Detecting QT prolongation from a single-lead ECG with deep learning.

For a number of antiarrhythmics, drug loading requires a 3-day hospitalization with continuous monitoring for QT-prolongation. Automated QT monitoring with wearable ECG monitors would enable out-of-hospital care. We therefore develop a deep learning model that infers QT intervals from ECG Lead-I-the lead that is often available in ambulatory ECG monitors-and use this model to detect clinically meaningful QT-prolongation episodes during Dofetilide drug loading. QTNet-a deep neural network that infers QT intervals from Lead-I ECG-was trained using over 3 million ECGs from 653 thousand patients at the Massachusetts General Hospital and tested on an internal-test set consisting of 633 thousand ECGs from 135 thousand patients. QTNet is further evaluated on an external-validation set containing 3.1 million ECGs from 667 thousand patients at another healthcare institution. On both evaluations, the model achieves mean absolute errors of 12.63ms (internal-test) and 12.30ms (external-validation) for estimating absolute QT intervals. The associated Pearson correlation coefficients are 0.91 (internal-test) and 0.92 (external-validation). Finally, QTNet was used to detect Dofetilide-induced QT prolongation in a publicly available database (ECGRDVQ-dataset) containing ECGs from subjects enrolled in a clinical trial evaluating the effects of antiarrhythmic drugs. QTNet detects Dofetilide-induced QTc prolongation with 87% sensitivity and 77% specificity. The negative predictive value of the model is greater than 95% when the pre-test probability of drug-induced QTc prolongation is below 25%. These results show that drug-induced QT prolongation risk can be tracked from ECG Lead-I using deep learning.

Clinical patterns and implications of prescription opioid use in a pediatric population for the management of urolithiasis in the emergency room.

Extrapolations from the adult population have suggested that opioids should be avoided in the management of pediatric urolithiasis, but the literature is sparse with regards to actual practice patterns and the downstream implications. We sought to investigate the rate of oral opioid administration for children presenting to the emergency room (ER) with urolithiasis and to identify associations between opioid administration and return visits and persistent opioid use. The TriNetX Research and Diamond Networks were used for retrospective exploratory and validation analyses, respectively. Patients <18 years presenting to the emergency room with urolithiasis were stratified by the receipt of oral opioids. Propensity score matching was performed in a 1:1 fashion. Incident cases of opioid administration and risk ratios (RRs) for a return ER visit within 14 days and the presence of an opioid prescription at 6 to 12 months were calculated. Of the 4672 patients in the exploratory cohort, 11.9% were prescribed oral opioids. Matching yielded a total of 1084 patients. Opioids at the index visit were associated with an increased risk of return visits (RR 1.51, 95% CI 1.04-2.20, P = 0.03) and persistent opioid use (RR 4.00, 95% CI 2.20-7.26, P < 0.001). The validation cohort included 6524 patients, of whom 5.7% were prescribed oral opioids. Matching yielded a total of 722 patients and demonstrated that opioids were associated with an increased risk of return visits (RR 1.50, 95% CI 1.04-2.16, P = 0.03) but not persistent opioid use (RR 1.70, 95% CI 0.79-3.67, P = 0.17). We find that the opioid administration rate for pediatric urolithiasis appears reassuringly low and that opioids are associated with a greater risk of return visits and persistent use.

Urologist-level variation in the management of T1a renal cell carcinoma: A population-based cohort study.

OBJECTIVES: Lack of strict indications in current guidelines have led to significant variation in management patterns of small renal masses. The impact of the urologist on the management approach for patients with small renal masses has not been explored previously. MATERIALS AND METHODS: Using the linked Surveillance, Epidemiology, and End Results-Medicare database, patients aged ≥66 years diagnosed with small renal masses from January 1, 2004 to December 31, 2013 were identified and assigned to primary urologists. Mixed-effects logistic models were used to evaluate factors associated with different management approaches, estimate urologist-level probabilities of each approach, assess management variation, and determine urologist impact on choice of approach. RESULTS: A total of 12,402 patients with 2,794 corresponding primary urologists were included in the study. At the individual urologist level, the estimated case-adjusted probability of different approaches varied markedly: nonsurgical management (mean, 12.8%; range, 4.9%-36.1%); thermal ablation (mean, 10.8%; range, 2.4%-66.3%); partial nephrectomy (mean, 30.1%; range, 10.1%-66.6%); and radical nephrectomy (mean, 40.4%; range, 17.7%-71.6%). Compared to patient and tumor characteristics, the primary urologist was a more influential measured factor, accounting for 13.6% (vs. 12.9%), 33.8% (vs. 2.1%), 15.1% (vs. 8.4%), and 13.5% (vs. 4.0%) of the variation in management choice for nonsurgical management, thermal ablation, partial nephrectomy, and radical nephrectomy, respectively. CONCLUSIONS: Significant variation exists in the management of small renal masses and appears to be driven primarily by urologist preference and practice patterns. Our findings emphasize the need for unified guidance regarding management of these masses to reduce unwarranted variation in care.

