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Kelly MS, Liu T, Routh JC, Castillo H, Tanaka ST, Smith K, Krach LE, Zhang A, Sherburne E, Castillo J, David J, Wiener JS. Comparing binary & ordinal definitions of urinary & stool continence outcomes: Data from the National Spina Bifida Patient Registry. J Pediatr Urol 2024:S1477-5131(24)00070-6. [PMID: 38368164 DOI: 10.1016/j.jpurol.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/17/2024] [Accepted: 01/29/2024] [Indexed: 02/19/2024]
Abstract
INTRODUCTION The National Spina Bifida Patient Registry (NSBPR) assesses bladder and bowel incontinence using ordinal categories, but prior NSBPR analyses employed binary classification. Our aims were to 1) perform the first NSBPR analysis of bladder and bowel incontinence as ordinal outcomes to compare to the binary definition and subject variables; 2) explore the correlation of incontinence with undergarment usage, and 3) assess incontinence status following continence surgeries. METHODS Data from NSBPR participants' most recent clinic visit from 2013 to 2020 were analyzed. Ordinal categories of incontinence were compared to previously used binary definitions. Incontinence surgical outcomes were analyzed for those with data at least three months post-operatively. Chi-square tests evaluated associations among categorical variables. Univariate and ordinal logistic regression models were used to test associations of ordinal incontinence status with patient and condition factors. Statistical tests were 2-sided; p values < 0.05 were considered significant. RESULTS Analysis of 7217 individuals using ordinal incontinence outcomes showed little difference from previously used binary outcomes. The final multivariable logistic regression models with ordinal multinomial outcomes showed that associations of incontinence with age, sex, race/ethnicity, health insurance, level of lesion, and continence management technique were similar to prior studies. Among those reporting never being incontinent of both bladder and bowel, 14% reported using protective undergarments. Of the 500 individuals who had bladder outlet surgery, 38% reported never being incontinent of urine. Of 1416 individuals who had appendicostomy (ACE) bowel surgery, 48% reported never being incontinent of stool. DISCUSSION Our current analysis showed that ordinal continence outcome classification had similar continence findings as previous studies using the binary definition of continence. Expanding the binary definition of continence to include monthly episodes of incontinence did not greatly increase the proportion of continent individuals and, therefore, would have not likely made meaningful differences in continence outcomes in prior NSBPR analyses. However, it is known that even mild incontinence can affect quality of life, therefore, capturing any level of incontiennce is of clinical importance. Confirmation of the association of continence outcomes with sociodemographic, condition-related, and interventional factors with both approaches further validates previous analyses using the binary definition of continence. CONCLUSION The previously used binary definition of bladder and bowel continence appears robust. Undergarment choice was a poor surrogate for reported incontinence. After bladder and bowel continence surgeries, 38% and 48%, respectively, reported never being incontinent.
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Affiliation(s)
- Maryellen S Kelly
- Division of Healthcare of Women and Children, Duke University School of Nursing, Durham NC, USA; Division of Pediatric Urology, Department of Urology, Duke University School of Medicine, Durham NC, USA.
| | - Tiebin Liu
- Birth Defects Monitoring and Research Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Jonathan C Routh
- Division of Pediatric Urology, Department of Urology, Duke University School of Medicine, Durham NC, USA.
| | - Heidi Castillo
- Division of Developmental and Behavioral Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA.
| | - Stacy T Tanaka
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Kathryn Smith
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Linda E Krach
- Physical Medicine and Rehabilitation, Gillette Children's Specialty Healthcare, St. Paul, MN, USA.
| | - Amy Zhang
- Birth Defects Monitoring and Research Branch, Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA; Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA.
| | - Eileen Sherburne
- Children's Hospital and Health System, Inc., Milwaukee, WI, USA.
| | - Jonathan Castillo
- Division of Developmental and Behavioral Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA.
| | - Joseph David
- Section of Pediatric Urology, University of Alabama Medical Center, Birmingham, AL, USA.
| | - John S Wiener
- Division of Pediatric Urology, Department of Urology, Duke University School of Medicine, Durham NC, USA.
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Ackerman AL, Torosis M, Jackson NJ, Caron AT, Kaufman MR, Lowder JL, Routh JC. The Persistency Index: a novel screening tool for identifying myofascial pelvic floor dysfunction in patients seeking care for lower urinary tract symptoms. Am J Obstet Gynecol 2023; 229:667.e1-667.e11. [PMID: 37633575 PMCID: PMC11000817 DOI: 10.1016/j.ajog.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/31/2023] [Accepted: 08/16/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Patients with myofascial pelvic floor dysfunction often present with lower urinary tract symptoms, such as urinary frequency, urgency, and bladder pressure. Often confused with other lower urinary tract disorders, this constellation of symptoms, recently termed myofascial urinary frequency syndrome, is distinct from other lower urinary tract symptoms and optimally responds to pelvic floor physical therapy. A detailed pelvic floor myofascial examination performed by a skilled provider is currently the only method to identify myofascial urinary frequency syndrome. Despite a high influence on quality of life, low awareness of this condition combined with no objective diagnostic testing leads to the frequent misdiagnosis or underdiagnosis of myofascial urinary frequency syndrome. OBJECTIVE This study aimed to develop a screening measure to identify patients with myofascial urinary frequency syndrome (bothersome lower urinary tract symptoms secondary to myofascial pelvic floor dysfunction) from patient-reported symptoms. STUDY DESIGN A population of patients with isolated myofascial urinary frequency syndrome was identified by provider diagnosis from a tertiary urology practice and verified by standardized pelvic floor myofascial examination and perineal surface pelvic floor electromyography. Least Angle Shrinkage and Selection Operator was used to identify candidate features from the Overactive Bladder Questionnaire, Female Genitourinary Pain Index, and Pelvic Floor Distress Index predictive of myofascial urinary frequency syndrome in a pooled population also containing subjects with overactive bladder (n=42), interstitial cystitis/bladder pain syndrome (n=51), and asymptomatic controls (n=54) (derivation cohort). A simple, summated score of the most discriminatory questions using the original scaling of the Pelvic Floor Distress Index 5 (0-4) and Genitourinary Pain Index 5 (0-5) and modified scaling of Female Genitourinary Pain Index 2b (0-3) had an area under the curve of 0.75. As myofascial urinary frequency syndrome was more prevalent in younger subjects, the inclusion of an age penalty (3 points added if under the age of 50 years) improved the area under the curve to 0.8. This score was defined as the Persistency Index (possible score of 0-15). The Youden Index was used to identify the optimal cut point Persistency Index score for maximizing sensitivity and specificity. RESULTS Using a development cohort of 215 subjects, the severity (Pelvic Floor Distress Index 5) and persistent nature (Female Genitourinary Pain Index 5) of the sensation of incomplete bladder emptying and dyspareunia (Female Genitourinary Pain Index 2b) were the most discriminatory characteristics of the myofascial urinary frequency syndrome group, which were combined with age to create the Persistency Index. The Persistency Index performed well in a validation cohort of 719 patients with various lower urinary tract symptoms, including overactive bladder (n=285), interstitial cystitis/bladder pain syndrome (n=53), myofascial urinary frequency syndrome (n=111), controls (n=209), and unknown diagnoses (n=61), exhibiting an area under the curve of 0.74. A Persistency Index score ≥7 accurately identified patients with myofascial urinary frequency syndrome from an unselected population of individuals with lower urinary tract symptoms with 80% sensitivity and 61% specificity. A combination of the Persistency Index with the previously defined Bladder Pain Composite Index and Urge Incontinence Composite Index separated a population of women seeking care for lower urinary tract symptoms into groups consistent with overactive bladder, interstitial cystitis/bladder pain syndrome, and myofascial urinary frequency syndrome phenotypes with an overall diagnostic accuracy of 82%. CONCLUSION Our study recommends a novel screening method for patients presenting with lower urinary tract symptoms to identify patients with myofascial urinary frequency syndrome. As telemedicine becomes more common, this index provides a way of screening for myofascial urinary frequency syndrome and initiating pelvic floor physical therapy even before a confirmatory pelvic examination.
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Affiliation(s)
- A Lenore Ackerman
- Division of Pelvic Medicine and Reconstructive Surgery, Department of Urology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA.
| | - Michele Torosis
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | - Nicholas J Jackson
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | - Ashley T Caron
- Michigan State University College of Human Medicine, Grand Rapids, MI
| | - Melissa R Kaufman
- Division of Reconstructive Urology and Pelvic Health, Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Jerry L Lowder
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Jonathan C Routh
- Division of Urologic Surgery, Department of Urology, Duke University School of Medicine, Durham, NC
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Tua-Caraccia R, Livingston A, Routh JC. Recurrent Papillary Bladder Tumors in a Boy With Lynch Syndrome. Urology 2023; 181:133-135. [PMID: 37422136 DOI: 10.1016/j.urology.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/10/2023]
Abstract
Lynch syndrome (LS) is an autosomal dominant genetic disorder defined by germline mutations in one of four mismatch repair genes including PMS2, MLH2, MSH1, MSH2, or deletion in the EPCAM gene.1 The most common urologic manifestation of LS is upper tract urothelial carcinoma, which occurs in up to 20% of patients with LS.2 While data are scarce, there is growing evidence of an increased relative risk of bladder malignancy in patients with LS.3,4 Bladder tumors in children are a rare entity and the link between pediatric bladder tumors and LS has not been previously reported to our knowledge.
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Affiliation(s)
| | - Austin Livingston
- Department of Urology, Duke University School of Medicine, Durham, NC
| | - Jonathan C Routh
- Department of Urology, Duke University School of Medicine, Durham, NC
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Ackerman AL, Jackson NJ, Caron AT, Kaufman MR, Routh JC, Lowder JL. Myofascial urinary frequency syndrome is a novel syndrome of bothersome lower urinary tract symptoms associated with myofascial pelvic floor dysfunction. Sci Rep 2023; 13:18412. [PMID: 37891217 PMCID: PMC10611808 DOI: 10.1038/s41598-023-44862-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
This study describes a novel, distinct phenotype of urinary symptoms named "myofascial urinary frequency syndrome" (MUFS) present in one-third of individuals presenting with urinary frequency. In addition to a characteristic symptom constellation suggestive of myofascial dysfunction, MUFS subjects exhibit "persistency": a persistent feeling of needing to urinate regardless of urine volume. On examination, 97% of MUFS patients demonstrated pelvic floor hypertonicity with either global tenderness or myofascial trigger points, and 92% displayed evidence of impaired muscular relaxation, hallmarks of myofascial dysfunction. To confirm this symptom pattern was attributable to the pelvic floor musculature, we confirmed the presence of "persistency" in 68 patients with pelvic floor myofascial dysfunction established through comprehensive examination and electromyography and corroborated by improvement with pelvic floor myofascial release. These symptoms distinguish subjects with myofascial dysfunction from subjects with OAB, IC/BPS, and asymptomatic controls, confirming MUFS is a distinct LUTS symptom complex.
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Affiliation(s)
- A Lenore Ackerman
- Division of Pelvic Medicine and Reconstructive Surgery, Department of Urology, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Box 951738, Los Angeles, CA, 90095-1738, USA.
| | - Nicholas J Jackson
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ashley T Caron
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Melissa R Kaufman
- Division of Reconstructive Urology and Pelvic Health, Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, USA
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Polites SF, Rhee DS, Routh JC, Lautz TB, Rodeberg DA, Dasgupta R. Critical elements of pediatric rhabdomyosarcoma surgery. Semin Pediatr Surg 2023; 32:151341. [PMID: 38042091 DOI: 10.1016/j.sempedsurg.2023.151341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
Rhabdomyosarcoma (RMS), the most common soft tissue sarcoma in children, requires multimodal therapy which is determined by risk group stratification. Local control may be achieved by surgical resection, radiation, or both. Resection may occur upfront or following induction chemotherapy as a delayed primary excision. An R1 resection may allow a reduction in radiation exposure; however, debulking is not indicated nor is excision of residual masses at the end of therapy. Regional lymph node assessment is an important component of surgical care, as positive nodal basins require radiation. Depending on the tumor site and biology, sentinel lymph node biopsy vs biopsy of clinically or radiographically concerning nodes is indicated. Therapeutic lymph node dissection is never indicated. Familiarity with site-specific oncologic principles for RMS and participation in a multidisciplinary team including Pediatric Oncology and Radiation Oncology are necessary components of surgical care to ensure optimal outcomes.
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Affiliation(s)
- Stephanie F Polites
- Division of Pediatric Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Daniel S Rhee
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan C Routh
- Department of Urology, Duke University School of Medicine, Durham, NC, USA
| | - Timothy B Lautz
- Division of Pediatric Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - David A Rodeberg
- Department of Surgery, Department of Pediatric Surgery, University of Kentucky, Lexington, KY, USA
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Medical Center, University of Cincinnati, Cincinnati, OH, USA.
