Recent Publications by CFE Educators

INTRODUCTION

Penile prosthetic devices are highly satisfactory in the management of erectile dysfunction but carry a number of risks including the potential for erosion. In some cases, impending extrusion can be identified and managed before frank erosion occurs.

AIMS

To report our results using a transglanular approach for management of impending distal erosion of penile prosthetic devices.

METHODS

Patients who presented with impending erosion of penile prosthetics were identified by retrospective chart review. Patients who were managed with a transglanular surgical approach constitute the study group.

MAIN OUTCOME MEASURES

Clinical data were culled from the charts. Identified patients were contacted and were asked a battery of questions regarding their subjective assessment of the treatment's efficacy.

RESULTS

Six men were identified. Mean age at time of surgery was 56 years. Four men had had implants placed within the past 2 years and two had implants that had been in place for greater than 12 years. Mean operative time was 25 minutes. Four patients were successfully managed with a single repair procedure. Two men required repeat revision surgery. Of men that were available for additional postoperative contact, three of four reported satisfaction with the procedure.

CONCLUSIONS

The transglanular approach for repair of impending distal erosion of penile prosthetics is a quick and minimally morbid procedure that produces satisfactory results in the majority of patients. Further refinements of technique will likely lead to greater overall improvement in outcomes.

INTRODUCTION

There has been limited investigation of the sexuality and sexual dysfunction in non-heterosexual subjects by the sexual medicine community. Additional research in these populations is needed.

AIMS

To investigate and compare sexuality and sexual function in students of varying sexual orientations.

METHODS

An internet-based survey on sexuality was administered to medical students in North American between the months of February and July of 2008.

MAIN OUTCOME MEASURES

All subjects provided information on their ethnodemographic characteristics, sexual orientation, and sexual history. Subjects also completed a series of widely-utilized instruments for the assessment of human sexuality (International Index of Erectile Function [IIEF], Female Sexual Function Index [FSFI], Premature Ejaculation Diagnostic Tool [PEDT], Index of Sex Life [ISL]).

RESULTS

There were 2,276 completed responses to the question on sexual orientation. 13.2% of male respondents and 4.7% of female respondents reported a homosexual orientation; 2.5% of male and 5.7% of female respondents reported a bisexual orientation. Many heterosexual males and females reported same-sex sexual experiences (4% and 10%, respectively). Opposite-sex experiences were very common in the male and female homosexual population (37% and 44%, respectively). The prevalence of premature ejaculation (PEDT > 8) was similar among heterosexual and homosexual men (16% and 17%, P = 0.7, respectively). Erectile dysfunction (IIEF-EF 26) was more common in homosexual men relative to heterosexual men (24% vs. 12%, P = 0.02). High risk for female sexual dysfunction (FSFI 26.55) was more common in heterosexual and bisexual women compared with lesbians (51%, 45%, and 29%, respectively, P = 0.005).

CONCLUSION

In this survey of highly educated young professionals, numerous similarities and some important differences in sexuality and sexual function were noted based on sexual orientation. It is unclear whether the dissimilarities represent differing relative prevalence of sexual problems or discrepancies in patterns of sex behavior and interpretation of the survey questions.

INTRODUCTION

Transforming growth factor-beta1 (TGF-beta1) contributes to the pathogenesis of Peyronie's disease (PD). Pentoxifylline (PTX) antagonizes the effects of TGF-beta1 and has been utilized in our clinic for the management of PD although the mechanisms of action are not entirely clear.

AIM

We studied cell-signaling pathways through which TGF-beta1 and PTX mediate collagen metabolism, elastin expression, and elastogenesis in tunica albuginea-derived fibroblasts (TADFs).

METHODS

TADFs from men with and without PD were cultured and treated with TGF-beta1 and PTX as monotherapy at differing concentrations and time points. Combination treatment (TGF-beta1 followed by PTX and vice versa) was also investigated.

