Assessing the readability and quality of online information about benign prostatic hyperplasia.

PURPOSE: Benign prostatic hyperplasia (BPH) affects nearly half of men in their fifties. Patients often search the Internet to better understand their diagnosis, but online health information is not well regulated and can be difficult for patients to comprehend. This study aims to evaluate not only readability, but also the quality of online information about BPH, as well as the effect of commercial bias on readability and quality. METHODS: Three search engines (Google, Bing, and DuckDuckGo) were used with broad search terms including "BPH," "BPH treatment," and "BPH surgery," to mimic a patient diagnosed with BPH seeking further information. 204 total websites were identified, of which 62 were unique websites. Among those unique websites, 23 were advertisements. Three readability formulas (Flesch-Kincaid Grade Level, Flesch-Kincaid Reading Ease, SMOG) were used to generate readability scores. DISCERN standardized questionnaire was used to evaluate website quality. RESULTS: Average reading level of online information about BPH was significantly higher than the recommended level by the American Medical Association (AMA) and United States Department of Health and Human Services (USDHHS). Advertisements had significantly easier readability than nonadvertisements. Average website quality was "excellent" for nonadvertisements, but only "fair" for advertisements. CONCLUSION: Although advertisements may hold optimal search result positions and have better readability than nonadvertisements, they have biased and lower quality information. It is important to guide patients to high quality online information of appropriate reading level. Continued efforts should be made to create and share with patients high quality resources with improved readability to facilitate comprehension and minimize misinformation.

Multicenter surgical outcomes of penile prosthesis placement in patients with corporal fibrosis and review of the literature.

Penile prosthesis (PP) insertion in the setting of corporal fibrosis can be challenging and a variety of techniques have been described to accomplish this, however the necessity of these maneuvers is debatable. Our objective was to investigate techniques and outcomes of PP placement in patients with corporal fibrosis at tertiary referral centers. Multicenter outcomes of 42 patients (mean age 53.4 ± 1.9 years) with corporal fibrosis who underwent placement of PP over a 10-year period were reviewed. The most common etiology of corporal fibrosis was prior PP explant due to either infection (40.5%) and/or erosion (16.7%). Fourteen patients (33.3%) had a history of priapism, 5 (11.9%) of which had one or more distal surgical penile shunts. Techniques used for PP placement included: sequential dilation (8-12 mm) with standard dilators in 15 (35.7%), dilation with cavernotomes in 25 (59.5%) and limited sharp corporal excision and dilation with cavernotomes in 1 (2.4%). Narrow cylinders were employed in ten patients (23.8%). Major complications occurred in one patient (2.4%) who underwent explant for infection and distal erosion. Most patients with corporal fibrosis can undergo successful placement of a PP using standard dilators or cavernotomes. Sharp corporal excision and other measures are rarely required.

Postoperative penile prosthesis pain: is it worse in diabetic patients?

Inflatable penile prosthesis (IPP) surgery is an effective, safe and satisfactory treatment option for medication-refractory erectile dysfunction. Postoperative complications include infection, mechanical failure, erosion, and pain. Current literature suggests the need for a better approach to postoperative pain management after IPP surgery. Clinical studies have demonstrated that postoperative pain is different in diabetic patients. We sought to determine if there is a difference in pain after IPP placement in diabetics. This is a single-institution retrospective review. The main outcome measure was the number of 30-day postoperative visits for pain. The secondary outcome included differences in how pain was managed. The top HbA1c quartile was compared with the other HbA1c quartiles. Diabetes was present in 92 (54.4%) patients and 96% of these had HbA1c > 8. Significant postoperative pain was more common in patients with HbA1c > 8 (41% vs 13%, p = 0.047) and resulted in more unplanned visits (27% vs 11%, p = 0.042). Patients with HbA1c > 8 with significant postoperative pain were more likely to be managed with opioids and gabapentin (30% vs 14%, p = 0.05). There were no statistical differences in age between diabetics and non-diabetics (mean 59 vs 61, p = 0.193). Hispanic and African-American patients represented 87% of the poorly controlled diabetics compared with only 13% of white patients (p < 0.001). Poorly controlled diabetics had more medical comorbidities (p < 0.001). On logistic regression, a HbA1c > 8 was predictive of an unplanned visit for pain with an OR of 2.83 (p = 0.04). Significant pain after IPP surgery was higher in diabetics with HbA1c > 8, which resulted in more unplanned 30-day postoperative visits. Patients with significant postoperative pain were managed with a combination of opioids and gabapentin. Future studies are required to optimize pain management in diabetics following IPP placement.

