Splenogonadal fusion in an 18-month-old

BACKGROUND

Splenogonadal fusion is rare abnormal congenital connection of splenic tissue and gonad. It commonly presents with either cryptorchidism or as a palpable mass. As a benign anomaly, orchiectomy is often unnecessary. Removal of the splenic component may be accomplished with preservation of the testicle.

METHODS

An 18-month-old boy presented with right cryptorchidism and left retractile testicle. Laparoscopic examination found a viable right testicle, and a successful orchiopexy was performed. The left testicle demonstrated splenogonadal fusion. Discontinuous accessory splenules were noted along the path of testicular descent. After confirmation from a radionucleotide liver-spleen scan the patient was brought back to the operating room for open excision of the adherent splenic tissue and orchiopexy of the testicle via an open inguinal approach.

CONCLUSION

Splenogonadal fusion is a rare condition, but may be suspected in children with cryptorchidism or palpable peri-testicular mass. As with the present patient, in most cases the splenic tissue may be successfully excised without injury to the testicle.

A snapshot of Chlamydia trachomatis genetic diversity using multilocus sequence type analysis in an Australian metropolitan setting

High-resolution screening methodologies which enable the differentiation of Chlamydia trachomatis at the strain level, directly from clinical samples, can provide the detailed information required for epidemiological questions such as the dynamics of treatment failure. In addition, they give a detailed snapshot of circulating C. trachomatis genetic variation, data which are currently lacking for the Australian population. In the context of two Australian clinical trials, we assessed the genetic diversity of C. trachomatis and compared these to strains circulating globally. We used high-resolution multilocus sequence typing (MLST) of five highly variable genetic regions of C. trachomatis to examine variation in Australia. Samples with established genovars were drawn from a pool of 880 C. trachomatis-positive samples from two clinical studies, whereby 76 sample pairs which remained C. trachomatis-positive for the same genovar after treatment underwent MLST analysis to distinguish between treatment failure and reinfection. MLST analysis revealed a total of 25 sequence types (STs), six new allele variants and seven new STs not described anywhere else in the world, when compared to those in the international C. trachomatis MLST database. Of the eight most common global STs, seven were found in Australia (four derived from men who have sex with men (MSM) and three from heterosexuals). Newly identified STs were predominantly found in samples from the MSM population. In conclusion, MLST provided a diverse C. trachomatis strain profile, with novel circulating STs, and could be used to identify local sexual networks to focus on interventions such as testing and partner notification to prevent reinfection.

Testicular sperm aspiration (TESA) for infertile couples with severe or complete asthenozoospermia

The aim of the study was to evaluate reproductive outcomes in a cohort of infertile couples with severe and complete asthenozoospermia undergoing TESA (testicular sperm aspiration) with ICSI. We conducted a retrospective study of 28 couples with complete or severe asthenozoospermia who underwent TESA between January 2010 and December 2015. We compared TESA-ICSI outcomes of these couples to ejaculate ICSI outcomes of 40 couples with severe asthenozoospermia treated during the same time period at our institution. Couples with female factor infertility and/or female aged ≥39 were excluded. Sperm retrieval rates and ICSI outcomes [(MII oocytes, fertilization rate, good embryo rate (transferred and frozen), couples with embryo transfer (per cycle started), clinical pregnancy (per embryo transfer)] were recorded. Patients were grouped based on whether they had ejaculated (Ej-group) or testicular (TESA-group) spermatozoa used. Testicular sperm patients were further classified based on whether they had complete asthenozoospermia (0% total motility) (Tc-group) or severe asthenozoospermia (≤1% progressive motility) (Ts-group). Mean (±SD) male and female ages were 36 ± 6 and 32 ± 4, respectively. Sperm recovery by testicular sperm aspiration (TESA) was successful in 100% (28/28) of the men. The overall clinical pregnancy rate (CPR) per cycle started was 34% (23/68) with a mean of 1.1 ± 0.4 embryos transferred per transfer. Fertilization rates were significantly lower in TESA-group compared to Ej-group (52% vs. 67%, respectively; p = 0.001), while male age was significantly higher in TESA-group compared to Ej-group (34 ± 6 vs. 37 ± 6, respectively; p = 0.03). Moreover, female age was significantly higher in Tc-group compared to Ts-group (30 ± 4 vs. 33 ± 3, respectively; p = 0.0285). However, there were no significant difference in clinical pregnancy rate per embryo transfer in the Tc-group, Ts-group, and Ej-group (50% vs. 45% vs. 57%, respectively; p = 0.8219). The data suggest that testicular sperm-ICSI is no better than ejaculated sperm-ICSI in couples with severe or complete asthenozoospermia. Randomized, controlled trials comparing ejaculated vs. testicular spermatozoa are needed to assess the true benefit of TESA-ICSI in these couples.

