Imaging Diagnosis: Thoracic radiographic features of toxoplasmosis in a 14-month-old Red Kangaroo (Macropus rufus).

A privately owned 14-month-old intact female red kangaroo (Macropus rufus) was presented for acute onset respiratory distress and lethargy. On presentation, the kangaroo was laterally recumbent, tachypneic, dyspneic, lethargic, and obtunded. Thoracic radiographs revealed a severe diffuse mixed pulmonary pattern (alveolar pattern superimposed on a bronchial pattern) and subjective mild generalized cardiomegaly. Due to the severity of clinical signs and grave prognosis, euthanasia was elected. Postmortem examination was consistent with systemic toxoplasmosis. Histopathology and immunohistochemistry staining on infected tissues confirmed Toxoplasma gondii. This is the first published report of radiographic findings for confirmed toxoplasmosis in a red kangaroo or marsupial.

Impact of an inpatient advanced practice provider on hospital length of stay after major urologic oncology procedures.

INTRODUCTION: Although timely hospital discharge is a complex and multifactorial process, this metric is consistently a focus for hospitals and health care systems. It also has been a long practice that the American Urological Association (AUA) supports the use of advanced practice providers (APPs) as an integral member of the urological care team. MATERIALS AND METHODS: Here, we performed a preliminary evaluation of the effectiveness of an inpatient APP in reducing hospital length of stay (LOS) following major urologic oncology procedures. Surgical outcomes, surgeon data, and LOS for open and minimally invasive urologic oncology procedures, including radical prostatectomy, partial or radical nephrectomy, and radical cystectomy, were compiled over a 4-year period (pre-APP: 2014-2016 and post-APP: 2018-2020). Univariate descriptive statistics analyzed the association of an inpatient APP in with reducing hospital LOS over time. RESULTS: Average LOS decreased in all surgical procedures and for all surgeons in the post-APP setting, irrespective of surgical approach (P< 0.05). CONCLUSIONS: An inpatient APP was associated with a decrease of hospital LOS for urologic oncology patients over time. Such observations underscore the likely economic benefit to the health care system and potential improved coordination of care and satisfaction for patients undergoing major urologic oncology procedures.

Improving Fluid Intake Behavior Among Patients With Kidney Stones: Understanding Patients' Experiences and Acceptability of Digital Health Technology.

OBJECTIVE: To understand kidney stone patients' experiences with increasing fluid intake, common barriers to adherence, and technology-mediated intervention techniques that may improve adherence in this population. Increasing fluid intake to produce at least 2.5 L of urine daily is a well-established preventive strategy to reduce the risk of kidney stones. Unfortunately, adherence with this well-known and inexpensive recommendation is commonly below 50%. MATERIALS AND METHODS: Patients with a history of kidney stones were recruited to participate in semistructured focus groups about their experiences with increasing fluid intake. Inductive content analysis was used to extract themes from focus group transcripts. RESULTS: Themes from discussions with 19 patients described current fluid intake strategies, barriers to increasing fluid intake, and desirable features in a digital tool for promoting fluid intake. Common barriers to increasing fluid intake included work habits, travel, leisure activities, forgetting to drink, limited access to water, and not feeling thirsty. Patients had tried to increase fluid intake using strategies such as carrying a water bottle, identifying contextual cues for drinking, self-monitoring fluid intake, and seeking social support. Patients expressed interest in wearing sensors to improve fluid intake if the sensor was aesthetically pleasing, had guaranteed benefit and was able to connect to existing devices. The most acceptable location to wear a sensor was as a wristband or bracelet. CONCLUSION: The use of automated and semiautomated tracking technology in combination with evidence-based behavior change techniques should be explored in efforts to improve adherence to fluid intake recommendations.

Accuracy of the NSQIP risk calculator for predicting complications following adrenalectomy.

PURPOSE: Adrenalectomy is performed to treat functional pathology and remove tumors of malignant concern. The National Surgical Quality Improvement Program (NSQIP) risk calculator predicts 30-day complications and length of stay following index surgical procedures. We assess whether this tool accurately predicts complications following adrenalectomy procedures at a tertiary care academic medical center. METHODS: A retrospective review was performed for all adrenalectomies at a single institution from 2004 to 2016. 197 patients underwent adrenalectomy without concurrent resections. Predicted risk for NSQIP complications was calculated for each patient. The mean predicted and observed risks (%) at 30 days across all patients within each category were determined, and these were compared with two-sided one-sample t tests. RESULTS: Of 197 adrenalectomies, 180 were laparoscopic and 17 were open. For laparoscopic adrenalectomy, ten (5.5%) complications were observed including nine (5%) graded Clavien III or greater. All observed complication rates were significantly different than predicted (p values for all < 0.005). Mean observed length of stay was also significantly less than predicted (1.6 versus 2.1 days, p < 0.001). In the open adrenalectomy subgroup, there were no observed complications with observed mean length of stay equivalent to predicted (5.8 versus 5.3, p = 0.08) without a higher readmission rate (5.9 versus 6.0%). CONCLUSIONS: Statistical differences were noted between the actual complication rates of adrenalectomy versus those predicted by the NSQIP calculator. Certain observed differences may not necessarily have clinical significance. Urology procedure-specific calculators may better refine predictions for sub-specialty procedures with future work requisite to determine performance across all practice settings.

