Patient Satisfaction in a Safety Net Urology Clinic.

INTRODUCTION: Patient satisfaction has become an important metric in medicine. In this study, we aim to identify modifiable factors contributing toward poor satisfaction amongst patients in a safety net urology clinic. We hypothesize that wait times and long distances traveled to clinic will have the largest contribution toward negative patient experiences. METHODS: We conducted a cross-sectional study of adult patients presenting to the urology clinic at Zuckerberg San Francisco General Hospital. Participants completed a survey using the RAND Patient Satisfaction Questionnaire-18 after their clinic visit. Associations among demographic factors, wait times, use of a translator and satisfaction were examined. RESULTS: Two hundred patients, 19 to 90 years old (median age 62), were enrolled. Overall, 65% of patients were satisfied with their experience in our clinic. Our results demonstrated a significant association among race, language and overall satisfaction scores (p=0.009 and p=0.003, respectively). Multivariable analysis showed that those who waited more than an hour to see a physician were less satisfied compared with those who waited less than 15 minutes (OR 0.25, 95% CI 0.08-0.74). Similarly, those who used a translator were less satisfied than those who did not use a translator (OR 0.29, 95% CI 0.08-1.01). CONCLUSIONS: In a safety net urology clinic, language differences and wait times may contribute to poor patient satisfaction. Future efforts toward improving language interpreter functionality and decreasing patient wait times will likely improve patient satisfaction.

Clinical Outcomes of Periprocedural Antithrombotic Therapy in Ischemic Priapism Management.

BACKGROUND: Priapism is a urologic emergency consisting of a painful erection lasting greater than 4 hours; antithrombotic therapy (ATT) have recently been recommended as an adjunct in the treatment of ischemic priapism. AIM: To determine the short- and long-term outcomes of periprocedural ATT in the management of acute ischemic priapism. METHODS: A retrospective review of patients seen at the University of California, San Francisco, from 2008 to 2019 was carried out to identify those evaluated for acute priapism. Information regarding duration of priapism, etiology, treatment, periprocedural and postprocedural ATT type and dose, and follow-up data was collected. OUTCOMES: ATT use was the exposure of interest; outcome variables included priapism resolution, repeat episodes, long-term complications, and follow-up. RESULTS: 70 patients with at least 1 detailed record of an acute priapism episode between 2008 and 2019 were identified. Of the 70 patients who underwent management for an acute episode of priapism, 59 (84%) received intracavernous injection of phenylephrine with or without corporal aspiration. Of the 4 patients who received ATT at the same time as intracavernous injection, none had additional priapism episodes. In the 55 patients who did not receive immediate ATT, 22 (40%) required at least 1 shunting procedure. The 9 patients who received ATT concurrently with shunting experienced less recurrence than the 13 patients who did not receive ATT (11% vs 69%, respectively P = .012). There were no significant differences in long-term erectile dysfunction (P = .627), fibrosis (P = .118), genitourinary pain (P = .474), and urinary issues (P = .158) between those who received ATT and those who did not. CLINICAL IMPLICATIONS: Our findings suggest that ATT has a role in preventing priapism recurrence; we observed that long-term repeat priapism episodes are less frequent in those who received periprocedural ATT compared with those who did not and that ATT may especially reduce recurrence in cases when shunting was required STRENGTHS & LIMITATIONS: This is the first study looking at the clinical outcomes of periprocedural ATT in the management of ischemic priapism. It is limited by the fact that it is a single-center study, types of ATT were heterogenous, and the exact timing of priapism management could not be measured for everyone. CONCLUSION: In spite of its limitations, these preliminary findings are promising and warrant further exploration of the use of ATT in the management of ischemic priapism. Ramstein JJ, Lee A, Cohen AJ, et al. Clinical Outcomes of Periprocedural Antithrombotic Therapy in Ischemic Priapism Management. J Sex Med 2020;17:2260-2266.

The Top 100 Cited Articles in Urethral Reconstruction.

OBJECTIVE: To examine the most cited literature in urethral reconstruction, review types of work published, and observe research trends. METHODS: The Web of Sciences Sci-Expanded Index was used to conduct a search for urethral reconstruction. References were assessed for relevance to urethral reconstruction by 2 independent reviewers and a final list of the top 100 articles ranked by citation count was obtained. For each article, citation count, publication date, corresponding author, origin institution, origin country, topic area, study design, level of evidence, and origin journal were collected. RESULTS: The mean citation count per publication was 108 (median = 94.5; range = 69-366, SD = 43) with a total of 10,874 citations for all papers since 1970. The top 100 articles were published between 1973 and 2011, came from 19 different countries and 16 different journals. Nearly half were case series and most studies were Level III evidence or lower. The United States was the largest contributor to the top 100 with 56 publications, followed by Italy (14), England (12), and Egypt (7). "Outcomes of surgical treatment for urethral stricture disease" was the most prevalent topic area comprising 55 articles in the top 100, with most articles including descriptions or outcomes of novel surgical techniques. CONCLUSION: In this study, we discovered that the most cited literature in the field of urethral reconstruction is singularly focused and lacking in high levels of evidence. The top 100 cited articles originate primarily from the United States, focus on short-term outcomes after surgical treatment for urethral stricture disease, and are predominantly case series.

