Assessment of Disparities Associated With a Crisis Standards of Care Resource Allocation Algorithm for Patients in 2 US Hospitals During the COVID-19 Pandemic.

Importance: Significant concern has been raised that crisis standards of care policies aimed at guiding resource allocation may be biased against people based on race/ethnicity. Objective: To evaluate whether unanticipated disparities by race or ethnicity arise from a single institution's resource allocation policy. Design, Setting, and Participants: This cohort study included adults (aged ≥18 years) who were cared for on a coronavirus disease 2019 (COVID-19) ward or in a monitored unit requiring invasive or noninvasive ventilation or high-flow nasal cannula between May 26 and July 14, 2020, at 2 academic hospitals in Miami, Florida. Exposures: Race (ie, White, Black, Asian, multiracial) and ethnicity (ie, non-Hispanic, Hispanic). Main Outcomes and Measures: The primary outcome was based on a resource allocation priority score (range, 1-8, with 1 indicating highest and 8 indicating lowest priority) that was assigned daily based on both estimated short-term (using Sequential Organ Failure Assessment score) and longer-term (using comorbidities) mortality. There were 2 coprimary outcomes: maximum and minimum score for each patient over all eligible patient-days. Standard summary statistics were used to describe the cohort, and multivariable Poisson regression was used to identify associations of race and ethnicity with each outcome. Results: The cohort consisted of 5613 patient-days of data from 1127 patients (median [interquartile range {IQR}] age, 62.7 [51.7-73.7]; 607 [53.9%] men). Of these, 711 (63.1%) were White patients, 323 (28.7%) were Black patients, 8 (0.7%) were Asian patients, and 31 (2.8%) were multiracial patients; 480 (42.6%) were non-Hispanic patients, and 611 (54.2%) were Hispanic patients. The median (IQR) maximum priority score for the cohort was 3 (1-4); the median (IQR) minimum score was 2 (1-3). After adjustment, there was no association of race with maximum priority score using White patients as the reference group (Black patients: incidence rate ratio [IRR], 1.00; 95% CI, 0.89-1.12; Asian patients: IRR, 0.95; 95% CI. 0.62-1.45; multiracial patients: IRR, 0.93; 95% CI, 0.72-1.19) or of ethnicity using non-Hispanic patients as the reference group (Hispanic patients: IRR, 0.98; 95% CI, 0.88-1.10); similarly, no association was found with minimum score for race, again with White patients as the reference group (Black patients: IRR, 1.01; 95% CI, 0.90-1.14; Asian patients: IRR, 0.96; 95% CI, 0.62-1.49; multiracial patients: IRR, 0.81; 95% CI, 0.61-1.07) or ethnicity, again with non-Hispanic patients as the reference group (Hispanic patients: IRR, 1.00; 95% CI, 0.89-1.13). Conclusions and Relevance: In this cohort study of adult patients admitted to a COVID-19 unit at 2 US hospitals, there was no association of race or ethnicity with the priority score underpinning the resource allocation policy. Despite this finding, any policy to guide altered standards of care during a crisis should be monitored to ensure equitable distribution of resources.

Evaluation of Reproductive Parameters in Men with Solitary Testis.

