Low-intensity shockwave therapy improves baseline erectile function: a randomized sham-controlled crossover trial.

Background: Low-intensity shockwave therapy for erectile dysfunction is emerging as a promising treatment option. Aim: This randomized sham-controlled crossover trial assessed the efficacy of low-intensity shockwave therapy in the treatment of erectile dysfunction. Methods: Thirty-three participants with organic erectile dysfunction were enrolled and randomized to shockwave therapy (n = 17) or sham (n = 16). The sham group was allowed to cross over to receive shockwave therapy after 1 month. Outcomes: Primary outcomes were the changes in Sexual Health Inventory for Men (SHIM) score and Erection Hardness Score at 1 month following shockwave therapy vs sham, and secondary outcomes were erectile function measurements at 1, 3, and 6 months following shockwave therapy. Results: At 1 month, mean SHIM scores were significantly increased in the shockwave therapy arm as compared with the sham arm (+3.0 vs -0.7, P = .024). Participants at 6 months posttreatment (n = 33) showed a mean increase of 5.5 points vs baseline (P < .001), with 20 (54.6%) having an increase ≥5. Of the 25 men with an initial Erection Hardness Score <3, 68% improved to a score ≥3 at 6 months. When compared with baseline, the entire cohort demonstrated significant increases in erectile function outcomes at 1, 3, and 6 months after treatment. Clinical Implications: In this randomized sham-controlled crossover trial, we showed that 54.6% of participants with organic erectile dysfunction met the minimal clinically important difference in SHIM scores after treatment with low-intensity shockwave therapy. Strengths and Limitations: Strengths of this study include a sham-controlled group that crossed over to treatment. Limitations include a modest sample size at a single institution. Conclusions: Low-intensity shockwave therapy improves erectile function in men with erectile dysfunction as compared with sham treatment, which persists even 6 months after treatment. Clinical Trial Registration: ClinicalTrials.gov NCT04434352.

First-Time Submassive Pulmonary Embolism Likely Caused by Testosterone-Enhancing Supplement.

Pulmonary embolism (PE) is a potentially fatal occurrence with a broad spectrum of risk factors. A 75-year-old male presented to the emergency room with five days of shortness of breath, back pain, and hemoptysis. A CT angiogram demonstrated bilateral pulmonary emboli with a larger thrombus on the right, as well as signs of right heart strain. The patient was started on IV heparin and ultimately underwent a successful embolectomy. Evaluation to determine the underlying etiology of this patient's first-time PE was performed to further stratify his risk of recurrence and the length of anticoagulation required. The provoking factor for his PE was initially unclear as he lacked any risk factors such as recent surgeries, periods of immobility, or previous diagnosis of malignancy. The patient was noted to be on an erectile dysfunction supplement called "Eroxin," and he had been taking it for the past six months. Eroxin contains an ingredient called fenugreek, which is believed to enhance testosterone levels by inhibiting aromatase and 5-alpha-reductase activity. Fenugreek has previously been associated with the formation of PEs, and likely contributed to the PE in this patient. This is likely due to testosterone-induced polycythemia and increased platelet aggregation. This case highlights the concern around supplements as their ingredients are poorly regulated and occasionally found to be tainted with unlisted ingredients. This also highlights the importance of gathering a complete supplement history from patients as their use can lead to serious illness. Lastly, it encourages considering testosterone use as a potential thrombogenic risk factor.

Surgeon-administered Transversus Abdominis Plane (TAP) Block is Associated With Decreased Opioid Usage and Length of Stay Following Radical Cystectomy.