Epidemiology of genitourinary foreign bodies in the united states emergency room setting and its association with mental health disorders.

The epidemiology of genitourinary foreign bodies (GUFB) has been mainly described through case reports and small series. The aim of this study is to investigate the epidemiologic, medical, and socioeconomic factors associated with GUFB, along with the resultant costs of care in emergency departments (EDs) nationwide. ED visits with the primary diagnosis of a GUFB between 2010 and 2014 were abstracted from the Nationwide Emergency Department Sample database. Between 2010 and 2014, a weighted estimate of 102,333 visits to the ED with GUFB were recorded in the US, representing a national incidence of 7.6 ED visits per 100,000 persons. Of these visits, 4.7% resulted in admission and males were more likely to be admitted (24.8% vs. 2.1%, p < 0.01). A third of patients had low income, 30% had no medical insurance, and a third of patients had Medicaid. Urethra/bladder and penile foreign bodies had a significant association with mental health disorders (35.6%). Vulvar/vaginal foreign bodies had a lower prevalence of mental health disorders (6.1%). Costs of managing patients in the ED averaged $3769. More importantly, penile or urethra/bladder foreign bodies incurred a higher cost ($30,071). This is the largest population-based study investigating the epidemiology of GUFB. GUFB are more common in young women and the majority of them are vulvar/vaginal. Urethral and bladder foreign bodies occurred in older male patients and are associated with longer hospital stays and costs. Over one third of male patients with urethra/bladder had significant mental health disorders.

Factors Associated With Long-term Outcomes After Injury: Results of the Functional Outcomes and Recovery After Trauma Emergencies (FORTE) Multicenter Cohort Study.

OBJECTIVE: The aim of this study was to determine factors associated with patient-reported outcomes, 6 to 12 months after moderate to severe injury. SUMMARY OF BACKGROUND DATA: Due to limitations of trauma registries, we have an incomplete understanding of factors that impact long-term patient-reported outcomes after injury. As 96% of patients survive their injuries, several entities including the National Academies of Science, Engineering and Medicine have called for a mechanism to routinely follow trauma patients and determine factors associated with survival, patient-reported outcomes, and reintegration into society after trauma. METHODS: Over 30 months, major trauma patients [Injury Severity Score (ISS) ≥9] admitted to 3 Level-I trauma centers in Boston were assessed via telephone between 6 and 12 months after injury. Outcome measures evaluated long-term functional, physical, and mental-health outcomes. Multiple regression models were utilized to identify patient and injury factors associated with outcomes. RESULTS: We successfully followed 1736 patients (65% of patients contacted). More than half (62%) reported current physical limitations, 37% needed help for at least 1 activity of daily living, 20% screened positive for posttraumatic stress disorder (PTSD), all SF-12 physical health subdomain scores were significantly below US norms, and 41% of patients who were working previously were unable to return to work. Age, sex, and education were associated with long-term outcomes, while almost none of the traditional measures of injury severity were. CONCLUSION: The long-term sequelae of trauma are more significant than previously expected. Collection of postdischarge outcomes identified patient factors, such as female sex and low education, associated with worse recovery. This suggests that social support systems are potentially at the core of recovery rather than traditional measures of injury severity.

Closed suction drain outputs at 12 and 24 hours after primary three-piece inflatable penile prosthesis surgery.

