Exploration of the association between chronic periodontal disease and erectile dysfunction from a population‐based view point

Several cross‐sectional studies have indicated an association between chronic periodontal disease (CPD) and cardiovascular disease and metabolic syndrome. Erectile dysfunction (ED) also shares pathological mechanisms with these diseases. Using a nationwide population‐based data set, we examined the association between ED and CPD and assessed the effect of dental extraction (DE) on ED prevalence in different aged CPD populations in Taiwan. We identified 5105 patients with ED and randomly selected 10 210 patients as controls. Of these patients, 2617 (17.09%) were diagnosed with CPD according to the index data: 1196 (23.43%) in the ED group and 1421 (13.92%) in the control group. After adjusting for comorbid factors, patients with ED were more likely to have been diagnosed with prior CPD than controls (OR = 1.79, 95% CI = 1.64–1.96, P < 0.001). Moreover, the association was much stronger in the populations aged less than 30 years (OR = 2.13, 95% CI = 1.23–3.70, P < 0.001) and more than 59 years (OR = 2.27, 95% CI = 1.99–2.59, P < 0.001). Dental extraction seems to attenuate damage to the penile endothelial beds caused by CPD‐related inflammation and overcame the process of ED in the middle‐aged and older populations.     

Surgical Management of Intracranial Neuroenteric Cysts: The UCSF Experience

Objective Modern surgical experience with intracranial neuroenteric cysts is limited in the literature. We review our 15-year institutional experience with these rare lesions. Design Single-institution retrospective study. Setting Large North American tertiary care center. Participants Histologically confirmed cases of intracranial neuroenteric cyst from January 2000 to September 2014. Main Outcome Measures Pre- and postoperative modified Rankin Scale (mRS) scores, extent of resection, and postoperative complications are reported. Clinical presentation, imaging features, pathology, and operative approach are discussed. Results Five spinal and six intracranial neuroenteric cysts were surgically treated over a 15-year period. Median age at presentation for the intracranial cysts was 38.5 years. Mean cyst diameter was 3.8 cm. Five cysts were located in the pre-pontomedullary cistern, and one was located in the third ventricle. Gross total resection was achieved in four of the five posterior fossa cysts through a far lateral transcondylar approach. Postoperative complications included aseptic meningitis (one), transient abducens palsy (one), and pseudomeningocele requiring reoperation (three). Postoperative mRS scores improved to ≤1 by 6.5 months median follow-up. Conclusions Intracranial neuroenteric cysts are rare lesions with a variable imaging appearance. Complete surgical resection through a far lateral transcondylar approach is possible and usually results in symptom improvement or resolution.     

A proposed set of metrics for standardized outcome reporting in the management of low back pain

Background and purpose

Outcome measurement has been shown to improve performance in several fields of healthcare. This understanding has driven a growing interest in value-based healthcare, where value is defined as outcomes achieved per money spent. While low back pain (LBP) constitutes an enormous burden of disease, no universal set of metrics has yet been accepted to measure and compare outcomes. Here, we aim to define such a set.

Patients and methods

An international group of 22 specialists in several disciplines of spine care was assembled to review literature and select LBP outcome metrics through a 6-round modified Delphi process. The scope of the outcome set was degenerative lumbar conditions.

Results

Patient-reported metrics include numerical pain scales, lumbar-related function using the Oswestry disability index, health-related quality of life using the EQ-5D-3L questionnaire, and questions assessing work status and analgesic use. Specific common and serious complications are included. Recommended follow-up intervals include 6, 12, and 24 months after initiating treatment, with optional follow-up at 3 months and 5 years. Metrics for risk stratification are selected based on pre-existing tools.

