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Therefore erectile dysfunction caused by stroke discount 100mg caverta fast delivery, studies to erectile dysfunction drugs staxyn purchase cheap caverta online quantify the erectogenic effect of oral assessment of the oscillation of the vascular tone at agents and the potentially antierectogenic effects of the glans penis before and after visual erotic stimu-- environmental agents [125-135] doctor for erectile dysfunction in bangalore buy caverta 100mg free shipping. It entails the direct observation of penile re-- togenic or anti-erectogenic effect of drugs in clinical sponses erectile dysfunction treatment comparison proven 100mg caverta. Therefore, it is useful for sep-- Based on the available evidence, these tests lack arating psychological and organic cases. Moreover, adequate sensitivity and reliability for routine clinical it appears to correlate well with corporeal smooth use [138,139]. The documented presence of a full erec-- iolocal mechanisms and mediated by somatic and tion indicates that the neurovascular axis is function-- autonomic pathways. To measure not only tumescence but sual, olfactory, and imaginative stimuli, are mediated also rigidity a Rigiscan® device may be used [120]. Relexogenic erections, The instrument has two loops, one to be placed elicited by tactile stimulation at the genital level, are around the base of the penis and the other towards mediated by a spinal relex arc consisting of afferent the tip, that tighten every ifteen or thirty seconds to somatic and efferent parasympathetic nerve ibers measure radial compression force. The medical history and physical exam-- it has been questioned whether the methodology of ination provide the basis for these tests [142,143]. The Valsalva’s manoeuvre, sustained isometric hand-- somatic nerves are evaluated by testing nerve con-- grip, mental arrhythmic task, or cold pressure. These tests rate variations relect parasympathetic function, have well-known reproducibility, validity and range while blood pressure variations relect sympathetic of confounding factors. Loss of variation is indicative for autonomic less reliable, because they simultaneously measure neuropathy, presuming absence of confounding fac-- a chain of events or reactions involving receptors, tors such as cardiac arrhythmia, nicotine, or caffeine small ibers, and target organs. Confounding factors use before testing, medication (especially antihyper-- such as medication, caffeine, temperature, hypo- tensives), hypo, or hypervolemia, and dysfunction of and hypervolemia, mental mood, and receptor or baroreceptors or target organs [150]. Basic questions regarding the signal and parasympathetic nerve systems, as in the pelvic recorded, and how to interpret it, are still unresolved. Moreover, Thus, despite some clinical use this test must be re-- efferent autonomic function tests involve the evalu-- garded as experimental [152-159]. Radioisotopic penography assesses standardised, therefore reproducibility, validity and the rate of washout of a radioisotope from the penis comparability of test results between laboratories following pharmacotesting or visual erotic stimula-- are dificult. Clinical indications are lumbar used and accepted test in urology was given a disc disorders, pelvic anatomical lesions, pelvic sur-- rating of 2B on the evidence available, and was gery etc[144]. It should be noted that these tion velocity along the sensory pathways from the four widely used tests can be performed alone, or genital region to the sensory cerebral cortex [147]. Improvements Thermal threshold measurements yield data on in diagnostic accuracy or reliability with combined the conductance of small sensory nerve ibres and testing has not been systematically investigated therefore may relect indirectly the function of the overall, and accordingly was not reviewed by this penile efferent (motoric) nerve ibers. Again, these procedures able to clinicians, who will be using it in everyday are not recommended for everyday clinical use clinical situations; and (3) The scale should be ac-- or routine application in everyday diagnostic ceptable to scientiic reviewers and journal editors assessment. The scale should have at minimum Finally, recent proposals have been made for rou-- an evidence-based rating of Grade B or C for consid-- tine use of Endothelial Dysfunction testing, either eration in clinical or research settings. Several of the via forearm occlusion methods or simple ofice scales and questionnaires the committee reviewed recording methods (EndoPat) for assessing endo-- are able to meet this standard. Similarly, biomarkers for endothelial dysfunction have been Most importantly, although valuable in recognizing proposed, but are not broadly accepted. Insufi-- and identifying sexual dysfunction, screening tools cient evidence was available for formal ranking of and questionnaires should not be substituted these proposed tests, although the committee rec-- for a thorough