THE BURDEN OF UROLOGIC DISEASES IN AMERICA

Chicken IgY reduces the risk of Pseudomonas aeruginosa urinary tract infections in a murine model

Introduction

Urinary tract infections (UTIs) with Pseudomonas aeruginosa are a severe problem in disposed patients in modern healthcare. Pseudomonas aeruginosa establishes recalcitrant biofilm infections and can develop antibiotic resistance. Gargling with avian egg yolk anti-Pseudomonas antibodies (IgY) has shown clinical effect in preventing onset of chronic P. aeruginosa lung infections in patients with cystic fibrosis (CF). Therefore, we speculated whether passive intravesically administered IgY immunotherapy could be a novel strategy against P. aeruginosa UTIs.

Aim

To evaluate if prophylactic repurposing of anti-Pseudomonas IgY can prevent UTIs with P. aeruginosa in a UTI mouse model.

Materials and methods

In vitro, P. aeruginosa (PAO1 and PAO3) was mixed with increasing concentrations of specific anti-Pseudomonas IgY (sIgY) or non-specific control IgY (cIgY) and/or freshly isolated human neutrophils. Bacterial growth was evaluated by the optical density at 600 nm. In vivo, via a temporary transurethral catheter, 10-week-old female Balb/c mice were intravesically infected with 50 ml of a bacterial suspension and sIgY, cIgY, or isotonic NaCl. IgY and NaCl were either co-instilled with the bacteria, or instilled prophylactically, 30 min prior to infection. The animals were euthanized 20 h after infection. Vesical bacteriology was quantified, and cytokine expression in the bladder homogenate was measured by multiplex cytokine assay.

Results

In vitro, sIgY concentrations above 2.5% reduced bacterial growth in a dose-dependent manner. In vivo, a UTI lasting for minimum 7 days was established by installing 5 × 106 colony-forming units (CFU) of P. aeruginosa PAO1. sIgY reduced vesical bacterial load if co-installed with P. aeruginosa PAO1. Prophylactic sIgY and cIgY reduced bacterial load when compared to isotonic NaCl. CXCL2 and G-CSF were both increased in infected bladders compared to non-infected controls which had non-detectable levels. Co-installation of sIgY and bacteria nearly completely inhibited the inflammatory response. However, the cytokine levels in the bladder did not change after prophylactic administration of sIgY or cIgY.

Conclusion

Prophylactic sIgY significantly reduces the amount of bacteria in the bladder in a mouse model of P. aeruginosa cystitis and may serve as a novel non-antibiotic strategy in preventing P. aeruginosa UTIs.

Comparison of urology residency training between the United States and China

OBJECTIVE

This study compares the present status and traits of urology residency programs in the United States and China.

METHODS

The flow path, structure, curriculum, operative experience, scholarly activities, evaluation systems and other aspects of training were comparatively evaluated between China and the United States.

RESULTS

Urology residency training programs are different between China and the United States in many aspects. Admission requirements for the United States urology residency program are more rigorous, and the specialty training program in the United States is more concentrated. Furthermore, residency programs in USA have much more practical clinical and research training, and their evaluation process is more diverse, and it has been designed to assess competencies. Moreover, job opportunities after residency substantially differ between these two countries. Becoming an independent urologic surgeon is not the specific goal of the Urology residency training program in China, and it would require more training time than in the United States.

CONCLUSION

Urology residency training programs in the United States and China have a unique format and characteristics. The training programs in China are focused on general techniques and procedures, while training programs in USA follow a more standardized curriculum. Both USA and China may complement each other to create training programs that would ultimately provide high-quality patient care.

AUA White Paper on Nonneurogenic Chronic Urinary Retention: Consensus Definition, Treatment Algorithm, and Outcome End Points

PURPOSE

The AUA (American Urological Association) QIPS (Quality Improvement and Patient Safety) committee created a white paper on the diagnosis and management of nonneurogenic chronic urinary retention.

MATERIALS AND METHODS

Recommendations for the white paper were based on a review of the literature and consensus expert opinion from the workgroup.

