Initial outcomes and surgical techniques of prostatic urethral lift for benign prostatic hyperplasia in Japan.

OBJECTIVES: The prostatic urethral lift (PUL) has been used as a minimally invasive surgery for benign prostatic hyperplasia (BPH) since April 2022 in Japan. This study evaluated the initial outcomes and surgical techniques of PUL for BPH. METHODS: In this prospective, single-center study, indications were based on the proper use guidelines for PUL in Japan. Preoperative patient status, postoperative progress at 1 and 3 months, and perioperative complications were evaluated. The surgical technique was changed twice, and the subgroup analysis and technique were evaluated. RESULTS: Of the 50 patients who underwent surgeries performed by a single surgeon, the median age and prostate volume were 71 years and 42.0 mL, respectively. Furthermore, the median operative time and number of implants used were 20 min and 5, respectively. No postoperative fever or severe hematuria requiring reoperation occurred. All patients were discharged from the hospital the day following the PUL, as scheduled. Postoperative International Prostate Symptom Score, quality of life score, maximum flow rate, and postvoid residual volume at 1 and 3 months were significantly improved compared with the preoperative values. A significant improvement in maximum flow rate was observed in the subgroup analysis from 1 month postoperatively in the group with an anterior channel creation focus. CONCLUSIONS: PUL is effective and safe in cases with prostate volumes of <100 mL. Lifting the bladder neck is important for opening an anterior prostatic urethral channel and improving urinary function during the early postoperative period.

Improving access to chronic pain care with central referral and triage: The 6-year findings from a single-entry model.

Background: Despite the established efficacy of multidisciplinary chronic pain care, barriers such as inflated referral wait times and uncoordinated care further hinder patient health care access. Aims: Here we describe the evolution of a single-entry model (SEM) for coordinating access to chronic pain care across seven hospitals in Toronto and explore the impact on patient care 6 years after implementation. Methods: In 2017, an innovative SEM was implemented for chronic pain referrals in Toronto and surrounding areas. Referrals are received centrally, triaged by a clinical team, and assigned an appointment according to the level of urgency and the most appropriate care setting/provider. To evaluate the impact of the SEM, a retrospective analysis was undertaken to determine referral patterns, patient characteristics, and referral wait times over the past 6 years. Results: Implementation of an SEM streamlined the number of steps in the referral process and led to a standardized referral form with common inclusion and exclusion criteria across sites. Over the 6-year period, referrals increased by 93% and the number of unique providers increased by 91%. Chronic pain service wait times were reduced from 299 (±158) days to 176 (±103) days. However, certain pain diagnoses such as chronic pelvic pain and fibromyalgia far exceed the average. Conclusions: The results indicate that the SEM helped reduce wait times for pain conditions and standardized the referral pathway. Continued data capture efforts can help identify gaps in care to enable further health care refinement and improvement.

Contexte: Malgré l'efficacité établie des soins multidisciplinaires dans le traitement de la douleur chronique, des obstacles tels que des délais d'attente prolongés et l'absence de coordination des soins entravent davantage l'accès des patients aux services de santé.Objectifs: Nous décrivons ici l'évolution d'un modèle à entrée unique visant à coordonner l'accès aux soins pour la douleur chronique dans sept hôpitaux de Toronto. Nous examinons également l'effet de ce modèle sur les soins aux patients six ans après sa mise en œuvre.Méthodes: En 2017, un modèle à entrée unique novateur a été mis en place pour orienter les patients souffrant de douleur chronique à Toronto et dans les régions avoisinantes. Les patients sont reçus de manière centralisée, triés par une équipe clinique et un rendez-vous leur est attribué en fonction du degré d'urgence et de l'établissement de soins ou du prestataire le plus approprié.Pour évaluer l'impact du modèle à entrée unique, une analyse rétrospective a été entreprise afin de déterminer les schémas de consultation, les caractéristiques des patients et les temps d'attente pour les demandes de consultation au cours des six dernières années.Résultats: La mise en œuvre d'un modèle à entrée unique a permis de rationaliser le nombre d'étapes du processus de demande de consultation et a conduit à l'élaboration d'un formulaire de demande de consultation normalisé comprenant des critères d'inclusion et d'exclusion communs à tous les sites. Au cours de la période de six ans, le nombre de demandes de consultation a augmenté et le nombre de prestataires uniques a augmenté de 91 %.Les temps d'attente pour les services de traitement de la douleur chronique ont diminué de 299 (±158) jours à 176 (±103) jours. Cependant, certains diagnostics de douleur, comme la douleur pelvienne chronique et la fibromyalgie, dépassent de loin la moyenne.Conclusions: Les résultats indiquent que le modèle à entrée unique a contribué à réduire les temps d'attente pour les affections douloureuses et à normaliser le parcours de consultation. La poursuite des efforts de collecte des données peut aider à recenser les lacunes dans les soins, permettant ainsi une amélioration continue des soins de santé.

