A 5-Year Single-Institution Experience Integrating Telehealth Into Urologic Care Delivery.

Objective: Telehealth is increasingly used in urology, but few studies have evaluated how it can be integrated with urology face-to-face (FTF) encounters and primary care (PC). We describe the 5-year experience of a Veterans Affairs urology service that has incorporated telehealth into their patient care program. Methods: We performed a retrospective review of encounters from 2013 to 2018 in telehealth urology clinics. To examine the way telehealth and FTF visits were utilized together, the key components of care were defined for the evaluation of three common referrals: elevated prostate-specific antigen (PSA), microscopic hematuria, and obstructive lower urinary tract symptoms (LUTS). A random convenience sample of 20 patients from each condition was abstracted to describe the setting of care for each component over a 2-year period. Results: We reviewed 811 unique patients who had a total of 2,008 telehealth visits. The mean utilization of telehealth (2.48) and FTF (2.42) encounters per patient were similar. The most common reasons for referral to telehealth clinics were sexual dysfunction (26.8%), LUTS (20.6%), hematuria (15.0%), prostate cancer (13.3%), and an elevated PSA (12.1%). Thirty-six percent of patients were managed by telehealth alone; 64% were by a combination of telehealth and FTF encounters. Telehealth was often used in conjunction with PC and FTF visits to perform components such as the physical exam and procedures. Conclusions: Telehealth was utilized for a wide array of diseases and often used in conjunction with PC and urologic FTF visits to deliver complete care for the three disease states we evaluated.

Variable validity of computer extracted problem lists for complications of diabetes mellitus within the VA Greater Los Angeles Health System.

PURPOSE: Electronic health data in the form of International Classification of Disease, Ninth Revision (ICD-9) codes is routinely used for clinical research, yet the accuracy of specific diagnoses is largely unknown. The purpose of this study is to assess the validity of computer extracted problem lists for diabetic retinopathy (DR) and other complications of diabetes mellitus (DM) within the VA Greater Los Angeles Health Administration (VHAGLA). METHODS: The study population consisted of patients at the VHAGLA with an ICD-9 diagnosis of DM between Jan 1st 1999 and March 22nd 2016 with visits to the eye clinic. Fifty patients either with or without an ICD-9 diagnosis of DR were randomly selected. The accuracy of ICD-9 codes for DR, as well as related co-morbidities such as hypertension, hyperlipidemia, coronary artery disease (CAD), and cerebrovascular accident (CVA), were assessed through chart review. RESULTS: A total of 3193 patients met our inclusion criteria. Of the 50 patients with an ICD-9 diagnosis of DR, the positive predictive value (PPV) was 0.7. For 50 patients without a ICD-9 diagnosis of DR, the negative predictive value (NPV) was 0.9. Of the other co-morbid medical conditions, NPV ranged from a low of 63% for obesity to a high of 98% for CVA and CAD. CONCLUSION: Validity of ICD-9 diagnoses of diabetic complications in this VA population varied considerably, with DR demonstrating moderate agreement, obesity being more under-documented, and CVA and CAD being more consistently documented. These discrepancies should be considered when using billing codes for research purposes.

Veterans Affairs Telemedicine: Bringing Urologic Care to Remote Clinics.

OBJECTIVE: To report the use of telemedicine to deliver general urologic care to remote locations within the Veterans Affairs Greater Los Angeles Healthcare System. We describe the diagnoses managed, patient satisfaction, safety, and benefit to patients in terms of saved travel time and expense. METHODS: We conducted a retrospective chart review examining care delivered through urology telemedicine clinics over a 6-month period. We examined the urologic conditions, patient satisfaction, and emergency department visits within 30 days of the visit. We estimated patient benefit by calculating travel distance and time and the saved travel-associated costs using Google Maps and US Census income data. RESULTS: Ninety-seven unique telemedicine visits were conducted and a total of 171 urologic diseases were assessed. The most common conditions were lower urinary tract symptoms (35%), elevated prostate-specific antigen level (15%), and prostate cancer (14%). One patient was seen in the emergency department within 30 days with an unpreventable urologic complaint. Patient satisfaction was "very good" to "excellent" in 95% of cases, and 97% would refer another veteran to the urology telemedicine clinic. Patients saved an average of 277 travel miles, 290 minutes of travel time, $67 in travel expenses, and $126 in lost opportunity cost. CONCLUSION: Telemedicine was successfully and safely used to evaluate and treat a wide range of urologic conditions within the Veterans Affairs Greater Los Angeles Healthcare System, and saves patients nearly 5 hours and up to $193 per visit. Further investigation of the potential of telemedicine for the delivery of urologic care in a cost-effective manner is warranted.