RESULTS

The workgroup defined nonneurogenic chronic urinary retention as an elevated post-void residual of greater than 300 mL that persisted for at least 6 months and documented on 2 or more separate occasions. It is proposed that chronic urinary retention should be categorized by risk (high vs low) and symptomatology (symptomatic versus asymptomatic). High risk chronic urinary retention was defined as hydronephrosis on imaging, stage 3 chronic kidney disease or recurrent culture proven urinary tract infection or urosepsis. Symptomatic chronic urinary retention was defined as subjectively moderate to severe urinary symptoms impacting quality of life and/or a recent history of catheterization. A treatment algorithm was developed predicated on stratifying patients with chronic urinary retention first by risk and then by symptoms. The proposed 4 primary outcomes that should be assessed to determine effectiveness of retention treatment are 1) symptom improvement, 2) risk reduction, 3) successful trial of voiding without catheterization, and 4) stability of symptoms and risk over time.

CONCLUSIONS

Defining and categorizing nonneurogenic chronic urinary retention, creating a treatment algorithm and proposing treatment end points will hopefully spur comparative research that will ultimately lead to a better understanding of this challenging condition.

Resident and Facility Factors Associated With the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set

Objective: This research examined resident and facility-specific factors associated with a diagnosis of a urinary tract infection (UTI) in the nursing home setting. Method: Minimum Data Set and Online Survey, Certification and Reporting system data were used to identify all nursing home residents in the United States on April 1, 2006, who did not have a UTI ( n = 1,138,418). Residents were followed until they contracted a UTI (9.5%), died (8.3%), left the nursing home (33.2%), or the year ended (49.0%). A Cox proportional hazards model was estimated, controlling for resident and facility characteristics and for the state of residence. Result: The presence of an indwelling catheter was the primary predictor of whether a resident contracted a UTI (adjusted incidence ratio = 3.35, p < .001), but only 6.1% of the residents in the sample had such a catheter. Therefore, only one eighth of the UTIs were contracted by residents with a catheter. Thus, subsequent analysis examined the populations with and without catheters separately. Demographic characteristics (such as age) have a much greater association with incidence among residents without catheters. The association with facility factors such as percentage of Medicaid residents, for-profit, and chain status was less significant. Estimates regarding staffing levels indicate that increased contact hours with more highly educated nursing staff are associated with less catheter use. Discussion: Several facility-specific risk factors are of significance. Of significance, UTIs may be reduced by modifying factors such as staffing levels.

Hospital-level Variation in the Quality of Benign Inpatient Urologic Surgery

OBJECTIVE

To examine hospital-level variation in outcomes following benign urologic surgeries given that hospital-level variation in surgical outcomes can portend quality and appropriateness of care concerns and identify quality improvement opportunities in perioperative care.

MATERIALS AND METHODS

Using the Washington State Comprehensive Hospital Abstract Reporting System, we identified patients who underwent transurethral resection of the prostate (TURP), percutaneous nephrostolithotomy (PCNL), and pyeloplasty from 2003 to 2008. We classified prolonged postoperative length of stay (LOS) as that exceeding the 75th percentile, and we measured the rate of Agency for Healthcare Quality Patient Safety Indicators, readmissions, and death. We calculated hospital-specific observed-to-expected event rates using random effects multilevel multivariable models adjusted for age and comorbidity.

RESULTS

We identified 6699 TURP patients at 54 hospitals, 2541 PCNL patients at 45 hospitals, and 584 pyeloplasty patients at 36 hospitals. Complication rates were highest after PCNL (22.9% prolonged LOS vs 17.3% for TURP and 13.9% for pyeloplasty, P < .001; 3.4% 90-day mortality vs 0.6% for TURP and 0% for pyeloplasty). Hospital-level variation was most substantial for LOS after TURP and pyeloplasty (8.1% and 14.3% of variance in prolonged LOS, respectively).

CONCLUSION

Hospital-level variation is common after benign inpatient urologic surgeries and may relate to difference in perioperative provider practice patterns. The morbidity of PCNL in this study was higher than expected and merits further investigation.

Attitude and perception of urology by medical students at the end of their medical school: An appraisal from Saudi Arabia

Objectives:

To evaluate the attitude and perception of the graduates of King Saud University (KSU) College of Medicine regarding the quality of their urology rotation, urology exposure during this rotation, confidence about managing common conditions, and career prospects.