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Tua-Caraccia R, Routh JC. Editorial Comment. J Urol 2023:101097JU000000000000354802. [PMID: 37254671 DOI: 10.1097/ju.0000000000003548.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Rafael Tua-Caraccia
- Department of Urology, Duke University School of Medicine, Durham, North Carolina
| | - Jonathan C Routh
- Department of Urology, Duke University School of Medicine, Durham, North Carolina
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Ackerman AL, Jackson NJ, Caron AT, Kaufman MR, Routh JC, Lowder JL. Myofascial Frequency Syndrome: A novel syndrome of bothersome lower urinary tract symptoms associated with myofascial pelvic floor dysfunction. medRxiv 2023:2023.04.14.23288590. [PMID: 37131628 PMCID: PMC10153318 DOI: 10.1101/2023.04.14.23288590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Patients presenting with lower urinary tract symptoms (LUTS) are historically classified to several symptom clusters, primarily overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS). Accurate diagnosis, however, is challenging due to overlapping symptomatic features, and many patients do not readily fit into these categories. To enhance diagnostic accuracy, we previously described an algorithm differentiating OAB from IC/BPS. Herein, we sought to validate the utility of this algorithm for identifying and classifying a real-world population of individuals presenting with OAB and IC/BPS and characterize patient subgroups outside the traditional LUTS diagnostic paradigm. Methods An Exploratory cohort of 551 consecutive female subjects with LUTS evaluated in 2017 were administered 5 validated genitourinary symptom questionnaires. Application of the LUTS diagnostic algorithm classified subjects into controls, IC/BPS, and OAB, with identification of a novel group of highly bothered subjects lacking pain or incontinence. Symptomatic features of this group were characterized by statistically significant differences from the OAB, IC/BPS and control groups on questionnaires, comprehensive review of discriminate pelvic exam, and thematic analysis of patient histories. In a Reassessment cohort of 215 subjects with known etiologies of their symptoms (OAB, IC/BPS, asymptomatic microscopic hematuria, or myofascial dysfunction confirmed with electromyography), significant associations with myofascial dysfunction were identified in a multivariable regression model. Pre-referral and specialist diagnoses for subjects with myofascial dysfunction were catalogued. Findings Application of a diagnostic algorithm to an unselected group of 551subjects presenting for urologic care identified OAB and IC/BPS in 137 and 96 subjects, respectively. An additional 110 patients (20%) with bothersome urinary symptoms lacked either bladder pain or urgency characteristic of IC/BPS and OAB, respectively. In addition to urinary frequency, this population exhibited a distinctive symptom constellation suggestive of myofascial dysfunction characterized as "persistency": bothersome urinary frequency resulting from bladder discomfort/pelvic pressure conveying a sensation of bladder fullness and a desire to urinate. On examination, 97% of persistency patients demonstrated pelvic floor hypertonicity with either global tenderness or myofascial trigger points, and 92% displayed evidence of impaired muscular relaxation, hallmarks of myofascial dysfunction. We therefore classified this symptom complex "myofascial frequency syndrome". To confirm this symptom pattern was attributable to the pelvic floor, we confirmed the presence of "persistency" in 68 patients established to have pelvic floor myofascial dysfunction through comprehensive evaluation corroborated by symptom improvement with pelvic floor myofascial release. These symptoms distinguish subjects with myofascial dysfunction from subjects with OAB, IC/BPS, and asymptomatic controls, confirming that myofascial frequency syndrome is a distinct LUTS symptom complex. Interpretation This study describes a novel, distinct phenotype of LUTS we classified as myofascial frequency syndrome in approximately one-third of individuals with urinary frequency. Common symptomatic features encompass elements in other urinary syndromes, such as bladder discomfort, urinary frequency and urge, pelvic pressure, and a sensation of incomplete emptying, causing significant diagnostic confusion for providers. Inadequate recognition of myofascial frequency syndrome may partially explain suboptimal overall treatment outcomes for women with LUTS. Recognition of the distinct symptom features of MFS (persistency) should prompt referral to pelvic floor physical therapy. To improve our understanding and management of this as-yet understudied condition, future studies will need to develop consensus diagnostic criteria and objective tools to assess pelvic floor muscle fitness, ultimately leading to corresponding diagnostic codes. Funding This work was supported by the AUGS/Duke UrogynCREST Program (R25HD094667 (NICHD)) and by NIDDK K08 DK118176 and Department of Defense PRMRP PR200027, and NIA R03 AG067993.
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Affiliation(s)
- A. Lenore Ackerman
- Division of Pelvic Medicine and Reconstructive Surgery, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Nicholas J. Jackson
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Ashley T. Caron
- Michigan State University College of Human Medicine, Grand Rapids, MI
| | - Melissa R. Kaufman
- Division of Reconstructive Urology and Pelvic Health, Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan C. Routh
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC
| | - Jerry L. Lowder
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
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9
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O'Shea M, Routh JC, Siddiqui NY. Robot-assisted laparoscopic anterior urethral diverticulectomy. Int Urogynecol J 2023; 34:589-592. [PMID: 36129481 DOI: 10.1007/s00192-022-05355-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/30/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS A 31-year-old patient with a history of fetal sacrococcygeal teratoma requiring tumor resection and pelvic reconstruction in infancy presented with a 3-year history of recurrent vulvar abscesses and voiding dysfunction. Magnetic resonance imaging demonstrated a fluid collection posterior to the pubic bone and inferior to the bladder. The objective was to demonstrate the key steps in the resection and repair of an anterior urethral diverticulum via robot-assisted laparoscopic approach. METHODS Cystoscopy followed by robot-assisted laparoscopic retropubic dissection was used for resection of an anterior urethral diverticulum followed by urethral reconstruction. RESULTS Cystoscopy revealed a large anterior cavity at the midpoint of the urethra consistent with an anterior urethral diverticulum. This likely tracked inferiorly toward her vulva during repeated episodes of infection expressing through her recurrent abscesses. Retropubic space exploration revealed dense fibrotic tissue adherent to the underside of the pubic tubercule contiguous with the anterior urethral diverticulum, which was successfully resected. CONCLUSIONS Female anterior urethral diverticulum is a rare entity. A robot-assisted laparoscopic approach can be safely utilized to identify and resect an anterior urethral diverticulum. Key points include optimization of port placement, use of a council-tip catheter to facilitate bladder drainage in the setting of distorted pelvic anatomy, and multi-layered tension-free urethral closure with flap placement.
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Affiliation(s)
- Michele O'Shea
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Duke University Health System, Durham, NC, USA.
| | - Jonathan C Routh
- Division of Urology, Department of Surgery, Duke University Health System, Durham, NC, USA
| | - Nazema Y Siddiqui
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Duke University Health System, Durham, NC, USA
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Fairchild RJ, Aksenov LI, Tejwani R, Hughes T, Johnston AW, Purves JT, Wiener JS, Routh JC. Single-port hidden incision endoscopic (HIdES) pediatric nephrectomy via pfannenstiel incision. J Pediatr Urol 2023:S1477-5131(23)00020-7. [PMID: 36746716 DOI: 10.1016/j.jpurol.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 10/12/2022] [Accepted: 01/15/2023] [Indexed: 01/22/2023]
Abstract
Laparoendoscopic single-site surgery (LESS) and hidden incision endoscopic surgery techniques are increasingly used in pediatric urology. For pediatric nephrectomy, access through a single Pfannenstiel incision is novel and may offer cosmetic benefit. In this retrospective study, we describe this approach and assess operative outcomes associated with this technique. Patients who underwent LESS nephrectomy through a single Pfannenstiel incision had minimal blood loss, short length of stay, low risk of surgical complications, and satisfactory wound healing. The Pfannenstiel approach to LESS nephrectomy is feasible, versatile, and achieves excellent operative and cosmetic outcomes, although direct comparison to other approaches is warranted.
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Affiliation(s)
- Rebecca J Fairchild
- Division of Urology, Department of Surgery, Duke University School of Medicine Durham, NC, 27710, USA.
| | - Leonid I Aksenov
- Division of Urology, Department of Surgery, Duke University School of Medicine Durham, NC, 27710, USA
| | - Rohit Tejwani
- Division of Urology, Department of Surgery, Duke University School of Medicine Durham, NC, 27710, USA
| | - Taylor Hughes
- Division of Urology, Department of Surgery, Duke University School of Medicine Durham, NC, 27710, USA
| | - Ashley W Johnston
- Division of Urology, Department of Surgery, Duke University School of Medicine Durham, NC, 27710, USA
| | - J Todd Purves
- Division of Urology, Department of Surgery, Duke University School of Medicine Durham, NC, 27710, USA
| | - John S Wiener
- Division of Urology, Department of Surgery, Duke University School of Medicine Durham, NC, 27710, USA
| | - Jonathan C Routh
- Division of Urology, Department of Surgery, Duke University School of Medicine Durham, NC, 27710, USA
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Szymanski KM, Adams CM, Alkawaldeh MY, Austin PF, Bowman RM, Castillo H, Castillo J, Chu DI, Estrada CR, Fascelli M, Frimberger DC, Gargollo PC, Hamdan DG, Hecht SL, Hopson B, Husmann DA, Jacobs MA, MacNeily AE, McLeod DJ, Metcalfe PD, Meyer T, Misseri R, O'Neil J, Rensing AJ, Routh JC, Rove KO, Sawin KJ, Schlomer BJ, Shamblin I, Sherlock RL, Slobodov G, Stout J, Tanaka ST, Weiss DA, Wiener JS, Wood HM, Yerkes EB, Blount J. Causes of death among people with myelomeningocele: A multi-institutional 47-year retrospective study. J Pediatr Rehabil Med 2023; 16:605-619. [PMID: 38073338 PMCID: PMC10789326 DOI: 10.3233/prm-220086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/31/2023] [Indexed: 01/01/2024] Open
Abstract
PURPOSE This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD. METHODS A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics. RESULTS Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47). CONCLUSION COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.
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Affiliation(s)
- Konrad M Szymanski
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Cyrus M Adams
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | | | - Paul F Austin
- Division of Urology, Texas Children's Hospital, Houston, TX, USA
| | - Robin M Bowman
- Division of Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Heidi Castillo
- Section of Developmental Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Jonathan Castillo
- Section of Developmental Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - David I Chu
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Carlos R Estrada
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Michele Fascelli
- Department of Urology, Glickman Urological and Kidney Institute Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Dominic C Frimberger
- Department of Urology, Oklahoma University Medical Center, Oklahoma City, OK, USA
| | | | - Dawud G Hamdan
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sarah L Hecht
- Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA
| | - Betsy Hopson
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Micah A Jacobs
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Andrew E MacNeily
- Division of Pediatric Urology, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Daryl J McLeod
- Section of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Theresa Meyer
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rosalia Misseri
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Joseph O'Neil
- Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Adam J Rensing
- Department of Urology, Oklahoma University Medical Center, Oklahoma City, OK, USA
| | | | - Kyle O Rove
- Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA
| | - Kathleen J Sawin
- Department of Nursing Research and Evidence-Based Practice, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Bruce J Schlomer
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Isaac Shamblin
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Gennady Slobodov
- Department of Urology, Oklahoma University Medical Center, Oklahoma City, OK, USA
| | - Jennifer Stout
- Surgery Office of Clinical Research, Duke University, Durham, NC, USA
| | - Stacy T Tanaka
- Division of Pediatric Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dana A Weiss
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John S Wiener
- Division of Urologic Surgery, Duke University, Durham, NC, USA
| | - Hadley M Wood
- Department of Urology, Glickman Urological and Kidney Institute Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Elizabeth B Yerkes
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jeffrey Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
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12
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Walton RF, Yeh C, Shannon R, Rosoklija I, Rague JT, Johnson EK, Alpern ER, Ellison JS, Routh JC, Tasian GE, Chu DI. Variation in care between pediatric and adult patients presenting with nephrolithiasis to tertiary care pediatric emergency departments in the United States (2009-2020). J Pediatr Urol 2022; 18:742.e1-742.e11. [PMID: 35945144 PMCID: PMC9771899 DOI: 10.1016/j.jpurol.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/06/2022] [Accepted: 07/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Individuals with nephrolithiasis frequently present to the Emergency Department (ED). Safety and quality principles are often applied in pediatric EDs to children presenting with nephrolithiasis, such as limiting ionizing radiation exposure and opioid analgesics. However, it is unknown whether pediatric EDs apply these same principles to adult patients who present with nephrolithiasis. We hypothesized that adult patients would be associated with higher use of radiation-based imaging and opioid analgesics. OBJECTIVE To assess variations in diagnostic and treatment interventions and hospital utilization between pediatric and adult patients presenting to the pediatric ED with nephrolithiasis. STUDY DESIGN A retrospective cohort study was conducted, examining outcomes for pediatric (<18-years-old) versus adult (≥18-years-old) patients in 42 pediatric EDs from 2009 to 2020 using the Pediatric Health Information System (PHIS) database. Patients with an ICD-9/10 principal diagnosis code of nephrolithiasis with no nephrolithiasis-related visits within the prior 6 months were included. Primary outcomes were imaging, medications, and surgical interventions. Secondary outcomes were hospital admissions, 90-day ED revisits, and 90-day readmissions. Generalized linear mixed models with random effects were used to adjust for confounding and clustering. RESULTS In total, 16,117 patients with 17,837 encounters were included. Most hospitals were academic (95.2%), and a plurality were located in the South (38.1%). Most patients were <18-years-old (84.4%, median (interquartile range): 15 (12-17)-years-old), female (57.9%), and White (76.3%), and 17.1% were Hispanic/Latino. Most had no complex chronic conditions (89.2%) and no chronic disease per pediatric medical complexity algorithm (51.5%). For the primary outcome, adults, relative to pediatric patients, who presented to the pediatric ED with nephrolithiasis had higher adjusted odds of receiving computerized tomography (CT) scans (Odds Ratio [OR] 1.43 [95% Confidence Interval [CI] 1.29-1.59]) and opioid analgesics (OR 1.45 [95%CI 1.33-1.58]) (Summary Figure). Secondary outcomes showed that adults, relative to pediatric patients, had lower adjusted odds of hospital admissions, 90-day ED revisits, and 90-day readmissions. DISCUSSION Our results suggest that certain pediatric safety and quality principles, such as limiting ionizing radiation exposure and opioid analgesic prescriptions, are not being equally applied to pediatric and adult patients who present to pediatric EDs with nephrolithiasis. The mechanism of these findings remains to be elucidated. CONCLUSIONS Variations in care for individuals with nephrolithiasis reflect an opportunity for quality improvement in pediatric EDs and inform work exploring optimal care pathways for all patients presenting to the pediatric ED with nephrolithiasis.
