Bradley Morganstern

The psychological context of quality of life: a psychometric analysis of a novel idiographic measure of bladder cancer patients' personal goals and concerns prior to surgery

BackgroundOver the past two decades, there has been an increasing focus on quality of life outcomes in urological diseases. Patient-reported outcomes research has relied on structured assessments that constrain interpretation of the impact of disease and treatments. In this study, we present content analysis and psychometric evaluation of the Quality of Life Appraisal Profile. Our evaluation of this measure is a prelude to a prospective comparison of quality of life outcomes of reconstructive procedures after cystectomy.MethodsFifty patients with bladder cancer were interviewed prior to surgery using the Quality of Life Appraisal Profile. Patients also completed the EORTC QLQ-C30 and demographics. Analysis included content coding of personal goal statements generated by the Appraisal Profile, examination of the relationship of goal attainment to content, and association of goal-based measures with QLQ-C30 scales.ResultsPatients reported an average of 10 personal goals, reflecting motivational themes of achievement, problem solving, avoidance of problems, maintaining desired circumstances, letting go of roles and responsibilities, acceptance of undesirable situations, and attaining milestones. 503 goal statements were coded using 40 different content categories. Progress toward goal attainment was positively correlated with relationships and activities goals, but negatively correlated with health concerns. Associations among goal measures provided evidence for construct validity. Goal content also differed according to age, gender, employment, and marital status, lending further support for construct validity. QLQ-C30 functioning and symptom scales were correlated with goal content, but not with progress toward goal attainment, suggesting that patients may calibrate progress ratings relative to their specific goals. Alternately, progress may reflect a unique aspect of quality of life untapped by more standard scales.ConclusionsThe Brief Quality of Life Appraisal Profile was associated with measures of motivation, goal content and progress, as well as relationships with demographic and standard quality of life measures. This measure identifies novel concerns and issues in treating patients with bladder cancer, necessary for a more comprehensive evaluations of their health-related quality of life.

Idiographic quality of life assessment before radical cystectomy.

We sought to determine if idiographic, or self‐defined, measures added to our understanding of patients with bladder cancers quality of life (QOL) prior to radical cystectomy (RC). We tested whether idiographic measures increased prediction of global QOL beyond standard (nomothetic) measures of QOL components.

A Unique Case of Pentaorchidism

Polyorchidism is a rare congenital anomaly with less than 200 case reports in literature. Triorchidism, the condition of having 3 testicles, is the most common presentation. We present an unusual case of a patient who was diagnosed with 5 testicles by magnetic resonance imaging. To the best of our knowledge, this rare presentation has not previously been reported in the medical literature.

PD35-04 PROSPECTIVE RANDOMIZED TRIAL OF ANTIBIOTIC PROPHYLAXIS DURATION FOR PERCUTANEOUS NEPHROLITHOTOMY: PRELIMINARY RESULTS

INTRODUCTION AND OBJECTIVES: Single institution studies have suggested possible benefit of a week of preoperative antibiotics prior to percutaneous nephrolithotomy (PNL). Yet prior studies are limited by lower methodology (Level IIa)1, including heterogeneous populations2, or utilizing quasi-sepsis definitions2. Other than the recommended peri-operative dose of IV antibiotics <24 hours per AUA Best Practice Statement, the duration/benefit of preoperative antibiotics remains unclear. We sought to perform a rigorous (adhering to CONSORT guidelines) multi-institutional trial assessing utility of preoperative PNL antibiotics for patients at low risk of infectious complications. METHODS: We performed a randomized controlled trial (RCT) coordinated across 7 academic stone centers for low risk PNL patients. Low risk patients were defined as those with negative urine cultures and under no antibiotic treatment course within 14 days of procedure, and without any urinary drains (catheters, stents, nephrostomy tubes). Patients randomized to the intervention arm received nitrofurantoin 100 mg twice daily for 7 days preceding surgery. All enrolled patients received standard preoperative dose of ampicillin (vancomycin if allergic) and gentamicin (ceftriaxone if eGFR<60 or allergic). PNL was performed per the usual practice of each treating surgeon. Baseline patient and stone characteristics were recorded. Perioperative infection related adverse events within the first 30 days were compared in both groups. RESULTS: Thirty-four patients were randomized to each arm. Adverse events occurring within the first 30 days of procedure are reported in Table 1. The infection rate after PNL in the intervention arm was 17.6% (6/34) versus 11.8% (4/34), p1⁄40.49. Two of the patients in the intervention arm with infectious complications needed readmission and two others required admission to the intensive care unit. Total length of hospital stay demonstrated no difference between the two groups (1.09 versus 1.47, p1⁄40.2). There was no mortality reported during this study period. CONCLUSIONS: There appears to be no advantage to providing one week of preoperative oral antibiotics in patients at low risk for infectious complications. Less than 24 hours peri-operative antibiotics as per AUA Best Practice Statement appears sufficient. We continue to analyze this low risk group with a more robust data set, as well as analyze preoperative antibiotic benefit in other stratified risk groups. 1. Mariappan et al. BJU Int 2006 2. Kumar et al. Urol Res 2012

