Declining emergency department visits and costs during the severe acute respiratory syndrome (SARS) outbreak.

BACKGROUND: The immediate and long-term impact of severe acute respiratory syndrome (SARS) outbreak on emergency department (ED) visits and hospital expenditures for these visits has not been thoroughly investigated. The objectives of this retrospective observational study investigated the impact of SARS outbreak on ED visits and the cost of these visits in a designated SARS medical center. METHODS: Data related to the total number of ED visits and their costs were collected for the SARS epidemic period in 2003 and the same period in the preceding year in 2002. Data collected included total number of ED visits, services provided, triage categories, and total expenditures for all patients. Data for before and during the outbreak were retrieved and compared. RESULTS: At the peak of the SARS epidemic, the reduction in daily ED visits reached 51.6% of pre-epidemic numbers (p < 0.01). In pediatric, trauma and non-trauma patients, the maximum mean decreases in number of visits were 80.0% (p < 0.01), 57.6% (p < 0.01) and 40.8% (p < 0.01), respectively. In triage 1, 2 and 3 patients, the maximum mean decreases were 18.1% (p < 0.01), 55.9% (p < 0.01) and 53.7% (p < 0.01), respectively. The maximum decrease in total costs was 37.7% (p < 0.01). The maximum mean costs per patient increased 35.9% (p < 0.01). The proportions of increases in mean costs for each patient were attributed to laboratory investigations (31.4%), radiography (21.9%) and medications (29.5%). CONCLUSION: The SARS outbreak resulted in a marked reduction in the number of ED visits which persisted for 3 months after the end of the epidemic. Total cost of treating individual patients showed a simultaneous marked increase, while overall operational costs in the ED showed a marked decrease. The increased total cost for each patient was attributed to the increased number of diagnostic procedures to screen for possible SARS in the ED.     

Appropriate triage allows aggressive primary debulking surgery with rates of morbidity and mortality comparable to interval surgery after chemotherapy

ObjectiveMorbidity and mortality (M/M) after primary debulking surgery (PDS) is often cited as a rationale for neoadjuvant chemotherapy and interval debulking surgery (IDS). We tested if using an evidence-based algorithm to identify patients fit for surgery would reduce M/M after PDS to that seen after IDS.MethodsWe included women who underwent PDS or IDS for advanced epithelial ovarian cancer (EOC) (1/2012–7/2016) guided by the use of a prospective triage algorithm. Outcomes were compared after applying inverse-probability of treatment weighting (IPTW) to adjust for covariate imbalance.ResultsOf 334 included patients, 232 (69.5%) underwent PDS and 102 (30.5%) were triaged to IDS. Relative to IDS group, PDS patients were younger (63.9 vs 67.5 years, P=0.01), were less likely to have low albumin (16.8% vs. 32.4%, P<0.001), had longer median operative times (315 vs 263 min, P <0.001), more high complexity surgeries and fewer low complexity surgeries (27.2% vs. 11.8% and 18.5% vs 36.3% respectively, P<0.001). The rates of the following outcomes were comparable for PDS and IDS, respectively: successful cytoreduction (complete, 62.5% vs 66.7%, P=0.47 and optimal, 95.3% vs 98.0%, P=0.36), 30-day grade 3+ complications (IPTW-adjusted 18.3% vs. 12.9%, P=0.22), 90-day mortality (IPTW-adjusted, 2.2% vs. 3.8%, P=0.42), length of hospitalization (P=0.29), and postoperative chemotherapy delivery (P=0.83). 3-year overall survival was higher for PDS group (IPTW-adjusted 64.1% vs. 42.6%, P=0.001).ConclusionsUse of our validated triage strategy allowed us to offer 70% of women with advanced EOC PDS surgery. Despite more complex surgery, M/M after this approach is low and comparable to IDS, with similar rates of complete resection and superior OS. Use of a validated triage system should be utilized when considering PDS vs neoadjuvant chemotherapy.     

Twin chorionicity and the risk of adverse perinatal outcome.

OBJECTIVE: To evaluate the impact of chorionicity on the perinatal outcomes of twin pregnancies complicated by twin-twin transfusion syndrome (TTS) or selective intrauterine growth restriction (sIUGR). METHOD: Pregnancies with 127 monochorionic (MC) and 109 dichorionic (DC) twins were followed up, and TTS and sIUGR incidence as well as morbidity and mortality were evaluated. RESULTS: The incidence of intrauterine fetal death was higher in MC than in DC pregnancies (6.5% vs. 1%), and higher in MC pregnancies complicated by TTS (5 deaths in 10 pregnancies [50%]) or sIUGR (2 in 9 [22%]). The incidence of sIUGR was similar in MC and DC pregnancies (7% vs. 5%), and the incidence of TTS was 8% in MC pregnancies (95% confidence interval, 3.2-12.8). Neonatal neurological and respiratory morbidity was higher among MC twins, and the increase in neonatal complications was linked to TTS and sIUGR. Uncomplicated MC and DC pregnancies had similar perinatal outcomes. CONCLUSION: The incidence of neonatal complications was higher in MC twins born of pregnancies complicated by TTS or sIUGR. Although the incidence of sIUGR was similar in MC and DC pregnancies, there was a trend towards worse outcomes in MC pregnancies affected by sIUGR.     

