


Assuntos
Cálculos Renais , Litotripsia , Nefrolitotomia Percutânea , Humanos , Idoso , Estudos Prospectivos , Cálculos Renais/cirurgia , Ureteroscopia/métodos , Resultado do Tratamento
2.
J Urol ; 202(6): 1136-1142, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31219763

RESUMO

PURPOSE: The BCAN (Bladder Cancer Advocacy Network) Patient Survey Network identified pain during intravesical procedures as a research priority for patients. Although intraurethral lidocaine is the standard of care in this setting, evidence of its use is equivocal. We systematically reviewed studies of interventions to reduce discomfort during cystoscopy and intravesical therapy of bladder cancer. We performed a meta-analysis of interventions using available randomized, controlled trials. MATERIALS AND METHODS: Search terms derived from the key questions were incorporated into the literature search constructed by a research librarian and the English medical literature from 1990 to 2017 was accessed. The initial search yielded 626 potential studies and the final review incorporated 62. We combined 12 trials into a meta-analysis with a random effects model of the efficacy of intraurethral lidocaine vs plain lubricant to reduce pain during flexible cystoscopy as measured on a 10-point visual analogue scale. RESULTS: Data from 12 randomized controlled trials in a total of 1,549 patients were included in the final intraurethral lidocaine meta-analysis. The standardized mean difference between visual analogue scale pain scores in patients who underwent flexible cystoscopy with intraurethral lidocaine and plain lubricant was -0.22 (95% CI -0.39--0.05). Evidence was insufficient to evaluate other interventions to mitigate the discomfort of invasive bladder procedures. CONCLUSIONS: Intraurethral lidocaine provides statistically significant pain reduction in men who undergo flexible cystoscopy, particularly with a longer dwell time. The evidence was insufficient for other tested interventions. A prospective study is needed to further clarify interventions to decrease patient discomfort during cystoscopy and other intravesical procedures in a diverse population.


Assuntos
Anestésicos Locais/uso terapêutico , Cistoscopia , Lidocaína/uso terapêutico , Manejo da Dor/métodos , Humanos , Masculino , Medição da Dor , Ensaios Clínicos Controlados Aleatórios como Assunto , Neoplasias da Bexiga Urinária/diagnóstico , Neoplasias da Bexiga Urinária/terapia
3.
J Urol ; 193(2): 473-478, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25150645

RESUMO

PURPOSE: Men diagnosed with atypical small acinar proliferation are counseled to undergo early rebiopsy because the risk of prostate cancer is high. However, random rebiopsies may not resample areas of concern. Magnetic resonance imaging/transrectal ultrasound fusion guided biopsy offers an opportunity to accurately target and later retarget specific areas in the prostate. We describe the ability of magnetic resonance imaging/transrectal ultrasound fusion guided prostate biopsy to detect prostate cancer in areas with an initial diagnosis of atypical small acinar proliferation. MATERIALS AND METHODS: Multiparametric magnetic resonance imaging of the prostate and magnetic resonance imaging/transrectal ultrasound fusion guided biopsy were performed in 1,028 patients from March 2007 to February 2014. Of the men 20 met the stringent study inclusion criteria, which were no prostate cancer history, index biopsy showing at least 1 core of atypical small acinar proliferation with benign glands in all remaining cores and fusion targeted rebiopsy with at least 1 targeted core directly resampling an area of the prostate that previously contained atypical small acinar proliferation. RESULTS: At index biopsy median age of the 20 patients was 60 years (IQR 57-64) and median prostate specific antigen was 5.92 ng/ml (IQR 3.34-7.48). At fusion targeted rebiopsy at a median of 11.6 months 5 of 20 patients (25%, 95% CI 6.02-43.98) were diagnosed with primary Gleason grade 3, low volume prostate cancer. On fusion rebiopsy cores that directly retargeted areas of previous atypical small acinar proliferation detected the highest tumor burden. CONCLUSIONS: When magnetic resonance imaging/transrectal ultrasound fusion guided biopsy detects isolated atypical small acinar proliferation on index biopsy, early rebiopsy is unlikely to detect clinically significant prostate cancer. Cores that retarget areas of previous atypical small acinar proliferation are more effective than random rebiopsy cores.


