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In-Hospital 30-Day Survival Among Young Adults With Coronavirus Disease 2019: A Cohort Study

Richardson, Safiya; Gitlin, Jordan; Kozel, Zachary; Levy, Sera; Rahman, Husneara; Hirsch, Jamie S; McGinn, Thomas; Diefenbach, Michael A
Background/UNASSIGNED:Our objective was to characterize young adult patients hospitalized with coronavirus disease 2019 (COVID-19) and identify predictors of survival at 30 days. Methods/UNASSIGNED:This retrospective cohort study took place at 12 acute care hospitals in the New York City area. Patients aged 18-39 hospitalized with confirmed COVID-19 between March 1 and April 27, 2020 were included in the study. Demographic, clinical, and outcome data were extracted from electronic health record reports. Results/UNASSIGNED:= .002) were independent predictors of in-hospital 30-day mortality. Conclusions/UNASSIGNED:Obesity was identified as the strongest negative predictor of 30-day in-hospital survival in young adults with COVID-19.
PMID: 34183983
ISSN: 2328-8957
CID: 4996232

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area

Richardson, Safiya; Hirsch, Jamie S; Narasimhan, Mangala; Crawford, James M; McGinn, Thomas; Davidson, Karina W; Barnaby, Douglas P; Becker, Lance B; Chelico, John D; Cohen, Stuart L; Cookingham, Jennifer; Coppa, Kevin; Diefenbach, Michael A; Dominello, Andrew J; Duer-Hefele, Joan; Falzon, Louise; Gitlin, Jordan; Hajizadeh, Negin; Harvin, Tiffany G; Hirschwerk, David A; Kim, Eun Ji; Kozel, Zachary M; Marrast, Lyndonna M; Mogavero, Jazmin N; Osorio, Gabrielle A; Qiu, Michael; Zanos, Theodoros P
Importance/UNASSIGNED:There is limited information describing the presenting characteristics and outcomes of US patients requiring hospitalization for coronavirus disease 2019 (COVID-19). Objective/UNASSIGNED:To describe the clinical characteristics and outcomes of patients with COVID-19 hospitalized in a US health care system. Design, Setting, and Participants/UNASSIGNED:Case series of patients with COVID-19 admitted to 12 hospitals in New York City, Long Island, and Westchester County, New York, within the Northwell Health system. The study included all sequentially hospitalized patients between March 1, 2020, and April 4, 2020, inclusive of these dates. Exposures/UNASSIGNED:Confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample among patients requiring admission. Main Outcomes and Measures/UNASSIGNED:Clinical outcomes during hospitalization, such as invasive mechanical ventilation, kidney replacement therapy, and death. Demographics, baseline comorbidities, presenting vital signs, and test results were also collected. Results/UNASSIGNED:A total of 5700 patients were included (median age, 63 years [interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7% female). The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%). At triage, 30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/minute, and 27.8% received supplemental oxygen. The rate of respiratory virus co-infection was 2.1%. Outcomes were assessed for 2634 patients who were discharged or had died at the study end point. During hospitalization, 373 patients (14.2%) (median age, 68 years [IQR, 56-78]; 33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, 81 (3.2%) were treated with kidney replacement therapy, and 553 (21%) died. Mortality for those requiring mechanical ventilation was 88.1%. The median postdischarge follow-up time was 4.4 days (IQR, 2.2-9.3). A total of 45 patients (2.2%) were readmitted during the study period. The median time to readmission was 3 days (IQR, 1.0-4.5) for readmitted patients. Among the 3066 patients who remained hospitalized at the final study follow-up date (median age, 65 years [IQR, 54-75]), the median follow-up at time of censoring was 4.5 days (IQR, 2.4-8.1). Conclusions and Relevance/UNASSIGNED:This case series provides characteristics and early outcomes of sequentially hospitalized patients with confirmed COVID-19 in the New York City area.
PMID: 32320003
ISSN: 1538-3598
CID: 4397182

