Browsing by Author "Lee, Matthew S."
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Item 765. Development of an Adaptable Roadmap for Implementation of the Infectious Diseases Society of America Core Antimicrobial Stewardship Curriculum in Infectious Diseases Fellowship Programs(Oxford University Press, 2023-11-27) Hojat, Leila S.; Patel, Payal K.; Nori, Priya; Hamilton, Keith W.; Justo, Julie Ann; Spicer, Jennifer O.; Logan, Ashleigh; Bennani, Kenza; Lee, Matthew S.; Bryson-Cahn, Chloe; Stohs, Erica J.; Willis, Zachary; Moenster, Ryan P.; Van Schooneveld, Trevor C.; Brennan-Krohn, Thea; Beeler, Cole; Kang, Amy Y.; Al Lawani, Hawra; Cherabuddi, Kartik; Fong, Gary; Ince, Dilek; Holubar, Marisa; Paras, Molly L.; Gaston, David; Shnekendorf, Rachel A.; Williams, Rostam; Luther, Vera; Medicine, School of MedicineBackground: The Infectious Diseases Society of America (IDSA) developed and disseminated a Core Antimicrobial Stewardship (AS) Curriculum intended to formalize AS training in infectious diseases (ID) fellowship programs in 2018. This study identified individual program approaches to curriculum implementation and intended to use this information to develop an implementation guide tailored to specific program needs. Methods: We distributed surveys to all fellowship program directors (PDs) who had previously implemented the Core AS Curriculum. Questions were designed to identify ID program structure, curriculum participants, curriculum sections and materials utilized, and resources and barriers to implementation. Both structured and qualitative responses were captured. The results were summarized descriptively and organized into a framework connecting barriers to proposed solutions. Results: PDs from 34 unique programs who had administered the Core Curriculum to an estimated 405 ID fellows responded to the survey, out of the 159 institutions invited (21.4%). Most represented adult programs which had administered the curriculum for at least 2 years (Table 1). Additional learners often included ID faculty and pharmacy trainees, and teachers were mostly AS program leadership. Most PDs reported limited faculty time as a barrier to implementation, whereas dedicated AS curricular time was a resource available to most programs (Figure 1). Approaches to curriculum implementation based on survey responses relating to each fellowship program feature were suggested, some of which applied to multiple program features (Figure 2). Qualitative feedback was generally positive, and most PDs indicated that they intended to continue to implement the curriculum. Additional materials such as a facilitator guide and demonstrations were proposed as other components which could assist with curriculum implementation. Roadmap with infectious diseases fellowship program features (rounded green boxes) connected to identified potential approaches to curriculum implementation (rectangular blue boxes). Program features are categorized as relating to conference structure, program resources, or program barriers. Suggested approaches with potential application to multiple program features are highlighted in orange. Conclusion: The IDSA Core AS curriculum provides an effective means of formalizing basic AS education into ID fellowship training. Curriculum implementation can be optimized by tailoring to training program resources and unique features. An implementation roadmap may be a useful tool to assist ID fellowship PDs with this task.Item A Cost Comparison of Holmium Laser Enucleation of the Prostate with and without Moses(American Urological Association, 2021) Lee, Matthew S.; Assmus, Mark; Agarwal, Deepak; Large, Tim; Krambeck, Amy; Urology, School of MedicineIntroduction: Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the treatment of benign prostatic hyperplasia. HoLEP has been shown to have excellent improvements in prostate symptom scores and maximum flow rates that have been durable for 2 decades. However, the steep learning curve associated with HoLEP has prevented its widespread adoption. New advancements in lasers, specifically the Moses™ pulse-modulation technology, have resulted in improvements in hemostasis and achieving same-day discharges and catheter removals. We aimed to perform a cost-comparison to analyze if Moses-augmented HoLEP (m-HoLEP) resulted in cost-savings. Methods: A retrospective review was performed of a single expert surgeon's experience from May 2018 to November 2020, comparing m-HoLEP with HoLEP. Perioperative and postoperative variables were abstracted from the medical record. Univariate and multivariate analyses were performed using SAS® 9.4. Two-sided significance was set at p <0.05. Results: A total of 312 men underwent HoLEP during the study period (192 in m-HoLEP group and 120 