Sensory sparing does not change long-term outcomes in motor complete spinal cord injuries

BACKGROUND CONTEXTIn the acute postinjury setting, the prognostic value of sensory sparing among motor complete spinal injury patients has been well demonstrated. However, once final AIS grade is achieved 1 year postinjury, the value of sensory sparing alone has not been elucidated. We hypothesized that sensory sparing would lead to better outcomes in AIS B over AIS A patients at long-term, postrecovery follow-up.PURPOSETo evaluate for differences in medical, Physical and Social outcomes between AIS A and B patients at least 1 year postinjury.STUDY DESIGNRetrospective Cohort.PATIENT SAMPLEAdults over the age of 18 with AIS A or B spinal cord injury sustained between January 1, 1995 and September 13, 2019. Data Collected from the Spinal Cord Injury Model Systems Database.OUTCOME MEASURESSelf-reported Measures: PHQ-9 score; SCI-QOL Resilience Short Form score; VAS pain score; Life Satisfaction Score; Self-reported depression and sleep disturbances.Physiologic Measures: Body Mass Index, Diabetes Mellitus, Hypertension, Hyperlipidemia, Mortality, Incidence of Pressure Sores.Functional Measures: Bowel and Bladder Management; Illicit Substance use; Level of Education; Marital Status; Rehospitalization Rate.METHODSPatient data from the Spinal Cord Injury Model Systems Database were extracted for patients with a final, recovered American Spinal Injury Association Impairment Scale (AIS) grade of A or B at 1-year postinjury. Variables related to physical, mental and social functioning were compared between the two groups.RESULTSA total of 2,562 AIS A and 675 AIS B patient met inclusion criteria. Occurrence of pressure ulcers was 7% less in AIS B versus A (34.5% vs. 41.9%, p=.003). There were no statistical differences between groups in pain, bowel or bladder accidents, urinary tract infections, or the level of assistance for bowel or bladder management. There was no statistical difference for PHQ-9 depression scores, SCI-QOL Resilience Scores, rates of suicidality or sleep disturbance. There was no difference for illicit drug or alcohol abuse, life satisfaction scores, perceived health, and marriage or divorce rates.CONCLUSIONSExcept for a 7% reduction in pressure ulcer occurrence, there is no apparent long-term outcome advantage for motor complete spinal cord injury patients with AIS B sensory sparing over AIS A sensory complete. All other physical function domains were not different, nor were mental and social outcomes.     

Robot-assisted radical cystectomy: Review of surgical technique,and perioperative,oncological and functional outcomes

Since the introduction of robot-assisted radical cystectomy, efforts have been made to meet the standards in terms of perioperative safety and oncological efficacy. Several randomized controlled studies and meta-analyses, and multi-institutional studies have shown comparable outcomes of robot-assisted radical cystectomy when compared with the conventional open approach. In this review, we aimed to describe the surgical technique of robot-assisted radical cystectomy and urinary diversion, and perioperative, pathological, oncological and functional outcomes.     

New Solutions to Reduce Discard of Kidneys Donated for Transplantation

Kidney transplantation is a cost-saving treatment that extends the lives of patients with ESRD. Unfortunately, the kidney transplant waiting list has ballooned to over 100,000 Americans. Across large areas of the United States, many kidney transplant candidates spend over 5 years waiting and often die before undergoing transplantation. However, more than 2500 kidneys (>17% of the total recovered from deceased donors) were discarded in 2013, despite evidence that many of these kidneys would provide a survival benefit to wait-listed patients. Transplant leaders have focused attention on transplant center report cards as a likely cause for this discard problem, although that focus is too narrow. In this review, we examine the risks associated with accepting various categories of donated kidneys, including discarded kidneys, compared with the risk of remaining on dialysis. With the goal of improving access to kidney transplant, we describe feasible proposals to increase acceptance of currently discarded organs.     

Patient engagement in the design and execution of urologic oncology research

Introduction

There have been significant effort and financial support to engage patients in the design and execution of medical research. However, little is known about the relative benefits or potential impact of involving patients in research, most efficient practices and systems to enhance their involvement, and potential barriers and challenges that are involved with engaging patients. In this review, we will discuss the value of patient centered research, review the challenges that many of these studies faced, and highlight potential future opportunities to enhance patient involvement in urologic research.

Incorporating the Patient into Urologic Cancer Research

Patient engagement in research has been increasingly prioritized by funders and adopted by health researchers. In this Seminars issue, we explore several different mechanisms of engagement in the reciprocal relationship between patients and researchers. This includes the generation of understandable patient health information, how patients engage in treatment decision-making for urologic cancers, patient involvement in the development of research ideas and research design, and patient engagement in their personalized survivorship care.     

