Global Practice Patterns and Variations in the Medical and Surgical Management of Non-Obstructive Azoospermia: Results of a World-Wide Survey, Guidelines and Expert Recommendations

PURPOSE

Non-obstructive azoospermia (NOA) is a common, but complex problem, with multiple therapeutic options and a lack of clear guidelines. Hence, there is considerable controversy and marked variation in the management of NOA. This survey evaluates contemporary global practices related to medical and surgical management for patients with NOA.

MATERIALS AND METHODS

A 56-question online survey covering various aspects of the evaluation and management of NOA was sent to specialists around the globe. This paper analyzes the results of the second half of the survey dealing with the management of NOA. Results have been compared to current guidelines, and expert recommendations have been provided using a Delphi process.

RESULTS

Participants from 49 countries submitted 336 valid responses. Hormonal therapy for 3 to 6 months was suggested before surgical sperm retrieval (SSR) by 29.6% and 23.6% of participants for normogonadotropic hypogonadism and hypergonadotropic hypogonadism respectively. The SSR rate was reported as 50.0% by 26.0% to 50.0% of participants. Interestingly, 46.0% reported successful SSR in <10% of men with Klinefelter syndrome and 41.3% routinely recommended preimplantation genetic testing. Varicocele repair prior to SSR is recommended by 57.7%. Half of the respondents (57.4%) reported using ultrasound to identify the most vascularized areas in the testis for SSR. One-third proceed directly to microdissection testicular sperm extraction (mTESE) in every case of NOA while others use a staged approach. After a failed conventional TESE, 23.8% wait for 3 months, while 33.1% wait for 6 months before proceeding to mTESE. The cut-off of follicle-stimulating hormone for positive SSR was reported to be 12-19 IU/mL by 22.5% of participants and 20-40 IU/mL by 27.8%, while 31.8% reported no upper limit.

CONCLUSIONS

This is the largest survey to date on the real-world medical and surgical management of NOA by reproductive experts. It demonstrates a diverse practice pattern and highlights the need for evidence-based international consensus guidelines.

Global Practice Patterns in the Evaluation of Non-Obstructive Azoospermia: Results of a World-Wide Survey and Expert Recommendations

PURPOSE

Non-obstructive azoospermia (NOA) represents the persistent absence of sperm in ejaculate without obstruction, stemming from diverse disease processes. This survey explores global practices in NOA diagnosis, comparing them with guidelines and offering expert recommendations.

MATERIALS AND METHODS

A 56-item questionnaire survey on NOA diagnosis and management was conducted globally from July to September 2022. This paper focuses on part 1, evaluating NOA diagnosis. Data from 367 participants across 49 countries were analyzed descriptively, with a Delphi process used for expert recommendations.

RESULTS

Of 336 eligible responses, most participants were experienced attending physicians (70.93%). To diagnose azoospermia definitively, 81.7% requested two semen samples. Commonly ordered hormone tests included serum follicle-stimulating hormone (FSH) (97.0%), total testosterone (92.9%), and luteinizing hormone (86.9%). Genetic testing was requested by 66.6%, with karyotype analysis (86.2%) and Y chromosome microdeletions (88.3%) prevalent. Diagnostic testicular biopsy, distinguishing obstructive azoospermia (OA) from NOA, was not performed by 45.1%, while 34.6% did it selectively. Differentiation relied on physical examination (76.1%), serum hormone profiles (69.6%), and semen tests (68.1%). Expectations of finding sperm surgically were higher in men with normal FSH, larger testes, and a history of sperm in ejaculate.

CONCLUSIONS

This expert survey, encompassing 367 participants from 49 countries, unveils congruence with recommended guidelines in NOA diagnosis. However, noteworthy disparities in practices suggest a need for evidence-based, international consensus guidelines to standardize NOA evaluation, addressing existing gaps in professional recommendations.

Prospective Longitudinal Assessment of Quality of Life After Stereotactic Ablative Radiotherapy for Oligometastases: Analysis of the Population-based SABR-5 Phase II Trial

AIMS

To evaluate longitudinal patient-reported quality of life (QoL) in patients treated with stereotactic ablative radiotherapy (SABR) for oligometastases.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases, conducted in six regional cancer centres in British Columbia, Canada from 2016 to 2020. Prospective QoL was measured using treatment site-specific QoL questionnaires at pre-treatment baseline and at 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. Patients with bone metastases were assessed with the Brief Pain Inventory (BPI). Patients with liver, adrenal and abdominopelvic lymph node metastases were assessed with the Functional Assessment of Chronic Illness Therapy-Abdominal Discomfort (FACIT-AD). Patients with lung and intrathoracic lymph node metastases were assessed with the Prospective Outcomes and Support Initiative (POSI) lung questionnaire. The two one-sided test procedure was used to assess equivalence between the worst QoL score and the baseline score of individual patients. The mean QoL at all time points was used to determine the trajectory of QoL response after SABR. The proportion of patients with 'stable', 'improved' or 'worsened' QoL was determined for all time points based on standard minimal clinically important differences (MCID; BPI worst pain = 2, BPI functional interference score [FIS] = 0.5, FACIT-AD Trial Outcome Index [TOI] = 8, POSI = 3).

