Clinical outcomes following ICSI cycles using surgically recovered sperm and the impact of maternal age: 2004-2015 SART CORS registry.

PURPOSE: The aims of this study were (1) to evaluate clinical outcomes after ICSI cycles using surgically recovered sperm and (2) to assess the influence of maternal age on those outcomes. METHODS: A retrospective cohort study of 24,763 IVF cycles of fresh autologous oocytes and ICSI using surgically recovered sperm reported to the SART CORS database from 2004 to 2015. RESULTS AND CONCLUSIONS: Older women had significantly longer stimulation (p < 0.001), a lower number of oocytes retrieved (p < 0.001), a lower number of 2PN zygotes (p < 0.001), a lower chance of having a blastocyst transferred (p < 0.001), and a higher number of fresh embryos transferred (p < 0.001). There was no significant association between the number of 2PNs per oocyte retrieved and maternal age (p = 0.214). Both clinical pregnancy rates and live birth rates (LBR) decreased with advanced maternal age (p < 0.001). LBR ranged from 50.4% in women < 30 to 7.2% in women > 42 years, and for cleavage-stage transfers, the LBR ranged from 47.3% in women< 30 to 6.3% in women > 42 years. There were no differences in gestational age at delivery, proportion of term deliveries, preterm deliveries, neonatal birth weight < 2500 g, neonatal birth weight > 4000 g and average birthweight of neonates for singleton pregnancies according to age. For twin pregnancies, women < 30 years had significantly higher number of live births, term deliveries, and lower preterm deliveries than older women. There was a similar number of female (6051) and male neonates (5858; p = 0.2). Overall, pregnancy outcomes with ICSI using surgically recovered sperm are reassuring and comparable to those of ICSI with ejaculated sperm.

The diagnostic value of fine needle aspiration in parotid lumps.

INTRODUCTION: Fine needle aspiration (FNA) is a safe and quick method of diagnosing superficial lumps, which aids preoperative planning. However, FNA of the parotid gland has not gained the widespread acceptance noted in other head and neck lumps. The aim of this study was to determine the ability of FNA of the parotid gland to differentiate benign and malignant disease, and to determine the impact on surgical outcome. METHODS: A retrospective analysis of 201 consecutive parotid operations with preoperative FNA in a large district hospital in the UK was performed. The diagnostic characteristics were calculated for benign and malignant disease, and the impact on surgical procedure was determined. RESULTS: In identifying benign disease, FNA has a sensitivity of 85% and a specificity of 76%. In detecting malignant disease, FNA has a sensitivity and specificity of 52% and 92% respectively. A false positive on FNA was associated with a higher incidence of neck dissection. CONCLUSIONS: FNA is a useful diagnostic test. However, owing to low sensitivity, it is necessary to interpret it in the context of all other clinical information.

Touch-less heartbeat detection and measurement-based cardiopulmonary modeling.

This paper presents a system for touch-less heartbeat detection and a cardiopulmonary signal modeling approach. Using a vector network analyzer, a microwave system is tested for the detection of the heartbeat signal at a distance of 1 m from a person. The proposed system shows the ability of detecting the heartbeat signals with the possibility of tuning both frequency and power. Measurements are performed at 2.4, 5.8, 10, 16, and 60 GHz, as well as at different power levels between 0 and -27 dBm. Based on measurements performed for both respiration and heart beatings, a model of the measured signals representing the cardiopulmonary activity is presented. The heartbeat rate and the heart rate variability are extracted from the modeling signal using wavelet and classic filters, for SNR between 0 and -20 dB.

Pediatric and adolescent transperineal anastomotic urethroplasty.