Degree of twisting and duration of symptoms are prognostic factors of testis salvage during episodes of testicular torsion

Howe, Adam S; Vasudevan, Vinaya; Kongnyuy, Michael; Rychik, Kevin; Thomas, Lisa A; Matuskova, Maria; Friedman, Steven C; Gitlin, Jordan S; Reda, Edward F; Palmer, Lane S
Background/UNASSIGNED:Testicular torsion is surgical emergency. Prompt diagnosis and treatment of testicular torsion is essential for testicular viability. At surgical exploration, the spermatic cord is seen twisted a variable number of times around its longitudinal axis. There is scant data regarding the degree of twisting and its association with testis outcomes. The purpose of our study is to explore how the degree of torsion factors into testicular outcome using follow-up data. Methods/UNASSIGNED:We retrospectively reviewed the records of adolescent males who presented with testicular torsion to our institution, looking at duration of pain symptoms, degree of torsion documented in the operative note, procedure performed (orchiopexy versus orchiectomy), and follow-up clinic data for whether testicular atrophy after orchiopexy was present. A non-salvageable testis was defined as orchiectomy or atrophy. Receiver operator characteristics (ROC), multivariate, and logistic regression analyses were performed to determine the probability of a non-salvageable torsed testis based on time and degree of twisting. Results/UNASSIGNED:Eighty-one patients met our study criteria, with 55 testes deemed viable and 26 non-salvageable. We found a 25.7% atrophy rate after orchiopexy. Cut-off values of 8.5 h and 495 degrees of torsion would provide sensitivities of 73% and 53%, respectively, with specificity of 80% for both. Only duration and age were correlated with the risk of non-salvage on multivariate analysis. Logistic regression generated linear probability formulas of 4 + (3 ¡Á hours) and 7 + (0.05 ¡Á degrees) in calculating the probability of non-salvage with strong correlation. Conclusions/UNASSIGNED:We were able to derive separate formulas to determine the viability of the torsed testis based on symptom duration and degrees of twisting. Fifteen h of symptoms and 860 degrees of torsion gives testes a 50% salvage rate. Interestingly, we also found that about 1 out of every 4 testes undergoes atrophy after orchiopexy.
PMID: 29354505
ISSN: 2223-4691
CID: 3939922

T-shaped Shunt With Intracavernosal Tunneling for a Pediatric Case of Refractory Ischemic Priapism [Case Report]

Seideman, Casey A; Gitlin, Jordan S
We present the first reported case of refractory pediatric priapism treated by intracavernosal tunneling T shunt. A 12-year-old male, with sickle cell disease, presented with 72 hours of painful erection. The patient failed conservative measures including aspiration, injection of phenylephrine, as well as distal shunt procedure. A T-T shunt was performed, as previously described in the adult literature. There was immediate resolution of the erection with no complications. At 1-year follow-up, he reports no subsequent episodes of priapism and normal erections. T shunt with tunneling can be performed in select cases of severe pediatric refractory ischemic priapism.
PMID: 27693479
ISSN: 1527-9995
CID: 3939902

Robot-assisted Laparoscopic Urachal Excision in Children

Ahmed, Haris; Howe, Adam S; Dyer, Lori L; Fine, Ronnie G; Gitlin, Jordan S; Schlussel, Richard N; Zelkovic, Paul F; Palmer, Lane S
OBJECTIVE:To report the first exclusively pediatric series of robot-assisted urachal remnant excisions in children. METHODS:We reviewed the medical records of all children who underwent robot-assisted excision of urachal remnants from 2010 to 2016. For the procedure, a 3-port approach was performed in all cases. Excision of the urachus was performed, along with partial cystectomy if there was clear or suspected bladder involvement. Outcomes and complications were reviewed. RESULTS:Sixteen cases of robotic urachal excision were performed during the study period in patients aged 0.8-16.5 years. Complete excision was accomplished in all cases with no conversions. Partial cystectomy was performed in 11 cases, in which a urinary catheter was left for 1 day in all cases (no catheter was left in the absence of partial cystectomy). The only complication was a bladder leak requiring open surgical repair. There were no bowel injuries or hernias. The median operative time was 107 minutes. The length of stay was 2 days with partial cystectomy and 1 day without partial cystectomy. All patients were well at follow-up. CONCLUSION:We report the largest known series of robot-assisted urachal remnant excisions in children, demonstrating this minimally invasive approach to be safe and effective.
PMID: 28431995
ISSN: 1527-9995
CID: 3939912

