Percutaneous thrombin injection with a distal embolic protection device for treatment of a common carotid artery pseudoaneurysm

Carotid artery pseudoaneurysm is a rare complication from placement of an internal jugular triple lumen catheter. Endovascular stenting is the favored treatment option in the setting of traumatic carotid injury. In other parts of the body, specifically the femoral artery, thrombin injection has become the standard of care. We intend to show that effective management of carotid pseudoaneurysms can also be achieved with thrombin injection after placement of a distal embolic protection device.

Sildenafil citrate improves erectile function and lower urinary tract symptoms independent of baseline body mass index or LUTS severity

OBJECTIVES

To evaluate the body mass index (BMI) and lower urinary tract symptom (LUTS) severity on treatment response to sildenafil in men with erectile dysfunction (ED) and moderate to severe LUTS associated with benign prostatic hyperplasia.

METHODS

A post hoc analysis of data from a 12-week, double-blind, placebo-controlled study of sildenafil (50 mg once daily titrated to 100 mg once daily) was conducted. The BMI categories were obese (> or = 30 kg/m(2)), overweight (> or = 25 to < 30 kg/m(2)), and normal weight (< 25 kg/m(2)). ED was defined as a score of < or = 25 on the erectile function domain of the International Index of Erectile Function, and LUTS was defined by an International Prostate Symptom Score of > or = 12. The maximal urinary flow rate was determined by uroflowmetry.

RESULTS

Patients receiving sildenafil (n = 189) had a significant improvement in the erectile function domain scores of the International Index of Erectile Function (P < .0001 vs placebo, n = 180), which did not vary across BMI groups. A greater improvement in LUTS score was observed with sildenafil compared with placebo for men with severe LUTS (-8.6 vs -2.4, P < .0001) than in men with moderate LUTS (-3.6 vs -1.7, P = .06). Also, the improvement in LUTS scores was significant (P < or = .02) for men taking sildenafil independent of BMI (obese, -8.9 vs -5.4; overweight, -7.3 vs -3.2; normal weight, -7.1 vs -0.84). No difference was found among the treatment groups in the change from baseline maximal urinary flow rate across all LUTS and BMI categories (range 4.5 to -4.2 mL/s).

CONCLUSIONS

The results of our study have shown that daily dosing with sildenafil improved ED and LUTS independent of baseline LUTS severity or BMI.

Safety of intravenous nitroglycerin after administration of sildenafil citrate to men with coronary artery disease: A double-blind, placebo-controlled, randomized, crossover trial*

OBJECTIVE

Although contraindicated, there are situations when a patient who has recently taken a phosphodiesterase 5 inhibitor (e.g., sildenafil) might need intravenous nitroglycerin (NTG) treatment. This study determined if, and at what dose, intravenous NTG could be administered safely to men with coronary artery disease who had recently ingested sildenafil.

DESIGN

Double-blind, placebo-controlled, randomized, crossover trial.

SETTING

Four clinical practice sites in Canada, Scotland, and the United States.

PATIENTS

A total of 34 men (>or=35 yrs) with a history of angina pectoris and coronary artery disease (>50% stenosis of at least one coronary artery), most of whom were taking antihypertensives.

INTERVENTIONS

Sildenafil (100 mg) or placebo (single dose; crossover after 3-7 days) followed 45 mins later by escalating doses of intravenous NTG (160 microg/min maximum).

MEASUREMENTS AND MAIN RESULTS

After sildenafil, there were slightly greater maximum (supine) blood pressure decreases and heart rate increases (e.g., 4 to 6 mm Hg [systolic] and <or=1 beat/min, at NTG doses of <or=80 microg/min) than after placebo. The median maximum tolerated NTG dose (range) was 80 (0-160) microg/min for sildenafil vs. 160 (20-160) microg/min for placebo (adjusted mean +/- se, 77 +/- 7 vs. 127 +/- 7; p < .0001; analysis of variance), and NTG 160 microg/min was tolerated by eight (25%) and 19 (59%) men, respectively (p = .0008). Treatment-related adverse events were mostly mild/moderate hypotension, headache, and dizziness, which are often associated with NTG alone. Sildenafil and metabolite plasma concentrations were lower than previously reported in healthy men.