Treatment of poisonous snakebites in northern Taiwan.

PURPOSE: We evaluated the epidemiology and outcomes of snakebites in northern Taiwan, and the effect of local antivenom injection to speed neutralization and reduce the spread of venom. METHODS: We retrospectively reviewed the medical records of 130 venomous snakebite patients treated in a general hospital in northern Taiwan during a 3-year period (1991-1994). Patients received either combined local and intravenous injection of antivenom or intravenous administration only, according to the physicians' decision. The species of snake involved, time of bite, and outcome of the patient were recorded. The effect sof local and systemic antivenom administration were analyzed using the duration of emergency department (ED) stay among patients discharged from the ED with medical approval as a treatment index. RESULTS: Most (76.1%) venomous snakebites were attributed to the green habu (68 patients) and the Taiwan habu (31 patients). All bites were to the extremities: 74 (57%) to the feet and 56 (43%) to the hands or arms. Most bites (n = 70, 53.9%) occurred between 2 PM and 9 PM. The peak months for snakebites were June through October (n = 84, 64.6%). Eighteen patients (13.8%) were admitted for further treatment after being cared for in the ED. The other 112 patients were discharged from the ED (86.2%), although three of these were admitted later because of infection. No patients died, but eight developed wound infections. Of the 93 patients discharged from the ED with medical approval, 26 (28.0%) received local injection plus systemic administration of antivenom. The duration of ED stay did not differ significantly between patients with local plus systemic administration and those who received systemic administration alone (23.7 +/- 19.5 hours vs 27.0 +/- 12.5 hours, p = 0.19). CONCLUSIONS: Most snakebites in northern Taiwan were due to habus and caused mild symptoms. Local antivenom injection plus intravenous administration of antivenom had no benefit over intravenous administration alone.     

Factors associated with frequent use of emergency services in a medical center.

BACKGROUND AND PURPOSE: Overuse of emergency department (ED) services can result in overcrowding and a substantial increase of health care cost. The purpose of this study was to characterize frequent ED users and to identify the factors associated with frequent ED use in a hospital in Taiwan. METHODS: This retrospective study used Andersen's Behavioral Model of Health Service Use as a framework. Frequent ED users (>/= 4 visits/year) and infrequent ED users (< 4 visits/ year) were selected randomly from patients visiting the adult ED of a medical center in central Taiwan from October 1, 2000 to September 30, 2001. Telephone interviews were completed for 200 frequent users and 600 infrequent users. Logistic regression analysis was performed to identify factors associated with frequent ED use. RESULTS: Frequent ED users comprised 3.5% of total ED patients, accounting for 14.3% of the ED visits. Significant factors associated with frequent ED use were: a regular source of care [odds ratio (OR), 2.79; 95% confidence interval (CI), 1.63 to 4.79], alcoholism (OR, 19.4; 95% CI, 3.84 to 98.0), high outpatient clinic use (OR, 2.66; 95% CI, 1.72 to 4.11), previous hospitalization (OR, 3.06; 95% CI, 1.94 to 4.82), chronic disease (OR, 3.07; 95% CI, 1.78 to 5.29), cancer (OR, 4.16; 95% CI, 1.29 to 13.4), gastrointestinal disease (OR, 6.28; 95% CI, 1.95 to 20.2), cardiovascular disease (OR, 8.41; 95% CI, 2.51 to 28.1), pulmonary disease (OR, 4.21; 95% CI, 1.04 to 17.1), low level of emergency (OR, 5.43; 95% CI, 3.40 to 8.68), and dissatisfaction with treatment outcome (OR, 2.62; 95% CI, 1.32 to 5.20). CONCLUSIONS: Frequent ED users were responsible for a disproportionate number of the total ED visits. Andersen's "need factors" were strongly associated with frequent ED use, while the investigated predisposing factors were not significant. Most patients who visited the ED had a low level of emergency. These findings suggest that implementation of an integrated delivery system may decrease ED use.     