Capturing Renal Cell Carcinoma Recurrences When Asymptomatic Improves Patient Survival.

INTRODUCTION: The purpose of this study was to explore whether the practice of postoperative renal cell carcinoma (RCC) surveillance affords a survival benefit by investigating whether detection of RCC recurrences in an asymptomatic versus symptomatic manner influences mortality. PATIENTS AND METHODS: We identified 737 patients who underwent partial or radical nephrectomy for M0 RCC between 1998 and 2016. Overall survival and disease-specific survival stratified by the type of recurrence detection (asymptomatic vs. symptomatic) was estimated using Kaplan-Meier probabilities both from the time of surgery and from the time of recurrence. Cox proportional hazard regression models were used to evaluate the impact of the type of recurrence detection on mortality. RESULTS: A total of 78 patients (10.6%) experienced recurrence after surgery, of whom 63 (80.8%) were asymptomatic (detected using routine surveillance) and 15 (19.2%) were symptomatic. The median postoperative follow-up was 47.2 months (interquartile range, 26.3-89.4 months). Five- and 10-year overall survival, from time of surgery, among patients with asymptomatic versus symptomatic recurrences was 57% and 39% versus 24% and 8%, respectively (P = .0002). As compared with asymptomatic recurrences, patients with symptomatic recurrences had an increased risk of overall (OD) and disease-specific death (DSD) both when examined from the time of surgery (OD: hazard ratio [HR], 3.16; 95% confidence interval [CI], 1.33-7.49; P = .0091 and DSD: HR, 3.44; 95% CI, 1.38-8.57; P = .0079) and from the time of recurrence (OD: HR, 2.93; 95% CI, 1.24-6.93; P = .0143 and DSD: HR, 3.62; 95% CI, 1.45-9.01; P = .0058). CONCLUSIONS: Capturing RCC recurrences in an asymptomatic manner during routine surveillance is associated with improved patient survival.

Acceptability of Mobile Health Technology for Promoting Fluid Consumption in Patients With Nephrolithiasis.

OBJECTIVE: To evaluate kidney stone patients' interest in lifestyle behavior modification and a variety of mobile health (mHealth) technologies to improve adherence to fluid consumption recommendations for the prevention of nephrolithiasis. Of particular interest was the acceptability of various intervention components for the design of a stone-specific mHealth technology. MATERIALS AND METHODS: Using a cross-sectional design, adult patients with a diagnosis of kidney stones (n = 94) were recruited from outpatient clinics to complete a three-part questionnaire. RESULTS: Patients reported being willing to make lifestyle changes to prevent kidney stones (97%). The majority of the patients recalled the recommendation to increase fluid intake (93%) but few monitored their daily fluid intake (30%). Most patients had never installed an app (95%) or owned a device (100%) to help with increasing fluid consumption, but believed an app or device could improve their adherence (72%) and would be interested in using an app or device (86%). The mHealth intervention components most widely perceived as useful included automated lapse detection with notifications, educational materials, self-monitoring tools, scheduler with prompts and/or reminders and/or notifications, connected water bottles and text message reminders to drink. CONCLUSION: Patients are interested in lifestyle behavior change to prevent stones but technology has not been widely adopted to improve adherence to fluid intake recommendations for stone prevention. This study identified a number of viable mHealth intervention components that should be considered when designing a stone-specific mHealth technology to support adherence to increased fluid consumption recommendations.

Topical rectal antiseptic at time of prostate biopsy: how a resident patient safety project has evolved into institutional practice.

