Comparison of the efficacy of low-intensity shock wave therapy and its combination with platelet-rich plasma in patients with erectile dysfunction

We aimed to compare the efficacy of low-intensity shock wave therapy (Li-SWT) alone and its combination with platelet-rich plasma (PRP) in the treatment of patients with erectile dysfunction (ED). Between January 2015 and October 2020, patients who did not benefit from the use of phosphodiesterase type 5 inhibitors (PDE5i; 5 mg/day) for at least 3 months and underwent Li-SWT or Li-SWT with PRP were evaluated retrospectively. There were 93 patients who were subjected to Li-SWT only (Group 1) and 91 patients subjected to Li-SWT with PRP (Group 2). Analysis of the International Index of Erectile Function-Erectile Function Area (IIEF-EF) scores showed a significant increase in both the groups post-treatment (Group 1: from 14.33 ± 4.39 to 23.8 ± 4.37, p = .001; Group 2: from 17.82 ± 3.44 to 26.3 ± 2.55, p = .001). When the increase in the IIEF-EF scores was compared pre- and post-treatment between the groups with respect to the ED grades, there was no statistically significant difference between them. Furthermore, while the intravaginal ejaculatory latency time (IELT) in successfully treated patients of Group 1 remained the same, Group 2 presented 1.5–3.5 times (mean, 2.4) prolongation. Their mean IELT score showed an increase from 2.2 (0.8–3.5) min to 5.3 (2.8–10.5) min. Our study shows that combination treatment of Li-SWT with PRP injections is not only safe for patients with ED, but also effective and safe in prolonging the IELT.     

Closed Incision Negative Pressure Wound Therapy for Elective Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BackgroundPersistent wound drainage after total joint arthroplasty (TJA) increases the risk of surgical site infections (SSIs). Closed incision negative pressure wound therapy (ciNPWT) decreases infections in traumatic wounds, but evidence for its use after elective TJA is limited. The purpose of this meta-analysis of level I studies is to determine the effect of ciNPWT on risk of SSI and wound complications following TJA.MethodsMEDLINE, EMBASE, CINAHL, and Cochrane Library were searched for randomized controlled trials comparing ciNPWT vs standard dressings after total hip (THA) and total knee arthroplasty (TKA). Studies exclusively involving THA for femoral neck fractures were excluded. Risk of SSI and noninfectious wound complications (blisters, seroma, hematoma, persistent drainage, dehiscence, and wound edge necrosis) following TJA were analyzed.ResultsSSI risk was lower with ciNPWT compared to standard dressings (3.4% vs 7%; relative risk [RR] 0.48, P = .007), specifically in revision THA and TKA (4.1% vs 10.5%; RR 0.41, P = .03). ciNPWT increased the noninfectious complication risk after primary TKA (RR 4.71, P < .0001), especially causing wound blistering (RR 12.66, P < .0001). ciNPWT decreased hospital length of stay by 0.73 days (P = .04) and reoperation rate (RR 0.28, P = .01).ConclusionciNPWT decreases SSI risk compared to standard dressings after revision TJA, but not primary TJA. ciNPWT is associated with >12-fold increased risk of wound blistering after primary TKA. ciNPWT plays a role in revision TJA management, but additional randomized controlled trials with uniform wound assessment methods must be performed to sufficiently power findings and draw conclusions on the use of ciNPWT after primary TJA.     

Predictive Factors of Extended Length of Hospital Stay Following Total Joint Arthroplasty in a Veterans Affairs Hospital Population

BackgroundImproved perioperative care for total joint arthroplasty (TJA) procedures has resulted in decreased hospital length of stay (LOS), including effective discharge on postoperative day (POD) 1 in many patients. It remains unclear what contributes to discharge delay in patients that are not discharged on POD 1. This study investigated factors associated with delayed discharge in patients whose original planned discharge was on POD 1.MethodsA retrospective cohort of 451 patients who underwent a hip or knee TJA procedure from April 2015 to March 2018 with planned discharge on POD 1 was analyzed. Patient characteristics included demographics, lab values, course of treatment, procedure, Charlson Comorbidity Index (CCI), complications, and other factors. Statistical regression was used to identify factors associated with delayed discharge; odds ratios (OR) were calculated for significant factors (α = 0.05).ResultsOf those studied, 70/451 (15.5%) experienced a delay from the planned POD 1 discharge. An increased likelihood of delayed discharge was associated with a nonhome discharge (P < .001, OR = 8.72 [95% CI: 4.22-18.06]) and higher CCI (P = .034, OR = 1.16 [95% CI: 1.01-1.32]). Inpatient physical therapy on the day of surgery was found to significantly correlate with successful discharge on POD 1 (P = .004, OR = 0.44 [95% CI: 0.25-0.77]).ConclusionMost patients can be discharged on POD 1 after TJA. Physical therapy on the day of surgery increased the likelihood of patients being discharged on POD 1. Those with a higher CCI and a nonhome discharge were more likely to have a discharge delay. This information can help surgeons counsel patients and prepare for postoperative care.     

