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.

Does Varicocele Repair Improve Conventional Semen Parameters? A Meta-Analytic Study of Before-After Data

PURPOSE

The purpose of this meta-analysis is to study the impact of varicocele repair in the largest cohort of infertile males with clinical varicocele by including all available studies, with no language restrictions, comparing intra-person conventional semen parameters before and after the repair of varicoceles.

MATERIALS AND METHODS

The meta-analysis was performed according to PRISMA-P and MOOSE guidelines. A systematic search was performed in Scopus, PubMed, Cochrane, and Embase databases. Eligible studies were selected according to the PICOS model (Population: infertile male patients with clinical varicocele; Intervention: varicocele repair; Comparison: intra-person before-after varicocele repair; Outcome: conventional semen parameters; Study type: randomized controlled trials [RCTs], observational and case-control studies).

RESULTS

Out of 1,632 screened abstracts, 351 articles (23 RCTs, 292 observational, and 36 case-control studies) were included in the quantitative analysis. The before-and-after analysis showed significant improvements in all semen parameters after varicocele repair (except sperm vitality); semen volume: standardized mean difference (SMD) 0.203, 95% CI: 0.129-0.278; p<0.001; I²=83.62%, Egger's p=0.3329; sperm concentration: SMD 1.590, 95% CI: 1.474-1.706; p<0.001; I²=97.86%, Egger's p<0.0001; total sperm count: SMD 1.824, 95% CI: 1.526-2.121; p<0.001; I²=97.88%, Egger's p=0.0063; total motile sperm count: SMD 1.643, 95% CI: 1.318-1.968; p<0.001; I²=98.65%, Egger's p=0.0003; progressive sperm motility: SMD 1.845, 95% CI: 1.537%-2.153%; p<0.001; I²=98.97%, Egger's p<0.0001; total sperm motility: SMD 1.613, 95% CI 1.467%-1.759%; p<0.001; l2=97.98%, Egger's p<0.001; sperm morphology: SMD 1.066, 95% CI 0.992%-1.211%; p<0.001; I²=97.87%, Egger's p=0.1864.

CONCLUSIONS

The current meta-analysis is the largest to date using paired analysis on varicocele patients. In the current meta-analysis, almost all conventional semen parameters improved significantly following varicocele repair in infertile patients with clinical varicocele.

Technical Aspects and Clinical Limitations of Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

PURPOSE

Sperm DNA fragmentation (SDF) is a functional sperm abnormality that can impact reproductive potential, for which four assays have been described in the recently published sixth edition of the WHO laboratory manual for the examination and processing of human semen. The purpose of this study was to examine the global practices related to the use of SDF assays and investigate the barriers and limitations that clinicians face in incorporating these tests into their practice.

MATERIALS AND METHODS

Clinicians managing male infertility were invited to complete an online survey on practices related to SDF diagnostic and treatment approaches. Their responses related to the technical aspects of SDF testing, current professional society guidelines, and the literature were used to generate expert recommendations via the Delphi method. Finally, challenges related to SDF that the clinicians encounter in their daily practice were captured.

RESULTS

The survey was completed by 436 reproductive clinicians. Overall, terminal deoxynucleotidyl transferase deoxyuridine triphosphate Nick-End Labeling (TUNEL) is the most commonly used assay chosen by 28.6%, followed by the sperm chromatin structure assay (24.1%), and the sperm chromatin dispersion (19.1%). The choice of the assay was largely influenced by availability (70% of respondents). A threshold of 30% was the most selected cut-off value for elevated SDF by 33.7% of clinicians. Of respondents, 53.6% recommend SDF testing after 3 to 5 days of abstinence. Although 75.3% believe SDF testing can provide an explanation for many unknown causes of infertility, the main limiting factors selected by respondents are a lack of professional society guideline recommendations (62.7%) and an absence of globally accepted references for SDF interpretation (50.3%).

CONCLUSIONS

This study represents the largest global survey on the technical aspects of SDF testing as well as the barriers encountered by clinicians. Unified global recommendations regarding clinician implementation and standard laboratory interpretation of SDF testing are crucial.

Pediatric testicular posttraumatic dislocation presenting as a testicular torsion: A case report

Traumatic dislocation of the testicle is a rare complication that occurs after blunt trauma to the scrotum or abdominopelvic injury. The majority of cases occur in young adults following severe scrotal trauma in a motorcycle accident. We report the case of a 1.5-year-old infant admitted for left scrotal swelling with a left inguinal mass. Ultrasound and Doppler examination showed a twisted necrotic testicle with inguinal adenopathy. Surgical exploration in the emergency room confirmed that the inguinal mass was a dislocated testicle with an intrascrotal hematoma that was evacuated followed by orchidopexy of the dislocated testicle.