Feasibility study of home telerehabilitation for physically inactive veterans.

The aim of this study was to develop a system for and determine the feasibility of monitoring home exercise for physically inactive older adults using a Health Buddy (HB) text messaging device (Robert Bosch Healthcare; Palo Alto, California). Questions and messages related to exercise adherence are displayed on the HB screen and participants choose a response by pressing the corresponding button on the device. Responses are transmitted through a landline connection and high-risk responses are highlighted by the system for follow-up. We developed the questions and messages based on input from patient and clinician focus groups. We evaluated feasibility by administering the intervention to inpatient and outpatient adults aged 60 or older. We gave participants a choice of exercise monitoring by HB (n = 20) or telephone (n = 18). The results showed that home exercise monitoring by HB and telephone is safe, as evidenced by low adverse event rates. We saw a decline in exercise adherence rates to both the HB and telephone after 8 weeks, although adherence was better for HB than telephone. Taken together, the results demonstrate the feasibility of using text messaging to monitor home exercise adherence in physically inactive older adults.

Preferences among five nicotine treatments based on information versus sampling.

Smokers' minimal exposure to nicotine replacement treatments (NRTs) may account for poor compliance and outcome with these treatments. This study tested effects of information versus sampling of NRTs on smokers' preferences and expectations. The study was a crossover comparing information-only (INF) with sampling (SMP) methods for five NRTs: gum (2 and 4 mg), lozenges (2 and 4 mg), and inhalers. Subjects were given computer-based presentations on NRTs (INF) and rated and ranked use variables (e.g., ease, sensory/ritual, perceived relief, embarrassment) and overall choice for "use to quit." After INF testing, subjects sampled each NRT (SMP) and again rated and ranked drugs. SMP was brief (4 min) to mimic potential use in practice. Results showed changes in perceptions and preferences post-SMP. NRT preferences shifted for overall "use to quit" (59%) and most use variables (43%-63%) post-SMP. Inhalers (generally top choice) showed a 20% drop in choice to quit (p<.04) and a 24% drop in anticipated "relief of withdrawal" (p<.04) post-SMP; 4-mg lozenge ratings increased for "relief of withdrawal" (p<.02). Ratings improved post-SMP for three of the five NRTs ("ease of use," p<.05) but were reduced overall for liking "sensory action" (p<.003) and reduced for all but 2-mg gum for "use to quit" (p<.03). Positive changes were seen in improved ratings of NRTs chosen post-SMP. Given that reactions to NRTs change with experience, sampling should allow for a more realistic choice of NRT (self-tailoring) and better compliance versus current trial-and-error methods.

Preferences among four combination nicotine treatments.

RATIONALE: Acute nicotine replacement treatments (NRTs) are disliked or misused, leading to insufficient nicotine intake and poor outcome. Patches provide steady nicotine but are slow and passive. Combining systems may improve efficacy with acute NRTs tailored for compliance. OBJECTIVE: To test initial reactions to and use preferences among combinations of NRTs. MATERIALS AND METHODS: Smokers (n=27) tested four combination NRTs in a 5-day crossover trial: 2/4-mg gum + 15-mg patch (G/P), 2/4-mg lozenges + 15-mg patch (L/P), inhaler + 15-mg patch (I/P), and 10 mg + 15-mg patches (P/P). Subjects rated an NRT combination each day after 5-6 h of use and ranked among the NRTs after testing all treatments. RESULTS: Double-patches (P/P) were ranked highest for "ease of use", "safety", and "use in public". However, for "help to quit", 70% preferred some form of acute-patch combination (A/P) compared to 30% choosing P/P. For "use under stress" (an immediate need), 93% preferred A/P systems compared to 7% choosing P/P. L/P ranked lowest for "ease of use", I/P and L/P were lowest on "safety", and I/P ranked lowest for "use in public". Expectations of NRTs changed with test experience for patches (better) and lozenges (worse). CONCLUSIONS: In brief testing, all combinations were acceptable. P/P was favored for ease, safety, and public use, but a majority chose A/P systems for help in quitting and use under stress. Combined use is viable and needs to be made known and accessible to smokers.

Theoretical study of the reaction of acrylonitrile on Si(001).

