Diabetes and sexual dysfunction: results from the Olmsted County study of urinary symptoms and health status among men

PURPOSE: We examined the association of diabetes and domains of sexual dysfunction in a population based sample of men residing in Olmsted County, Minnesota. MATERIALS AND METHODS: A cohort of 2,115 white men 40 to 79 years old as of January 1, 1990 was randomly selected from the Olmsted County population. Men who had a history of prostate or bladder surgery, urethral surgery or stricture, or medical or other neurological condition that could affect normal urinary function were excluded from analysis. Diabetes itself was not used as an exclusionary criterion, although those with end stage organ failure as a result of diabetes were excluded. A previously validated male sexual function index was included in the questionnaires administrated to the cohort in 1996, which consisted of 11 questions on the 5 sexual function domains of sexual drive, erectile function, ejaculatory function, sexual problem assessment and sexual satisfaction. The baseline questionnaire also included whether they had ever been diagnosed by a physician as having diabetes. Only men with regular sexual partners were included. RESULTS: Individuals with diabetes at baseline had significantly greater dysfunction in all 5 sexual function domains. In multivariate adjusted analyses diabetes was significantly associated with all sexual dysfunction domains. The associations remained significant after adjusting for numerous predictors of sexual dysfunction. CONCLUSIONS: The presence of diabetes at baseline was significantly associated not only with erectile dysfunction but with all aspects of sexual dysfunction, including sexual drive, ejaculatory function, sexual problems and sexual satisfaction in this population based sample of men residing in Olmsted County.     

Minimally invasive treatment of ureteropelvic junction obstruction: long-term experience with an algorithm for laser endopyelotomy and laparoscopic retroperitoneal pyeloplasty

PURPOSE: First line treatment of ureteropelvic junction obstruction is still open dismembered pyeloplasty. The development of videoendoscopic techniques like endopyelotomy and laparoscopy offers less invasive alternatives. The long-term outcome of an algorithm selectively using these techniques is presented. MATERIALS AND METHODS: From February 1995 to March 2006, 256 patients with ureteropelvic junction obstruction were treated with 113 laser endopyelotomies and 143 laparoscopic retroperitoneal pyeloplasties. According to changing selection criteria, an early group (92 in 1995 to 1999) treated with laser endopyelotomy for extrinsic as well as intrinsic stenoses, and a late group (164 in 2000 to 2006) treated with laser endopyelotomy for intrinsic stenosis, were evaluated. In the late group extrinsic ureteropelvic junction obstruction was treated with nondismembered pyeloplasty in cases of anteriorly and by dismembered pyeloplasty in cases of posteriorly crossing vessels or a redundant renal pelvis. RESULTS: Operating time of laser endopyelotomy averaged 34 (range 10 to 90) minutes with a complication rate of 5.3% and a success rate of 72.6% (intrinsic 85.7% vs extrinsic 51.4%). Operating time of laparoscopic retroperitoneal pyeloplasty averaged 124 (range 37 to 368) minutes with a 6.3% complication rate and an overall success rate of 94.4% (intrinsic 100% vs extrinsic 93.8%). In the late group the LAP success rate was 98.3% with no significant differences related to the cause of ureteropelvic junction obstruction (intrinsic 100% vs extrinsic 98.1%) or the type of pyeloplasty (YV plasty 97.0% vs Anderson-Hynes 97.7%). CONCLUSIONS: Laparoscopic retroperitoneal pyeloplasty yields an efficacy similar to that of open surgery. The inferior success of laser endopyelotomy even in optimally selected cases and the increasing expertise with endoscopic suturing may favor laparoscopic pyeloplasty with or without robotic assistance in the future.     

Encouraging patients to self‐care – the preliminary development and validation of the VeLUSET©, a self‐efficacy tool for venous leg ulcer patients,aged 60 years and over

Venous leg ulceration has a high recurrence rate. Patients with healed or frequently recurring venous ulceration are required to perform self‐care behaviours to prevent recurrence or promote healing, but evidence suggests that many find these difficult to perform. Bandura's self‐efficacy theory is a widely used and robust behaviour change model and underpins many interventions designed to promote self‐care in a variety of chronic conditions. By identifying areas where patients may experience difficulty in performing self‐care, interventions can be developed to strengthen their self‐efficacy beliefs in performing these activities successfully. There are currently a variety of self‐efficacy scales available to measure self‐efficacy in a variety of conditions; but not a disease‐specific scale for use with venous ulcer patients. The aim of this study, therefore, was to develop and validate a disease‐specific, patient‐focused self‐efficacy scale for patients with healed venous leg ulceration. This scale will need further validation studies; however, it is ready for use in clinical practice and will enable practitioners to identify those patients who may need additional support in performing self‐care activities to prevent recurrence.     

