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Background: Driving physician behavior change has been an elusive goal for quality improvement efforts aimed at reducing low-value care. We proposed the use of "nudge" interventions at the surgeon level in order to reduce post-surgical opioid overprescribing in accordance with consensus guidelines., Methods: We used 2017 Medicare data to identify outlier surgeons. A peer data benchmarking report that showed each surgeon the average number of opioid tablets they prescribed for an open inguinal hernia repair procedure from January 1, 2017 to December 31, 2017. We conducted a 1:1 randomized controlled trial providing outlier surgeons a report of their opioid prescribing patterns for a standard operation compared to the national average and prescribing guidelines., Results: There were 489 surgeons randomized to the intervention, of which 180 (36.8%) had data in the post-intervention period. Data was available for 87 surgeons in the intervention group and 93 surgeons in the control group. 97.7% of surgeons in the intervention group reduced their opioid prescribing pattern compared to 95.7% in the control group. Surgeons who received the data benchmarking report intervention prescribed 14.3% less opioids than surgeons in the control group (10.54 (SD 5.34) vs. 12.30 (SD 6.02), P = .04). The intervention was associated with a 1.83 lower mean number of opioid tablets prescribed per patient in the multivariable linear regression model after controlling for other factors (Intervention group vs. control group 95% CI [-3.61, -.04], P = .04)., Discussion: The implementation of a peer data benchmarking intervention can drive physician behavior change towards high-value care., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In Manchester, feminising genitoplasty is offered to children with 46XX Congenital Adrenal Hyperplasia (CAH) when there is a single perineal opening and/or enlarged clitoris. Our aims are to describe the anatomical reconstructive technique and present long-term outcomes. Our hypothesis is that 'the common channel (CC) length and distance to the vagina from perineal skin is mostly due to virilisation and hypertrophy of perineal tissue over the almost normally positioned vaginal introitus (V-I) in relation to the perineal body (PB)'. METHOD AND RESULTS: This is a retrospective notes review of all consecutive 46XX CAH operations from 1976 to December 2021. 99 patients, who had feminising genitoplasty and being followed-up, were included. 15 patients who were lost to follow up were excluded. Median age at surgery was 15 months. In 91, midline division of the labia majora, spongiosum, bulbo-spongiosus muscle (BSM) and CC down to PB was performed. This was sufficient to expose the V-I at the same level or within 5 mm depth of PB in 88. In 78 V-I was adequate taking 10/12fr dilator (Type 1). In 10, CC resembled a male urethra and V-I was narrow (Type 2), requiring widening by 5-10 mm incision at 6 o'clock position. Dartos of labia majora was attached to BSM to reduce the distance to V-I from perineal skin and the gap was lined with inner foreskin to create a vestibule. Out of 70 who were post-pubertal, 75% (53/70) had adequate calibre vaginal openings. 5 had introitoplasty and 2 had dilatation under anaesthesia. 10 needed self dilators only. 29 patients, of one of the three surgeons, had measurements of clitoris, CC, urethra and vagina. A hymen was found in 86% (25/29). There was significant strong, inverse correlation between the CC length and the urethral length (r = -0.708, p < 0.001, n = 27) but not between CC and vaginal lengths. After adjusting for age, the urethral length of Type 2 patients was 3.825 mm shorter than those of Type 1 (p = 0.017). CONCLUSION: Our data show that 'high' confluence is mostly due to virilisation of genitalia; and the anatomical technique of reversing the fusion of the urethral folds, spongiosum and bulbo-spongiosus muscle could be performed with all degrees of virilisation with success in early childhood with no need of local flaps or mobilisation of the urethro-vaginal complex. About 10% require surgery to treat narrowing of vaginal opening post puberty., Competing Interests: Conflicts of interest There is no conflict of interest., (Copyright © 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: This study aims to characterise and evaluate the largest 100 hospitals in the USA that have adopted aggressive collection tactics to pursue patients with unpaid medical bills, such as lawsuits, wage garnishments and liens., Design: Cross-sectional study., Setting: We examined state and county court record systems to measure the magnitude and prevalence of these practices at the largest 100 hospitals in the UA between 1 January 2018 and 31 July 2020., Main Outcomes Measures: The main outcome of this study was the number of lawsuits, wage garnishments and liens. A secondary outcome was the characterisation of a hospital's safety, charitability, size and financial practices., Results: Between 1 January 2018 and 