RESULTS

All enrolled patients with baseline QoL assessment and at least one follow-up assessment were analysed (n = 133). On equivalence testing, the patients' worst QoL scores were clinically different from baseline scores and met MCID (BPI worst pain mean difference: 1.8, 90% confidence interval 1.19 to 2.42]; BPI FIS mean difference: 1.68, 90% confidence interval 1.15 to 2.21; FACIT-AD TOI mean difference: -8.76, 90% confidence interval -11.29 to -6.24; POSI mean difference: -4.61, 90% confidence interval -6.09 to -3.14). However, the mean FIS transiently worsened at 9, 18 and 21 months but eventually returned to stable levels. The mean FACIT and POSI scores also worsened at 36 months, albeit with a limited number of responses (n = 4 and 8, respectively). Most patients reported stable QoL at all time points (range: BPI worst pain 71-82%, BPI FIS 45-78%, FACIT-AD TOI 50-100%, POSI 25-73%). Clinically significant stability, worsening and improvement were seen in 70%/13%/18% of patients at 3 months, 53%/28%/19% at 18 months and 63%/25%/13% at 36 months.

CONCLUSIONS

Transient decreases in QoL that met MCID were seen between patients' worst QoL scores and baseline scores. However, most patients experienced stable QoL relative to pre-treatment levels on long-term follow-up. Further studies are needed to characterise patients at greatest risk for decreased QoL.

Predictors of Quality of Life Decline in Patients with Oligometastases treated with Stereotactic Ablative Radiotherapy: Analysis of the Population-Based SABR-5 Phase II Trial

AIMS

Most patients experience stable quality of life (QoL) after stereotactic ablative radiotherapy (SABR) treatment for oligometastases. However, a subset of patients experience clinically relevant declines in QoL on post-treatment follow-up. This study aimed to identify risk factors for QoL decline.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases. Prospective QoL was measured using treatment site-specific tools at pre-treatment baseline and 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. The time to persistent QoL decline was calculated as the time from SABR to the first decline in QoL score meeting minimum clinically important difference with no improvement to baseline score on subsequent assessments. Univariable and multivariable logistic regression analyses were carried out to determine factors associated with QoL decline.

RESULTS

One hundred and thirty-three patients were included with a median follow-up of 32 months (interquartile range 25-43). Thirty-five patients (26%) experienced a persistent decline in QoL. The median time until persistent QoL decline was not reached. The cumulative incidence of QoL decline at 2 and 3 years were 22% (95% confidence interval 14.0-29.6) and 40% (95% confidence interval 28.0-51.2), respectively. In multivariable analysis, disease progression (odds ratio 5.23, 95% confidence interval 1.59-17.47, P = 0.007) and adrenal metastases (odds ratio 9.70, 95% confidence interval 1.41-66.93, P = 0.021) were associated with a higher risk of QoL decline. Grade 3 or higher (odds ratio 3.88, 95% confidence interval 0.92-16.31, P = 0.064) and grade 2 or higher SABR-associated toxicity (odds ratio 2.24, 95% confidence interval 0.85-5.91, P = 0.10) were associated with an increased risk of QoL decline but did not reach statistical significance.

CONCLUSIONS

Disease progression and adrenal lesion site were associated with persistent QoL decline following SABR. The development of grade 3 or higher toxicities was also associated with an increased risk, albeit not statistically significant. Further studies are needed, focusing on the QoL impact of metastasis-directed therapies.

Pre-Conceptional and Antenatal Care for Improved Newborn and Child Survival in India: A Review

There is sufficient scientific evidence that quality pre-conceptional care and antenatal care can improve newborn survival. This review was conducted to understand the concept of pre-conceptional care and its implementation status in India. The review documents the specific interventions that have been proven to effectively improve pregnancy outcome when provided as pre-conception care. Healthcare providers, particularly obstetricians/gynecologists and general physicians, should prioritize pre-conception care as an essential component of healthcare for women. However, the lack of continuum of care and program linkages are some of the key barriers in ensuring pre-conceptional and ante-natal care in India. Culturally and linguistically appropriate care should be provided to ensure that all women can access and understand the information and services needed to optimize their reproductive health and improve pregnancy outcomes. Prioritizing pre-conception and prenatal care, healthcare providers can improve maternal and fetal outcomes, reduce healthcare costs, and promote lifelong health for women and their families. The primary healthcare reforms being done in India can be and should be used to strengthen pre-conceptional and ante-natal care services and quality.