sexual, medical, and psychoso-- ommended that further research be done on these cial history [162]. Whenever possible, the temporal association or causal relationship between the symptoms should C. Therefore the use of self-administered based; and (iii) psychometric validation studies in symptom scales has become essential in clinical re-- both patient and non-patient groups [164]. Typically, search in sexual medicine, and has been applied ex-- at least two quantitative validation studies are re-- tensively in everyday clinical practice in many settings. For question-- tionnaires are essential in sexual medicine not only naires which are designed to serve as diagnostic 50 Comittee 06. In common with all psychometric and validated, self-report measures of sexual satis-- scales or instruments, the two fundamental and nec-- faction or quality of life (e. Reliability satisfaction and others are directed at psychosocial refers to the consistency or replicability of data, with outcomes of treatment (e. It is reliability «coeficients» serving as formal indicators important to make distinctions between the concep-- of measurement consistency. These need to be re-- tual focus or theoretical rationale for each of these ported with every scale or questionnaire, and should outcome measures, in addition to the psychometric include both test-retest and inter-item reliabilities. These Each of these aspects of reliability can be deter-- measures differ also in the degree to which they mined using standard psychometric measures (e. Substantial progress has been made in recent years in the development In contrast to consistency of measurement, validity and validation of several excellent tools in this area, addresses the essence of what is being measured; which can be reviewed according to pre-set criteria. Unlike reliabil-- terms of: (i) the conceptual focus of the measure; ity, which is established through a speciic, rigor-- (ii) qualitative and quantitative psychometrics; (iii) ously prescribed series of statistical exercises, the extent of clinical use; (iv) overall recommendations. Nunnally cent guidelines have emphasized the need for these [163] has likened the validation process to «.. Development of any new measure of sexual to an instrument’s capacity to discriminate sexually function should include all three of these compo-- dysfunctional individuals from those persons who nents of scale development and validation. In addi-- are sexually healthy (its sensitivity and speciicity tion to questionnaire measures of sexual function in in epidemiological terms, or discriminant validity in men and women, various questionnaires have been psychometric terms), while the latter refers to an developed for monitoring sexual satisfaction and instrument’s capacity to register treatment-induced quality of life. These are valuable adjunctive mea-- change (longitudinal validity in psychometric terms). Both are essential features of instruments designed to serve as diagnostic and/or eficacy measures in both clinical settings and in clinical research. The inding of the intervention 16 contemporary instruments designed to measure study can be used to demonstrate the responsive-- the status of an individual or couple’s sexual function. The 14-item self report scale can be completed designed speciically for use in clinical trials, most in about 5 minutes. Concurrent validity has been established by function status in the indicated populations. The instrument was also able to demonstrate differential rates of sexual dysfunction associated with speciic antidepressant medications [169]. This varies Validated in English and Spanish [170], with linguis-- from questionnaire to questionnaire as follows. Anita Clayton, University of Virginia a) Changes in Sexual Functioning Medical Center. A 14- conceptual domains have been empirically con-- item short-form has been developed and validated irmed through factor analysis [172]. Test-retest tivity to treatment-induced changes in both general assessment involved a comparison of scores from clinical research and in clinical trials. Women in therapy showed higher rates of Gender-keyed actuarial norms (in terms of area T- dysfunction across subscales compared to the con-- scores) are available for all versions of the test. An aggregate total score for each The following questionnaire measures have been respondent is also used to summarise the quality of validated and developed for use speciically for use in relationship and sexual functioning in the couple. A total score is computed by of models of female sexual function (n=2), psycho-- summation of all 19 items and is used to represent physiological studies (n=6), studies assessing sexu-- overall sexual function. Higher scores on to-- geographical populations, or populations of women tal score and each of the subscales indicate better with particular diseases or conditions (n=111), and sexual function. As would be expected, the Locke- Grade A, Level 1 Wallace Marital Adjustment score correlation (r=. In For use in pre and post-menopausal women who are a subsequent study, a cut-point for the total score dissatisied with their sexual function. Internal consistency of the subscales was acceptably high Strong correlations were demonstrated for the and ranged from. It has been validated also as a screening of sexually-related personal distress existed [183]. Women in a sexual relationship or having taken part in sexual activity within the previous month. There is also good evidence Norms are available for women with no sexual of convergent validity with other measures of dis-- dysfunction. Available on more sensitive to distress arising from low sexual request from the senior author.
