Kristy Borawski - Academia.edu (original) (raw)

Papers by Kristy Borawski

PLOS ONE, Jul 21, 2015

Objective To evaluate trends in urodynamic procedures in the U.S. males from 2000-2012 and determ... more Objective To evaluate trends in urodynamic procedures in the U.S. males from 2000-2012 and determine if a 2010 decline in reimbursement was associated with decreased utilization. Subjects and methods We analyzed 2000-2012 administrative healthcare claims from Truven Health's Marketscan Database and evaluated males 18 years of age. We identified cystometrograms and any concurrent procedures using procedure billing codes. Covariates included age, year of cystometrogram, region and associated diagnosis codes. We estimated standardized cystometrogram utilization rates per 10,000 person-years (PY). We used age, region, and calendar year adjusted Poisson regression models to estimate the independent effect of calendar year and region.

The Journal of Urology, Apr 1, 2014

incontinence and detrusor overactivity (DO), standardization of terminology and protocol in urody... more incontinence and detrusor overactivity (DO), standardization of terminology and protocol in urodynamics (UDS) is paramount. Variations may in part explain the discrepancies observed in trials involving UDS measurements. Our objective was to perform a meta-analysis on the effects of posture in the detection of DO using UDS in adult patients with lower urinary tract symptoms (LUTS). METHODS: Medline, Scopus, and ISI Web of Science databases were queried using specified search terms for articles written in English between 1963 and June 2013. References from the primary citations were manually checked to identify articles not captured. Studies were included if they investigated patients presenting with LUTS, controlled for any provocation maneuvers (e.g. cough provocation performed in both postures or no provocation performed in either posture), and if the study used the same cystometric technique for assessment in both postures. All data was extracted independently by 2 reviewers. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess bias of all included studies. The odds ratios (OR) and 95% confidence intervals (CI) for detecting DO were calculated for cystometry in an erect (sitting or standing) compared to supine posture. Effect size estimates of ORs were calculated using DerSirmonian and Laird random-effects models. RESULTS: An initial 175 articles were identified. A total of 9 articles (n¼1186 patients) met the inclusion criteria. In all 9 articles, the supine posture was compared with an erect posture. Cystometry in an erect posture was 3.38 times more likely to detect DO compared to the supine cystometry (OR: 3.38, 95% CI: 2.0-5.7, p<0.001). Standing cystometry was more likely to detect DO compared to sitting (OR: 1.46, 95% CI: 1.13-1.88, p¼0.003) and trended towards significance compared to the supine cystometry (OR: 3.58, 95% CI: 0.940-13.618, p¼0.062). When using erect cystometry as the reference standard, supine cystometry alone would miss nearly half of the cases of DO (47.4%, p<0.001). CONCLUSIONS: Cystometry in an erect posture significantly increases the odds of detecting DO. Moreover, standing cystometry is significantly more likely to detect DO compared to cystometry in the sitting posture. Given the dramatic substantial effect of patient posture on UDS outcomes, particular emphasis must be placed when interpreting UDS results. Trials involving UDS should adjust or control for posture in analyses and patient posture should be reported in trial results.

Urology, 2021

OBJECTIVE To evaluate the geographic impact of away rotations on regional interview invitations a... more OBJECTIVE To evaluate the geographic impact of away rotations on regional interview invitations and matching. METHODS AND MATERIALS Urology applicants who participated in the 2019-2020 cycle were invited to complete a survey post-match. Questions covered demographics, scholastic achievements, number and region of away rotations, number and locations of interview invitations, and matching results. One-way analysis of variance (ANOVA) and t-tests were used for continuous variables. Chi-square and fisher exact tests were used for categorical variables. RESULTS Of 349 applicants, 88 (25.2%) completed the survey. Geographic location was a top consideration for away rotation selection; 86% placed it in their top 3 with 40% selecting it as number 1. Furthermore, 36.4% "agreed" and 37.5% "strongly agreed" that geographic distribution of home and away rotations impacted their interview invitations. On ANOVA analysis, the ratio of regional to total interview invitations was higher among applicants completing a rotation (either home or away) in a specific AUA section (p<0.01). However, completing more away rotations (≥3 vs. 0-2) did not increase the ratio of interview invitations to total applications (p=0.49), and rotation location was not associated with matching in that region (p>0.05). CONCLUSION Geography is a key driver in away rotation selection among applicants and may increase the proportion of regional interview invitations. However, match results were not associated with geography of away rotations. With unprecedented changes coming to the urology residency match cycle, these findings suggest that loss of away rotations may have limited impact on interview invitations or match result.

