Alfuzosin and Its Effect on Ejaculatory Dysfunction: A Systematic Review.

Studies have demonstrated that alfuzosin not only improves lower urinary tract symptoms (LUTS) but also appears to preserve ejaculatory dysfunction (EjD). The objective of this study was to evaluate the impact of alfuzosin on ejaculatory function using the 'Male Sexual Health Questionnaire (MSHQ)-EjD Short Form' - a validated, abridged-version of the 25-item MSHQ specifically assessing EjD. A systematic search of MEDLINE, PubMed, Scopus, Embase, and grey literature was performed in January 2017 to identify relevant cohort studies. Search terms were 'alfuzosin', 'benign prostatic hyperplasia', 'ejaculatory dysfunction' and their synonyms without exclusions. Six cohort studies conducted between 2008 to 2015 were selected for analysis. Three of these were conducted in Korea, one in Thailand, one in China, and one in Tunisia. Overall, 1,371 patients were enrolled in these studies with a median age of 62.3 years. All studies quantified patient LUTS and ejaculatory function using the International Prostate Symptom Score (IPSS) and MSHQ-EjD Short Form, respectively. IPSS had a median decrease of 6.6 while MSHQ-EjD had a median increase of 1.9. This review highlights the very real association between sexual function and LUTS. This systematic review confirms that alfuzosin may improve ejaculatory function in addition to LUTS and should be considered in men who are sexually active or who already complain of deteriorating ejaculation.

Antimicrobial stewardship in the primary care setting: from dream to reality?

BACKGROUND: Clinicians who work in primary care are potentially the most influential healthcare professionals to address the problem of antibiotic resistance because this is where most antibiotics are prescribed. Despite a number of evidence based interventions targeting the management of community infections, the inappropriate antibiotic prescribing rates remain high. DISCUSSION: The question is how can appropriate prescribing of antibiotics through the use of Antimicrobial Stewardship (AMS) programs be successfully implemented in primary care. We discuss that a top-down approach utilising a combination of strategies to ensure the sustainable implementation and uptake of AMS interventions in the community is necessary to support clinicians and ensure a robust implementation of AMS in primary care. Specifically, we recommend a national accreditation standard linked to the framework of Core Elements of Outpatient Antibiotic Stewardship, supported by resources to fund the implementation of AMS interventions that are connected to quality improvement initiatives. This article debates how this can be achieved. The paper highlights that in order to support the sustainable uptake of AMS programs in primary care, an approach similar to the hospital and post-acute care settings needs to be adopted, utilising a combination of behavioural and regulatory processes supported by sustainable funding. Without these strategies the problem of inappropriate antibiotic prescribing will not be adequately addressed in the community and the successful implementation and uptake of AMS programs will remain a dream.

Older patients' preferences and views related to non-face-to-face diabetes chronic care management: a qualitative study from southeast Louisiana.

Background: Management of diabetes may be uniquely challenging for older individuals with multiple chronic conditions. Health systems and policymakers have attempted to reduce barriers to chronic care management (CCM) through incentives to provide non-face-to-face care. This qualitative study aimed to investigate and present views on non-face-to-face care management held by elderly patients with diabetes and other chronic conditions in order to contribute to improved programming for this population. Materials and methods: Semi-structured interviews were conducted with patients over the age of 64 who have been diagnosed with diabetes and at least one other chronic health condition. Interview recordings were transcribed and analyzed by experienced researchers using a thematic analytic approach, and an illustrative case study was developed. Results: Thirty individuals participated in this study. Participants were drawn from three health systems in south Louisiana, an area with high rates of morbidity and mortality related to chronic diseases. We identified themes related to lived experiences with diabetes and other medical conditions, perception of personal health status, perceived value of non-face-to-face programs, and support needs for future programming. Additionally, we present one case study describing in detail an individual patient's experience with non-face-to-face CCM. Conclusion: Health systems should consider intentionally recruiting participants who would benefit most from non-face-to-face care, including higher-need, less self-sufficient patients with resource constraints, while continuing to offer in-person services. Future research should examine whether tailoring non-face-to-face programming and support to address unique barriers can further enhance diabetes care at the population level.

