Subinguinal microsurgical varicocelectomy for male factor subfertility: ten-year experience

OBJECTIVE

To investigate the impact of subinguinal microsurgical varicocelectomy on semen parameters and pregnancy outcomes in couples with male factor subfertility.

DESIGN

Case series.

SETTING

Male Infertility Clinic in an academic institution in Hong Kong.

PATIENTS

The clinical records of 42 consecutive subfertile male patients who had subinguinal microsurgical varicocelectomy (from January 2000 to December 2009) were retrospectively reviewed. All the patients had a known history of subfertility and abnormalities in one or more semen parameters. Female subfertility factors were not addressed. Only grade 2 or higher clinically palpable varicoceles were operated on.

MAIN OUTCOME MEASURES

Preoperative and postoperative semen analyses based on the World Health Organization criteria; the outcome measures included changes in semen parameters and whether a pregnancy ensued.

RESULTS

The mean age of patients and their spouses were 38 and 33 years, respectively. The mean duration of infertility was 4 years; 37 patients had primary infertility and five had secondary infertility. The mean (± standard deviation) sperm concentration improved from 12 ± 19 million/mL to 23 ± 29 million/mL following varicocelectomy (P<0.001), the mean sperm motility improved from 26% ± 16% to 32% ± 18% (P<0.001), and the mean normal morphology increased from 5% ± 7% to 6% ± 6% (P<0.001). Postoperatively, 23 (55%) of the patients achieved pregnancy, 11 (26%) being spontaneous, 1 (2%) by intrauterine insemination, and 11 (26%) by in-vitro fertilisation. Among 20 patients with severe preoperative oligospermia (<5 million/mL), statistically significant improvements occurred in postoperative mean sperm concentration, motility and morphology (all P<0.001), and five (25%) of them achieved a spontaneous pregnancy. There was one intra-operative injury to the testicular artery with immediate repair and no testicular atrophy. Five (12%) of the patients had recurrences. No preoperative factors appeared predictive of a pregnancy ensuing.

CONCLUSIONS

In couples with male infertility due to varicoceles, subinguinal microsurgical varicocelectomy was shown to improve sperm concentrations, motility and morphology, and the likelihood of a pregnancy. Spontaneous pregnancy was achieved in 25% of the couples in which the man had severe oligospermia.

Thoracoscopic resection of congenital cystic lung lesions is associated with better post-operative outcomes

INTRODUCTION

The incidence of congenital cystic lung lesions has been increasing in recent years due to better antenatal detection. With the introduction and maturation of thoracoscopy, the operative management for these lesions has seen advancement in the last decade. In this study, we aimed to compare the post-operative outcomes of patients who had thoracoscopic resection with those who underwent open resection.

METHODS

A retrospective review of all patients who underwent surgery for congenital cystic lung lesions between January 1996 and June 2012 in a tertiary referral center was conducted. Patients' demographics, operative procedures and post-operative outcomes were analyzed.

RESULTS

Sixty-seven patients were identified over the past 15 years. Thirty-nine patients had thoracoscopic resections and 28 had open resections. Thirteen patients in the thoracoscopic group required conversion. Both groups had similar demographics in terms of age, body weight and laterality of lesions. The mean operative time and blood loss in the two groups were comparable. Patients in the thoracoscopic group had significantly shorter duration of chest tube drainage (4.3 vs. 6.9 days, p = 0.004), shorter intensive care unit stay (2.5 vs. 5.9 days, p = 0.003) and shorter hospital stay (6.9 vs. 12.0 days, p < 0.001). Post-operative complication rate was similar between the two groups. Patients with body weight less than 5 kg showed a significantly higher conversion to open surgery as compared to those with body weight more than 5 kg (62.5 vs. 25.8 %, p = 0.049).

CONCLUSION

Successful thoracoscopic resection for congenital cystic lung lesions results in better post-operative outcomes. However, this technique remains technically challenging in patients with body weight less than 5 kg.

