A comprehensive inner-city asthma program reduces hospital and emergency room utilization.

OBJECTIVE: To evaluate the efficacy of a comprehensive asthma program on emergency department (ED) visits and hospital admission rates in an inner-city pediatric population. DESIGN: A12-month prospective randomized trial. METHODS: Three hundred asthma patients, ages 2 to 17 years, were recruited and randomized in an inner-city pediatric ED, to obtain asthma care in a specialty clinic or to continue receiving care by other health resources. The specialty clinic provided intensive medical and environmental control, education, close monitoring, and 24-hour availability. For the prospective study, monthly questionnaires were sent to the caregivers of these children to evaluate use of hospital facilities for asthma care. For the retrospective study, use of hospital resources by the study participants was analyzed using a hospital database. RESULTS: One hundred twenty-nine patients (60 in the treatment group and 69 in the control group) were included in the final analysis. Asthma severity index was significantly higher for the patients in the treatment versus the control group (35% versus 16.2%, P = .05). Fewer patients in the treatment group visited the ED at least once during the first study year, 32 versus 46, (P = .11), and they made fewer visits, 73 versus 269. The mean number of ED visits of the patients who used the ED was 0.1 versus 0.326 for the control group (P = .01). There were also fewer admissions in the treatment group, 22 versus 29 (P < .59). The 53 patients remaining in the treatment group in the second study year made fewer visits to the ED versus the control group (P < .03). In comparison to the first year, fewer patients in the treatment group visited the ED or were hospitalized in the second year (P = .007 and P = .04, respectively). CONCLUSIONS: A comprehensive asthma care program is efficacious in reducing hospital utilization.

Artificially stimulated ejaculation in the brain dead patient: a case report.

Cutaneous vibratory stimulation and rectal probe electroejaculation are highly successful methods of obtaining semen in the anejaculate patient. We report a case in which spermatozoa were retrieved in a brain dead man by artificially stimulated ejaculation. The specimen was cryopreserved to be used at a later date in combination with assisted reproductive techniques.

A closed system for corporeal irrigation in the treatment of refractory priapism.

The treatment of priapism, although considered a urologic emergency, has been historically diverse and often unsuccessful. We propose a method of corporeal aspiration and irrigation in an entirely closed system for priapism refractory to conservative measures. The advantages of this system are a reduced risk of body fluid exposure and corporeal contamination and the capacity for extended irrigation without repeated corporeal puncture.

The correlation of internal spermatic vein palpability with ultrasonographic diameter and reversal of venous flow.

A gold standard that defines the presence of a subclinical varicocele does not exist. No one has accurately demonstrated at what diameter an internal spermatic vein becomes palpable. We correlated the clinical examination of the scrotum with ultrasonographic measurements of internal spermatic vein diameter and reversal of venous flow in 156 testicles. The internal spermatic vein became palpable at diameters of 3.0 to 3.5 mm. Reversal of flow was found in all veins larger than 3.5 mm. and did not occur in any veins smaller than 2.5 mm. In veins with diameters of 2.5 to 3.5 mm. neither palpability nor internal spermatic vein diameter correlated with the reversal of flow by duplex Doppler color ultrasound. If the internal spermatic vein is nonpalpable during the diagnostic evaluation of the infertile man we do not advocate further radiographic studies. If the palpability of the internal spermatic vein is questionable duplex Doppler color ultrasound is indicated.

Can semen analysis predict the presence of antisperm antibodies in patients with primary infertility?

A retrospective study was performed to evaluate the ability to predict sperm-surface antisperm antibodies (ASA) in patients with primary infertility on the basis of semen analysis. In particular, the ability to predict ASA status on the basis of impaired sperm motility was assessed. The clinical and seminal characteristics of 70 consecutive ASA-positive infertility patients detected by routine screening were reviewed. Similar analysis was performed on 128 consecutive patients with infertility who were found on routine screening to be ASA-negative. The association between the presence of ASA and sperm motility, concentration, and clumping was examined using multivariate analysis. Two variables were found to have a significant joint association with the presence of ASAs. Patients with sperm concentrations of > 20 million/ml were significantly more likely to be ASA-positive (P = 0.002). Second, after adjustment for sperm concentration, patients with lower motilities were significantly more likely to be ASA-positive (P = 0.016). Although impaired motility was seen significantly more often in ASA-positive patients, this seminal defect alone should not be used for predictive screening, since 39% of ASA-positive patients had sperm motilities of > 60%. Furthermore, when a normal sperm concentration (> 20 million/ml) was combined with impaired sperm motility (< 60%) as an indication for ASA testing in this population, the result was a sensitivity of only 43%, a specificity of 77%, and positive and negative predictive values of 50% and 77%, respectively. Despite the association between normal sperm concentrations and impaired motility, it appears that the results of semen analysis cannot be used as a sole indication for ASA testing.

The post-vasectomy length of the testicular vasal remnant: a predictor of surgical outcome in microscopic vasectomy reversal.

