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With heightened awareness of health care outcomes and efficiencies and reimbursement-based metrics, it is ever more important that urologists consider the effects of integrated care models on physicians/staff/clinics fulfillment and patient outcomes, and whether and how to optimally implement these models within their unique practice settings. Despite growing evidence that integrating care improves outcomes, uncertainty persists regarding which approach is most efficient and achievable in terms of specialty considerations and financial resources. In this article, we discuss strategies for integrating urologic care and its impact on current and future health care delivery.The emergence of the COVID-19 pandemic and subsequent public health emergency (PHE) have propelled telemedicine several years into the future. With the rapid adoption of this technology came socioeconomic inequities as minority communities disproportionately have yet to adopt telemedicine. Telemedicine offers solutions to patient access issues that have plagued urology, helping address physician shortages in rural areas and expanding the reach of urologists. The Centers for Medicare & Medicaid Services have adopted changes to expand coverage for telemedicine services. The expectation is that telemedicine will continue to be a mainstay in the health care system with gradual expansion in utilization.The nation's undersupply of urology services disproportionately affects Medicare beneficiaries compared to the general population. Advanced Practice Providers (APPs), most commonly nurse practitioners and physician assistants may be a vehicle to meet this need. The increased use of APPs in urology is hampered by physician discomfort with delegating responsibility to APPs. This discomfort may be compounded by complexities with billing issues and interstate variation in scope of practice regulations. To expand access to urological services while simultaneously ensuring service quality, it is imperative that urologists engage with APPs individually and as a specialty.The millennial generation has become the largest generation thus far and continues to grow, as it makes up a substantial part of the workforce. Often misunderstood, those identifying as millennials offer skills, traits, and characteristics that previous generations have been unable to provide. Learning to understand these millennials and all they have to offer serves key to a successful training program or practice. A millennial's understanding of technology, grasp of patient-provider relationships, and desire to work hard contribute to their success as urologists.The presence of women in genitourinary (GU) specialty training and practice has lagged significantly behind other fields. Current challenges include maternity leave, sexual harassment, and pay disparities. Despite these obstacles, the prevalence of women in GU specialty training has risen rapidly. One consequence of retiring male providers and higher numbers of female graduates will be a notable demographic shift in the percentage of GU care provided by these younger women. It will be essential to anticipate and acknowledge the unique concerns of this workforce, particularly in light of the concomitant aging of the US population and the associated increase in demand for GU care.The complexity of health care today along with the drive towards value-based care are strong forces in support of growing and expanding the physician leadership workforce. Physician led organizations are associated with improved physician engagement, quality of care and cost efficiency. Physicians would benefit from more formal leadership training which incorporates a structed leadership curriculum, mentorship and on the job progressive leadership experience. Special attention must be placed on increasing the diversity of our physician leaders. There are many important characteristics to look for in our physician leaders including emotional intelligence, integrity, visioning, humility, persuasion and the ability to listen.Physician burnout is an issue having an impact on all of medicine but having a significant impact on the field of urology. Burnout begins in medical school and worsens in residency. selleck compound Increased workload leads to increased burnout both in residency and in practice. Issues with work-life balance, electronic medical record usage, decreasing reimbursements, and increased Centers for Medicare & Medicaid Services burden all have an impact on physician satisfaction with their practices. Burnout should be acknowledged, and measures for prevention should be taken by hospitals and residency programs to decrease and prevent physician burnout.The future supply of urologists is not on pace to account for future demands of urologic care. This impending urologic shortage sits on a backdrop of multiple other workforce issues. In this review, we take an in-depth look at several pressing issues facing the urologic workforce, including the impending urology shortage, gender and diversity concerns, growing levels of burnout, and the effects of the coronavirus pandemic. In doing so, we highlight specific areas of clinical practice that may need to be addressed from a health care policy standpoint.Psoriasis is a chronic inflammatory skin disease that affects 2% to 3% of the U.S. population. The immune response in psoriasis includes enhanced activation of T cells and myeloid cells, platelet activation, and up-regulation of interferons, tumor necrosis factor-α, and interleukins (ILs) IL-23, IL-17, and IL-6, which are linked to vascular inflammation and atherosclerosis development. Patients with psoriasis are up to 50% more likely to develop cardiovascular disease (CV) disease, and this CV risk increases with skin severity. Major society guidelines now advocate incorporating a psoriasis diagnosis into CV risk prediction and prevention strategies. Although registry data suggest treatment targeting psoriasis skin disease reduces vascular inflammation and coronary plaque burden, and may reduce CV risk, randomized placebo-controlled trials are inconclusive to date. Further studies are required to define traditional CV risk factor goals, the optimal role of lipid-lowering and antiplatelet therapy, and targeted psoriasis therapies on CV risk.
