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Kanji FF, Choi E, Dallas KB, Avenido R, Jamnagerwalla J, Pannell S, Eilber K, Catchpole K, Cohen TN, Anger JT. The impact of resident training on robotic operative times: is there a July Effect? J Robot Surg 2024; 18:208. [PMID: 38727857 PMCID: PMC11087355 DOI: 10.1007/s11701-024-01929-3] [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] [Received: 03/08/2024] [Accepted: 03/24/2024] [Indexed: 05/13/2024]
Abstract
It is unknown whether the July Effect (a theory that medical errors and organizational inefficiencies increase during the influx of new surgical residents) exists in urologic robotic-assisted surgery. The aim of this study was to investigate the impact of urology resident training on robotic operative times at the beginning of the academic year. A retrospective chart review was conducted for urologic robotic surgeries performed at a single institution between 2008 and 2019. Univariate and multivariate mix model analyses were performed to determine the association between operative time and patient age, estimated blood loss, case complexity, robotic surgical system (Si or Xi), and time of the academic year. Differences in surgery time and non-surgery time were assessed with/without resident presence. Operative time intervals were included in the analysis. Resident presence correlated with increased surgery time (38.6 min (p < 0.001)) and decreased non-surgery time (4.6 min (p < 0.001)). Surgery time involving residents decreased by 8.7 min after 4 months into the academic year (July-October), and by an additional 5.1 min after the next 4 months (p = 0.027, < 0.001). When compared across case types stratified by complexity, surgery time for cases with residents significantly varied. Cases without residents did not demonstrate such variability. Resident presence was associated with prolonged surgery time, with the largest effect occurring in the first 4 months and shortening later in the year. However, resident presence was associated with significantly reduced non-surgery time. These results help to understand how new trainees impact operating room times.
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Affiliation(s)
- Falisha F Kanji
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eunice Choi
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kai B Dallas
- Division of Urology and Urologic Oncology, Department of Surgery, City of Hope, Lancaster, CA, USA
| | - Raymund Avenido
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Karyn Eilber
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ken Catchpole
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer T Anger
- Department of Urology, University of California, San Diego, 9400 Campus Point Drive, #7897, La Jolla, CA, 92037, USA.
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Naser-Tavakolian A, Gale R, Luu M, Masterson JM, Venkataramana A, Khodyakov D, Anger JT, Posadas E, Sandler H, Freedland SJ, Spiegel B, Daskivich TJ. Use of Persuasive Language in Communication of Risk during Prostate Cancer Treatment Consultations. Med Decis Making 2024; 44:320-334. [PMID: 38347686 DOI: 10.1177/0272989x241228612] [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: 04/04/2024]
Abstract
BACKGROUND Physician treatment preference may influence how risks are communicated in prostate cancer consultations. We identified persuasive language used when describing cancer prognosis, life expectancy, and side effects in relation to a physician's recommendation for aggressive (surgery/radiation) or nonaggressive (active surveillance/watchful waiting) treatment. METHODS A qualitative analysis was performed on transcribed treatment consultations of 40 men with low- and intermediate-risk prostate cancer across 10 multidisciplinary providers. Quotes pertaining to cancer prognosis, life expectancy, and side effects were randomized. Coders predicted physician treatment recommendations from isolated blinded quotes. Testing characteristics of consensus predictions against the physician's treatment recommendation were reported. Coders then identified persuasive strategies favoring aggressive/nonaggressive treatment for each quote. Frequencies of persuasive strategies favoring aggressive/nonaggressive treatment were reported. Logistic regression quantified associations between persuasive strategies and physician treatment recommendations. RESULTS A total of 496 quotes about cancer prognosis (n = 127), life expectancy (n = 51), and side effects (n = 318) were identified. The accuracy of predicting treatment recommendation based on individual quotes containing persuasive language (n = 256/496, 52%) was 91%. When favoring aggressive treatment, persuasive language downplayed side effect risks and amplified cancer risk (recurrence, progression, or mortality). Significant predictors (P < 0.05) of aggressive treatment recommendation included favorable side effect interpretation, downplaying side effects, and long time horizon for cancer risk due to longevity. When favoring nonaggressive treatment, persuasive language amplified side effect risks and downplayed cancer risk. Significant predictors of nonaggressive treatment recommendation included unfavorable side effect interpretation, favorable interpretation of cancer risk, and short time horizon for cancer risk due to longevity. CONCLUSIONS Physicians use persuasive language favoring their preferred treatment, regardless of whether their recommendation is appropriate. IMPLICATIONS Clinicians should quantify risk so patients can judge potential harm without solely relying on persuasive language. HIGHLIGHTS Physicians use persuasive language favoring their treatment recommendation when communicating risks of prostate cancer treatment, which may influence a patient's treatment choice.Coders predicted physician treatment recommendations based on isolated, randomized quotes about cancer prognosis, life expectancy, and side effects with 91% accuracy.Qualitative analysis revealed that when favoring nonaggressive treatment, physicians used persuasive language that amplified side effect risks and downplayed cancer risk. When favoring aggressive treatment, physicians did the opposite.Providers should be cognizant of using persuasive strategies and aim to provide quantified assessments of risk that are jointly interpreted with the patient so that patients can make evidence-based conclusions regarding risks without solely relying on persuasive language.
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Affiliation(s)
| | - Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Luu
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John M Masterson
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Jennifer T Anger
- Department of Urology, University of California, San Diego, San Diego, CA, USA
| | - Edwin Posadas
- Department of Medicine, Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Section of Urology, Durham VA Medical Center, Durham, NC, USA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, Divisions of Gastroenterology and Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Timothy J Daskivich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Anger JT, Case LK, Baranowski AP, Berger A, Craft RM, Damitz LA, Gabriel R, Harrison T, Kaptein K, Lee S, Murphy AZ, Said E, Smith SA, Thomas DA, Valdés Hernández MDC, Trasvina V, Wesselmann U, Yaksh TL. Pain mechanisms in the transgender individual: a review. Front Pain Res (Lausanne) 2024; 5:1241015. [PMID: 38601924 PMCID: PMC11004280 DOI: 10.3389/fpain.2024.1241015] [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: 06/15/2023] [Accepted: 01/25/2024] [Indexed: 04/12/2024] Open
Abstract
Specific Aim Provide an overview of the literature addressing major areas pertinent to pain in transgender persons and to identify areas of primary relevance for future research. Methods A team of scholars that have previously published on different areas of related research met periodically though zoom conferencing between April 2021 and February 2023 to discuss relevant literature with the goal of providing an overview on the incidence, phenotype, and mechanisms of pain in transgender patients. Review sections were written after gathering information from systematic literature searches of published or publicly available electronic literature to be compiled for publication as part of a topical series on gender and pain in the Frontiers in Pain Research. Results While transgender individuals represent a significant and increasingly visible component of the population, many researchers and clinicians are not well informed about the diversity in gender identity, physiology, hormonal status, and gender-affirming medical procedures utilized by transgender and other gender diverse patients. Transgender and cisgender people present with many of the same medical concerns, but research and treatment of these medical needs must reflect an appreciation of how differences in sex, gender, gender-affirming medical procedures, and minoritized status impact pain. Conclusions While significant advances have occurred in our appreciation of pain, the review indicates the need to support more targeted research on treatment and prevention of pain in transgender individuals. This is particularly relevant both for gender-affirming medical interventions and related medical care. Of particular importance is the need for large long-term follow-up studies to ascertain best practices for such procedures. A multi-disciplinary approach with personalized interventions is of particular importance to move forward.
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Affiliation(s)
- Jennifer T. Anger
- Department of Urology, University of California San Diego, San Diego, CA, United States
| | - Laura K. Case
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Andrew P. Baranowski
- Pelvic Pain Medicine and Neuromodulation, University College Hospital Foundation Trust, University College London, London, United Kingdom
| | - Ardin Berger
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, United States
| | - Rebecca M. Craft
- Department of Psychology, Washington State University, Pullman, WA, United States
| | - Lyn Ann Damitz
- Division of Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, NC, United States
| | - Rodney Gabriel
- Division of Regional Anesthesia, University of California San Diego, San Diego, CA, United States
| | - Tracy Harrison
- Department of OB/GYN & Reproductive Sciences, University of California San Diego, San Diego, CA, United States
| | - Kirsten Kaptein
- Division of Plastic Surgery, University of California San Diego, San Diego, CA, United States
| | - Sanghee Lee
- Department of Urology, University of California San Diego, San Diego, CA, United States
| | - Anne Z. Murphy
- Neuroscience Institute, Georgia State University, Atlanta, GA, United States
| | - Engy Said
- Division of Regional Anesthesia, University of California San Diego, San Diego, CA, United States
| | - Stacey Abigail Smith
- Division of Infection Disease, The Hope Clinic of Emory University, Atlanta, GA, United States
| | - David A. Thomas
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD, United States
| | - Maria del C. Valdés Hernández
- Department of Neuroimaging Sciences, Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Victor Trasvina
- Department of Urology, University of California San Diego, San Diego, CA, United States
| | - Ursula Wesselmann
- Departments of Anesthesiology and Perioperative Medicine/Division of Pain Medicine, Neurology and Psychology, and Consortium for Neuroengineering and Brain-Computer Interfaces, The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tony L. Yaksh
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
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Castaneda PR, Chen A, Kuhlmann P, Anger JT, Eilber KS. Variation in Defining Retention After Onabotulinum Toxin A for Overactive Bladder: A Systematic Review. Urogynecology (Phila) 2024:02273501-990000000-00184. [PMID: 38465990 DOI: 10.1097/spv.0000000000001460] [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] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
IMPORTANCE Urinary retention is a common adverse effect after intravesical injection of onabotulinum toxin A (BTX) for overactive bladder (OAB). Reported retention rates range from 1.6% to more than 40%. This variation may be due to varying definitions of retention in the literature. OBJECTIVE We aimed to assess the variation in definitions of urinary retention across studies of BTX for the treatment of OAB. STUDY DESIGN We performed a systematic review of studies of BTX for OAB by querying MEDLINE and EMBASE according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included original research studies on adults with overactive bladder treated with BTX and urinary retention reported as an outcome from January 2000 to December 2020. RESULTS From 954 results, we identified 53 articles that met inclusion criteria. There were 6 definitions for urinary retention. The majority of studies (60.4%) reported initiating clean intermittent catheterization (CIC) as the metric for retention. Five (9.5%) studies provided no definition despite reporting retention as an adverse event. Twenty studies (37.7%) specified a postvoid residual volume (PVR) threshold for initiating CIC in asymptomatic patients; 19 (35.8%) specified a PVR threshold for CIC in symptomatic patients. The PVR thresholds ranged from 100 to 400 mL. Twenty-three studies (43.4%) did not address asymptomatic elevation of PVR, and 22 (41.5%) did not address how symptomatic patients were managed. CONCLUSIONS Urinary retention after BTX injection is inconsistently defined in the literature. Lack of standardization in reporting retention after intravesical BTX prevents accurate assessment of the risk of urinary retention and comparison of outcomes between studies.
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Affiliation(s)
- Peris R Castaneda
- From the Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Andrew Chen
- From the Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Paige Kuhlmann
- Department of Urology, UT Southwestern Medical Center, Dallas, TX
| | | | - Karyn S Eilber
- From the Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
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Kalavacherla S, Riviere P, Kalavacherla S, Anger JT, Murphy JD, Rose BS. Prostate Cancer Screening Uptake in Transgender Women. JAMA Netw Open 2024; 7:e2356088. [PMID: 38353948 PMCID: PMC10867675 DOI: 10.1001/jamanetworkopen.2023.56088] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/17/2023] [Indexed: 02/16/2024] Open
Abstract
Importance There is no consensus in prostate-specific antigen (PSA) screening guidelines regarding transgender women despite their known prostate cancer risk. Objective To identify factors associated with recent (within the last 2 years) PSA screening in transgender women compared with cisgender men. Design, Setting, and Participants This case-control study used data from the 2018 and 2020 Behavioral Risk Factor Surveillance System (BRFSS) surveys to characterize rates of PSA screening for prostate cancer within the past 2 years and multivariable logistic regressions to characterize factors associated with recent screening among transgender women. The BRFSS program of the Centers for Disease Control and Prevention annually surveys over 400 000 US adults on behavioral risk factors, chronic illnesses, and use of preventive services. Respondents to the BRFSS who were cisgender men or transgender women 40 years or older and who had complete PSA testing responses and no prostate cancer history were included; 313 transgender women and 138 937 cisgender men met inclusion criteria. Matching was performed by age, race and ethnicity, educational level, employment, annual income, survey year, and cost barriers to care. Data were collected on November 2, 2022, and analyzed from November 2, 2022, to December 3, 2023. Main Outcomes and Measures Rates of and factors associated with recent PSA screening in transgender women. Results Among the 1275 participants included in the matched cohort (255 transgender women and 1020 cisgender men; 570 [44.7%] aged 55-69 years), recent PSA screening rates among transgender women and cisgender men aged 55 to 69 were 22.2% (n = 26) and 36.3% (n = 165), respectively; among those 70 years and older, these rates were 41.8% (n = 26) and 40.2% (n = 98), respectively. In the matched cohort, transgender women had lower univariable odds of recent screening than cisgender men (odds ratio [OR], 0.65 [95% CI, 0.46-0.92]; P = .02). In a hierarchical regression analysis adding time since the last primary care visit, effect size and significance were unchanged (OR, 0.61 [95% CI, 0.42-0.87]; P = .007). After adding whether a clinician recommended a PSA test, there was no statistically significant difference in odds of screening between transgender women and cisgender men (OR, 0.83 [95% CI, 0.45-1.27]; P = .21). The results were further attenuated when clinician-led discussions of PSA screening advantages and disadvantages were added (OR, 0.87 [95% CI, 0.47-1.31]; P = .32). In a multivariable logistic regression among transgender women, having a recommendation for PSA testing was the factor with the strongest association with recent screening (OR, 12.40 [95% CI, 4.47-37.80]; P < .001). Conclusions and Relevance In this case-control study of one of the largest cohorts of transgender women studied regarding PSA screening, the findings suggest that access to care or sociodemographic factors were not principal drivers of the screening differences between transgender women and cisgender men; rather, these data underscore the clinician's role in influencing PSA screening among transgender women.