To identify another preoperative predictor of surgical outcome in vasal reconstruction, we prospectively measured the post-vasectomy length of the testicular vas deferens from the cauda of the epididymis to the site of the vasectomy in 26 patients undergoing vasal reconstruction. Intraoperatively, the vasal fluid was microscopically inspected and classified as whole sperm present or whole sperm absent. The length of the testicular vasal remnant was correlated with the intraoperative status of the vasal fluid. A testicular vasal remnant length greater than 2.7 cm. predicted the presence of fluid with whole sperm present in 30 of 32 testicles (94%). A testicular vasal length of less than 2.7 cm. predicted the presence of fluid without whole sperm in 17 of 20 testicles (85%). The length of the testicular vasal remnant can be measured preoperatively and knowledge of this length may be used to advise patients regarding the likelihood of successful vasal reconstruction.

PIP: Urologists measured the length of the testicular vasal remnant of 26 consecutive vasectomized patients at hospitals of Emory University in Atlanta, Georgia, and of Baylor College of Medicine in Houston, Texas, to test the hypothesis that the remnant's length predicts the likelihood of successful vasal reconstruction. 32 testicles of 19 patients (13 bilateral and 6 unilateral) had whole sperm in the vasal fluid. 20 testicles in 13 patients (7 bilateral and 6 unilateral) had no whole sperm. 6 patients had ipsilateral whole sperm. The mean testicular vasal remnant length for the whole sperm group was significantly longer than that for the group with no whole sperm (4.45 cm vs. 2.27 cm; p = .003). For each centimeter increase in testicular vasal remnant length, the probability of whole sperm being present increased 4 fold. The researchers agreed on 2.7 cm being the threshold. A remnant less than 2.7 cm predicted 85% (17/20) of testicles with no whole sperm in the vasal fluid. A remnant greater than 2.7 cm predicted 94% (30/32) of testicles with whole sperm in the vasal fluid. The interval between vasectomy and vasectomy reversal did not affect the likelihood of having whole sperm present in vasal fluid (8.25 years for the whole sperm group and 8 years for the no whole sperm group). Other research shows that when whole sperm are present, the vasal patency rate is 90%, and the pregnancy rate is 54%. These figures for no whole sperm are 60% and 30%, respectively. These doubles suggest that urologists should ligate the vas deferens as high in the scrotum as possible when performing vasectomies to help preserve testicular function in men who might want to undergo vasectomy reversal later.

Varicocele: a progressive or static lesion?

Varicoceles are associated with ipsilateral testicular atrophy in the adolescent. To determine if varicoceles are capable of causing progressive loss of fertility, we conducted a date-matched, retrospective study. We reviewed 2,989 patients evaluated for infertility at our institution from 1985 to 1990. A total of 285 (8.5%) patients were diagnosed with secondary infertility. A varicocele was identified as the cause of the patient's infertility in 177 (69%) men with secondary infertility. When matched by date to an identical number of men with primary infertility in whom 128 (50%) were infertile on the basis of a varicocele effect, the difference was significant (p < 0.0001). We conclude that a varicocele in some men is a progressive and not a static lesion resulting in the loss of previously established fertility. In addition, varicoceles are not only the leading cause of infertility in men with secondary infertility, but also occur with a greater frequency than in men with primary infertility.

Ejaculatory failure.

Although anejaculation is a relatively uncommon occurrence in the general population, over 12,000 new cases are reported annually. Anejaculation may result from spinal cord injury (SCI), retroperitoneal lymph node dissection (RPLND), diabetes mellitis, transverse myelitis, multiple sclerosis, or psychogenic disorders. At least 30% of men with this problem are or will be married and many will seek help to remedy their infertile state. The evolution of technique and instrumentation over the least 30 years has made electroejaculation an accessible and acceptable form of therapy. Recent successes in inducing ejaculation by means of rectal probe electrostimulation or vibratory stimulation combined with assisted reproductive techniques, such as zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), and in vitro fertilization (IVF), have provided these men a means of producing their own biologic offspring.

The effect of semen quality of the electrical current and heat generated during rectal probe electroejaculation.

Rectal probe electroejaculation is effective in procuring sperm from spinal cord injured patients with ejaculatory incompetence. The seminal quality in these patients is usually suboptimal and the motility is almost always low. We conducted an in vitro experiment to determine whether the heat and current generated during rectal probe electroejaculation impaired sperm motility or forward progression, or if the poor semen quality is the result of existing testicular dysfunction.

Traumatic laceration of intracavernosal arteries: the pathophysiology of nonischemic, high flow, arterial priapism.

Two forms of priapism are known to occur. The more common type, veno-occlusive priapism, presents with a prolonged painful erection, and it is characterized by ischemia and pooling of blood within the corpora cavernosa. The less common form, high flow priapism, is characterized by lack of pain and ischemia. The pathophysiology of this disorder is poorly understood and the treatment is unclear. We report 2 cases of nonischemic priapism, one of which occurred after blunt perineal trauma and the other after intracavernosal self-injection with papaverine and phentolamine. Based on our 2 cases as well as a review of the literature (5 cases), we propose that the pathophysiological mechanism of this disorder is unregulated arterial inflow into the corpora, classify it as arterial priapism, and describe a diagnostic and therapeutic algorithm for its management.