PURPOSE: Pediatric urethral stricture disease represents a significant surgical challenge because of smaller pelvic confines, decreased caliber and increased tissue fragility. Operative series of pediatric urethral reconstruction usually involve small numbers. In this study, we examined the outcome of open reconstructive techniques for pediatric and adolescent patients with posterior urethral distraction injuries. PATIENTS AND METHODS: Between February 2002 and September 2005, 15 patients from Kasr ElAini hospital presenting with posterior urethral distraction defects due to motor vehicle accidents were included in our study. Their age ranged between 5 and 17 years (mean 12.5). We used the progressive perineal approach to achieve a tension-free spatulated anastomosis. RESULTS: Mean follow-up was 28.4 months. Initial and ultimate success rates were 80 and 86.6%, respectively. Other than re-stricture, one child had a bladder stone treated by cystolithotomy 6 months after surgery. No penile curvature, shortening or urethral diverticulae were noted during follow-up. CONCLUSION: Using the appropriate modern guidelines of urethroplasty, consistent success can be achieved in pediatric and adolescent patients with posterior urethral injuries. Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results with minimal morbidity. Urethral reconstruction is strongly recommended as the primary treatment option, especially in the pediatric urethral stricture population, because of the repair durability.

Predicted performance of clay-barrier landfill covers in arid and semi-arid environments.

Conventional landfill cover systems for municipal solid waste include low-permeability compacted clay barriers to minimize infiltration into the landfilled waste. Such layers are vulnerable in climates where arid to semi-arid conditions prevail, whereby the clay cover tends to desiccate and crack, resulting in drastically higher infiltration, i.e., lower cover efficiency. To date, this phenomenon, which has been reported in field observations, has not been adequately assessed. In this paper, the performance of a cover system solely relying on a clay barrier was simulated using a numerical finite element formulation to capture changes in the clay layer and the corresponding modified hydraulic characteristics. The cover system was guided by USEPA Subtitle-D minimum requirements and consisted of a clay layer underlying a protective vegetated soil. The intrinsic characteristics of the clay barrier and vegetative soil cover, including their saturated hydraulic conductivities and their soil-water characteristic curves, were varied as warranted to simulate intact or "cracked" conditions as determined through the numerical analyses within the proposed methodology. The results indicate that the levels of percolation through the compromised or cracked cover were up to two times greater than those obtained for intact covers, starting with an intact clay hydraulic conductivity of 10(-5)cm/s.

Ultrastructural changes in rat livers perfused in vitro and in vivo with a high dose of methotrexate.

Methotrexate is an antifolate that is widely used in the treatment of malignant tumours and other diseases. The present study was undertaken to examine the short-term effects of high doses of methotrexate (HD-MTX) on the ultrastructure and metabolic activity of isolated rat livers. The authenticity of the drug-induced changes was substantiated by the concomitant use of in vivo experiments. Isolated rat livers were infused with HD-MTX via the portal vein for 3 hours (total dose for each liver 2000 mg). For in vivo experiments, each rat received a single intravenous injection of a maximum tolerated dose of MTX (100 mg/kg body weight) that allowed the animals to survive for 3 days. At the end of each experimental period, MTX-treated and control livers were processed for light microscopy (LM), scanning (SEM) and transmission electron (TEM) microscopy. Oxygen consumption and thyroxine metabolism were measured in treated and control isolated livers. With the exception of a few minor differences, the structural changes in the hepatocytes after MTX treatment in vitro and vivo were similar. There were focal changes consisting of disruption of normal hepatic plates and swelling and vacuolation of the hepatocytes, with no clear evidence of restriction to a specific hepatic zone. SEM revealed striking changes in the plasma membrane, the microvillar system, intercellular junctions and the sinusoidal endothelium. TEM revealed disorganized endoplasmic reticulum, dispersion of the polyribosomes, a variety of mitochondrial changes, and glycogen redistribution. In MTX-treated isolated rat livers, the uptake of tetraiodothyronine (T4) was not affected, but triiodothyronine (T3) release was impaired. Oxygen consumption was increased in livers treated with MTX. Employing an organotypic liver perfusion model in conjunction with the in vivo experiment and the use of SEM, TEM and hepatic thyroxine measurements, this investigation revealed that infusion of HD-MTX induced early ultrastructual changes in cell membrane, intercellular junctions and cell organelles and disturbance in the functional integrity of the hepatocytes in isolated rat liver.

Immunomonitoring of renal transplant recipients in the early posttransplant period by sequential analysis of chemokine and chemokine receptor gene expression in peripheral blood mononuclear cells.

