Very small pediatric donor kidney transplantation in pediatric recipients.

Kidneys from very small pediatric donors (age <5 years, weight <21 kg) may be a means to increase the donor pool for pediatric recipients. Transplantation of small pediatric kidneys is more commonly performed in adult recipients due to the increased risks of technical complications, thrombosis, and early graft failure. While these risks are abrogated in adult recipients by limiting the donor weight to ≥10 kg and using the EB technique, it is unknown whether pediatric recipients achieve comparable results. US national data were assessed for all first-time, deceased-donor, kidney-only pediatric recipients, 1/1996-10/2013, who received very small pediatric donor grafts or grafts from ideal adult donors. We identified 57 pediatric EB, 110 pediatric SK, and 2350 adult transplants. The primary outcome was 3-year all-cause graft survival. Kaplan-Meier curves showed worse outcomes for pediatric grafts compared to adult ideal grafts (P=.042). On multivariate analysis, pediatric recipients of SK grafts had significantly higher HRs (aHR 2.01, 95% CI 1.34-3.00) and pediatric recipients of EB grafts had somewhat higher non-significant HRs (1.57; 95% CI 0.88-2.79) for graft survival. These results suggest cautionary use of very small pediatric donors as a source to expand the donor pool for pediatric candidates.

Effect of HCV, HIV and coinfection in kidney transplant recipients: mate kidney analyses.

Reports of kidney transplantation (KTX) in recipients with hepatitis C virus (HCV+), human immunodeficiency virus (HIV+) or coinfection often do not provide adequate adjustment for donor risk factors. We evaluated paired deceased-donor kidneys (derived from the same donor transplanted to different recipients) in which one kidney was transplanted into a patient with viral infection (HCV+, n = 1700; HIV+, n = 243) and the other transplanted into a recipient without infection (HCV- n = 1700; HIV- n = 243) using Scientific Registry of Transplant Recipients data between 2000 and 2013. On multivariable analysis (adjusted for recipient risk factors), HCV+ conferred increased risks of death-censored graft survival (DCGS) (adjusted hazard ratio [aHR] 1.24, 95% confidence interval [CI] 1.04-1.47) and patient survival (aHR 1.24, 95% CI 1.06-1.45) compared with HCV-. HIV+ conferred similar DCGS (aHR 0.85, 95% CI 0.48-1.51) and patient survival (aHR 0.80, 95% CI 0.39-1.64) compared with HIV-. HCV coinfection was a significant independent risk factor for DCGS (aHR 2.33; 95% CI 1.06, 5.12) and patient survival (aHR 2.88; 95% CI 1.35, 6.12). On multivariable analysis, 1-year acute rejection was not associated with HCV+, HIV+ or coinfection. Whereas KTX in HIV+ recipients were associated with similar outcomes relative to noninfected recipients, HCV monoinfection and, to a greater extent, coinfection were associated with poor patient and graft survival.

Bariatric Surgery for Congestive Heart Failure Patients Improves Access to Transplantation and Long-term Survival.

INTRODUCTION: Obese patients with congestive heart failure (CHF) are often denied access to heart transplantation until they obtain significant weight loss to achieve a certain BMI threshold, often less than 35 kg/m2. It is unknown whether the rapid weight loss associated with bariatric surgery leads to improved waitlist placement, and as such improved survival for morbidly obese patients with CHF. METHODS: A decision analytic Markov state transition model was created to simulate the life of morbidly obese patients with CHF who were deemed ineligible to be waitlisted for heart transplantation unless they achieved a BMI less than 35 kg/m2. Life expectancy following medical weight management (MWM), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) was estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed. Markov parameters were extracted from literature review. RESULTS: RYGB improved survival compared with both SG and MWM. RYGB patients had higher rates of transplantation, leading to improved mean long-term survival. Base case patients who underwent RYGB gained 2.1 additional years of life compared with patient's who underwent SG and 7.4 additional years of life compared with MWM. SG patients gained 5.3 years of life compared with MWM. CONCLUSIONS: When strict waitlist criteria were applied, bariatric surgery improved access to heart transplantation and thereby increased long-term survival compared with MWM. Morbidly obese CHF patients who anticipate need for heart transplantation should be encouraged to pursue surgical weight management strategies, necessitating discussion between bariatric surgeons, cardiologists, and cardiac surgeons for appropriate perioperative risk management.