Efficacy of Dienogest in Adolescent Endometriosis: A Narrative Review

Teenage endometriosis is seen as a chronic condition that can worsen if untreated. Treatment objectives include relief of symptoms, prevention of disease development, and preservation of future fertility. In many regions, dienogest (DNG), an oral progestin, has emerged as a key treatment in suppressing endometriosis. The usage of DNG for endometriosis in adolescents was researched in papers published between 2015 and 2022 using PubMed and Google Scholar. A thorough search of all identified studies' reference lists and previously published literature reviews was carried out. The study's nature and geographic scope were not restricted. After reviewing these publications, the authors decided on which ones were the most pertinent in light of their personal experiences. The final study consisted of 14 studies that satisfied inclusion requirements. The trials showed that taking DNG 2 mg daily efficiently lowers endometriotic lesions, eases painful endometriosis symptoms, and improves quality-of-life indicators. In most of these investigations, DNG was shown to be safe and tolerated, with predictable and moderate side effects, good patient compliance rates, and low withdrawal rates. Although endometrioma did not enlarge while receiving treatment, significant regression was not typical. Overall, the studies found that DNG is safe and effective in reducing symptoms of endometriosis in adolescents.

Does Quality Certification Work? An Assessment of Manyata, a Childbirth Quality Program in India's Private Sector

BACKGROUND

In India, more than 60% of hospital beds are in private facilities, yet several studies have observed suboptimal quality of care in private facilities. We aimed to understand the role of Manyata, a quality improvement initiative in private facilities focused on mentorship and clinical standards, to improve the knowledge and skills of health care providers, their adherence to key childbirth-related clinical practices, and health outcomes for women and newborns.

METHODS

We conducted a secondary analysis of Manyata program data collected from 466 private facilities across 3 states (Jharkhand, Maharashtra, and Uttar Pradesh) in India from October 2016 to February 2019. We calculated means and 95% confidence intervals for knowledge and skills assessment, adherence to facility standards was analyzed by calculating the proportion of facilities passing a given quality standard at baseline and endline, and changes in pregnancy outcomes were assessed with autoregression modeling.

RESULTS

From assessments conducted before and after training among providers in Manyata, we observed a significant increase in average knowledge score (6.3 vs. 13.2 of 20) and skill score (8.0 vs. 34.3 of 40). Overall, a significant increase occurred in adherence to clinical standards between baseline and endline assessments (29% vs. 93%). The standards with the greatest improvements were identification and management of eclampsia/preeclampsia, postpartum hemorrhage, and neonatal resuscitation. There were no significant changes over time in absolute rate of reported complications; however, referral rates from private facilities for preeclampsia and newborn sepsis identification and management declined.

CONCLUSION

Our analysis indicates private facilities' adherence to quality standards and nurses' childbirth knowledge and practical skills increased during Manyata. Additional efforts are needed to ensure high-quality care during cesarean deliveries at private facilities. Future studies with rigorous design are required to evaluate the impact of this quality improvement initiative in improving pregnancy outcomes.

Effect of reproductive and lifestyle factors on anti-mullerian hormone levels in women of Indian origin

Background:

Infertility is a world-wide problem and one third females. Over the years, anti-mullerian hormone (AMH) has emerged as a major marker of ovarian reserve. There is also increasing interest in determining the factors which can impact AMH levels.

Aims:

To correlate the association of reproductive and lifestyle factors on AMH levels in women of Indian origin.

Settings and Design:

Multicentric cross sectional study.

Materials and Methods:

The study was conducted using data extracted from the patient records of seven private fertility practices located in North India. Women who were attending these clinics for fertility treatment were requested to fill the questionnaire related to reproductive and lifestyle factors.

Statistical Analysis used:

Our outcome variable was level of AMH measured in the past 3 months, and was assessed as normal or low. All analyses were conducted using STATA 17.

Results:

We found a direct association of low AMH with increasing age, short cycles, amenorrhea and women with family history of premature menopause. We found a direct correlation of high AMH and women with polycystic ovary syndrome and those whose partners had Oligoasthenoteratozoospermia (OATS) or azoospermia. There was no correlation with smoking, sleep, diet, body mass index, cell phone or laptop use in our study.

