An electronic registry to improve adherence to active surveillance monitoring among men with prostate cancer at a safety-net hospital: protocol for a pilot study.

BackgroundThe evidence-based practice of active surveillance to monitor men with favorable-risk prostate cancer in lieu of initial definitive treatment is becoming more common. However, there are barriers to effective implementation, particularly in low-resource settings. Our goal is to assess the efficacy and feasibility of a health information technology registry for men on active surveillance at a safety-net hospital to ensure patients receive guideline-recommended care.MethodsWe developed an electronic registry for urology clinic staff to monitor men on active surveillance. The health information technology tool was developed using the Systems Engineering Initiative for Patient Safety model and iteratively tailored to the needs of the clinic by engaging providers in a co-design process. We will enroll all men at Zuckerberg San Francisco General Hospital and Trauma Center who choose active surveillance as a treatment strategy. The primary outcomes to be assessed during this non-randomized, pragmatic evaluation are number of days delayed beyond recommended date of follow-up testing, the proportion of men who are lost to follow-up, the cancer stage at active treatment, and the feasibility and acceptability of the clinic-wide intervention with clinic staff. Secondary outcomes include appointment adherence within 30 days of the scheduled date.DiscussionUse of a customized electronic approach for monitoring men on active surveillance could improve patient outcomes. It may help reduce the number of men lost to follow-up and improve adherence to timely follow-up testing. Evaluating the adoption and efficacy of a customized registry in a safety-net setting may also demonstrate feasibility for implementation in diverse clinical contexts.Trial registrationClinicalTrials.gov identifier NCT03553732, An Electronic Registry to Improve Adherence to Active Surveillance Monitoring at a Safety-net Hospital. Registered 11 June 2018

Primary prevention of sudden cardiac death in adults with transposition of the great arteries: A review of implantable cardioverter-defibrillator placement

Transposition of the great arteries encompasses a set of structural congenital cardiac lesions that has in common ventriculoarterial discordance. Primarily because of advances in medical and surgical care, an increasing number of children born with this anomaly are surviving into adulthood. Depending upon the subtype of lesion or the particular corrective surgery that the patient might have undergone, this group of adult congenital heart disease patients constitutes a relatively new population with unique medical sequelae. Among the more common and difficult to manage are cardiac arrhythmias and other sequelae that can lead to sudden cardiac death. To date, the question of whether implantable cardioverter-defibrillators should be placed in this cohort as a preventive measure to abort sudden death has largely gone unanswered. Therefore, we review the available literature surrounding this issue

The effect of follicular fluid hormones on oocyte recovery after ovarian stimulation: FSH level predicts oocyte recovery.

BackgroundOvarian stimulation for assisted reproductive technology (ART) overcomes the physiologic process to develop a single dominant follicle. However, following stimulation, egg recovery rates are not 100%. The objective of this study is to determine if the follicular fluid hormonal environment is associated with oocyte recovery.MethodsThis is a prospective study involving patients undergoing ART by standard ovarian stimulation protocols at an urban academic medical center. A total of 143 follicular fluid aspirates were collected from 80 patients. Concentrations of FSH, hCG, estradiol, progesterone, testosterone and prolactin were determined. A multivariable regression analysis was used to investigate the relationship between the follicular fluid hormones and oocyte recovery.ResultsIntrafollicular FSH was significantly associated with oocyte recovery after adjustment for hCG (Adjusted odds ratio (AOR) = 1.21, 95%CI 1.03-1.42). The hCG concentration alone, in the range tested, did not impact the odds of oocyte recovery (AOR = 0.99, 95%CI 0.93-1.07). Estradiol was significantly associated with oocyte recovery (AOR = 0.98, 95% CI 0.96-0.99). After adjustment for progesterone, the strength of association between FSH and oocyte recovery increased (AOR = 1.84, 95%CI 1.45-2.34).ConclusionThe relationship between FSH and oocyte recovery is significant and appears to work through mechanisms independent of the sex hormones. FSH may be important for the physiologic event of separation of the cumulus-oocyte complex from the follicle wall, thereby influencing oocyte recovery. Current methods for inducing the final stages of oocyte maturation, with hCG administration alone, may not be optimal. Modifications of treatment protocols utilizing additional FSH may enhance oocyte recovery

Qualitative Analysis of the Content Found in Online Discussion Boards for Urethral Stricture Disease and Urethroplasty.

ObjectiveTo describe the patient experience and chief concerns with urethroplasty to improve physician understanding and patient education. Online discussion boards allow patients with urethral stricture disease (USD) to connect with other USD patients. It is unknown how men use these web resources and what information is available about urethroplasty.MethodsThree online forums featuring urethroplasty were identified by Google search. Thematic analysis categorized the content of posts using manually applied codes, with inter-rater reliability and descriptive statistics generated by Dedoose (Los Angeles, CA).ResultsA total of 140 unique posters contributed 553 posts to the forums. Posts were categorized as information support (n = 651), issues posturethroplasty (n = 470), own experience preurethroplasty (n = 336), feelings towards other posters (n = 312), what to expect posturethroplasty (n = 265), feelings after urethroplasty (n = 228), and considerations before urethroplasty (n = 134). Experience navigating the healthcare system with USD (n = 141) and weak urine stream (n = 70) were the most frequent preurethroplasty complaints. Postoperative pain (n = 164) was the most frequent issue. Patients expressed more positivity (n = 126) and satisfaction (n = 120) than negativity (n = 33) with urethroplasty.ConclusionPatients participated in online discussions to share experiences with USD and urethroplasty, receive emotional support, and find answers. Men were more often satisfied than not with their urethroplasty outcomes, with 88% of postoperative feelings coded as positive or satisfied compared to negative. This study provides physicians with insight into the experiences of patients and how to best educate them