Thrombosis of the deep dorsal vein of the penis caused by vaccine-induced thrombotic thrombocytopenia: First reported case

The first described case of deep dorsal vein thrombosis of the penis secondary to vaccine-induced thrombotic thrombocytopenia (VITT), a complication of COVID adenoviral vector vaccines. The patient reported pain in the penis one month after vaccination. On ultrasound, a deep dorsal vein thrombosis was found and a biological workup was ordered to confirm the VITT trail. Anticoagulant therapy was immediately initiated and the patient responds well while suffering from erectile dysfunction. VITT is a potentially serious event that can be life-threatening; every practitioner should know how to deal with it.

Knotted double j ureteral stent: a case report and literature review

Many complications due to double j (DJ) stent placement have been reported. DJ stent knotting is a rare complication, with only a few cases reported in the literature. We presented a case of DJ stent knotting and reviewed the literature regarding this complication. We reported a 20-year-old man with a history of cystinuria and ureteral stone managed with retrograde ureteroscopy and holmium laser three months ago. The patient comes for DJ stent removal. Firstly, we tried to remove the DJ stent via the cystoscopic procedure, which failed. A fluoroscopic image revealed a knotted DJ stent lodged at the ureteropelvic junction and was removed via holmium laser ureteroscopic procedure without complications. In conclusion, when cystoscopic procedure with simple traction fails to remove DJ stents, multimodality urological procedures such as holmium laser should be tried, especially in patients with urolithiasis predisposing factors.

Halothermal and hydrothermal time models describe germination responses of canola seeds to ageing

Hydrothermal time (HTT) and halothermal time (HaloTT) models were used to quantitatively characterize the combined effects of temperature (T), water potential (ψ) and NaCl concentration on seed germination of canola after different accelerated ageing periods (AAP) at 42 °C and 100% humidity. Seed germination time courses were observed and electrical conductivities of seed leachates were measured in all experiments. The cardinal temperatures estimated by both models were 4.6, 28 and 35 °C for the base (T_b ), optimum (T_o ) and ceiling (T_c ) temperatures in water (0 MPa), respectively, when the seeds were not aged. The T_b increased with AAP, while the T_c decreased and the T_o remained constant at all AAP. Below T_o , the median base water potentials (ψ_b (50)) were -1.07, -0.73, -0.48 and -0.39 MPa for the AAP levels of 0, 24, 36 and 48 h, respectively. These values were more negative when germination occurred in salt solutions (the base NaCl concentrations converted to ψ were -1.25, -0.81, -0.51 and -0.41 MPa, respectively), due to uptake of salt ions. Thresholds became more positive above T_o and reached zero at T_c in all AAP. Seed osmotic adjustment capacity declined linearly with increasing AAP while the conductivity of seed leachates increased in association with the loss of seed vigour. Significant correlations between conductivity results and the parameters of HTT and HaloTT models suggest that they could be considered as effective descriptors of canola seed vigour.

Does maxillary advancement alter vocal acoustic parameters in class III skeletal patients?

Any change in the maxillary position can affect the length of the vocal tract. This cross-sectional study aimed to assess the vocal acoustic parameters in 24 class III skeletal patients who underwent Le Fort I osteotomy for maxillary advancement. The vocal acoustic parameters (fundamental frequency, and jitter and shimmer perturbation indexes) were studied before, and at three, seven, and 10 months after maxillary advancement. The age and gender of the patients were the variables of the study. The amount of maxillary advancement was the predictive factor, and the changes in vocal acoustic parameters the study outcomes. Repeated-measures ANOVA were used to analyse the vocal acoustic parameters at different time points. Mean (SD) maxillary advancement was 3.5 (0.59) mm (range 3 - 6 mm). Data analysis did not demonstrate any significant correlation between the mean amount of maxillary advancement and changes in vocal acoustic parameters except for frequency of the 'i' sound. The results did not show a substantial change in the vocal acoustic parameters at 10 months after orthognathic surgery compared with baseline. These changed at three and seven months, but had returned to their baseline preoperative state 10 months after surgery.

