"Pills Don't Teach Skills": ADHD Coaching, Identity Work, and the Push toward the Liminal Medicalization of ADHD.

Despite physicians' near monopoly over medicalization historically, various stakeholder groups shape an increasingly complex process today. This study examines a relatively new initiative, "health coaching," within the context of the changing nature of medicalization. Utilizing 51 in-depth interviews with attention deficit hyperactivity disorder (ADHD) coaches, participant observation from seven ADHD symposia, and ADHD coach publications, I examine coaching's emergence as a partial challenge to medicalization. Findings reveal a field comprised mainly of individuals personally affected by ADHD whose dissatisfaction with institutionalized framings and practices underpins a push for liminal medicalization. Members move between medical and nonmedical discourses to frame ADHD as a paradox of pathology and gift. Additionally, they leverage and commodify personal experience alongside institutional and alternative knowledge into an adjunct or substitute to medication and potential challenge to therapy-one aimed at "self-actualization" versus "treatment." Such efforts highlight (de)medicalization's dimensionality, simultaneous medicalization and demedicalization, and a lay-driven enterprise's role in such processes.

Deserving but not entitled: The social construction of autism spectrum disorder in federal policy.

Public policies play an influential role in shaping public opinion about health conditions, who is affected by them, and potential pathways for identification and intervention. This study draws upon a social constructionist perspective of policy design and disability to examine how autism spectrum disorder (ASD) has been framed in United States federal legislation. Qualitative content analysis of autism legislation passed between 1973 and 2019 indicates that policies reinforced ASD as a largely medicalized, neurobiological condition of childhood; this was reflected in both the policy aims, sources of knowledge and groups prioritized to address ASD; and the symbolic or material resources committed (or not committed) by enacted federal legislation to specific constituencies. Policy aims of early ASD legislation were symbolic in nature, focusing predominantly on framing children with ASD as a group worthy of public recognition. More recent legislation, in contrast, conferred material resources - albeit in targeted ways. Funding for surveillance and medical research on causation, early detection, treatment, and health professional training were prioritized with little attention to either service delivery needs of individuals with ASD and their families, supports over the lifecourse, or the social factors influencing ASD.

Mapping mental health inequalities: The intersecting effects of gender, race, class, and ethnicity on ADHD diagnosis.

While the effects of social stratification by gender, race, class, and ethnicity on health inequalities are well-documented, our understanding of the intersecting consequences of these social dimensions on diagnosis remains limited. This is particularly the case in studies of mental health, where "paradoxical" patterns of stratification have been identified. Using a Bayesian multi-level random-effects Poisson model and a nationally representative random sample of 138,009 households from the National Survey of Children's Health, this study updates and extends the literature on mental health inequalities through an intersectional investigation of one of the most commonly diagnosed psychiatric conditions of childhood/adolescence: attention-deficit hyperactivity disorder (ADHD). Findings indicate that gender, race, class, and ethnicity combine in mutually constitutive ways to explain between-group variation in ADHD diagnosis. Observed effects underscore the importance and feasibility of an intersectional, multi-level modelling approach and data mapping technique to advance our understanding of social subgroups more/less likely to be diagnosed with mental health conditions.

The Effect of Medical Home on Shared Decision-Making for Caregivers of Children with Emotional, Developmental, or Behavioral Health Conditions.

INTRODUCTION: Known as the "pinnacle of patient-centered care," shared decision-making (SDM) is the process that enables and encourages the health care provider, the patient, and/or their caregiver (parent or guardian) to participate collaboratively in medical decisions. Prior research indicates that children with emotional, developmental, or behavioral health conditions (EDB) are less likely to attain SDM than children with other special health care needs (SHCNs). This study investigates whether the presence of a medical home reduces disparities in SDM among children with EDB when compared to children with other SHCNs and the general pediatric population. METHODS: Using the 2016 National Survey of Children's Health, we conducted weighted descriptive statistics to investigate the prevalence of medical home and SDM for children with (1) EDB, (2) other SHCNs, and (3) no SHCNs. We then employed a nested multivariate logistic regression model to examine whether the presence of a medical home reduced the disparity between children with EDB and their counterparts. RESULTS: Nationally, 21% of children with EDB (n = 647,274), 14.0% of children with other SHCNs (n = 1,086,068), and 13% of children with no SHCNs (n = 883,969) did not attain caregiver-reported SDM in medical care. In each of the health condition groups, the presence of a medical home significantly improved the odds of SDM (p < 0.001). Presence of a medical home also reduced the disparities observed in caregiver-reported SDM among children with EDB as compared to those with other SHCNs and no SHCNs. DISCUSSION: Ongoing investment in medical homes may reduce disparities in SDM experienced by children with EDB.