INTRODUCTION: We sought to determine whether sequential changes in chemokine ligand/receptor gene expression in the early posttransplant period of human renal allografts can be detected in peripheral blood mononuclear cells (PBMCs) and whether any such changes are predictive of clinical events. METHODS: Blood samples from 106 renal transplant recipients and 29 donor nephrectomy patients were taken preoperatively and daily for 14 days. Within the study period 22 patients had biopsy-proven acute rejection. From each blood sample PBMCs were separated and gene expression levels for chemokines CCL3, CCL4, CCL5, CXCL10, and their receptors CCR1, CCR5, and CXCR3, were determined using real-time quantitative PCR. RESULTS: Different gene expression patterns were seen between the rejector and nonrejector groups with decreases in CCL4 and CCR5 expression on days 6 to 8 and increases in CCR1 expression on days 9 and 10 posttransplant. With CXCL10, decreases in expression were seen in the nonrejector group but increases were seen in the rejector group posttransplant. With data aligned to time of rejection diagnosis, statistically significant increases, that preceded the clinical detection of acute rejection were seen in CCR1 and CXCL10 expression. Both their expression levels returned to pretransplant baseline values after successful antirejection therapy. CONCLUSION: We have demonstrated that changes in chemokine receptor/ligand gene expression by sequential monitoring in PBMCs can be detected in the early posttransplant period. In particular, CCR1 and CXCL10, which showed increased expression prior to rejection and returned to baseline levels with antirejection therapy, may have potential use in immunomonitoring and as predictive factors of rejection prior to its clinical manifestation.

Surgical management of ejaculatory duct obstruction

"Objective: The aim of this work is to evaluate the efficiency of transurethral resection (unroofing) of the obstructed ejaculatory ducts (TURED) as a treatment alternative for cases of obstructive ductal azoo-/ oligozoospermia Patients and Methods: Thirty-two patients; aged 26 to 45 (mean age 34 years) with varying degrees of ejaculatory duct obstruction (EDO) were selected from a large pool of infertile patients with low semen volume presenting to the outpatient clinic of the Andrology Department of Kasr el Aini Hospital; Cairo; Egypt. The patients (24 with complete and 8 with partial EDO) were then transferred to the Urology Department of the same hospital for surgical treatment performed by one surgeon. The treated patients were sent back to the Andrology Department for follow-up lasting 6 to 30 months (mean 18 months). Follow-up included history taking; physical examination and repeated semen analysis. Results: There was a statistically significant improvement in all ""mean"" semen parame-ters following TURED. Furthermore; 42of the azoospermic (bilateral complete EDO) and 63of the oligozoospermic patients (partial EDO) showed improvement in their semen parameters after TURED yielding an overall improvement rate of 47among treated patients. Pregnancy was achieved in about 17of the azoospermic and in 25of the oligozoospermic patients. The overall pregnancy rate was 19. Prolonged hematuria was the only complication; encountered in only 2 patients; and was managed conservatively. Conclusion: TURED is an effective line of treatment for cases of EDO. Used judiciously; this technique can yield satisfactory results with limited morbidity in this challenging patient population. The better response of partial EDO as compared to TURED warrants further studies involving a larger number of patients."

Timing of urgent laparoscopic cholecystectomy does not influence conversion rate.

BACKGROUND: The optimal treatment of acute gallstone disease is urgent laparoscopic cholecystectomy, but there is confusion about the effect of delay in operation on conversion rates. Most reports suggest that delay beyond 3 or 4 days leads to a higher conversion rate. This study assessed the conversion rate in relation to the timing of laparoscopic surgery. METHODS: This institution operates a specialist-led protocol for the urgent management of all admissions with acute gallstone disease. Data were collected prospectively over 6 months. RESULTS: Between March and August 2002, 84 patients with acute gallstone disease underwent urgent laparoscopic cholecystectomy at the index admission with an overall conversion rate of 12 per cent. Four of 40 procedures carried out within 3 days of admission were converted, compared with six of 44 after 3 days. Five of 46 carried out within 4 days of admission were converted, compared with five of 38 after 4 days. There were no deaths and one common bile duct injury. CONCLUSION: As long as the procedure is carried out by experienced upper gastrointestinal surgeons working within a specialist-led protocol, the conversion rate for laparoscopic cholecystectomy can be as low as 12 per cent. The timing of urgent laparoscopic cholecystectomy has no impact on the conversion rate.

