A Mobile App for Wound and Symptom Surveillance After Colorectal Surgery: Protocol for a Feasibility Randomized Controlled Trial.

BACKGROUND: Surgical site infections (SSIs) are the most common nosocomial infection and occur in 16.3% of patients undergoing colorectal surgery at our institution (The Ottawa Hospital), the majority of which are identified after discharge from hospital. Patients who suspect having an SSI generally present to the emergency department or surgery clinic. Both options for in-person interaction are costly to the health care system and patients. A mobile app, how2trak, has proven to be beneficial for patients with complex wounds at our institution by facilitating at-home monitoring and virtual consultations. OBJECTIVE: This study aims to assess the feasibility of a randomized controlled trial to assess if how2trak can improve patients' experience and increase detection of SSIs after colorectal surgery while reducing patients' risk of COVID-19 exposure. METHODS: In this single-center prospective feasibility trial, eligible patients undergoing colorectal surgery will be randomized to either standard care or how2trak postoperative monitoring of their incision, symptoms, and ostomy function. Patient self-assessments will be monitored by a nurse specialized in wound and ostomy care who will follow-up with patients with a suspected SSI. The primary outcome is feasibility as measured by enrollment, randomization, app usability, data extraction, and resource capacity. RESULTS: This study was approved by our institution's ethics board on February 26, 2021, and received support from The Ottawa Hospital Innovation and Care Funding on November 12, 2021. Recruitment started June 3, 2021, and 29 were patients enrolled as of September 2021. We expect to publish results in spring 2022. CONCLUSIONS: This study will determine the feasibility of using a mobile app to monitor patients' wounds and detect SSIs after colorectal surgery. If feasible, we plan to assess if this mobile app facilitates SSI detection, enhances patient experience, and optimizes their care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04869774; https://clinicaltrials.gov/ct2/show/NCT04869774. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26717.

Impact of Perioperative Complications on Living Kidney Donor Health-Related Quality of Life and Mental Health: Results From a Prospective Cohort Study.

BACKGROUND: Although living kidney donation is safe, some donors experience perioperative complications. OBJECTIVE: This study explored how perioperative complications affected donor-reported health-related quality of life, depression, and anxiety. DESIGN: This research was a conducted as a prospective cohort study. SETTING: Twelve transplant centers across Canada. PATIENTS: A total of 912 living kidney donors were included in this study. MEASUREMENTS: Short Form 36 health survey, Beck Depression Inventory and Beck Anxiety Inventory. METHODS: Living kidney donors were prospectively enrolled predonation between 2009 to 2014. Donor perioperative complications were graded using the Clavien-Dindo classification system. Mental and physical health-related quality of life was assessed with the 3 measurements; measurements were taken predonation and at 3- and 12-months postdonation. RESULTS: Seventy-four donors (8%) experienced a perioperative complication; most were minor (n = 67 [91%]), and all minor complications resolved before hospital discharge. The presence (versus absence) of a perioperative complication was associated with lower mental health-related quality of life and higher depression symptoms 3-month postdonation; neither of these differences persisted at 12-month. Perioperative complications were not associated with any changes in physical health-related quality of life or anxiety 3-month postdonation. LIMITATIONS: Minor complications may have been missed and information on complications postdischarge were not collected. No minimal clinically significant change has been defined for kidney donors across the 3 measurements. CONCLUSIONS: These findings highlight a potential opportunity to better support the psychosocial needs of donors who experience perioperative complications in the months following donation. TRIAL REGISTRATION: NCT00319579 and NCT00936078.

CONTEXTE: Bien que le don vivant d'un rein soit une procédure sécuritaire, certains donneurs souffrent tout de même de complications périopératoires. OBJECTIFS: Cette étude a examiné l'incidence des complications périopératoires sur la qualité de vie liée à la santé et les symptômes de dépression et d'anxiété rapportés par les donneurs. TYPE D'ÉTUDE: Étude de cohorte prospective. CADRE: Douze centers de transplantation à travers le Canada. SUJETS: 912 donneurs vivants d'un rein. MESURES: Un questionnaire abrégé de 36 questions sur l'état de santé, l'inventaire de dépression Beck et l'inventaire d'anxiété Beck. MÉTHODOLOGIE: Les donneurs ont été inscrits avant le don de façon prospective entre 2009 et 2014. Les complications périopératoires des donneurs ont été classées à l'aide du système de classification Clavien-Dindo. La qualité de vie liée à la santé physique et mentale a été évaluée à l'aide des trois outils de mesure; ces mesures ont été faites avant le don, puis 3 et 12 mois après le don. RÉSULTATS: Au total, 74 donneurs (8 %) ont souffert d'une complication périopératoire; la plupart étaient mineures (n = 67 [91 %]) et ont été résolues avant le congé de l'hôpital. La présence (par rapport à l'absence) d'une complication périopératoire a été associée à une plus faible qualité de vie liée à la santé mentale et à des symptômes de dépression plus graves 3 mois après le don; aucune de ces différences n'a persisté après 12 mois. Les complications périopératoires n'ont pas été associées à des changements dans la qualité de vie liée à la santé physique ou à l'anxiété 3 mois après le don. LIMITES: Certaines complications mineures ont pu être manquées. L'information sur les complications survenues après le congé n'a pas été recueillie. Dans les trois outils de mesure, aucune variation minimale cliniquement significative n'a été définie pour les donneurs d'un rein. CONCLUSION: Ces résultats soulignent une occasion de mieux répondre aux besoins psychosociaux des donneurs d'un rein qui présentent des complications périopératoires dans les mois suivant le don.

