Is varicocelectomy indicated in subfertile men with clinical varicoceles who have asthenospermia or teratospermia and normal sperm density?

OBJECTIVE: Varicocele is the most common treatable cause of male infertility and is associated with progressive decline in testicular function. Varicocelectomy, a commonly performed operation, is indicated in infertile males with varicoceles who have oligospermia, asthenospermia, teratospermia or a combination of these factors. It is not clear if varicocelectomy is indicated if the patients have normal sperm density associated with asthenospermia or teratospermia. METHODS: We reviewed 167 patients with varicocele-associated male infertility over a 7-year period (December 1999-November 2005). Pre- and post-varicocelectomy seminal fluid analyses, assessed using the World Health Organization criteria, were obtained at intervals of 4-6 months. Wilcoxon signed rank tests were used to evaluate for statistical significance and P < or = 0.05 was considered significant. RESULTS: The mean age of the patients and their spouses were 35 and 28 years, respectively. The mean duration of infertility was 3.2 years (range, 1.5-7.5). Oligospermia, teratospermia, asthenospermia, oligospermia, asthenospermia and teratospermia (OAT) syndrome and azoospermia were found preoperatively in 106 (63.5%), 58 (34.7%), 154 (92%), 118 (71%) and 15 (9%) patients, respectively. Overall, significant improvements in semen volume (P < 0.001), sperm density (P < 0.001), sperm motility (P < 0.001) and sperm vitality (P < 0.001) were obtained after varicocelectomy. There was, however, no significant improvement in sperm morphology after varicocelectomy (P = 0.220). When patients with preoperative oligospermia (sperm density, <20 million/mL) were considered separately, varicocelectomy led to significant improvement in all the semen parameters except the sperm morphology (P = 0.183). Conversely, when varicocele patients with a sperm density of > or =20 million/mL (normospermia) associated with asthenospermia and/or teratospermia were considered separately, they did not show significant improvement in any of the semen parameters after varicocelectomy (P > 0.05). In addition, azoospermic patients did not show significant improvement in any of the semen parameters (P > 0.05) CONCLUSION: No significant improvement in semen parameters may be obtained in patients with clinical varicocele and preoperative normospermia. It is possible that only patients with preoperative oligospermia may benefit from varicocelectomy. Larger multi-institutional studies are needed to determine more definitively if asthenospermia or teratospermia in normospermic subfertile males with clinical varicoceles are in fact indications for varicocelectomy.     

Management of Acute and Chronic Retention in Men

Urinary retention is complex and may present in various ways as a result of a myriad of pathologic processes. Retention is >10 times more common in men than in women, and acute urinary retention (AUR) is rare in younger men; men in their 70 s are at five times more risk of AUR than men in their 40 s. Most of the epidemiologic data referred to in the literature are for AUR; data for chronic urinary retention (CUR) are sparse. Management of urinary retention must begin with modifying risk factors for developing AUR by using 5α-reductase inhibitors, follow-up, and early surgical intervention for those who may benefit. Once retention occurs, delay of surgery when possible must be the aim to reduce the risk of perioperative morbidity and mortality as well as to allow the bladder to recover its contractility. Finally, perhaps it is time to use suprapubic catheterisation for retention patients as a first-line approach.     

Management of penile cancer patients during the COVID-19 pandemic: An eUROGEN accelerated Delphi consensus study

ObjectivesTo develop an international consensus on managing penile cancer patients during the COVID-19 acute waves. A major concern for patients with penile cancer during the coronavirus disease 2019 (COVID-19) pandemic is how the enforced safety measures will affect their disease management. Delays in diagnosis and treatment initiation may have an impact on the extent of the primary lesion as well as the cancer-specific survival because of the development and progression of inguinal lymph node metastases.Materials and methodsA review of the COVID-19 literature was conducted in conjunction with analysis of current international guidelines on the management of penile cancer. Results were presented to an international panel of experts on penile cancer and infection control by a virtual accelerated Delphi process using 4 survey rounds. Consensus opinion was defined as an agreement of ≥80%, which was used to reconfigure management pathways for penile cancer.ResultsLimited evidence is available for delaying penile cancer management. The consensus rate of agreement was 100% that penile cancer pathways should be reconfigured, and measures should be developed to prevent perioperative nosocomial transmission of COVID-19. The panel also reached a consensus on several statements aimed at reconfiguring the management of penile cancer patients during the COVID-19 pandemic.ConclusionsThe international consensus panel proposed a framework for the diagnostic and invasive therapeutic procedures for penile cancer within a low-risk environment for COVID-19.     

