Outcomes of the "BRCA Quality Improvement Dissemination Program": An initiative to improve patient receipt of cancer genetics services at five health systems.

OBJECTIVE: A quality improvement initiative (QII) was conducted with five community-based health systems' oncology care centers (sites A-E). The QII aimed to increase referrals, genetic counseling (GC), and germline genetic testing (GT) for patients with ovarian cancer (OC) and triple-negative breast cancer (TNBC). METHODS: QII activities occurred at sites over several years, all concluding by December 2020. Medical records of patients with OC and TNBC were reviewed, and rates of referral, GC, and GT of patients diagnosed during the 2 years before the QII were compared to those diagnosed during the QII. Outcomes were analyzed using descriptive statistics, two-sample t-test, chi-squared/Fisher's exact test, and logistic regression. RESULTS: For patients with OC, improvement was observed in the rate of referral (from 70% to 79%), GC (from 44% to 61%), GT (from 54% to 62%) and decreased time from diagnosis to GC and GT. For patients with TNBC, increased rates of referral (from 90% to 92%), GC (from 68% to 72%) and GT (81% to 86%) were observed. Effective interventions streamlined GC scheduling and standardized referral processes. CONCLUSION: A multi-year QII increased patient referral and uptake of recommended genetics services across five unique community-based oncology care settings.

Delayed Presentation of First Rib Osteomyelitis Following Trauma.

Rib osteomyelitis can be caused by a contiguous infection after a traumatic fracture. Post traumatic osteomyelitis can present as chronic six or more weeks after bone infection. However, this patient developed first rib osteomyelitis 17 years after trauma, following the initiation of anticoagulation therapy. 17 years ago, a 55-year-old male patient was in a motor vehicle collision. He was diagnosed with a left first rib fracture and an internal carotid dissection. He subsequently underwent a left subclavian central venous catheter placement. His rib fracture was managed nonoperatively and the carotid dissection was treated with endovascular stent placement. He now presents with symptomatic carotid stent stenosis which is treated with anti-platelet and anticoagulation therapy. He then developed a hematoma over the old rib fracture, and subsequently developed acute osteomyelitis. As seen here, a remote history of traumatic first rib fracture remains a risk factor for osteomyelitis despite the passage of time.

A Contemporary Evaluation of Urological Outcomes After Renal Transplantation.

INTRODUCTION: Urological surgery after renal transplantation leaves patients at risk of infection and further urological complications. Our objective was to discern patient factors associated with adverse outcomes following renal transplantation to identify patients who would benefit from close urological follow-up. METHODS: Retrospective chart review was conducted for patients undergoing renal transplantation between August 1, 2016 and July 30, 2019 at a tertiary care academic center. Data on patient demographics, medical history, and surgical history were collected. Primary outcomes observed were urinary tract infection, urosepsis, urinary retention, unexpected urology visit, and urological procedures within 3 months of transplant. Variables determined significant by hypothesis testing were used in logistic regression modeling for each primary outcome. RESULTS: Of the 789 renal transplant patients, 217 (27.5%) developed postoperative urinary tract infection and 124 (15.7%) developed postoperative urosepsis. Patients with postoperative urinary tract infection were more likely to be female (OR 2.2, P < .01), have pre-existing prostate cancer (OR 3.1, P < .01), and recurrent urinary tract infections (OR 2.1, P < .01). After renal transplant, unexpected urology visits were observed in 191 (24.2%) patients, and urological procedures were performed in 65 (8.2%) patients. Postoperative urinary retention was noted in 47 (6.0%) patients and seen more often in patients with benign prostatic hyperplasia (OR 2.8, P = .033) and prior prostate surgery (OR 3.0, P = .072). CONCLUSIONS: Identifiable risk factors associated with urological complications after renal transplantation include benign prostatic hyperplasia, prostate cancer, urinary retention, and recurrent urinary tract infections. Female renal transplant patients are at increased risk of postoperative urinary tract infection and urosepsis. These patient subsets would benefit from establishing urological care and pre-transplant urological evaluation including urinalysis, urine cultures, urodynamic studies, and close follow-up post-transplant.

A 40-Year Litigation Review of Transurethral Surgeries for Benign Prostatic Hyperplasia.

OBJECTIVE: To describe litigation patterns of transurethral surgery in the treatment of benign prostatic hyperplasia including verdicts, types of lawsuits, plaintiff claims, and timing of the claims. METHODS: Data was gathered by searching for litigation cases between January 1, 1980 and December 1, 2021 in the Westlaw legal database using keywords for transurethral surgeries for benign prostatic hyperplasia. Extracted data included case type, general description of the plaintiffs and defendants, plaintiff claims, and whether the claim involved preoperative, perioperative, or postoperative management, verdict, and indemnity awards. RESULTS: The Westlaw search yielded 44 unique cases after removing duplicate and irrelevant cases. The most common surgery resulting in a lawsuit was transurethral resection of the prostate (70%) and urologists were the most frequently named defendant (80%). The most common plaintiff claims were sexual dysfunction (36%), irritative lower urinary tract symptoms (32%), and lack of consent (27%). Among malpractice cases, the verdict was in favor of the defendant in most cases (71%) and among Eighth Amendment violation cases, the verdict was in favor of the defendant in every case. The average indemnity payment was $565,845 and the highest indemnity payment was $1,020,000. CONCLUSION: Complications of transurethral surgeries and lack of consent are common reasons for patient's filing a lawsuit. Healthcare providers should ensure patient understanding of surgical risks and thoroughly document the conversation. Providers should be aware of the causes for litigation among transurethral surgeries for benign prostatic hyperplasia and of the possibility of Eighth Amendment violation lawsuits when treating prison inmates.