Assuntos
Células Acinares/diagnóstico por imagem , Células Acinares/patologia , Imageamento por Ressonância Magnética , Próstata/diagnóstico por imagem , Próstata/patologia , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/patologia , Ultrassonografia de Intervenção , Proliferação de Células , Humanos , Biópsia Guiada por Imagem , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
4.
J Urol ; 194(1): 105-111, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25623751

RESUMO

PURPOSE: Magnetic resonance imaging detects extracapsular extension by prostate cancer with excellent specificity but low sensitivity. This limits surgical planning, which could be modified to account for focal extracapsular extension with image directed guidance for wider excision. In this study we evaluate the performance of multiparametric magnetic resonance imaging in extracapsular extension detection and determine which preoperative variables predict extracapsular extension on final pathology when multiparametric magnetic resonance imaging predicts organ confined disease. MATERIALS AND METHODS: From May 2007 to March 2014, 169 patients underwent pre-biopsy multiparametric magnetic resonance imaging, magnetic resonance imaging/transrectal ultrasound fusion guided biopsy, extended sextant 12-core biopsy and radical prostatectomy at our institution. A subset of 116 men had multiparametric magnetic resonance imaging negative for extracapsular extension and were included in the final analysis. RESULTS: The 116 men with multiparametric magnetic resonance imaging negative for extracapsular extension had a median age of 61 years (IQR 57-66) and a median prostate specific antigen of 5.51 ng/ml (IQR 3.91-9.07). The prevalence of extracapsular extension was 23.1% in the overall population. Sensitivity, specificity, and positive and negative predictive values of multiparametric magnetic resonance imaging for extracapsular extension were 48.7%, 73.9%, 35.9% and 82.8%, respectively. On multivariate regression analysis only patient age (p=0.002) and magnetic resonance imaging/transrectal ultrasound fusion guided biopsy Gleason score (p=0.032) were independent predictors of extracapsular extension on final radical prostatectomy pathology. CONCLUSIONS: Because of the low sensitivity of multiparametric magnetic resonance imaging for extracapsular extension, further tools are necessary to stratify men at risk for occult extracapsular extension that would otherwise only become apparent on final pathology. Magnetic resonance imaging/transrectal ultrasound fusion guided biopsy Gleason score can help identify which men with prostate cancer have extracapsular extension that may not be detectable by imaging.


Assuntos
Imageamento por Ressonância Magnética , Próstata/patologia , Prostatectomia , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Idoso , Humanos , Biópsia Guiada por Imagem , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Estudos Prospectivos , Prostatectomia/métodos , Medição de Risco
5.
JAMA ; 313(4): 390-7, 2015 Jan 27.
Artigo em Inglês | MEDLINE | ID: mdl-25626035

RESUMO

IMPORTANCE: Targeted magnetic resonance (MR)/ultrasound fusion prostate biopsy has been shown to detect prostate cancer. The implications of targeted biopsy alone vs standard extended-sextant biopsy or the 2 modalities combined are not well understood. OBJECTIVE: To assess targeted vs standard biopsy and the 2 approaches combined for the diagnosis of intermediate- to high-risk prostate cancer. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 1003 men undergoing both targeted and standard biopsy concurrently from 2007 through 2014 at the National Cancer Institute in the United States. Patients were referred for elevated level of prostate-specific antigen (PSA) or abnormal digital rectal examination results, often with prior negative biopsy results. Risk categorization was compared among targeted and standard biopsy and, when available, whole-gland pathology after prostatectomy as the "gold standard." INTERVENTIONS: Patients underwent multiparametric prostate magnetic resonance imaging to identify regions of prostate cancer suspicion followed by targeted MR/ultrasound fusion biopsy and concurrent standard biopsy. MAIN OUTCOMES AND MEASURES: The primary objective was to compare targeted and standard biopsy approaches for detection of high-risk prostate cancer (Gleason score ≥ 4 + 3); secondary end points focused on detection of low-risk prostate cancer (Gleason score 3 + 3 or low-volume 3 + 4) and the biopsy ability to predict whole-gland pathology at prostatectomy. RESULTS: Targeted MR/ultrasound fusion biopsy diagnosed 461 prostate cancer cases, and standard biopsy diagnosed 469 cases. There was exact agreement between targeted and standard biopsy in 690 men (69%) undergoing biopsy. Targeted biopsy diagnosed 30% more high-risk cancers vs standard biopsy (173 vs 122 cases, P < .001) and 17% fewer low-risk cancers (213 vs 258 cases, P < .001). When standard biopsy cores were combined with the targeted approach, an additional 103 cases (22%) of mostly low-risk prostate cancer were diagnosed (83% low risk, 12% intermediate risk, and 5% high risk). The predictive ability of targeted biopsy for differentiating low-risk from intermediate- and high-risk disease in 170 men with whole-gland pathology after prostatectomy was greater than that of standard biopsy or the 2 approaches combined (area under the curve, 0.73, 0.59, and 0.67, respectively; P < .05 for all comparisons). CONCLUSIONS AND RELEVANCE: Among men undergoing biopsy for suspected prostate cancer, targeted MR/ultrasound fusion biopsy, compared with standard extended-sextant ultrasound-guided biopsy, was associated with increased detection of high-risk prostate cancer and decreased detection of low-risk prostate cancer. Future studies will be needed to assess the ultimate clinical implications of targeted biopsy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00102544.