Automated individualization of dialysate sodium concentration reduces intradialytic plasma sodium changes in hemodialysis

In standard care, hemodialysis patients are often treated with a center‐specific fixed dialysate sodium concentration, potentially resulting in diffusive sodium changes for patients with plasma sodium concentrations below or above this level. While diffusive sodium load may be associated with thirst and higher interdialytic weight gain, excessive diffusive sodium removal may cause intradialytic symptoms. In contrast, the new hemodialysis machine option “Na control” provides automated individualization of dialysate sodium during treatment with the aim to reduce such intradialytic sodium changes without the need to determine the plasma sodium concentration. This proof‐of‐principle study on sodium control was designed as a monocentric randomized controlled crossover trial: 32 patients with residual diuresis of ≤1000 mL/day were enrolled to be treated by high‐volume post‐dilution hemodiafiltration (HDF) for 2 weeks each with “Na control” (individually and automatically adjusted dialysate sodium concentration) versus “standard fixed Na” (fixed dialysate sodium 138 mmol/L), in randomized order. Pre‐ and post‐dialytic plasma sodium concentrations were determined at bedside by direct potentiometry. The study hypothesis consisted of 2 components: the mean plasma sodium change between the start and end of the treatment being within ±1.0 mmol/L for sodium‐controlled treatments, and a lower variability of the plasma sodium changes for “Na control” than for “standard fixed Na” treatments. Three hundred seventy‐two treatments of 31 adult chronic hemodialysis patients (intention‐to‐treat population) were analyzed. The estimate for the mean plasma sodium change was ?0.53 mmol/L (95% confidence interval: [?1.04; ?0.02] mmol/L) for “Na control” treatments and ?0.95 mmol/L (95% CI: [?1.76; ?0.15] mmol/L) for “standard fixed Na” treatments. The standard deviation of the plasma sodium changes was 1.39 mmol/L for “Na control” versus 2.19 mmol/L for “standard fixed Na” treatments (P = 0.0004). Whereas the 95% CI for the estimate for the mean plasma sodium change during “Na control” treatments marginally overlapped the lower border of the predefined margin ±1.0 mmol/L, the variability of intradialytic plasma sodium changes was lower during “Na control” versus “standard fixed Na” treatments. Thus, automated dialysate sodium individualization by “Na control” approaches isonatremic dialysis in the clinical setting.     

A decision-analytic economic evaluation of valaciclovir prophylaxis for the prevention of cytomegalovirus infection and disease in renal transplantation

OBJECTIVE: This analysis evaluates the cost-effectiveness of valaciclovir prophylaxis using clinically and economically important health outcomes including graft failure, life-years, and quality-adjusted life-years (QALYs). METHODS: A Markov model was developed using a randomized, placebo-controlled trial of valaciclovir prophylaxis, together with a published epidemiological study and national renal transplant registry data. The model's population was stratified into two risk groups by donor/recipient cytomegalovirus (CMV) serostatus at transplantation: donor-positive/recipient-negative (D+R-) and recipient-positive (R+) patients. The model estimated costs and health outcomes over a 30-yr period from the perspective of Australian health care providers. RESULTS: The total health care cost was $3619 lower for D+R- patients receiving valaciclovir prophylaxis compared with those not receiving prophylaxis. D+R- patients receiving valaciclovir gained an extra 0.33 yr of life and 0.27 QALYs. R+ patients receiving valaciclovir prophylaxis gained an extra 0.07 yr of life and 0.05 QALYs, with an incremental cost of $914. This equates to $17 127 per QALY gained, which is highly cost-effective compared with other drugs and health interventions. CONCLUSIONS: Valaciclovir for the prophylaxis of CMV disease in renal transplant recipients is a cost-effective intervention, significantly reducing the burden of CMV disease to patients and health care providers.     

Arteriovenous brain malformations: is functional MR imaging reliable for studying language reorganization in patients? Initial observations

PURPOSE: To determine whether the blood flow abnormalities frequently associated with arteriovenous malformations (AVMs) can alter functional magnetic resonance (MR) imaging evaluation of language lateralization and whether reorganization of language function occurs in patients with brain AVMs. MATERIALS AND METHODS: Eleven patients with left-hemisphere brain AVMs and 10 age-matched control subjects were examined with 1.5-T blood oxygen level-dependent (BOLD) functional MR imaging. Verbal fluency, sentence repetition, and story listening tasks were performed. The functional MR imaging laterality index in the frontal and temporal lobes was defined as the (L - R)/(L + R) ratio, where L and R are the numbers of activated pixels in the left and right hemispheres, respectively. Statistical analyses were performed with Wilcoxon signed rank, Fisher exact, and Kruskal-Wallis tests. RESULTS: Control subjects had left-sided language dominance, although symmetric pixel counts were observed in the frontal lobes in two subjects and in the temporal lobes in one subject. Six patients had left-sided language dominance similar to that observed in control subjects. Five of these patients had AVMs outside frontal or temporal language areas, without flow abnormalities. Five patients had abnormally right-sided asymmetric indexes (below mean control subject value - 2 SDs), which suggested language reorganization (P <.05). Results of Wada examination and/or postembolization functional MR imaging performed in two of these patients showed that the abnormal laterality indexes were at least partly due to severe flow abnormalities that impaired detection of BOLD MR imaging signal intensity. CONCLUSION: These data suggest that flow abnormalities may interfere with language lateralization assessment with functional MR imaging.     