This is a single-institution retrospective study of closed suction drain outputs in primary three-piece IPP cases performed between 2014 and 2017 by a single surgeon. The aim was to investigate the impact of closed suction drains (CSD) during penile prosthesis placement. One hundred and sixty-nine patients underwent intraoperative placement of a closed suction drain. Drain outputs were measured at 12 and 24 h, and postoperative complications were documented. There were no hematomas or infections observed within the patient cohort. The drain output decreased significantly between the first and subsequent 12 h period. Surgical time was associated with statistically significant increases in CSD output at 12 and 24 h with a near linear relationship between surgical times and CSD at 12 and 24 h. Penile prosthesis placement in patients on aspirin did not affect the CSD output volume. Closed suction drains should be considered in all patients undergoing placement of inflatable penile prosthesis, particularly in those cases with longer operative time.

The impact of in-hospital complications on the long-term functional outcome of trauma patients: A multicenter study.

BACKGROUND: The long-term consequences of in-hospital complications remain largely unknown. We sought to study the effect of complications on the long-term functional outcome of trauma patients. METHODS: Patients with an Injury Severity Score ≥ 9 admitted to 3, level I trauma centers between 2015 and 2017 were contacted 6 to 12 months postinjury and administered a validated trauma quality-of-life survey, assessing for the presence of any functional limitation. Functional limitation was defined as the inability to perform independently one or more activities of daily living (eg, driving, walking on flat surfaces/upstairs, dressing). Medical records and the trauma registry were reviewed systematically for all patient and injury variables. The occurrence of predefined in-hospital complications (eg, pneumonia, surgical site infection) was recorded. The impact of in-hospital complications on functional limitation was assessed using multivariate logistic regression models. RESULTS: Of 1,709 patients, 1,022 completed the study. The mean age was 58 y, 56% were male, 94% had blunt trauma, and the mean Injury Severity Score was 15. A total of 168 patients (16.4%) had a minimum of 1 in-hospital complication and reported significantly more functional limitations in most activities of daily living at 6 to 12 months, compared with those without complications. In multivariable analyses adjusting for confounders, the occurrence of complications was associated with a greater likelihood of functional limitation 6 to 12 months postinjury (odds ratio = 1.82, 95% confidence interval 1.22-2.69, P = .003). CONCLUSION: Trauma patients with in-hospital complications have a worse long-term functional outcome. In addition to prevention of primary complications, more rehabilitation resources should be made available to trauma patients who survive complications.

Long-term social dysfunction after trauma: What is the prevalence, risk factors, and associated outcomes?

BACKGROUND: Social functioning-the ability to participate in organized or informal family, friend, or peer groups and communal activities-is intertwined with physical and emotional health. Although trauma can have a lasting effect on both the physical and emotional well-being of patients, little is known about the long-term impact of injury on social functioning. We sought to determine the prevalence of, risk factors for, and outcomes associated with long-term social dysfunction after trauma. METHODS: Adults with moderate-to-severe injuries managed at three Level I trauma centers were contacted at 6 to 12 months after injury to inquire about social dysfunction. Demographics, socioeconomic parameters, and injury-related and hospital course information were also obtained. A stepwise backward logistic regression model was fitted to determine independent risk factors of social dysfunction, and multiple logistic regression models were used to determine associations between social dysfunction and post-traumatic stress disorder, functional limitations, and return to work. RESULTS: Of the 805 screened patients, 45.2% reported social dysfunction. Patients with social dysfunction were more likely to be African American, be Medicaid beneficiaries, be of lower education, require mechanical ventilation, be discharged less often to home, have a lower mean age and had longer hospital stays. In multivariable analysis, low education, longer hospital stay, past psychiatric illness, and African-American race independently increased the risk for social dysfunction. Furthermore, patients with social dysfunction were more likely to screen positive for post-traumatic stress disorder (odds ratio: 16.25 [95% confidence interval: 9.49-27.85]), be experiencing functional limitations (odds ratio: 2.80 [95% confidence interval: 1.76-4.44]), and to not have returned to work (odds ratio: 5.65 [95% confidence interval: 3.92-8.14]). CONCLUSION: Lower educational attainment, long hospital stay, past pyschiatric illness, and African-American race appear to predispose to social dysfunction after trauma, which in turn is associated with a positive post-traumatic stress disorder screen, functional limitations, and delayed return to work.