A Scoping Review of Interventions to Improve Occupational Safety and Health of Construction Workers.

OBJECTIVE: This review comprehensively examines interventions which sought to improve the occupational safety and/or health of construction workers. Factors that explain the (in)effectiveness of interventions were also summarized. DATA SOURCE: This review consisted of a search using two electronic databases, PubMed and Web of Science. STUDY INCLUSION AND EXCLUSION CRITERIA: Targeted workers in the construction industry; had at least one primary outcome that aimed to improve occupational safety and/or health; were published between January 01, 1990 and December 01, 2019; and were written in English. DATA EXTRACTION AND SYNTHESIS: Two researchers independently carried out the process of reviewing the titles, abstracts and full texts, and extracted all data. If there were differences, discussions were held until a consensus was reached. RESULTS: A total of 1297 articles were retrieved and 24 were selected for final evaluation. Seventeen studies reported significant intervention effects, while 7 found their primary outcome not significantly improved. CONCLUSION: Future research should place more effort on interventions aimed at improving both occupational safety and health outcomes in an integrated manner, with environmental interventions that accompany behavioral interventions at the individual level. Besides, additional effort is also needed to ensure the involvement of relevant stakeholders in designing the intervention, avoiding contamination effects (through cluster randomization), optimizing the "dosage" of intervention, and improving measurement of outcomes.

Local Injection for Treating Mood Disorders (LIFT-MOOD): A Pilot Feasibility RCT of Stellate Ganglion Block for Treatment-Resistant Depression.

Background: With nearly one-third of patients with major depressive disorder being resistant to available antidepressants, there is a need to develop new treatments for this population. Stellate ganglion block (SGB) is a procedure used to block sympathetic input to the central autonomic system; it has been administered to treat several conditions, including pain. Recently, indications for SGB have extended and the potential benefits for psychiatric disorders are under investigation. Methods: The Local Injection For Treating Mood Disorders (LIFT-MOOD) study investigated the feasibility of a trial of 2 right-sided injections of bupivacaine 0.5% (7 mL) at the stellate ganglion in participants with treatment-resistant depression (TRD) using a randomized, placebo-controlled, pilot trial. Ten participants were randomized in a 1:1 allocation to receive active treatment or placebo (saline). Primary feasibility outcomes included recruitment rate, withdrawal, adherence, missing data, and adverse events. As a secondary, exploratory objective, we explored the efficacy of SGB in improving symptoms of depression by calculating the change in scores from baseline to follow-up on day 42 for each treatment group. Results: The recruitment rate was reasonable and sufficient, retention and adherence were high, missing data were low, and adverse events were mild and temporary. Both treatment groups demonstrated decreases in Montgomery-Åsberg Depression Rating Scale scores, compared to baseline, by the end of the study. Conclusion: This study supports the feasibility of a confirmatory trial of SGB in participants with TRD. Conclusions regarding efficacy cannot be made based on this preliminary study due to the small number of participants who completed active treatment. Larger-scale randomized controlled trials with long-term follow-ups and alternate sham procedures are needed to assess the efficacy and duration of symptom improvement with the use of SGB in TRD.

