10 July 2009

Respiratory System

Respiratory System

* Process of air exchange
* Oxygen is obtained and carbon dioxide is eliminated
* Gas exchange occurs in the alveoli

Four parts of respiration
* Ventilation – movement of air between the atmosphere and alveoli
* Perfusion – blood flow through the lungs
* Diffusion – oxygen and carbon dioxide are transferred between alveoli and blood
* Regulation – respiratory muscles and nervous system

Respiratory Tract
* Nose, pharynx, larynx, trachea, bronchi
* Series of tubes that function as airway passages
* Filter, warm and humidify incoming air

Heimlich Maneuver
Heimlich Maneuver - Infant
Cilia - Smokers
Lack of Surfactant
Nervous System Role
Disorders of Respiratory System
Drugs for Asthma and Broncho-constrictive Disorders
* Airway disorder characterized by
o Hyper-reactivity to various stimuli - trigger
o Broncho-constriction
o Inflammation
Clinical Manifestations - Asthma
Precipitating Factors - Triggers
Drug to Treat Asthma
Quick Relief
Long Term Control
Mild Persistent Asthma
Moderate Persistent Asthma
Action of Corticosteroids
When to call MD or go to ED
Emergency Treatment
Intermediate Acting Corticosteroid
Peak Flow Meter
Hyper-inflated Lungs in Asthma
COPD - Chronic Bronchitis
COPD - Emphysema
COPD - Clinical Manifestations
Side Effects - Complications
Leukotriene Modifiers
Mast Cell Stabilizer
Toxicity of Drugs
Bronchodilator Overdose
Theophylline Overdose
Antihistamines and Allergic Disorders
Types of Allergic Reactions
Allergic Rhinitis
Allergic Dermatitis
Allergic Drug Reactions
Anaphylaxis – Life-threatening allergy
Emergency Treatment
Use with Caution
H1 receptor antagonists
Management of common cold
Cold Remedies
Cough Remedies
Antitussive Drugs
Mucolytic Drugs
Nasal Sprays

Respiratory System.ppt


Skin – Immune Disorders

Skin – Immune Disorders
By:Jan Bazner-Chandler

Key Function of Skin
* Protection – shield from internal injury.
* Immunity – contains cells that ingest bacteria and other substances.
* Thermoregulation – heat regulation through sweating, shivering, and subcutaneous insulation
* Communication / sensation / regeneration

Developmental Variances
* Sweat glands function by the time the child is 3-years-old.
* The visco-elastic property of the dermis becomes completely functional at about 2 years.
* The neonate’s dermis is thin and very hydrated, thus is at greater risk for fluid loss and serves as an ineffective barrier.

Diagnostic Tests
* Cultures
* Scraping
* Skin biopsy
* Skin testing
* Woods lamp
Neonatal skin lesions
* Vascular birth marks: hemangioma
* Port wine stain
* Abnormal pigmentation: Mongolian spots
* Neonatal acne: small red papules and pustules appear on face trunk.
* Milia: white or yellow, 1-2mm papules appearing on cheeks, nose, chin, and forehead
Inflammatory Skin Disorders
* Diaper dermatitis
* Contact dermatitis
* Atopic dermatitis or eczema
Cradle Cap
Baby Care
Acne Vulgaris
Management of Acne
Signs and Symptoms
Empty nit case
Viable nit
Causative agent
Impetigo / cellulitis
Clinical Manifestations
Poison Oak, Ivy and Sumac
Poison Ivy
Poison Oak
Systemic Response
Burns in Children
Management of Burns
Flame Burn
Percentage of Areas Affected
Depth of Burns
First Degree Burn
Second Degree Burn
Third Degree or Full-thickness
Wound Management
Children and Their Families
Skin Grafts
Removal of split-thickness
Skin graft with dermatone.
Healed donor site
Compartment Syndrome
Escharotomy / fasciotomy in a severely burned arm.
Burn Wound Covering
Therapy to Prevent Complications Elasticized garment and “air-plane” splints.
Physical therapy to prevent contracture deformity.
Flash burn from gasoline.
Electrical burn caused by biting of electrical cord.
Ball & Bender
Keep Kids Safe
Infants Immune System
Immune Response
Neonatal Sepsis
Major Risk Factors
Minor Risk Factors
Diagnostic Tests
Clinical Manifestations
Blood Test
Medical Management
Nursing Interventions
Acquired Immunodeficiency Syndrome / AIDS
Killer T-cells
Blood Testing in Infants
Treating Infants in Utero
Modes of Transmission
Interdisciplinary Interventions
Community Interventions
Changes in HIV

Skin – Immune Disorders.ppt


Drugs Affecting Respiratory System

Drugs Affecting Respiratory System
By:Jan Bazner-Chandler MSN, CNS, RN, CPNP

Common Cold
* Most cold are caused by viral infections
o Rhinovirus
o Influenza
* Virus invade the mucosa of the upper respiratory tract, nose, pharynx and larynx which leads to the upper respiratory system.
* Signs and symptoms: excessive mucous production leads to sore throat, coughing, upset stomach.
* Treatment: reduce symptoms
* Note: antibiotics do not help viral infections

* Herbal Therapy
* Has been shown in clinical trials to reduce cold symptoms and recovery time when taken early in the illness.
* Adverse effects: dermatitis, upset stomach, dizziness, headache, and unpleasant taste.

* Action: act directly on histamine receptor sites H1 blockers.
* Used as an inflammatory mediator for allergic disorders, allergic rhinitis (hay fever and mold, and dust allergies), anaphylaxis, angioedema, insect bites and urticaria (itching).

* Antihistamines associated with sedation (CNS)
* Non-sedating antihistamines

Antihistamines: sedating
* Classification: H1 antihistamine
o chlorphenramine (Chlor-Trimeton)
o dephenhydramine (Benadryl)

* Trade name: Benadryl
* One of the oldest anti-histamines
* Action: Antagonizes the effects of histamine at the H1 receptor sites.
* Adverse Effects: Significant CNS depressant: drowsiness, dizziness, hypotension, dry mouth.
o Onset: immediate to 60 minutes
o Peak: 1-4 hours
o Duration: 4-8 hours

Non-sedating Antihistamine
* The drugs were developed to eliminate the unwanted adverse effects; mainly sedation.
* Action: Works peripherally (do not cross the blood brain barrier) to block the actions of histamine.