OBJECTIVE: To study the effect of surgeon-administered Transversus Abdominis Plane block (sTAP) on opioid usage and length of stay (LOS). METHODS: Starting in April 2018, two surgeons at our institution gradually introduced sTAP for radical cystectomy (RC) patients. We performed a retrospective observational cohort analysis of RC patients catalogued in a prospectively maintained database using the Enhanced Recovery After Surgery Interactive Auditing System. Two surgeons adopted the sTAP block technique in April 2018. We included patients undergoing RC for bladder malignancy under Enhanced Recovery After Surgery protocol between January 2017 and August 2020. Primary outcomes included LOS, and postoperative day (POD) 0-3 total opioids consumption measured by morphine milligram equivalents (MME). Multivariable linear or logistic models evaluated the association of TAP with outcomes while controlling for potential confounders. RESULTS: Among 178 patients included in analysis, 84 patients underwent sTAP block and 94 did not. Multivariable analysis demonstrated significantly lower POD 0-3 total opioid usage (106.4 vs 192.2 MME, P = .004), and mean LOS (5.6 vs 7.7 days, P <.001) among the sTAP group. CONCLUSION: sTAP appears to be an effective adjunct to RC care associated with improved LOS, and POD 0-3 opioid consumption. Further studies are needed to optimize TAP block technique and anesthetic composition.

Safety of decreasing ureteral stent duration following radical cystectomy.

PURPOSE: We aim to assess the safety of decreasing ureteral stenting duration following Radical Cystectomy with Urinary Diversion (RCUD). MATERIALS AND METHODS: We analyzed a prospectively and retrospectively collected dataset for cystectomy patients at our tertiary center. Adult patient who underwent RCUD for malignancy from January 2013 to February 2018 were included. Patients with a history of abdominal/pelvic radiation and continent diversions were excluded. The patient population was divided to late stent removal group (LSR-POD 14) and early stent removal group (ESR-POD5). Our endpoints were total stent duration, 90-day readmission, 90-day total-UTI, 90-day urinary-readmissions, complications and Ureteroenteric Stricture (UES) rates. Statistical methods included t test, Chi-squared test and multivariate logistic regression. RESULTS: One hundred and seventy-eight patients were included in the final analysis after inclusion/exclusion criteria were applied. The LSR (n = 74) and ESR (n = 104) groups were similar in preoperative characteristics except higher intracorporeal ileal conduit formation in ESR. The duration of stenting decreased significantly from approximately 15.5-5 days (P < 0.001). The LSR had higher 90-day overall readmission rates (OR = 2.57, 95% CI 1.19-5.53, P = 0.016) and total-UTIs (OR = 2.36, 95%CI 1.11-5.04, P = 0.026). With a median follow-up of 9.8 months, UES was similar between the two groups. CONCLUSION: Shorter ureteral stent duration is a safe and non-inferior option following RCUD. It allows for stent removal prior to discharge and less outpatient visits. In addition, decreasing stent duration was linked decreased readmissions and total-UTIs without increased risk of UES. However, future studies are needed to establish causality and promote stent duration change.

Implementation of a Dedicated Enhanced Recovery after Surgery (ERAS) Program for Radical Cystectomy Patients is Associated With Decreased Postoperative Inpatient Opioid Usage and Pain Scores.

OBJECTIVE: To measure differences in post-operative opioid usage and pain scores between pre- and post-Enhanced Recovery after Surgery (ERAS) radical cystectomy (RC) patients in an effort to optimize outcomes. STUDY DESIGN: We performed a retrospective cohort study from a single institution from January 1, 2015 to July 31, 2018 among 86 and 108 pre- and post-ERAS RC patients. The primary endpoints were total mean opioid usage (morphine equivalent daily dosing or MEDD) and mean pain scores (Visual Analog Scale) on postoperative days (POD) 1-3. Secondary endpoints were number of opioid pills prescribed at discharge and within 30 days of discharge. Multivariable model selection was carried out with forward selection and backward elimination to identify variables associated with key outcomes. RESULTS: Total mean usage of opioids and mean pain scores were significantly lower in post-ERAS vs pre-ERAS patients across POD 1-3, respectively (32.90 MEDD vs 99.86 MEDD, P ≤ .001; 3.51 vs 4.17, P = .003). The median number of opioid pills prescribed at discharge was significantly lower in the post-ERAS group compared to pre-ERAS (30 pills vs 45 pills, P = .046) as well as the median number opioid pills prescribed within 30 days of discharge (40 pills vs 50 pills, P = .001). CONCLUSION: Our study suggests that a dedicated ERAS protocol following RC might be superior to traditional, non-ERAS methods in reducing postoperative opioid use and pain scores.