Standardized education and parental awareness are lacking for testicular torsion

Friedman, Ariella A; Ahmed, Haris; Gitlin, Jordan S; Palmer, Lane S
INTRODUCTION/BACKGROUND:Testicular torsion leads to orchiectomy in 30-50% of cases, which may cause psychological upset and parental guilt over a potentially avertable outcome. Presentation delay is an important modifiable cause of orchiectomy; yet, families are not routinely educated about torsion or its urgency. The present study assessed parental knowledge regarding acute scrotal pain. MATERIALS AND METHODS/METHODS:An anonymous survey was distributed to parents in Urology and ENT offices, asking about their children's gender and scrotal pain history, urgency of response to a child's acute scrotal pain, and familiarity with testicular torsion. RESULTS:Surveys of 479 urology and 59 ENT parents were analyzed. The results between the two were not statistically different. Among the urology parents, 34% had heard of testicular twisting/torsion, most commonly through friends, relatives or knowing someone with torsion (35%); only 17% were informed by pediatricians (Summary Figure). Parents presenting for a child's scrotal pain were significantly more likely to have heard of torsion (69%) than those presenting for other reasons (30%, OR 5.24, P < 0.0001). Only 13% of parents of boys had spoken with their children about torsion. Roughly three quarters of them would seek emergent medical attention - by day (75%) or night (82%) - for acute scrotal pain. However, urgency was no more likely among those who knew about torsion. DISCUSSION/CONCLUSIONS:This was the first study to assess parental knowledge of the emergent nature of acute scrotal pain in a non-urgent setting, and most closely approximating their level of knowledge at the time of pain onset. It also assessed parents' hypothetical responses to the scenario, which was markedly different than documented presentation times, highlighting a potential area for improvement in presentation times. Potential limitations included lack of respondent demographic data, potential sampling bias of a population with greater healthcare knowledge or involvement, and assessment of parents only. CONCLUSIONS:Parental knowledge of testicular torsion was lacking, suggesting both ineffective education in the well-child setting and inappropriately timed education during or after pain occurrence. Awareness was most commonly anecdotal or taught unreliably, as even familiar parents were no more likely to seek emergent attention. Therefore, standardized, effective parental education on testicular torsion and the need for prompt presentation is needed, as is improvement in the quality of information taught in the healthcare setting. Further assessment of knowledge among preadolescent and adolescent boys regarding testicular torsion is warranted. It is hopeful that pre-hospital delay may be minimized and greater rates of testicular salvageability may be achieved through these efforts.
PMID: 26994588
ISSN: 1873-4898
CID: 3939892

Barriers to use of semen analysis in the adolescent with a varicocele: Survey of patient, parental, and practitioner attitudes