An assessment of the efficacy and safety of sildenafil administered to patients with erectile dysfunction referred for posterior urethroplasty: a single-center experience

IntroductionUrethral trauma is often associated with erectile dysfunction (ED). Reconstructive surgery is complex and may impact negatively on sexual function.AimThe aim of this article is to investigate ED in patients with pelvic fracture urethral distraction defects (PFUDD) who underwent urethroplasty, and efficacy of treatment with sildenafil citrate.Main Outcome MeasuresA total of 41 patients with urethral stricture who suffered from PFUDD were assessed to exclude systemic diseases that may cause ED, such as hypertension, diabetes mellitus, heart disease, and chronic liver disease. The International Index of Erectile Function‐5 was used as an evaluation tool. Assessments were made at three time points: the time of admission, two weeks after urethroplasty, and 3 months post‐treatment with sildenafil.MethodsPharmacopenile duplex ultrasonography was used to examine blood flow of the cavernosum in order to distinguish arterial ED, venous ED, and nonvascular ED. All patients were treated with oral sildenafil, 100 mg once daily, three times a week, for 3 months.ResultsThe incidence of ED following injury was 95.12%. There were no significant changes in scores following surgery. However, sildenafil had a success rate of approximately 81%, which appeared to be independent of age. Drug treatment seemed most effective for those with less severe ED at the outset. There was no significant difference in scores post‐treatment between those who had vascular and nonvascular ED. Overall, the incidence of side effects due to sildenafil was 19.5%.ConclusionsUrethral trauma is frequently associated with ED. Sildenafil citrate is useful in the drug treatment of ED in these patients and appears to be well‐tolerated. Fu Q, Sun XJ, Tang CY, Cui RJ, and Chen L. An assessment of the efficacy and safety of sildenafil administered to patients with erectile dysfunction referred for posterior urethroplasty: A single‐center experience. J Sex Med 2012;9:282–287.     

Predictors of survival and hospital outcome of prehospital cardiac arrest in southern Taiwan.

BACKGROUND AND PURPOSE: Despite recent improvements in emergency care medicine, outcome for prehospital cardiac arrest patients remains poor in southern Taiwan due to lack of training and authorization of emergency medical technicians to perform advanced life support. The purpose of this study was to analyze the characteristics of these patients and to identify possible predictive factors for final hospital discharge. METHODS: We retrospectively reviewed the characteristics of 361 prehospital cardiac arrest patients (male:female, 226:135; median age, 69 years) undergoing cardiopulmonary resuscitation (CPR) on arrival at the emergency department (ED) between January 1, 2001 and December 31, 2003. Multivariate analysis was performed by fitting explanatory variables into logistic regression models with respect to the outcomes of admission and to hospital discharge. RESULTS: The overall survival rate was 21.1% (n = 76) to hospital admission and 7.2% (26) to hospital discharge. About half (54%) of the 26 patients who survived had cardiac disease. Only 3 patients received CPR from a bystander, and 2 of them survived. None of the patients received electrical defibrillation before arriving at hospital because emergency personnel were not authorized to perform advanced cardiac life support (ACLS) in Southern Taiwan during the study period. Factors that predicted survival to hospital discharge included a short interval between the cardiac arrest and arrival at the ED, initial rhythm of ventricular tachycardia/ventricular fibrillation (VT/VF), lower atropine dose, higher level of hemoglobin, less multiple organ failure, and shorter duration of resuscitation in the ED. Nine of the 32 patients (28%) with VT/VF survived compared with 5 of 49 (10%) with pulseless electrical activity and only 12 of 231 (5%) with asystole. No patients who required resuscitation for longer than 20 minutes in the ED survived to hospital discharge. CONCLUSION: The results of this study illustrate that patients with VT/VF have good potential for successful resuscitation. Prompt resuscitation and easy access for ACLS are the key factors for success. Survival rates are likely to improve if more lay people perform CPR and if emergency unit personnel are trained and allowed to perform ACLS.     

Glycosylated serum protein may improve our ability to predict endothelial and erectile dysfunction in nonorganic patients