Anyplex II HPV28 detection and Anyplex II HPV HR detection assays are highly concordant with other commercial assays for detection of high-risk HPV genotypes in women with high grade cervical abnormalities

PURPOSE

to evaluate the performance of Anyplex II HPV28 and HPV HR Detection assays against the EuroArray HPV, Cobas 4800 HPV (Cobas), HPV Amplicor (Amp), Linear Array HPV (LA) and Hybrid Capture 2 (HC2) in detection of high-risk HPV (HR-HPV) from liquid-based cervical cytology samples.

METHODS

cervical specimens from 404 women undergoing management of high-grade cytological abnormality were evaluated by Anyplex II HPV28 and HPV HR Detection assays for detection of HR-HPV genotypes and prediction of histologically-confirmed cervical intraepithelial neoplasia grade 2 or higher (≥CIN2). The results were compared to EuroArray, HC2, Cobas, Amp, and LA.

RESULTS

specimens were evaluated from 404 women with an average age of 30 years, including 336 with a histological diagnosis of ≥ CIN2 and 68 with ≤ CIN1. Concordance of HR-HPV detection between Anyplex II HPV28 and other genotyping assays was 94.79 % (κ = 0.84; EuroArray) and 97.27 % (κ = 0.91; LA); and between Anyplex II HPV HR and other HR-HPV detection assays was 86.35 % (κ = 0.62; HC2), 96.03 % (κ = 0.87; Cobas) and 96.77 % (κ = 0.89; Amp). Using HR-HPV detection for prediction of ≥ CIN2 by Anyplex II HPV28 and HPV HR, sensitivity (90.18, 95 % CI 86.48-93.14; 90.77, 95 % CI 87.16-93.65) and specificity (both 67.16, 95 % CI 54.60-78.15) were not significantly different to the other HPV assays tested, with one exception. Both Anyplex assays had significantly higher sensitivity than HC2 (p < 0.0001), with a specificity of 96 % (p > 0.05) of HC2 in this high-risk population.

CONCLUSIONS

both Anyplex II HPV detection assays were concordant with other commercial assays for HR-HPV detection, with comparable sensitivity and specificity for ≥ CIN2 detection.

Comparison of Kinemyography and Electromyography during Spontaneous Recovery from Non-Depolarising Neuromuscular Blockade