Characterization of a xenograft model for anti-CD19 CAR T cell studies

PURPOSE

Chimeric antigen receptor (CAR) T cell development for B cell malignancies treatment has triggered a paradigm shift in oncology. The development of anti-CD19 CAR T cells relies primarily on a panel of cell line-derived xenograft models, including Raji cells; however, the behavior of this model is under debate. We attempted to characterize this lymphoma model and propose outcome measures for CAR T cell studies METHODS: Raji cell line was inoculated into NOG mice via intra-venous (IV), intra-peritoneal (IP), and subcutaneous (SC) routes with different inoculum sizes, and consequent clinical and histopathological outcomes were assessed.

RESULTS

Inoculum sizes of 10⁵-10⁶ resulted in a complete take rate. The mice with IV and SC-inoculated Raji cells presented the shortest and longest survival among lymphoma-bearing mice, respectively (P < 0.01). The IP group had the highest number of both infiltrated organs (P < 0.05; compared to SC) and involvement of lymphatic sites (P < 0.05; compared to IV). The number of lymphoma lesions on the liver was higher in the IV compared to IP (P < 0.001) and SC (P < 0.05).

CONCLUSION

We demonstrate that the Raji cell line inoculation route could determine the xenograft model system behavior in terms of survival, tumor burden, and dissemination pattern and gives the model the specific features suitable for testing the specific hypothesis in CAR T cell therapy. We also conclude outcome measures for CAR T cell studies that do not require imaging techniques.

Centrifugal Detachment of Compound Droplets from Fibers

This article presents the first experimental-computational study on the centrifugal detachment of a compound droplet (e.g., a primary water droplet cloaked by an immiscible oil) from a fiber. The work was intended to establish a method for quantifying the force needed to detach compound droplets of different compositions from a fiber. More importantly, our study was aimed at improving the understanding of the interplay between interfacial and external forces acting on a compound droplet during forceful detachment. The experiments were conducted using DI water, for the primary droplet, and silicone or mineral oil, for the cloaking fluid. It was observed from the experiments that the silicone-oil-cloaked droplets behave differently from the mineral-oil-cloaked droplets. It was also observed that detachment force decreases with increasing the oil-to-water volume ratio. The simulations were performed using the Surface Evolver (SE) finite element code programmed for the complicated four-phase (air, water, oil, and solid) interfacial problem at hand. Our simulations revealed the evolution of the interfacial forces between the interacting phases under an increasing external body force on the droplet. The simulations also allowed us to define effective interfacial tensions and contact angles for detaching compound droplets, for the first time. Reasonable agreement was observed between the experimental measurements and computational results.

Evaluation of the effect of endoscopic partial middleturbinectomy surgery on the quality of life of patients with chronic rhinosinusitis and nasal polyps

BACKGROUND

Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease. Endoscopic sinus surgery is recommended as a standard method when medical treatment fails. The effectiveness of various complementary surgical methods such as endoscopic partial middle-turbinectomy is controversial in the improvement of CRS symptoms in these patients. This study aimed to investigate the effect of endoscopic partial middle-turbinectomy on the quality of life (QOL) of patients with chronic rhinosinusitis and nasal polyps (CRSwNP) in Iran.

METHOD

Ninety patients with CRSwNP of grades 3 and 4 were randomly assigned to either an intervention (45 patients) or control group (45 patients). In the control group, endoscopic sinus surgery without middle turbinectomy was performed and in the intervention group, endoscopic partial middle-turbinectomy was performed in addition to endoscopic sinus surgery. To evaluate the outcomes, the SNOT-22 QOL questionnaire was used, and the results were analyzed using SPSS version 24.

RESULTS

Most of the patients were male and had a mean age of 39 years. The mean SNOT-22 QOL questionnaire scores were 49.13 ± 16.72 and 52.51 ± 16.95 before surgery in the control and intervention groups respectively, which did not show any significant difference. In contrast, after endoscopic surgery these scores changed to 28.46 ± 12.38 and 11.13 ± 5.55 in the control and intervention groups, respectively and there was a significant difference between both groups. Although there was a significant improvement in both groups, the patients in the intervention group experienced more improvement than the control group (41.4 (± 16.46)) vs 30.7 (±18.27), respectively CONCLUSION: According to this study, it appears that the use of endoscopic partial middle-turbinectomy in addition to endoscopic sinus surgery improves CRS symptoms and the QOL of patients compared with endoscopic sinus surgery alone.