MP66-03 PRESCRIBING NARCOTIC SHOULD BE SELECTIVE AFTER MANY PEDIATRIC UROLOGIC SURGERIES

INTRODUCTION AND OBJECTIVES: Morrison’s survey of SPU members reported no clear consensus in managing peri-operative pain in pediatric patients undergoing common urological procedures. We posit that non-narcotic analgesia allows withholding narcotic use following simple urologic surgery in out-patient surgery in most patients. METHODS: We prospectively tracked analgesic use and pain scales of patients undergoing outpatient penile (non-hypospadias) or groin surgery (hernia, orchidopexy). Parents marked an analgesic usage form and Wong-Baker FACES pain scale on the day of surgery (DOS) and post-operative day 1 (POD1). Patients received a caudal nerve block, unless contraindicated or refused by parents, or a penile block. Postoperative analgesics were either non-narcotic agents or narcotics prescribed at surgeon’s discretion. Descriptive statistics, contingency table analyses, and t-test were performed. RESULTS: 249 male patients, median age 36 mo (2-216mo) underwent penile (64%) or groin (36%) surgery. Caudal (92) or local block (147) was used in 96% of cases. Narcotics prescribed in 152 (61%) was associated with older age (74mo vs 47mo; p 1⁄40.0002). Overall, no difference in analgesic use was noted (p1⁄4NS) on DOS (72%) and POD (62%) and were not affected by surgery or block type. Among patients prescribed narcotics, 76% used any analgesic on DOS and 66% on POD 1 (p1⁄4NS); narcotic use on DOS (91 cases 65 took 1 dose) declined on POD1 (57; p1⁄40.0001) and was unaffected by surgery type or block type. Analgesic type used was similar between surgery types and between DOS and POD1 regardless of block used. Among patients not prescribed narcotics, 72% took 1+ doses of analgesics on DOS which declined to 59% on POD 1 (p1⁄4NS); usage was similar based on surgery type and from DOS to POD1 for both surgery and block types. Pain scale differences were not significant on DOS between non-narcotics and narcotic users (3.2 v 3.6, p1⁄4NS) but were on POD 1 (2.8 v 3.6, p1⁄40.0003). Pain significantly decreased for those using non-narcotics between DOS and POD1 (p1⁄40.004) but not for those using narcotics, perhaps due to pain perception in older children. CONCLUSIONS: Narcotic availability leads to its usage following uncomplicated urologic surgery. Given the efficacy of nonnarcotic analgesics, and the associated costs and potential side effects, prescribing narcotics should be highly selective.