IntroductionEarly prediction of erectile dysfunction (ED) is critical in the treatment of impotence. Underlying pathogenesis may be the reason for ED without organic causes in young men.AimWe evaluated the early predictive value of glycosylated serum protein (GSP) in young patients whose ED was diagnosed as “nonorganic” in origin according to general criteria.MethodsA total of 150 young men with ED and 27 healthy men without ED were evaluated, including International Index of Erectile Function‐5 (IIEF‐5), causes of ED, influential or risk factors for ED, vascular parameters, and serum biochemical markers. Fifty‐two ED patients aged 20–40 years without known etiology and 22 age‐matched normal subjects were enrolled. The further assessment of two groups focused on vascular endothelial function and glycometabolic state.Main Outcome MeasuresRelationships among the IIEF‐5 scores, flow‐mediated dilation (FMD), and GSP were analyzed in cases vs. controls, using Pearson's correlation and multiple linear regression analysis.ResultsNo significant differences in baseline characteristics, cardiovascular risks, and conventional biomarkers were found between testing and control groups, except fasting blood glucose level (4.69 ± 0.50 vs. 4.29 ± 0.48, P = 0.003). FMD values were significantly reduced in cases compared with controls and correlated positively with IIEF‐5 scores (r = 0.629, P < 0.001). GSP levels were significantly increased in the ED cases compared with controls and correlated negatively with IIEF‐5 scores (r = ?0.504, P < 0.001) and FMD values (r = ?0.469, P < 0.001). These parameters independently predicted ED presence. The positive predictive value of FMD > 11.55% for excluding ED and of GSP > 210.50 mg/L for diagnosing ED were 86.4% (area under the curve [AUC]: 0.942, specificity: 88.4%) and 84.5% (AUC: 0.864, specificity: 72.7%), respectively.ConclusionsUnderlying glycometabolic disorder and subclinical endothelial dysfunction may be served as early markers for organic ED in young ED patients without well‐known related risk factors. GSP level may improve our ability to predict endothelial dysfunction and erectile dysfunction. Huang Y, Sun X, Liu G, Yao F, Zheng F, Dai Y, Tu X, Xie X, Deng L, Zhang D, Zhang Y, Bian J, Gao Y, Ye Y, Deng C, and Zhang Y. Glycosylated serum protein may improve our ability to predict endothelial and erectile dysfunction in non‐organic patients. J Sex Med 2011;8:840–850.     

A Survey of Erectile Dysfunction in Taiwan: Use of the Erection Hardness Score and Quality of Erection Questionnaire

IntroductionThere are currently no studies in the Asia-Pacific region using the erection hardness score (EHS) and Quality of Erection Questionnaire (QEQ) to assess erectile dysfunction (ED).AimsTo provide up-to-date data on the prevalence of ED in Taiwanese men and to validate the EHS and QEQ in this population.MethodsA representative sample of 1,060 men aged ≥30 years completed a telephone interview. ED status was confirmed via direct questioning and using the abridged five-item version of the 15-item International Index of Erectile Function (IIEF-5). Responses regarding EHS, QEQ, marital and sexual satisfaction, and attitude to treatment were also recorded.Main Outcome MeasuresIIEF, EHS, and QEQ.ResultsThe prevalence of ED, as defined by IIEF-5, was 27% among all respondents and 29% among those aged ≥40 years. Although, the prevalence of ED increased with age, men of all ages tended to underestimate their erectile problems. Among men who indicated that they did not have ED, 25% were found to have mild to moderate ED according to the IIEF-5 assessment. An EHS ≤3, indicating the presence of ED, was reported in 26% of men. The EHS was consistent with the QEQ: When the EHS was 4, the satisfaction of each domain of QEQ ranged from 85% to 90%. The QEQ score correlated well with the IIEF-5 score and significantly affected both sexual and marital satisfaction (P < 0.005).ConclusionsThese data indicate that EHS is a simple, practical tool for clinical use. QEQ scores appear to be independently associated with sexual and marital satisfaction, and may be of value in the assessment and monitoring of ED patients. While ED is a common health problem in Taiwan and the prevalence of ED increases with age, affected men lack awareness regarding the presence of erectile problems and the importance of initiating timely and effective treatment. Hwang TIS, Tsai T-F, Lin Y-C, Chiang H-S, and Chang LS. A survey of erectile dysfunction in Taiwan: Use of the erection hardness score and quality of erection questionnaire.     

Vitamin D and Erectile Dysfunction

IntroductionEndothelial dysfunction has been demonstrated to play an important role in pathogenesis of erectile dysfunction (ED) and vitamin D deficiency is deemed to promote endothelial dysfunctions.AimTo evaluate the status of serum vitamin D in a group of patients with ED.MethodsDiagnosis and severity of ED was based on the IIEF‐5 and its aetiology was classified as arteriogenic (A‐ED), borderline (BL‐ED), and non‐arteriogenic (NA‐ED) with penile‐echo‐color‐Doppler in basal condition and after intracaversous injection of prostaglandin E1. Serum vitamin D and intact PTH concentrations were measured.Main Outcome MeasuresVitamin D levels of men with A‐ED were compared with those of male with BL‐ED and NA‐ED.ResultsFifty patients were classified as A‐ED, 28 as ED‐BL and 65 as NA‐ED, for a total of 143 cases. Mean vitamin D level was 21.3 ng/mL; vitamin D deficiency (<20 ng/mL) was present in 45.9% and only 20.2% had optimal vitamin D levels. Patients with severe/complete‐ED had vitamin D level significantly lower (P = 0.02) than those with mild‐ED. Vitamin level was negatively correlated with PTH and the correlation was more marked in subjects with vitamin D deficiency. Vitamin D deficiency in A‐ED was significantly lower (P = 0.01) than in NA‐ED patients. Penile‐echo‐color‐Doppler revealed that A‐ED (PSV ≤ 25 cm/second) was more frequent in those with vitamin D deficiency as compared with those with vitamin >20 ng/dL (45% vs. 24%; P < 0.05) and in the same population median PSV values were lower (26 vs. 38; P < 0.001) in vitamin D subjects.ConclusionOur study shows that a significant proportion of ED patients have a vitamin D deficiency and that this condition is more frequent in patients with the arteriogenic etiology. Low levels of vitamin D might increase the ED risk by promoting endothelial dysfunction. Men with ED should be analyzed for vitamin D levels and particularly to A‐ED patients with a low level a vitamin D supplementation is suggested. Barassi A, Pezzilli R, Colpi GM, Corsi Romanelli MM, and Melzi d'Eril GV. Vitamin D and erectile dysfunction. J Sex Med 2014;11:2792–2800.     

