The Impact of Single-Use Cystoscopes on Clinical Time Workflow in an Outpatient Setting.

OBJECTIVE: To evaluate the change in overall clinical encounter time and clinical capacity after transitioning to single-use cystoscopes (Ambu A/S, Ballerup, Denmark) in an outpatient urology setting. METHODS: A single-institution prospective study in an outpatient urology procedure clinic was performed. Discrete categories for each portion of nursing care responsibilities were defined, and time spent during each category was recorded. Two separate clinic days were observed and analyzed: one where the clinic exclusively used reusable cystoscopes and the other after the transition to single-use cystoscopes occurred. Additionally, clinic schedules were reviewed from all procedure clinics in the 3-month periods before and after the transition to single-use cystoscopes. Outcomes included overall clinical encounter time and the number of procedures per clinic day. RESULTS: There were 12 flexible cystoscopies performed during each of the observed clinic days. Preliminary cystoscope cleaning and transportation tasks by nursing staff were eliminated when utilizing single-use cystoscopes. Average total encounter time decreased from 66 to 44 minutes, resulting in a 34% reduction in clinical encounter time. The median number of flexible cystoscopy procedures increased after the transition from 9 (IQR 7-12) to 16 (IQR 11-17), representing a 78% increase (P = .003). CONCLUSION: Transition to a completely single-use cystoscopy outpatient procedure clinic improved clinical efficiency and facilitated an increased number of procedures per clinic day.

Exploring optimal settings for safe and effective thulium fibre laser lithotripsy in a kidney model.

OBJECTIVES: To explore the optimal laser settings and treatment strategies for thulium fibre laser (TFL) lithotripsy, namely, those with the highest treatment efficiency, lowest thermal injury risk, and shortest procedure time. MATERIALS AND METHODS: An in vitro kidney model was used to assess the efficacy of TFL lithotripsy in the upper calyx. Stone ablation experiments were performed on BegoStone phantoms at different combinations of pulse energy (EP ) and frequency (F) to determine the optimal settings. Temperature changes and thermal injury risks were monitored using embedded thermocouples. Experiments were also performed on calcium oxalate monohydrate (COM) stones to validate the optimal settings. RESULTS: High EP /low F settings demonstrated superior treatment efficiency compared to low EP /high F settings using the same power. Specifically, 0.8 J/12 Hz was the optimal setting, resulting in a twofold increase in treatment efficiency, a 39% reduction in energy expenditure per unit of ablated stone mass, a 35% reduction in residual fragments, and a 36% reduction in total procedure time compared to the 0.2 J/50 Hz setting for COM stones. Thermal injury risk assessment indicated that 10 W power settings with high EP /low F combinations remained below the threshold for tissue injury, while higher power settings (>10 W) consistently exceeded the safety threshold. CONCLUSIONS: Our findings suggest that high EP /low F settings, such as 0.8 J/12 Hz, are optimal for TFL lithotripsy in the treatment of COM stones. These settings demonstrated significantly improved treatment efficiency with reduced residual fragments compared to conventional settings while keeping the thermal dose below the injury threshold. This study highlights the importance of using the high EP /low F combination with low power settings, which maximizes treatment efficiency and minimizes potential thermal injury. Further studies are warranted to determine the optimal settings for TFL for treating kidney stones with different compositions.

Use of Low-Dose Computed Tomography in Children With Nephrolithiasis: An Analysis From 2 Tertiary Pediatric Centers.

INTRODUCTION: Although ultrasound (US) is the preferred first-line imaging for pediatric nephrolithiasis, CT may be necessary in cases of a nondiagnostic US or when US in not available. Utilization of dose reduction strategies in children undergoing CT for nephrolithiasis is not well described. We compared use of low-dose CT (LDCT) in children presenting to 2 pediatric centers. METHODS: We performed a retrospective chart review of children ≤ 17 years of age presenting with suspected nephrolithiasis to 2 tertiary children's hospitals, inclusive of those referred to these centers from nonpediatric facilities between 2013 and 2019. Children were included with an index CT scan from either the pediatric or referring center while those who had prior documented CT for nephrolithiasis within the study period or missing radiation dose assessment were excluded. The primary outcome was LDCT as defined as radiation dose < 3 mGy. The primary comparator was pediatric vs outside referral center. Exploratory analysis evaluated other factors associated with LDCT, including radiation dosage as a continuous variable. RESULTS: A total of 155 individuals met inclusion criteria, with 126 (81.3%) receiving standard dose and 29 (18.7%) receiving LDCT. Pediatric facilities were more likely to utilize LDCT as compared to referral centers (P < .05). Older age and higher BMI were also found to be associated with increased radiation dose exposure. CONCLUSIONS: Pediatric facilities utilized LDCT more frequently, although age and BMI may also influence imaging choices. An understanding of the factors associated with dose reduction in CT will impact future efforts to explore optimum imaging stewardship in pediatric nephrolithiasis.