* Generic name: loratadine
* Trade name: Claritin
* Action: blocks peripheral effects of histamine released during allergic reactions.
* Therapeutic Effects: decreased symptoms of allergic reactions (nasal stuffiness, red swollen eyes)
o Onset within 1-3 hours
o Peak within 8-12 hours
o Duration: > 24 hours

* Trade name: Zyrtec
* Therapeutic classification: allergy, cold, and cough remedies, antihistamine
* Action: Antagonizes the effects of histamine at H1-receptor sites; anticholinergic effects are minimal.
o Onset: 30 minutes
o Peak: 4-8 hours
o Duration: 24 hours

* Nasal congestion is due to excessive nasal secretions and inflamed and swollen nasal mucosa.
o Three types of decongestants
+ adrenergic
+ anticholinergic
+ corticosteroids

Route of administration

* Orally to produce systemic effect
* Inhaled: directly to lungs with some systemic effects
* Nasally: local with some systemic effects

Nasal Drugs

* Adrenergic Drugs: topical application directly into the nares provides a very potent decongestive effect.
* Main side effect: rebound effect (after a few days of use if discontinued can have rebound congestion).

Adrenergic Nasal Drugs
* Afrin
* Neo-Synephrine
* Sinex

Intranasal Steroids
* Often used prophylactically to prevent nasal congestion in patients with chronic upper respiratory tract infections.
* Action: aimed at the anti-inflammatory response
* Trade names
o Nasacort
o Flonase
o Nasalide

Drugs to Treat Coughs
* Antitussives
o Opioid
o Non-opioid
* Expectorants

Antitussive Drugs
* Opioid drugs all have antitussive effects
* Codeine is the only opioid used as a cough medicine
* Action: suppress the cough reflex through direct action on the cough center in the CNS (medulla).
* Adverse effects: CNS and respiratory depression and addictive potential

Antitussive Drugs
* Non opioid
* Generic: dextromethorphan
* Trade names:
o Vicks Formula 44
o Robitussin DM
o Safe, non-addicting and does not cause CNS or respiratory depression.

* Aid in the coughing up and spitting out of the excess mucous that has accumulated in the respiratory tract by breaking down and thinning the secretions.
* Action:
o Loosening and thinning the respiratory tract secretions
o Direct stimulation of the secretory glands in the respiratory tract.
* Guaifenesin is the only drug currently available.
* Trade names: Robitussin, Humibid, Guiatuss
* Therapeutic effect: relief of respiratory congestion and cough suppression

Bronchodilators and Other Respiratory Drugs
* Right side has 3 lobes
* Left side 2 lobes
* Contains the lower respiratory structures

* Definition: The bronchi are small air passages, composed of hyaline cartilage, that extend from the trachea to the bronchioles. There are two bronchi in the human body that branch off from the trachea. The bronchi are lined with mucous membranes that secrete mucus and cilia that sweep the mucus and particles up and out of the airways.

* Have a very thin membrane that allows rapid diffusion of oxygen and carbon dioxide between capillary blood and alveolar air spaces.
* Lined with surfactant to prevent alveolar collapse.

* Essential fluid that lines the alveoli and smallest bronchioles.
* Reduces surface tension of the lung allowing the oxygen and carbon dioxide across the membrane.

Lack of Surfactant
Nervous System Role
* Nervous system regulates the rate and depth of respirations.
* Medulla oblongata is the respiratory control system of the brain.
* Cough reflex is stimulated by nervous system.

Diseases of Respiratory System
* Upper respiratory tract: colds, rhinitis, hay fever
* Lower respiratory tract: asthma, emphysema and chronic bronchitis
o All involve obstruction of airflow through the airways.

Bronchial Asthma

* Recurrent and reversible shortness of breath that occurs when the bronchi and bronchioles become narrow as a result of bronchospasm, inflammation, and edema of the bronchial mucosa, and the production of viscid (sticky) mucous.

Allergic Asthma

* Caused by hypersensitivity to an allergen or allergens in the environment.
o Allergen is substance that elicits an allergic reaction.
o Antigen: Substance (usually a protein) that causes the formation of an antibody and reacts with the antibody.
o Antibody: Immunoglobulins produced by Lymphocytes in response to bacteria, viruses, or other antigen substances. (IgE)

Stepwise Therapy for Management of Asthma
* Step 1: mild intermittent
Treatment of mild intermittent Asthma
* Quick relief:
o Short-acting inhaled B2 agonists
+ Albuterol or Proventil

Albuterol (short acting bronchodilator)
* Therapeutic classification: bronchodilators
* Pharmacologic classification: adrenergic
* Indications: Used as a bronchodilator in the management of reversible airway obstruction.
* Action: Binds to beta 2-adrenergic receptors in airway smooth muscle.
* Therapeutic effects: bronchodilator

* Adverse effects:
o Nervousness, restlessness, tremor, headache, insomnia
o Cardiovascular: chest pain, palpitations, angina, hypertension, tachycardia

* Inhaled:
o Onset 15 to 30 minutes
o Peak: 2-3 hours
o Duration: 8 hours

Albuterol INH - Nebulizer
* May give up to 3 treatments at 20 minute intervals
* If taking more than one inhaled medications take 5 minutes apart
* Encourage fluid intake
* Signs and symptoms of respiratory distress
* If no relief need to call PMD or go to ED

Mild Persistent Asthma
* Step 2:
o Short acting inhaled B2 agonist prn
+ Proventil (albuterol)
+ Xopenex (levoalbuterol)
o Low dose inhaled corticosteroids (beclomethasone, fluticasone, triamcinolone
+ Pulmicort, Flovent, Azmacort
o Cromolyn (particularly in children)

* Classification: Mast cell stabilizer
* Trade name: Intal, NasalCrom
* Indications: adjunct in the prophylaxis (long-term control) of allergic disorders including rhinitis and asthma
* Action: prevents the release of histamine and slow-reacting substance of anaphylaxis (SRS-A) from sensitized mast cells.
* Route: inhalation, solution for nebulization or nasal solution.

Inhaled Corticosteroids
* Generic name: fluticasone
* Trade name: Flovent
* Action: potent locally acting anti-inflammatory and immune modifier.
* Therapeutic effects:
o Decrease frequency of asthma attacks
o Prevention of pulmonary damage associated with chronic asthma.

Inhaled Corticosteroids
* Adverse reactions and side effects:
o EENT: hoarseness, oropharyngeal fungal infections
o Dry mouth, esophageal candidia.