Socioeconomic determinants of racial disparities in survival outcomes among patients with renal cell carcinoma.

PURPOSE: Racially driven outcomes in cancer are challenging to study. Studies evaluating the impact of race in renal cell carcinoma (RCC) outcomes are inconsistent and unable to disentangle socioeconomic disparities from inherent biological differences. We therefore seek to investigate socioeconomic determinants of racial disparities with respect to overall survival (OS) when comparing Black and White patients with RCC. METHODS: We queried the National Cancer Database (NCDB) for patients diagnosed with RCC between 2004 and 2017 with complete clinicodemographic data. Patients were examined across various stages (all, cT1aN0M0, and cM1) and subtypes (all, clear cell, or papillary). We performed Cox proportional hazards regression with adjustment for socioeconomic and disease factors. RESULTS: There were 386,589 patients with RCC, of whom 46,507 (12.0%) were Black. Black patients were generally younger, had more comorbid conditions, less likely to be insured, in a lower income quartile, had lower rates of high school completion, were more likely to have papillary RCC histology, and more likely to be diagnosed at a lower stage of RCC than their white counterparts. By stage, Black patients demonstrated a 16% (any stage), 22.5% (small renal mass [SRM]), and 15% (metastatic) higher risk of mortality than White patients. Survival differences were also evident in histology-specific subanalyses. Socioeconomic factors played a larger role in predicting OS among patients with SRMs than in patients with metastasis. CONCLUSIONS: Black patients with RCC demonstrate worse survival outcomes compared to White patients across all stages. Socioeconomic disparities between races play a significant role in influencing survival in RCC.

Clinicopathologic and Survival After Cystectomy Outcomes in Squamous Cell Carcinoma of the Bladder.

BACKGROUND: Squamous cell carcinoma of the bladder (SqCC) is a rare disease with limited management data. Thus, we sought to characterize the clinicopathologic and survival outcomes amongst patients with SqCC and explore the association of squamous differentiation within urothelial carcinoma (UC w/Squam), as compared to muscle invasive pure UC. METHODS: We conducted a single-center retrospective cohort study of patients, stratified by histology, who underwent cystectomy for MIBC. Baseline clinicopathologic characteristics were compared, and overall survival was assessed using Kaplan-Meier method. RESULTS: We identified 1,034 patients; 37 (3.58%) with SqCC histology, 908 (87.81%) with UC histology, and 89 (8.61%) with UC w/ Squam histology. Among SqCC patients, a higher proportion were Black and similarly a higher proportion were women; amongst patients with UC w/ Squam a higher proportion had lower BMI; and amongst patients with UC a higher proportion had lower clinical (c) T, cN, pathological (p) T, and pN stages. Patients presenting with UC were more likely to receive intravesical therapy; patients presenting with SqCC were less likely to receive neoadjuvant chemotherapy (NAC). Adjuvant chemotherapy rates were similar. With post-hoc Bonferroni analysis, overall survival, cancer-specific survival, and recurrence-free survival were significantly worse for the UC w/ Squam cohort. CONCLUSIONS: UC w/ Squam histology was associated with worse survival outcomes after cystectomy for muscle invasive bladder cancer compared to UC. Our results suggest that UC w/ Squam is associated with more advanced disease compared to UC, warranting further prospective work on consideration of combination therapies for patients with this disease state.

Implications of Opioid Prescriptions for Acute Renal Colic in the Emergency Setting on Return Visits and Long-Term Opioid Dependence.