PURPOSE: To report outcomes 5 years after a resident quality initiative incorporated topical rectal antiseptic into our ultrasound-guided prostate needle biopsy (TRUS PNB) protocol. METHODS: A chart review was conducted on 1007 men who underwent TRUS PNB between 2010 and 2017. Comparison groups include those who received a topical rectal antiseptic (N = 437) compared to those who did not (N = 570). Povidone-iodine (N = 303) or 4% chlorhexidine solution without alcohol (N = 134) were topical agents. Outcomes of interest included post-biopsy infection (urinary tract infection and/or sepsis), hospital admission, and need for ICU monitoring. RESULTS: Median age and PSA of men included in this study were 64 years and 12 ng/mL. Almost 90% of patients were Caucasian, 13% had diabetes, 3% were on immunosuppression, 32% had at least one prior biopsy, 14% received antibiotics, and 7% were hospitalized in the past 6 months. 22 patients (2.2%) developed a post-biopsy infection with a significant reduction in the group receiving topical rectal antiseptic (0.8 vs. 3.3%, p = 0.01). Post-biopsy UTI rates (p = 0.04) and hospital admission (p = 0.03) were also lower in the topical antiseptic group with trends to reduction in sepsis and need for ICU monitoring. CONCLUSIONS: What started as a resident quality safety project 5 years ago has demonstrated a reduction in infections and hospital admissions following TRUS PNB. Our institutional practice now routinely uses povidone-iodine or chlorhexidine as an adjunct to oral quinolones for TRUS PNB perioperative prophylaxis.

Preoperative urine culture is unnecessary in asymptomatic men prior to prostate needle biopsy.

PURPOSE: To determine the clinical utility of preoperative urine cultures in asymptomatic men undergoing prostate needle biopsy (PNB). METHODS: One hundred fifty asymptomatic men had urine cultures obtained 14-days prior to PNB. As per study protocol, positive cultures were not treated. Antibiotic prophylaxis prior to PNB included ciprofloxacin 500 mg the night before and morning of the biopsy. Repeat urine cultures were obtained immediately prior to PNB with colony-forming units (CFUs) annotated. Infectious complications post-biopsy were recorded. RESULTS: Of the 150 men, six patients (4%) had evidence of asymptomatic bacteriuria with > 10,000 CFU/mL on office urine culture. Repeat urine cultures on morning of biopsy in all 150 patients noted a mean bacterial count of 55 CFU/mL (range 0-1000). All six patients with positive office urine cultures had < 100 CFU/mL at time of PNB. Following biopsy, four patients (2.7%) developed an infectious complication including two with sepsis and two with culture-positive UTIs. The causative organism in all cases was quinolone-resistant E. coli. None of the six patients with preoperative positive urine cultures developed an infectious complication following PNB. CONCLUSIONS: In this prospective observational study, under 5% of asymptomatic men had positive office cultures prior to PNB. Furthermore, repeat urine culture on the morning of biopsy showed resolution in these patients, and none developed post-biopsy infectious complications. Routine office urine culture in the asymptomatic male prior to PNB was unnecessary.

Comparison of two indices to annotate complications after radical nephroureterectomy.

INTRODUCTION: The Clavien-Dindo (CD) and Comprehensive Complication Index (CCI) are two grading systems that annotate adverse events following surgical procedures. We compare these two classification systems in a cohort of patients undergoing radical nephroureterectomy (RNU). MATERIALS AND METHODS: The charts of 110 consecutive RNU patients were reviewed for complications occurring within 30 days of surgery. Grading by the CD classification system and values for CCI were calculated. Bivariate and multivariate analysis identified associations between perioperative variables and complications, as well as relationship to hospital length of stay. RESULTS: Sixty-seven men and 43 women with a median age of 71, body mass index of 29, estimated glomerular filtration rate (eGFR) of 64 mL/min/1.73 m², and Charlson score of 4 were included. Seventy-five percent underwent a minimally invasive RNU, 47% had a lymph node dissection, and 7% received neoadjuvant chemotherapy. Median hospital length of stay was 4 days (range, 2-22). Overall, 39 patients (35%) experienced a total of 56 complications including 12 major (≥ Clavien III) and 44 minor. Median CCI patients with complications cohort was 20.9 (range, 8.7-100). The upper quartile of CCI (> 75th %) was associated with higher Charlson score (p = 0.03), lower baseline eGFR (p = 0.005), intraoperative transfusion (p = 0.004), and absence of symptoms at presentation (p = 0.015). Major CD complications were associated with these same variables. On multivariate analysis, only the upper quartile of CCI was associated with length of stay (8.25 versus 5.61 days, p < 0.0001) whilst major CD complications were not (7.98 versus 6.32, p = 0.211). CONCLUSIONS: The CCI and CD classification schemes are both associated with similar baseline and perioperative characteristics for RNU patients. However, the cumulative nature of CCI appears to permit more accurate prediction of length of stay following surgery compared to the CD system.

