Health disparities and access to advanced therapy for overactive bladder.

AIMS: Refractory overactive bladder (OAB) is among the most common reasons for referral to specialists in voiding dysfunction. Significant racial and ethnic disparities exist in prevalence, severity, and management of OAB, presenting care barriers for marginalized patients. We aim to explicate these disparities and explore the factors that led to their existence and persistence. We will additionally offer suggestions to mitigate such disparities and approach equitable care for our patients. METHODS: This is a narrative review of pertinent articles related to health disparities in OAB. Articles on OAB prevalence stratified by race and ethnicity, and variations in treatment patterns for patients of marginalized backgrounds were identified from the PubMed database. We also included a review of evidence from governmental and historical sources to provide sociocultural context. RESULTS: Patients from marginalized backgrounds are underrepresented in OAB literature. There appear to be differences in symptom severity and prevalence based on race. OAB severity seems closely entwined with social determinants of health. Patients from marginalized populations experience numerous care barriers impeding the treatment of OAB. Finally, White patients are more likely to receive advanced management for OAB. CONCLUSIONS: Numerous health disparities exist in the diagnosis and management of OAB. This review is grounded in societal context: health injustice in the United States ultimately stems from systemic racism. Improving our understanding of care disparities and the systems that allow them to persist will bring us closer to equity and allow our patients from marginalized backgrounds to obtain the evidence-based care they deserve.

Timing of Ureteral Stent Removal After Ureteroscopy on Stent-Related Symptoms: A Validated Questionnaire Comparison of 3 and 7 Days Stent Duration.

Objectives: To determine whether urinary symptoms are significantly improved with a shorter duration of stent placement without an increase in complications. Methods: A total of 100 patients were prospectively randomized to two groups, either a 3-day (n = 59, Group 1) or 7-day (n = 41, Group 2) stent placement group depending on date of operation. Patients submitted Ureteral Stent Symptom Questionnaires both while stents were in situ and 2 to 3 days after removal. Results: Group 2 reported greater urinary symptoms (p < 0.001) and pain (p < 0.001) with stents in situ compared with Group 1. Urinary symptoms (p < 0.001), pain (p = 0.003), and general health (p = 0.02) were more severe in Group 2 after stent removal as well. The analysis also revealed that urinary symptoms, pain, and general health improved after stent removal compared with stent in situ (p < 0.001). There were no significant differences in work-related functioning between two groups. There was one complication in Group 1 requiring bilateral stent replacement. There were no significant differences in emergency department visits, unplanned clinic visits, or hospitalizations between Groups 1 and 2. Conclusions: Patients with stent removal at 3-day group had better reported urinary, pain, and general health score compared with 7-day group. Patients after stent removal had improved urinary symptoms, pain symptom, and general health compared with ureteral stent in situ. There was no statistically significant difference in complications between the groups.

Risk of Retention After OnabotulinumtoxinA Injection for Overactive Bladder in a Diverse Urban Population With High BMI and Comorbidity Rates.

IMPORTANCE: OnabotulinumtoxinA (BTX-A) injection is a third-line therapy for overactive bladder (OAB). Patients undergoing treatment have a 6.5% chance of requiring clean intermittent catheterization (CIC) due to postoperative urinary retention (POUR). OBJECTIVE: The aim of this study was to evaluate risk factors for retention after BTX-A injections for OAB to decrease treatment hesitancy and enhance shared decision-making. STUDY DESIGN: This is a retrospective review of patients who underwent BTX-A injection for OAB at an urban university hospital between November 2015 and January 2021. Patients with neurogenic OAB, incomplete follow-up, or concomitant vaginal surgery were excluded. The primary outcome was POUR requiring CIC or postvoid residual volume (PVR) >200 mL at follow-up visit. Secondary outcomes included number of BTX-A injections, interval to reinjection, and whether patients reported symptom improvement. RESULTS: Our sample (N = 185) was 84% female with high prevalence of obesity (50%) and diabetes (32%). Twenty-one (11.4%) met the criteria for POUR with 17 (9.2%) requiring CIC. The retention and nonretention groups were similar in age, sex, smoking history, body mass index (BMI), hemogloblin A1c, and birth history, but significantly differed in preoperative PVR. Logistic regression revealed that patients with preoperative PVR 100+ mL had nearly 4-fold higher odds of POUR compared with patients with PVR less than 50 mL (odds ratio, 3.77; 95% confidence interval, 1.08-16.19). CONCLUSIONS: Our findings reassure patients with high BMI, as well as their physicians, that retention after BTX-A injection is not associated with BMI. However, patients presenting with high baseline PVR (100 + mL) should be counseled regarding a potentially higher risk of retention after BTX-A injection.

