Discordance in patient and physician global assessment in relapsing polychondritis.

OBJECTIVES: Relapsing polychondritis (RP) is a rare, heterogeneous, systemic inflammatory disease that targets cartilage. Patient-reported outcome measures may differ from physician assessment. This study compared patient global assessment (PtGA) and physician global assessment (PhGA) scores in a prospective cohort of patients with RP. METHODS: Adult patients with RP underwent a standardized comprehensive evaluation at ∼6 month intervals. At each visit, three physicians scored PhGA by consensus. The patient independently completed four patient-reported outcomes: PtGA, 36-item Short Form Health Survey (SF-36), Brief Illness Perception Questionnaire (BIPQ) and Multidimensional Fatigue Inventory (MFI). Patient-physician discordance was defined as a difference between PtGA and PhGA of ≥3 on a 0-10 scale. RESULTS: A total of 76 patients were evaluated over 154 visits. The median PhGA was 3 [interquartile range (IQR) 2-3] and the median PtGA was 5 (IQR 4-7). PtGA and PhGA were concordant in 66 visits (42.9%) and patients scored disease severity ≥3 points higher than physicians scored disease activity (positive discordance) in 84 visits (54.5%). Compared with visits with concordance, visits with positive discordance were associated with significantly worse scores on the MFI, BIPQ, SF-36 physical component score and SF-36 mental component score. CONCLUSION: Patients with RP typically self-report high PtGA that does not align with PhGA. Discordance is likely driven by the high physical and psychological burden of illness experienced by patients. Multifaceted treatment approaches that address the burden of disease in RP from the patient perspective are needed.

Physician Global Assessment as a Disease Activity Measure for Relapsing Polychondritis.

OBJECTIVE: Relapsing polychondritis (RP) is a systemic inflammatory disorder of cartilage that lacks validated disease activity measures. Our objective was to test physician global assessment (PhGA), a measure of disease activity commonly used in rheumatic diseases, in a cohort of patients with RP, which has not been done before. METHODS: Adult patients in an observational cohort of RP underwent standardized, comprehensive evaluation at approximately 6-month intervals. PhGA was scored by 3 physicians from the evaluating institution on a scale of 0-10 for each visit. A random subset of 20 visits was scored by 3 independent physicians not affiliated with the evaluating institution. Treatment change between consecutive visits was categorized as increased, decreased, or unchanged. RESULTS: In total, 78 patients were evaluated over 164 visits. The intraclass correlation coefficient (ICC2,1 ) for the 3 raters from the evaluating institution was excellent (0.79 [95% confidence interval (95% CI) 0.73, 0.84]) but was poor in the subset of cases scored by the additional raters (ICC2,1 0.27 [95% CI -0.01, 0.53]). Median PhGA was 3 (range 0-7). PhGA weakly correlated with C-reactive protein level (rs = 0.30, P < 0.01). In response to increased treatment, median PhGA decreased from 3 (interquartile range [IQR] 2, 4) to 2 (IQR 2, 3) (P < 0.01) but rarely went to 0. CONCLUSION: Within a single center, PhGA can be used to quantify disease activity and monitor disease response in RP. Persistent disease activity despite treatment, rather than a relapsing-remitting pattern, is observed for most patients with RP. Reliability of PhGA may not generalize across different institutions. A validated disease-specific activity index is needed in RP.

The cost of operating room delays in an endourology center.

INTRODUCTION: This study sought to characterize delays and estimate resulting costs during nephrolithiasis surgery. METHODS: Independent observers documented delays during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) procedures. Fifty index cases over a period of three months was considered sufficient to observe the generalizable trends. Operating room staff, excluding the surgeons, were blinded. Time-related metrics and delays preventing case progression were recorded using a smartphone-accessible data-collection instrument. Delays were categorized as: 1) missing equipment; 2) missing personnel; 3) equipment malfunction; or 4) delay due to case complexity. The first two categories were regarded as preventable and the latter two non-preventable. RESULTS: Forty URS and 18 PCNL cases were included. There was a total of 56 delays in 35 (65%) cases. Twelve (67%) PCNLs and 23 (58%) URSs had delays (p=0.57). The mean cumulative delay per case was 3.5±3.2 minutes. Pre-start delays (n=17) were 4.5±3.5 minutes on average while intraoperative delays (n=39) were 3.1±2.9 minutes (p=0.167). Delays were evenly spread among the four categories. Thirty-one (55%) delays were preventable (mean 3.7±3.2 minutes) while 25 (45%) were non-preventable (mean 3.2±3.2 minutes) (p=0.58). This translates to $137 per case in preventable costs. CONCLUSIONS: Preventable operative delays are encountered frequently in nephrolithiasis surgery, translating to significant additional charges and costs. We demonstrate a rationale for the development of improved communication and workflow protocols to increase efficiency in endourological surgeries. Key limitations are the observational nature of the study and sample size.

A DNA-Based Assessment of the Phylogenetic Position of a Morphologically Distinct, Anchialine-Lake-Restricted Seahorse.

Isolated populations provide special opportunities to study local adaptation and incipient speciation. In some cases, however, morphological evolution can obscure the taxonomic status of recently founded populations. Here, we use molecular markers to show that an anchialine-lake-restricted population of seahorses, originally identified as Hippocampus reidi, appears on the basis of DNA data to be Hippocampus erectus We collected seahorses from Sweetings Pond, on Eleuthera Island, Bahamas, during the summer of 2014. We measured morphological traits and sequenced 2 genes, cytochrome b and ribosomal protein S7, from 19 seahorses in our sample. On the basis of morphology, Sweetings Pond seahorses could not be assigned definitively to either of the 2 species of seahorse, H. reidi and H. erectus, that occur in marine waters surrounding the Bahamas. However, our DNA-based phylogenetic analysis showed that the Sweetings Pond fish were firmly nested within the H. erectus clade with a Bayesian posterior probability greater than 0.99. Thus, Sweetings Pond seahorses most recently shared a common ancestor with H. erectus populations from the Western Atlantic. Interestingly, the seahorses from Sweetings Pond differ morphologically from other marine populations of H. erectus in having a more even torso to tail length ratio. The substantial habitat differences between Sweetings Pond and the surrounding coastal habitat make Sweetings Pond seahorses particularly interesting from the perspectives of conservation, local adaptation, and incipient speciation.

Disparities in Quality of Park Play Spaces between Two Cities with Diverse Income and Race/Ethnicity Composition: A Pilot Study.

This study investigated the differences in the quality of park play spaces between an affluent and a non-affluent community in a large US Southeastern metropolitan area. Two cities were purposefully selected to reflect differences in household income and race/ethnicity characteristics. Using the Playable Space Quality Assessment Tool (PSQAT), all parks (n = 11, with six in the affluent city, and five in the non-affluent city) in these two cities were evaluated. The data were analyzed across three aspects of environmental features of the PSQAT: Location, Play Value and Care and Maintenance between parks in the two cities. The Mann-Whitney U test was used to test the study hypotheses. Results indicated significant differences between parks in the two cities in all three aspects of the PSQAT with p-values ≤ 0.03 and effect sizes of > 0.65, suggesting that the affluent city had parks of a higher quality than the non-affluent city. Significant disparity in Play Value (p = 0.009) in parks between these two communities suggests that children and young people are likely to have different experiences of the play spaces in their locality and therefore may experience different physical and psychological health benefits.