Injury severity score associated with concurrent bladder injury in patients with blunt urethral injury.

BACKGROUND: Delayed diagnosis of concurrent bladder damage in a patient with blunt urethral trauma can lead to a high rate of morbidity. In patients with a high index of suspicion, genitourinary workup is recommended. In complicated patients with multi-trauma, this workup has a risk of being delayed. A proven prognostic indicator to evaluate the likelihood of bladder injury in this population has not been established. The aim of this study was to determine if there was a clinical association between the Injury Severity Score (ISS) and bladder injury involvement among these patients. METHODS: Retrospective analysis was performed on a cohort of 98 patients who presented with blunt urethral trauma to R. Adams Cowley Shock Trauma Center between 2002 and 2014. Univariate analysis was performed to determine if there was an association between concurrent bladder injuries and ISS among other factors. A receiver operating characteristic curve plot was performed to analyze the association between ISS and bladder involvement. RESULTS: Of the 98 patients with blunt urethral trauma, 28 had concurrent bladder injury. ISS was shown to have a significant correlation with concurrent bladder injury (OR = 2.2 per 10 unit change in ISS, p = 0.0001). ROC curve analysis showed an area under the curve for the prediction of bladder injury. Patients with ISS ≥ 34 had a 54% chance of bladder injury, while patients with ISS < 34 had a 13% chance. CONCLUSION: ISS ≥ 34, a score in the range of severe multi-trauma, may be a clinical indicator of bladder injury in patients presenting with blunt urethral trauma. FUNDING: This research was supported in part by the Proposed Research Initiated by Students and Mentors (PRISM) Program, University of Maryland School of Medicine Office of Student Research.

Predictors of Treatment Referral after AUDIT-C Screening for Heavy Drinking.

OBJECTIVES: The Veterans Health Administration has implemented annual screening for heavy drinking during primary care encounters using the 3-item Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire and made specialized services available to patients with alcohol use disorders (AUDs). We sought to identify the factors that influence whether a patient who has an elevated AUDIT-C score receives appropriate care in the context of an integrated mental health services program. We focused on higher AUDIT-C scores, as these are seen in individuals who are most likely to have a moderate-to-severe AUD and more severe alcohol-related consequences. METHODS: Utilizing electronic health record data, we conducted a four-year retrospective study of veterans at high-risk for an AUD, based upon an AUDIT-C score >=8 recorded during a primary care encounter at a Veterans Affairs Medical Center and its community-based outpatient clinics. RESULTS: In multivariate analysis, the predictors of treatment referral were younger age, being non-white, higher AUDIT-C score, and main campus location. Among patients referred for treatment, younger age and being white were associated with an increased likelihood of completing a pre-treatment assessment. CONCLUSIONS: Efforts to increase the consistency of treatment referrals, according to established clinical guidelines, could enhance the effectiveness of AUDIT-C screening during primary care visits. Subgroups of patients who may benefit from such efforts include individuals with high-risk but sub-maximal AUDIT-C scores, older patients, and patients who are seen at community-based outpatient clinics.

Tumor Growth Kinetics and Oncologic Outcomes of Patients Undergoing Active Surveillance for Residual Renal Tumor following Percutaneous Thermal Ablation.

PURPOSE: To evaluate growth kinetics and oncologic outcomes of patients with renal tumors undergoing active surveillance (AS) for residual viable tumor following percutaneous ablation. MATERIALS AND METHODS: Following percutaneous thermal ablation, residual tumor was detected in 21/133 (16%) patients on initial follow-up imaging, and AS was undertaken in 17/21 (81%) patients. Initial tumor volumes and volumes after ablation were assessed from cross-sectional imaging to calculate volumetric growth rate (VGR) and volume doubling time (VDT) of residual tumor. The rate of metastasis, overall survival, and renal cell carcinoma (RCC)-specific survival were compared between patients in the AS group and in the routine follow up group of patients who did not have residual tumor. RESULTS: Median tumor volume prior to ablation, after first ablation, and at final follow-up were 25 cm(3), 6 cm(3), and 6 cm(3), respectively, in patients with residual tumor. Stable, mild, and moderate VGR occurred in 8/17 (47%), 4/17 (24%), and 5/17 (29%) cases, respectively. The 4 cases with fastest VDT underwent delayed intervention with ablation (n = 1) and nephrectomy (n = 3) without subsequent residual, recurrence, or metastasis. There was no significant difference in the rates of RCC metastasis, overall survival, or RCC-specific survival between AS and routine follow-up groups. Metastatic RCC and subsequent death occurred in 1 patient in the AS group, after the patient had refused offers for retreatment for local progression over 60.7 months of follow-up. CONCLUSIONS: In cases when patients are not amenable to further intervention, AS of residual tumor may be an acceptable alternative and allows for successful delayed intervention when needed.