Pre-operative stenting and complications following pancreatoduodenectomy for pancreatic cancer: an analysis of the ACS-NSQIP registry.

BACKGROUND: Historically, pre-operative biliary stenting has been associated with higher infectious complication rates following pancreatoduodenectomy. However, alleviation of biliary obstruction is necessary for consideration of pre-operative chemotherapy, which may improve disease-free survival, or for mitigation of symptoms while awaiting surgery. Our aim is to compare contemporary post-operative complication risk among patients with pre-operative endoscopic retrograde cholangiopancreatography (ERCP) stenting compared to those without. METHODS: Patients who underwent a pancreatoduodenectomy for pancreatic cancer with biliary obstruction within the ACS-NSQIP registry from 2014 to 2017 were identified. The primary outcome was to compare the risk of 30-day complication (composite outcome) between patients with and without pre-operative ERCP stenting. Propensity score matching was used to ensure balanced baseline characteristics and log-binomial regression models were used to estimate risk ratios for overall perioperative complication between groups. RESULTS: From 6073 patients with obstructive jaundice undergoing pancreatoduodenectomy for pancreatic cancer, 92% (5564) were eligible for the study. After performing a propensity score matching on 20 baseline characteristics, 952 patients without stenting were matched to up to four patients who received pre-operative ERCP stenting (n = 3467) for a matched cohort of 4419. A total of 1901 (55%) patients with pre-operative ERCP stenting experienced a post-operative complication compared to 501 (53%) patients without stenting (risk ratio 1.04, 95% CI 0.97-1.11, p = 0.23). CONCLUSION: Pre-operative ERCP stenting was not associated with an increased risk of post-operative complication in patients undergoing pancreatoduodenectomy with obstructive jaundice. Biliary stenting may be safely considered for symptom relief and to potentially facilitate pre-operative chemotherapy for pancreatic cancer.

Prioritizing resident and patient safety while maintaining educational value: emergency restructuring of a Canadian surgical residency program during COVID-19.

Summary: Surgical programs are facing major and fluctuating changes to the resident workforce because of decreased elective volumes and high exposure risk during the coronavirus disease 2019 pandemic. Rapid restructuring of a residency program to protect its workforce while maintaining educational value is imperative. We describe the experience of the Division of General Surgery at the University of Ottawa in Ontario, Canada. The residency program was restructured to feature alternating "on" and "off" weeks, maintaining a healthy resident cohort in case of exposure. Teams were restructured and subdivided to maximize physical distancing and minimize resident exposure to pathogens. Educational initiatives doubled, with virtual sessions targeting every resident year and incorporating intraoperative teaching. The divisional research day and oral exams proceeded uninterrupted, virtually. A small leadership team enabled fast and flexible restructuring of a system for patient care while prioritizing resident safety and maintaining a commitment to resident education in a pandemic.

Can Split Renal Volume Assessment by Computed Tomography Replace Nuclear Split Renal Function in Living Kidney Donor Evaluations? A Systematic Review and Meta-Analysis.

BACKGROUND: As part of their living kidney donor assessment, all living donor candidates complete a computed tomography (CT) angiogram, but some also receive a nuclear renogram for split renal function (SRF%). OBJECTIVE: We considered whether split renal volume (SRV%) assessed by CT can predict SRF%. DESIGN: Systematic review and meta-analysis. SETTING: Living donor candidates undergoing evaluation as potential living kidney donors. PATIENTS: Living donor candidates who received both a nuclear renogram for split function and CT for SRV as part of their living donor work-up. MEASUREMENTS: Split renal volume from CT scans and SRF from nuclear renography. METHODS: We performed a systematic review and meta-analysis of the literature, abstracting data and digitizing plots where possible. We searched Medline, EMBASE, and the Cochrane Library. We added data from donor candidates assessed in London, Ontario from 2013 to 2016. We used fixed and random-effects models to pool Fisher's z-transformed Pearson's correlation coefficient (r). We conducted random-effects meta-regression on digitized and aggregate data. Studies were restricted to living kidney donors or living donor candidates. RESULTS: After pooling 19 studies (n = 1479), we obtained a pooled correlation of r = 0.74 (95% confidence interval [CI] = 0.61-0.82). By linear regression using individual-level data, we observed a 0.76% (95% CI = 0.71-0.81) increase in SRF% for every 1% increase in SRV%. Split renal volume had a specificity of 88% for discriminating SRF at a threshold that could influence the decision of which kidney is to be removed (between-kidney difference ≥10%). Predonation SRV and SRF both moderately predicted kidney function 6 to 12 months after donation: r = 0.75 for SRV and r = 0.73 for SRF; Δr = 0.05 (-0.02, 0.13). LIMITATIONS: Most studies were retrospective and measured SRV and SRF only on selected living donor candidates. Efficiency gains in removing the SRF from the evaluation will depend on the transplant program. CONCLUSION: Split renal volume has the potential to replace SRF for some candidates. However, it is uncertain whether it can do so reliably and routinely across different transplant centers. The impact on clinical decision-making needs to be assessed in well-designed prospective studies. TRIAL REGISTRATION: The digitized data are registered with Mendeley Data (doi10.17632/dyn2bfgxxj.2).

