Comparative Cost Analysis: Teleurology vs Conventional Face-to-Face Clinics.

OBJECTIVE: To compare costs associated with teleurology vs face-to-face clinic visits for initial outpatient hematuria evaluation. MATERIALS AND METHODS: The analysis included 3 cost domains: transportation, clinic operations, and patient time. Transportation cost was based on standard government travel reimbursement. Clinic staff cost was based on hourly salary plus fringe benefits. For a face-to-face clinic encounter, patient time included time spent for travel, parking, walking to and from clinic, checking in and checking out, nursing evaluation, urologic evaluation, laboratory, and waiting. Patient time cost was based on the Federal minimum wage. Provider and laboratory times were excluded from the cost analysis as these were similar for both encounters. RESULTS: We included 400 hematuria evaluations: 300 teleurology and 100 face-to-face. Both groups had similar median age (63 vs 64 years, P = .48) and median travel distance/time (58 vs 54 miles, P = .19; 94 vs 82 minutes, P = .09, respectively). Average patient time was greater for face-to-face encounters (266 vs 70 minutes teleurology, P < .001). Transportation was the primary driver of overall costs ($83.47 per encounter), followed by patient time ($32.87/encounter) and clinic staff cost ($18.68/encounter). The average cost per encounter was $135.02 for face-to-face clinic vs $10.95 for teleurology (P < .001) exclusive of provider and laboratory times. Cost savings associated with each telehematuria encounter totaled $124.07. CONCLUSION: Teleurology offers considerable cost savings of $124 per encounter for the initial evaluation of hematuria compared to face-to-face clinic. With 1.5 million annual hematuria encounters nationally, implementation of teleurology for hematuria evaluation offers cost savings approaching $200 million per year.

Patient Acceptance of Teleurology via Telephone vs Face-to-Face Clinic Visits for Hematuria Consultation at a Veterans Affairs Medical Center.

INTRODUCTION: We evaluated the experience and preferences of patients undergoing hematuria consultation via teleurology compared to a conventional face-to-face clinic visit. METHODS: Patients evaluated for hematuria with teleurology or face-to-face clinic visit were surveyed regarding their experience and preferences. The survey consisted of 27 questions evaluating overall acceptance and satisfaction (8 questions), impact factors (17) and preference (2). RESULTS: A total of 450 patients participated in the survey at a 2-to-1 ratio (300 via teleurology, 150 via face-to-face visits). Overall, patient satisfaction level was higher with teleurology compared to face-to-face clinic visits (mean score 9.2 vs 8.4, p <0.0001). This finding was observed in all 8 domains (acceptance, efficiency, convenience, friendliness, quality of interview, communication and care, provider professionalism and privacy protection, all p <0.001). Transportation related issues were the most common underlying reason that influenced patient opinion, with at least 1 transportation factor being reported by 280 of 300 teleurology patients (93.3%) and 133 of 150 patients seen face-to-face (88.7%). Clinic operation and provider interaction factors similarly impacted patient satisfaction and preference. Time to access was significantly better for teleurology (12 days) compared to face-to-face clinics (72 days, p <0.001). Overall incidence of bladder cancer was 5.6% (25 of 450 patients), which was observed in 6.3% of the teleurology group (19 of 300) and 4.0% of the face-to-face group (6 of 150, p = 0.386). CONCLUSIONS: Patients prefer teleurology to face-to-face clinic visits for the initial evaluation of hematuria. Teleurology positively impacts compliance and access by potentially eliminating common challenges facing patients, and by improving efficiency, convenience and flexibility.

Three-dimensional cell culture model utilization in cancer stem cell research.

Three-dimensional (3D) cell culture models are becoming increasingly popular in contemporary cancer research and drug resistance studies. Recently, scientists have begun incorporating cancer stem cells (CSCs) into 3D models and modifying culture components in order to mimic in vivo conditions better. Currently, the global cell culture market is primarily focused on either 3D cancer cell cultures or stem cell cultures, with less focus on CSCs. This is evident in the low product availability officially indicated for 3D CSC model research. This review discusses the currently available commercial products for CSC 3D culture model research. Additionally, we discuss different culture media and components that result in higher levels of stem cell subpopulations while better recreating the tumor microenvironment. In summary, although progress has been made applying 3D technology to CSC research, this technology could be further utilized and a greater number of 3D kits dedicated specifically to CSCs should be implemented.