Multifocal sinonasal inverted papilloma with middle ear involvement.

Inverted papilloma of the nasal cavity is a benign neoplasm, although it can be locally invasive and has the potential for malignant degeneration. Inverted papilloma of the temporal bone is extremely rare. We describe a case of a 44-year-old woman who was treated for nasal inverted papilloma and was later found to have inverted papilloma of her temporal bone. The patient required several procedures to remove the inverted papilloma from the nasal cavity and temporal bone, and she is currently free of recurrence.

A method for the treatment of ureteric complications following renal transplantation.

Over an 8-year period, 117 renal transplants (97 cadaveric and 20 living related) were performed at the Sir Charles Gairdner Hospital, Perth, Western Australia, Australia. Ureteric complications following renal transplantation occurred following seven transplants (6%). The technique of using a multiply fenestrated vesicocutaneous stent/drain to manage this problem is described. This was uncomplicated in all cases with the exception of one case in which the stent/drain was removed early because of blockage and sepsis, but most importantly on no occasion was the graft lost. We therefore recommend this technique for the management of this complication, whether early or late. We observed a disproportionate number of ureteric complications in living related transplants, a feature not described previously.

HLA-DR and -DQ genotyping in anti-GBM disease.

Anti-GBM disease has been associated with the HLA genes of the major histocompatibility complex (MHC) in previous serological studies, with an increased incidence of HLA-DR2 in patients. In this study, 36 patients with anti-GBM disease were genotyped by restriction fragment length polymorphism (RFLP) analysis using cDNA probes for DRB, DQA, and DQB. The frequency of HLA-DRw15(Dw2), a split of DR2, was significantly increased in the patients compared with the controls (63.9 per cent versus 23.3 per cent, chi 2 = 22.4, p(corr) less than 0.0001), and all but one of the patients were positive for either DRw15(Dw2) or DR4 (p less than 0.0001). The frequencies of the remaining DR antigens were not decreased randomly, with a significant decrease in DR7 in the patient group (chi 2 = 8.6, p(corr) less than 0.05). The closely linked gene HLA-DQw6 was found to be significantly increased in frequency in the patients compared with the controls (p(corr) less than 0.0001). No correlations could be made between the genetic data and clinical features of the disease.

The effect of pyridoxine on oxalate dynamics in three cases of primary hyperoxaluria (with glycollic aciduria).

We have measured glomerular filtration rate (GFR), extracellular fluid volume (ECF), oxalate distribution volume (OxDV), plasma oxalate concentration (POx.), plasma total clearance of oxalate (PCOx.), oxalate metabolic pool size [(OxDV) X (POx.)], renal clearance of oxalate (RCOx.), oxalate excretion, tissue clearance of oxalate (TCOx.) and tissue oxalate accumulation rate [(TOx.A) = (TCOx.) X (POx.)] in three patients with type I primary hyperoxaluria (hyperoxaluria with hyperglycollic aciduria) when they were taking pyridoxine and after discontinuation of the vitamin. Seven days after stopping pyridoxine the plasma oxalate concentration, oxalate metabolic pool size and the urinary excretion of oxalate had all increased between seven- and eight-fold in two of the patients. The third patient showed no changes on stopping pyridoxine. These results support the view that pyridoxine acts by reducing oxalate biosynthesis in some patients with type I primary hyperoxaluria. The possible biochemical basis for this effect is discussed.

Effects of low-dose warfarin on antithrombin III levels in morbidly obese patients.

Morbid obesity has been associated with increased risks for thrombotic diseases. Patients with morbid obesity are shown to have decreased activity and decreased concentration of antithrombin (AT) III. This deficit can be corrected by giving the patients low doses of the oral anticoagulant warfarin. The same beneficial effect was not observed in normal lean control volunteers in whom the levels of AT III were normal at all times. Thus, it may be possible to offer prophylactic protection against the effects of having depressed levels of AT III in patients at increased risk for thrombotic diseases without using full anticoagulant doses of warfarin, including morbidly obese patients.

Toxic shock syndrome -- some new features.