Materials and Methods:

In 2013, a questionnaire regarding the students’ perceptions of urology rotation was developed and E-mailed to all final (5^th) year medical students and interns of KSU College of Medicine, Riyadh, Saudi Arabia. Individual responses were recorded, tabulated and compared using descriptive statistics.

Results:

The overall response rate was 67.7%. Respondents included 101 (49.8%) males and 102 (50.2%) females. All the respondents but 18 (8.9%) were enrolled in a urology rotation during undergraduate years. Only 27 (13.3%) were willing to choose urology specialty as a future career. Significant gender differences were found regarding choice of urology as a future career (P = 0.002) and the need for more urology exposure during surgical rotation (P = 0.002).

Conclusions:

Knowledge of medical school graduates is insufficient in many urologic subjects, and there is a need for more urology exposure. Social reasons and lack of knowledge about urology hinder the choice of urology specialty as a future career. Clearance of learning objectives, immediate and prompt feedback on performance and adequate emphasis of common problems and ambulatory care are some aspects that should be taken into account by curriculum planners as they consider improvements to urology rotation program.

Attitudes of GP trainees towards the training received in urology on the GP training scheme

INTRODUCTION

The majority of patients with scrotal problems or urinary symptoms will first present to their general practitioner (GP). The importance of the initial examination performed by the GP is often underestimated; however, it frequently determines the course of investigation and ultimately treatment. Unfortunately, medical schools have devoted increasingly less time to teaching urology over the past decade. The impact of this decline in teaching on a GP trainee's assessment of urological complaints remains unclear. The aim of this study was to investigate the self-reported competency of GP trainees in assessing urological presentations.

METHODS

A questionnaire was circulated to 101 GP trainees from five separate training programmes. Respondents rated their confidence in evaluating four different urological presentations. They were also invited to give their opinion regarding the teaching of urology on their current scheme and whether they would be in favour of the addition of urology as an optional rotation.

RESULTS

Only 18 trainees (19 %) felt urology was adequately covered on their curriculum. A small yet significant number of respondents felt uncomfortable in their assessment of testicular (28 %, 28/101) or prostate (35 %, 35/101) pathology and male (17 %, 17/101) or female (10 %, 10/101) urinary symptoms. Twenty-six trainees (26 %) would choose a rotation in urology if available. Another ten trainees felt that attending urology outpatient clinics would benefit training.

CONCLUSION

This study highlights a number of concerns among GP trainees in relation to their training in urology. These issues should be addressed to ensure that the training scheme sufficiently prepares GPs to manage common urological conditions.

Morbidity and psychological impact of prostate biopsy: the future calls for a change

Currently transrectal ultrasound-guided prostate biopsy (TRUS-Bx) is one of the most common urological procedures, with more than 1 million performed per year in Europe and the United States.1 Among patients undergoing TRUS-Bx, approximately one-third will receive a diagnosis of prostate cancer (PCa), while two-thirds receive a negative result on initial biopsy. Negative biopsy patients maintain an estimated risk of repeated biopsy of 12% at 1 year and 38% at 5 years.2 Standard TRUS-Bx is likely to systematically miss significant tumors, particularly in the anterior and apical parts of the gland.3 A crucial aim of urologists in the next decade is to increase the accuracy of the procedure and avoid the use of inappropriate biopsies.

Host-specific induction of Escherichia coli fitness genes during human urinary tract infection

Uropathogenic Escherichia coli (UPEC) is the predominant etiological agent of uncomplicated urinary tract infection (UTI), manifested by inflammation of the urinary bladder, in humans and is a major global public health concern. Molecular pathogenesis of UPEC has been primarily examined using murine models of UTI. Translational research to develop novel therapeutics against this major pathogen, which is becoming increasingly antibiotic resistant, requires a thorough understanding of mechanisms involved in pathogenesis during human UTIs. Total RNA-sequencing (RNA-seq) and comparative transcriptional analysis of UTI samples to the UPEC isolates cultured in human urine and laboratory medium were used to identify novel fitness genes that were specifically expressed during human infection. Evidence for UPEC genes involved in ion transport, including copper efflux, nickel and potassium import systems, as key fitness factors in uropathogenesis were generated using an experimental model of UTI. Translational application of this study was investigated by targeting Cus, a bacterial copper efflux system. Copper supplementation in drinking water reduces E. coli colonization in the urinary bladder of mice. Additionally, our results suggest that anaerobic processes in UPEC are involved in promoting fitness during UTI in humans. In summary, RNA-seq was used to establish the transcriptional signature in UPEC during naturally occurring, community acquired UTI in women and multiple novel fitness genes used by UPEC during human infection were identified. The repertoire of UPEC genes involved in UTI presented here will facilitate further translational studies to develop innovative strategies against UTI caused by UPEC.

