Wait times, patient satisfaction scores, and the perception of care.

OBJECTIVES: To analyze the impact of waiting time on patient satisfaction scores; not only of satisfaction with the provider in general, but also with the specific perception of the quality of care and physician abilities. STUDY DESIGN: Using surveys regarding patient satisfaction with provider care, data was collected from a sample of 11,352 survey responses returned by patients over the course of 1 year across all 44 ambulatory clinics within a large academic medical center. While a small minority of patients volunteered identification, the surveys were made anonymously. METHODS: A questionnaire with Health Consumer Assessment of Healthcare Providers and Systems patient satisfaction and waiting time queries was administered via mail to all clinic patients-roughly 49,000-with a response rate of 23%. Employing a standard statistical approach, results were tabulated and stratified according to provider scores and wait time experience, and then analyzed using statistical modeling techniques. RESULTS: While it is well established that longer wait times are negatively associated with clinical provider scores of patient satisfaction, results indicated that every aspect of patient experience-specifically confidence in the care provider and perceived quality of care-correlated negatively with longer wait times. CONCLUSIONS: The clinical ambulatory patient experience is heavily influenced by time spent waiting for provider care. Not only are metrics regarding the likelihood to recommend and the overall satisfaction with the experience negatively impacted by longer wait times, but increased wait times also affect perceptions of information, instructions, and the overall treatment provided by physicians and other caregivers.

Laparoscopic partial cystectomy for treatment of adenocarcinoma of the urachus.

The treatment of choice for urachal carcinoma has traditionally been an open approach, either by radical cystectomy or the more recently adopted bladder-sparing approach of extended partial cystectomy and umbilectomy. We report for the first time a laparoscopic technique for an extended partial cystectomy with en bloc umbilectomy for the management of urachal carcinoma in a 41-year-old man.

Effect of neonatal circumcision on penile neurologic sensation.

OBJECTIVES: To evaluate penile sensory thresholds in neonatally circumcised and uncircumcised men. METHODS: We evaluated 125 patients, 62 uncircumcised men and 63 neonatally circumcised men. All patients completed the Erectile Function domain of the International Index of Erectile Function questionnaire. Of the 125 patients, 29 (International Index of Erectile Function score of between 25 and 30) were placed in the functional group, and 96 in the dysfunctional group. The patients were tested on the dorsal midline glans of the penis (foreskin retracted). Quantitative somatosensory testing was performed and included vibration, pressure, spatial perception, and warm and cold thermal thresholds. RESULTS: In the functional group, t-test analysis demonstrated a significant (P <0.001) difference, with worse vibration and better pressure sensation for uncircumcised men. When controlling for age, hypertension, and diabetes, all t-test significance was lost. In the dysfunctional group, circumcised men (49 +/- 16 years) were significantly younger (P <0.01) than uncircumcised men (56 +/- 13 years). For the dysfunctional group, t-test analysis also demonstrated worse vibration sensation for uncircumcised men (P <0.01). Again, when controlling for age, hypertension, and diabetes, all t-test significance was lost. CONCLUSIONS: We present a comparative analysis of uncircumcised and circumcised men using a battery of quantitative somatosensory tests that evaluate the spectrum of small to large axon nerve fiber function. Our study controlled for factors, including age, erectile function status, diabetes, and hypertension, that have been shown to alter neurologic testing. In our study of neonatally circumcised men, we demonstrated that circumcision status does not significantly alter the quantitative somatosensory testing results at the glans penis.

Periurethral masses: etiology and diagnosis in a large series of women.

OBJECTIVE: To describe the differential diagnosis of periurethral masses in a consecutive series extracted from a single tertiary urogynecologic practice database. METHODS: A patient database of a private urology and urogynecology practice with 1,950 women was searched for patients who were found to have a periurethral mass during the accrual dates of 1994 to 2002, and these records were reviewed for diagnostic testing and results. All women provided a history, completed a questionnaire, and underwent physical examination, voiding diary, cystoscopy, and videourodynamic testing; selected patients then underwent additional imaging. RESULTS: Seventy-nine (4%) patients aged 41.2 +/- 14 years were identified. Of these, 72 (91%) had been referred for evaluation of persistent irritative lower urinary tract symptoms or incontinence. Seven patients (9%) had been referred specifically because of a periurethral mass. Sixty-six patients (84%; 95% confidence interval [CI] 73%, 91%) had urethral diverticula, of which 4 (6%; 95% CI 2%, 14.8%) contained malignancies. Six patients (7%; 95% CI 3%, 15%) had vaginal cysts histologically identified as fibromuscular tissue, 4 (5%; 95% CI 1%, 12%) had leiomyomata, and 2 (2.5%; 95% CI 0.03%, 8.8%) had ectopic ureteroceles. Two patients had vaginal squamous cell carcinomas (2.5%; 95% CI 0.03%, 8.8%), and 1 had an infected granuloma. Masses were palpable in 42 patients (53.8%; 95% CI 42%, 64%) and in 37 patients either were encountered at surgery (n = 5) or were urethral diverticula diagnosed by voiding cystourethrogram (n = 32). CONCLUSION: Periurethral masses were encountered in less than 4% of our patient sample. Most masses were urethral diverticula; however, the differential diagnosis included leiomyoma, vaginal cysts, and malignancy. Masses were generally either palpable or seen at imaging studies performed during evaluation of lower urinary tract symptoms.

