Accuracy of subjective vesicoureteral reflux timing assessment: supporting new voiding cystourethrogram guidelines.

BACKGROUND: Bladder volume at the onset of vesicoureteral reflux (VUR) is an important prognostic indicator of spontaneous resolution and the risk of pyelonephritis. OBJECTIVE: We aim to determine whether pediatric urologists and pediatric radiologists can accurately estimate the timing of reflux by examining voiding cystourethrogram (VCUG) images without prior knowledge of the instilled contrast volume. MATERIALS AND METHODS: Total bladder volume and the volume at the time of reflux were collected from VCUG reports to determine the volume at the onset of VUR. Thirty-nine patients were sorted into three groups: early-/mid-filling reflux, late-filling and voiding only. Thirty-nine images were shown to three pediatric urologists and two pediatric radiologists in a blinded fashion and they were then asked to estimate VUR timing based on the above categories. A weighted kappa statistic was calculated to assess rater agreement with the gold standard volume-based report of VUR timing. RESULTS: The mean patient age at VCUG was 3.1±2.9 months, the median VUR was grade 3, and 20 patients were female. Overall agreement among all five raters was moderate (k=0.43, 95% confidence interval [CI] 0.36-0.50). Individual agreement between rater and gold standard was slight to moderate with kappa values ranging from 0.13 to 0.43. CONCLUSION: Pediatric radiologists and urologists are unable to accurately and reliably characterize VUR timing on fluoroscopic VCUG. These findings support the recently published American Academy of Pediatrics protocol recommending the routine recording of bladder volume at the onset of VUR as a standard component of all VCUGs to assist in a more accurate assessment of the likelihood of resolution and risk of recurrent urinary tract infections.

Gender and acute respiratory distress syndrome in critically injured adults: a prospective study.

BACKGROUND: The acute respiratory distress syndrome (ARDS) is a proinflammatory condition that often complicates trauma and critical illness. Animal studies have shown that both gender and sex hormones play an important role in inflammatory regulation. Human data are scant regarding the role of gender and sex hormones in developing ARDS. Our objective was to describe gender and hormonal differences in patients who develop ARDS in a large cohort of critically injured adults. METHODS: A prospective cohort study of adult trauma patients requiring intensive care unit admission for at least 48 hours was performed. Demographic and clinical data were collected prospectively, and sex hormones were assayed at study entry (48 hours). The primary outcome was the development of ARDS. Multivariate logistic regression was used to determine the adjusted odds of death associated with differences in gender. RESULTS: Six hundred forty-eight patients met entry criteria, and 180 patients developed ARDS (31%). Women were more likely to develop ARDS (35% vs. 25%, p=0.02). This association remained after adjusting for age, mechanism of injury, injury severity, and blood product transfusion (odds ratio, 1.6; 95% confidence interval: 1.1-2.4; p=0.02). Of patients with ARDS, there was no difference in mortality related to gender (22% mortality in women with ARDS vs. 20% in men; p=not significant). A proinflammatory sex hormone profile (low testosterone and high estradiol) was associated with ARDS in both men and women. CONCLUSION: Women are more likely than men to develop ARDS after critical injury. Despite the increased incidence in ARDS, the mortality in patients with ARDS does not differ according to gender. The inflammatory properties of sex hormones may contribute to ARDS, but they do not fully explain observed gender differences.

Assessment of health literacy in adolescents with spina bifida and their caregivers: a multi-institutional study.