Epidemiology of Penile Fractures in United States Emergency Departments: Access to Care Disparities May Lead to Suboptimal Outcomes.

INTRODUCTION: The epidemiology of penile fractures in the emergency setting is not well described. AIM: Examine the incidence, evaluation, management, risk factors predicting surgical repair or hospital transfer, and use of financial resources in patients presenting with penile fractures to the emergency departments (ED) nationwide in the Unites States. METHODS: ED visits with a primary diagnosis of penile fractures (International Classification of Diseases, Ninth Edition codes) between 2010-2014 were abstracted from the Nationwide Emergency Department Sample. MAIN OUTCOME MEASURE: Penile fracture incidence, disposition, hospital, and clinical factors which were associated with immediate surgical repair or transfer to another institution, and cost were investigated. RESULTS: 8,029 ED visits for penile fracture in the United States were observed, which represents a national incidence of 1.02 per 100,000 male subjects per year. No meaningful trends in incidence were observed over the 5-year period. 63.9% were treated non-surgically or discharged from the ED, 25.7% underwent surgical repair, and 10.3% were transferred to other institutions. Hospital factors which predicted surgical repair included Northeast region, teaching hospital status, trauma hospital status, high volume ED, and urban location. Clinical risk factors which predicted surgical repair included hypertension, smoking, alcohol dependence, drug abuse, erectile dysfunction, hematuria, urethral injury, and urinary retention. Factors leading to patient transfers included non-academic, rural and non-trauma hospitals, low economic income and low emergency department volume. In addition, weekend and spring presentation were associated with higher transfer rates, while summer presentation was associated with surgical repair. CLINICAL IMPLICATIONS: A large proportion of penile fractures are discharged from the ED, indicating possible health care access disparity. STRENGTHS & LIMITATIONS: This is one of the first population-based study of penile fracture incidence, disposition, risk factors which predict surgery or transfer, and cost in the US ED setting. The unexpected high number of discharges may be a result of misdiagnosis; alternatively these data may reveal previously under-reported management patterns in the community. CONCLUSION: This large retrospective study of penile fractures in the US ED setting demonstrates a stable incidence of penile fractures presenting to the US emergency departments. A quarter of patients undergo immediate surgical repair, 10% are transferred to other institutions and 63.9% of patients are discharged home. The high proportion of ED discharges may be due to access to health care disparities. Rodriguez D, Li K, Apoj M, et al. Epidemiology of Penile Fractures in United States Emergency Departments: Access to Care Disparities May Lead to Suboptimal Outcomes. J Sex Med 2019;16:248-256.

Simulation Training in Penile Implant Surgery: Assessment of Surgical Confidence and Knowledge With Cadaveric Laboratory Training.

INTRODUCTION: Constraints on surgical resident training (work-hour mandates, shorter training programs, etc.) and availability of expert surgical educators may limit the acquisition of prosthetic surgical skills. As a result, training courses are being conducted to augment the prosthetic surgery learning experience. AIM: To evaluate the impact of a hands-on cadaver-based teaching program on resident procedural knowledge and procedural confidence with placement of a penile prosthesis. MAIN OUTCOME MEASURE: Changes in procedural knowledge and self-confidence following a focused training program on penile prosthetics. METHODS: As part of the 2017 Society of Urologic Prosthetic Surgeons and the Sexual Medicine Society of North America Annual Meeting, 31 urology residents participated in a simulation lab in prosthetic urology. The lab included didactic lectures and a hands-on cadaveric laboratory. Participants completed surveys before and after the course. Wilcoxon Signed Rank tests for matched pairs were used to compare respondents' pre- and postcourse knowledge (% questions answered correctly) and confidence ratings. Prior implant experience was assessed. RESULTS: 31 residents participated in this study. The majority of the participants were 4th- (41.9%) and 5th-year residents (38.7%). Participants showed a significant improvement in procedural knowledge test scores (68.8±13.4 vs 74.2 ± 13.0, P < .05) and self-reported increased median surgical confidence levels (4 vs 3, P value < .001) after completion of the cadaveric course. Subgroup analysis demonstrated that residents with prosthetic surgery experience of <10 cases benefited the most. In addition, improvement in surgical confidence levels observed was greater than the improvement in surgical knowledge. The overall cost of the simulation training course was approximately $1,483 per resident. CONCLUSION: Simulation training in prosthetic surgery seems to improve surgical confidence and knowledge. Further research is needed to better understand the benefits and limitations of simulation training. Lentz AC, Rodríguez D, Davis LG. Simulation training in penile implant surgery: Assessment of surgical confidence and knowledge with cadaveric laboratory training. Sex Med 2018;6:332-338.