Assuntos
Biópsia Guiada por Imagem/métodos , Imageamento por Ressonância Magnética/métodos , Neoplasias da Próstata/diagnóstico , Ultrassonografia de Intervenção/métodos , Idoso , Biópsia/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Próstata/patologia , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Risco
6.
J Urol ; 192(6): 1642-8, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25117476

RESUMO

PURPOSE: Prostate specific antigen sensitivity increases with lower threshold values but with a corresponding decrease in specificity. Magnetic resonance imaging/ultrasound targeted biopsy detects prostate cancer more efficiently and of higher grade than standard 12-core transrectal ultrasound biopsy but the optimal population for its use is not well defined. We evaluated the performance of magnetic resonance imaging/ultrasound targeted biopsy vs 12-core biopsy across a prostate specific antigen continuum. MATERIALS AND METHODS: We reviewed the records of all patients enrolled in a prospective trial who underwent 12-core transrectal ultrasound and magnetic resonance imaging/ultrasound targeted biopsies from August 2007 through February 2014. Patients were stratified by each of 4 prostate specific antigen cutoffs. The greatest Gleason score using either biopsy method was compared in and across groups as well as across the population prostate specific antigen range. Clinically significant prostate cancer was defined as Gleason 7 (4 + 3) or greater. Univariate and multivariate analyses were performed. RESULTS: A total of 1,003 targeted and 12-core transrectal ultrasound biopsies were performed, of which 564 diagnosed prostate cancer for a 56.2% detection rate. Targeted biopsy led to significantly more upgrading to clinically significant disease compared to 12-core biopsy. This trend increased more with increasing prostate specific antigen, specifically in patients with prostate specific antigen 4 to 10 and greater than 10 ng/ml. Prostate specific antigen 5.2 ng/ml or greater captured 90% of upgrading by targeted biopsy, corresponding to 64% of patients who underwent multiparametric magnetic resonance imaging and subsequent fusion biopsy. Conversely a greater proportion of clinically insignificant disease was detected by 12-core vs targeted biopsy overall. These differences persisted when controlling for potential confounders on multivariate analysis. CONCLUSIONS: Prostate cancer upgrading with targeted biopsy increases with an increasing prostate specific antigen cutoff. Above a prostate specific antigen threshold of 5.2 ng/ml most upgrading to clinically significant disease was achieved by targeted biopsy. In our population this corresponded to potentially sparing biopsy in 36% of patients who underwent multiparametric magnetic resonance imaging. Below this value 12-core biopsy detected more clinically insignificant cancer. Thus, the diagnostic usefulness of targeted biopsy is optimized in patients with prostate specific antigen 5.2 ng/ml or greater.


Assuntos
Imageamento por Ressonância Magnética , Antígeno Prostático Específico/sangue , Próstata/patologia , Neoplasias da Próstata/sangue , Neoplasias da Próstata/patologia , Ultrassonografia de Intervenção , Biópsia por Agulha/métodos , Humanos , Biópsia Guiada por Imagem , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Próstata/diagnóstico por imagem , Neoplasias da Próstata/diagnóstico por imagem
7.
Curr Urol Rep ; 15(9): 439, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25007892

RESUMO

Nocturia, or waking at night to void, is a common symptom that leads to substantial morbidity. Men and women are both affected across a wide age range, such that the objective evaluation of nocturia remains a challenge, due largely to its multifactorial etiology. While for some patients, nocturia is caused by common structural conditions such as prostatic obstruction, for others it is due to a complex interplay between multiple underlying systemic diseases. For this reason, persistent nocturia merits particularly careful consideration. The purpose of this review is to describe the most recent salient research in the field of nocturia, with a particular emphasis on its evaluation and management.