Client Teaching
* Take medication as directed.
* Do not discontinue without consulting MD
* When using corticosteroids and bronchodilators use bronchodilators first and follow 5 minutes later with corticosteroids.
* Rinse and spit after inhalation therapy to prevent oral fungal infections.
* Use a tight fitting mask in infant / small child

Oral Thrush
Moderate Persistent Asthma
Antileukotriene Drugs
Severe Persistent Asthma
Exercise Induced Asthma
Chronic Bronchitis
Moderate COPD
Treatment of COPD

Drugs Affecting Respiratory System.ppt


Pediatric Malignancies

Pediatric Malignancies
By:Jan Bazner-Chandler

Pediatric Malignancies
* Genetic alteration
* Environmental influences
* No know prevention
* Metastasic disease
Response to Treatment
Classification of Tumors
Cardinal Signs of Cancer
* Unusual mass or swelling
* Unexplained paleness and loss of energy
* Spontaneous bruising
* Prolonged, unexplained fever
* Headaches in morning
* Sudden eye or vision changes
* Excessive – rapid weight loss.
Diagnostic Tests
* X-ray
* Skeletal survey
* CT scan
* Ultrasound
* Bone marrow aspiration
* Identify cell to determine type of treatment
Treatment Modalities
* Determined by:
o Type of cancer
o Location
o Extent of disease

Radiation Therapy
Goals of Chemotherapy
Chemotherapy Drugs
Bone Marrow Transplant
Gene Therapy
Management of Cancer
Pain Management
Pain Control
Immunosuppression and Infection
Treatment of Neutropenia
Varicella Immunizations
Central Venous Access Devices
CVAD Infection Prevention
Chemotherapy Side Effect
Management of Side Effects
Nutrition Interventions
Nausea and Vomiting Interventions
Mucositis Interventions
Hair Loss
Psychosocial Support
Growth and Development
Peripheral Blood Smear
Bone Marrow
Acute Lymphoid Leukemia
3 Phase Treatment
Induction Therapy
CNS Therapy
Nursing Interventions
Leukemia Time Line
CNS Tumors
Brain Tumors
Large right frontal lobe
neoplasm with small area of necrosis
Hodgkin's Disease
Long Term Side Effects
Wilm’s Tumor
CT Scan Wilm’s Tumor
Osteogenic Sarcoma
Osteosarcoma Tumor
Limb Salvage
Ewing Sarcoma
Pupil reflex
“Cat Eyes”

Pediatric Malignancies.ppt


Gastrointestinal Disorders

Gastrointestinal Disorders
By:Jan Bazner-Chandler

Embryonic Development
* Failure to fuse = cleft lip and palate
* Failure to differentiate = duodenal stenosis
* Atresia or abnormal closing of structure:
o Esophogeal atresia
o Anal-rectal malformation
o Biliary atresia

Fetal Development
* Fistula is an abnormal connection
* Incomplete or abnormal placement
Prenatal History
* Birth weight
* Prematurity
* History of maternal infection
* Polyhydramnios
* Down Syndrome
Health History
* Congenital anomalies
* Growth or feeding problems
* Travel
* Economic status
* Food preparation
* General hygiene
* Family history of allergies

Present Illness
* Onset and duration of symptoms
* Weight loss or gain
* Recent changes in diet
Nursing Assessment
* Abdominal distention
* Abdominal pain
* Abdominal assessment
Measuring Abdominal Girth
Bowden Text
Diagnostic Tests
* Flat plate of abdomen
* Barium swallow or UGI
Diagnostic Tests
* Ultrasound
* CT scan = tumors, abscess, obstruction
* 24 hour probe = Gastro esophogeal reflux
* Biopsy of liver, esophagus, stomach, intestine
Stool and Blood
* White blood cells
* Ova and Parasite
* Bacterial cultures
* Blood

Cleft Lip and Palate
Incomplete fusion of the primitive oral cavity
Post Surgery Care
Cleft Lip Repair
Cleft Palate
Palate Repair
Devices For Feeding
Whaley & Wong
Post Surgery Repair
Long Term Referrals
Esophageal Atresia
Failure of the esophagus
Clinical Manifestations
X-ray Findings
Pre-surgery Care
Post Surgery Care
Ball & Bindler
Post Operative Care
Long Term Complications
Pyloric Stenosis
Clinical Manifestations
Management Pre-surgery
Feeding Post-operatively
Inguinal Hernia
Umbilical Hernia
Diaphragmatic Hernia
Clinical Manifestations
X-ray Diaphragmatic Hernia
* Ventilator support
* Chest tube
* Umbilical artery catheter
* NG tube
* Surgical correction when stable
Long Term Problems
Abdominal Defects
Immediate Nursing Intervention
Gastroschisis Repair
Silastic Silo
Prune Belly
Clinical Manifestation
Diagnostic X-ray
Surgical Intervention
Hirschsprung Disease
Clinical Manifestations
Diagnosis and Treatment
Typical X-ray
Colostomy at Birth
Pull-through Surgery
Long Term Complications
Clinical Manifestations
Ruptured Appendix
Interventions for Perforation
Post Operative Care
Nursing Interventions
Inflammatory Bowel Disease
Ulcerative Colitis
Crohn’s Disease
Diagnostic Tests
Drug Therapy
Gastro-esophageal Reflux
Clinical Manifestations GEF
Conservative Management GER
GERD: Gastro-esophageal Reflux Disease
Diagnostic Work-up for GERD
Pharmacologic Therapy
Surgical Management: GERD
Necrotizing Enterocolitis
Celiac Disease
Dietary Restrictions
Lactose Intolerance

Gastrointestinal Disorders.ppt


Before and after fistula repair

Before and after fistula repair

Tracheoesohpageal fistula

An omphalocele is an abdominal wall defect at the base of the umbilical cord (umbilicus); the infant is born with sac protruding through the defect which contains small intestine, liver, and large intestine.

Surgical repair of abdominal wall defects involves replacing the abdominal organs back into the abdomen through the abdominal wall defect, repairing the defect if possible, or creating a sterile pouch to protect the intestines while they are gradually pushed back into the abdomen.

Anorectal malformations; Anal atresia
Imperforate anus is a relatively common congenital malformation that occurs in about 1 out of 5,000 infants.
signs & symptoms
o absence of anal opening
o misplaced anal opening
o anal opening very near the vaginal opening in the female
o no passage of first stool within 24 to 48 hours after birth
o stool passed by way of vagina or urethra
o Abdomianl distention
o vomiting if infant is fed
o Asymmetry in leg positions
o Asymmetry of the thigh fat folds
o After 3 months of age, asymmetry of rotation of the leg and apparent shortening of the affected leg
o Diminished movement in the affected side

Signs & tests
Pediatricians routinely screen all newborns and infants for hip dysplasia. There are several maneuvers that can detect a dislocated hip or a hip that is able to be dislocated. A hip that is truly dislocated in an infant should be picked up but some cases are subtle and some develop after birth, which is why multiple examinations are recommended. Some mild cases are "silent"; and cannot be picked up on physical exam.

