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Total ankle arthroplasty was developed to reduce pain and retain motion of the ankle joint in patients with osteoarthritis. The ankle joint has unique, complex anatomic and biomechanical characteristics that must be considered in a successful total ankle arthroplasty prosthesis. Initial designs from the 1960s to the 1970s had many failures. Current designs use two or three components, and recent reports on total ankle arthroplasty show consistent good to excellent intermediate clinical results, with up to 90% decreased pain and high patient satisfaction. The follow-up time of these studies is limited, however, and long-term studies with 10- to 15-year follow-ups are needed. Also, a wide variety of complications has been reported, including osteomyelitis and osteolysis. To limit the number of complications and improve clinical outcome of total ankle arthroplasty, careful patient selection and surgeon experience are important.

The recent Food and Drug Administration approval of drotrecogin alfa (activated) and the potential of several other new therapies may represent the beginning of a breakthrough in the management of critical illness in the intensive care unit. However, their use in clinical practice will likely be dependent on a rigorous appraisal not only of their effects, but also of their costs. Novel therapies can no longer be judged simply by their effectiveness in treating illness, but must also be evaluated on an institutional and societal level on the basis of their cost. These considerations have important implications for the practicing intensivist, who will need to better understand the conduct and design of economic evaluations, including their strengths and weaknesses. In this article, we review the rationale behind economic evaluations of new therapies and the alternative economic approaches available. We then discuss in more detail the elements contained in a cost-effectiveness analysis, the preferred approach to pharmacoeconomic evaluation today.

Purpose: We determine if paternity is reduced among men with monorchidism (absent or removed testis) compared to men with unilateral cryptorchidism corrected during childhood by orchiopexy and controls. The group of men with an absent testis was determined among males presenting during childhood with only 1 descended testis.Materials and Methods: Data were obtained by medical record review and a detailed questionnaire. Only men who had been successful at or attempted paternity for whom we had complete data were included in the study from the entire cohort of 584 men with former cryptorchidism, 23 with absent testis, 26 treated with orchiectomy and 706 controls.Results: Percentages of men reporting success after attempting paternity did not differ among men with an absent testis (15 of 15, 100%), treated with orchiectomy (17 of 20, 85.0%), with corrected unilateral cryptorchidism (313 of 349, 89.7%) and controls (412 of 442, 93.2%). There was no difference for a subgroup of men with cryptorchidism ...

Purpose: We determined whether there are differences indicative of the function of the Leydig cell-pituitary axis in formerly unilateral cryptorchid men. Parameters were compared with those in control men.Materials and Methods: We determined luteinizing hormone, testosterone, free testosterone, follicle-stimulating hormone, inhibin B, sperm density, motility and morphology, testicular volume, patient weight and age at orchiopexy or at other nonrelated childhood surgery in controls.Results: Significant correlations were noted between hormone levels and other parameters. An inverse correlation between age of surgery and testosterone suggested the detrimental effect of deferring orchiopexy during childhood. Correlations of testosterone with sperm density, motility and morphology suggested a direct relationship between spermatogenesis and testosterone in cryptorchid men. An inverse relationship between body weight and testosterone was observed in each group. There was considerable variation in the range of pa...

Infertility may be a consequence of cryptorchidism. We previously reported, using a large study cohort, that 38% of formerly bilateral cryptorchid men, 10% of unilateral cryptorchid men, and 5% of the control group were infertile. Men from this cohort donated blood and semen samples for inhibin B, FSH, LH, testosterone, free testosterone, and semen analyses. Results are reported comparing the entire group; some comparisons are based on normal or low sperm density. Data are also presented for men who had fathered children or had unsuccessfully attempted paternity. Mean (+/-SD) inhibin B levels were lower for the cryptorchid men (109 +/- 59 pg/mL) than the control men (153 +/- 60; P0.001), and FSH levels were higher (7.4 +/- 6.2 and 4.0 +/- 3.2; P0.0001). Inhibin B levels correlated with all other parameters for the cryptorchid group; however, correlations for the control group were only found with gonadotropins. Among the cryptorchid men, levels were significantly greater among men with normal sperm counts than men with low sperm counts (124 +/- 47 vs. 75 +/- 48 pg/mL; P0.0001). No difference was present for the control group (155 +/- 61 vs. 149 +/- 63 pg/mL). When the fertile group (based on paternity) vs. the infertile group (based on attempted paternity) were compared, significant differences were found for the cryptorchid group (117 +/- 62 vs. 73 +/- 52 pg/mL; P0.03), but not the control group (163 +/- 62 vs. 146 +/- 73 pg/mL). These data reveal relationships not apparent among the control group of men, which includes infertile men. Inhibin B data suggest that a larger portion of formerly cryptorchid men have compromised testicular function than indicated by paternity data. Low levels of inhibin B among individuals are an indication of diminished seminiferous tubule function and thus compromised potential for fertility. Low inhibin B levels together with elevated FSH levels and decreased sperm density are indicative of a high risk of infertility.