MAIN OUTCOME MEASURES

Reverse-transcription polymerase chain reaction and Western blotting were utilized to assess differences in elastin metabolism and cellular signaling between groups. Alpha-1 antitrypin (AAT1) expression was assayed.

RESULTS

At doses greater than 0.1 ng/Ml, TGF-beta1 increased messenger ribonucleic acid (mRNA) and protein expression of elastin in a time-dependent fashion in TADF. PTX did not interfere with TGF-beta1 mediated upregulation of elastin mRNA and protein in TADF. However, pretreatment of TADF with PTX was associated with decreased expression of AAT1, decreased activity of the Smad1/5 pathway, and enhanced phosphorylation of the inhibitory Smad6.

CONCLUSION

Expression of elastin mRNA and protein is upregulated in TADF by TGF-beta1. PTX has no effect on elastin production but attenuates elastogenesis in TADF through an AAT1-related mechanism.

BACKGROUND

Efforts to maximize kidney transplantation are tempered by concern for the live donor's safety. Case series and center surveys exist, but national aggregate data are lacking. We sought to determine predictors of early clinical and economic outcomes following living donor nephrectomy.

DESIGN

A retrospective cross-sectional analysis using 1999-2005 discharge data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample was performed. Cases were identified by International Classification of Diseases, Ninth Revision (ICD-9), codes. Clinical and economic outcomes were analyzed with regard to patient and provider characteristics using bivariate and multivariate regression analyses.

SETTING

Healthcare Cost and Utilization Project Nationwide Inpatient Sample.

PATIENTS

Patients undergoing living donor nephrectomy, identified by the ICD-9 codes.

INTERVENTIONS

Clinical and economic outcomes were analyzed with regard to patient and provider characteristics using bivariate and multivariate regression analyses.

MAIN OUTCOME MEASURES

In-hospital complications, mortality, mean length of stay (LOS), and mean total hospital costs.

RESULTS

A total of 6320 cases were identified with 0% mortality and a complication rate of 18.4%. The mean (SD) LOS was 3.3 (0.3) days, and the mean inpatient cost was $10 708 ($505). Independent predictors of donor complications included older age (odds ratio [OR], 1.01), male sex (OR, 1.19), Charlson Comorbidity Index of at least 1 (OR, 1.49), obesity (OR, 1.76), medium-size hospitals (OR, 1.88), and low-volume hospitals (OR, 1.37). Predictors of longer LOS included older age, female sex, Charlson score of at least 1, lower household income, low-volume and urban hospitals, and low-volume surgeons.

CONCLUSIONS

Kidney donation is associated with a low mortality rate but an 18% complication rate. Donation by those with advanced age or obesity is associated with higher risks. Informed consent should include discussion of these risks.

Delirium is a commonly encountered clinical problem and, contrary to popular belief, should be treated as an acute neurologic emergency. It can be caused by a multitude of conditions and is frequently observed in hospitalized patients. In some cases, delirium results from the direct effect of a toxin, as observed with anticholinergic medications, or from neuronal injury, as seen in herpes simplex virus encephalitis. Because the treatment of delirium rests on the identification and treatment of the underlying illness, the astute clinician must tease apart these various possibilities with a careful history and physical examination and judicious use of laboratory tests and imaging studies. This chapter will review an approach to the patient with delirium and discuss management strategies based on current evidence.

INTRODUCTION

Transforming growth factor-β1 (TGF-β1) has been implicated in the pathogenesis of Peyronie's disease (PD) and also plays a role in collagen and elastin metabolism. Pentoxifylline (PTX) antagonizes the effects of TGF-β1 and has been utilized in our clinic for the management of PD.

AIM

We studied the effects of TGF-β1 and PTX on collagen metabolism and elastogenesis in tunica albuginea-derived fibroblasts (TADFs).

METHODS

TADFs from men with and without PD were cultured and treated with TGF-β1 and PTX as monotherapy at differing concentrations and time points. Combination treatment (TGF-β1 followed by PTX and vice versa) was also investigated.