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Indeed, the risk of road traffic injury which is estimated to cause up to 40% of hospital deaths after road traffic accidents could be avoided if appropriate treatment by qualified and trained personnel in appropriately equipped hospitals was available to all victims (Haegi, 2002). The best estimate from the Global Burden of Disease study of the World Health Organization suggests that more than 1 in 3 road traffic fatalities in the European Union are due to alcohol, with males accounting for 15,000 of the 17,000 alcohol related traffic deaths (Anderson & Baumberg, 2006). Alcohol also affects others, including an estimated 10,000 deaths in drink-driving accidents for people other than the drink-driver, and property damage due to drink-driving estimated to be ˆ10bn (ibid). The underreporting of road traffic injuries in police records seems to be particularly high for pedestrians (by a factor of 1. Indeed, more than 40% of vulnerable road user fatalities are recorded among individuals over the age of 60, with the rate being approximately two and half times higher among older men compared to older women (Bauer & Steiner, 2009). Persons over the age of 60 are four times more likely to die when injured by a car compared to younger people (Sklar at al. Not surprisingly, a survey of factors associated with ‘road risk’ in 23 European countries showed that rates of speeding and drink driving were much higher among young men and led to the conclusion that: “When we combine the various findings of this survey we understand that, generally speaking, younger drivers (18-24) engage and admit to more dangerous behaviours. Factors like inexperience, low risk observation, high-risk acceptance, lifestyles, over-estimation of own driving skill, high exposure, can help to explain their engagement in ‘unsafe’ driving behaviour. Such overconfidence in driving ability has been shown to be associated with young men engaging in more frequent reckless driving (Sarker & Andreas, 2004; Farrow & Brissing, 1990); being less likely than young women to consider speeding, drunk driving or distracted driving as dangerous driving behaviours (Sarker & Andreas, 2004), and being less likely to expect a negative consequence to result from such driving behaviour (Farrow & Brissing, 1990). These findings are borne out by a recent Eurobarometer (2010) survey on road safety which found that men were less likely than women to identify as a ‘major problem’ (i) not wearing a seat belt; (ii) driving under the influence of alcohol; (iii) exceeding speed limits; and (iv) driving while talking on a mobile phone (Fig. In Denmark, for example, the rate of accidents involving male drink drivers aged 18–24 is still approximately three times that of 25 to 64 year-olds (Bernhoft et al. Similarly in Ireland, men account for 90% of drink driving offences during the period 2003-2007 (Mongan at al. Luxembourg, Office for Official Publications There are considerable variations between countries, with the highest number of fatal accidents occuring in Italy and Germany (Fig. It is acknowledged that such differences are, to a large extent, the result of methodological differences in surveillance of workplace accidents. Construction, manufacturing and transport, storage and communication account for the highest proportion of fatal accidents (Fig. Approximately two-thirds (68%) of non-fatal accidents occurring among craft and related trade workers, machine operators, 37 or workers employed in an elementary occupation. Over 70% of non fatal accidents injuries arising from non fatal accidents are sustained as wounds and superficial injuries, dislocations, sprains and strains. Luxembourg, Office for Official Publications Advances in occupational health and health and safety have resulted in reductions in the rate of accidents at work. Between 1997 and 2007, there has been a decline in the standardised incidence rate of fatal accidents at work, with Ireland having achieved the most notable reduction (Fig. Although a large proportion of accidents entailed fewer than 14 days of absence (45. Workplace accidents and occupational injuries pose a considerable economic burden to employers, employees and to society as a whole. In addition to the personal costs in terms of pain and disability to