Ultrasound of the hip is the most important imaging study and will demonstrate hip deformity. A hip X-ray joint X-ray) is helpful in older infants and children.

In early infancy, positioning with a device to keep the legs apart and turned outward (frog-leg position) will usually hold the femoral head in the socket. If there is difficulty in maintaining proper position, a plaster cast may be applied and changed periodically to accommodate growth. Operative management may be necessary if early measures to reduce the joint (put the joint back in place) are unsuccessful, or if the defect is first detected in an older child.

If the dysplasia is picked up in the first few months of life, it can almost always be treated successfully with bracing. In a few cases surgery is necessary to put the hip back in joint.The older the age at diagnosis, the worse the outcome and the bigger the surgery needed to repair the problem.

Talipes equinovarus; Talipes or Clubfoot
Signs & Symtptoms:
The physical appearance of the deformity may vary.
Treatment should be initiated as early as possible.
Fingers or toes (digits) may be fused together (syndactyly) or the webbing between them (inter-digital webbing) may extend far up the digits. Syndactyly is seen commonly between the 2nd and 3rd toes, and is usually associated with a syndrome.
Signs & symptoms
Malignant teratoma
Inborn errors of metabolism
Galactosemia - nutritional considerations; Fructose intolerance - nutritional considerations; Maple sugar urine disease (MSUD) - nutritional considerations; Phenylketonuria (PKU) - nutritional considerations; Branched chain ketoaciduria - nutritional considerations

Genetic disorders (numbering in the dozens) in which the body cannot metabolize food components normally. These disorders usually involve minute changes in the breakdown of proteins, fats and carbohydrates. The body can become malnourished even when eating a well-balanced diet. See also galactosemia, PKU, lactose intolerance, and maple syrup urine disease

Inborn errors of metabolism often demand diet changes. The type and extent of the changes depends the specific metabolic error. Registered dietitians and physicians can help with the diet modifications needed for each disease.

o jaundice (yellowish discoloration of the skin and the whites of the eyes)
o vomiting
o poor feedig
o poor weight gain
o lethargy
o irritability
o convulsions
o pupil, white spots

Signs & tests
o hepatomegaly (enlarged liver)
o hypoglycemia (low blood sugar)
o aminoaciduria (amino acids are present in the urine)
o cirrhosis
o ascites (fluid collects in the abdomen)
o mental retardation
o cataract formation
Causes & risks
Trisomy 18 also known as Edwards syndrome
Down syndrome; Trisomy 21; Mongolism
Common autosomal aberrations

Before and after fistula repair.ppt


Neonatal Surgery

Neonatal Surgery
By:Juan E Gonzalez, CRNA, MS, ARNP
Based on prior lecture by
John P. McDonough, CRNA, Ed.D., ARNP
Professor & Director
Anesthesiology Nursing

Anatomical Differences
Pedi vs. Adult Airway
More Vertical
Less vertical
R mainstem bronchus
Shape of Epiglottis
Narrowest Point
Laryngeal location

Head Position
Visual Alignment of Oral/Pharyngeal/Laryngeal axes
Attempt to achieve “sniffing” position will OBSTRUCT pt
To intubate or not to intubate…
Is that a question??
Choice of Intubating Technique
Choice of Intubating Technique
(patient factors)
Blood Pressure Control
Surgeries in the First Week of Life
* Congenital Diaphragmatic Hernia (CDH)
* Omphalocele & Gastroschisis
* Tracheoesophageal Fistula (TEF) (hrs-days to diagnose)
* Intestinal Obstruction (hr-days to diagnose)
* Meningomyelocele
Confounding Factors
* Prematurity
* Associated Congenital Anomalies
Maternal Cocaine Use in Pregnancy
Congenital Diaphragmatic Hernia
Embriologic features of CDH
CDH scenarios
CDH Clinical Presentations
Surgery & CDH
Anesthesia & CDH
Delivery Room Management of Gastroschisis
Gastroschisis Periop Concerns
Postop Care of Gastroschisis & Omphalocele
Tracheoesophageal Fistula (TEF)
TEF Clinical Presentation
TEF Anesthetic Considerations
Tracheoesophogeal Fistula
“VATER” syndrome
Vertebral defects
Anal atresia
Esophageal atresia
Renal dysplasia
Intestinal Obstruction (Upper GI obstruction)
Intestinal Obstruction (Lower GI obstruction)
Lower GI obstruction
Hydrocephalus Anesthetic Approach
Surgical Procedures in the First Month of Life
Inguinal Hernia Repair (IHR)
Inguinal Hernia Repair Anesthetic Techniques
Inguinal Hernia Repair Post Op Apnea in Premies
Ligation of PDA
Placement of Central Venous Catheter

Neonatal Surgery.ppt


Abdominal Wall Defects: Omphalocele vs. Gastroschisis

Abdominal Wall Defects: Omphalocele vs. Gastroschisis
By:Joanna Thomson,
Surgery Clerkship

Embryology Review
* The Midgut gives rise to:
o Duodenum distal to the bile duct
o Jejunum
o Ileum
o Cecum
o Appendix
o Ascending colon
o Hepatic flexure of the colon
o Proximal two-thirds of transverse colon.

Physiological Umbilical Herniation
* As a result of rapid growth and expansion of the liver, the abdominal cavity temporarily becomes too small to contain all the intestinal loops.
* The intestinal loops enter the extraembyronic cavity within the umbilical cord during the sixth week of development.
* As herniation occurs, the loop undergoes a 90 degree counterclockwise rotation around the superior mesenteric artery.

Return to Abdominal Cavity
* During 10th week of development, herniated intestinal loops begin to return to the abdominal cavity.
* Undergoes additional 180 degree counterclockwise rotation about the superior mesenteric artery.
* Factors responsible for this return are not precisely known... It is thought that regression of the mesonephros (kidney), reduced growth of the liver, and expansion of the abdominal cavity all play roles.

* Herniation of abdominal viscera through an enlarged umbilical ring.
o Failure of the bowel to return to the body cavity following physiological umbilical herniation. Defective mesodermal growth causes incomplete central fusion and persistent herniation of the midgut.
* Extruded viscera may include LIVER, small and large intestines, stomach, spleen, or bladder.
* Covered by amnion and peritoneum

* Herniation of intestinal loops through the anterior abdominal wall.
* Defect lateral to the umbilicus (right>left)
o Abnormal involution of the right umbilical vein or vascular accident involving the omphalomesenteric artery causes localized abdominal wall weakness.
* No sac covers the extruded viscera.