Pad test by mail for home evaluation of urinary incontinence.

AIMS: To present a simple, cost-effective, and convenient method of home pad test using the mail system and evaluating change in pad weight over time. MATERIALS AND METHODS: A series of nine kinds of commonly available commercial brands of urinary incontinence pads ranging from thin liners less than 10 g in dry weight to large diapers weighing over 100 g each were assembled. Two or three of each variety were individually weighed on an OHAUS LS2000 Portable Standard scale accurate to +/- 1 g. The pads were then wet uniformly with 20 cc of saline, placed individually in sealable plastic bags, sealed, and reweighed. Random groups of three pads were mailed by standard 1st class mail to the Urocenter of New York. The sealed pads were reweighed at 8 and 14 days from the original wetting. Concurrently, ten incontinence pads soiled with urine were similarly examined to confirm that there would be no detectable difference between urine and saline for the purpose of the study. In the second part of the study, 20 pads of the same type (13 inch-long pads with absorbent gel) were divided into 4 groups of 5 pads; each group was uniformly wet with 5, 10, 20, or 50 g of saline. These pads were mailed and reweighed at 7 and 14 days from the initial wetting. RESULTS: Twenty-four pads were used in the first part of the study. The dry weights of 22/24 (92%) of the pads were within 2 g of the average weight for their brand. At the first reweighing, 22 pads (92%) weighed within 2 g of their initial wet weights (Fig. 1). Only two pads on day 8 differed substantially from their initial weights: one pad appeared to have lost 4 g and another one 9 g. On day 14, 23/24 pads remained within 1 g of their day 8 weight and 1 differed by 2 g, and the total weight of the 24 pads on day 14 was only 4 g different from their initial weight (P = 0.71, Fig. 1). The soiled pads exhibited weight changes that were indistinguishable from the saline pads. The average cost of mailing the pads by 1st class mail was $4 and the average length of time in the mail was 5 days +/- 1 day. In the second part of the study, 18/20 pads had lost less than 1 g at 1 week, and at 2 weeks, 19/20 had lost less than 2 g when compared to their initial weights (Fig. 2). One pad had lost 3 g. Pads in the low volume groups (5 and 10 g) lost an average of 1.4 and 1.2 g, respectively, while pads in the high volume groups (20, 50 g) lost an average of 1.8 and 2 g at 2 weeks. CONCLUSIONS: Dry pads of any single brand have a relatively standard weight that varies insignificantly between pads. Up to 2 weeks of delay in the weighing of individually sealed pads does not significantly affect the clinical measurement of weight at a variety of low (5 g) or high (50 g) volumes of simulated incontinence. Home pad test using the mail system is a feasible, inexpensive, and clinically accurate method of evaluating incontinence. Patients can be instructed in techniques for home pad test, allowing for greater compliance, and convenience for both physicians and patients.

Quantitative somatosensory testing of the penis: optimizing the clinical neurological examination.