Conclusion:

Reproductive and lifestyle factors may affect ovarian reserve and but there was a dearth of human studies in this area. To the best of our knowledge this is the first human study on the effect of AMH on Laptop and Cell phone use. We urgently need more studies to confirm or refute our findings so that we can counsel our patients well.

Comparative Analysis of Surgically Retrieved Sperms in Cases of Obstructive and Nonobstructive Azoospermia Treated for Infertility

Background

Azoospermia is a highly evolving subject in the last few decades. In the past, use of donor sperm was the only option providing a realistic chance of conception for couples affected by azoospermia. Introduction of sperm retrieval techniques and assisted reproductive technologies, especially intracytoplasmic sperm injection (ICSI), has provided these men a chance to father their genetically own child and changed the management approach significantly.

Objective

The objective was to compare the sperm retrieval rate (SRR) and ICSI outcomes of surgically retrieved sperms in cases of obstructive and nonobstructive azoospermia (NOA) as well as to evaluate the efficacy of sperm retrieval techniques.

Materials and Methods

A total of sixty azoospermic patients were included in the study. The patients were divided between OA (16) and NOA groups (44). A retrospective outcome analysis was done on SRR and ICSI results among them.

Results

The overall SRR in patients with NOA and OA was 47.7% and 100%, respectively (P < 0.001). On subgroup analysis, higher serum follicle-stimulating hormone has shown significantly decreased sperm retrieval. The size of testes was not found to be related to sperm retrieval. Fertilization and embryo formation rate were found to be higher in OA cases in comparison to those of NOA cases. Clinical pregnancy rate showed no significant difference.

Conclusion

Various sperm retrieval techniques can provide new dimensions for successful ICSI and managing azoospermia patients. Although SRRs as well as ICSI outcomes are lower in NOA patients than patients with OA, still they are potentially fertile. A systematic approach especially in patients with NOA is an important step. Microdissection testicular sperm extraction is an attractive option for NOA patients in order to increase the chances of successful sperm retrieval.

SARS-CoV-2 and Assisted Reproductive Technology Practice: An Asia Pacific Initiative on Reproduction (ASPIRE) Position Paper

Background: Asia Pacific Initiative on Reproduction (ASPIRE) aims to improve knowledge and awareness of Assisted Reproductive Technology (ART) and infertility-related services, with the aim of improving the quality of patient care.

Methods: A survey was developed and responded by a group of 10 ASPIRE board members to gather in-depth information about current practices, recommendations, and perceptions about SARS-CoV-2 and ART. The collected data were summarized and individual responses pooled among questions requiring voting. The overall rates were computed by response category. The group discussed the summary evidence, until a consensus was reached concerning a series of recommendation on how to make decisions concerning ART service provision during the current (and any future) pandemic. A two-tier recommendation was developed based on agreement rate and implementation priority. Tier 1 comprises recommendations in which the rate of “absolutely agree” responses were [Formula: see text]60%, whereas tier 2 refers to recommendations in which the rate of “absolutely agree” plus “agree” was >60%, but the rate of “absolutely agree” was [Formula: see text]50%.

Results: The survey was responded by all participants between July 24 and July 30, 2020. Nine tier 1 and five tier 2 recommendations are provided concerning prevention, testing, personal protective equipment, informed consent, and quality management. The former indicates the situations in which most individuals should receive the intervention/procedure, whereas the latter relates to those that may be suitable for individual clinics and patients.

Conclusions: This document provides the ASPIRE viewpoint on better managing infertile patients seeking ART during the COVID-19 pandemic. This expert opinion guide aims to help both competent authorities and healthcare providers to deliver quality and safe ART.

First Observation of Multiple Transverse Wobbling Bands of Different Kinds in ^{183}Au

We report the first observation of two wobbling bands in ^{183}Au, both of which were interpreted as the transverse wobbling (TW) band but with different behavior of their wobbling energies as a function of spin. It increases (decreases) with spin for the positive (negative) parity configuration. The crucial evidence for the wobbling nature of the bands, dominance of the E2 component in the ΔI=1 transitions between the partner bands, is provided by the simultaneous measurements of directional correlation from the oriented states ratio and the linear polarization of the γ rays. Particle rotor model calculations with triaxial deformation reproduce the experimental data well. A value of spin, I_{m}, has been determined for the observed TW bands below which the wobbling energy increases and above which it decreases with spin. The nucleus ^{183}Au is, so far, the only nucleus in which both the increasing and the decreasing parts are observed and thus gives the experimental evidence of the complete transverse wobbling phenomenon.

