Risk of major adverse cardiovascular events in rural vs urban settings among patients with erectile dysfunction: a propensity-weighted retrospective cohort study of 430 621 men

BACKGROUND

The relationship between erectile dysfunction (ED) and cardiovascular (CV) events has been postulated, with ED being characterized as a potential harbinger of CV disease. Location of residence is another important consideration, as the impact of rural residence has been associated with worse health outcomes.

AIM

To investigate whether men from rural settings with ED are associated with a higher risk of major adverse CV events (MACEs).

METHODS

A propensity-weighted retrospective cohort study was conducted with provincial health administrative databases. ED was defined as having at least 2 ED prescriptions filled within 1 year. MACE was defined as the first hospitalization for an episode of acute myocardial infarction, heart failure, or stroke that resulted in a hospital visit >24 hours. We classified study groups into ED urban, ED rural, no ED urban, and no ED rural. A multiple logistic regression model was used to determine the propensity score. Stabilized inverse propensity treatment weighting was then applied to the propensity score.

OUTCOMES

A Cox proportional hazard model was used to examine our primary outcome of time to a MACE.

RESULTS

The median time to a MACE was 2731, 2635, 2441, and 2508 days for ED urban (n = 32 341), ED rural (n = 18 025), no ED rural (n = 146 358), and no ED urban (n = 233 897), respectively. The cohort with ED had a higher proportion of a MACE at 8.94% (n = 4503), as opposed to 4.58% (n = 17 416) for the group without ED. As compared with no ED urban, no ED rural was associated with higher risks of a MACE in stabilized time-varying comodels based on inverse probability treatment weighting (hazard ratio, 1.06-1.08). ED rural was associated with significantly higher risks of a MACE vs no ED rural, with the strength of the effect estimates increasing over time (hazard ratio, 1.10-1.74).

CLINICAL IMPLICATIONS

Findings highlight the need for physicians treating patients with ED to address CV risk factors for primary and secondary prevention of CV diseases.

STRENGTHS AND LIMITATIONS

This is the most extensive retrospective study demonstrating that ED is an independent risk factor for MACE. Due to limitations in data, we were unable to assess certain comorbidities, including obesity and smoking.

CONCLUSIONS

Our study confirms that ED is an independent risk factor for MACE. Rural men had a higher risk of MACE, with an even higher risk among those who reside rurally and are diagnosed with ED.

Defining a Framework and Evaluation Metrics for Sustainable Global Surgical Partnerships: A Modified Delphi Study

OBJECTIVE

The aim of this study was to use expert consensus to build a concrete and realistic framework and checklist to evaluate sustainability in global surgery partnerships (GSPs).

BACKGROUND

Partnerships between high-resourced and low-resourced settings are often created to address the burden of unmet surgical need. Reflecting on the negative, unintended consequences of asymmetrical partnerships, global surgery community members have proposed frameworks and best practices to promote sustainable engagement between partners, though these frameworks lack consensus. This project proposes a cohesive, consensus-driven framework with accompanying evaluation metrics to guide sustainability in GSPs.

METHODS

A modified Delphi technique with purposive sampling was used to build consensus on the definitions and associated evaluation metrics of previously proposed pillars (Stakeholder Engagement, Multidisciplinary Collaboration, Context-Relevant Education and Training, Bilateral Authorship, Multisource Funding, Outcome Measurement) of sustainable GSPs.

RESULTS

Fifty global surgery experts from 34 countries with a median of 9.5 years of experience in the field of global surgery participated in 3 Delphi rounds. Consensus was achieved on the identity, definitions, and a 47-item checklist for the evaluation of the 6 pillars of sustainability in GSPs. In all, 29% of items achieved consensus in the first round, whereas 100% achieved consensus in the second and third rounds.

CONCLUSIONS

We present the first framework for building sustainable GSPs using the input of experts from all World Health Organization regions. We hope this tool will help the global surgery community to find noncolonial solutions to addressing the gap in access to quality surgical care in low-resource settings.

Anesthetic options for Rezūm water vapour therapy: Is minimal sedation tolerable for a minimally invasive procedure?

INTRODUCTION

There has been a rapid expansion of the armamentarium for managing benign prostatic hyperplasia (BPH). Given the invasiveness and complication risks of traditional surgical management, minimally invasive procedures have emerged. Rezūm water vapour therapy is a safe, effective alternative. Given the minimally invasive nature, there is interest in administering conscious sedation over general anesthesia (GA) to decrease procedural times and costs and increase accessibility by completing procedures in an office-based setting. We sought to assess and describe patient-reported tolerability for Rezūm completed under oral and deep intravenous sedation.

METHODS

Patients who underwent Rezūm between April and November of 2022 under conscious sedation with oral sedation and local anesthesia (OSLA) or deep intravenous sedation (DIS) were enrolled. Baseline information was collected, and followup interviews were conducted where patient tolerability scores, future anesthetic preferences, and complication data was prospectively obtained.

