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There are several choices for the correction of complex transposition of the great arteries and double outlet right ventricle not amenable to the Rastelli-type surgery, but outcome data are limited to small series. This study aims to report results after the aortic root translocation and en bloc rotation of the outflow tract procedures.This is a retrospective, multicentric, observational study. Clinical, anatomy, procedural, and detailed follow-up data (median, 4.43 years) were collected.A total of 70 patients (62.9% male; median age, 1 year; range 4 days to 12.4 years) were included: n = 43 in the aortic root translocation group and n = 27 in the en bloc rotation group. Those in the aortic root translocation group were older (P = .01) and more likely to have had previous procedures (P .0001), but cardiac anatomy was similar in both groups. Aortic root translocation and en bloc rotation early mortality (30 days) was similar (4.7% vs 3.7%, P = .8). Late survival and freedom from any cardiac reintervention were 92.7% and 16.9% at 15 years overall, respectively. Freedom from right ventricular outflow tract/conduit reintervention was better in the en bloc rotation group than in the aortic root translocation group (100% vs 24.5%, P = .0003), but more patients in the en bloc rotation group had moderate (or worse) aortic valve regurgitation during follow-up (16% vs 2.6%, P = .07).Both aortic root translocation and en bloc rotation are valuable surgical options for the treatment of complex transposition of the great arteries and double outlet right ventricle. In the en bloc rotation group, there was better freedom from right ventricular outflow tract reinterventions, but a higher probability of aortic valve regurgitation. Identifying the main driving forces for these observed differences requires further study of these procedures.

OBJECTIVES To examine the effect of hospital volume on short and long-term outcomes for radical nephroureterectomy (RNUx). Upper tract urothelial carcinoma is a rare malignancy that few surgeons have experience with. The hospital volume-outcome relationship has been well established for other cancers but not RNUx. METHODS The National Cancer Database was queried for all cases of upper tract urothelial carcinoma that underwent RNUx from 2004 to 2016. Average annual hospital volume for radical nephroureterectomy was stratified into tertiles. The upper tertile, defined as 6 or more RNUx per year, was considered high volume while low volume was less than 6 RNUx per year. Kaplan-Meier and Cox proportional hazards regression were used to identify independent predictors of overall survival, and logistic regression was used to identify predictors of perioperative outcomes. RESULTS We identified 37,479 RNUx performed across 1290 hospitals. There were no differences in baseline health or cancer staging between patients who presented at low- versus high-volume centers. Both peri-operative survival (30- and 90-day mortality) and long-term overall survival were improved in patients treated at high-volume centers. On multivariable survival analysis, treatment at a high-volume center was associated with improved hazards of survival. This relationship for long-term survival remained consistent on landmark analysis where patients who died within 90 days of surgery were removed. CONCLUSIONS Treatment at a high-volume hospital was associated not only with improved short-term perioperative outcomes but also with improved overall long-term survival. The mechanism behind this is likely multifactorial with surgeon volume, and ancillary support services all playing critical roles.

Sepsis following transrectal prostate biopsy occurs in 2%-5% of cases and the risk is increasing. We performed a comprehensive literature search for the cost of post-prostate biopsy sepsis to define the potential cost savings of reducing infectious complications. Reporting of cost is varied and presents a challenge to interpretation. Length of hospitalization ranged from 1.1 to 14 days and the percent admitted to an ICU ranged from 1.1% to 25%. The estimated cost of sepsis post-prostate biopsy, adjusted for inflation, ranged from $8,672 to $19,100. Healthcare costs of treating post-biopsy infection are substantial. Our findings should guide payers and policymakers, especially in value-based care models.