Stellate Ganglion Block for Psychiatric Disorders: A Systematic Review of the Clinical Research Landscape.

Stellate ganglion block (SGB) is a procedure involving the injection of a local anesthetic surrounding the stellate ganglion to inhibit sympathetic outflow. The objective of this review was to summarize existing evidence on the use of SGB in adults with psychiatric disorders. A systematic search identified 17 published studies and 4 registered clinical trials. Eighty-eight percent of published studies, including 2 randomized controlled trials (RCTs), used SGB for posttraumatic stress disorder (PTSD), although its use for schizophrenia spectrum disorders was also explored. Administration of 1 to 2 SGBs using right-sided laterality with 0.5% ropivacaine was most common. Preliminary evidence from clinical trials and case studies supports the feasibility of SGB for treating psychiatric disorders involving dysregulation of the sympathetic nervous system, although effectiveness evidence from RCTs is mixed. One RCT concluded that improvement in PTSD symptoms was significant, while the other concluded that it was nonsignificant. Improvements were noted within 5 minutes of SGB and lasted 1 month or longer. Registered clinical trials are exploring the use of SGB in new psychiatric disorders, including major depressive disorder and borderline personality disorder. More studies with larger sample sizes and alternate protocols are needed to further explore therapeutic potential of SGB for psychiatric disorders.

Our health, our planet: a cross-sectional analysis on the association between health consciousness and pro-environmental behavior among health professionals.

One possible predictive factor that affects both pro-environmental behavior and health behavior is health consciousness (a psychological state where an individual is aware of and involved in his/her health condition). We examined the relationship between health consciousness and two pro-environmental behaviors (recycling and green purchasing) within health professionals in a Japanese large hospital. Multivariate linear regression analysis revealed a significant association between health consciousness and recycling behavior, while there was no association between health consciousness and green purchasing behavior. We assume that health consciousness can certainly be a factor promoting pro-environmental behavior, but that it may have been insufficient to cause green purchasing, because of the organizational norm of recycling in the Japanese context. Given that there is previous evidence about the relationship between health consciousness and health behavior, health consciousness might be a predictive factor that encourages both health behavior and pro-environmental behavior simultaneously.

Durable Efficacy and Safety of Long-Term OnabotulinumtoxinA Treatment in Patients with Overactive Bladder Syndrome: Final Results of a 3.5-Year Study.

PURPOSE: These are the final results of the prospective, multicenter, long-term (3.5-year) study of the efficacy/safety of onabotulinumtoxinA for overactive bladder syndrome. MATERIALS AND METHODS: Patients who completed either of 2, 24-week phase 3 trials could enter a 3-year extension and continue treatment with onabotulinumtoxinA 100 U as needed to control overactive bladder symptoms. Data were analyzed by the treatment(s) received (up to 6) and in discrete subgroups that received 1, 2, 3, 4, 5 or 6 treatments (to evaluate the consistency of the response after repeat treatments in the same patient groups). Assessments included the change from baseline in the number of urinary incontinence episodes per day and the proportion of patients who reported improvement/great improvement in urinary symptoms on the TBS (Treatment Benefit Scale) at week 12 as co-primary end points. Other end points were the change from baseline in I-QOL (Incontinence Quality of Life), the number of urgency and micturition episodes per day; duration of effect; the number of adverse events; and the initiation of intermittent catheterization. RESULTS: Consistent mean reductions in urinary incontinence were observed following continued onabotulinumtoxinA treatment, ranging from -3.1 to -3.8 in the overall population and -2.9 to -4.5 in the discrete subgroups. Durable improvements were seen in overactive bladder symptoms and quality of life. A high proportion of patients rated their condition as improved/greatly improved. The median duration of effect was 7.6 months. The most common adverse event was urinary tract infection. The rate of de novo catheterization after the first treatment was 4.0% and it ranged from 0.6% to 1.7% after subsequent treatments. CONCLUSIONS: Long-term onabotulinumtoxinA treatment consistently decreased overactive bladder symptoms and improved quality of life with no new safety signals.