Non-oncologic Indications for Male Fertility Preservation.

PURPOSE OF REVIEW: To explore non-oncologic indications for male fertility preservation. RECENT FINDINGS: Common scenarios in which male fertility could be irreversibly compromised include autoimmune conditions requiring treatment with cyclophosphamide, gender dysphoria prior to starting hormone therapy, military deployment, and critical illness. Fertility preservation should be considered with particular attention to the timing and logistics specific to each scenario. Recognition and familiarity with such situations will help physicians provide better counseling to patients and their families, improve the quality of decision-making, and ultimately reduce missed opportunities and regret.

Sleep disturbance and symptom burden in sarcoidosis.

INTRODUCTION: Sarcoidosis is a systemic inflammatory disease associated with myriad symptoms, including fatigue. It can affect physiological processes like sleep, leading to poor sleep quality and excessive daytime sleepiness. We hypothesized that sarcoidosis patients would report more severe sleep disturbance than healthy controls and that relationships would be found with sleep disturbance and the severity of other symptoms. METHODS: We enrolled 84 sarcoidosis patients and 30 healthy controls and recorded demographic and clinical characteristics. Self-report measures were used to assess sleep disturbance, psychosocial symptoms, and quality of life at enrollment and longitudinally. Relationships between different self-report outcomes were analyzed using correlation statistics. RESULTS: Using the General Sleep Disturbance Scale, 54% of sarcoidosis patients reported frequent and occasional sleep disturbance compared to only 17% of healthy controls (p < 0.0001). This significant increase in sleep disturbance found in sarcoidosis patients strongly correlated with multiple psychosocial symptoms, including fatigue, depression, and cognitive dysfunction, and negatively impacted quality of life (p < 0.01). Traditional measures of sarcoidosis disease severity or activity were not associated with sleep disturbance. Sleep disturbance scores remained stable at follow-up (mean time between first and last administration of questionnaire was 17.3 months) in 56 of the sarcoidosis patients. CONCLUSIONS: Sarcoidosis patients experienced significant sleep disturbance that correlated with higher levels of fatigue, depression, and cognitive dysfunction, and poorer quality of life. These associations were present regardless of disease severity or activity and result in decrements in quality of life and mental health.

Tyrosine Kinase Inhibitors and Male Reproductive Health.

Tyrosine kinase inhibitors (TKIs) are a targeted class of cancer therapies effective against a range of malignancies and their use is growing significantly each year. Many men taking TKIs desire children, yet very little is known about the potential for reproductive harm of these medications. The mechanism of action of TKIs suggest a possible route to impairment of sperm functional properties or spermatogenesis.

Clinical and Biological Insights from the University of California San Francisco Prospective and Longitudinal Cohort.

INTRODUCTION: Sarcoidosis is a systemic inflammatory disease characterized by non-necrotizing granulomas in involved organs, most commonly the lung. Description of patient characteristics in the Western United States is limited. Furthermore, blood-based measures that relate to clinical sarcoidosis phenotypes are lacking. We present an analysis of a prospective, longitudinal sarcoidosis cohort at a Northern Californian academic medical center. METHODS: We enrolled 126 sarcoidosis subjects and 64 healthy controls and recorded baseline demographic and clinical characteristics. We used regression models to identify factors independently associated with pulmonary physiology. We tested whether blood transcript levels at study entry could relate to longitudinal changes in pulmonary physiology. RESULTS: White, non-Hispanics composed ~70% of subjects. Hispanics and Blacks had a diagnostic biopsy at an age ~7 years younger than whites. Obstructive, but not restrictive, physiology characterized Scadding Stage IV patients. Subjects reporting use of immunosuppression had worse FEV1%p, FVC%p, and DLCO%p compared to subjects never treated, regardless of Scadding stage. We defined sarcoidosis disease activity by a drop in pulmonary function over 36 months and found that subjects meeting this definition had significant repression of blood gene transcripts related to T cell receptor signaling pathways, referred to as the "TCR factor." CONCLUSION: Obstructive pulmonary physiology defined Stage IV patients which were mostly white, non-Hispanics. Genes comprising the composite gene expression score, TCR factor, may represent a blood-derived measure of T-cell activity and an indirect measure of active sarcoidosis inflammation. Validation of this measure could translate into individualized treatment for sarcoidosis patients.

IFN-γ-Producing T-Helper 17.1 Cells Are Increased in Sarcoidosis and Are More Prevalent than T-Helper Type 1 Cells.