Oocyte Vitrification: A Comparative Analysis Between Fresh and Cryopreserved Oocytes in an Oocyte Donation Program

Background: Oocyte Cryopreservation has become an important part of infertility treatment for various reasons such as fertility preservation in women going for oncological treatment; in oocyte donation cycles; in eliminating several religious, ethical, and legal concerns of embryo freezing and in women who wish to delay childbirth. The newer ”vitrification” technique for freezing has further improved the success rates for actual conception than the earlier method of slow freezing. A successful oocyte freezing program can help in establishment of oocyte banks, which would help to provide compatible oocytes immediately, thus would eliminate the several problems of fresh donor cycles.

Methods: In this retrospective observational study, total 60 oocyte donation cycles were included (38 were fresh and 22 were vitrified oocytes cycle, respectively). After a thorough screening, controlled ovarian hyperstimulation for donors was performed using flexible antagonist protocol. All mature oocytes were allocated into “vitrified oocytes” and “fresh oocytes” groups. Vitrification technique using Cryotop method was used for oocyte freezing. Both clinical and laboratory outcomes of vitrified and fresh oocytes in donor cycles were compared.

Results: A total of 600 oocytes (226 “vitrified oocytes” and 374 fresh oocytes), were studied. After warming 218 oocytes survived resulting in survival rate of 96.4%. Fertilization rate and embryo formation rate was 86.2% and 93.6%, respectively. Results of frozen-thawed oocyte donor cycles were compared with fresh donation cycles. For fresh oocyte group, fertilization rate and embryo formation rate was 83.4% and 92.6%, respectively. On comparing clinical outcomes, clinical pregnancy rate was 60.5% in fresh group and 63.6% in vitrified group.

Conclusions: Both clinical and laboratory results obtained in the study suggest that oocyte cryopreservation can be performed with reproducible success, thus vitrification technique can be provided as a useful tool for achieving highly successful outcomes in an oocyte donor program.

Exploring the structure of Xe isotopes in A ~ 130 region: Single particle and collective excitations

High and medium spin structures of 130,131Xe have been studied using α-induced fusion-evaporation reaction and the Indian National Gamma Array (INGA) coupled with a digital data acquisition system. Various new band structures and near yrast levels of 131Xe have been established. The multipolarities of the observed transitions have been assigned on the basis of the DCO ratios and the polarization asymmetry measurements. Band structures based on 1-quasi-particle (qp), 3-qp configurations have been observed. A new Magnetic Rotational (MR) band based on 5-qp configuration has also been established in 131Xe. The MR band has been interpreted in terms of shears mechanism with principal axis cranking (SPAC) calculations. Shell Model calculations are carried out to describe the non yrast states of 131Xe above the 11/2− isomer. New excited states have also been identified in 130Xe, produced in the same reaction.

Role of the Δ Resonance in the Population of a Four-Nucleon State in the ^{56}Fe→^{54}Fe Reaction at Relativistic Energies

The ^{54}Fe nucleus was populated from a ^{56}Fe beam impinging on a Be target with an energy of E/A=500  MeV. The internal decay via γ-ray emission of the 10^{+} metastable state was observed. As the structure of this isomeric state has to involve at least four unpaired nucleons, it cannot be populated in a simple two-neutron removal reaction from the ^{56}Fe ground state. The isomeric state was produced in the low-momentum (-energy) tail of the parallel momentum (energy) distribution of ^{54}Fe, suggesting that it was populated via the decay of the Δ^{0} resonance into a proton. This process allows the population of four-nucleon states, such as the observed isomer. Therefore, it is concluded that the observation of this 10^{+} metastable state in ^{54}Fe is a consequence of the quark structure of the nucleons.

Clinical characteristics of relapses and re-infections in Clostridium difficile infection

The purpose of this study was to identify factors associated with relapses or re-infections in patients with recurring Clostridium difficile infections (CDIs). From September 2008 to January 2012, cases with two or more isolates from consecutive CDI episodes were included. PCR-ribotyping and multilocus variable-number tandem-repeat analysis were performed using paired isolates. Among 473 patients, 68 (14.4%) experienced one to five recurrences. Fifty-one of these with two or more isolates from consecutive CDI episodes were included in the study; 25 (49%) were classified as relapses and 26 (51%) as re-infections. Recurrence interval was shorter in the relapse group (26.0 versus 67.5 p 0.001), but more patients in the re-infection group were hospitalized during recurrence interval (53.8% versus 8.0%, p<0.001). Relapse rates in infections by ribotype 017, ribotype 018 and other ribotypes were 63.6%, 63.6% and 22.2%, respectively (p 0.274, p 0.069, and p 0.005). In multivariate logistic regression, infections by ribotypes 017 and 018 were associated with CDI relapse (OR 4.77, 95% CI 1.02-22.31, p 0.047; OR 11.49, 95% CI 2.07-63.72, p 0.005). Conversely, admission during recurrence interval lowered the risk of relapse (OR 0.044, 95% CI 0.006-0.344, p 0.003). In conclusion, relapse was more likely when infection was caused by PCR ribotypes 017 and 018.