Practical Urodynamics for the Clinician, 2016

Urology, 2012

To describe the patterns in the use of bladder augmentation and urinary diversion to manage urolo... more To describe the patterns in the use of bladder augmentation and urinary diversion to manage urologic sequelae among patients with spinal cord injury in the United States. Discharge estimates were derived from the Nationwide Inpatient Sample. All patients underwent bladder augmentation or ileal conduit diversion from 1998 to 2005 and had a diagnosis of spinal cord injury. Ileal loop diversion was performed in an estimated 1919 patients and bladder augmentation in 1132 patients with spinal cord injury from 1998 to 2005. Patients undergoing urinary diversion tended to be older (mean age 46 vs 34 years; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001) and to have Medicare as the primary payer (55.0% vs 30.8%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). Patients who underwent urinary diversion appeared to use more healthcare resources, with a longer length of stay (15 vs 9 days), higher hospital charges ($58,626 vs $37,222), and a greater use of home healthcare services after discharge (all P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). Patients at teaching institutions were more likely to undergo bladder augmentation (42%) than those at nonteaching institutions (23%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). Bladder augmentation is used in approximately one-third of cases to manage the urologic complications of spinal cord injury. These patients likely constitute a clinically distinct population that uses fewer healthcare resources. The lower augmentation rates at nonteaching institutions may indicate an opportunity for quality improvement.

Urology, 2006

Renal calculi in the spinal cord injury population present a diagnostic dilemma for urologists. H... more Renal calculi in the spinal cord injury population present a diagnostic dilemma for urologists. However, 7% of all patients with spinal cord injury will develop renal calculi. Undiagnosed stone disease can lead to significant morbidity and mortality in this population. This case demonstrates the subtlety of the presenting symptoms of renal calculi in the patient with spinal cord injury.

Neurourology and Urodynamics, 2007

Aims: Pad per day (PPD) usage is a frequently utilized measure of urinary incontinence. The 24-ho... more Aims: Pad per day (PPD) usage is a frequently utilized measure of urinary incontinence. The 24-hour pad weight test (24PWT) is a reproducible test for quantifying incontinence volumes. We investigated whether PPD validly reports the magnitude of urinary incontinence. Methods: This was a retrospective review of patients undergoing stress incontinence surgery from July 2002 to 2005. Inclusion criteria were a documented 24PWT and patient-reported PPD usage. Grams of urine loss per pad (GPP) provided a third measure of incontinence. Descriptive statistics and correlations between all variables and signi¢cance were noted. Factor analysis was performed on the three measures of leakage and age for all patients over age 50. Results: One hundred forty-¢ve male and 116 female patients met inclusion criteria. Correlated against 24PWT, GPP has the strongest association with a correlation of 0.80 for males and 0.88 for females. PPD has a weaker correlation of 0.64 for males and 0.61 for females (R 2 ¼ 0.38 overall). Factor analysis identi¢ed two components associated with incontinence. A ''leakage'' component correlated best with 24PWT and GPP. Additionally, an ''age'' component implies that despite stable 24PWT values, older patients increase GPP while PPD decreases. Conclusions: Self-reported PPD is an unreliable measure of incontinence as this variable only measures 38% of the variation of urinary incontinence volume. Patients at a given PPD level present with a wide range of 24PWT values. Older patients have higher per-pad leakage. Future incontinence studies should report 24PWT to ensure the most reliable and uniform data.