PURPOSE: Quantitative somatosensory testing, including vibration, pressure, spatial perception and thermal thresholds of the penis, has demonstrated neuropathy in patients with a history of erectile dysfunction of all etiologies. We evaluated which measurement of neurological function of the penis was best at predicting erectile dysfunction and examined the impact of location on the penis for quantitative somatosensory testing measurements. MATERIALS AND METHODS: A total of 107 patients were evaluated. All patients were required to complete the erectile function domain of the International Index of Erectile Function (IIEF) questionnaire, of whom 24 had no complaints of erectile dysfunction and scored within the "normal" range on the IIEF. Patients were subsequently tested on ventral middle penile shaft, proximal dorsal midline penile shaft and glans penis (with foreskin retracted) for vibration, pressure, spatial perception, and warm and cold thermal thresholds. RESULTS: Mixed models repeated measures analysis of variance controlling for age, diabetes and hypertension revealed that method of measurement (quantitative somatosensory testing) was predictive of IIEF score (F = 209, df = 4,1315, p <0.001), while site of measurement on the penis was not. To determine the best method of measurement, we used hierarchical regression, which revealed that warm temperature was the best predictor of erectile dysfunction with pseudo R(2) = 0.19, p <0.0007. There was no significant improvement in predicting erectile dysfunction when another test was added. Using 37C and greater as the warm thermal threshold yielded a sensitivity of 88.5%, specificity 70.0% and positive predictive value 85.5%. CONCLUSIONS: Quantitative somatosensory testing using warm thermal threshold measurements taken at the glans penis can be used alone to assess the neurological status of the penis. Warm thermal thresholds alone offer a quick, noninvasive accurate method of evaluating penile neuropathy in an office setting.

Full-thickness human foreskin transplantation onto nude rats as an in vivo model of acute human wound healing.

Current wound-healing models do not fully duplicate the in vivo human environment. The feasibility of grafting human full-thickness foreskin onto nude rats, as a model of acute wound healing, was evaluated. Incisions were then created on the grafted skin, and wound healing was evaluated. Full-thickness human skin was obtained after elective circumcision and was grafted subcutaneously onto the dorsal thorax of nude rats. At 10 days after transplantation, graft beds were judged for graft viability, on the basis of gross appearance, texture, and adherence. Full-thickness wounds were then made in the foreskin. Graft wounds were left to close by secondary intention. The wounds were allowed to heal for 7 days. Wounds were excised and tested for breaking stress. Histological evaluations included proliferating cell nuclear antigen, factor VIII, hematoxylin and eosin, and trichrome staining. Twenty grafts were performed, with 100 percent viability. Upon incision, all grafts bled freely, indicating a rich vascular supply and tissue viability. Graft viability was confirmed by the presence of proliferating cells in the parabasal stratum of the epithelium. Furthermore, there was evidence of angiogenesis, as confirmed by staining for factor VIII. Breaking stress was evaluated by tensiometry, 7 days after wounding. Histological evaluations revealed viable grafts and active wound-healing events. Full-thickness human skin can be successfully transplanted onto nude rats, providing a larger, more physiological model of human wound healing. This model closely parallels the in vivo situation, providing a promising model for study of the complex biological processes of acute human wound healing, in a reproducible manner.

Enhanced adenoviral-vector mediated gene transfer using human albumin solder.

BACKGROUND AND OBJECTIVE: Laser tissue welding with human albumin solder (HAS) has been used as an alternative method of wound closure. Adenoviral vectors have been used to introduce various cytokine genes into wounds to accelerate wound closure. In the present study, we were interested in the effect of HAS on adenoviral vector transfer of the beta-galactosidase (beta-gal) gene in vitro and in vivo. STUDY DESIGN/MATERIALS AND METHODS: 3T3 fibroblasts were used to study the effect of HAS on beta-gal gene transfer in vitro. The presence of beta-gal was determined by Western blot, and its activity by a colorimetric assay. A punch biopsy model of wound healing in pigs was used for in vivo experiments. RESULTS: HAS increased the efficiency of adenoviral-mediated beta-gal transduction and stabilized the adenovirus at room temperature. HAS protected adenovirus from inactivation by laser, both in vitro and in vivo. CONCLUSIONS: HAS may stabilize adenoviral vectors to deliver cytokine genes in future wound healing experiments.

Ex vivo evaluation of human fetal membrane closure.

BACKGROUND AND OBJECTIVE: This study compares stress and leak point pressure of human fetal membranes following closure with suture, laser welding, or a new tissue sealant, SynthaSeal. STUDY DESIGN/MATERIALS AND METHODS: Samples of fetal membrane were bisected and repaired with suture, laser welding with albumin solders, or a tissue sealant. Representative tissue samples were assessed by histology. Anastomotic strength was evaluated by tensiometry. Additionally, leak pressure was measured after membrane samples were placed onto an infusion pump/pressure transducer, incised, and repaired as above. RESULTS: Membrane stress was strongest (P<0.001) for the tissue sealant group. Sutured samples were stronger than laser-welded samples. Membrane leak pressure was greatest for the tissue sealant group. The suture group demonstrated a higher leak pressure than the laser-welded group. CONCLUSIONS: Human fetal membranes were not suited for repair with laser welding under the conditions tested. A new tissue sealant, SynthaSeal, may provide a simple, effective method for membrane closure following fetoscopy, amniocentesis, and open fetal surgery.