Barriers to accessing urethroplasty.

Urethroplasty is an effective treatment for men with anterior urethral strictures, but is utilized less frequently than ineffective treatments such as internal urethrotomy. We sought to identify provider-level barriers to urethroplasty. An anonymous online survey was emailed to all Mid-Atlantic American Urological Association members. Six scenarios in which urethroplasty was the most appropriate treatment were presented. Primary outcome was recommendation for urethroplasty in ≥ three clinical scenarios. Other factors measured include practice zip code, urethroplasty training, and proximity to a urethroplasty surgeon. Multivariate logistic regression identified factors associated with increased likelihood of urethroplasty recommendation. Of 670 members emailed, 109 (16%) completed the survey. Final analysis included 88 respondents. Mean years in practice was 17.2. Most respondents received formal training in urethroplasty: 43 (49%) in residency, 5 (6%) in fellowship, and 10 (11%) in both; 48 respondents (55%) had a urethroplasty surgeon in their practice, whereas 18 (20%) had a urethroplasty surgeon within 45 minutes of his or her primary practice location. The only covariate that was associated with an increased likelihood of recommending urethroplasty in ≥ three scenarios was formal urethroplasty training. Most members (68%) reported no barriers to referring patients for urethroplasty; the most common barriers cited were long distance to urethroplasty surgeon (n 5 13, 15%) and concern about complications (n 5 8, 9%). Urethroplasty continues to be underutilized in men with anterior urethral strictures, potentially due to lack of knowledge dissemination and access to a urethroplasty surgeon. Appropriate urethroplasty utilization may increase with greater exposure to urethroplasty in training.

Impact of onabotulinumtoxinA on quality of life and practical aspects of daily living: A pooled analysis of two randomized controlled trials.

OBJECTIVE: To evaluate the impact of onabotulinumtoxinA on individual domains of the quality of life questionnaires in a pooled analysis of two phase 3 trials in overactive bladder patients with urinary incontinence who were inadequately managed by ≥1 anticholinergic. METHODS: Patients received intradetrusor injections of onabotulinumtoxinA 100U (n = 557) or placebo (n = 548). The proportions of patients with a positive response (condition "greatly improved" or "improved") on the Treatment Benefit Scale, and changes in Incontinence Quality of Life scores and King's Health Questionnaire domain scores were analyzed in the overall population and subgroups with clean intermittent catheterization use and urinary tract infection status during the first 12 weeks of treatment. Responses to individual King's Health Questionnaire items were also assessed. RESULTS: Significantly greater proportions of onabotulinumtoxinA-treated patients achieved positive Treatment Benefit Scale response versus placebo (61.8% vs. 28.0%; P < 0.001). OnabotulinumtoxinA showed significantly greater improvements versus placebo in Incontinence Quality of Life total (22.5 vs. 6.6), Incontinence Quality of Life subscale scores and all domains of the King's Health Questionnaire. Notably, a similar trend was observed regardless of clean intermittent catheterization/urinary tract infection status. Additionally, onabotulinumtoxinA resulted in significantly greater improvements than the placebo in practical aspects of patients daily lives, including pad use, need to change undergarments, sleep, relationship with partner and work life/daily activities. CONCLUSION: In overactive bladder patients with urinary incontinence, onabotulinu-mtoxinA 100U demonstrated significant improvements across the individual domains of the quality of life questionnaires, regardless of clean intermittent catheterization or urinary tract infection status, and provided a positive impact on practical aspects of patients' daily lives.

The impact of transitioning from a 24-hour to a 16-hour call model amongst a cohort of Canadian anesthesia residents at McMaster University - a survey study.