the individual and lost income, workplace accidents are associated with decreased productivity, staff replacement costs and increased demands on public services, such as healthcare and social security (European Agency for Safety and Health at Work, 2005). Estimated Member State costs due to work accidents vary from 1–3 % of gross national product (ibid). Notwithstanding the clear progress that is being made in reducing workplace injuries, it is noteworthy that there has been little questioning or conceptualisation as a health issue, of the disproportionate incidence of work- related injuries and fatalities among men, particularly working-class men (Schofield at al. As men continue to dominate those industries that 276 have high levels of occupational injury and death – the construction industry, work involving heavy machinery and dangerous tools, most transport work, and most work in heavily polluted environments – this continues to be taken for granted as normal and expected masculine practice, as ‘men’s work’ (Connell, 1995). Future policy directed at reducing workplace injuries needs to take account of the gendered patterns of workplace accident and injury and the wider cultural and institutional masculine ideologies within workplaces in which accidents are more prevalent. Home & leisure accidents refer to a diverse category that comprises all accidents other than transport and workplace accidents. The diversity implies also various legal and administrative responsibilities, imposing a challenge for coordinated prevention efforts. It is beyond the scope of this report to cover all aspects of this category, therefore the following discussion of falls, poisoning & sport injuries should be seen as merely exemplary. There is also large variability between countries, ranging from a rate of approximately 2 for males in Portugal to 25 for males in Slovenia (Fig. Over the last available 3 years of the study period, accidental falls accounted for the majority of unintentional injury deaths (51%). There was also great variability across countries, with rates (per 100,000 person-years) ranging from =15 (Spain and Greece) to >150 (Hungary and Czech Republic). The authors hypothesised that the inter-country injury 278 variability could be related to the prevalence of osteoporosis linked to climate and nutritional differences; variations in the sources used for coding the cause of death among different countries; and differences in coding with respect to the role of falls in conjunction with leading chronic causes of death at older ages. It is estimated that approximately 6 in 1000 unintentional fatal injuries can be attributed to sports such as rock climbing, boating sports or horse related sports (Baur & Steiner, 2009). When drowning (in natural water and swimming pools) and non- traffic bicycle accidents are included, 36 in 1,000 unintentional injuries can be attributed to sporting activities. Adolescents/young people are over-represented in most categories of sports-related injuries. For example, in an audit of sports injuries in children (n=238) attending an Accident & Emergency department in Scotland, the incidence of injury was much higher in boys (71%) than in girls, with football (39%) and rollerblading (14%) accounting for the highest proportion of injuries (Boyce & Quigley, 2003). Team ball 280 sports account for approximately 40% of all hospital-treated sports injuries (ibid). The overall incidence of sports-related injuries is higher in men (67%) than in women, reflecting, in part, men’s higher participation levels in sport (Eurobarometer, 2010). For example, in a review of sports injuries (n=2270) over a one year period in the Accident and Emergency Department at the Royal Infirmary, Edinburgh, 88. In a review of 152 accidental deaths associated with mountain tourism and sports in the Republic of Kabardino-Balkaria, most of the victims were found to be male under the age of 30 (Mechukaev & Mechukaev, 2006). For men, taking risks and foregoing safety through sport, have long been regarded as masculine defining, and are practices that are valorised and sustained through wider gendered systems and structures within sporting organisations (Sabo, 1995; Messner, 1992, Connell, 1995). There has been an increasing focus on sports-related violence as a form of interpersonal violence (Fields et al. Violence and intimidation are more common in heavy-contact and collision sports, giving rise to a tendency to tolerate sports-related violence ‘as part of the game’ (Shields, 1999). Nevertheless, sports-related violence has been found to result in serious physical and psychological injuries to its victims (Campo et al. It has also been proposed that the focus in the sports media on personal rivalry, conflict, and fierce competition reinforces the social attitude that violence and aggression are normal and natural expressions of masculine identity (Children Now, 1999). From a sex and gender differences perspective, such distinctions are important, since women have