Two recent experiments for adsorbed acrylonitrile on the Si(001) surface reported different adsorption structures at 110 and 300 K. We investigate the reaction of acrylonitrile on Si(001) by first-principles density-functional calculations. We find that the so-called [4+2] structure in which acrylonitrile resides between two dimer rows is not only thermodynamically favored over other structural models but also easily formed via a precursor where the N atom of acrylonitrile is attached to the down atom of the Si dimer. The additional initial-state theory calculation for the C 1s core levels of adsorbed acrylonitrile provides an interpretation for the observed low- and room-temperature adsorption configurations in terms of the precursor and [4+2] structures, respectively.

First principles calculation of anomalous Hall conductivity in ferromagnetic bcc Fe.

We perform a first principles calculation of the anomalous Hall effect in ferromagnetic bcc Fe. Our theory identifies an intrinsic contribution to the anomalous Hall conductivity and relates it to the k-space Berry phase of occupied Bloch states. This dc conductivity has the same origin as the well-known magneto-optical effect, and our result accounts for experimental measurement on Fe crystals with no adjustable parameters.

The Carbomedics Top Hat supraannular aortic valve: a multicenter study.

BACKGROUND: Introduced in 1993, the Carbomedics Top Hat (Sulzer, Carbomedics, Austin, TX) valve is a bileaflet mechanical aortic prosthesis designed to be placed in a supraannular position. Five institutions pooled their clinical experiences to evaluate early outcome in patients with this prosthesis. METHODS: From 1994 to 2000, 639 patients underwent aortic valve replacement with Top Hat (Sulzer Carbomedics) valves at 5 institutions. Mean age was 60 +/- 13 years. In this heterogeneous population, 28% of patients had previous cardiac operations and 64% had concomitant procedures, including procedures involving more than 1 heart valve in 32%. Implanted prostheses sizes included the 19 mm (15%), 21 mm (37%), 23 mm (33%), 25 mm (13%), and 27 mm (2%). Mean follow-up was 2.0 +/- 1.5 years, and there were 1,206 patient-years of follow-up available for analysis. RESULTS: Thirty-day mortality was 5.3%. Five-year survival was 74%. Risk factors for death included older age (p = 0.01), decreased ejection fraction (p = 0.007), and increased New York Heart Association functional class (p = 0.003). Five-year freedoms from thromboembolism and hemorrhage were 90% and 85%, respectively. Five-year freedoms from explant and endocarditis were both 99%. There were no structural valve failures. CONCLUSIONS: The Top Hat valve outcomes have been similar to those of the standard Carbomedics intraannular prostheses. The unique design of the Top Hat valve, with all its components in the aortic sinuses, has particular advantages in the small aortic root, in settings where leaflet entrapment may occur, and in multiple valve replacement.

Peroxynitrite inhibits Ca2+-activated K+ channel activity in smooth muscle of human coronary arterioles.

We examined the hypothesis that ONOO-, a product of the interaction between superoxide (O2*-) and nitric oxide (NO), inhibits calcium-activated K+ (KCa) channel activity in vascular smooth muscle cells (VSMCs) of human coronary arterioles (HCAs), thereby reducing hyperpolarization-mediated vasodilation. HCAs were dissected from right atrial appendages. The interaction of ONOO- with microvessels was determined by immunohistochemistry using a nitrotyrosine antibody. Strong staining was observed in arteries exposed to authentic ONOO- or to sodium nitroprusside (SNP)+xanthine (XA)+xanthine oxidase (XO). Dilation to 10(-8) mol/L bradykinin (BK) was abolished in vessels exposed to ONOO- (-2.5+/-8%; P<0.05) but not DC-ONOO- (65+/-8%). Reduced dilation to BK was also observed after application of XO and SNP. Dilation to NS1619 (KCa channel opener) was reduced in endothelial denuded arterioles treated with ONOO-. In isolated VSMCs, whole-cell peak K+ current density was reduced by ONOO- (control 65+/-15 pA/pF; ONOO- 42+/-9 pA/pF; P<0.05). Iberiotoxin had no further effect on whole-cell K+ current. In inside-out patches, ONOO- but not DC-ONOO- decreased open state probability (NP(o)) of KCa channel by 50+/-12%. O2*- generated by XA+XO had no effect on BK-induced dilation and NP(o) of KCa channels. These results suggest that ONOO-, but not O2*-, inhibits KCa channel activity in VSMCs possibly by a direct effect. This mechanism may contribute to impaired EDHF-mediated dilation in conditions such as ischemia/reperfusion where increased activity of NO synthase occurs in the presence of excess of O2*-.