Introduction: We sought to examine the practice patterns of pain management in the emergency room (ER) for renal colic and the impact of opioid prescriptions on return ER visits and persistent opioid use. Methods: TriNetX is a collaborative research enterprise that collects real-time data from multiple health care organizations within the United States. The Research Network obtains data from electronic medical records and the Diamond Network provides claims data. We queried the Research Network for adults who visited the ER for urolithiasis, stratified by receipt of oral opioid prescriptions, to calculate the risk ratio (RR) of patients returning to the ER within 14 days and persistent opioid use ≥6 months from the initial visit. Propensity score matching was performed to control for confounders. The analysis was repeated in the Diamond Network as a validation cohort. Results: There were 255,447 patients in the research network who visited the ER for urolithiasis, of whom 75,405 (29.5%) were prescribed oral opioids. Black patients were less likely to receive opioid prescriptions than other races (p < 0.001). After propensity score matching, patients who were prescribed opioids had an increased risk of a return ER visit (RR 1.25, confidence interval [95% CI] 1.22-1.29, p < 0.001) and persistent opioid use (RR 1.12, 95% CI 1.11-1.14, p < 0.001) compared with patients who were not prescribed opioids. These findings were confirmed in the validation cohort. Conclusions: A significant proportion of patients presenting to the ER for urolithiasis receive opioid prescriptions, which carries a markedly increased risk of return ER visits and long-term opioid use.

Evaluation of Growth Rates for Small Renal Masses in Elderly Patients Undergoing Active Surveillance.

Background: As the adoption of active surveillance (AS) for small renal masses (SRMs) grows, the number of elderly patients enrolled for a prolonged period of time will increase. However, our understanding of comparative growth rates (GRs) in aging patients with SRMs remains poor. Objective: To examine whether particular age cutoffs are associated with an increased GR for patients undergoing AS for SRMs. Design setting and participants: We identified all patients with SRMs enrolled in the multi-institutional, prospective Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry since 2009 who elected for AS. Outcome measurements and statistical analysis: Two definitions of GR were examined: GR from the initial image (GRi) and GR from the prior image (GRp). Image measurements were dichotomized based on patient age at the time of imaging. Multiple age cutoffs were examined: 65, 70, 75, and 80 yr. Mixed-effect linear regression examined the associations between age and GR, with controlling to account for multiple measurements from the same individual. Results and limitations: We examined 2542 measurements from 571 patients. The median age at enrollment was 70.9 yr (interquartile range [IQR] 63.2-77.4) with a median tumor diameter of 1.8 cm (IQR 1.4-2.5). As a continuous variable, age was not associated with GRi (-0.0001 cm/yr, 95% confidence interval [CI] -0.007 to 0.007, p = 0.97) or GRp (0.008 cm/yr, 95% CI -0.004 to 0.020, p = 0.17) after adjustment. The only age thresholds associated with an increased GR were 65 yr for GRi and 70 yr for GRp. Limitations include the one-dimensional nature of the measurements used. Conclusions: Increased age for patients on AS for SRMs is not associated with increased GRs. Patient summary: We examined whether patients undergoing active surveillance (AS) exhibited accelerated growth of their small renal masses (SRMs) after a certain age. No demonstrable change was seen, suggesting that AS is a safe and durable management option for aging patients with SRMs.

Longitudinal analysis of YouTube videos discussing post-prostatectomy erectile dysfunction.

BACKGROUND: YouTube is heavily utilized by patients as an educational resource, but this content can be fraught with misinformation. We sought to characterize the quality of videos on YouTube discussing postprostatectomy erectile dysfunction and to evaluate metrics associated with retaining a top position in search results over time. METHODS: In October 2019, we watched the first 100 YouTube videos using the search query "radical prostatectomy erectile dysfunction." Videos not relevant to the topic were excluded. Video metrics were collected, and content quality was evaluated using the DISCERN instrument. In June 2022, the search was repeated and video metrics were updated. Video characteristics were associated with search rank and the ability to remain in the top 100 spots using the Pearson correlation coefficient (r) and logistic regression, respectively. RESULTS: We included 81 videos which amassed 529,428 views in 2019. The median total DISCERN score was 29 (IQR 21-42), which is interpreted as a poor quality video. Self-promotion or commercial bias was present in 42 videos (51.9%); false claims were present in 16 (19.8%). There was no correlation between DISCERN score and search rank (r = 0.08, p = 0.49). In 2022, 15 videos remained in the top 100 search results and had a higher median DISCERN score than videos no longer in the top 100 (46 vs. 28.5, p = 0.01). Each additional DISCERN point was associated with a 7% higher odds of remaining in the top 100 (OR 1.07, 95% CI 1.01-1.11, p = 0.003). CONCLUSIONS: The quality of the top 100 YouTube videos discussing postprostatectomy erectile dysfunction is low. Higher quality videos had a higher odds of remaining in the top 100 search results over time but do not correlate with the order in which they are ranked.

