Randomized trial of prophylactic antibiotics vs. placebo after midshaft-to-distal hypospadias repair: the PROPHY Study.

BACKGROUND: Use of prophylactic antibiotics after stented hypospadias repair is very common, but most research has not identified any clinical benefits of this practice. Only one study has found that postoperative prophylaxis reduces symptomatic urinary tract infections (UTIs). Data from the same trial suggested that prophylaxis may also reduce urethroplasty complications. No studies on this subject have been placebo-controlled. OBJECTIVE: We performed a randomized, double-blind, placebo-controlled study to evaluate the effect of postoperative prophylactic antibiotics on the incidence of infection or urethroplasty complications after stented repair of midshaft-to-distal hypospadias. STUDY DESIGN: Boys were eligible for this multicenter trial if they had a primary, single-stage repair of mid-to-distal hypospadias with placement of an open-drainage urethral stent for an intended duration of 5-10 days. Participants were randomized in a double-blind fashion to receive oral trimethoprim-sulfamethoxazole or placebo twice daily for 10 days postoperatively. The primary outcome was a composite of symptomatic UTI, surgical site infection (SSI), and urethroplasty complications, including urethrocutaneous fistula, meatal stenosis, and dehiscence. Secondary outcomes included each component of the primary outcome as well as acute adverse drug reactions (ADRs) and C. difficile colitis. RESULTS: Infection or urethroplasty complications occurred in 10 of 45 boys (22%) assigned to receive antibiotic prophylaxis as compared with 5 of 48 (10%) who received placebo (relative risk [RR], 2.1; 95% confidence interval [CI], 0.8 to 5.8; p = 0.16). There were no significant differences between groups in symptomatic UTIs, SSIs, or any urethroplasty complications. Mild ADRs occurred in 3 of 45 boys (7%) assigned to antibiotics as compared with 5 of 48 (10%) given placebo (RR, 0.6; 95% CI, 0.2 to 2.5; p = 0.72). There were no moderate-to-severe ADRs, and no patients developed C. difficile colitis. CONCLUSIONS: In this placebo-controlled trial of 93 patients, prophylactic antibiotics were not found to reduce infection or urethroplasty complications after stented mid-to-distal hypospadias repair. The study did not reach its desired sample size and was therefore underpowered to independently support a conclusion that prophylaxis is not beneficial. However, the result is consistent with most prior research on this subject. GOV IDENTIFIER: NCT02096159.

Modeling duration of time lived in a residence, a community and mobility in rural areas of Merced and Ventura, California to assess potential health risks to airborne contaminants.

A de novo population mobility survey of 800 households (random digit dialing-based phone interviews) was conducted in high demand areas of the agricultural fumigant, 1,3-dichloropropene (1,3-D) in Merced and Ventura counties of California. The survey included approximately 20 questions relating to the length of time individuals had lived in the high demand areas in each county, and also relating to weekly and annual mobility patterns. Lifetime inhalation exposures to 1,3-D are determined, in part, by the number of years individuals spend in an area where the fumigant is used. The purpose of the survey was to provide location-specific data for probabilistic modeling of long-term inhalation exposures to 1,3-D. The survey found that the majority of residents do not live in a high demand area or in the same house (99.99%) for 70years (a default assumption used by some regulatory agencies). It was also observed that residents move frequently and are mobile day-to-day and week-to-week, within the use area. Finally, estimates of total residency duration, derived from the survey results indicate that median times spent within a high demand area (which could include more than one residential location) were 18 and 26years for Ventura and Merced high demand areas, respectively. The average time spent in the high demand areas was 22 and 27years for the Ventura and Merced community, respectively. Less than 0.01% of the populations in either of the high demand areas spend 70years in the same house.

Low Serum Testosterone Level Predisposes to Artificial Urinary Sphincter Cuff Erosion.