Prenatal Diagnosis
* Elevated maternal serum alpha fetoprotein
* Ultrasound
Omphalocele Gastroschisis

* Prevalence:
o Omphalocele: 1/5,000 births
o Gastroschisis: 1/10,000 births
+ Increasing in frequency, especially in young women.
* Mortality:
o Omphalocele: 25%
+ Related directly to presence of chromosomal and other abnormalities
o Gastroschisis: <5%

Omphalocele Associated Anomalies
* Chromosomal abnormalities (50%)
* Neural tube defects (40%)
* Beckwith-Wiedemann syndrome
* Pentalogy of Cantrell

Gastroschisis Associated Anomalies
* Additional gastrointestinal problems
Initial Management
* Acute management aimed at maintaining circulation to bowel and preventing infection while stabilizing infant (temperature/fluids) :
o Cover the defect with sterile dressing soaked in warm saline to prevent fluid loss
o Nasogastric decompression
o IV fluids with glucose
o Antibiotics

Surgical Treatment
* Surgery performed to return the viscera to the abdominal cavity and close the defect.
o Primary Surgical Closure: Success dependent on size of the defect and size of the abdominal and thoracic cavities.

o Staged Closure: Gradual reduction of the contents into the abdominal cavity using an extra-abdominal extension of the peritoneal cavity (termed a silo) and using gentle pressure. Usually requires 1-3 weeks, after which the defect is then primarily closed.

Abdominal Wall Defects.ppt


05 July 2009

Sexually Transmitted Diseases What’s New?

Sexually Transmitted Diseases What’s New?
By:Linda Creegan, FNP
California STD/HIV Prevention Training Center

Common STDs

* Humanpapilloma Virus
* Trichomoniasis
* Chlamydia
* Genital herpes
* Gonorrhea
* Hepatitis B
* Syphilis

Overview of Complications of Sexually Transmitted Diseases

Fetal Wastage*
Low Birthweight*
Congenital Infection*
Upper Tract Infection
Systemic Infection
Ectopic Pregnancy*
Chronic Pelvic Pain
HIV Infection*
Cervical Cancer*
* Potentially Fatal
Increased Transmission of HIV in the Presence of Other STDs
* Transmission increased 3-5 times
* Increased susceptibility
* Increased infectiousness
Risk Factors
P&S Syphilis
Genital Herpes
Herpes simplex virus type 2
Genital Warts
What’s New with Chlamydia Infection?
Chlamydia Infections in Women and Neonates
Genital Chlamydia in Women: Complications
Untreated genital CT infection
Ectopic pregnancy
Chronic pelvic pain
Public Health Approaches to Chlamydia Control
Chlamydia Screening & Treatment
CT Screening Cost-Effective
Chlamydia Screening Recommendations
Chlamydia Testing Current Diagnostic Methods
Chlamydia Testing Nucleic Acid Amplification Tests
Hybrid Capture
Genital Chlamydia Diagnostic Tests
Urine-Based CT Tests
Cost Effectiveness of NAAT
Chlamydia Follow-up
Is Test-of-Cure Necessary?
Chlamydia Partner Management
What’s New with Gonorrhea?
Gonorrhea Infection
Gonorrhea Clinical Presentation
Gonorrhea Complications
Gonorrhea Diagnosis
Gonorrhea Anal and Pharyngeal Infections
Gonorrhea Treatment
Uncomplicated Genital and Rectal Infections,
Non-Pregnant Adults
GC Partner Management
Use of Fluoroquinolones to Treat GC Infection:Recommendations
GC LCR Screening
Gonorrhea Screening Recommendations
What’s New with Syphilis?
Syphilis Elimination Public Health Importance
National Plan for Syphilis Elimination Five Key Strategies
Understanding STD Trends in MSM
Syphilis Management in HIV Co-Infected Patients
Syphilis Diagnostic Testing
Syphilis New Therapies
What’ s New with Genital Herpes?
Herpes: Overview
Genital Herpes Infection Epidemiology
HSV-2 Seropositivity
Human Herpesvirus Family
Genital Herpes Transmission
Genital Herpes Natural History
Genital Herpes Categories of Infection
Genital Herpes First Clinical Episodes
Genital Herpes Reactivation of Virus
Genital Herpes Educating to Recognize Symptoms
Genital Herpes Patient’s Perception of Etiology
Genital Herpes Asymptomatic Shedding
Genital Herpes Spectrum of Presentations
Neonatal Herpes Infection
Herpes Transmission in Pregnancy
Herpes Diagnostic Tests
Herpes Diagnosis Serologic Tests
HSV Serology Testing
Genital Herpes Principles of Treatment
Antiviral Medications for Uncomplicated HSV
Genital Herpes What’s New in Treatment?
Genital Herpes Treatment in Pregnancy
Genital Herpes Vaccine Development
Dermal HPVs
Thin-Layer Pap Preparations
ThinPrep Pap Specimen Collection
ThinPrep Pap Test
Utility of HPV Testing
Conduct HPV test on stored specimen
HPV Disease Management of HIV Infected MSM
Prevention of Genital HPV Infection and Sequelae:
Abnormal Flora in Bacterial Vaginosis (BV)
BV: Complications in Pregnancy
BV: Diagnostic Criteria
Amsel Criteria
BV: Screening in Pregnancy
BV: Treatment Non-Pregnant Women
Trichomoniasis: Diagnosis
Culture System for T. vaginalis
Trichomoniasis Treatment During Pregnancy
Recommended regimen:
Role in Urethritis

Sexually Transmitted Diseases What’s New?.ppt


Forensic Serology

Forensic Serology

Forensic serology is the application of the study of blood, semen, saliva and other body fluids, to legal matters. The field generally is comprised of the detection of enzymes and antigens, as in the identification of seminal stains or blood typing (ABO and secretor status) and DNA typing (by PCR or RFLP analysis).

The serology section of a forensic laboratory may deal with any or all of the following:
* blood typing
* characterization of unknown blood
* blood spatter analysis for crime reconstruction
* paternity testing
* semen identification in rape cases
* DNA techniques used for identification

The Composition of Blood
Blood is a mixture of many components:
cells inorganic substances (salts)
enzymes water
Forensic Characterization of Bloodstains
Three questions that must be answered by the forensic investigator:
1) Is it blood? Use presumptive tests:
Leuchomalachite Green
2) Is it human blood?
Precipitin Test
3) Can it be associated with an individual?