31 July 2020, 26 hospitals filed 38 965 court actions (lawsuits, wage garnishments and liens) against patients for unpaid medical debt. For 16 of 26 hospitals, the dollar amount pursued in the court claim was available for 100% of cases, totalling US$71.8 million. The average aggregate amount sought by hospital lawsuits during the study period was US$4.5 million. Three hospitals filed US$56.2 million in amounts pursued in court, or 78.3% of the total amount pursued by all hospitals in the sample. In the remaining 74 hospitals, the study team did not identify extraordinary collection actions through the court system., Conclusions: Standardised medical debt collections best practices and metrics of medical debt collections quality are needed to increase public accountability for hospitals, particularly non-profit hospitals. There is a need to re-evaluate Internal Revenue Service rules pertaining to non-profit hospitals' tax-exempt status to ensure tax-exempt hospitals provide community benefits commensurate with the value of tax exemption., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aims to characterise and evaluate the National Institutes of Health's (NIH's) grant allocation speed and pattern of COVID-19 research., Design: Cross-sectional study., Setting: COVID-19 NIH RePORTER Dataset was used to identify COVID-19 relevant grants., Participants: 1108 grants allocated to COVID-19 research., Main Outcomes and Measures: The primary outcome was to determine the number of grants and funding amount the NIH allocated for COVID-19 by research type and clinical/scientific area. The secondary outcome was to calculate the time from the funding opportunity announcement to the award notice date., Results: The NIH awarded a total of 56 169 grants in 2020, of which 2.0% (n=1108) wwas allocated for COVID-19 research. The NIH had a US$45.3 billion budget that year, of which 4.9% (US$2.2 billion) was allocated to COVID-19 research. The most common clinical/scientific areas were social determinants of health (n=278, 8.5% of COVID-19 funding), immunology (n=211, 25.8%) and pharmaceutical interventions research (n=208, 47.6%). There were 104 grants studying COVID-19 non-pharmaceutical interventions, of which 2 grants studied the efficacy of face masks and 6 studied the efficacy of social distancing. Of the 83 COVID-19 funded grants on transmission, 5 were awarded to study airborne transmission of COVID-19 and 2 grants on transmission of COVID-19 in schools. The average time from the funding opportunity announcement to the award notice date was 151 days (SD: ±57.9)., Conclusion: In the first year of the pandemic, the NIH diverted a small fraction of its budget to COVID-19 research. Future health emergencies will require research funding to pivot in a timely fashion and funding levels to be proportional to the anticipated burden of disease in the population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To analyse the outcomes of retroperitoneoscopic upper and lower moiety hemi-nephroureterectomy (HNU) and to assess the different variables that may have an impact on outcome; remnant moiety damage, morbidity and the need for secondary surgery., Methods: Prospectively recorded data of retroperitoneoscopic HNU's performed by a single surgeon from 2005 to 2018 were analysed. Patients were split into 2 groups according to moiety affected (UMHNU and LMHNU). Clinical presentation, underlying pathology, remnant moiety DRF on renal scintigraphy, and need for further surgery were recorded. Detailed operation notes were studied regards to renal vasculature, degree of dilatation, inflammatory changes and operative difficulties encountered. Renal loss was defined as remnant moiety DRF <10% post-operatively. Change in DRF was assessed regards to the moiety, pathology and age at surgery (<1 year, 1-2 years and ≥2 years). UMHNU group was further sub-divided into 3 subgroups: ureteroceles, ectopic ureters and 'other' pathology. Statistical analysis was performed using Fishers Exact test; findings were considered statistically significant at p < 0.05., Results: 78 operations met the inclusion criteria on 75 patients (3 bilateral). There were no conversions to open, and 67% were performed as day-case procedures (53/78 patients). In 91.2% (71/78) patients the procedure was definitive in resolving pathology and symptoms. 7 patients needed further procedures after HNU, 5 for ureterocele/ureteric stump. Overall, there was remnant moiety renal loss in 5.1% (4/78) patients, all with UM surgery (3 ectopic ureters and 1 ureterocele). All 4 operations were recorded prospectively as 'difficult operations' due to grossly dilated UM ureter/pelvis measuring >2 cm in diameter. 