Implementation of a Tele-urology Program for Outpatient Hematuria Referrals: Initial Results and Patient Satisfaction.

OBJECTIVE: To report on results from a new tele-urology pathway for managing hematuria consults, including a survey of patient attitudes and satisfaction with such a program. Recent guideline changes have relaxed the definition of microscopic hematuria and may have significantly increased the number of hematuria evaluations. MATERIALS AND METHODS: Patients referred to the Atlanta Veterans Administration Medical Center with hematuria were scheduled for a tele-urology clinic encounter utilizing a telephone call to obtain hematuria-related clinical information via a standardized algorithm. At subsequent cystoscopy, patients were evaluated with a 29-question survey regarding overall acceptance and satisfaction of the clinic (8 questions) and impact factors (21 questions). RESULTS: One hundred fifty veterans participated in the survey. Median time from consult request to appointment was 12 days and thereafter to cystoscopy was 16 days. Patients reported high acceptance and overall satisfaction with telephone evaluation; mean scores exceeded 9 out of 10 for overall satisfaction, efficiency, convenience, friendliness, care quality, understandability, privacy, and professionalism. When presented with a choice, nearly all patients (98%) preferred telephone-based encounters to face-to-face clinic visits. Underlying negative factors responsible for patients' preferences included transportation-related issues (97%) and logistical clinic issues (65%). Ninety-seven percent of patients reported high-quality evaluation. CONCLUSION: Patients report high acceptance and satisfaction with telephone clinics as a mechanism for expedited hematuria evaluation, primarily due to avoiding barriers related to transportation and clinical operations, as well as a perceived high quality of evaluation. Telephone appointments have potential to positively impact healthcare access and productivity.

Impaired glucose metabolism treatment and carcinogenesis.

Carbohydrate metabolism disorders increase the risk of carcinogenesis. Diabetes mellitus alters numerous physiological processes that may encourage cancer growth. However, treating impaired glucose homeostasis may actually promote neoplasia; maintaining proper glucose plasma concentrations reduces metabolic stresses, however, certain medications may themselves result in oncogenic effects. A number of previous studies have demonstrated that metformin reduces the cancer risk. However, the use of sulfonylurea derivatives correlates with an increased risk of developing a malignancy. Another form of treatment, insulin therapy, involves using various forms of insulin that differ in pharmacodynamics, pharmacokinetics and efficacy. Previous studies have indicated that certain insulin variants also affect the cancer risk. The results from analyses that address the safety of long-lasting insulin types raise the most concern regarding the increased risk of malignancy. Rapid development of novel diabetic medications and their widespread use carries the risk of potentially increased rates of cancer, unnoticeable in limited, randomized, controlled trials. In the present review, the results of clinical and epidemiological studies are evaluated to assess the safety of anti-hyperglycemic medications and their effect on cancer risk and outcomes.

Impact of remote monitoring and supervision on resident training using new ACGME milestone criteria.

INTRODUCTION: The study objective was to determine the impact of remote monitoring and supervision (RMS) in integrated endourology suites (IES) on residents achieving endoscopic training milestones. MATERIALS AND METHODS: Twenty-one urology residents evaluated RMS in IES using a 25-question survey. IES provided audio-visual communication for faculty to supervise residents remotely. Questionnaire used a linear visual scale of 1-10 to assess acceptability (8 questions), impact on training (10 questions), supervision level (1 question), and pre- and post-training milestone self-assessments (6 questions). Improvements in Patient Care Milestone #7 (upper/lower tract endoscopic procedures) and Patient Care Milestone #9 (office-based procedures) were analyzed. RESULTS: Twenty-one urology residents (out of potential 23) evaluated RMS in IES using a 25-question survey (91.3% response rate). Overall RMS acceptability and satisfaction was high (mean score = 9.1/10) with a majority (95.2%) feeling comfortable being alone with the patient. Residents reported positively on the following parameters: autonomy without compromising safety (8.7), supervision level (8.6), achieving independence (8.4), education quality (8.3), learning rate (8.1), clinical decision-making (8.0), and reducing case numbers to achieve proficiency (7.6). Residents perceived no issues with under- or over-supervision, and a majority (76.2%) expressed that RMS should be standard of training in residency programs. Residents reported mean level increases of 2.5 and 2.8 (out of 5) in Patient Care Milestones for endoscopic procedures and office-based procedures, respectively (p < 0.0001). CONCLUSIONS: RMS in integrated endourology suites may enhance resident education and endoscopic training. The study demonstrated an increase in competency levels reported by residents trained using RMS.

