Richard Berman

Introduction: Sepsis secondary to urinary tract infection after kidney stone surgery is associated with considerable morbidity. Limited research examines the use of hemoglobin A1c (HbA1c) to predict postoperative sepsis after endourologic procedures. We developed a machine learning (ML) model trained on demographic and clinical data to predict postoperative sepsis and better identify patients requiring preoperative optimization. Methods: Patients undergoing ureteroscopy, shockwave lithotripsy, or percutaneous nephrolithotomy at a tertiary care center were identified. Postoperative sepsis was defined as Systemic Inflammatory Response Syndrome (SIRS) scores ≥2. Five supervised ML models were developed: elastic-net penalized logistic regression, random forest, neural network, support vector machine, and naïve Bayes. The dataset was partitioned into training (80%) and testing (20%) sets; fivefold cross-validation was employed. Models were assessed for accuracy, discrimination via area under the receiver operating characteristic curve (AUCROC), calibration, and Brier score on the hold-out test set. Results: A total of 382 patients with complete data from a total cohort of 2,938 patients undergoing stone surgery from 2020 to 2023 were included with a mean age of 59.9 years (standard deviation [SD] ±14.9). Mean HbA1c was 6.34% (SD ±1.39). 15.2% (58/382) of patients in the study group developed postoperative sepsis, however the overall sepsis rate was 3.1% in the total cohort. Random forest modeling achieved the best performance in the hold-out test set with 91% accuracy, 0.88 AUCROC, calibration slope of 1.26, calibration intercept of −0.21, and Brier score of 0.09. The five most important urosepsis predictors, in descending order, were preoperative hemoglobin, HbA1c, stone size, length of surgery, and body mass index. The random forest model may be accessed at https://urol.shinyapps.io/sepsis_predict/ . Conclusions: A random forest model performed well in predicting sepsis after kidney stone surgery. Our model may help guide preoperative surgical optimization and planning as well as postoperative monitoring, pending further validation.

Purpose: Elevated glycated hemoglobin A1c (HbA1c) has not been specifically evaluated as a risk factor for urosepsis after kidney stone procedures. Moreover, there are no current guidelines for perioperative HbA1c optimization, nor recommendations for the optimal timing to treat non-urgent kidney stones in the setting of poor glycemic control. We evaluated the association between perioperative HbA1c levels and sepsis risk after ureteroscopy with lithotripsy. Methods: Patients undergoing ureteroscopy with lithotripsy from January 2020 to June 2023 at a tertiary center were retrospectively reviewed. Postoperative sepsis was defined as Systemic Inflammatory Response Syndrome scores ≥2 within 30 days after ureteroscopy. The risk of sepsis at various HbA1c thresholds was evaluated via multivariate logistic regression. Results: A total of 1454 patients underwent ureteroscopy with lithotripsy, and 319 patients had HbA1c collected within 90 days of their procedures. The mean preoperative Charlson Comorbidity Index (CCI) score was 3.22 (±2.77). An increased risk of sepsis was observed among patients with HbA1c levels between 8.0% and 9.9% (odds ratio [OR] 4.42, p = 0.025) and ≥10% (OR 8.17, p = 0.003). Positive preoperative urine culture despite treatment (OR 4.53, p < 0.001) and higher CCI (OR 1.17, p = 0.045) were also associated with increased odds of sepsis. Conclusion: The odds of sepsis after ureteroscopy with lithotripsy follow a dose–response relationship with elevated perioperative HbA1c. These data underscore the clinical utility of incorporating HbA1c into preprocedural optimization and may justify certain patients to delay elective ureteroscopy to improve glycemic control before endourologic intervention.

Introduction: Renal colic is frequently treated with opioids; however, narcotic analgesic use can lead to dependence and abuse. We evaluated use trends of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management of kidney stones in United States emergency departments (EDs) from 2015 to 2021. Methods: Kidney stone encounters were identified using National Hospital Ambulatory Medical Care Survey data. We applied a multistage survey weighting procedure to account for selection probability, nonresponse, and population weights. Medication use trends were estimated through logistic regressions on the timing of the encounter, adjusted for selected demographic and clinical characteristics. Results: Between 2015 and 2021, there were an estimated 9,433,291 kidney stone encounters in United States EDs. Opioid use decreased significantly (annual odds ratio [OR]: 0.87, p = 0.003), and there was no significant trend in NSAID use. At discharge, male patients were more likely than females (OR: 1.93, p = 0.001) to receive opioids, and Black patients were less likely than White patients (OR: 0.34, p = 0.010) to receive opioids. Regional variation was also observed, with higher odds of discharge prescriptions in the West (OR: 3.15, p = 0.003) and Midwest (OR: 2.49, p = 0.010), compared with the Northeast. Thirty-five percent of patients received opioids that were stronger than morphine. Conclusion: These results suggest improved opioid stewardship from ED physicians in response to the national opioid epidemic. However, regional variation as well as disparities in discharge prescriptions for Black and female patients underscore opportunities for continued efforts.

Background: Same-day HIV testing and antiretroviral therapy (ART) initiation is being widely implemented. However, the optimal timing of ART among patients with tuberculosis (TB) symptoms is unknown. We hypothesized that same-day treatment (TB treatment for those diagnosed with TB; ART for those not diagnosed with TB) would be superior to standard care in this population. Methods and findings: We conducted an open-label trial among adults with TB symptoms at initial HIV diagnosis at GHESKIO in Haiti; participants were recruited and randomized on the same day. Participants were randomized in a 1:1 ratio to same-day treatment (same-day TB testing with same-day TB treatment if TB diagnosed; same-day ART if TB not diagnosed) versus standard care (initiating TB treatment within 7 days and delaying ART to day 7 if TB not diagnosed). In both groups, ART was initiated 2 weeks after TB treatment. The primary outcome was retention in care with 48-week HIV-1 RNA p = 0.14). Two new grade 3 or 4 events were reported per group; none were judged to be related to the intervention. The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain. Conclusions: In patients with TB symptoms at HIV diagnosis, we found that same-day treatment was not associated with superior retention and viral suppression. In this study, a short delay in ART initiation did not appear to compromise outcomes. Trial registration: This study is registered with ClinicalTrials.gov NCT03154320.

This paper describes the case report of a patient admitted to hospital with severe and complex pain and subacute bowel obstruction, who failed to respond to multiple analgesic regimens including ketamine burst and opioid rotation, and was subsequently successfully managed with a parecoxib infusion.