Umbilical cord cysts in the second and third trimesters: significance and prenatal approach.

OBJECTIVES: This study was carried out to determine the prognosis, and the clinical approach, in fetuses with umbilical cord cysts, during the second and third trimesters of gestation, according to our experience and data in the current literature. METHODS: We identified 10 fetuses with umbilical cord cysts that were diagnosed during the second and third trimesters of pregnancy at three referral centers. All underwent detailed ultrasound evaluation at the time of diagnosis and during follow-up. Prenatal karyotype testing was offered to all women. A MEDLINE review of the literature published from 1980 to 2009 was carried out to identify previous studies and case reports of fetuses with umbilical cord cysts. RESULTS: In our series of 10 cases, significant additional abnormalities were observed in two during a detailed sonogram. In one case, trisomy 18 was diagnosed, leading to pregnancy termination, and in the other case a neonate with heart defects and a normal karyotype was born. These results differ from those reported in the literature, in which the association between second- and third-trimester umbilical cord cysts and fetal anomalies ranged from 38 to 100%. CONCLUSIONS: In our study, as in other publications, an association was found between the presence of second- and third-trimester umbilical cord cysts and fetal anomalies. The strong association between second- and third-trimester umbilical cord cysts and aneuploidy in the literature seems to be biased, mainly because of the tendency to report abnormal cases. When these findings are accompanied by additional sonographic abnormalities, the association with aneuploidy is clear and should be an indication for fetal karyotype testing.

Recurrent tetraamelia and pulmonary hypoplasia with multiple malformations in sibs.

A term amelic female infant was born to an apparently nonconsanguineous Arab Moslem couple. This was followed by the birth of 4 normal children. Afterwards, in 2 subsequent pregnancies, 2 amelic fetuses were diagnosed by transabdominal ultrasonography in the 18th and 12th week of gestation. Pregnancies were terminated and on autopsy both amelic fetuses had severe lung hypoplasia and aplasia of the peripheral pulmonary vessels. The first fetus also had apparently low-set ears and micrognathia, whereas the last had hydrocephaly and left cleft lip beside the lung hypoplasia and aberrant pulmonary artery. This appears to be a new autosomal recessive malformation syndrome.

Fetal heart rate response to amniocentesis in cases of decreased fetal movements.

Eleven women with fetal distress as manifested by a decrease of fetal movements up to cessation underwent amniocentesis for amniotic fluid evaluation under continuous FHR monitoring. All the fetuses showed abnormal heart rate response, manifested by absence of FHR acceleration or early or late deceleration. The pathologic response, or lack of response of fetal heart rate during amniocentesis is suggested as an additional test to evaluate the severity of fetal distress.

Thromboplastic activity in amniotic fluid during pregnancy.

Thromboplastic activity of amniotic fluid (TAAF) was determined in 97 normal and pathologic pregnancies using a modification of Quick's one-stage method for prothrombin time. It was shown that amniotic fluid (AF) has thromboplastic activity. This activity was found to increase with the progression of pregnancy, showing a very high correlation coefficient (r = -0.86). In cases of pathologic pregnancies such as those associated with diabetes, toxemia, IUGR, and Rh incompatibility, the values of TAAF do not differ from normal pregnancies. However, in 7 of 10 cases of postmature pregnancies the TAAF was below 45 seconds while no preterm or term pregnancy showed TAAF of less than 45 seconds.

Thromboplastic activity of amniotic fluid in term and postmature gestations.

The danger to the newborn inherent in a postmature pregnancy has gained recognition. However, the diagnosis of postmaturity remains a difficult problem. The thromboplastic activity of amniotic fluid (TAAF) increases with the gestational age. Based on this phenomenon, the TAAF of 45 women in the 41st to 43rd weeks of gestation was established, using their amniotic fluid as a source of thromboplastin. It was found that in all cases in which the TAAF value was less than 42 seconds, the newborns exhibited clinical evidence of postmaturity.