CONTEXTE: Dans le cadre de leur évaluation comme donneur, tous les candidats au don de rein vivant passent une angiographie par tomodensitométrie (CT), mais certains sont également soumis à un rénogramme nucléaire qui mesure la fonction rénale séparée (% de la FRS). OBJECTIF: Nous souhaitions vérifier si le volume rénal séparé (% du VRS) évalué par tomodensitométrie pouvait prédire le pourcentage de la FRS. TYPE D'ÉTUDE: Une revue systématique et une méta-analyse. CADRE: Évaluation des candidats au don d'un rein de leur vivant. SUJETS: Les candidats au don d'organes vivants qui, dans le cadre de leur évaluation, ont été soumis à un rénogramme nucléaire (mesure de la FRS) et à une tomodensitométrie (mesure du VRS). MESURES: Le volume rénal séparé mesuré par tomodensitométrie et la fonction rénale séparée mesurée par rénogramme nucléaire. MÉTHODOLOGIE: Nous avons effectué une revue systématique et une méta-analyse de la littérature sur Medline, EMBASE et Cochrane Library dont nous avons extrait les données et, dans la mesure du possible, numérisé les schémas. Les données des candidats donateurs évalués à London, en Ontario, entre 2013 et 2016 ont été ajoutées. Nous avons utilisé des modèles à effets fixes et aléatoires pour regrouper la transformation de Fisher du coefficient de corrélation de Pearson (r). Nous avons procédé à une méta-régression des données numérisées et agrégées. Les études ont été limitées aux donneurs vivants d'un rein ou aux candidats au don d'organes vivants. RÉSULTATS: Après la mise en commun de 19 études (n = 1 479 sujets), nous avons obtenu une corrélation combinée (r) de 0,74 (IC à 95 %: 0,61-0,82). Par régression linéaire, en utilisant les données individuelles, nous avons observé une augmentation de 0,76 % (IC à 95 %, 0,71-0,81) du pourcentage de la FRS pour chaque augmentation de 1 % du VRS. Ce dernier présentait une spécificité de 88 % pour la discrimination de la FRS à un seuil qui pourrait influencer la décision dans le choix du rein à retirer (différence entre les reins ≥ 10 %). Le VRS et la FRS pré-don se sont tous deux avérés modérément sensibles pour prédire la fonction rénale six à douze mois après le don: r = 0,75 pour le VRS et r = 0,73 pour la FRS; Δr = 0,05 [-0,02 à 0,13]. LIMITES: La plupart des études retenues étaient rétrospectives et ne mesuraient le VRS et la FRS que pour certains candidats. Les gains d'efficacité obtenus en supprimant la mesure de la FRS de l'évaluation dépendront du programme de transplantation. CONCLUSION: La mesure du VRS pourrait remplacer la mesure de la FRS chez certains candidats. On ignore toutefois s'il est possible de le faire de manière fiable et systématique dans différents centres de transplantation. L'impact de ce remplacement sur la prise de décision clinique doit être évalué dans le cadre d'études prospectives bien conçues.

Recomendaciones para el estudio genético e inmunológico en la disfunción reproductiva / Recommendations regarding the genetic and immunological study of reproductive dysfunction

Varios miembros de diferentes asociaciones científicas y expertos de la reproducción han actualizado las recomendaciones de estudio genético e inmunológico en las parejas con disfunción en la reproducción con el fin de mejorar la asistencia sanitaria. El estudio se ha considerado altamente recomendable cuando la prueba diagnóstica es relevante para la toma de decisiones, moderada cuando estas han mostrado un resultado poco consistente y baja, cuando el beneficio de la prueba es incierto. Con la indicación de estas recomendaciones obtendremos una información relevante para el diagnóstico, pronóstico y tratamiento de la pareja con disfunción en la reproducción

In this article several members of diverse scientific associations and reproduction experts from Spain have updated different genetic and immunological procedure recommendations in couples affected by reproductive dysfunction with the goal of providing a set of useful guidelines for the clinic. The laboratory test has been considered as highly recommendable for making clinical decisions when the result of the diagnostic test is relevant, moderately recommendable when the results are of limited evidence because they are inconsistent, and low when the benefit of the test is uncertain. It is expected that these recommendations will provide some useful guidelines for the diagnosis, prognosis and treatment of couples presenting reproductive dysfunction

Perioperative Complications During Living Donor Nephrectomy: Results From a Multicenter Cohort Study.