OBJECTIVE: To examine the association between decreased serum testosterone levels and artificial urinary sphincter (AUS) cuff erosion. MATERIALS AND METHODS: We evaluated serum testosterone levels in 53 consecutive patients. Low testosterone was defined as <280 ng/dL and found in 30/53 patients (56.6%). Chi-square and Student t tests, Kaplan-Meier analysis, binary logistic regression, and Cox regression analysis were used to determine statistical significance. RESULTS: Nearly all men with AUS cuff erosions had low serum testosterone (18/20, 90.0%) compared to those without erosions (12/33, 36.4%, P < .001). Mean time to erosion was 1.70 years (0.83-6.86); mean follow-up was 2.76 years (0.34-7.92). Low testosterone had a hazard ratio of 7.15 for erosion in a Cox regression analysis (95% confidence interval 1.64-31.17, P = .009) and Kaplan-Meier analysis demonstrated decreased erosion-free follow-up (log-rank P = .002). Low testosterone was the sole independent risk factor for erosion in a multivariable model including coronary artery disease and radiation (odds ratio 15.78; 95% confidence interval 2.77-89.92, P = .002). Notably, history of prior AUS, radiation, androgen ablation therapy, or concomitant penile implant did not confound risk of cuff erosion in men with low testosterone levels. CONCLUSION: Men with low testosterone levels are at a significantly higher risk to experience AUS cuff erosion. Appropriate counseling before AUS implantation is warranted and it is unclear whether testosterone resupplementation will mitigate this risk.

Recognizing Differences in Hospital Quality Performance for Pediatric Inpatient Care.

BACKGROUND: Hospital quality-of-care measures are publicly reported to inform consumer choice and stimulate quality improvement. The number of hospitals and states with enough pediatric hospital discharges to detect worse-than-average inpatient care remains unknown. METHODS: This study was a retrospective analysis of hospital discharges for children aged 0 to 17 years from 3974 hospitals in 44 states in the 2009 Kids' Inpatient Database. For 11 measures of all-condition or condition-specific quality, we assessed the number of hospitals and states that met a "power standard" of 80% power for a 5% level significance test to detect when care is 20% worse than average over a 3-year period. For this assessment, we approximated volume as 3 times actual 2009 admission volumes. RESULTS: For all-condition quality, 1380 hospitals (87% of all pediatric discharges) and all states met the power standard for the family experience-of-care measure; 1958 hospitals (95% of discharges) and all states met the standard for adverse drug events. For condition-specific quality measures of asthma, birth, and mental health, 203 to 482 hospitals (52%-90% of condition-specific discharges) met the power standard and 40 to 44 states met the standard. One hospital and 16 states met the standard for sickle cell disease. No hospital and ≤27 states met the standard for the remaining measures studied (appendectomy, cerebrospinal fluid shunt surgery, gastroenteritis, heart surgery, and seizure). CONCLUSIONS: Most children are admitted to hospitals in which all-condition measures of quality have adequate power to show modest differences in performance from average, but most condition-specific measures do not. Policies regarding incentives for pediatric inpatient quality should take these findings into account.

Androgen supplementation in rats increases the inflammatory response and prolongs urethral healing.

OBJECTIVE: To describe the effects of androgens on urethral wound healing, we compared the urethral healing process in castrated Sprague-Dawley rats with and without testosterone supplementation. METHODS: Of 30 castrated male Sprague-Dawley rats, 15 received testosterone cypionate (3 mg/kg; T+ rats). All rats underwent an urethroplasty procedure and were sacrificed at postoperative days 5, 10, and 20. Neutrophils, macrophages, vessels, myofibroblasts, Ki67+ cells, collagen, and cytokines were quantified with immunofluorescence and real-time polymerase chain reaction. RESULTS: Penile length was significantly increased in T+ rats (21.8 vs 13.25 mm; P <.001) and operative time decreased (20.8 vs 23.3 minutes; P <.017). On day 5, T+ rats showed elevated neutrophil (727.4 vs 30.75 per high power field; P = .051) and macrophage counts (1295.8 vs 481.5 per high power field; P = .051) compared with those of T- rats. This elevation persisted throughout day 10 (291.7 vs 34; P = .002 and 1283.7 vs 110.2; P = .005) and day 20 (252.7 vs 12.2; P <.001 and 1672.7 vs 115.2; P <.001) reflecting increased and prolonged inflammation. Myofibroblasts were decreased in T+ rats on day 5 (215.7 vs 808.3; P <.001) and increased by day 10 (1490.1 vs 263.0; P = .001) and day 20 (1964.0 vs 210.0; P <.001) consistent with a delayed onset but with prolongation of the proliferative phase. Limitations include the use of castrated rats, which may have been exposed to androgens before castration. CONCLUSION: Testosterone supplementation leads to an increased inflammatory response and myofibroblast proliferation accompanied by prolonged inflammatory and proliferative phases. These novel findings suggest a delayed and possibly impaired urethral healing in the presence of excessive androgens.

