Microhematuria in Postmenopausal Women: Adherence to Guidelines in a Tertiary Care Setting

Prevalence and predictors of iron deficiency anaemia among children with sickle cell disease in Dodoma, Tanzania: a cross-sectional study

BACKGROUND

Patients with sickle cell disease (SCD) are prone to iron profile derangements. This study aimed to determine the prevalence of iron deficiency anaemia (IDA) and their predictors among children with SCD aged between 6 months and 14 years. Assessment of the prevalence of IDA and its predictors helps to understand ways of alleviating the magnitude of the problem so as to prevent possible complications such as shortness of breath and chest pain.

METHODS

This was a cross-sectional analytical hospital-based study which included 174 patients with SCD attending SCD clinics at St. Gema hospital and Dodoma regional referral hospital in Dodoma city from October 2020 to March 2021. The cut-off points for detection of IDA was serum ferritin level < 30 µg/L and low mean corpuscular volume (MCV) for age. Data were analyzed using SPSS software version 25.0. Multivariate logistic regression analysis was used to determine the predictors of IDA. P-value less than 0.05 was considered significant.

RESULTS

The prevalence of IDA in this study was (16.1%, n = 28). Family income of less than 70,000/= TZS/month (AOR = 2.2, 95% CI = 1.07-2.49, p = 0.023), being transfused with blood less than 3 times from the time of being diagnosed with SCD (AOR = 5.5, 95% CI = 1.03-8.91, p = 0.046), and eating red meat at least once per month (AOR = 3.60, 95% CI = 1.37-9.46, p = 0.010) remained the independent predictors of IDA in multivariate regression analysis.

CONCLUSION

The findings of this study have shown that, support of families with children suffering from SCD in terms of financial support for improving medical services including optimal blood transfusion and affordability of diet which is rich in iron such as red meat is imperative.

Synergistic effect of proteinuria on dipstick hematuria-related decline in kidney function: The Japan Specific Health Checkups (J-SHC) Study

BACKGROUND

The effect of isolated hematuria without proteinuria on kidney function decline, and the modification by the severity of proteinuria in general population are not fully elucidated.

METHODS

Participants were included in the Japan Specific Health Checkups Study between 2008 and 2014. The exposure of interest was the frequency of dipstick hematuria during the observation. In each proteinuria frequency category (non-, occasional, persistent), hematuria-related decline in the eGFR rate was examined by analysis of covariance (ANCOVA). eGFR decline trajectories were also assessed using mixed-effects models.

RESULTS

Among the 552,951 participants, 146,753 (26.5%) had hematuria, and 56,021 (10.1%) and 8,061 (1.5%) had occasional and persistent proteinuria, respectively. During the median follow-up of 3.0 years, annual change in eGFR decline in participants with hematuria was significantly faster than in those without hematuria (mean [95% confidence interval]: - 0.95 [- 0.98 to - 0.92] vs - 0.86 [- 0.87 to - 0.84] mL/min/1.73 m2/year; P < 0.001). In ANCOVA, the hematuria-related annual eGFR decline rate increased as proteinuria frequency categories increased (differences in annual eGFR decline rate between participants with and without hematuria: 0.08 [0.06 to 0.09] in participants with non-proteinuria category, 0.17 [0.15 to 0.18] in occasional proteinuria category, and 0.68 [0.65 to 0.71] mL/min/1.73 m2/year in persistent proteinuria category; P for interaction < 0.001). Similar results were obtained by the linear mixed-effect model.

CONCLUSIONS

Proteinuria has a synergistic effect on dipstick hematuria-related decline in kidney function. Among the general population without proteinuria throughout the observational period, the "isolated hematuria"-related eGFR decline was statistically significant but the difference was small.

Improving the diagnostic process for patients with possible bladder and kidney cancer: a mixed-methods study to identify potential missed diagnostic opportunities

BACKGROUND

Patients with bladder and kidney cancer may experience diagnostic delays.

AIM

To identify patterns of suboptimal care and contributors of potential missed diagnostic opportunities (MDOs).

DESIGN AND SETTING

Prospective, mixed-methods study recruiting participants from nine general practices in Eastern England between June 2018 and October 2019.