Sonographic guided hydrostatic saline enema reduction of childhood intussusception: a prospective study

Background

The management of childhood intussusception in our sub-region is still via surgical intervention. Currently, the gold standard of treatment is non-operative reduction. We sought to assess the suitability of hydrostatic (saline) reduction of intussusception in children in our institution.

Materials and methods

A prospective study was conducted between January 2016 and June 2017 in all children with ultrasound confirmed intussusception at a tertiary teaching hospital in Nigeria. All children excluding those with signs of peritonitis, bowel gangrene and intestinal prolapse were selected for ultrasound-guided hydrostatic reduction (USGHR). We allowed a maximum of three attempts at reduction.

Results

The age range was 3 months to 48 months with a mean of 10.8?±?9.1 months. Forty percent (N?=?18) presented after 24 h of onset of symptoms. The success rate of hydrostatic reduction with saline enema was 84.4% (N?=?38). Two (4.4%) perforations occurred during the procedure. Three (7.5%) patients had recurrent intussusception within six months. The duration of symptoms greater than 24 h, age and sex of patients did not influence successful reduction p?>?0.05. The duration of admission between those who had successful non-operative reduction and those who subsequently had operative reduction and or resection attained statistical significant difference, p?=?0.001. There was no mortality. We achieved a 68% decrease in the operative reduction of intussusception using USGHR as the primary modality of treatment.

Conclusion

Our study found out that USGHR is a suitable alternative for the treatment of childhood intussusception.

     

Hospitalizations and Costs Incurred at the Facility Level after Scale-up of Malaria Control: Pre-Post Comparisons from Two Hospitals in Zambia

There is little evidence on the impact of malaria control on the health system, particularly at the facility level. Using retrospective, longitudinal facility-level and patient record data from two hospitals in Zambia, we report a pre-post comparison of hospital admissions and outpatient visits for malaria and estimated costs incurred for malaria admissions before and after malaria control scale-up. The results show a substantial reduction in inpatient admissions and outpatient visits for malaria at both hospitals after the scale-up, and malaria cases accounted for a smaller proportion of total hospital visits over time. Hospital spending on malaria admissions also decreased. In one hospital, malaria accounted for 11% of total hospital spending before large-scale malaria control compared with < 1% after malaria control. The findings demonstrate that facility-level resources are freed up as malaria is controlled, potentially making these resources available for other diseases and conditions.     

Induction of Rabies Virus Infection in Mice Brain may Up and Down Regulate Type II Interferon gamma via epigenetic modifications

Metabolic Brain Disease - As feared and deadly human diseases globally, Rabies virus contrived mechanisms to escape early immune recognition via suppression of the interferon response. This study,...     

Assessing decision-making capacity at end of life

Objective

Patients with terminal illness often face important medical decisions that may carry ethical and legal implications, yet they may be at increased risk for impaired decisional capacity. This study examined the prevalence of impairment on the four domains of decisional capacity relevant to existing legal standards.

Method

Twenty-four adults diagnosed with a terminal illness completed the MacArthur Competence Assessment Tool for Treatment, a semi-structured measure of decision-making capacity and measures of cognitive functioning and psychological distress.

Results

Approximately one third of the sample demonstrated serious impairment on at least one domain of decisional capacity. The greatest proportion of impairment was found on subscales that rely heavily on verbal abilities. Decisional capacity was significantly associated with cognitive functioning and education, but not with symptoms of anxiety or depression.

Conclusions

This study is the first to examine decisional capacity in patients with terminal illness relative to legal standards of competence. Although not universal, decisional impairment was common. Clinicians working with terminally ill patients should frequently assess capacity as these individuals are called on to make important medical decisions. Comprehensive assessment will aid clinicians in their responsibility to balance respect for patient autonomy with their responsibility to protect patients from harm resulting from impaired decisional capacity.