The exstrophy experience: A national survey assessing urinary continence, bladder management, and oncologic outcomes in adults.

INTRODUCTION AND OBJECTIVE: The bladder exstrophy-epispadias complex (BEEC) is a rare spectrum of congenital genitourinary malformations with an incidence of 1:10,000 to 1:50,000. Advances in reconstructive surgical techniques have improved clinical outcomes, but there is a paucity in data about disease sequela in adulthood. This is the largest survey to date in the United States exploring the urinary continence, bladder management, and oncologic outcomes in adults with BEEC. METHODS: Respondents were over the age of 18 with a diagnosis of bladder exstrophy, cloacal exstrophy, or epispadias. They were treated at the authors' institution, included in the Association for the Bladder Exstrophy Community (A-BE-C) mailing list, and/or engaged in A-BE-C social media. A survey was created using uniquely designed questions and questionnaires. Survey responses between May 2020 and July 2020 were processed using Research Electronic Data Capture (REDCap). Quantitative and qualitative statistics were used to analyze the data with significance at p < 0.05. RESULTS: A total of 165 patients completed the survey. The median age was 31.5 years (IQR 25.9-45.9). Many patients considered themselves continent of urine, with a median satisfaction score of 74 (IQR 50-97) on a scale from 0 (consider themselves to be completely incontinent) to 100 (consider themselves to be completely continent). There was less leakage among those with a continent urinary diversion compared to those who void or catheterize per urethra (p = 0.003). Patients with intestinal-urinary tract reconstruction, such as augmentation cystoplasty or neobladder creation, were more likely to perform bladder irrigations (p = 0.03). Patients with continent channels were more likely to report UTI than all other forms of bladder management (89.0% vs. 66.2%, p = 0.003). Three (1.9%) patients were diagnosed with bladder cancer. A small portion of patients (27.2%) were given bladder cancer surveillance recommendations by a physician. DISCUSSION: Most patients achieved a satisfactory level of urinary continence, with the highest continence rates in those with a continent urinary diversion. Those with intestinal-urinary tract reconstruction were more likely to perform bladder irrigations, perhaps to avoid complications from intestinal mucous production. The rates of self-reported UTI and were higher in patients with continent channels, but recurrent UTIs were not affected by the type of genitourinary reconstruction. Bladder cancer exists in this population, highlighting the need for long-term follow-up. CONCLUSION: Most BEEC patients achieve a satisfactory level of urinary continence, with the best outcomes in those with a continent urinary diversion. This population requires long-term follow-up with a transitional urologist to ensure adequate oncologic care.

Abdominal Mass in a Phenotypic Female with 46,XY Differences in Sex Development.

We present a case of a large intra-abdominal mass found to be localized pure seminoma within a retained gonad of a 53-year-old phenotypic female with 46,XY differences in sex development (DSD) and androgen insensitivity syndrome (AIS). Our management included extirpation of the mass with contralateral gonadectomy. Historically, patients with AIS would undergo gonadectomy to mitigate the lifetime risk of testicular germ cell tumor development; however, growing evidence suggests safety in retention and surveillance of these gonads into adulthood. This case highlights the importance of lifetime surveillance of patients with 46,XY DSD who elect to retain their gonads.

QTNet: Deep Learning for Estimating QT Intervals Using a Single Lead ECG.