Fine, Ronnie G; Gitlin, Jordan; Reda, Edward F; Palmer, Lane S
BACKGROUND:The American Society for Reproductive Medicine Practice Committee recommends obtaining a semen analysis (SA) in pediatric patients presenting with a varicocele in the absence of significant testicular atrophy. Among infertile adults with a varicocele, surgery is indicated in the presence of abnormal semen analysis regardless of testicular atrophy. Despite these two statements, semen analysis is not widely utilized by pediatric urologists in the USA managing a patient with a varicocele. OBJECTIVE:We explored the attitudes of patients, parents, and practitioners toward SA to identify potential barriers to the use of SA in the evaluation of the adolescent varicocele. STUDY DESIGN/METHODS:We conducted a survey of Society for Pediatric Urology members regarding their management of adolescent varicoceles, with focus on the utilization of SA. The survey consisted of 14 multiple choice questions and two open-ended questions regarding use of SA in practice, barriers to its use, indications for varicocelectomy, and demographics. We also surveyed patients presenting for initial evaluation of a varicocele, as well as their parents, regarding their knowledge about SA and their attitude towards obtaining it. Statistical analysis was performed (p < 0.05 significant). RESULTS:The practitioner survey response rate was 53% (168). Only 13.1% routinely incorporated SA in their practice, with 48% of all responders having some degree of discomfort asking for a SA. Of practitioners who cited discomfort, 90% never order a SA for patients with varicoceles. From the 46% of physicians who ordered a SA, we noted significant practice variability (see Figure). The patient/parent survey demonstrated that this population was uncomfortable with the notion of obtaining a SA, with most patients/parents citing lack of knowledge about SA as the main barrier. Patient and parent knowledge was found to correlate. DISCUSSION/CONCLUSIONS:This study uniquely addresses an issue that has not been discussed in the adolescent varicocele literature to date. It can increase awareness of the option of incorporating SA data in management of the adolescent who presents with a varicocele. CONCLUSION/CONCLUSIONS:Recognizing and then breaking through the barriers to obtaining a SA, would improve patient care, providing a direct assessment of the impact of a varicocele on fertility potential and thus best determining which patients require surveillance versus surgical intervention. This study suggested that the barriers to SA are surmountable.
PMID: 26342542
ISSN: 1873-4898
CID: 5014932

Tunneled buccal mucosa tube grafts for repair of proximal hypospadias

Fine, Ronnie; Reda, Edward F; Zelkovic, Paul; Gitlin, Jordan; Freyle, Jaime; Franco, Israel; Palmer, Lane S
PURPOSE/OBJECTIVE:Buccal mucosa is the favored graft material for patients with long urethral defects and a paucity of skin. Since 2007, we have used the novel tunneled buccal mucosa tube graft urethroplasty technique in these patients. We describe this operative technique and report our surgical and functional outcomes. MATERIALS AND METHODS/METHODS:Between 2007 and 2013, 37 males with proximal hypospadias underwent tunneled buccal mucosa tube graft urethroplasty. After the penile shaft was optimized at a prior stage a free buccal graft was tubularized and tunneled under the intact ventral shaft skin and into the glans. We retrospectively reviewed all charts to report our results. We assessed uroflowmetry and bladder ultrasound for post-void residual urine. RESULTS:The overall complications rate in 34 patients with more than 1-year followup was 32% (11), including fistula in 5, proximal stricture in 4 and meatal stenosis in 2. In the first 10 patients a total of 7 complications (70%) developed but there were only 4 complications in the next 24 (16%). Surgeon experience was the only significant predictor of complications (p = 0.003). We obtained uroflow and post-void residual urine data on 13 of 37 patients, of whom 9 achieved a normal flow pattern and post-void residual urine, and 4 had a blunted flow pattern. CONCLUSIONS:The novel technique of the tunneled buccal mucosa tube graft in patients with proximal hypospadias represents a good alternative for a long urethroplasty in patients with a paucity of skin. After the learning curve plateaus the rate and degree of complications decrease. Furthermore, voiding function is adequate, as assessed by uroflow studies and post-void residual urine measurement.
PMID: 25817150
ISSN: 1527-3792
CID: 5014452