BACKGROUND: Immune checkpoint-inhibitor (ICI)-based therapy is the standard of care for first-line treatment of metastatic renal cell carcinoma (mRCC). It is unclear whether prior removal of the primary tumor influences the efficacy of these treatments. We performed a systematic review and meta-analysis of studies of first-line ICI in mRCC to determine whether the efficacy of ICI-therapy, compared to sunitinib, is altered based on receipt of prior nephrectomy. METHODS: We systematically reviewed studies indexed in MEDLINE (PubMed), Embase, and Scopus and conference abstracts from relevant medical societies as of August 2020 to identify randomized clinical trials assessing first-line immunotherapy-based regimes in mRCC. Studies were included if overall survival (OS) and progression-free survival (PFS) outcomes were reported with data stratified by nephrectomy status. We pooled hazard ratios (HRs) stratified by nephrectomy status and performed random effects meta-analysis to assess the null hypothesis of no difference in the survival advantage of immunotherapy-based regimes based on nephrectomy status, while accounting for study level correlations. RESULTS: Among 6 randomized clinical trials involving 5,121 patients, 3,968 (77%) had undergone prior nephrectomy. We found an overall survival benefit for immunotherapy-based regimes, compared to sunitinib, among both patients who had undergone nephrectomy (HR 0.75, 95% CI 0.63 −0.88) and those who had not (HR 0.74, 95% CI 0.59 −0.92), without evidence of difference based on nephrectomy history (P = 0.70; I(2) = 36%). Results assessing PFS were similar (P = 0.45, I(2) = 0%). CONCLUSIONS: These clinical data suggest that prior nephrectomy does not affect the efficacy of ICI-based regimens in mRCC relative to sunitinib. © 2021 Elsevier Inc. All rights reserved.

Objective To measure decisional quality in patients being counseled on treatment for small renal masses and identify potential areas of improvement. Materials and Methods A total of 73 patients diagnosed with small renal masses at the University of California, Los Angeles Health completed an instrument measuring decisional conflict, patient satisfaction with care, disease-specific knowledge, and patient impression that shared decision-making occurred in the visit after counseling by a specialist. Participant characteristics were compared between those with high and low decisional conflict using chi-square or Student t test (or Wilcoxon rank-sum test). Results Participants were mostly older (mean age 63.5), white (84%), in a relationship (61%), and unemployed or retired (63%). Mean knowledge score was 59% correct. The mean (standard deviation) decisional conflict score was 16.4 (18.4) indicating low levels of decisional conflict but with a wide range of scores. Comparing participants with high decisional conflict with those with low decisional conflict, there were significant differences in knowledge scores (Wilcoxon P = .0069), patient satisfaction with care ( P = .0011), and perceived shared decision-making ( P Conclusion Patients with small renal masses generally have low levels of decisional conflict and can identify a preferred treatment after a physician visit. However, both groups lack overall knowledge about their disease even after counseling, and thus may be heavily influenced by paternalistic care. Those patients with decisional conflicts are less likely to perceive their care as satisfactory and are less likely to be involved in decision-making.

Background By 2022, there will be 18 million predicted cancer survivors, which is an estimated 30% more than the number of survivors in 2012. In prostate cancer alone, the most common cancer in American men other than skin cancer, 1 in 7 men will be diagnosed during their lifetime. Nevertheless, only approximately 1 in 39 will actually die of the disease. Although life expectancy is often good, these men have multiple treatment management options to choose from, including active surveillance, surgery, or radiotherapy, each of which carries its own array of long-term adverse effects. The same applies to renal cancer where patient have to sift through information to decide among active surveillance, partial nephrectomy, racial nephrectomy, robotic vs. open surgery, and ablation. Basic procedures Ultimately, patient, providers, and stakeholders lack high-quality evidence to effectively guide treatment decisions, and these decisions become even harder to discern when considering end-of-life care, palliative care, and the ethics regarding the new End of Life Option Act. As of November 1, 2016, the number of open urologic cancer clinical trials listed on ClinicalTrials.gov was 843. Main findings Although we continue to make tremendous strides in urologic cancer care, our options for choosing the best treatment from a patient and provider standpoint are seemingly growing murkier. We need to continue to understand how health-related quality of life varies from patient to patient, and ultimately, incorporate patient preferences and values into the treatment decision in order to make high-quality treatment decisions. Conclusions The remained of this articles will focus on the significant strides made in urologic oncology regarding these difficult decisions from localized disease to end-of-life care and also will detail what needs to be done as we continue to pivot forward.