In vitro investigation of stone ablation efficiency, char formation, spark generation, and damage mechanism produced by thulium fiber laser.

To investigate stone ablation characteristics of thulium fiber laser (TFL), BegoStone phantoms were spot-treated in water at various fiber tip-to-stone standoff distances (SDs, 0.5 ~ 2 mm) over a broad range of pulse energy (Ep, 0.2 ~ 2 J), frequency (F, 5 ~ 150 Hz), and power (P, 10 ~ 30 W) settings. In general, the ablation speed (mm3/s) in BegoStone decreased with SD and increased with Ep, reaching a peak around 0.8 ~ 1.0 J. Additional experiments with calcium phosphate (CaP), uric acid (UA), and calcium oxalate monohydrate (COM) stones were conducted under two distinctly different settings: 0.2 J/100 Hz and 0.8 J/12 Hz. The concomitant bubble dynamics, spark generation and pressure transients were analyzed. Higher ablation speeds were consistently produced at 0.8 J/12 Hz than at 0.2 J/100 Hz, with CaP stones most difficult yet COM and UA stones easier to ablate. Charring was mostly observed in CaP stones at 0.2 J/100 Hz, accompanied by strong spark-generation, explosive combustion, and diminished pressure transients, but not at 0.8 J/12 Hz. By treating stones in parallel fiber orientation and leveraging the proximity effect of a ureteroscope, the contribution of bubble collapse to stone ablation was found to be substantial (16% ~ 59%) at 0.8 J/12 Hz, but not at 0.2 J/100 Hz. Overall, TFL ablation efficiency is significantly better at high Ep/low F setting, attributable to increased cavitation damage with less char formation.

In Pursuit of the Optimal Dusting Settings with the Thulium Fiber Laser: An In Vitro Assessment.

Objective: Low energy and high frequency settings are used in stone dusting for holmium lasers. Such settings may not be optimal for thulium fiber laser (TFL). With the seemingly endless combination of settings, we aim to provide guidance to the practicing urologists and assess the efficiency of the TFL platform in an automated in vitro "dusting model." Materials/Methods: Three experimental setups were designed to investigate stone dusting produced by an IPG Photonics TLR-50 W TFL system using 200 µm fiber and soft BegoStone phantoms. The most popular 10 and 20 W dusting settings among endourologist familiar with TFL were evaluated. We directly compared short pulse (SP) vs long pulse (LP) mode using various combinations of pulse energy (Ep) and pulse frequency (F). Thereafter, we tested the 10 and 20 W settings and compared them among each other to elucidate the most efficient settings at each power. Treatments were performed under the same total laser energy delivered to the stone at four different standoff distances (SDs) with a clinically relevant scanning speed of either 1 or 2 mm/sec. Ablation volumes were quantified by optical coherence tomography to assess stone dusting efficiency. Fragment size after ablation at different pulse energies was evaluated by sieving and evaluating under a microscope after treatment. Results: Overall, SP provided greater ablation volume when compared with LP. Our dusting efficiency model demonstrated that the maximum stone ablation was achieved at the combination of high energy/low frequency settings (p < 0.005) and at a SD of 0.2 mm. At all tested pulse energies, no stone phantoms were broken into fragments >1 mm. Conclusions: During stone dusting with TFL, SP offers superior ablation to LP settings. Optimal dusting at clinically relevant scanning speeds of 1 and 2 mm/sec occurs at high energy/low frequency settings. Thulium lithotripsy with high Ep does not result in increased fragment size.

Impact of Acetazolamide on Perioperative Pain Control in Robotic Assisted Laparoscopic Prostatectomy.