METHOD

Patients with possible bladder and kidney cancer were identified using eligibility criteria based on National Institute for Health and Care Excellence (NICE) guidelines for suspected cancer. Primary care records were reviewed at recruitment and at 1 year for data on symptoms, tests, referrals, and diagnosis. Referral predictors were examined using logistic regression. Semi-structured interviews were undertaken with 15 patients to explore their experiences of the diagnostic process, and these were analysed thematically.

RESULTS

Participants (n = 940) were mostly female (n = 657, 69.9%), with a median age of 71 years (interquartile range 64-77 years). In total, 268 (28.5%) received a referral and 465 (48.5%) had a final diagnosis of urinary tract infection (UTI). There were 33 (3.5%) patients who were diagnosed with cancer, including prostate (n = 17), bladder (n = 7), and upper urothelial tract (n = 1) cancers. Among referred patients, those who had a final diagnosis of UTI had the longest time to referral (median 81.5 days). Only one-third of patients with recurrent UTIs were referred despite meeting NICE referral guidelines. Qualitative findings revealed barriers during the diagnostic process, including inadequate clinical examination, female patients given repeated antibiotics without clinical reviews, and suboptimal communication of test results to patients.

CONCLUSION

Older females with UTIs might be at increased risk of MDOs for cancer. Targeting barriers during the initial diagnostic assessment and follow-up might improve quality of diagnosis.

An evidence-based microscopic hematuria care pathway optimizes decision-making among providers

INTRODUCTION AND HYPOTHESIS

Microscopic hematuria (MH) has many etiologies in women and requires specific gynecologic evaluation. We created a standardized MH pathway to serve as an evidence-based decision aid for providers in our practice.

METHODS

Using a modified Delphi process, a multidisciplinary team reviewed existing guidelines for MH diagnosis and treatment to reach consensus on care pathway components.

RESULTS

Entry into the care pathway by an advanced practice provider is determined by the finding of ≥3 red blood cells per high-power field (RBC/HPF) on microscopic urinalysis. Initial evaluation includes history and physical exam. If there are signs of a gynecologic cause of MH, the conditions are treated and repeat urinalysis is performed in 6 months. If repeat urinalysis shows persistent MH or there are no other apparent causes for MH, we proceed with risk stratification. Through shared decision-making, low-risk patients may undergo repeat urinalysis in 6 months or cystoscopy with urinary tract ultrasound. For intermediate-risk patients, cystoscopy and urinary tract ultrasound are recommended. For high-risk patients, cystoscopy and axial upper urinary tract imaging are recommended. If evaluation is positive, urology referral is provided. If evaluation is negative, low-risk patients are released from care, but intermediate-risk or high-risk patients undergo repeat urinalysis in 12 months. If repeat urinalysis is positive, shared decision-making is used to determine a plan.

CONCLUSIONS

We developed an MH care pathway to standardize care of women with MH across a multidisciplinary group. This pathway serves as a component of value-based care and supports evidence-based care by providers.

Cost-effectiveness of mass screening for dipstick hematuria in Japan

BACKGROUND

Dipstick urine tests are a simple and inexpensive method for detecting kidney and urological diseases, such as IgA nephropathy and bladder cancer. The nationwide mass screening program, Specific Health Checkup (SHC), started in Japan in 2008 and targeted all adults between 40 and 74 years of age. Dipstick urine tests for proteinuria and glucosuria are mandatory as part of the SHC, but dipstick urine tests for hematuria are not. However, the dipstick hematuria test is often administered simultaneously with these mandatory tests by some health insurers. Hematuria is common in Japanese general screening participants, particularly elderly women, and the necessity of mass screening using the dipstick hematuria test has been discussed. This study aimed to evaluate the cost-effectiveness of mass screening for dipstick hematuria tests in addition to the SHC.

METHODS

Using a decision tree and Markov modeling, we conducted a cost-effectiveness analysis from a Japanese societal perspective.

RESULTS

Compared with the current SHC, mass screening for dipstick hematuria tests, in addition to the SHC, costs less and gains more, which means cost-saving. Similar findings were observed in the sex-specific analysis.