Increased composite maternal and neonatal morbidity associated with ultrasonographically suspected fetal macrosomia

Objective: To determine the composite risk of maternal and neonatal morbidity in pregnancies with suspected fetal macrosomia. Methods: In a retrospective study of laboring women delivering singleton, term neonates, we defined 3 groups of patients by estimated fetal weight (EFW) in grams, using ultrasound: (1) <4000, (2) 4000–4499, and (3) 4500+, and tested them for association with a composite outcome using multivariable logistic regression models. The measure of composite morbidity included: shoulder dystocia, third/fourth degree perineal laceration, postpartum hemorrhage, maternal length of stay (LOS)≥ 5 days, neonatal birth trauma, meconium aspiration syndrome, perinatal infection, and neonatal LOS ≥ 5 days. Because of potential interactions between diabetes and birthweight, women with maternal diabetes were examined separately. Results: Of 8,843 deliveries, the proportion with composite morbidity by group was: (1): 26.2%, (2): 41.2%, and (3): 63.6% (p < 0.0001). The OR (95% CI) for groups (2) and (3) were: 1.9 (1.2–2.9) and 2.1 (0.6–7.2), for diabetics (9.7% of the final study population), and 2.3 (1.9–2.7) and 3.9 (2.2–6.9), for non-diabetics. Conclusions: Suspected fetal macrosomia appeared associated with increased risk for a composite measure of childbirth morbidity.     

Role of Serum High-Sensitivity C-Reactive Protein as a Predictor of Therapeutic Response to Tadalafil in Patients With Erectile Dysfunction: A Prospective Observational Study

IntroductionHigh-sensitivity C-reactive protein (hs-CRP), a marker of inflammation, is known to be elevated in patients with erectile dysfunction (ED). However, its role in predicting therapeutic response to phosphodiesterase-5 inhibitors is incompletely understood.AimThe aim of this study was to understand the relationship among hs-CRP, mechanism of ED, and therapeutic response of ED to tadalafil, a phosphodiesterase-5 inhibitor.MethodsA total of 282 men (mean age 36.6 ± 12.0 years) with ED were included. All subjects underwent detailed evaluation, including estimation of a 6-item abbreviated version of the International Index of Erectile Function (IIEF-6) score, penile Doppler studies, and measurement of hs-CRP. IIEF-6 scoring and hs-CRP measurement were repeated after 6 weeks of tadalafil therapy (10 mg/day). The patients were categorized into vasculogenic and nonvasculogenic ED groups based on penile Doppler findings.Main Outcome MeasureThe main outcome measure was the therapeutic response to tadalafil, in relation to the mechanism of ED and hs-CRP levels.ResultsVasculogenic ED was much less common (23.8% of the subjects) than non-vasculogenic ED. Subjects with vasculogenic ED were older, had higher prevalence of cardiovascular risk factors, had more severe (mean IIEF-6 score 9.2 ± 4.6 vs 14.8 ± 4.7; P < .001) and longer duration ED, and responded less favorably to therapy (response rate 10.4% vs 75.0%; P < .001). Those showing improvement with tadalafil had lower hs-CRP at baseline (median 1.5 mg/L [interquartile range 0.9?2.3] vs 2.0 mg/L [interquartile range 1.1?3.1; P = .034]) and had proportionately greater reduction in its level. However, on multivariate analysis, only shorter duration of ED (P = .008), non-vasculogenic origin (P = .025), and higher IIEF-6 score at baseline (P = .013) were independent predictors of response to treatment.Clinical ImplicationsSerum hs-CRP is elevated in patients who are less likely to respond to vasodilator therapy but does not have an independent predictive value for this purpose.Strengths & LimitationsThis is the largest study to evaluate the relationship among the mechanism of ED, serum hs-CRP level, and therapeutic response of ED to tadalafil. All patients underwent a penile Doppler study to characterize the type of ED. The limitations were nonrandomized nature of the study and nearly 22% dropout rate.ConclusionSerum hs-CRP level is higher in vasculogenic ED compared with non-vasculogenic ED, and is associated with poorer response to tadalafil therapy. However, this association is not independent of underlying risk factors and mechanism of ED.Jamaluddin, Bansal M, Srivastava GK, et al. Role of Serum High-Sensitivity C-Reactive Protein as a Predictor of Therapeutic Response to Tadalafil in Patients With Erectile Dysfunction: A Prospective Observational Study. J Sex Med 2019;16:1912–1921.     