BACKGROUND: While living kidney donation is considered safe in healthy individuals, perioperative complications can occur due to several factors. OBJECTIVE: We explored associations between the incidence of perioperative complications and donor characteristics, surgical technique, and surgeon's experience in a large contemporary cohort of living kidney donors. DESIGN: Living kidney donors enrolled prospectively in a multicenter cohort study with some data collected retrospectively after enrollment was complete (eg, surgeon characteristics). SETTING: Living kidney donor centers in Canada (n = 12) and Australia (n = 5). PATIENTS: Living kidney donors who donated between 2004 and 2014 and the surgeons who performed the living kidney donor nephrectomies. MEASUREMENTS: Operative and hospital discharge medical notes were collected prospectively, with data on perioperative (intraoperative and postoperative) information abstracted from notes after enrollment was complete. Complications were graded using the Clavien-Dindo system and further classified into minor and major. In 2016, surgeons who performed the nephrectomies were invited to fill an online survey on their training and experience. METHODS: Multivariable logistic regression models with generalized estimating equations were used to compare perioperative complication rates between different groups of donors. The effect of surgeon characteristics on the complication rate was explored using a similar approach. Poisson regression was used to test rates of overall perioperative complications between high- and low-volume centers. RESULTS: Of the 1421 living kidney donor candidates, 1042 individuals proceeded with donation, where 134 (13% [95% confidence interval (CI): 11%-15%]) experienced 142 perioperative complications (55 intraoperative; 87 postoperative). The most common intraoperative complication was organ injury and the most common postoperative complication was ileus. No donors died in the perioperative period. Most complications were minor (90% of 142 complications [95% CI: 86%-96%]); however, 12 donors (1% of 1042 [95% CI: 1%-2%]) experienced a major complication. No statistically significant differences were observed between donor groups and the rate of complications. A total of 43 of 48 eligible surgeons (90%) completed the online survey. Perioperative complication rates did not vary significantly by surgeon characteristics or by high- versus low-volume centers. LIMITATIONS: Operative and discharge reporting is not standardized and varies among surgeons. It is possible that some complications were missed. The online survey for surgeons was completed retrospectively, was based on self-report, and has not been validated. We had adequate statistical power only to detect large effects for factors associated with a higher risk of perioperative complications. CONCLUSIONS: This study confirms the safety of living kidney donation as evidenced by the low rate of major perioperative complications. We did not identify any donor or surgeon characteristics associated with a higher risk of perioperative complications. TRIAL REGISTRATIONS: NCT00319579: A Prospective Study of Living Kidney Donation (https://clinicaltrials.gov/ct2/show/NCT00319579)NCT00936078: Living Kidney Donor Study (https://clinicaltrials.gov/ct2/show/NCT00936078).

CONTEXTE: Bien que le don vivant d'un rein soit sécuritaire chez un individu en santé, plusieurs facteurs sont susceptibles d'engendrer des complications périopératoires. OBJECTIF: Nous avons exploré l'association entre l'incidence des complications périopératoires et les caractéristiques du donneur, la technique chirurgicale employée et l'expérience du chirurgien au sein d'une vaste cohorte contemporaine de donneurs vivants d'un rein. TYPE D'ÉTUDE: Une étude de cohorte multicentrique où certaines données (notamment les renseignements concernant le chirurgien) ont été recueillies rétrospectivement, après l'inclusion complète des sujets (donneurs vivants d'un rein). CADRE: Des centres de transplantation au Canada (n=12) et en Australie (n=5). SUJETS: Des individus ayant fait don d'un rein entre 2004 et 2014, et les chirurgiens qui ont procédé à la néphrectomie. MESURES: Les notes médicales au dossier, opératoires et à la sortie de l'hôpital, ont été recueillies de façon prospective; les données concernant les renseignements périopératoires (peropératoires et postopératoires) ayant été extraites des notes une fois l'inclusion du sujet complétée. Les complications ont été catégorisées selon la classification de Clavien-Dindo, puis caractérisées comme étant mineures ou majeures. En 2016, les chirurgiens ayant pratiqué les néphrectomies ont été invités à répondre à un sondage en ligne au sujet de leur formation et de leur expérience. MÉTHODOLOGIE: Des modèles de régression logistique multivariée utilisant des équations d'estimation généralisées ont été employés pour comparer les taux de complications périopératoires entre les différents groupes de donneurs. L'effet exercé sur le taux de complications par les caractéristiques du chirurgien a été exploré selon une approche similaire. Une régression de Poisson a été utilisée pour évaluer et comparer les taux globaux de complications entre les centres à volume élevé et les centres à faible volume. RÉSULTATS: Des 1 421 candidats répertoriés, 1 042 individus ont subi une néphrectomie, desquels 134 (13 % [IC 95 %: 11­15 %]) ont vécu un total de 142 complications périopératoires (55 peropératoires; 87 postopératoires). La complication peropératoire la plus fréquente était une lésion à l'organe, alors qu'un iléus s'est avéré la principale complication postopératoire. Aucun donneur n'est décédé en période périopératoire. La plupart des complications rencontrées étaient mineures (90 % des 142 complications répertoriées [IC 95 %: 86­96 %]). Toutefois, 12 donneurs (1 % des 1 042 donneurs [IC 95 %: 1­2 %]) ont souffert de complications majeures. Aucune différence significative du point de vue statistique n'a été observée entre les groupes de donneurs et le taux de complications. Des 48 chirurgiens admissibles, 43 (90 %) ont répondu au sondage en ligne. Les taux de complications périoperatoires n'ont pas varié de façon significative en fonction des caractéristiques des chirurgiens, ou selon le volume de patients de l'hôpital. LIMITES: La façon d'inscrire les renseignements médicaux (opératoires ou à la sortie de l'hôpital) dans les dossiers des patients n'est pas normalisée et varie d'un chirurgien à l'autre. Certaines complications pourraient ne pas avoir été notées. Le sondage en ligne destiné aux chirurgiens a été rempli rétrospectivement, il reposait sur des déclarations volontaires et n'avait pas fait l'objet d'une validation. Nous ne disposions d'une puissance statistique que pour détecter les effets importants des facteurs associés à un risque accru de complications périopératoires. CONCLUSION: Cette étude confirme le caractère sécuritaire d'un don vivant de rein, comme en témoigne le très faible taux de complications périopératoires majeures. Nous n'avons pu établir de caractéristiques, du donneur ou du chirurgien, qui soit associées à un risque accru de complications périopératoires.