RESULTS

Fourteen patients were enrolled in each group. The OSLA and DIS cohorts had a median tolerability score of 8 (interquartile range [IQR] 3.5) and 9 (IQR=1.75), respectively, indicating highly tolerable experiences. There was no significant difference between groups (p=0.13). On followup, 85.7% of patients in the OSLA and 100% in DIS groups expressed their future preference for conscious sedation over GA, with no significant difference between the two groups (p=0.46).

CONCLUSIONS

Our study demonstrates OSLA and DIS are both viable conscious sedation methods for Rezūm, with patients reporting high tolerability to the procedure regardless of sedation choice. Almost all patients receiving conscious sedation would choose to undergo Rezūm using conscious sedation again and had minimal complications.

The utility of three-dimensional modeling and printing in pediatric surgical patient and family education: a systematic review

BACKGROUND

Three-dimensional (3D) modeling and printing are increasingly being used in surgical settings. This technology has several applications including pre-operative surgical planning, inter-team communication, and patient education and counseling. The majority of research on 3D technology has focused on adult populations, where it has been found to be a useful tool for educating patients across various surgical specialties. There is a dearth, however, of research on the utility of 3D modeling and printing for patient and family education in pediatric populations. Our objective was to systematically review the current literature on how this modality is being utilized in pediatric surgical settings for patient and family education and counselling.

METHODS

We conducted a systematic review in accordance with PRISMA and CASP guidelines. The MEDLINE, CINAHL, Embase, and Web of Science databases were searched from inception to October 21, 2023, with no restrictions on language or geographical location. Citation chaining was used to ensure relevant papers were included. Articles were doubly screened and data was extracted independently by two authors. In the case of disagreement, a third author was consulted. Any articles pertaining to 3D modeling and printing in pediatric surgical settings for patient and family education and counseling were included.

RESULTS

Six articles met inclusion criteria and were used for qualitative analysis. Two involved questionnaires given to parents of children to assess their understanding of relevant anatomy, surgical procedure, and risks after viewing conventional CT images and again after viewing a 3D-printed model. One involved a quasi-experimental study to assess young patients' pre-operative surgical understanding and anxiety after undergoing conventional teaching as compared to after viewing a 3D storybook. One involved questionnaires given to parents of children in control and study groups to assess the usefulness of 3D printed models compared to conventional CT images in their understanding of relevant anatomy and the surgical procedure. Another study looked at the usefulness of 3D printed models compared to 2D and 3D CT images in providing caregiver understanding during the pre-operative consent process. The last article involved studying the impact of using 3D printing to help patients understand their disease and participate in decision-making processes during surgical consultations. In all six studies, utilizing 3D technology improved transfer of information between surgical team members and their patients and families.

CONCLUSION

Our systematic review suggests that 3D modeling and printing is a useful tool for patient and family education and counselling in pediatric surgical populations. Given the very small number of published studies, further research is needed to better define the utility of this technology in pediatric settings.

Evaluating Patient Tolerability for Urological Procedures Under Conscious Sedation: A Prospective Study

OBJECTIVE

To prospectively evaluate patient-reported tolerability and surgical outcomes of urologic procedures with conscious sedation with or without local anesthesia. Administration of general or spinal anesthesia is associated with anesthetic-related complications, long wait times, and high costs. Using intravenous conscious sedation and/or local anesthesia is an emerging alternative for a myriad of urologic procedures.

METHODS

Patients were enrolled from June-August 2021 at a tertiary care hospital. All procedures were completed using fentanyl, midazolam, or both with patient and procedural data recorded upon completion. Patients were telephoned 4-6 weeks post-procedure with a standardized patient tolerability questionnaire. A multivariable adjusted logistic regression analysis was performed to evaluate whether a patient would opt for conscious sedation again as opposed to general anesthesia.

RESULTS

A total of 196 procedures were performed by 6 attending urologists with an overall success rate of 98.5% and 0% intraoperative complication rate. At 4-6 weeks follow-up, 85.6% of patients reported they would opt for conscious sedation as opposed to general anesthesia. Predictors of opting for conscious sedation in the future were older age (Odds Ratio (OR): 1.049; P = .017) and surgeon perceived level of patient tolerability (OR: 2.124; P <.001, scored 1-10).

CONCLUSION

Physician directed, nursing administered IV conscious sedation is a viable alternative for various urologic procedures and has minimal risk of perioperative complications.

The impact of misinformation on patient perceptions at a men's health clinic: a cross-sectional study

Misinformation is a rising concern for providers and patients alike. We aimed to assess where patients acquire information prior to their andrological urologic appointment and assess patients' perception regarding the reliability of this information. A cross-sectional study was conducted at an outpatient men's health clinic between June and August of 2022 with questionnaires distributed to adult males seen for their primary visit. The study included 314 consenting adult patients who independently completed the questionnaire (mean age: 51.2 ± 17.2). Overall, 55.1% of patients indicated they searched for their condition online. However, 39.2% and 27.7% of respondents agreed and strongly agreed, respectively, that misinformation is a concern when searching for health information. Only 59.9% of patients discussed their concerns with others and those that did not chose not wanting to (65.1%) as their top choice. However, 27.4% of respondents were embarrassed to do so. Finally, 38.2% and 12.4% of patients agreed and strongly agreed, that learning information prior to your appointment affects their relationship with the physician. These findings emphasize the need for urologists to be aware of where their patients are gathering health information and to address concerns regarding misinformation.