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Affiliation(s)
- Ryan F Walton
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Chen Yeh
- Northwestern University, Department of Preventive Medicine, Division of Biostatistics, Chicago, IL, USA.
| | - Rachel Shannon
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Ilina Rosoklija
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - James T Rague
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Emilie K Johnson
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Elizabeth R Alpern
- Northwestern University, Department of Pediatrics, Division of Emergency Medicine, Chicago, IL, USA.
| | - Jonathan S Ellison
- Children's Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA.
| | | | | | - David I Chu
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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13
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Aksenov LI, Fairchild RJ, Dionise ZR, Tejwani R, Purves JT, Wiener JS, Routh JC. Framing the picture: Impact of radiographic imaging on parental vesicoureteral reflux management preferences. J Pediatr Urol 2022; 18:674.e1-674.e8. [PMID: 36085190 DOI: 10.1016/j.jpurol.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/06/2022] [Accepted: 08/14/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION/OBJECTIVE Given the variety of treatment options for vesicoureteral reflux (VUR), shared decision making between clinicians and parents is essential. Despite its importance, shared decision making is limited by the framing effect - people process the same information differently depending on how it is presented. Studies have also demonstrated that showing patients their radiology images can impact behaviors. In this pilot study, we sought to determine if showing parents radiographic images could serve as a framing tool that impacts the decision of whether to pursue surgery, endoscopic intervention, or conservative management for VUR. METHODS We designed a survey instrument which provided background on VUR and a hypothetical scenario of a 2-year-old child with VUR who had a breakthrough febrile urinary tract infection (UTI). Guideline-concordant management options were presented: (1) change antibiotics, (2) endoscopic management, or (3) open or laparoscopic surgery. All options were similarly presented regarding risks, benefits, and length of stay. Respondents were randomized into a group with no image accompanying the clinical scenario or a group which had a labeled image of a voiding cystourethrogram (VCUG) demonstrating unilateral VUR. Respondents also answered demographic and health experience questions. The instrument was published on Amazon's Mechanical Turk online work interface which provides reliable and validated results in VUR experiments. Parents aged 18-60 years old were eligible. Responses with failed attention questions, duplicate internet addresses, or submission times <1 or >30 min were disqualified. Data were analyzed using t-test, chi-square, and multinomial logistic regression. Sensitivity analyses were performed after excluding all responses submitted under 2, 3, and 5 min. RESULTS There were a total of 914 responses, 426 met inclusion criteria. The presence or absence of a VCUG image did not result in a statically significant difference in the management decision (p = 0.081). Multinomial logistic regression demonstrated that prior UTI experience influenced the management decision (p = 0.027). Sensitivity analyses revealed a significant difference in the management decision when excluding responses <5 min (p = 0.039). CONCLUSION In this analysis, there was no statistically significant framing effect by radiographic images on parental management decision for VUR. Multinomial analyses suggested that prior experience with UTI has an impact on VUR management decisions. These results need to be considered within the limitations of this pilot study - the respondents were given a hypothetical clinical scenario and the survey instrument cannot replace an in-office discussion. Further analyses on framing and its role in pre-operative counseling is warranted.
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Affiliation(s)
- Leonid I Aksenov
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA.
| | - Rebecca J Fairchild
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Zachary R Dionise
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Rohit Tejwani
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - J Todd Purves
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - John S Wiener
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
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14
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Aksenov LI, Fairchild RJ, Hobbs KT, Tejwani R, Wiener JS, Routh JC. Financial toxicity among individuals with spina bifida and their families: A qualitative study and conceptual model. J Pediatr Urol 2022; 18:290.e1-290.e8. [PMID: 35410804 DOI: 10.1016/j.jpurol.2022.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/02/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Spina bifida is the most common permanently disabling birth defect in the United States and requires lifelong, multi-specialty care. The cost of such care has the potential to result in financial toxicity - the 'objective financial burden' and 'subjective financial distress' which can negatively impact clinical outcomes. While this concept has been extensively studied in other areas of medicine, particularly oncology, financial toxicity has not yet been examined in pediatric urology or in individuals with spina bifida and their families/caregivers. OBJECTIVE To qualitatively explore the presence of financial toxicity in individuals with spina bifida and their caregivers with the objective of identifying themes and creating a conceptual model. MATERIALS AND METHODS We conducted semi-structured interviews with individuals with spina bifida and/or their caregivers with the aim of eliciting information regarding financial distress associated with spina bifida care. Interviews were transcribed and qualitative thematic analysis was performed to identify recurring themes. These insights were used to create a conceptual model of financial toxicity among individuals with spina bifida. RESULTS A total of 14 interviews were conducted (total of 6 patients and 13 parents/caregivers). Average patient age was 17.9 years. Five dominant themes were identified: 1) resources (insurance type, community support, etc.), 2) direct costs (copays, deductibles, travel expenses, etc.), 3) indirect costs (lost work time, hindered career advancement, resource navigation burden, etc.), 4) coping (work adjustments, decreased spending, etc.), and 5) affect (lack of control, uncertainty, worry, etc.). These insights were used to create a conceptual model. DISCUSSION This is the first study to explore financial toxicity in spina bifida and establish a conceptual model. Our findings are corroborated by prior spina bifida literature and are closely mirrored by studies in cancer patients. Given that financial toxicity is associated with negative outcomes in other medical domains, the impact of financial toxicity on health outcomes among individuals with spina bifida warrants further study, particularly in instrument development to better understand and quantify financial toxicity in this group. CONCLUSION Financial toxicity is a concern among individuals with spina bifida and their caregivers. This concept will need to be investigated further in order to develop validated measurement tools, identify solutions, and provide optimal care; our conceptual model will help guide these future investigations.
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Affiliation(s)
- Leonid I Aksenov
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - Rebecca J Fairchild
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - Kevin T Hobbs
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - Rohit Tejwani
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - John S Wiener
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - Jonathan C Routh
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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15
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Tejwani R, Lee HJ, Hughes TL, Hobbs KT, Aksenov LI, Scales CD, Routh JC. Predicting postoperative complications in pediatric surgery: A novel pediatric comorbidity index. J Pediatr Urol 2022; 18:291-301. [PMID: 35410802 PMCID: PMC9233007 DOI: 10.1016/j.jpurol.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/25/2022] [Accepted: 03/06/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION/BACKGROUND Comorbidity-driven surgical risk assessment is essential for informed patient counseling, risk-stratification, and outcomes-based health-services research. Existing mortality-focused comorbidity indices have had mixed success at risk-adjustment in children. OBJECTIVE To develop a new comorbidity-driven multispecialty surgical risk index predicting 30-day postoperative complications in children. STUDY DESIGN This retrospective cohort study investigated children undergoing surgical procedures across seven specialties in 2014-2015 using the MarketScan® Research databases. The risk index was derived separately for ambulatory and inpatient surgery patients using logistic regression with backward selection. The performance of the novel index in discriminating postoperative complications vis-à-vis three existing comorbidity indices was compared using bootstrapping and area under the receiver operating characteristics curves (AUC). RESULTS We identified 190,629 ambulatory and 22,633 inpatient patients. The novel index had the best performance for discriminating postoperative complications for inpatients (AUC 0.76, 95% confidence interval [CI] 0.75-0.77) relative to the Charlson Comorbidity Index (CCI, 0.56, 95% CI 0.56-0.57), Van Walraven Index (VWI, 0.60, 95% CI 0.60-0.61), and Rhee Score (RS, 0.69, 95% CI 0.68-0.70). In the ambulatory cohort, the novel index outperformed all three existing indices, though none demonstrated excellent discriminatory ability for complications (novel score 0.68, 95% CI 0.67-0.68; CCI 0.53, 95% CI 0.52-0.53; VWI 0.53, 95% CI 0.52-0.53; RS 0.50, 95% CI 0.49-0.50). DISCUSSION In both inpatient and ambulatory pediatric settings, our novel comorbidity index demonstrated better performance at predicting postoperative complications than three widely used alternatives. This index will be useful for research and may be adaptable to clinical settings to identify high-risk patients and facilitate perioperative planning. CONCLUSION We developed a novel pediatric comorbidity index with better performance at predicting postoperative complications than three widely used alternatives.
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Affiliation(s)
- Rohit Tejwani
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Taylor L Hughes
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin T Hobbs
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Leonid I Aksenov
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Charles D Scales
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
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16
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Sabharwal P, Hurst JH, Tejwani R, Hobbs KT, Routh JC, Goldstein BA. Correction to: Combining adult with pediatric patient data to develop a clinical decision support tool intended for children: leveraging machine learning to model heterogeneity. BMC Med Inform Decis Mak 2022; 22:128. [PMID: 35549699 PMCID: PMC9097075 DOI: 10.1186/s12911-022-01846-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Paul Sabharwal
- Department of Computer Science, Duke University, Durham, NC, USA.,Children's Health and Discovery Initiative, Department of Pediatrics, Duke University, Durham, NC, USA
| | - Jillian H Hurst
- Children's Health and Discovery Initiative, Department of Pediatrics, Duke University, Durham, NC, USA.,Division of Infectious Diseases, Department of Pediatrics, Duke University, Durham, NC, USA
| | - Rohit Tejwani
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Kevin T Hobbs
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Benjamin A Goldstein
- Children's Health and Discovery Initiative, Department of Pediatrics, Duke University, Durham, NC, USA. .,Department of Biostatistics and Bioinformatics, Duke University, 2424 Erwin Road, Durham, NC, 27705, USA.
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17
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Sabharwal P, Hurst JH, Tejwani R, Hobbs KT, Routh JC, Goldstein BA. Combining adult with pediatric patient data to develop a clinical decision support tool intended for children: leveraging machine learning to model heterogeneity. BMC Med Inform Decis Mak 2022; 22:84. [PMID: 35351109 PMCID: PMC8961261 DOI: 10.1186/s12911-022-01827-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/24/2022] [Indexed: 01/23/2023] Open
Abstract
Background Clinical decision support (CDS) tools built using adult data do not typically perform well for children. We explored how best to leverage adult data to improve the performance of such tools. This study assesses whether it is better to build CDS tools for children using data from children alone or to use combined data from both adults and children. Methods Retrospective cohort using data from 2017 to 2020. Participants include all individuals (adults and children) receiving an elective surgery at a large academic medical center that provides adult and pediatric services. We predicted need for mechanical ventilation or admission to the intensive care unit (ICU). Predictor variables included demographic, clinical, and service utilization factors known prior to surgery. We compared predictive models built using machine learning to regression-based methods that used a pediatric or combined adult-pediatric cohort. We compared model performance based on Area Under the Receiver Operator Characteristic. Results While we found that adults and children have different risk factors, machine learning methods are able to appropriately model the underlying heterogeneity of each population and produce equally accurate predictive models whether using data only from pediatric patients or combined data from both children and adults. Results from regression-based methods were improved by the use of pediatric-specific data. Conclusions CDS tools for children can successfully use combined data from adults and children if the model accounts for underlying heterogeneity, as in machine learning models.
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Affiliation(s)
- Paul Sabharwal
- Department of Computer Science, Duke University, Durham, NC, USA.,Children's Health and Discovery Initiative, Department of Pediatrics, Duke University, Durham, NC, USA
| | - Jillian H Hurst
- Children's Health and Discovery Initiative, Department of Pediatrics, Duke University, Durham, NC, USA.,Division of Infectious Diseases, Department of Pediatrics, Duke University, Durham, NC, USA
| | - Rohit Tejwani
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Kevin T Hobbs
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Benjamin A Goldstein
- Children's Health and Discovery Initiative, Department of Pediatrics, Duke University, Durham, NC, USA. .,Department of Biostatistics and Bioinformatics, Duke University, 2424 Erwin Road, Durham, NC, 27705, USA.
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18
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Boucher NA, Alkazemi MH, Tejwani R, Routh JC. Parents of Children with Newly Diagnosed Disorders of Sex Development Identify Major Concerns: A Qualitative Study. Urology 2022; 164:218-223. [PMID: 35038494 DOI: 10.1016/j.urology.2022.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 12/29/2021] [Accepted: 01/02/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To develop a conceptual framework to understand and define the impact of DSD diagnosis and management from the perspective of parents of recently diagnosed children. METHODS Semi-structured interviews were conducted with parents of children diagnosed with 46 XX, 46 XY, or chromosomal DSD including complete or partial androgen insensitivity, congenital adrenal hyperplasia, or 5-alpha reductase deficiency. Analysis was completed using content analysis with an inductive approach by three coders. RESULTS Parents of six patients agreed to be interviewed, consistent with saturation points for prior similar studies; a total of 16 recurring themes were identified which were further grouped by similarity and categorized into one of three meta-themes: a) personal impact (effect of diagnosis on parents psyche, happiness, gender/sexual identity, anatomic function, mental health), b) family impact (relationships with parents/siblings, parental guilt); and c) societal impact (bullying, need for secrecy, future desirability, societal openness to DSD individuals). CONCLUSIONS Personal, family, and societal concerns amongst parents following a DSD diagnosis have significant potential psychosocial impacts for both parents as well children. The nexus between these categories provides a framework for approaching diagnosis and management of DSD and has implications for patients, families, and clinicians. Improved resource allocation, education, and clinical tools conceived through this framework may considerably alleviate potent psychosocial stressors for parents of children born with DSD.
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Affiliation(s)
- Nathan A Boucher
- Duke University, Sanford School of Public Policy, Durham, NC, USA; Duke University, School of Medicine, Durham, NC, USA; Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health System, Durham, NC, USA; Duke-Margolis Center for Health Policy, Durham, NC, USA.
| | | | - Rohit Tejwani
- Duke University, School of Medicine, Durham, NC, USA; Division of Urologic Surgery, Duke University School of Medicine, Durham, NC
| | - Jonathan C Routh
- Duke University, School of Medicine, Durham, NC, USA; Division of Urologic Surgery, Duke University School of Medicine, Durham, NC
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19
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Hobbs KT, Choe N, Aksenov LI, Reyes L, Aquino W, Routh JC, Hokanson JA. Machine Learning for Urodynamic Detection of Detrusor Overactivity. Urology 2022; 159:247-254. [PMID: 34757048 PMCID: PMC8865755 DOI: 10.1016/j.urology.2021.09.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To develop a machine learning algorithm that identifies detrusor overactivity (DO) in Urodynamic Studies (UDS) in the spina bifida population. UDS plays a key role in assessment of neurogenic bladder in patients with spina bifida. Due to significant variability in individual interpretations of UDS data, there is a need to standardize UDS interpretation. MATERIALS AND METHODS Patients who underwent UDS at a single pediatric urology clinic between May 2012 and September 2020 were included. UDS files were analyzed in both time and frequency domains, varying inclusion of vesical, abdominal, and detrusor pressure channels. A machine learning pipeline was constructed using data windowing, dimensionality reduction, and support vector machines. Models were designed to detect clinician identified detrusor overactivity. RESULTS Data were extracted from 805 UDS testing files from 546 unique patients. The generated models achieved good performance metrics in detecting DO agreement with the clinician, in both time- and frequency-based approaches. Incorporation of multiple channels and data windowing improved performance. The time-based model with all 3 channels had the highest area under the curve (AUC) (91.9 ± 1.3%; sensitivity: 84.2 ± 3.8%; specificity: 86.4 ± 1.3%). The 3-channel frequency-based model had the highest specificity (AUC: 90.5 ± 1.9%; sensitivity: 68.3 ± 5.3%; specificity: 92.9 ± 1.1%). CONCLUSION We developed a promising proof-of-concept machine learning pipeline that identifies DO in UDS. Machine-learning-based predictive modeling algorithms may be employed to standardize UDS interpretation and could potentially augment shared decision-making and improve patient care.
