P-106 Total motile sperm count and oral ovulation induction protocols are not predictors of success in donor insemination cycles: Results from a large retrospective cohort study

Study question

to investigate the effect of total motile sperm (TMS) count, and ovulation induction on clinical pregnancy rate in artificial insemination with donor (AID) cycles.

Summary answer

TMS count is not a predictor of sucess, and natural cycles are as effective as oral ovulation induction in donor inseminations

What is known already

There are inconsistent results regarding the effect of sperm parameters on success rates of artificial insemination with donor (AID). Besides, the use of gonadotropin stimulation for ovulation induction in this category of patients is questionable, and its effectiveness over natural cycles is not yet confirmed in the literature.

Study design, size, duration

Patients who underwent AID cycles at the university-affiliated fertility center-OVO clinic in Montreal, Canada between 2011 and 2015 were retrospectively selected. A total of 4333 AID cycles were performed on 1179 patients, resulting in 744 pregnancies.

Participants/materials, setting, methods

Cycles were divided into 8 groups based on TMS count: <0.5, [0.5-1[, [1-5[, [5-10[, [10-20[, [20-40[, [40-80[, and ≥80. A TMS of 10 to 20 million was selected as a reference level. Ovulation induction was divided into oral stimulation, combined oral and gonadotropin stimulation and gonadotropin-only stimulation, and compared to natural cycles. Regression analysis and a predictive model of clinical pregnancy in AID cycles were generated from patient demographic and cycle characteristics.

Main results and the role of chance

There was no significant difference in positive β-hCG result, clinical pregnancy, multiple pregnancy and miscarriage rates when comparing all ranges of TMS count to a reference of 10 to 20 million. When dividing patients based on the protocol for ovulation induction, clinical pregnancy rate was significantly higher in the gonadotropin-only stimulation group (OR 4.116,[1.379,12.287]) but not in other types of stimulation, as compared to natural cycles. hCG triggering resulted in a similar clinical pregnancy and miscarriage rates, but a higher multiple pregnancy rate when compared to urinary LH testing (7.7% versus 1.3%, p = 0.045). A multivariate logistic regression analysis for predictors of clinical pregnancy accounting for relevant demographic and cycle characteristics was conducted. No significant difference was noted in different ranges of TMS and the groups of ovulation induction. In this model, age was found to be a significant predictor. In particular, with every one-year increase in age, the odds of clinical pregnancy decreases by 6.4% (Adjusted OR 0.936; 95%CI [0.914, 0.958]).

Limitations, reasons for caution

In our study, cycles with TMS count below 1 million are limited. Thus, results should be viewed with caution in this group, without cycle cancellation, since clinical pregnancy can be achieved. Moreover, our results cannot be generalized on infertile couples given the characteristics of our population of interest.

Wider implications of the findings

Minimal or maximal cut-off values for TMS in AID cycles should not be used as indicators for cycle cancellation. Natural cycles are as successful as oral ovulation induction. hCG trigger, unless indicated, should not be used as it is associated with higher risk of multiple pregnancy without increasing clinical pregnancy.

Trial registration number

not applicable

Quality of life of patients irradiated for head and neck cancer and impact of rehabilitation with a removable dental prosthetic: 1-year follow-up study

Background

Head and neck cancer and its treatment cause significant functional, aesthetic, and social disabilities. These disabilities have a major impact on the quality of life of patients. When irradiation is required, removable dental prostheses are often the treatment of choice. This study investigated whether removable prosthetic rehabilitation improved patient function and aesthetics over the long term.

Material and Methods

In this prospective study, we assessed quality of life in 78 patients with the General Oral Health Assessment Index (GOHAI) questionnaire. Assessments were performed before, and 1 week, 3 months, 6 months, and 12 months after denture insertion. We evaluated whether quality of life was influenced by the type of removable prosthesis and the primary tumour location.

Results

We constructed mixed-effects linear regression models to identify correlates of the overall GOHAI score (GOAHI-add score) and the three domain-scores (functional, psychosocial, and discomfort/pain) in a longitudinal analysis over a 12-month follow-up. We compared scores (GOHAI-add score and domain-scores) in multivariate analyses between baseline (T0) and four post-insertion timepoints to determine significant changes.