Molecular genetic diagnosis of Glanzmann syndrome in Iranian population; reporting novel and recurrent mutations

BACKGROUND

Glanzmann thrombasthenia (GT) is a rare autosomal recessive abnormality of platelet aggregation with quantitative and/or qualitative abnormality of αIIbβ3 integrin. The αIIbβ3 is a platelet fibrinogen receptor, which is required for platelet aggregation, firm adhesion, and also spreading. The disease is more prevalent in the populations with a higher rate of consanguineous marriages as in some Middle Eastern populations including Iraq, Jordan, and Iran. Different types of mutations in ITGA2B and ITGB3 genes have been previously reported to cause the disease.

RESULT

In this study, 16 patients with the clinical diagnosis of GT were studied. Direct sequencing of the exons and exon-intron boundaries of the above genes revealed mutations in 14 patients (detection rate: 87.5%). Briefly, out of fifteen types of identified mutations, 14 were novel. Seven mutations in the ITGB3 gene included 4 missense [c.2T > C, c.155 G > T, c. 538 G > A, c.1990 G > T], one nonsense mutation [c.1303 G > T], a small deletion [c.1656_1658delCTC] and a deletion of one nucleotide [c.401delA]. Mutations in the ITGA2B were 8 different mutations consisting 2 missense [c.286 T > A, c.842 C > T], 2 deletions [c.1899 del T, c.189-319_236del], an insertion [c.1071_1072insG] and one splice site mutations [c.409-3 C > G], one synonymous mutation that might alter the normal splicing process [c.1392 A > G] and a nonsense mutation [c.1555 C > T]. The causative mutation in 2 patients remained unknown. Using long-range PCR and sequencing, we found a rather large deletion. The break point of this deletion covers 319 nt from the last part of the first intron and 48 nt from the beginning of the second exon of ITGA2B gene. The deletion was also detected in two unrelated patients with the same ethnicity. In addition, in silico analyses of novel mutations were performed.

CONCLUSION

There was no recurrent mutation in the studied population. This may be due to either small sample size or the heterogeneity of the studied population.

Droplet Mobility on Hydrophobic Fibrous Coatings Comprising Orthogonal Fibers

Water droplet mobility on a hydrophobic surface cannot be guaranteed even when the droplet exhibits a high contact angle (CA) with the surface. In fact, droplet mobility on a surface, especially a fibrous surface, has remained an unsolved empirical problem. This paper is a combined experimental-computational study focused on droplet mobility on a fibrous surface. Electrospun polystyrene (PS) coatings were used in this work for their ability to exhibit high CAs simultaneously with low droplet mobility. To simplify this otherwise complicated problem and better isolate droplet-fiber interactions, the orientation of the fibers in the coatings was limited to the x and y directions. As the earth gravity was not strong enough to mobilize small droplets on PS coatings, experiments were conducted using ferrofluid droplets, and a magnet was used to make them move on the surface. Experimentally validated numerical simulations were used to enhance our understanding of the forces acting on a droplet before moving on the surface. Effects of Young-Laplace CA and fiber-fiber spacing on droplet mobility were investigated. In particular, it was found that droplet mobility depends strongly on the balance of forces exerted on the droplet by the fibers on the receding and advancing sides.

Robust watermarking in non-ROI of medical images based on DCT-DWT

Increasing demand and utilization of telemedicine require transmission of medical information and images over internet. Since authenticity of received images is crucial and patient's information should be included with minimum changes in images, robust watermarking schemes are needed. In this paper, we propose a robust watermark method that embeds patient's information outside the region of interest (ROI) in medical image. In order to find appropriate regions for embedding, we use saliency as a means of measuring importance of regions and find blocks having minimum overlap with the ROI. The algorithm employs wavelet transform and also discrete cosine transform (DCT) domains in the embedding stage and redundantly embeds watermark to increase robustness against possible alterations. Moreover, voting is utilized in the extraction phase. Experimental results show the efficiency of the proposed method and better results are obtained as compared to comparable methods with same size of the watermarked data.