A thirty-year-old female presented with a high fever, conjunctivitis, confusion, vomiting, watery diarrhoea, diffuse erythroderma, shock and oliguric renal failure. Staphylococcus aureus phage 29/52 (Group 1) was isolated from a high vaginal swab. In addition to all the previously reported features which defined toxic shock syndrome, there were pustular skin vesicles, altered red cell morphology, and severe myocardial involvement. Treatment with fluid replacement, cloxacillin, haemodialysis, positive inotropic agents, and supportive measures resulted in a full recovery.

Renal transplantation. 12-Year experience.

The results of cadaveric renal transplantation in one centre over 12 years are reviewed. One hundred and sixty-eight grafts have been performed in 147 recipients. At one year after transplantation, patient survival rate was 86%, and graft survival rate was 63%. Analysis of factors influencing graft survival show that the age of recipients, the lack of blood transfusions, and the use of poorly matched grafts (three to four HLA mismatches against 0 to two mismatches), all had adverse effect on survival. Death was a significant cause of graft loss in patients over the age of 45 years. Patients who had not received blood transfusions, and who received grafts which were mismatched for three to four HLA antigens, did especially badly, graft survival rate at six months being only 24% compared with that of 70% in patients who received blood transfusions.

The diagnosis and treatment of lymphocoeles associated with renal transplantation. A report of 6 cases and a review of the literature.

Six patients have developed a lymphocoele after renal transplantation, an incidence of 4%. A lymphocoele should be suspected in a patient who develops a rising creatinine with a pelvic mass or pressure effects on the pelvic veins 1 or more months after operation. The diagnosis is confirmed by intravenous urography, venography and ultrasonography: the use of the latter as a diagnostic measure is recommended. Treatment is by marsupialisation into the peritoneum or external drainage with breakdown of all loculi. Aspiration is unsatisfactory.

The management of urinary fistulae following cadaveric renal transplantation.

Vesicoureteric, ureteric and calyceal fistulae in cadaver transplants may be successfully treated by early exploration and nephrostomy splintage with silastic tubing for a period of not less than 6 weeks.

Results of adrenal surgery in patients with hypertension, aldosterone excess, and low plasma renin concentration.

Fifty patients with hypertension, aldosterone excess, and low plasma renin concentration underwent adrenal surgery. There was a highly significant fall in mean systolic and diastolic pressures after the operation. The mean postoperative diastolic pressure fell to strictly normal levels, however, in only 19 out of 38 patients from whom an adrenocortical adenoma was removed and in only two out of 10 non-tumour patients. There was a significant correlation between the fall in blood pressure during spironolactone treatment and after adrenal surgery though levels were generally slightly lower during the former therapy. It is suggested that removal of an aldosterone-producing adenoma is the treatment of choice provided a good preoperative hypotensive response to spironolactone occurs, while the treatment of choice for non-tumour patients is often long-term spironolactone.

Comparison of surgery and prolonged spironolactone therapy in patients with hypertension, aldosterone excess, and low plasma renin.

The effect of prolonged preoperative treatment with spironolactone has been studied in a series of 67 patients with hypertension, aldosterone excess, and low plasma renin. In the series as a whole a highly significant reduction in both systolic and diastolic pressures was achieved, with no evidence of escape from control during therapy lasting several years in some cases. The drug was equally effective in controlling blood pressure in patients with and without adrenocortical adenomata. Occasional unresponsive patients were encountered in both groups; pretreatment blood urea levels in these were significantly higher than in the responsive patients. The hypotensive effect of spironolactone usually predicted the subsequent response to adrenal surgery.Spironolactone in all cases corrected plasma electrolyte abnormalities; significant increases in total exchangeable (or total body) potassium and significant reductions in total exchangeable sodium, total body water, extracellular fluid, and plasma volumes were seen. Plasma urea rose during treatment and there was a slight fall in mean body weight. Significant increases in peripheral venous plasma renin and angiotensin II concentrations occurred during treatment.In two patients no increase in aldosterone secretion rate was found during treatment, although plasma aldosterone rose in three of four subjects studied.Severe side effects were rare; in only two of the 67 patients did the drug have to be stopped.In addition to its routine preoperative use, spironolactone can now be advised as long-term therapy in selected patients.