Assuntos
Antagonistas Adrenérgicos alfa/uso terapêutico , Antidiuréticos/uso terapêutico , Toxinas Botulínicas Tipo A/uso terapêutico , Desamino Arginina Vasopressina/uso terapêutico , Comportamento de Ingestão de Líquido , Antagonistas Muscarínicos/uso terapêutico , Noctúria/terapia , Feminino , Humanos , Masculino , Noctúria/diagnóstico , Qualidade de Vida
8.
J Hand Surg Am ; 38(7): 1340-5, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23746398

RESUMO

PURPOSE: Proximal row carpectomy (PRC) is used as a treatment for a variety of wrist pathologies to maintain motion and to improve strength and decrease pain. Several studies have looked at how PRC alters wrist characteristics, although they did not provide an explanation for the variability observed in outcomes. Studies have classified the capitate into 3 unique types: round, V-shaped, or flat. We hypothesized that these differences in morphology could affect the contact biomechanics between the radius and the capitate after PRC. METHODS: A total of 14 cadaveric wrists underwent PRC. They were classified by capitate morphology and then loaded to 200 N in a neutral position, flexion, and extension. We measured contact area, contact pressure, and location using pressure-sensitive film in all 3 positions and compared their morphology types. RESULTS: Nine wrists had a round-type capitate, 4 had a V-shaped capitate, and 1 had a flat capitate, which we excluded from statistical analysis. Comparing round and V-shaped types, we found no differences in contact area, pressure, or location in any wrist position For the V-shaped capitates, there was increased contact pressure in flexion and extension compared with the wrist in neutral. Center of pressure translated dorsal and radial in flexion to volar and ulnar in extension for all types. CONCLUSIONS: When we compared V-shaped and round-type capitates, we found no significant differences in contact characteristics of the wrist after PRC. There were some differences in contact pressure for V-shaped capitates in various wrist positions. CLINICAL RELEVANCE: Differences between round and V-shaped capitates do not appear to affect contact biomechanics after PRC. Thus, these 2 capitate shapes may not necessarily be a factor in the decision-making process to perform PRC.


Assuntos
Capitato/anatomia & histologia , Capitato/fisiologia , Articulação do Punho/anatomia & histologia , Articulação do Punho/fisiologia , Fenômenos Biomecânicos , Cadáver , Capitato/cirurgia , Humanos , Amplitude de Movimento Articular/fisiologia , Articulação do Punho/cirurgia
9.
BME Front ; 20222022.
Artigo em Inglês | MEDLINE | ID: mdl-37090444

RESUMO

Nephrolithiasis is a common, painful condition that requires surgery in many patients whose stones do not pass spontaneously. Recent technologic advances have enabled the use of ultrasonic propulsion to reposition stones within the urinary tract, either to relieve symptoms or facilitate treatment. Burst wave lithotripsy (BWL) has emerged as a noninvasive technique to fragment stones in awake patients without significant pain or renal injury. We review the preclinical and human studies that have explored the use of these two technologies. We envision that BWL will fill an unmet need for the noninvasive treatment of patients with nephrolithiasis.

10.
J Endourol ; 36(10): 1377-1381, 2022 10.
Artigo em Inglês | MEDLINE | ID: mdl-35652350

RESUMO

Introduction and Objective: Guidelines from the American Urological Association (AUA) and American College of Radiology (ACR) recommend that patients with suspected nephrolithiasis undergo low-dose CT of the kidney, ureter, and bladder (LD CT KUB) as opposed to higher dose conventional imaging. We hypothesized that even at institutions with established LD protocols, higher dose imaging is common. Materials and Methods: We identified four academic medical centers where LD CT KUB protocols were implemented to yield an effective dose (EDose) consistent with national guidelines. Fifty consecutive adult patients who underwent CT KUB specifically for the evaluation of nephrolithiasis were retrospectively reviewed at each site. Patient age, sex, body mass index (BMI), imaging location, and EDose (millisieverts [mSv]) were recorded. Results: Two hundred patients with a mean age of 54 years were identified. Forty-six patients (23%) underwent CT KUB with an EDose ≤4 mSv, accounting for 10% to 48% of each institution's cohort. One hundred sixteen patients had a BMI <30, and would have been expected to receive LD CTs by the AUA criteria for LD CT KUB. Within this subset, only 37 patients (32%) actually underwent LD CT KUB. The highest dose CT KUB at each institution resulted in an EDose of 33.8 to 44.6 mSv, exceeding the recommended exposure of LD CT KUB by 10-fold. Conclusions: At academic institutions where LD CT KUB was implemented for the evaluation of nephrolithiasis, a minority of patients with BMI <30 received guideline-concordant imaging. Differences in patient BMI did not account for the variation in radiation exposure. Further research is necessary to elucidate barriers to LD CT implementation.


