Closing the gap: evidence-based surgical treatment of rectus diastasis associated with abdominal wall hernias.

PURPOSE: Rectus diastasis (RD) associated with abdominal hernias present a surgical challenge associated with a paucity in treatment guidelines. The objective of this systematic review is to review surgical techniques and assess complication and recurrence rates of RD in patients with concurrent abdominal hernias. METHODS: PubMed and EMBASE databases were systematically searched, and data extraction was performed on articles which met the inclusion criteria. Pooled analyses of complication and recurrence rates were performed to compare open vs. minimally invasive surgery. Student t tests were performed to compare differences in continuous outcomes. RESULTS: Twenty-eight studies were included in this review. RD can be surgically repaired by both open and laparoscopic approaches using both non-absorbable and absorbable sutures. The majority of the techniques reported included mesh insertion either above the aponeurosis, retromuscular, preperitoneal, or intraperitoneal. Open techniques, compared to laparoscopic approaches, were associated with a significantly higher rate of skin dehiscence (6.79% vs. 2.86%; p = 0.003) and hematoma formation (4.73% vs. 1.09%; p < 0.001) and a significantly lower rate of post-operative seroma formation (2.47% vs. 8.29%; p < 0.001). No significant difference in RD recurrence rates were observed between open and laparoscopic repair (0.22 vs. 0.63%, p = 0.17). CONCLUSION: Both open and laparoscopic surgery are safe and effective methods that can be used to repair RD in patients with RD and concurrent abdominal hernias as evident by the low recurrence and complication rates and almost negligible major complications post repair.

[Unilateral testicular cancer: incidence and effects of a contralateral testiculopathy on the sperm output]. / Neoplasia testicolare monolaterale: frequenza ed effetti di una coincidentale testiculopatia controlaterale sul quadro spermatico.

AIM: The aim of this paper was to evaluate the incidence of a non-tumoral, contralateral primitive testiculopathy and its relative influence on sperm quality of patients with unilateral testicular cancer. METHODS: Twenty-four patients (mean age 26 years, range 19-38) with testicular germ cell cancer (seminomas, SEM, in 10 cases; nonseminomas, NSEM, in the remaining 14 patients) after orchiectomy and before radiotherapy or chemotherapy underwent semen analysis, physical examination and scrotal ultrasound of their survivor testis. RESULTS: Patients with SEM had sperm concentration, total sperm count and forward motility significantly higher than those found in patients with NSEM. Altogether, 5 out of 24 patients (2 SEM; 3 NSEM) (20.8%) showed azoospermia; 10 patients (41.7%) (3 SEM; 7 NSEM) had oligo-, astheno- and/or terato-zoospermia (OAT). The remaining 9 patients (37.5%) (5 SEM; 4 NSEM) showed normal sperm parameters. The testicular volume of the left over testis was reduced (<12 ml) in 4 out of 5 (80%) azoospermic patients, in 7 out of 10 patients (70%) of OAT patients, but in no patient (0%) with normozoospermia. A testicular biopsy performed on the survivor testis of 5 patients with azoospermia (4 of them had a reduced testicular volume) confirmed the primitive testiculopathy, showing a histological pattern of Sertoli cell syndrome only in 4 of them (80%) and maturation arrest in the other case (20%). CONCLUSIONS: Less (OAT) or more severe (azoospermia) sperm output impairment in patients with unilateral testicular cancer is associated with a coincidental, contralateral to unilateral testicular cancer, primitive testiculopathy expressed as reduced testicular volume and impairment spermatogenesis at the testicular biopsy.

Sperm aneuploidy in infertile men.