Neurourology and Urodynamics, 2007

Aims: The purpose of this study was to determine whether a percutaneous needle electrode (PNE) te... more Aims: The purpose of this study was to determine whether a percutaneous needle electrode (PNE) technique or a surgical ¢rst stage lead placement (FSLP) better predicted whether a patient would progress to implantation of a pulse generator (IPG) in older urge incontinent women. Methods: Thirty subjects 55 years with refractory urge incontinence who had been selected to undergo a test stimulation procedure were randomized to either PNE or FSLP. Thirteen underwent PNE placement and seventeen underwent FSLP placement. If during the test stimulation period subjects had greater than 50% improvement in their incontinence parameters they quali¢ed for permanent lead and/or IPG implantation of the Interstim 1 device. Results: Twenty-one subjects (70%) responded to the test stimulation and underwent implantation, 15/17 (88%) in the FSLP group and 6/ 13 (46%) in the PNE group. Subjects who were randomized to the FSLP group were signi¢cantly more likely to proceed to implantation of the IPG (P ¼ 0.02) than those in the PNE group. There was no signi¢cant di¡erence in demographics, pre-test stimulation incontinence parameters or poststimulation visual analog pain scores between the randomized groups or between test stimulation responders and non-responders. When comparing FSLP and PNE responders, there was no signi¢cant di¡erence in the percent improvement in 24-hr pad weight, daily pad usage, or daily incontinence. Conclusion: FSLP better predicted progression to implantation of the IPG than a test stimulation with a PNE in an older urge incontinent cohort. Neurourol. Urodynam.

The Journal of Urology, 2008

Purpose: Reference values for stone risk factors in 24-hour urine samples for nonstone forming ch... more Purpose: Reference values for stone risk factors in 24-hour urine samples for nonstone forming children are limited. We measured urinary stone risk factors in healthy children 3 to 18 years old, and sought to determine whether the risk factors are affected by age. Materials and Methods: A total of 48 healthy subjects with no history of stone disease, endocrine abnormalities or urological surgery were recruited from the Naval Medical Center in San Diego. Subjects were then further divided into 4 age groups, each separated by 5 years. A single outpatient 24-hour urine sample was obtained and analyzed. Urine chemistries were adjusted for urinary creatinine and body weight. Results: After excluding under collected samples 46 urine samples were analyzed. Urinary pH and volume decreased with increasing age, although the difference in pH did not reach statistical significance. Unadjusted urinary parameters failed to show statistical difference among the age groups. When adjusted for urinary creatinine and body weight all urinary parameters (calcium, oxalate, uric acid, citrate, magnesium, sodium, phosphorus and potassium) decreased with increasing age (statistically significant except for calcium). Conclusions: Stone risk factors in 24-hour urine samples decrease with increasing age in healthy, nonstone forming children. Normative data, derived by adjustment with urinary creatinine or body weight and stratified according to quintiles of age, should be useful in defining abnormal stone risk factors in children with stones.

The Journal of Urology, 2010

Patients with type Ia glycogen storage disease have an increased recurrent nephrolithiasis rate. ... more Patients with type Ia glycogen storage disease have an increased recurrent nephrolithiasis rate. We identified stone forming risk factors in patients with type Ia glycogen storage disease vs those in stone formers without the disease. Patients with type Ia glycogen storage disease were prospectively enrolled from our metabolic clinic. Patient 24-hour urine parameters were compared to those in age and gender matched stone forming controls. We collected 24-hour urine samples from 13 patients with type Ia glycogen storage disease. Average +/- SD age was 27.0 +/- 13.0 years and 6 patients (46%) were male. Compared to age and gender matched hypocitraturic, stone forming controls patients had profound hypocitraturia (urinary citrate 70 vs 344 mg daily, p = 0.009). When comparing creatinine adjusted urinary values, patients had profound hypocitraturia (0.119 vs 0.291 mg/mg creatinine, p = 0.005) and higher oxalate (0.026 vs 0.021 mg/mg creatinine, p = 0.038) vs other stone formers. Patients with type Ia glycogen storage disease have profound hypocitraturia, as evidenced by 24-hour urine collections, even compared to other stone formers. This may be related to a recurrent nephrolithiasis rate greater than in the overall population. These findings may be used to support different treatment modalities, timing and/or doses to prevent urinary lithiasis in patients with type Ia glycogen storage disease.