Assuntos
Cálculos Renais , Exposição à Radiação , Adulto , Humanos , Pessoa de Meia-Idade , Doses de Radiação , Radiografia Abdominal , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos
11.
Urol Pract ; 9(5): 364-370, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-37145718

RESUMO

INTRODUCTION: µ-Opioid-receptor antagonists are a standard component of enhanced recovery after surgery (ERAS) pathways following radical cystectomy (RC) as they reduce ileus and shorten length of stay (LOS). Prior studies have used alvimopan; however, naloxegol is a less expensive medication in the same class. We compared differences in postoperative outcomes between patients receiving alvimopan or naloxegol following RC. METHODS: We retrospectively reviewed all patients undergoing RC over 20 months at an academic center during which standard practice transitioned from using alvimopan to naloxegol, while maintaining all other components of our ERAS pathway. We utilized bivariate comparisons as well as negative binomial and logistic regression to compare return of bowel function, rates of ileus and LOS following RC. RESULTS: Of 117 eligible patients, 59 (50%) received alvimopan and 58 (50%) received naloxegol. There were no differences in baseline clinical, demographic or perioperative factors. Median postoperative LOS was 6 days in each group (p=0.3). Time to flatus (2 versus 2 days, p=0.2) and ileus (14% versus 17%, p=0.6) were similar between the alvimopan and naloxegol groups, respectively. In multivariable models controlling for patient and surgical factors, µ-opioid antagonist agent was associated with neither LOS nor ileus. Cost difference was -$344.20/day, equivalent to a $2,065.20 savings over a 6-day hospital stay with naloxegol. CONCLUSIONS: In patients undergoing RC managed with a standard ERAS pathway, there were no differences in postoperative recovery based on the use of alvimopan versus naloxegol. Substitution of naloxegol for alvimopan may allow for significant cost savings without compromising outcomes.

12.
Urology ; 160: 60-68, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34757049

RESUMO

OBJECTIVE: To convene a multi-disciplinary panel to develop a pathway for Emergency Department (ED) patients with suspected nephrolithiasis and then prospectively evaluate its effect on patient care. MATERIALS AND METHODS: The STONE Pathway was developed and linked to order sets within our Electronic Health Record in April 2019. Records were prospectively reviewed for ED patients who underwent ultrasound or Computerized Tomography (CT) to evaluate suspected nephrolithiasis between January 2019 and August 2019 within our institution. The primary outcome measure was the proportion of patients whose ED CT was low dose (<4 mSv). Secondary outcome measures included receipt of pathway-concordant pain medications and urine strainers. Order set utilization was evaluated as a process measure. Balance measures assessed included repeat ED visits, imaging, hospitalizations, and a urologic clinic visit or surgery within 30 days of discharge. RESULTS: 441 patients underwent ED imaging, of whom 261 (59%) were evaluated for suspected nephrolithiasis. The STONE Pathway was used in 50 (30%) eligible patients. Patients treated with the Pathway were more likely to undergo low-dose CTs (49% vs 23%, P <.001), and receive guideline-concordant pain medications such as NSAIDs (90% vs 62%, P <.001), and were less likely to return to the ED within 30 days (13% vs 2%, P = .01). These measures demonstrated special cause variation following Pathway release. CONCLUSION: Clinical pathways increase compliance with evidence-based practices for pain control and imaging in nephrolithiasis emergency care and may improve the delivery of value-based care.