This study compared two commercially available quantitative neuromuscular function monitoring techniques, kinemyography (KMG) and electromyography (EMG), to assess whether KMG could be used interchangeably with EMG to exclude residual neuromuscular blockade (RNMB). Train-of-four (TOF) ratios were recorded every 20 seconds using KMG at the adductor pollicis and EMG at the first dorsal interosseous of the same hand during spontaneous recovery from shallow neuromuscular blockade. TOF ratios were compared using Bland–Altman analysis for repeated measurements. The precision of each device was assessed by the repeatability coefficient. Agreement between devices was assessed by the bias and limits of agreement. Clinically acceptable agreement was defined as a bias <0.025 within limits of agreement ±0.05. We recorded 629 sets of TOF ratios from 23 patients. The repeatability coefficient for KMG was 0.05 (95% confidence interval [CI] 0.05 to 0.06) and for EMG 0.10 (95% CI 0.10 to 0.11). Overall, the bias of KMG TOF ratios against EMG TOF ratios was 0.11 (95% CI 0.10 to 0.12), with limits of agreement −0.11 to 0.32. In the 0.80 to 0.99 TOF range, the bias was 0.08 (95% CI 0.06 to 0.09) and the limits of agreement were-0.12 to 0.27. Overall, TOF ratios measured by KMG were on average 0.11 higher than EMG. In the 0.80 to 0.99 TOF range, KMG TOF ratios were 0.08 higher. EMG and KMG are not interchangeable because the bias is large and the limits of agreement are wide. Thus a maximum TOF ratio of 1.0 on KMG may not exclude RNMB.

EUROarray human papillomavirus (HPV) assay is highly concordant with other commercial assays for detection of high-risk HPV genotypes in women with high grade cervical abnormalities

The purpose of this study was to evaluate the performance of the EUROIMMUN EUROArray HPV genotyping assay against the Roche Cobas 4800, Roche HPV Amplicor, Roche Linear Array and Qiagen Hybrid Capture 2 assays in the detection of high-risk HPV (HR-HPV) from liquid based cervical cytology samples collected from women undergoing follow-up for abnormal cervical cytology results. Cervical specimens from 404 women undergoing management of high-grade cytological abnormality were evaluated by EUROarray HPV for detection of HR-HPV genotypes and prediction of histologically-confirmed cervical intraepithelial neoplasia grade 2 or higher (≥CIN2). The results were compared to Hybrid Capture 2, Cobas 4800 HPV, Amplicor and Linear Array HPV. Positivity for 14 HR-HPV types was 80.0 % for EUROarray (95 % CI; 75.7-83.8 %). Agreement (κ, 95 % CI) between the EUROarray and other HPV tests for detection of HR-HPV was good to very good [Hybrid Capture κ = 0.62 (0.54-0.71); Cobas κ = 0.81 (0.74-0.88); Amplicor κ = 0.68 (0.60-0.77); Linear Array κ = 0.77 (0.70-0.85)]. For detection of HR-HPV, agreement with EUROarray was 87.90 % (Hybrid Capture), 93.58 % (Cobas), 92.84 % (Amplicor) and 92.59 % (Linear Array). Detection of HR-HPV was not significantly different between EUROarray and any other test (p < 0.001). EUROarray was concordant with other assays evaluated for detection of high-risk HPV and showed sensitivity and specificity for detection of ≥ CIN2 of 86 % and 71 %, respectively.

High-Risk Residual Gastric Content in Fasted Patients Undergoing Gastrointestinal Endoscopy: A Prospective Cohort Study of Prevalence and Predictors

In this prospective cohort study, we examined the residual gastric contents of 255 fasted patients undergoing gastrointestinal endoscopy. The volume and pH of residual gastric contents collected by suction under direct visualisation during gastroscopy were accurately quantified. All patients completed the minimum two-hour fast for clear fluids and 97.2% of patients completed the minimum six-hour fast for solids. High-risk residual gastric content, defined as volume >25 ml and pH <2.5, was present in 12.2% (95% CI 8.7% to 16.7%) of patients. We used multiple logistic regression analysis to identify demographic and clinical factors associated with high-risk residual gastric content. The odds of having high-risk residual gastric content were reduced with increase in age (adjusted odds ratio 0.77, 95% CI 0.61 to 0.96, P=0.0230), and use of a proton pump inhibitor or histamine type 2 receptor antagonist (adjusted odds ratio 0.24, 95% CI 0.10 to 0.55, P=0.0013), and were increased in male patients (adjusted odds ratio 2.36, 95% CI 1.06 to 5.28, P=0.0348). Notably, residual gastric content was classified as high-risk in 20.4% of patients who did not take a proton pump inhibitor or histamine type 2 receptor antagonist versus only 5.6% of those who did. Our findings suggest that, despite currently recommended fasting, males presenting for endoscopy are more likely to have high-risk gastric content than females, and that the incidence appears to be reduced with increasing age, and by the use of proton pump inhibitors or histamine type 2 receptor antagonists, we were unable to confirm or exclude an effect of body mass index, peptic pathology, diabetes or other clinical or demographic factors in our study population.