QT prolongation often leads to fatal arrhythmia and sudden cardiac death. Antiarrhythmic drugs can increase the risk of QT prolongation and therefore require strict post-administration monitoring and dosage control. Measurement of the QT interval from the 12-lead electrocardiogram (ECG) by a trained expert, in a clinical setting, is the accepted method for tracking QT prolongation. Recent advances in wearable ECG technology, however, raise the possibility of automated out-of-hospital QT tracking. Applications of Deep Learning (DL) - a subfield within Machine Learning - in ECG analysis holds the promise of automation for a variety of classification and regression tasks. In this work, we propose a residual neural network, QTNet, for the regression of QT intervals from a single lead (Lead-I) ECG. QTNet is trained in a supervised manner on a large ECG dataset from a U.S. hospital. We demonstrate the robustness and generalizability of QTNet on four test-sets; one from the same hospital, one from another U.S. hospital, and two public datasets. Over all four datasets, the mean absolute error (MAE) in the estimated QT interval ranges between 9ms and 15.8ms. Pearson correlation coefficients vary between 0.899 and 0.914. By contrast, QT interval estimation on these datasets with a standard method for automated ECG analysis (NeuroKit2) yields MAEs between 22.29ms and 90.79ms, and Pearson correlation coefficients 0.345 and 0.620. These results demonstrate the utility of QTNet across distinct datasets and patient populations, thereby highlighting the potential utility of DL models for ubiquitous QT tracking.Clinical Relevance- QTNet can be applied to inpatient or ambulatory Lead-I ECG signals to track QT intervals. The method facilitates ambulatory monitoring of patients at risk of QT prolongation.

Characterizing Tumor Thrombus Arising from Non-Clear Cell Renal Cell Carcinoma.

Background: Renal cell carcinoma (RCC) can exhibit a unique vascular tropism that enables tumor thrombus extension into the inferior vena cava (IVC). While most RCC subtypes that form tumor thrombi are of clear cell (cc) histology, non-clear cell (ncc) subtypes can also exhibit this unique growth pattern. Objective: To characterize clinicopathologic differences and survival outcomes among patients with IVC tumor thrombus arising from ccRCC versus nccRCC. Design setting and participants: Patients diagnosed with IVC tumor thrombus secondary to RCC in our institutional experience from 2003 to 2021 were identified. Outcome measurements and statistical analysis: Clinicopathologic characteristics were compared by histology. Perioperative and oncologic outcomes including recurrence-free (RFS), overall (OS), and cancer-specific (CSS) survival were assessed using multivariable Cox regression analyses. Results and limitations: The analyzed cohort included 103 patients (82 ccRCC and 21 nccRCC). There were no significant differences in baseline demographic parameters. Patients with nccRCC were more likely to have regional lymph node involvement (42.9% vs 20.7%, p = 0.037). No differences in perioperative outcomes, IVC resection, or IVC reconstruction were observed between groups. The median follow-up time was 30 mo. The median RFS was 30 (nccRCC) versus 53 (ccRCC) mo (p = 0.1). There was no significant difference in OS or CSS. This study was limited by its small sample size. Conclusions: Patients with IVC tumor thrombus arising from ccRCC and nccRCC exhibit similar perioperative and oncologic outcomes. While surgical appropriateness was not impacted by histologic subtype, multimodal strategies are needed to improve outcomes for patients with tumor thrombus. Patient summary: Renal cell carcinoma (RCC) can uniquely invade vasculature and form a tumor thrombus. This study examined the difference in outcomes of patients with tumor thrombus based on RCC subtype (clear cell vs non-clear cell). We found that patients exhibited similar surgical and survival outcomes regardless of RCC type.

Differential changes in self-reported quality of life in elderly populations after diagnosis of a genitourinary malignancy.

BACKGROUND: The time of cancer diagnosis is a major event during which quality of life (QOL) can be affected and represents a crucial time to identify patients at high risk of decline. We sought to compare the differential effects of the diagnosis of 3 major urologic malignancies on QOL. METHODS: The Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey database was queried for patients who completed a QOL questionnaire (SF-36 or VR-12) before and after a diagnosis of bladder, kidney, or prostate cancer. Primary outcome measures were the mental component summary (MCS), and physical component summary (PCS) scores. Mixed effects linear regression was performed with cancer diagnosis as the primary variable of interest, with race and cardiovascular comorbidity status included as potentially confounding independent variables. RESULTS: There were 3,258 patients with urologic cancers. Both MCS and PCS scores dropped after diagnosis in all disease states. Bladder and kidney cancer patients demonstrated the greatest decline in MCS score (-1.762 points, 95% CI-2.571 to -0.952, P < 0.001) and PCS score (-3.769 points, 95% CI-5.042 to -2.496, P < 0.001), respectively, after adjustment for potential confounders. By contrast, prostate cancer patients demonstrated the smallest decline in both domains. Race and cardiovascular comorbidity status were independently associated with QOL, with an association 2 to 3 times greater than that of cancer diagnosis. CONCLUSIONS: Diagnosis of a urologic cancer was associated with a decline in patient-reported QOL, particularly in those with bladder or kidney cancer. Changes in physical health were more prominent than in mental health. Race and cardiovascular comorbidity status influenced QOL domains to a greater extent than specific urologic cancer diagnosis.