Assuntos
Procedimentos Clínicos , Cálculos Renais , Emergências , Serviço Hospitalar de Emergência , Feminino , Hospitalização , Humanos , Masculino , Dor
13.
Urology ; 153: 228-235, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33561469

RESUMO

OBJECTIVE: To describe opioid prescribing patterns for patients undergoing kidney cancer surgery and evaluate associations with medical resource utilization in the postoperative setting. METHODS: Linked Surveillance, Epidemiology, and End Results - Medicare data were used to identify patients with kidney cancer who underwent partial or radical nephrectomy (open vs. minimally invasive) from 2007 to 2015. Total dose of discharge opioid prescriptions was quantified into 3 exposure groups based on observed tertiles: 1-199 (low), 200-300 (moderate), and >300 (high) oral morphine milligram equivalents. Associations between exposure groups and patient demographics, clinical factors, and hospital volumes were measured using multivariate logistic regression. Additionally, we identified associations with prior opioid exposure and postoperative medical resource utilization. RESULTS: Of 4538 patients meeting inclusion criteria, exposure group distributions were 35% (low), 43.5% (moderate) and 21.6% (high). Over one-third of patients (39.5%) received an opioid prescription within 6 months preceding surgery. High opioid prescriptions were associated with prior exposure, younger age, rural residence and open surgery (P < .001). High opioid prescriptions had increased risk of 90-day readmissions (OR 1.21; CI 1.01-1.45) and long-term opioid exposure (OR 1.34; CI 1.17-1.53). CONCLUSION: Prescribing patterns after kidney cancer surgery vary widely. Higher prescribed dose of post-surgical opioids is associated with 90-day hospital readmissions and long-term exposure. Prior opioid exposure conveys a higher risk of medical resource utilization. More judicious opioid prescribing may limit medical resource utilization and help combat the opioid epidemic.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Neoplasias Renais/cirurgia , Nefrectomia , Dor Pós-Operatória/tratamento farmacológico , Alta do Paciente , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino
14.
Urol Pract ; 8(1): 82-87, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-37145436

RESUMO

INTRODUCTION: Concern regarding radiation exposure has led to increased interest in the use of ultrasound for the initial imaging of suspected renal colic in the emergency department. It is unknown whether such an approach simply defers computerized tomography to outpatient followup. We analyzed national imaging patterns to explore this relationship. METHODS: Using the MarketScan® insurance claims database we reviewed adult patients newly diagnosed with nephrolithiasis in U.S. emergency departments between 2007 and 2015. Patients were excluded if they had been diagnosed with or undergone treatment for nephrolithiasis in the preceding 180 days. RESULTS: From 2007 to 2015, 830,785 emergency department nephrolithiasis encounters met inclusion criteria. The ultrasound-only rate increased from 2.7% to 6.9%, while the computerized tomography-only rate remained stable at 85.8%. A history of computerized tomography in the 30 days before emergency department presentation increased the rate of ultrasound-only imaging from 4.6% to 8.9%. The mean cumulative computerized tomography scans from the emergency department visit to 90 days after was significantly lower in those imaged with emergency department ultrasound (0.82±0.77) compared to those imaged with emergency department computerized tomography (1.2±0.51, p <0.001). CONCLUSIONS: Patients who undergo ultrasonography in the emergency department for evaluation of renal colic undergo fewer cumulative computerized tomography scans in the 90 days following their visit than do patients initially imaged with computerized tomography. Ultrasound use for the evaluation of renal colic has increased while computerized tomography rates have remained stable.

15.
Urol Pract ; 7(5): 373-377, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-37296548

RESUMO

INTRODUCTION: Postoperative kidney cancer surveillance is predominantly based on imaging and laboratory evaluation rather than physical exam. We sought to characterize the burden of kidney cancer surveillance in a low resource population with an aim to identify opportunities for telehealth implementation. METHODS: We retrospectively reviewed patients who underwent partial or radical nephrectomy between November, 2016 and May, 2018 at an academic medical center. We reviewed patient demographic characteristics, travel distance to hospital, and Center for Medicare & Medicaid Services designation of home ZIP code as low income area or health professional shortage area. Followup visits were reviewed for imaging and laboratory studies as well as new physical exam findings. RESULTS: We identified 156 patients who attended 234 followup visits at mean 2.4 months (SD=2.9 months) postoperatively. Patient home ZIP codes were designated as low income area or health professional shortage area in 93 (59.6%) cases. One-way travel was mean 194 miles (SD=438 miles) per visit. When intended, laboratory or imaging studies were not obtained ahead of followup visits in 34 of 196 cases (17%). Based on the absence of new physical exam findings or procedures performed 201 (86%) visits could have potentially been performed remotely. CONCLUSIONS: Patients living in low income areas and health professional shortage areas are asked to travel long distances to perform kidney cancer surveillance often to review data that could be obtained remotely. Necessary imaging or laboratory studies are frequently not obtained ahead of appointments, further diminishing visit value. Kidney cancer surveillance may offer a promising opportunity for telehealth implementation within urology.