Persistent Vaginal Leakage in the Setting of an Apical Vaginal Sinus Tract: A Case Report.

Fistulas are defined as abnormal connections between 2 organ, vessels, or structures. They can often present in the genitourinary tract as a result of iatrogenic injury during pelvic surgery. A 46-year-old female presents many years after a hysterectomy for persistent vaginal leakage with concern for a vesicovaginal fistula. Computed tomography urogram, intravenous retrograde pyelogram, and cystoscopy were negative for vesicovaginal fistula; however, a vaginal sinus tract was noted and further explored. This case report will describe the use of both laparoscopy and concomitant vaginoscopy to diagnose and, ultimately, surgically excise a salpingovaginal fistula.

Lower urinary tract autonomic dysfunction evaluation in spinal cord injury patients: an applied example.

INTRODUCTION: The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) is a measure for motor-sensory dysfunction following spinal cord injury (SCI) but does not assess the autonomic nervous system dysfunction. The International Standards to document remaining Autonomic Dysfunction after Spinal Cord Injury (ISAFSCI) has been recommended to study autonomic dysfunction in such patients. We present a case presentation to demonstrate how to use the ISAFSCI and ISCoS urodynamics data set in persons with SCIs. CASE PRESENTATION: A 24-year-old caucasian male presents with T4 ASIA SCI. We followed the patient over the course of 18 months. We present his clinical picture at different stages and how to apply ISAFSCI and ISCoS urodynamic data set to this patient. DISCUSSION: The ISAFSCI and ISCoS urodynamics data sets are important tools in the repertoire of the clinician assessing autonomic dysfunction in persons with SCIs. They allow efficient clinical assessment of patients and standard communication between clinical care providers.

Association Between Gasdermin A and Gasdermin B Polymorphisms and Susceptibility to Adult and Childhood Asthma Among Jordanians.

INTRODUCTION: Gasdermin A (GSDMA) and gasdermin B (GSDMB) have been associated with childhood, and to a lesser extent with adult, asthma in many populations. AIMS: In this study, we investigated the association between GSDMA and GSDMB variants and the incidence of adult and childhood asthma among Jordanians. METHODS: Subjects were divided into two groups: adults and children. Within the adult group there were 129 asthma patients and 111 healthy controls. In the pediatric group there were 98 asthma patients and 112 healthy children. Gasdermin A (GSDMA) (rs7212938, T/G) and Gasdermin B (rs7216389, T/C) polymorphisms were genotyped using the PCR-RFLP method. Three analysis models were applied to the genotype data: co-dominant, dominant and recessive. RESULTS: An association between the GSDMB T/C single nucleotide polymorphism (SNP) genotype and the incidence of childhood asthma was found (< 0.05). GSDMB T/C SNP in children also showed a very high tendency toward significance with p = 0.0532 in the single locus analysis. In adults, no significant differences in the allelic frequencies of any of the SNPs analyzed were found between the case and control populations. At the haplotype level, GC haplotype was found to be associated with the risk of asthma in children while none of the tested haplotypes were found to be associated with asthma risk in adults. CONCLUSIONS: The findings of this study confirm the previously reported association between the GSDMB gene and the risk of childhood asthma.

The acute effects of waterpipe smoking on lung function and exercise capacity in a pilot study of healthy participants.