Is It Blood? Presumptive Tests for Blood

* Red blood cells contain hemoglobin (Hb) – the protein responsible for transporting oxygen
* Each Hb contains four iron (Fe) containing hemes
False Positives
Precipitin Test Procedure
* animal (usually a rat or rabbit) is injected with human blood
* animal’s blood forms antibodies
* antibodies are harvested from animal’s blood serum (“antiserum”)
* in a test tube, an extract from the suspected bloodstain is addedto the antiserum
* if a precipitate forms where the two meet, it is human blood

Confirmatory Tests
Blood Typing: Antigens
Blood Typing Example
A sample of unknown blood is mixed with three anti-sera samples:
Tube 1 (Anti-A): No reaction
Tube 2 (Anti B): No reaction
Tube 3 (Anti Rh): Cloudy reaction
Characteristics of Blood
Rh factor
Bloodstain Analysis
Categories of Bloodstains:
Passive (dripping)
Transfer (smearing)
Projected Bloodstain Analysis
Two Important Determinations:
a. direction of spatter
b. angle of impact with surface
Forensic Characterization of Semen
Many crimes involve sexual assault. Forensic Investigators may need to search for semen stains at a crime scene. Bedding, clothing, carpets, cushions, vehicle seats, etc.

Seminal Fluid contains:
* water, spermatozoa, enzymes, inorganic salts
Presumptive Tests

Confirmatory Test Required
Microscopic examination of sperm
False Positives
Forensic Characterization of Saliva

Forensic Serology.ppt


Male Reproductive Problems

Male Reproductive Problems
By:Fertilization Specialists
Joshua Prince
Preston Moore
Candace Lindler

* Infertility is the inability of a couple to become pregnant

Normospermia with functional defects
Asthenospermia and teratozoospermia
Untreatable subfertility
Reversible toxin effects
Disorders of sexual function
Gonadotropin deficiency
Obstructive azoospermia
Sperm autoimmunity
Treatable conditions
Primary seminiferous tubule failure
Untreatable sterility

Table 1. Classification Of Male Infertility By Effectiveness Of Medical Intervention To Improve Natural Conception Rate
* Sperm count equals the number of sperm per cm3 or cc
* The average has dropped in the past 20 years
* 85-90% are treated with medication or surgery
* Lifestyle changes

Normal Reproduction
* Ovulation
* Spermatogenesis
* Sperm meets with egg in fallopian tube
* Fertilization
* Implantation

Male Reproductive System
Female Reproduction System
Normal Spermatogenesis
* Spermatogonium (2N)
* Primary Spermatocyte (2N)
Meiosis I
* Secondary Spermatocytes
Meiosis II
* Spermatids
* Spermatozoa
* Seminferous Tubules
90% of the testis
* Thousands of sperm per second although spermatogenesis 8-10 weeks
* Stored for months
* Degraded and deposited into the circulatory system if not ejaculated
Klinefelter Syndrome
* XXY instead of XX or XY
* usually male
* lower levels of testosterone
* improper formation of semineferous tubules

Bilateral Anorchia
* vanishing testes syndrome
* testes originally present but reabsorbed before or after birth
* having too few sperm
* due to:
excessive alcohol

* total lack of sperm in ejaculate
* due to:
undescended testicle
obstructions of seminal vesicles
testicle infection

* 30% of males born premature
* 3% of males carried to term
* Predisposes the person to risk of torsion
* Androgen receptor
* Bilateral has six times the impact on infertility
* Increase in Temperature
* Testicular atrophy
* Treated at Childhood

* Testicular torsion
of the spermatic cord cuts off the venous drainage, leading to hemorrhagic infarction
It is the twisting of the spermatic cords
Immediate treatment
* Testicular cancer

* Acute
* Chronic
* Fibropapilloma
* Testicular Failure
* Androgen receptors
* Cirrhosis
* Tumors
* Illegal steroid
* Feminine characteristics

* Inflammation would cause pain
* Lack of hair
* Normal volume equals 15 to 35 ml
* Small is equal to 5 ml or less and would also signal androgen deficiency
* Hard lumps would signal tumors
* Softness would signal reduced spermatogenesis

* Enlarged and twisted varicose veins
* 15-20% of men
* Elevates the temperature
* Obstructs passage of semen
* Obstructs oxygen supply
* Polychlorinated biphenyls
* Testosterone
* Free Radicals
* Emotional stress

Physical Obstruction to Gamete Movement
* Blocked or absent seminal ducts
* Seminal fluid disorders
* Retrograde ejaculation
* Inability to ejaculate

Blocked or Absent Ducts
* Bilateral congenital absence of the vas deferens
* Obstruction of the epididymis or vas deferens
* Mechanical blockage during hernia repairs
* Blocked seminal vesicles

Seminal Fluid Disorders
* Absent antioxidant factors
* Abundant circulating free radicals

Retrograde Ejaculation
* Reverse ejaculation into the bladder
* Causes:
o Prostate surgery
o Certain medications
o Diabetes
o Spinal cord injuries
Inability to Ejaculate
* Erectile dysfunction
o Diabetes
o Prostate surgery
o Urethra surgery
o Blood pressure medications

Hormonal Obstruction to Gamete Movement
* Endocrine disorders
* Steroids
* Unexplained low levels of needed hormones

Endocrine Disorders
* Pituitary disorder
* Feminization
* Kallmann’s syndrome
* Hypothyroidism
* Other Causes

Improper Fusion of Sperm and Egg
* Antisperm Antibodies
o Immobilization
o Agglutinating
o Sperm-cervical mucus interaction
o Penetration of the egg
o Sperm fertilization
o Zygote development
Improper Fusion of Pronuclei
Chemical Miscarriage
Molar Pregnancy

http://www.babycenter.com/0_molar- pregnancy_1363614.bc?Ad=com.bc.common.AdInfo%40575bc872

Male Reproductive Problems.ppt


Using NCCLS Standards to Create Procedure Manuals

Using NCCLS Standards to Create Procedure Manuals
by:Mary E. Gray

What is NCCLS?
* A nonprofit, educational organization that provides a communication forum for the development, promotion and use of national and international standards.
* Founded in 1968 and accredited by the American National Standards Institute.
* Based on the principle that voluntary consensus standards are essential for performing clinical laboratory testing at the high level necessary for quality patient care
* Describes laboratory procedures, bench and reference methods, and evaluation protocols applicable within all the major laboratory disciplines