Prevalence,incidence, and natural course of anorexia and bulimia nervosa among adolescents and young adults

We aimed to assess the prevalence, incidence, age-of-onset and diagnostic stability of threshold and subthreshold anorexia nervosa (AN) and bulimia nervosa (BN) in the community. Data come from a prospective-longitudinal community study of 3021 subjects aged 14–24 at baseline, who were followed up at three assessment waves over 10 years. Eating disorder (ED) symptomatology was assessed with the DSM-IV/M-CIDI at each wave. Diagnostic stability was defined as the proportion of individuals still affected with at least symptomatic eating disorders (EDs) at follow-ups. Baseline lifetime prevalence for any threshold ED were 2.9 % among females and 0.1 % among males. For any subthreshold ED lifetime prevalence were 2.2 % for females and 0.7 % for males. Symptomatic expressions of EDs (including core symptoms of the respective disorder) were most common with a lifetime prevalence of 11.5 % among females and 1.8 % among males. Symptomatic AN showed the earliest onset with a considerable proportion of cases emerging in childhood. 47 % of initial threshold AN cases and 42 % of initial threshold BN cases showed at least symptomatic expressions of any ED at any follow-up assessment. Stability for subthreshold EDs and symptomatic expressions was 14–36 %. While threshold EDs are rare, ED symptomatology is common particularly in female adolescents and young women. Especially threshold EDs are associated with a substantial risk for stability. A considerable degree of symptom fluctuation is characteristic especially for subthreshold EDs.     

Stroke volume measurements with first-pass dynamic positron emission tomography: Comparison with cardiovascular magnetic resonance

Background  The assessment of forward stroke volume (SV) using dynamic, first-pass cardiac positron emission tomography (PET) was shown to be feasible in a limited number of studies with small numbers of subjects. The aim of this study was to compare first-pass derived SV with cardiovascular magnetic resonance imaging (CMR)-obtained values in a larger population of subjects. Methods and Results  Fifty-nine subjects with varying degrees of cardiac function were studied. Stroke volume was assessed using oxygen-15-labeled water (H₂ ¹⁵O) dynamic first-pass PET for both the right ventricle (RV) and left ventricle (LV), and compared with the findings of aorta velocity-encoded phase-contrast CMR. The PET-estimated SV was higher for the RV than for the LV (133±34 vs 116±31 mL, P<.01, ±SD), and both were higher compared with values obtained by CMR (81±20 mL, both P<.01,±SD). Although significant, the correlations between PET and CMR were moderate for both the RV (r=0.37, P<.01) and the LV (r=0.40, P<.01,±SD). Bland-Altman analysis revealed a progressive overestimation with increasing SV measured in either ventricle. Conclusions  First-pass dynamic H₂ ¹⁵O PET for the assessment of forward SV is feasible, although values are progressively overestimated with increasing SV, particularly when the RV is used, and correlations with aorta velocity-encoded phase-contrast CMR are moderate. These findings are probably protocol-dependent and warrant further study before the use of first-pass dynamic H₂ ¹⁵O PET in clinical or research settings can be advocated.     

Treatment of stress urinary incontinence using polyacrylamide hydrogel in women after radiotherapy: 1-year follow-up

Introduction and hypothesis

Information on urethral bulking therapy in women after previous pelvic radiotherapy is lacking. This study compared the safety and efficacy of polyacrylamide intraurethral injections in patients with and without previous radiotherapy.

Methods

A total of 46 patients with severe stress urinary incontinence (SUI) were enrolled in this multicenter prospective trial. Group A consisted of 24 patients with previous radiotherapy to the pelvis for the treatment of a gynaecological malignancy. Group B consisted of 22 patients without previous radiotherapy. All patients were treated with a transurethral injection of a bulking solution (Bulkamid). The average follow-up was 12.4 months. The paired Wilcoxon test was used to compare the results before and after the procedure within the groups, and the two-sample Wilcoxon test was used for comparisons between groups.

Results

Complete continence was achieved in 25 % of patients in group A and in 36.4 % of patients in group B. Significantly reduced urine leakage was observed in both groups (p?=?0.0164 in group A and p?=?0.0002 in group B). The total scores in the International Consultation on Incontinence Questionnaire decreased by 5.2 in group A (p?=?0.0000) and 6.36 in group B (p?=?0.0001). The scores for the Total Patient Perception of Bladder Condition decreased by 1.54 in group A (p?=?0.0001) and 2.59 in group B (p?=?0.0000), with a significant difference between groups (p?=?0.0224). No clinically significant changes in urodynamic parameters were observed. No severe adverse events were noted.

Conclusions

Based on our results, we conclude that urethral bulking therapy is a valuable treatment option in patients with severe SUI who have undergone pelvic radiotherapy for the treatment of gynaecological malignancy.