Procedural povidone iodine rectal preparation reduces bacteriuria and bacteremia following prostate needle biopsy.

INTRODUCTION: To determine if a povidone iodine rectal preparation (PIRP) reduces rates of bacteriuria and bacteremia following transrectal ultrasound guided prostate needle biopsy (TRUS PNB). MATERIALS AND METHODS: Men undergoing TRUS PNB were prospectively enrolled in a study comparing the impact of PIRP versus standard of care (two pills of ciprofloxacin 500 mg). Urine, blood, and rectal cultures were obtained 30 minutes post-procedure with colony forming units (CFUs) determined after 48 hours. Patients were called 7 and 30 days post-procedure to evaluate for infections. RESULTS: A total of 150 men were accrued into this study including 95 receiving PIRP and 55 the standard of care. Two-thirds of patients were undergoing an initial biopsy, 19% used antibiotics within the previous 6 months, and median number of biopsy cores was 14. There were no differences between the two cohorts with respect to baseline or biopsy characteristics. In the PIRP cohort, rectal cultures before and after PIRP administration noted a 97.2% reduction in microorganism colonies (2.4 x 10 5 CFU/mL versus 6.7 x 10³CFU/mL, p < 0.001). Mean urine bacterial counts following TRUS PNB were 1 CFU/mL for PIRP versus 7 CFU/mL for standard cohort (p < 0.001). Mean serum bacterial counts following TRUS PNB were 0 CFU/mL for PIRP versus 3 CFU/mL for standard of care (p = 0.01). One patient in the PIRP cohort (1.1%) developed post-biopsy sepsis while 3 (5.5%) in the standard cohort had an infectious complication (1 UTI, 2 sepsis). CONCLUSION: A PIRP regimen reduced bacteruria and bacteremia following TRUS PNB.

Povidone Iodine Rectal Preparation at Time of Prostate Needle Biopsy is a Simple and Reproducible Means to Reduce Risk of Procedural Infection.

Single institution and population-based studies highlight that infectious complications following transrectal ultrasound guided prostate needle biopsy (TRUS PNB) are increasing. Such infections are largely attributable to quinolone resistant microorganisms which colonize the rectal vault and are translocated into the bloodstream during the biopsy procedure. A povidone iodine rectal preparation (PIRP) at time of biopsy is a simple, reproducible method to reduce rectal microorganism colony counts and therefore resultant infections following TRUS PNB. All patients are administered three days of oral antibiotic therapy prior to biopsy. The PIRP technique involves initially positioning the patient in the standard manner for a TRUS PNB. Following digital rectal examination, 15 ml of a 10% solution of commercially available povidone iodine is mixed with 5 ml of 1% lidocaine jelly to create slurry. A 4 cmx4 cm sterile gauze is soaked in this slurry and then inserted into the rectal vault for 2 min after which it is removed. Thereafter, a disposable cotton gynecologic swab is used to paint both the perianal area and the rectal vault to a distance of 3 cm from the anus. The povidone iodine solution is then allowed to dry for 2-3 min prior to proceeding with standard transrectal ultrasonography and subsequent biopsy. This PIRP technique has been in practice at our institution since March of 2012 with an associated reduction of post-biopsy infections from 4.3% to 0.6% (p=0.02). The principal advantage of this prophylaxis regimen is its simplicity and reproducibility with use of an easily available, inexpensive agent to reduce infections. Furthermore, the technique avoids exposing patients to additional systemic antibiotics with potential further propagation of multi-drug resistant organisms. Usage of PIRP at TRUS PNB, however, is not applicable for patients with iodine or shellfish allergies.

Critical analysis of 30 day complications following radical nephroureterectomy for upper tract urothelial carcinoma.

INTRODUCTION: Patients with upper tract urothelial carcinoma (UTUC) are often elderly and comorbid owing to associated risk factors for developing this malignancy. Perioperative complications may be significant in such a surgical population. We define the incidence and risk factors associated with perioperative complications occurring within 30 days of radical nephroureterectomy (RNU). MATERIALS AND METHODS: Medical records of 92 consecutive patients undergoing RNU were reviewed. Complications occurring within 30 days of surgery were graded using the modified Clavien-Dindo classification. The number, severity, and type of complications were recorded. Minor complications were classified as Clavien II or less, while major complications were Grade III or greater. Univariate and multivariate analyses determined variables associated with complications. RESULTS: Fifty-seven men and 35 women with a median age of 70 years were included. Three-quarters of the cohort underwent a minimally invasive RNU and 45% had a regional lymph node dissection. Final pathology noted that 53% had muscle-invasive and 70% had high grade UTUC. Overall, 35 patients (38%) experienced complications within 30 days of RNU including 11 (12%) with major complications. Ten patients (11%) had multiple complications. Hematologic, gastrointestinal, and infectious etiologies comprised over 75% of complications. On univariate analysis, patient age, ECOG performance status, surgical approach, non-organ confined disease, and cardiac history were associated with complications. In a multivariate model including these variables, only ECOG ≥ 2 (OR 3.9, 95% CI 1.6-7.4, p < 0.001) was independently associated with post-RNU complications. CONCLUSION: Almost 40% of patients in this cohort experienced a perioperative complication after RNU. One-third of complications were Clavien III or greater. Poor performance status conferred a four-fold greater risk of a perioperative complication. Such knowledge may guide patient counseling and surgical expectations for the postoperative period.

