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.

Relationship between patient self-assessment of erectile function and the erectile function domain of the international index of erectile function

OBJECTIVES

To assess the validity of severity classes on the erectile function (EF) domain of the International Index of Erectile Function by determining their relationship with the self-assessment of EF, before and after treatment, in an independent cohort of patients.

METHODS

Two hundred forty-seven men with clinically diagnosed erectile dysfunction (ED) and in a stable heterosexual relationship were enrolled in a randomized, double-blind, multicenter, placebo-controlled, parallel-group, 12-week, flexible-dose study. Patients assessed their degree of ED as severe, moderate, minimal/mild, or no problem at baseline and after treatment. They also responded to the six questions of the EF domain, with the total score indicating the following degrees of ED: severe, EF score 1 to 10; moderate, EF score 11 to 16; mild to moderate, EF score 17 to 21; mild, EF score 22 to 25; and no ED, EF score 26 to 30. Descriptive profiles of the two diagnostic instruments were compared. The correlations between the instruments were evaluated with Kendall's tau-b at baseline, after treatment at 12 weeks, and at change from baseline.

RESULTS

The two measures gave generally similar descriptive profiles of ED severity. The correlations were 0. 65 (95% confidence interval 0.57 to 0.73) at baseline, 0.86 (95% confidence interval 0.83 to 0.89) after 12 weeks of treatment, and 0. 73 (95% confidence interval 0.67 to 0.79) at change from baseline.

CONCLUSIONS

The moderate-to-high correlation between the patients' self-assessment of EF and the EF domain of the International Index of Erectile Function provides a validation of this domain for the reliable diagnostic classification of ED severity.

Peripheral venous access ports: outcomes analysis in 109 patients

PURPOSE

To perform a retrospective outcomes analysis of central venous catheters with peripheral venous access ports, with comparison to published data.

METHODS

One hundred and twelve central venous catheters with peripherally placed access ports were placed under sonographic guidance in 109 patients over a 4-year period. Ports were placed for the administration of chemotherapy, hyperalimentation, long-term antibiotic therapy, gamma-globulin therapy, and frequent blood sampling. A vein in the upper arm was accessed in each case and the catheter was passed to the superior vena cava or right atrium. Povidone iodine skin preparation was used in the first 65 port insertions. A combination of Iodophor solution and povidone iodine solution was used in the last 47 port insertions. Forty patients received low-dose (1 mg) warfarin sodium beginning the day after port insertion. Three patients received higher doses of warfarin sodium for preexistent venous thrombosis. Catheter performance and complications were assessed and compared with published data.

RESULTS

Access into the basilic or brachial veins was obtained in all cases. Ports remained functional for a total of 28,936 patient days. The port functioned in 50% of patients until completion of therapy, or the patient's expiration. Ports were removed prior to completion of therapy in 18% of patients. Eleven patients (9.9% of ports placed) suffered an infectious complication (0.38 per thousand catheter-days)-in nine, at the port implantation site, in two along the catheter. In all 11 instances the port was removed. Port pocket infection in the early postoperative period occurred in three patients (4.7%) receiving a Betadine prep vs two patients (4.2%) receiving a standard O.R. prep. This difference was not statistically significant (p = 0.9). Venous thrombosis occurred in three patients (6.8%) receiving warfarin sodium and in two patients (3%) not receiving warfarin sodium. This difference was not statistically significant (p = 0.6). Aspiration occlusion occurred in 13 patients (11.7%). Intracatheter urokinase was infused in eight of these patients and successfully restored catheter function in all but two instances. These complication rates are comparable to or better than those reported with chest ports.

CONCLUSION

Peripheral ports for long-term central venous access placed by interventional radiologists in the interventional radiology suite are as safe and as effective as chest ports.

Translumbar placement of paired hemodialysis catheters (Tesio catheters) and follow-up in 10 patients

For lack of other suitable access, 10 consecutive patients received paired hemodialysis catheters for long-term hemodialysis using a translumbar approach to the inferior vena cava (IVC). All attempts were successful. Five paired catheters were placed using the single-puncture technique, and five using the dual-puncture technique. Catheters were in place for a total of 2252 catheter days. The average duration of catheter placement was 250 days (range 30-580 days). All catheters were functioning up to the time the study was completed or the patient died. The most common complication was partial dislodgment of the catheter in 3 of 23 catheters (13%), all occurring in obese patients. One episode of retroperitoneal hemorrhage was noted in a patient having the single-access technique. There were no episodes of infection or IVC thrombosis.

Endovascular management of ureteroarterial fistula

Ureteroarterial fistulas, although rare, appear to be increasing in frequency. Because open surgical repair may be difficult and associated with significant risk for complications, endovascular intervention may provide an attractive treatment alternative. We review the diagnosis and management of a ureteroarterial fistula and iliac pseudoaneurysm that presented with massive hematuria during ureteral stent removal. The patient was treated by means of the percutaneous embolization of the right hypogastric artery and placement of an expanded polytetrafluoroethylene stent-graft. Endovascular stent-graft placement may serve as a safe and practical alternative in the treatment of these patients, whose cases are challenging.