in HoLEP group). The m-HoLEP group had more same-day discharges (p <0.001) and emergency department visits (6.3% vs 1.7%, p=0.0071). m-HoLEP resulted in hospital cost savings of $840 for the initial surgical episode (p=0.0297). When factoring in emergency department visits/readmissions, the cost savings decreased to $747 per case (p=0.0574). Conclusions: m-HoLEP was associated with same-day discharge and hospital cost savings of $840 for the initial surgical episode. Further study in other institutions with surgeons of varying experience levels will need to be performed to see if these findings can be replicated.Item Ambulatory PCNL may be cost-effective compared to Standard PCNL(Mary Ann Liebert, 2021) Lee, Matthew S.; Assmus, Mark A.; Agarwal, Deepak; Rivera, Marcelino E.; Large, Tim; Krambeck, Amy; Urology, School of MedicineAbstract Background COVID-19 changed the practice of medicine in America. During the March 2020 lockdown, elective cases were cancelled to conserve hospital beds/resources resulting in financial losses for health systems and delayed surgical care. Ambulatory percutaneous nephrolithotomy (aPCNL) has been shown to be safe and could be a strategy to: ensure patients receive care that has been delayed, conserve hospital resources, and maximize cost-effectiveness. We aimed to compare the safety and cost-effectiveness of patients undergoing ambulatory percutaneous nephrolithotomy (aPCNL) against standard PCNL (sPCNL). Materials and Methods 98 patients underwent PCNL at Indiana University Methodist hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. The primary outcome of the study was to compare the 30-day rates of ED-visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included: cost analysis and stone free rates (SFRs). Prospensity-score matching was performed to ensure the groups were balanced. Statistical analyses were performed using SAS 9.4 using independent t-tests for continuous variables and chi-square analyses for categorical variables. Results 98 patients underwent PCNL during the study period (sPCNL=75 and aPCNL=23). After propensity-score matching, 42 patients were available for comparison (sPCNL=19 and aPCNL=23). We found no difference in 30-day ED-visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5327±442 per case. Stone free rates were higher for aPCNL compared to sPCNL. Conclusions aPCNL appears safe to perform and does not have a higher rate of ED-visits or readmissions compare to sPCNL. aPCNL may also be cost-effective compared to sPCNL.Item Ex Vivo Comparison of Efficiency, Safety, and Surgeon Satisfaction in Four Commercial Morcellators(Mary Ann Liebert, 2021) Lee, Matthew S.; Assmus, Mark A.; Cooley, Lauren; Li, Eric; Large, Tim; Krambeck, Amy; Urology, School of MedicineIntroduction Holmium Laser Enucleation of the Prostate (HoLEP) is a size-independent treatment option for the management of benign prostatic hypertrophy. While advancements in laser technology have led to clinical improvements in the enucleation portion of HoLEP, the morcellation aspect of HoLEP is often the rate-limiting step. We sought to compare efficiency and surgeon satisfaction in four commercial morcellators. Methods This was an ex vivo study comparing four commercial morcellators: the Wolf Piranha, the Lumenis VersaCut, the JenaSurgical MultiCut Solo, and the Hawk Morcellator. Four surgeons with significant experience performing HoLEPs participated. Surgeons tested each device to morcellate two different prostate models 1) morcellating as much microwave-cooked chicken breast in 10 minutes and 2) timed morcellation of bull testicles. Surgeons completed subjective surveys after each morcellator trial. Objective outcomes included: morcellation efficiency (g/min morcellated) and aspiration power (time to aspirate 1 L of saline). Means of continuous variables were compared using ANOVA. Categorical variables were compared using chi-square tests. Statistical analyses were performed using SAS 9.4 (2019). Results Comparing subjective outcomes, the Piranha was chosen as the safest morcellator (p=0.0058). The least safe morcellator was thought to be the MultiCut by 75% of surgeons (p=0.046). The Piranha was chosen as the most effective morcellator by 75% of surgeons (p=0.046). Comparing objective parameters between the morcellators, the Piranha had the fastest aspiration time (43.50±10.34 s, p=0.0116). There were no significant differences in morcellation efficiency when using chicken breast (p=0.3096). However, when comparing the morcellation efficiency using bull testicles, the Piranha had the highest efficiency at 39.68±3.57 g/min (p=0.0268). Conclusion In this ex-vivo study comparing four different commercially available morcellators, the Piranha had the highest aspiration