Characteristics of Participants in the American Urological Association Quality (AQUA) Registry and Early Impact of Participation on Quality of Care.

INTRODUCTION: The American Urological Association Quality Registry (AQUA) is an approved Qualified Clinical Data Repository that was created in 2013 to serve as a platform of quality assessment and improvement. Little is known about how such specialty specific platforms are adopted and used. We describe AQUA participants and report early impact on quality metrics. METHODS: We compared characteristics of practices and urologists participating in AQUA from 2014-2017 to those of the broader urologist workforce as reported in the 2017 American Urological Association Census, and examined pass rates of 4 measures reported to the Centers for Medicare and Medicaid Services after participation in AQUA. RESULTS: Participation increased during the first 4 years and included >125 practices and 1,148 urologists (9.2% of practicing U.S. urologists). Of AQUA participants 97.6% were in private practice, 1.9% were in academic practice and the rest (0.5%) were employed by private or public hospitals, compared to 59.1%, 25.5% and 11.2%, respectively, of urologists nationally. Among AQUA participants 95.9% lived in metropolitan areas, compared to 89.9% of urologists nationally. A total of 17 quality measures were reported to the Centers for Medicare and Medicaid Services through AQUA, of which 4 were urology specific and 13 were crosscutting. The average pass rate across the 4 select urological measures was 31.1% prior to AQUA dashboard access and 48.8% after access was gained, a 56.9% improvement (17.1% absolute difference). CONCLUSIONS: Early participants in AQUA were mostly community practitioners. Participation in AQUA seemed to facilitate quality score improvements, although whether this was due to improved measurement vs clinical care is unknown at this time.

Oxygen dissociation in human erythrocytes: its response to hyperbaric environments.

Hyperbaric nitrogen at a pressure of 100 atmospheres increases significantly the affinity of erythrocytic hemoglobin for oxygen. This results in oxygen dissociation curves which are shifted to lower than normal oxygen partial pressures. The pressure effect is completely reversible and can therefore be observed only during exposure of the blood cells to the hyperbaric gas.

Nature of fetal hemoglobin in the Greek type of hereditary persistence of fetal hemoglobin with and without concurrent beta-thalassemia.

The fetal hemoglobin in the affected members of three Greek families with the hereditary persistence of fetal hemoglobin has only gamma-chains of the type with alanine in position 136. Although certain Negro families had been considered to have only this type of gamma-chains in their fetal hemoglobin, further studies required that they be reclassified. Consequently, the Greek cases are the sole examples of this class among the heterozygotes for the hereditary persistence of fetal hemoglobin. In Greek double heterozygotes for beta-thalassemia and the hereditary persistence of fetal hemoglobin, fetal hemoglobin is increased above the level of hemoglobin F in simple heterozygotes and gamma-chains with glycine in position 136 become apparent. In these individuals, gamma-chains with alanine in position 136 apparently derive from the chromosome for the hereditary persistence of fetal hemoglobin and are present in the hemoglobin F with gamma-chains of both types from the chromosome for beta-thalassemia. When these data are correlated with earlier knowledge of the genetic state of the Greek individuals, modifications of our previous ideas about deletions as the genetic basis of the hereditary persistence of fetal hemoglobin must be considered.

Further studies of the frequency and significance of the Tgamma-chain of human fetal hemoglobin.

A further study of the Tgamma-chain in a variety of conditions has revealed its presence in the cord bloods of ethnic groups previously unstudied. Heterozygous newborn average 17-19% Tgamma-chain while the mean value in four presumed homozygotes was 31%. The Tgamma-chain is readily detectable in beta-thalassemia of various ethnic groups (although infrequent in Blacks) as well as in deltabeta-thalassemia. Studies of a few families have provided an opportunity to determine whether or not certain individuals are heterozygous or homozygous for the Tgamma-gene. The Tgamma-chain has not been detected in the human fetal hemoglobin that is synthesized in increased amounts in persons with the hereditary persistence of fetal hemoglobin. Although the Tgamma-chain is detectable in sickle cell anemia, its frequency appears to be lower than in normal individuals. By focusing upon the relationship of the percentage of Tgamma-chain to the sources of human fetal globulin from determinants in cis and in trans, the conclusion has been reached that the Tgamma-chain is the product of a mutant Agamma-locus which should be named the TAgamma-chain.