Identifying Patient-Centered Research Priorities in Overactive Bladder by Crowdsourcing and Targeted Recruitment.

INTRODUCTION: Patient perspectives in quality-of-life improvement are critical to measuring treatment outcomes. We aimed to identify patient priorities for overactive bladder (OAB) research. METHODS: Participants were recruited utilizing the Amazon Mechanical Turk database, an online marketplace where individuals receive payment for completing tasks. Those who scored 4 or higher on the OAB-V3, a simple 3-question screening survey, were requested to complete an "OAB-q and Prioritization Survey," which identified preferences for future OAB research priorities, demographic and clinical data, and symptom severity via the OAB-q. Participants must have correctly answered an attention-confirming question to have their responses included in the final analysis. RESULTS: Of 555 responders, 352 screened positive on the OAB-V3 and 232 completed the followup survey and met study criteria. The top 3 research preferences were: discovering the etiology of OAB (31%); individualized treatment based on age, race, gender and comorbidities (19%); and identifying the fastest OAB treatments (15%). Participants who selected etiology of OAB in the top 3 research priorities (56%) were older (38.7±2.1 vs 33.9±1.5 years, p=0.05) and had significantly lower mean health-related quality of life scores than those who did not (25.1±2.5 vs 35.5±3.9, p=0.02). CONCLUSIONS: Using Amazon Mechanical Turk, we present the first report of OAB research priorities identified by patients experiencing OAB symptoms. Crowdsourcing offers a timely and cost-effective manner to learn directly from people with OAB symptoms. Few participants sought treatment for OAB despite having bothersome symptoms.

Video-Based Coaching as an Educational Platform for Urological Residency Training: A Pilot Study.

INTRODUCTION: Surgical experience requires skills traditionally taught through real-time operating room education and a variety of supplemental educational strategies. Video-based coaching is a modality that may offer potential advantages of immediate, direct and targeted feedback. The objective of this study was to demonstrate and evaluate the utility and educational value of video-based coaching in urology by conducting a qualitative analysis with a coding schema. METHODS: Residents and attendings were recorded operating during randomly selected cases in the operating room. Video-based coaching sessions were held during urology grand rounds and required residents to describe a selected portion of the operating room video and attendings to provide teaching points. Audio recordings from the operating room and video-based coaching sessions were reviewed by 2 independent coders. A coding scale classifying surgical educational goals into 5 categories (information, operative technique, questioning, response to resident interaction and unrelated commenting) was used to identify the interactions and was adjusted for time. RESULTS: Four urological cases were selected for recording. In the video-based coaching sessions compared to the operating room, attendings made more teaching points per hour, provided more information to residents (mean teaching points 7.7 for video-based coaching vs 2.9 for operating room, p <0.005), emphasized operative skills and technique (mean teaching points 10.5 for video-based coaching vs 4.1 for operating room, p <0.005), and were more likely to ask open-ended discussion leading questions (mean teaching points 28.5 for video-based coaching vs 4.4 for operating room, p <0.05). CONCLUSIONS: Video-based coaching delivered in short time frames offers an easily implementable additional learning opportunity for resident education to further enhance skills learned in the urological operating room.

Contemporary use of prescription medications for neurogenic lower urinary tract dysfunction.

OBJECTIVES: First-line treatment for patients with neurogenic detrusor overactivity (NDO) is anticholinergic or beta-3 agonist medication. The addition of a secondary medication in patients with NDO may avoid progression to third- and fourth-line therapies. We aim to identify patterns of medication use for patients with neurogenic lower urinary tract dysfunction (NLUTD) using a national database. METHODS: The National Ambulatory Medical Care Survey (NAMCS) database was queried for a sample of ambulatory patient visits from 2003 to 2015. Outpatient visits were included for all patients aged 18 years or older diagnosed with NLUTD. Dual therapy was defined as prescription of two anticholinergics or one anticholinergic + beta-3 agonist on the same visit. Visits in which medications were prescribed were analyzed with descriptive statistics. RESULTS: Out of a weighted sample of 5 391 680 patient visits with a primary diagnosis of NLUTD, 1 602 705 (30%) were prescribed medical therapy. Of included patients prescribed NDO medications, the majority were white (80%), located in the Northeast (71%), and of a mean age of 51 ± 3. Of these patients, at least 93% of patients were prescribed anticholinergics, and 37% were prescribed dual therapy. Patients 65 years and older were more likely to initiate a new NDO medication at their visit (43%) than patients under 65 (7%). CONCLUSIONS: This is the first study to analyze the use of medical therapy for NLUTD in a large outpatient setting. Further prospective evaluation of patient satisfaction and efficacy of both single anticholinergic medication and dual therapy is needed.