A recent line of research has shown that infertile male patients produce cytogenetically abnormal spermatozoa, despite a normal somatic karyotype, as a result of an altered intra-testicular environment that affects negatively the mechanisms controlling chromosome segregation during cell division. The rate of aneuploid spermatozoa production is significantly higher in patients with abnormal sperm parameters compared with those of normozoospermic subjects or infertile patients with normal sperm parameters. All chromosomes are subject to aneuploidy, although at a different rate; the heterochromosomes are more often altered than are the autosomes. A negative correlation has been reported to exist between aneuploidy and the main sperm parameters, suggesting that greater testicular damage is associated with a greater chance of chromosome malsegregation events. Abnormally-shaped spermatozoa are more likely to have chromosome abnormalities, particularly those with an enlarged head. More studies are necessary, however, to evaluate whether other types of sperm head abnormalities are also associated with an abnormal sperm chromosome complement. The possibility of retrieving testicular or epididymal spermatozoa in patients with azoospermia and using them in assisted reproduction techniques has prompted the evaluation of their chromosomal status. Studies have shown that testicular and epididymal spermatozoa have a greater rate of aneuploidy compared with that of ejaculated spermatozoa. Some authors have also shown that patients with non-obstructive azoospermia have a significantly higher sperm aneuploidy rate compared with that of patients with obstructive azoospermia. Sperm aneuploidy seems to have a negative impact on assisted reproduction technique outcome. Although it does not affect the fertilization rate, an elevated sperm aneuploidy rate is associated with a greater rate of pregnancy failure. Nevertheless, some patients with elevated sperm aneuploidy rate can still achieve a pregnancy, but with an increased risk of generating an aneuploid offspring. Thus, sperm aneuploidy evaluation is recommended in infertile patients with abnormal semen parameters, particularly if they undergo IVF programmes.

Spontaneous transmission from a father to his son of a Y chromosome microdeletion involving the deleted in azoospermia (DAZ) gene.

Microdeletions of the so-called azoospermia factor (AZF) locus of the Y chromosome long arm (Yq) have been recognized as an etiological factor of severe oligozoospermia or azoospermia. Because of this, patients affected are generally infertile unless assisted reproductive techniques are used. We report the case of an oligozoospermic patient (proband) who inherited an extensive Yq microdeletion from his father through a spontaneous pregnancy. Leukocyte DNA was extracted using a commercially available kit. A total of 22 pairs of sequence-tagged site (STSs) based primers, spanning the entire AZF region, were used for the screening. Both the proband and his father carried a Yq microdeletion of the most distal AZF subregion (AZFc) where the deleted in azoospermia (DAZ) gene is located. The proband's father was a sixty-nine-yr-old man who had 3 other children, 2 females and 1 male. This case adds further evidence that the deletion of the DAZ gene is associated with different phenotypic expressions, including normal fertility.

Spontaneous regression over time of the germinal epithelium in a Y chromosome-microdeleted patient: Case report.

Azoospermia factor (AZF) region microdeletions, which account for about 10-15% of patients with oligoazoospermia, seem to lack a close genotype-testicular phenotype correlation. Although many genetic and non-genetic factors may contribute to this outcome, it was thought that a spontaneous regression of testicular germ cells might also play a relevant role. The opportunity for carrying out two different testicular biopsies one year apart in an AZFc-microdeleted patient enabled corroboration of this possibility. Indeed, the first biopsy showed a spermatocyte maturation arrest with mean Johnsen scores of 4 and 3.9 in the right and left testes respectively. One year later, the right testicular biopsy showed a picture of Sertoli cell-only syndrome in 90% of the tubules examined, and of spermatogonial maturation arrest in the remaining tubules, with a mean Johnsen score of 2.1. The almost complete absence of germinal cells was confirmed by four left testicular sperm aspirations (TESA), conducted at the same time as the biopsy during an intracytoplasmic sperm injection cycle, which showed the almost exclusive presence of Sertoli cells (85% of the whole cell population). No spermatozoa could be retrieved by TESA or testicular biopsy. To our knowledge, this is the first case of a spontaneous regression of the germinal cell epithelium over time in a patient with a Yq microdeletion without the apparent intervention of any cause known to affect the germinal epithelium.

Aneuploidy rate in spermatozoa of selected men with abnormal semen parameters.