Conclusions

We found that removable prosthetic rehabilitation had an influence on the evolution of quality of life. The psychosocial component scores increased steadily over the year and changed more significantly than the functional and discomfort-pain components. The mandibular location of the primary lesion had a negative influence on quality of life. The type of removable prosthesis did not influence the results.

Key words:Quality of life, head and neck cancer, GOHAI, dental prosthesis, radiotherapy.

LSN MS guidelines for the management of multiple sclerosis

OBJECTIVE

The prevalence of multiple sclerosis (MS) in Lebanon is unknown, as there are no available or reliable epidemiological studies to date. The circumstances of Middle East countries are different from those of Europe and North America in terms of differential diagnoses and disease management. The aim of the conference is to establish guidelines for diagnosis, treatment, follow-up and management of patients with MS in Lebanon. Another objective is to discuss and participate in research projects based on epidemiology, clinical trials and more fundamental aspects of the disease in the future.

METHODS

Under the authority of the Lebanese Society of Neurology (LSN), a group of neurologists took the initiative to participate in this LSN MS committee with the purpose of establishing a consensus for the management of patients with MS, and under the supervision of a Coordinator (A.T.) designed by the LSN board.

RESULTS

Diagnostic and therapeutic, follow-up and research recommendations were proposed with special emphasis on the specific needs and circumstances of Lebanon. The experts highlighted the importance of considering particular needs, the identification of patients at high risk of developing MS in order to maximize therapeutic opportunities, and cost-effective control of treatment efficacy, as well as global assessment of disability.

CONCLUSIONS

The experts established guidelines concerning diagnosis, treatment, and follow-up of patients with MS in Lebanon. Furthermore, they recommended some clinical and fundamental research projects.

Safety and efficacy of sorafenib in hepatocellular carcinoma: the impact of the Child-Pugh score

BACKGROUND

Sorafenib increases median survival and time to radiological progression in patients with advanced hepatocellular carcinoma, but its benefit for Child-Pugh B patients remains uncertain.

AIM

To evaluate the safety and efficacy of sorafenib in real-life clinical practice conditions and to assess the influence of Child-Pugh class B on safety and efficacy.

METHODS

All patients treated with sorafenib for advanced hepatocellular carcinoma in our institution were included prospectively. Adverse events, overall survival and time to progression were recorded. A case control study was performed to compare outcome of patients with comparable stages of hepatocellular carcinoma, but a different Child-Pugh class.

RESULTS

From March 2007 to May 2009, 120 patients were included. Overall survival was 11.1 months, Child-Pugh A patients (n=100) had significantly higher median survival than Child-Pugh B patients (n=20) (13 vs. 4.5 months, P=0.0008). In multivariate analysis, Child-Pugh class B, α-fetoprotein level and total size of lesions were independent predictive factors of death. Patients with radiological progression in the first 3 months had shorter median survival (5.4 vs. 17.4 months). In a case control study, time to symptomatic progression (2.5 vs. 3.6 months), frequency of adverse events and discontinuation of sorafenib were not correlated with Child-Pugh class.

CONCLUSIONS

Patients with advanced hepatocellular carcinoma treated with sorafenib had a median survival of 11 months. Sorafenib therapy must be considered with caution in Child-Pugh B patients due to their poor survival. Radiological assessment of tumour progression at an early stage may be advantageous when tailoring sorafenib therapy.

Sphenoid and optic nerve sheath meningioma revealed by recurrent brain infarctions

Meningioma, though benign, may invade adjacent structures such as bone, soft tissues, dural sinuses and arteries. However brain infarctions secondary to meningioma involving the cavernous sinus and encasing and narrowing the intracranial carotid artery are rare. We report the case of a young man with recurrent left carotid artery infarctions due to a left sphenoid meningioma infiltrating the posterior optic nerve sheath through the optic canal and circumscribing the intracranial carotid artery. The patient had a gradually progressive occlusion of the middle cerebral artery, the distal internal carotid artery and finally the anterior cerebral artery ipsilateral to the sphenoid meningioma.