Implementation of a specialist-led service for the management of acute gallstone disease.

BACKGROUND: The 'gold standard' treatment for acute cholecystitis and biliary colic requiring hospital admission is urgent laparoscopic cholecystectomy. This is not routinely available in all hospitals. METHODS: A retrospective audit of emergency admissions with acute cholecystitis or biliary colic from January to December 2000 led to the development and implementation of a specialist-led protocol for the urgent management of acute gallstone disease. A second audit was carried out covering the 6 months after implementation. RESULTS: One hundred and fifty-eight patients were admitted with acute cholecystitis or biliary colic in the first audit period and 110 in the second interval. The rate of cholecystectomy at index admission increased from 37.3 to 67.3 per cent, at a median of 3 days after admission, and the conversion rate to open surgery fell from 32 to 12 per cent. Median hospital stay fell from 9 to 5.5 days, and the unplanned readmission rate decreased from 19.0 to 3.6 per cent. CONCLUSION: Urgent cholecystectomy for the management of acute gallstone disease is feasible and achievable in an acute services hospital with a specialist upper gastrointestinal team. It can lead to a reduced conversion rate, shorter hospital stay, fewer unplanned readmissions, an acceptable operating time and a low complication rate. The protocol is recommended for implementation in other hospitals.

Recurrent small bowel obstruction after laparoscopic surgery for gallstone ileus.

Gallstone ileus is an uncommon cause of small bowel obstruction. A patient presenting with gallstone ileus was managed in our department by laparoscopic enterolithotomy. Postoperatively, the patient developed recurrent small bowel obstruction due to the presence of a second gallstone. It is therefore important to exclude the possibility of multiple gallstones at the initial operation.

Developmental morphological and histological studies on structures of the human fetal shoulder joint.

In the present work, morphological changes in the interior structures of the developing human shoulder joint were studied at different prenatal ages (9, 12, 16, 23 and 40 weeks) and were compared with the same structures in the adult joint. It was found that the shoulder joint had gone through important developmental changes during the 12th week of the prenatal life and it is assumed that genetic factors operative during this stage of development were more important than mechanical factors. A subsequent development of the intracapsular glenohumeral ligaments was present at the 16th week. The glenoid labrum, the biceps tendon and the three glenohumeral ligaments formed a complete ring around the glenoid fossa which constituted a functional unit, which seemed to have a role in stabilizing the joint. In the present work, histological prenatal studies were done on sagittal and radial sections from the glenoid fossa and its associated structures and the results were compared with the same structures in adults. At a crown-rump length of 30 mm (9 weeks), intermingling of the collagen fibres of the superior labrum and the biceps tendon was observed and the superior labrum could be considered as an extension of the biceps tendon. While the superior and inferior parts of the labrum appeared fibrous, the posterior labrum appeared as a primitive cellular condensation. At the 12th week, it became a fibrocellular structure and changed to a fibrocartilaginous structure at the 16th week. But until full term, no definitive fibrocartilage was found due to its hypercellularity compared to the adult. It was found that at all ages, the capsule was formed of cellular and fibrous elements, its collagenous content was progressively increased with age and at full term, it became generally fibrous but was still different compared to adults. In all stages of development, the synovial tissue of different regions of the same joint exhibited marked variations in thickness, vascularity, cellular density and collagenous content. It lined the capsule, surrounded the biceps tendon and reflected on the labrum. Its cell density as well as their vascular and collagenous contents were progressively increased with age. At full term, the synovial tissue was thickest at its inferior reflection and forming large folds. The synovial tissue lining the capsule was thinner than the synovial tissue at its reflection from the labrum, many villi and processes arising from it and projecting into the joint cavity.