MP66-13 NOVEL SONOGRAPHIC EVALUATION OF ADOLESCENT VARICOCELES

INTRODUCTION AND OBJECTIVES: Concern exists regarding overuse of computed tomography (CT) children with nephrolithiasis. While guidelines for pediatric nephrolithiasis call for imaging such as plain film of the kidney-ureter-bladder (KUB) or renal ultrasound (US) to minimize ionizing radiation in both initial and follow-up management, little is known regarding follow-up imaging practices. We explored nationwide imaging patterns in children following emergency department (ED) evaluations for nephrolithiasis, hypothesizing that initial imaging choice and need for admission or readmission increase the risk of follow-up CT scans. METHODS: Claims from MarketScan (2007-2013), an employer-based dataset of privately insured patients, were used to assess children 1-18 presenting to the ED an acute nephrolithiasis event, defined as no prior ED visits or surgical interventions for nephrolithiasis within 6 months. Independent variables were age, gender, region of care and insurance status, initial imaging modality, need for hospital admission, and return ED visits. Primary outcome was imaging modality 90 days following an encounter. Appropriate imaging was defined as either KUB or US. Using logistic regression, odds for receiving CT or appropriate imaging in follow-up were calculated. RESULTS: A total of 871 children with an ED visit for nephrolithiasis met inclusion criteria. Median age was 16 (range 1-18) and the majority of patients were female (550, 63.0%). KUB was the most common initial modality (520, 59.7%) followed by CT (196, 22.5%) and US (150, 17.2%). A total of 282 (30.9%) children received no follow-up imaging. Of children receiving any follow-up imaging, appropriate imaging was obtained in 306 (51.9%) and CT obtained in 283 (48.0%) children. Of children initially receiving a CT, 79 (40.3%) had a CT in follow-up. Predictors for imaging patterns are shown in the Table. CONCLUSIONS: Overuse of CT in children with nephrolithiasis is not limited to initial presentation as one third of all children presenting to the ED received a CT in follow-up. Identifiable risk factors for followup CT include younger age, complexity of stone event, and region of care. Clinical pathways directing imaging strategies for pediatric nephrolithiasis should focus on follow-up imaging as well as initial evaluation.

Abstract A69: Quality of life among ethnically diverse prostate cancer survivors: A first look

Health disparities in prostate cancer (i.e., increased risk among African American men) require a better understanding of the meaning of race/ethnicity in prostate cancer research, but research thus far on quality of life (QOL) after prostate cancer for men of color and participants from underserved communities is scarce. The goal of this pilot study was to explore issues of race/ethnicity and QOL in a diverse urban population of prostate cancer survivors. The specific aims were: (1) To pilot a method for collecting detailed race/ethnicity data in this population; (2) To examine differences in QOL indicators in this ethnically, linguistically, and educationally underserved and understudied population, 1-2 years post treatment; and (3) To determine whether prostate cancer-specific QOL (i.e., sexual and/or urinary functioning) was associated with global QOL in these populations. Participants were 54 prostate cancer survivors from one of the lowest income counties in the Northeast, recruited from a large, urban medical center and treated with either radical prostatectomy or prostate brachytherapy. Participants identified their primary race as African American or black (48%); white (26%); Hispanic (22%); and other (4%). Age ranged from 46 to 83 years (mean 65.5 years). All participants were interviewed orally using an IRB-approved protocol. Socio-demographic information was collected using a template adapted from the Family Access to Care Study on HIV (Bruce Rapkin, PI) that included in-depth questions regarding race and ethnicity with the option to check multiple categories and give detailed background information. Results for Aim 1 from the in-depth race/ethnicity and other demographic questions indicated more ethnic background variability than could be captured by the categories “African American,” “Hispanic,” and “white.” In each group, there was significant within-group diversity; 20% of participants identified with more than one ethnicity (i.e., among African American or black participants, 24% also identified as Caribbean, 11% as African-Black, etc.). Of the Hispanic participants, 15% spoke Spanish as their primary language and chose to be interviewed in Spanish. Nineteen percent of participants did not finish high school, 33% had a high school degree, and 48% had some education beyond high school. In terms of Aim 2, differences in QOL were not found based on demographic variables, indicating that in this pilot sample, ethnicity, education, and language were not associated with QOL. For Aim 3, a linear regression analysis indicated that in terms of sexual functioning, frequency of erections was significantly associated with global QOL, R 2 = .06, R 1 , 52) = 4.63, p = .04. Urinary functioning, however, was not significantly associated with global QOL. To summarize, this study represents an important first step in examining nuances of race/ethnicity and QOL issues, both prostate cancer-specific and global, in an underserved, ethnically diverse sample of prostate cancer survivors. Research that is conducted multi-lingually can better assess QOL among ethnically, linguistically, and educationally varied populations. Findings suggest that detailed, open-ended assessment of race/ethnic background is fruitful in conducting culturally competent QOL research in diverse communities. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A69.