Organization of ventricular fibrillation in the human heart: experiments and models

Sudden cardiac death is a major health problem in the industrialized world. The lethal event is typically ventricular fibrillation (VF), during which the co-ordinated regular contraction of the heart is overthrown by a state of mechanical and electrical anarchy. Understanding the excitation patterns that sustain VF is important in order to identify potential therapeutic targets. In this paper, we studied the organization of human VF by combining clinical recordings of electrical excitation patterns on the epicardial surface during in vivo human VF with simulations of VF in an anatomically and electrophysiologically detailed computational model of the human ventricles. We find both in the computational studies and in the clinical recordings that epicardial surface excitation patterns during VF contain around six rotors. Based on results from the simulated three-dimensional excitation patterns during VF, which show that the total number of electrical sources is 1.4 +/- 0.12 times greater than the number of epicardial rotors, we estimate that the total number of sources present during clinically recorded VF is 9.0 +/- 2.6. This number is approximately fivefold fewer compared with that observed during VF in dog and pig hearts, which are of comparable size to human hearts. We explain this difference by considering differences in action potential duration dynamics across these species. The simpler spatial organization of human VF has important implications for treatment and prevention of this dangerous arrhythmia. Moreover, our findings underline the need for integrated research, in which human-based clinical and computational studies complement animal research.

Formes pauci symptomatiques de CADASIL après 60 ans

INTRODUCTION

CADASIL is a hereditary cerebral arteriopathy leading to progressive disability and dementia usually observed at 60 years.

OBSERVATION

We report four patients aged>60 years with typical Notch3 mutations leading to CADASIL who did not have dementia or disability. Three of them presented with only transient neurological manifestations. MRI results showed extensive hyperintense signals in the white-matter on T2-weighted images contrasting with very few lacunar infarcts.

CONCLUSION

These observations suggest that silent or symptomatic infarcts, which were rare in the present cases may be responsible for the clinical severity in this disorder.

Arm position and blood pressure: an audit

Although arm position significantly alters blood pressure, this aspect of clinical behaviour has not been evaluated. Consequently, an audit of arm position preference involving 182 clinicians including physicians, general practitioners and nurses was performed. A marked variation in standing and sitting arm position preference, both between and within the three groups, was recorded, although approximately two-thirds of clinicians preferred the same arm position in the standing and sitting position. In particular, only 8 and 4% of clinicians chose the horizontal arm position in sitting and standing subjects, respectively. Choosing the dependent arm is a behaviour likely to lead to the overdiagnosis of hypertension and inappropriate treatment of hypertension because the dependent arm falsely elevates both systolic and diastolic blood pressure. These results should encourage national and international organizations to reaffirm the importance of the horizontal arm in the measurement of blood pressure.

Arm position and blood pressure: a risk factor for hypertension?

The objective of this study was to re-evaluate the effect of arm position on blood pressure (BP) measurement with auscultatory and oscillometric methods including ambulatory blood pressure monitoring (ABPM). The setting was the hospital outpatient department and the subjects chosen were normotensive and hypertensive. The effect of lowering the arm from heart level on indirect systolic BP (SBP) and diastolic BP (DBP) measurement as well as the importance of supporting the horizontal arm were measured. In the sitting position, lowering the supported horizontal arm to the dependent position increased BP measured by a mercury device from 103+/-10/60+/-7 to 111+/-14/67+/-10 mmHg in normotensive subjects, a mean increase of 8/7 mmHg (P<0.01). In hypertensive subjects, a similar manoeuvre increased BP from 143+/-21/78+/-17 to 166+/-29/88+/-20 mmHg, an increase of 23/10 mmHg (P<0.01). Combined results from normotensive and hypertensive subjects demonstrate a direct and proportional association between BP (SBP and DBP) and the increase produced by arm dependency. Similar changes and associations were noted with oscillometric devices in the clinic situation. However, supporting the horizontal arm did not alter BP. Of particular interest, analysis of 13 hypertensive subjects who underwent ABPM on two occasions, once with the arm in the 'usual' position and once with the arm held horizontally for BP measurement during waking hours, demonstrated changes comparable to the other devices. The mean 12-hour BP was 154+/-19/82+/-10 mmHg during the former period and significantly decreased to 141+/-18/74+/-9 mmHg during the latter period (P<0.01). Regression analysis of the change in SBP and DBP with arm position change again demonstrated a close correlation (r(2)=0.8113 and 0.7273; P<0.001) with the artefact being larger with higher systolic and diastolic pressures. In conclusion, arm movements lead to significant artefacts in BP measurement, which are greater, the higher the systolic or diastolic pressure. These systematic errors occur when using both auscultatory and oscillometric (clinic and ABPM) devices and might lead to an erroneous diagnosis of hypertension and unnecessary medication, particularly in individuals with high normal BP levels. Since clinical interpretations of heart level vary, the horizontal arm position should be the unambiguous standard for all sitting and standing BP auscultatory and oscillometric measurements.