OBJECTIVE: To evaluate the efficacy of peri-operative acetazolamide for pain control in robotic assisted laparoscopic prostatectomy (RALP). Prior studies have demonstrated that preoperative acetazolamide decreased postoperative referred pain in the postsurgical period for laparoscopic procedures. The proposed mechanism is acetazolamide mediated inhibition of carbonic anhydrase, thereby preventing formation of carbonic acid and subsequent peritoneal acidosis with referred pain. This has yet to be demonstrated in the setting of RALP. METHODS AND MATERIALS: Patients undergoing RALP were randomized to receive either preoperative saline or acetazolamide prior to the procedure. Overall pain scores were recorded at multiple time points post operatively, as well as total morphine equivalents administered for adjunctive pain control. RESULTS: Thirty-one patients were included in the study: 16 patients (51.6%) received perioperative acetazolamide, and 15 patients (48.4%) received perioperative saline as placebo. Overall pain scores were similar for patients receiving acetazolamide compared to placebo at various time points: first responsive (3.5 ± 3.1 vs 4.1 ± 1.7, P = .28), immediately prior to leaving PACU (2.8 ± 2.9 vs 2.9 ± 2.9, P = .48), at 4 hours post-procedure (3.1 ± 3.0 vs 2.9 ± 1.8, P = .362), or at 24 hours post-procedure (2.3 ± 1.7 vs 2.2 ± 1.6, P = .5). Shoulder tip pain was not present in either cohort. No statistically significant difference was observed for total morphine equivalents delivered between acetazolamide and placebo (17.3 vs 20.5, P= .2, respectively). CONCLUSION: Acetazolamide does not appear to impact overall pain or shoulder tip pain in the observed cohort of patients undergoing RALP.

An Introduction to Cystoscopy for OB/GYN Residents.

INTRODUCTION: OB/GYN residents' preparedness to perform cystoscopy after residency may vary as the ACGME requires only 10 cystoscopic cases to be performed during training. Given residents' potentially limited exposure to cystoscopy, supplemental educational activities centered around increasing familiarity with the procedure may be useful. The objective of this workshop was to provide an opportunity for OB/GYN residents to become more comfortable with cystoscopic equipment and performing cystoscopy. METHODS: We showed a video of common pathology seen on cystoscopy and then progressed through two hands-on stations. One station focused on equipment familiarity, with learners identifying equipment and then practicing assembling and disassembling the cystoscope. The other station allowed for simulated cystoscopy utilizing a pig bladder. We used a checklist assessment and pre- and postcourse surveys to evaluate familiarity with equipment and anxiety surrounding performing cystoscopy. RESULTS: Twenty residents ranging from PGY 1s to PGY 4s who participated in this workshop over the past 2 years completed both pre- and postcourse evaluations. There was statistically significant improvement in ratings of familiarity with equipment and anxiety surrounding the procedure. All participants whom we assessed showed improvement in identifying and assembling equipment as well as in performing the steps of the procedure independently. DISCUSSION: This workshop provided OB/GYN residents with an opportunity for hands-on cystoscopic experience. Through direct assessment and evaluation forms, the workshop was shown to be a beneficial activity for improving cystoscopic knowledge.

Risk factors for subsequent stone events in pediatric nephrolithiasis: A multi-institutional analysis.

INTRODUCTION: Children with nephrolithiasis have a 50% risk of recurrence 3 years following an index urinary stone event. The American Urological Association guidelines for medical management of nephrolithiasis suggest metabolic evaluations be stratified according to risk of future stone events. However, no such risk stratification exists across the pediatric population with urinary stone disease. We aim to assess the risk factors among pediatric patients for a subsequent stone event (SSE). MATERIALS AND METHODS: A retrospective review for children <17 years of age with a diagnosis of nephrolithiasis and at least one completed follow-up at two tertiary-care children's hospitals within our state between 2012 and 2017 was performed. Children with known monogenic stone disease were excluded as well as those with follow-up less than 1 year. SSEs following initial diagnosis and treatment for nephrolithiasis were defined as follows: subsequent surgical intervention, new stone on imaging, reported stone passage, or ED evaluation for renal colic. Clinical and demographic factors were compared between patients with and without SSEs and analyzed using univariate and multivariate analyses via Cox proportional hazard models. Survival curves for significant associations for SSEs were generated and evaluated using Log-Rank and Wilcoxon comparisons. RESULTS: A total of 200 patients with median clinical follow-up of 2.9 years were analyzed. Median age was 11.5 years (IQR: 6.0-15.5), with 109 (54.5%) males and 91 (45.5%) females, 94 (47%) of whom had a relevant comorbidity. An SSE occurred in 82 patients (41.0%). Age >12 (HR 2.21, 95%CI 1.42-3.45), reported stone event prior to enrollment encounter (i.e. personal history of nephrolithiasis) (HR 1.82, 95%CI 1.14-2.89), and family history of nephrolithiasis (HR 1.62, 95%CI 1.05-2.51) were associated with SSE on univariate analysis while age >12 (HR 2.09, 95%CI 1.33-3.27) and personal history of nephrolithiasis (HR 1.63, 1.02-2.6) retained significance on multivariable analysis. Survival analysis shows increased risk of recurrence with accumulation of risk factors (Summary Figure). Sensitivity analysis accounting for missing family history data retained significance for all three variables. CONCLUSIONS: Adolescent age and a personal history of nephrolithiasis are independent risk factors for SSE in children. Understanding these risk factors and the nature of SSE among the pediatric population can potentially enhance counseling for further metabolic work-up and tailored clinical follow-up.