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Affiliation(s)
- Sandhya Kalavacherla
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
- Center for Health Equity, Education, and Research, University of California, San Diego, La Jolla
| | - Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
- Center for Health Equity, Education, and Research, University of California, San Diego, La Jolla
| | - Sruthi Kalavacherla
- Center for Health Equity, Education, and Research, University of California, San Diego, La Jolla
- Department of Biology, Massachusetts Institute of Technology, Cambridge
| | - Jennifer T. Anger
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
- Department of Urology, University of California, San Diego, La Jolla
| | - James D. Murphy
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
- Center for Health Equity, Education, and Research, University of California, San Diego, La Jolla
| | - Brent S. Rose
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
- Center for Health Equity, Education, and Research, University of California, San Diego, La Jolla
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Niino CA, Tholemeier LN, Bresee C, De Hoedt AM, Barbour KE, Kim J, Freedland SJ, Anger JT. Bladder instillation patterns in a cohort of women with interstitial cystitis/bladder pain syndrome. Urogynecology (Phila) 2023; 29:914-919. [PMID: 38107872 PMCID: PMC10723800 DOI: 10.1097/spv.0000000000001369] [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] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Purpose To determine intravesical instillation patterns among women receiving treatment for interstitial cystitis/bladder pain syndrome (IC/BPS). Methods Using the Veterans Affairs Informatics and Computing Infrastructure, active female users of the Veterans Affairs system with an ICD-9 diagnosis of IC/BPS (595.1) were randomly sampled. Patients were considered to have IC/BPS (by chart review) if they had two visits complaining of bladder-centric pain in the absence of positive urine culture ≥6 weeks apart or history of bladder pain with one additional visit for bladder-centric pain. We abstracted the dates of intravesical instillations for each patient. A "course" of instillations was defined as ≥1 instillations made with <21 days between visits. Results We identified 641 women with confirmed diagnosis of IC/BPS, 78 of whom underwent a total of 344 intravesical instillations. On average each subject had 1.5 +/- 0.8 courses between October 2004-July 2016. Each course was an average of 3.1 +/- 2.6 instillations. 55% of courses consisted of one instillation. Only 22% of courses had 6 or more instillations, the number typically recommended to achieve clinical response. Each instillation within a course was an average of 9.4 +/- 4.0 days apart. Most instillations (77%) were a cocktail of two or more drugs. Conclusions In our cohort, few women with IC/BPS received a recommended treatment course of six weekly instillations, with most receiving only one per course. Future studies are needed to determine if instillation courses were altered from the guideline due to provider practice patterns, early improvement, or poor tolerance of instillations.
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Affiliation(s)
- Clarissa A. Niino
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Lauren N. Tholemeier
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Catherine Bresee
- Biostatistics Core at the Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | - Jayoung Kim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen J. Freedland
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
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Carlton CE, Souders CP, Chertack NA, Goueli RS, Lemack GE, Anger JT, McClelland L, Carmel ME. Understanding a decade of safety reporting for sacral neuromodulation in the Food and Drug Administration Manufacturer and User Facility Device Experience database. Neurourol Urodyn 2023; 42:1655-1667. [PMID: 37497812 DOI: 10.1002/nau.25248] [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] [Received: 03/16/2023] [Revised: 05/26/2023] [Accepted: 07/06/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Over 350 000 sacral neuromodulation (SNM) devices have been implanted since approval by the Food and Drug Administration (FDA) in 1998. SNM technology and clinical applications have evolved, with minimal safety updates after initial trials. We aim to provide an updated overview of real-world SNM safety. These insights will guide informed consent, preoperative counseling, and patient expectation-setting. MATERIALS AND METHODS The FDA Manufacturer and User Facility Device Experience (MAUDE) database is a repository for medical device safety reports. We performed MAUDE categorical (1/1/98-12/31/10) and keyword (1/1/11-9/30/21) searches for "Interstim." A random sample of 1000 reports was reviewed and categorized by theme. To corroborate our MAUDE database analysis, a legal librarian searched the Public Access to Court Electronic Records (PACER) database, as well as Bloomberg Law's dockets database for all lawsuits related to SNM devices. RESULTS Our search of the MAUDE database returned 44 122 SNM-related adverse events (AEs). The figure illustrates the prevalence of event categories in the random sample. The largest proportion of reports (25.6%) related to a patient's need for assistance with device use, followed by loss/change of efficacy (19.0%). Interestingly, a fall preceded issue onset in 32% of non-shock pain, 30% of lead/device migration, and 27% of painful shock reports. Our legal search revealed only four lawsuits: one for patient complications after an SNM device was used off-label, one case of transverse myelitis after implant, one for device migration or poor placement, and the fourth claimed the device malfunctioned requiring removal and causing permanent injury. CONCLUSIONS This review confirms the real-world safety of SNM devices and very low complication rates as seen in the original clinical trials. Our findings indicate that 43.2% (95% confidence interval 40.1%-46.3%) of SNM "complications" are not AEs, per se, but rather reflect a need for improved technical support or more comprehensive informed consent to convey known device limitations to the patient, such as battery life. Similarly, the number of lawsuits is shockingly low for a device that has been in the market for 24 years, reinforcing the safety of the device. Legal cases involving SNM devices seem to relate to inappropriate patient selection-including at least one case in which SNM was used for a non-FDA approved indication-lack of appropriate follow-up, and/or provider inability to assist the patient with utilizing the device after implantation.
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Affiliation(s)
- Caitlin E Carlton
- Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
| | - Colby P Souders
- Department of Urology, University of Kansas, Kansas City, Kansas, USA
| | - Nathan A Chertack
- Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
| | - Ramy S Goueli
- Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
| | - Gary E Lemack
- Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
| | - Jennifer T Anger
- Department of Urology, University of California San Diego, San Diego, California, USA
| | - Lynn McClelland
- School of Law, University of California Los Angeles, Los Angeles, California, USA
| | - Maude E Carmel
- Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
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8
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Zamudio J, Woodward J, Kanji FF, Anger JT, Catchpole K, Cohen TN. Demands of surgical teams in robotic-assisted surgery: An assessment of intraoperative workload within different surgical specialties. Am J Surg 2023; 226:365-370. [PMID: 37330385 DOI: 10.1016/j.amjsurg.2023.06.010] [Citation(s) in RCA: 3] [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] [Received: 03/03/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Current approaches to assessing workload in robotic-assisted surgery (RAS) focus on surgeons and lack real-world data. Understanding how workload varies by role and specialty aids in identifying effective ways to optimize workload. METHODS SURG-TLX surveys with six domains of workload were administered to surgical staff at three sites. Staff reported workload perceptions for each domain on a 20-point Likert scale, and aggregate scores were determined per participant. RESULTS 188 questionnaires were obtained across 90 RAS procedures. Significantly higher aggregate scores were reported for gynecology (Mdn = 30.00) (p = 0.034) and urology (Mdn = 36.50) (p = 0.006) than for general (Mdn = 25.00). Surgeons reported significantly higher scores for task complexity (Mdn = 8.00) than both technicians (Mdn = 5.00) (p = 0.007), and nurses (Mdn = 5.00). CONCLUSIONS Staff reported significantly higher workload during urology and gynecology procedures, and experienced significant differences in domain workload by role and specialty, elucidating the need for tailored workload interventions.
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Affiliation(s)
- Jennifer Zamudio
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Jeffrey Woodward
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA.
| | - Falisha F Kanji
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Jennifer T Anger
- Department of Urology, University of California San Diego, La Jolla, CA, 92037, USA.
| | - Ken Catchpole
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA.
| | - Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
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Gonzalez RR, Rosamilia A, Eilber K, Kahn BS, White AB, Anger JT. Three-year patient-reported outcomes of single-incision versus transobturator slings for female stress urinary incontinence are equivalent. Int Urogynecol J 2023; 34:2265-2274. [PMID: 37099159 DOI: 10.1007/s00192-023-05538-w] [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] [Received: 11/14/2022] [Accepted: 01/13/2023] [Indexed: 04/27/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Patient-reported outcome measures (PROMs) are important for understanding the success of surgery for stress urinary incontinence, as patient perception of success does not always correlate with physician perception of success. We report PROMS after single-incision slings (SIS) and transobturator mid-urethral slings (TMUS). METHODS This was a planned outcome analysis of secondary endpoints in a study in which the primary aim was to compare efficiency and safety using a non-inferiority design (results reported previously). In this analysis of quality of life (QOL), validated PROMs were collected at baseline, 6, 12, 18, 24, and 36 months to quantify incontinence severity (Incontinence Severity Index), symptom bother (Urogenital Distress Inventory), disease-specific QOL impact (Urinary Impact Questionnaire), and generic QOL impact (PGI-I; not applicable at baseline). PROMs were analyzed within treatment groups as well as between groups. Propensity score methods were used to adjust for baseline differences between groups. RESULTS A total of 281 subjects underwent the study procedure (141 SIS, 140 TMUS). Baseline characteristics were balanced after propensity score stratification. Participants had significant improvement in incontinence severity, disease-specific symptom bother, and QOL impact. Improvements persisted through the study and PROMs were similar between treatment groups in all assessment at 36 months CONCLUSIONS: Following SIS and TMUS, patients with stress urinary incontinence had significant improvement in PROMs including Urogenital Distress Inventory, Incontinence Severity Index, and Urinary Impact Questionnaire at 36 months, indicating disease-specific QOL improvement. Patients have a more positive impression of change in stress urinary incontinence symptoms at each follow-up visit, indicating generic QOL improvement.
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Affiliation(s)
- Ricardo R Gonzalez
- Urology and Female Pelvic Medicine and Reconstructive Surgery, Houston Methodist Hospital, Houston, TX, 77030, USA.
| | - Anna Rosamilia
- Department of Obstetrics and Gynaecology, Monash Medical Centre and Cabrini Hospital, Melbourne, Australia
| | - Karyn Eilber
- Division of Urology, Cedars-Sinai Health System, Los Angeles, CA, USA
| | - Bruce S Kahn
- Department of Obstetrics and Gynecology, Scripps Clinic, San Diego, CA, USA
| | - Amanda B White
- Department of Women's Health, Dell Medical School, University of Texas at Austin, TX, USA, Austin, USA
| | - Jennifer T Anger
- Department of Urology, University of California San Diego Health, San Diego, CA, USA
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10
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Zamudio J, Kanji FF, Lusk C, Shouhed D, Sanchez BR, Catchpole K, Anger JT, Cohen TN. Identifying Workflow Disruptions in Robotic-Assisted Bariatric Surgery: Elucidating Challenges Experienced by Surgical Teams. Obes Surg 2023; 33:2083-2089. [PMID: 37147465 PMCID: PMC10162850 DOI: 10.1007/s11695-023-06620-4] [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: 02/02/2023] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE Bariatric surgery is an effective and durable treatment for weight loss for patients with extreme obesity. Although traditionally approached laparoscopically, robotic bariatric surgery (RBS) has unique benefits for both surgeons and patients. Nonetheless, the technological complexity of robotic surgery presents new challenges for OR teams and the wider clinical system. Further assessment of the role of RBS in delivering quality care for patients with obesity is necessary and can be done through a human factors approach. This observational study sought to investigate the impact of RBS on the surgical work system via the study of flow disruptions (FDs), or deviations from the natural workflow progression. MATERIALS AND METHODS RBS procedures were observed between October 2019 and March 2022. FDs were recorded in real time and subsequently classified into one of nine work system categories. Coordination FDs were further classified into additional sub-categories. RESULTS Twenty-nine RBS procedures were observed at three sites. An average FD rate of 25.05 (CI = ± 2.77) was observed overall. FDs were highest between insufflation and robot docking (M = 29.37, CI = ± 4.01) and between patient closing and wheels out (M = 30.00, CI = ± 6.03). FD rates due to coordination issues were highest overall, occurring once every 4 min during docking (M = 14.28, CI = ± 3.11). CONCLUSION FDs occur roughly once every 2.4 min and happen most frequently during the final patient transfer and robot docking phases of RBS. Coordination challenges associated with waiting for staff/instruments not readily available and readjusting equipment contributed most to these disruptions.
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Affiliation(s)
- Jennifer Zamudio
- Department of Surgery, Cedars-Sinai Medical Center, 6500 Wilshire Blvd, Los Angeles, CA, 90048, USA.
| | - Falisha F Kanji
- Department of Surgery, Cedars-Sinai Medical Center, 6500 Wilshire Blvd, Los Angeles, CA, 90048, USA
| | - Connor Lusk
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Daniel Shouhed
- Department of Surgery, Cedars-Sinai Medical Center, 436 N Bedford Dr Suite 311, Beverly Hills, CA, 90210, USA
| | - Barry R Sanchez
- Department of Surgery, Ventura County Medical Center, 300 Hillmont Ave, Ventura, CA, 93003, USA
| | - Ken Catchpole
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Jennifer T Anger
- Department of Urology, University of California San Diego, 9400 Campus Point Drive #7897, La Jolla, CA, 92037, USA
| | - Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
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11
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Nik-Ahd F, De Hoedt A, Butler C, Anger JT, Carroll PR, Cooperberg MR, Freedland SJ. Prostate Cancer in Transgender Women in the Veterans Affairs Health System, 2000-2022. JAMA 2023; 329:1877-1879. [PMID: 37119522 PMCID: PMC10148974 DOI: 10.1001/jama.2023.6028] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/28/2023] [Indexed: 05/01/2023]
Abstract
This case series investigates the rate of prostate cancer diagnoses among transgender women treated in the Veterans Affairs health system.