Can we reduce ischemic cholangiopathy rates in donation after cardiac death liver transplantation after 10 years of practice? Canadian single-centre experience

Background: Outcomes in liver transplantation with organs obtained via donation after cardiocirculatory death (DCD) have been suboptimal compared to donation after brain death, attributed mainly to the high incidence of ischemic cholangiopathy (IC). We evaluated the effect of a 10-year learning curve on IC rates among DCD liver graft recipients at a single centre. Methods: We analyzed all DCD liver transplantation procedures from July 2006 to July 2016. Patients were grouped into early (July 2006 to June 2011) and late (July 2011 to July 2016) eras. Those with less than 6 months of follow-up were excluded. Primary outcomes were IC incidence and IC-free survival rate. Results: Among the 73 DCD liver transplantation procedures performed, 70 recipients fulfilled the selection criteria, 32 in the early era and 38 in the late era. Biliary complications were diagnosed in 19 recipients (27%). Ischemic cholangiopathy was observed in 8 patients (25%) in the early era and 1 patient (3%) in the late era (p = 0.005). The IC-free survival rate was higher in the late era than the early era (98% v. 79%, p = 0.01). The warm ischemia time (27 v. 24 min, p = 0.049) and functional warm ischemia time (21 v. 17 min, p = 0.002) were significantly lower in the late era than the early era. Conclusion: We found a significant reduction in IC rates and improvement in ICfree survival among DCD liver transplantation recipients after a learning curve period that was marked by more judicious donor selection with shorter procurement times.

Contexte: L'issue des greffes de foie suite à un don d'organe après décès cardiocirculatoire (DDC) a été sous-optimale comparativement aux dons suivant la mort cérébrale. Cela serait surtout attribuable à une forte incidence de cholangiopathie ischémique (CI). Nous avons évalué l'effet d'une courbe d'apprentissage échelonnée sur 10 ans sur les taux de CI chez des receveurs de greffe de foie après DDC dans un seul centre. Méthodes: Nous avons analysé toutes les greffes de foie consécutives à des DDC entre juillet 2006 et juillet 2016. Les patients ont été regroupés en 2 époques, la première, de juillet 2006 à juin 2011, et la seconde, de juillet 2011 à juillet 2016. Ceux pour lesquels on disposait de moins de 6 mois de suivi ont été exclus. Les paramètres principaux étaient l'incidence de CI et le taux de survie sans CI. Résultats: Parmi les 73 greffes de foie par suite de DDC, 70 receveurs répondaient aux critères de sélection, 32 pour la première époque et 38 pour la seconde époque. Des complications biliaires ont été diagnostiquées chez 19 receveurs (27 %). La cholangiopathie ischémique a été observée chez 8 patients (25 %) de la première époque et 1 patient (3 %) de la seconde (p = 0,005). Le taux de survie sans CI a été plus élevé pendant la seconde époque que pendant la première (98 % c. 79 %, p = 0,01). Le temps d'ischémie chaude (27 minutes c. 24, p = 0,049) et le temps d'ischémie chaude fonctionnelle (21 minutes c. 17, p = 0,002) ont été significativement plus courts durant la seconde époque que durant la première. Conclusion: Nous avons observé une réduction significative des taux de CI et une amélioration de la survie sans CI chez les receveurs de greffes de foie par DDC après une courbe d'apprentissage qui a été marquée par une sélection plus judicieuse des donneurs et des délais d'obtention plus courts.

Recomendaciones para el estudio genético e inmunológico en la disfunción reproductiva / Recommendations regarding the genetic and immunological study of reproductive dysfunction

Varios miembros de diferentes asociaciones científicas y expertos de la reproducción han actualizado las recomendaciones de estudio genético e inmunológico en las parejas con disfunción en la reproducción con el fin de mejorar la asistencia sanitaria. El estudio se ha considerado altamente recomendable cuando la prueba diagnóstica es relevante para la toma de decisiones, moderada cuando estas han mostrado un resultado poco consistente y baja, cuando el beneficio de la prueba es incierto. Con la indicación de estas recomendaciones obtendremos una información relevante para el diagnóstico, pronóstico y tratamiento de la pareja con disfunción en la reproducción

In this article several members of diverse scientific associations and reproduction experts from Spain have updated different genetic and immunological procedure recommendations in couples affected by reproductive dysfunction with the goal of providing a set of useful guidelines for the clinic. The laboratory test has been considered as highly recommendable for making clinical decisions when the result of the diagnostic test is relevant, moderately recommendable when the results are of limited evidence because they are inconsistent, and low when the benefit of the test is uncertain. It is expected that these recommendations will provide some useful guidelines for the diagnosis, prognosis and treatment of couples presenting reproductive dysfunction

Recommendations regarding the genetic and immunological study of reproductive dysfunction. / Recomendaciones para el estudio genético e inmunológico en la disfunción reproductiva.

In this article several members of diverse scientific associations and reproduction experts from Spain have updated different genetic and immunological procedure recommendations in couples affected by reproductive dysfunction with the goal of providing a set of useful guidelines for the clinic. The laboratory test has been considered as highly recommendable for making clinical decisions when the result of the diagnostic test is relevant, moderately recommendable when the results are of limited evidence because they are inconsistent, and low when the benefit of the test is uncertain. It is expected that these recommendations will provide some useful guidelines for the diagnosis, prognosis and treatment of couples presenting reproductive dysfunction.