Socioeconomic Disparities and Risk Factors in Patients Presenting With Ischemic Priapism: A Multi-Institutional Study.

OBJECTIVES: To evaluate contemporary clinical presentations of priapism, their association with socioeconomic characteristics, and the role of prescribing providers in priapism episodes in a large cohort of patients managed at 3 major academic health systems. METHODS: We identified all consecutive patients presenting with ischemic priapism to the emergency departments of three major academic health systems (2014 -2019). Demographic characteristics, priapism etiologies, and clinical management were evaluated. Univariable and multivariable analyses were used to assess the contribution of socioeconomic characteristics and the role of prescribing providers in priapism episodes. RESULTS: We identified 102 individuals with a total of 181 priapism encounters. Hispanic race, lower income quartile, sickle-cell disease, and illicit drug use were associated with increased risk of recurrent episodes. Of ICI users, 57% received their prescriptions from non-urological medical professionals (NUMPs); the proportion with recurrent episodes was higher for NUMPs compared to urologists (24% vs 0%, P = 0.06) with no demographic differences identified between patients treated by either group. CONCLUSION: Socioeconomic disparities exist among patients presenting with recurrent episodes of priapism, potentially highlighting systemic issues with access to care and patient education. With most patients who developed ischemic priapism from ICI being prescribed these medications by NUMPs, further investigation is required to elucidate the prescribing and counseling patterns of these providers. Increased awareness of disparities and complications may improve patient safety.

The prognostic value of digital rectal exam for the existence of advanced pathologic features after prostatectomy.

BACKGROUND: Accurate staging at the time of prostate cancer diagnosis is fundamental to risk stratification and management counseling. Digital rectal exam (DRE) is foundational in clinical staging of prostate cancer, even with a known limited interexaminer agreement and poor sensitivity for detecting extraprostatic disease. We sought to evaluate the prognostic value of DRE for the presence of advanced pathologic features (APFs) following radical prostatectomy (RP). METHODS: All patients undergoing RP as primary treatment for clinically localized prostate cancer in the National Cancer Database between 2008 and 2014 were identified. Patients with additional malignancies, prior treatment with radiation or systemic therapy, incongruent clinical staging and DRE findings or without fully evaluable clinical staging were excluded. The primary outcome was the presence of postsurgical APFs, defined as positive surgical margins, nodal disease, or pathologic stage T3 or greater. Multivariable logistic regression analysis was performed to account for prostate-specific antigen (PSA), biopsy grade group, percent of positive biopsy cores, and clinical stage. RESULTS: In total, 91,525 patients consisting of 69,182 cT1, 20,641 cT2, and 1702 cT3-T4 were included. The average age was 61.1 ± 7.0 years, and the average PSA was 8.6 ± 10.3 ng/ml. On multivariable analysis, cT3 and T4 were associated with the presence of APFs (odds ratio [OR] 11.12, p < .01 and 5.28, p = .04), however, cT2 was only slightly associated with the presence of APFs when compared with cT1 (OR 1.15, p < .01). Furthermore, cT2 was associated with more node-positive disease (OR 1.63, p < .01), positive margins (OR 1.06, p < .01), and more than or equal to pT3 disease (OR 1.22, p < .01). CONCLUSIONS: Overall, advanced clinical stage as assessed by DRE was independently associated with an increasing risk of APFs. For individual APFs, the greatest effect is noticed between clinical stage and nodal positivity and less so between clinical stage and positive margins. DRE continues to hold value, particularly for patients with locally advanced disease and potential lymph node disease.