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Affiliation(s)
| | - Amanda De Hoedt
- Division of Urology, Veterans Affairs Health Care System, Durham, North Carolina
| | - Christi Butler
- Department of Urology, University of California, San Francisco
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12
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Cunningham AR, Gu L, Dubinskaya A, De Hoedt AM, Barbour KE, Kim J, Freedland SJ, Anger JT. Quality-of-life impact of interstitial cystitis and other pelvic pain syndromes. Front Pain Res (Lausanne) 2023; 4:1149783. [PMID: 37305204 PMCID: PMC10248078 DOI: 10.3389/fpain.2023.1149783] [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: 01/23/2023] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Objective To compare health-related quality of life (HRQOL) and pelvic pain levels over time in patients with interstitial cystitis/bladder pain syndrome (IC/BPS) and those with other pelvic pain conditions (OPPC) including chronic prostatitis, dyspareunia, vaginismus, vulvodynia, and vulvar vestibulitis. Methods We prospectively enrolled male and female patients from any Veterans Health Administration (VHA) center in the US. They completed the Genitourinary Pain Index (GUPI) quantifying urologic HRQOL and the 12-Item Short Form Survey version 2 (SF-12) quantifying general HRQOL at enrollment and 1 year later. Participants were classified by ICD diagnosis codes and confirmed by chart review to be IC/BPS or OPPC (308 and 85 patients respectively). Results At baseline and follow-up, IC/BPS patients, on average, had worse urologic and general HRQOL than OPPC patients. IC/BPS patients demonstrated improvement in urologic HRQOL measures over the study but demonstrated no significant change in any general HRQOL measure suggesting a condition-specific impact. Patients with OPPC demonstrated similar improvements in urologic HRQOL but had deteriorating mental health and general HRQOL at follow-up suggesting a wider general HRQOL impact for these diseases. Conclusions We found that patients with IC/BPS had worse urologic HRQOL compared to other pelvic conditions. Despite this, IC/BPS showed stable general HRQOL over time, suggesting a more condition-specific impact on HRQOL. OPPC patients showed deteriorating general HRQOL, suggesting more widespread pain symptoms in these conditions.
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Affiliation(s)
- Andrew R. Cunningham
- Brody School of Medicine, East Carolina University, Greenville, NC, United States
- Durham VA Health Care System, Veterans Health Administration, United States Department of Veterans Affairs, Durham, NC, United States
| | - Lin Gu
- Durham VA Health Care System, Veterans Health Administration, United States Department of Veterans Affairs, Durham, NC, United States
| | - Alexandra Dubinskaya
- Department of Urology, Cedars Sinai Medical Center, Los Angeles, CA, United States
| | - Amanda M. De Hoedt
- Durham VA Health Care System, Veterans Health Administration, United States Department of Veterans Affairs, Durham, NC, United States
| | - Kamil E. Barbour
- Division of Population Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States
| | - Jayoung Kim
- Department of Urology, Cedars Sinai Medical Center, Los Angeles, CA, United States
| | - Stephen J. Freedland
- Durham VA Health Care System, Veterans Health Administration, United States Department of Veterans Affairs, Durham, NC, United States
- Department of Urology, Cedars Sinai Medical Center, Los Angeles, CA, United States
- Center for Integrated Research on Cancer and Lifestyle, Cedars Sinai Medical Center, Los Angeles, CA, United States
| | - Jennifer T. Anger
- Department of Urology, University of California, San Diego, La Jolla, CA, United States
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Nik-Ahd F, Anger JT, Cooperberg MR, Freedland SJ. Prostate cancer is not just a man's concern - the use of PSA screening in transgender women. Nat Rev Urol 2023:10.1038/s41585-023-00780-9. [PMID: 37217694 DOI: 10.1038/s41585-023-00780-9] [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] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- Farnoosh Nik-Ahd
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA.
| | - Jennifer T Anger
- Department of Urology, University of California, San Diego, San Diego, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Section of Urology, Durham VA Medical Center, Durham, NC, USA
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14
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Swisher MW, Dolendo IM, Sztain JF, Alexander BS, Tsuda PS, Anger JT, Said ET. Intrathecal Morphine Injection for Postoperative Analgesia Following Gender-Affirming Pelvic Surgery: A Retrospective Case-Control Study. Cureus 2023; 15:e36748. [PMID: 37123779 PMCID: PMC10139671 DOI: 10.7759/cureus.36748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/29/2023] Open
Abstract
Background Gender-affirming pelvic surgery (GAPS) can be associated with significant postoperative pelvic pain. Given the lack of available peripheral nerve blocks to the perineum, intrathecal morphine (ITM) injection could offer a potent analgesic modality for this patient population. No prior studies to date have been performed examining the analgesic effects of intrathecal morphine for these patients. Methods This retrospective case-control study aims to understand the postoperative analgesic effects of intrathecal morphine for these patients with a historical comparison group of patients who did not receive intrathecal morphine. Results Fourteen patients presented for gender-affirming pelvic surgery over an eight-month period at a single institution and were offered intrathecal morphine for postoperative analgesia. Their analgesic results were compared to a similar historical group of 13 patients who were not offered or declined intrathecal morphine. Conclusions Intrathecal morphine injection is a potent analgesic modality for patients presenting for gender-affirming pelvic surgery.
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15
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Dubinskaya A, Anger JT. Female genitalia in pornography: a source of labiaplasty trends? J Sex Med 2023; 20:124-125. [PMID: 36763915 DOI: 10.1093/jsxmed/qdac037] [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] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 01/13/2023]
Affiliation(s)
- Alexandra Dubinskaya
- Division of Urology, Cedars Sinai Medical Center, Los Angeles, CA 90211, United States
| | - Jennifer T Anger
- Department of Urology, UC San Diego, La Jolla, CA 92093, United States
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16
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Naser-Tavakolian A, Venkataramana A, Spiegel B, Almario C, Kokorowski P, Freedland SJ, Anger JT, Leppert JT, Daskivich TJ. The impact of life expectancy on cost-effectiveness of treatment options for clinically localized prostate cancer. Urol Oncol 2023; 41:205.e1-205.e10. [PMID: 36737259 DOI: 10.1016/j.urolonc.2023.01.004] [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: 08/17/2022] [Revised: 12/22/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Life expectancy (LE) impacts effectiveness and morbidity of prostate cancer (CaP) treatment, but its impact on cost-effectiveness is unknown. We sought to evaluate the impact of LE on the cost-effectiveness of radical prostatectomy (RP), radiation therapy (RT), and active surveillance (AS) for clinically localized disease. METHODS We created a Markov model to calculate incremental cost-effectiveness ratios (ICERs) for RP, RT, and AS over a 20-year time horizon from a Medicare payer perspective for low- and intermediate-risk CaP. Mortality outcomes varied by tumor risk and PCCI score, a validated proxy for LE. We performed 1,000 Monte Carlo simulations with 1-way sensitivity analyses of PCCI within each tumor risk subgroup to compare cost/quality-adjusted life years (QALYs) between treatments. RESULTS AS dominated RP and RT for low- and intermediate-risk disease in men with LE ≤10 years (PCCI ≥7 and ≥9, respectively). However, AS failed to dominate RP and RT for men with longer LE. For men with low-risk cancer and LE>10 years (PCCI 0-6), AS had the greatest effectiveness, but failed to dominate due to higher cost relative to RP. For men with intermediate-risk cancer with LE>10 years, AS failed to dominate due to higher cost relative to RP (PCCI 0-8) and lower effectiveness relative to RT (PCCI 0-3). The range of QALYs between RP, RT, and AS varied <13% (range: 0%-12.9%) while costs varied up to 521% (range 0.5%-521%) across PCCI scores. CONCLUSIONS LE strongly modulates the cost of CaP treatments. This results in AS dominating RP and RT in men with LE ≤10 years. However, in men with longer LE, AS fails to dominate primarily due to its high cumulative costs, underscoring the need for risk-adjusted AS protocols.
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Affiliation(s)
| | - Abhishek Venkataramana
- The Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Christopher Almario
- Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Paul Kokorowski
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Section of Urology, Durham VA Medical Center, Durham, NC
| | | | | | - Timothy J Daskivich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA.
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17
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Andebrhan SB, Caron AT, Szlachta-McGinn A, Parameshwar PS, Jackson NJ, Rosenman AE, Anger JT, Ackerman AL. Pelvic organ prolapse recurrence after pregnancy following uterine-sparing prolapse repair: a systematic review and meta-analysis. Int Urogynecol J 2023; 34:345-356. [PMID: 35920935 DOI: 10.1007/s00192-022-05306-2] [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: 06/03/2022] [Accepted: 07/07/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION We sought to determine rates of pelvic organ prolapse (POP) recurrence following pregnancy and delivery in reproductive-age women with prior hysteropexy. METHODS Scopus, MEDLine, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched from inception to May 2020 for combinations of any of the keywords: "pregnancy", "delivery", "fertility", or "cesarean" with a comprehensive list of uterine-sparing surgical procedures for POP repair. Using approach, 1,817 articles were identified describing surgical, uterine-sparing POP repair techniques and subsequent pregnancy and delivery outcomes in reproductive-age women. RESULTS: Twenty-seven studies describing 218 pregnancies, including 215 deliveries and 3 abortions, were summarized using narrative review and descriptive statistics. Successful pregnancies were reported following a diverse range of uterine-sparing prolapse repairs, both native tissue and mesh-augmented, that utilized vaginal, open abdominal, and laparoscopic approaches. We observed shifts from native tissue repairs to mesh-augmented laparoscopic repairs over time. POP recurrence occurred in 12% of subjects overall, 15% after vaginal and 10% after abdominal prolapse repairs. While meta-analysis identified higher recurrence rates after vaginal delivery (15%) than cesarean section (10%), due to small study numbers, multiple confounders, and heterogeneity between studies, no significant differences in recurrence rates could be identified between vaginal and abdominal surgical approaches, utilization of mesh augmentation, or mode of delivery. CONCLUSION Although literature on pregnancy following uterine-sparing POP repair is limited, available data suggest that prolapse recurrence after pregnancy and delivery remains similar to that after prolapse repair without subsequent pregnancies with few documented perinatal complications. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021247722.
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Affiliation(s)
- Sarah B Andebrhan
- Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, IL, USA
| | - Ashley T Caron
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Alec Szlachta-McGinn
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Nicholas J Jackson
- Department of Internal Medicine and Health Services Research, UCLA, Los Angeles, CA, USA
| | - Amy E Rosenman
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jennifer T Anger
- Department of Urology, University of California, San Diego, CA, USA
| | - A Lenore Ackerman
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. .,Department of Urology, Division of Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Box 951738, Los Angeles, CA, 90095-1738, USA.
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18
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Jarman A, Janes JL, Shorter B, Moldwin R, De Hoedt AM, Barbour KE, Kim J, Freedland SJ, Anger JT. Food Sensitivities in a Diverse Nationwide Cohort of Veterans With Interstitial Cystitis/Bladder Pain Syndrome. J Urol 2023; 209:216-224. [PMID: 36001744 PMCID: PMC10542818 DOI: 10.1097/ju.0000000000002938] [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: 04/15/2022] [Accepted: 07/28/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Prior studies suggest that certain foods exacerbate interstitial cystitis/bladder pain syndrome symptoms. However, these studies were limited in size and demographics. We assessed the presence of diet sensitivities among patients with interstitial cystitis/bladder pain syndrome and compared them with patients with other pelvic pain conditions and healthy controls. MATERIALS AND METHODS We identified Veterans Affairs patients nationwide by querying ICD-9/10 codes for interstitial cystitis/bladder pain syndrome. Patients were assigned to interstitial cystitis, other pelvic pain, or healthy control cohorts after chart review. We mailed all patients the Shorter-Moldwin Food Sensitivity Questionnaire to evaluate the self-perceived effects of specific foods/beverages on urinary symptoms and/or bladder pain. RESULTS In the interstitial cystitis/bladder pain syndrome cohort, 70% had ≥1 food sensitivity vs 37% of the other pelvic pain cohort and 32% of healthy controls (P < .001). The average number of sensitivities were similar between other pelvic pain conditions and healthy control cohorts, which were significantly less than in interstitial cystitis/bladder pain syndrome patients. Interstitial cystitis/bladder pain syndrome patients were more sensitive to acidic, spicy foods, and certain beverages vs other cohorts (all P < .001). Within the interstitial cystitis/bladder pain syndrome cohort, Black patients had significantly higher sensitivity to alcoholic and noncaffeinated beverages than Whites. Black patients did report significantly worsened urinary urgency than Whites (P < .05). CONCLUSIONS In a diverse population of veterans, interstitial cystitis/bladder pain syndrome patients had significantly more food sensitivities than those without interstitial cystitis/bladder pain syndrome. This suggests that food sensitivities could be suggestive of interstitial cystitis/bladder pain syndrome, which could make the Shorter-Moldwin Food Sensitivity Questionnaire a helpful diagnostic tool and aid in distinguishing interstitial cystitis/bladder pain syndrome from conditions often confused with interstitial cystitis/bladder pain syndrome.