Purpose: Evaluation of the fertility of a cohort of formerly bilaterally cryptorchid men in comparison with a group of formerly unilaterally cryptorchid men, and a group of control men. Materials and Methods: Using a detailed questionnaire concerning paternity and factors related to paternity, a cohort of formerly bilateral cryptorchid men were studied and compared with men who had undergone orchiopexy for unilateral cryptorchidism, and a group of control men. All study subjects had had surgery at the Children’s Hospital of Pittsburgh, Pittsburgh, Pa., between 1955 and 1975. A subset of the full cohort underwent clinical evaluation that included a physical examination, serum hormonal determination and semen analyses. Results: Paternity rates are significantly lower among the formerly bilaterally cryptorchid men who have attempted to father a child (65.3%) as compared to the formerly unilaterally cryptorchid (89.7%; p < 0.001) and control men (93.2%; p < 0.001). Differences in the ability to father children are also apparent when semen and hormone levels are compared between the three groups. The bilateral group has significantly lower sperm density and inhibin B levels, and higher FSH and LH levels, than the unilateral and control groups. Conclusions: Men born with bilateral cryptorchidism have severely compromised fertility in adulthood. This reduction in fertility is clearly shown in comparisons of both paternity rates, and in semen and hormone analyses, between the formerly bilateral, formerly unilateral, and control groups.

Objective: To further evaluate whether fertility is decreased among a cohort of men with previous unilateral cryptorchidism as compared with a control group of men. Subjects and Methods: Formerly unilateral cryptorchid men who had undergone orchiopexy between the years of 1955 and 1975 at the Children’s Hospital of Pittsburgh and a control group of men who were matched for age of an unrelated surgery at the same institution were evaluated by review of medical records and by completion of a questionnaire. 359 previously cryptorchid men were identified as having attempted paternity. Of these men, 320 had information concerning preoperative testicular location and 163 for preoperative testicular size. 106 of these men had levels of testosterone, inhibin B, FSH, and LH measured, while 95 of the men had semen analyses. Results: Among men who had attempted paternity, there was no statistical difference in success of paternity between the previously unilateral group (89.7%) and the control group (93.7%). There was no difference in the mean time to conception (7.1 ± 0.7 months for the unilateral group vs. 6.9 ± 2.3 for the control group). Within the unilateral group in regard to success at paternity, no difference was found compared with the age of orchiopexy, preoperative testicular location, or preoperative testicular size. Inhibin B levels were lower among the unilateral group. FSH, LH, testosterone, sperm density, motility and morphology were not different, but considerable variation was noted within the cryptorchid group. Conclusions: In this continued evaluation of a cohort of previously cryptorchid men who had undergone unilateral orchiopexy, paternity does not appear to be significantly compromised after unilateral cryptorchidism. Unilateral cryptorchidism appears to be one of several factors contributing to infertility, similar to those found in the general population. No correlation was found between success at paternity and the age of orchiopexy, preoperative testicular size or preoperative testicular location. Inhibin B levels were lower while FSH, LH, T and sperm parameters did not differ.

Purpose: We determined differences in paternity and levels of the hormones inhibin B, follicle- stimulating hormone, luteinizing hormone, testosterone and free testosterone based on the preoperative location of the undescended testis in men with previous unilateral cryptorchidism.Materials and Methods: Testicular location was determined by a review of the medical records and paternity or attempted paternity using a detailed questionnaire administered to 320 men with previous unilateral cryptorchidism. In 103 cases we performed semen analysis and measured the levels of the hormones inhibin B, luteinizing hormone, follicle-stimulating hormone, testosterone and free testosterone. Paternity, sperm count and hormonal parameters were compared with cryptorchid testicular location using analysis of variance and chi-square analysis. Logistic regression was done to analyze pretreatment testicular location as a risk factor for infertility.Results: Paternity, duration of attempted conception in men who achieved pater...