Uterine skin grafts and fertility control in the rat.

Autologous intrauterine skin grafting was studied as a method of fertility control in the rat. Skin taken from the ear was grafted onto the right horn in 52 rats. All skin grafts "took" and developed into one of three forms: (1) replacement of endometrium over a wide area, (2) polypoid formations, or (3) skin bridges. Curettage before the skin grafting did not affect the "take" or subsequent course of the graft. After mating, no pregnancy occurred in skin-grafted horns, whereas control horns behaved like those in control rats. Results obtained in rat uteri indicate another approach to the treatment of uterine bleeding and possibly to contraception.

Potentially deleterious effect of cornstarch glove powder in tubal reconstructive surgery.

Even with the most painstaking techniques, cornstarch granules used as surgical glove powder are deposited in the abdominal cavity during laparotomy. In tubal reconstructive surgery, aimed at the elimination of fibrous adhesions, this deposition may have undesirable consequences. After a successful operation, starch particles introduced in the abdominal cavity may result in the formation of new adhesions. It is therefore desirable to develop an alternative, completely nonreactive, glove powder.

PIP: This study attempted to determine whether cornstarch granules when used as surgical glove powder are deposted in the peritoneal cavity during surgery. To this end 10 women undergoing tubal reconstructive surgery by microsurgical techniques and 10 women undergoing total abdominal hysterectomy were studied. Their abdominal cavities were washed 2 times; once at the start of the operation and once at its close using 50 ml of normal saline to irrigate before 20 ml fluid samples were extracted from the pouch of Douglas for cytological examination. All 40 fluid samples were heavily contaminated with starch particles; some of the fluid samples from the end of surgery also showed phagocytosis beginning. Therefore, even with microsurgical techniques designed to minimize adhesion formation postoperatively, the cornstarch in which surgical gloves are packed may result in pelvic adhesion formation. A new nonreactive glove powder must be developed.

Electroejaculation and assisted fertility in men with psychogenic anejaculation.

OBJECTIVES: To evaluate sperm characteristics and fertility potential in ejaculates obtained after electroejaculation in men with psychogenic anejaculation. DESIGN: Retrospective clinical study. SETTING: In Vitro Fertilization Unit, Bikur Cholim Hospital, Jerusalem, Israel. PATIENTS: Twenty men with psychogenic anejaculation who underwent 55 sessions of electroejaculation and their spouses. INTERVENTIONS: Electroejaculation, assisted reproduction technologies. MAIN OUTCOME MEASURES: Semen analysis, IVF, intracytoplasmic injection (ICSI), fertilization rates, and pregnancy rates. RESULTS: In all patients, sperm density and motility rates were unsatisfactory (98 +/- 127 x 10(6) with 14.6% +/- 15% motility in the antegrade portions and 42 +/- 42 x 10(6) with 9.7% +/- 15.6% motility in the retrograde samples). Intrauterine inseminations performed in eight couples did not result in a pregnancy. Four couples underwent IVF-ET treatments. Two pregnancies were achieved with overall success rates of 22% per cycle. Five couples were treated using the ICSI procedure. Although good quality embryos were transferred, none of the treatments resulted in a pregnancy. CONCLUSIONS: Psychogenic failure to ejaculate may be treated by electroejaculation. However, the average motility of the sperm obtained is diminished. The combination of electroejaculation with IVF, including the ICSI procedure, should improve chances of fertilization and pregnancy in these cases.

Pregnancy rates after communal growth of preimplantation human embryos in vitro.