Resumen Introduccion y objetivos Las infecciones en dispositivos de electroestimulacion cardiaca son cada vez mas frecuentes debido a las indicaciones cada vez mas amplias de estos sistemas. Algunos aspectos sobre su tratamiento son controvertidos y aportamos aqui nuestra amplia experiencia. Metodos Se atendieron 325 infecciones (196 locales y 129 sistemicas) durante los anos 1985 a 2015, el 28,5% de ellas procedentes de otros centros: 229 marcapasos, 69 desfibriladores automaticos implantables y 27 pacientes con terapia de resincronizacion cardiaca, con un seguimiento minimo de 1 ano tras el alta hospitalaria. Resultados La traccion percutanea (TPC) fue la tecnica utilizada mas frecuentemente (n = 280), en infecciones tanto locales (n = 166) como sistemicas (n = 114), con una tasas de extraccion completa del sistema del 82,5% del total y de curacion, del 89%; las complicaciones fueron escasas (2 muertes achacables a la tecnica). La mortalidad total fue del 1% en infecciones locales y el 8% en las sistemicas. Tras 212 TPC completas, se reimplanto un nuevo sistema contralateral en 209: en 152 de ellas en el mismo acto (73%) y en 57 en un segundo tiempo; no se apreciaron diferencias en el numero de recidivas en el nuevo sistema (2 en 1 tiempo y 1 en 2 tiempos). Conclusiones La TPC en manos expertas arroja buenos resultados en terminos de eficacia, con escasas complicaciones. Se puede realizar el reimplante de dispositivos en un solo tiempo sin que ello conlleve un mayor riesgo de recidiva.

Introduction and objectives Infections in cardiac implantable electronic devices are increasing due to the expansion of the indications of these devices. The management of some aspects is controversial. Here, we report our broad experience. Methods Between 1985 and 2015, 325 infections (196 local and 129 systemic) were registered; 28.5% of them were referred from other centers: 229 pacemakers, 69 implantable cardioverter-defibrillators, and 27 patients with cardiac resynchronization therapy. The follow-up was at least 1 year after hospital discharge. Results Percutaneous traction (PCT) was the most frequent procedure (n = 280) in local (n = 166) and systemic infections (n = 114), with complete extraction of the system in 82.5% of the patients, clinical success in 89%, and few complications (2 deaths attributable to the technique). Overall mortality was 1% in local infections and 8% in systemic infections. After 212 complete PCT, a new device was placed in 209: of these, a contralateral system was implanted in the same procedure in 152 (73%) and in a second procedure in 57, with no differences in relapses (2 in the 1-stage procedure, and 1 in the 2-stage procedure). Conclusions Percutaneous traction in experienced hands has good results with very few complications. It is possible to perform contralateral implantation of the new device on the same day without increasing the risk of relapse.

We investigated provider and regional variation in payments made to surgeons by the Centers for MedicareMedicaid Services (CMS) by indexing payments to unique beneficiaries treated and examined the proportion of charges that resulted in payments. Understanding variation in care within CMS may prove actionable by identifying modifiable, and potentially unwarranted, variations.We analyzed the Medicare Part B Provider Utilization and Payment Data released by CMS for 2012. We included Medicare B participants in the fee-for-service program. We calculated for each provider the ratio of number of services provided to individual beneficiaries, and the ratio of total submitted charges to total Medicare payments. We also categorized each provider into deciles of total Medicare payments, and calculated the means per decile of total Medicare payment for surgeons and urologists. To determine any associations with ratio of services to beneficiaries, we conducted multivariate linear regressions.The 20th, 40th, 60th, and 80th percentiles for the services-per-beneficiary ratios are 1.6, 2.2, 3.1, and 5.0, respectively (n = 83,376). Greater-earning surgeons offered more services per beneficiary, with a precipitous increase from the lowest decile to the highest. Charges were consistently greater than payments by a factor of 3. In our multivariate analysis of services per beneficiary ratio, female providers had lower ratios (P .01), and we noted significant regional variation in the ratio of services per unique beneficiary (P .001 for each of the 10 Standard Federal Regions).We found significant variation in patterns of payments for surgical care in CMS.