INTRODUCTION: and Objective: Health literacy is defined as the ability to obtain, integrate, and appraise health-related knowledge. It is known to correlate with disparities in clinical outcomes in adults with chronic disease. Patients with spina bifida represent a potentially vulnerable cohort as they often have multiple comorbidities. The authors aimed to characterize health literacy in adolescent patients with spina bifida and their caregivers. STUDY DESIGN: The Newest Vital Sign (NVS), a validated assessment of health literacy and numeracy, was administered to patients (aged ≥10 years) and caregivers in outpatient pediatric urology and multidisciplinary spina bifida clinics. Subjects not fluent in English or Spanish and those with cognitive delay were excluded. Survey responses and demographic information were analyzed and compared between the spina bifida and control groups. RESULTS: Three hundred eleven caregivers (caregivers for patients with spina bifida: 185, caregivers for the controls: 126) and 84 adolescents (those with spina bifida: 46, controls: 38) completed the NVS. Although there was no difference in health literacy between caregivers (p = 0.98), adolescents with spina bifida demonstrated lower NVS scores (spina bifida 1 [0-3] vs. control 2 [2-4]; p = 0.02) (Figure). Health literacy of patients with spina bifida and controls increased with age (p = 0.002). Adjusting for age and gender, the odds of having limited literacy were 5.5 times higher in patients with spina bifida than in the controls (p = 0.004). Inadequate caregiver health literacy was associated with a lower education level (p < 0.001). DISCUSSION: Spina bifida is among the most complex birth defects compatible with life and affects a multitude of systems. Although it is well established that limited health literacy in adults with chronic disease is associated with adverse outcomes, there are considerably fewer data in the pediatric population. The authors found that caregivers of patients with spina bifida exhibited health literacy and numeracy comparable with parents in the control group, despite lower education levels. In contrast, adolescents with spina bifida demonstrated poorer health literacy than the controls. Multidisciplinary care is necessary, given the medical complexity of spina bifida; therefore, impaired understanding of adults' own needs may pose a barrier to successful transition to their care and subsequent outcomes. CONCLUSIONS: The majority of surveyed caregivers for patients with spina bifida exhibited adequate health literacy, especially those with some college education; however inadequate health literacy was more likely among adolescents with spina bifida when compared with the controls. Screening for health literacy may be useful to assess readiness for transition to more independent self-care among patients with spina bifida.

Spiral nesbit plication: A simple method for simultaneous correction of penile torsion and chordee ("spiral chordee").

Penile torsion and chordee may be corrected by a variety of techniques; however, when corporal body disproportion is involved plication may be necessary. Herein we describe a technique of placing oblique plication sutures to simultaneously correct both conditions, which we term "spiral chordee". The spiral Nesbit plication (SNP) has been performed on 21 boys at our institution. Median preoperative penile torsion and chordee were 49° (range 30-90°) and 35° (range 15-60°) respectively. Surgical success was 84.6% with two patients exhibiting mild residual chordee (15°) requiring no further treatment. This technique provides a simple and effective surgical option for correction of spiral chordee.

A Rare Case of Pediatric Vaginal Yolk Sac Tumor.

A 14-month-old girl was evaluated for intermittent vaginal bleeding. Vaginoscopy revealed a friable tumor, and biopsy results confirmed a yolk sac tumor. Alpha-fetoprotein was elevated (1386 ng/mL) at diagnosis but quickly normalized with chemotherapy. The patient remained tumor-free 12 months after diagnosis without the need for radical surgery. Although rare, malignant tumors of the vagina must be included in the differential diagnosis of prepubertal girls who present with vaginal bleeding. Primary yolk sac tumor of the vagina is seen in girls less than 3 years of age and is treated with chemotherapy with or without surgical excision. Prognosis is good with appropriate treatment.

Bench-Top Feasibility Testing of a Novel Percutaneous Renal Access Technique: The Laser Direct Alignment Radiation Reduction Technique (DARRT).

INTRODUCTION: Traditional techniques for obtaining percutaneous renal access utilize continuous fluoroscopy. In an attempt to minimize radiation exposure, we describe a novel laser direct alignment radiation reduction technique (DARRT) for percutaneous access and test it in a bench-top model. METHODS: In this randomized-controlled bench-top study, 20 medical personnel obtained renal accesses using both the conventional bullseye technique and the laser DARRT. The primary endpoint was total fluoroscopy time. Secondary endpoints included insertion time, puncture attempts, course corrections, and subjective procedural difficulty. In the laser DARRT, fluoroscopy was used with the C-arm positioned with the laser beam at a 30° angle. The access needle and hub were aligned with the laser beam. Effective caliceal puncture was confirmed with fluoroscopy and direct vision. The Paired samples Wilcoxon signed rank test was used for statistical analysis with significance at p < 0.05. RESULTS: A total of 120 needle placements were recorded. Fluoroscopy time for needle access using the laser DARRT was significantly lower than the bullseye technique in all groups as follows: attendings (7.09 vs 18.51 seconds; p < 0.001), residents (6.55 vs 13.93 seconds; p = 0.001), and medical students (6.69 vs 20.22 seconds; p < 0.001). Students rated the laser DARRT easier to use (2.56 vs 4.89; p < 0.001). No difference was seen in total access time, puncture attempts, or course corrections between techniques. CONCLUSION: The laser DARRT reduced fluoroscopy time by 63%, compared with the conventional bullseye technique. The least experienced users found the laser DARRT significantly easier to learn. This novel technique is promising and merits additional testing in animal and human models.