Is Opioid-free Post-Vasectomy Analgesia a Pain? A Single Surgeon Experience.

OBJECTIVE: To determine the impact of transitioning from opioid to non-opioid analgesia post-vasectomy on unplanned opioid prescriptions and health encounters. METHODS: A retrospective review for patients who underwent vasectomy from October 2018 through December 2019 was performed. Beginning February 1st, 2019, patients were counseled to take scheduled acetaminophen and ibuprofen in lieu of acetaminophen with codeine, with an opioid prescription only provided upon request. Analysis was performed comparing 200 consecutive patients before and after this transition. Baseline patient characteristics, unplanned postoperative encounters for pain within 30 days of vasectomy, and associated narcotic prescriptions were compared between groups. RESULTS: 400 patients were included, consisting of 200 patients pre and 200 patients postintervention. There were no differences in socioeconomic characteristics between groups. No differences between the pre- and postintervention groups were observed in terms of generating telephone calls to clinic (9% vs 11%, P = .5), clinic visits (2.5% vs 2.5%, P = 1), or ED visits (0% vs 1%), P = .5) for the pre and postintervention cohorts, respectively. CONCLUSIONS: Patients that are not prescribed opioids after vasectomy do not generate additional phone calls, clinic, or ED visits compared to those that were routinely prescribed prior to our institutional change. We have permanently discontinued the routine use of opioids for post-vasectomy analgesia. Other physicians performing vasectomy should consider making this change as well.

Pain management following robotic-assisted radical prostatectomy: transitioning to an opioid free regimen.

Few studies demonstrate the safety and efficacy of postoperative pain regimens that exclude opioids altogether in patients undergoing robot-assisted radical prostatectomy (RARP). To reduce opioid use, we sought to develop an opioid-free regimen for RARP and determine perioperative outcomes before and after implementation. A retrospective, pre-post-interventional study was performed at a single institution between 8/2018 and 10/2019. An opioid-free pain regimen was developed and instituted on 3/7/2019, and all patients received preoperative counseling regarding pain expectations and management. Postoperative pain score was the primary outcome. Secondary outcomes included postoperative opioid use, length of stay, adverse events and unplanned health encounters within 30 days of discharge. Pearson's chi-squared and Student's t-tests were performed on categorical and continuous variables, respectively. Multivariable analysis was performed to determine risk factors for postoperative opioid use in the opioid-free cohort. A total of 89 patients were included for analysis; consisting of 47 (53%) pre-intervention and 42 (47%) post-intervention patients. Baseline characteristics were similar between groups. A significantly lower proportion of patients in the post-intervention group were administered opioids postoperatively (5% vs 53%, p < 0.01), despite having similar postoperative pain scores (2.69 vs 3.11, p = 0.19) and length of stay (1.0 days vs 1.2 days, p = 0.07). The post-intervention group had a significantly lower rate of opioid discharge prescriptions (14% vs 96%, p < 0.01). The rate of ED visits (12% vs 15%, p = 0.68), pain-related phone calls (17% vs 19%, p = 0.76) or adverse events (19% vs 13%, p = 0.42) were similar between groups. Among the opioid-free group, older patients were less likely to be administered postoperative opioids (OR 0.84, p = 0.046). A structured opioid-free pain regimen following RARP is non-inferior compared to traditional opioid-based standard of care. Adoption of similar regimens can help address the ongoing opioid epidemic in the United States and future work is needed to apply these principles broadly.

Factors Influencing Patient Selection of Urologists.