Comparison of Efficacy and Safety of Transcatheter Aortic Valve Implantation in Patients With Bicuspid Versus Tricuspid Aortic Valves

Bicuspid aortic valve (BAV) stenosis has been considered a contraindication to transcatheter aortic valve implantation (TAVI). The aim of this study is to compare the efficacy and safety of TAVI in patients with BAV with those with tricuspid aortic valve (TAV) using balloon-expandable and self-expanding transcatheter heart valves. This retrospective study included 823 consecutive patients with severe, symptomatic aortic valve stenosis undergoing TAVI in 2 institutions, Baylor Heart and Vascular Hospital (Dallas, TX) and The Heart Hospital Baylor Plano (Plano, TX), from January 2012 to February 2016. Efficacy was evaluated by postprocedural valve function as mean gradient, peak velocity, effective orifice area, and ≥moderate paravalvular leak. Safety end points included all-cause 30-day and 1-year mortality, immediate postprocedural mortality and 30-day cardiovascular mortality, procedural success, pacemaker implantation, and procedural complications. Of the 823 included patients, 735 had TAV and 77 had BAV. Baseline characteristics were similar between the 2 groups. Procedural success was high in both BAV and TAV (98.7% vs 99.1%, p = ns). There were no significant differences between groups in valve hemodynamics after TAVI, pacemaker implantation rate, or procedural complications. There were no differences regarding immediate postprocedural mortality (BAV vs TAV, 1.1% vs 0.8%, p = ns), nor 30-day cardiovascular mortality (3.4% vs 2.3%, p = ns). All-cause mortality at 30 days (3.4% vs 3.1%, p = ns) and 1-year (8.5% vs 10.5%) were similar. Patients with BAV showed similar procedural and clinical outcomes to patients with TAV. Therefore, TAVI appears to be a safe and effective procedure for patients with BAVs as well as those with TAVs

Slope of the anterior mitral valve leaflet: A new measurement of left ventricular unloading for left ventricular assist devices and systolic dysfunction

Left ventricular assist device (LVAD)-supported patients are evaluated routinely with use of transthoracic echocardiography. Values of left ventricular unloading in this unique patient population are needed to evaluate LVAD function and assist in patient follow-up. We introduce a new M-mode measurement, the slope of the anterior mitral valve leaflet (SLAM), and compare its efficacy with that of other standard echocardiographically evaluated values for left ventricular loading, including E/e′ and pulmonary artery systolic pressures. Average SLAM values were determined retrospectively for cohorts of random, non-LVAD patients with moderately to severely impaired left ventricular ejection fraction (LVEF) (<0.35, n=60). In addition, pre- and post-LVAD implantation echocardiographic images of 81 patients were reviewed. The average SLAM in patients with an LVEF <0.35 was 11.6 cm/s (95% confidence interval, 10.4–12.8); SLAM had a moderately strong correlation with E/e′ in these patients. Implantation of LVADs significantly increased the SLAM from 7.3 ± 2.44 to 14.7 ± 5.01 cm/s (n=42, P <0.0001). The LVAD-supported patients readmitted for exacerbation of congestive heart failure exhibited decreased SLAM from 12 ± 3.93 to 7.3 ± 3.5 cm/s (n=6, P=0.041). In addition, a cutpoint of 10 cm/s distinguished random patients with LVEF <0.35 from those in end-stage congestive heart failure (pre-LVAD) with an 88% sensitivity and a 55% specificity. Evaluating ventricular unloading in LVAD patients remains challenging. Our novel M-mode value correlates with echocardiographic values of left ventricular filling in patients with moderate-to-severe systolic function and dynamically improves with the ventricular unloading of an LVAD

‘That Melancholy Fiend’: Charles Ludlam’s Bluebeard and the Horrific City

Throughout his twenty-nine plays over two decades, North American auteur Charles Ludlam straddled the contradictions of US entertainment through work that was wild, eccentric, brilliant, and queer. And yet, despite having secured a legacy not only as a downtown New York City innovator, but also a singular theatrical voice, Ludlam has been largely positioned by scholars almost entirely through the queer lens, with a primary focus on his use of camp. This paper aims to consider Ludlam’s legacy differently, through a focus on one of his most important works, Bluebeard, and its use of horror tropes as a means to engage its city’s decadent decline on the cusp of the 1970s fiscal crisis that almost brought the city to bankruptcy. By examining that play’s use of affective body horror as decadent embrace of the erotic, the violent, and the hilarious all at once, I argue that Ludlam’s play might have functioned not merely as camp for his queer community, but also as a reflection of the declining NYC for his more mainstream audiences. Ludlam’s use of grotesque monstrosity, I argue, allowed his audience to both recognize and valorize their city’s decline with an ambivalent, decadent pride. Through an analysis both of the show as it exists in published form and of the contemporary reviews, this article aims to consider new levels of Ludlam’s multiplicitous appeal, and also to suggest how provocative, decadent theatre can so poignantly engage and challenge a cultural zeitgeist