CONCLUSIONS

With close monitoring of blood pressure and heart rate, men with stable coronary artery disease who have taken sildenafil may tolerate intravenous NTG (<or=160 microg/min) with low starting dosage and gradual upward titration. The hemodynamic response might be different in subgroups not specifically examined in the study (e.g., men presenting with acute coronary symptoms). The explanation for the lower than expected plasma concentrations remains uncertain.

Clinically meaningful improvement on the Self-Esteem And Relationship questionnaire in men with erectile dysfunction

PURPOSE

To estimate the minimal clinically meaningful improvement (MCMI) on the Self-Esteem And Relationship (SEAR) questionnaire.

METHODS

Using combined data from the 2 pivotal SEAR trials of men treated with sildenafil for erectile dysfunction (ED), MCMIs were estimated as the lower limit of the 2-sided 95% confidence intervals of SEAR mean change scores (from baseline to end of study) for 2 anchor groups: (1) men who improved 1 ED severity category on the Erectile Function domain of the International Index of Erectile Function, and (2) men who improved 5-60% (inclusive) on these erectile function scores.

RESULTS

Both anchors gave comparable results. A 10-point MCMI was proposed because the estimates of 95% lower bounds centered on around 10 points for most SEAR components (Sexual Relationship, Confidence, Self-Esteem, Overall Score). An exception was the Overall Relationship whose 95% lower bounds were too low to recommend them as an MCMI.

CONCLUSIONS

Two anchor-based approaches suggest that a change of about 10 points represents an MCMI on most components of the SEAR questionnaire.

Early sildenafil dose optimization and personalized instruction improves the frequency, flexibility, and success of sexual intercourse in men with erectile dysfunction

We investigated the effect of early sildenafil dose optimization and personalized instructions on sexual intercourse success in 1109 men beginning sildenafil therapy for erectile dysfunction. In phase 1 (4 weeks), patients followed the instructions contained in the sildenafil (50 mg) sample pack and had 1.4 sexual intercourse attempts per week with 82% success. Patients (17%) had a second intercourse attempt (80% successful): 58% occurred within 4 h, 20% within 5-8 h, and 22% within 9-24 h of the first attempt. In phase 2 (4 weeks), sildenafil was adjusted as needed (53% to 100 mg, and 2% to 25 mg), and investigators provided personalized instructions to facilitate patient success. Sexual intercourse attempts increased to 1.7 per week, with 91% success, and 18% were followed by a second attempt, of which 91% were successful. Most patients requested the 100-mg dose, which helped improve sexual intercourse frequency, flexibility and success.

Sildenafil Citrate Improves Self‐Esteem, Confidence, and Relationships in Men with Erectile Dysfunction: Results from an International, Multi‐Center, Double‐Blind, Placebo‐Controlled Trial

INTRODUCTION

Erectile dysfunction (ED) can significantly impact a man's relationships and well-being.

AIM

We assessed changes in self-esteem, confidence, sexual relationship satisfaction, and overall relationship satisfaction in men with ED using the validated Self-Esteem And Relationship questionnaire (SEAR).

METHODS

This was a 12-week, double-blind, placebo-controlled, flexible-dose (25, 50, 100 mg, as needed) international study of sildenafil in men > or =18 years of age in Mexico, Brazil, Australia, and Japan.

MAIN OUTCOME MEASURES

The primary study outcome was change in self-esteem from baseline to the end of treatment. Secondary study measures were changes in other SEAR components, International Index of Erectile Function (IIEF) domains, percentage of intercourse attempts that were successful, and the response to a global efficacy question at the end of treatment.

RESULTS

Patients were well balanced for age and duration of ED (placebo = 149 and sildenafil = 151). Compared with placebo, sildenafil significantly improved self-esteem, confidence, sexual relationship satisfaction, and overall relationship satisfaction (P < 0.0001). The psychosocial measures of well-being assessed with the SEAR were positively correlated (range 0.60-0.86, P < 0.0001) with erectile function, the frequency of achieving erections that allowed satisfactory sexual intercourse, the percentage of successful sexual intercourse attempts, and global treatment efficacy.