PURPOSE: The primary objective of this study was to assess anesthesia residents' opinions and perceptions on wellness/burnout, fatigue, education, and patient safety after the initiation of a reduced call model (16-hour call). METHODS: A prospective cohort study was conducted at three time points during the 2013-2014 academic year. A web-based questionnaire consisting of 23 questions was electronically distributed to all anesthesia residents from postgraduate years (PGY) 1 to 5 who were part of the active call roster (n=84) at McMaster University in Hamilton, Ontario. Descriptive summaries were calculated, counts and percentages were used for categorical variables, and answers to open text questions were reviewed for themes. RESULTS: A response rate of 67% was obtained for this study. A majority of anesthesia residents (65%) approved of 16-hour call, felt that their overall quality of life as a senior resident (PGY3 or greater) or junior resident (PGY2 and below) had improved (73% and 55%, respectively), and reported overall feeling less fatigued. Most respondents indicated that the quality of education remained unchanged (47%), or had improved (31%). And most felt better prepared for the royal college exam (52%). Most felt patient safety had improved or was unchanged (both 48%). CONCLUSION: The study demonstrates that 16-hour call improved resident wellness, reduced burnout and fostered an environment where residents are less fatigued and more satisfied with their educational experience promoting an environment of patient safety. Overall, the anesthesia residency group demonstrated that not only is 16-hour call preferred but beneficial.

Treatment satisfaction and improvement in health-related quality of life with onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity.

AIMS: OnabotulinumtoxinA significantly reduces urinary incontinence (UI) and improves bladder management in patients with neurogenic detrusor overactivity (NDO). We evaluated the impact of onabotulinumtoxinA on patient-reported outcomes (PROs) in patients with UI due to NDO in a double-blind, placebo-controlled study. METHODS: Patients with UI due to NDO (from multiple sclerosis or spinal cord injury) were randomized to intradetrusor placebo (n = 92) or onabotulinumtoxinA 200 U (n = 92) or 300 U (n = 91). PROs included Incontinence Quality of Life (I-QOL) Questionnaire to assess health-related quality of life (HRQoL), the 16-item modified Overactive Bladder-Patient Satisfaction with Treatment Questionnaire (OAB-PSTQ) to assess treatment satisfaction, and Patient Global Assessment to assess treatment goal achievement. RESULTS: Mean improvement in I-QOL total score at weeks 6 and 12 was significantly greater with both onabotulinumtoxinA 200 U and 300 U versus placebo (Δ12.3 for 200 U and Δ14.9 for 300 U vs. placebo; P < 0.001), and was clinically meaningful. For those patients who completed the OAB-PSTQ, improvement in satisfaction at weeks 6 and 12 was significantly greater for onabotulinumtoxinA versus placebo (P < 0.001, all comparisons). At 6 weeks, greater proportions of onabotulinumtoxinA-treated patients than placebo reported being somewhat or very satisfied (200 U, 77.5% and 300 U, 67.8% vs. placebo, 39.5%), and significant progress toward or complete achievement of primary treatment goal (200 U, 62.9% and 300 U, 61.6% vs. placebo, 16.5%). CONCLUSIONS: NDO patients treated with onabotulinumtoxinA 200 or 300 U had significantly greater improvement in HRQoL and greater treatment satisfaction compared with placebo-treated patients, with no clinically relevant differences between onabotulinumtoxinA doses.

Human papillomavirus testing in men.

Despite the morbidity associated with anogenital condylomas and the mortality associated with anal, penile, and cervical carcinoma as a direct consequence of human papillomavirus (HPV), the US Centers for Disease Control and Prevention currently does not recommend routine screening for HPV in immuno competent men. However, findings of emerging research focusing on the high-risk populations of men who have sex with men and men who test positive for human immunodeficiency virus, in whom HPV infection is pervasive and persistent, suggest that these populations may benefit from screening. Therefore, HPV screening, including anal cytology, should be considered for these men in settings where appropriate follow-up, including high-resolution anoscopy, is available.

Safety and efficacy of once-daily trospium chloride extended-release in male patients with overactive bladder.