Comparison of morphology and mechanical properties of PLGA bioscaffolds

In this study, bioscaffolds using poly(DL-lactide-co-glycolide) acid (PLGA) were fabricated and studied. The gas foaming/salt leaching technique in a batch foaming setup was employed, and the effects of material composition of PLGA on the morphology and mechanical properties using this process were investigated. Two material compositions of PLGA 50/50 and 85/15 were used, and characterization of scaffolds fabricated with these materials showed that a lower relative density can be achieved with an increasing poly(DL-lactide) acid (PDLLA) content; however, higher open-cell porosity was obtained with lower PDLLA content. Furthermore, the effect of PLGA composition on modulus of the scaffolds was minor.

Novel mutations and mutation pattern of epidermal growth factor receptor (EGFR) gene in Chinese patients with primary lung adenocarcinoma

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Background: EGFR mutation is a diverse and complex phenomenon. Shigematsu et al (JNCI 97:339,2005), analyzing NSCLC samples from multiple ethnicities and histologic cell types, reported 11 types of in-frame deletions in exon 19 (46%), 9 missense mutation in exons 18, 20, 21 (45%) and 8 in-frame insertion in exons 20 (9%). 3/130 tumors (2.3%) had multiple mutations. Here we report the incidence, mutation pattern and novel finding of EGFR mutation in a homogenous ethnic group with adenocarcinoma of lung. Methods: Between 2004 and 2006 we isolated genomic DNA from 194 (archival 53, prospective 141) primary lung adenocarinoma for PCR amplification of EGFR exon 18–21. We isolated tumor cell by micro-dissection. PCR products were purified and sequenced using the BigDye Terminator Cycly Sequencing Ready Reaction Kit (Applied Biosystem) and run on Applied Biosystem 3100 Genetic Analyzer. Results: We found 79 EGFR mutations in 73 tumors (37.6%). Six (8.2%) had double mutations. IN-FRAME DEL: 10 types in exon 19 (39 cases, 49.4%); 1 type in exon 18 (1 case). MISSENSE MUTATION: 2 types in exon 18 (2 cases); 4 types in exon 20 (5 cases) and 2 types in exon 21 (29 cases, 36.7%) IN-FRAME INSERTION: 3 types in exon 20 (3 cases). Typical exon 19 E746-A750del and exon 21 L858R mutations accounted for 31% and 34%, respectively. We found 11 types of mutations not previously described.( Table ) Four pts with novel mutations received EGFR TKI and 3 attained PR (all with exon 19 del). Two pts have T790M mutations without prior exposure to EGFR TKI and both with double mutations. Conclusion: Mutation pattern of EGFR gene in Chinese pts with adenocarcinoma is similar to the Shigematsu report. The overall incidence of EGFR mutation and multiple mutations are higher but in-frame insertion in exon 20 is less common. Majority of the novel mutations are rare mutations involving exon 18 and 20.

No significant financial relationships to disclose.

[Table: see text]

Use of canalicular membrane vesicles (CMVs) from rats, dogs, monkeys and humans to assess drug transport across the canalicular membrane

INTRODUCTION

A novel application of a Ultrafree filter cartridge/centrifugation method was evaluated to determine uptake in canalicular membrane vesicles (CMVs) from SD rats, beagle dogs, cynomolgus monkeys (common safety species in the pharmaceutical industry) and humans to assess biliary transport.

METHODS

CMVs prepared from fresh livers of rats, dogs, monkeys and humans (four donors) were characterized for enrichment, basolateral and Golgi contamination and orientation. The presence of MRP2 and p-glycoprotein (P-gp) were confirmed by Western blots. Uptake of [3H]-leukotriene C4 (LTC4) and [3H]-estradiol-17beta-d-glucuronide (E2-Gluc) was determined at a low substrate concentration and/or by kinetic measurements (K(m) and V(max)). Correlation of in vitro data with in vivo findings was achieved by determining the biliary clearance of E2-Gluc in rats after a single i.v. dose and with literature in vivo data for LTC4.