Fasted Exercise and Increased Dietary Protein Reduces Body Fat and Improves Strength in Jockeys

The present study assessed the effects of a diet and exercise intervention in jockeys on body composition, metabolism, bone and mental health. 10 jockeys followed an individually prescribed 6-wk diet (Carbohydrate=2.5-3.5 g/kg, Protein=2.5 g/kg, Fat=1.0 g/kg). Body mass (59.2±4.6 vs. 57.6±4.5 kg), fat mass (7.5±3.5 vs. 6.2±2.6) and body fat (13.1±5.9 vs. 11.5±4.9%) all decreased (P<0.05) from pre to post-intervention whilst lean mass (47.1±5.3 vs. 47.0±5.5 kg) was maintained (P=0.80). RMR (1703±329 vs. 1975±313 kcal.d(-1)), VO2max (3.8±0.8 vs. 4.1±0.7 L/min(- 1)) chest strength (65±11 vs. 71±13 kg), leg strength (160±28 vs. 175±29 kg) and jumping height (40±6 vs. 48±5 cm) significantly increased (P<0.05). Bone health (DXA) did not change (P>0.05) at hip (-1.04±1.29 vs. - 0.76±0.71) or lumbar sites (-1.32±0.76 vs. - 1.31±0.77). Psychometrics (GHQ-12 and EAT-26) remained unchanged (10.3±4.3 vs. 8.9±3.8 and 14.8±9.6 vs. 11.0±5.6, P>0.05, respectively). This approach represents a marked difference from jockeys' habitual weight-making that largely involves dehydration and food deprivation.

Presence and absence of non-native fish species in the Wet Tropics region, Australia

Distributional records of non-native fish species were identified in the Wet Tropics region, Far North Queensland, Australia, through a compilation of published records and expert knowledge. A total of 1106 records were identified comprising 346 presence and four uncertain records for at least 13 species, and 756 absence records. All current presence records consist of six species from the families Cichlidae and Poeciliidae with established self-sustaining populations in the region, probably affecting the highly diverse native fish fauna.

Probing the repulsive core of the nucleon-nucleon interaction via the (4)He(e,e'pN) triple-coincidence reaction

We studied simultaneously the (4)He(e,e'p), (4)He(e,e'pp), and (4)He(e,e'pn) reactions at Q(2)=2(GeV/c)(2) and x(B)>1, for an (e,e'p) missing-momentum range of 400 to 830  MeV/c. The knocked-out proton was detected in coincidence with a proton or neutron recoiling almost back to back to the missing momentum, leaving the residual A=2 system at low excitation energy. These data were used to identify two-nucleon short-range correlated pairs and to deduce their isospin structure as a function of missing momentum, in a region where the nucleon-nucleon (NN) force is expected to change from predominantly tensor to repulsive. The abundance of neutron-proton pairs is reduced as the nucleon momentum increases beyond ∼500  MeV/c. The extracted fraction of proton-proton pairs is small and almost independent of the missing momentum. Our data are compared with calculations of two-nucleon momentum distributions in (4)He and discussed in the context of probing the elusive repulsive component of the NN force.

A reverse shoulder arthroplasty with increased offset for the treatment of cuff-deficient shoulders with glenohumeral arthritis

Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley–Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p <  0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42°(sd 30) and 9° (sd 15) respectively pre-operatively to 78° (sd 39) and 24° (sd 17) post-operatively (p < 0.001). A total of 20 patients required further surgery for complications; 13 required revision of components. No patient developed scapular notching.