MAIN OUTCOME MEASURES

Cell proliferation assay, enzyme-linked immunosorbent assay, and immunohistochemistry were utilized to assess the impact of TGF-β1 and PTX on TADF with respect to elastin and collagen I metabolism.

RESULTS

PTX inhibited fibroblast proliferation at doses of 100 µM. TGF-β1 stimulated elastogenesis and collagen I fiber deposition in TADF in a dose- and time-dependent fashion. Pretreatment with PTX dramatically attenuated TGF-β1-mediated elastogenesis and collagen fiber deposition in TADF from men with and without PD. Interestingly, production of collagen I was higher in untreated Peyronie's tunica (PT) cells relative to normal tunica (NT) cells; furthermore, PTX attenuated collagen production to levels similar to untreated control TADF in PT cells but not in NT cells, suggesting important intrinsic differences between PT and NT cells.

CONCLUSION

Both elastin and collagen are upregulated by TGF-β1 in TADF. This likely contributes to the PD phenotype. Pretreatment with PTX attenuates both collagen fiber deposition and elastogenesis in TADF exposed to TGF-β1; these effects suggest a useful role for PTX in the management of PD.

OBJECTIVE

To determine the prevalence of complementary and alternative medicine (CAM) use among couples seeking fertility care and to identify the predictors of CAM use in this population.

DESIGN

Prospective cohort study.

SETTING

Eight community and academic infertility practices.

PATIENT(S)

A total of 428 couples presenting for an infertility evaluation.

INTERVENTION(S)

Interviews and questionnaires.

MAIN OUTCOME MEASURE(S)

Prevalence of complementary and alternative medicine therapy.

RESULT(S)

After 18 months of observation, 29% of the couples had utilized a CAM modality for treatment of infertility; 22% had tried acupuncture, 17% herbal therapy, 5% a form of body work, and 1% meditation. An annual household income of > or = $200,000 (odds ratio 2.8, relative to couples earning $100,000), not achieving a pregnancy (odds ratio 2.3), and a positive attitude toward CAM use at baseline were independently associated with CAM use.

CONCLUSION(S)

A substantial minority of infertile couples use CAM treatments. CAM was chosen most commonly by wealthier couples, those not achieving a pregnancy, and those with a baseline belief in the effectiveness of CAM treatments.

BACKGROUND

Lp(a), implicated in both atherogenesis and thrombosis pathways, varies significantly by demographic and metabolic factors, providing challenges for its use in Coronary Heart Disease (CHD) risk. The purpose of this study was to investigate whether type-2 diabetic subjects, relative to non-diabetics, might benefit more from Lp(a) measurement in the prediction of CHD risk, as measured by coronary artery calcium (CAC).

METHODS

We performed cross sectional analyses in two community-based studies: the Penn Diabetes Heart Study [N = 1299 with type-2 diabetes] and the Study of Inherited Risk of Coronary Atherosclerosis [N = 860 without diabetes].

RESULTS

Blacks had 2-3 fold higher Lp(a) levels than whites in diabetic and non-diabetic samples. There was significant difference by gender (interaction p0.001), but not race, in the association of Lp(a) with CAC in type-2 diabetic subjects. In age and race adjusted analysis of diabetic women, Lp(a) was associated with CAC [Tobit regression ratio 2.76 (95% CI 1.73-4.40), p0.001]. Adjustment for exercise, medications, Framingham risk score, metabolic syndrome, BMI, CRP and hemoglobin A1c attenuated this effect, but the association of Lp(a) with CAC remained significant [2.25, (1.34-3.79), p = 0.002]. This relationship was further maintained in women stratified by race, or by the use of HRT or lipid lowering drugs. In contrast, Lp(a) was not associated with CAC in diabetic men, nor in non-diabetic men and women.

CONCLUSIONS

Lp(a) is a strong independent predictor of CAC in type-2 diabetic women, regardless of race, but not in men. Lp(a) does not relate to CAC in men or women without type-2 diabetes.