The Journal of Urology, 2009

The Journal of Urology, 2010

The Journal of Urology, 2008

The Journal of Urology, 2010

The Journal of Urology, 2007

Purpose: Citrus fruits and juices are a known natural source of dietary citrate. Of all the citru... more Purpose: Citrus fruits and juices are a known natural source of dietary citrate. Of all the citrus juices, lemon juice appears to have the highest concentration of citrate. Therefore, lemonade therapy has been proposed as a potential treatment for patients with hypocitraturia. We retrospectively evaluated the impact of long-term lemonade therapy on urinary metabolic parameters and stone formation in patients with hypocitraturic nephrolithiasis. Materials and Methods: A total of 32 patients were identified as being on long-term lemonade therapy for hypocitraturic nephrolithiasis. The 11 patients on lemonade therapy who met the entrance criteria for evaluation were compared to an age and sex matched control group of patients treated with oral slow release potassium citrate. Pre-therapy and post-therapy urinary parameters were recorded for both groups. The effect of lemonade therapy on stone burden and stone formation rate was calculated. New stone formation was defined as passage, surgical removal or appearance of new stones, or an increase in the size of existing stones on radiographic imaging. Results: Four males and 7 females (mean age 52.7 years) were treated with lemonade therapy for a mean of 44.4 months. The control group consisted of 4 males and 7 females (mean age 54.5 years) treated with potassium citrate for a mean of 42.5 months. Of the 11 patients on lemonade 10 demonstrated increased urinary citrate levels (mean increase ϩ383 mg per day, p Ͻ0.05). All potassium citrate therapy subjects demonstrated an increase in urinary citrate (mean increase ϩ482 mg per day, p Ͻ0.0001). Mean pretreatment and posttreatment stone burden in the lemonade group was 37.2 and 30.4 mm 2 , respectively (p Ͼ0.05). During lemonade therapy the stone formation rate decreased from 1.00 to 0.13 stones per patient per year (p Ͼ0.05). Conclusions: Due to its significant citraturic effect, lemonade therapy appears to be a reasonable alternative for patients with hypocitraturia who cannot tolerate first line therapy. Future study in the form of a prospective, randomized trial is needed to validate these findings.

The Journal of Urology, 2012

The Journal of Urology, 2008

The Journal of Urology, 2008

Background: Since January 2003, all clinical scientific articles published in the American volume... more Background: Since January 2003, all clinical scientific articles published in the American volume of The Journal of Bone and Joint Surgery (JBJS-A) have included a level-of-evidence rating. The aim of the current study was to evaluate the interobserver agreement among reviewers, with varying levels of epidemiology training, in categorizing the levels of evidence of these clinical studies.

The Journal of Urology, 2007

The concept of levels of evidence is one of the guiding principles of evidence based clinical pra... more The concept of levels of evidence is one of the guiding principles of evidence based clinical practice. It is based on the understanding that certain study designs are more likely to be affected by bias than others. We provide an assessment of the type and levels of evidence found in the urological literature. Three reviewers rated a random sample of 600 articles published in 4 major urology journals, including 300 each in 2000 and 2005. The level of evidence rating system was adapted from the Center of Evidence Based Medicine. Sample size was estimated to detect a relative increase in the proportion of studies that provided a high level of evidence (I and II combined) from 0.2 to 0.3 with 80% power. Of the 600 studies reviewed 60.3% addressed questions of therapy or prevention, 11.5% addressed etiology/harm, 11.3% addressed prognosis and 9.2% addressed diagnosis. The levels of evidence provided by these studies from I to IV were 5.3%, 10.3%, 9.8% and 74.5%, respectively. A high level of evidence was provided by 16.0% of studies in 2000 and by 15.3% in 2005 (p = 0.911). This study suggests that a majority of studies in the urological literature provide low levels of evidence that may not be well suited to guide clinical decision making. We propose that editors of leading urology journals should promote awareness for this guiding principle of evidence based clinical practice by providing a level of evidence designation with each published study.

BJU International, 2010

6 0 5 research and statistical methods in the urology literature. J Urol 2005; 174 : 1374-9 4 Sca... more 6 0 5 research and statistical methods in the urology literature. J Urol 2005; 174 : 1374-9 4 Scales CD Jr, Norris RD, Keitz SA et al. A critical assessment of the quality of reporting of randomized, controlled trials in the urology literature. J Urol 2007; 177 : 1090-5 5 Welk B, Afshar K, MacNeily AE.