An Updated Review on Physician Burnout in Urology.

Physician burnout is an issue having an impact on all of medicine but having a significant impact on the field of urology. Burnout begins in medical school and worsens in residency. Increased workload leads to increased burnout both in residency and in practice. Issues with work-life balance, electronic medical record usage, decreasing reimbursements, and increased Centers for Medicare & Medicaid Services burden all have an impact on physician satisfaction with their practices. Burnout should be acknowledged, and measures for prevention should be taken by hospitals and residency programs to decrease and prevent physician burnout.

Medical students are accurate in interpreting the presence of pathologic interstitial edema on focused lung ultrasound compared to expert reviewers.

BACKGROUND: Over the past two decades, studies have demonstrated that lung ultrasound is useful in diagnosing alveolar interstitial syndrome, which is seen in patients with decompensated congestive heart failure (CHF). METHODS: We studied medical students performing lung ultrasound on patients admitted to the hospital with a presumed diagnosis of decompensated CHF in a prospective convenience observation study. Two ultrasound fellowship-trained emergency medicine attendings independently reviewed the lung ultrasounds at a later date, blinded to the students' interpretation and other clinical information, to confirm ultrasound findings and assess for inter-rater reliability of the lung ultrasound using intraclass correlation coefficients (ICCs). RESULTS: Thirty-six patients were enrolled in the study resulting in 653 unique lung zones scanned. The zones were imaged and classified as being normal (B-lines < 3) or pathologic (B-lines ≥ 3). The novice scanners' interpretation was compared to expert reviews using ICCs. The ICC was 0.88, with a 95% confidence interval of 0.87 to 0.90, for all lung zones scanned. CONCLUSION: There was almost perfect agreement between novice practitioners and experts when determining the presence of pathologic B-lines in individual patients.

Fornix-Based Trabeculectomy Conjunctival Closure: Winged Sutures versus Modified Wise Closure.

PURPOSE: To compare the midterm safety and efficacy profile of winged sutures versus modified Wise closure for fornix-based trabeculectomy. DESIGN: Retrospective comparative study. PARTICIPANTS: Consecutive cases that underwent fornix-based trabeculectomy by a single surgeon between January 5, 2015, and May 8, 2017. METHODS: Potential cases were identified using the Current Procedural Terminology code, and their charts were reviewed thoroughly. Only 1 eye per patient was included. Demographic and clinical data were collected. MAIN OUTCOME MEASURES: Primary outcomes were bleb leak and subsequent surgical revision rates. Secondary outcomes included intraocular pressure (IOP), number of glaucoma medications (NGM), visual acuity (VA), and other complications. RESULTS: A total of 313 patients were identified, 157 with winged sutures and 156 with modified Wise closure. Baseline demographic and clinical characteristics were similar between the 2 groups. Twenty-six cases (16.6%) of winged sutures and 10 cases (6.4%) of modified Wise group developed bleb leak (P = 0.007), but only a total of 10 eyes needed bleb revision (P = 0.336). Other complications were similar in rates between the groups (P > 0.05). At 6 months, the modified Wise group had significantly greater IOP reduction (-3.10±1.29 [standard error], P = 0.016). Number of glaucoma medications reduction and VA evolution were similar between the 2 groups (P > 0.05). CONCLUSIONS: Fornix-based trabeculectomy with either closure technique was effective in lowering IOP and NGM with comparable safety profile at 6 months. Furthermore, modified Wise closure provided larger IOP reduction and lower bleb leak rate, suggesting a potential superiority to winged sutures. Our study was limited by mitomycin C (MMC) delivery method change near the time of conjunctival closure change, although MMC delivery methods did not show significance in any outcome model.