Management of Priapism: Results of a Nationwide Survey and Comparison with International Guidelines.

OBJECTIVE: The aim of this study is to evaluate current urologic practice regarding the management of priapism in Turkey and compare with international guidelines. METHODS: Urologists and urology residents were invited to an online survey consisting of 30 multiple-choice questions on priapism-related clinical practices that were consid- ered most important and relevant to practices by using Google Forms. RESULTS: Total number of responses was 340. Respondents reported that they recorded a detailed patient's medical history and physical examination findings (n = 340, 100%) and laboratory testing, which includes corporal blood gas analysis (n=323, 95%). Participants announced that they performed Doppler ultrasound for 1/4 cases (n = 106, 31%), but 22% of the participants (n=75) replied that they performed in >75% of cases. Participants (n=311, 91%) responded that the first-line treatment of ischemic priapism is decompression of the corpus cavernosum. Moreover, most respondents (n = 320, 94%) stated that sympathomimetic injection drugs should be applied as the second step. About three-quarters of respondents (n = 247, 73%) indicated adrenaline as their drug of choice. Phosphodiesterase type 5 inhibitors seems to be the most pre- ferred drug for stuttering priapism (n=141, 41%). Participants (n=284, 84%) replied that corpora-glanular shunts should be preferred as the first. A large number of par- ticipants (n = 239, 70%) declared that magnetic resonance imaging can be performed in cases with delayed (>24 hours) priapism to diagnose corporal necrosis. Most of the participants (84%) responded that penile prosthesis should be preferred to shunts in cases with delayed (>48 hours) priapism. CONCLUSION: It would be appropriate to improve the training offered by professional associations and to give more training time to the management of priapism during residency.

An Evaluation of Aspirin Treatment Preferences ORIGINAL INVESTIGATION of Physicians in Hypertensive Patients in Terms of Current Guidelines: A Subgroup Analysis of the ASSOS Trial in Turkey.

BACKGROUND: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial has been the largest study ever conducted among patients in Turkey regarding aspirin treatment. In the subgroup analysis of the hypertensive group of the Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial, we aimed to evaluate the physicians' adherence to current guidelines regarding their aspirin treatment preferences. METHODS: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial is a cross-sectional and multicenter study conducted among 5007 consecutive patients aged ≥18 years. The study population consisted of outpatients on aspirin treatment (80-300 mg). The patient data were obtained from 30 different cardiology clinics of 14 cities from all over Turkey. In this subgroup analysis, patients were divided into 2 groups: the hypertensive group (n=3467, 69.3%) and the group without hypertension (n=1540, 30.7%) according to the 2018 European Society of Cardiology/ European Society of Hypertension Guidelines for the Management of Arterial Hypertension. RESULTS: Aspirin use for primary prevention was higher in patients with hypertension compared to patients without hypertension [328 (21.3%); 1046 (30.2%); P < .001]. Treatment with a dose of 150 mg aspirin (n=172, 5%) was mostly preferred by internists for hypertensive patients (n =226, 6.5%); however, a daily dose of 80-100 mg aspirin therapy (n=1457, 94.6%) was mostly prescribed by cardiologists (n=1347, 87.5%) for patients without hypertension. CONCLUSION: Aspirin was found to be used commonly among patients with hypertension for primary prevention despite the current European Society of Cardiology Arterial Hypertension Guideline not recommending aspirin for primary prevention in patients with hypertension.

Inappropriate Use of Aspirin in Real-Life Cardiology Practice: Results from the Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study (ASSOS) Study.