Analysis of primary urethral wound healing in the rat.

OBJECTIVE: To analyze the process of urethral healing, which is the basis of urethral reconstructive surgery but remains poorly understood, we have developed a rat model of urethroplasty. Understanding this process may provide strategies to prevent aberrant urethral healing and improve the healing process. METHODS: We performed urethroplasties on 36 male Sprague-Dawley rats. On postoperative days 2, 4, 6, 8, 10, and 12, animals were sacrificed. The number of neutrophils, macrophages, fibroblasts, blood vessels, and Ki67 proliferative index was evaluated with immunostaining and collagen I and III contents with picrosirius staining. Expression of VEGF, PDGF, TNFα, TGFß, and FGF was analyzed with quantitative real-time PCR. RESULTS: Urethral healing occurs in phases of inflammation, proliferation, maturation, and remodeling analogous to dermal healing, however, with extended duration of each phase. The inflammatory phase reached to postoperative day 4 being characterized by neutrophil and macrophage predominance and high levels of VEGF, PDGF, TGFß, TNFα, and IL-10. The proliferative phase extended until day 10 characterized by myofibroblast proliferation and angiogenesis. Maturation and remodeling started on day 10 with decreasing proliferation and angiogenesis, increasing collagen I formation, and periurethral alignment of connective tissue. The healing process involved >50% of the periurethral/spongiosum area in the inflammatory and >80% in the maturation and remodeling phase. CONCLUSION: Urethral healing occurs in phases similar to those observed in dermal healing, however, with extension of each phase. The healing process is not limited to the site of injury but involves the vast majority of periurethral tissue and corpus spongiosum. This appears to be the result of the unique anatomical features of the urethra.

Hospital readmission and parent perceptions of their child's hospital discharge.

OBJECTIVE: To describe parent perceptions of their child's hospital discharge and assess the relationship between these perceptions and hospital readmission. DESIGN: A prospective study of parents surveyed with questions adapted from the care transitions measure, an adult survey that assesses components of discharge care. Participant answers, scored on a 5-point Likert scale, were compared between children who did and did not experience a readmission using a Fisher's exact test and logistic regression that accounted for patient characteristics associated with increased readmission risk, including complex chronic condition and assistance with medical technology. SETTING: A tertiary-care children's hospital. PARTICIPANTS: A total of 348 parents surveyed following their child's hospital discharge between March and October 2010. INTERVENTION: None. MAIN OUTCOME MEASURE: Unplanned readmission within 30 days of discharge. RESULTS: There were 28 children (8.1%) who experienced a readmission. Children had a lower readmission rate (4.4 vs. 11.3%, P = 0.004) and lower adjusted readmission likelihood [odds ratio 0.2 (95% confidence interval 0.1, 0.6)] when their parents strongly agreed (n = 206) with the statement, 'I felt that my child was healthy enough to leave the hospital' from the index admission. Parent perceptions relating to care management responsibilities, medications, written discharge plan, warning signs and symptoms to watch for and primary care follow-up were not associated with readmission risk in multivariate analysis. CONCLUSIONS: Parent perception of their child's health at discharge was associated with the risk of a subsequent, unplanned readmission. Addressing concerns with this perception prior to hospital discharge may help mitigate readmission risk in children.

Carbonate-templated self-assembly of an alkylthiolate-bridged cadmium macrocycle.

In the presence of Cd(ClO4)2 and a base, a new mixed N,S-donor alkylthiolate ligand supported both carbonate formation from atmospheric CO2 and the self-assembly of a novel bicapped puckered (CdS)6 molecular wheel. The remarkable stability of the complex was demonstrated by slow intermolecular ligand exchange on the (2)J(HH) and J((111/113)Cd(1)H) time scales at elevated temperature. Both CO2 and the base were required to convert amorphous "CdLClO4" precipitated in the absence of air to the carbonate complex. The complex shares structural features with the ζ-carbonic anhydrase class associating cadmium(II) with the biogeochemical cycling of carbon and is the first structurally characterized carbonate complex of any metal involving an alkylthiolate ligand.