Peri-procedural povidone-iodine rectal preparation reduces microorganism counts and infectious complications following ultrasound-guided needle biopsy of the prostate.

PURPOSE: The purpose of the study was to evaluate whether a peri-procedural povidone-iodine rectal preparation (PIRP) prior to transrectal ultrasound-guided prostate needle biopsy (TRUS PNB) can reduce microorganism colony counts and infectious complications. METHODS: Our institutional TRUS PNB database was reviewed to identify infectious post-biopsy complications (defined as fever >38.5 °C with positive culture). The last 570 biopsy patients were divided into those administered only preoperative oral and/or parenteral antibiotics (n = 456; chronologically cohorts A-D) versus men receiving peri-procedural PIRP in conjunction with standard preoperative antibiotics (n = 114; cohort E). Rectal cultures were obtained in the PIRP cohort to quantify changes in microorganism colony counts. RESULTS: Mean baseline PSA for patients was 11.6 ng/ml, 63 % were undergoing an initial biopsy, and 17 % had documented use of antibiotic therapy within the previous 6 months. A reduction in infectious complications was observed when comparing the conventional antibiotic (cohorts A-D) versus PIRP (cohort E) group (1.8 vs. 0 %), with the largest magnitude of decline occurring in the concurrent contemporary cohorts (cohort D-5.3 % vs. cohort E-0 %, p = 0.03). Rectal cultures obtained in 92 men before and after PIRP administration noted a 97 % reduction in microorganism colonies (2.1 × 10(5) vs. 6.3 × 10(3) CFU/ml, p < 0.001). No adverse reactions to the PIRP were reported by patients 7 days post-biopsy. CONCLUSIONS: Peri-procedural PIRP decreased microorganism colony counts and effectively reduced infectious complications following TRUS PNB. This safe, cheap, and simple strategy may be a reasonable alternative to systemic or targeted antibiotic therapy to reduce post-biopsy infections.

An obese body habitus does not preclude a minimally invasive partial nephrectomy.

INTRODUCTION: Partial nephrectomy (PN) via open or minimally invasive (MI) techniques is the referent standard for managing renal cell carcinoma (RCC) whenever possible. Outcomes of MIPN in the obese patient population are incompletely defined. We investigate the feasibility of MIPN in obesity class I-III patients via comparison of surgical outcomes to those with a lower body mass index (BMI). MATERIALS AND METHODS: The electronic medical records of 184 consecutive patients undergoing MIPN via laparoscopic (n = 109) or robotic (n = 75) techniques were reviewed. Patients were classified into the following patient cohorts stratified by BMI: 1) BMI < 30; 2) BMI 30-35 - obesity class I; 3) BMI 35-40 - obesity class II; 4) BMI > 40 - obesity class III. The association between obesity class and perioperative and pathologic outcomes was determined. RESULTS: Ninety-five men and 89 women with a median age of 55 years, BMI of 31, tumor size of 2.9 cm, and RENAL nephrometry score of 6 were included. Median operative time was 218 minutes, ischemia duration was 23.5 minutes, estimated blood loss (EBL) was 150 cc, and length of stay was 3.0 days. Of the 184 patients, 71 (39%) were non-obese, 58 (32%) had class I obesity, 33 (18%) patients had class II obesity, and 22 (12%) had class III obesity. Compared to patients with a BMI < 30, neither an obese body habitus nor the degree of obesity was associated with any adverse perioperative or pathologic outcomes. In a multivariate model querying variables associated with complications, only a RENAL nephrometry ≥ 8 (HR 5.1, 95% CI 2.4-7.9, p < 0.001) was significant. CONCLUSION: An increase in obesity classification was not associated with adverse outcomes following MIPN. Increasing nephrometry score was the sole variable associated with perioperative complications. The presence of an obese body habitus alone should not preclude offering appropriate patients a MIPN.