What are the different types of publications?
* Standard: clearly identifies specific, essential requirements for materials, methods, or practices for use in an unmodified form. May contain discretionary elements.
* Guideline: describes criteria for a general operating practice, procedure, or material for the clinical community. May be modified by the user.
* Report: document that has not been subjected to consensus review
What is the consensus process?
* A voluntary process is a protocol establishing formal criteria for:
o The authorization of a standards project
o The development and open review of documents
o The revision of documents in response to comments by laboratory users
o The acceptance of a document as a clinical laboratory standard
How is consensus reached?
* Consists of formal procedures describing the development of an NCCLS document and criteria for its acceptance as a clinical laboratory standard
* Most NCCLS documents are subject to 2 levels of consensus
o Proposed
o Approved
What are the levels of consensus?
* Proposed: document undergoes the first stage of review.
* Tentative: a tentative standard or guideline made available for review and comment
* Approved: has achieved consensus within the clinical laboratory testing community

How does one design a NCCLS clinical laboratory technical procedure manual?
* Determined by the laboratory’s needs
* Start each procedure on a new page
* Consider using tabs and a table of contents
* Use a numbering system
* Provide supplementary materials where necessary
* Use electronic word-processing equipment

What sources can I use?
* Manufacturer product literature
* Scientific journals
* Textbooks
* Standards publications
* Research and validation data
* Written personal communications

What style must be used in a technical procedure?
* Uniform style
* Month and year adopted
* Page number and total number of pages
* The author and initials of approving authority
* Dated, noted, and signed corrections
* Does it replace a previous procedure

How should I title my procedures?
* Should be concise and descriptive
* Considerations
o The type of specimen
+ Semen Agglutination
o The specific method or instrumentation
+ Mycotrim GM Triphasic Culture System for Identification of Mycoplasma hominis and Ureaplasma urealyticum
o The particular property for which the test procedure is designed
+ Fructose in Seminal Plasma

What is in the principle?
* Includes type of reaction(s), specimen(s), or organism(s) involved
* Clinical reason for performing the test
* Written in paragraph form
* Example:
* Principle: Examine semen specimen for presence of sperm, dead or alive, to evaluate effectiveness of patient vasectomy.

What should be included in specimen collection?
* Specific instructions, such as fasting and special diets, written instructions to the patient that are given for their preparation, and drug regimes that should be noted on the requisition form
* An outline of the steps involved in complicated specimen-collection procedures

Patient Preparation: Patient given written instructions (see Patient Instructions for Semen Collection and Transport of Semen form. (1 of 4)
* Patient Instructions for Collection and Transport of Semen for Laboratory Analysis
* In order to avoid delays and the increased cost of repeat testing, please follow these instruction for preparing for the semen analysis and for properly collecting the semen specimen.
* 1. You must have an appointment in order to have your semen specimen evaluated.
* 2. You must have abstained from (no ejaculation) for a period of 3-5 days (ideally 3 days) before you collect the sample unless otherwise advised by your physician.
* 3. If collected at the laboratory, you will collect in a private room adjacent to the testing area. You may bring your own magazines or videotapes. Check with lab personnel regarding the availability of a VCR.
* 4. If you collect your specimen outside the laboratory collection room, you must
+ keep the sample near body temperature (25°-40°C or 77°-104° F)
+ deliver your sample to the laboratory within 45 minutes of collection

Patient Instructions for Semen Collection and Transport of Semen (2 of 4)
* 5. Collection method
* 6. Preparation for collection
Patient Instructions for Semen Collection and Transport of Semen (3 of 4)
* 7. Collection
* 8. Following collection
Patient Instructions for Semen Collection and Transport of Semen (4 of 4)
* 9. Complete your patient information form. Deliver the semen specimen and the patient information form to the laboratory technologist. The technologist will review the information provided, and may ask for additional information.

What else should I include regarding the specimen?
* Specimen type
* Semen specimen collected per Patient Instructions for Semen Collection and Transport of Semen. Handling conditions
o Special timing considerations
+ Semen should be used within 3 hours of collecting. ImmunoSpheres Detection of Sperm Reactive Antibodies
o Special equipment

Specimen Type
* Preferred type and acceptable sources
o Semen specimen collected per Patient Instructions for Semen Collection and Transport of Semen. Liquefied semen samples are required. It is recommended that the test begin no more than three hours after sample collection. The performance of the test with frozen samples has not been established. Testing can also be performed on serum or bromelain-solubilized cervical mucus.
* ImmunoSpheres Detection of Sperm Reactive Antibodies

Specimen Type
* Optimum and minimum amount
* Acceptable collection containers
o Specimen Collection:
o Semen should be collected in clean cup. The semen sample should be stored at room temperature until use. Semen should be used within 3 hours of collecting.
o ImmunoSpheres Detection of Sperm Reactive Antibodies
* Stability of specimen and storage requirements.
* It is recommended that the test begin no more than three hours after sample collection. The performance of the test with frozen samples has not been established. ImmunoSpheres Detection of Sperm Reactive Antibodies
* Criteria for unacceptable specimen and action to be taken
* Semen collected in a condom or by coitus interruptus is not acceptable for evaluation. If you are unable to collect by masturbation, contact your physician to discuss an alternative collection method.
* Physical characteristics that can compromise the test results
* Drugs that can interfere with test results

What about calibration?
* List when needed
* Include standard preparation
o Name and chemical formula when possible
o Acceptable grade; usual source
o Directions for prep including special cleaning or quality of glassware and volumetric equipment
o Degree of accuracy required
o Storage requirements
* Include calibration procedure
o Detailed instructions in tabular form
o Frequency to be performed
o Photometric specifications
o Type of calibration graph, point of origin, type of graph paper
o Acceptable tolerances

How do I assess the quality of my results?
* Quality control
* No standard controls are used, but you may use photos or video to become familiar with normal and abnormal values.
What do I need to do the test?
* Equipment
* Materials
* Preparation and storage of reagents
* Performance parameters
* Procedural notes

Hazardous Materials
* Specify any protective clothing and safety equipment required
* Specify type of spill kit or disposal method
* Set health and safety instruction
Finally…What do we include in the procedures?
* Quality control
* List equipment and reagents
* List storage requirement
* Include step-by-step instructions

Now, what about my results?
* Include reference ranges with reporting format and any necessary calculations
* State procedure for abnormal results
o Repeat procedure if chamber counts do not agree within ±5%.
* List any limitations of the procedure
o Semen odor is an individual interpretation, and description of the odor will vary among technologists. Analysis of Semen Odor

Where did I get my information?
* Manufacturer Product Literature
* Textbooks
* Standards Publications (NCCLS)
* Written Personal communications

What if we change procedures?
* Establish a system of authority to conduct procedure reviews and system for noting changes
* Review each procedure at least annually
* Minor changes
* Major changes
* Interim changes
* Document review and any changes

Using NCCLS Standards to Create Procedure Manuals.ppt


Male Obesity and Semen Analysis Parameters

Male Obesity and Semen Analysis Parameters
By:Joseph Petty, MD
Samuel Prien, PhD
Amantia Kennedy, MSIV
Sami Jabara, MD

Background: Obesity
Background: Semen Parameters
* What parameters best predict fertility?
* National Cooperative Reproductive Medicine Network: 765 infertile couples (no conception after 12 months), and 696 fertile couples
* greatest discriminatory power was in the percentage of sperm with normal morphologic features.