CONCLUSION

Our results suggest that mandating the dipstick hematuria test could be justifiable as an efficient use of finite healthcare resources. The results have implications for mass screening programs not only in Japan but worldwide.

Microhematuria in Women: Prevalence of Malignancy and Risk Score Evaluation

OBJECTIVES

To (1) determine the prevalence of urologic malignancy in women evaluated for microhematuria (MH) in a large university-based urology practice, (2) describe clinical features shared by women with MH, and (3) evaluate a risk score for urologic malignancy in women with MH.

METHODS

A retrospective chart review identified women with MH evaluated by a large, university-based urology practice between 2010 and 2020. Clinical and demographic variables associated with their evaluation, referral pattern, appropriateness of referral and evaluation, workup completed, and resulting diagnoses were reported. Patterns of repeat evaluations were also described. Patients were stratified as low-, intermediate-, or high-risk according to AUA/SUFU recommended risk stratification.

RESULTS

4456 charts resulted from an initial query based on females with ICD-9 and ICD-10 codes for MH between 2010-2020. 1730 patients (95.5% referrals v. 4.5% established urology patients) met criteria for inclusion in the study, and 1350 underwent evaluation for MH at the practice. Over 30% of referrals were considered inappropriate. 13 patients were diagnosed with urologic malignancy, all of whom were classified as intermediate- or high-risk according to AUA/SUFU criteria. Over 10% of patients had at least 2 evaluations for MH, with only 1 malignancy discovered on repeat evaluation for persistent MH.

CONCLUSIONS

Inappropriate referrals for MH are common. Incidence of urologic malignancy is incredibly low among women evaluated for MH, but especially among those classified as low- and intermediate-risk by new guidelines. Repeat evaluations for persistent, stable MH appear low yield in detecting malignancy.

Assessment of Diagnostic Yield of Cystoscopy and Computed Tomographic Urography for Urinary Tract Cancers in Patients Evaluated for Microhematuria: A Systematic Review and Meta-analysis

IMPORTANCE

Microhematuria (MH) is a common finding that often leads to further evaluation for urinary tract cancers. There is ongoing debate about the extent to which patients with MH should be evaluated for cancer.

OBJECTIVE

To assess the diagnostic yield for detection of urinary tract cancers, specifically bladder cancer, upper tract urothelial carcinoma (UTUC), and kidney cell carcinoma, among patients evaluated for MH using cystoscopy and computed tomographic (CT) urography.

DATA SOURCES

MEDLINE, Scopus, and Embase were systematically searched for eligible studies published between January 1, 2009, and December 31, 2019.

STUDY SELECTION

Original prospective and retrospective studies reporting the prevalence of cancer among patients evaluated for MH were eligible. Two authors independently screened the titles and abstracts to select studies that met the eligibility criteria and reached consensus about which studies to include. Among 5802 records identified, 5802 articles were screened using titles and abstracts. After exclusions, 55 full-text articles were assessed for eligibility, with 39 studies selected for systematic review.

DATA EXTRACTION AND SYNTHESIS

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Studies were quantitatively synthesized using a random-intercept logistic regression model.

MAIN OUTCOMES AND MEASURES

The primary outcome was diagnostic yield, defined as the proportion of patients with a diagnosis of urinary tract cancer (bladder cancer, UTUC, or kidney cell carcinoma) after presentation with MH. Studies were stratified by the percentage of cystoscopy and CT urography use and by high-risk cohorts. The diagnostic yields of CT urography and cystoscopy were calculated for each cancer type.

RESULTS

A total of 30 studies comprising 24 366 patients evaluated for MH were included in the meta-analysis. The pooled diagnostic yield among all patients was 2.00% (95% CI, 1.30%-3.09%) for bladder cancer, 0.02% (95% CI, 0.0%-0.15%) for UTUC, and 0.18% (95% CI, 0.09%-0.36%) for kidney cell carcinoma. Stratification of studies that used cystoscopy and/or CT urography for 95% or more of the cohort produced diagnostic yields of 2.74% (95% CI, 1.81%-4.12%) for bladder cancer, 0.09% (95% CI, 0.01%-0.75%) for UTUC, and 0.10% (95% CI, 0.04%-0.23%) for kidney cell carcinoma. In high-risk cohorts, the diagnostic yields increased to 4.61% (95% CI, 2.34%-8.90%) for bladder cancer and 0.45% (95% CI, 0.22%-0.95%) for UTUC.