Background/Purpose: Although fertility is decreased after cryptorchidism, the importance of risk factors, including parencymal testicular suture, is unknown. The aim of this study was to examine the relationship between parencymal testicular suture and failure to conceive a child for 1 year or longer among formerly cryptorchid men. Methods: Men who underwent orchidopexy between 1955 and 1972 at the Children's Hospital of Pittsburgh (n = 619) were surveyed by questionnaire and their medical records reviewed. Only the men who attempted to conceive a child (n = 387) are included. Results: Logistic regression analysis determined significant risk factors for infertility. Testicular suture was strongly related to infertility (RR, 7.56; 95% Cl, 1.66, 34.39) as were bilateral cryptorchidism (RR, 5.51; 95% Cl, 1.58, 19.24), varicocele (RR, 4.72; 95% Cl, 1.42, 15.75), hormone treatment before surgery (RR, 3.69; 95% Cl, 1.22, 11.11), and partner conception problem (RR, 3.32; 95% Cl, 1.11, 9.90). Conclusions: Testicular suture was a potent independent determinant of infertility among formerly cryptorchid men who have orchidopexy. Bilateral cryptorchidism, hormone treatment, varicocele, and partner conception problems also were associated with increased infertility.

The purpose of this study was to determine how well men recall reproductive information. By using a questionnaire, the authors surveyed men who had undergone orchiopexy for undescended testes and a group of matched control men, all of whom had had surgery at the Children's Hospital of Pittsburgh in Pittsburgh, Pennsylvania (n = 77), and their spouses. Subjects were a random subset of a larger (n = 1,212) male fertility study, which has been ongoing since 1992. In 1994, the spouses of men who participated in the study completed a short telephone survey that contained questions previously asked of their partners. Pearson correlations and kappa statistics were calculated to evaluate the accuracy of male recall of reproductive information. For the continuous measures, such as time to conception and frequency of intercourse, the correlations were high to moderate (r = 0.84 (p < 0.001) and r = 0.45 (p < 0.001), respectively). Agreement between the men and their spouses on the majority of bivariate (yes/no) questions, such as those concerning the use of birth control, as measured by the kappa statistic, was moderate to very good (K ranged from 0.14 to 0.69). Statistics were similar for formerly cryptorchid and control men. Male participants' responses to questions about their reproductive histories were accurate as compared with the responses given by their spouses. In this sample from a large cohort study, men appeared to recall reproductive information with acceptable accuracy.

Objective. To determine if paternity is decreased among formerly unilateral cryptorchid men compared with a control group of men. Subjects and Methods. Formerly unilateral cryptorchid men who had orchiopexy between 1955 and 1971 at the Children's Hospital of Pittsburgh and a group of control men have had their medical records reviewed and have been surveyed by questionnaire. Results. Among the men who had ever married and had attempted paternity, significantly more of the unilateral cryptorchid men had been unable to father children (10.5%) than among the control group (5.4%). No difference was found when the groups were compared for the duration of regular intercourse without contraception to conception of their first child. There was no relationship between the age of orchiopexy or lifestyle factors and paternity or between the age of orchiopexy and months of regular unprotected intercourse to conception. Paternity among both groups was related to femalerelated infertility factors and to the presence of vericoceles. Conclusion. When compared with a control group, paternity was compromised after unilateral cryptorchidism. Infertility is about twice as frequent among the unilateral group. There was no evidence of subfertility requiring a longer exposure of regular intercourse without contraception among the fertile subgroup. No correlation was found between age of orchiopexy and paternity.

Purpose: We determined whether there are differences in hormone levels, such as inhibin B, follicle-stimulating hormone (FSH), luteinizing hormone and testosterone, and sperm density in men with a history of unilateral cryptorchidism as stratified by age at orchiopexy.Materials and Methods: A total of 84 men with a history of unilateral cryptorchidism presented to our institution for serum hormone measurement and semen analysis. These parameters were compared using Pearson's correlations and analysis of variance among 4 groups stratified according to age at orchiopexy (range 1 month to 11 years).Results: Comparison by Pearson's correlation analysis showed that age at orchiopexy significantly correlated inversely with inhibin B (r = -0.274, p = 0.012) and positively correlated with FSH (r = 0.229, p = 0.036). Comparison of mean hormone levels and sperm density by analysis of variance for linear trend revealed a significant relationship between age at surgery with inhibin B (p = 0.032) and testoster...