Characterization of Campylobacter spp. using restriction fragment length polymorphism and SDS-polyacrylamide gel electrophoresis

Twenty four Campylobacter jejuni and coli isolates obtained from Egyptian children were characterized using restriction fragment length polymorphism (RFLP) of flagellin genes and polyacrylamide gel electrophoresis of whole cell and glycine-extracted proteins. The isolates were found to fall into nine polymorphism groups, eight of which were reported previously in Egypt but one group displayed by 3 isolates represented a new group that was not reported before. Furthermore, the relative prevalence of polymorphic groups in the population studied is different from that reported previously. Analysis of whole-cell and acid glycine-extracted proteins showed that the profiles of these isolates are typical profiles of Campylobacters isolated from other humans.

Campylobacter-associated diarrhoea in Egyptian infants: epidemiology and clinical manifestations of disease and high frequency of concomitant infections

A diarrhoeal disease survey in Alexandria, Egypt determined the prevalence, seasonality, and household risk factors for Campylobacter-associated diarrhoea in young children. The study population was 880 children (mean age = 9.8 months) presenting with diarrhoea at one of two hospitals. A control group consisted of 1,079 healthy children (mean age = 8.8 months) attending two nearby vaccination clinics. The overall isolation frequencies for Campylobacter spp. were 16.8% for cases and 6.4% for the comparison group (p = 1 x 10(-8)). Other enteropathogens detected in diarrhoeal stools were: rotavirus (28.6%), Giardia lamblia trophozoites (21.3%), enterotoxigenic Escherichia coli (8.7%), Entamoeba histolytica (3.9%), Salmonella spp. (2.7%), and Shigella spp. (1.8%). There were few or no isolates of Aeromonas spp., Vibrio spp., Yersinia spp., or Plesiomonas spp. Comparisons among cases showed that Campylobacter spp. isolations were more prevalent during the rainy season (p = 0.001) and positively associated with keeping fowl in the home (p = 0.003) or having an outdoor source of drinking water (p = 0.029). Among Campylobacter-positive diarrhoeal patients, 69.0% had faecal leukocytes present and 16.3% had bloody stools. Patients with Campylobacter-positive diarrhoeal stools were frequently co-infected with rotavirus (28.6%) or G. lamblia (24.5%).

[Diagnosis of extruded herniated disks]

In a patient with disk herniation it is often difficult to establish that the disk is free in the spinal canal. A retrospective medical record study comparing 65 cases of free herniated disk (FHD) confirmed upon surgery and 65 cases of disk protrusion (DP) demonstrated that FHD was more common in young male blue collar workers, especially those who worked in the sitting position. No clinical findings were diagnostic of FHD although the straight-leg raising test was positive at smaller angles than in disk protrusion. In this study, sensitivity and specificity of CT scan for the diagnosis of FHD were 75% and 80%, respectively. CT scan findings suggestive of FHD included a free disk fragment, found in 22.5% of cases, and an acute connecting angle. Saccoradiculography was more sensitive but less specific than CT scan in this study. In FDH, migration was common and ragged hernia contours were seen on the saccoradiculography images.

Relative resistance to erythromycin in Chlamydia trachomatis

Recent Chlamydia trachomatis isolates were tested in a tissue culture system for susceptibility to tetracycline, erythromycin, rosaramicin, rifampin, and clindamycin. Rifampin was the most active drug (minimal inhibitory concentration, less than or equal to 0.02 microgram/ml). Tetracycline and rasaramicin were highly active, with a concentration of less than or equal to 0.25 microgram/ml being chlamydicidal. Clindamycin was least active on a weight basis, requiring up to 16 microgram/ml to prevent the passage of chlamydiae into a drug-free tissue culture system. Relative resistance to erythromycin was detected; two isolates were capable of limited replication in 1 microgram/ml.