2 patients had a thinned out lower moiety (LM) sitting on top of the UM renal pelvis like a pancake with all vessels stretched over this dilated pelvis/ureter causing difficulty in accurate identification. There was intra-operative concern about some damage to LM vessels in 3 patients. Age <1year was also related to increased renal loss (2/8 patients <1 year, 1/25 patients 1-2 years, 1/45 patients ≥2 years of age P = 0.005)., Conclusion: Retroperitoneoscopic LMHNU is a safe and definitive procedure with rapid recovery and minimal scarring. UMHNU has higher rates of remnant moiety loss due to more complex renal pathology, but remains a safe, successful operation on the majority of patients. Renal damage was also related to age <1year (p = 0.005) and re-operation risk after UMHNU correlated to the presence of ureterocele (p = 0.003)., (Copyright © 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Isolated urogenital sinus can cause distended bladder and/or vagina and may present with an abdominal mass and sepsis during infancy. Older children may present with recurrent urinary tract infections and hematocolpos. We describe a 3-year-old girl with recurrent urinary tract infections thought to be secondary to vesicoureteric reflux. On further investigation, an isolated urogenital sinus anomaly with a calculus inside one of the hemivaginae was noted. She was managed expectantly with a plan to intervene at puberty. At puberty, during removal of the stone, the hemivaginal introitus was found to be stenotic. Gradually increasing sizes of Amplatz type graduated renal dilators were introduced from the introitus of the urogenital sinus into the hemivaginal stone until a size 22F Amplatz sheath could be passed easily. Size 10F cystoscope was passed through this channel, and the stone was fragmented using electrohydraulic lithotripsy. At a later date, she underwent staged anterior sagittal transvulval mobilization of the urogenital sinus., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The epidemiology and risk factors for paediatric urolithiasis (UL) in developed countries are evolving, with increasing rates of metabolic stone-formers. In the United Kingdom (UK), only a single London cohort has been studied in the past three decades. Regional disease patterns across the UK remain unknown. UL has been associated with an increased risk of chronic kidney disease in adults, but long-term paediatric outcomes remain poorly understood., Methods: We assessed the epidemiology of paediatric UL by defining the demographics, incidence, aetiology, recurrence rates and outcomes at tertiary nephro-urology centres in Greater Manchester. Health records of 177 consecutive paediatric urology referrals (0-18 years) for UL between 2002 and 2015 were retrospectively included for observational analysis. Metabolic screening was performed in 105 children., Results: The incidence of paediatric urology referrals for UL was 1.77/100,000 person-years, increasing annually by 13.6%. Mean patient age was 8.2 years and the male:female ratio was 1.3:1. The upper urinary tract was involved in more than 90% of cases and 45% of children presented with multiple calculi. Metabolic abnormalities were identified in 52% of children screened: hypercalciuria (64%), hyperoxaluria (18%) and cystinuria (11%) were the most common. Significant family history was predictive of metabolic abnormalities (OR 4.9:1, 95% CI 1.4-17.0). 30% of children had infective stones, which were more common in children less than 6 years. Ultrasound was found to be 90% sensitive for UL detection. Dimercaptosuccinic acid (DMSA) imaging identified renal scarring in 33 of the 55 children tested (60%). Recurrence was observed in 18% of children over mean 6.4 year follow-up and was more common in metabolic stone-formers. Spontaneous passage was observed in 83% of stones ≤ 5 mm, 69% between 5 and 10 mm and only one calculi > 10 mm., Conclusions: The incidence of paediatric urology referrals for UL is rising in North West England. Metabolic abnormalities were detected in half of the children tested, justifying comprehensive screening. Recurrence is common following paediatric UL, reinforcing the need for stone prevention strategies. The majority of calculi less than 10 mm were found to pass spontaneously with supportive measures, which favours an initial observation period over surgical intervention for small calculi. UL was associated with renal scarring in the analysed population and therefore, children with UL require long-term assessment of blood pressure and proteinuria., (Copyright © 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

We describe the successful use of an osmotic self-inflating tissue expander for complex pediatric hypospadias repair. A 5-year-old boy, who had undergone previous hypospadias repair and subsequent fistula repair, presented with significant rotation of the penile shaft, with extensive scar tissue but insufficient native penile shaft skin for redo surgery. A 15 × 6 mm Osmed self-inflating cylindrical expander was used to allow excision of scar tissue and cover with expanded native skin. An excellent cosmetic and functional outcome was achieved at clinic review, 18 months postoperatively. The use of self-inflating tissue expanders offers a novel technique to achieve adequate native skin in the management of complex pediatric hypospadias., (Copyright © 2015 Elsevier Inc. All rights reserved.)