Hemoglobin Istanbul: substitution of glutamine for histidine in a proximal histidine (F8(92) ).

A presumably spontaneous mutation has resulted in the formation of Hemoglobin (Hb) Istanbul in which glutamine is substituted for histidine in the proximal position of the beta-chain (F8(92)). The anemia and other physiological effects that occur in the presence of Hb Istanbul were much ameliorated by splenectomy. Hb Istanbul is a relatively unstable molecule which produces a rather moderate case of "unstable hemoglobin hemolytic anemia."In the determination of structure, a method of preferential cleavage of an aspartyl-proline bond at residues 99-100 of the beta-chain was used.

Hemoglobin Pasadena,alpha 2 beta 275(E19)Leu leads to Arg. Identification by high performance liquid chromatography of a new unstable variant with increased oxygen affinity.

This report describes structural and functional characteristics of a new hemoglobin variant, Hb Pasadena [beta 75(E19)Leu leads to Arg] and illustrates the use of high performance liquid chromatography in the analysis of the substitution. As a consequence of this substitution, there is compensated hemolysis, instability, increased oxygen affinity, and reduced cooperativily. However, the health of the individual is hardly affected.

Hemoglobin F Lódz (G gamma I 44 Ser replaced by Arg). A newly identified variant from an American infant of Polish descent.

An electrophoretically slowly migrating hemoglobin variant was identified in a neonate of Polish parents from a cord blood hemoglobin survey. Structural analysis of the gamma chain of the mutant hemoglobin, with fractionation of the tryptic peptides by means of high-performance liquid chromatography, demonstrated a substitution of serine-44 by arginine. Glycine was identified at position 136 of the gamma chain and isoleucine at position 75. Serine residue 44 appears not to be a heme contact site, but as a result of the substitution in this mutant hemoglobin, the possibility exists for formation of a salt bridge between the arginine and a heme propionate group. The infant's hematologic findings suggested the possibility of mild hemolysis, but these changes may have been due to isoimmune disease.

Splenic B cell lymphoma with lymphocyte clusters in peripheral blood smears.

EDTA induced clumping of lymphoid cells, both benign and malignant, in peripheral blood samples has been reported only rarely. Such clustering presents the laboratory and pathologist with unique difficulties in the accurate diagnosis of these disorders. A case of low grade B cell splenic lymphoma is presented with lymphocyte clumping in smears made from EDTA anticoagulated peripheral blood, the fourth case described in which neoplastic lymphoid cells form clusters in vitro in peripheral blood. The association with splenic lymphomas (three of the four cases) is intriguing but its significance remains uncertain.

Merkel cell carcinoma of the lower lip: a case report and histopathologic study.

Merkel cell carcinoma of the lower lip is a rare clinical entity. It is generally thought to be more aggressive than the more common skin cancers of the lips and oral cavity. The literature reveals that delayed diagnoses and poor survival are common among patients with these malignancies. Recommended treatment is surgical excision with wide margins and treatment of cervical metastases with either surgery or radiotherapy or both. Unlike other malignant neoplasms, the occurrence of Merkel cell carcinoma in a relatively older population makes comorbid conditions a key factor in treatment planning.

The incidence of unexpected antibodies in blood products collected at a military donor center.

The objective of the study was to determine the frequency of unexpected antibodies in a population of Air Force personnel thought to be representative of the population involved in combat situations. Recipients of blood transfusions in combat situations may not be screened for the presence of unexpected (non-A, non-B) antibodies. The records of the Wilford Hall Medical Center/59th Medical Defense Wing Donor Center and Transfusion Medicine Laboratory were reviewed for the calendar years 1995 and 1996 to determine the frequency of unexpected antibodies in this center's donor population, the vast majority of whom are Air Force basic trainees. The frequency of unexpected antibodies in the basic trainee donor population was 4/10,000. Clinically significant antibodies were present in 2/10,000. Because this donor pool probably represents the potential population of combat casualties, this information is reassuring in assessing the risks associated with blood transfusion in combat situations.