Purpose Cost estimates through traditional hospital accounting systems are often arbitrary and ambiguous. We used time-driven activity-based costing (TDABC) to determine the true cost of low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy for prostate cancer and demonstrate opportunities for cost containment at an academic referral center. Methods and Materials We implemented TDABC for patients treated with I-125, preplanned LDR and computed tomography based HDR brachytherapy with two implants from initial consultation through 12-month followup. We constructed detailed process maps for provision of both HDR and LDR. Personnel, space, equipment, and material costs of each step were identified and used to derive capacity cost rates, defined as price per minute. Each capacity cost rate was then multiplied by the relevant process time and products were summed to determine total cost of care. Results The calculated cost to deliver HDR was greater than LDR by $2,668.86 ($9,538 vs. $6,869). The first and second HDR treatment day cost $3,999.67 and $3,955.67, whereas LDR was delivered on one treatment day and cost $3,887.55. The greatest overall cost driver for both LDR and HDR was personnel at 65.6% ($4,506.82) and 67.0% ($6,387.27) of the total cost. After personnel costs, disposable materials contributed the second most for LDR ($1,920.66, 28.0%) and for HDR ($2,295.94, 24.0%). Conclusions With TDABC, the true costs to deliver LDR and HDR from the health system perspective were derived. Analysis by physicians and hospital administrators regarding the cost of care afforded redesign opportunities including delivering HDR as one implant. Our work underscores the need to assess clinical outcomes to understand the true difference in value between these modalities.

Resumen Exponemos el caso de una indicacion de ECMO como puente a la decision y la aparicion de una complicacion grave asociada a estos dispositivos. Se trata de un varon de 63 anos con multiples factores de riesgo cardiovascular y revascularizacion coronaria quirurgica previa. Ingresa por sindrome coronario agudo con elevacion de ST, que se revasculariza percutaneamente de forma parcial. Evoluciona hacia shock cardiogenico refractario, detectandose ademas ictus de capsula interna, seudoaneurisma de pared ventricular y comunicacion interventricular. Se decide intubacion, colocacion de balon de contrapulsacion intraaortico (BCIA) e implantacion de ECMO veno-arterial por via femoral. Tras comprobar buena respuesta neurologica a la retirada de la sedacion, se incluye en alarma 0 de trasplante cardiaco. Tras mejoria hemodinamica inicial se retira el BCIA. Requirio antitrombina iii para mantener rango de anticoagulacion. Finalmente, evoluciono a disfuncion multiorganica, desestimandose el trasplante cardiaco, presentando hemoptisis masiva secundaria a anticoagulacion. Se opta por retirar la ECMO, falleciendo el paciente a las pocas horas. La ECMO es una herramienta fundamental en el manejo del shock cardiogenico refractario para ganar tiempo con vistas a decidir una actitud definitiva pero puede condicionar situaciones de peligro vital como la hemorragia secundaria a la anticoagulacion que requiere el dispositivo.

Coordination between health and social services is a key point in caring for an increasing number of people affected by different types of health problems. The change in demographic and epidemiological patterns in our societies evidences the need of this coordination, usually not covered by our care systems. A sector in which the coordination is particularly important is the care of people with disabilities related to the suffering from severe mental disorders. This is a field that has been too long on the sidelines of the general health and social care systems as a result of the social stigma and traditional psychiatric institutions, setting in motion a vicious circle that must be broken in order to identify and to respond to the needs of such persons. In fact, the processes of change towards community care, with targets for recovery and not mere palliative or marginalizing care, necessarily incorporate this coordination as a cornerstone strategy for social inclusion and citizenship. Although there are still significant gaps in this regard, especially in Spain. However, there are experiences of change, such as that of Andalusia, which set the tone for the development of a strategy for integrated care, whose foundations and main elements we try to summarize in the present article.