CONCLUSIONS

Significant improvements in self-esteem, confidence, sexual relationship satisfaction, and overall relationship satisfaction after treatment of ED with sildenafil were consistent among countries. These data suggest a substantial cross-cultural improvement in well-being after successful treatment of ED with sildenafil.

Comparison Between Sildenafil‐Treated Subjects with Erectile Dysfunction and Control Subjects on the Self‐Esteem And Relationship Questionnaire

INTRODUCTION

Erectile dysfunction (ED) can negatively impact psychosocial measures of a patient's sexual life.

AIM

To evaluate self-esteem, confidence, and relationships in men with ED, before and after treatment with sildenafil citrate (Viagra), with reference to controls without ED.

METHODS

Sildenafil-naïve patients with ED were enrolled in a 10-week, open-label, flexible-dose (25 mg, 50 mg, or 100 mg) trial of sildenafil. In a separate study, men without ED who did not take sildenafil also completed the Self-Esteem And Relationship (SEAR) questionnaire. In addition to traditional statistical testing, equivalency testing was applied to compare the ED group, before and after treatment, with the control group and to examine whether the ED group improved to normative ranges on the SEAR questionnaire after treatment (within half a standard deviation of the normative or control group mean).

MAIN OUTCOME MEASURES

Baseline and end-of-treatment responses on psychosocial aspects of ED were measured with the validated SEAR.

RESULTS

Mean SEAR scores between subjects with ED (N = 93, mean age 55.0 years) at baseline and control subjects without ED (N = 94, mean age 52.5 years) were statistically different from zero and not statistically equivalent. Conversely, mean SEAR scores between ED subjects after treatment and control subjects were statistically equivalent and not statistically different from zero.

CONCLUSIONS

The results indicate that sildenafil is associated with normalization of relationships, confidence, and self-esteem in men with ED.

Association between the Erectile Dysfunction Inventory of Treatment Satisfaction and the Self-Esteem and Relationship Questionnaire following treatment with sildenafil citrate for men with erectile dysfunction

OBJECTIVES

Research is lacking on the correlation between treatment satisfaction and confidence, self-esteem, and relationships for men receiving treatment for erectile dysfunction (ED). We sought to correlate scores between the validated Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) index and the validated Self-Esteem And Relationship (SEAR) questionnaire following treatment with sildenafil citrate (VIAGRA).

METHODS

This study was based on an open-label, flexible-dose trial of 93 sildenafil-naive patients with ED. Pearson correlation coefficients between EDITS index and SEAR questionnaire scores, each of which can range from 0 to 100 (most favorable), were calculated at end of treatment (EOT). An analysis of covariance model was applied to associate changes from baseline to EOT in SEAR scores with EDITS score at EOT, controlling for baseline SEAR score.

RESULTS

Significant and sizable Pearson's correlations between SEAR and EDITS scores (P < or = 0.0001; range: 0.49-0.84) were observed. A 10-point higher EDITS scores at EOT corresponded to a significant and tangible average improvement in SEAR scores from baseline to EOT (P < or = 0.0001; range: 6.6-8.7). Average SEAR scores at EOT were markedly different between patients with greater treatment satisfaction at EOT (EDITS score > or = median EDITS score of 88.6; n = 50) and those with lesser treatment satisfaction at EOT (EDITS score <88.6; n = 43).

CONCLUSIONS

The data add to the validity of the SEAR questionnaire, suggest a tangible relationship between treatment satisfaction and psychosocial benefit among men with ED treated with sildenafil, and highlight the importance of assessing the psychosocial impact of ED in men undergoing treatment.

Quality of life, mood, and sexual function: a path analytic model of treatment effects in men with erectile dysfunction and depressive symptoms

Erectile dysfunction (ED) is commonly associated with depressed mood and diminished quality of life (QoL), but few studies have investigated the causal associations involved. Therefore, we evaluated the correlation between several measures of mood, QoL, and sexual function in a retrospective analysis of a sample of depressed men (n=152), with ED enrolled in a clinical trial of sildenafil citrate (VIAGRA). Strong correlations were observed at baseline among measures of erectile function (EF), mood, and overall QoL. Significant treatment effects were observed on all three domains, with significant interactions between changes in mood and QoL. Based on multiple regression and path analysis, a model was developed in which EF changes were associated with improved mood and quality of sexual life, which resulted in improved partner satisfaction, family life, and overall life satisfaction. These data suggest that QoL changes associated with ED therapy may be mediated by changes in sexual function, mood, and family relationships.