power. No significant differences were found in morcellation efficiency using microwave-cooked chicken breast. The Piranha was felt to be the safest and most effective morcellator.Item Implementing the Infectious Diseases Society of America Antimicrobial Stewardship Core Curriculum: Survey Results and Real-World Strategies to Guide Fellowship Programs(Oxford University Press, 2024-10-02) Hojat, Leila S.; Patel, Payal K.; Ince, Dilek; Kang, Amy Y.; Fong, Gary; Cherabuddi, Kartik; Nori, Priya; Al Lawati, Hawra; Stohs, Erica J.; Beeler, Cole; Van Schooneveld, Trevor C.; Lee, Matthew S.; Hamilton, Keith W.; Justo, Julie Ann; Spicer, Jennifer O.; Logan, Ashleigh; Bennani, Kenza; Williams, Rostam; Shnekendorf, Rachel; Bryson-Cahn, Chloe; Willis, Zachary I.; Moenster, Ryan P.; Brennan-Krohn, Thea; Paras, Molly L.; Holubar, Marisa; Gaston, David C.; Advani, Sonali D.; Luther, Vera P.; Medicine, School of MedicineBackground: The Infectious Diseases Society of America (IDSA) developed the Core Antimicrobial Stewardship (AS) Curriculum to meet the increasing demand for infectious diseases (ID) providers with AS expertise. Notable diversity in implementation approaches has been observed among ID fellowship programs using the curriculum. We sought to describe individual approaches and develop a curriculum implementation roadmap. Methods: We surveyed ID fellowship programs that had previously implemented the IDSA Core AS curriculum. The survey included questions regarding program characteristics, curriculum participants and presentation format, resources and barriers, and implementation strategies. Commonly reported program features were summarized in the context of the self-reported implementation strategies. Implementation guides were developed based on the most common characteristics observed. Results: Of 159 programs that had purchased the curriculum, 37 responded, and 34 (21%) were included in the analysis. The curriculum was primarily taught by AS physicians (85%) and AS pharmacists (47%). The most common conference structure was a longitudinal conference series (32%), and eLearning was the most common presentation format. Limited AS faculty time (76%) and limited first-year fellow availability (62%) were frequently reported as barriers, and dedicated AS curricular time was a resource available to most programs (67%); implementation guides were created for these 3 program features. Conclusions: Programs reported a variety of implementation barriers and resources, with several common themes emerging, allowing for the development of tailored curriculum planners for 3 commonly observed program characteristics. This work will equip fellowship programs with curriculum implementation strategies and guide future enhancements of the IDSA Core and Advanced AS curricula.Item Management of Nephrolithiasis in Pregnancy: Multi-Disciplinary Guidelines From an Academic Medical Center(Frontiers Media, 2021-12-22) Lee, Matthew S.; Fenstermaker, Michael A.; Naoum, Emily E.; Chong, Suzanne; Van de Ven, Cosmas J.; Bauer, Melissa E.; Kountanis, Joanna A.; Ellis, James H.; Shields, James; Ambani, Sapan; Krambeck, Amy E.; Roberts, William W.; Ghani, Khurshid R.; Radiology and Imaging Sciences, School of MedicineIntroduction: The management of nephrolithiasis during pregnancy can be stressful for urologists due to concerns for investigations and treatments that may pose risk of fetal harm, and unfamiliarity with optimal management of these complex patients. In response, we created multi-disciplinary evidence-based guidelines to standardize the care for obstetric patients presenting with flank pain and suspicion for nephrolithiasis. Methods: A multi-disciplinary team involving Urology, Obstetric Anesthesiology, Obstetrics and Gynecology, Diagnostic Radiology, and Interventional Radiology from a single academic medical center was assembled. A PubMed search was performed using keywords of pregnancy/antepartum, nephrolithiasis/calculi/kidney stones, ureteroscopy, non-obstetric surgery, complications, preterm delivery, MRI, computerized tomography, renal bladder ultrasound (RBUS), and anesthesia to identify relevant articles. Team members reviewed their respective areas to create a comprehensive set of guidelines. One invited external expert reviewed the guidelines for validation purposes. Results: A total of 54 articles were reviewed for evidence synthesis. Four guideline statements were constructed to guide diagnosis and imaging, and seven statements to guide intervention. Guidelines were then used to create a diagnostic and intervention flowchart for ease of use. In summary, RBUS should be the initial diagnostic study. If diagnostic uncertainty still exists, a non-contrast CT scan should be obtained. For obstetric patients presenting