OBJECTIVE: To evaluate the effect of communal growth of preimplantation human embryos on pregnancy rates in IVF-ET. DESIGN: Prospective randomized study. SETTING: In Vitro Fertilization Unit, Bikur Cholim Hospital, Jerusalem, Israel. PATIENTS: Ninety-one women undergoing 91 cycles of IVF-ET. INTERVENTION: In 42 cycles (control) embryos were grown singly, in 49 cycles (study) embryos were grown in groups until transfer. MAIN OUTCOME MEASURES: Proportion of women achieving pregnancy in study and control groups. RESULTS: Communal growth of embryos resulted in significantly improved pregnancy rates. Intrauterine transfer of embryos grown in groups produced 43% pregnancy rates per transfer, whereas, with embryos grown individually, 24% pregnancy rates were obtained (odds ratio = 2.4). CONCLUSIONS: Our study suggests that, in IVF, the potential of preimplantation human embryos to produce pregnancy tends to increase when embryos are grown in groups.

Retrograde seeding of endometrium: a sequela of tubal flushing.

The problem of retrograde seeding of endometrial tissue fragments to the peritoneum was investigated by injecting fluids through the cervical canal into the uterus before and after curettage. Fluid samples were collected from the peritoneal cavity through a laparoscope. Endometrial glands were detected in almost all of the fluids samples, and seeding was greater after curettage than before. It is concluded that any procedure in which fluids are pushed through the uterus may cause peritoneal seeding of endometrium.

Male hyperprolactinemia:effects on fertility.

Male hyperprolactinemia was detected in 4% (7 of 171) of infertile men. In seven patients with excessive serum prolactin concentrations, the clinical manifestations were infertility, hypogonadism, impotence, and galactorrhea and the etiologic factors were pituitary adenoma, hypothalamic dysfunction, drug use, and idiopathic. The testes and prostate were small or normal and the semen analysis revealed low semen volume, normal or low sperm count, and normal or impaired sperm motility. The testicular biopsy showed normally preserved seminiferous tubules with normal or decreased spermatogenesis and damaged or fibrotic seminiferous tubules among normal ones. Patients with hyperprolactinemia were investigated by sellar polytomography, visual field examinations, and hormone assays. Treatment with bromocriptine (Parlodel) gave satisfactory results in all patients. The use of bromocriptine with human menopausal gonadotropin and human chorionic gonadotropin was beneficial in treating hypogonadotropic hypogonadism with hyperprolactinemia.

Foreign body granulomas in peritubal and periovarian adhesions: a possible cause for unsuccessful reconstructive surgery in infertility.

A major problem in tubal reconstructive surgery is the recurrence of peritubal and periovarian adhesions which negate the surgical endeavors. In many cases the etiology of these adhesions is obscure. Histologic re-evaluation with polarized light of 49 resected adhesions revealed residual cornstarch glove powder and suture material in seven specimens. It is concluded that cornstarch powder may be an active agent, and may not be as innocuous as its widespread use indicates.

Electroejaculation before chemotherapy in adolescents and young men with cancer.

OBJECTIVE: To evaluate the outcome of repeated electroejaculation for obtaining semen from adolescents and young men before initiation of anticancer therapies. DESIGN: Retrospective clinical study. SETTING: Bikur Cholim Hospital, Jerusalem, Israel. PATIENT(S): Six young male patients (average age, 18+/-3 years) with diagnosed cancer who underwent 12 procedures of electroejaculation before chemotherapy. INTERVENTION(S): Transrectal electroejaculation. Semen was cryopreserved in small aliquots. MAIN OUTCOME MEASURE(S): Semen analysis. RESULT(S): In all patients, semen was obtained by electroejaculation. Sperm count and motility were relatively low; mean values were 16 x 10(6) (range, 0--45 x 10(6)) and 14% (range, 0--53%) respectively. CONCLUSION(S): If necessary, electroejaculation can be performed in adolescents, and sperm may be obtained by repeated treatments over a short period.

Electroejaculation in combination with intracytoplasmic sperm injection in patients with psychogenic anejaculation results in lower fertilization rates.