PURPOSE: We evaluated reproductive parameters of men with a solitary testis compared to men with bilateral testes. MATERIALS AND METHODS: We conducted a cross-sectional case-control study comparing infertility evaluation parameters in men with a solitary testis to men with 2 testes. Men presenting for fertility consultation with semen analysis data collected within 90 days of clinical and hormonal assessment were included. Differences in semen and hormonal levels were characterized using descriptive statistics, multivariate analysis on matched semen parameters and evaluation of hypogonadism subtypes. RESULTS: A total of 837 men were identified. After applying exclusion criteria, we analyzed 29/39 men (74%) with a solitary testis and compared them to 656/798 men (82%) with 2 testes. A 1:1 match on sperm concentration and motility showed follicle-stimulating hormone was more elevated in men with a solitary testis (median 13.9 mIU/ml, IQR 5.8-24.2) than in men with bilateral testes (5.0, 3.4-9.8, p=0.009). Men with bilateral testes were uniformly azoospermic after a follicle-stimulating hormone level of 25.0 mIU/ml, whereas men with a solitary testis had some sperm in the ejaculate at follicle-stimulating hormone levels as high as 54.6 mIU/ml. Testosterone levels were similar between men with a solitary testis (median 381 ng/dl, IQR 248-500) and 2 testes (387, 296-507). The prevalence of compensated hypogonadism (high luteinizing hormone and normal testosterone) was higher in men with a solitary testis (8/29, 28%) than in men with bilateral testes (54/656, 8.2%, p=0.002). CONCLUSIONS: Men with a solitary testis have compensated pituitary strain as indicated by higher serum follicle-stimulating hormone and luteinizing hormone levels for the same testosterone and semen parameters compared to men with bilateral testes. Followup is needed to evaluate any detrimental consequences of this compensated state that may lead to pituitary burnout and decreased testicular function.

Effects of Tocilizumab in COVID-19 patients: a cohort study.

BACKGROUND: Due to the lack of proven therapies, we evaluated the effects of early administration of tocilizumab for COVID-19. By inhibition of the IL-6 receptor, tocilizumab may help to mitigate the hyperinflammatory response associated with progressive respiratory failure from SARS-CoV-2. METHODS: A retrospective, observational study was conducted on hospitalized adults who received intravenous tocilizumab for COVID-19 between March 23, 2020 and April 10, 2020. RESULTS: Most patients were male (66.7%), Hispanic (63.3%) or Black (23.3%), with a median age of 54 years. Tocilizumab was administered at a median of 8 days (range 1-21) after initial symptoms and 2 days (range 0-12) after hospital admission. Within 30 days from receiving tocilizumab, 36 patients (60.0%) demonstrated clinical improvement, 9 (15.0%) died, 33 (55.0%) were discharged alive, and 18 (30.0%) remained hospitalized. Successful extubation occurred in 13 out of 29 patients (44.8%). Infectious complications occurred in 16 patients (26.7%) at a median of 10.5 days. After tocilizumab was administered, there was a slight increase in PaO2/FiO2 and an initial reduction in CRP, but this effect was not sustained beyond day 10. CONCLUSIONS: Majority of patients demonstrated clinical improvement and were successfully discharged alive from the hospital after receiving tocilizumab. We observed a rebound effect with CRP, which may suggest the need for higher or subsequent doses to adequately manage cytokine storm. Based on our findings, we believe that tocilizumab may have a role in the early treatment of COVID-19, however larger randomized controlled studies are needed to confirm this.

Anastomosing hemangioma of the ovary mimics metastatic ovarian cancer.

Anastomosing hemangioma (AH) is an uncommon benign vascular tumor reported to occur in the kidney and, in rare instances, the ovary. While most cases of AH in the ovary are incidental findings, we report a case of ovarian AH presenting with abdominal ascites and elevated CA-125 suggestive of metastatic ovarian cancer. Postoperative histopathologic examination demonstrated a tumor consisting of numerous vascular spaces lined by benign-appearing endothelial cells with exuberant hilus cell hyperplasia. These characteristics led to the diagnosis of anastomosing hemangioma of the ovary. A summary of the characteristics of AH, along with a review of all previously reported cases and possible theories for its presentation, are discussed.

The microbiome of the infertile male.

PURPOSE OF REVIEW: Contrary to historic dogma, many tissues and organs in the human body contain a resident population of bacteria, fungi, and viruses collectively known as the microbiome. The microbiome plays a role in both homeostatic symbiosis and also pathogenic dysbiosis in a wide array of diseases. Our understanding of the relationship between the microbiome and male factor infertility is in its infancy but is slowly evolving. RECENT FINDINGS: Recent literature indicates that semen (and likely the testis) is not sterile and contains a distinct microbiome, and these changes in its composition are associated with alterations in semen quality and fertility status. Preliminary investigation indicates that manipulating the human microbiome may have implications in improving semen parameters and fertility. SUMMARY: In this review, we describe relationships between the microbiome and the genitourinary system, discuss the prior work on the relationship among bacteriospermia, leukocytospermia and male factor infertility, and summarize the current literature utilizing 16s rRNA-based next-generation sequencing on the seminal and testicular microbiome. We explore the specific microbial taxa implicated in various aspects of spermatic dysfunction and introduce preliminary evidence for therapeutic approaches to alter the microbiome and improve fertility status.