The Bayley–Walker prosthesis provides reliable pain relief and reasonable functional improvement for patients with symptomatic cuff-deficient shoulders. Compared with other designs of RSA, it offers a modest improvement in forward elevation, but restores external rotation to some extent and prevents scapular notching. A longer follow-up is required to assess the survival of the prosthesis and the clinical performance over time.

Cite this article: Bone Joint J 2014;96-B:936–42.

Universal coverage of IVF pays off

STUDY QUESTION

What was the clinical and economic impact of universal coverage of IVF in Quebec, Canada, during the first calendar year of implementation of the public IVF programme?

SUMMARY ANSWER

Universal coverage of IVF increased access to IVF treatment, decreased the multiple pregnancy rate and decreased the cost per live birth, despite increased costs per cycle.

WHAT IS KNOWN ALREADY

Public funding of IVF assures equality of access to IVF and decreases multiple pregnancies resulting from this treatment. Public IVF programmes usually mandate a predominant SET policy, the most effective approach for reducing the incidence of multiple pregnancies.

STUDY DESIGN, SIZE, DURATION

This prospective comparative cohort study involved 7364 IVF cycles performed in Quebec during 2009 and 2011 and included an economic analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

IVF cycles performed in the five centres offering IVF treatment in Quebec during 2009, before implementation of the public IVF programme, were compared with cycles performed at the same centres during 2011, the first full calendar year following implementation of the programme. Data were obtained from the Canadian Assisted Reproductive Technologies Register (CARTR). Comparisons were made between the two periods in terms of utilization, pregnancy rates, multiple pregnancy rates and costs.

MAIN RESULTS AND THE ROLE OF CHANCE

The number of IVF cycles performed in Quebec increased by 192% after the new policy was implemented. Elective single-embryo transfer was performed in 1.6% of the cycles during Period I (2009), and increased to 31.6% during Period II (2011) (P < 0.001). Although the clinical pregnancy rate per embryo transfer was lower in 2011 than in 2009 (24.9 versus 39.9%, P < 0.001), the multiple pregnancy rate was greatly reduced (6.4 versus 29.4%, P < 0.001). The public IVF programme increased government costs per IVF treatment cycle from CAD$3730 to CAD$4759. Despite increased costs per cycle, the efficiency defined by the cost per live birth, which factored in downstream health costs up to 1 year post delivery, decreased from CAD$49 517 to CAD$43 362 per baby conceived by either fresh and frozen cycles.

LIMITATIONS, REASONS FOR CAUTION

The costs described in the economic model are likely an underestimate as they do not factor in many of the long-term costs that can occur after 1 year of age. The information collected in the Canadian ART register precludes the calculation of cumulative pregnancy rates.

WIDER IMPLICATIONS OF THE FINDINGS

Our study confirms that the implementation of a public IVF programme favouring eSET not only sharply decreases the incidence of multiple pregnancy, but also reduces the cost per live birth.

STUDY FUNDING/COMPETING INTEREST(S)

M.P.V. holds a fellowship award from the Canadian Institutes of Health Research (CIHR). The economic analysis performed by M.P.C. was supported by an unrestricted grant from Ferring Pharmaceutical.

A new ex vivo animal simulation model for skills training in laparoscopic colorectal surgery

The opportunity for using simulation in medical training has expanded in recent years. 1–3 Laparoscopic surgery is an area that is ideally suited to the use of simulators for the acquisition of clinical skills. 4 Simulation allows educators to have control over pre-selected scenarios, without distressing patients or encountering complications. 5

Highly prevalent colorectal cancer-infiltrating LAP⁺ Foxp3⁻ T cells exhibit more potent immunosuppressive activity than Foxp3⁺ regulatory T cells