Molecular basis of carcinogenesis in diabetic patients (review).

The most important molecular mechanisms promoting carcinogenesis in patients with diabetes mellitus (DM) include oxidative stress, excessive generation of free radicals and nitrous oxide, damage to cellular membranes and DNA, overproduction of lactate, overabundance of protein glycosylation storage products, overexpression of pathological enzyme isoforms, and leakage of cytochromes from organelles. Additionally, dysfunctional signal transduction pathways, especially in pathways involving phosphoinositide 3­kinase (PI3K)/phosphatase and tensin homolog (PTEN)/Akt, RAS/Raf/ERK, and mammalian target of rapamycin (mTOR), have been implicated in malignant transformation and progression. Obesity and metabolic disorders, such as DM, may contribute to a dysfunctional immune system with a suppressed immune response by inducing a chronic inflammatory state, abnormal humoral and cellular mediated immunity, and lower counts and activity levels of natural killer (NK) cells and natural killer T cells (NKT cells). Recent advances in molecular biology will allow for better understanding of abnormal cellular pathways, as well as elucidating how metabolic disorders contribute to oncogenesis. Knowledge gained through these studies may lead to more efficacious oncologic therapies.

The Value of Pathological Examination of the Foreskin Following Circumcision.

INTRODUCTION: We determined the clinical impact and value of routine histopathological examination of the foreskin following circumcision. METHODS: We performed a retrospective study of 225 consecutive adult circumcisions. Indications for circumcision were categorized as benign or malignant based on preoperative clinical evaluation. Histopathological results were similarly classified as benign or malignant. Preoperative clinical impression and postoperative histological diagnosis were compared and reported as concordant (in agreement) or discordant (in disagreement). The cost impact of histopathology examination was analyzed with respect to study findings. RESULTS: Of the 225 patients 209 (92.9%) had clinically benign disease on preoperative evaluation and 16 (7.1%) had foreskin lesions suspicious for malignancy. Mean age was 57.0 years (range 23 to 92). Patients were younger in the benign group than in the malignant group (56.5 vs 62.8 years, p = 0.018). Black patients represented 65.8% of the study population and were similarly distributed between the 2 groups (p = 0.405). There was no statistical difference in patient height, weight, body mass index or comorbidities between the 2 groups. Preoperative clinical impression and postoperative histological diagnosis were concordant in all 209 patients in the benign group. Of the 16 patients suspected to have malignant disease preoperatively 9 (56.2%) had malignancy and 7 (43.8%) had benign disease on histopathological examination. CONCLUSIONS: Routine histological examination of a foreskin specimen in the absence of clinical suspicion for malignancy appears to have diminished benefit in the setting of benign preoperative indications. Omitting this traditional practice in patients with benign surgical indications may positively impact health care costs without compromising quality of care.

DNA damage differentially activates regional chromosomal loci for Tn7 transposition in Escherichia coli.

The bacterial transposon Tn7 recognizes replicating DNA as a target with a preference for the region where DNA replication terminates in the Escherichia coli chromosome. It was previously shown that DNA double-strand breaks in the chromosome stimulate Tn7 transposition where transposition events occur broadly around the point of the DNA break. We show that individual DNA breaks actually activate a series of small regional hotspots in the chromosome for Tn7 insertion. These hotspots are fixed and become active only when a DNA break occurs in the same region of the chromosome. We find that the distribution of insertions around the break is not explained by the exonuclease activity of RecBCD moving the position of the DNA break, and stimulation of Tn7 transposition is not dependent on RecBCD. We show that other forms of DNA damage, like exposure to UV light, mitomycin C, or phleomycin, also stimulate Tn7 transposition. However, inducing the SOS response does not stimulate transposition. Tn7 transposition is not dependent on any known specific pathway of replication fork reactivation as a means of recognizing DNA break repair. Our results are consistent with the idea that Tn7 recognizes DNA replication involved in DNA repair and reveals discrete regions of the chromosome that are differentially activated as transposition targets.