A large proportion of patients with oligoasthenoteratozoospermia (OAT) have an abnormal karyotype and hence they produce aneuploid gametes. However, a normal karyotype does not exclude the chance of having germ cell aneuploidy, since an altered intra-testicular environment not only damages spermatogenesis, but may also disrupt the mechanisms controlling chromosomal segregation during meiosis. Therefore, this study was undertaken to evaluate the rate of aneuploidy in the spermatozoa of selected patients with abnormal sperm parameters. For this purpose, sperm aneuploidy rate for chromosomes 8, 12, 18, X and Y was evaluated by multicolour fluorescence in-situ hybridization (FISH) in nine patients with teratozoospermia alone and 19 OAT patients of presumably testicular origin. Thirteen normozoospermic healthy men served as controls. Patients with teratozoospermia or OAT had significantly greater disomy and diploidy rates compared with controls, whereas the rate of nullisomy was similar. XY disomy was very low in all groups, suggesting that chromosomal non-disjunction occurs mainly during the second meiotic division. Autosome 12 disomy rate was low in both patients and controls. There was a marked variability of total sperm aneuploidy rate in both groups of patients. Sperm aneuploidy rate was negatively correlated with sperm concentration and particularly with the percentage of normal forms. In conclusion, patients with teratozoospermia or OAT have an increased rate of sperm aneuploidy. This increase is similar in both groups, suggesting that teratozoospermia may be the critical sperm parameter associated with aneuploidy.

High sperm aneuploidy rate in unselected infertile patients and its relationship with intracytoplasmic sperm injection outcome.

BACKGROUND: Men with oligoasthenoteratozoospermia (OAT) frequently undergo intracytoplasmic sperm injection (ICSI) as a treatment for their infertility. However, there is an increased risk of transmitting chromosomal abnormalities to the offspring given that natural selection is bypassed by the use of this technique and patients have an increased rate of sperm aneuploidy which, in addition, may negatively affect ICSI outcome. For this reason, the rate of sperm aneuploidy in unselected patients undergoing ICSI and its impact on ICSI performance have been evaluated. METHODS: Aneuploidy and diploidy were evaluated in spermatozoa separated by swim-up for oocyte injection, using DNA probes for chromosomes 8, 12, 18, X and Y. RESULTS: ICSI patients had sperm aneuploidy and diploidy rates significantly higher than those of 13 normozoospermic men who served as controls. Although the total aneuploidy rate varied considerably between the 18 patients, 15 of them (83%) had values above the upper range of the control group. Eighteen ICSI cycles were performed with an overall fertilization rate of 95% and a pregnancy rate of 39%. The aneuploidy rate of the 11 patients whose wives did not achieve pregnancy was slightly higher than that of pregnant couples, but the difference did not reach statistical significance. However, 10 patients in this group (91%) had a sperm aneuploidy rate well above the upper limit of the controls as compared with two patients in the "pregnant" group (29%). CONCLUSIONS: This study has shown that unselected patients undergoing ICSI had an elevated sperm aneuploidy rate. Lack of pregnancy was associated with a tendency towards an increased aneuploidy rate; however, pregnancy occurred even in the presence of an elevated sperm aneuploidy rate.

Expression of metabotropic glutamate receptors in the rat and human testis.

The G protein-coupled receptor kinase type 4 mediates the homologous desensitisation of type-1 metabotropic glutamate (mGlu1) receptors and is predominantly expressed in the testis. Hence, we searched for the expression of mGlu1 or other mGlu receptor subtypes in rat and human testes. RT-PCR analysis showed the presence of mGlu1, -4 and -5 (but not -2 or -3) receptor mRNA in the rat testis. The presence of mGlu1 and -5 (but not mGlu2/3) receptor proteins was also demonstrated by Western blot analysis. In the rat testis, both mGlu1a and -5 receptors were highly expressed in cells of the germinal line. It is likely that these receptors are functional, because the agonist, (1S,3R)-1-aminocyclopentane-1,3-dicarboxylic acid, was able to stimulate inositol phospholipid hydrolysis in slices prepared from rat testes. Immunocytochemical analysis of bioptic samples from human testes showed a high expression of mGlu5 receptors inside the seminiferous tubuli, whereas mGlu1a immunoreactivity was restricted to intertubular spaces. mGlu5 receptors were also present in mature spermatozoa, where they were localised in the mid-piece and tail. This localisation coincided with that of beta-arrestin, a protein that is critically involved in the homologous desensitisation and internalisation of G protein-coupled receptors. Taken collectively, these results offer the first evidence for the expression of any glutamate receptor in testes, and suggest that at least mGlu5 receptors are present and functionally active in mature human sperm.