been found to be over- represented among victims of intimidation and psychological violence, while men are more at risk of physical violence and assault (European Foundation for the improvement of living and working conditions, 2003). Measuring violence presents a number of challenges, not least being the inconsistencies that are to be found in defining and collecting data on violence across different countries. A German study that explored men’s experiences of interpersonal violence noted that: “Certain forms of violence are so normal in men’s lives that the men themselves do not perceive them as violence and therefore have only limited memory of them. Children who are exposed to violence are also more likely to become a violent offender themselves in later life (Moses, 1999). In addition to the more obvious physical effects, interpersonal violence can have severe repercussions on mental health. This can include feelings of dissociation, post-traumatic stress disorder-like symptoms, anger and depression (Buka at al. It should also be acknowledged that interpersonal violence data derived from mortality and hospitalisation data is likely to represent a mere fraction of the overall incidence of interpersonal violence, with only a small minority of physical assaults resulting in death or severe injury requiring hospitalisation (Harrison & Tyson, 1993; Voukelatos & Mitchell, 2009). Connell (1995) highlights the prevalence of violence in maintaining what he describes as the ‘patriarchal dividend’, and that it is predominantly men who hold and use violence to sustain their dominance. A number of studies (see Hong, 2002) have linked traditional male gender roles and hegemonic masculinity with violence, and with a much greater propensity for men to be perpetrators and victims of violence: 284 “The motivation for all male violence is related to males attempting to reinforce and render incontestable their heterosexual masculinity. The sense of obligation to uphold ‘honour’ or to reciprocate violence can be magnified considerably in the context of drinking (Brooks, 2001). Meuser (2002) differentiates between two forms of male violent action, emphasizing that both are gendered in specific ways: ‘reciprocal’ versus ‘asymmetrical’. Reciprocal violence, though directly targeting other men and not women, contributes to the reproduction of hegemonic masculinity and the masculine habitus. Whereas male violence against women solely degrades its victims, thus reinforcing women’s subordinated position in the gender order. Reciprocal violence allows for mutual acknowledgement within the competitive relations between men, related to notions of male honour. According to Meuser (2002), male violence should not be viewed as a case of disorder or deviance, but rather as a resource: a means of reproducing the gender order and male dominance. Like Meuser, Whitehead (2005) distinguishes two forms of male violence, though giving them different names: ‘inclusive’ and ‘exclusive’ violence.
Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenafil citrate erectile dysfunction kits discount 100 mg caverta with mastercard. Desc: organic 81% erectile dysfunction causes prescription drugs cheap caverta 100mg, psychogenic 9% can erectile dysfunction cause prostate cancer order 50 mg caverta amex, mixed 10% erectile dysfunction los angeles order generic caverta on-line, diabetes 22%, Rx: sildenafil [25,100]T Discont. Desc: organic 83%, psychogenic 8%, mixed 9%, diabetes 25%, Rx: Placebo [25,100]T Discont. Desc: Rx: seldenafil followed by placebo Grp: 3 Placebo then sildenafil age: 53(36,69) duration: 3. Sildenafil citrate (Viagra) is effective and well tolerated for treating erectile dysfunction of psychogenic or mixed aetiology. Desc: organic 1%, psychogenic 59%, mixed 40%, Rx: sildenafil 10 Lost: /1/ Discontinued: /7/ Discont. Desc: organic 1%, psychogenic 61%, mixed 38%, Rx: sildenafil 25 Lost: /1/ Discontinued: /7/ Discont. Desc: organic 0%, psychogenic 59%, mixed 41%, Rx: sildenafil 50 Lost: /0/ Discontinued: /11/ Discont. Desc: Rx: sildenafil 10 Grp: 5 Mixed etiology patients on 10mg sildenafil age: duration: Pts: 36 Pt. Desc: Rx: sildenafil 10 Grp: 6 Psychogenic patients on 25 mg sildenafil age: duration: Pts: 52 Pt. Desc: Rx: sildenafil 25 Grp: 7 Mixed etiology pts on 25 mg sildenafil age: duration: Pts: 32 Pt. Desc: Rx: sildenafil 25 Grp: 8 Psychogenic patients on 50 mg sildenafil age: duration: Pts: 48 Pt. Desc: Rx: sildenafil 50 Grp: 9 Mixed etiology patients on 50 mg sildenafil age: duration: Pts: 33 Pt. Desc: Rx: sildenafil 50 Copyright © 2005 American Urological Association Education and Research, Inc. Desc: organic 0%, psychogenic 54%, mixed 46%, Rx: Placebo 999 Lost: /4/ Discontinued: /9/ Discont. Desc: Rx: Placebo Grp: 92 Mixed etiology patients on placebo age: duration: Pts: 44 Pt. Desc: organic 29%, psychogenic 31%, mixed 38%, diabetes 16%, hypertension Rx: sildenafil [25,100]T 21%, ischaemic heart disease 21%, Grp: 1 Entire sildenafil group age: 55(24,77) duration: 