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Affiliation(s)
- Aubrey Jarman
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jessica L. Janes
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
| | - Barbara Shorter
- Long Island University, Professor of Nutrition Emeritus, Brookville, NY
| | - Robert Moldwin
- The Arthur Smith Institute for Urology, Zucker School of Medicine at Hofstra-Northwell, Lake Success, NY
| | - Amanda M. De Hoedt
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
| | - Kamil E. Barbour
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jayoung Kim
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen J. Freedland
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
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Nik-Ahd F, Jarjour A, Figueiredo J, Anger JT, Garcia M, Carroll PR, Cooperberg MR, Vidal AC, Freedland SJ. Prostate-Specific Antigen Screening in Transgender Patients. Eur Urol 2023; 83:48-54. [PMID: 36344317 DOI: 10.1016/j.eururo.2022.09.007] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/05/2022] [Accepted: 09/06/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT Approximately 0.4-1.3% of the worldwide population is transgender. Although the exact prevalence is unknown, there is an increase in open identification as transgender. Among transgender women (TW), the prostate is retained even after gender-affirmation surgery, thus necessitating ongoing screening for prostate cancer (CaP). However, little is known about CaP screening in this population. OBJECTIVE To assess our current understanding of CaP incidence and prostate-specific antigen (PSA) screening in TW. EVIDENCE ACQUISITION We performed a nonsystematic narrative review of all PubMed publications through June 2022 according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. Given the limited primary research on this subject, case reports were also included. Studies were reviewed to understand PSA screening practices and reports of CaP in this population, as applicable. EVIDENCE SYNTHESIS There is no consensus regarding PSA screening in TW from any of the major societies, and TW are largely absent from guidelines. Case report data suggest that TW with CaP may have more aggressive disease, and these cancers may have been pre-existing prior to present before gender-affirming hormone therapy (GAHT) or be castrate-resistant. CONCLUSIONS We are in the infancy of our understanding of PSA screening in TW. Important avenues for future research include understanding the risks/benefits of PSA screening in TW, how best to mitigate potential negative psychological effects of PSA screening in TW, establishing baseline PSA values for those on GAHT (and determining what values should be considered "elevated"), establishing when to initiate PSA screening for those on GAHT, and establishing the accuracy of biomarkers for those undergoing GAHT. PATIENT SUMMARY We examined patterns of prostate cancer screening for transgender women. Little is known about prostate cancer incidence or screening in this population. Additional research is needed to establish guidelines for screening in this population.
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Affiliation(s)
- Farnoosh Nik-Ahd
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA.
| | - Andrew Jarjour
- College of Osteopathic Medicine of the Pacific, Western University, Pomona, CA, USA
| | - Jane Figueiredo
- Samuel Oschin Comprehensive Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer T Anger
- Department of Urology, University of California-San Diego Health System, La Jolla, CA, USA
| | - Maurice Garcia
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Peter R Carroll
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Adriana C Vidal
- Samuel Oschin Comprehensive Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen J Freedland
- Samuel Oschin Comprehensive Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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20
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Simko S, Dallas K, Molina AL, Siedhoff MT, Wright KN, Anger JT, Truong MD. Rates of Complications and Reoperation after Myomectomy-the Impact of Surgical Approach: A Statewide Population-based Cohort Study from 2005-2018. J Minim Invasive Gynecol 2022; 29:1157-1164. [PMID: 35781056 DOI: 10.1016/j.jmig.2022.06.021] [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: 04/14/2022] [Revised: 06/23/2022] [Accepted: 06/25/2022] [Indexed: 12/30/2022]
Abstract
STUDY OBJECTIVE To assess rates of and factors associated with complications and reoperation after myomectomy. DESIGN Population-based cohort study. SETTING All non-Veterans Affairs facilities in the state of California from January 1, 2005, to December 31, 2018. PARTICIPANTS Women undergoing abdominal or laparoscopic myomectomy for myoma disease were identified from the Office of Statewide Health Planning and Development datasets using appropriate International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes. INTERVENTIONS Demographics, surgery facility type, facility surgical volume, and surgical approach were identified. Primary outcomes included complications occurring within 60 days of surgery and reoperations for myomas. Patients were followed up for over an average of 7.3 years. Univariate and multivariable associations were explored between the above factors and rates of complications and reoperation. All odds ratios (ORs) are adjusted ORs. MEASUREMENTS AND MAIN RESULTS Of the 66 012 patients undergoing myomectomy, 5265 had at least one complication (8.0%). Advanced age, black, Asian race, MediCal and Medicare payor status, academic facility, and medical comorbidities were associated with increased odds of a complication. Minimally invasive myomectomy (MIM) was associated with decreased complications compared with abdominal myomectomy (AM) (OR, 0.29; 95% confidence interval [CI], 0.25-0.33; p <.001). Overall, 17 377 patients (26.3%) underwent reoperation. Medicare and MediCal payor status and medical comorbidities were associated with increased odds of a repeat surgery. Reoperation rates were higher in the MIM group over the entire study period (OR, 2.33; 95% CI, 1.95-2.79; p <.001). However, the odds of reoperation after MIM decreased each year (OR, 0.93; 95% CI 0.92-0.95; p <.001), with the odds of reoperation after AM surpassing MIM in 2015. CONCLUSION This study identifies outcome disparities in the surgical management of myomas and describes important differences in the rates of complications and reoperations, which can be used to counsel patients on surgical approach. These findings suggest that MIM can be considered a lasting and safe approach in properly selected patients.
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Affiliation(s)
- Sarah Simko
- Department of Obstetrics and Gynecology, Adventist Health White Memorial Medical Center (Dr. Simko), University of California San Diego, Los Angeles, California.
| | - Kai Dallas
- Division of Urology, Department of Surgery, City of Hope Medical Center (Dr. Dallas), University of California San Diego, Los Angeles, California
| | - Andrea L Molina
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
| | - Matthew T Siedhoff
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
| | - Kelly N Wright
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
| | - Jennifer T Anger
- Division of Urology, Department of Surgery, University of California San Diego (Dr. Anger), Los Angeles, California
| | - Mireille D Truong
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
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21
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Cohen TN, Anger JT, Kanji FF, Zamudio J, DeForest E, Lusk C, Avenido R, Yoshizawa C, Bartkowicz S, Nemeth LS, Catchpole K. A Novel Approach for Engagement in Team Training in High-Technology Surgery: The Robotic-Assisted Surgery Olympics. J Patient Saf 2022; 18:570-577. [PMID: 35797490 PMCID: PMC9391262 DOI: 10.1097/pts.0000000000001056] [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] [Indexed: 11/26/2022]
Abstract
INTRODUCTION There is ongoing interest in the development of technical and nontechnical skills in healthcare to improve safety and efficiency; however, barriers to developing and delivering related training programs make them difficult to implement. Unique approaches to training such as "serious games" may offer ways to motivate teams, reinforce skill acquisition, and promote teamwork. Given increased challenges to teamwork in robotic-assisted surgery (RAS), researchers aimed to develop the "RAS Olympics," a game-based educational competition to improve skills needed to successfully perform RAS. METHODS This pilot study was conducted at an academic medical center in Southern California. Robotic-assisted surgery staff were invited to participate in the "RAS Olympics" to develop their skills and identify opportunities to improve processes. Impact of the activity was assessed using surveys and debriefs. RESULTS Sixteen operating room team members participated and reacted favorably toward the RAS-Olympics (average score, 4.5/5). They enjoyed the activity, would recommend all staff participate, felt that it was relevant to their work, and believed that they practiced and learned new techniques that would improve their practice. Confidence in skills remained unchanged. Participants preferred the RAS Olympics to traditional training because it provided an interactive learning environment. CONCLUSIONS The successful implementation of the RAS Olympics provided insight into new opportunities to engage surgical staff members while also training technical and nontechnical skills. Furthermore, this shared experience allowed surgical staff members to gain a greater appreciation for their teammates and an understanding of the current challenges and methods to improve teamwork and communication while promoting safety and efficiency in RAS.
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Affiliation(s)
- Tara N. Cohen
- Research Scientist and Associate Professor, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90069
| | - Jennifer T. Anger
- Vice Chair of Research, Gender Affirming Surgery, Urologic Reconstruction, and Female Pelvic Medicine, University of California San Diego, Department of Urology, 9400 Campus Point Drive #7897, La Jolla, CA 92037
| | - Falisha F. Kanji
- Clinical Research Assistant, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90069
| | - Jennifer Zamudio
- Clinical Research Assistant, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90069
| | - Elise DeForest
- Program Assistant, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425
| | - Connor Lusk
- Postdoctoral Scholar, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425
| | - Ray Avenido
- Robotic Surgery Specialist, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048
| | - Christine Yoshizawa
- Assistant Nurse Manager, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048
| | - Stephanie Bartkowicz
- Clinical Nurse IV, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048
| | - Lynne S. Nemeth
- Professor, College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Ken Catchpole
- Endowed Chair in Clinical Practice and Human Factors, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC
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22
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Nickel JC, Stephens A, Ackerman AL, Anger JT, Lai HH, Ehrlich GD. The healthy urinary microbiome in asymptomatic participants in the MAPP Network Study: Relation to gender, age, and menopausal status. Can Urol Assoc J 2022; 16:E448-E454. [PMID: 35426787 PMCID: PMC9484748 DOI: 10.5489/cuaj.7775] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
INTRODUCTION To understand the role of the urinary microbiome in disease states and interpret non-culture-based diagnostic urine testing of midstream urine specimens, we must have a better understanding of the urinary microbiome in asymptomatic, healthy individuals. We examined the impact of gender, age, and menopausal status on the healthy human urinary microbiome in asymptomatic control subjects enrolled in the multi-institution National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Multidisciplinary Approach to the Study of Chronic Pelvic Pain Network (MAPP) study. METHODS Asymptomatic, healthy controls, recruited to be ageand sex-matched to patients in the Trans-MAPP Epidemiology and Phenotyping Study, provided midstream urine collection for polymerase chain reaction (PCR)-electrospray ionization mass spectrometry identification of urinary microbiota. The microbiomes of male and female participants were described and analyzed for differences in composition and diversity at the species and genus level by sex, age, and, in females, by menopausal status. RESULTS Sixty-six total species were detected with a mean of 1.2 species (standard deviation [SD] 1.1) per male (n=97; mean age=43) and 2.3 (SD 1.3) per female (n=110, mean age=38) in asymptomatic, healthy controls. Species and genera diversity analyses showed significantly greater richness and diversity in females. With regard to species, Bifidobacterium subtile, Lactobacillus crispatus, and Lactobacillus johnsonii were more predominant in females. The genera Bifidobacterium, Staphylococcus, Lactobacillus, and Corynebacterium were more predominant in females, while for males the most prevalent organisms included Staphylococcus and Propionibacterium; only Propionibacterium approached a significant difference between genders. No significant difference in the presence and/or diversity of micro-organisms with menopausal status could be observed. Sex-specific age trends, particularly diversity, were larger for females than males. CONCLUSIONS These results suggest the urinary microbiome of healthy, asymptomatic subjects differed between genders and age in females, but not menopausal status. Gender differences may be attributable to the detection of urethral/vaginal organisms in females and prostate organisms in males. These findings will better allow us to interpret the results of microbiome reports in the midstream urine specimens of patients with urinary symptoms.
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Affiliation(s)
- J. Curtis Nickel
- Department of Urology, Queen’s University School of Medicine, Kingston, ON, Canada
| | - Alisa Stephens
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - A. Lenore Ackerman
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | | | - Henry H. Lai
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MI, United States
| | - Garth D. Ehrlich
- Department of Microbiology & Immunology, Drexel University College of Medicine, Philadelphia, PA, United States
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23
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Anger JT, Dallas KB, Bresee C, De Hoedt AM, Barbour KE, Hoggatt KJ, Goodman MT, Kim J, Freedland SJ. National prevalence of IC/BPS in women and men utilizing veterans health administration data. Front Pain Res 2022; 3:925834. [PMID: 36093391 PMCID: PMC9448885 DOI: 10.3389/fpain.2022.925834] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/27/2022] [Indexed: 12/30/2022] Open
Abstract
Importance Interstitial cystitis/bladder pain syndrome (IC/BPS) is an immense burden to both patients and the American healthcare system; it is notoriously difficult to diagnose. Prevalence estimates vary widely (150-fold range in women and >500-fold range in men). Objectives We aimed to create accurate national IC/BPS prevalence estimates by employing a novel methodology combining a national population-based dataset with individual chart abstraction. Study design In this epidemiological survey, all living patients, with ≥2 clinic visits from 2016 to 2018 in the Veterans Health Administration, with an ICD-9/10 code for IC/BPS (n = 9,503) or similar conditions that may represent undiagnosed IC/BPS (n = 124,331), were identified (other were controls n = 5,069,695). A detailed chart review of random gender-balanced samples confirmed the true presence of IC/PBS, which were then age- and gender-matched to the general US population. Results Of the 5,203,529 patients identified, IC/BPS was confirmed in 541 of 1,647 sampled charts with an IC/BPS ICD code, 10 of 382 charts with an ICD-like code, and 3 of 916 controls. After age- and gender-matching to the general US population, this translated to national prevalence estimates of 0.87% (95% CI: 0.32, 1.42), with female and male prevalence of 1.08% (95% CI: 0.03, 2.13) and 0.66% (95% CI: 0.44, 0.87), respectively. Conclusions We estimate the prevalence of IC/BPS to be 0.87%, which is lower than prior estimates based on survey data, but higher than prior estimates based on administrative data. These potentially represent the most accurate estimates to date, given the broader and more heterogeneous population studied and our novel methodology of combining in-depth chart abstraction with administrative data.
