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OBJECTIVE: To determine if accurate documentation of bladder cancer risk was associated with a clinician surveillance recommendation that is concordant with AUA guidelines among patients with nonmuscle invasive bladder cancer (NMIBC). METHODS: We prospectively collected data from cystoscopy encounter notes from four Department of Veterans Affairs (VA) sites to ascertain whether they included accurate documentation of bladder cancer risk and a recommendation for a guideline-concordant surveillance interval. Accurate documentation was a clinician-recorded risk classification matching a gold standard assigned by the research team. Clinician recommendations were guideline-concordant if the clinician recorded a surveillance interval that was in line with the AUA guideline. RESULTS: Among 296 encounters, 75 were for low-, 98 for intermediate-, and 123 for high-risk NMIBC. 52% of encounters had accurate documentation of NMIBC risk. Accurate documentation of risk was less common among encounters for low-risk bladder cancer (36% vs 52% for intermediate- and 62% for high-risk, P < .05). Guideline-concordant surveillance recommendations were also less common in patients with low-risk bladder cancer (67% vs 89% for intermediate- and 94% for high-risk, P < .05). Accurate documentation was associated with a 29% and 15% increase in guideline-concordant surveillance recommendations for low- and intermediate-risk disease, respectively (P < .05). CONCLUSION: Accurate risk documentation was associated with more guideline-concordant surveillance recommendations among low- and intermediate-risk patients. Implementation strategies facilitating assessment and documentation of risk may be useful to reduce overuse of surveillance in this group and to prevent unnecessary cost, anxiety, and procedural harms.
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Neoplasias de la Vejiga Urinaria , Veteranos , Humanos , Invasividad Neoplásica , Neoplasias de la Vejiga Urinaria/diagnóstico , Neoplasias de la Vejiga Urinaria/epidemiología , Neoplasias de la Vejiga Urinaria/terapia , Vejiga Urinaria , DocumentaciónRESUMEN
INTRODUCTION: To evaluate patient preference for sperm disposition in case of death based on demographic factors and infertility etiology. MATERIALS AND METHODS: This retrospective cohort study was performed at a university hospital-affiliated fertility center. Charts of 550 men undergoing cryopreservation for assisted reproductive technologies (ART) between 2016-2019 were reviewed to create a descriptive dataset. Patients previously signed consent forms stating their preference for sperm transfer to their partner or disposal in the event of their subsequent death. Patients undergoing sperm cryopreservation for the purpose of ART were analyzed to assess associations between demographic characteristics and etiology of infertility and their choice to either transfer sperm to their partner or discard. RESULTS: A total of 84.9% (342/403) of patients included in final analyses elected to transfer their sperm to their partner in the event of their death. Factors associated with a significantly increased likelihood to transfer versus discard included a male-factor infertility diagnosis compared to female-factor infertility diagnosis (transfer rate 89.3% vs. 79.9%; p = .022) and commercial insurance coverage versus non-commercial/no insurance coverage (transfer rate 86.3% vs. 75.0%, p = .029). No significant differences relating to age, race/ethnicity, occupation classification, marital status or duration of marriage, or prior paternity were found. CONCLUSION: A majority of male patients seeking sperm cryopreservation for ART elected to transfer their sperm to their partner if future death should occur. There does not appear to be a clear factor that would impact this decision based on demographic characteristics.
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Infertilidad Masculina , Semen , Humanos , Femenino , Masculino , Estudios Retrospectivos , Criopreservación , Infertilidad Masculina/terapia , Prioridad del PacienteAsunto(s)
Hidroclorotiazida , Cálculos Renales , Humanos , Hidroclorotiazida/uso terapéutico , RiñónRESUMEN
OBJECTIVE: To review pharmacology, efficacy, safety, and considerations for use, of second-generation androgen receptor (AR) antagonists in treatment of nonmetastatic castrate-resistant prostate cancer (M0CRPC). DATA SOURCES: Conducted search in PubMed and Google scholar (January, 1, 2002-December 31, 2022), using relevant terms. STUDY SELECTION AND DATA EXTRACTION: Relevant English-language studies, conducted in humans evaluating second-generation AR antagonists for M0CRPC, and additional articles and package inserts were considered. DATA SYNTHESIS: Apalutamide, darolutamide, and enzalutamide are effective in delaying the time to development of metastatic prostate cancer in men with M0CRPC with a rapid prostate-specific antigen (PSA) doubling time (<10 months). No head-to-head, randomized, clinical trials have been conducted. The most common adverse effects include fatigue and hypertension, and quality of life is maintained in most patients. Cost is similar among the agents (~$15,000/month). Drug-drug interactions vary among these agents and should be considered, when selecting therapy as well as likely adherence. Darolutamide is administered twice daily with the others once daily. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Second-generation AR antagonists are effective in reducing time to development of metastatic disease and prolonging overall survival in patients with M0CRPC and a PSA doubling time of <10 months. Recent imaging advances may alter how we evaluate outcomes. CONCLUSIONS: Second-generation AR antagonists improve disease control and overall survival. Generally, they are well tolerated and QOL is maintained. Selection of the best agent is based on the adverse effect profile, potential for drug- and disease-interactions, administration, cost, and patient preference.