Clinical characteristics predicting early clinical failure after 72 h of antibiotic treatment in women with community-onset acute pyelonephritis: a prospective multicentre study

In patients with community-onset acute pyelonephritis (CO-APN), assessing the risk factors for poor clinical response after 72 h of antibiotic treatment (early clinical failure) is important. The objectives of this study were to define those risk factors, and to assess whether early clinical failure influences mortality and treatment outcomes. We prospectively collected the clinical and microbiological data of women with CO-APN in South Korea from March 2010 to February 2012. The numbers of cases in the early clinical success and early clinical failure groups were 840 (79.1%) and 222 (20.9%), respectively. Final clinical failure and mortality were higher in the early clinical failure group than in the early clinical success group (14.9% vs 2.3%, p <0.001; 6.8% vs 0.1%, p 0.001, respectively). In a multiple logistic regression model, the risk factors for early clinical failure among the total 1062 patients were diabetes mellitus (OR 1.5; 95% CI 1.1-2.1), chronic liver diseases (OR 3.3; 95% CI 1.6-6.7), malignancy (OR 2.2; 95% CI 1.1-4.4), Pitt score ≥2 (OR 2.5; 95% CI 1.6-3.8), presence of azotaemia (OR 1.8; 95% CI 1.2-2.7), white blood cell count ≥20 000/mm(3) (OR 2.5; 95% CI 1.6-4.0), serum C-reactive protein level ≥20 mg/dL (OR 1.7; 95% CI 1.2-2.4), and history of antibiotic usage within the previous year (OR 1.5; 95% CI 1.1-2.2). Analysing the subgroup of 743 patients with CO-APN due to Enterobacteriaceae, fluoroquinolone resistance of the uropathogen was another factor associated with early clinical failure (OR 1.7; 95% CI 1.1-2.5). Simple variables of underlying diseases, previous antibiotic usage and initial laboratory test outcomes can be used to decide on the direction of treatment in CO-APN.

Clinical characteristics of community-acquired acute pyelonephritis caused by ESBL-producing pathogens in South Korea

OBJECTIVES

The aim of this study was to determine the risk factors and clinical characteristics of community-acquired acute pyelonephritis (CA-APN) caused by extended-spectrum β-lactamase (ESBL)-producing organisms.

METHODS

From March 2010 to February 2011, patients with CA-APN were recruited in 11 hospitals in South Korea. Clinical and microbiological data were collected prospectively, and the ESBLs and multilocus sequence types of the ESBL-producing Escherichia coli were characterized. Comparison between CA-APN caused by ESBL-producing Enterobacteriaceae and those by non-ESBL-producing organisms was performed.

RESULTS

A total of 566 patients were recruited. Enterobacteriaceae were detected in 526 patients. Forty-six isolates (46/526, 8.7 %) were positive for ESBLs. Clinical and microbiological failure did not differ between the two groups, despite there being fewer patients with ESBL-positive isolates provided with appropriate antibiotics initially (19.6 vs. 93.8 %, p < 0.001). However, the duration of hospitalization was longer in the ESBL group (10.5 vs. 7.0 days, p = 0.012). In a logistic regression model, Charlson score ≥1 point [odds ratio (OR) 3.4, 95 % confidence interval (CI) 1.6-7.0, p = 0.001], antibiotics usage during the previous year (OR 3.1, 95 % CI 1.4-7.2, p = 0.008), and urinary catheterization during the previous month (OR 4.4, 95 % CI 1.1-17.6, p = 0.035) were associated with the risks of CA-APN by ESBL producers. CTX-M-15 (48 %) and CTX-M-14 (38 %) were the most common ESBLs. ST131 was the most common clone (7/24, 29.1 %), which was more frequently resistant to cefepime, fosfomycin, and temocillin.

CONCLUSIONS

The risk factors for CA-APN by ESBL producers were Charlson score ≥1 point, antibiotics usage during the previous year, and urinary catheterization during the previous month.