Progression and treatment of incident lower urinary tract symptoms (LUTS) among men in the California Men's Health Study

OBJECTIVES

To characterise the progression and treatment of lower urinary tract symptoms (LUTS) among men aged 45-69 years in the California Men's Health Study.

PATIENTS AND METHODS

A total of 39,222 men, aged 45-69 years, enrolled in the Southern California Kaiser Permanente Health Plan were surveyed in 2002-2003 and again in 2006-2007. Those men who completed both surveys who did not have a diagnosis of benign prostatic hyperplasia (BPH) and were not on medication for LUTS at baseline were included in the study (N = 19,505). Among the men with no or mild symptoms at baseline, the incidence of moderate/severe LUTS (American Urological Association Symptom Index [AUASI] score ≥8) and odds of progression to severe LUTS (AUASI score ≥20) was estimated during 4 years of follow-up.

RESULTS

Of the 9640 men who reported no/mild LUTS at baseline, 3993 (41%) reported moderate/severe symptoms at follow-up and experienced a 4-point change in AUASI score on average. Of these men, 351 (8.8%) had received a pharmacological treatment, eight (0.2%) had undergone a minimally invasive or surgical procedure and 3634 (91.0%) had no treatment recorded. Men who progressed to severe symptoms (AUASI score ≥20; n = 165) were more likely to be on medication for BPH (odds ratio [OR] 8.09, 95% confidence interval [CI] 5.77-11.35), have a BPH diagnosis (OR 4.74, 95% CI 3.40-6.61) or have seen a urologist (OR 2.49, 95% CI 1.81-3.43) when compared with men who did not progress to severe symptoms (AUASI score <20).

CONCLUSION

These data show that the majority of men who experienced progression did not have pharmacological or surgical therapy for their symptoms and, therefore, may prove to be good candidates for a self-management plan.

Extracting data from electronic medical records: validation of a natural language processing program to assess prostate biopsy results

OBJECTIVE

The extraction of specific data from electronic medical records (EMR) remains tedious and is often performed manually. Natural language processing (NLP) programs have been developed to identify and extract information within clinical narrative text. We performed a study to assess the validity of an NLP program to accurately identify patients with prostate cancer and to retrieve pertinent pathologic information from their EMR.

MATERIALS AND METHODS

A retrospective review was performed of a prospectively collected database including patients from the Southern California Kaiser Permanente Medical Region that underwent prostate biopsies during a 2-week period. A NLP program was used to identify patients with prostate biopsies that were positive for prostatic adenocarcinoma from all pathology reports within this period. The application then processed 100 consecutive patients with prostate adenocarcinoma to extract 10 variables from their pathology reports. The extraction and retrieval of information by NLP was then compared to a blinded manual review.

RESULTS

A consecutive series of 18,453 pathology reports were evaluated. NLP correctly detected 117 out of 118 patients (99.1%) with prostatic adenocarcinoma after TRUS-guided prostate biopsy. NLP had a positive predictive value of 99.1% with a 99.1% sensitivity and a 99.9% specificity to correctly identify patients with prostatic adenocarcinoma after biopsy. The overall ability of the NLP application to accurately extract variables from the pathology reports was 97.6%.

CONCLUSIONS

Natural language processing is a reliable and accurate method to identify select patients and to extract relevant data from an existing EMR in order to establish a prospective clinical database.

The advanced practice wound ostomy continence nurse in homecare

Wound ostomy continence (WOC) programs are essential in any healthcare organization, including home care agencies, to provide comprehensive, high-quality care. Advanced practice nurses (APNs) with assessment, diagnostic, and coordination skills are well suited to manage the complex patients being cared for by home care agencies. A number of research studies have assessed the credibility and value of APNs in the home care setting, caring for complex, frail patients. This article describes the role of the APN, and the role of the WOC specialist nurse, comparing similarities and differences. The advanced practice WOC nurse is now essential in the home care setting to manage the care of complex patients.