Initiating Maintenance Dialysis Before Living Kidney Donor Transplantation When a Donor Candidate Evaluation Is Well Underway.

BACKGROUND: Preemptive kidney transplants result in better outcomes and patient experiences than transplantation after dialysis onset. It is unknown how often a person initiates maintenance dialysis before living kidney donor transplantation when their donor candidate evaluation is well underway. METHODS: Using healthcare databases, we retrospectively studied 478 living donor kidney transplants from 2004 to 2014 across 5 transplant centers in Ontario, Canada, where the recipients were not receiving dialysis when their donor's evaluation was well underway. We also explored some factors associated with a higher likelihood of dialysis initiation before transplant. RESULTS: A total of 167 (35%) of 478 persons with kidney failure initiated dialysis in a median of 9.7 months (25th-75th percentile, 5.4-18.7 months) after their donor candidate began their evaluation and received dialysis for a median of 8.8 months (3.6-16.9 months) before kidney transplantation. The total cohort's dialysis cost was CAD $8.1 million, and 44 (26%) of 167 recipients initiated their dialysis urgently in hospital. The median total donor evaluation time (time from evaluation start to donation) was 10.6 months (6.4-21.6 months) for preemptive transplants and 22.4 months (13.1-38.7 months) for donors whose recipients started dialysis before transplant. Recipients were more likely to start dialysis if their donor was female, nonwhite, lived in a lower-income neighborhood, and if the transplant center received the recipient referral later. CONCLUSION: One third of persons initiated dialysis before receiving their living kidney donor transplant, despite their donor's evaluation being well underway. Future studies should consider whether some of these events can be prevented by addressing inappropriate delays to improve patient outcomes and reduce healthcare costs.

Optimizing associated liver partition and portal vein ligation for staged hepatectomy outcomes: Surgical experience or appropriate patient selection?

BACKGROUND: Early reports of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) outcomes have been suboptimal. The literature has confirmed that learning curves influence surgical outcomes. We have 54 months of continuous experience performing ALPPS with strict selection criteria. This study aimed to evaluate the impact of the learning curve on ALPPS outcomes. METHODS: We retrospectively compared patients who underwent ALPPS between April 2012 and March 2016. Patients were grouped into 2 24-month (early and late) periods. All candidates had a high tumour load requiring staged hepatectomy after chemotherapy response, a predicted future liver remnant (FLR) less than 30% and good performance status. RESULTS: Thirty-three patients underwent ALPPS during the study period: 16 in the early group (median age 65 yr, mean body mass index [BMI] 27) and 17 in the late group (median age 60 yr, mean BMI 25). Bilobar disease was comparable in both groups (94% v. 88%, p > 0.99). Duration of surgery was not statistically different. Intraoperative blood loss and need for transfusion were significantly lower in the late group (200 ± 109 mL v. 100 ± 43 mL, p < 0.05). The late group had a higher proportion of monosegment ALPPS (4:1). There were no deaths within 90 days in either cohort. Rates of postoperative complications were not statistically significant between groups. The R0 resection rate was similar. The entire 1-year disease-free and overall survival were 52% and 84%, respectively. CONCLUSION: Excellent results can be obtained in innovative complex surgery with careful patient selection and good technical skills. Additionally, the learning curve brought confidence to perform more complex procedures while maintaining good outcomes.

CONTEXTE: Les premiers résultats sur l'association de la partition hépatique et de la ligature portale pour l'hépatectomie en 2 temps (ALPPS) sont sous-optimaux. La littérature a confirmé que les courbes d'apprentissage influencent les résultats des interventions chirurgicales. Notre étude reposait sur 54 mois consécutifs d'utilisation de la technique ALPPS selon des critères de sélection rigoureux. Elle visait à évaluer l'effet de la courbe d'apprentissage sur les résultats liés à l'ALPPS. MÉTHODES: Nous avons procédé à une comparaison rétrospective des patients traités par l'ALPPS entre avril 2012 et mars 2016. Nous avons divisé les patients en 2 groupes de 24 mois (précoce et tardif). Tous les candidats avaient une charge tumorale élevée nécessitant une hépatectomie en 2 temps après une réponse à la chimiothérapie, un volume estimé de futur foie résiduel (FFR) inférieur à 30 % et un indice fonctionnel favorable. RÉSULTATS: Trente-trois patients ont été traités par l'ALPPS pendant la période de l'étude : 16 dans le groupe précoce (âge médian 65 ans, indice de masse corporelle [IMC] moyen 27) et 17 dans le groupe tardif (âge médian 60 ans, IMC moyen 25). Le taux de maladie bilobaire était comparable entre les 2 groupes (94 % c. 88 %, p > 0,99). La durée de la chirurgie n'était pas statistiquement différente. Les pertes de sang peropératoires et le besoin de transfusion étaient significativement inférieurs dans le groupe tardif (200 ± 109 mL c. 100 ± 43 mL, p < 0,05). Le groupe tardif avait une proportion plus élevée d'ALPPS mono-segmentaires (4:1). Il n'y a eu aucun décès dans les 90 jours parmi les 2 cohortes. Les taux de complications postopératoires n'étaient pas statistiquement significatifs entre les groupes. Le taux de résection R0 était similaire. Les taux de survie sans récidive après une année complète et de survie globale étaient de 52 % et de 84 %, respectivement. CONCLUSION: L'innovation dans le domaine des chirurgies complexes peut donner d'excellents résultats lorsqu'on sélectionne attentivement les patients et que l'on possède de bonnes habiletés techniques. De plus, la courbe d'apprentissage a eu pour effet d'accroître la confiance dans la capacité de réaliser des interventions complexes tout en produisant de bons résultats.