Circulating levels of interleukin-35 in patients with multiple sclerosis: evaluation of the influences of FOXP3 gene polymorphism and treatment program

The regulatory T (Treg) cells play a major role in the control of the autoimmunity and inflammation, and IL-35 has been described as an immunosuppressive cytokine that is mainly produced by CD4(+)FOXP3(+) Treg cells. The aim of this study was to evaluate the serum levels of IL-35 and a single nucleotide polymorphism (SNP), rs3761548, in FOXP3 gene in patients with multiple sclerosis. The blood samples were collected from 140 multiple sclerosis (MS) patients (including 51 untreated and 89 treated patients) and 140 healthy subjects as a control group. The serum levels of IL-35 were measured by ELISA. The DNA was analyzed for SNP rs3761548 in FOXP3 gene using SSP-PCR. There was no significant difference between untreated MS patients and control group regarding the mean serum levels of IL-35, although this parameter was higher in untreated patients. However, the mean serum level of IL-35 in treated MS patients was significantly higher than that in the control group (P < 0.008). The mean serum levels of IL-35 in patients who were treated with interferon-β, methylprednisolone, or with the both interferon-β and methylprednisolone were significantly higher than that in the healthy group (P < 0.01, P < 0.01, and P < 0.2, respectively). The frequencies of AA and AC genotypes at rs3761548 in the FOXP3 gene were significantly higher in MS group as compared with healthy subjects (P < 0.05). The frequency of CC genotype at rs3761548 was significantly lower in the MS group in comparison with healthy control subjects (P < 0.001). Moreover, the frequency of A allele was significantly higher whereas the frequency of C allele was significantly lower in MS patients in comparison to healthy subjects (P < 0.001). The mean serum level of IL-35 was significantly lower in MS patients or healthy subjects with AA genotype as compared with those with CC genotype at rs3761548 in FOXP3 gene (P < 0.01 and P < 0.001, respectively). These results showed higher serum levels of IL-35 in treated MS patients representing that the benefit effects of treatment may in part performed through the upregulation of the IL-35 production. The SNP rs3761548 may influence the susceptibility to MS disease and the serum levels of IL-35.

Chemical composition of essential oil of Ferulago macrocarpa (Fenzl) Boiss. fruits

Water-distilled essential oil of Ferulago macrocarpa (Umbelliferae) fruits was analyzed using GC-MS for the first time. Forty-two components comprising 99.5% of the total oil were identified, of which bornyl acetate (40.8%), 2,3,6-trimethyl benzaldehyde (7.2%), δ-selinene (5.5%), 1,10-di-epi-cubenol (5.1%), germacrene D (3.5%), β-phellandrene (3.5%) and α-pinene (3.4%) were found to be the major components. The oil of F. macrocarpa fruits consisted of 15 monoterpene hydrocarbons (21.4%), 6 oxygenated monoterpenes (42.2%), 17 sesquiterpene hydrocarbons (22.4%) and one oxygenated sesquiterpene (5.1%). Three benzenoid derivatives also comprised 8.4% of the oil. Monoterpenes and sesquiterpenes comprised 63.6% and 27.5% of the F. macrocarpa fruits essential oil respectively; however, bornyl acetate (40.8%) was identified as the most abundant component of the oil.

Iranian Azeri's Y-Chromosomal Diversity in the Context of Turkish-Speaking Populations of the Middle East

BACKGROUND

The main goal of this study was to conduct a comparative population genetic study of Turkish speaking Iranian Azeries as being the biggest ethno-linguistic community, based on the polymorph markers on Y chromosome.

METHODS

One hundred Turkish-speaking Azeri males from north-west Iran (Tabriz, 2008-2009) were selected based on living 3 generations paternally in the same region and not having any relationship with each other. Samples were collected by mouth swabs, DNA extracted and multiplex PCR done, then 12 Single Nucleotide Polymorphisms (SNPs) and 6 Microsatellites (MS) were sequenced. Obtained data were statistically analyzed by Arlequin software.

RESULTS

SNPs and Microsatellites typing were compared with neighboring Turkish-speaking populations (from Turkey and Azerbaijan) and Turkmens representing a possible source group who imposed the Turkish language during 11-15(th) centuries AD. Azeris demonstrated high level of gene diversity compatible with patterns registered in the neighboring Turkish-speaking populations, whereas the Turkmens displayed significantly lower level of genetic variation. This rate of genetic affiliation depends primarily on the geographic proximity.

CONCLUSION

The imposition of Turkish language to this region was realized predominantly by the process of elite dominance, i.e. by the limited number of invaders who left only weak patrilineal genetic trace in modern populations of the region.

The Study of Total IgE Reference Range in Healthy Adults in Tehran, Iran

BACKGROUND

IgE is an antibody class that regarded as an important factor in the pathogenesis of allergic diseases, asthma, immune responses to parasitic infection and it could be responsible for the late- phase allergic response. The objective of this study was to evaluate total IgE in healthy Iranian adults, establishment of reference range of total IgE and assess helpfulness of this value in clinical diagnosis atopic and allergic diseases.