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Affiliation(s)
- Kevin T. Hobbs
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC
| | - Nathaniel Choe
- Department of Electrical and Computer Engineering, Duke University, Durham, NC
| | - Leonid I. Aksenov
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC
| | - Lourdes Reyes
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC
| | - Wilkins Aquino
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC
| | - Jonathan C. Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC
| | - James A. Hokanson
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI,Corresponding Author. James Hokanson, PhD, Biomedical Engineering, Translational and Biomedical Research Center, 8701 W Watertown Plank Road, Milwaukee, WI, 53226,
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20
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Yerkes EB, Cheng EY, Wiener JS, Austin JC, Tu DD, Joseph DB, Routh JC, Tanaka ST. Translating pediatric urodynamics from clinic into collaborative research: Lessons and recommendations from the UMPIRE study group. J Pediatr Urol 2021; 17:716-725. [PMID: 34412976 DOI: 10.1016/j.jpurol.2021.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/02/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
Pediatric patients present unique challenges in the performance and interpretation of urodynamic studies. Interpretation of urodynamics to guide clinical management at an institutional level is accepted as reliable. Challenges arise however when multi-site collaborations incorporate urodynamics into study design to determine primary or secondary outcomes or to direct decision-making. Although standardized terminology has been established by ICCS, the application of this shared language to performance and interpretation of pediatric urodynamics to across multiple sites may not be intuitive or reliable. With a primary goal of defining the care necessary to protect future renal function, the UMPIRE protocol (Urologic Management to Preserve Initial REnal function) utilizes a urodynamics-based risk stratification to determine medical management for infants with myelomeningocele. Iterative changes in the protocol are based upon the clinical progress of the enrolled children. Despite a team experienced in subtleties of urodynamics and despite efforts to minimize variability across sites, the UMPIRE study group identified several areas in which the language of urodynamics required additional clarification or creation of more explicit definitions to standardize performance and interpretation across sites. This article reviews the foundations of current urodynamics practice, describes limitations and challenges unique to pediatric studies, and the shares the humble lessons learned by the UMPIRE study group on their journey toward standardized urodynamic language for management of infants and children with myelomeningocele.
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Affiliation(s)
- Elizabeth B Yerkes
- Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Avenue, Pediatric Urology #24, Chicago, IL, 60611, USA.
| | - Earl Y Cheng
- Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Avenue, Pediatric Urology #24, Chicago, IL, 60611, USA
| | - John S Wiener
- Duke University Medical Center, Box 3831, Durham, NC, 27710, USA
| | | | - Duong D Tu
- Texas Children's Hospital / Baylor College of Medicine, 6701 Fannin St, Suite 620, Houston, TX, 77030, USA
| | - David B Joseph
- Children's of Alabama, 1600 7th Ave South, Lowder 318, Birmingham, AL, 35233, USA
| | - Jonathan C Routh
- Duke University Medical Center, Box 3831, Durham, NC, 27710, USA
| | - Stacy T Tanaka
- Vanderbilt University Medical Center, 2200 Children's Way. 4102 DOT, Nashville, TN, 37232, USA
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21
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Tanaka ST, Yerkes EB, Routh JC, Tu DD, Austin JC, Wiener JS, Vasquez E, Joseph DB, Ahn JJ, Wallis MC, Williams T, Rose C, Baum MA, Cheng EY. Urodynamic characteristics of neurogenic bladder in newborns with myelomeningocele and refinement of the definition of bladder hostility: Findings from the UMPIRE multi-center study. J Pediatr Urol 2021; 17:726-732. [PMID: 34011486 PMCID: PMC11008495 DOI: 10.1016/j.jpurol.2021.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Infants with myelomeningocele are at risk for chronic kidney disease caused by neurogenic bladder dysfunction. Urodynamic evaluation plays a key role to risk stratify individuals for renal deterioration. OBJECTIVE To present baseline urodynamic findings from the Urologic Management to Preserve Initial Renal function for young children with spina bifida (UMPIRE) protocol, to present the process that showed inadequacies of our original classification scheme, and to propose a refined definition of bladder hostility and categorization. STUDY DESIGN The UMPIRE protocol follows a cohort of newborns with myelomeningocele at nine children's hospitals in the United States. Infants are started on clean intermittent catheterization shortly after birth. If residual volumes are low and there is no or mild hydronephrosis, catheterization is discontinued. Baseline urodynamics are obtained at or before 3 months of age to determine further management. Based on protocol-specific definitions, urodynamic studies were reviewed by the clinical site in addition to a central review team; and if necessary, by all site urologists to achieve 100% concurrence. RESULTS We reviewed 157 newborn urodynamic studies performed between May 2015 and September 2017. Of these 157 infants, 54.8% were boys (86/157). Myelomeningocele closure was performed in-utero in 18.4% (29/157) and postnatally in 81.5% (128/157) of newborns. After primary review, reviewers agreed on overall bladder categorization in 50% (79/157) of studies. Concurrence ultimately reached 100% with further standardization of interpretation. We found that it was not possible to reliably differentiate a bladder contraction due to detrusor overactivity from a volitional voiding contraction in an infant. We revised our categorization system to group the "normal" and "safe" categories together as "low risk". Additionally, diagnosis of detrusor sphincter dyssynergia (DSD) with surface patch electrodes could not be supported by other elements of the urodynamics study. We excluded DSD from our revised high risk category. The final categorizations were high risk in 15% (23/157); intermediate risk in 61% (96/157); and low risk in 24% (38/157). CONCLUSION We found pitfalls with our original categorization for bladder hostility. Notably, DSD could not be reliably measured with surface patch of electrodes. The effect of this change on future renal outcomes remains to be defined.
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Affiliation(s)
- Stacy T Tanaka
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way. 4102 DOT, Nashville, TN, 37232,, USA.
| | - Elizabeth B Yerkes
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Pediatric Urology #24, Chicago, IL, 60611,, USA
| | - Jonathan C Routh
- Division of Urology, Box 383, Duke University Medical Center, Durham, NC, 27710,, USA
| | - Duong D Tu
- Division of Urology, Texas Children's Hospital/Baylor College of Medicine, 6701 Fannin St, Suite 620. Houston, TX, 77030,, USA
| | - J Christopher Austin
- Department of Urology, Oregon Health Sciences University, Pediatric Urology, CDW6, 3181 SW Sam Jackson Park Road. Portland, OR, 97239,, USA
| | - John S Wiener
- Division of Urology, Box 383, Duke University Medical Center, Durham, NC, 27710,, USA
| | - Evalynn Vasquez
- Division of Urology, Children's Hospital Los Angeles, 4650 Sunset Blvd. MS#114. Los Angeles, CA, 90027,, USA
| | - David B Joseph
- Department of Urology, Children's of Alabama. 1600 7th Ave South, Birmingham, AL, 35233,, USA
| | - Jennifer J Ahn
- Division of Pediatric Urology, Seattle Children's Hospital, 4800 Sand Point Way NE OA.9.220. Seattle, WA, 98105,, USA
| | - M Chad Wallis
- Division of Urology, Primary Children's Hospital, 100 N. Mario Capecchi Drive, Suite 3550. Salt Lake City, UT, 84113-1100, USA
| | - Tonya Williams
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, MS S106-3, 4700 Buford Hwy. Atlanta, GA, 30341-3717,, USA
| | - Charles Rose
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop E-87. Atlanta, GA, 30329-4018,, USA
| | - Michelle A Baum
- Division of Nephrology, Boston Children's Hospital, 300 Longwood Avenue, BCH 3038. Boston, MA, 02115,, USA
| | - Earl Y Cheng
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Pediatric Urology #24, Chicago, IL, 60611,, USA
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Hobbs KT, Krischak M, Tejwani R, Purves JT, Wiener JS, Routh JC. The Importance of Early Diagnosis and Management of Pediatric Neurogenic Bladder Dysfunction. Res Rep Urol 2021; 13:647-657. [PMID: 34513742 PMCID: PMC8421253 DOI: 10.2147/rru.s259307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/17/2021] [Indexed: 11/23/2022] Open
Abstract
Neurogenic bladder dysfunction is a major source of urologic morbidity in children, especially in those with spina bifida (SB). Complications from progression of bladder dysfunction can include urinary tract infections (UTIs), urinary incontinence, upper tract deterioration, and renal dysfunction or failure. In these children, there has been a recent trend toward proactive rather than expectant management of neurogenic bladder. However, there is a lack of consensus on how to best achieve the three main goals of neurogenic bladder management: 1) preserving kidney function, 2) achieving continence (if desired by the family/individual), and 3) achieving social and functional urologic independence (if appropriate). Hence, our objective was to perform a narrative literature review to evaluate the approaches to diagnosis and management of pediatric neurogenic bladder dysfunction, with special focus on children with SB. The approach strategies vary across a spectrum, with a proactive strategy on one end of the spectrum and an expectant strategy at the other end. The proactive management strategy is characterized by early and frequent labs, imaging, and urodynamic (UDS) evaluation, with early initiation of clean intermittent catheterization (CIC) and proceeding with pharmacotherapy, or surgery if indicated. The expectant management strategy prioritizes surveillance labs and imaging prior to proceeding with invasive assessments and interventions such as UDS or pharmacotherapy. Both treatment strategies are currently utilized and data have historically been inconclusive in demonstrating efficacy of one regimen over the other. We performed a narrative literature evaluating proactive and expectant treatment strategies as they relate to diagnostics and management of Spina Bifida. From the available literature and our practice, a proactive strategy favors greater benefit in preventative management and may decrease risk of renal dysfunction compared with expectant management.
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Affiliation(s)
- K Tyler Hobbs
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Rohit Tejwani
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - J Todd Purves
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
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Simmons KL, Chandrapal JC, Wolf S, Rice HE, Tracy EE, Fitzgerald T, Pomann GM, Routh JC. Open versus minimally-invasive surgical techniques in pediatric renal tumors: A population-level analysis of in-hospital outcomes. J Pediatr Urol 2021; 17:534.e1-534.e7. [PMID: 33849794 PMCID: PMC8449787 DOI: 10.1016/j.jpurol.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 01/31/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Minimally-invasive surgery (MIS) has been adopted slowly in pediatric oncology. We attempted to describe contemporary national trends in MIS use; we hypothesized that adolescents (who are more likely to have relatively small renal cell carcinomas) would have a higher proportion of MIS than younger children (who are more likely to have relatively large Wilms tumors) and that this relationship would vary by region. OBJECTIVE To explore whether pediatric urologic oncology outcomes vary by patient age or by surgical technique. METHODS We queried the 1998-2014 National Inpatient Sample (NIS) and included encounters in children aged ≤ 18 y, ICD-9 diagnostic code for renal tumor, and procedure code for open or MIS partial or radical nephrectomy. All analyses used weighted descriptive statistics and outcomes are compared based on age group (</>10 y) or surgery type; Wald-Chi square test was used for differences in proportions and unadjusted weighted ANOVA was used to test for differences in means. RESULTS 9259 weighted encounters were included; 91% were <10 years old and 50.7% were female. MIS surgery accounted for 1.8% of encounters; there was a difference in proportions by age group (1% <9 y vs. 9.9% >9 y, p < 0.01). The proportion of surgery type was similar across regions within age groups, however. Complications occurred in 13.3% of encounters; mean inpatient length of stay was 8.9 days (SD: 0.3); mean cost was $ 34,457.68 (SD: $1197.00). There was no evidence of a difference between surgery type and proportion of post-operative complications, mean inpatient length of stay or mean inpatient cost. DISCUSSION The admission-based, retrospective design of NIS left us unable to assess long-term outcomes, repeated admissions, or to track a particular patient across time; this is particularly relevant for oncologic variables on interest such as tumor stage or event-free survival. We were similarly limited in evaluating the effect of pre-surgical referral patterns on patient distributions. CONCLUSION In this preliminary descriptive analysis, MIS techniques were infrequently used in children, but there was a higher proportion of MIS use among adolescents. There were similar proportions of surgery type across geographic regions within the United States. Whether this infrequent usage is appropriate is as yet unclear given the lack of Level I evidence regarding the relative merits of MIS and open surgery for pediatric and adolescent renal tumors.
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Affiliation(s)
- Kirsten L Simmons
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jason C Chandrapal
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Steven Wolf
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Henry E Rice
- Division of Pediatric Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Elisabeth E Tracy
- Division of Pediatric Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Tamara Fitzgerald
- Division of Pediatric Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Gina-Maria Pomann
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA; Surgical Center for Outcomes Research, Duke University School of Medicine, Durham, NC, USA.
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24
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Hughes TL, Simmons KL, Tejwani R, Barton KD, Wiener JS, Todd Purves J, Routh JC. Sexual Function and Dysfunction in Individuals with Spina Bifida: A Systematic Review. Urology 2021; 156:308-319. [PMID: 33930458 DOI: 10.1016/j.urology.2021.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To conduct a systematic review of self-reported experiences of sexual function and dysfunction in individuals with spina bifida (SB). MATERIALS AND METHODS Medline, Embase, and Web of Science were systematically searched. Studies included contained self-reported data from SB patients on one or more of the following sexual function domains: Genital sensitivity, orgasm, erectile function, ejaculation, lubrication, and/or dyspareunia. Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Studies included contained self-reported data from SB patients on one or more of the following sexual function domains: Genital sensitivity, orgasm, erectile function, ejaculation, lubrication, and/or dyspareunia. RESULTS Systematic search yielded 23 studies representing 1441 patients (816 males, 625 females). Eight utilized questionnaires validated in non-SB adults; the remainder used semi-structured interviews and non-validated instruments. Eleven assessed dysfunctions in both sexes, 10 in males, and 2 in females. Erectile function and orgasm were the most commonly assessed outcomes in males and females respectively. 12%-88% of males experienced erectile dysfunction; a majority (51%-90%) reported normal ejaculatory function. Many females were unable to experience orgasm (28%-63%). CONCLUSION Males with SB report significant erectile and ejaculatory dysfunction. Both sexes report impaired orgasms and genital sensitivity. SB-specific instruments assessing sexual dysfunction are needed in order to improve multidisciplinary care for this population.