An unusual abdominal mass in a renal transplant recipient.

Renal transplant recipients are at increased risk of malignancy and infection. We present the case of a 72-year-old-man with recurrent bladder carcinoma, abdominal aortic aneurysm repair, and end-stage renal failure due to renovascular disease. He received a cadaveric renal allograft into his left iliac fossa, was given cyclosporin A, azathioprine, and prednisolone triple therapy immunosuppression, and had no rejection episodes. He presented four years post-transplantation with a two-year history of intermittent sweats and fevers. Previous episodes had been investigated with no firm diagnosis made. This time he had right iliac fossa pain of three weeks' duration. Examination revealed a tender mass. Investigations showed unchanged graft function, but elevated inflammatory indices. Ultrasonography and computed tomography detailed an infiltrating mass associated with the sigmoid colon, which colonoscopy failed to visualise. At laparotomy a 6-cm tumor was removed, with adherent sigmoid colon and bladder dome. Macroscopically the mass was an abscess, and microscopy found acute and chronic inflammatory giant cells and fibrillary masses suggestive of actinomycosis, with no malignancy. The patient recovered uneventfully on antibiotics. At six months' follow-up, examination, inflammatory markers, and radiographic imaging showed no evidence of recurrence. Twelve months later the patient died of rupture of his proximal abdominal aorta. There was no evidence of recurrence at postmortem examination. We conclude with a brief review of actinomycosis in transplant recipients.

Temporal bone dissection: a possible route for prion transmission?

The aim of this study was to determine whether neural tissue is present in the bone 'dust' given off during temporal bone drilling. Bone 'dust' from three temporal bone dissections was collected and examined. Evidence of neural tissue was present in two out of the three specimens. Neural tissue is present in the bone dust given off during temporal bone drilling. This poses the question as to the risk of prion transmission during such dissection.

Sequential monitoring of peripheral T-lymphocyte cytokine gene expression in the early post renal allograft period.

BACKGROUND: Despite numerous studies, the precise role of cytokines in acute renal allograft rejection remains unclear. In this study we have monitored sequential changes in peripheral T cell cytokine gene expression, correlating the changes with clinical events after adult renal transplantation, to provide a deeper insight of the role of cytokines in allograft rejection. METHODS: Sequential changes in peripheral Th-1 [interleukin- (IL) 2 and interferon-gamma] and Th-2 (IL-4, IL-5, IL-10, and IL-13) cytokine gene expression in 43 patients with (n=15) and without (n=28) episodes of biopsy-proven rejection was monitored in the first 6 weeks after renal transplantation using a sensitive, semi-quantitative reverse-transcriptase polymerase chain reaction ELISA approach. RESULTS: Th-2 cytokines: IL-5 and IL13 expression increased before and during acute rejection, and decreased after successful antirejection therapy. A significant fall in IL-4 expression after transplantation and subsequent return to its baseline level of expression was observed in both nonrejectors and rejectors. IL-10 showed persistently high expression in nonrejectors, but in rejectors the expression fell during acute rejection, with a subsequent rise after antirejection therapy. Th-1 cytokines: IL-2 and IFN-gamma decreased in expression in the first week posttransplant in the rejectors, at the time of acute rejection (IL-2 only) and immediately after completion of antirejection therapy. CONCLUSIONS: Sequential monitoring of peripheral T cell cytokine gene expression after renal transplantation detected changes in expression that correlated with episodes of acute rejection and response to antirejection therapy. This approach may be applicable in the clinical laboratory for monitoring posttransplant changes in T cell alloreactivity and immunosuppression.

Influence of patient and donor cytokine genotypes on renal allograft rejection: evidence from a single centre study.