4. Desc: organic 29%, psychogenic 31%, mixed 38%, diabetes 16%, hypertension Rx: sildenafil [25,100]T 21%, ischaemic heart disease 21%, Discontinued: /35/ Discont. Desc: organic 29%, psychogenic 31%, mixed 38%, diabetes 16%, hypertension Rx: sildenafil [25,100]T 21%, ischaemic heart disease 21%, Grp: 1. Desc: mixed 100%, Rx: sildenafil [25,100]T Grp: 90 entire placebo group age: 54(23,82) duration: 5. Desc: organic 29%, psychogenic 32%, mixed 35%,undefined 2%, diabetes Rx: Placebo [25,100]T 15%, hypertension 19%, ischaemic heart disease 6%, Grp: 90 entire placebo group age: 54(23,82) duration: 5. Desc: organic 29%, psychogenic 32%, mixed 35%,undefined 2%, diabetes Rx: Placebo [25,100]T 15%, hypertension 19%, ischaemic heart disease 6%, Discontinued: /77/ Discont. Desc: mixed 2%, Rx: Placebo [25,100]T Copyright © 2005 American Urological Association Education and Research, Inc. Desc: organic 65%, psychogenic 12%, mixed 24%, diabetes 38%, Rx: sildenafil [25,100]T Hypertension 22%, Visual disturbance 17%, Grp: 1 Slidenafil age: 52. Desc: organic 65%, psychogenic 12%, mixed 24%, diabetes 38%, Rx: sildenafil [25,100]T Hypertension 22%, Visual disturbance 17%, Grp: 90 Placebo age: 50. Desc: organic 61%, psychogenic 14%, mixed 24%, diabetes 34%, Rx: Placebo [25,100]T Hypertension 26%, Visual disturbance 20%, Grp: 90 Placebo age: 50. Desc: organic 61%, psychogenic 14%, mixed 24%, diabetes 34%, Rx: Placebo [25,100]T Hypertension 26%, Visual disturbance 20%, 700023 Palmer, J. Desc: neurogenic 100%, Rx: Lost: /2/ Grp: 1 25 mg sildenafil age: (19,35) duration: Pts: 17 Pt. Desc: neurogenic 100%, Rx: sildenafil 25 Grp: 2 50 mg sildenafil age: (19,35) duration: Pts: 17 Pt. Desc: neurogenic 100%, Rx: sildenafil 50 Grp: 3 All patients getting sildenafil age: duration: Pts: 17 Pt. Desc: Rx: sildenafil Grp: 90 25 mg placebo = placebo #1 age: (19,35) duration: Pts: 17 Pt. Desc: neurogenic 100%, Rx: Placebo 25 Grp: 91 50 mg placebo = placebo #2 age: (19,35) duration: Pts: 17 Pt. Desc: neurogenic 100%, Rx: Placebo 50 Grp: 92 All patients getting placebo age: duration: Pts: 17 Pt. Quality of life in patients with spinal cord injury receiving Viagra (sildenafil citrate) for the treatment of erectile dysfunction. Randomized, double-blind, placebo-controlled trial of sildenafil (Viagra) for erectile dysfunction after rectal excision for cancer and inflammatory bowel disease. Desc: Post-proctectomy for rectal cancer 38%, Post-proctectomy for Rx: inflammatory bowel disease 62%, Lost: /0/ Discont. Desc: Rx: sildenafil [25,100]T Copyright © 2005 American Urological Association Education and Research, Inc. Desc: Rx: sildenafil T Grp: 3 All pts receiving sildenafil (before and after age: duration: Pts: 9 crossover) s/p rectal cancer resection Pt. Desc: organic 93%, psychogenic 0%, mixed 8%, diabetes 100%, Rx: sildenafil [25,100]T hypogonadism 0%, spinal cord injury 0%, Grp: 3 All patients on sildenafil (group 1 and 2) age: duration: Pts: 293 Pt. Desc: organic 97%, psychogenic 0%, mixed 3%, diabetes 100%, Rx: Placebo [25,100]T hypogonadism 0%, spinal cord injury 0%, Grp: 92 All patients on placebo (group 90 and 91) age: duration: Pts: 189 Pt. Efficacy and safety of sildenafil citrate (Viagra) in black and Hispanic American men. Desc: Rx: sildenafil [25,100]T Grp: 6 1 risk factor on sildenafil age: duration: Pts: Pt. Desc: Rx: sildenafil [25,100]T Grp: 7 2 or more risk factors on sildenafil age: duration: Pts: Pt. Desc: Rx: sildenafil [25,100]T Grp: 90 Black patients on placebo age: 54(23,81) duration: 5. Desc: Rx: Placebo [25,100]T Grp: 95 1 risk factor on placebo age: duration: Pts: Pt. Desc: Rx: Placebo [25,100]T Grp: 96 2 or more risk factors on placebo age: duration: Pts: Pt. Desc: Rx: Placebo [25,100]T Copyright © 2005 American Urological Association Education and Research, Inc. Desc: organic 63%, psychogenic 13%, mixed 24%, diabetes 17%, prior surgery Rx: sildenafil [50,100]T 28%, hypertension 33%, Lost: /4/ Discont. Desc: organic 54%, psychogenic 20%, mixed 27%, diabetes 21%, prior Rx: Placebo [50,100]T urogenital surgery 23%, hypertension 21%, Lost: /3/ Discont. Desc: organic 39%, psychogenic 44%, mixed 16%, Rx: Grp: 1 Patients taking sildenafil age: 57. Efficacy and safety of flexible-dose oral sildenafil citrate (Viagra) in the treatment of erectile dysfunction in Brazilian and Mexican men. Desc: organic 41%, psychogenic 20%, mixed 39%, diabetes 24%, hypertension Rx: sildenafil [25,100]T 24%, visual disturbance 4%, Discontinued: /15/ Discont. Desc: organic 41%, psychogenic 15%, mixed 44%, diabetes 18%, hypertension Rx: Placebo [25,100]T 24%, visual disturbance 580%, Discontinued: /16/ Discont. Desc: organic 59%, psychogenic 15%, mixed 26%, Rx: Grp: 1 Sildenafil treatment in broad spectrum study age: duration: Pts: Pt. Desc: spinal cord injury 100%, Rx: Grp: 2 Sildenafil treatment for spinal cord injury age: duration: Pts: 178 study. Desc: organic 78%, psychogenic 9%, mixed 13%, diabetes 13%, post- Rx: sildenafil [25,100] prostatectomy 12%, hypertension 30%, ishcemic heart disease 