Determination of target sequence bound by PapX, repressor of bacterial motility, in flhD promoter using systematic evolution of ligands by exponential enrichment (SELEX) and high throughput sequencing

Most uncomplicated urinary tract infections (UTIs) are caused by uropathogenic Escherichia coli (UPEC). Both motility and adherence are integral to UTI pathogenesis, yet they represent opposing forces. Therefore, it is logical to reciprocally regulate these functions. In UPEC strain CFT073, PapX, a non-structural protein encoded by one of the two pap operons encoding P fimbria adherence factor, represses flagella-mediated motility and is a putative member of the winged helix transcription factor family. The mechanism of this repression, however, is not understood. papX is found preferentially in more virulent UPEC isolates, being significantly more prevalent in pyelonephritis strains (53% of isolates) than in asymptomatic bacteriuria (32%) or fecal/commensal (12.5%) strains. To examine PapX structure-function, we generated papX linker insertion and site-directed mutants, which identified two key residues for PapX function (Lys(54) and Arg(127)) within domains predicted by modeling with I-TASSER software to be important for dimerization and DNA binding, respectively. To determine the PapX binding site in the CFT073 genome, systematic evolution of ligands by exponential enrichment (SELEX) in conjunction with high throughput sequencing was utilized for the first time to determine a novel binding site for a bacterial transcription factor. This method identified a 29-bp binding site within the flhDC promoter (TTACGGTGAGTTATTTTAACTGTGCGCAA), centered 410 bp upstream of the flhD translational start site. Gel shift experiments demonstrated that PapX binds directly to this site to repress transcription of flagellar genes.

Uropathogenic E. coli infection provokes epigenetic downregulation of CDKN2A (p16INK4A) in uroepithelial cells

Host cell and bacterial factors determine severity and duration of infections. To allow for bacteria pathogenicity and persistence, bacteria have developed mechanisms that modify expression of host genes involved in cell cycle progression, apoptosis, differentiation and the immune response. Recently, Helicobacter pylori infection of the stomach has been correlated with epigenetic changes in the host genome. To identify epigenetic changes during Escherichia coli induced urinary tract infection (UTI), we developed an in vitro model of persistent infection of human uroepithelial cells with uropathogenic E. coli (UPEC), resulting in intracellular bacteria colonies. Cells inoculated with FimH-negative E. coli (N-UPEC) that are not internalized and non-inoculated cells were used as controls. UPEC infection significantly induced de novo methyltransferase (DNMT) activity (12.5-fold P=0.002 UPEC vs non-inoculated and 250-fold P=0.001 UPEC vs N-UPEC inoculated cells) and Dnmt1 RNA expression (6-fold P=0.04 UPEC vs non-inoculated cells) compared with controls. DNMT1 protein levels were significantly increased in three uroepithelial cell lines (5637, J82, HT-1197) in response to UPEC infection as demonstrated by confocal analysis. Real-time PCR analysis of candidate genes previously associated with bacteria infection and/or innate immunity, revealed UPEC-induced downregulation of the tumor suppressor gene CDKN2A (3.3-fold P=0.007 UPEC vs non-inoculated and 3.3-fold P=0.001 UPEC vs N-UPEC) and the DNA repair gene MGMT (9-fold P=0.03 UPEC vs non-inoculated). Expression of CDH1, MLH1, DAPK1 and TLR4 was not affected. Pyrosequencing of CDKN2A and MGMT CpG islands revealed increased methylation in CDKN2A exon 1 (3.8-fold P=0.04 UPEC vs N-UPEC and UPEC vs non-inoculated). Methylation of MGMT was not affected. UPEC-induced methylation of CDKN2A exon 1 may increase bladder cancer and presage UTI risk, and be useful as a biological marker for UTI susceptibility or recurrence.