Changes in Serum Concentration of Antidepressants After Bariatric Surgery and Recommendations for Postbariatric Surgery Antidepressant Therapy.

BACKGROUND: Bariatric surgery affects the absorption of medications including antidepressants, but data regarding these effects are limited. OBJECTIVES: Our objectives were to review publicly available data regarding changes in antidepressant serum concentration following bariatric surgery in order to develop medication dosing recommendations in this patient population. METHODS: A comprehensive literature review was performed utilizing key search terms in Pubmed. Additional data were retrieved from the Food and Drug Administration and DrugBank Online resources. RESULTS: A total of twelve published articles were included in addition to the publicly available data from the Food and Drug Administration and DrugBank. The serum concentration of antidepressants following bariatric surgery demonstrated considerable variability between and within drug classes due to unique pharmacokinetic features, drug preparation, and formulation. Recommendations were developed from published data regarding changes in serum concentration and drug-specific pharmacokinetic data. CONCLUSIONS: To our knowledge, this is the first study to propose medication dose-adjustment recommendations for patients on antidepressants undergoing bariatric surgery. We were limited by the relatively small amount of data available and recommend monitoring patients and use of clinical judgment along with this guidance.

Is robot-assisted laparoscopic bilateral extravesical ureteral reimplantation associated with greater morbidity than unilateral surgery? A comparative analysis.

INTRODUCTION: Voiding dysfunction after bilateral extravesical ureteral reimplantation for vesicoureteral reflux has long remained a concern. Robotic approach with improved visualization that enables focused and minimal dissection may help with this concern. OBJECTIVES: To compare postoperative outcomes after bilateral robot-assisted laparoscopic ureteral reimplantation to unilateral robot-assisted laparoscopic ureteral reimplantation. STUDY DESIGN: This was a retrospective study using data abstracted from an institutional review board-approved registry prospectively maintained at our institution since 2012. Patient demographics, preoperative characteristics, and postoperative outcomes were analyzed. Patients with postoperative febrile urinary tract infection (UTI) underwent voiding cystourethrogram (VCUG). Surgical success is defined as absence of febrile UTI or febrile UTI with negative VCUG. RESULTS: 92 patients with a median follow-up of 14 (25th and 75th IQR 5, 28) months. Median operative time (150 vs. 178 min, p = 0.01) and median hospital stay (33 vs. 37 h, p = 0.01) were longer in the bilateral cohort. Weight-adjusted morphine equivalents requirement was also higher in the bilateral group (0.45 vs. 0.59, p = 0.019). DISCUSSION: Early postoperative voiding dysfunction is influenced by anesthesia, postoperative pain, analgesics, age, surgical dissection, and preoperative voiding issues. Effective preoperative management of voiding dysfunction, minimizing surgical dissection and cautery, and minimizing opiate use will aid improving outcomes after surgery and enable bilateral surgeries on uretero-vesical junction. A robotic approach to facilitate such strategies could help outcomes after bilateral ureteral reimplantation. Limitations of this study include its retrospective design, the absence of routine postoperative VCUG after ureteral reimplantation, and unknown confounding variables. CONCLUSION: Robot-assisted laparoscopic bilateral extravesical ureteral reimplantation is not associated with an increased risk of postoperative morbidity compared with unilateral surgery.