METHOD

Three hundred sixty six healthy adults from blood transfusion volunteers (18 to 60 years) were selected in this study. A specific questionnaire (including demographic factors, smoking status and …) was filled out for each person. Also, we evaluated effect of race and education on total IgE. These adults had no history of allergic disease. The total serum IgE level using a commercial enzyme immunoassay and CBC (Eosinophil count) was determined in them.

RESULTS

Mean of age was 37.32± 10.93 yrs and 219 cases were males and 147 females. The geometric mean of total IgE was 20.84 IU/ml (2-373 IU/ml) (95% percentile= 250) (95% confidence interval=46.27-62.70). No differences was observed between mean of IgE log in males and females (P= NS) but mean of total IgE log in females is more than males.

CONCLUSION

Normal range of serum total IgE obtained in this study could be helpful for diagnosis of IgE-dependent allergic disease, as reference ranges in Iranian healthy adults.

[Lobular intra-epithelial neoplasia: atypical lobular hyperplasia and lobular carcinoma in situ]

OBJECTIVE

To review main knowledge about lobular intra-epithelial neoplasia with special interest for daily practice management.

MAIN RESULTS

Intra-epithelial lobular neoplasias (ILN) are non invasive proliferations within the terminal ducto-lobular unit of monomorphic loosely cohesive small cells. A lack of expression of the E-cadherin adhesion molecule is often observed as in invasive lobular breast cancer. ILN are infrequent, however, a rise in incidence partly, due to the generalization of mammographic screening, is observed. Actually ILN are usually asymptomatic and diagnosed after breast biopsy for unspecified microcalcifications. ILN are associated with an increased risk of breast cancer that persists over 20 years after the initial diagnosis. The average risk is 4.2 % for the ipsilateral breast and 3,5 % for the controlateral breast. However, a great variability in the risk estimation is observed between the studies. There is no consensus on how to treat ILN. Surgical options have varied from biopsy to bilateral mastectomy. Current tendency is favouring lumpectomy.

Frequency of ABO blood group in peptic ulcer disease in Iranian subjects

The relationship between ABO blood group distribution and Peptic Ulcer Disease (PUD) has been widely evaluated in the past. But data concerning the same evaluation are very limited in Iran. This study sought to determine the distribution of ABO blood group in patients with PUD in Iranian subjects. Eighty-one patients with PUD (51 male and 30 female; mean age: 49 +/- 18 years) who attended our endoscopy section were enrolled. Blood samples were used for ABO/Rhesus (Rh) blood group antigen typing. The ABO blood group phenotype distribution in subjects was as follows: 37.1% (30/81) for group A, 23.4% (19/81) for group B, 35.6% (28/81) for group O and 4.9% (4/81) for group AB. Rh positivity was found in 63% (51/81) of patients. In local healthy population, ABO/Rh blood group distribution was 33.8, 20.7, 34.7, 8.4 and 89.6% for A, B, O, AB and Rh, respectively. AB blood group distribution in healthy population was higher than PUD (8.4 vs 4.9%). In contrast, Rh positivity of PUD in Iran is lower than healthy subjects (63 vs 89.6%). Variation in the results of studies is related to different study communities. According to these results, probably ABO/Rh blood group has an important role in patients with peptic ulceration. The functional significance of ABO blood group distribution might be associated with biological behavior of PUD. The impact of blood group on PUD may be a focus for further studies.

Spoligotyping of Mycobacterium tuberculosis in anthracotic bronchitis

BACKGROUND

Mycobacterium tuberculosis infection has been shown to be associated with anthracotic bronchitis. However, the typical manifestation of infection is not usually present in infected patients, which raises the question of whether a particular strain of M. tuberculosis is associated with this group of patients.

OBJECTIVE

To determine whether a particular strain of M. tuberculosis is associated with anthracotic bronchitis.

DESIGN

We assessed the predominant space oligonucleotide (spoligotype) patterns of M. tuberculosis complex isolated from patients with anthracotic bronchitis and compared the results with tuberculosis (TB) subtype patterns in Iran and other countries.