Pediatric readmission prevalence and variability across hospitals.

IMPORTANCE: Readmission rates are used as an indicator of the quality of care that patients receive during a hospital admission and after discharge. OBJECTIVE: To determine the prevalence of pediatric readmissions and the magnitude of variation in pediatric readmission rates across hospitals. DESIGN, SETTING, AND PATIENTS: We analyzed 568,845 admissions at 72 children's hospitals between July 1, 2009, and June 30, 2010, in the National Association of Children's Hospitals and Related Institutions Case Mix Comparative data set. We estimated hierarchical regression models for 30-day readmission rates by hospital, accounting for age and Chronic Condition Indicators. Hospitals with adjusted readmission rates that were 1 SD above and below the mean were defined as having "high" and "low" rates, respectively. MAIN OUTCOME MEASURES: Thirty-day unplanned readmissions following admission for any diagnosis and for the 10 admission diagnoses with the highest readmission prevalence. Planned readmissions were identified with procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. RESULTS: The 30-day unadjusted readmission rate for all hospitalized children was 6.5% (n = 36,734). Adjusted rates were 28.6% greater in hospitals with high vs low readmission rates (7.2% [95% CI, 7.1%-7.2%] vs 5.6% [95% CI, 5.6%-5.6%]). For the 10 admission diagnoses with the highest readmission prevalence, the adjusted rates were 17.0% to 66.0% greater in hospitals with high vs low readmission rates. For example, sickle cell rates were 20.1% (95% CI, 20.0%-20.3%) vs 12.7% (95% CI, 12.6%-12.8%) in high vs low hospitals, respectively. CONCLUSIONS AND RELEVANCE: Among patients admitted to acute care pediatric hospitals, the rate of unplanned readmissions at 30 days was 6.5%. There was significant variability in readmission rates across conditions and hospitals. These data may be useful for hospitals' quality improvement efforts.

Early administration of oxybutynin improves bladder function and clinical outcomes in newborns with posterior urethral valves.

PURPOSE: Abnormal bladder function following posterior urethral valve ablation can lead to deleterious effects on renal function and urinary continence. We performed a pilot study to determine if bladder dysfunction could be ameliorated by the early administration of oxybutynin. MATERIALS AND METHODS: We enrolled infants who underwent primary posterior urethral valve ablation by the age of 12 months. On initial urodynamics patients demonstrating high voiding pressures (greater than 60 cm H(2)O) and/or small bladder capacity (less than 70% expected) were started on oxybutynin. Urodynamics and ultrasound were performed every 6 months until completion of toilet training, at which time oxybutynin was discontinued. RESULTS: Oxybutynin was started in 18 patients at a mean age of 3.4 months and was continued for a mean of 2.2 years. Urodynamics revealed that initial high voiding pressures improved from a mean of 148.5 to 49.9 cm H(2)O in 15 of 17 patients. All 8 patients with initially poor bladder compliance demonstrated improvement on oxybutynin. All 7 patients with initially low bladder capacity (mean 47.7% expected bladder capacity) demonstrated improvement while on oxybutynin (mean 216% expected bladder capacity). CONCLUSIONS: This pilot study demonstrates that early use of anticholinergic therapy in infants with high voiding pressures and/or small bladder capacity after primary posterior urethral valve ablation has beneficial effects on bladder function.

Hemiscrotal agenesis: new variation in a rare anomaly.

Scrotal agenesis is a rarely encountered developmental anomaly of the scrotum, with only 6 cases of complete agenesis reported in published studies. We report, to our knowledge, the first case of hemiscrotal agenesis. The specific embryologic basis of scrotal agenesis is unknown but is likely multifactorial, involving localized androgen insensitivity, localized 5α-reductase deficiency, and/or failure of labioscrotal fold formation.

Hospital utilization and characteristics of patients experiencing recurrent readmissions within children's hospitals.

