A government mandated consent safely reduces opioid utilization for major pediatric genitourinary surgeries

INTRODUCTION

We describe the effect of a state mandated opioid consent on opioid utilization and multimodal pain use for major pediatric genitourinary surgeries.

METHODS

All patients who underwent an inpatient pediatric genitourinary surgery at the Children's Hospital of Pittsburgh between August 2015 and February 2020 were identified. Inpatient and outpatient multimodal pain control utilization were assessed. Delayed prescriptions or emergency department visits within 30 days were identified and when applicable referenced against National Surgical Quality Improvement Program data.

RESULTS

After accounting for a 6-month transition period following policy implementation, 462 major pediatric genitourinary procedures were identified. The frequency of discharge opiate prescriptions decreased from 68.4% prior to the transition period to 10.7% afterward(p<0.001). Morphine milligram equivalents per prescription decreased from 75(IQR 45-150) to 45(IQR 22.5-75)(p<0.001). The rate of delayed non-opioid analgesic prescriptions (6.6% vs 7.4%), delayed opioid prescriptions (1.5% vs 0.3%), or emergency department visits (11.8% vs 12.6%)(p = 0.809) remained unchanged. Data agreed with National Surgical Quality Improvement Program data in 98.5% of cases. After excluding one surgeon who departed after the transition period, regional block utilization did not change from 61/115(53%) to 147/320(45.9%)(p = 0.425).

CONCLUSIONS

A state mandated opioid consent safely reduced opioid utilization for most major pediatric genitourinary surgeries.

LEVEL OF EVIDENCE

Level III.

Point-of-care ultrasound is an accurate, time-saving, and cost-effective modality for post-operative imaging after pyeloplasty

BACKGROUND

Dismembered pyeloplasty is considered the gold standard treatment for ureteropelvic junction obstruction (UPJO). Although the frequency and timing of follow up imaging after pyeloplasty is variable, renal ultrasound (RUS) is commonly utilized. With minimal training, point-of-care ultrasound (POCUS) can be easily performed by a urologist during a post-operative visit.

OBJECTIVE

Our hypothesis is that POCUS is an accurate, time-saving, and cost-effective alternative to a complete retroperitoneal ultrasound (CRUS) performed by the Radiology Department after pyeloplasty.

STUDY DESIGN

The clinical records of all children who underwent pyeloplasty (by any method) over a 12 month period at our institution were retrospectively reviewed. The exact timing and method (POCUS vs. CRUS) of follow up imaging was surgeon-dependent. Statistical analysis was performed to compare the time and cost of POCUS vs. CRUS. The clinical course of each patient who had each type of imaging was assessed.

RESULTS

A total 45 patients were included in this analysis. Over a mean follow up period of 29 months, a total of 73 CRUS and 67 POCUS were performed. Each CRUS on average added 2 h to each patient's healthcare encounter. Had the 73 CRUS been performed as POCUS instead, this would have corresponded to $83,751 less charges to payers. There was no difference in the rate of the detection of worsening, stable, or improved hydronephrosis (HN) between either modality (p > 0.05). The recommended follow up time for observed HN was no different between CRUS and POCUS (p > 0.05). Children with worsening HN on POCUS underwent functional studies without confirmatory CRUS. Interestingly, two patients had metachronous, contralateral UPJO discovered during post-operative imaging. These were both discovered by POCUS. Nineteen (42%) patients who had attended at least one post-operative visit were eventually loss to follow-up. This occurred exclusively in those who did not have worsening ultrasound (p < 0.01). There was no difference in the loss to follow-up after POCUS (8) or CRUS (12) (p > 0.05).

CONCLUSIONS

POCUS performed by a urologist is an accurate assessment of HN after pyeloplasty with time and cost savings to compared to a CRUS performed by a radiologist. POCUS is not associated with any difference in rate of detection of worsening HN or rate of loss to follow up.

The intravesical phallus in patients with cloacal exstrophy: An embryologic conundrum

BACKGROUND

Phalluses present inside the extrophied bladder of cloacal exstrophy (CE) newborns have been sporadically reported in the literature; this clinical entity has largely unknown origins and may represent an extremely rare anomaly of CE.

OBJECTIVE

Along with nearly doubling the number of reported intravesical phalluses in the literature, this study aims to outline the common anatomic features and discuss the implications for theories of CE embryogenesis.

STUDY DESIGN

The authors retrospectively identified patients with CE and a potential intravesical phallus between 1997 and 2017 at two high-volume centers. Information was obtained about karyotype, age at closure, neurologic and renal anomalies, diastasis, phallus anatomy, and phallus biopsy pathology.

RESULTS

Six genotypic males met the inclusion criteria. Five of six had a diastasis greater than 6 cm. Four of six had paired corporal bodies in the intravesical phallus, one had a single corporal body, and one had a corporal-like structure. Five of six patients had a phallus located midline in the caudal aspect of the bladder; one was located midline in the bladder dome. Phallic biopsies were obtained in three of six patients. Two showed glanular and corporal tissue while the other showed vascular proliferation morphologically similar to that of erectile tissue.

DISCUSSION

Previous reports suggested that a superior vesicle fissure configuration, fusion of the corporal bodies, and fused bladder plates were common findings with an intravesical phallus. With the addition of new cases, the only consistent variable between patients is a phallus located anywhere along the bladder plate that can comprise a corporal-like structure, a single corporal body, or fused corporal bodies. These findings have implications for several embryologic theories. Although this is a retrospective review with a limited number of patients, the condition is exceedingly infrequent making it only observable retrospectively over decades at high volume centers.