RESULTS

CMVs were highly enriched and minimally contaminated based on marker enzyme activities. Uptake clearance among different species varied by approximately ten-fold (rat > dog = human > monkey) for LTC4 and less than two-fold for E2-Gluc. The lower uptake of LTC4 by human than rat CMVs may be attributed to a higher Km value for human than rat CMVs. Uptake of LTC4 or E2-Gluc by human CMVs showed little inter-subject variability (2-5-fold). Differences in in vitro uptake clearance (10-fold) between LTC4 and E2-Gluc in rat CMVs seemed to correlate with differences in their biliary clearance (4-fold) in rats, consistent with LTC4 and E2-Gluc being a high and a low clearance substrate, respectively.

DISCUSSION

A novel application of a Ultrafree filter cartridge/centrifugation method was developed to determine uptake in CMVs from different preclinical animal safety species and humans, and may represent a useful approach to study the mechanism of biliary excretion during drug discovery and development.

The ability of an oligomeric human immunodeficiency virus type 1 (HIV-1) envelope antigen to elicit neutralizing antibodies against primary HIV-1 isolates is improved following partial deletion of the second hypervariable region

Partial deletion of the second hypervariable region from the envelope of the primary-like SF162 virus increases the exposure of certain neutralization epitopes and renders the virus, SF162DeltaV2, highly susceptible to neutralization by clade B and non-clade B human immunodeficiency virus (HIV-positive) sera (L. Stamatatos and C. Cheng-Mayer, J. Virol. 78:7840-7845, 1998). This observation led us to propose that the modified, SF162DeltaV2-derived envelope may elicit higher titers of cross-reactive neutralizing antibodies than the unmodified SF162-derived envelope. To test this hypothesis, we immunized rabbits and rhesus macaques with the gp140 form of these two envelopes. In rabbits, both immunogens elicited similar titers of binding antibodies but the modified immunogen was more effective in eliciting neutralizing antibodies, not only against the SF162DeltaV2 and SF162 viruses but also against several heterologous primary HIV type 1 (HIV-1) isolates. In rhesus macaques both immunogens elicited potent binding antibodies, but again the modified immunogen was more effective in eliciting the generation of neutralizing antibodies against the SF162DeltaV2 and SF162 viruses. Antibodies capable of neutralizing several, but not all, heterologous primary HIV-1 isolates tested were elicited only in macaques immunized with the modified immunogen. The efficiency of neutralization of these heterologous isolates was lower than that recorded against the SF162 isolate. Our results strongly suggest that although soluble oligomeric envelope subunit vaccines may elicit neutralizing antibody responses against heterologous primary HIV-1 isolates, these responses will not be broad and potent unless specific modifications are introduced to increase the exposure of conserved neutralization epitopes.

A randomized controlled trial of azithromycin and amoxycillin/clavulanate in the management of subacute childhood rhinosinusitis

OBJECTIVE

Subacute childhood rhinosinusitis is a disorder commonly seen in children with allergic rhinitis. Antibiotics have been recommended as a major component of the treatment regime. The objective of the present study was to compare the effectiveness of a 3-day course of azithromycin and a 2-week course of amoxycillin/clavulanate in the treatment of subacute childhood rhinosinusitis.

METHODOLOGY

A randomized single-blinded control study of subacute rhinosinusitis was conducted, comparing a 3-day course of azithromycin and a 2-week course of amoxycillin/clavulanate. Inclusion criteria were children aged between 5 and 16 years, duration of nasal blockage or discharge between 30 and 120 days, and abnormal sinus radiographs. All enrolled children were prescribed budesonide nasal spray (Rhinocort Aqua Nasal Spray, Astra Pharmaceuticals, Sodertalje, Sweden) as adjuvant treatment.

RESULTS

Forty-two children were recruited into the study and one defaulted on follow-up. Failure occurred in 6 of 20 for the azithromycin group and 5 of 21 for the amoxycillin/clavulanate group. The odds ratio was 1.46 (95%CI 0.37-5. 80, P = 0.73). No relapse occurred in azithromycin group and 5 of 21 in amoxycillin/clavulanate group. The odds ratio was 0.16 (95%CI 0. 017-1.51, P = 0.18). Both antibiotics were well tolerated, however, two children, one from each group, complained of mild transient epigastric discomfort.