PLOS ONE, Jul 21, 2015

Objective To evaluate trends in urodynamic procedures in the U.S. males from 2000-2012 and determ... more Objective To evaluate trends in urodynamic procedures in the U.S. males from 2000-2012 and determine if a 2010 decline in reimbursement was associated with decreased utilization. Subjects and methods We analyzed 2000-2012 administrative healthcare claims from Truven Health's Marketscan Database and evaluated males 18 years of age. We identified cystometrograms and any concurrent procedures using procedure billing codes. Covariates included age, year of cystometrogram, region and associated diagnosis codes. We estimated standardized cystometrogram utilization rates per 10,000 person-years (PY). We used age, region, and calendar year adjusted Poisson regression models to estimate the independent effect of calendar year and region.

The Journal of Urology, Apr 1, 2014

incontinence and detrusor overactivity (DO), standardization of terminology and protocol in urody... more incontinence and detrusor overactivity (DO), standardization of terminology and protocol in urodynamics (UDS) is paramount. Variations may in part explain the discrepancies observed in trials involving UDS measurements. Our objective was to perform a meta-analysis on the effects of posture in the detection of DO using UDS in adult patients with lower urinary tract symptoms (LUTS). METHODS: Medline, Scopus, and ISI Web of Science databases were queried using specified search terms for articles written in English between 1963 and June 2013. References from the primary citations were manually checked to identify articles not captured. Studies were included if they investigated patients presenting with LUTS, controlled for any provocation maneuvers (e.g. cough provocation performed in both postures or no provocation performed in either posture), and if the study used the same cystometric technique for assessment in both postures. All data was extracted independently by 2 reviewers. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess bias of all included studies. The odds ratios (OR) and 95% confidence intervals (CI) for detecting DO were calculated for cystometry in an erect (sitting or standing) compared to supine posture. Effect size estimates of ORs were calculated using DerSirmonian and Laird random-effects models. RESULTS: An initial 175 articles were identified. A total of 9 articles (n¼1186 patients) met the inclusion criteria. In all 9 articles, the supine posture was compared with an erect posture. Cystometry in an erect posture was 3.38 times more likely to detect DO compared to the supine cystometry (OR: 3.38, 95% CI: 2.0-5.7, p<0.001). Standing cystometry was more likely to detect DO compared to sitting (OR: 1.46, 95% CI: 1.13-1.88, p¼0.003) and trended towards significance compared to the supine cystometry (OR: 3.58, 95% CI: 0.940-13.618, p¼0.062). When using erect cystometry as the reference standard, supine cystometry alone would miss nearly half of the cases of DO (47.4%, p<0.001). CONCLUSIONS: Cystometry in an erect posture significantly increases the odds of detecting DO. Moreover, standing cystometry is significantly more likely to detect DO compared to cystometry in the sitting posture. Given the dramatic substantial effect of patient posture on UDS outcomes, particular emphasis must be placed when interpreting UDS results. Trials involving UDS should adjust or control for posture in analyses and patient posture should be reported in trial results.

Urology, 2021

OBJECTIVE To evaluate the geographic impact of away rotations on regional interview invitations a... more OBJECTIVE To evaluate the geographic impact of away rotations on regional interview invitations and matching. METHODS AND MATERIALS Urology applicants who participated in the 2019-2020 cycle were invited to complete a survey post-match. Questions covered demographics, scholastic achievements, number and region of away rotations, number and locations of interview invitations, and matching results. One-way analysis of variance (ANOVA) and t-tests were used for continuous variables. Chi-square and fisher exact tests were used for categorical variables. RESULTS Of 349 applicants, 88 (25.2%) completed the survey. Geographic location was a top consideration for away rotation selection; 86% placed it in their top 3 with 40% selecting it as number 1. Furthermore, 36.4% "agreed" and 37.5% "strongly agreed" that geographic distribution of home and away rotations impacted their interview invitations. On ANOVA analysis, the ratio of regional to total interview invitations was higher among applicants completing a rotation (either home or away) in a specific AUA section (p<0.01). However, completing more away rotations (≥3 vs. 0-2) did not increase the ratio of interview invitations to total applications (p=0.49), and rotation location was not associated with matching in that region (p>0.05). CONCLUSION Geography is a key driver in away rotation selection among applicants and may increase the proportion of regional interview invitations. However, match results were not associated with geography of away rotations. With unprecedented changes coming to the urology residency match cycle, these findings suggest that loss of away rotations may have limited impact on interview invitations or match result.