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Affiliation(s)
- Taylor L Hughes
- School of Medicine, Duke University Medical Center, Durham, NC
| | | | - Rohit Tejwani
- Division of Urology, Duke University Medical Center, Durham, NC
| | - Karen D Barton
- Duke University Medical Center Library & Archives, Durham, NC
| | - John S Wiener
- Division of Urology, Duke University Medical Center, Durham, NC
| | - J Todd Purves
- Division of Urology, Duke University Medical Center, Durham, NC
| | - Jonathan C Routh
- Division of Urology, Duke University Medical Center, Durham, NC.
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25
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Rogers TN, Seitz G, Fuchs J, Martelli H, Dasgupta R, Routh JC, Hawkins DS, Koscielniak E, Bisogno G, Rodeberg DA. Surgical management of paratesticular rhabdomyosarcoma: A consensus opinion from the Children's Oncology Group, European paediatric Soft tissue sarcoma Study Group, and the Cooperative Weichteilsarkom Studiengruppe. Pediatr Blood Cancer 2021; 68:e28938. [PMID: 33522706 PMCID: PMC9019908 DOI: 10.1002/pbc.28938] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/16/2020] [Accepted: 01/14/2021] [Indexed: 12/14/2022]
Abstract
The treatment of paratesticular rhabdomyosarcoma (PT-RMS) has varied over time and by cooperative group. The International Soft Tissue Sarcoma Database Consortium (INSTRuCT) is a collaboration of the Children's Oncology Group (COG) Soft Tissue Sarcoma Committee, European pediatric Soft tissue sarcoma Study Group (EpSSG), and the Cooperative Weichteilsarkom Studiengruppe (CWS). The INSTRuCT surgical committee has been given charge of the development of internationally applicable consensus guidelines for the surgical treatment of rhabdomyosarcoma. This clinical consensus opinion document addresses accepted principles and areas of controversy, such as scrotal violation and retroperitoneal nodal evaluation, providing an evidence-based guideline for the surgical treatment for PT-RMS.
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Affiliation(s)
- Timothy N. Rogers
- Department of Paediatric Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Guido Seitz
- Department of Pediatric Surgery, University Hospital Giessen-Marburg, Marburg, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children’s Hospital, Hoppe-Seyler-Strasse 1, 72076 Tuebingen, Germany
| | - Helene Martelli
- Department of paediatric surgery, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Saclay, Le Kremlin Bicêtre, France
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Jonathan C. Routh
- Departments of Surgery and Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Douglas S. Hawkins
- Division of Hematology/Oncology, Seattle Children’s Hospital, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
| | - Ewa Koscielniak
- Klinikum Stuttgart, Zentrum für Kinder-, Jugend-und Frauenmedizin, Olgahospital, Pediatrics 5 (Pediatric Oncology Hematology and Immunology), Kriegsbergstrasse 62, 70174 Stuttgart, Germany
| | - Gianni Bisogno
- Hematology and Oncology Division, Department of Women’s and Children’s Health, Padova University Hospital, Padova, Italy
| | - David A. Rodeberg
- Division Pediatric Surgery, East Carolina University, Greenville, NC, US
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26
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Dionise ZR, Gonzalez JM, Garcia-Roig ML, Kirsch AJ, Scales CD, Wiener JS, Purves JT, Routh JC. Parental preferences for vesicoureteral reflux treatment: Profile case best-worst scaling. J Pediatr Urol 2021; 17:86.e1-86.e9. [PMID: 33309608 DOI: 10.1016/j.jpurol.2020.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 11/04/2020] [Accepted: 11/10/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Vesicoureteral reflux is a common pediatric urologic condition that often has several reasonable treatment options depending on condition severity. In order to choose the best treatment for their child, parents are expected to make judgements that weigh attributes such as treatment cost, effectiveness, and complication rate. Prior research has shown that factors such as treating hospital and surgeon also influence patient treatment choice. OBJECTIVES This study evaluates parental preferences for reflux treatment using profile case best-worst scaling, an emerging technique in both urologic and health care preference estimation. The study also uses latent class analysis (LCA) to identify parental sub-classes with different preferences. STUDY DESIGN Data were collected from a community sample of parents via a multimedia best-worst scaling survey instrument published to Amazon's Mechanical Turk online community. After extensive review of the literature, reflux attributes and attribute levels were selected to correspond with available treatments. The profile case best-worst scaling exercise elicited preferences for granular attributes of reflux treatments. Data were analyzed using multinomial logistic regression and class analysis to distinguish preference heterogeneity. Probability scaled values (PSVs) reflected the order of desirability of the attributes. Attribute preference importance was rescaled into dollar units for comparison as well. RESULTS We analyzed data for 248 respondents. The highest treatment effectiveness was more desirable than all other leveled treatment attributes (PSV 17.8, all p < 0.01) (Table). Low complication rate and doctor recommendation were amongst the other most desirable treatment attributes (PSV 11.3 and 9.0, respectively). Latent class analysis identified a class with more extreme preferences, for whom doctor recommendation and avoiding hospitalization were particularly desirable. DISCUSSION In this community-based sample, high treatment effectiveness and low complication rate were the most desirable treatment attributes to parents, though parents likely have heterogenous treatment preference structures. Shared parent-physician decision-making that incorporates parental preferences will likely allow more effective, targeted decision-making in the future.
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Affiliation(s)
- Zachary R Dionise
- Division of Urology, Duke University Medical Center, Durham, NC, USA.
| | | | - Michael L Garcia-Roig
- Department of Pediatric Urology, Emory University and Children's Healthcare of Atlanta, Atlanta GA, USA
| | - Andrew J Kirsch
- Department of Pediatric Urology, Emory University and Children's Healthcare of Atlanta, Atlanta GA, USA
| | - Charles D Scales
- Division of Urology, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - John S Wiener
- Division of Urology, Duke University Medical Center, Durham, NC, USA
| | - J Todd Purves
- Division of Urology, Duke University Medical Center, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urology, Duke University Medical Center, Durham, NC, USA.
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27
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Lautz TB, Chi YY, Li M, Wolden SL, Casey DL, Routh JC, Granberg CF, Binite O, Rudzinski ER, Hawkins DS, Venkatramani R, Rodeberg DA. Benefit of delayed primary excision in rhabdomyosarcoma: A report from the Children's Oncology Group. Cancer 2021; 127:275-283. [PMID: 33079399 PMCID: PMC7790947 DOI: 10.1002/cncr.33275] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/22/2020] [Accepted: 09/27/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most children with intermediate-risk rhabdomyosarcoma (RMS) have gross disease (group III) at the initiation of chemotherapy. Delayed primary excision (DPE) after induction chemotherapy allows for a reduction in adjuvant radiation dose, but with the risk of potential surgical morbidity. The objectives of this study were to compare outcomes in children with group III RMS who did and did not undergo DPE and to assess surgical morbidity. METHODS The study included 369 patients who had clinical group III RMS at sites amenable to DPE from intermediate-risk Children's Oncology Group studies D9803 (encouraged DPE) and ARST0531 (discouraged DPE). RESULTS The primary tumor site was bladder/prostate (136 patients; 37%), extremity (97 patients; 26%), trunk (24 patients; 7%), retroperitoneum (91 patients; 25%), or intrathoracic/perineum/perianal (21 patients; 6%). In total, 112 patients (53.9%) underwent DPE in D9803, and 26 patients (16.2%) underwent DPE in ARST0531 (P < .001), with loss of vital organ or function in 30 of 138 patients (22%). DPE allowed for a reduced radiation dose in 110 of 135 patients (81%; 51% were reduced to 36 Gy, and 30% were reduced to 42 Gy). Patients who underwent DPE had improved unadjusted overall survival (P = .013). In adjusted regression analysis, the risk of death (hazard ratio, 0.71; 95% CI 0.43-1.16) was similar for patients who did and did not undergo DPE and was improved for the subset of patients who had tumors of the trunk and retroperitoneum (hazard ratio, 0.44; 95% CI, 0.20-0.97). CONCLUSIONS Children with group III RMS have equivalent or improved outcomes with DPE and can receive a decreased radiation dose for definitive local control. The choice of local control modality should weigh the potential morbidity of surgery versus that of higher dose irradiation.
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Affiliation(s)
- Timothy B. Lautz
- Department of Surgery, Ann & Robert H Lurie Children’s Hospital of Chicago; Northwestern University, Chicago, IL USA
| | - Yueh-Yun Chi
- Department of Pediatrics and Preventive Medicine, University of Southern California, Los Angeles, CA USA
| | - Minjie Li
- Department of Biostatistics, University of Florida, Gainesville, FL USA
| | - Suzanne L. Wolden
- Division of Radiation Oncology, Memorial Sloan Kettering Cancer Center; New York, NY USA
| | - Dana L. Casey
- Division of Radiation Oncology, University of North Carolina, Chapel Hill, NC USA
| | - Jonathan C. Routh
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC USA
| | | | - Odion Binite
- Department of Orthopedic Surgery, Moffitt Cancer Center, Tampa, FL USA
| | - Erin R. Rudzinski
- Department of Pathology, Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - Douglas S. Hawkins
- Division of Hematology/Oncology, Seattle Children’s Hospital, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Rajkumar Venkatramani
- Division of Hematology/Oncology, Texas Children’s Cancer Center, Baylor College of Medicine, Houston, TX
| | - David A. Rodeberg
- Division of Pediatric Surgery, Department of Surgery, East Carolina University
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Chandrapal J, Simmons K, Purves JT, Wiener JS, Routh JC. Association between race and in-hospital outcomes in children with spina bifida following inpatient urologic surgery. J Pediatr Rehabil Med 2021; 14:597-604. [PMID: 34864697 PMCID: PMC9941957 DOI: 10.3233/prm-200699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Post-operative complication rates may vary among racial and/or ethnic groups and have not been previously described in individuals with spina bifida (SB) undergoing urologic surgery. The aim of this study was to compare in-hospital complication frequencies of individuals with SB following urologic surgery by race/ethnicity. METHODS The Nationwide Inpatient Sample was used to identify pediatric patients with SB who underwent inpatient urologic procedures. A pediatric cohort (<18 years old) with SB that underwent urologic surgery were assessed. All analyses report weighted descriptive statistics, outcomes, and race/ethnicity was the primary predictor variable. The primary outcome of interest was post-operative complications which were defined using NSQIP ICD-9 code definitions. Secondary analysis included length of stay (LOS), and encounter cost was estimated using the cost-to-charge ratio files provided by the Healthcare Cost and Utilization Project. RESULTS The unadjusted model showed no differences in complications, LOS, and cost. In the adjusted model there were no differences in complications, LOS, and cost between Black and White encounters. However, Hispanic ethnicity was associated with a 20%(95%CI: 4-40%) increase in LOS and 18%(95%CI: 2-35%, p = 0.02) increase in cost compared to White encounters. CONCLUSION There was no evidence of variation for in-hospital complication rates among racial/ethnic groups undergoing urologic surgery. Hispanic ethnicity was associated with higher costs and longer LOS in pediatric SB encounters.
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Affiliation(s)
- Jason Chandrapal
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Kirsten Simmons
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - J Todd Purves
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - John S Wiener
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
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29
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Johnston AW, Routh JC, Purves JT, Wiener JS, Sinani A, Holl EK. Immune Expression in Children With Vesicoureteral Reflux: A Pilot Study. Urology 2020; 148:254-259. [PMID: 33049235 DOI: 10.1016/j.urology.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/25/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To perform an exploratory, descriptive pilot study of the systemic and local immune environment in patients with vesicoureteral reflux (VUR) and bladder-bowel dysfunction (BBD). METHODS Consecutive children with VUR undergoing intravesical ureteral reimplantation were enrolled. Patients were assessed for presence of BBD by reported patient history and validated questionnaire. Fresh blood and bladder tissue, collected at the time of surgery, were immediately processed for analysis. Immune cell compositions were determined via flow cytometry. Immune cell activation was also defined at the time of analysis. LegendPlex assay analysis was utilized to define levels of circulating chemokines and cytokines. RESULTS A total of 7 patients were enrolled. Although percentages of circulating immune cells in the blood of those with VUR/BBD and VUR alone were similar, within bladder tissue, VUR/BBD demonstrated increased immune infiltrates compared to VUR alone. Bladder sample analysis showed that B cells, and Effector Memory and Naïve T cell percentages were significantly increased in VUR/BBD patients compared to VUR patients. T cell expression of PD1 was increased in bladder tissues of BBD/VUR. Additionally, analysis of circulating neutrophils displayed significantly increased upregulation of PDL-1 in patients with VUR/BBD vs those with VUR only. CONCLUSION These pilot data suggest an immune-rich microenvironment is present within VUR. Severity of inflammation appeared to correlate with presence of BBD. This implies that targeting pelvic inflammation may be a novel therapy for children with VUR- or non-VUR-related BBD. Follow-up studies are currently underway.
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Affiliation(s)
- Ashley W Johnston
- Division of Urologic Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC.
| | - Jonathan C Routh
- Division of Urologic Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - J Todd Purves
- Division of Urologic Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - John S Wiener
- Division of Urologic Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Angela Sinani
- Dept of Chemical and Biomolecular Engineering, University of Delaware, Newark, DE
| | - Eda K Holl
- Division of Surgical Sciences, Department of Surgery, Duke University School of Medicine, Durham, NC
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Routh JC, Cost NG, Wiener JS. Pediatric urologic oncology in the 21st century: where we stand and where we’re headed. Transl Androl Urol 2020; 9:2329-2330. [PMID: 33209706 PMCID: PMC7658112 DOI: 10.21037/tau-2019-pum-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jonathan C Routh
- Division of Pediatric Urology, Duke University, Durham, NC, USA.
| | - Nicholas G Cost
- Colorado Children's Hospital, University of Colorado, Aurora, CO, USA.
| | - John S Wiener
- Division of Pediatric Urology, Duke University, Durham, NC, USA.