Invisible work and changing roles: Health information technology implementation and reorganization of work practices for the inpatient nursing team.

Hospitals have invested heavily in health information technology (HIT) which has been promoted as an integral component of quality, safe, and efficient health-care delivery. Research on the expanding use of such technology, however, has shown that user/technology interactions are shaped through practices of use that can yield far from normative, even unexpected outcomes. Drawing upon focus group and interview data from an inpatient, two-hospital health system in the United States, this paper considers the perceived impact of HIT implementation on work practices and roles for nurse managers and unit clerks. We find that HIT implementation generated significant reconfigurations of work practices at the expense of nurse/patient interaction. Following such changes, nursing leadership described re-prioritizing patient care and interaction - perceived to them as essential to the patient experience and unit functioning - through realignments in staffing that prioritized more versatile staff and task delegation of largely invisible, articulation work to unit clerks. Despite maintaining an integral role as "gatekeeper" and the "face on the floor," unit clerks experienced significant reconfigurations of their work and some concomitant uncertainty about their role. We consider the implications of our findings for literature on the socio-materiality of HIT, with particular attention to literature on work practices, roles, and the visibility of work within organizational power hierarchies.

The Impact of an Electronic Medication Administration Record (eMAR) and Computerized Physician Order Entry (CPOE) on Nurse Extender and Unit Clerk Staffing.

OBJECTIVE: The aim of this study is to describe the impact of the introduction of health information technology (HIT) on the utilization and payroll costs of nurse extenders and unit clerks in medicine and surgery units in a large regional health system. BACKGROUND: Long-term policy goals of HIT implementation are reported to include system-level reductions in labor costs, achieved through improved efficiency. METHODS: Using a retrospective cohort model, we analyzed how hours worked per patient day and staffing costs per patient day varied with the implementation of HIT over time at 2 different hospitals within a health system. RESULTS: Implementation of electronic medication administration records was not associated with significant changes in staffing or labor costs. Both labor hours and costs associated with nurse extenders and unit clerks were significantly reduced after the subsequent addition of computerized provider order entry. Simultaneously, units that did not implement any HIT experienced a significant increase in both labor hours and costs. CONCLUSION: Health information technology implementation in the inpatient setting is associated with significant savings in labor hours and costs in non-registered nursing roles.

Arginine vasopressin, copeptin, and the development of relative AVP deficiency in hemorrhagic shock.

BACKGROUND: Arginine vasopressin (AVP) is critical for maintaining vasomotor tone and low levels have been associated with the development of irreversible shock. We investigated the clinical relationship between AVP, copeptin (the C-terminal fragment of the AVP precursor), and the development of relative AVP deficiency following hemorrhagic shock. METHODS: A prospective, observational study of 21 hypotensive (SBP<90 mmHg X 2) or presumptively bleeding trauma patients was conducted. Demographics, mechanism of injury, vital signs, laboratory values, transfusions, crystalloid volume, and blood samples were collected on arrival and serially for 48 h. AVP and copeptin were measured post hoc. RESULTS: AVP and copeptin levels were markedly elevated on admission, but decreased rapidly over time (p < 0.001). AVP and copeptin levels were positively correlated on admission (r = 0.769, p < 0.001), in the ICU (r = 0.768, p < 0.001), and at 48 h (r = 0.537, p = 0.02). Initial AVP and copeptin levels predicted the need for ≥10 unit blood product transfusion (AUC = 81% and 87%, respectively). The development of a relative AVP deficiency occurred frequently and was associated with an increased need for blood product transfusion. CONCLUSION: Copeptin correlates well with AVP and initial values predict the need for massive transfusion in trauma patients. Copeptin demonstrates promise as a clinical biomarker in hemorrhagic shock.

Hourly rounding and patient falls: what factors boost success?