Practical Urodynamics for the Clinician, 2016

Urology, 2012

To describe the patterns in the use of bladder augmentation and urinary diversion to manage urolo... more To describe the patterns in the use of bladder augmentation and urinary diversion to manage urologic sequelae among patients with spinal cord injury in the United States. Discharge estimates were derived from the Nationwide Inpatient Sample. All patients underwent bladder augmentation or ileal conduit diversion from 1998 to 2005 and had a diagnosis of spinal cord injury. Ileal loop diversion was performed in an estimated 1919 patients and bladder augmentation in 1132 patients with spinal cord injury from 1998 to 2005. Patients undergoing urinary diversion tended to be older (mean age 46 vs 34 years; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001) and to have Medicare as the primary payer (55.0% vs 30.8%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). Patients who underwent urinary diversion appeared to use more healthcare resources, with a longer length of stay (15 vs 9 days), higher hospital charges ($58,626 vs $37,222), and a greater use of home healthcare services after discharge (all P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). Patients at teaching institutions were more likely to undergo bladder augmentation (42%) than those at nonteaching institutions (23%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). Bladder augmentation is used in approximately one-third of cases to manage the urologic complications of spinal cord injury. These patients likely constitute a clinically distinct population that uses fewer healthcare resources. The lower augmentation rates at nonteaching institutions may indicate an opportunity for quality improvement.

Urology, 2006

Renal calculi in the spinal cord injury population present a diagnostic dilemma for urologists. H... more Renal calculi in the spinal cord injury population present a diagnostic dilemma for urologists. However, 7% of all patients with spinal cord injury will develop renal calculi. Undiagnosed stone disease can lead to significant morbidity and mortality in this population. This case demonstrates the subtlety of the presenting symptoms of renal calculi in the patient with spinal cord injury.

Neurourology and Urodynamics, 2007

Aims: Pad per day (PPD) usage is a frequently utilized measure of urinary incontinence. The 24-ho... more Aims: Pad per day (PPD) usage is a frequently utilized measure of urinary incontinence. The 24-hour pad weight test (24PWT) is a reproducible test for quantifying incontinence volumes. We investigated whether PPD validly reports the magnitude of urinary incontinence. Methods: This was a retrospective review of patients undergoing stress incontinence surgery from July 2002 to 2005. Inclusion criteria were a documented 24PWT and patient-reported PPD usage. Grams of urine loss per pad (GPP) provided a third measure of incontinence. Descriptive statistics and correlations between all variables and signi¢cance were noted. Factor analysis was performed on the three measures of leakage and age for all patients over age 50. Results: One hundred forty-¢ve male and 116 female patients met inclusion criteria. Correlated against 24PWT, GPP has the strongest association with a correlation of 0.80 for males and 0.88 for females. PPD has a weaker correlation of 0.64 for males and 0.61 for females (R 2 ¼ 0.38 overall). Factor analysis identi¢ed two components associated with incontinence. A ''leakage'' component correlated best with 24PWT and GPP. Additionally, an ''age'' component implies that despite stable 24PWT values, older patients increase GPP while PPD decreases. Conclusions: Self-reported PPD is an unreliable measure of incontinence as this variable only measures 38% of the variation of urinary incontinence volume. Patients at a given PPD level present with a wide range of 24PWT values. Older patients have higher per-pad leakage. Future incontinence studies should report 24PWT to ensure the most reliable and uniform data.