CONTEXT: Early hospital readmission is emerging as an indicator of care quality. Some children with chronic illnesses may be readmitted on a recurrent basis, but there are limited data describing their rehospitalization patterns and impact. OBJECTIVES: To describe the inpatient resource utilization, clinical characteristics, and admission reasons of patients recurrently readmitted to children's hospitals. DESIGN, SETTING, AND PATIENTS: Retrospective cohort analysis of 317,643 patients (n = 579,504 admissions) admitted to 37 US children's hospitals in 2003 with follow-up through 2008. MAIN OUTCOME MEASURE: Maximum number of readmissions experienced by each child within any 365-day interval during the 5-year follow-up period. RESULTS: In the sample, 69,294 patients (21.8%) experienced at least 1 readmission within 365 days of a prior admission. Within a 365-day interval, 9237 patients (2.9%) experienced 4 or more readmissions; time between admissions was a median 37 days (interquartile range [IQR], 21-63). These patients accounted for 18.8% (109,155 admissions) of all admissions and 23.2% ($3.4 billion) of total inpatient charges for the study cohort during the entire follow-up period. Tests for trend indicated that as the number of readmissions increased from 0 to 4 or more, the prevalences increased for a complex chronic condition (from 22.3% [n = 55,382/248,349] to 89.0% [n = 8225/9237]; P < .001), technology assistance (from 5.3% [n = 13,163] to 52.6% [n = 4859]; P < .001), public insurance use (from 40.9% [n = 101,575] to 56.3% [n = 5202]; P < .001), and non-Hispanic black race (from 21.8% [n = 54,140] to 34.4% [n = 3181]; P < .001); and the prevalence decreased for readmissions associated with an ambulatory care-sensitive condition (from 23.1% [62,847/272,065] to 14.0% [15,282/109,155], P < .001). Of patients readmitted 4 or more times in a 365-day interval, 2633 (28.5%) were rehospitalized for a problem in the same organ system across all admissions during the interval. CONCLUSIONS: Among a group of pediatric hospitals, 18.8% of admissions and 23.2% of inpatient charges were accounted for by the 2.9% of patients with frequent recurrent admissions. Many of these patients were rehospitalized recurrently for a problem in the same organ system.

Effectiveness of the computer enhanced visual learning method in teaching the society for fetal urology hydronephrosis grading system for urology trainees.

OBJECTIVE: A novel educational tool, Computer Enhanced Visual Learning (CEVL), has been used to improve resident performance of routine orchiopexy. Our objective was to assess the effect of a CEVL teaching module on the diagnostic accuracy of medical trainees in grading neonatal hydronephrosis on ultrasound using the Society for Fetal Urology (SFU) grading system. METHODS: The authors designed an online-based computerized tutorial to teach the grading of hydronephrosis using multimedia, practice cases and a grading checklist. In a crossover design trial, 29 residents and medical students were asked to grade 16 standard neonatal renal ultrasounds using the SFU grading system before and after viewing the web-based e-learning module. Primary outcome was percent improvement in grading accuracy. RESULTS: The mean percentages of ultrasounds that were graded correctly before and after CEVL intervention were 51% and 72% respectively (mean improvement 21%, 95% CI 3-13%, P < 0.001). Residents graded correctly 56% of ultrasounds before and 74% after CEVL (mean 18%, 7-28%, P = 0.002). Medical students graded correctly 37% before and 69% after CEVL (mean improvement 32%, 95% CI 16-48%, P = 0.002). CONCLUSION: Exposure to a computer-based learning module based on the CEVL platform improved urology residents' and medical students' correct assignment of SFU hydronephrosis grading to newborn renal ultrasounds.

Active learning: a resident's reflection on the impact of a student-centred curriculum.

Classic medical education pedagogy typically involves the model of an active teacher and a passive student. There has been a shift in education theory to a more student-centred approach, and this is being reflected in resident education. Concepts, such as "competencies," "curricula" and "objectives," are becoming part of the fabric of the residency training equation. The University of British Columbia Department of Urologic Sciences had previously created a urology residency curriculum for its 15 residents in 2000. This curriculum was based on competencies and objectives outlined by the Royal College of Physicians and Surgeons of Canada. In an attempt to address a required change in the formal curriculum, an "accidental" student-centred curriculum emerged. This paper outlines this active learning approach, its benefits and challenges in implementation.

Fetal pyelectasis as predictor of decreased differential renal function.