Incidence of exit-site infection with various exchange systems in continuous ambulatory peritoneal dialysis.

BACKGROUND AND PURPOSE: The disconnect twin-bag (TB) system was first introduced in Taiwan for use as an exchange system in continuous ambulatory peritoneal dialysis (CAPD) in 1995. Following its introduction, the incidence of CAPD-associated peritonitis declined, but the incidence of exit-site infection (ESI) increased. To determine the cause of the increase in ESI incidence after the introduction of the TB system, this study compared the incidence of ESI among patients using the O set, ultraviolet antiseptic (UV) device, and the TB system. METHODS: A total of 170 patients who had received CAPD for more than 3 months were enrolled in this study. Poisson test and Kaplan-Meier survival analysis were used to compare the ESI incidence and ESI-free catheter survival among patients using the O set, UV device, or TB system. Cox stepwise forward proportional hazard analysis was used to assess the impact of sex, education, cause of uremia, age, and type of exchange system on ESI. RESULTS: The incidences of ESI differed significantly among patients using the three exchange systems, with 20.9, 13.8, and 4.0 episodes per 100 patient-years for patients using the TB system, O set, and UV device, respectively. New patients using the TB system also had a shorter mean interval of ESI-free catheter survival than those using the UV device (26.9 vs 58.8 months, p = 0.002). In the Cox stepwise forward proportional hazard analysis, non-lupus patients had a lower risk of developing ESI than lupus patients (relative risk [RR] 0.40, p = 0.03). The RR of ESI in patients using the UV device was also lower than in those using the TB system (RR 0.15, p < 0.01). CONCLUSION: In this study, use of the TB system was associated with a higher incidence of ESI. The increased ESI incidence may be related to the heavier mini-transfer set of the TB system. Therefore, special attention should be given to fastening the mini-transfer set tightly during the exchanging procedure to prevent traction on the exit-site, which is associated with an increased incidence of subsequent ESI.     

Laparoscopic Surgery for Endometrial Cancer: Why Don’t All Patients Go Home the Day After Surgery?

Study ObjectiveTo identify risk factors for hospital length of stay (LOS) longer than 1 postoperative day in patients undergoing laparoscopic hysterectomy because of endometrial cancer.DesignRetrospective observational study (Canadian Task Force classification II-2).SettingTertiary-care university hospital.PatientsOne hundred thirty-three patients undergoing laparoscopic hysterectomy because of endometrial cancer between August 2006 and August 2010.InterventionsOne hundred thirty-three women underwent traditional laparoscopy. In 101 of these patients, lymph node sampling was performed.Measurements and Main OutcomesSeventy-four women (55%) were discharged on postoperative day 1. The percentage of women discharged on postoperative day 1 (POD1) vs after POD 1 did not differ by extent of staging. Risk of perioperative complications was associated with hospital LOS longer than POD1 (odds ratio [OR], 11.45; 95% confidence interval [CI], 1.40–94.39). Procedure start time after 3:00 pm (OR, 3.20; 95% CI, 1.14–9.04) and procedure end time after 5:00 pm (OR, 2.47; 95% CI, 1.17–5.20) were independent factors associated with hospital LOS beyond POD1. There was a nonsignificant tendency toward later hospital discharge with administration of intravenous narcotic agents.ConclusionsLaparoscopic surgery to treat endometrial cancer should be preferentially scheduled early in the day to facilitate discharge on POD1. The extent of staging lymphadenectomy performed does not increase hospital stay beyond POD1.     