No difference in postoperative complications,pain, and functional outcomes up to 2 years after incidental durotomy in lumbar spinal fusion: a prospective,multi-institutional,propensity-matched analysis of 1,741 patients

BackgroundIncidental durotomies occur in up to 17% of spinal operations. Controversy exists regarding the short- and long-term consequences of durotomies.PurposeThe primary aim of this study was to assess the effect of incidental durotomies on the immediate postoperative complications and patient-reported outcome measures.Study designProspective study.Patient sampleA total of 1,741 patients undergoing index lumbar spine fusion were selected from a multi-institutional prospective data registry.Outcome measuresPatient-reported outcome measures used in this study included back pain (BP-Visual Analog Scale), leg pain (LP-Visual Analog Scale), and Oswestry Disability Index.MethodsA total of 1,741 patients were selected from a multi-institutional prospective data registry, who underwent primary lumbar fusion for low back pain and/or radiculopathy between January 2003 and December 2010. We collected and analyzed data on patient demographics, postoperative complications, back pain, leg pain, and functional disability over 2 years, with risk-adjusted propensity score modeling.ResultsIncidental durotomies occurred in 70 patients (4%). Compared with the control group (n=1,671), there was no significant difference in postoperative infection (p=.32), need for reoperation (p=.85), or symptomatic neurologic damage (p=.66). At 1- and 2-year follow-up, there was no difference in patient-reported outcomes of back pain (BP-Visual Analog Scale), leg pain (LP-Visual Analog Scale), or functional disability (Oswestry Disability Index) (p>.3), with results remaining consistent in the propensity-matched cohort analysis (p>.4).ConclusionWithin the context of an on-going debate on the consequences of incidental durotomy, we found no difference in neurologic symptoms, infection, reoperation, back pain, leg pain, or functional disability over a 2-year follow-up period.     

Blood loss during radical prostatectomy: impact on clinical, oncological and functional outcomes and complication rates

Study Type – Outcomes (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? It is generally accepted in the medical community that total and intra‐operative blood loss after RALP is significantly lower in comparison with ORRP. This has led to speculation that less bleeding results in better visualization of the operative field resulting in superior potency and continence. Blood loss (BL) during ORRP does not adversely impact clinical and functional outcomes irrespective of how BL is defined. Thus, the lower BL associated with RALP would not be expected to improve functional or oncological outcomes.

OBJECTIVE

• ? To determine the short‐ and long‐term impact of blood loss (BL) on clinical, oncological and functional outcomes as well as complication rates after an open radical retropubic prostatectomy (ORRP).

PATIENTS AND METHODS

• ? Between 2000 and 2008, 1567 men who underwent an ORRP participated in our prospective longitudinal outcomes study.
• ? Haematocrit (Hct) levels, transfusion rates, BL and complications were recorded prospectively.
• ? Validated, self‐administered quality‐of‐life (QoL) questionnaires were completed at baseline, 3, 6 and 12 months and yearly thereafter.
• ? Urinary function and erectile dysfunction were assessed using AUA Symptom Score and the UCLA Prostate Cancer Index and analysis of variance (anova )/chi‐square tests were used to compare clinical, BL, biochemical recurrence (BCR) and QoL outcomes amongst the three groups for continuous/categorical variables.

RESULTS

• ? The mean estimated BL was 742.7 (45 to 3500) mL and 5.4% and 3.8% received an autologous (AU) or allogeneic (AL) blood transfusions, respectively.
• ? The average baseline, induction, postoperative and discharge Hct was 43.8%, 48.3%, 35.7% and 34.1%, respectively.
• ? The estimated BL and the rate of change of Hct correlated moderately (r = 0.41, P < 0.0001).
• ? Tertiles of BL were based on the difference between induction and discharge Hct (Delta 1) and the average Delta 1 for Groups 1, 2 and 3 were 7.9%, 12.7% and 17.2%, respectively.
• ? Intra‐operative, early/delayed complications, length of hospital stay (LoS), SM surgical margins status, anastomotic stricture and BCR were not statistically different (P < 0.001) and the mean AUASS, UCLA Prostate Cancer urinary bother scores, urinary function scores, sexual bother/function scores at 24 months were similar amongst all tertiles (P > 0.05).

CONCLUSIONS

• ? BL during ORRP does not adversely impact clinical and functional outcomes irrespective of how BL is defined.
• ? Thus, the lower BL associated with robotic‐assisted laparoscopic prostatectomy (RALP) in and of itself would not be expected to improve functional or oncological outcomes.