Detection of DNA damage in cumulus cells using a chromatin dispersion assay.

DNA damage in cumulus cells (CCs) might be related with the developmental competence of the enclosed oocytes, however, conclusive studies are missing, partially due to the lack of a reliable, cheap, fast, and reproducible DNA damage test. We report the development of a chromatin dispersion test that allows for a fast evaluation of double strand DNA (ds-DNA) damage in CCs. The whole experiment was performed using CCs from 103 oocyte retrieval cycles evaluating the prototype D3-MAX ability (a chromatin dispersion based assay) to detect DNA breaks against in situ nick translation (ISNT) and a two tailed comet assay (TT-comet). Samples were collected from women younger than 35 years of age with a good response to stimulation. Pooled cumulus cells of MII oocytes were used. The chromatin dispersion assay results correlate with the double strand-DNA breaks values assessed by the TT-comet assay (Spearman Rho = 0.624; p = 0.003;), while the correlation was poor when compared to the single strand DNA (ss-DNA) breaks observed also with the TT-comet assay (Spearman Rho = -0.141; p = 0.554). ISNT showed a correspondence in the same cells between enzymatic incorporation of modified nucleotides and halos of chromatin dispersion. We conclude that D3-Max test detects mainly ds-DNA breaks in cumulus cells and is a reliable, fast, and easy reproducible assay suitable for routine clinical practices once the influence on oocyte quality has been established.

Ruptured choledochal cyst: a rare presentation and unique approach to management.

We present the rare case of a ruptured choledochal cyst (CC) in a young woman presenting with a two-day history of worsening upper abdominal pain. Imaging revealed a contracted gallbladder, dilated common bile duct (CBD), and a large amount of peritoneal fluid. Percutaneous paracentesis was performed, obtaining bilious fluid. Further imaging revealed cystic dilatation of the CBD and the diagnosis of rupture CC type I was made. The patient was initially managed conservatively with percutaneous drains, IV antibiotic therapy, and sphincterotomy through an ERCP. Elective cyst resection and Roux-en-Y hepatojejunostomy was performed 8 weeks later. It is important to differentiate a ruptured CC from other surgical emergencies without exploratory laparotomy. Initial conservative management could be considered, followed by elective resection once inflammation, infection, and other complications have resolved, avoiding the increased risk associated with an emergency operation or two-stage laparotomy.

Assessment of follicular fluid leptin levels and insulin resistance as outcome predictors in women undergoing in vitro fertilization-intracytoplasmic sperm injection.

OBJECTIVE: To analyze follicular fluid leptin (FFL) levels, abdominal obesity, and insulin resistance as predictors of in vitro fertilization (IVF)-intracytoplasmic sperm injection (ICSI) outcome. DESIGN: Observational study. SETTING: Academic medical center. PATIENT(S): A sample of 130 infertile women aged 26-40 years without polycystic ovary syndrome. INTERVENTION(S): Measurement of FFL levels in controlled ovarian hyperstimulation cycles with an antagonist and agonist protocol for IVF-ICSI. MAIN OUTCOME MEASURE(S): Live birth rate. RESULT(S): Mean FFL values were significantly higher in pregnancies not ending in a live birth, even after adjustment for waist circumference and insulin resistance. A multivariable model obtained with the use of logistic binary regression analysis showed that waist circumference and insulin resistance had no influence over IVF-ICSI outcomes, but a higher number of follicles, lower serum progesterone levels on the day before α-hCG administration, and lower FFL concentrations were significantly associated with a higher probability of having a live birth. The multivariate model reached a sensitivity of 87% and a specificity of 71% for predicting the possibility of pregnancy ending in a live birth. CONCLUSION(S): High FFL levels were associated with abdominal obesity, insulin resistance, and a lower live birth rate after IVF-ICSI. Further investigations are warranted to define the precise roles of leptin, obesity, and insulin resistance on IVF-ICSI outcomes.

¿A qué velocidad «muere» el ácido desoxirribonucleico del espermatozoide tras descongelar muestras seminales procedentes de donantes? / At what speed does sperm deoxyribonucleic acid “die” after donor semen samples are thawed?

Objetivo. Analizar los niveles de daño que se registran en el ADN de espermatozoides de donantes y estimar la velocidad a la que este se degrada tras la descongelación. Material y métodos. Dosis seminales procedentes de donantes (n = 50) y un grupo control formado por pacientes normozoospérmicos (n = 40). Se estudiaron los valores de fragmentación del ADN espermático (SDF) en su nivel basal, así como los valores de SDF tras incubación de las muestras a 37 °C durante 2, 6 y 24 h. Se calcularon las velocidades de degradación del ADN por tramos de incubación. Resultados. El semen criopreservado de donante presenta unos niveles basales de SDF 2 veces inferiores a los observados en los controles, y su ADN es 2,5 veces más longevo que el del grupo control. Niveles basales de SDF sobre un 8% generan una sensibilidad de un 82% y una especificidad de un 65% para discriminar entre los donantes y los controles. Los valores de incremento del daño de 1,8% por hora, analizados durante las 2 primeras horas de incubación, identifican a los donantes con un 77% de sensibilidad y un 65% de especificidad. Ambos valores no muestran ninguna correlación dentro del grupo de los controles, ni entre los donantes. Conclusiones. El establecimiento de este tipo de valores umbral se podría utilizar para identificar donantes considerados como «superdonantes» en relación con sus bajos niveles de SDF y su alta estabilidad de la cromatina. Los donantes que se seleccionaron en las diferentes clínicas presentan características equiparables para estos parámetros(AU)