Infectious diseases in the nursing home setting: challenges and opportunities for clinical investigation

The global population is aging. With the high prevalence of dementia and functional decline in older Americans, many aging adults with disabilities reside in nursing homes in their final stage of life. Immunosenescence, multiple comorbid diseases, and grouped quarter living all coalesce in nursing home residents to increase the risk for infectious disease. The unique issues involved with diagnosis, prognosis, and management of infectious diseases in nursing home residents make research based in the nursing home setting both necessary and exciting for the physician investigator. This review discusses the opportunities and challenges involved with research of the evolving public health problem of infections among nursing home residents.

Validity of administrative coding in identifying patients with upper urinary tract calculi

PURPOSE

Administrative databases are increasingly used for epidemiological investigations. We performed a study to assess the validity of ICD-9 codes for upper urinary tract stone disease in an administrative database.

MATERIALS AND METHODS

We retrieved the records of all inpatients and outpatients at Johns Hopkins Hospital between November 2007 and October 2008 with an ICD-9 code of 592, 592.0, 592.1 or 592.9 as one of the first 3 diagnosis codes. A random number generator selected 100 encounters for further review. We considered a patient to have a true diagnosis of an upper tract stone if the medical records specifically referenced a kidney stone event, or included current or past treatment for a kidney stone. Descriptive and comparative analyses were performed.

RESULTS

A total of 8,245 encounters coded as upper tract calculus were identified and 100 were randomly selected for review. Two patients could not be identified within the electronic medical record and were excluded from the study. The positive predictive value of using all ICD-9 codes for an upper tract calculus (592, 592.0, 592.1) to identify subjects with renal or ureteral stones was 95.9%. For 592.0 only the positive predictive value was 85%. However, although the positive predictive value for 592.1 only was 100%, 26 subjects (76%) with a ureteral stone were not appropriately billed with this code.

CONCLUSIONS

ICD-9 coding for urinary calculi is likely to be sufficiently valid to be useful in studies using administrative data to analyze stone disease. However, ICD-9 coding is not a reliable means to distinguish between subjects with renal and ureteral calculi.

Economic impact of tension-free vaginal tape surgery for urinary incontinence in an ambulatory regimen compared with hospital admission

OBJECTIVES

To determine the cost per patient of a tension-free vaginal tape procedure involving major ambulatory surgery (MAS) compared with inpatient surgery in 2002 and 2003, and to analyse the medical care given following each procedure in a public hospital in Spain.

MATERIAL AND METHODS

The method used was activity-based costing, which involves designing a protocol of processes of caring for the patient with the help of professionals and subsequently calculating the cost of each process; this system was applied retrospectively to patients cared for in 2002 and 2003. In addition, the clinical histories of these patients were reviewed in order to evaluate complementary care given by the emergency service and admissions to hospital immediately following surgery. The relation between these events and each sample group was analysed by means of a non-parametric test and CIs for a 95% level of significance were obtained in order to make the calculations more robust.

RESULTS

The mean cost for the patients in the ambulatory group was 42.43% lower than that for the hospitalized patients. Whereas 5.5% of the ambulatory patients subsequently required admission and a further 7.3% required complementary medical care, 19.2% of the patients who had been hospitalized for the surgery required complementary medical care and 1.4% were readmitted after intervention. In spite of these results, there was no dependence between these variables according to the chi(2) test.

CONCLUSION

MAS produced better results in terms of minimizing costs; under our conditions it was less costly but was of equal efficacy to the surgical intervention.

What every graduating medical student should know about urology: the stakeholder viewpoint

OBJECTIVES

What should every medical student know about urology upon graduating from medical school? To answer this question, we conducted a survey of key stakeholders in an effective medical student education in urology.

METHODS

Directors of the generalist residencies in the United States (emergency medicine, family medicine, internal medicine, and pediatrics), directors of urology residencies, medical student educators in urology, and applicants to the 2006 urology residency match were invited to complete an online survey. Participants were asked to select the 5 most important topics to be included in a core urology curriculum for all medical students.

RESULTS

Among 1859 stakeholders surveyed, response rates by stakeholder cohort ranged from 67% to 26% (overall 44%). There was marked homogeneity among participant groups as to what respondents considered to be the most important topics for a core urology curriculum for medical students. Based on aggregate data, the 8 most commonly cited topics included urinary stone disease (75% of respondents), hematuria (65%), urinary tract infections in adults (53%), benign prostatic hyperplasia (52%), urinary incontinence (45%), prostate cancer (45%), screening with prostate-specific antigen (33%), and testis torsion (24%).

