User-centered design of quality of life reports for clinical care of patients with prostate cancer.

BACKGROUND: Primary treatment of localized prostate cancer can result in bothersome urinary, sexual, and bowel symptoms. Yet clinical application of health-related quality-of-life (HRQOL) questionnaires is rare. We employed user-centered design to develop graphic dashboards of questionnaire responses from patients with prostate cancer to facilitate clinical integration of HRQOL measurement. METHODS: We interviewed 50 prostate cancer patients and 50 providers, assessed literacy with validated instruments (Rapid Estimate of Adult Literacy in Medicine short form, Subjective Numeracy Scale, Graphical Literacy Scale), and presented participants with prototype dashboards that display prostate cancer-specific HRQOL with graphic elements derived from patient focus groups. We assessed dashboard comprehension and preferences in table, bar, line, and pictograph formats with patient scores contextualized with HRQOL scores of similar patients serving as a comparison group. RESULTS: Health literacy (mean score, 6.8/7) and numeracy (mean score, 4.5/6) of patient participants was high. Patients favored the bar chart (mean rank, 1.8 [P = .12] vs line graph [P < .01] vs table and pictograph); providers demonstrated similar preference for table, bar, and line formats (ranked first by 30%, 34%, and 34% of providers, respectively). Providers expressed unsolicited concerns over presentation of comparison group scores (n = 19; 38%) and impact on clinic efficiency (n = 16; 32%). CONCLUSION: Based on preferences of prostate cancer patients and providers, we developed the design concept of a dynamic HRQOL dashboard that permits a base patient-centered report in bar chart format that can be toggled to other formats and include error bars that frame comparison group scores. Inclusion of lower literacy patients may yield different preferences.

Cutaneous corpuscular receptors of the human glans clitoris: descriptive characteristics and comparison with the glans penis.

INTRODUCTION: The female genital sensory pathways that initiate sexual arousal reflexes begin with cutaneous corpuscular receptors in the glabrous genital skin, including those of the glans clitoris. AIM: The aim of this study is to characterize the corpuscular receptors of the glans clitoris. In addition, we compared basic features with the receptors of the glans penis. MAIN OUTCOME MEASURE: Number of stained receptors. METHODS: Five cadaveric vulvectomy specimens and four cadaveric penile specimens were used. They were serially sectioned and stained with hematoxylin and eosin. Selected blocks were stained with Masson's trichrome, and immunohistochemical staining was done with neuronal markers S-100 and neurofilament. RESULTS: Using the three stains, we identified an abundance of corpuscular receptors within the glans clitoris, as compared with the surrounding prepuce. These receptors were of varied arrangements, situated in the subepithelial tissues of the glans clitoris. They were indistinguishable from the receptors of the glans penis. The number of receptors per 100× high-powered field ranged from 1 to 14, whereas the receptor density in the glans penis ranged from 1 to 3. A second type of receptor, the Pacinian corpuscle, was identified within the suspensory ligament along the trunks of the dorsal nerve but not within the glans itself. CONCLUSIONS: The glans clitoris is densely innervated with cutaneous corpuscular receptors, and these receptors are morphologically similar to the corpuscular receptors of the glans penis. The glans clitoris has greater variability in receptor density compared with the glans penis.

Reoperation after sacral neuromodulation therapy: a single-institution experience.

OBJECTIVES: Sacral neuromodulation has become an accepted treatment for various types of lower urinary tract dysfunction. However, despite technologic advances in device implantation and a trial stimulation period, sacral neuromodulation still has a significant reoperation rate. We report our single-institution experience of reoperation rates. METHODS: We performed a retrospective review of our patients who had undergone the implantation of the InterStim device from April 1999 to December 2011 for lower urinary tract dysfunction. RESULTS: A total of 155 InterStim devices were implanted by 2 surgeons. Of the 142 patients with complete follow-up, 55 (38.2%) patients required reoperation, for either revision or explantation of the device. Revisions were performed in 30 (21.1%) patients, most commonly for mechanical failure of device, battery end-of-service, and pain, either at the site of the implanted pulse generator or with stimulation. Of the 30 patients who underwent revision, 14 had successful results, 6 had persistent symptoms, and 10 progressed to eventual explantation.The overall explantation rate was 24.6% (35 of 142 patients), and the average time to removal was 44 months. Most of the explantations were performed for poor symptom control and failure to maintain response (74.3%).Reoperation was not associated with age, sex, obesity, diabetes, chronic pain, use of the tined lead, or type of lower urinary tract dysfunction. CONCLUSIONS: Sacral neuromodulation has a substantial revision and explantation rate, without any clear predictors for these complications. Patients should be counseled to these complications before surgery.