Development and validation of the Self-Esteem And Relationship (SEAR) questionnaire in erectile dysfunction

Development and validation of a patient-reported measure of psychosocial variables in men with erectile dysfunction (ED) is described. Literature review, focus groups, and medical specialists identified 86 potential items. Redundant, ambiguous, or low item-to-total correlation items were removed. Data from 98 men reporting diagnosed ED and 94 controls assisted in final item selection and psychometric evaluation. Treatment responsiveness was evaluated in 93 men with ED in a 10-week open-label trial of sildenafil citrate (Viagra). The 14 chosen items resolved into two domains: Sexual Relationship (eight items) and Confidence (six items), the latter comprising Self-Esteem (four items) and Overall Relationship (two items) subscales. The resulting Self-Esteem And Relationship (SEAR) questionnaire demonstrated validity and reliability. The intervention study demonstrated responsiveness to beneficial treatment with significant improvement in scores (P=0.0001). The SEAR questionnaire possesses strong psychometric properties that support its validity and reliability for measuring sexual relationship, confidence, and particularly self-esteem.

Efficacy of sildenafil citrate for the treatment of erectile dysfunction in men taking serotonin reuptake inhibitors

OBJECTIVE

This study was an evaluation of whether sildenafil citrate is effective for the treatment of erectile dysfunction in men taking concomitant serotonin-reuptake-inhibiting antidepressants.

METHOD

A retrospective subanalysis of combined data from 10 phase II/III double-blind, placebo-controlled, fixed- and flexible-dose trials (12-26 weeks) identified a group of men with erectile dysfunction receiving 5 to 200 mg/day of sildenafil (N=65) or placebo (N=33) and concomitant serotonin-reuptake-inhibiting antidepressants. Efficacy was measured by responses to questions from the International Index of Erectile Function on ability to achieve erection, ability to maintain erection, ejaculation frequency, orgasm frequency, and sexual desire.

RESULTS

Patients with erectile dysfunction receiving sildenafil and concomitant serotonergic antidepressants had significantly greater improvements in ability to achieve and maintain an erection, frequency of ejaculation, and orgasm frequency than did patients receiving placebo, without increased sexual desire.

CONCLUSIONS

Sildenafil significantly improved erectile dysfunction in patients taking concomitant serotonergic antidepressants.

Radiologic placement of a low profile implantable venous access port in a pediatric population

PURPOSE

To evaluate the feasibility and complications of placement of a low-profile venous access port in the chest in children requiring long-term venous access.

METHOD

A low-profile peripheral arm port (PAS port; Sims Deltec, St. Paul, MN, USA) was implanted in the chest in 22 children over a 4-year period. The mean age of the study group was 6 years (range: 9 months to 20 years). Ports were placed for the administration of chemotherapy, hyperalimentation and frequent blood sampling. Sonographic guidance was used to access the internal jugular or subclavian vein in each case. A review of all inpatient and outpatient charts was undertaken to assess catheter performance and complications.

RESULTS

Access to the central venous circulation was successfully achieved in each case without complication. Ports remained implanted for 6579 catheter-days (mean: 299 days). Ten ports have been removed. Of three patients (13%) experiencing device-related infections (0.45 infections/1000 catheter days), two (9.1%) were unresponsive to antibiotics and removed (0.3 infections/1000 catheter days). One port was removed because of pain in the shoulder adjacent to the port implantation site. One port was removed because of difficult access. The final port was removed in order to place a dual-lumen catheter prior to bone marrow transplant. Twelve ports remain implanted. Aspiration occlusion occurred in four patients (18%). Deep venous thrombosis did not occur in any patient.

CONCLUSION

Low-profile chest ports placed by interventional radiologists in the interventional radiology suite can be placed in children as safely as traditional chest ports placed in the operating room. The incidence of infection, venous thrombosis and aspiration occlusion is comparable to that of ports placed operatively.