OBJECTIVES: This study used pooled data from 2 large, phase III, double-blind, randomized, placebo-controlled studies for a subgroup analysis of the safety and efficacy of trospium chloride extended-release (XR) in men with overactive bladder (OAB). METHODS: A subgroup analysis was performed on data from the 176 male patients (trospium XR, 94; placebo, 82) who participated in 1 of the 2 studies. Patients received either trospium XR 60 mg or placebo once daily for 12 weeks. RESULTS: The mean age was 66.2 years for trospium XR and 63.1 years for placebo. A history of benign prostatic hyperplasia was recorded for 29 trospium XR recipients (30.9%) and 23 placebo recipients (28.0%). A total of 19 patients (20.2%) receiving trospium XR and 15 (18.3%) receiving placebo experienced ≥1 treatment-emergent adverse event considered at least possibly related to the study medication. Two trospium XR patients (2.1%) developed urinary retention; both were aged ≥75 years, and 1 had a history of prostate enlargement. Treatment with trospium XR compared with placebo resulted in significantly greater decreases from baseline in the mean number of daily toilet voids (-2.5 vs -1.5; P < .05) and urgency urinary incontinence episodes (-2.3 vs -1.4; P < .05) in men at week 12 (the coprimary efficacy variables). CONCLUSIONS: Trospium XR is safe and effective in men with OAB. The risk of urinary retention is low and may be further decreased by careful patient selection.

Effect of tolterodine extended release with or without tamsulosin on measures of urgency and patient reported outcomes in men with lower urinary tract symptoms.

PURPOSE: We evaluated the efficacy of tolterodine extended release and/or tamsulosin on micturition related urgency episodes, urgency severity and patient reported outcomes in men who met entry criteria for prostatic enlargement and overactive bladder trials. MATERIALS AND METHODS: Men 40 years old or older with an International Prostate Symptom Score of 12 or greater, frequency (8 or more voids per 24 hours) and urgency (3 or more episodes per 24 hours) with or without urgency urinary incontinence were randomized to placebo, 4 mg tolterodine extended release, 0.4 mg tamsulosin or tolterodine extended release plus tamsulosin for 12 weeks. Subjects completed 5-day diaries; the Patient Perception of Bladder Condition and Urgency Perception Scale at baseline, and weeks 1, 6 and 12; Overactive Bladder Questionnaire at baseline, and weeks 6 and 12; Perception of Treatment Satisfaction question at weeks 1, 6 and 12; and Willingness to Continue question at week 12. Subjects rated the urgency associated with each micturition on a 5-point scale and micturition related urgency episodes were those rated 3 or greater. Urgency severity was measured using frequency-urgency sum, defined as the sum of urgency ratings for all micturitions. RESULTS: Compared with placebo, tolterodine extended release plus tamsulosin significantly reduced daytime and nocturnal micturition related urgency episodes as well as frequency-urgency sum at weeks 1, 6 and 12. It also improved Patient Perception of Bladder Condition scores at weeks 1, 6 and 12; improved Urgency Perception Scale and Overactive Bladder Questionnaire, Symptom Bother and Health Related Quality of Life scores at weeks 6 and 12; and increased the percentage of subjects who reported treatment satisfaction at weeks 6 and 12, and willingness to continue at week 12. CONCLUSIONS: Treatment with tolterodine extended release plus tamsulosin significantly improved urgency variables and patient reported outcomes in men meeting entry criteria for overactive bladder and prostatic enlargement trials.

Overactive bladder: treatment options in primary care medicine.

Overactive bladder is a highly prevalent condition, affecting approximately 33 million adults in the United States. Despite the considerable impact this condition has on patients' quality of life, overactive bladder remains underrecognized and undertreated as a result of patient embarrassment and reluctance to seek medical help, as well as a lack of proactive questioning by physicians. The present article encourages physicians to initiate a dialogue with patients regarding urinary control and, specifically, overactive bladder. Treatment options for overactive bladder recommended in the current article include both nonpharmacologic and pharmacologic therapies. Properties of antimuscarinic agents, including three new drug therapies, are reviewed and provided for physicians to optimize therapy options, particularly among elderly patients.