Long-term NSAID use and incident urothelial cell carcinoma in the VITamins and Lifestyle (VITAL) study.

PURPOSE: Literature on the chemopreventive role of nonsteroidal anti-inflammatory drugs (NSAIDs) in urothelial carcinoma of the bladder (UC) is conflicting. A recent pooled analysis of 3 cohorts reported regular use of nonaspirin NSAIDs was associated with reduced risk of urothelial carcinoma (UC) among nonsmokers only; however, nonsmokers are a group with a low risk of UC. We examine the association between NSAID use and UC risk. MATERIALS AND METHODS: Study participants were members of the VITamins and Lifestyle (VITAL) cohort of 77,048 Washington State residents aged 50-76 years who completed a baseline questionnaire in 2000-2002 on NSAID use and cancer risk factors. Ten-year use of aspirin and other NSAIDs was categorized as none, low-use (1-3 d/wk or <4 years), or high-use (≥ 4 d/wk and ≥ 4 years). Incident UC cases were prospectively identified via linkage to a local cancer registry. Hazard ratios (HR) were estimated by multivariate Cox regression. RESULTS: A total of 385 incident cases of UC were diagnosed over a mean follow-up of 7 years. There was no association with NSAID use and risk of UC. However, the association of use of nonaspirin NSAIDs with UC risk differed by smoking status (P for interaction = 0.02). Specifically, among long-term former smokers (quit ≥ 10 years), nonaspirin NSAID use was associated with a 31% reduction in risk of UC in low-users (HR 0.69, 95% CI 0.46-1.04), and 48% reduction in risk for high-users (HR 0.52, 95% CI 0.24-1.11, P for trend = 0.02). CONCLUSIONS: Our results show a risk reduction with nonaspirin NSAID use among long-term quitters, a group with significant risk of UC.

The pars intermedia: an anatomic basis for a coordinated vascular response to female genital arousal.

INTRODUCTION: The pars intermedia is an area of the vulva that has been inconsistently described in the literature. AIM: We conducted anatomic studies to better describe the tissues and vascular structures of the pars intermedia and proposed a functional rationale of the pars intermedia in the female sexual response. METHODS: Nine cadaveric vulvectomy specimens were used. Each was serially sectioned and stained with hematoxylin and eosin and Masson's trichrome. MAIN OUTCOME MEASURES: Histologic ultrastructural description of the pars intermedia. RESULTS: The pars intermedia contains veins traveling longitudinally in the angle of the clitoris, supported by collagen-rich stromal tissues. These veins drain the different vascular compartments of the vulva, including the clitoris, the bulbs, and labia minora; also, the interconnecting veins link the different vascular compartments. The pars intermedia is not composed of erectile tissue, distinguishing it from the erectile tissues of the corpora cavernosa of the clitoris as well as the corpus spongiosum of the clitoral (vestibular) bulbs. CONCLUSIONS: The venous communications of the pars intermedia, linking the erectile tissues with the other vascular compartments of the vulva, appear to provide the anatomic basis for a coordinated vascular response during female sexual arousal.

Health-related quality of life after cystectomy and urinary diversion for bladder cancer.

With multiple options for urinary diversion after radical cystectomy for bladder cancer that have comparable cancer control and complication rates, health-related quality of life (HRQOL) has become an important consideration. This article reviews the methods for defining HRQOL, the challenges in measuring HRQOL in bladder cancer, and the literature comparing HRQOL after various methods of urinary diversion. Recent contributions include the validation of HRQOL instruments specific to bladder cancer and the publication of several prospective studies measuring HRQOL outcomes after cystectomy and urinary diversion. There is no convincing evidence from existing literature that any particular method of urinary diversion offers superior HRQOL outcomes. Rather, there is growing evidence that good HRQOL can be achieved with patient education and consideration of each patient's clinical and psychosocial situation. Future research should utilize the validated bladder cancer specific HRQOL instruments and perhaps explore the impact of preoperative counseling on postoperative HRQOL.