CONCLUSIONS

This small study did not provide evidence of a difference between 14 days of amoxycillin/clavulanate and 3 days of azithromycin. Larger studies will be needed to determine which, if any, antibiotic regimen should be used in treating subacute childhood rhinosinusitis.

Disseminated toxoplasmosis following T cell-depleted related and unrelated bone marrow transplantation

More than 95% of reported cases of disseminated toxoplasmosis following BMT have occurred following an unmodified transplant. Most have been fatal, diagnosed at autopsy and without antemortem institution of specific therapy. From 1989 to 1999, we identified 10 cases of disseminated toxoplasmosis, in 463 consecutive recipients of a T cell-depleted (TCD) BMT. Transplants were from an unrelated donor (n = 5), an HLA-matched sibling (n = 4) or an HLA-mismatched father (n = 1). In 40%, both the donor and recipient had positive IgG titers against T. gondii pre-transplant; in 30%, only the recipient was sero-positive. Three recipients of an unrelated TCD BMT developed toxoplasmosis despite both donor and host testing negative pretransplant. All 10 patients presented with high grade fever. CNS involvement ultimately occurred in seven patients, with refractory respiratory failure and hypotension developing in nine. Eight of 10 cases were found only at autopsy, involving the lungs (n = 7), heart (n = 5), GI tract (n = 5), brain (n = 8), liver and/or spleen (n = 5). The only survivor, treated on the day of presentation with fever and headache, was diagnosed by detection of T. gondii DNA by polymerase chain reaction (PCR) performed on the blood and spinal fluid. This study demonstrates the similar incidence of toxoplasmosis following TCD BMT and that reported post T cell-replete BMT, and underscores the need for rapid diagnostic tests in an effort to improve outcome.

Increased DNA vaccine delivery and immunogenicity by electroporation in vivo

DNA vaccines have been demonstrated to be potent in small animals but are less effective in primates. One limiting factor may be inefficient uptake of DNA by cells in situ. In this study, we evaluated whether cellular uptake of DNA was a significant barrier to efficient transfection in vivo and subsequent induction of immune responses. For this purpose, we used the technique of electroporation to facilitate DNA delivery in vivo. This technology was shown to substantially increase delivery of DNA to cells, resulting in increased expression and elevated immune responses. The potency of a weakly immunogenic hepatitis B surface Ag DNA vaccine was increased in mice, as seen by a more rapid onset and higher magnitude of anti-hepatitis B Abs. In addition, the immunogenicity of a potent HIV gag DNA vaccine was increased in mice, as seen by higher Ab titers, a substantial reduction in the dose of DNA required to induce an Ab response, and an increase in CD8+ T cell responses. Finally, Ab responses were enhanced by electroporation against both components of a combination HIV gag and env DNA vaccine in guinea pigs and rabbits. Therefore, cellular uptake of DNA is a significant barrier to transfection in vivo, and electroporation appears able to overcome this barrier.

Tear break-up time: clinical procedures and their effects

Three successive (representative) values of fluorescein-instillation TBUT (tear break-up time) were obtained from a group of young Hong Kong (HK)-Chinese. The median TBUT1, TBUT2 and TBUT3 were 3.2, 3.8 and 4.5 sec, respectively. Wilcoxon signed-rank tests showed that TBUT1 was significantly different from TBUT2 and TBUT3, but there was no difference between TBUT2 and TBUT3. It is therefore important, when measuring the TBUT, to specify which TBUT value was taken as the representative TBUT. Fluorescein was reapplied about six min after the first application, and the TBUT value re-determined (TBUTR). The median TBUTR was not significantly different from TBUT1. The subjects were requested to return another day and TBUT values (TBUTW) were determined, with the subjects opening their eyes as wide as possible, such that the palpebral aperture size was increased. The mean +/- SD normal palpebral aperture size was 10.0 +/- 1.3 mm, and the mean +/- SD palpebral aperture size with the eyes wide open was 11.4 +/- 1.5 mm. The median TBUTW (3.6 sec) was significantly longer than the median TBUT1 (3.0 sec), but this difference appeared to be due to the extremely long TBUTW of one subject; no significant difference was found between the median TBUTW (3.4 sec) and TBUT1 (2.8 sec) when data from this subject were excluded. There was no significant correlation between changes in palpebral size and TBUT value.