with a septic obstructing stone, urgent decompression should be achieved. We recommend ureteral stent placement as the preferred intervention if local factors allow. Conclusions: We present a standardized care pathway for the management of nephrolithiasis during pregnancy. Our aim is to standardize and simplify the clinical management of these complex scenarios for urologists.Item Same Day Discharge Following Holmium Laser Enucleation in Patients Assessed to have Large Gland Prostates (≥175mL)(Liebert, 2021) Assmus, Mark A.; Large, Tim; Lee, Matthew S.; Agarwal, Deepak K.; Rivera, Marcelino E.; Krambeck, Amy E.; Urology, School of MedicineBackground: Holmium laser enucleation of the prostate (HoLEP) is a highly effective and durable minimally invasive surgery for benign prostatic hyperplasia. Historically, alternative treatments for large glands (≥175mL) are associated with prolonged length of stay (LOS) and postoperative catheterization. However, advances in laser technology combined with surgical technique optimization have early evidence supporting same day discharge. We look to examine contemporary same day discharge outcomes for large glands. Materials & Methods: With IRB approval we queried our EMR and retrospective clinical registry to examine perioperative outcomes of large gland (≥175mL) prostates that underwent HoLEP with consideration for same day discharge. Results: From 12/10/2019 to 09/29/2020 we identified 55 patients with a preoperative prostate size ≥175mL (39 CT, 12 MRI, 4 TRUS), of which 45 were scheduled for same day discharge and 10 for admission. Mean preop prostate size was 229.9mL (range 175-535mL) and 36 (65.5%) were in urinary retention. Mean preop PSA was 8.58ng/mL, AUA Symptom Score 22.3, and Qmax 8.8mL/s. At 3 months postop follow up mean AUASS was 6.7, PSA 0.87ng/mL and Qmax 20.4mL/s. All comer same day discharge rate was 70% (38/55). Of patients planned for same day discharge 38/45 (84%) were successful. Average LOS for all patients was 11.8h with catheterization of 21.2h. When compared to 2010 published large gland outcomes, our current LOS represents a 220% reduction. Looking specifically at patients planned for same day discharge, average LOS and catheter duration was 8.8h and 17.0h, while LOS and catheter duration for patients planned for admission was 25.7h and 39.4h, respectively. Conclusions: We report the first outcomes of preoperatively planned same day discharge for HoLEP in large glands (≥175mL). A combination of technologic advances and optimization of technique have allowed for a safe adoption of same day discharge, providing additional advantages over alternative large gland treatments.Item Understanding holmium laser enucleation of the prostate (HoLEP) recovery: Assessing patient expectations and understanding(Canadian Urological Association, 2022) Assmus, Mark A.; Lee, Matthew S.; Large, Tim; Krambeck, Amy E.; Urology, School of MedicineIntroduction: Although holmium laser enucleation of the prostate (HoLEP) is a highly effective surgery, there is a variable recovery period where patients may experience hematuria, dysuria, or urinary incontinence (UI). Despite preoperative consultation, there is a paucity of literature examining the effectiveness of physician-patient communication in preparing the patient for the postoperative recovery period. We sought to examine recovery expectations as a patient-reported outcome (PRO) metric for HoLEP. Methods: With institutional review board approval, we queried our electronic medical record and retrospective clinical registry to identify 50 consecutive patients that underwent HoLEP from November 2019 to March 2020 by two endourologists. Patients were provided questionnaires via Twistle© ≥6 months postoperatively. Patient demographics and perioperative course was examined in the context of responses. Our primary objective was determining whether patients felt they had a reasonable understanding of the recovery process. Results: We observed a 92% (46/50) response rate, with an average patient age of 69.4 years (range 55-88). Overall, 91.3% (42/46) felt they had a reasonable understanding of the recovery. Additionally, 97.8% (45/46) were aware of temporary UI, with 87% having ≥1 episodes of UI after catheter removal. We found 47.8% (22/46) of patients expected UI to resolve within 30 days, while 8.6% expected >90 days of UI. All patients were aware of the risk of hematuria, with 93.5% (43/46) expecting resolution within 30 days (<7 days: 47.8%; 7-14 days: 28.3%; 15-30 days: 17.4%). Conclusions: Although surgical technique continues to improve HoLEP, ensuring adequate physician-patient communication to optimize expectations is crucial. We report patient understanding of HoLEP recovery and areas for future improvement.