CONCLUSIONS

This survey has identified the most important urology topics about which medical students should learn before graduation. Work is currently under way under the aegis of the American Urological Association to develop materials to standardize student education in these core topics across the United States.

Excessive antibiotic use in men with prostatitis

BACKGROUND

Prostatitis accounts for 2 million outpatient visits annually. The majority of prostatitis cases fit the definition of chronic pelvic pain syndrome, for which routine antibiotic use is not indicated.

METHODS

Inpatient, outpatient, and pharmacy datasets from the Veterans Health Administration were used to quantify the magnitude of antibiotic use attributable to chronic pelvic pain syndrome. Specifically, men with a diagnosis of infectious/acute prostatitis or a urinary tract infection were excluded, and the remaining men with a diagnosis of prostatitis were defined as having chronic pelvic pain syndrome.

RESULTS

The annual prevalence of chronic pelvic pain syndrome was 0.5%. Prescriptions for fluoroquinolone antibiotics were filled in 49% of men with a diagnosis of chronic pelvic pain syndrome compared with 5% in men without chronic pelvic pain syndrome. Men with chronic pelvic pain syndrome were more than 7 times more likely to receive a fluoroquinolone prescription independently of age, race/ethnicity, and comorbid conditions. Increased use of other antibiotics also was observed. High use was similar in men with either infectious/acute prostatitis or chronic pelvic pain syndrome.

CONCLUSION

Despite evidence that antibiotics are not effective in the majority of men with chronic pelvic pain syndrome, they were prescribed in 69% of men with this diagnosis. Some increased use is probably due to uncontrolled confounding by comorbid conditions or inaccurate diagnostic coding. However, a 7-fold higher rate of fluoroquinolone usage suggests that strategies to reduce unnecessary antibiotic use in men with prostatitis are warranted.

The current status of medical student urological education in the United States

PURPOSE

The current status of urological education in medical schools in the United States was investigated.

MATERIALS AND METHODS

A questionnaire regarding medical student teaching was sent to the program directors of the 118 urological residency programs in the United States.

RESULTS

Of the 118 individuals 95 (81%) completed and returned the questionnaire. Three urology programs were not affiliated with medical schools and had no contact with medical students. In 29 programs (32%) there were no urology faculty lectures in the preclinical years. At 46 schools (50%) there was no urology lecture in the physical diagnosis course. Compared to a decade ago program directors believed that exposure to urology was about the same at 41 schools (45%), increased at 20 (22%) but decreased at 31 (34%). Finally, 60 program directors (65%) stated that it was possible for a student to graduate from the school without any clinical exposure to urology.

CONCLUSIONS

This survey identifies alarming trends that, if left uncorrected, could adversely affect patient care in the future, particularly as the population of the United States ages. In addition, these trends may jeopardize the number and quality of future urological residency applicants.

Asymptomatic bacteriuria and urinary tract infection in older adults

Asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) are common in older community dwellers (ages 65 and older) and nursing home residents. The challenge involved in distinguishing ASB from UTI in this population results from other comorbid illnesses that may present with symptoms similar to UTI and from elderly adults who have cognitive impairment not being able to report their symptoms. This article reviews the most updated information on diagnosis, microbiology, management, and prevention of ASB and UTI as they pertain to older community dwellers and nursing home residents.

Assessment of the core learning objectives curriculum for the urology clerkship

PURPOSE

The traditional approach to the surgical clerkship has limitations, including variability of clinical exposure. To optimize student education we developed and introduced the core learning objectives curriculum, which is designed to allow students freedom to direct their learning and focus on core concepts. We performed a prospective, randomized, controlled study to compare the efficacy of core learning objectives vs traditional curricula through objective and subjective measures.

MATERIALS AND METHODS

Medical students were randomly assigned to the core learning objectives or traditional curricula during the 2-week urology clerkship. Faculty was blinded to student assignment. Upon rotation completion all students were given a 20-question multiple choice examination covering basic urology concepts. In addition, students completed a questionnaire addressing subjective clerkship satisfaction, comprising 15 questions.