This data article presents the supplementary material for the review paper “Healthcare Costs of Post-Prostate Biopsy Sepsis” (Gross et al., 2019). A general overview is provided of 18 papers, including the details about year and journal of publication, country of dataset, data population characteristics, cost basis, and potential for bias evaluation. Quality assessment and the risk of bias of the 18 papers are detailed and summarized. Keywords: Sepsis, Health care costs, Prostate, Biopsy, Prostatic neoplasms, Cost and cost analysis, Urology

Introduction: Stroke recurrence is an important issue in stroke registries, but direct patient contact months after stroke is not always feasible. Telephone assessment is often used to evaluate long term stroke outcome, treatments and recurrences. Our aim is to evaluate telephone interview in a stroke registry. Material and methods: Three hundred and eighty patients with a stroke or TIA were prospectively registered, evaluating baseline characteristics and type of event. At 6 months, 248 patients were reviewed by structured telephone interview and 132 were reviewed by direct contact. We analysed stroke outcome and disability, treatments and stroke or TIA recurrences. Results: There were no differences in baseline characteristics and type or severity of the index event. At 6 months, treatments were similar between both groups and 10.5% (40 patients) had a recurrent event. There were no differences in recurrent ischemic strokes (6.1% in direct contact vs 4.4% telephone, P = .49), but we detected a higher number of TIA in direct examination compared to phone interview (9.1% vs 4.0%, P = .04). Conclusions: Telephone assessment of stroke patients is reliable and facilitates stroke registries in detecting long-term treatments and stroke recurrences. However, it is probable that new transient events or TIA are under-estimated. Resumen: Introducción: La recurrencia de ictus o AIT es un aspecto clave en la mayoría de los registros de ictus, pero la revisión presencial de todos los pacientes no siempre es viable. Con frecuencia, la revisión telefónica es utilizada para evaluar las recurrencias, la situación funcional y los tratamientos a largo plazo. El objetivo es evaluar la revisión telefónica en un registro de ictus. Material y métodos: Se registraron prospectivamente 380 pacientes con ictus o AIT valorando las características basales y tipo de evento. Posteriormente, fueron evaluados a los 6 meses tras el evento inicial. Doscientos cuarenta y ocho pacientes fueron revisados telefónicamente mediante una entrevista estructurada y 132 fueron revisados físicamente en consulta. Se compararon ambos grupos analizando las diferencias detectadas en las escalas funcionales, tratamientos y recurrencias (AIT o ictus). Resultados: No hubo diferencias en las características basales de ambos grupos, ni en el tipo de evento o gravedad al inicio. A los 6 meses, los tratamientos realizados fueron similares en ambos grupos, presentando un 10,5% (40 pacientes) recurrencia de ictus o AIT. No hubo diferencias significativas en la tasa de nuevos ictus isquémicos (6,1% revisión física vs 4,4% telefónica, p = 0,49), pero se detectó un mayor número de AIT en la revisión física frente a la telefónica (9,1% vs 4,0%, p = 0,04). Conclusiones: La revisión telefónica de los pacientes con ictus es viable y facilita la realización de registros de ictus, permitiendo una adecuada identificación de los tratamientos y recurrencias de ictus. Sin embargo, es probable que los nuevos eventos transitorios o AIT estén infraestimados. Keywords: Stroke outcome, Telephone interview, Cerebral ischaemia, Transient, Stroke registry, Disability evaluation, Stroke recurrence, Palabras clave: Evolución del ictus, Entrevista telefónica, Accidente isquémico transitorio, Registro de ictus, Evaluación de discapacidad, Recurrencia de ictus