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Chu DI, Liu T, Patel P, Routh JC, Ouyang L, Baum MA, Cheng EY, Yerkes EB, Isakova T. Kidney Function Surveillance in the National Spina Bifida Patient Registry: A Retrospective Cohort Study. J Urol 2020; 204:578-586. [PMID: 32141805 PMCID: PMC7415638 DOI: 10.1097/ju.0000000000001010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Chronic kidney disease affects 25% to 50% of patients with spina bifida. Guidelines recommend kidney function surveillance in these patients but practice patterns are unknown. Variations in kidney function surveillance were assessed in patients with spina bifida based on the hypothesis that the treating clinic and spina bifida type would be associated with kidney function surveillance. MATERIALS AND METHODS A retrospective cohort study was conducted of U.S. patients in the National Spina Bifida Patient Registry from 2013 to 2018. Followup was anchored at the 2013 visit. Participants with either an outcome event within 2 years of followup or more than 2 years of followup without an outcome event were included. Primary outcome was kidney function surveillance, defined as at least 1 renal ultrasound and serum creatinine within 2 years of followup. Primary exposures were clinic and spina bifida type, which were analyzed with covariates including sociodemographic and clinical characteristics in logistic regression models for their association with the outcome. Sensitivity analyses were performed using different kidney function surveillance definitions. RESULTS Of 8,351 patients 5,445 were included with a median followup of 3.0 years. Across 23 treating clinics kidney function surveillance rates averaged 62% (range 6% to 100%). In multivariable models kidney function surveillance was associated with treating clinic, younger patient age, functional lesion level, nonambulatory status and prior bladder augmentation. Treating clinic remained a significant predictor of kidney function surveillance in all sensitivity analyses. CONCLUSIONS Within the National Spina Bifida Patient Registry wide variation exists in practice of kidney function surveillance across treating clinics despite adjustment for key patient characteristics.
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Affiliation(s)
- David I. Chu
- Division of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine at Northwestern University
| | - Tiebin Liu
- Centers for Disease Control and Prevention
| | - Priya Patel
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, Tennessee
| | | | | | | | - Earl Y. Cheng
- Division of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | | | - Tamara Isakova
- Division of Nephrology and Hypertension, Feinberg School of Medicine at Northwestern University
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine at Northwestern University
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Routh JC, Dasgupta R, Chi YY, Shnorhavorian M, Tian J, Walterhouse DO, Breneman J, Wolden SL, Arndt CA, Hawkins DS, Rodeberg DA. Impact of local control and surgical lymph node evaluation in localized paratesticular rhabdomyosarcoma: A report from the Children's Oncology Group Soft Tissue Sarcoma Committee. Int J Cancer 2020; 147:3168-3176. [PMID: 32525556 DOI: 10.1002/ijc.33143] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/24/2020] [Accepted: 05/14/2020] [Indexed: 01/20/2023]
Abstract
Paratesticular rhabdomyosarcoma (PT-RMS) carries a favorable prognosis, but questions persist regarding optimal management. Our goal was to determine the importance of primary tumor resection and surgical assessment of retroperitoneal lymph nodes during staging in patients with PT-RMS. We analyzed patients with localized PT-RMS enrolled onto one of four Children's Oncology Group studies (D9602, ARST0331, D9803 or ARST0531). Surgical resection of the primary tumor prior to chemotherapy and radiotherapy was encouraged when possible with retroperitoneal lymph node dissection (RPLND) recommended for patients ≥10 years of age. Among 279 patients (median 8.1 years old), most tumors were resected with negative margins (78.5%) and most patients did not have radiographic enlargement of regional lymph nodes (90.3%). In patients older than 10 years, imaging alone will miss over 51.5% of nodal disease. Five-year event-free survival (EFS) was 92.0% (95% CI 88.4%-95.6%). Sampling ≥7 to 12 retroperitoneal lymph nodes appeared optimal for detecting positive nodes; while there was a trend toward improved EFS among those undergoing template RPLND, this was not statistically significant (P = .068). Age (P = .28), N-stage (P = .39), T-stage (P = .11) and pathologic node involvement (P = .53) were not associated with overall survival. However, older age and larger tumor size had an additive impact on EFS (P = .027) though not overall survival (P = .13). In conclusion, outcomes for patients with PT-RMS are excellent. Reliance on imaging to detect nodal involvement will miss pathologic node involvement and may result in undertreatment. Surgical nodal staging requires at least 7 to 12 nodes to accurately identify patients with regional nodal disease.
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Affiliation(s)
- Jonathan C Routh
- Division of Urology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Yueh-Yun Chi
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Margarett Shnorhavorian
- Division of Pediatric Urology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Jing Tian
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - David O Walterhouse
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John Breneman
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Carola A Arndt
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas S Hawkins
- Division of Hematology/Oncology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - David A Rodeberg
- Department of Surgery, East Carolina University, Greenville, North Carolina, USA
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Alkazemi MH, Johnston AW, Meglin D, Adkins D, Routh JC. Community perspectives on difference of sex development (DSD) diagnoses: A crowdsourced survey. J Pediatr Urol 2020; 16:384.e1-384.e8. [PMID: 32409277 PMCID: PMC7308206 DOI: 10.1016/j.jpurol.2020.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 03/27/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVES Differences of sex development (DSD) engender ethical, social and psychosexual complexities that can complicate medical decision-making. We performed a web-based pilot study to estimate the utility value of a DSD diagnosis and to identify community concerns regarding DSD management. METHODS A cross-sectional survey was posted on Amazon's Mechanical Turk, an online crowdsourcing platform. Respondents were ≥18y and were randomized to receive information on one of three common DSD conditions: Congenital Adrenal Hyperplasia (CAH), Mixed Gonadal Dysgenesis (MGD), and Partial Androgen Insensitivity Syndrome (PAIS). Time trade-off methodology was used to estimate utility values. Likert scale and statement-ranking questions were used to assess respondent perceptions. RESULTS Of 1,628 respondents, median age was 34y; most respondents were parents (59.1%), white (77.1%), and previously unfamiliar with DSD (60.4%). The median overall utility value was 0.70 (IQR 0.50-0.90), similar to moderately severe chronic health conditions. Utility estimates varied based on the DSD scenario presented (0.80 CAH vs. 0.70 MGD vs. 0.80 PAIS, p = 0.0006), respondent gender (p < 0.0001), race (p = 0.002), religion (p = 0.005), and prior knowledge of DSD (p < 0.0001). Reported concerns included gender identity (23.4%), urinary function (20.5%) and surgical complications (17.4%). Most (67.5%) supported early surgical intervention at 6-18 mo; 10.4% thought surgery should occur ≥18 y. COMMENT Limitations of this study include that survey participants were aware of the nature of the study, thus some respondents may have participated to skew the results. Given the nature of this pilot study, the representation of families with children with DSD within the study is severely limited given the rarity of DSDs. This means that their opinions may be diluted by the large sample size. However, because utility values are classically estimated according to community opinions, the utility data presented should be taken to reflect that of the specific sample studied and is not reflective of that of families with a vested interest in such cases. CONCLUSIONS Community-based respondents perceived that DSD conditions were associated with a reduction in utility values (0.70-0.80), on par with moderately severe chronic health conditions. Estimates varied based on respondents' gender, race, religion and prior knowledge of DSD. Gender identity was the most concerning aspect for respondents.
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Affiliation(s)
| | - Ashley W Johnston
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Diane Meglin
- Duke University School of Medicine, Durham, NC, USA
| | - Deanna Adkins
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Jonathan C Routh
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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Thibadeau J, Walker WO, Castillo J, Dicianno BE, Routh JC, Smith KA, Ouyang L. Philosophy of care delivery for spina bifida. Disabil Health J 2020; 13:100883. [PMID: 31928964 PMCID: PMC7477785 DOI: 10.1016/j.dhjo.2019.100883] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 12/06/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
The multidisciplinary model (MCM) is described as one that utilizes skills and experience from practitioners belonging to various disciplines, each treating patients from a specific clinical perspective.1 The Spina Bifida Association (SBA) supports and recommends that clinical care for people with Spina Bifida (SB) be provided in specialty clinics of which the MCM is an example; that care be coordinated; and that there be a plan for transitional care.2 This paper explores the challenges the MCM faces with a transitioning and aging population in a care system that calls for a positive patient experience, engaged health care professionals, desired outcomes, with consideration of cost.
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Affiliation(s)
- Judy Thibadeau
- Spina Bifida Association, 1600 Wilson Blvd., Suite 800, Arlington, VA, 22209, USA.
| | - William O Walker
- Chief, Division of Developmental Medicine, Seattle Children's Hospital, Robert A. Aldrich Professor, Department of Pediatrics, University of Washington School of Medicine, USA
| | - Jonathan Castillo
- Developmental-Behavioral Pediatrics, Texas Children's Hospital, Baylor College of Medicine, USA
| | - Brad E Dicianno
- University of Pittsburgh School of Medicine, Department of Physical Medicine and Rehabilitation, Pittsburgh, PA, USA; Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | - Kathryn A Smith
- USC University Center for Excellence in Developmental Disabilities, Spina Bifida Program, Children's Hospital Los Angeles, Clinical Pediatrics, Keck School of Medicine, University of Southern California, USA
| | - Lijing Ouyang
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, USA
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Johnston AW, Wolf S, Alkazemi MH, Pomann GM, Wood H, Wiener JS, Routh JC. Patterns of inpatient care for prostate cancer in men with spina bifida. Disabil Health J 2020; 13:100866. [DOI: 10.1016/j.dhjo.2019.100866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/28/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022]
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Lautz TB, Chi YY, Tian J, Gupta AA, Wolden SL, Routh JC, Casey DL, Dasgupta R, Hawkins DS, Rodeberg DA. Relationship between tumor response at therapy completion and prognosis in patients with Group III rhabdomyosarcoma: A report from the Children's Oncology Group. Int J Cancer 2020; 147:1419-1426. [PMID: 32012255 DOI: 10.1002/ijc.32896] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/20/2019] [Accepted: 01/15/2020] [Indexed: 12/17/2022]
Abstract
A subset of patients with initially unresected (Clinical Group III) rhabdomyosarcoma achieve less than a complete response (CR) despite multimodal therapy. We assessed outcome based upon tumor response at the completion of all planned therapy. We studied 601 Clinical Group III participants who completed all protocol therapy without developing progressive disease on two Children's Oncology Group studies ARST0531 (n = 285) and D9803 (n = 316). Response was defined by imaging and categorized by response; complete resolution (CR), partial response (PR) or no response (NR). Failure-free survival (FFS) and overall survival (OS) between response groups were compared using the log-rank test. We found that radiographic response was CR in 393 (65.4%) and PR/NR in 208 (34.6%) patients. Achieving CR status was associated with study D9803, nonparameningeal (PM) primary sites, tumors ≤5 cm, noninvasive tumors and alveolar histology/FOXO fusion-positive tumors. The overall 5-year FFS was 75% for those achieving CR and 66.5% in those with PR/NR (adj. p = 0.094). Patients with PM primary site who achieved CR had significantly improved FFS (adj. p = 0.037) while those with non-PM primary sites had similar outcomes (adj. p = 0.47). Radiographic response was not associated with OS (adj. p = 0.21). Resection of the end-of-therapy mass did not improve FFS (p = 0.12) or OS (p = 0.37). In conclusion, CR status at the end of protocol therapy in patients with PM Clinical Group III RMS was associated with improved FFS but not OS. Efforts to understand the biology and treatment response in patients with PM primary site are under investigation.
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Affiliation(s)
- Timothy B Lautz
- Department of Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
| | - Yueh-Yun Chi
- Department of Biostatistics, University of Florida, Gainesville, FL
| | - Jing Tian
- Department of Biostatistics, University of Florida, Gainesville, FL
| | - Abha A Gupta
- Division of Hematology and Oncology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Suzanne L Wolden
- Division of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC
| | - Dana L Casey
- Division of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Douglas S Hawkins
- Division of Hematology/Oncology, Seattle Children's Hospital, University of Washington, Fred, Hutchinson Cancer Research Center, Seattle, WA
| | - David A Rodeberg
- Division of Pediatric Surgery, Department of Surgery, East Carolina University, Greenville, NC
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Johnston AW, Longo TA, Davis LG, Zapata D, Freedland SJ, Routh JC. Bone scan positivity in non-metastatic, castrate-resistant prostate cancer: external validation study. Int Braz J Urol 2020; 46:42-52. [PMID: 31851457 PMCID: PMC6968912 DOI: 10.1590/s1677-5538.ibju.2019.0225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/24/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction: Tables predicting the probability of a positive bone scan in men with non-metastatic, castrate-resistant prostate cancer have recently been reported. We performed an external validation study of these bone scan positivity tables. Materials and Methods: We performed a retrospective cohort study of patients seen at a tertiary care medical center (1996-2012) to select patients with non-metastatic, castrate-resistant prostate cancer. Abstracted data included demographic, anthropometric, and disease-specific data such as patient race, BMI, PSA kinetics, and primary treatment. Primary outcome was metastasis on bone scan. Multivariable logistic regression was performed using generalized estimating equations to adjust for repeated measures. Risk table performance was assessed using ROC curves. Results: We identified 6.509 patients with prostate cancer who had received hormonal therapy with a post-hormonal therapy PSA ≥2ng/mL, 363 of whom had non-metastatic, castrate-resistant prostate cancer. Of these, 187 patients (356 bone scans) had calculable PSA kinetics and ≥1 bone scan. Median follow-up after castrate-resistant prostate cancer diagnosis was 32 months (IQR: 19-48). There were 227 (64%) negative and 129 (36%) positive bone scans. On multivariable analysis, higher PSA at castrate-resistant prostate cancer (4.67 vs. 4.4ng/mL, OR=0.57, P=0.02), shorter time from castrate-resistant prostate cancer to scan (7.9 vs. 14.6 months, OR=0.97, P=0.006) and higher PSA at scan (OR=2.91, P <0.0001) were significantly predictive of bone scan positivity. The AUC of the previously published risk tables for predicting scan positivity was 0.72. Conclusion: Previously published risk tables predicted bone scan positivity in men with non-metastatic, castrate-resistant prostate cancer with reasonable accuracy.