Deploying the Behavioral and Environmental Sensing and Intervention for Cancer Smart Health System to Support Patients and Family Caregivers in Managing Pain: Feasibility and Acceptability Study.

BACKGROUND: Distressing cancer pain remains a serious symptom management issue for patients and family caregivers, particularly within home settings. Technology can support home-based cancer symptom management but must consider the experience of patients and family caregivers, as well as the broader environmental context. OBJECTIVE: This study aimed to test the feasibility and acceptability of a smart health sensing system-Behavioral and Environmental Sensing and Intervention for Cancer (BESI-C)-that was designed to support the monitoring and management of cancer pain in the home setting. METHODS: Dyads of patients with cancer and their primary family caregivers were recruited from an outpatient palliative care clinic at an academic medical center. BESI-C was deployed in each dyad home for approximately 2 weeks. Data were collected via environmental sensors to assess the home context (eg, light and temperature); Bluetooth beacons to help localize dyad positions; and smart watches worn by both patients and caregivers, equipped with heart rate monitors, accelerometers, and a custom app to deliver ecological momentary assessments (EMAs). EMAs enabled dyads to record and characterize pain events from both their own and their partners' perspectives. Sensor data streams were integrated to describe and explore the context of cancer pain events. Feasibility was assessed both technically and procedurally. Acceptability was assessed using postdeployment surveys and structured interviews with participants. RESULTS: Overall, 5 deployments (n=10 participants; 5 patient and family caregiver dyads) were completed, and 283 unique pain events were recorded. Using our "BESI-C Performance Scoring Instrument," the overall technical feasibility score for deployments was 86.4 out of 100. Procedural feasibility challenges included the rurality of dyads, smart watch battery life and EMA reliability, and the length of time required for deployment installation. Postdeployment acceptability Likert surveys (1=strongly disagree; 5=strongly agree) found that dyads disagreed that BESI-C was a burden (1.7 out of 5) or compromised their privacy (1.9 out of 5) and agreed that the system collected helpful information to better manage cancer pain (4.6 out of 5). Participants also expressed an interest in seeing their own individual data (4.4 out of 5) and strongly agreed that it is important that data collected by BESI-C are shared with their respective partners (4.8 out of 5) and health care providers (4.8 out of 5). Qualitative feedback from participants suggested that BESI-C positively improved patient-caregiver communication regarding pain management. Importantly, we demonstrated proof of concept that seriously ill patients with cancer and their caregivers will mark pain events in real time using a smart watch. CONCLUSIONS: It is feasible to deploy BESI-C, and dyads find the system acceptable. By leveraging human-centered design and the integration of heterogenous environmental, physiological, and behavioral data, the BESI-C system offers an innovative approach to monitor cancer pain, mitigate the escalation of pain and distress, and improve symptom management self-efficacy. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/16178.

Active Surveillance versus Immediate Intervention for Small Renal Masses: A Cost-Effectiveness and Clinical Decision Analysis.

PURPOSE: Active surveillance (AS) with the possibility of delayed intervention (DI) is emerging as a safe alternative to immediate intervention for many patients with small renal masses (SRMs). However, limited comparative data exist to inform the most appropriate management strategy for SRMs. MATERIALS AND METHODS: Decision analytic Markov modeling was performed to estimate the health outcomes and costs of 4 management strategies for 65-year-old patients with an incidental SRM: AS (with possible DI), immediate partial nephrectomy, radical nephrectomy, and thermal ablation. Mortality, direct medical costs, quality-adjusted life-years, and incremental cost-effectiveness ratios were evaluated over 10 years. RESULTS: The 10-year all-cause mortality was 22.6% for AS, 21.9% for immediate partial nephrectomy, 22.4% for immediate radical nephrectomy, and 23.7% for immediate thermal ablation. At a willingness-to-pay threshold of $100,000/quality-adjusted life-year, AS was the most cost-effective management strategy. The results were robust in univariate, multivariate, and probabilistic sensitivity analyses. Clinical decision analysis demonstrated that the tumor's metastatic potential, patient age, individual preferences, and health status were important factors influencing the optimal management strategy. Notably, if the annual probability of metastatic progression from AS was sufficiently low (under 0.35%-0.45% for most ages at baseline), consistent with the typical metastatic potential of SRMs <2 cm, AS would achieve higher health utilities than the other strategies. CONCLUSIONS: Compared to immediate intervention, AS with timely DI offers a safe and cost-effective approach to managing patients with SRMs. For patients harboring tumors of very low metastatic potential, AS may lead to better patient outcomes than immediate intervention.