8%, Grp: 1 All sildenafil patients age: 58(24,87) duration: 3. Desc: organic 78%, psychogenic 9%, mixed 13%, diabetes 13%, post- Rx: sildenafil [25,100] prostatectomy 12%, hypertension 30%, ishcemic heart disease 8%, Grp: 1. Desc: organic 77%, psychogenic 10%, mixed 13%, diabetes 15%, post- Rx: Placebo 125 prostatectomy 10%, hypertension 26%, ischemic heart disease 8%, Discontinued: /36/216 Discont. Desc: organic 55%, psychogenic 14%, mixed 31%, diabetes 8%, post- Rx: sildenafil [25,100]T prostatectomy 9%, hypertension 24%, ischemic heart disease 15%, Discontinued: /9/163 Discont. Desc: mixed 100%, Rx: Copyright © 2005 American Urological Association Education and Research, Inc. Desc: organic 63%, psychogenic 16%, mixed 22%, diabetes 11%, post- Rx: prostatectomy 11%, hypertension 28%, ishcemic heart disease 8%, Discontinued: /13/166 Discont. Desc: Rx: Placebo 100 Copyright © 2005 American Urological Association Education and Research, Inc.
Option: Arterial reconstructive surgery is a treatment option only in healthy individuals with recently acquired erectile dysfunction secondary to a focal arterial occlusion and in the absence of any evidence of generalized vascular disease. Despite these advances, however, many of the issues raised still remain controversial while other knowledge gaps have arisen. In order to develop new and more effective agents for treatment, research is needed in the areas of pathophysiology, natural history, and epidemiology. In addition, a clinically applicable test of neurological function of the corpora cavernosa should be developed. Evidence-based criteria are needed in order to categorize patients to arterial or venous etiologies. Despite the increasing number of properly planned and executed randomized controlled clinical trials in the literature, extraction of data for comparison and meta-analysis remains a challenge. The Panel now recognizes a need for standardized inclusion and exclusion criteria, as well as outcome measures to be incorporated in future study designs: • Patients enrolled in these studies have varied in their disease severity and duration, etiology, success with other treatments, and in-office success with therapy. If outcomes are not stratified by patient characteristics, both study and guideline results are biased. While statistically adjusting results can be a useful way to overcome patient differences, reporting results stratified by those characteristics can be more useful for later patient/physician decision making. A standardized measure of patient-partner satisfaction beyond Copyright @2005 American Urological Association Education and Research, Inc. The Panel noted that future research in penile prosthesis implantation should always express survival using Kaplan-Meier methods and include data on the numbers of patients censored. Change from baseline, mean change, and/or percentage change are frequently the most meaningful outcome measures particularly when patients vary with regard to baseline values. In addition, measures of variance of change and percentage of change are needed to meta-analyze change data. While presentation of results adjusted for patient variables compensates for patient differences, meta-analysis is possible only if adjustments are identical. Because investigators do not report details of the adjustment process, raw data should be made available. When previously reported study outcomes are regrouped or reanalyzed in a subsequent publication, the investigator should indicate such so that patients will not be counted more than once in a meta-analysis. Because direct comparisons of the therapies via meta-analyses are not possible with the available data, comparative trials still are required. Trial design should use comparable doses and not use titration-to-response, which can be biased by the available doses. If data presentation Copyright @2005 American Urological Association Education and Research, Inc. The initial purpose of revisiting the 1996 Report was to revise the outcomes tables, particularly to include treatments that were not available when the 1996 Report was in development. However, as will be explained below, the actual result of this update is somewhat different. Third, upon review of the evidence, it was determined that generation the of outcomes tables was not possible with the available evidence, although the development of guideline statements was feasible based on the extant evidence. Search, Categorization of Results, and Designation of Topics for Review the 1996 Report was based on data from 1882 citations. In all cases, Copyright @2005 American Urological Association Education and Research, Inc. Citations found through subsequent targeted searches, such as those specifically focused on individual treatments, also were added to the database. When all searches were completed, a total of 7151 citations had been included in the database. After each search was performed, the Panel chairmen reviewed the captured citations and their abstracts for