16.
Urol Pract ; 7(6): 515-520, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-37287155

RESUMO

INTRODUCTION: The overprescribing of opioids after urological surgery places patients at risk for opioid overuse and dependency. However, few guidelines exist to help urologists consistently prescribe appropriate quantities of pain medications. We sought to characterize the variation in opioid prescribing habits at time of discharge following nephrectomy. METHODS: We performed a retrospective review of patients who underwent partial or radical nephrectomy between November 2016 and May 2018 at an academic medical center. We reviewed patient, procedure and provider level variables potentially associated with high opioid use. Daily inpatient opioid use and discharge opioid prescriptions were tabulated in oral morphine equivalents. RESULTS: We identified 173 eligible patients who used a daily average of 36 oral morphine equivalents during their hospitalization weaning to 27 oral morphine equivalents on the day of discharge. All but 2 patients were prescribed opioids at discharge with an average of 367 oral morphine equivalents per prescription (SD 284). On multiple linear regression preoperative opioid use, open vs minimally invasive approach, length of stay and last day opioid use were associated with discharge oral morphine equivalents (R2=0.51, p <0.05). CONCLUSIONS: Patients were discharged with excessive opioids with an average discharge prescription equivalent to 13.6 times the last inpatient day's use. When combined with other potential predictors of discharge opioid prescriptions inpatient use accounts for less than 50% of the variance between prescriptions. Systems are needed to help minimize variability in opioid prescribing practices and reduce the overall quantity prescribed.

17.
Malar J ; 7: 86, 2008 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-18492282

RESUMO

BACKGROUND: The ability to transfect and create transgenic cultured malaria parasites has transformed the study of Plasmodium falciparum over the last decade. With the completion of the annotated genome sequence, the process of gene discovery now routinely includes gene knockouts, over-expression and complementation analysis. However, while this technology has proven extremely valuable, significant limitations exist. In particular, P. falciparum DNA is often unstable and difficult to clone because of its AT-rich, repetitive nature. As a result, transgene expression constructs can be difficult to assemble due to the need to include two expression cassettes on a single plasmid, one to drive expression of the transgene of interest and a second for expression of the selectable marker. In addition, transgene expression levels are usually not regulatable, making it difficult to assess phenotypes that are sensitive to the amount of protein expressed. RESULTS: A plasmid based system for transgene expression is described that uses a single, bidirectional promoter to drive expression of both the transgene and the selectable marker, thus greatly reducing the size of the construct and enhancing stability. Further, by altering the concentration of drug used for selection, it is possible to modulate the copy number of the concatameric episomes and thereby regulate the expression level of the transgene through a range greater than 10 fold. CONCLUSION: The transgene expression system described here should prove useful for both routine protein over-expression and complementation experiments as well as for experiments in which precisely manipulating the expression level of candidate proteins is desirable. This should provide an additional level of precision to the tools used to study the molecular biology of malaria parasites.


Assuntos
Animais Geneticamente Modificados , Biologia Molecular/métodos , Plasmodium falciparum/genética , Animais , Dosagem de Genes , Expressão Gênica , Regulação da Expressão Gênica , Genes Reporter , Teste de Complementação Genética , Luciferases/biossíntese , Plasmídeos , Regiões Promotoras Genéticas
20.
Urology ; 85(6): 1291-9, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25881866

RESUMO

OBJECTIVE: To evaluate published evidence on nocturia in men and derive expert recommendations. METHODS: The International Consultations on Urological Diseases-Société Internationale d'Urologie convened a Consultation of experts on male lower urinary tract symptoms. The Consultation assigned standardized levels of evidence and grades of recommendation to various studies of nocturia epidemiology, pathophysiology, assessment, and treatment. RESULTS: Evidence review and consensus recommendations were made in the areas of epidemiology, pathophysiology, assessment, and treatment. CONCLUSION: The review presents a condensed summary of the International Consultations on Urological Diseases-Société Internationale d'Urologie evaluation of nocturia, which offers contemporaneous expert consensus on this topic, with an assessment algorithm emphasizing the potential contribution of systemic conditions to the symptom.


Assuntos
Sintomas do Trato Urinário Inferior/diagnóstico , Sintomas do Trato Urinário Inferior/terapia , Noctúria/diagnóstico , Noctúria/terapia , Humanos , Masculino
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