Although elevated CD4⁺Foxp3⁺ regulatory T cell (Treg) frequencies within tumors are well documented, the functional and phenotypic characteristics of CD4⁺Foxp3⁺ and CD4⁺Foxp3⁻ T cell subsets from matched blood, healthy colon, and colorectal cancer require in-depth investigation. Flow cytometry revealed that the majority of intratumoral CD4⁺Foxp3⁺ T cells (Tregs) were Helios⁺ and expressed higher levels of cytotoxic T-lymphocyte antigen 4 (CTLA-4) and CD39 than Tregs from colon and blood. Moreover, ∼30% of intratumoral CD4⁺Foxp3⁻ T cells expressed markers associated with regulatory functions, including latency-associated peptide (LAP), lymphocyte activation gene-3 (LAG-3), and CD25. This unique population of cells produced interleukin-10 (IL-10) and transforming growth factor-β (TGF-β), and was ∼50-fold more suppressive than Foxp3⁺ Tregs. Thus, intratumoral Tregs are diverse, posing multiple obstacles to immunotherapeutic intervention in colorectal malignancies.

A case-control study of risk factors for wound infection in a colorectal unit

INTRODUCTION

Postoperative wound infections have been responsible for increasing morbidity and are associated with an increased use of hospital resources. Previous studies have identified several risk factors. However, most studies are outdated, and few relate to the era of enhanced recovery and laparoscopic surgery. This study investigated the association between patient and operative factors and the development of postoperative wound infections in colorectal surgery.

METHODS

Patients with documented wound infections or dehiscences were identified from a database of elective and emergency colorectal surgery. Patients with wound infections were matched by operation type to a control group of colorectal patients. Differences in patient and operative factors between case and control group were analysed using conditional logistic regression.

RESULTS

A total of 56 patients with wound infection were identified from 647 operations (8.6%). Fifty-seven per cent were emergency operations and eighty-eight per cent were performed as open surgery or as laparoscopic surgery converted to open. Forty per cent of patients had high ASA (American Society of Anesthesiologists) grades (3 or 4). Multivariate logistical regression showed that obese patients and those having open surgery had the highest risk of infections. The median postoperative hospital stay for patients with wound infections was twice as long as for those patients without wound infections.

CONCLUSIONS

Open surgery and obesity are independent risk factor for wound infections. An increase in laparoscopically performed operations and new strategies for managing wounds in obese patients may help to reduce the rate of wound infection.

Patient satisfaction with the use of an enhanced recovery programme for primary arthroplasty

INTRODUCTION

Enhanced recovery programmes (ErPs) are increasingly being used for arthroplasty. One of the core aims of an ErP is to improve the quality of patient experience. However, there is currently no published evaluation of patient satisfaction in relation to this new programme of care within orthopaedic surgery. The aim of this study was to compare the ErP against the standard care programme (SCP) at one centre.

METHODS

A satisfaction survey addressing patient opinions on the key objectives of the ErP was conducted by telephone, using a set script. Of the 226 patients contacted, 143 (63.3%) responded (69 from the ErP and 74 from the SCP). Of the respondents, 71 received a total hip arthroplasty and 72 a total knee arthroplasty. Patients were contacted at a mean time from operation to survey of 27.2 weeks. They were asked to rate satisfaction on a five-point scale and complete the EQ-5D™ health questionnaire (EuroQol, rotterdam, Netherlands) to measure healthcare outcomes.

RESULTS

The mean patient satisfaction score of 4.07 for speed of recovery in the ErP group was significantly higher than the SCP group's score of 3.68 (p=0.037). Adjusting for the preoperative health score, the postoperative health score was higher for ErP patients at 74.1 compared with 64.7 for SCP patients (p=0.0029). Furthermore, the percentage of patients who had a better than expected recovery was significantly greater in the ErP group at 85.5% compared with 58.1% (p=0.0004) in the SCP group.

CONCLUSIONS

We believe that the previously established reduction in length of hospital stay delivered by ErPs is not achieved at the expense of the patient's experience.