Cytokines are key immune mediators and it has been suggested that cytokine gene polymorphisms affecting expression influence rejection or tolerance. This study sought to examine this hypothesis with the aim of identifying predictive genotype markers for rejection. The study group consisted of 120 consecutive first cadaveric recipient-donor pairs transplanted at a single centre, between 1994 and 1997. PCR utilising sequence-specific primers (SSP) methodology was optimised for genotyping recipient and donor DNA for the following polymorphisms: tumour necrosis factor (TNF) -alpha (-308, G/A), interleukin (IL)-10 (-1082, G/A), IL-4 (-590, C/T), transforming growth factor (TGF) -beta1 (+915, G/C). Recipient-donor pairs were divided into rejectors (n = 28) and non-rejectors (n = 92). Each group was further stratified according to number of rejection episodes and HLA-DR mismatching. Recipient-donor pairs both lacking the IL-4*T allele (recipient low producer/donor low producer) were significantly increased in the rejector group (P = 0.02). Also, the combination of recipient IL-10*A negative/donor IL-10*A positive (recipient high producer/donor low producer), was significantly decreased in multiple rejectors (P = 0.04). No significant associations were detected between TNF-alpha and TGF-beta1, and rejection. This study suggests that the combination of recipient-donor IL-4 and IL-10 genotypes may be important in renal transplantation outcome. The results appear to corroborate the protective role of both of these cytokines, possibly due to their ability to suppress inflammation. However, due to conflicting results from this and other studies, a multi-centre collaborative study may be required to determine whether cytokine genotypes are significant, independent predictors of renal allograft rejection.

Environmental management of quarries as waste disposal facilities.

Problems associated with the disposal of municipal solid waste have become a source of public concern worldwide as awareness of potential adverse environmental impacts and health threats from solid waste has increased. Communities are concerned about the generation and management of solid waste to the extent of refusing to allow new disposal facilities near their homes, often after witnessing the legacy of existing facilities. Under these conditions, the development of national policies for the management of solid waste becomes highly political, all while requiring appropriate technical solutions that ensure environmental protection and proper management plans that support an acceptable solution for the disposal of municipal solid waste. In some locations, the conversion of old quarries into well-engineered and controlled landfills appears as a promising solution to a continuously increasing problem, at least for many decades to come. This paper describes the environmental impacts associated with solid waste disposal in a converted quarry site and the mitigation measures that can be adopted to alleviate potential adverse impacts. Environmental management and monitoring plans are also discussed in the context of ensuring adequate environmental protection during and after the conversion process.

The efficacy of topical anaesthesia in flexible nasendoscopy: a double-blind randomised controlled trial.

The routine use of topical anaesthesia during flexible nasendoscopy has been questioned, and the degree to which topical vasoconstrictors can affect patient discomfort has yet to be elucidated. Patients' experiences with Lignocaineand phenylephrine, Lignocaine alone, xylometazoline and no preparation were compared. One hundred patients were recruited in this double-blind, randomised control trial and put into these four groups. Each patient completed a visual analogue scoring chart to determine the severity of unpleasantness and other undesirable effects (pain, bad taste, burning, choking, numbness and difficulty in swallowing). The results confirmed that vasoconstriction is a major contributing factor towards reducing overall unpleasantness (P = 0.022), topical anaesthesia can produce a bad taste (P = 0.022), and that none of the preparations have any effect on the pain during nasendoscopy. In conclusion, xylometazoline is recommended for nasendoscopy as it is effective and is significantly cheaper than the other preparations. Not using any preparations leads to the experience of severe symptoms.

The inferior vena caval conduit--a neglected technique in transplantation of the right cadaveric kidney?

A short right renal vein may reduce access or compromise optimal positioning during transplantation of the right cadaveric kidney. This difficulty could be overcome by using the inferior vena cava (IVC) as a venous conduit to lengthen the short right renal vein. This manoeuvre would also facilitate training by ensuring safe tension-free vascular anastomoses since the kidney can be lifted up a comfortable distance, thus improving exposure of the operative field. In a postal survey, only a third of UK renal transplant units utilised the IVC conduit. Despite 81.5% of units claiming that they harvest the IVC during organ retrieval, a 2-year retrospective audit revealed that only 4.3% of imported right kidneys had the IVC. The IVC remains a much under-utilised resource in the UK despite its potential benefit as a venous conduit in transplanting the right cadaveric kidney. We urge all retrieving surgeons to routinely harvest the IVC with right cadaveric kidneys during organ procurement.