Lessons learned while compiling a quantitative exposure database from the published literature.

The published literature was reviewed and then a quantitative hydrocarbon solvent exposure database was compiled. The data was then analyzed to determine trends in documented worker exposures to hydrocarbon solvents. It was found that an all too common limitation of the published literature was the incomplete reporting of results by the authors.

Effects of progesterone on sperm function: mechanisms of action.

Progesterone stimulates sperm functions, e.g. hyperactivation, acrosome reaction, binding to oocyte zona pellucida and penetration rate into the hamster oocyte. The physiological relevance of these effects has been shown using female genital tract fluids which modulate sperm function according to their progesterone content. Progesterone interacts with specific sperm binding sites that, unlike the classic nuclear receptors, are located on the plasma membrane of the spermatozoon. Binding studies have revealed the presence of two classes of progesterone receptors in the human spermatozoon, one class has an elevated affinity constant (nanomolar) and is specific for progesterone, whereas the other class has an affinity constant in the micromolar range and binds equally well other hydroxylated progesterone derivatives. Following exposure to progesterone, the main event is a rapid (within seconds) increase of the intracellular free calcium concentration, followed by a sustained rise lasting for several minutes (plateau phase). Both these calcium transients are dependent upon entry of extracellular calcium. The nature of the calcium channel that mediates the effects of progesterone is, currently, unknown. It has been postulated that it may be: (i) part of the progesterone receptor; (ii) voltage-dependent; or (iii) operated by second messengers following activation of the progesterone receptor. Progesterone also modulates sperm function by stimulating a trypsin-like proteolytic activity, the biosynthesis of polyamine (putrescine and spermidine), phospholipase A2 activity and protein tyrosine kinase activity in the sperm cell. Recent studies have shown that chloride ion efflux is vital for progesterone to promote the acrosome reaction. This effect is achieved by interaction with a sperm membrane receptor which resembles the neuronal GABA(A) receptor. Accordingly, GABA(A) receptors have been found in the spermatozoon plasma membrane and GABA stimulates hyperactivation and promotes the acrosome reaction.

Hydrocarbon solvent exposure data: compilation and analysis of the literature.

An occupational exposure database for hydrocarbon solvent end-use applications was constructed from the published literature. The database provides exposure assessment information for such purposes as regulatory risk assessments, support of industry product stewardship initiatives, and identification of applications in which limited exposure data are available. It is quantitative, documented, and based on credible data. Approximately 350 articles containing quantitative hydrocarbon solvent exposure data were identified using a search of computer databases of published literature. Many articles did not report sufficient details of the exposure data for inclusion in the database (e.g., full-shift exposure or task-based exposure data). Others were excluded because only limited summary statistics were provided, which precluded statistical analysis of the data (e.g., arithmetic mean concentration presented, but no sample number). Following evaluation, 16,880 hydrocarbon solvent exposure measurements from 99 articles were entered into a database for analysis. Methods used to identify and evaluate published solvent exposure data are described along with more detailed analysis of worker exposure to hydrocarbon solvents in three major end-use applications: painting and coating, printing, and adhesives. Solvent exposures were evaluated against current ACGIH threshold limit values (TLVs) and trends were identified. Limited quantitative data are available prior to 1970. In general, reported hydrocarbon solvent exposures decreased fourfold from 1960 to 1998, were below the TLVs applicable to specific hydrocarbon solvents at the time, and on average have been below 40% of the TLV since 1980. The database already has proved valuable; however, the utility of published exposure data could be further improved if authors consistently reported essential data elements and supporting information.

Exposure-response of asphalt fumes with changes in pulmonary function and symptoms.