Erectile Dysfunction after Sickle Cell Disease–Associated Recurrent Ischemic Priapism: Profile and Risk Factors

IntroductionRisk factors associated with erectile dysfunction (ED) that results from recurrent ischemic priapism (RIP) in sickle cell disease (SCD) are incompletely defined.AimThis study aims to determine and compare ED risk factors associated with SCD and non‐SCD‐related “minor” RIP, defined as having ≥2 episodes of ischemic priapism within the past 6 months, with the majority (>75%) of episodes lasting <5 hours.MethodsWe performed a retrospective study of RIP in SCD and non‐SCD patients presenting from June 2004 to March 2014 using the International Index of Erectile Function (IIEF), IIEF‐5, and priapism‐specific questionnaires.Main Outcome MeasuresPrevalence rates and risk factor correlations for ED associated with RIP.ResultsThe study was comprised of 59 patients (40 SCD [mean age 28.2 ± 8.9 years] and 19 non‐SCD [15 idiopathic and four drug‐related etiologies] [mean age 32.6 ± 11.7 years]). Nineteen of 40 (47.5%) SCD patients vs. four of 19 (21.1%) non‐SCD patients (39% overall) had ED (IIEF <26 or IIEF‐5 <22) (P = 0.052). SCD patients had a longer mean time‐length with RIP than non‐SCD patients (P = 0.004). Thirty of 40 (75%) SCD patients vs. 10 of 19 (52.6%) non‐SCD patients (P = 0.14) had “very minor” RIP (episodes regularly lasting ≤2 hours). Twenty‐eight of 40 (70%) SCD patients vs. 14 of 19 (73.7%) non‐SCD patients had weekly or more frequent episodes (P = 1). Of all patients with very minor RIP, ED was found among 14 of 30 (46.7%) SCD patients vs. none of 10 (0%) non‐SCD patients (P = 0.008). Using logistic regression analysis, the odds ratio for developing ED was 4.7 for SCD patients, when controlling for RIP variables (95% confidence interval: 1.1–21.0).ConclusionsED is associated with RIP, occurring in nearly 40% of affected individuals overall. SCD patients are more likely to experience ED in the setting of “very minor” RIP episodes and are five times more likely to develop ED compared with non‐SCD patients. Anele UA and Burnett AL. Erectile dysfunction after sickle cell disease–associated recurrent ischemic priapism: Profile and risk factors. J Sex Med 2015;12:713–719.     

Obstetric and fetal triage

Triage in healthcare is sorting patients by acuity to prioritize them for full evaluation. Standardizing this process with the use of triage acuity classification tools has been shown to improve patient flow and quality of care in the emergency department. The American College of Obstetricians and Gynecologists recommends that pregnant women be triaged based on acuity, rather than time of arrival, and that obstetric triage acuity scales can serve as templates for use at the facility level. Three obstetric triage acuity scales developed in North America are reviewed and the implementation of one in a system with 40 birth hospitals is described. Use of obstetric triage acuity scales resulted in timelier initial assessment and decreased wait times. Acuity, volume, and trends data helped improve nurse and provider staffing in triage units. These findings support the promise of obstetric triage acuity scales to promote efficient care.     

Influence of Vascular Comorbidities and Race on Erectile Dysfunction after Prostate Cancer Radiotherapy

IntroductionVascular comorbidities (VC) (hypertension, diabetes, and hyperlipidemia) are known factors related to erectile dysfunction (ED) in men. However, no data are yet available for the effects of VC on ED incidence after prostate cancer radiotherapy (XRT).AimTo investigate the influence of VC on post‐XRT ED incidence and to further characterize ED incidence by racial groups.Main Outcome MeasuresED incidence.MethodsWe reviewed 732 charts of patients (267 Caucasian and 465 African American [AA]) who received prostate XRT (external beam radiotherapy and/or brachytherapy) with or without hormone therapy between 1999 and 2010. The number of pre‐XRT VC (0, 1, 2, or 3) was determined by medical history and medication list. ED (defined by use of erectile aids or by documentation of moderate or high sexual dysfunction on patient history) was determined pre‐XRT as well as 1, 2, and 4 years post‐XRT.ResultsED incidence progressively increased from 22% pre‐XRT to 58% 4 years post‐XRT (P < 0.01). Additionally, ED incidence significantly increased with number of VC—4‐year incidence between patients with 1 vs. 0 (P = 0.02), 2 vs. 0 (P < 0.01), 3 vs. 0 (P < 0.01), 3 vs. 1 (P < 0.01), and 3 vs. 2 (P = 0.04) VC (2 vs. 1 VC was nonsignificant). Compared with the Caucasian patients, ED incidences were slightly higher for the AA group with 0, 1, 2, and 3 comorbidities at 4 years follow‐up (but statistically nonsignificant).ConclusionsThe number of VCs have a significant effect on development of post‐XRT ED. Pre‐ and post‐XRT ED appear to be independent of race when number of VCs are considered. Our results can be used to guide physicians in counseling patients on the incidence of ED by number of VC and as preliminary data for prospective efforts aimed at reducing post‐XRT ED. Wang Y, Liu T, Rossi PJ, Watkins‐Bruner D, Hsiao W, Cooper S, Yang X, and Jani AB. Influence of vascular comorbidities and race on erectile dysfunction after prostate cancer radiotherapy. J Sex Med 2013;10:2108–2114.     