BACKGROUND: Indications and appropriateness of aspirin use have not been well investigated in Turkey. AIMS: To investigate the prescription patterns and appropriateness of aspirin in a real-world clinical setting. STUDY DESIGN: Cross-sectional study. METHODS: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study (ASSOS) is a cross-sectional and multicenter study that included 5007 consecutive patients aged 18 or over who presented to 30 different cardiology outpatient clinics from 14 cities throughout Turkey. Only patients using aspirin (80-325 mg) were included. The study population was divided into 2 groups regarding the use of aspirin: primary prevention (PP) group and secondary prevention (SP) group. The indication of aspirin use was evaluated following the 2016 European Society of Cardiology (ESC) and the 2016 United States Preventative Services Task Force (USPTF) guidelines in the PP group. RESULTS: A total of 5007 patients (mean age 62.15 ± 11.05, 39% female) were enrolled. The PP group included 1132 (22.6%) patients, and the SP group included 3875 (77.4%) patients. Of the 1132 patients, inappropriate use of aspirin was determined in 100% of the patients according to the ESC guidelines, and 71% of the patients according to the USPTF guidelines. Multivariate logistic regression analysis showed age OR: 0.98 CI (0.97-0.99) P = .037, smoking OR: 0.60 CI (0.44-0.82) P = .001, heart failure OR: 2.11 CI (1.14-3.92) P = .017, hypertension OR: 0.51 CI (0.36-0.74) P < .001, diabetes mellitus OR: 0.34 CI (0.25-0.47) P < .001, oral anticoagulant use OR: 3.01 CI (1.10-8.25) P = .032, and female sex OR: 2.73 CI (1.96-3.80) P < .001 were independent predictors of inappropriate aspirin use in PP patients. CONCLUSION: Although there are considerable differences between the USPTF and the ESC guidelines with respect to recommendations for aspirin use in PP, inappropriate use of aspirin in Turkey is frequent in real-world practice for both guidelines. Besides, heart failure, oral anticoagulant use, and the female sex of the patients were independent predictors of inappropriate use of aspirin.

Efficacy of silodosin or mirabegron in medical expulsive therapy for ureteral stones: a prospective, randomized-controlled study.

OBJECTIVE: To evaluate the efficacy of silodosin or mirabegron as a medical expulsive therapy for ureteric stones in adults. PATIENTS-METHOD: This is a prospective, randomized multicentric study. Patients who had ureter stones in size between 4 and 10 mm were assessed prospectively. Patients were divided into three groups with equal randomization. Group 1 was the control group; group 2 took silodosin 8 mg, and group 3 took mirabegron 50 mg once daily. RESULTS: All 169 patients were included in the final analysis. The spontaneous expulsion rate was similar between groups. In patients with distal localization, the stone expulsion interval was shorter in the silodosin group (7.1 ± 4.5 days) than the control (12 ± 8.7) (p = 0.034). In patients with stone size smaller than 6 mm, the stone expulsion interval was shorter in the silodosin group (5.8 ± 4) than the control (12.2 ± 2.8) (p = 0.004); the analgesic requirement was less in the silodosin group (1.4 ± 1.3) than in the control (3.6 ± 2.8) (p = 0.028). Mirabegron had no effect on stone expulsion interval in any analysis. In patients with distal localization or stone size bigger or equal to 6 mm, the need for an analgesic was less in the mirabegron group (1.8 ± 1.9) (1.9 ± 1.8) than in the control (3.6 ± 2.3) (3.2 ± 1.8), respectively (p = 0.004) (p = 0.017). CONCLUSIONS: Silodosin or mirabegron does not improve the stone expulsion rate. Silodosin improves the stone expulsion interval and decreases the need for an analgesic or < 6 mm stones. Mirabegron has no effect on the stone expulsion interval, but decreases the need for an analgesic in patients with distal or sized ≥ 6 mm stones.

Bioimpedance spectroscopy for the differential diagnosis of hyponatremia.

BACKGROUND: Hyponatremia is classified according to volume status with the help of physical examination, biochemical measures, urine and serum osmolalities, and echocardiography. Bioimpedance spectroscopy (BIS) has been getting popularity for revealing tissue compositions of various patient groups. The aim of this observational study was to investigate the role of BIS for the differential diagnosis of hyponatremia (ClinicalTrials.gov Identifier: NCT01838759). PATIENTS AND METHODS: Personal characteristics of age, sex, weight, height, and blood pressure were recorded. Body composition monitor (BCM) was used for hydration status for each individual. Primary outcome was investigated by the accuracy of volume status measured by BIS. STATISTICS: Kappa statistic (K) is a measure of agreement between two sources, which is measured on a binary scale (i.e., condition present/absent). K statistic can take values between 0 and 1: poor agreement: K < 0.20, fair agreement: 0.2.0-0.3.9, moderate agreement: 0.40-0.59, substantial: 0.60-0.79, very good agreement: 0.80-1.00. RESULTS: Fifty-eight hyponatremia-diagnosed patients, 32 (55.2%) of male with the mean age of 65.2 ± 11 (40-89) years were included. Kappa statistic (K) were very good (K = 0.925) for male (p < 0.00), substantial agreement (K = 0.601) for female (p < 0.002) with the use of BIS for the differential diagnosis of either hypo or hypervolemia in hyponatremic patients compared with gold standard tests which were the combination of echocardiography, serum, and urine osmolality biochemical tests, and physical examination. CONCLUSION: Bioimpedance spectroscopy is a practical and an inexpensive method. This is the first study in the literature showing the role of BIS for the determination of the volume status and differential diagnosis of hyponatremia when compared with echocardiography.