CONTEXT: Waterpipe tobacco smoking (WTS) has gained popularity, but its physiologic effects have not been extensively studied: rather, studies have focused on WTS's chronic effects or have evaluated limited respiratory/cardiac parameters. OBJECTIVE: We sought to characterize in a more detailed manner the acute effects of WTS on lung function and exercise capacity. METHOD: We recruited 24 healthy WTS males. We used a pilot single-group pre-test (abstained from WTS for ≥48 h) post-test (within 0.5 h of a 45-min WTS session) design. We performed spirometry, diffusing lung capacity and time-limited CPE testing (CPET; cycloergometer; 2-min 20-Watt warm-up and 25-Watt increase every 2-min for 10 min). RESULTS: Mean age was 20.4 years; Post-WTS, the following significant changes were observed: CO level increased from 3.7 ppm to 24.4; oxygen consumption decreased (from 1.86 L/min to 1.7); baseline respiratory rate increased (from 17.7 breath/min to 19.7); forced expiratory flow over the middle half of the forced vital capacity decreased (from 5.51 L to 5.29); and perceived exertion (measured by Borg scale) at mid and peak exercise increased. Baseline resting systolic blood pressure, pulse pressure, and pulse pressure product increased post-WTS (from 118.9 mmHg to 129.2; from 45.3 mmHg to 55.6; and from 9.9 mmHg/min to 11.1 post-WTS, respectively). During exercise, a decrease in oxygen pulse was observed post-WTS (from 10.89 ml/beat to 9.97), while the heart rate-oxygen consumption relationship increased post-WTS (from 3.52 beats/ml/kg to 3.91). CONCLUSION: Acute WTS appears to induce impairment in lung function and exercise capacity. Larger studies are warranted to further characterize the nature and extent of such impairment.

Smoking abstinence rates and reasons for failure to quit smoking in cancer patients in Jordan.

BACKGROUND: Failure to quit smoking in cancer patients is associated with the development of a second primary tumor and a suboptimal response to chemotherapy. However, data characterizing cancer patients' ability to quit is scarce, particularly in developing countries. Such information is valuable in highlighting the potential of cessation interventions in countries where smoking rates are high and antismoking policies are not yet fully implemented. OBJECTIVES: To measure the abstinence rates and identify reasons for the failure to quit smoking in patients visiting a smoking cessation clinic in a comprehensive cancer center in Jordan. METHODS: Through retrospective medical chart review and prospective follow-up by phone, we studied long-term abstinence rates and reasons for the failure to quit smoking in 156 cancer patients referred to the smoking cessation clinic to receive counseling and pharmacological treatment. Patient demographics, clinical and smoking characteristics and long-term abstinence at 12 months were recorded, as were reasons for the failure to quit smoking. RESULTS: The 12-month abstinence rate was 21.2%. The main reasons for failing to quit smoking included personal or professional stressful situations, not being able to handle withdrawal and the belief that quitting had no value. CONCLUSION: Abstinence rates in Jordanian cancer patients fall at the lower end of the range that has been reported in the literature for cancer patients. Efforts to improve these rates should focus on assisting patients in handling stress, and in adjusting medications to improve withdrawal symptoms.

Perceptions of young Jordanian adults to proposed anti-tobacco pictorial warning labels.

BACKGROUND: In commitment to the Framework Convention on Tobacco Control (FCTC), four new pictorial warnings are now being proposed for display on cigarette packages sold in Jordan. The aim of this study was to gauge the immediate perceptions of young Jordanian adults towards these new pictorials and compare these perceptions to those of the pictorial currently being used in the country. METHODS: A cross-sectional survey was conducted on a convenience sample of youth aged 17-26. The interviewer-administered survey gauged participants' perceptions of salience, fear elicitation, and gained information as well as participants' motivation to remain non-smokers or quit smoking after viewing each of the four proposed new pictorials as well as the current pictorial used in Jordan. Perceptions regarding each new pictorial were compared to the current pictorial. RESULTS: A total of 450 surveys were included in the analysis. The sample (mean age 20.9) was 51.6% female and 31.3% cigarette (regular or occasional) smokers. In smokers, only one proposed pictorial had significantly more smokers perceiving it as salient or adding to information when compared to the current pictorial. More smokers reported fear when observing the proposed pictorials compared with current pictorial, but overall proportions reporting fear were generally less than 50%. Furthermore, all new pictorials motivated significantly more smokers to consider quitting compared with the current pictorial; however, the overall proportion of smokers reporting motivation was < 25%. Among nonsmokers, significantly more respondents perceived the new pictorials as salient and fear-eliciting compared to the old pictorial, but there were no major differences in information added. Motivation to remain non-smokers was comparable between the old and new pictorials. CONCLUSION: Given the variability of response across both smokers and nonsmokers, and across the three elements of perception (salience, added information, fear) for each pictorial, further testing of the pictorials in a more diverse sample of Jordanian young adults prior to launch is recommended.