Sexual Health in the Elderly Population.

PURPOSE OF REVIEW: Among the growing elderly population, sexual health remains an important concern for individuals and couples. An understanding of the expected changes with aging and taking care of aging men and women is important for treating sexual dysfunction. Sexual health issues related to aging can be both linked between men and women and independent. The aim of this study is to determine the most important considerations that contribute to sexual satisfaction in men and women in this population. RECENT FINDINGS: Many factors contribute to the overall sexual health of men and women. Hypogonadism and erectile dysfunction both warrant thorough evaluation and consideration of treatment to improve sexual satisfaction. Underlying cardiovascular issues may be present in men presenting with these concerns. In addition to hormone replacement and traditional therapy for erectile dysfunction, therapeutic stem cell injection has shown some promise. Menopause, vaginal dryness, and dyspareunia play important roles in sexual satisfaction in women. Vaginal moisturizers, topical estrogen, and MonaLisa Touch laser therapy all may aid in improving these symptoms and ultimately sex lives. Studies have also demonstrated some benefit in populations with arousal disorders, which can be present in the elderly. SUMMARY: Male patients often describe issues related to erectile dysfunction and hypogonadism, and issues with sexual drive. The pathophysiology is linked between these conditions and treatment of one component can provide symptom relief on a larger scale. A combination of testosterone therapy, lifestyle modifications, and therapy for erectile dysfunction relates to sexual satisfaction in men. In women, an understanding of the physiological process of menopause and offering therapy when indicated can improve the quality of sexual health and provide satisfaction to both patient and partner. While aging can diminish drive and desire, proper counseling and treatment may significantly benefit some patients. A multimodal approach involving the physician, patient, and partner will optimize care and may improve the quality of life in the elderly. This review outlines some normal changes due to aging and identifies some current treatment options for a population in which sexual health can be often ignored or dismissed. By understanding the available tools, a more comprehensive approach can be taken to achieve satisfaction in couples and individuals alike.

Characteristics predictive of response to collagenase clostridium histolyticum for Peyronie's disease: a review of the literature.

PURPOSE: To evaluate characteristics predictive of successful treatment outcomes of Peyronie's disease (PD) with collagenase clostridium histolyticum (CCH) METHODS: CCH is the only FDA-approved medication for treating PD. We reviewed the literature that addresses pre-treatment clinical characteristics that may predict favorable response to CCH therapy. RESULTS: Despite significant heterogeneity in reporting treatment success, we identified four well-studied characteristics that may be predictive of favorable response to CCH therapy: baseline penile curvature, baseline IIEF, duration of PD, and presence of calcification. CCH demonstrated a favorable response in those with pre-treatment curvature 30°-60°, longer duration of disease, mild to moderate baseline sexual function, and low calcification within plaques. Of all factors, calcification is emerging as the most significant factor likely because CCH is unable to degrade the calcified plaques. There is difficulty interpreting results because of differences in reporting outcomes. Some studies compared treatment groups to placebo, others reported changes in curvature, while others reported > 20% curvature correction as treatment success. Additionally, not all studies reported outcomes after completion of four cycles of CCH, and recent studies utilized a shortened, high dose, modified protocol. CONCLUSIONS: The ideal candidate for CCH therapy remains elusive. Based on the available literature, the man with PD who will have the greatest chance of curvature improvement will have curvature between 30° and 60°, longer duration of disease, an IIEF > 17, no calcification, and set to receive all four cycles. For a greater understanding of CCH treatment success in PD, prospectively collected registry reporting standardized outcomes are needed.