BACKGROUND: Falls are a persistent problem in all healthcare settings, with rates in acute care hospitals ranging from 1.3 to 8.9 falls per 1,000 inpatient days, about 30% resulting in serious injury. METHODS: A 30-day prospective pilot study was conducted on two units with pre- and postimplementation evaluation to determine the impact of patient-centered proactive hourly rounding on patient falls as part of a Lean Six Sigma process improvement project. Nurse leaders and a staff champion from Unit 1 were involved in the process from the start of the implementation period, while Unit 2 was introduced to the project for training shortly before the intervention began. RESULTS: On Unit 1, where staff and leadership were engaged in the project from the outset, the 1-year baseline mean fall rate was 3.9 falls/1,000 patient days. The pilot period fall rate of 1.3 falls/1,000 patient days was significantly lower than the baseline fall rate (P = 0.006). On Unit 2, where there was no run-in period, the 1-year baseline mean fall rate was 2.6 falls/1,000 patient days, which fell, but not significantly, to 2.5 falls/1,000 patient days during the pilot period (P = 0.799). DISCUSSION: Engaging an interdisciplinary team, including leadership and unit champions, to complete a Lean Six Sigma process improvement project and implement a patient-centered proactive hourly rounding program was associated with a significant reduction in the fall rate in Unit 1. Implementation of the same program in Unit 2 without engaging leadership or front-line staff in program design did not impact its fall rate. CONCLUSIONS: The active involvement of leadership and front-line staff in program design and as unit champions during the project run-in period was critical to significantly reducing inpatient fall rates and call bell use in an adult medical unit.

The impending globalization of ADHD: notes on the expansion and growth of a medicalized disorder.

Attention Deficit Hyperactivity Disorder (ADHD) has been medicalized in the United States since the 1960s. Primarily used in North America until the 1990s, ADHD diagnosis and treatment have increasingly been applied internationally. After documenting the expansion of ADHD in a global context, this paper presents five brief international examples examining ADHD usage and expansion: the United Kingdom, Germany, France, Italy and Brazil. We then identify and describe several vehicles that facilitate the migration of the ADHD diagnosis: the transnational pharmaceutical industry; the influence of western psychiatry; moving from ICD to DSM diagnostic criteria; the role of the Internet including the related advent of easily accessible online screening checklists; and advocacy groups. Finally, we discuss what this globalization of a diagnosis reflects about the potential global medicalization of other conditions.

Globalization and cognitive enhancement: emerging social and ethical challenges for ADHD clinicians.

Globalization of ADHD and the rise of cognitive enhancement have raised fresh concerns about the validity of ADHD diagnosis and the ethics of stimulant drug treatment. We review the literature on these two emerging phenomena, with a focus on the corresponding social, scientific and ethical debates over the universality of ADHD and the use of stimulant drug treatments in a global population of children and adolescents. Drawing on this literature, we reflect on the importance of ethically informed, ecologically sensitive clinical practices in relation to ADHD diagnosis and treatment.

Negotiating health-related uncertainties: biomedical and religious sources of information and support.

This article explores how people experience health-related uncertainties and how they look to biomedical and religious sources of information in response. Data were gathered in a larger project focused on spirituality in everyday life. Respondents were not asked any direct questions about their health or health care, but almost all of the 95 participants brought up the topics in response to other questions. About one-third spoke of being uncertain about some aspect of their health or healthcare. We explore the health-related topics about which people were uncertain and how they looked to biomedical and religious sources of information, most often seeing the religious as a support for the biomedical. We outline the range of ways they experienced God in this process pointing to the multiple complex ways they make sense of health-related uncertainties.

Management of the ptotic or hypertrophic breast in immediate autologous breast reconstruction: a comparison between the wise and vertical reduction patterns for mastectomy.

BACKGROUND: The Wise pattern can be used in mastectomies to address the excess skin in the ptotic or hypertrophic breast; however, limitations include mastectomy flap necrosis (MFN) and poor shape. The vertical pattern can potentially reduce the amount of MFN with improved aesthetic results. This study compares the Wise and vertical mastectomy patterns in immediate, autologous breast reconstruction. METHODS: Thirty-three patients with grade 2 or 3 ptosis who elected to undergo immediate, autologous breast reconstruction were prospectively recruited into 2 nonrandomized cohorts. Of total, 17 patients (26 reconstructions) had Wise pattern and 16 (28 reconstructions) had vertical pattern. All patients were followed for MFN, time for wound healing, and postoperative complications. Patient and surgeon surveys rated the aesthetics of the reconstructions. RESULTS: The 2 groups did not differ in age, body mass index, smoking, or breast measurements. The Wise group had significantly larger areas of MFN, higher number of postoperative visits, and longer wound-healing periods, compared with the vertical group (P < 0.05). There was no difference in time to adjuvant therapy or additional procedures. Patient surveys rated both incisions with equal satisfaction, except for symmetry that rated better in the Wise group. Surgeon surveys showed better scores for the vertical incision. CONCLUSIONS: The Wise pattern is associated with significantly more MFN and prolonged wound care. Despite this complication, patients rate their breast reconstructions favorably, regardless of the type of incision. Both the Wise and vertical patterns can be safely used in skin-sparing mastectomies with immediate, autologous breast reconstruction with good aesthetic outcomes. The authors recommend the vertical pattern because of less MFN and surgeon-preferred aesthetics.