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Affiliation(s)
- Ashley W Johnston
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Thomas A Longo
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Leah Gerber Davis
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Daniel Zapata
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
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Kelly MS, Wiener JS, Liu T, Patel P, Castillo H, Castillo J, Dicianno BE, Jasien J, Peterson P, Routh JC, Sawin K, Sherburne E, Smith K, Taha A, Worley G. Neurogenic bowel treatments and continence outcomes in children and adults with myelomeningocele. J Pediatr Rehabil Med 2020; 13:685-693. [PMID: 33325404 PMCID: PMC8776357 DOI: 10.3233/prm-190667] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Neurogenic bowel dysfunction (NBD) is a common comorbidity of myelomeningocele (MMC), the most common and severe form of spina bifida. The National Spina Bifida Patient Registry (NSBPR) is a research collaboration between the CDC and Spina Bifida Clinics. Fecal continence (continence) outcomes for common treatment modalities for NBD have not been described in a large sample of individuals with MMC. NSBPR patients with MMC and NBD were studied to determine variation in continence status and their ability to perform their treatment independently according to treatment modality and individual characteristics. METHODS Continence was defined as < 1 episode of incontinence per month. Eleven common treatments were evaluated. Inclusion criteria were established diagnoses of both MMC and NBD, as well as age ⩾ 5 years (n= 3670). Chi-square or exact statistical tests were used for bivariate analyses. Logistic regression models were used to estimate the odds of continence outcomes by age, sex, race/ethnicity, level of motor function, and insurance status. RESULTS At total of 3670 members of the NSBPR met inclusion criteria between November 2013 and December 2017. Overall prevalence of continence was 45%. Prevalence ranged from 40-69% across different treatments. Among continent individuals, 60% achieved continence without surgery. Antegrade enemas were the most commonly used treatment and had the highest associated continence rate. Ability to carry out a treatment independently increased with age. Multivariable logistic regression showed significantly higher odds of continence among individuals aged ⩾ 12 years, female, non-Hispanic white, and with private insurance.
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Affiliation(s)
- Maryellen S Kelly
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - John S Wiener
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA.,Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Tiebin Liu
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Priya Patel
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, TN, USA
| | - Heidi Castillo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Jonathan Castillo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Brad E Dicianno
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joan Jasien
- Division of Pediatric Neurology, Department of Pediatrics, Duke University, Durham, NC, USA
| | - Paula Peterson
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jonathan C Routh
- Division of Urology, Department of Surgery, Duke University, Durham, NC, USA
| | - Kathleen Sawin
- Department of Nursing Research, Children's Hospital of Wisconsin, USA and Self-management Science Center, College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Eileen Sherburne
- Department of Nursing Research, Children's Hospital of Wisconsin, USA and Self-management Science Center, College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Kathryn Smith
- Department of Pediatrics, Keck School of Medicine, Los Angeles, CA, USA
| | - Asma Taha
- Doernbecher Children's Hospital and School of Nursing, Oregon Health Sciences University, Portland, OR, USA
| | - Gordon Worley
- Division of Pediatric Neurology, Department of Pediatrics, Duke University, Durham, NC, USA.,Division of Urology, Department of Surgery, Duke University, Durham, NC, USA.,National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Holl EK, Routh JC, Johnston AW, Frazier V, Rice HE, Tracy ET, Nair SK. Immune expression in children with Wilms tumor: a pilot study. J Pediatr Urol 2019; 15:441.e1-441.e8. [PMID: 30981637 DOI: 10.1016/j.jpurol.2019.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/13/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Given improvements in multimodality therapy, survival among children with Wilms tumor (WT) exceeds 90%. However, 15% of children with favorable histology and 50% of children with anaplastic WT experience recurrence or progression. Of patients with advanced disease, only 50% survive to adulthood. In adult malignancies (including renal tumors), patient survival has improved with the advent of immunotherapy. However, little is known about the immune microenvironment of WT, making the potential role of immunotherapy unclear. OBJECTIVE The objective of the study is to perform an exploratory, descriptive analysis of the immune milieu in WT. STUDY DESIGN Between 2016 and 2017, all pediatric patients with WT, some of whom received neoadjuvant chemotherapy, underwent ex vivo wedge biopsy at the time of nephrectomy. The fresh tumor tissue and peripheral blood samples were analyzed for infiltrating immune infiltrate and effector cells using flow cytometry. Immunohistochemistry was performed for CD4, CD8, and PD-L1 expression. Matched blood samples were obtained for each patient, and circulating immune cells were analyzed by flow cytometry. RESULTS A total of six patients were enrolled. One patient with neuroblastoma was excluded. The remaining five patients included the following: two with unilateral WT (resected before chemotherapy), two with bilateral WT (resected after neoadjuvant chemotherapy), and one with Denys-Drash syndrome, end-stage renal disease, and history of WT in the contralateral kidney. Immune analysis showed that WT were infiltrated by immune cells regardless of chemotherapy status. CD8 and CD4 T cells were present in the tumor tissue and exhibited an activated phenotype. Elevated levels of natural killer (NK) cells were observed in the tumors (Figure). Immune checkpoint PD-L1 was also found expressed in one of the tumors stained. DISCUSSION In this pilot study, it was found that WTs were infiltrated by immune cells (CD45+) both before and after chemotherapy. Elevated levels of NK cells infiltrating the tumor specimens, which were quantitatively increased compared with levels of NK cells circulating in the blood, were noted. T cells, particularly CD4+ and CD8+ T cells, were present in tumor specimens. Tumor-infiltrating CD4 and CD8 T cells displayed an activated phenotype as defined by increased expression of human leukocyte antigen-DR isotype (HLA-DR), programmed cell death protein 1 (PD1), and CD57. Together, these findings suggest that WT microenvironment is immune engaged and may be susceptible to immunotherapy similar to other malignancies. CONCLUSIONS These pilot data suggest an immune-engaged tumor microenvironment is present within WT. This implies that WT may be susceptible to immunotherapy similar to adult renal tumors and other adult malignancies. Follow-up studies are currently underway.
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Affiliation(s)
- E K Holl
- Division of Surgical Sciences, Dept of Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - J C Routh
- Division of Pediatric Surgery, Dept of Surgery, Duke University School of Medicine, Durham, NC, USA; Division of Urologic Surgery, Dept of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - A W Johnston
- Division of Urologic Surgery, Dept of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - V Frazier
- Division of Surgical Sciences, Dept of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - H E Rice
- Division of Pediatric Surgery, Dept of Surgery, Duke University School of Medicine, Durham, NC, USA; Division of Urologic Surgery, Dept of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - E T Tracy
- Division of Pediatric Surgery, Dept of Surgery, Duke University School of Medicine, Durham, NC, USA; Division of Urologic Surgery, Dept of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - S K Nair
- Division of Surgical Sciences, Dept of Surgery, Duke University School of Medicine, Durham, NC, USA
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Inouye BM, Dionise ZR, Jiang R, Wolf S, Nicholl L, Pomann GM, Wiener JS, Purves JT, Routh JC. National Imaging and Antibiotic Practice Patterns in Children Presenting With Urinary Tract Infection to Community Practices: Little Impact From the American Academy of Pediatrics Guidelines? Clin Pediatr (Phila) 2019; 58:1302-1308. [PMID: 31165627 PMCID: PMC7649738 DOI: 10.1177/0009922819853003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our objective was to use community-based, national databases to evaluate diagnostic imaging and antibiotic prophylaxis practice patterns before and after the release of the 2011 American Academy of Pediatrics guidelines for acute febrile urinary tract infection. Using the National Ambulatory and Hospital Ambulatory Medical Care Surveys, urinary tract infection encounters were identified for patients aged 2 months to 18 years. Primary outcomes were utilization of antibiotics (as proxy for prophylaxis) and diagnostic imaging during encounters. Weighted multivariate logistic regression models were used to examine the association between time period (before and after 2011) and each of the primary outcomes. Among 8 588 035 weighted encounters, adjusting for covariates, there was insufficient evidence to suggest a difference between time periods for antibiotic utilization (odds ratio = 0.66, P = .12) or diagnostic imaging (odds ratio = 1.16, P = .56). Thus, we did not find evidence of changes in antibiotic utilization or diagnostic imaging practice patterns after the release of the 2011 American Academy of Pediatrics guidelines.
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Johnston AW, Jiang R, Alkazemi MH, Wolf S, Pomann GM, Lipkin ME, Scales CD, Routh JC. Nationwide Readmission Rates Following Percutaneous Nephrolithotomy: Does Age Matter? J Endourol 2019; 33:704-711. [PMID: 31232120 DOI: 10.1089/end.2019.0239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Introduction/Objectives: Despite minimal evidence that evaluates the effect of age on percutaneous nephrolithotomy (PCNL) morbidity, pediatric and elderly patients are considered high-risk groups. Our objective was to assess the effect of the extremes of ages on PCNL readmission and postoperative complication rates. Methods: We identified all PCNL encounters in the 2013 and 2014 Nationwide Readmission Database. Encounters were divided into five age groups: pediatric (<18 years old), young adult (18-25 years old), adult (26-64 years old), geriatric (65-74 years old), and elderly (≥75 years old). Weighted descriptive statistics were used to describe population demographics. We fit an adjusted weighted logistic regression model for 30-day readmission and complication rates. Results: We identified 23,357 encounters. Testing average effect of pediatric and elderly encounters to all other age groups did not reveal a difference in odds for 30-day readmissions, but did result in increased odds for 30-day GU readmissions (odds ratio: 17.7 [95% confidence interval (CI): 2.65-118.9]; p = 0.003). Compared to all other age groups, elderly encounters had 7.5 (95% CI: 2.5-22.7; p = 0.0004) times the odds of a 30-day readmission and 68.3 (95% CI: 29.1-160.4; p < 0.0001) times the odds of a postoperative complication. Conclusions: When comparing the average effect of the extremes of ages to all other age groups, we did not find evidence to suggest a difference in odds for 30-day GU readmissions, but did find increased odds for complications. Further examination revealed that PCNL encounters of elderly patients had significantly increased odds for both readmission and complications, whereas PCNL encounters of pediatric patients did not.
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Affiliation(s)
- Ashley W Johnston
- Division of Urology, Duke University Medical Center, Durham, North Carolina
| | - Ruiyang Jiang
- Division of Urology, Duke University Medical Center, Durham, North Carolina
| | | | - Steven Wolf
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Gina-Maria Pomann
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Michael E Lipkin
- Division of Urology, Duke University Medical Center, Durham, North Carolina
| | - Charles D Scales
- Division of Urology, Duke University Medical Center, Durham, North Carolina
| | - Jonathan C Routh
- Division of Urology, Duke University Medical Center, Durham, North Carolina
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Casey DL, Chi YY, Donaldson SS, Hawkins DS, Tian J, Arndt CA, Rodeberg DA, Routh JC, Lautz TB, Gupta AA, Yock TI, Wolden SL. Increased local failure for patients with intermediate-risk rhabdomyosarcoma on ARST0531: A report from the Children's Oncology Group. Cancer 2019; 125:3242-3248. [PMID: 31174239 DOI: 10.1002/cncr.32204] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/13/2019] [Accepted: 03/22/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND The objective of this study was to evaluate local control for patients with intermediate-risk rhabdomyosarcoma (RMS) treated on Children's Oncology Group (COG) protocol ARST0531. METHODS This study analyzed 424 patients with intermediate-risk RMS. Patients were randomized to chemotherapy with either vincristine, dactinomycin, and cyclophosphamide (VAC) or VAC alternating with vincristine and irinotecan. With the goal of improving local control, radiation therapy (RT) was delivered early at week 4 and was concurrent with irinotecan in the experimental arm. Individualized local control plans for children 24 months old or younger were allowed. Local failure on ARST0531 was compared with local failure on the preceding COG intermediate-risk study, D9803. RESULTS For patients with group I/II alveolar RMS (n = 55), the 5-year cumulative incidence of local failure was 13.4%; for group III alveolar RMS (n = 141), it was 20.2%; and for group III embryonal RMS (n = 228), it was 27.9% (P = .03). Among patients with group III disease, local failure did not differ by histology, site, nodal status, RT modality, or treatment arm. Local failure was worse for a tumor size >5 cm (32.3% vs 16.7%; P = .001). Among patients with group III embryonal RMS, local failure was higher on ARST0531 than D9803 (27.9% vs 19.4%; P = .03). After the exclusion of patients 24 months old or younger or patients who did not receive radiation, local failure remained significantly increased on ARST0531 (P = .02). After adjustments for clinical prognostic factors, event-free survival and overall survival were worse on ARST0531 (P = .004 and P = .05, respectively). CONCLUSIONS Despite interventions designed to enhance local control, local control was inferior on ARST0531 in comparison with D9803. The reason for this is unclear, but it could be the reduced cyclophosphamide dose on ARST0531.
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Affiliation(s)
- Dana L Casey
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Douglas S Hawkins
- Seattle Children's Hospital, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington
| | - Jing Tian
- University of Florida, Gainesville, Florida
| | | | | | | | | | - Abha A Gupta
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Torunn I Yock
- Massachussets General Hospital, Boston, Massachusetts
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43
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Dionise ZR, Gonzalez JM, Garcia-Roig ML, Kirsch AJ, Scales CD, Wiener JS, Purves JT, Routh JC. Parental Preferences for Vesicoureteral Reflux Treatment: A Crowd-sourced, Best-worst Scaling Study. Urology 2019; 128:71-77. [PMID: 30878684 PMCID: PMC6525647 DOI: 10.1016/j.urology.2019.01.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/14/2019] [Accepted: 01/31/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To quantitatively evaluate parental preferences for the various treatments for vesicoureteral reflux using crowd-sourced best-worst scaling, a novel technique in urologic preference estimation. METHODS Preference data were collected from a community sample of parents via 2 best-worst scaling survey instruments published to Amazon's Mechanical Turk online community. Attributes and attribute levels were selected following extensive review of the reflux literature. Respondents completed an object case best-worst scaling exercise to prioritize general aspects of reflux treatments and multiprofile case best-worst scaling to elicit their preferences for the specific differences in reflux treatments. Data were analyzed using multinomial logistic regression. Results from the object-case provided probability scaled values (PSV) that reflected the order of importance of attributes. RESULTS We analyzed data for 248 and 228 respondents for object and multiprofile case BWS, respectively. When prioritizing general aspects of reflux treatment, effectiveness (PSV = 20.37), risk of future urinary tract infection (PSV = 14.85), and complication rate (PSV = 14.55) were most important to parents. Societal cost (PSV = 1.41), length of hospitalization (PSV = 1.09), and cosmesis (PSV = 0.91) were least important. Parents perceived no difference in preference for the cosmetic outcome of open vs minimally invasive surgery (P = .791). Bundling attribute preference weights, parents in our study would choose open surgery 74.9% of the time. CONCLUSION High treatment effectiveness was the most important and preferred attribute to parents. Alternatively, cost and cosmesis were among the least important. Our findings serve to inform shared parent-physician decision-making for vesicoureteral reflux.