CONCLUSIONS AND RELEVANCE

This study's findings suggest that, given the low diagnostic yield of CT urography and the associated risks and costs, limiting its use to high-risk patients older than 50 years is warranted. Risk stratification, as recommended by the recent American Urology Association guidelines on MH, may be a better approach to tailor further evaluation.

Quality of the diagnostic process in patients presenting with symptoms suggestive of bladder or kidney cancer: a systematic review

OBJECTIVES

In urological cancers, sex disparity exists for survival, with women doing worse than men. Suboptimal evaluation of presenting symptoms may contribute.

DESIGN

We performed a systematic review examining factors affecting the quality of the diagnostic process of patients presenting with symptoms of bladder or kidney cancer.

DATA SOURCES

We searched Medline, Embase and the Cochrane Library from 1 January 2000 to 13 June 2019.

ELIGIBLE CRITERIA

We focused on one of the six domains of quality of healthcare: timeliness, and examined the quality of the diagnostic process more broadly, by assessing whether guideline-concordant history, examination, tests and referrals were performed. Studies describing the factors that affect the timeliness or quality of the assessment of urinary tract infections, haematuria and lower urinary tract symptoms in the context of bladder or kidney cancer, were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were independently performed by two authors. Due to the heterogeneity of study design and outcomes, the results could not be pooled. A narrative synthesis was performed.

RESULTS

28 studies met review criteria, representing 583 636 people from 9 high-income countries. Studies were based in primary care (n=8), specialty care (n=12), or both (n=8). Up to two-thirds of patients with haematuria received no further evaluation in the 6 months after their initial visit. Urinary tract infections, nephrolithiasis and benign prostatic conditions before cancer diagnosis were associated with diagnostic delay. Women were more likely to experience diagnostic delay than men. Patients who first saw a urologist were less likely to experience delayed evaluation and cancer diagnosis.

CONCLUSIONS

Women, and patients with non-cancerous urological diagnoses just prior to their cancer diagnosis, were more likely to experience lower quality diagnostic processes. Risk prediction tools, and improving guideline ambiguity, may improve outcomes and reduce sex disparity in survival for these cancers.

Inappropriate oophorectomy at time of benign premenopausal hysterectomy

OBJECTIVE

We assessed rates of oophorectomy during benign hysterectomy around the release of the American College of Obstetricians and Gynecologists 2008 practice bulletin on prophylactic oophorectomy, and evaluated predictors of inappropriate premenopausal oophorectomy.

METHODS

A cross-sectional administrative database analysis was performed utilizing the California Office of Statewide Health Planning Development Patient Discharge Database for years 2005 to 2011. After identifying all premenopausal women undergoing hysterectomy for benign conditions, International Classification of Diseases (ICD)-9 diagnosis codes were reviewed to create a master list of indications for oophorectomy. We defined appropriate oophorectomy as cases with concomitant coding for ovarian cyst, breast cancer susceptibility gene carrier status, and other diagnoses. Using patient demographics and hospital characteristics to predict inappropriate oophorectomy, a logistic regression model was created.

RESULTS

We identified 57,776 benign premenopausal hysterectomies with oophorectomies during the period studied. Of the premenopausal oophorectomies, 37.7% (21,783) were deemed "inappropriate" with no documented reason for removal. The total number of premenopausal inpatient hysterectomies with oophorectomy decreased yearly (12,227/y in 2005 to 5,930/y in 2011). However, the percentage of inappropriate oophorectomies remained stable. In multivariate analysis, Hispanic and African American ethnicity/race associated with increased odds of inappropriate oophorectomy (P < 0.001). Urban and at low Medi-Cal utilization hospitals showed increased odds of inappropriate oophorectomy.