CONCLUSIONS

The study outlined common anatomic features of the intravesical phallus in cloacal exstrophy and discussed the subsequent embryologic implications. In cloacal exstrophy newborns with presumed aphallia, meticulous inspection of the bladder plate and biopsy of any potential phallic structures can prevent resection of phallic tissue.

Testicular Hypoplasia Is Driven by Defective Vascular Formation

OBJECTIVE

To determine if vanishing testis could result from a fault in embryological development as a result of an arrest in endothelial cell migration rather than secondary to just a random physical torsion/twist. A testicular nubbin or vanishing testis is considered to be secondary to a neonatal torsion and is usually associated with a hemosiderin deposit.

MATERIALS AND METHODS

Cases of vanishing testis excision were compared with age-matched controls from cadaveric testes without known genitourinary pathology. To assess the testis microvasculature, we performed immunohistochemistry using an automated staining platform with controlled and standardized conditions and positive and negative controls. We used cluster of differentiation (CD) 34 to stain blood vessel endothelium, stem cells, and interstitium; CD31 (all endothelium); and D2-40 for lymphatic endothelium. Morphometric analysis was carried out, % of the total tissue with CD31 and CD34 positive stain was assessed, and the number of the lymphatic vessels (D2-40) per mm² was counted.

RESULTS

Of the 10 cases, 7 had evidence of hemosiderin deposit and calcification. The % distribution of CD34 in controls was higher, 13.4 ± 3.1 (mean ± standard deviation), compared to nubbin cases, 4.5 ± 2.9 (P ≤ .001). The % distribution of CD31 was 2.8 ± 0.83 in controls compared to 1.31 ± 0.60 in cases (P ≤ .001). The lymphatic distribution was similar in both groups, cases (6.4 ± 4.3 n/mm²) and controls (6.4 ± 1.7 n/mm²) (P = .99) CONCLUSION: This histopathological study suggests that disturbances in endothelial development may be a contributing factor leading to testicular hypoplasia and a resultant nubbin testis, independent of a physical torsion event.

Use of ecological niche models to predict the distribution of invasive species: a scientometric analysis

We conducted a scientometric analysis to determine the main trends and gaps of studies on the use of ecological niche models (ENMs) to predict the distribution of invasive species. We used the database of the Thomson Institute for Scientific Information (ISI). We found 190 papers published between 1991 and 2010 in 82 journals. The number of papers was low in the 1990s, but began to increase after 2003. One-third of the papers were published by researchers from the United States of America, and consequently, the USA was also the most studied region. The majority of studies were carried out in terrestrial environments, while only a few investigated aquatic systems, probably because important aquatic predictor variables are scarce or unavailable for most regions in the world. Species-occurrence records were mainly composed of presence-only records, and almost 70% of the studies were carried out with plants and insects. Twenty-three different distribution modelling methods were used. The Genetic Algorithm for Rule-set Production (GARP) was used most often. Our scientometric analysis showed a growing interest in the use of ENMs to predict the distribution of invasive species, especially in the last decade, which is probably related to the increase in species introductions worldwide. Among some important gaps that need to be filled, the relatively small number of studies conducted in developing countries and in aquatic environments deserves careful attention.

Spectral reflectance and responsivity of Ge- and InGaAs-photodiodes in the near-infrared: measurement and model

The spectral reflectance and responsivity of Ge- and InGaAs-photodiodes at (nearly) normal and oblique incidence (45 degrees) were investigated. The derived data allow a calculation of the photodiodes responsivities for any incident angle. The measurements were carried out with s- and p-polarized radiation in the wavelength range from 1260 to 1640 nm. The spectral reflectance of the photodiodes was modeled by using the matrix approach developed for thin-film optical assemblies. The comparison between the calculated and measured reflectance shows a difference of less than 2% for the Ge-photodiode. For the InGaAs-photodiode, the differences between measured and calculated reflectance are larger, i.e., up to 6% for wavelengths between 1380 and 1580 nm. Despite the larger differences between calculated and measured spectral reflectances for the InGaAs-photodiode, the difference between calculated and measured spectral responsivity is even smaller for the InGaAs-photodiode than for the Ge-photodiode, i.e., < or =1.2% for the InGaAs-photodiode compared to < or =2.2% for the Ge-photodiode. This is because the difference in responsivity is strongly correlated to the absolute spectral reflectance level, which is much lower for the InGaAs-photodiode. This observation also shows the importance of having small reflectances, i.e., appropriate antireflection coatings for the photodiodes. The relative standard uncertainty associated with the modeled spectral responsivity is about 2.2% for the Ge-photodiode and about 1.2% for the InGaAs-photodiode for any incident angle over the whole spectral range measured. The data obtained for the photodiodes allow the calculation of the spectral responsivity of Ge- and InGaAs-trap detectors and the comparison with experimental results.

Spontaneous vesicle formation at lipid bilayer membranes

Unilamellar vesicles are observed to form spontaneously at planar lipid bilayers agitated by exothermic chemical reactions. The membrane-binding reaction between biotin and streptavidin, two strong transmembrane neutralization reactions, and a weak neutralization reaction involving an "antacid" buffer, all lead to spontaneous vesicle formation. This formation is most dramatic when a viscosity differential exists between the two phases bounding the membrane, in which case vesicles appear exclusively in the more viscous phase. A hydrodynamic analysis explains the phenomenon in terms of a membrane flow driven by liberated reaction energy, leading to vesicle formation. These results suggest that energy liberated by intra- and extracellular chemical reactions near or at cell and internal organelle membranes can play an important role in vesicle formation, membrane agitation, or enhanced transmembrane mass transfer.