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Affiliation(s)
| | | | - Michael L Garcia-Roig
- Department of Pediatric Urology, Emory University and Children's Healthcare of Atlanta, Atlanta, GA
| | - Andrew J Kirsch
- Department of Pediatric Urology, Emory University and Children's Healthcare of Atlanta, Atlanta, GA
| | - Charles D Scales
- Division of Urology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - John S Wiener
- Division of Urology, Duke University Medical Center, Durham, NC
| | - J Todd Purves
- Division of Urology, Duke University Medical Center, Durham, NC
| | - Jonathan C Routh
- Division of Urology, Duke University Medical Center, Durham, NC.
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Routh JC, Wolf S, Tejwani R, Jiang R, Pomann GM, Goldstein BA, Maciejewski ML, Allori AC. Early Impact of the Patient Protection and Affordable Care Act on Delivery of Children's Surgical Care. Clin Pediatr (Phila) 2019; 58:453-460. [PMID: 30666879 PMCID: PMC7417205 DOI: 10.1177/0009922818825156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The impact of the Patient Protection and Affordable Care Act (PPACA) on children's access to surgical care is not well-defined. Our objective was to describe the early impact of PPACA on children's surgical care before and after Medicaid expansion in 2014. We compared pediatric and young adult surgical outcomes in 2013 and 2014 in Medicaid expansion and nonexpansion states; young adults were included as a control group. From 4 states, 1 597 708 encounters met all inclusion criteria. Comparing expansion to nonexpansion states, modest increases were noted in elective instead of urgent/emergent admissions; in ambulatory instead of inpatient surgeries; in inpatient length of stays; in discharges to home instead of other inpatient care facilities; and in charges for inpatient admissions. A modest decrease of -1.1% was noted in ambulatory admission charges. Overall, we conclude that Medicaid expansion likely increased children's access to surgical care, resulting in improved delivery and slightly reduced charges.
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Affiliation(s)
| | - Steven Wolf
- Duke University Medical Center, Durham, NC, USA
| | | | | | | | | | - Matthew L. Maciejewski
- Duke University Medical Center, Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA
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45
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Inouye BM, Jiang R, Alkazemi MH, Wang HHS, Wolf S, Pomann GM, Tejwani R, Wiener JS, Purves JT, Routh JC. Hospital and ED charges for spina bifida care in the United States between 2006 and 2014: Over $2 billion annually. Disabil Health J 2019; 12:431-436. [PMID: 30711573 DOI: 10.1016/j.dhjo.2019.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 12/21/2018] [Accepted: 01/14/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND More children with spina bifida (SB) are surviving into adulthood. Unfortunately, little data exist regarding the economic implications of modern SB care. OBJECTIVE We examined economic data from two national databases to estimate the annual nationwide hospital and emergency charges of SB from 2006-14. METHODS We analyzed the 2006-2014 Nationwide Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS). SB patients were defined using ICD-9-CM codes. Demographic and charge data were obtained from each database. Multiple imputation was used to estimate missing data (1.6% for NIS and 22% in NEDS). The principal outcomes were mean, median, and total charges for encounters each year. RESULTS There were 725,646 encounters for individuals with SB between 2006 and 2014. The average age of captured SB patients who were admitted to a hospital or seen in an ER was 29 years. In 2014, the median charge for inpatient encounters was $31,071 (IQR: $15,947, $63,063) and for ER encounters was $2407.02 (IQR: $1321.91, $4211.35). In total, the sum of charges from all SB-related admissions in 2014 was $1,862,016,217 (95% CI: $1.69 billion, $2.03 billion), while the sum of charges of all SB-related ER encounters in 2014 was $176,843,522 (95% CI: $158 million, $196 million). There was a steady increase in charges over the study period. CONCLUSION Charges for SB-related inpatient and emergency care in the US in 2014 was in excess of $2 billion in contrast to $1.2 billion in 2006, after adjusting for inflation; this is an impressively high figure for a relatively small number of patients.
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Affiliation(s)
- Brian M Inouye
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ruiyang Jiang
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - M Hassan Alkazemi
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Hsin-Hsiao S Wang
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Steven Wolf
- Department of Biostatistics, Duke University School of Medicine, Durham, NC, USA
| | - Gina-Maria Pomann
- Department of Biostatistics, Duke University School of Medicine, Durham, NC, USA
| | - Rohit Tejwani
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - J Todd Purves
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
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Routh JC. Editorial comment: Birth prevalence of hypospadias and hypospadias risk factors in newborn males in the United States from 1997 to 2012. J Pediatr Urol 2019; 15:103-104. [PMID: 30600201 DOI: 10.1016/j.jpurol.2018.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 11/27/2022]
Affiliation(s)
- J C Routh
- Duke University School of Medicine, Durham, NC, USA.
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Hughes FM, Hirshman NA, Inouye BM, Jin H, Stanton EW, Yun CE, Davis LG, Routh JC, Purves JT. NLRP3 Promotes Diabetic Bladder Dysfunction and Changes in Symptom-Specific Bladder Innervation. Diabetes 2019; 68:430-440. [PMID: 30425063 PMCID: PMC6341307 DOI: 10.2337/db18-0845] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/06/2018] [Indexed: 12/12/2022]
Abstract
The NLRP3 inflammasome senses diabetic metabolites and initiates inflammation implicated in diabetic complications and neurodegeneration. No studies have investigated NLRP3 in diabetic bladder dysfunction (DBD), despite a high clinical prevalence. In vitro, we found that numerous diabetic metabolites activate NLRP3 in primary urothelial cells. In vivo, we demonstrate NLRP3 is activated in urothelia from a genetic type 1 diabetic mouse (Akita) by week 15. We then bred an NLRP3-/- genotype into these mice and found this blocked bladder inflammation and cystometric markers of DBD. Analysis of bladder innervation established an NLRP3-dependent decrease in overall nerve density and Aδ-fibers in the bladder wall along with an increase in C-fiber populations in the urothelia, which potentially explains the decreased sense of bladder fullness reported by patients and overactivity detected early in DBD. Together, the results demonstrate the role of NLRP3 in the genesis of DBD and suggest specific NLRP3-mediated neuronal changes can produce specific DBD symptoms.
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Affiliation(s)
- Francis M Hughes
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC
- Department of Bioengineering, Clemson University, Clemson, SC
| | - Nathan A Hirshman
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC
| | - Brian M Inouye
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC
| | - Huixia Jin
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC
| | - Eloise W Stanton
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC
| | - Chloe E Yun
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC
| | - Leah G Davis
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC
- Duke Cancer Center Biostatistics, Duke University Medical Center, Durham, NC
| | - Jonathan C Routh
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - J Todd Purves
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC
- Department of Bioengineering, Clemson University, Clemson, SC
- Department of Pediatrics, Duke University Medical Center, Durham, NC
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Inouye BM, Hughes FM, Jin H, Lütolf R, Potnis KC, Routh JC, Rouse DC, Foo WC, Purves JT. Diabetic bladder dysfunction is associated with bladder inflammation triggered through hyperglycemia, not polyuria. Res Rep Urol 2018; 10:219-225. [PMID: 30533402 PMCID: PMC6247963 DOI: 10.2147/rru.s177633] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Purpose Diabetes is a grave and progressive condition characterized by debilitating complications. Diabetic bladder dysfunction (DBD) is a very common complication with no specific treatments currently available. Unlike other tissues affected by this disease, the bladder is subjected to two independent insults; 1) polyuria, created by the osmotic effects of glucose in the urine, and 2) hyperglycemia itself. Based on our understanding of inflammation as a major contributor to the underlying organ damage in several other diabetic complications, its presence in the bladder during DBD and the contribution of polyuria and hyperglycemia to its development were assessed. Methods Awake, restrained cystometry was performed on wild type C57BL/6 mice and diabetic (Akita) mice on a C57BL/6 background at 15 weeks of age. A subgroup of the Akita mice were treated with phlorizin, an inhibitor of sodium-glucose linked transporter types 1 and 2 that prevents glucose reabsorption in the kidney. All groups were assessed for serum glucose, 4-hour voiding totals, and inflammation in the bladder (Evans blue assay). Results Akita mice develop cystometrically-defined DBD by 15 weeks of age, as evidenced by an increase in urinary frequency, a decrease in voiding volume, and an increase in post-voiding residual volume. Phlorizin effectively normalized serum glucose in these animals while increasing the urine output. Inflammation in the bladder was present in the diabetic animals at this time point, but not detectable in animals receiving phlorizin. Conclusion Inflammation in the bladder of diabetic mice correlates with the development of DBD and is triggered by hyperglycemia, not polyuria.
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Affiliation(s)
- Brian M Inouye
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA,
| | - Francis M Hughes
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA, .,Department of Bioengineering, Clemson University, Clemson, SC, USA,
| | - Huixia Jin
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA,
| | - Robin Lütolf
- Department of Health Science and Technology, ETH Zurich, Zürich 8092, Switzerland
| | - Kunal C Potnis
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA,
| | - Jonathan C Routh
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA, .,Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Douglas C Rouse
- Division of Laboratory Animal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Wen-Chi Foo
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - J Todd Purves
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA, .,Department of Bioengineering, Clemson University, Clemson, SC, USA, .,Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Kelly MS, Routh JC, Davis LG, Purves JT, Wiener JS, Maciejewski ML. Lower Urinary Tract Symptoms in Older Children With and Without Diabetes Mellitus. Clin Pediatr (Phila) 2018; 57:1576-1581. [PMID: 30146901 PMCID: PMC6173650 DOI: 10.1177/0009922818796605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lower urinary tract symptoms (LUTS) are an underrecognized complication of diabetes mellitus (DM) in adults and have undergone limited investigation in children. We estimated the prevalence of LUTS in 120 older children (11-17 years) with and without DM and identified patient factors associated with LUTS in logistic regression. Older children (11-17 years) completed a validated LUTS measure and questions about age, ethnicity, gender, body mass index, and degree of bother secondary to LUTS. The unadjusted prevalence of LUTS was 20.87% in the overall cohort, and LUTS was twice as prevalent in children with DM (33.3% vs 16.7%) than children without DM. In logistic regression, Hispanic/Latino ethnicity was positively associated with LUTS (odds ratio = 8.45, P = .011). LUTS may be a prevalent but underrecognized condition, which is more prevalent in Hispanic/Latino and diabetic children.
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Affiliation(s)
- Maryellen S. Kelly
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA,Corresponding author: Maryellen Kelly, DNP, Department of Surgery, Division of Urology, Box 3831, Duke University Medical Center, Durham, NC 27710, , Phone: 919-684-6994, Fax: 919-681-5507
| | - Jonathan C. Routh
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Leah G. Davis
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA,Duke Cancer Center Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - J. Todd Purves
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - John S. Wiener
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Matthew L. Maciejewski
- Health Services Research & Development Center of Excellence, Durham VA Medical Center, Durham, NC, USA,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
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Ortiz TK, Velazquez N, Ding L, Routh JC, Wiener JS, Seed PC, Ross SS. Predominant bacteria and patterns of antibiotic susceptibility in urinary tract infection in children with spina bifida. J Pediatr Urol 2018; 14:444.e1-444.e8. [PMID: 29709445 DOI: 10.1016/j.jpurol.2018.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 03/08/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Urinary tract infection is more common in children with spina bifida (SB) than neurologically intact children, and Escherichia coli is the most common urinary pathogen in the general pediatric population. Less is known of the pathogens responsible for urinary tract infections (UTI) in the pediatric SB population or their evolving antimicrobial resistance patterns. The goal of this study is to determine the epidemiology and antimicrobial resistance patterns of SB-associated urinary pathogens. METHODS Between January 1996 and August 2013, 231 patients aged 1 month to 18 years were identified with a diagnosis of SB-NB and at least one symptomatic urinary tract infection (UTI) event (Table). Two-hundred and thirty-one normally voiding children with a single symptomatic UTI were age-matched based on age at diagnosis of UTI at a 1:1 ratio. Chi-square tests and Generalized Estimating Equation analysis, controlling for clinicopathological factors, were performed to compare rates of pathogen-associations with UTI between groups and likelihood of UTI with multi-drug resistant (MDR) organisms. RESULTS Children in the SB-NB group had a higher rate of non-E. coli UTI compared with controls (64% vs. 41%, p < 0.01), particularly associated with Klebsiella species the SB-NB group had an overall higher infection rate with MDR organisms (21% vs. 10%, p < 0.01) and E. coli isolates, with a trend towards increased rates of antibiotic resistance to aminoglycosides, fluoroquinolones, cephalosporins, extended spectrum β-lactams, and TMP-SMZ. Additionally, patients in the SB-NB group had a 10-fold increase of urosepsis with 57% of events caused by MDR organisms. CONCLUSIONS Children with SB-NB are more likely to have non-E. coli UTI, UTIs with MDR organisms, and urosepsis than the general pediatric population.
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Affiliation(s)
- Tara K Ortiz
- Carl R. Darnall Army Medical Center, Department of Surgery, Division of Urology, Fort Hood, TX, USA.
| | - Nermarie Velazquez
- New York University School of Medicine, Department of Urology, New York City, NY, USA
| | - Laura Ding
- Duke University Medical Center, Department of Surgery, Division of Urology, Durham, NC 27710, USA
| | - Jonathan C Routh
- Duke University Medical Center, Department of Surgery, Division of Urology, Durham, NC 27710, USA
| | - John S Wiener
- Duke University Medical Center, Department of Surgery, Division of Urology, Durham, NC 27710, USA
| | - Patrick C Seed
- Northwestern University Feinberg School of Medicine, Department of Pediatrics, Division of Infectious Disease, Chicago, IL, USA
| | - Sherry S Ross
- The University of North Carolina at Chapel Hill School of Medicine, Department of Urology, Chapel Hill, NC, USA
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