PURPOSE: A decreased percent of differential function is a common indication for infant pyeloplasty but there is no recognized fetal ultrasound parameter to predict this deficit. We determined whether there is a correlation between fetal pyelectasis and the newborn percent differential function that may enhance prenatal counseling and guide postnatal evaluation. MATERIALS AND METHODS: Our database was queried for fetal and newborn measures with fetal pyelectasis on ultrasound and the percent of differential function on renal scintigraphy. Fetal pyelectasis data were stratified by estimated gestational age and the percent of differential function. The affected cohort was defined as having 35% or less differential function and the unaffected cohort was defined as having greater than 35%. The Wilcoxon 2-sample test was used for statistical analysis with logistic regression to generate estimated probability models of a decreased percent of differential function vs mm fetal pyelectasis. RESULTS: A total of 831 cases had fetal and newborn ultrasound data available with a total of 229 renal scans identified. Of the 229 cases 36 (16%) had 35% or less differential function on scintigraphy. At estimated gestational age 33 weeks or less the affected cohort had 8 mm greater pyelectasis than the unaffected cohort (OR 1.2, p <0.0001). At estimated gestational age greater than 33 weeks the affected cohort had 4 mm greater pyelectasis than the unaffected cohort (OR 1.07, p <0.07). Subgroup analysis before 33 weeks of estimated gestational age showed similar significance (OR >1, p

Computer-enhanced visual learning method: a paradigm to teach and document surgical skills.

INNOVATION: Changes in health care are stimulating residency training programs to develop new methods for teaching surgical skills. We developed Computer-Enhanced Visual Learning (CEVL) as an innovative Internet-based learning and assessment tool. The CEVL method uses the educational procedures of deliberate practice and performance to teach and learn surgery in a stylized manner. AIM OF INNOVATION: CEVL is a learning and assessment tool that can provide students and educators with quantitative feedback on learning a specific surgical procedure. Methods involved examine quantitative data of improvement in surgical skills. Herein, we qualitatively describe the method and show how program directors (PDs) may implement this technique in their residencies. RESULTS: CEVL allows an operation to be broken down into teachable components. The process relies on feedback and remediation to improve performance, with a focus on learning that is applicable to the next case being performed. CEVL has been shown to be effective for teaching pediatric orchiopexy and is being adapted to additional adult and pediatric procedures and to office examination skills. The CEVL method is available to other residency training programs.

Ultrasound fails to delineate significant renal pathology in children with urinary tract infections: a case for dimercapto-succinic acid scintigraphy.

PURPOSE: Routine radiological evaluation in children with urinary tract infections includes ultrasound. Additional dimercapto-succinic acid scintigraphy in this setting is a common but not routine practice to determine whether there is parenchymal injury. Because dimercapto-succinic acid scintigraphy involves further time, expense and radiation, we determined whether ultrasound findings could substitute for dimercapto-succinic acid scintigraphy. Therefore, in children with urinary tract infections we researched the incidence of discordant findings between dimercapto-succinic acid scintigraphy and normal ultrasound. MATERIALS AND METHODS: A retrospective review of children with a history of urinary tract infections who had normal ultrasound and dimercapto-succinic acid scintigraphy within 6 weeks of each other was performed through a chart review. Children with pyelonephritis within 4 months of the radiological tests were excluded. Dimercapto-succinic acid scintigraphy was considered abnormal if there was less than 40% differential function, global atrophy or focal defects. RESULTS: From January 2005 to December 2006, 100 children met inclusion criteria. Median patient age was 4.5 years (range 4 months to 19 years) and 84% were female. Of the 100 children 74 (74%) demonstrated vesicoureteral reflux and 18 (18%) showed abnormal dimercapto-succinic acid scintigraphy despite normal ultrasound. Children with vesicoureteral reflux showed an increased incidence of abnormal dimercapto-succinic acid scintigraphy compared to those without vesicoureteral reflux (20.3% vs 11.5%), although this did not attain statistical significance (p = 0.04). CONCLUSIONS: Although dimercapto-succinic acid scintigraphy is not part of routine practice in all children with urinary tract infections and/or vesicoureteral reflux, it is frequently abnormal despite normal ultrasound. Therefore, dimercapto-succinic acid scintigraphy should be considered in these patients to evaluate cortical defects and possibly guide further management.