Diffusion of oxygen in slices of rat brain.

A new method for the joint determination in tissue slices of the diffusion coefficient of oxygen (D) and the fluorescence-quenching coefficient (K') of pyrenebutyric acid (PBA) is introduced. Values of D and K' in rat brain at temperatures (Tc) from 20 to 40 degrees C were determined and referred to the values in water. D = DH2O (0.72 - 0.0074 Tc) +/- 0.079 X 10(-5) cm2/s for 80-microns slices. D = DH2O (1.01 - 0.0074 Tc) +/- 0.12 X 10(-5) cm2/s for 160-microns slices. K' = K'H2O (0.72 + 0.025 Tc) +/- 0.56 X 10(-4) mmHg-1. The temperature dependence of both these parameters in tissue is different from their temperature dependence, and comparison with parameter values obtained with other methods leads us to conclude that factors affecting the diffusion of oxygen in tissue are heterogenous rather than homogenous. The variation in the different parameters, D and K', probably exceeds a twofold range.

High performance liquid chromatography in the identification of human hemoglobin variants.

A description is given of the nature of column packings for reverse phase high performance liquid chromatography (HPLC) and of the equipment that is available for HPLC procedures. HPLC methods have been applied to the identification of abnormal hemoglobins. In most instances, the variant peptide(s) is easily detected on the chromatogram. The effect of differences in column packings and developer sequences is described; modifications in either provide many means for achieving desired separations. Thus, HPLC separates peptides well and is a rapid, sensitive method for studying hemoglobin. Although the emphasis has been on the examination of peptides of abnormal hemoglobins, the procedure can be extended to other aspects such as the separation of hemoglobin chains themselves.

Cellular immunity to myelin basic protein in man and in animal model systems as measured by the macrophage migration inhibition test.

Lymphocytes from patients with neoplastic disease were tested for sensitization to encephalitogenic factor (EF) by the macrophage migration inhibition test. Sensitization to EF was demonstrated in 71% of patients with various forms of neoplastic disease. Sensitization to EF was also demonstrated for 31% of subjects with no evidence of neoplastic disease; these included patients with warts, chronic bronchitis and hernias. In contrast, healthy subjects showed no sensitization to myelin basic protein. These observations suggest that sensitization to EF may not be confined to patients with neoplastic disease. Lymphocytes from hamsters bearing a transplanted virus induced tumour were sensitized to EF prepared from both human and hamster brain. Sensitization was also seen in hamsters infected with influenza virus but not in animals with acute tubular necrosis produced by glycerol treatment. The development of an animal model system provides a method for the investigation of possible mechanisms of sensitization.

Anisotropic diffusion of oxygen in slices of rat muscle.

The diffusion coefficient of oxygen (D) and the fluorescence quenching coefficient (K') of pyrenebutyric acid (PBA) were measured in sections of rat hamstring muscles. Values of D and K' at temperatures (Tc) of 20, 30, and 40 degrees C were determined and referred to the values in water. In sections cut parallel to the muscle fibers, D = DH2O (0.380 +/- 0.038), whereas in sections cut across the grain of the fibers, D = DH2O (0.985 +/- 0.039). Oxygen diffuses along the length of a muscle fiber over twice as rapidly as it diffuses in directions perpendicular to the long axis of the fiber. This suggests that fibers, myofibrils, or myofilaments offer substantial barriers to the diffusion of oxygen, whereas extracellular space and spaces around fibers or myofibrils or myofilaments offer no more resistance than water to the diffusion of oxygen. Corresponding estimates for K' were K' = K'H2O[0.14 (1 + 0.25 Tc)] and K' = K'H2O[0.21 (1 + 0.25 Tc)] for slices cut parallel to the long axis of muscle fibers and across the long axis, respectively. Standard deviations of K' were 9%.