Neurourology and Urodynamics, 2007

Aims: The purpose of this study was to determine whether a percutaneous needle electrode (PNE) te... more Aims: The purpose of this study was to determine whether a percutaneous needle electrode (PNE) technique or a surgical ¢rst stage lead placement (FSLP) better predicted whether a patient would progress to implantation of a pulse generator (IPG) in older urge incontinent women. Methods: Thirty subjects 55 years with refractory urge incontinence who had been selected to undergo a test stimulation procedure were randomized to either PNE or FSLP. Thirteen underwent PNE placement and seventeen underwent FSLP placement. If during the test stimulation period subjects had greater than 50% improvement in their incontinence parameters they quali¢ed for permanent lead and/or IPG implantation of the Interstim 1 device. Results: Twenty-one subjects (70%) responded to the test stimulation and underwent implantation, 15/17 (88%) in the FSLP group and 6/ 13 (46%) in the PNE group. Subjects who were randomized to the FSLP group were signi¢cantly more likely to proceed to implantation of the IPG (P ¼ 0.02) than those in the PNE group. There was no signi¢cant di¡erence in demographics, pre-test stimulation incontinence parameters or poststimulation visual analog pain scores between the randomized groups or between test stimulation responders and non-responders. When comparing FSLP and PNE responders, there was no signi¢cant di¡erence in the percent improvement in 24-hr pad weight, daily pad usage, or daily incontinence. Conclusion: FSLP better predicted progression to implantation of the IPG than a test stimulation with a PNE in an older urge incontinent cohort. Neurourol. Urodynam.

The Journal of Urology, 2008

Purpose: Reference values for stone risk factors in 24-hour urine samples for nonstone forming ch... more Purpose: Reference values for stone risk factors in 24-hour urine samples for nonstone forming children are limited. We measured urinary stone risk factors in healthy children 3 to 18 years old, and sought to determine whether the risk factors are affected by age. Materials and Methods: A total of 48 healthy subjects with no history of stone disease, endocrine abnormalities or urological surgery were recruited from the Naval Medical Center in San Diego. Subjects were then further divided into 4 age groups, each separated by 5 years. A single outpatient 24-hour urine sample was obtained and analyzed. Urine chemistries were adjusted for urinary creatinine and body weight. Results: After excluding under collected samples 46 urine samples were analyzed. Urinary pH and volume decreased with increasing age, although the difference in pH did not reach statistical significance. Unadjusted urinary parameters failed to show statistical difference among the age groups. When adjusted for urinary creatinine and body weight all urinary parameters (calcium, oxalate, uric acid, citrate, magnesium, sodium, phosphorus and potassium) decreased with increasing age (statistically significant except for calcium). Conclusions: Stone risk factors in 24-hour urine samples decrease with increasing age in healthy, nonstone forming children. Normative data, derived by adjustment with urinary creatinine or body weight and stratified according to quintiles of age, should be useful in defining abnormal stone risk factors in children with stones.

The Journal of Urology, 2010

Patients with type Ia glycogen storage disease have an increased recurrent nephrolithiasis rate. ... more Patients with type Ia glycogen storage disease have an increased recurrent nephrolithiasis rate. We identified stone forming risk factors in patients with type Ia glycogen storage disease vs those in stone formers without the disease. Patients with type Ia glycogen storage disease were prospectively enrolled from our metabolic clinic. Patient 24-hour urine parameters were compared to those in age and gender matched stone forming controls. We collected 24-hour urine samples from 13 patients with type Ia glycogen storage disease. Average +/- SD age was 27.0 +/- 13.0 years and 6 patients (46%) were male. Compared to age and gender matched hypocitraturic, stone forming controls patients had profound hypocitraturia (urinary citrate 70 vs 344 mg daily, p = 0.009). When comparing creatinine adjusted urinary values, patients had profound hypocitraturia (0.119 vs 0.291 mg/mg creatinine, p = 0.005) and higher oxalate (0.026 vs 0.021 mg/mg creatinine, p = 0.038) vs other stone formers. Patients with type Ia glycogen storage disease have profound hypocitraturia, as evidenced by 24-hour urine collections, even compared to other stone formers. This may be related to a recurrent nephrolithiasis rate greater than in the overall population. These findings may be used to support different treatment modalities, timing and/or doses to prevent urinary lithiasis in patients with type Ia glycogen storage disease.