We determine if paternity is reduced among men with monorchidism (absent or removed testis) compared to men with unilateral cryptorchidism corrected during childhood by orchiopexy and controls. The group of men with an absent testis was determined among males presenting during childhood with only 1 descended testis.Data were obtained by medical record review and a detailed questionnaire. Only men who had been successful at or attempted paternity for whom we had complete data were included in the study from the entire cohort of 584 men with former cryptorchidism, 23 with absent testis, 26 treated with orchiectomy and 706 controls.Percentages of men reporting success after attempting paternity did not differ among men with an absent testis (15 of 15, 100%), treated with orchiectomy (17 of 20, 85.0%), with corrected unilateral cryptorchidism (313 of 349, 89.7%) and controls (412 of 442, 93.2%). There was no difference for a subgroup of men with cryptorchidism judged to have an atrophic testis at orchiopexy (17 of 20, 85%) or those who underwent orchiectomy at initial attempted orchiopexy (8 of 10, 80%) and men who had subsequently undergone orchiopexy (9 of 10, 90.0%). Paternity was also not reduced in the group of men with only 1 testis (32 of 35, 91.4%) (monorchism plus orchiectomy) compared to either the corrected unilateral cryptorchid group or the control group. Of 637 testes 183 were recorded as impalpable on examination before surgery and 23 testes were absent, including 7 recorded as palpable. In fact, 12.1% (23 of 190) of testes that should have been recorded as impalpable were absent.This study failed to indicate that paternity is diminished among men with a single testis compared with the general population, regardless of the origin of the loss. About 12% of unilateral impalpable testes judged to be impalpable on examination before surgery were found to be absent after surgical exploration.

We determined whether there are differences indicative of the function of the Leydig cell-pituitary axis in formerly unilateral cryptorchid men. Parameters were compared with those in control men.We determined luteinizing hormone, testosterone, free testosterone, follicle-stimulating hormone, inhibin B, sperm density, motility and morphology, testicular volume, patient weight and age at orchiopexy or at other nonrelated childhood surgery in controls.Significant correlations were noted between hormone levels and other parameters. An inverse correlation between age of surgery and testosterone suggested the detrimental effect of deferring orchiopexy during childhood. Correlations of testosterone with sperm density, motility and morphology suggested a direct relationship between spermatogenesis and testosterone in cryptorchid men. An inverse relationship between body weight and testosterone was observed in each group. There was considerable variation in the range of parameters, sometimes extending into the abnormal range. However, results indicated no differences in mean free testosterone, testosterone or luteinizing hormone in the formerly cryptorchid and control groups, and no difference in time to conception in fertile, formerly cryptorchid men and controls. Furthermore, there were no differences in hormone levels in fertile (as indicated by paternity) and infertile formerly cryptorchid men.This study suggests that men who underwent orchiopexy in later childhood have subclinically decreased Leydig cell function. It may result in a less than optimal hormonal milieu for adult reproductive function. These data provide support for orchiopexy during infancy to preserve Leydig cell function and, thereby, potentially enhance fertility.

We compared characteristics related to fertility between formerly unilaterally cryptorchid men.We compared sperm counts and gonadotropin levels before and after gonadotropin-releasing hormone stimulation between formerly unilaterally cryptorchid men and controls who had completed a detailed questionnaire on fertility and other pertinent paternity information. These parameters were also compared between the subsets of formerly cryptorchid men who reported paternity and unsuccessful attempts at paternity.Sperm density and total count, and basal and gonadotropin-releasing hormone stimulated follicle-stimulating hormone (FSH) levels were different in the cryptorchidism and control groups. Higher FSH levels and lower sperm counts correlated inversely in the cryptorchidism group, while luteinizing hormone, testosterone and other results of semen analysis did not differ. Furthermore, FSH levels were higher and sperm counts were lower in the subset who reported unsuccessful attempts at paternity compared with those reporting paternity. Other measured parameters did not differ between these groups.FSH levels are significantly higher and sperm counts are significantly lower in formerly cryptorchid men than in controls. In the cryptorchidism group the same differences are found in fertile and infertile men. Thus, elevated FSH and low sperm counts may be considered risks for infertility in formerly cryptorchid men.