Resumen: Introducción: La recurrencia de ictus o AIT es un aspecto clave en la mayoría de los registros de ictus, pero la revisión presencial de todos los pacientes no siempre es viable. Con frecuencia, la revisión telefónica es utilizada para evaluar las recurrencias, la situación funcional y los tratamientos a largo plazo. El objetivo es evaluar la revisión telefónica en un registro de ictus. Material y métodos: Se registraron prospectivamente 380 pacientes con ictus o AIT valorando las características basales y tipo de evento. Posteriormente, fueron evaluados a los 6 meses tras el evento inicial. Doscientos cuarenta y ocho pacientes fueron revisados telefónicamente mediante una entrevista estructurada y 132 fueron revisados físicamente en consulta. Se compararon ambos grupos analizando las diferencias detectadas en las escalas funcionales, tratamientos y recurrencias (AIT o ictus). Resultados: No hubo diferencias en las características basales de ambos grupos, ni en el tipo de evento o gravedad al inicio. A los 6 meses, los tratamientos realizados fueron similares en ambos grupos, presentando un 10,5% (40 pacientes) recurrencia de ictus o AIT. No hubo diferencias significativas en la tasa de nuevos ictus isquémicos (6,1% revisión física vs 4,4% telefónica, p = 0,49), pero se detectó un mayor número de AIT en la revisión física frente a la telefónica (9,1% vs 4,0%, p = 0,04). Conclusiones: La revisión telefónica de los pacientes con ictus es viable y facilita la realización de registros de ictus, permitiendo una adecuada identificación de los tratamientos y recurrencias de ictus. Sin embargo, es probable que los nuevos eventos transitorios o AIT estén infraestimados. Abstract: Introduction: Stroke recurrence is an important issue in stroke registries, but direct patient contact months after stroke is not always feasible. Telephone assessment is often used to evaluate long term stroke outcome, treatments and recurrences. Our aim is to evaluate telephone interview in a stroke registry. Material and methods: Three hundred and eighty patients with a stroke or TIA were prospectively registered, evaluating baseline characteristics and type of event. At 6 months, 248 patients were reviewed by structured telephone interview and 132 were reviewed by direct contact. We analysed stroke outcome and disability, treatments and stroke or TIA recurrences. Results: There were no differences in baseline characteristics and type or severity of the index event. At 6 months, treatments were similar between both groups and 10.5% (40 patients) had a recurrent event. There were no differences in recurrent ischaemic strokes (6.1% in direct contact vs 4.4% telephone, P = .49), but we detected a higher number of TIA in direct examination compared to phone interview (9.1% vs 4.0%, P = .04). Conclusions: Telephone assessment of stroke patients is reliable and facilitates stroke registries in detecting long-term treatments and stroke recurrences. However, it is probable that new transient events or TIA are under-estimated. Palabras clave: Evolución del ictus, Entrevista telefónica, Accidente isquémico transitorio, Registro de ictus, Evaluación de discapacidad, Recurrencia de ictus, Keywords: Stroke outcome, Telephone interview, Cerebral ischaemia, transient, Stroke registry, Disability evaluation, Stroke recurrence

A high-performance liquid chromatographic assay with diode-array detection has been developed for the in-process control of zolpidem synthesis and for the analysis of the drug and its synthetic intermediates. The separation uses a 4.6 mm i.d. reversed-phase Kromasil C 18 (150 mm) column, 5 μm particle size with a gradient elution mode of acetonitrile and 0.02 M NH 4 OAc (adjusted to pH 8.0) as the mobile phase (flow rate 1.0 ml min −1 ). The analysis is performed in 12 min. The method is simple, rapid and highly specific.

A high-performance liquid chromatographic assay coupled with UV detection (239 nm) has been developed for the determination of midazolam and its synthesis precursors. The separation of the analytes was performed on a Kromasil C8 column (15 cm x 4.6 mm i.d., 5 microm) at 30 degrees C. The mobile phase [ammonium chloride (pH 5.5, 1 g l(-1))-methanolacetonitrile (45:22:33, v/v/v)] was pumped at a flow-rate of 1.5 ml min(-1). This method is rapid (less than 11 min), sensitive (limit of detection (LOD) ranged between 0.05 and 0.5 mg l(-1)) and selective for the determination of midazolam, and it could be used for monitoring different synthetic routes.