Role of strengthening during nonoperative treatment of lateral epicondyle tendinopathy

IntroductionLateral epicondyle tendinopathy (LET) is the most common cause of lateral elbow pain. The literature on rehabilitation of the condition encompasses a plethora of interventions with most current evidence indicating that stretches and some form of strengthening are vital components. However, patient outcomes are infrequently reported further than 12 weeks from the start of therapy and it is unclear which components of a home exercise program are necessary to alleviate symptoms up to one year from the initiation of a therapy program.Purpose of the StudyThe purpose of the study is to determine if a therapy program with 4 to 6 visits spaced out over 12 weeks focusing on self-management and strengthening is more effective in reducing pain and improving function long term than the same program without strengthening, for individuals with LET.Study DesignThis is a randomized controlled trial.MethodsNinety-four patients were randomly allocated into two groups: both groups received the interventions of education in pertinent pathoanatomy, stretching, pain management through rest and icing, and activity modification. Group 1 (n = 38) was also provided with a strengthening component to the home exercise program, whereas group 2 did not (n = 21). Our primary outcome measure was pain at rest and pain with activity; our secondary measure was the level of functional impairment as measured by the quick disabilities of arm shoulder and hand. Outcome measurements were assessed at baseline, 6, 12, 24, and 52 weeks after initiation of therapy.ResultsBoth groups demonstrated statistically significant improvement with a moderate to large effect size in pain and function scores when compared with previous time point at 6, 12, and 24 weeks. Pain continued to decrease for both groups from 24 weeks to 52 weeks, but interestingly, there was a significant increase with moderate effect size in the quick disabilities of arm shoulder and hand score at 52 weeks when compared with week 24. No statistically significant difference was found between the two groups at any time point up to 52 weeks from the start of therapy.ConclusionsThis study demonstrates that a therapy program consisting of a low number of visits spaced out over 12 weeks based on education, stretches, activity modification, and pain management techniques is effective at reducing pain and increasing function in patients with LET. The addition of strengthening to this program did not improve outcomes. The therapy approach used in this study is consistent with the International Classification of Function guidelines and focuses on engaging patients in self-management of the condition through patient education and self-empowerment.     

Cost-effectiveness of postmastectomy hypofractionated radiation therapy vs conventional fractionated radiation therapy for high-risk breast cancer

BackgroundThe phase 3 NCT00793962 trial demonstrated that postmastectomy hypofractionated radiation therapy (HFRT) was noninferior to conventional fractionated radiation therapy (CFRT) in patients with high-risk breast cancer. This study assessed the cost-effectiveness of postmastectomy HFRT vs CFRT based on the NCT00793962 trial.MethodsA Markov model was adopted to synthesize the medical costs and health benefits of patients with high-risk breast cancer based on data from the NCT00793962 trial. Main outcomes were discounted lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). We employed a time-dependent horizon from Chinese, French and USA payer perspectives. Model robustness was evaluated with one-way and probabilistic sensitivity analyses.ResultsPatients receiving CFRT versus HFRT gained an incremental 0.0163 QALYs, 0.0118 QALYs and 0.0028 QALYs; meanwhile an incremental cost of $2351.92, $4978.34 and $8812.70 from Chinese, French and USA payer perspectives, respectively. Thus CFRT versus HFRT yielded an ICER of $144,281.47, $420,636.10 and $3,187,955.76 per QALY from Chinese, French and USA payer perspectives, respectively. HFRT could maintain a trend of >50% probabilities of cost-effectiveness below a willingness-to-pay (WTP) of $178,882.00 in China, while HFRT was dominant relative to CFRT, regardless of the WTP values in France and the USA. Sensitivity analyses indicated that the ICERs were most sensitive to the parameters of overall survival after radiotherapy.ConclusionsPostmastectomy HFRT could be used as a cost-effective substitute for CFRT in patients with high-risk breast cancer and should be considered in appropriately selected patients.     

The role of CDK4/6 inhibitors in early breast cancer

The use of cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) has proven to be a successful strategy in the treatment of advanced hormone receptor-positive (HR⁺) and human epidermal growth factor receptor 2-negative (HER2^-) breast cancer (BC), leading to a strong interest in their possible role in the treatment of early luminal BC. In this review we collect the most relevant and recent information on the use of CDK4/6i for the treatment of early BC in the neoadjuvant and adjuvant settings. Specifically, we evaluate the results of the large phase 3 adjuvant trials recently released, which have yielded apparently divergent results. We also examine the relevance of biomarkers as response predictive factors for CDI4/6i, the combination between radiotherapy and CDK4/6i, and provide a critical discussion on the evidence that we have so far and future directions of the role of these drugs in the treatment of early BC.     

The effect of postmastectomy radiation therapy on high-risk patients with T1-2N0 breast cancer

BackgroundThe prognostic impact of postmastectomy radiation therapy (PMRT) on high-risk patients with T1-2N0 breast cancer is controversial. We aimed to investigate the effect of PMRT on high-risk patients with T1-2N0 breast cancer.MethodsA total of 3439 patients diagnosed with T1-2N0 breast cancer who received mastectomy between 2000 and 2016 in our institute were retrospectively analyzed. Leveraging the Fine and Gray competing risks regression in unirradiated patients, risk factors of locoregional recurrence (LRR) were identified. All patients were stratified into high-risk (3 or 4 risk factors) and low-risk (no more than 2 risk factors) groups. The prognostic effect of PMRT was estimated in two subgroups. This subgroup analysis was also performed in patients with T2N0 breast cancer.ResultsThe median follow-up was 89 months. The 5-year cumulative incidence of LRR was 2.2% in unirradiated patients. Tumor size, estrogen receptor (ER) status, histologic grade and lymphovascular invasion (LVI) were identified as independent risk factors of LRR. In the high-risk group, PMRT was correlated with a 8.3% risk reduction of 5-year LRR, 7.8% risk reduction of 5-year distant recurrence (DR), and 6.4% risk reduction of 5-year breast cancer mortality (BCM), whereas it was not correlated with LRR, DR, or BCM in low-risk group. In patients with T2N0 breast cancer, PMRT was associated with decreased LRR, DR and BCM in high-risk group, other than low-risk group.ConclusionsPMRT presented heterogenous effect on patients with T1-2N0 breast cancer. Patients at high risk of LRR were more likely to benefit from PMRT.