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Antagonistas de Receptores Androgénicos , Neoplasias de la Próstata Resistentes a la Castración , Masculino , Humanos , Antagonistas de Receptores Androgénicos/efectos adversos , Neoplasias de la Próstata Resistentes a la Castración/tratamiento farmacológico , Neoplasias de la Próstata Resistentes a la Castración/patología , Calidad de Vida , Antígeno Prostático Específico/uso terapéutico , Resultado del TratamientoRESUMEN
BACKGROUND: While advancements in surgery and reduced complication rates have made total knee arthroplasty (TKA) one of the most successful and cost-effective procedures in orthopaedic surgery, routine postoperative laboratory tests are still being ordered without evidence as to their necessity. With expansion of the bundled payment models, there may exist an opportunity to cut overall costs while maintaining quality of care by eliminating unnecessary interventions. The objective of this study was to examine the utility of routine postoperative laboratory tests in TKA. METHODS: A retrospective review of 319 TKAs performed at a single institution over a 2-year period was performed. The primary outcomes were the rates of acute blood loss anemia requiring transfusion, acute kidney injury (AKI), electrolyte abnormalities, and 90-day emergency department visits and readmissions. Multivariate logistic regression analysis was also performed to identify the risk factors associated with abnormal laboratory values. RESULTS: 89 patients (27.9%) had abnormal postoperative laboratory results, of which 78% were exclusively due to electrolyte (sodium or potassium) abnormalities. The rates of AKI and blood transfusion were 3.8% and 1% respectively. Factors associated with electrolyte abnormalities were abnormal baseline electrolyte levels (pâ¯=â¯0.002 andâ¯=â¯0.006 for sodium and potassium respectively) and anemia (pâ¯=â¯0.049). Factors associated with blood transfusion were ASA score ≥3, preoperative anemia, and no tranexamic acid use. Factors associated with AKI were chronic kidney disease or having at least two of the following: age >65 years, BMI> 35, ASA score ≥3, diabetes, heart disease, and/or anemia. Laboratory results did not change the course of care in 305 of 319 patients (95.6%). There was no increased risk for 90-days ED visits or readmissions with abnormal laboratory values (pâ¯=â¯0.356). CONCLUSION: With increasing pressure for cost containment in an era of bundled payment models, the very low rate of laboratory associated interventions suggest that routine postoperative laboratory tests is not justified. Obtaining laboratory after primary, unilateral TKA should be driven by patients' risk factors.
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Neoplasias Abdominales , Paraganglioma , Neoplasias Abdominales/irrigación sanguínea , Neoplasias Abdominales/diagnóstico por imagen , Neoplasias Abdominales/cirugía , Humanos , Riñón/cirugía , Masculino , Persona de Mediana Edad , Nefrectomía , Paraganglioma/irrigación sanguínea , Paraganglioma/diagnóstico por imagen , Paraganglioma/cirugía , Venas Renales/cirugía , Vena Cava Inferior/cirugíaRESUMEN
OBJECTIVE: Little is known about the natural history and management of aneurysmal aortic arch branch vessels (AABVs). The objectives of this study were to assess the natural history of aneurysmal AABVs and to examine the outcomes of operative intervention. METHODS: A retrospective review of the Yale radiologic database from 1999 to 2016 was performed. Only those patients with an aneurysmal AABV and a computed tomography scan were selected for review. Patients' demographics, aneurysm characteristics, management, and follow-up information were collected. RESULTS: There were 105 patients with 147 aneurysmal AABVs; 76 were male (72%), with a mean age of 70 years (range, 17-93 years). We identified 63 innominate, 50 left subclavian, 30 right subclavian, and 4 common carotid artery aneurysms. On computed tomography, 65 (62%) had aortic aneurysms and six (6%) had suffered an aortic dissection. Most were asymptomatic (104 [99%]); one had chest pain and an enlarging swollen mass. Twelve (11%) patients underwent operative repair (OR) for 12 aneurysmal AABVs because of symptoms, growth, or concomitant aortic operations; 93 (89%) were observed in the no operative repair (NOR) group with cross-sectional imaging. The overall mean vessel diameter was 2.08 ± 0.68 cm. The mean diameters in the OR and NOR groups were 3.32 ± 1.24 cm and 1.97 ± 0.46 cm, respectively (P = .002). OR included nine bypasses with resection, two stent grafts, and one resection without reconstruction. Two patients developed postoperative hemorrhage requiring re-exploration, one patient developed stent thrombosis, and one patient required pseudoaneurysm repair 20 years after index operation. Mean follow-up was 52 ± 51 months for the NOR group, with no ruptures or emboli. The growth rate was 0.04 ± 0.10 cm/y. On multivariable regression analysis, a descending aortic aneurysm (P = .041) and a left subclavian artery aneurysm (P = .016) were associated with higher growth rates, whereas height was associated with a lower growth rate (P = .001). CONCLUSIONS: Aneurysmal AABVs tend to have a benign natural history with slow growth rates and low rates of complications, including rupture and embolization. We recommend expectant observational management for small, incidentally detected aneurysms.