A multicenter, community-based study of doxazosin in the treatment of concomitant hypertension and symptomatic benign prostatic hyperplasia: the Hypertension and BPH Intervention Trial (HABIT)

As men age, the incidence of both benign prostatic hyperplasia (BPH) and hypertension increases. Concomitant occurrence of these conditions also increases with age, and the 2 are frequently encountered together in primary care practice. In addition, many patients with hypertension require >1 antihypertensive agent to adequately control blood pressure. In a multicenter, community-based, 8-week, uncontrolled, open-label study, we evaluated doxazosin, a selective alpha1-adrenergic-receptor antagonist, in 491 patients with concomitant symptomatic BPH (American Urological Association [AUA] symptom score > or =12) and hypertension, some previously untreated and some with inadequately controlled hypertension (systolic blood pressure 120-179 mm Hg or diastolic blood pressure [DBP] 80-109 mm Hg) despite taking 1 or 2 antihypertensive agents. Patients were allocated to 1 of 4 groups at baseline according to their diastolic blood pressure (control was considered DBP <90 mm Hg) and whether they had received antihypertensive medication before the study. Thus the 4 groups were treated/well-controlled, treated/poorly controlled, untreated/hypertensive, and untreated/normotensive. In all patient groups, doxazosin therapy significantly improved AUA total symptom and bothersomeness scores and BPH-specific indices of health status and interference with activities (P<0.001). Significant improvements in BPH symptoms were observed with doxazosin, regardless of whether initial symptoms were moderate or severe (P<0.001). Clinically important blood pressure lowering occurred only in the patient groups in which blood pressure had been elevated at baseline. Patients whose blood pressure was poorly controlled at baseline, either without or with treatment (predominantly with angiotensin-converting enzyme inhibitors or calcium channel blockers), achieved adequate blood pressure control (reduction to <140/90 mm Hg) with the addition of doxazosin. Similar improvements in blood pressure and BPH symptoms were seen in both older (> or =65 years) and younger (45 to 64 years) patients, and doxazosin was well tolerated by both groups. The most frequent treatment-related adverse event was dizziness (13.0% of patients); however, patients classified the dizziness as mild in approximately 75% of reports, and severe dizziness was reported by only 2 patients (0.4%). Doxazosin is an effective antihypertensive agent when used in combination with agents from other antihypertensive classes in patients with poorly controlled hypertension and BPH, and is also successful as monotherapy for controlling both BPH and hypertension in patients with mild to moderate hypertension.

Endovascular stent graft for management of ureteroarterial fistula after orthotopic bladder substitution

We describe the first case of an ureteroarterial fistula developing after orthotopic neobladder substitution and its minimally invasive management using endovascular stent grafting. We outline the risk factors for the development of ureteroarterial fistulae and trace the evolution of diagnostic and therapeutic modalities used in the management of these life-threatening complications. Minimally invasive management with endovascular stent grafting and exclusion of two pseudoaneurysms in the iliac artery system was performed successfully. After successful endovascular exclusion of two pseudoaneurysms, the patient's hematuria resolved and he recovered fully. Three-dimensional computed tomography performed 3 months later documented a patent aortoiliac arterial system without evidence of pseudoaneurysm or endovascular leak. Ureteroarterial fistula after orthotopic bladder substitution was managed with an endovascular stent graft without the need for extra-anatomical vascular bypass. Early recognition, stabilization, and angiographic evaluation followed by this minimally invasive technique may avoid open operative repair and attendant morbidity.

Access to occluded infrainguinal bypass grafts with a loopsnare

Thrombolysis for the treatment of occluded bypass grafts is used in selected clinical circumstances. Unfortunately, a minority of these procedures are technical failures because of the inability to access the occluded graft. We describe a technique that greatly increases the chances of technical success.

Ultrasound characteristics of subdermally implanted Implanon contraceptive rods

This study was designed to define sonographic characteristics and the optimal sonographic technique for localization of the single rod Implanon system. Diagnostic ultrasonography was performed in eight women who had the Implanon rod implanted in the medial aspect of the upper arm. All implants were scanned in the longitudinal and transverse direction using 3.5 MHz, 5 MHz, and 7.5 MHz linear array transducers. Scanning was performed both directly against the skin and with 2 and 4 cm Kiteco ultrasound stand-off pads. Each image obtained was evaluated for detectability of the Implanon rod and the grade of acoustic shadowing produced by the Implanon rod by two independent observers. Discrepancies in evaluation were adjudicated by a third observer. The Implanon rod implant was not directly identified using the transducer and standoff pad combinations. Implanon rods were indirectly identified as a result of the posterior acoustic shadow cast by the Implanon. Best demonstration was achieved with the 5 or 7.5 MHz transducer and a 2 cm stand-off pad in the transverse direction. Appropriate ultrasonographic technique and familiarity with posterior acoustic shadowing patterns generated by the implant provide a noninvasive method for localization of nonpalpable, single rod implants prior to removal.