Association Between Temperature and Inpatient Stone Admission in a Pediatric Population.

Background: Higher temperatures have been associated with increased stone formation and subsequent utilization of hospital resources, including inpatient admission. However, these observations have been derived from the adult population. We sought to examine if this purported association extends to the pediatric population. Methods: We used the 2016 Kids' Inpatient Database to identify nationwide pediatric inpatient admissions related to nephrolithiasis. Temperature data from the National Oceanic and Atmospheric Administration was linked to each admission. Comparative statistics analyzed patient and admission characteristics. Multivariable logistic regression analyzed associations between stone-related admissions and temperature. As a frame of reference, this analysis was replicated using the National Inpatient Sample from 2016 to evaluate associations in the adult population. Results: Of the 2,496,257 pediatric admissions, 8453 (0.33%) were related to nephrolithiasis. Temperatures at the time of stone admission were higher than those during nonstone admission (55.9°F vs 54.8°F, p < 0.001). The stone admission group had a higher proportion of females than the nonstone admission group (64.8% vs 55.4%, p < 0.001). Stone admission was significantly associated with temperature (odds ratio [OR] 1.025 per 10°F, confidence interval [95% CI] 1.003-1.049, p = 0.03) and female gender (OR 1.097, 95% CI 1.027-1.171, p = 0.006). In the adult population, 380,520 out of 30,000,941 patients (1.3%) were admitted with a stone. The effect of temperature on stone admissions was similar to that in the pediatric population (OR 1.020, 95% CI 1.014-1.026, p < 0.001), but women were >20% less likely to be admitted for stones than men (OR 0.770, 95% CI 0.757-0.784, p < 0.001). Conclusions: Increased temperatures were associated with an increased risk of stone-related admission in both the pediatric and adult populations. Females were at increased risk for stone-related admissions during childhood, but this trend reverses in adulthood.

Validity and Feasibility of the Monitoring and Modeling Family Eating Dynamics System to Automatically Detect In-field Family Eating Behavior: Observational Study.

BACKGROUND: The field of dietary assessment has a long history, marked by both controversies and advances. Emerging technologies may be a potential solution to address the limitations of self-report dietary assessment methods. The Monitoring and Modeling Family Eating Dynamics (M2FED) study uses wrist-worn smartwatches to automatically detect real-time eating activity in the field. The ecological momentary assessment (EMA) methodology was also used to confirm whether eating occurred (ie, ground truth) and to measure other contextual information, including positive and negative affect, hunger, satiety, mindful eating, and social context. OBJECTIVE: This study aims to report on participant compliance (feasibility) to the 2 distinct EMA protocols of the M2FED study (hourly time-triggered and eating event-triggered assessments) and on the performance (validity) of the smartwatch algorithm in automatically detecting eating events in a family-based study. METHODS: In all, 20 families (58 participants) participated in the 2-week, observational, M2FED study. All participants wore a smartwatch on their dominant hand and responded to time-triggered and eating event-triggered mobile questionnaires via EMA while at home. Compliance to EMA was calculated overall, for hourly time-triggered mobile questionnaires, and for eating event-triggered mobile questionnaires. The predictors of compliance were determined using a logistic regression model. The number of true and false positive eating events was calculated, as well as the precision of the smartwatch algorithm. The Mann-Whitney U test, Kruskal-Wallis test, and Spearman rank correlation were used to determine whether there were differences in the detection of eating events by participant age, gender, family role, and height. RESULTS: The overall compliance rate across the 20 deployments was 89.26% (3723/4171) for all EMAs, 89.7% (3328/3710) for time-triggered EMAs, and 85.7% (395/461) for eating event-triggered EMAs. Time of day (afternoon odds ratio [OR] 0.60, 95% CI 0.42-0.85; evening OR 0.53, 95% CI 0.38-0.74) and whether other family members had also answered an EMA (OR 2.07, 95% CI 1.66-2.58) were significant predictors of compliance to time-triggered EMAs. Weekend status (OR 2.40, 95% CI 1.25-4.91) and deployment day (OR 0.92, 95% CI 0.86-0.97) were significant predictors of compliance to eating event-triggered EMAs. Participants confirmed that 76.5% (302/395) of the detected events were true eating events (ie, true positives), and the precision was 0.77. The proportion of correctly detected eating events did not significantly differ by participant age, gender, family role, or height (P>.05). CONCLUSIONS: This study demonstrates that EMA is a feasible tool to collect ground-truth eating activity and thus evaluate the performance of wearable sensors in the field. The combination of a wrist-worn smartwatch to automatically detect eating and a mobile device to capture ground-truth eating activity offers key advantages for the user and makes mobile health technologies more accessible to nonengineering behavioral researchers.