Epidemiology of Clostridium difficile infections in a tertiary-care hospital in Korea

To survey healthcare-associated Clostridium difficile infection (HA-CDI) in a 900-bed tertiary-care hospital, we prospectively investigated the epidemiology of CDI and distribution of PCR-ribotypes. From February 2009 through January 2010, all patients with HA-CDI were enrolled. Epidemiological information and prescription records for antibiotics were collected. The C. difficile isolates were characterized using reference strains and were tested for antibiotic susceptibility. During the survey, incidence of HA-CDI was 71.6 per 100 000 patient-days. In total, 140 C. difficile isolates were obtained from 166 patients with HA-CDI. The PCR-ribotyping yielded 38 distinct ribotypes. The three most frequently found ribotypes made up 56.4% of all isolates; they comprised 37 isolates (26.4%) of PCR-ribotype 018, 22 (15.7%) of toxin A-negative PCR-ribotype 017, and 20 (14.3%) of PCR-ribotype 001. Clostridium difficile PCR-ribotype 018 was present in all departments throughout the hospital during the 11 months, whereas ribotype 017 and ribotype 001 appeared mostly in the pulmonary department. Hypervirulent C. difficile PCR-ribotype 027 was detected in 1 month on two wards. The incidence of CDI in each department showed a seven-fold difference, which correlated significantly with the amount of prescribed clindamycin (R = 0.783, p 0.013) or moxifloxacin (R = 0.733, p 0.025) in the departments. The rates of resistance of the three commonest ribotypes to clindamycin and moxifloxacin were significantly higher than those of other strains (92.1% versus 38.2% and 89.5% versus 27.3%, respectively). CDI is an important nosocomially acquired infection and this study emphasizes the importance of implementing country-wide surveillance to detect and control CDI in Korea.

Barriers to conducting clinical research in reproductive medicine: India

Research in India is evolving at a rapid pace. Ergo, we need faster approval processes and review timelines. Improvement in the quality of institutional review boards would also contribute to good research practices. Clinical research should be included as a part of the undergraduate medical and pharmacy curriculum, and leading hospitals and practitioners should openly endorse research.

Congenital angiomyoma of the tongue: case report

Angiomyomas of the oral cavity are rare benign vascular neoplasms. In particular, the congenital form has not been reported before in the English language literature. We present a congenital angiomyoma of the tongue that was found on the posterior middle of the tongue in an infant. On MRI, the mass showed an isointense signal to muscle on the T₁ weighted image and a slightly hyperintense signal on the T₂ weighted image. Immunohistochemically, tumour cells were positive to desmin and smooth muscle actin, but negative to vimentin and S100. The treatment was surgical excision and no recurrence was found during the 26 month follow-up period.

Population-based study of biochemical and survival outcomes after permanent 125I brachytherapy for low- and intermediate-risk prostate cancer

OBJECTIVES

To analyze the biochemical and survival outcomes after permanent low-dose-rate prostate brachytherapy in a large, consecutive, population-based cohort of patients.

METHODS

A total of 1006 consecutive implants were performed from July 20, 1998 to October 23, 2003 for men with low-risk and "low-tier" intermediate-risk prostate cancer. The prescribed minimal peripheral dose was 144 Gy, using 0.33 mCi (125)I sources and a preplan technique with a strong posterior-peripheral dose bias. Most patients (65%) had received 6 months of androgen deprivation therapy. Supplemental external beam radiotherapy was not used. The prognostic features, dose metrics, and follow-up data were prospectively collected. Kaplan-Meier and Cox regression analyses were used to assess the factors associated with freedom from biochemical recurrence and survival.

RESULTS

The median patient age at treatment was 66 years. The median follow-up was 54 months for biochemical outcomes and 66 months for survival. The actuarial freedom from biochemical recurrence rate was 95.6% +/- 1.6% at 5 years and 94.0% +/- 2.2% at 7 years. On multivariate analysis, the pretreatment prostate-specific antigen level (P = .03) and androgen deprivation therapy use (P = .04) were predictive of the freedom from biochemical recurrence. The actuarial rates of distant metastasis and disease-specific death at 5 years were both <1%. The overall survival rate at 5 years was 95.2% +/- 1.4% and was 93.4% +/- 1.8% at 7 years. On multivariate analysis, only age was predictive of overall survival (P = .011).

CONCLUSIONS

When consistently planned and delivered, low-dose-rate brachytherapy, without supplemental external beam radiotherapy or intraoperative planning, can produce cancer-specific outcomes for men with low- and "low-tier" intermediate-risk prostate cancer at least equal to that produced by dose-escalated external beam radiotherapy or surgical prostatectomy.