     

Prospective, randomized trial of steroid withdrawal in kidney recipients treated with mycophenolate mofetil and cyclosporine

Our transplant centre began a prospective, randomized trial of steroid withdrawal in low risk renal transplant recipients on triple immunosuppression consisting of mycophenolate mofetil (MMF), microemulsion cyclosporine (CSA), and prednisone. One hundred and twenty patients were randomized either to discontinue or remain on steroids (60 patients per group). Study design consisted of analyses of 1-yr outcomes after study entry. This report includes the 1-yr results plus results at last follow-up (mean follow-up 3.7 yr). There were no significant differences in rates of patient and graft survival at 1 yr or at last follow-up. Additionally, the incidences of acute and chronic rejection as well as graft function were the same at 1 yr and at last follow-up. Significant improvement was noted in total serum cholesterol and bone density at 1 yr and last follow-up. Initial improvement in patient weight at 1 yr was not sustained at last follow-up. No significant impact of steroid withdrawal on serum triglycerides, blood pressure, or post-transplant diabetes mellitus was observed. To date, we have observed no immunologic risk, and some significant benefit in regards to side effects, of steroid withdrawal between 6 and 36 months after transplantation in low risk renal transplant recipients maintained on prednisone, MMF, and microemulsion CSA. CONCLUSION: Steroid withdrawal in low risk kidney transplant recipients is safe and ameliorates many of the unwanted sides effects of steroid use.     

Outcomes of patients with appendicitis who present to an outer metropolitan hospital

Background: The present study investigates patients with acute appendicitis who presented to a hospital with no acute surgical service (group A) and compares the outcomes of these patients with those that presented to a tertiary centre with an acute surgical service within the same health network (group B). All group A patients were transferred to the group B hospital for appendicectomy. Methods: During a 10‐month period, 257 patients (80 in group A, 177 in group B) with acute appendicitis were analysed retrospectively. Demographics, emergency department parameters, time to waiting bay, time to surgery, operative time, complications, length of stay and the stage of appendicitis were all noted for each group. A comparison of each of these parameters was made between the two groups of patients. Results: There were 80 patients in group A and 177 patients in group B. There was a significant difference between the two groups in the fields of length of stay in the emergency department (P= 0.003), bed availability (P= 0.038), time to waiting bay (P= 0.006) and time to surgery (P= 0.006). There was no significant difference in the total length of stay and complication rates between the two groups (P= 0.58 and 0.78, respectively). Conclusion: This study concludes that patients with acute appendicitis presenting to a hospital with no acute surgical services had a greater waiting period prior to surgery. However, this did not translate into greater complication rates or length of stay for these patients. We propose a prospective study to further analyse the outcomes in such patients.     

A new cemented femoral stem: a prospective study of the Stryker accolade C with 2- to 5-year follow-up

This prospective study evaluates the short-term results of a recently released cemented femoral stem design in primary cemented and hybrid total hip arthroplasty (THA). There were 100 all-cemented and 100 hybrid THAs in the 2-year study group. Good to excellent results were obtained in 96%. There was one reoperation for recurrent dislocation in each cohort (1%) and one single-staged reoperation for sepsis in the cemented cohort. There were 47 THA available for 5-year follow-up. Good to excellent results were maintained in 98%. One additional patient had a revision because of late recurrent dislocation. This study has demonstrated excellent early results and safety with this cemented femoral stem. The features include a dual-wedge geometry with a 0.88-microm Ra surface roughness, proximal macro-normalizations, distal anti-rotation grooves, and an optimized head-and-neck ratio approaching 4:1 using a standard 28-mm head.     

Measuring the impact of burn injury on the parent-reported health outcomes of children 1-to-5 years: Item pool development for the Preschool1–5 Life Impact Burn Recovery Evaluation (LIBRE) Profile

Modern, reliable, and valid outcome measures are essential to understanding the health needs of young children with burn injuries. Burn-specific and age-appropriate legacy assessment tools exist for this population but are hindered by the limitations of existing paper-based instruments. The purpose of this study was to develop item pools comprised of questions appropriate for children aged 1–5 with burn injuries. Item development was based on a framework provided by previous work to develop the Preschool Life Impact Burn Recovery Evaluation (LIBRE) Conceptual Model. The Preschool LIBRE Conceptual Model work established four sub-domains of functioning for children with burns aged 1–5. Item development involved a systematic literature review, a qualitative item review process with clinical experts, and parent cognitive interviews. Four item pools were established: (1) communication and language development; (2) physical functioning; (3) psychological functioning and (4) social functioning for preschool-aged children with burn injuries. We selected and refined candidate items, recall periods, survey instructions, and response option choices through clinical and parental feedback during the qualitative review and cognitive interview processes. Item pools are currently being field-tested as part of the process to calibrate and validate the Preschool_1–5 LIBRE Computer Adaptive Test (CAT) Profile.