OBJECTIVE: To describe the factors affecting patients' selection of a urologist, and the utilization of the Internet and social media. MATERIALS AND METHODS: All new patients presenting to a single-institution for evaluation were invited to complete an anonymous 26-item questionnaire between April 2018 and October 2018, including demographic information, use of Internet and social media resources, and relative importance of factors when selecting a urologist. Descriptive statistics were reported, and a stratified analysis was performed for age, gender, and education. RESULTS: A total of 238 patients responded. More than half (53%) of patients searched their medical condition prior to presentation. When stratified by age, younger patients were 3 times as likely to utilize Internet resources (Group 1 vs Group 2; OR 3.3, 95%CI 1.5-7.2, P <.01). Few patients utilized Facebook (7%) or Twitter (1%). The 3 most important surveyed urologist selection factors included hospital reputation (4.3 ± 1.0), in-network providers (4.0 ± 1.3), and appointment availability (3.9 ± 1.0). The 3 least important included medical school attended (2.7 ± 1.3), urologist on social media (1.9 ± 1.2), and TV, radio, and/or billboard advertisements (1.7 ± 1.3). CONCLUSION: This study suggests a significant proportion of patients search the Internet regarding their medical condition prior to presenting to clinic. Further, younger patients utilize this methodology significantly more than the senior population. Important factors when selecting a urologist may be driven by a hospital's reputation, in addition to scheduling convenience.

Depth of Muscularis Propria Invasion Does Not Prognosticate Survival in T2 Esophageal Adenocarcinoma.

AIM: Although tumor depth of invasion is strongly associated with risk of lymph node metastasis and long-term survival in patients with esophageal adenocarcinoma, the significance of differential T2 invasion (inner circular layer versus outer longitudinal layer) is unknown. The current study was undertaken to explore the hypothesis that greater T2-specific depth of invasion is associated with inferior long-term outcomes in patients with esophageal adenocarcinoma treated with esophagectomy. PATIENTS AND METHODS: Demographic, treatment, and outcome data were collected for patients with resected pT2N0-3M0 esophageal adenocarcinoma treated between 2005 and 2015 pooled from four U.S. academic medical centers. Two blinded pathologists evaluated depth of muscularis propria tumor invasion. Univariate and Cox proportional hazard regression analyses were performed to identify prognostic factors for overall (OS) and disease-free (DFS) survival, and Kaplan-Meier analysis to compare survival differences specific to prognostic factors. RESULTS: A total of 84 patients were identified for analysis (53 with circular invasion; 31 with longitudinal invasion), with a median age of 66 years. Sixty percent of patients (50/84) received induction therapy prior to esophagectomy. The median OS and DFS was 58 months (95% confidence interval(CI)=42 months-not reached) and 27 months (95% CI=13.7-66 months) respectively. Depth of muscularis propria invasion did not correlate with OS or DFS on univariate (p=0.42; and p=0.34, respectively) or multivariate (p=0.15 and p=0.21, respectively) analysis after adjustment for age, nodal status, perineural invasion, and tumor grade. These findings did not vary by induction therapy status. CONCLUSION: Depth of muscularis propria invasion does not appear to correlate with survival in patients with esophageal adenocarcinoma.

An Atypical Presentation of Retroperitoneal Fibrosis.

A 69-year-old man with a psoriatic arthritis treated with infliximab for 1 month presented to the urology clinic for lower urinary tract symptoms. He was found to have a new diagnosis of elevated creatinine. Computed tomography of the abdomen and pelvis revealed bilateral severe hydronephrosis with abnormal soft tissue thickening of the right renal pelvis and proximal ureter. Bilateral stents were placed after ureteroscopy demonstrated no abnormalities. A computed tomography-guided biopsy of the peri-ureteral lesions revealed fibroadipose tissue with sclerosis and extensive chronic inflammation consistent with retroperitoneal fibrosis. Infliximab was discontinued and the patient was started on corticosteroids. Follow-up magnetic resonance imaging of the abdomen and pelvis at 2 months revealed total resolution of soft tissue and inflammation along the proximal ureter bilaterally. Repeat imaging demonstrated no hydronephrosis after stents removal, and the patient's creatinine remains normal at 12 months follow-up.

Physical Activity in an Underserved Population: Identifying Technology Preferences.