Role of hysteroscopy prior to assisted reproductive techniques

BACKGROUND

There have been numerous advances in the area of assisted reproduction. Among the various reasons of implantation failure, intrauterine lesions play an important role.

OBJECTIVE

The aim of the present study is to evaluate the role of hysteroscopy prior to any assisted reproductive technique.

MATERIALS AND METHODS

It is a retrospective study of 292 women who attended our infertility clinic over a period of 18 months, who had a variable number of failed IVF cycles previously.

RESULTS

Out of the 292 women studied, in 74 women, that is 25%, intrauterine pathology was detected, which when rectified by hysteroscopy, gave a considerable increase in pregnancy rate.

CONCLUSION

According to this study it can be concluded that evaluating the uterine cavity is an important step before any assisted reproductive procedures.

A feasibility study of an intensive combined modality smoking cessation program in the radiation oncology clinic

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Background: Radiotherapy (RT) patients present for daily treatment over many weeks, often accompanied by friends and family. This represents a unique opportunity for intensive smoking intervention concurrently with RT in both cancer patients and their companions. Methods: Eligible participants included smoking cancer patients scheduled to receive = 3 weeks of RT and their smoking family/friends. All participants received bupropion and 9 individualized behavioral interventions (BI) in the RT clinic with an addiction professional, followed by 9–12 scheduled intensive relapse prevention encounters (in person or by telephone). The primary endpoint was feasibility determined by accrual and program completion. Other endpoints included carbon-monoxide (CO) confirmed and participant-reported tobacco abstinence. During 4 months of enrollment, smoking and basic eligibility data were prospectively collected on consultations seen in clinic. Results: Over 8 months 20 cancer patients and 3 family members were enrolled. Based on our sampling, this represented greater than 40% of eligible smokers seen in clinic. Six cancer patients withdrew, all on or before the third BI. 13 participants completed all 9 BIs while 4 patients completed 7–8 BIs. 11 participants reported compliance with bupropion therapy. One participant discontinued bupropion citing increased depression. No other possible adverse events to bupropion or BI were discovered. At the completion of BI, 16 participants had exhaled CO concentrations < 10ppm and 14 participants self-reported tobacco abstinence. Of the 17 participants completing 7–9 behavioral interventions, the median number of relapse prevention sessions was 4 (range 0–8). With a median follow-up of 5.85 months, the 3-month crude self-reported abstinence rate was 41% (7/17). Conclusions: Tobacco cessation with bupropion and intensive BI for cancer patients and their companions during RT was feasible. A significant number of eligible smokers enrolled and completed BI during RT. However, few participants completed scheduled prevention encounters following RT.

No significant financial relationships to disclose.

The expression of NMDA receptor 1 is associated with clinicopathological parameters and prognosis in the oral squamous cell carcinoma

BACKGROUND

Glutamate activates the N-methyl-d-aspartate (NMDA) receptors and this receptor is involved in the proliferation and migration of various tumour cells in vitro. However, the relationship between NMDA receptor expression and clinical parameters in cancer patients is unclear. Therefore, NMDA receptor 1 (NMDAR1) expression along with its clinical significance was examined in patients with oral squamous cell carcinoma (OSCC).

METHODS

Eighty-one tumour specimens from OSCC patients were used to determine the NMDAR1 expression level by immunohistochemical staining. The control was obtained from a matched normal adjacent mucosa. The cases were considered to be positive if reactivity was displayed in >25% of the cells.

RESULTS

The NMDAR1 reactivity was positive in 50 of 81 cases, while it was negative in the control. NMDAR1 expression was significantly associated with a lymph node metastasis (P = 0.008), the tumour size (P < 0.001), and the cancer stage (P = 0.034). The patients whose tumours expressed NMDAR1 had a significantly poorer survival than the patients who were NMDAR1-negative (log-rank = 6.45, d.f. = 1, P = 0.011).

CONCLUSIONS

The NMDAR1 overexpression was significantly associated with the prognosis-related factors. Therefore, it might be one of the prognostic markers of OSCC.

Evolution of TEM-related extended-spectrum beta-lactamases in Korea

TEM-52, differing from TEM-1 by having the substitutions Glu-104-->Lys, Met-182-->Thr, and Gly-238-->Ser, has previously been described as the most prevalent extended-spectrum beta-lactamase (ESBL) in Korea. In a further survey, we discovered the ESBLs TEM-15, which is like TEM-52 but lacks the substitution at residue 182, and TEM-88, which is like TEM-52 with an additional Gly-196-->Asp substitution. TEM-88 retained the activity of TEM-52 against moxalactam. Otherwise, the kinetic properties of the three ESBLs failed to show an advantage to this evolution.