Natural history of antiplatelet nonresponders undergoing carotid artery stenting

OBJECTIVE

Routine antiplatelet responsiveness testing for patients undergoing carotid artery stenting procedures is not performed at most endovascular centers and remains a topic of controversy within the neurointerventional community. The objective of this study was to determine if nonresponsiveness to acetylsalicylic acid or clopidogrel was associated with the development of symptomatic thromboembolic events in patients undergoing carotid stenting procedures.

METHODS

A prospective study was conducted at the Foothills Medical Centre in Calgary, Alberta, Canada, from August 2019 to July 2021. Patients undergoing carotid artery stenting procedures and who were receiving dual antiplatelet therapy were enrolled in the study. Responsiveness to the antiplatelet medications was determined through whole blood impedance aggregometry. The primary outcome was development of a symptomatic thromboembolic event within 90 days after the procedure. The treating physicians were blinded to the aggregometry results for the duration of the study.

RESULTS

One hundred two procedures were performed in 100 patients. Eight thromboembolic events (8%) occurred during the study. Age (p = 0.03) and nonresponsiveness to clopidogrel (p = 0.003) were associated with the development of thromboembolic events. The multivariable model showed that clopidogrel nonresponsiveness was independently associated with the development of a thromboembolic event (adjusted OR 6.14, 95% CI 1.25-30.11, p = 0.03).

CONCLUSIONS

This study demonstrated that patients who were identified as clopidogrel nonresponders, using whole blood impedance aggregometry, were at an increased risk of developing thromboembolic events. Larger studies are needed to assess the utility of routine platelet function testing prior to carotid artery stenting procedures.

Intra-arterial injection of mesenchymal stem cells to accelerate neointima formation after endovascular stenting in a rabbit model

OBJECTIVE

Delayed neointima formation over a neurovascular stent is associated with thrombotic complications that can lead to stroke. The purpose of this study was to evaluate whether an intra-arterial injection of mesenchymal stem cells (MSCs) after stent placement leads to improved neointima and reduced thrombus formation over the device.

METHODS

Solitaire stents were placed into the aortas of rabbits that were divided into MSC and control groups. The MSC group received an intra-arterial injection of MSCs through the same microcatheter used for stent deployment. Optical coherence tomography (OCT) was used to evaluate and compare neointima and thrombus formation in a blinded fashion. Explanted specimens were also imaged with scanning electron microscopy (SEM) and evaluated by observers blinded to group allocation using an endothelialization scoring system.

RESULTS

The 3-day MSC group was similar to the 7-day controls in terms of stent strut coverage ratio and maximum neointimal thickness, but these values were significantly higher than the 3-day control group based on a hierarchical mixed-effects linear regression analysis. SEM revealed a significantly higher endothelialization score for the MSC group compared with controls at the same time point. There was no difference in thrombus formation between any of the groups.

CONCLUSIONS

The intra-arterial injection of MSCs after endovascular stenting accelerated early neointima formation but had no effect on thrombus formation in this study. Larger studies are required to verify these findings and determine the durability and mechanism of this effect.

An update on male infertility and intratesticular testosterone-insight into novel serum biomarkers

Intratesticular testosterone is vital for spermatogenesis, male fertility, and virility. Currently the only method to assess levels of intratesticular testosterone is to perform testicular biopsy which is invasive and can lead to several complications. Approaches to assess intratesticular testosterone have been understudied but hold promise as future male contraceptive agents and may grant the ability to monitor patients undergoing hormonal changes from therapeutic and diagnostic perspectives. Previous studies have sought to assess the utility of 17-hydroxyprogesterone (17-OHP) and insulin-like factor 3 (INSL3) as accurate surrogate biomarkers of intratesticular testosterone. The aim of this review is thus to highlight the importance of intratesticular testosterone and the consequent advances that have been made to elucidate the potential of biomarkers for intratesticular testosterone in the context of male infertility.

Promoting endothelialization of flow-diverting stents: a review

Intracranial flow-diverting (FD) stents have revolutionized the treatment of intracranial aneurysms in recent years, but complications resulting from failed endothelialization can still occur. Approaches to promote endothelialization are understudied, but hold promise in mitigating both short- and long-term complications associated with FD stent insertion. The aim of this review is to highlight the various features of and modifications that have been made to FD stents in order to expedite endothelialization. More specifically, we focus on how endothelialization can be influenced by the stent design, wall apposition, surface modifications, and the inclusion of biological agents.