Regulation of interleukin-10 gene expression: possible mechanisms accounting for its upregulation and for maturational differences in its expression by blood mononuclear cells

Interleukin-10 (IL-10) downmodulates phagocytic immune responses and accentuates humoral responses. Human neonates exhibit broad immune deficits that parallel actions of IL-10. We postulated that IL-10 production would be diminished in neonatal blood cells. We found that IL-10 production by lipopolysaccharide-stimulated peripheral blood mononuclear cells (PBMNCs) in vitro was greater by adult cells than by term cells and preterm cells. Additional studies were undertaken to identify mechanisms responsible for the developmental differences in IL-10 gene expression. IL-10 transcription was present in freshly isolated adult and neonatal cells in the absence of detectable levels of transcript. Transcription rates were not different between adult and neonatal cells. IL-10 transcripts were approximately 40% more abundant in adult cells than in term cells and were consistent with differences in secreted protein; however, no differences were noted in mRNA stability. IL-10 half-life was 60 minutes for both adult and term PBMNCs. We conclude that up-regulation of IL-10 gene expression in PBMNCs is modulated at the post-transcriptional level, that IL-10 protein production and mRNA content are greater in activated cells from adults compared with those from neonates, and that maturational differences in IL-10 expression are not due to differences in transcription rate or mRNA stability. Maturational differences in IL-10 expression might be due to differences in subpopulations of cytokine-producing cells or differences in nucleo-cytoplasmic transport.

Tumor control probability of nasopharyngeal carcinoma: a comparison of different mathematical models

PURPOSE

Radiation dose and tumor volume are factors known to affect the local control of a given type of tumor. Local tumor control is a major factor to consider when a treatment plan is evaluated. This article reports the correlation between tumor control probability, dose, and volume in a retrospective study of 142 patients with nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

The tumor volume was outlined and calculated from a computed tomographic scan. Patients were categorized according to tumor volume and radiation dose received in treatment. Local control rate was calculated for each category by the Kaplan-Meier method. Mathematical models were fitted to correlate the local control rate, dose, and volume. Both empirical and mechanistic approaches were attempted; the former included logistic models with two and three parameters, and the latter, the formulation from Brenner and Bentzen with a radiobiological basis.

RESULTS

Brenner's model estimated alpha at 0.041 Gy(-1) with 95% confidence limits (-0.032, 0.113) Gy(-1). The volume dependent constant h was estimated at 0.160 cm(-3) with 95% confidence limits (-0.729, 1.048) cm(-3). The Pearson correlation coefficient was 0.64. The magnitude and sign of the fitted parameters were reasonable and consistent with reported clinical experience. The other models were fitted with slightly better goodness of fit (r = 0.65 - 0.68), but with less interpretable parameters.

CONCLUSION

Brenner's model is considered appropriate for a description of the dose and volume effect on the local control of the NPC. It could be used in combination with normal tissue complication probability for treatment plan evaluation to optimize treatment results.

Reverse iontophoresis: noninvasive glucose monitoring in vivo in humans

PURPOSE

To demonstrate that "reverse iontophoresis" can be used to noninvasively obtain information about systemic glucose levels in vivo in humans.

METHODS

The passage of current across the skin in vivo drives ions into the tissue, from the electrode chambers positioned on the skin surface, and simultaneously pulls ions from the body in the opposite direction. Because of the net negative charge on the skin, under normal conditions, the membrane is permselective to cations, and a potential gradient also results, therefore, in electroosmotic convection of solvent in the direction of counterion flow (i.e., from anode to cathode). Thus, it is also possible to enhance the transport of polar, yet uncharged, species using iontophoresis. In an earlier study, the in vitro extraction of glucose, by "reverse iontophoresis" was established, and extension of the approach to an in vivo model was indicated. The idea has therefore been further explored in vivo in humans.