The Journal of Urology, 2009

The Journal of Urology, 2010

The Journal of Urology, 2008

The Journal of Urology, 2010

The Journal of Urology, 2007

Purpose: Citrus fruits and juices are a known natural source of dietary citrate. Of all the citru... more Purpose: Citrus fruits and juices are a known natural source of dietary citrate. Of all the citrus juices, lemon juice appears to have the highest concentration of citrate. Therefore, lemonade therapy has been proposed as a potential treatment for patients with hypocitraturia. We retrospectively evaluated the impact of long-term lemonade therapy on urinary metabolic parameters and stone formation in patients with hypocitraturic nephrolithiasis. Materials and Methods: A total of 32 patients were identified as being on long-term lemonade therapy for hypocitraturic nephrolithiasis. The 11 patients on lemonade therapy who met the entrance criteria for evaluation were compared to an age and sex matched control group of patients treated with oral slow release potassium citrate. Pre-therapy and post-therapy urinary parameters were recorded for both groups. The effect of lemonade therapy on stone burden and stone formation rate was calculated. New stone formation was defined as passage, surgical removal or appearance of new stones, or an increase in the size of existing stones on radiographic imaging. Results: Four males and 7 females (mean age 52.7 years) were treated with lemonade therapy for a mean of 44.4 months. The control group consisted of 4 males and 7 females (mean age 54.5 years) treated with potassium citrate for a mean of 42.5 months. Of the 11 patients on lemonade 10 demonstrated increased urinary citrate levels (mean increase ϩ383 mg per day, p Ͻ0.05). All potassium citrate therapy subjects demonstrated an increase in urinary citrate (mean increase ϩ482 mg per day, p Ͻ0.0001). Mean pretreatment and posttreatment stone burden in the lemonade group was 37.2 and 30.4 mm 2 , respectively (p Ͼ0.05). During lemonade therapy the stone formation rate decreased from 1.00 to 0.13 stones per patient per year (p Ͼ0.05). Conclusions: Due to its significant citraturic effect, lemonade therapy appears to be a reasonable alternative for patients with hypocitraturia who cannot tolerate first line therapy. Future study in the form of a prospective, randomized trial is needed to validate these findings.

The Journal of Urology, 2012

The Journal of Urology, 2008

The Journal of Urology, 2008

Background: Since January 2003, all clinical scientific articles published in the American volume... more Background: Since January 2003, all clinical scientific articles published in the American volume of The Journal of Bone and Joint Surgery (JBJS-A) have included a level-of-evidence rating. The aim of the current study was to evaluate the interobserver agreement among reviewers, with varying levels of epidemiology training, in categorizing the levels of evidence of these clinical studies.

The Journal of Urology, 2007

The concept of levels of evidence is one of the guiding principles of evidence based clinical pra... more The concept of levels of evidence is one of the guiding principles of evidence based clinical practice. It is based on the understanding that certain study designs are more likely to be affected by bias than others. We provide an assessment of the type and levels of evidence found in the urological literature. Three reviewers rated a random sample of 600 articles published in 4 major urology journals, including 300 each in 2000 and 2005. The level of evidence rating system was adapted from the Center of Evidence Based Medicine. Sample size was estimated to detect a relative increase in the proportion of studies that provided a high level of evidence (I and II combined) from 0.2 to 0.3 with 80% power. Of the 600 studies reviewed 60.3% addressed questions of therapy or prevention, 11.5% addressed etiology/harm, 11.3% addressed prognosis and 9.2% addressed diagnosis. The levels of evidence provided by these studies from I to IV were 5.3%, 10.3%, 9.8% and 74.5%, respectively. A high level of evidence was provided by 16.0% of studies in 2000 and by 15.3% in 2005 (p = 0.911). This study suggests that a majority of studies in the urological literature provide low levels of evidence that may not be well suited to guide clinical decision making. We propose that editors of leading urology journals should promote awareness for this guiding principle of evidence based clinical practice by providing a level of evidence designation with each published study.

BJU International, 2010

6 0 5 research and statistical methods in the urology literature. J Urol 2005; 174 : 1374-9 4 Sca... more 6 0 5 research and statistical methods in the urology literature. J Urol 2005; 174 : 1374-9 4 Scales CD Jr, Norris RD, Keitz SA et al. A critical assessment of the quality of reporting of randomized, controlled trials in the urology literature. J Urol 2007; 177 : 1090-5 5 Welk B, Afshar K, MacNeily AE.