Kidney, Ureter, and Bladder (KUB): A Novel Grading System for Encrusted Ureteral Stents.

OBJECTIVE: To introduce a grading system (kidney, ureter, and bladder [KUB]) to identify encrusted stents that may require multiple surgeries, multimodal surgery, and operative time > 180 minutes for successful removal. METHODS: One hundred ten retained encrusted ureteral stents were retrospectively scored using the KUB grading system and this score was correlated with operative time, need for multiple surgeries or multimodal surgery, and stone-free rate. Data analysis was performed with t test, Mann-Whitney U test, and chi-square tests. A P value of <0.05 was considered statistically significant. RESULTS: Average indwelling stent time was 17.2 months (0.7-139.0). There were 83.6% of stents removed in a single surgery, with 63.0% of these requiring multimodal surgery. K score ≥ 3 was associated with multiple surgeries (odds ratio [OR] 3.59, P = .006), multimodal surgery (OR 2.44, P = .04), operative time > 180 minutes (OR 3.80, P = .001), and lower stone-free rate (OR 0.23, P = .02). U score ≥ 3 was associated with operative time > 180 minutes (OR 3.28, P = .003). B score ≥ 3 was associated with lower stone-free rate (OR 0.23, P = .020). Total score ≥ 9 was associated with multiple surgeries (OR 4.19, P = .001), operative time > 180 minutes (OR 3.45, P = .002), and lower stone-free rate (OR 0.13, P = .001). CONCLUSION: The KUB system identifies stents at risk for requiring multiple surgeries, multimodal surgery, and operative time > 180 minutes. It also correlates with stone-free rate. This grading system can help surgeons manage patient expectations and predict surgical complexity.

A prospective, randomized, controlled trial assessing diazepam to reduce perception and recall of pain during transrectal ultrasonography-guided biopsy of the prostate.

BACKGROUND AND PURPOSE: The effect of oral anxiolytics in diminishing patient discomfort and pain perception has been demonstrated in GI endoscopy, percutaneous coronary interventions, and various procedures in the emergency department setting, but has not been prospectively studied in the setting of prostate biopsy. The purpose of this study was to investigate the effect of diazepam on pain perception during and after prostate biopsy. PATIENTS AND METHODS: Sixty patients undergoing prostate biopsy at a single academic institution were enrolled into a prospective, randomized, placebo-controlled study. A questionnaire was administered prebiopsy to determine baseline discomfort and pain history. A visual analog pain scale was used to determine pain associated with each step of the transrectal Ultrasonography-guided prostate biopsy and was administered 20 minutes after biopsy and 1 week later. Responses were compared between groups using the Mann-Whitney U test, Fisher exact test, and Wilcoxon signed rank test as appropriate. RESULTS: A total of 60 patients (29 diazepam, 31 placebo) completed pre- and postbiopsy surveys for analysis. The number of cores sampled during biopsy was controlled during analysis and was found to have no correlation with total pain measured. There were no differences between diazepam and placebo groups in age, prebiopsy survey results, immediate and 1 week postbiopsy survey results. There was no difference in the patients' willingness to undergo a repeated procedure in the control and treatment groups. Complications of taking diazepam prebiopsy included drowsiness, chills, and ankle injury. CONCLUSIONS: Diazepam does not improve patient pain perception immediately after or at 1-week recall after prostate biopsy. Omitting diazepam simplifies the biopsy regimen and allows the patient to drive himself home. Based on these results, routine use of diazepam in prostate biopsy is not recommended.