Urologist Use of Cystoscopy for Patients Presenting With Hematuria in the United States.

OBJECTIVE: To evaluate the prevalence of cystoscopy and factors associated with use among hematuria patients presenting to urologists, based on results from a nationally representative survey. METHODS: Using the National Ambulatory Medical Care Survey (2006-2012), we identified outpatient visits to urologists for hematuria, and excluded visits associated with benign diagnoses (eg, urinary tract infection). Our primary outcome was performed or planned cystoscopy. We hypothesized that major risk factors (ie, gross hematuria, tobacco use, age >50, male gender) would be associated with increased cystoscopy use. We used multivariable logistic regression to evaluate the relationship between available patient, provider, and practice setting factors and use of cystoscopy. RESULTS: Among an estimated 10.8 million hematuria visits to urologists, cystoscopy was planned or performed after 34.7% of visits (95% confidence interval [CI] 30.7-39.0). Patients with gross hematuria (adjusted odds ratio 2.17, 95% CI 1.28-3.69) and current tobacco users (adjusted odds ratio 2.48, 95% CI 1.40-4.39) had over twice the odds of undergoing cystoscopy compared to patients without those risk factors. We estimated that there are over 20,000 missed cancer cases annually among moderate- and high-risk hematuria patients, and nearly 230,000 excess cystoscopy cases annually for patients with near-zero cancer risk. CONCLUSION: Despite guidelines emphasizing the importance of cystoscopy in hematuria evaluations, just over one-third of patients diagnosed with hematuria by urologists undergo this procedure. There also appears to be considerable misallocation of cystoscopy for hematuria patients, with excessive use among low-risk patients and significant potential for missed cancer cases among those at higher risk of malignancy.

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.

Patterned neuroprotection in the Inpp4a(wbl) mutant mouse cerebellum correlates with the expression of Eaat4.

The weeble mutant mouse has a frame shift mutation in inositol polyphosphate 4-phosphatase type I (Inpp4a). The phenotype is characterized by an early onset cerebellar ataxia and neurodegeneration, especially apparent in the Purkinje cells. Purkinje cell loss is a common pathological finding in many human and mouse ataxic disorders. Here we show that in the Inpp4a(wbl) mutant, Purkinje cells are lost in a specific temporal and spatial pattern. Loss occurs early in postnatal development; however, prior to the appearance of climbing fibers in the developing molecular layer, the mutant has a normal complement of Purkinje cells and they are properly positioned. Degeneration and reactive gliosis are present at postnatal day 5 and progress rapidly in a defined pattern of patches; however, Inpp4a is expressed uniformly across Purkinje cells. In late stage mutants, patches of surviving Purkinje cells appear remarkably normal with the exception that the climbing fibers have been excessively eliminated. Surviving Purkinje cells express Eaat4, a glutamate transporter that is differentially expressed in subsets of Purkinje cells during development and into adult stages. Prior to Purkinje cell loss, reactive gliosis and dendritic atrophy can be seen in Eaat4 negative stripes. Our data suggest that Purkinje cell loss in the Inpp4a(wbl) mutant is due to glutamate excitotoxicity initiated by the climbing fiber, and that Eaat4 may exert a protective effect.