Objective. The study was made to analyze the baseline levels of damage recorded in sperm DNA fragmentation (SDF) and to estimate sperm DNA longevity as observed in donors after thawing. Material and methods. Fifty donors and forty individuals attending a clinic and classified as a normo-zoospermic population were compared. The baseline SDF levels and the increasing rate of SDF (r-SDF) obtained after thawing when the sperm was incubated for a period of 24 h with different sub-sampling performed after 2, 6 and 24 h of incubation were considered as the independent variables and compared. Results. Cryopreserved donor sperm exhibited baseline SDF values approximately 2 times lower than those observed in the control group. DNA stability was 2.5 times higher than that observed in the control cohort. Baseline values of SDF of approximately 8% generates 65% sensitivity and 82% specificity to discriminate between the donors and controls. Values of increase of damage of 1.8% per hour, analyzed during the first hours of incubation, identify the donor characteristics with 77% sensibility and 65% specificity. Neither value show any correlation within the control and donor cohorts group. Conclusion. The establishment of these types of threshold values can be used to identify donors considered as “super-donors” in relation to their low levels of SDF and high chromatin stability. The donors selected from the different clinics participating in this study showed similar characteristics for these parameters(AU)

The paternal effect of chromosome translocation carriers observed from meiotic segregation in embryos.

BACKGROUND: Human translocation carriers may present alterations in meiosis. Understanding the mechanism of meiotic segregation of reciprocal translocations is important for estimation of the risk of either pregnancy loss or birth defects. The objective of this work was to estimate meiotic segregation rates in preimplantation embryos from preimplantation genetic diagnosis (PGD) cycles of female and male reciprocal translocation carriers. METHODS: In 20 cycles for 14 couples, PGD was performed on 118 day three embryos using fluorescence in situ hybridization (FISH) with specific probes for each translocation. The meiotic segregation modes and the effect of the paternal origin of translocated carrier were estimated. RESULTS: Overall, the proportions of alternate segregation for normal or balanced chromosome contents in preimplantation embryos from PGD cycles in reciprocal male and female carriers were not significantly different (35.5 versus 23.8%). However, the frequencies of adjacent-1 and adjacent-2 segregation were lower in embryos from female reciprocal translocation carriers than from male carriers. For male translocations, alternate segregation was the most frequent mode. The proportion of 3:1 segregation was the most frequent in female translocations carriers. CONCLUSIONS: We report differences in segregation modes in embryos obtained from PGD cycles according to the gender of reciprocal translocation carrier. However, these differences did not affect the proportion of balanced embryos and the take home baby rate. The analysis of the meiotic behaviour of chromosomes and the differences between the meiotic products of female and male for a chromosomal rearrangement could help predict the outcome of PGD for translocation carriers.

Recomendaciones para el estudio genético de la pareja con alteraciones en la reproducción / Recommendations for the genetic study of couples with impaired reproduction

Siempre se debe garantizar un asesoramiento genético apropiado a la pareja, tanto antes como después del estudio genético. Las pruebas genéticas se han clasificado como pruebas altamente recomendables, recomendables u opcionales, según su resultado modifique el pronóstico. La indicación de las pruebas genéticas en la mujer con alteraciones en la reproducción se ha clasificado sobre la base de la historia clínica personal y familiar y puede abarcar el cariotipo en sangre periférica, el estudio molecular del gen CFTR (cystic fibrosis transmembrane conductance regulator), de X frágil, del factor II, del factor V y de metilentetrahidrofolatoreductasa (MTHFR). Respecto a los varones con alteraciones en la reproducción, cualquier estudio genético debe ir precedido por un estudio andrológico, que debe incluir al menos una historia clínica personal, familiar y el análisis de semen. Se puede indicar el cariotipo en sangre periférica, el estudio molecular de CFTR, las microdeleciones en el cromosoma Y, la hibridación fluorescente in situ (FISH, por sus siglas en inglés) en espermatozoides, el estudio de meiosis en tejido testicular y la fragmentación del ADN (AU)

In order to improve the care and follow up of couples with impaired reproduction, several scientific societies and experts have established specific recommendations for genetic testing in the evaluation of reproductive disorders in couples with impaired reproduction. Appropriate genetic counselling must be given to the couple before and after the genetic testing. Genetic tests have been classified as “highly recommended,” “recommended” or “optional” depending on whether the results have changed the prognosis of the corresponding pathology. The indication for genetic testing in women with impaired reproduction is classified on the basis of personal and family medical history and can include the karyotype in peripheral blood, the molecular study of CFTR, Fragile X, factor II, factor V and MTHRF. As regards men with impaired reproduction, every genetic study should be preceded by an andrological study, which must include at least the personal and family history and a semen analysis. A medical indication can be made for the karyotype in peripheral blood, the molecular study of CFTR, microdeletions on the Y chromosome, FISH sperm FISH, meiosis in testicular tissue studies, and DNA fragmentation (AU)