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Affiliation(s)
- Jennifer T. Anger
- Department of Urology, UC San Diego Health, San Diego, CA, United States
- *Correspondence: Jennifer T. Anger
| | | | - Catherine Bresee
- Department of Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Amanda M. De Hoedt
- Urology Section, Department of Surgery, Veterans Affairs Medical Centers Division of Population Health, Durham, NC, United States
| | - Kamil E. Barbour
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Katherine J. Hoggatt
- Center for Study of Healthcare Implementation, Innovation and Policy Veterans Health Administration, Los Angeles, CA, United States
| | - Marc T. Goodman
- Cedars-Sinai Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jayoung Kim
- Cedars-Sinai Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Department of Surgery and Biomedical Science, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Stephen J. Freedland
- Urology Section, Department of Surgery, Veterans Affairs Medical Centers Division of Population Health, Durham, NC, United States
- Cedars-Sinai Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Department of Surgery and Biomedical Science, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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24
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Alfred M, Del Gaizo J, Kanji F, Lawton S, Caron A, Nemeth LS, Alekseyenko AV, Shouhed D, Savage S, Anger JT, Catchpole K, Cohen T. A better way: training for direct observations in healthcare. BMJ Qual Saf 2022; 31:744-753. [DOI: 10.1136/bmjqs-2021-014171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 08/07/2022] [Indexed: 11/03/2022]
Abstract
Direct observation is valuable for identifying latent threats and elucidating system complexity in clinical environments. This approach facilitates prospective risk assessment and reveals workarounds, near-misses and recurrent safety problems difficult to diagnose retrospectively or via outcome data alone. As observers are an instrument of data collection, developing effective and comprehensive observer training is critical to ensuring the reliability of the data collection and reproducibility of the research. However, methodological rigour for ensuring these data collection properties remains a key challenge in direct observation research in healthcare. Although prior literature has offered key considerations for observational research in healthcare, operationalising these recommendations may pose a challenge and unless guidance is also provided on observer training. In this article, we offer guidelines for training non-clinical observers to conduct direct observations including conducting a training needs analysis, incorporating practice observations and evaluating observers and inter-rater reliability. The operationalisation of these guidelines is described in the context of a 5-year multisite observational study investigating technology integration in the operating room. We also discuss novel tools developed during the course our project to support data collection and examine inter-rater reliability among observers in direct observation studies.
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25
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Daskivich TJ, Gale R, Luu M, Naser-Tavakolian A, Venkataramana A, Khodyakov D, Anger JT, Posadas E, Sandler H, Spiegel B, Freedland SJ. Variation in Communication of Competing Risks of Mortality in Prostate Cancer Treatment Consultations. J Urol 2022; 208:301-308. [PMID: 35377775 PMCID: PMC11070128 DOI: 10.1097/ju.0000000000002675] [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] [Accepted: 03/17/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Men with prostate cancer prefer patient-specific, quantitative assessments of longevity in shared decision making. We sought to characterize how physicians communicate the 3 components of competing risks-life expectancy (LE), cancer prognosis and treatment-related survival benefit-in treatment consultations. MATERIALS AND METHODS Conversation related to LE, cancer prognosis and treatment-related survival benefit was identified in transcripts from treatment consultations of 42 men with low- and intermediate-risk disease across 10 multidisciplinary providers. Consensus of qualitative coding by multiple reviewers noted the most detailed mode of communication used to describe each throughout the consultation. RESULTS Physicians frequently failed to provide patient-specific, quantitative estimates of LE and cancer mortality. LE was omitted in 17% of consultations, expressed as a generalization (eg "long"/"short") in 17%, rough number of years in 31%, probability of mortality/survival at an arbitrary timepoint in 17% and in only 19% as a specific number of years. Cancer mortality was omitted in 24% of consultations, expressed as a generalization in 7%, years of expected life in 2%, probability at no/arbitrary timepoint in 40% and in only 26% as the probability at LE. Treatment-related survival benefit was often omitted; cancer mortality was reported without treatment in 38%, with treatment in 10% and in only 29% both with and without treatment. Physicians achieved "trifecta"-1) quantifying probability of cancer mortality 2) with and without treatment 3) at the patient's LE-in only 14% of consultations. CONCLUSIONS Physicians often fail to adequately quantify competing risks. We recommend the "trifecta" approach, reporting 1) probability of cancer mortality 2) with and without treatment 3) at the patient's LE.
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Affiliation(s)
- Timothy J. Daskivich
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Luu
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Abhi Venkataramana
- Department of Urology, University of Southern California, Los Angeles, CA
| | | | - Jennifer T. Anger
- Department of Urology, University of California, San Diego, San Diego, CA
| | - Edwin Posadas
- Department of Medicine, Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Howard Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA
- Department of Medicine, Divisions of Gastroenterology and Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen J. Freedland
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
- Section of Urology, Durham VA Medical Center, Durham, NC
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26
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CADISH LA, FORD CB, Wu JM, Anger JT. Mortality and Reoperation Following Midurethral Sling Versus Urethral Bulking in Older Women. Urology 2022; 165:144-149. [PMID: 35460678 PMCID: PMC9940270 DOI: 10.1016/j.urology.2022.03.033] [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: 12/02/2021] [Revised: 03/22/2022] [Accepted: 03/31/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine differences in mortality, retreatment rates, and comorbidities that may be risk factors for retreatment among Medicare beneficiaries (age 65+) undergoing midurethral sling vs urethral bulking. MATERIALS AND METHODS This was a retrospective cohort study using the 5% limited data set from the Center for Medicare and Medicaid Services between 2010 and 2018. Beneficiaries age 65 or older who underwent sling or bulking without concomitant surgery from 2011 to 2014 were included and followed until reoperation or retreatment, loss of Medicare, death, or December 31, 2018. Repeat procedures for ongoing stress incontinence or complication were included. Associations between index treatment and need for a secondary procedure were evaluated using Cox proportional hazards models. RESULTS Median follow-up time was 5.7 years for 1,700 patients undergoing sling and 5.2 years for 875 patients undergoing bulking. Within 5 years, 10.2% of sling patients and 23.2% of bulking patients had died. When controlling for age, race, and comorbidities, bulking patients were 1.73 times more likely than sling patients to die during the study period. Bulking patients were significantly more likely to have 12 of the 16 of the medical comorbidities evaluated. By 5 years, 6.7% of sling patients had been retreated for stress urinary incontinence (SUI) compared with 24.6% of bulking patients. Apart from hypertension, none of the comorbidities evaluated was associated with a difference in the risk of a subsequent surgical procedure. Members of racial and ethnic minority groups were less likely to be retreated. CONCLUSION Older adults undergoing bulking are notably sicker and have shorter life expectancy as compared with those undergoing sling, suggesting these factors heavily guide patient selection. Comorbidities do not predispose patients to reoperation or retreatment.
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Affiliation(s)
- Lauren A. CADISH
- Urogynecology, Department of Obstetrics and Gynecology, Providence Saint John’s Health Center, Santa Monica, CA
| | - Cassie B. FORD
- Department of Population Health Science, Duke University School of Medicine, Durham, NC
| | - Jennifer M. Wu
- Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC
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Tholemeier LN, Bresee C, De Hoedt AM, Barbour KE, Kim J, Freedland SJ, Anger JT. Do medication prescription patterns follow guidelines in a cohort of women with interstitial cystitis/bladder pain syndrome? Neurourol Urodyn 2022; 41:1121-1126. [PMID: 35391498 PMCID: PMC10460127 DOI: 10.1002/nau.24923] [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: 12/17/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe prescription prevalence of oral bladder pain medications among women with interstitial cystitis/bladder pain syndrome (IC/BPS) and to compare with current treatment guidelines. METHODS We sampled female patients with an ICD-9/10 diagnosis of IC/BPS (595.1/N30.10) by querying active users of the Veterans Health Administration. Medical records were reviewed to determine whether patients met IC/BPS diagnostic criteria. A cohort of women with other pelvic pain disorders was identified. Prescription prevalence of typical non-narcotic oral bladder pain medications was compared between the two groups and healthy controls. Prescription prevalence was also compared before and after the diagnosis of IC/BPS was made using Poisson regression. RESULTS There were 641 women who met criteria for IC/BPS and 197 women with "Other pelvic pain" disorders. Women with IC/BPS were prescribed a pain medication more often than those with "Other pelvic pain" (77% vs. 59%, p < 0.0001). Of the women with IC/BPS, 44% tried three or more pain medications. Of women with a diagnosis of IC/BPS, only 67% were prescribed an American Urological Association-recommended medication. Prescription prevalence increased after diagnosis for both pentosan polysulfate (10%-29%, p < 0.0001) and hydroxyzine (17%-40%, p < 0.0001), but not for amitriptyline or cimetidine. Amitriptyline was prescribed to 223 women with IC/BPS, only 125 of which (56%) had a documented history of depression. CONCLUSIONS Many women with IC/BPS required multiple bladder prescriptions, highlighting the difficulty in finding an effective treatment for IC/BPS. Pentosan polysulfate and hydroxyzine were preferred IC/BPS medications. Our next step will be to analyze treatment patterns in those patients who did not receive medications.
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Affiliation(s)
- Lauren N Tholemeier
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Catherine Bresee
- Biostatistics Core at the Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Kamil E Barbour
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jayoung Kim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stephen J Freedland
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jennifer T Anger
- Department of Urology, UC San Diego Medical Center, La Jolla, California, USA
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28
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Dallas KB, Bresee C, De Hoedt A, Senechal JF, Barbour KE, Kim J, Freedland SJ, Anger JT. Demographic Differences and Disparities in the Misdiagnosis of Interstitial Cystitis/Bladder Pain Syndrome in a National Cohort of VA Patients. Urology 2022; 163:22-28. [PMID: 34348123 PMCID: PMC10461430 DOI: 10.1016/j.urology.2021.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To explore association between misdiagnosis of IC/BPS and demographics. Interstitial cystitis/bladder pain syndrome (IC/BPS) is associated with significant diagnostic uncertainty, resulting in frequent misdiagnosis as there is little known about the potential impact of key demographic factors. METHODS All patients in the VA system between 1999-2016 were identified by ICD-9/10 codes for IC/BPS (595.1/N30.10) (n = 9,503). ICD code accuracy for true IC/BPS (by strict criteria) was assessed by in-depth chart abstraction (n = 2,400). Associations were explored between rates of misdiagnosis and demographics. RESULTS IC/BPS criteria were met in only 651 (48.8%) of the 1,334 charts with an ICD code for IC/BPS reviewed in depth. There were no differences in the misdiagnosis rate by race (P=.27) or by ethnicity (P=.97), after adjusting for differences in age and gender. In IC/BPS-confirmed cases, female patients were diagnosed at a younger age than males (41.9 vs. 58.2 years, P<.001). Black and Hispanic patients were diagnosed at a younger age compared to White (41.9 vs. 50.2 years, P<.001) and non-Hispanic patients, respectively (41.1 vs. 49.1 years, P=.002). CONCLUSION There was a high rate of misdiagnosis of IC/BPS overall, with only 48.8% of patients with an ICD code for IC/BPS meeting diagnostic criteria. There were no significant associations between diagnostic accuracy and race/ethnicity. Black and Hispanic patients were more likely to receive a diagnosis of IC/BPS at a younger age, suggesting there may be differing natural histories or presentation patterns of IC/BPS between racial/ethnic groups.
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Affiliation(s)
- Kai B Dallas
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Catherine Bresee
- Department of Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Amanda De Hoedt
- Veterans Affairs Medical Centers, Urology Section, Durham, NC
| | | | - Kamil E Barbour
- National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA
| | - Jayoung Kim
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen J Freedland
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jennifer T Anger
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
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29
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Burton CS, Gonzalez G, Choi E, Bresee C, Nuckols TK, Eilber KS, Wenger NS, Anger JT. The Impact of Provider Sex and Experience on the Quality of Care Provided for Women with Urinary Incontinence. Am J Med 2022; 135:524-530.e1. [PMID: 34861198 PMCID: PMC9261287 DOI: 10.1016/j.amjmed.2021.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 07/16/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although specialists are skilled in the management of urinary incontinence, primary care clinicians are integral in early diagnosis and initiation of management in order to decrease overuse of specialty care and improve the quality of specialist visits. We measured the quality of incontinence care provided by primary care clinicians prior to referral to a specialist and evaluated the impact of provider variables on quality of care. METHODS We performed a retrospective review of 200 women referred for urinary incontinence to a Female Pelvic Medicine and Reconstructive Surgery specialist between March 2017 and July 2018. We measured primary care adherence to 12 quality indicators in the 12 months prior to specialist consultation. We stratified adherence to quality indicators by clinician sex and years of experience. RESULTS Half of women with incontinence underwent a pelvic examination or had a urinalysis ordered. Few patients with urge urinary incontinence were recommended behavioral therapy (14%) or prescribed medication (8%). When total aggregate scores were compared, female clinicians performed the recommended care 47% ± 25% of the time, compared with 35% ± 23% for male clinicians (P = .003). Increasing years of experience was associated with worse overall urinary incontinence care (r -0.157, P = .02). CONCLUSIONS We found low rates of adherence to a set of quality indicators for women with urinary incontinence, with male clinicians performing significantly worse than female clinicians. Improvement of incontinence care in primary care could significantly reduce costs of care and preserve outcomes.