Endorectal T2-weighted MRI does not differentiate between favorable and adverse pathologic features in men with prostate cancer who would qualify for active surveillance.

OBJECTIVE: With the increased diagnosis of low grade, low volume, potentially non-lethal disease, active surveillance (AS) has become an increasingly popular alternative for select men with low-risk prostate cancer. The absence of precise clinical staging modalities currently makes it difficult to predict which patients are most appropriate for AS. The goal of our study was to evaluate the ability of endorectal MRI (eMRI) to predict adverse pathologic features in patients who would otherwise qualify for an AS program. MATERIALS AND METHODS: We retrospectively reviewed our institution's radical prostatectomy (RP) database from 1991 to 2007 and identified 172 patients who would have qualified for AS and underwent preoperative staging eMRI with T2-weighted (T2W) sequences. MRI findings were correlated to final pathology in order to assess the ability of staging eMRI to predict adverse pathologic features in patients suitable for AS. RESULTS: The mean age of our cohort was 59.8 ± 6.2 years. The mean PSA at the time of diagnosis was 5.2 ± 2.2 ng/ml. In 51% of patients, no discrete tumor was visualized on eMRI and in 49% of patients a discrete tumor was detected. At the time of RP, Gleason score upgrading, extracapsular extension, and a positive surgical margin occurred in 17%, 6%, and 5% of cases, respectively. Patients with documented tumor on eMRI did not have an increased incidence of adverse pathologic findings with regard to tumor volume (P = 0.31), extra-capsular extension (P = 0.82), Gleason upgrading (P = 0.92), seminal vesicle invasion (P = 0.97), or positive surgical margin rate (P = 0.95) compared with those in whom no tumor was seen. CONCLUSION: Discrete tumor identification on eMRI is not predictive of adverse pathologic features in patients who would otherwise qualify for AS. eMRI likely does not provide additional information when prospectively evaluating patients for AS protocols.

Complications following thoracic trauma managed with tube thoracostomy.

INTRODUCTION: Tube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mechanism of injury traditionally does not alter chest tube management, complication rates may vary depending on the severity of injury. The purpose of this study was to investigate the incidence of and risk factors associated with chest tube complications (CTCs) following thoracic trauma. METHODS: A retrospective chart review of all trauma patients (≥16 years old) admitted to an urban level 1 trauma centre (1/2007-12/2007) was conducted. Patients who required chest tube (CT) therapy for thoracic injuries within 24 h of admission and survived until CT removal were included. CTCs were defined as a recurrent pneumothorax or residual haemothorax requiring CT reinsertion within 24 h after initial tube removal or addition of new CT >24 h after initial placement. Variables including demographic data, mechanism, associated injuries, initial vital signs, chest abbreviated injury score (AIS), injury severity score (ISS), Glasgow coma score (GCS) and length of stay (LOS) and CT-specific variables (e.g. indication, timing of insertion, and duration of therapy) were compared using the chi square test, Mann-Whitney test, and multivariate analysis. RESULTS: 154 patients were included with 22.1% (n=34) developing a CTC. On univariate analysis, CTCs were associated with longer ICU and hospital LOS (p=0.02 and p<0.001), increased chest AIS (p=0.01), and the presence of an extrathoracic injury (p=0.047). Results of the multivariate analysis indicated that only increased chest AIS (OR 2.49; p=0.03) was a significantly independent predictor of CTCs. CONCLUSIONS: CTCs following chest trauma are common and are associated with increased morbidity. The severity of the thoracic injury, as measured by chest AIS, should be incorporated into the development of CT management guidelines in order to decrease the incidence of CTCs.

Behavioral and perceived stressor effects on urinary catecholamine excretion in adult Samoans.