Long term outcomes of lymphatic sparing laparoscopic varicocelectomy

Rizkala, Emad; Fishman, Andrew; Gitlin, Jordan; Zelkovic, Paul; Franco, Israel
OBJECTIVE:To assess the long-term occurrence of hydroceles and varicocele recurrence in patients receiving lymphatic sparing laparoscopic varicocelectomy (LSLV) compared to those receiving plain laparoscopic varicocelectomy (PLV), and also to assess the growth of testicular volume postoperatively. METHODS:We employed a standard three-trocar configuration. The spermatic vessels were identified in the retroperitoneum above the internal inguinal ring. Lymphatics were dissected free from the spermatic artery and veins based on laparoscopic appearance. The spermatic artery and veins were divided between plastic locking clips. We performed a retrospective chart review of all pediatric patients who underwent laparoscopic varicocelectomy between June 2003 and January 2009. RESULTS:Of a total of 97 patients, 67 underwent LSLV with mean follow-up of 45.8 ± 20.7 months and 30 underwent PLV with mean follow-up of 40.8 ± 25.3 months (p = 15). There was a 4.5% hydrocele rate in the LSLV group compared to 43.3% in the PLV group. Of the patients who underwent a PLV and subsequently developed a hydrocele, 31% (n = 4) required a hydrocelectomy, vs none of those who developed a hydrocele after LSLV. Varicocele rate was 6% in the LSLV group vs 3.3% in the PLV group. However, when the artery was not preserved, the probability of recurrence in the LSLV group was 1.3%. Time to hydrocele formation was 16 months in the LSLV group vs 37 months in the PLV group. There was catch-up testicular growth in both groups. CONCLUSIONS:There appears to be increased risk of need for a hydrocelectomy after a PLV as compared to LSLV. Performing a lymphatic sparing, non-artery preserving, laparoscopic varicocelectomy has success and complication rates comparable with those of subinguinal microsurgical varicocelectomy. There appears to be excellent catch-up testicular growth with either laparoscopic varicocelectomy technique.
PMID: 23498876
ISSN: 1873-4898
CID: 5014432

Evaluating compensatory hypertrophy: a growth curve specific for solitary functioning kidneys

Krill, Aaron; Salami, Simpa; Rosen, Lisa; Friedman, Steven C; Gitlin, Jordan; Palmer, Lane S
PURPOSE/OBJECTIVE:While compensatory hypertrophy is expected in solitary kidneys, the definition of appropriate hypertrophy remains unclear. The normal renal growth rate in children age 1 to 18 years with 2 kidneys has been defined as 0.28 × age (years) + 6.1. Solitary kidneys appear to grow faster and larger and, thus, require a separate growth curve. MATERIALS AND METHODS/METHODS:The records of all patients 18 years old or younger with solitary functioning kidneys were reviewed from 2001 to 2011. Exclusion criteria were greater than SFU (Society for Fetal Urology) grade 2 hydronephrosis, posterior urethral valves, vesicoureteral reflux or any ipsilateral obstruction. Ordinary least squares regression modeled the renal length as a function of age by using only the initial sonogram per subject. The distribution of mean kidney length by age was plotted and compared to published normal values. RESULTS:A total of 91 subjects were included in the study. Patients were evenly split by laterality and gender. Multicystic dysplastic kidney comprised 34% and solitary kidneys 66% of subjects. Of these subjects 55% underwent their first sonogram at younger than 1 year old. There were 61 subjects with multiple sonograms but the initial 91 were included in the study. Age was a better predictor of renal length for subjects age 1 year or older (r(2) = 0.7312) than for those younger than 1 year old (r(2) = 0.6138). For children age 1 to 18 years we used the equation, length = 0.38 × age + 7.2. Solitary kidney values were approximately 2 standard deviations greater than normal values. CONCLUSIONS:The equation 0.4 × age (years) + 7 can be used to accurately estimate expected renal length in children (age 1 to 18 years) with solitary kidneys and can be used as a quick reference to evaluate for renal compensatory hypertrophy.
PMID: 22910263
ISSN: 1527-3792
CID: 5015812