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Affiliation(s)
- Claire S Burton
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | | | - Eunice Choi
- Division of Urology, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Catherine Bresee
- Biostatistics Core, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Teryl K Nuckols
- Division of General Internal Medicine, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Karyn S Eilber
- Division of Urology, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, Calif
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Cohen TN, Anger JT, Shamash K, Catchpole KR, Avenido R, Ley EJ, Gewertz BL, Shouhed D. The Application of Human Factors Engineering to Reduce Operating Room Turnover in Robotic Surgery. World J Surg 2022; 46:1300-1307. [DOI: 10.1007/s00268-022-06487-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 11/25/2022]
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Javier-DesLoges J, Salmasi A, Jamieson CA, Anger JT. RE: Cancer Stage, Treatment, and Survival Among Transgender Patients in the United States. J Natl Cancer Inst 2022; 114:1203-1204. [PMID: 35191502 PMCID: PMC9360451 DOI: 10.1093/jnci/djac039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Juan Javier-DesLoges
- Correspondence to: Juan Javier-DesLoges, MD, MS, Department of Urology, UC San Diego Moores Comprehensive Cancer Center, University of California, San Diego, 3855 Health Sciences Dr, La Jolla, CA 92037, USA (e-mail: )
| | - Amirali Salmasi
- Department of Urology, UC San Diego Moores Comprehensive Cancer Center, University of California, La Jolla, San Diego, CA, USA
| | - Christina Am Jamieson
- Department of Urology, UC San Diego Moores Comprehensive Cancer Center, University of California, La Jolla, San Diego, CA, USA
| | - Jennifer T Anger
- Department of Urology, UC San Diego Moores Comprehensive Cancer Center, University of California, La Jolla, San Diego, CA, USA
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Reynolds WS, Suskind AM, Anger JT, Brucker BM, Cameron AP, Chung DE, Daignault-Newton S, Lane GI, Lucioni A, Mourtzinos AP, Padmanabhan P, Reyblat PX, Smith AL, Tenggardjaja CF, Lee UJ. Incomplete bladder emptying and urinary tract infections after botulinum toxin injection for overactive bladder: Multi-institutional collaboration from the SUFU research network. Neurourol Urodyn 2022; 41:662-671. [PMID: 35019167 PMCID: PMC8891079 DOI: 10.1002/nau.24871] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/08/2021] [Accepted: 12/05/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Onabotulinumtoxin A (BTX-A) is an effective therapy for overactive bladder (OAB), however, adverse events may prevent patients from initiating therapy. The study objective was to report real-world rates of incomplete emptying and urinary tract infection (UTI) in men and women undergoing BTX-A for OAB. METHODS Eleven clinical sites performed a retrospective study of adults undergoing first-time BTX-A injection (100 units) for idiopathic OAB in 2016. Exclusions included: postvoid residual (PVR) > 150 ml, prior BTX-A, pelvic radiation, or need for preprocedure catheterization. Primary outcomes at 6 months were incomplete emptying (clean intermittent catheterization [CIC] or PVR ≥ 300 ml without the need for CIC); and UTI (symptoms with either positive culture or urinalysis or empiric treatment). We compared rates of incomplete emptying and UTI within and between sexes, using univariate and multivariable models. RESULTS 278 patients (48 men and 230 women) met inclusion criteria. Mean age was 65.5 years (range: 24-95). 35% of men and 17% of women had incomplete emptying. Men had 2.4 (95% CI: 1.04-5.49) higher odds of incomplete emptying than women. 17% of men and 23.5% of women had ≥1 UTI, the majority of which occurred within the first month following injection. The strongest predictor of UTI was a history of prior UTI (OR: 4.2 [95% CI: 1.7-10.3]). CONCLUSIONS In this multicenter retrospective study, rates of incomplete emptying and UTI were higher than many previously published studies. Men were at particular risk for incomplete emptying. Prior UTI was the primary risk factor for postprocedure UTI.
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Affiliation(s)
- William Stuart Reynolds
- Division of Reconstructive Urology and Pelvic Health, Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anne M. Suskind
- Department of Urology, University of California San Francisco, San Francisco, California, USA
| | - Jennifer T. Anger
- Department of Urology, UC San Diego Health, San Diego, California, USA
| | - Benjamin M. Brucker
- Department of Urology, New York University, Langone Health, New York, New York, USA
| | - Anne P. Cameron
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Doreen E. Chung
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | | | - Giulia I. Lane
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Arthur P. Mourtzinos
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
| | - Priya Padmanabhan
- Department of Urology, Beaumont Health, Farmington Hills, Michigan, USA
| | | | - Ariana L. Smith
- Division of Urology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Una J. Lee
- Virginia Mason Medical Center, Seattle, Washington, USA
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Mwesigwa PJ, Jackson NJ, Caron AT, Kanji F, Ackerman JE, Webb JR, Scott VCS, Eilber KS, Underhill DM, Anger JT, Ackerman AL. Unsupervised Machine Learning Approaches Reveal Distinct Phenotypes of Perceived Bladder Pain: A Pilot Study. Front Pain Res (Lausanne) 2022; 2. [PMID: 35036991 PMCID: PMC8758057 DOI: 10.3389/fpain.2021.757878] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Interstitial cystitis/bladder pain syndrome (IC/BPS) is defined as an unpleasant sensation perceived to be related to the bladder with associated urinary symptoms. Due to difficulties discriminating pelvic visceral sensation, IC/BPS likely represents multiple phenotypes with different etiologies that present with overlapping symptomatic manifestations, which complicates clinical management. We hypothesized that unique bladder pain phenotypes or "symptomatic clusters" would be identifiable using machine learning analysis (unsupervised clustering) of validated patient-reported urinary and pain measures. Patients (n = 145) with pelvic pain/discomfort perceived to originate in the bladder and lower urinary tract symptoms answered validated questionnaires [OAB Questionnaire (OAB-q), O'Leary-Sant Indices (ICSI/ICPI), female Genitourinary Pain Index (fGUPI), and Pelvic Floor Disability Index (PFDI)]. In comparison to asymptomatic controls (n = 69), machine learning revealed three bladder pain phenotypes with unique, salient features. The first group chiefly describes urinary frequency and pain with the voiding cycle, in which bladder filling causes pain relieved by bladder emptying. The second group has fluctuating pelvic discomfort and straining to void, urinary frequency and urgency without incontinence, and a sensation of incomplete emptying without urinary retention. Pain in the third group was not associated with voiding, instead being more constant and focused on the urethra and vagina. While not utilized as a feature for clustering, subjects in the second and third groups were significantly younger than subjects in the first group and controls without pain. These phenotypes defined more homogeneous patient subgroups which responded to different therapies on chart review. Current approaches to the management of heterogenous populations of bladder pain patients are often ineffective, discouraging both patients and providers. The granularity of individual phenotypes provided by unsupervised clustering approaches can be exploited to help objectively define more homogeneous patient subgroups. Better differentiation of unique phenotypes within the larger group of pelvic pain patients is needed to move toward improvements in care and a better understanding of the etiologies of these painful symptoms.
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Affiliation(s)
- Patricia J Mwesigwa
- Department of Obstetrics and Gynecology, Center for Women's Pelvic Health, 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
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Falisha Kanji
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - James E Ackerman
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jessica R Webb
- Cedars-Sinai Medical Group, Department of Internal Medicine, Los Angeles, CA, United States
| | - Victoria C S Scott
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Karyn S Eilber
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - David M Underhill
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jennifer T Anger
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - A Lenore Ackerman
- Division of Pelvic Medicine and Reconstructive Surgery, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Cohen TN, Kanji FF, Souders C, Dubinskaya A, Eilber KS, Sax H, Anger JT. A Human Factors Approach to Vaginal Retained Foreign Objects. J Minim Invasive Gynecol 2022; 29:626-632. [PMID: 34986410 DOI: 10.1016/j.jmig.2021.12.018] [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: 11/16/2021] [Revised: 12/14/2021] [Accepted: 12/25/2021] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE To apply a structured human factors analysis to understand conditions contributing to vaginal retained foreign objects (RFO). DESIGN All potential vagina RFO events from January 1, 2000, to May 21, 2019, were analyzed by trained human factors researchers. Each narrative was reviewed to identify contributing factors, classified using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare). SETTING An 890-bed, academic medical center in Southern California. PATIENTS Patients who underwent a vaginal procedure in which a vaginal RFO-related event occurred were included in this study. However, no patient information was included, only the relevant details from their procedures. INTERVENTIONS No interventions were developed or implemented. MEASUREMENTS AND MAIN RESULTS Over the 19-year period, 45 events were reported. The most common items were vaginal packing and vaginal sponges (53.33%). Less frequently retained items involved broken instruments (20.20%). The majority of cases were laparoscopic hysterectomies or vaginal deliveries. Based on HFACS, 75 contributing factors were identified, consisting primarily of preconditions for unsafe acts (communication challenges, coordination breakdowns and issues with the design of tools/technology) and unsafe acts (errors). CONCLUSION While rare, vaginal RFOs do occur. The top two contributing factors were skill-based errors and communication breakdowns. Both types of errors can be addressed and improved with human factors interventions, including simulation, teamwork training, and streamlining workflow to reduce the opportunity for errors.
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Affiliation(s)
- Tara N Cohen
- Research Scientist, Associate Professor, Cedars-Sinai Medical Center, Department of Surgery, 8687 Melrose Ave., Suite G-555 West Hollywood CA, 90069, USA.
| | - Falisha F Kanji
- Research Assistant, Cedars-Sinai Medical Center, Department of Surgery, 8687 Melrose Ave., Suite G-550 West Hollywood CA, 90069, USA.
| | - Colby Souders
- FPMRS Fellow, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, USA.
| | - Alexandra Dubinskaya
- FPMRS Fellow, Cedars-Sinai Medical Center, Department of Surgery, 8700 Beverly Blvd., Los Angeles CA, USA.
| | - Karyn S Eilber
- Associate professor Urology and Obstetrics & Gynecology, Associate Program Director, Urology Residency Training Program, Co-Director, FPMRS Fellowship Training Program, Cedars-Sinai Health System, Department of Surgery, Division of Urology, 99 N. La Cienega Blvd, Beverly Hills, CA, 90211 USA.
| | - Harry Sax
- Professor and Executive Vice Chair, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd., 8215NT, Los Angeles, CA 90048, USA.
| | - Jennifer T Anger
- Vice Chair of Research, Gender Affirming Surgery, Urologic Reconstruction, and Female Pelvic Medicine, University of California San Diego, Department of Urology, 9400 Campus Point Drive #7897, La Jolla, CA 92037.
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Cohen TN, Wiegmann DA, Kanji FF, Alfred M, Anger JT, Catchpole KR. Using flow disruptions to understand healthcare system safety: A systematic review of observational studies. Appl Ergon 2022; 98:103559. [PMID: 34488190 DOI: 10.1016/j.apergo.2021.103559] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 05/12/2021] [Accepted: 08/15/2021] [Indexed: 06/13/2023]
Abstract
This systematic review provides information on the methodologies, measurements and classification systems used in observational studies of flow disruptions in clinical environments. The PRISMA methodology was applied and authors searched two databases (PubMed and Web of Science) for studies meeting the following inclusion criteria: (a) were conducted in a healthcare setting, (b) explored systems-factors leading to deviations in care processes, (c) were prospective and observational, (d) classified observations, and (e) were original research studies published in peer-reviewed journals. Thirty studies were analyzed and a variety of methods were identified for observer training, data collection and observation classification. Although primarily applied in surgery, comparable research has been successfully conducted in other venues such as trauma care, and delivery rooms. The findings of this review were synthesized into a framework of considerations for conducting rigorous methodological studies aimed at understanding clinical systems.
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Affiliation(s)
- Tara N Cohen
- Cedars-Sinai Medical Center, Department of Surgery, 8687 Melrose Ave., Suite G-555, West Hollywood, CA, 90069, USA.
| | - Douglas A Wiegmann
- University of Wisconsin-Madison, College of Engineering, 1415 Engineering Drive, Madison, WI, 53706, USA
| | - Falisha F Kanji
- Cedars-Sinai Medical Center, Department of Surgery, 8687 Melrose Ave., Suite G-555, West Hollywood, CA, 90069, USA
| | - Myrtede Alfred
- University of Toronto, Department of Mechanical and Industrial Engineering, 5 King's College Road, M5S 3G8 (MB114) Toronto, Ontario, Canada
| | - Jennifer T Anger
- University of California San Diego, Department of Urology, 9400 Campus Point Drive, # 7897 La Jolla, CA 92037, USA
| | - Ken R Catchpole
- Medical University of South Carolina, Department of Anesthesia and Perioperative Medicine, Storm Eye Building, Ashley Avenue, Charleston, SC, 29425, USA
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Daskivich TJ, Gale R, Luu M, Khodyakov D, Anger JT, Freedland SJ, Spiegel B. Patient Preferences for Communication of Life Expectancy in Prostate Cancer Treatment Consultations. JAMA Surg 2021; 157:70-72. [PMID: 34757389 DOI: 10.1001/jamasurg.2021.5803] [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] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Timothy J Daskivich
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, California
| | - Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Luu
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Jennifer T Anger
- Department of Urology, University of California, San Diego, San Diego
| | - Stephen J Freedland
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, California.,Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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Kim J, De Hoedt A, Wiggins E, Haywood K, Jin P, Greenwood B, Narain NR, Tolstikov V, Bussberg V, Barbour KE, Kiebish MA, Freedland S, Anger JT. Diagnostic Utility of Serum and Urinary Metabolite Analysis in Patients with Interstitial Cystitis/Painful Bladder Syndrome. Urology 2021; 157:85-92. [PMID: 34010675 PMCID: PMC10461181 DOI: 10.1016/j.urology.2021.05.005] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To identify the potential biomarkers of interstitial cystitis/painful bladder syndrome (IC), a chronic syndrome of bladder-centric pain with unknown etiology that has an adverse impact on quality of life, we analyzed the urine and serum metabolomes of a cohort of IC patients and non-disease controls (NC). METHODS Home collection of serum and urine samples was obtained from 19 IC and 20 NC females in the Veterans Affairs (VA) Health Care System. IC was diagnosed independently by thorough review of medical records using established criteria. Biostatistics and bioinformatics analyses, including univariate analysis, unsupervised clustering, random forest analysis, and metabolite set enrichment analysis (MSEA), were then utilized to identify potential IC biomarkers. RESULTS Metabolomics profiling revealed distinct expression patterns between NC and IC. Random forest analysis of urine samples suggested discriminators specific to IC; these include phenylalanine, purine, 5-oxoproline, and 5-hydroxyindoleacetic acid. When these urinary metabolomics-based analytes were combined into a single model, the AUC was 0.92, suggesting strong potential clinical value as a diagnostic signature. Serum-based metabolomics did not provide potential IC discriminators. CONCLUSION Analysis of serum and urine revealed that women with IC have distinct metabolomes, highlighting key metabolic pathways that may provide insight into the pathophysiology of IC. The findings from this pilot study suggest that integrated analyses of urinary metabolites, purine, phenylalanine, 5-oxoproline, and 5-HIAA, can lead to promising IC biomarkers for pathophysiology of IC. Validation of these results using a larger dataset is currently underway.