OBJECTIVE: To evaluate the outcome of intracytoplasmic sperm injection (ICSI) with sperm obtained by electroejaculation in men with psychogenic anejaculation. DESIGN: Retrospective clinical study. SETTING: In Vitro Fertilization Unit, Bikur Cholim Hospital, Jerusalem, Israel. PATIENT(S): Seven men with psychogenic anejaculation who underwent 16 sessions of electroejaculation in combination with ICSI. INTERVENTION(S): Electroejaculation, ICSI. MAIN OUTCOME MEASURE(S): Semen analysis, ICSI, fertilization rates. RESULT(S): All patients had poor sperm motility. One hundred forty-seven oocytes were injected, with a fertilization rate of 27% (39/142). One ongoing pregnancy was achieved. CONCLUSION(S): Sperm obtained by electroejaculation have low motility and reduced fertilization potential. Nevertheless, ICSI should be offered to improve the possibility of successful pregnancy.

Volume and shape of normal human spermatozoa.

An improved apparatus for measuring the electrical size of particles, developed in this laboratory and based on the principle of the Coulter counter, is used to size human spermatozoa. The typical size distribution is unimodel, with a skew to the right. The actual quantity determined by the measuring system is electrical size (i.e., shape factor X volume); in order to extract the volume, it is necessary to obtain an independence measure of particle shape. This is done by estimating the relative contributions of each part of the spermatozoon, and gives a weighted value for the shape factor of 1.28. The mean value of spermatozoa from 25 normal human seminal fluid specimens is found to be 17.4+/-1.46 cu micronm and the modal volume, 15.2+/-1.27 cu micronm. These values are compared with data reported in the literature after correcting the latter for the effects of particle shape. Zaponin does not affect the cell volume distributions, even when used in high concentrations, provided measurements are carried out within the hour.

Nocturnal sperm emission in men with psychogenic anejaculation.

OBJECTIVE: To evaluate sperm characteristics and fertilization potential in sperm obtained from nocturnal emission in men with psychogenic anejaculation. DESIGN: Retrospective study. SETTING: In Vitro Fertilization Unit, Bikur Cholim Hospital, Jerusalem, Israel. PATIENT(S): Six men with psychogenic anejaculation. INTERVENTION(S): Nocturnal emission, electroejaculation, sperm cryopreservation, and assisted reproduction technologies. MAIN OUTCOME MEASURE(S): Semen analysis, intracytoplasmic sperm injection (ICSI), fertilization rates. RESULT(S): In four patients, the concentration and motility of sperm obtained from freeze-thawed nocturnal emission were decreased compared with sperm from electroejaculation. Fertilization rates after ICSI using the nocturnal emission sperm were relatively low (45%). One clinical pregnancy was achieved after intrauterine insemination. CONCLUSION(S): The quality of sperm from nocturnal emissions is variable, but it can be used in assisted reproduction procedures to avoid aggressive procedures such as electroejaculation or testis biopsy.

Cocaine: maternal use during pregnancy and its effect on the mother, the fetus, and the infant.

Cocaine was previously regarded as a soft drug causing only mild damage. Its use during pregnancy, however, creates a variety of grave medical problems which necessitate immediate attention not only on the part of internists and psychiatrists but also, and more particularly, by obstetricians and pediatricians. The pregnancy of a cocaine-using woman must be carefully managed and regarded as a high-risk one. This in view of the numerous obstetric risks caused by the drug, notably premature separation of the placenta, increased incidence of stillbirths, congenital malformations, premature births, and intrauterine growth retardation. The neonatal monitoring must be focused on prevention of complications resulting from the withdrawal syndrome and associated conditions such as pneumonia, severe weight loss, and contagion from the mother. Moreover, efforts must be made to ensure a strict observation of the infant outside the hospital in view of the far greater incidence of idiopathic infant death in such cases. Owing to the sharp rise of the regular and occasional use of the drug and since pregnant women tend on anamnesis to deny any drug taking, we recommend a test of maternal urine for cocaine and other drugs whenever a suspicion to this effect arises. It is also advisable to test for the presence of such drugs in the urine of the neonate in cases of reasonable suspicion of maternal use during pregnancy, though a negative outcome of the urine test naturally does not rule out a possible use. Strict monitoring of positive cases, accompanied by preventive treatment, may contribute a great deal toward a reduction of perinatal morbidity and mortality associated with cocaine use use.