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.

Falls and Orthostatic Hypotension in Older Adults: Re-examining Limits.

Background: Orthostatic hypotension (OH) is defined using substantial thresholds of blood pressure (BP) drops with standing, which may be insufficient for identifying falls risk. Objective: To assess associations between falls risk and (1) consensus-defined OH (cOH), (2) standing BP levels, (3) BP changes with standing, (4) combined standing BP levels and BP changes with standing. Design: Observational study of normative aging. Setting: Baltimore Longitudinal Study of Aging. Participants: Participants ≥65 years with first visits evaluating OH and self-reported falls (2004-2010). Measurements: BP was measured supine and 3 minutes after standing. A drop in systolic BP (SBP) ≥20mmHg or a drop in diastolic BP (DBP) ≥10mmHg upon standing defined cOH. Participants self-reported the number of falls experienced in the previous 12 months. Results: Among 400 participants (45% women; 30% black; mean age 74.8 years), 113 (28%) reported ≥1 fall; 19 (4.8%) had cOH. In adjusted models, cOH (OR=2.77, 95% CI: 1.00-7.71 p=0.051) and continuous SBP-drops per 5mmHg (OR=1.21, 1.00-1.47 p=0.046) were associated with having any fall and multiple falls (cOH: OR=3.94, 1.04-14.96 p=0.044; SBP 5mmHg drops: OR=1.34, 1.00-2.15 p=0.020). Attained SBP with standing was not associated with falls either alone (OR=1.01, 0.99-1.02 p=0.369) or in combination with SBP-drops (interaction OR=1.03, 0.96-1.09 p=0.414). Limitations: Cross-sectional design, prohibiting conclusions about causal relationships. Conclusions: Findings suggest that postural SBP-drops that are much lower than current OH definition thresholds indicate increased falls risk in older adults, regardless of absolute SBP level. This has implications for standard clinical falls risk assessment and communication of falls risk to patients.

Series: Concepts in end-of-life care: palliative care medicine.

The goals of palliative care are to provide the best quality of life for the patient and family at a critical time in the patient's life. Ethical principles of patient autonomy, beneficence, and justice are very important at this time. Good communication is paramount in respecting patients' values and preferences. Appropriate surrogates, as directed by the patient, should be included in discussions and decisions. Physical, social, emotional, and spiritual suffering must be addressed.

Pathophysiology of hypertension in the elderly.

The importance of hypertension as a cardiovascular risk factor increases progressively with aging, but diastolic blood pressure plateaus at age 50, which leads to a rise in pulse pressure in the elderly. Thus, isolated systolic hypertension with a widened pulse pressure is the most common type of hypertension seen in persons older than 65 years of age. Pulse pressure is the most robust blood pressure measurement in predicting cardiovascular disease. This rise in systolic blood pressure and pulse pressure with aging is a consequence of arterial stiffness. With aging, both structural and functional changes occur that result in a less compliant aorta and large vessels. Investigators who use pulse-wave velocity and augmentation index as measures of large artery stiffness have repeatedly shown an increase in arterial stiffness with aging. Early return of the reflected pulse wave to the aorta during systole has been shown to be the primary mechanism accounting for the rise in systolic and decline in diastolic pressure that occurs with arterial stiffness. Several factors have been shown to decrease arterial stiffness including aerobic exercise, decreased sodium intake, n-3 fatty acids, estrogen replacement therapy, nitrates, and ACE inhibitors. Drugs that specifically lower systolic blood pressure but not diastolic pressure, such as vasopeptidase inhibitors, are under investigation in treating isolated systolic hypertension.

HLA disease association and protection in HIV infection among African Americans and Caucasians.

In a previous investigation, we demonstrated an increased progression of overt AIDS in the African American population compared to the Caucasian population as reflected by the significantly lower absolute number of CD4+ lymphocytes detected in the African American population in an earlier study. The present study elucidates some of the possible genetic factors which may contribute to disease association or protection against HIV infection. The HLA phenotypes expressed as A, B, C, DR and DQw antigens were revealed by the Amos-modified typing procedure. NIH scoring was utilized to designate positive cells taking up trypan blue. A test of proportion equivalent to the chi 2 approximation was used to compare the disease population (n = 62; 38 African Americans, 24 Caucasians) to race-matched normal heterosexual local controls (323 African Americans, 412 Caucasians). Significant p values were corrected for the number of HLA antigens tested. HLA markers associated with possible protection from infection for African Americans were Cw4 and DRw6, whereas Caucasians expressed none. Disease association markers present in the African American population were A31, B35, Cw6, Cw7, DR5, DR6, DRw11, DRw12, DQw6 and DQw7, whereas in the Caucasian population A28, Aw66, Aw48, Bw65, Bw70, Cw7, DRw10, DRw12, DQw6 and DQw7 were demonstrated. The highest phenotypic frequency for a disease association marker in the study was for HLA-DR5 (62.9%) in the HIV-infected African American population without Kaposi's sarcoma compared to a frequency of 28.9% for the regional control group (p = 0.0012). We conclude that genetic factors do have a role in HIV infection since only 50-60% of those exposed to the AIDS virus will become infected.

The frequency of radiolucencies underlying cephalohematomas.

The authors studied skull radiographs of 66 infants with cephalohematoma. Twenty-three (35%) had radiolucencies in the skull; most of the radiolucent defects were associated with beginning or extensive ossification over the cephalohematoma. Radiolucency associated with cephalohematoma is a frequent finding and rarely indicates local infection.

Bilateral temporal-middle cerebral artery anastomosis for Moyamoya syndrome.

Moyamoya syndrome has been recognized for approximately 15 years. Medical and surgical treatment by sympathectomy and ganglionectomy has proved futile. This report presents a case treated by bilateral superficial temporal artery, middle cerebral artery anastomosis in a black American male.

Organizing hematoma in a child presenting as a 'doughnut lesion' on nuclear scan. Case report.

We report a 4 1/2-year-old boy who presented with a 4-week history of frontal headaches and fever, and generalized convulsion 5 months previously. Papilledema, an abnormal EEG and a brain scan with a frontal mass and 'doughnut' sign were found. The association of the clinical history with brain scan findings strongly suggested a brain abscess. At surgery the lesion proved to be an encapsulated hematoma; Histological findings suggest underlying microangiomata.