Prospective Evaluation of Intradetrusor Injections of OnabotulinumtoxinA in Adults With Spinal Dysraphism.

OBJECTIVE: To prospectively evaluate the effectiveness of OnabotulinumtoxinA (BTX-A) on neurogenic overactive bladder (nOAB) in adults with congenital spinal dysraphism (CSD). METHODS: We conducted a prospective, nonrandomized pilot study of 24 adults with CSD and neurogenic overactive bladder. Patients were evaluated with baseline video-urodynamics (UDS) and validated questionnaires, underwent injection 200U BTX-A, and then underwent repeat evaluation with questionnaires and UDS 1-3 months postinjection. A high-risk subgroup was separately analyzed based on adverse clinical characteristics (ie, decrease bladder compliance, vesicoureteral reflux, hydronephrosis, chronic kidney disease). RESULTS: BTX-A injection improved patient recorded outcome measures seen in both I-QOL Score total (67.9 vs 75.5, P = .007) and Neurogenic Bladder Symptom Score total (38.0 vs 29.0, P = .001). On UDS, BTX-A injection significantly improved end filling pressure (16.0 vs 8.8, P = .036) and also improved bladder compliance (mL/cm H2O) (89.38 vs 135.81, P = .445). High-risk patients were found to have similar improvements in most subjective questionnaire scoring, a significant decrease in end filling pressures, and improved bladder compliance on UDS. CONCLUSION: BTX-A can be used as an effective treatment in adults with CSD. We found that BTX-A significantly improved quality of life from patient reported outcome measurements as well as improving end filling pressures and bladder compliance. These improvements were seen even within our high-risk subgroup. Further studies are needed to evaluate long-term efficacy and appropriate follow-up of this at-risk population.

Management of Recurrent Urinary Tract Infections in Women: How Providers Can Improve the Patient Experience.

OBJECTIVE: To provide guidance to providers on how to improve the patient experience for women with recurrent urinary tract infections (rUTIs). METHODS: The recently updated 2019 American Urological Association (AUA) guidelines for recurrent uncomplicated acute cystitis and other contemporary publications pertaining to recurrent UTIs in women were reviewed. These data were used to summarize practice-based methodology to formulate recommendations with an emphasis on education to enhance the patient experience. RESULTS: We summarize the guideline-based management of patients with rUTI and augment this with a patient-focused perspective to provide recommendations for how to best counsel patients regarding evaluation, treatment using antibiotic stewardship practices, and a comprehensive prevention plan. We focus on patient education as the foundation for successful provider-patient relationships as well as patient compliance with care pathways. CONCLUSION: rUTIs are costly, time-consuming, and painful for patients. For providers, rUTIs represent a frustrating aspect of clinical care facing the balance of antibiotic stewardship with effective treatment and patient expectations with limited data supporting nonantibiotic therapies. Urologists have the skills and knowledge to provide this patient population with competent and compassionate care. By investing in these patients, being responsive to their concerns and offering education, patients will have a better overall experience with this chronic condition.

Nonclinical Barriers to Care for Neurogenic Patients Undergoing Complex Urologic Reconstruction.

OBJECTIVE: To identify nonclinical factors affecting postoperative complication rates in patients with neurogenic bladder undergoing benign genitourinary (GU) reconstruction. METHODS: Adult patients with neurogenic bladder undergoing benign GU reconstruction between October 2010 and November 2015 were included. Patients were excluded if a diversion was performed for malignancy, if patients had a history of radiation or if a new bowel segment was not utilized at the time of the operation. Clinical and nonclinical factors were abstracted from the patients' electronic medical records. Health literacy was assessed via the Brief Health Literacy Screen (BHLS), a validated 3-question assessment. Education, marital status, and distance from the medical center were also queried. RESULTS: Forty-nine patients with a neurogenic bladder undergoing complex GU reconstruction met inclusion and exclusion criteria. On average, patients lived 111 miles (standard deviation 89) from the hospital. Overall, mean BHLS score was 10.4 (standard deviation 4.6) with 35% of patients scoring a BHLS of ≤9. Mean years of educational attainment was 9.7, and only 31% of patients completed high school education. In the first month after surgery, 37 patients (76%) experienced a complication, and 22% were readmitted; however, analysis of complication data did not identify an association between any nonclinical variables and complication rates. CONCLUSION: Nonclinical factors including unmarried status, poor health literacy, and marked distance from quaternary care are prevalent in patients with neurogenic bladder undergoing complex GU reconstruction. To mitigate these potential risk factors, the authors recommend acknowledgment of these factors and multidisciplinary support perioperatively to counteract them.