RESULTS

Between June 2005 and January 2007, 10 core learning objectives students and 10 traditional students completed the urology clerkship. The average +/- SEM multiple choice examination score was 12.1 +/- 0.87 and 9.8 +/- 0.59 for students assigned to the core learning objectives and traditional curricula, respectively (p <0.05). Subjective scores were higher in the core learning objectives cohort, although this result did not attain statistical significance (124.9 +/- 3.72 vs 114.3 +/- 4.96, p = 0.1). Core learning objectives students reported higher satisfaction in all 15 assessed subjective end points.

CONCLUSIONS

Our experience suggests that the core learning objectives model may be an effective educational tool to help students achieve a broad and directed exposure to the core urological concepts.

Wound, Ostomy, Continence Nurse Consulting

Wound, Ostomy, and Continence (WOC) Nurses provide healthcare organizations with a wealth of experience and expertise across the care continuum. The WOC nurse improves care processes by aligning best practice for patients with wounds. ostomies and incontinence. WOC nursing lowers the cost of poor quality, reduces the risk of litigation and improves staff, patient and caregiver satisfaction.

Prevalence and trends of selected urologic conditions for VA healthcare users

BACKGROUND

Conducted as part of the Urologic Diseases in America project whose aim was to quantify the burden of urologic diseases on the American public, this study focuses on Veterans Health Administration (VHA) users as a special population to supplement data on overall prevalence rates and trends in the United States. Veterans comprise 25% of the male population 18 years or older and contribute substantially to the overall burden of urologic conditions. The objective of this study is to describe the prevalence rates and trends of urologic cancers and selected benign conditions from 1999 to 2002 for VHA users.

METHODS

VHA administrative files for 1999-2002 and Medicare claims files for the same years were used to identify those who had a diagnosis of qualifying urologic conditions.

RESULTS

Among the conditions evaluated, prostate cancer was listed as a primary diagnosis for 5.4% of VHA users in 2002, followed in decreasing prevalence by erectile dysfunction (2.9%), renal mass (1.5%), interstitial cystitis (1.4%), and prostatitis (1.1%). Age-adjusted rates showed significant increases for renal mass (31%), interstitial cystitis (14%), and erectile dysfunction (8%) between 1999 and 2002. Systematic variations in prevalence rates and trends were observed by age, race/ethnicity, and region. Those in the Western region generally had lower age-adjusted prevalence rates and their increases were also slower than other regions. Addition of Medicare data resulted in large increases (21 to 489%) in prevalence among VHA users, suggesting substantial amount of non-VA urological care provided to VHA users.

CONCLUSION

Prevalence rates for many urologic diseases increased between 1999 and 2002, which were not entirely attributable to the aging of veterans. This changing urologic disease burden has substantial implications for access to urologic care and treatment capacity, especially in light of the level of urologic care delivered to veterans by Medicare providers outside the VA. Further study on the factors associated with these increases and how they affect the patterns, cost, and quality of care in veterans is needed.

The continued decline of formal urological education of medical students in the United States: does it matter?

PURPOSE

Survey analyses of 50 years document a substantial decline in the formal urological education of United States medical students, resulting in repeated calls by urologists to reverse this trend. Has this trend continued during the last decade? If so, should we be concerned? We performed a national survey to provide an updated assessment of urological education at United States medical schools.

MATERIALS AND METHODS

All 321 applicants to the 2003 to 2004 United States urology residency match and 527 applicants to a Boston area emergency medicine residency program in 2003 to 2004 from accredited United States medical schools were invited to participate in the study. On a validated, anonymous online survey, these students were asked 1) did their school offer a required and/or elective clinical rotation in urology, and 2) if so, what was its duration and in which year was it usually completed.

RESULTS

Curricular data were obtained on 110 of 125 (88%) accredited United States medical schools. Of United States schools 17% (17.3%, SE 1.2%, 19 of 110) have required clinical rotations in urology; these required rotations are 1 to 2 weeks in duration and, in 79% of cases, conducted in year 3 of medical school. Those medical schools that require a clinical rotation in urology do not have a greater percentage of their students entering the urology match (Mann-Whitney U test p = 0.540).

CONCLUSIONS

Formal urological education of United States medical students has continued to erode during the last decade, but the impact of this trend on student learning and career choice is not clear. Further research is required to determine whether these changes are of concern for the quality of applicants to urological training and for the future of urological care in the United States.