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Affiliation(s)
- Jayoung Kim
- Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | | | - Peng Jin
- Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | | | | | - Kamil E. Barbour
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, GA
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Gonzalez G, Arora A, Choi E, Bresee C, Perley J, Anger JT. Outcomes of the Supris® Sling in an Urban Latina Population. Urology 2021; 163:3-7. [PMID: 34637838 DOI: 10.1016/j.urology.2021.07.054] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/20/2021] [Accepted: 07/23/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To analyze patient reported outcomes, safety, and efficacy of the Supris® mid-urethral sling in a diverse population. METHODS A retrospective chart review of 101 women who underwent a mid-urethral Supris® sling procedure was conducted. Baseline characteristics and peri-operative parameters were collected. Post-operative results and patient reported outcomes were collected at an average follow-up time of 19 months using the Urogenital Distress Inventory-6 (UDI-6) and Patient Global Impression of Improvement (PGI-I) validated questionnaires. Subjective cure rates were compared using the nonparametric Wilcoxon Rank Sum Test. RESULTS The median age of women was 57 years old, and 86.1% identified as Latina. 28% and 72% of women had a SUI and MUI diagnosis, respectively. Women, on average, used two pads pre-operatively and none post-operatively. There was a 3% surgical revision rate. 80 women completed the questionnaires. 82% of the MUI group reported being very much improved or much better. The SUI group reported being 94% very much improved or much better. The UDI-6 questions related to urgency and leakage of small amounts of urine were significantly different between the MUI and SUI groups (p = 0.002 and p = 0.044). CONCLUSIONS In our primarily Latina patient population, the majority of whom had MUI, the Supris® retropubic sling greatly improved symptoms. Although reported outcomes were excellent in both groups, those with pre-operative urge incontinence were more likely to experience urge symptoms post-operatively. Despite persistent urge symptoms, patients reported improvement of their overall symptoms.
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Affiliation(s)
- Gabriela Gonzalez
- Department of Urology, University of California, Davis School of Medicine, Sacramento, CA
| | - Aman Arora
- University of California, Davis School of Medicine, Sacramento, CA
| | - Eunice Choi
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Beverly Hills, CA
| | - Catherine Bresee
- Department of Statistics, Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Jennifer T Anger
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Beverly Hills, CA.
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Gonzalez G, Dallas K, Arora A, Kobashi KC, Anger JT. Underrepresentation of Racial and Ethnic Diversity in Research Informing the American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Stress Urinary Incontinence Guideline. Urology 2021; 163:16-21. [PMID: 34536408 DOI: 10.1016/j.urology.2021.08.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/16/2021] [Accepted: 08/27/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To characterize the racial/ethnic representation in the studies used in the American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction stress urinary incontinence guideline. METHODS Cited studies were reviewed using inclusion and exclusion criteria. The inclusion criteria focused on United States literature to allow for demographic comparison with census data. To compare the racial representation in a study to the diversity in the surrounding city, we calculated the differences between county census data and the study race reported data and performed regression analyses. RESULTS Eighty-seven cited studies were reviewed, of which 33 were excluded and 52 studies were further evaluated. Seventeen studies were US studies, nine of which reported race. Eighty percent of the women included in the 9 studies were non-Hispanic white women. A diverse geographic region did not correlate with increased study enrollment of non-White patients. CONCLUSION The majority of cited studies used to develop the stress urinary incontinence management guidelines did not report the race/ethnicity of participants. Among those studies that did, Asian, Black, and Hispanic women were included at lower rates than non-Hispanic white women, identifying an area of opportunity to improve research recruitment and promote health equity. Non-Hispanic women were consistently overrepresented while other women were either under-represented or completely excluded.
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Affiliation(s)
- Gabriela Gonzalez
- Department of Urology, University of California, Davis School of Medicine, Sacramento, CA
| | - Kai Dallas
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Aman Arora
- University of California, Davis School of Medicine, Sacramento, CA
| | | | - Jennifer T Anger
- Department of Urology, University of California, San Diego School of Medicine, La Jolla, CA.
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Chen A, Kuhlmann P, Souders C, Moradzadeh A, Chun A, Anger JT, Eilber KS. Assessing the Impact of Urology Resident Involvement on Overall Patient Satisfaction. J Surg Educ 2021; 78:1655-1659. [PMID: 33558192 DOI: 10.1016/j.jsurg.2021.01.019] [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] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/03/2021] [Accepted: 01/30/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION To assess the impact of resident participation on patient satisfaction by comparing post-discharge satisfaction scores between academic faculty, private urologists who work with residents, and private urologists with no involvement in resident education. METHODS Post-discharge Hospital Consumer Assessment of Healthcare Providers and Systems surveys from academic and private urologists at a single institution with an accredited Urology residency program from January 1, 2014 to December 31, 2016 (n = 530) were reviewed. The surveys were de-identified and categorized based on 3 subgroups of providers: academic faculty, private with residents, and private without residents. Overall rating, physician (MD) communication, nursing (RN) communication, discharge information, and overall management during their hospitalization were assessed. RESULTS The faculty group received an overall patient satisfaction score of 88.3% (percentage of 9 or 10). The private with resident group had an overall satisfaction score of 92.0% and the private without resident group had an overall satisfaction score of 96.7%. There was no statistical difference in patient satisfaction scores between groups across all categories with the exception of MD and RN communication. Private urologists with residents had better MD and RN communication scores than the 2 other groups (p < 0.001, p = 0.013, respectively). CONCLUSIONS Resident involvement in patient care with faculty or private attendings did not have a negative effect on patient satisfaction scores of any factor measured. Patients were more satisfied with MD and RN communication when residents worked with private attendings.
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Affiliation(s)
- Andrew Chen
- Cedars-Sinai Medical Center, Department of Surgery, Division of Urology, Los Angeles, California.
| | - Paige Kuhlmann
- Cedars-Sinai Medical Center, Department of Surgery, Division of Urology, Los Angeles, California
| | - Colby Souders
- Cedars-Sinai Medical Center, Department of Surgery, Division of Urology, Los Angeles, California
| | - Ariel Moradzadeh
- Cedars-Sinai Medical Center, Department of Surgery, Division of Urology, Los Angeles, California
| | - Alein Chun
- Cedars-Sinai Medical Center, Department of Surgery, Division of Urology, Los Angeles, California
| | - Jennifer T Anger
- Cedars-Sinai Medical Center, Department of Surgery, Division of Urology, Los Angeles, California
| | - Karyn S Eilber
- Cedars-Sinai Medical Center, Department of Surgery, Division of Urology, Los Angeles, California
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Kanji F, Cohen T, Alfred M, Caron A, Lawton S, Savage S, Shouhed D, Anger JT, Catchpole K. Room Size Influences Flow in Robotic-Assisted Surgery. Int J Environ Res Public Health 2021; 18:7984. [PMID: 34360275 PMCID: PMC8345669 DOI: 10.3390/ijerph18157984] [Citation(s) in RCA: 9] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/22/2021] [Accepted: 07/24/2021] [Indexed: 11/17/2022]
Abstract
The introduction of surgical technology into existing operating rooms (ORs) can place novel demands on staff and infrastructure. Despite the substantial physical size of the devices in robotic-assisted surgery (RAS), the workspace implications are rarely considered. This study aimed to explore the impact of OR size on the environmental causes of surgical flow disruptions (FDs) occurring during RAS. Fifty-six RAS procedures were observed at two academic hospitals between July 2019 and January 2021 across general, urologic, and gynecologic surgical specialties. A multiple regression analysis demonstrated significant effects of room size in the pre-docking phase (t = 2.170, df = 54, β = 0.017, p = 0.035) where the rate of FDs increased as room size increased, and docking phase (t = -2.488, df = 54, β = -0.017, p = 0.016) where the rate of FDs increased as room size decreased. Significant effects of site (pre-docking phase: p = 0.000 and docking phase: p = 0.000) were also demonstrated. Findings from this study demonstrate hitherto unrecognized spatial challenges involved with introducing surgical robots into the operating domain. While new technology may provide benefits towards patient safety, it is important to consider the needs of the technology prior to integration.
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Affiliation(s)
- Falisha Kanji
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (T.C.); (A.C.); (D.S.); (J.T.A.)
| | - Tara Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (T.C.); (A.C.); (D.S.); (J.T.A.)
| | - Myrtede Alfred
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA; (M.A.); (S.L.); (K.C.)
| | - Ashley Caron
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (T.C.); (A.C.); (D.S.); (J.T.A.)
| | - Samuel Lawton
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA; (M.A.); (S.L.); (K.C.)
| | - Stephen Savage
- Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Daniel Shouhed
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (T.C.); (A.C.); (D.S.); (J.T.A.)
| | - Jennifer T. Anger
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (T.C.); (A.C.); (D.S.); (J.T.A.)
| | - Ken Catchpole
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29425, USA; (M.A.); (S.L.); (K.C.)
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Masterson JM, Zhao H, Choi E, Kim HH, Anger JT. Characteristics and Long Term Follow up of Men Who Suffer Ischemic Priapism Secondary to Recreational Use of Intracavernosal Injectable Medications. Urology 2021; 156:163-168. [PMID: 34273403 DOI: 10.1016/j.urology.2021.06.036] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/01/2021] [Accepted: 06/28/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To better understand patient experience, risk factors, culture, and ED outcomes surrounding recreational ICI use that led to ischemic priapism. METHODS After IRB approval, men presenting for ischemic priapism secondary to recreational ICI use from January 2010 to December 2018 were contacted by mail and then via telephone. Standardized questions were asked of all study participants on the topics of erectile function (IIEF-5), sexual practices, and at-risk behavior at the time of priapism. Qualitative data analysis was performed using grounded theory methodology. RESULTS 14 men age 24-59 were successfully recruited. All men described themselves as men having sex with men (MSM) and one (7.1%) as having both male and female sexual partners. Average follow up IIEF-5 among participants was 13 (SD 4.0). Eleven men (78.6 %) described illicit drug use at the time of priapism. Qualitative data analysis yielded several preliminary themes: concomitant drug use, naivety, peer pressure, and delay in seeking treatment. Men frequently reported illicit drug use in group sex scenarios and ICI use under pressure to perform sexually or to counteract effects of illicit substances. CONCLUSIONS Recreational ICI in this cohort was part of a lifestyle of risky behavior. Methamphetamine use and group sex encounters strongly motivate recreational ICI use. Substance abuse centers may offer an entry point into this population for counseling and primary prevention.
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Affiliation(s)
- John M Masterson
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Hanson Zhao
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Eunice Choi
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Howard H Kim
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jennifer T Anger
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA.
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Chen A, Shahiyan RH, Anger JT. Interstitial Cystitis/Bladder Pain Syndrome Treatment: A Systematic Review of Sexual Health Outcomes. Sex Med Rev 2021; 10:71-76. [PMID: 34219009 DOI: 10.1016/j.sxmr.2020.12.005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic condition with highly prevalent negative consequences on sexual health and quality of life. However, there is a lack of consensus regarding treatment options that improve sexual function in this population. This study aims to review the current literature on sexual health outcomes in patients treated for IC/BPS. METHODS We conducted a systematic review of the literature on sexual health outcomes after treatment of IC/BPS. PubMed, MEDLINE, EMBASE, CINHAL, and Google Scholar were queried, and results were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria for this review were: IC/BPS was clearly defined in the cohort, sexual health outcomes were measured as the primary or a secondary outcome, manuscript was written in English from January 2000 to April 2020. Studies on cystectomy were excluded as radical surgery is a confounding factor for sexual dysfunction. RESULTS We identified 1611 items with our search algorithm and determined that 10 studies ultimately met inclusion criteria. 4 of 10 studies reported improved sexual function after treatment. 4 of 10 studies were randomized control trials and reported no improvement in sexual function in each of the therapies that were investigated. Data were conflicting regarding the effect of intravesical hyaluronic acid. CONCLUSION This systematic review demonstrates the lack of focus on sexual health outcomes in studies of the IC/BPS. There was no strong evidence that any modality used to treat IC/BPS also improves sexual function despite the higher prevalence in this population. Chen A, Shahiyan RH, Anger J. Interstitial Cystitis/Bladder Pain Syndrome Treatment: A Systematic Review of Sexual Health Outcomes. Sex Med Rev 2021;xx:xx-xx.
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Affiliation(s)
- Andrew Chen
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Jennifer T Anger
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Zhao H, Souders CP, Kuhlmann PK, Dallas K, Eilber K, Anger JT. Adverse Events Associated With Synthetic Male Slings: An Analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience Database. Int Neurourol J 2021; 25:172-176. [PMID: 33957719 PMCID: PMC8255823 DOI: 10.5213/inj.2040294.147] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE We sought to describe and analyze the adverse events associated with synthetic male slings reported to the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database. METHODS We queried the MAUDE database for all entries including the terms "Male Sling," "InVance," "Virtue," or "Advance" from January 1st, 2009 to December 31st, 2018. We collected and analyzed information about the event type, date received, report source, source type, and manufacturer. We reviewed and categorized the event description text for each medical device report (MDR). RESULTS A total of 497 adverse events related to the male sling were identified. The adverse events were classified as injury (95.4%), malfunction (4.2%), and other (0.4%). There were no deaths described. The slings involved were the Advance or Advance XP sling (69.8%), InVance (15.5%), Virtue Quadratic (12.3%), or unknown (2.4%). The 4 most common adverse events described were urinary incontinence (46.7%), sling erosion (9.1%), mechanical malfunction (8.2%), and pain/numbness (8.2%). There was no increase in the number of reports in the years following the FDA warnings for urogynecologic mesh. CONCLUSION There was an overall modest number of MDRs related to male slings and the majority of them were reported by the manufacturer. The reporting of adverse events for male slings does not seem to be affected by the controversy and scrutiny towards transvaginal mesh and midurethral slings. Further clinical studies and more objective and detailed databases are needed to investigate the safety of these synthetic slings.