OBJECTIVES: The effects of perceptions and behaviors related to culturally patterned socioeconomic obligations on catecholamine excretion rates were studied in a cross-sectional sample of Samoan adults. METHODS: A total of 378 participants, ages 29-62 years, from 9 villages throughout Samoa, provided timed overnight urine specimens, and self-reported perceptions and behaviors associated with contributions to one's family, aiga, and chief, matai, and communal gift exchanges, fa'alavelave. Urinary norepinephrine and epinephrine excretion rates were measured by high performance liquid chromatography with electrochemical detection. Age (≤40 vs. >40 years) and gender-specific regression models were estimated to detect associations with catecholamine excretion. RESULTS: Young women who contribute more to their matai, who consider fa'alavelave to be a financial strain, and who view their contribution to their matai to be "just right," had significantly higher residence-adjusted norepinephrine excretion. Young women who contribute more to their matai, who consider fa'alavelave to be a financial strain, and who consider their contribution to their aiga not to be a burden, had higher epinephrine excretion. Older men who contribute more to their aiga and who perceive their contribution to their aiga to be "just right" had increased residence-adjusted epinephrine excretion. CONCLUSIONS: Individual-level perceptions and behaviors related to traditional socioeconomic obligations are a significant correlate of increased overnight catecholamine excretion rates. Higher excretion rates may be attributed to psychosocial stress arousal associated with a discordance between personal desires for upward social mobility, and family and community-based socioeconomic obligations. Changes in patterns of individual-level psychosocial stress arousal may contribute to cardiovascular disease risk in modernizing Samoans.

Improved survival after pulmonary metastasectomy for soft tissue sarcoma.

INTRODUCTION: Survival after pulmonary metastasectomy for soft tissue sarcoma (STS) has been lower than in osteosarcoma (14-40% versus 40-50%). With improved patient selection criteria and advanced chemotherapy agents, we hypothesized that survival after metastasectomy for STS has improved in recent years. METHODS: Retrospective study of 48 patients undergoing pulmonary metastasectomy for STS between 1995 and 2007. Potential predictors of overall survival and disease-free survival (DFS) were examined using the log-rank test or Cox regression. Multivariate analysis was conducted using Cox regression. RESULTS: Overall survival after initial metastasectomy was 67% and 52% at 3 and 5 years, respectively; DFS was 17% and 10% at 3 and 5 years. Univariate analysis indicated that ≤2 pulmonary metastases (p = 0.03), diameter of largest metastasis ≤2 cm (p = 0.09), and the absence of extrapulmonary metastases (p = 0.10) were associated with longer overall survival. Absence of extrapulmonary metastases (p = 0.07) and smaller size of the largest pulmonary metastasis (p = 0.06) were associated with longer DFS. Before 2001, 46.7% of patients received adjuvant chemotherapy versus 72.7% after (p = 0.10). Neither use of chemotherapy nor chemotherapy type was related to overall survival or DFS. CONCLUSION: Five-year overall survival is substantially higher after pulmonary metastasectomy for STS in our study relative to previously published results (52% versus 14-40%). This improvement does not seem to be the result of greater use of, or newer, chemotherapeutic regimens. Among potential explanations, improved patient selection is the most likely factor.

Detecting intimate partner violence: more than trauma team education is needed.

BACKGROUND: Intimate partner violence (IPV) is an underappreciated cause of morbidity and mortality in female trauma patients. We investigated the impact of a domestic violence education program for trauma residents on the detection of IPV. STUDY DESIGN: In January 2008, an educational IPV program was implemented for all trauma residents. A retrospective review of all female patients evaluated by the trauma service before and after institution of the IPV program was performed. Medical records were reviewed for demographic data, injury mechanism, social habits, and IPV documentation. Chi-square and Fisher's exact tests were used to compare patients before and after institution of the educational IPV program. RESULTS: The records of 645 female trauma patients evaluated in 2007 and 2008 were reviewed. Patients were not routinely asked about IPV, despite implementation of the educational program; 39.9% were asked about IPV in 2007 versus 46.1% in 2008 (p = 0.11). The positive disclosure of IPV did not increase from 2007 to 2008 (20.1% versus 21.2%; p = 0.83). Documentation about social habits increased considerably. In 2008, patients were asked more regularly about alcohol (71.8% versus 80.8%; p = 0.01), drugs (64.1% versus 73.7%; p = 0.01), and tobacco use (67.0% versus 78.1%; p = 0.002). Importantly, patients with documented IPV (n = 57) frequently presented to the trauma team with nonviolent mechanisms of injury (n = 30, 52.6%). CONCLUSIONS: IPV is a frequent finding in female trauma patients. Despite increased education, questions about IPV are not documented routinely. In addition, screening at-risk patients by mechanism will underestimate the prevalence of IPV. Universal screening should be mandated to increase IPV detection and enhance opportunities for intervention.