Safety and efficacy of doxazosin in benign prostatic hyperplasia: a pooled analysis of three double-blind, placebo-controlled studies

OBJECTIVES

To present the results of a pooled analysis of three double-blind, placebo-controlled studies of doxazosin in benign prostatic hyperplasia (BPH). Heterogeneous symptom and bother score data collected using different symptom indices were transformed to enable a comparison of the data and to conduct a pooled, in-depth analysis.

METHODS

Urinary flow rates, and symptom and bother score data were shown by analysis of covariance methods to give consistent estimates of the efficacy of doxazosin across different studies, thus confirming the validity of pooling the results. Prior to analysis, symptom and bother score data were transformed so that all scales started from zero (least symptoms or bother) and were expressed as a percentage of the maximum score.

RESULTS

Doxazosin produced a significantly greater improvement than placebo in peak urinary flow rate (P = 0.0017), symptom severity (P < 0.0001), and bother caused by symptoms (P < 0.0001). Stratification showed that a greater improvement was obtained during doxazosin treatment by those with more severe symptoms at baseline (P = 0.0001). Stratification by age showed that age did not affect the capacity to benefit from treatment. Analysis of the pooled peak flow-rate data showed that doxazosin produced a consistently greater increase in flow compared with placebo. Doxazosin was well tolerated, with 10% of patients having withdrawn due to adverse events versus 4% with placebo (P < 0.05).

CONCLUSIONS

Doxazosin is well tolerated and effective in the treatment of BPH. Pooling of data has enabled more extensive and robust conclusions to be drawn than was possible for each one of the individual three studies.

Use of a snare wire to perform nephrostomy access in the presence of obstructive staghorn calculi

We describe a technique for gaining access to the central collecting system via a chosen calyx, utilizing an alternative entry point to that calyx. An Amplatz nitinol loop snare is then used to convert this access to a traditional approach.

Tunneled central venous access catheter placement in the pediatric population: comparison of radiologic and surgical results

PURPOSE

To compare the success and infection rates of radiologic placement with those of surgical placement of tunneled central venous access catheters (TCVACs) in infants and small children.

MATERIALS AND METHODS

In 17 pediatric patients, TCVACs were placed with vascular access under ultrasound or fluoroscopic guidance in the radiology department. In 29 other patients, TCVACs were placed with percutaneous puncture or surgical cutdown in the surgery department.

RESULTS

Two (11%) of 18 attempts at radiologic placement were unsuccessful; six (38%) of the 16 radiologically placed catheters necessitated removal because of dislodgment, malfunction, or infection; six (38%) were electively removed; and four (25%) still function. Eight (23%) of 35 attempts at surgical placement were unsuccessful; 17 (63%) of the 27 surgically placed catheters required removal because of dislodgment, malfunction, or infection; nine (33%) were electively removed; and one (4%) still functions.

CONCLUSION

The success and infection rates of radiologic placement of TCVACs were similar to those of surgical placement. Radiologic placement required fewer attempts and was slightly less expensive.

Peritoneal dialysis catheters: repositioning with new fluoroscopic technique

From April 1990 to December 1992, the authors evaluated a new technique for radiologic manipulation of malfunctioning peritoneal dialysis catheters (PDCs). In 25 patients (16 male and nine female patients, aged 15-81 years), 25 PDCs were fluoroscopically manipulated 38 times for failure to drain (n = 22) or painful dialysis (n = 3). The PDC was backed out of its initial position with use of a wire and stiffener. Immediate success was obtained in 34 of 38 manipulations (89%), 21 manipulations (55%) were successful at 1 week, and durable success (function for more than 1 month or until the catheter was no longer needed) was achieved in 16 manipulations (42%). This is an effective alternative procedure to surgical catheter replacement or hemodialysis.

Acute urinary retention in an infant: an unusual presentation of a paraureteral diverticulum

We present a case of a male infant with no previous urological symptoms who presented in acute urinary retention caused by compression of the posterior urethra by a paraureteral diverticulum. We discuss the etiology, evaluation and management of bladder outlet obstruction secondary to a paraureteral diverticulum in children.