Right ventricular isovolumic acceleration in acute pulmonary embolism.

OBJECTIVE: In this study, we examined the role of isovolumic acceleration (IVA) measured with right ventricle (RV) tissue Doppler imaging (TDI) to predict the presence of acute pulmonary embolism (APE) in hemodynamically stable patients with clinical suspicion of APE. MATERIALS AND METHOD: This study included 25 hemodynamically stable (systolic blood pressure >90 mmHg) patients diagnosed with APE for the first time. Twenty-five subjects with similar demographic characteristics in whom APE was excluded due to preexisting clinical suspicion were also enrolled as the control group. All control group subjects were enrolled after proved to have no evidence of APE on imaging. Both groups were compared with respect to RV-IVA measured with TDI in addition to conventional echocardiographic parameters. RESULTS: Among the echocardiography parameters, only RV-IVA was impaired in patients with hemodynamically stable APE compared to controls (2.85 [1.37-6.42] m/sec(2) vs. 3.32 [2.24-6.52] m/sec(2) , respectively; P = 0.02). A receiver operating characteristic (ROC) analysis was performed to determine the RV-IVA value to predict clinically suspected APE. A cutoff level of 3.22 m/sec(2) had a sensitivity of 64% and a specificity of 60%; a cutoff level of 3.17 m/sec(2) had a sensitivity of 64% and a specificity of 64%; and a cutoff level of 3.10 m/sec(2) had a sensitivity of 60% and specificity of 64% (ROC area under curve: 0.691, 95% CI: 0.543-0.839, P = 0.02). CONCLUSION: Results of our study suggest that RV-IVA may be a useful parameter to detect subtle alterations in RV and may predict the presence of APE in hemodynamically stable patients.

Plateletcrit and red cell distribution width are independent predictors of the slow coronary flow phenomenon.

BACKGROUND AND PURPOSE: Endothelial dysfunction may play a role in the pathogenesis of the slow coronary flow (SCF) phenomenon. A detailed examination of blood cellular components has not been performed for this condition. We investigated the relationship between SCF and whole blood cell counts. METHOD: Records of 17,315 patients who underwent coronary angiography between January 2006 and December 2012 were evaluated retrospectively. A total of 146 patients with SCF were compared with 148 patients with normal coronary arteries according to demographic data, complete blood count, and biochemical parameters. RESULTS: The following parameters were significantly higher in SCF patients than in patients with normal coronary arteries: percentage of smokers (36.3% vs. 25%, p=0.036), body mass index (26.69 ± 2.84 vs. 26.07 ± 3.15, p=0.049), white blood cells (WBCs) (7.52 ± 1.43 × 10(3)mm(-3) vs. 7.01 ± 1.42 × 10(3)mm(-3), p=0.002), red cell distribution width (RDW) (13.68 ± 1.42% vs. 13.15 ± 1.13%, p<0.001), platelets (250.29 ± 50.96 × 10(3)mm(-3) vs. 226.10 ± 38.02 × 10(3)mm(-3), p<0.001), plateletcrit (PCT) (0.214 ± 0.40% vs. 0.184 ±0.29%, p<0.001), mean platelet volume (8.63 ± 1.10fL vs. 8.22 ± 0.83 fL, p<0.001), platelet distribution width (PDW) (16.58 ± 0.76% vs. 16.45 ± 0.57%, p=0.028), and neutrophils (4.44 ± 1.25 × 10(3)mm(-3) vs. 4.12 ± 1.24 × 10(3)mm(-3), p=0.029). Positive PCT values [odds ratio (OR), 4.165; 95% confidence interval (CI), 2.493-6.959; p<0.001) and RDW (OR, 1.304; 95% CI, 1.034-1.645; p=0.025) were independent predictors of SCF. CONCLUSION: Although within the normal range, the increased numbers of WBCs and neutrophils in patients with SCF suggest that SCF may be a subclinical inflammatory condition. Furthermore, increased RDW and PDW in SCF patients may cause microvascular blood flow resistance due to impaired cell deformability. The PCT provides reliable data regarding total platelet mass and may be a useful predictor of SCF.