Can delivery room management impact the length of hospital stay in premature infants?

OBJECTIVES: To evaluate the impact of initiating early nasal continuous positive airway pressure (ENCPAP) on the length of hospital stay (LOS) for the very low birth weight (VLBW) infants. STUDY DESIGN: LOS at the George Washington University Hospital (GW) after the institution of ENCPAP policy was compared to benchmark values using two-tail t-tests. The incidence of neonatal morbidity was calculated using Bonferroni corrected 95% confidence interval as compared to benchmark rates (alpha=0.001). Comparisons were repeated after stratification of the population into four birth weight subcategories: group A (GrpA) (501 to 750 g), GrpB (751 to 1000 g), GrpC (1001 to 1250 g) and GrpD (1251 to 1500 g). RESULTS: We studied 228 consecutive VLBW infants (birth weight: 995+/-294 g and gestational age: 27.7+/-2.7 weeks). Compared to benchmark values, the GW experience was associated with a significant reduction of 5.1 days in LOS (55.9+/-25.2 vs 61+/-32 days; P=0.04). The decrease in LOS was consistent in all subgroups, but was most noticeable in infants of the smallest weight subcategory (LOS in GrpA=86+/-21 vs 104+/-32, P=0.004; in GrpB=69.9+/-16.7 vs 79+/-27, P=0.018; in GrpC=48.2+/-13 vs 56+/-22, P<0.001 and in GrpD=31.7+/-12.5 vs 40+/-19, P=0.003).In the overall population, a lower incidence of chronic lung disease (CLD) (17.8 vs 29%, P<0.001) was also noted. There were no differences in mortality rates (9 vs 14%), or the incidence of necrotizing enterocolitis (NEC) (8 vs 6%) or intraventricular hemorrhage (6.2 vs 9%) between GW and the established benchmark rates. CONCLUSION: ENCPAP may reduce LOS in VLBW infants in our study population. This relatively shorter LOS was associated with a lower incidence of CLD, which may be a contributing factor.     

Management and Outcome of Reduced Fetal Movements—is Ultrasound Necessary?

Objective

To review the management and outcome of pregnancies of women presenting to obstetrical triage with decreased fetal movements (DFM).

Choosing the best candidates for penile rehabilitation after bilateral nerve-sparing radical prostatectomy

IntroductionControversy exists regarding the ideal candidates for penile rehabilitation after bilateral nerve‐sparing radical prostatectomy (BNSRP).AimTo test the effect of penile rehabilitation according to preoperative patient characteristics.MethodsWe included 435 consecutive patients treated with BNSRP between 2004 and 2008. Preoperative age, International Index of Erectile Function (IIEF) and Charlson Comorbidity Index (CCI) were used to subdivide patients into three groups according to foreseen risk of erectile dysfunction (ED) after surgery: low (age ≤65, IIEF‐erectile function (EF) ≥26, CCI ≤1; N = 184), intermediate (age 66–69 or IIEF‐EF 11–25, CCI ≤1; N = 115), and high (age ≥70 or IIEF‐EF ≤10 or CCI ≥2; N = 136). The Kaplan–Meier method was used to test the difference in EF recovery rates among patients left untreated after surgery (N = 193), those receiving on‐demand phosphodiesterase type 5 inhibitors (PDE5‐I; N = 147), and those treated with chronic use of PDE5‐I (taken every day or every other day for 3–6 months; N = 95). The same analyses were repeated within each risk category.Main Outcome MeasureErectile function (EF) was evaluated using the International Index of Erectile Function (IIEF). Recovery of EF after BNSRP was defined as an IIEF‐EF domain score ≥22.ResultsNo difference in terms of EF recovery was found between patients receiving on‐demand vs. daily PDE5‐I (P = 0.09) in the overall population. Similarly, comparable efficacy of the two treatment schedules (on‐demand vs. chronic) was demonstrated in patients with low and high risk of ED (all P ≥ 0.8). Conversely, daily therapy with PDE5‐I showed significantly higher efficacy for the EF recovery rate compared with the on‐demand PDE5‐I administration schedule in patients with intermediate risk of ED (3‐year EF recovery: 74% vs. 52%, respectively; P = 0.02).Conclusions.The ideal candidates for penile rehabilitation after surgery are patients at intermediate risk of ED. Briganti A, Di Trapani E, Abdollah F, Gallina A, Suardi N, Capitanio U, Tutolo M, Passoni N, Salonia A, DiGirolamo V, Colombo R, Guazzoni G, Rigatti P, and Montorsi F. Choosing the best candidates for penile rehabilitation after bilateral nerve‐sparing radical prostatectomy. J Sex Med 2012;9:608–617.