The distribution of outcomes research papers across clinical journals.

This study examines the distribution of health outcomes research (HOR) studies in the clinical literature by clinical areas and journal impact factor. The authors reviewed 535 journals and divided the sample into higher and lower impact journals across four clinical area. Mann-Whitney and Kruskal-Wallis tests were used to examine differences across four categories of outcomes research articles published, specifically the incidence of articles in higher versus lower impact journals and differences across clinical areas. All high-impact journals published more safety and quality articles than process assessment, quality of life, or cost analysis studies. The number of each type of outcomes research study published was highly variable across all clinical areas. Only arthritis and outcomes research journals showed statistically significant differences between higher versus lower impact journals. Authors may benefit from considering these differences in their clinical specialty area when deciding where to submit HOR studies.

Evaluating the use of a barbed suture for skin closure during autologous breast reconstruction.

This study compared the use of barbed suture to a traditional skin closure method for incision closure in free flap breast reconstruction. A retrospective study compared the two closure methods in consecutive series of patients undergoing autologous breast reconstruction between January 2007 and January 2009. Outcomes included total duration of operation and wound complications. We also performed a cost analysis. Use of the barbed suture significantly decreased operative time for unilateral cases by an average of 45 minutes (405 versus 360 minutes, P = 0.02). For bilateral cases, the mean operative time was decreased by an average of 10 minutes (510 versus 500 minutes, P = 0.44). There were more episodes of delayed wound healing in the bilateral barbed suture group (33/46 [72%] versus 15/31 [48%], P = 0.04). No statistical difference was noted between the two groups with regard to dehiscence, infection, or suture extrusion. Use of the barbed suture was, however, more cost-effective. The use of a barbed suture in the closure of abdominal and breast incisions in free flap breast reconstruction may expedite wound closure and reduce the cost of the procedure but may increase wound complications.

Pelvic anatomy on preoperative magnetic resonance imaging can predict early continence after robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE: Postoperative incontinence is multifactorial after radical prostatectomy. Using endorectal coil MRI, we examined features of the male urethra and accompanying muscular sphincter to predict continence after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: 80 patients underwent preoperative 1.5 Tesla endorectal coil MRI. Urethral length was measured in the coronal plane. All patients underwent RARP. Questionnaires were completed by patients at monthly intervals. The primary end point was time to continence defined as necessitating 0 to 1 pad per day (PPD). Statistical analysis was performed using Cox regression models to create both univariate and multivariate survival models. RESULTS: Mean age was 59.7 (standard deviation [SD] 7.1); 98% had bilateral nerve sparing. Mean urethral length was 17.1 mm (SD 4.5 mm). Mean prostate size was 34.7 g (SD 17.8). By 3 months, 60 patients achieved 1 PPD (mean 8.1 weeks, SD 9.4) and 34 patients achieved 0 PPD (mean 10.5 weeks, SD 8.0). Time to social continence was significantly related to prostate size both as a continuous variable (P=0.01), and as a dichotomized variable of ≥ 50 vs<50 g (P=0.02). Increased urethral length was related to decreased time to continence both as a continuous variable (P=0.06), and when dichotomized to ≥ 20 vs<20 mm (P=0.08). In addition to larger prostate size (hazard ratio [HR] 0.97, P<0.04), older age (0.95 P<0.025) was also associated with a longer time to achieve 0 PPD. Multivariate analysis revealed that longer urethral length was associated with a faster recovery of continence (HR 1.11, P<0.01). After controlling for age and urethral length, patients with a prostate size ≥ 50 g had 75% lower likelihood of achieving continence at all time points when compared with patients with prostate size <50 g (HR 0.25; 95% confidence interval: 0.06, 1.06; P=0.06). CONCLUSIONS: Longer urethral length increased the likelihood of achieving continence at all time points postoperatively. Advanced age and larger prostate size were negatively associated with continence outcomes.