Urinary-cutaneous Fistulae Following Conservative Management of Extraperitoneal Bladder Ruptures.

OBJECTIVE: To evaluate our experience with urinary-cutaneous fistulae (UCFs) in patients following conservative management of extraperitoneal bladder ruptures (EBRs) caused by blunt trauma. MATERIALS AND METHODS: Patients with blunt-trauma related EBR who underwent primary management with urethral catheter drainage alone from 2000 to 2015 were identified in our institutional trauma registry. The demographics, the hospital courses, and the outcomes of patients who developed UCF were analyzed. RESULTS: A total of 96 patients with EBR were identified, of which 56 (58%) were managed with urethral catheter drainage. 10 patients (18%) developed major urologic complications including urosepsis (2), infected pelvic hardware (1), persistent extravasation without cutaneous fistulization (1), and UCF formation (6). Of the patients with UCF, the median time to diagnosis of EBR was 1.5 days (range 0-12), whereas the median time to diagnosis of UCF was 11 days (range 3-31). Two patients developed UCF to the perineum, whereas 4 developed UCF to the thigh. Four (66.7%) underwent nonurologic operations without cystorrhaphy before the development of UCF. One patient died without a resolution of her fistula. The remaining 5 patients all required operative repair, with a median time to repair from diagnosis of 21 days (range 2-106). The median time to resolution from diagnosis was 64 days (range 35-155). CONCLUSION: UCFs are an under-reported but morbid complication of the nonoperative management of EBR. Although rare, UCF in this setting should prompt surgical intervention given the potential for prolonged convalescence and a low probability of spontaneous resolution.

Medicaid Patient Access to Urological Care in the Era of the Patient Protection and Affordable Care Act: A Baseline to Measure Policy Effectiveness.

INTRODUCTION: Medicaid expansion under PPACA (Patient Protection and Affordable Care Act) sought to increase access to health care by expanding access to insurance. The association between access to Medicaid and access to urological health care, however, has not been tested to our knowledge. To test this association we performed a prospective, survey based analysis of Medicaid acceptance rates and new appointment wait times for a patient seeking urological care. This study presents baseline data collected prior to Medicaid expansion in 2014. METHODS: A primary cohort representing 20% of all urological surgeons in a nationwide database was surveyed using a simulated patient script. The data were collected in November 2013 prior to Medicaid expansion. The primary outcome measures were Medicaid acceptance and new patient appointment wait times. A practice level, secondary cohort was also analyzed. RESULTS: A total of 650 urological surgeons were successfully sampled in the primary cohort, of whom 271 (41.7%) did not accept any Medicaid, 205 (31.5%) accepted some but not all Medicaid and 174 (26.8%) accepted all Medicaid insurance plans. The median wait time for a new patient appointment was 18 days. Medicaid acceptance rates were similar in the secondary cohort. The percentage of urologists accepting all forms of Medicaid varied by state, ranging from 10% to 90%. CONCLUSIONS: Medicaid patient access to urological care is restricted, suggesting that access to Medicaid insurance coverage may not translate into access to urological care. Subsequent data collection will assess trends in Medicaid patient access to urological care following Medicaid expansion.

The Same Fish: Creating Space for Therapeutic Relationships, Play, and Development in a School for Children with Special Needs.

This paper represents and attempts to describe psychoanalytically informed work applied in a school setting with children with special needs. While many therapists at the Parkside School are trained in analytic techniques and principles, these ideas have not traditionally been applied to children with language-based learning difficulties. Over the years, we have found that analytic ideas such as transference, countertransference, projective identification, containment, and attachment are especially salient to our understanding of these very complex children. Despite being in a school--a nontraditional setting for psychoanalysis--children are seen in individual and group therapy, often more than once a week. We believe that therapeutic relationships and play (sometimes bringing a child to a place of being able to play) are especially mutative with children with language-based learning challenges. Play and relationship provide a holding environment that, over time, allows for the reorganization of a child's often immature developmental capacities into a sense of agency that captures more clearly a child's innate potential. This article includes case studies of children with complex language-based learning difficulties, including autism spectrum disorders.