Adults with congenital heart disease (CHD) have been considered potentially high risk for novel coronavirus disease-19 (COVID-19) mortality or other complications.
This study sought to define the impact of COVID-19 in adults with CHD and to identify risk factors associated with adverse outcomes.
Adults (age 18 years or older) with CHD and with confirmed or clinically suspected COVID-19 were included from CHD centers worldwide. Data collection included anatomic diagnosis and subsequent interventions, comorbidities, medications, echocardiographic findings, presenting symptoms, course of illness, and outcomes. Predictors of death or severe infection were determined.
From 58 adult CHD centers, the study included 1,044 infected patients (age 35.1 ± 13.0 years; range 18 to 86 years; 51% women), 87% of whom had laboratory-confirmed coronavirus infection. The cohort included 118 (11%) patients with single ventricle and/or Fontan physiology, 87 (8%) patients with cyanosis, and 73 (7%) patients with pulmonary hypertension. There were 24 COVID-related deaths (case/fatality 2.3%; 95% confidence interval 1.4% to 3.2%). Factors associated with death included male sex, diabetes, cyanosis, pulmonary hypertension, renal insufficiency, and previous hospital admission for heart failure. Worse physiological stage was associated with mortality (p=0.001), whereas anatomic complexity or defect group were not.
COVID-19 mortality in adults with CHD is commensurate with the general population. The most vulnerable patients are those with worse physiological stage, such as cyanosis and pulmonary hypertension, whereas anatomic complexity does not appear to predict infection severity.
COVID-19 mortality in adults with CHD is commensurate with the general population. The most vulnerable patients are those with worse physiological stage, such as cyanosis and pulmonary hypertension, whereas anatomic complexity does not appear to predict infection severity.
Infective endocarditis (IE) is a common and serious complication in patients receiving chronic hemodialysis (HD).
This study sought to investigate whether there are significant differences in complications, cardiac surgery, relapses, and mortality between IE cases in HD and non-HD patients.
Prospective cohort study (International Collaboration on Endocarditis databases, encompassing 7,715 IE episodes from 2000 to 2006 and from 2008 to 2012). Descriptive analysis of baseline characteristics, epidemiological and etiological features, complications and outcomes, and their comparison between HD and non-HD patients was performed. Risk factors for major embolic events, cardiac surgery, relapses, and in-hospital and 6-month mortality were investigated in HD-patients using multivariable logistic regression.
A total of 6,691 patients were included and 553 (8.3%) received HD. North America had a higher HD-IE proportion than the other regions. link2 The predominant microorganism was Staphylococcus aureus (47.8%), follassociated infection chiefly caused by S. aureus, with increasing rates of enterococcal IE. Mortality and relapses are very high and significantly larger than in non-HD-IE patients, whereas cardiac surgery is less frequently performed.
Evidence from prospective studies has suggested that long working hours are associated with incident coronary heart disease (CHD) events. link3 However, no previous study has examined whether long working hours are associated with an increased risk of recurrent CHD events among patients returning to work after a first myocardial infarction (MI).
The purpose of this study was to examine the effect of long working hours on the risk of recurrent CHD events.
This is a prospective cohort study of 967 men and women age 35 to 59 years who returned to work after a first MI. Patients were recruited from 30 hospitals across the province of Quebec, Canada. The mean follow-up duration was 5.9 years. Long working hours were assessed on average 6weeks after their return to work. Incident CHD events (fatal or nonfatal MI and unstable angina) occurring during follow-up were determined using patients' medical files. Hazard ratios were estimated using Cox proportional hazard regression models. Splines and fractional polynomialevents. Secondary prevention interventions aiming to reduce the number of working hours among these patients may lower the risk of CHD recurrence.
Calcified nodule (CN) has a unique plaque morphology, in which an area of nodular calcification causes disruption of the fibrous cap with overlying luminal thrombus. CN is reported to be the least frequent cause of acute coronary thrombosis, and the pathogenesis of CN has not been well studied.
The purpose of this study is to provide a comprehensive morphologic assessment of the CN in addition to providing an evolutionary perspective as to how CN causes acute coronary thrombosis in patients with acute coronary syndromes.
A total of 26 consecutive CN lesions from 25 subjects from our autopsy registry were evaluated. Detailed morphometric analysis was performed to understand the plaque characteristics of CN and nodular calcification.
The mean age was 70 years, with a high prevalence of diabetes and chronic kidney disease. CNs were equally distributed between men and women, with 61.5% of CNs found in the right coronary artery (n=16), mainly within its mid-portion (56%). All CNs demonstrated surface nonocclusive luminal thrombus, consisting of multiple nodular fragments of calcification, protruding and disrupting the overlying fibrous cap, with evidence of endothelial cell loss.