CONCLUSIONS

In premenopausal women undergoing benign hysterectomy, over one-third undergo oophorectomy without an appropriate indication documented. The rate of inappropriate oophorectomy in California has not changed since the 2008 American College of Obstetricians and Gynecologists guidelines. Whereas the absolute number of inpatient hysterectomies for benign indications has decreased, our work suggests persistent utilization of oophorectomy in premenopausal women, despite well-documented long-term adverse health implications.

Changes in microscopic analysis of the urinary sediment in postmenopausal women who receive vaginal conjugated oestrogens

Introduction

Microscopic haematuria is common in adults and it has been reported in 13% of postmenopausal women.

Objective

To evaluate the changes in urinary sediment after the use of vaginal conjugated oestrogens.

Material and methods

Postmenopausal women with vaginal dryness were studied. In all them a urinalysis was done, looking for density, pH, and the presence of leukocytes and erythrocytes. In order to be included in the study, all of the women had to have microscopic haematuria, considered as the presence of 3 or more erythrocytes in the urinary sediment. All received vaginally 1 g of conjugated equine oestrogens cream 3 times per week for one month, moment in which a new urinalysis was carried out and the same parameters were evaluated.

Results

Twenty-four women were studied. The median age was 62 years (40-83), and the time since menopause was 144 months (24-336). When comparing the values between baseline and end of treatment urinalyses, no significant differences in pH and urinary density were found. The number of leukocytes significantly decreased after treatment (3.0 [1-6] vs. 1.0 [1-6], p < 0.026), and the erythrocytes number decreased (4.5 [3-12] vs. 0.0 [0-2], p < 0.001).

Conclusion

In postmenopausal women with microscopic haematuria and vaginal dryness, it is worth considering administration of local oestrogen for one month, and after repeat the urine exam, before deciding to begin the microscopic haematuria study protocol.

Haematuria work-up in general care-A German observational study

BACKGROUND

Haematuria is a common finding in the population and the diagnostic workflow of this symptom represents a large proportion of "work-load" in the urological outpatient clinic.

AIMS

The intention of this study was to verify if the intensive diagnostic procedures of haematuria patients is justified by detection of a significant proportion of genito-urinary tract cancers.

MATERIALS AND METHODS

In a retrospective design 1049 consecutive patients, who presented themselves with macro- or microhaematuria in the outpatient clinic PURR in the time from 2011 to 2012, were included in the study and the diagnostic procedures including ultrasound, intravenous urography, computed tomography of the abdomen and urethrocystoscopy as well as therapeutic consequences with its results were analysed.

RESULTS

The study group comprised 570 women (54.3%) and 479 men (45.7%) with a median age of 58 years and macrohaematuria occurred in 89 patients. Diagnostics revealed seven patients with renal cell cancer, six patients with urothelial cell cancer of the renal pelvis, four patients with urothelial cell cancer of the ureter, 65 patients with urothelial cell cancer of the lower urinary tract and 17 patients with prostate cancer. Age, male gender and macrohaematuria were associated with a higher risk of cancer.

CONCLUSIONS

The high incidence of urinary tract cancer in the data presented here support the rationale for diagnostic work-up of patients with micro- or macrohaematuria. Prospective randomised trials are necessary to identify index patients for second work-up after a primarily negative investigation as well as the role of molecular markers, which possibly enable to omit invasive work-up.

Healthcare policy and urologic practice

PURPOSE OF REVIEW

Healthcare policy is currently a topic of national debate, with numerous implications for the practice of urology.

RECENT FINDINGS

Healthcare policy has broad reaching effects, both predicted and unforeseen. The effects of healthcare policy are manifested through clinical practice guidelines, payment reform and the overall structure of the healthcare system. This review describes each of these topics and their impact on clinical practice, with a specific focus on urology and urologic practice.

SUMMARY

Guidelines are useful for guiding and determining what is considered appropriate clinical practice, but there are drawbacks including poor implementation and overabundance. Payment reform is constantly evolving, with multiple efforts being implemented to move away from a fee-for-service model of reimbursement. The structure of healthcare delivery is moving toward more outpatient procedures, with varying amount of physician ownership of facilities and equipment, which is itself a controversial topic.