Association of atretic left internal mammary graft with internal mammary to pulmonary vasculature fistula: a case series.

Left internal mammary artery (LIMA) graft to pulmonary vasculature (PV) fistula is a rare complication of coronary artery bypass surgery (CABG), with only a handful of cases being reported. The fistula in these cases connects to a distal branch of the pulmonary artery. The etiology of these fistulae is uncertain, but is thought to be related to post surgical injury and inflammation leading to adhesions and neorevascularization. The association of an atretic LIMA with these fistulae has not been previously reported. We report six cases of LIMA to PV fistulae that were identified on coronary angiography. All six cases were associated with an atretic LIMA graft. All fistulae were small and did not appear to have significant hemodynamic or clinical consequences. This report describes a previously undescribed association of atretic LIMA graft with small LIMA to PV fistula and discusses possible mechanisms for this association.

The first case report of the treatment of transplant coronary artery disease with dextran sulfate adsorption lipid apheresis.

In patients who have undergone a heart transplant, the major cause of death is coronary artery disease (CAD). The etiology of cardiac-allograft vasculopathy is thought to be multifactorial, but due in large part to immune mechanisms that cause elevations in serum cholesterol levels. The dextran sulfate cellulose low-density lipoprotein (LDL) adsorption (DSA) apheresis procedure has been shown to reduce lipoprotein levels and markers of blood rheology to improve coronary perfusion to the transplanted heart. We report the first described case of the stabilization and reversal of progressive transplant CAD with DSA. We followed a 50-year-old male orthotopic heart transplant recipient with familial hyperlipidemia refractory to lipid lowering therapy with bi-weekly LDL-apheresis (DSA system) for 12 months. Quarterly pre- and post-apheresis blood investigations were obtained, as well as annual adenosine thallium (AT) studies. Creatinine kinase (CPK), creatinine, LDL, fibrinogen, and lipoprotein (a) were reduced by 70%, 26%, 23%, 47%, and 47%, respectively. AT before the initiation of apheresis revealed a small to medium sized, partially reversible perfusion defect in the anterolateral and inferoapical walls, with an ejection fraction (EF) of 49%, elevated left ventricular volume (171 mL), and an elevated pulmonary-to-myocardial (PMR) count ratio of 0.67 (normal <0.52). After 12 months of LDL apheresis with DSA, a repeat AT demonstrated no fixed or reversible perfusion abnormality, an EF of 51%, and the PMR had normalized (0.46). This is the first reported case demonstrating that in a heart transplant survivor with hyperlipidemia and progression of coronary artery disease, LDL apheresis with DSA therapy can lead to regression and is an effective treatment of post-transplant coronary disease.

Comparison of different low density lipoprotein apheresis machines on brain natriuretic Peptide levels in patients with familial hypercholesterolemia.

B-type natriuretic peptide (BNP) is a hormone released from cardiac ventricles during episodes of hemodynamic overload. Low density lipoprotein (LDL) apheresis, a procedure for patients with familial hypercholesterolemia (FH) and coronary artery disease (CAD), lowers plasma cholesterol and immediately reduces blood viscosity and coronary vascular resistance while improving myocardial blood flow and microvascular perfusion. Previous studies have demonstrated the ability of LDL apheresis to reduce BNP chronically. We undertook this study to evaluate the difference in reduction of BNP levels following a single treatment with two dissimilar LDL apheresis devices. We conducted a prospective trial involving 27 patients (19 F; age = 59 +/- 9 years) with FH who received at least 6 months of bi-weekly LDL apheresis therapy with either the Secura heparin extracorporeal LDL precipitation (HELP) system (N = 17 patients, B. Braun, Inc., Melsungen, Germany) or the Liposorber LA-15 dextran sulfate absorber (DSA) system (N = 10 patients, Kaneka, Inc., Osaka, Japan). We measured BNP levels immediately before and after one treatment of LDL apheresis. Following LDL apheresis, BNP levels were reduced by an average of 40 +/- 17% (P < 0.001). Despite treating equal amounts of plasma, the HELP system reduced BNP (45 +/- 18%) significantly more than the DSA system (31 +/- 11%, P = 0.031). In conclusion, LDL apheresis therapy, possibly through its immediate improvement of vascular flow and/or removal of the peptide from plasma, results in a significant reduction of BNP levels. The increased reduction of BNP by HELP may result from its superior acute alterations of rheological markers.