OBJECTIVES: This study examines possible associations between asphalt fumes and workshift changes in lung function and symptoms among 170 workers exposed to asphalt fumes. METHODS: The workers were from 5 segments of the asphalt industry, and most of them participated for 2 consecutive workdays. The primary response variables were changes in lung function (measured at the beginning and end of the shift) and incidence of symptoms (measured before, 3 times during, and at the end of the shift). Exposure was estimated from breathing-zone samples of total particulate (TP), respirable particulate (RP), the benzene-soluble fraction of the TP (BSF), volatile hydrocarbons collected on a charcoal tube (VHC), nitrogen dioxide, sulfur dioxide, formaldehyde, carbon monoxide, and hydrogen sulfide. Ozone and wet bulb/dry bulb temperature, as a measure of heat stress, were measured as area samples. In addition, daily cigarette smoking was determined by questionnaire. The exposure-response associations were assessed by both parametric and nonparametric statistical techniques. RESULTS: Overall, no consistent association was observed between an acute reduction in lung function or the incidence of symptoms and exposure to asphalt fumes. Concentrations in the neighborhood of the maximum levels constitute no-observed adverse effect levels: TP (<1.5 mg/m3 to maximum 6.2 mg/m3), RP (<0.6 mg/m3 to maximum 1.4 mg/m3), BSF (<0.6 mg/m3 to maximum 1.3 mg/m3), VHC (<8 mg/m3 to maximum 19.8 mg/m3). There were no exposure-response trends with ozone, heat stress, cigarettes smoked, or length of workday.

Structure of spermatodesms of Orthoptera Tettigonioidea.

Examination of spermatodesms collected from the male and female genital tracts of numerous Orthoptera Tettigonioidea revealed an overall morphological and ultrastructural organization that is generally similar in individuals of the same sex but considerably different between males and females of even the same species. In the male genital tracts each spermatodesm is composed of a limited number of spermatozoa whose nuclei and acrosomes are covered by a mucous cap. The spermatozoa inside each bundle are mainly arranged in parallel rows and are always distinctly separate. The number of spermatozoa per spermatodesm may vary within the same individual although it does not seem to exceed a maximum value that we could only determine exactly in Tettigoniidae species. The most characteristic feature of spermatozoa of all the species examined is a conspicuous elongation of the plasma membrane in the acrosomal region that is not present in the female genital tracts. In addition, spermatodesms from females are composed of highly numerous tightly packed spermatozoa that are linked together via the acrosomal region. This characteristic of spermatodesms, never previously reported in other insect species, would involve their reorganization during transfer from the male to the female genital tracts and would seem to take place in the spermatophore. The probable role of spermatodesms in the reproductive physiology of Tettigonioidea might be related to the degree of maturity of the sex cells transferred to the female; the reorganization of the spermatozoa out of the male genital tracts seems to support this hypothesis.

The dilemma of anonymous reporting in child protective services.

Anonymous reports are routinely accepted for investigation as part of a nationwide effort to counteract child abuse and neglect. However, these reports pose practical difficulties for investigators and frequently prove false. The authors discuss the results of their study of anonymous reporting in one catchment area, which has implications for risk assessment and legislative and administrative changes in child protection services policy.

The screening unit: an experimental approach to child protective service.

The Bronx screening unit was established on the assumption that in a populous urban area, a central registry reporting system would receive a sizable number of bogus or malicious reports. The unit tried to identify some of these reports by their characteristics and then to verify these suspicions through the diagnostic skill of experienced and highly motivated workers. The short-term goal was the easing of a workload crisis. The experiences of the screening unit showed that the process was highly successful, and represents an important way to use staff more efficiently in case management. During the 19-month period, an average of 93 regular CPS workers processed 4282 cases, or 46 cases per worker. During that same period, four screening workers averaged 186 cases per worker. The screening process allows the regular CPS worker additional time to focus on serious cases. It also minimizes intrusion into the lives of persons harassed by bogus reporting. The process meets the legally mandated requirements of New York State and the federal government and provides for adequate case recording and record maintenance. One aspect of the Bronx screening unit worthy of special mention is the emphasis on referrals to community services. More than a third of the "unfounded" cases, though not requiring agency intervention, did warrant some type of social service and were referred for assistance. It is important that screening unit workers be familiar with community social service programs in order to serve as resource persons for clients. There exists a tendency to prematurely view cases for screening as easy or unfounded. Determining that a child abuse or neglect report is unfounded is the result of a specific investigative process, and only some cases lend themselves to shortening of this process. Administrative awareness of screening unit limitations will enable these units to function effectively and fulfill their primary responsibility of safeguarding children. Screening units can be a valuable adjunct to a child protective program, but they must not be viewed as a panacea for agency budget and staffing problems.