Relationship between patient self-assessment of erectile dysfunction and the sexual health inventory for men

BACKGROUND

The Sexual Health Inventory for Men (SHIM) has been shown to possess favorable statistical properties in diagnosing the presence and severity of erectile dysfunction (ED). However, the SHIM has not been compared with patient self-assessment of ED.

OBJECTIVE

This article describes an independent-validation study examining the correlation and agreement between the SHIM and patient self-assessment of ED with respect to the severity of ED at baseline and after treatment, and in terms of change from baseline.

METHODS

The study population consisted of 247 male outpatients with ED participating in a multicenter, double-blind, placebo-controlled, flexible-dose (25-100 mg/d) Phase IIIb clinical trial in which they were randomized equally to sildenafil citrate or placebo. Patients assessed their degree of ED as severe, moderate, minimal/mild, or no problem at baseline and after 12 weeks of treatment. They also responded to the 5 questions on the SHIM, after which their degree of ED was calculated based on the SHIM total score.

RESULTS

In general, the SHIM and the single-item self-assessment question produced similar descriptive profiles of the severity of ED. Kendall tau-b correlations were 0.66 (95% CI, 0.58-0.74) at baseline, 0.86 (95% CI, 0.82-0.90) after treatment, and 0.72 (95% CI, 0.67-0.77) for change from baseline. Agreement between instruments, measured by the weighted kappa statistic, mirrored the correlations at baseline and after treatment. As expected, both measures correlated moderately with improvement in erections and treatment satisfaction of both patient and partner.

CONCLUSION

The moderate-to-high correlation and agreement between the SHIM and patient self-assessment of ED validate the SHIM for use in the diagnostic classification of ED severity.

Characterization of radial forces in Z stents

RATIONAL AND OBJECTIVES

The purpose of this study was to evaluate the effects of variation in design parameters on the resultant radial force. We evaluated the influence of wire gauge, leg length, and number of bends on the radial force produced by z stents and compared these with radial forces produced by commercial stents. A second goal was to develop an engineering model for predicting radial forces generated by z stents.

METHODS

Z stents were fashioned by hand using stainless steel wire and solder that connected the ends. The radial force was measured as a function of wire gauge, vessel diameter, leg length, and number of bends and compared with the theoretical values of radial force calculated by combining Castigliano's theorem and the law of Laplace.

RESULTS

Theoretically predicted radial forces were within 8% of each observed value of radial force up to 70% spring compression.

CONCLUSIONS

These results suggest that the z-stent model can be used to build custom stents with preselected values of radial force for clinical use. In addition, they can be used to design model investigational stents made of similar materials and surface areas to test the effects of radial force on biological response.

Patient and partner satisfaction with Viagra (sildenafil citrate) treatment as determined by the Erectile Dysfunction Inventory of Treatment Satisfaction Questionnaire

OBJECTIVES

To assess the efficacy and safety of Viagra (sildenafil citrate) in male outpatients with erectile dysfunction and patient and partner satisfaction with treatment using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS).

METHODS

A total of 247 patients with erectile dysfunction of broad-spectrum etiology were treated in a randomized, double-blind, parallel-group, multicenter study conducted at outpatient clinics. Patients receiving oral sildenafil (25, 50, and 100 mg) were compared with patients receiving placebo during a 12-week period. The principal efficacy measures were responses to question 3 (ability to achieve an erection) and question 4 (ability to maintain an erection) on the International Index of Erectile Function and three global efficacy questions. Patient and partner satisfaction with treatment were assessed, for the first time, using the EDITS questionnaire.

RESULTS

Efficacy scores for the International Index of Erectile Function questions and the global efficacy questions were significantly higher for patients receiving sildenafil than for those receiving placebo (P <0.001). Both patients and partners receiving sildenafil also had significantly higher EDITS scores than those receiving placebo (P <0.001). Adverse events were chiefly mild or moderate. Two patients receiving sildenafil and none receiving placebo discontinued treatment because of adverse events.

CONCLUSIONS

Sildenafil was an effective, well-tolerated treatment for erectile dysfunction in an outpatient setting. Partner evaluations corroborated patient assessments. The results from the EDITS questionnaire indicated that after 12 weeks of receiving sildenafil both patients and partners reported higher levels of treatment satisfaction relative to placebo.