Differences in sex, angiographic frequency, and parameters in patients with coronary artery anomalies: single-center screening of 25 368 patients by coronary angiography.

BACKGROUND: Although the prevalence of coronary artery anomalies varies in different series, the precise population frequency is unknown. MATERIALS AND METHODS: The medical records of all patients who underwent coronary angiography between January 2002 and August 2012 were retrieved, and 238 cases with coronary anomalies were evaluated. Unlike other studies, we compared several angiographic parameters (fluoroscopy time, number of images, and catheters used) in addition to frequency and sex data. RESULTS: The angiographic frequency of coronary artery anomalies was 0.94%. The most common coronary anomaly was a left anterior descending-circumflex artery originating from separate ostia (0.29%). The second most common anomaly was a right coronary artery (RCA) originating from the left sinus of Valsalva (sV) (0.23%). Overall, coronary artery anomalies (1.28 vs. 0.80%; P<0.001) and a left anterior descending-circumflex artery originating from separate ostia (41.3 vs. 25.3%, P=0.010) were more frequent in women than in men. The percentage of patients requiring more than two catheters during the procedure was significantly higher for an RCA originating from the left sV (45.7 vs. 16.7%, P<0.001) and in hypertensive patients (85.7 vs. 70.8%, P=0.015). On comparing the three most common coronary anomalies, an anomalous RCA originating from the left sV had a significantly higher value for at least one angiographic parameter. CONCLUSION: An anomalous RCA originating from the left sV is the most difficult type of anomaly to perform the ostial coronary cannulation during procedure. The results of this study may lead to the development of more suitable diagnostic catheters for an anomalous RCA originating from the left sV.

Pigtail catheter fracture and embolization into the abdominal aorta: an extremely rare angiographic complication.

Coronary angiography is a widely used diagnostic method for coronary artery disease. In clinical practice, although complications of the procedure often involve the vascular access point, there is no previous report of the fracture and embolization of the distal tip of a pigtail catheter. Herein, we present the case of a 51-year-old woman whose left ventriculography was interrupted by fracture of the curved tip of a pigtail catheter, which remained at the renal artery level in the abdominal aorta.

Severe main coronary artery disease in a young woman with ankylosing spondylitis.

Patients with ankylosing spondylitis (AS) have an approximately two-fold increased death rate compared to the general population, which is predominately caused by increased cardiovascular risk. The prevalence rate for myocardial infarction is approximately 2-3 fold increased as compared with the general population. The inflammatory process appears to have an important role in causing this excess cardiovascular risk. In this paper, we present a case of severe coronary artery disease which could be demonstrated clearly by computer tomography in a 27-year-old woman who is being followed with AS.

Prolonged P wave dispersion in pre-diabetic patients.

BACKGROUND: It is known that overt diabetes as well as chronic hyperglycaemia can lead to atrial fibrillation. A P wave dispersion (PWD) represents heterogeneity in atrial refractoriness. AIM: To investigate PWDs in patients with pre-diabetes. METHOD: Based on the results of examinations, 84 pre-diabetic patients (the pre-DM group; 50 female, 34 male; mean age 54 ± 8.6 years) who had no overt diabetes, coronary artery disease or hypertension, whose fasting blood glucose was higher than 100 mg/dL and/or whose 2 h glucose concentrations on an oral glucose tolerance test was in the range of 140 to 199 mg/dL, and 48 healthy volunteers (the non-DM group, 30 female, 18 male; mean age 51.7 ± 7.3 years) with no illnesses, were enrolled in this study. Standard 12-lead electrocardiograms of all patients were taken at 50 mm/s and 20 mm/mV standardisation. Maximum (P(max)) and minimum (P(min)) P-wave durations were measured. The PWD was defined as the difference between P(max) and P(min). RESULTS: The P(max) and PWD values were significantly higher in pre-DM compared to non-DM (104 ± 13 ms vs 98 ± 12 ms; p < 0.05, 42 ± 13 ms vs 34 ± 11 ms; p <0.01 respectively). A positive correlation was found between PWD and fasting blood glucose (r = 0.32; p < 0.01). There was no correlation between PWD and HbA(1c) levels (r = 19; p > 0.05). Multivariate regression analysis showed no relationship between PWD and age, left atrial diameter, E, A, E/A or HbA(1c). However, there was a relationship between PWD and fasting blood glucose. CONCLUSIONS: The P(max) and PWD are increased in pre-diabetic patients who have no coronary artery disease, hypertension or left ventricular hypertrophy