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Affiliation(s)
- Hanson Zhao
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Colby P. Souders
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Paige K. Kuhlmann
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kai Dallas
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Karyn Eilber
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer T. Anger
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Cohen TN, Kanji FF, Burton CS, Patel DC, Lenore Ackerman A, Eilber KS, Anger JT. Applying a Human Factors Approach to Improve Patient Experience with Sacral Neuromodulation. Urology 2021; 156:78-84. [PMID: 34015396 DOI: 10.1016/j.urology.2021.05.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To apply a human factors approach, the study of interactions between humans and complex systems, to investigate patient preparedness, satisfaction, and perceived usability with sacral neuromodulation (SNM) and develop interventions aimed at improving patient experience. MATERIALS AND METHODS Ten patients with overactive bladder undergoing staged SNM were observed, and data including pre-operative preparedness, satisfaction, perceived usability and barriers impacting patient experience were collected. Interventions were developed and an additional ten patients were observed. All patients were English-speaking and at least 18 years of age. RESULTS Pre-intervention patients had difficulty understanding the risks of the procedure, did not know what to expect post-operatively and were unsatisfied with pre-operative materials. Interventions included: A pre-procedure educational video and informational sheet, detailed discharge instructions; and a nursing inservice. Pre-operative preparedness (Stage I: U = 100, z = 3.785, P = .000; Stage II: U = 80, z = 2.864, P = .003), post-operative satisfaction (Stage I: U = 100, z = 3.788, P = .000; Stage II: U = 77.5, z = 2.665, P = .006.) and perceptions of usability (Stage I: U = 77.00, z = 2.056, P = .043.; Stage II: U = 80.50, z = 2.308, P = .019) increased significantly after the intervention. CONCLUSION Our observations highlight the value of implementing a human factors approach to identify and mitigate barriers impacting patient experiences with SNM. Through the implementation of systems-level interventions (ie, interventions that impact the non-clinical aspects of surgery such as patient and/or staff education), significant improvements can be made.
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Affiliation(s)
- Tara N Cohen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Falisha F Kanji
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Claire S Burton
- Department of Urology, University of California Los Angeles, Los Angeles, CA
| | - Deven C Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - A Lenore Ackerman
- Department of Surgery, Division of Female Pelvic Medicine and Reconstructive Surgery, University of California Los Angeles, Los Angeles, CA
| | - Karyn S Eilber
- Department of Surgery, Division of Urology, Cedars-Sinai Health System, Los Angeles, CA
| | - Jennifer T Anger
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Urology, University of California, Los Angeles, CA
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Laden BF, Bresee C, De Hoedt A, Dallas KB, Scharfenberg A, Saxena R, Senechal JF, Barbour KE, Kim J, Freedland SJ, Anger JT. Comorbidities in a Nationwide, Heterogenous Population of Veterans with Interstitial Cystitis/Bladder Pain Syndrome. Urology 2021; 156:37-43. [PMID: 33901534 DOI: 10.1016/j.urology.2021.04.015] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To examine the prevalence of comorbid conditions in a nationwide population of men and women with IC/BPS utilizing a more heterogeneous sample than most studies to date. METHODS Using the Veterans Affairs Informatics and Computing Infrastructure, we identified random samples of male and female patients with and without an ICD-9/ICD-10 diagnosis of IC/BPS. Presence of comorbidities (NUAS [chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, migraines], back pain, diabetes, and smoking) and psychosocial factors (alcohol abuse, post-traumatic stress disorder, sexual trauma, and history of depression) were determined using ICD-9 and ICD-10 codes. Associations between these variables and IC/BPS status were evaluated while adjusting for the potential confounding impact of race/ethnicity, age, and gender. RESULTS Data was analyzed from 872 IC/BPS patients (355 [41%] men, 517 [59%] women) and 558 non-IC/BPS patients (291 [52%] men, 267 [48%] women). IC/BPS patients were more likely than non-IC/BPS patients to have a greater number of comorbidities (2.72+/-1.77 vs 1.73+/-1.30, P < 0.001), experience one or more NUAS (chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and migraines) (45% [388/872] vs. 18% [101/558]; P < 0.001) and had a higher prevalence of at least one psychosocial factor (61% [529/872] v. 46% [256/558]; P < 0.001). Differences in the frequencies of comorbidities between patients with and without IC/BPS were more pronounced in female patients. CONCLUSION These findings validate the findings of previous comorbidity studies of IC/BPS in a more diverse population.
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Affiliation(s)
- Bethany F Laden
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
| | - Catherine Bresee
- Department of Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Amanda De Hoedt
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
| | - Kai B Dallas
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - April Scharfenberg
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
| | - Roopali Saxena
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
| | - Justin F Senechal
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC
| | - Kamil E Barbour
- National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA
| | - Jayoung Kim
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen J Freedland
- Urology Section, Department of Surgery, Veterans Affairs Health Care System, Durham, NC; Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jennifer T Anger
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA.
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Zhao H, Souders C, Carmel M, Anger JT. Low Rates of Urologic Side Effects Following Coronavirus Disease Vaccination: An Analysis of the Food and Drug Administration Vaccine Adverse Event Reporting System. Urology 2021; 153:11-13. [PMID: 33864857 PMCID: PMC8056847 DOI: 10.1016/j.urology.2021.04.002] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/28/2021] [Accepted: 04/01/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To quantify and describe urologic adverse events and symptoms after vaccination with the Pfizer-BioNTech and Moderna COVID-19 vaccines. METHODS AND MATERIALS We queried the FDA Vaccine Adverse Event Reporting System (VAERS) for all reported symptoms following the Pfizer-BioNTech and Moderna vaccines as of February 12th, 2021. All urologic symptoms were isolated and the reported adverse events associated with each symptom were reviewed. RESULTS Out of 15,785 adverse event reports, only 0.7% (113) described urologic symptoms. A total of 156 urologic symptoms were described amongst the 113 adverse event reports. The Pfizer-BioNTech vaccine was responsible for 61% of these reports and the Moderna vaccine was responsible for 39%. These symptoms were grouped into five different categories: Lower Urinary Tract Symptoms (n = 34, 22%), Hematuria (n = 22, 14%), Urinary Infection (n = 41, 26%), Skin and/or Soft Tissue (n = 16, 10%), and Other (n = 43, 28%). The median age of the patients reporting urologic symptoms was 63 years (IQR 44-79, Range: 19-96) and 54% of the patients were female. CONCLUSION Urologic symptoms reported after COVID-19 vaccination are extremely rare. Given the common prevalence of many of these reported symptoms in the general population, there does not appear to be a correlation between vaccination and urologic symptoms, but as the vaccination criteria expands, further monitoring of the Vaccine Adverse Event Reporting System is needed.
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Affiliation(s)
- Hanson Zhao
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Colby Souders
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Maude Carmel
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Jennifer T Anger
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA.
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Burton CS, Gonzalez G, Vaculik K, Khalil C, Zektser Y, Arnold C, Almario CV, Spiegel BMR, Anger JT. Female Lower Urinary Tract Symptom Prevention and Treatment Strategies on Social Media: Mixed Correlation With Evidence. Urology 2021; 150:139-145. [PMID: 32673678 PMCID: PMC9354551 DOI: 10.1016/j.urology.2020.06.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/21/2020] [Accepted: 06/28/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the level of evidence behind recommendations on social media for disease prevention in five lower urinary tract symptoms. MATERIALS AND METHODS We conducted a digital analysis of anonymous online posts on social media sites collected by a social media data mining service. One thousand posts about pelvic organ prolapse, stress urinary incontinence, overactive bladder, urinary tract infection, and interstitial cystitis/bladder pain syndrome were randomly selected. We analyzed these posts for recommendations regarding the prevention and treatment of these diseases, which were then compared to recommendations in available clinical guidelines and assessed for level of evidence. RESULTS A total of 158 of 1000 posts contained 239 prevention strategies. For pelvic organ prolapse, there were 41 strategies identified, 25 (61%) of which had no evidence. For urinary tract infection 14 of 58 (29%) had no evidence, including recommendations for dietary modifications and urinary alkalization. For overactive bladder 8 of 28 (29%) had level 4 or no evidence. For stress urinary incontinence, 12 of 34 (36%) of prevention strategies had no evidence, such as laser rejuvenation and bladder training. Interstitial cystitis had the highest number of prevention strategies, and most were low or nonevidence based (70/79, 89%). CONCLUSION Prevention and treatment strategies are common in online discussions of pelvic floor disorders, but at least one third of these recommendations have no evidential support. There is a role for further online education and social media engagement by health care specialists to promote evidence-based practices.
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Affiliation(s)
- Claire S Burton
- Department of Urology, David Geffen School of Medicine, UCLA, Los Angeles, CA
| | - Gabriela Gonzalez
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Kristina Vaculik
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Carine Khalil
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Yuliya Zektser
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Corey Arnold
- Medical Imaging Informatics, Department of Radiology, UCLA, Los Angeles, CA
| | | | - Brennan M R Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA
| | - Jennifer T Anger
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA.
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Lane GI, Gracely A, Uberoi P, Lee U, Smith AL, Anger JT, Theva D, DeLong J, Kowalik C, Padmanabhan P, Powell CR, Carmel ME, Clemens JQ, Cameron AP, Gupta P. Changes in patient reported outcome measures after treatment for female urethral stricture. Neurourol Urodyn 2021; 40:986-993. [PMID: 33719145 DOI: 10.1002/nau.24653] [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] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION There is a paucity of patient reported outcome measure (PROM) data for women with urethral strictures. To address this gap, we aim to evaluate change in PROM among women who underwent surgery for a stricture. METHODS American Urological Association Symptom Index (AUA-SI) and Urogenital Distress Inventory (UDI-6) data from a multi-institutional retrospective cohort study of women treated for urethral stricture was assessed. RESULTS Fifty-seven women had either AUA-SS or UDI-6 and 26 had baseline and postoperative data for either. Most women underwent urethroplasty (77%) and the majority (73%) remained stricture free at median follow-up of 21 months (interquartile range [IQR] 7-37). The median baseline AUA-SI was 21 (IQR 12-28) and follow-up was 10 (IQR 5-24). After treatment, there was a median decrease of 12 (IQR -18 to -2) in AUA-SI (p = 0.003). The median AUA Quality of life (QOL) score at baseline and follow-up were 6 (IQR 4-6) and 3 (IQR 2-5), respectively. There was a median AUA-QOL improvement of 2 points (-5,0; p = 0.007) from a baseline 5 (unhappy) to 3 (mixed). Median UDI-6 scores were 50 (IQR 33-75) at baseline and 17 (IQR 0-39), at follow-up. After treatment, there was a median decrease of 19 (-31 to -11; p = 0.01). CONCLUSION Women with urethral strictures have severe lower urinary tract symptoms which improved after surgery. This study substantiates the claims that recognizing and treating women with urethral stricture disease greatly improves lower urinary tract symptoms and QOL.
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Affiliation(s)
- Giulia I Lane
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Alyssa Gracely
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Una Lee
- Virginia Mason, Seattle, Washington, USA
| | - Ariana L Smith
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Didi Theva
- Memorial Hospital Miramar, Miramar, Florida, USA
| | | | - Casey Kowalik
- Kansas University Medical Center, Kansas City, Kansas, USA
| | - Priya Padmanabhan
- Kansas University Medical Center, Kansas City, Kansas, USA.,Beaumont Hospital, Royal Oak, Michigan, USA
| | | | - Maude E Carmel
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - J Quentin Clemens
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne P Cameron
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Priyanka Gupta
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
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Gonzalez G, Vaculik K, Khalil C, Zektser Y, Arnold CW, Almario CV, Spiegel BMR, Anger JT. Social media analytics of overactive bladder posts: what do patients know and want to know? Int Urogynecol J 2021; 32:2729-2736. [PMID: 33710426 DOI: 10.1007/s00192-021-04686-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/17/2020] [Accepted: 01/10/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess women's knowledge, patient experience, and treatment decision making regarding overactive bladder (OAB) using digital ethnography. METHODS Online posts were identified using a data mining service. Two hundred randomized posts were reviewed and coded using grounded theory. We then applied a latent Dirichlet allocation (LDA) probabilistic topic modeling process to review the entire collection of identified posts. RESULTS A total of 2618 posts by 1867 unique users from 203 different websites were identified. Our analysis yielded six themes: the impact of OAB on quality of life, patient-physician interactions, online engagement, symptom management, patient knowledge acquisition, and alternative therapies. CONCLUSION Overall, online communities are a source of support for women to self-manage the OAB symptom complex and help overcome treatment pathway challenges. Digital ethnography provides insight into patient knowledge and barriers to patient-centered care, which are important to improve patient outreach. Additionally, we identify similar findings to prior work, indicating the reliability of studying social media.
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Affiliation(s)
- Gabriela Gonzalez
- Department of Urology, Davis School of Medicine, University of California, Sacramento, CA, USA
| | - Kristina Vaculik
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Carine Khalil
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Yuliya Zektser
- David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Corey W Arnold
- Computational Diagnostics, Departments of Radiology and Pathology, UCLA, Los Angeles, CA, USA
| | - Christopher V Almario
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Brennan M R Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Jennifer T Anger
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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