RATIONALE: Pulmonary sarcoidosis is classically defined by T-helper (Th) cell type 1 inflammation (e.g., IFN-γ production by CD4(+) effector T cells). Recently, IL-17A-secreting cells have been found in lung lavage, invoking Th17 immunity in sarcoidosis. Studies also identified IL-17A-secreting cells that expressed IFN-γ, but their abundance as a percentage of total CD4(+) cells was either low or undetermined. OBJECTIVES: Based on evidence that Th17 cells can be polarized to Th17.1 cells to produce only IFN-γ, our goal was to determine whether Th17.1 cells are a prominent source of IFN-γ in sarcoidosis. METHODS: We developed a single-cell approach to define and isolate major Th-cell subsets using combinations of chemokine receptors and fluorescence-activated cell sorting. We subsequently confirmed the accuracy of subset enrichment by measuring cytokine production. MEASUREMENTS AND MAIN RESULTS: Discrimination between Th17 and Th17.1 cells revealed very high percentages of Th17.1 cells in lung lavage in sarcoidosis compared with controls in two separate cohorts. No differences in Th17 or Th1 lavage cells were found compared with controls. Lung lavage Th17.1-cell percentages were also higher than Th1-cell percentages, and approximately 60% of Th17.1-enriched cells produced only IFN-γ. CONCLUSIONS: Combined use of surface markers and functional assays to study CD4(+) T cells in sarcoidosis revealed a marked expansion of Th17.1 cells that only produce IFN-γ. These results suggest that Th17.1 cells could be misclassified as Th1 cells and may be the predominant producer of IFN-γ in pulmonary sarcoidosis, challenging the Th1 paradigm of pathogenesis.

Longitudinal analysis of sarcoidosis blood transcriptomic signatures and disease outcomes.

Previously, we demonstrated concordance in differentially expressed genes in sarcoidosis blood and lung, implicating shared dysfunction of specific immune pathways. In the present study, we hypothesised that expression levels of candidate genes in sarcoidosis blood could predict and track with disease outcomes longitudinally. We applied Ingenuity Pathway Analysis to a cross-sectional derivation microarray dataset (n=38) to identify canonical pathways and candidate genes associated with sarcoidosis. In a separate longitudinal sarcoidosis cohort (n=103), we serially measured 48 candidate gene transcripts, and assessed their relation to disease chronicity and severity. In the cross-sectional derivation study, pathway analysis showed upregulation of genes related to interferon signalling and the role of pattern recognition receptors, and downregulation of T-cell receptor (TCR) signalling pathways in sarcoidosis. In the longitudinal cohort, factor analysis confirmed coregulation of genes marking these pathways and identified CXCL9 as an additional candidate pathway. CXCL9 and TCR factors discriminated between chronic versus nonprogressive disease, and CXCL9 predicted disease outcomes longitudinally. Interferon factor was similarly increased in both disease phenotypes. Factors associated with lung function decline included decreased TCR factor and increased CXCL9. These findings demonstrate blood transcriptomic signatures reflecting TCR signalling and CXCL9 predict sarcoidosis chronicity and correlate with disease severity longitudinally.

Interferon-inducible chemokines reflect severity and progression in sarcoidosis.

BACKGROUND: Identification of serum proteins that track with disease course in sarcoidosis may have clinical and pathologic importance. We previously identified up-regulated transcripts for interferon-inducible chemokines CXCL9, and CXCL10, in blood of sarcoidosis patients compared to controls. The objective of this study was to determine whether proteins encoded by these transcripts were elevated in serum and identified patients with remitting vs. chronic progressive sarcoidosis longitudinally. METHODS: Serum levels of CXCL9, CXCL10, and proteins associated with inflammation and/or disease activity (sIL2R, ACE, ESR and CRP) were measured in a prospective cohort of sarcoidosis subjects and controls. Comparisons were made between groups and clinical course using pulmonary function measures and a severity score developed by Wasfi et al. RESULTS: In a cross-sectional analysis of 36 non-immunosuppressed sarcoidosis subjects, serum CXCL9, CXCL10, and sIL2R were significantly elevated compared to 46 controls (p < 0.0001). CXCL9 and CXCL10 were strongly inter-correlated (p = 0.0009). CXCL10 and CXCL9 were inversely correlated with FVC% predicted and DLCO% predicted, respectively. CXCL10 and CXCL9 significantly correlated with sarcoidosis severity score. sIL2R, ESR, CRP, and ACE serum levels did not correlate with pulmonary function measures or severity score. In the longitudinal analysis of 26 subjects, changes in serum CXCL10 level over time corresponded with progression versus remission of disease. CONCLUSIONS: Interferon-γ-inducible chemokines, CXCL9 and CXCL10, are elevated in sarcoidosis and inter-correlated with each other. Chemokine levels correlated with measures of disease severity. Serial measurements of CXCL10 corresponded to clinical course.