RESULTS

During a 7-month period (April--October 2006), we enrolled 87 patients (30 men and 57 women) with anthracotic bronchitis, 26% (n = 23) of whom had TB. Spoligotyping of M. tuberculosis among these 23 patients showed four distinct patterns: East-African-Indian (11, 47.8%) and Central-Asian (7, 30.4%), Haarlem I (4, 17.4%) and T-1 (1, 4.3%). When compared with spoligotype patterns of M. tuberculosis in Middle Eastern countries, including Iran, anthracotic bronchitis had similar patterns.

CONCLUSION

Our results indicate that the atypical manifestations of TB in anthracotic patients are not caused by any particular subtypes of M. tuberculosis. We conclude that anthracotic bronchitis is actually an atypical presentation of tuberculous infection with common subtypes inside the bronchial mucosa.

Lipomatose médiastinale précoce

BACKGROUND

Corticosteroid-induced lipomatosis results from hypertrophy within adipose tissue; the condition is frequently asymptomatic and its incidence is underestimated. We report a case of mediastinal lipomatosis that is rare in terms of both site and presenting symptoms.

CASE REPORT

A 46-year-old woman with no disease history other than obesity with a weight of 90 kg had been treated since 2002 for mixed connective tissue disease (profound lupus and dermatomyositis). She had been treated with oral corti costeroids (1 mg/kg/d). Two months after the start of treatment, she presented chest pains, resting dyspnea particularly aggravated in dorsal decubitus, chest edema in the subclavicular space and jugular turgescence. Chest x-ray revealed widening of all levels of the mediastinum. The chest CT scan showed lipomatosis throughout the entire mediastinum with no associated chest abnormalities or pericardial effusion. Rapid downward dosage adjustment ofcorticosteroids to 10 mg/d coupled with synthetic antimalarials resulted in gradual reduction of symptoms. The chest scan performed two months later short stabilization of the patient's mediastinal lipomatosis.

DISCUSSION

The effects of long-term of glucocorticosteroid therapy are well-known, in particular Cushing's syndrome. Lipomatosis has been described more recently and affects different axial regions. Mediastinal localization is seen in 15% of patients treated. This presentation is less common than orbital and epidural localizations. Although often asymptomatic, as in our own report, it may present with worrying symptoms that pose real diagnostic problems. The diagnostic examinations of choice are CT scan or MRI. Regression following discontinuation or reduction of corticosteroids is inconsistent and often gradual.

Association concomitante préopératoire de radiothérapie et de chimiothérapie dans les cancers du col utérin opérables de stades IB2, IIA et IIB proximal de gros volume

PURPOSE

To evaluate preliminary results in terms of toxicity, local tumour control, and survival after preoperative concomitant chemoradiation for operable bulky cervical carcinomas.

PATIENTS AND METHODS

Between December 1991 and October 2001, 42 patients (pts) with bulky cervical carcinomas stage IB2 (11 pts), IIA (15 pts), and IIB (16 pts) with 1/3 proximal parametrial invasion. Median age was 45 years (range: 24-75 years) and clinical median cervical tumour size was 5 cm (range: 4.1-8 cm). A clinical pelvic lymph node involvement has been observed in 10 pts. All patients underwent preoperative external beam pelvic radiation therapy (EBPRT) and concomitant chemotherapy during the first and the fourth radiation weeks combining 5-fluorouracil and cisplatin. The pelvic dose was 40.50 Gy over 4.5 weeks. EBPRT was followed by low-dose-rate uterovaginal brachytherapy with a total dose of 20 Gy in 17 pts. After a rest period of 5-6 weeks, all pts underwent class II modified radical hysterectomy with bilateral lymphadenectomy. Para-aortic lymphadenectomy was performed in eight pts without pathologic para-aortic lymph node involvement. Twenty-one of 25 pts who had not received preoperative uterovaginal brachytherapy underwent postoperative low-dose-rate vaginal brachytherapy of 20 Gy. The median follow-up was 31 months (range: 3-123 months).

RESULTS

Pathologic residual tumour or lymph node involvement was observed in 23 pts. Among the 22 pts with pathologic residual cervical tumour (<0.5 cm: nine pts; >or=0.5 to <or=1 cm: three pts; >1 cm: 10 pts), seven underwent preoperative EBRT followed by uterovaginal brachytherapy vs. 15 treated with preoperative EBRT alone (P = 0.23). Four pts had pathologic lymph node involvement, three pts had vaginal residual tumour, and four pts had pathologic parametrial invasion. The 2- and 5-year overall survival rates were 85% and 74%, respectively. The 2- and 5-year disease-free survival (DFS) rates were 80% and 71%, respectively. After multivariate analysis, the pathologic residual cervical tumour size was the single independent factor decreasing the probability of DFS (P = 0.0054). The 5-year local control rate and metastatic failure rate were 90% and 83.5%, respectively. Haematological effects were moderate. However, six pts had grade 3 acute intestinal toxicity. Four severe late complications requiring surgical intervention were observed (one small bowel complication, three ureteral complications).