relevance. Citations were considered relevant for further consideration when selected by at least one chairman. If both chairmen believed a citation was irrelevant, further review was not conducted. Except for some of these targeted searches that were reviewed by specific Panel members, the results of each subsequent search were reviewed by the chairmen. The initial winnowing process yielded 1021 articles that were subjected to a preliminary review and extraction. Nine residents and fellows from the Cleveland Clinic and the Johns Hopkins Medical Center were trained as data extractors. The purpose of this initial extraction process was to determine the nature and potential utility of the citations and not to actually extract the data. The required information was recorded on an article review form and entered into a database. Statistics on the data compiled for the four proposed topics were prepared for Panel review. While there was little evidence of sufficient quality for addressing the management of priapism, the Panel believed that there was a clear need for a review of the Copyright @2005 American Urological Association Education and Research, Inc. The guideline for the pharmacologic treatment of premature ejaculation released a year later included a full review of the literature but did not include a meta-analysis due to the lack of meta- analyzable data. The initial plan was to conduct a full review, data extraction, and meta-analysis of the U. The Panel also decided to perform focused reviews of specific surgical therapies: implantable devices and vascular bypass and repair. The review of implantable devices was restricted to the question of mechanical failure/replacement rates. The review of arterial vascular surgical therapy focused on an Index Patient who differed from the standard Index Patient defined for other treatments. A special review of herbal therapies was performed later in the guideline process since few citations on herbal therapies were initially extracted. The sections on vacuum constriction devices and intracavernous vasoactive drug injection were not updated as no new evidence was found that materially affected the recommendations for these treatments. The Panel also decided against reviewing the data on testosterone as it was beyond the scope of the guideline, and on apomorphine since it was not approved for use in the United States. Double extraction was performed initially followed by quality checks on approximately 10% of the remaining extractions. Twenty-seven papers were rejected for lack of relevant data or inadequate quality. Of the accepted articles (Appendices 2-D and 2-E), nine reported the results of two or more trials that were extracted as separate studies. Data were ® entered into a Microsoft Access database that was used to produce evidence tables for review by ® the Panel. The measures “ability to have intercourse” and “return to normal” also were used in a number of studies as well as an “erection grade” of 4 or 5 on a five-point scale for intra-urethral alprostadil suppositories. Adverse event data were categorized under major headings (Appendix 2-F) designated by the Panel after a review of the extracted data. Some of these differences were solely a function of terminology, so the Panel attempted to group the measures that were essentially similar. This exercise resulted in 52 grouped measures with 86 measures considered ungroupable. Although the erectile function domain and questions 3 and 4 were the most commonly reported, some studies reported other domains and combinations of questions. In addition to wide variability of outcome measures used in the trials, the following limitations were identified: 1. Although the ideal outcome measure would have been the change in a measure of erectile function from pretreatment values, very few studies reported a measure of variance (standard deviation, standard error, or confidence intervals) of change data, which is a necessary component for a meta-analysis. Many of the sildenafil studies were published as abstracts only; the Panel elected not to include abstracts because the data presented were incomplete. Studies evaluating the efficacy and safety of vardenafil and tadalafil excluded men who did not respond to sildenafil. Thus, comparing results with those of the sildenafil studies was impossible as patients were not preselected using the same criteria. Because many of the studies identified through the original literature search used mathematical models to compensate for patient variability in age, race, smoking status, and 17,18,19,20,21 baseline function (e. Many of the sildenafil publications appeared to reanalyze data that had been published previously, but these redundancies were difficult to confirm. Studies evaluating the use of alprostadil intra-urethral suppositories used a preselection design. Only patients who had a positive response to therapy in the office setting were randomized for the "at home" trials.
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