RESULTS

Using small, simple, prototypical electrode chambers, attached to the ventral forearm surface, direct current iontophoresis at 0.25 mA/cm2 for periods of up to 1 hour, and a sensitive analytical procedure to measure the quantities of glucose extracted, it has been shown that iontophoretic sampling of glucose is feasible. However, the shorter periods (15 minutes or less) of extraction considered yield results which are "contaminated" (it is believed) by glucose that is a product of lipid metabolism within the skin. While this material is expected to complicate the initial calibration of the approach, the problem is effectively resolved within one hour, by which time the glucose arriving in the electrode chambers on the skin surface is expected to directly reflect the subcutaneous tissue concentration.

CONCLUSIONS

Based upon these initial observations, further investigation can now be directed towards optimization of electroosmotic flow and sampling time, improved reproducibility and the development of a practical assay methodology.

Correlation of high-frequency esophageal ultrasonography and manometry in the study of esophageal motility

BACKGROUND & AIMS

No studies correlate manometric measurements with morphological changes during the esophageal peristaltic sequence. The aim of this study was to develop and use a system for sonographically imaging the esophageal wall while simultaneously recording esophageal pressure changes.

METHODS

An ultrasonography transducer attached to a manometric probe was used to evaluate the esophagus.

RESULTS

Four sonographic phases of an esophageal peristaltic sequence were identified. The esophageal lumen was not open at rest in phase 1 (resting), increased to a maximum mean circumference of 4.90 +/- 0.57 cm in phase 2 (passive distention), and returned to a closed position in phases 3 (contraction) and 4 (relaxation). The muscle layers of the esophageal wall were baseline resting width in phase 1, decreased in width during phase 2, increased and reached maximum mean widths during phase 3, and returned to baseline widths during phase 4. The measurement of esophageal intraluminal pressure remained at a baseline resting level during phases 1 and 2, increased to a maximum mean peak of 67.95 +/- 9.18 mm Hg during phase 3, and returned to baseline during phase 4.

CONCLUSIONS

A combined ultrasonography transducer/manometry probe was used to dynamically and simultaneously evaluate esophageal wall motion, muscle thickness, and esophageal pressure changes during peristalsis.

Novel antithrombotic therapeutics targeted against platelet glycoprotein IIb/IIIa

Platelet aggregation is one of the best understood examples of adhesive cell-cell interactions. The platelet glycoprotein IIb/IIIa membrane receptor plays a pivotal role in platelet aggregation through its binding of fibrinogen. It is intimately involved in the pathogenesis of platelet-rich arterial thromboses. The IIb/IIIa receptor is an important target for recently described novel antiplatelet therapeutics. The development and clinical evaluation of this class of antiplatelet therapeutics are reviewed in this article.

Effect of electroporation on transdermal iontophoretic delivery of luteinizing hormone releasing hormone (LHRH) in vitro

Electroporation, the creation of transient, enhanced membrane permeability using short duration (microseconds to millisecond) electrical pulses, can be used to increase transdermal drug delivery. The effect of an (electroporative) electric pulse (1000 V, tau = 5 msec) on the iontophoretic transport of LHRH through human skin was studied in vitro. Fluxes achieved with and without a pulse under different current densities (0- 4 mA/cm2) were compared. The results indicated that the application of a single pulse prior to iontophoresis consistently yielded higher fluxes (5-10 times the corresponding iontophoretic flux). For example, at 0.5 mA/cm2 fluxes were 0.27 +/- 0.08 and 1.62 +/- 0.05 micrograms/hr/cm2 without and with the pulse, respectively. At each current density studied, the LHRH flux decreased after iontophoresis, approaching pre-treatment values. The results show that electroporation can significantly and reversibly increase the flux of LHRH through human skin. These results also indicate the therapeutic utility of using electroporation for enhanced transdermal transport.