CONCLUSION

Primary concomitant chemoradiation followed surgery for bulky operable stage I-II cervical carcinomas can be employed with acceptable toxicity. However, systematic preoperative uterovaginal brachytherapy should increase local tumour control.

[Operable stage IB and II cancer of the uterine neck: retrospective comparison between preoperative utero-vaginal curietherapy and initial surgery followed by radiotherapy]

PURPOSE

To identify prognostic factors and treatment toxicity in a series of operable stages IB and II cervical carcinomas.

PATIENTS AND METHODS

Between May 1972 and January 1994, 414 patients (pts) with cervical carcinoma staged according to the 1995 FIGO staging system underwent radical hysterectomy with (n = 380) or without (n = 34) bilateral pelvic lymph node dissection. Lateral ovarian transposition to preserve ovarian function was performed on 12 pts. The methods of radiation therapy (RT) were not randomised and depended on the usual practices of the surgical teams. Group I: 168 pts received postoperative RT (64 pts received vaginal brachytherapy alone [mean total dose (MD): 50 Gy], 93 pts had external beam pelvis RT (EBPRT) [MD: 45 Gy over 5 weeks] followed by vaginal brachytherapy [MD: 20 Gy], and 11 pts had EBPRT alone [MD: 50 Gy over 6 weeks]. Group II: 246 pts received preoperative utero-vaginal brachytherapy [MD: 65 Gy], and 32 of theses 246 pts also received postoperative EBPRT [MD: 45 Gy over 5 weeks] delivered to the parametric and the pelvic lymph nodes with a midline pelvic shield. The mean follow-up was 106 months.

RESULTS

The 10-year disease-free survival (DFS) rate was 80%. From 75 recurrences, 35 were isolated locoregional. Multivariate analysis showed that independent factors decreasing the probability of DFS were: both exo and endocervical tumour site (p = 0.047), lymph-vascular space invasion (p = 0.041), age < or = 51 yr (p = 0.013), 1995 FIGO staging system (stage IB1 vs stage IIA, p = 0.004, stage IB1 vs stage IB2, p = 0.0009, and stage IB1 vs stage IIB with 1/3 proximal parametrical infiltration, p = 0.00002), and histological pelvic involved lymph nodes (p = 0.00009). Methods of adjuvant RT did not influence the probability of DFS (group I vs group II, p = 0.10). The postoperative complication rate was 10.2% in group I and 8.9% in group II (p = 0.7) but the postoperative urethral complication rate necessitating surgical intervention with reimplantation was lower in group I than in group II (0.6% vs 2.3%, respectively, p = 0.03). The 10-year rate for grade 3 and 4 late radiation complications according to the LENT-SOMA scoring system was 10.4%. EPRT significantly increased the 10-year rate for grade 3 and 4 late radiation complications (yes vs no: 22% vs 7%, respectively, p = 0.0002).

CONCLUSION

In our series, the methods of adjuvant RT (primary surgery vs preoperative uterovaginal brachytherapy) do not seem to influence the prognosis of the stage IB, IIA, and IIB (with 1/3 proximal parametrical involvement only) cervical carcinomas. The postoperative EPRT applied according to histopathological risk factors after surgical treatment increases the risk of late radiation complications.

BMP signaling regulates Nkx2-5 activity during cardiomyogenesis

Nkx2-5 regulates the transcription of muscle-specific genes during cardiomyogenesis. Nkx2-5 expression can induce cardiomyogenesis in aggregated P19 cells but not in monolayer cultures. In order to investigate the mechanism by which cellular aggregation regulates Nkx2-5 function, we examined the role of bone morphogenetic protein 4 (BMP4). We showed that the expression of the BMP inhibitor, noggin, was sufficient to inhibit the induction of cardiomyogenesis by Nkx2-5 during cellular aggregation. Furthermore, soluble BMP4 could activate Nkx2-5 function in monolayer cultures, resulting in the formation of cardiomyocytes. Therefore, BMP signaling is necessary and sufficient for the regulation of Nkx2-5 activity during cardiomyogenesis in P19 cells.