A multicenter study of post-traumatic stress disorder after injury: Mechanism matters more than injury severity.

BACKGROUND: Traumatic injury is strongly associated with long-term mental health disorders, but the risk factors for developing these disorders are poorly understood. We report on a multi-institutional collaboration to collect long-term patient-centered outcomes after trauma, including screening for post-traumatic stress disorder. The objective of this study is to determine the prevalence of and risk factors for the development of post-traumatic stress disorder after traumatic injury. METHODS: Adult trauma patients (aged 18-64) with moderate to severe injuries (Injury Severity Score ≥ 9) admitted to 3 level I trauma centers were screened between 6 and 12 months after injury for post-traumatic stress disorder. Patients were divided by mechanism: fall, road traffic injury, and intentional injury. Multiple logistic regression models were used to determine the association between baseline patient and injury-related characteristics and the development of post-traumatic stress disorder for the overall cohort and by mechanism of injury. RESULTS: A total of 450 patients completed the screen. Overall 32% screened positive for post-traumatic stress disorder, but this differed significantly by mechanism, with the lowest being after a fall (25%) and highest after intentional injury (60%). Injury severity was not associated with post-traumatic stress disorder for any group, but lower educational level was associated with post-traumatic stress disorder within all the groups. Only 21% of patients who screened positive for post-traumatic stress disorder were receiving treatment at the time of the survey. CONCLUSION: Post-traumatic stress disorder is common after traumatic injury, and the prevalence varies significantly by injury mechanism but is not associated with injury severity. Only a small proportion of patients who screen positive for post-traumatic stress disorder are currently receiving treatment.

Association of pain after trauma with long-term functional and mental health outcomes.

BACKGROUND: Chronic pain after trauma is associated with serious clinical, social, and economic burden. Due to limitations in trauma registry data and previous studies, the current prevalence of chronic pain after trauma is unknown, and little is known about the association of pain with other long-term outcomes. We sought to describe the long-term burden of self-reported pain after injury and to determine its association with positive screen for posttraumatic stress disorder (PTSD), functional status, and return to work. METHODS: Trauma survivors with moderate or severe injuries and one completed follow-up interview at either 6 months or 12 months after injury were identified from the Functional Outcomes and Recovery after Trauma Emergencies project. Multivariable logistic regression models clustered by facility and adjusting for confounders were used to obtain the odds of positive PTSD screening, not returning to work, and functional limitation at 6 months and 12 months after injury, in trauma patients who reported to have pain on a daily basis compared to those who did not. RESULTS: We completed interviews on 650 patients (43% of eligible patients). Half of patients (50%) reported experiencing pain daily, and 23% reported taking pain medications daily between 6 months and 12 months after injury. Compared to patients without pain, patients with pain were more likely to screen positive for PTSD (odds ratio [OR], 5.12; 95% confidence interval [CI], 2.97-8.85), have functional limitations for at least one daily activity (OR, 2.42; 95% CI, 1.38-4.26]), and not return to work (OR, 1.86; 95% CI, 1.02-3.39). CONCLUSIONS: There is a significant amount of self-reported chronic pain after trauma, which is in turn associated with positive screen for PTSD, functional limitations, and delayed return to work. New metrics for measuring successful care of the trauma patient are needed that span beyond mortality, and it is important we shift our focus beyond the trauma center and toward improving the long-term morbidity of trauma survivors. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.