Residual CIS after neoadjuvant chemotherapy and radical cystectomy for muscle invasive bladder cancer: Implications for neoadjuvant trials.

PURPOSE: To better define surrogate endpoints for neoadjuvant chemotherapy (NAC) trials in patients with muscle-invasive bladder cancer. We compared survival in patients with carcinoma in-situ (CIS) only vs. complete response following NAC and radical cystectomy (RC). MATERIALS AND METHODS: Patients with cT2-4N0M0 disease treated with NAC and RC between 2001 and 2018 were stratified by response: complete response (CR, pT0N0), partial response (PR, pTaN0, pT1N0+/-CIS), CIS-only (pTisN0), stable disease (SD, pT2N0), or progressive disease (PD, >pT2N0). Primary endpoints were overall survival (OS) and risk of recurrence in patients with CIS-only vs. CR. Multivariable Cox proportional hazards regression model was used for OS and a competing risks proportional hazards model was used for risk of recurrence. RESULTS: Of 1,406 patients in our institution cohort, 340 patients met inclusion criteria. Kaplan-Meier mean estimates of OS for CR and CIS-only were 108.9 months (95% CI 89.7-127.9) and 125.8 months (95% CI 112.3-139.3), respectively (P = 0.13). Cox proportional hazards model found no difference in OS between patients with PR (HR 1.06, 95% CI 0.33-2.58, P = 0.897) or CIS-only (HR 0.422, 95% CI 0.15-1.18, P = 0.101) when compared to CR. The risk of recurrence was similar between patients with CIS-only (HR 0.73, 95% 0.29-1.84, P = 0.49) and PR (HR 1.32, 95% CI 0.54-3.29, P = 0.54) when compared to CR on competing risks analysis. CONCLUSIONS: Residual CIS-only after NAC and RC demonstrated similar survival outcomes when compared to patients with pathologic CR. Further study in large multi-institutional cohorts may further validate CIS-only as an additional surrogate endpoint after NAC and may inform future trials.

Urologist Scores in the Era of the Merit-Based Incentive Payment System (MIPS).

INTRODUCTION: The shift from fee-for-service to value-based payment introduces a new set of challenges and opportunities for the practicing physician. It is unknown how urologists have been impacted by the recent implementation of the merit-based incentive payment system (MIPS). We describe the MIPS performance scores of urologists and investigate their association with practice patterns. METHODS: Urologists were identified in the 2018 MIPS performance score database and classified by participation status: individual practice, group practice or alternative payment model (APM). The overall MIPS score is comprised of 4 categories: quality, promoting interoperability, cost and improvement activities. Comparative statistics were performed using Tukey's honest significance test and chi-square analysis. Multinomial logistic regression was performed to test associations. RESULTS: A total of 9,055 urologists were included with the following average scores: quality 82.5, promoting interoperability 88.9, cost 74.4, improvement activities 37.3 and overall 86.9. When stratified by participation status, urologists in group practices scored higher than individual urologists in each category except cost; urologists in APMs often scored even higher. Preference for group practice or APMs was more common among urologists who graduated medical school more recently. Geographic location also appears to be a contributing factor when evaluating practice type. CONCLUSIONS: Urologists who participated as a group practice or APM scored higher across most MIPS categories than those in an individual practice. Introduction of a new reimbursement schedule will likely result in further evolution of practice patterns in the future.