BACKGROUND: This study aims to identify patterns of use and preferences related to technology platforms that could support physical activity (PA) programs in an underserved population. METHODS: A 29-item questionnaire was administered at 5 health and wellness sites targeting low income communities in Chicago. Frequency tables were generated for Internet, cell phone, and social media use and preferences. Chi-squared analysis was used to evaluate differences across age and income groups. RESULTS: A total of 291 individuals participated and were predominantly female (69.0%). Majority reported incomes less than $30,000 (72.9%) and identified as African American/Black/Caribbean (49.3%) or Mexican/Mexican American (34.3%). Most participants regularly used smartphones (63.2%) and the Internet (75.9%). Respondents frequently used Facebook (84.8%), and less commonly used Instagram (43.6%), and Twitter (20.0%). Free Internet-based exercise programs were the most preferred method to increase PA levels (31.6%), while some respondents (21.0%) thought none of the surveyed technology applications would help. CONCLUSION: Cell phone, Internet, and social media use is common among the surveyed underserved population. Technology preferences to increase PA levels varied, with a considerable number of respondents not preferring the surveyed technology platforms. Creating educational opportunities to increase awareness may maximize the effectiveness of technology-based PA interventions.

Metformin exposure is associated with improved progression-free survival in diabetic patients after resection for early-stage non-small cell lung cancer.

OBJECTIVE: There are little clinical data assessing the antineoplastic effect of metformin in patients with non-small cell lung cancer. We hypothesized that in diabetic patients undergoing pulmonary resection for early-stage non-small cell lung cancer, metformin exposure is associated with improved survival. METHODS: An institutional database was used to identify patients with stage I or II non-small cell lung cancer who underwent pulmonary resection between 2004 and 2013. Patients were divided into 3 cohorts: type II diabetic patients with metformin exposure (cohort A, n = 81), type II diabetic patients without metformin exposure (cohort B, n = 57), and nondiabetic individuals (cohort C, n = 77). Univariate, multivariate, and propensity-matched analyses were performed to assess progression-free and overall survivals between groups. RESULTS: A total of 215 patients with stage I and II non-small cell lung cancer treated with surgical resection were identified for analysis with a median follow-up of 19.5 months. Patients in cohort A had lower T- and N-stage tumors than those in cohorts B or C. However, on multivariate analysis adjusting for age, gender, and T and N stage, progression-free survival was greater for cohort A than cohort B (hazard ratio [HR], 0.410; 95% confidence interval, 0.199-0.874; P = .022) or cohort C (HR, 0.415; 95% confidence interval, 0.201-0.887; P = .017). Likewise, when propensity-matched analyses were performed, cohort A demonstrated a trend toward improved progression-free survival compared with cohort B (P = .057; HR, 0.44; c-statistic = 0.832) and improved progression-free survival compared with cohort C (P = .02; HR, 0.41; c-statistic = 0.843). No differences were observed in overall survival. CONCLUSIONS: Metformin exposure in diabetic patients with early-stage non-small cell lung cancer may be associated with improved progression-free survival, but no effect was seen on overall survival. Further studies are warranted to evaluate if there is a therapeutic role for metformin in the treatment of non-small cell lung cancer.

Number of Ribs Resected is Associated with Respiratory Complications Following Lobectomy with en bloc Chest Wall Resection.

PURPOSE: Pulmonary lobectomy with en bloc chest wall resection is a common strategy for treating lung cancers invading the chest wall. We hypothesized a direct relationship exists between number of ribs resected and postoperative respiratory complications. METHODS: An institutional database was queried for patients with non-small cell lung cancer that underwent lobectomy with en bloc chest wall resection between 2003 and 2014. Propensity matching was used to identify a cohort of patients who underwent lobectomy via thoracotomy without chest wall resection. Patients were propensity matched on age, gender, smoking history, FEV1, and DLCO. The relationship between number of ribs resected and postoperative respiratory complications (bronchoscopy, re-intubation, pneumonia, or tracheostomy) was examined. RESULTS: Sixty-eight patients (34 chest wall resections; 34 without chest wall resection) were divided into 3 cohorts: cohort A = 0 ribs resected (n = 34), cohort B = 1-3 ribs resected (n = 24), and cohort C = 4-6 ribs resected (n = 10). Patient demographics were similar between cohorts. The 90-day mortality rate was 2.9 % (2/68) and did not vary between cohorts. On multivariate analysis, having 1-3 ribs resected (OR 19.29, 95 % CI (1.33, 280.72); p = 0.03), 4-6 ribs resected [OR 26.66, (1.48, 481.86); p = 0.03), and a lower DLCO (OR 0.91, (0.84, 0.99); p = 0.02) were associated with postoperative respiratory complications. CONCLUSIONS: In patients undergoing lobectomy with en bloc chest wall resection for non-small cell lung cancer, the number of ribs resected is directly associated with incidence of postoperative respiratory complications.