Objective: To critically assess the possibility that gonorrhea or chlamydia causes male infertility. Design: Comprehensive literature review structured to evaluate the epidemiologic tenets for causality, including biologic plausibility, strength of association, dose response, consistency, temporality, and treatment effect. Result(s): It is biologically plausible that gonorrhea and/or chlamydia could cause male infertility. There is clinical and pathologic evidence linking these pathogens to urethritis, linking urethritis to epididymo-orchitis, and linking epididymo-orchitis to infertility. Retrospective epidemiologic results also support an association between chlamydia serologies and male infertility, which in most of these small studies does not reach the level of statistical significance. However, there is no consistent epidemiologic evidence that these pathogens alter sperm characteristics. We discuss the methodologic limitations of previous epidemiologic studies and suggest strategies for future research. Conclusion(s): Whether gonorrhea and/or chlamydia cause male infertility is currently unclear. Sound methodologic research strategies must be applied to future studies.

Objective: To determine whether time to conception is increased among men who were formerly bilaterally or unilaterally cryptorchid compared with a group of matched control men. Design: Retrospective cohort study. Setting: Human volunteers in an academic research environment. Patient(s): Men who underwent orchidopexy between 1955 and 1971 at the Children's Hospital of Pittsburgh (n = 547) and a group of matched control men (n = 463) were surveyed by questionnaire. Result(s): Of the men who attempted paternity, the mean time to conception for the bilateral cases, unilateral cases, and control men was 33.90, 11.11, and 8.78 months, respectively. KaplanMeier survival analysis showed a significantly longer time to conception among bilateral cases compared with unilateral cases and controls, but not between unilateral cases and control men. Adjustment for confounders and covariates using a Cox Proportional Hazards model showed that former bilaterally cryptorchid men were 68% (95% CI=55% to 81%) less likely than former unilaterally cryptorchid men or controls to conceive per month of unprotected intercourse. Conclusion(s): Time to conception was increased among former bilaterally cryptorchid men compared with both former unilaterally cryptorchid and control men. However, there were no significant differences in time to conception between the unilateral cryptorchid men and the control men.

Objective: To compare paternity among men with former bilateral cryptorchidism (referred to as the bilateral group) with a group of men with former unilateral cryptorchidism (referred to as the unilateral group) and a control group. Design: Epidemiologic survey of study cohort. Setting: Large urban pediatric hospital. Subjects: Men with former bilateral and unilateral cryptorchidism who underwent orchiopexy between 1955 and 1971 at the Children's Hospital of Pittsburgh, Pittsburgh, Pa, and a group of control men have been surveyed by questionnaire concerning paternity and factors related to paternity. Main Outcome Measure: Paternity. Results: Among the married men who had bilateral cryptorchidism, 50% had fathered children, compared with 76% in the control group and 74% in the unilateral group. Data were similar when the men who were cohabitating were included with the married men. When men who had married and had attempted paternity were evaluated, 62% of the men in the bilateral group had been able to father children compared with 94% of the control group and 89% of the men in the unilateral group. No relationship was noted between the age of orchiopexy or life-style factors and paternity. Paternity among all groups was related to female-related infertility factors and to the presence of varicoceles. Conclusions: Paternity was compromised after bilateral cryptorchidism when compared with men with former unilateral cryptorchidism and a control group. Among the bilateral group, infertility is about 3.5 times as frequent than the unilateral group and more than 6 times as frequent among the control group. No correlation was found between age of orchiopexy and paternity for either group. Arch Pediatr Adolesc Med. 1997;151:260-263

Delirium occurs in as many as 80% of mechanically ventilated (MV) medical intensive care unit (ICU) patients and is associated with poor outcomes. MV patients spend 43% of all ICU days in delirium, while all patients who become delirious spend about 25% of their ICU days in delirium. The 2002 SCCM sedation and analgesia guidelines call for routine delirium screening and treatment with haloperidol. We sought to understand whether these guidelines represented a change from current practice by examining haloperidol use in the ICUs of a large tertiary care academic medical center.