Prolonged CD4+ lymphocytopenia and thrombocytopenia in a chimpanzee persistently infected with human immunodeficiency virus type 1

The immunologic and virologic status of a chimpanzee inoculated with multiple isolates of the human immunodeficiency virus type 1 (HIV-1) were assessed over 57 months to determine whether prolonged thrombocytopenia and CD4+ lymphocytopenia observed in the animal might be associated with long-term HIV infection. Although the chimpanzee showed no signs of disease, it lost both CD4+ (as low as 134 cells/microliter) and CD8+ lymphocytes approximately 30 months after initial infection, followed by thrombocytopenia that has persisted for greater than 2 years. Lymphopenia and thrombocytopenia were preceded by or coincided with the appearance of antibodies cross-reactive with histone H2B and decreased levels of complement component C4; an eightfold decrease in HIV-specific antibody titers; the inability of CD8+ lymphocytes to suppress virus replication; impaired proliferative responses to T cell mitogens; and the isolation of cell-free HIV from plasma. These data suggest that, given sufficient time, HIV-infected chimpanzees may develop disease.

Code 9: a systematic approach for responding to medical emergencies occurring in and around a hospital

Members of the public expect to receive efficient and appropriate medical care if they become acutely ill or injured while in or around a hospital. Our institution became aware of the need for an organized system to respond to such emergencies involving patients, visitors, local community residents, and hospital employees, both inside the hospital and on the grounds surrounding the building. A search of the literature did not provide information regarding such a response; a survey of surrounding hospitals revealed no such plan in effect in other institutions. We therefore designed a plan to be superimposed onto our existing system for responding to in-house cardiac and respiratory arrests ("codes"). The results after one and one-half years appear encouraging. We recommend the establishment of such an emergency response system in all health care institutions.

Tongue ischemia from a soft-drink can: report of case

A young girl was brought to the emergency department because her tongue became entrapped while she was drinking from an aluminum soft-drink can. A dental drill was used to remove the can. The tongue was observed for 48 hours, during which an ischemic area recovered spontaneously.

Clinical disorders associated with T cell subset abnormalities

Monoclonal antibodies have been used to enumerate T cell subsets in many different diseases, only a portion of which have been reviewed here. These studies have increased our understanding of T cell immunoregulation in these diseases. In the future, other diseases will similarly be analyzed regarding their immunoregulatory T cell defects. That different investigators have reported conflicting results regarding the same disease is not unexpected. Different patients at different stages of the same disease may not always have the same T cell abnormalities. Patient subgroups with different etiologies and prognoses may well have different T cell subsets. Many of the diseases described in this chapter with decreased T suppressor-cytotoxic cell number and function are associated with autoimmune or autocytotoxic disorders. The lack of T cell suppressor activity may result in a lack of regulation of both autoantibody production and autocytotoxic activity. Increased T cell suppressor-cytotoxic cell numbers have been found in certain viral infections, such as EBV, CMV, and HBV. Other viral agents may produce similar changes in T cell subsets as the immune system attempts to clear and combat these agents. These virus-induced changes in the immune system may be responsible for the transient immunosuppression observed in several of these illnesses. Decreased T helper cell number has been observed in transient hypogammaglobulinemia of infancy. This common pediatric problem seems to result from an immature or delayed development of T helper cell activity. The disease is a transient one, and return to normal gammaglobulin synthesis occurs with the return of normal T helper cell numbers. Increased T helper cell number seems to occur in diseases with excessive immune activity, such as sarcoidosis and granuloma annulare. This excessive activity of T helper cells may be responsible for the disease manifestations. In the future, one can expect more studies regarding T cell subset abnormalities in a wide variety of diseases. Cure and therapy of many diseases may be monitored in the future by T cell subset abnormalities. This will be a most exciting area in the future for pediatrics.

A longitudinal study of a patient with acquired immunodeficiency syndrome using T cell subset analysis

Acquired Immunodeficiency Syndrome (AIDS) has recently been documented in patients in association with opportunistic infections, Kaposi's sarcoma, cytomegalovirus infections, and recreational drug use. AIDS is characterized by cutaneous energy, diminished peripheral lymphocyte responses to mitogens and antigens, and abnormal T cell subpopulations. These patients have been described as having decreased total T (T3+) cell numbers, virtual elimination of the T helper (T4+) cell population, and an increased percentage of the T suppressor-cytotoxic (T8+) cell population. T cell subset monitoring has not been performed during the course of this disorder. A four month longitudinal study of the T cell subsets of a 30 year old bisexual male with AIDS revealed changes in his T cell subpopulations and in his ability to respond in a one way mixed lymphocyte culture (MLC). The results indicated that the patient's previously abnormal T cell subpopulations returned to near normal values during a period of spontaneous clinical improvement. The patient's MLC response also returned to normal in association with the return of the T helper cell population. The patient's T cell subpopulation and MLC response subsequently became abnormal and remained abnormal until the patient died. Thus, it appears that T cell subpopulations may spontaneously improve during the course of this disorder. T cell subset analysis may offer a means of monitoring the clinical course of this disorder as well as the response to therapeutic agents.