Interpretation

The outcome measures recommended here are structured around specific etiologies of LBP, span a patient’s entire cycle of care, and allow for risk adjustment. Thus, when implemented, this set can be expected to facilitate meaningful comparisons and ultimately provide a continuous feedback loop, enabling ongoing improvements in quality of care. Much work lies ahead in implementation, revision, and validation of this set, but it is an essential first step toward establishing a community of LBP providers focused on maximizing the value of the care we deliver.Measurement of outcomes in healthcare has well documented benefits as well as challenges (Porter 2005, Institute of Medicine 2006). Simply asking providers to report their outcomes has been shown to improve performance (Porter et al. 2010). Additionally, understanding one’s results empowers a provider to continuously learn from and refine the care he or she delivers (Porter and Teisberg 2004). On a broad scale, outcome reporting also facilitates dissemination of best practices between physicians and makes it possible to compare the quality delivered by different providers, allowing patients to make intelligent choices about where to seek care (Porter and Teisberg 2004). This type of continuous improvement and informed decision making could be an important driving force in improving healthcare delivery by refocusing the system on value (defined as the outcomes of care divided by the cost). The concept of “value-based healthcare” has been gaining attention both throughout the medical field (Porter and Teisberg 2005, Porter 2009) and specifically within the realm of spine care (McGirt et al. 2014a, 2014b). With evolving reimbursement systems in many countries, it is also conceivable that there will be growing interest in “value-based reimbursement” in the future, with payment levels adjusted based on outcomes. This type of scheme will only be fair with a broadly-accepted and risk-adjusted set of outcome metrics.Low back pain (LBP) is a growing problem and constitutes a major component of the global burden of disease (Murray et al. 2012). Measuring outcomes in the field of low back pain is challenging. Numerous disease states affect the lower back, resulting in low back pain, leg pain, or both; to compare outcomes, patients must be accurately stratified by both diagnosis and severity. Moreover, existing treatment algorithms are complex and often controversial, including both operative and nonoperative options and frequently requiring multidisciplinary provider teams. Additionally, low back pain rarely causes death or other objective endpoints, so outcomes are best measured with patient-reported metrics, which are inherently subjective and require thorough psychometric testing.A substantial amount of work on the design of outcome metrics has already been done in the field of low back pain, and there are several well-validated tools for measuring disease-specific outcomes (Longo et al. 2010). Similarly, several large registries are already in existence, collecting outcomes along with many other data points (Röder et al. 2005, McGirt et al. 2013, Strömqvist et al. 2013, add later spine registry study, will be published in the same issue). Previous consensus-based efforts have been made to define sets of outcome measures or domains for research purposes (Deyo et al. 1998, Pincus et al. 2008, Chiarotto et al. 2014, Deyo et al. 2014). Still, the field of low back pain care has not yet developed a universal international set of outcomes to be measured and compared as a part of standard clinical practice. This type of outcome set requires availability and validity in many languages, requires capacity for case-mix adjustment to ensure that comparisons are made fairly, and should focus on the outcomes that matter most to patients. The purpose of this study was to define such a set based on international and interdisciplinary expert and patient opinion.     

Sphenoid sinus pseudoaneurysm with carotid cavernous fistula presenting with delayed subarachnoid hemorrhage: A case report

Rationale:Sphenoid sinus pseudoaneurysm arising from the cavernous segment of the internal carotid artery (ICA) caused by traumatic vessel injury is rare, and rarer is a concomitant carotid-cavernous fistula (CCF). In particular, delayed subarachnoid hemorrhage (SAH) due to pseudoaneurysm rupture has not been reported to-date in literature. Here, we report a case of sphenoid sinus pseudoaneurysm with CCF presenting with delayed SAH.Patient concerns:A 73-year-old man presented with traumatic brain injury due to motorcycle accident.Diagnoses:Twenty-four days after admission, the patient''s neurological status suddenly deteriorated. Brain computed tomography (CT) showed acute SAH along interhemispheric cisterns and suprasellar intracerebral hematoma. Brain CT angiography and digital subtraction angiography revealed giant sphenoid sinus pseudoaneurysm with CCF and the daughter sac of the pseudoaneurysm extended to the intracranial part via fracture in the superior wall of the sphenoid sinus.Interventions:As the sphenoid sinus pseudoaneurysm and CCF shared one rupture point, endovascular treatment with intraarterial approach using coil and liquid embolic material by balloon assisted technique was performed simultaneously.Outcomes:The origin of the pseudoaneurysmal sac and CCF was sufficiently blocked after injection of liquid embolic material and the lesions completely resolved immediately after endovascular treatment.Lessons:Sphenoid sinus pseudoaneurysm and CCF rarely occur following head trauma through a series of processes involving fracture of the lateral wall of the sphenoid sinus and ICA cavernous segment injury. Sphenoid sinus pseudoaneurysm may present as SAH through intracranial rupture with concomitant superior wall fracture of the sphenoid sinus. Therefore, early diagnosis using CT or magnetic resonance angiography and appropriate treatment through understanding the disease mechanism is necessary.