Recent Studies
Sexual function
Hormonal Profile
Interventions: Gastric Bypass
Study Design
* Retrospective chart review for all couples and individual patients presenting for an infertility consultation and evaluation at the Texas Tech Physicians Center for Fertility and Reproductive Surgery from September 2005 through January 2008.
* Intake questionnaire: demographic, medical, surgical and fertility history.
* Previous pregnancies fathered: current or previous partner
* Psychiatric disorders included any degree of depression, bipolar disorder or any other psychiatric disorder requiring medical therapy.
* Tobacco and alcohol users: whether they admitted to light, moderate, or heavy use, patient underreporting.
* Chemical exposures: contact with pesticides, herbicides, and heavy metals.
* Sexual dysfunction: mainly erectile dysfunction and decreased libido.
* Genitourinary anomalies: hypospadias, varicocele, genitourinary surgery, testicular torsion or inguinal hernia or trauma
* Other medical problems included mainly diabetes, hypertension, thyroid disease, autoimmune disease, and cancer.
* Patients grouped according to their BMI as normal (20-24 kg/m2, N = 24), overweight (25-30 kg/m2, N = 43), or obese (>30 kg/m2, N = 45), as standardized by the World Health Organization
* Semen analysis parameters: morphology, volume, concentration, percent motility, and presence of absence of agglutination, in accordance with World Health Organization (WHO) guidelines
* SPSS statistical software was used to run analysis of variance (ANOVA) and post-hoc Tukey HSD tests between the groups. A p-value <0.05 was considered statistically significant.
Exclusion Criteria
* Inconsistencies
* Small sample size
* Kort and data interpretation
* Change the normal hormonal milieu, addressed by Jensen study.
* Sertoli cell function, increased aromatase, role of leptin
* Aggerholm study: altered hormones not correlated with semen abnormalities in overweight men (25.1-30.0 kg/m2), slightly decreased sperm concentration in overweight but not in obese

Future Studies

Male Obesity and Semen Analysis Parameters.ppt


Male Infertility

Male Infertility: Definitions
By:Jeanne O’Brien MD
Assistant Professor of Urology and Male Infertility
University of Rochester Medical Center, Department of Urology

* Primary infertility: inability to achieve pregnancy > 1yr
* Secondary infertility: previously fertile, now unable >1 yr
* Azoospermia: no sperm in semen
* Oligospermia: reduced sperm concentration <20 million/ml
* Asthenospermia: reduced percent motility <50%
* Teratospermia: reduced percent normal forms <30%
* IVF: in vitro fertilization
* ICSI: intra-cytoplasmic sperm injection

Etiology of Male Infertility
* Varicocele
* Idiopathic
* Infection
* Genetic
* Endocrine
* Immunologic
* Obstruction
* Cryptorchidism

Male Infertility: Evaluation
* Basic Evaluation:
o History (Questionnaire)
o Physical examination
o Standard semen analysis
o Hormonal evaluation
* Optional Additional Evaluation:
o Genetic counseling and evaluation
o Specialized sperm function tests
o Imaging studies
o Testis biopsy

Male Infertility: History
* Duration of infertility
o Previous treatments
o Female-factor (anovulation, tubal obstruction)
* Sexual history
o timing and mechanics of intercourse
o lubricants (peanut oil, olive oil, egg whites ok)

* Childhood & Development
o cryptorchidism
o pubertal development
* Medical History
o systemic illness
* Surgical History
o abdominal, pelvic or scrotal surgery
* Infections
o STDs, prostatitis, orchitis (post-pubertal mumps)
* Environmental gonadotoxins
o smoking
o radiation, chemicals, pesticides, chemotherapy
o Heat exposure (short order cook, tanning booths, hot tub/bath)
* Medications (steroids, herbal supplements, hair growth products)

History: Medications
* Hormonal (pre-testicular)
o e.g. androgens, anti-androgens, estrogens
* Gonadotoxic (testicular)
o e.g. chemotherapy/alkylating agents
* Sperm-toxic (post-testicular)
o e.g. Ca-channel blockers

Anatomy of the male reproductive tract

Physical Examination
* General
o Body habitus (muscle mass), hair distribution
o Evidence of normal virilization
o visual fields (r/o pituitary adenoma)
o sense of smell (Kallmann’s Syndrome - HypoHypo)
* Abdomen/Pelvis
o Surgical scars
* Genital/Prostate
* Penis:
o length (normal development)
o position of urethral meatus (deposition of semen)
* Prostate :
o size
o firmness
o tenderness
o presence of cysts (ejaculatory duct)
* Testis:
o -position (cryptorchid?)
o -volume (normal ~15-25ml)
o -firmness (normal = firm)

o -Seminiferous tubules
+ Germ cells
+ Sertoli cells
o -Interstitium
+ Leydig cells
+ macrophages, endothelial cells
o ~74 days in humans (epididymal transit ~15 days)
o Clinical correlate: Need to wait 3 months after any intervention (medical or surgical) to see a change in semen quality
* Epididymis:
o -fullness
o -cystic changes
* Vas deferens:
o -congenital absence of vas (CAVD)
+ Cystic fibrosis mutations
+ Woolfian duct anomalies

Genital tubercule Penis
Overview of sexual differentiation in the male
(modified from Male Reproductive Biology, eds Lipshultz, Howards)
Varicocele: Diagnosis
* Definition: dilated testicular veins due to reflux of blood
* Established by physical examination (in a warm room)
* Other modalities used to diagnose a sub-clinical varicocele:ultrasound, venography, doppler stethoscope
* However, the subclinical varicocele does not require repair!
* WHO Fertil Steril 1985
* Howards Fertil Steril 1992

* Etiology: probably multi-factorial
Varicocele: Prevalence
Varicocele-Induced Pathology
* Testis atrophy
* Testis histology (non-specific)
* Leydig cell dysfunction
o Lower serum Testosterone (T) levels
o Blunted T rise in response to LH stimulation
* Testicular Pain
o Mechanism unknown

Semen Analysis
* Semen Parameters Normal range (WHO)
* Volume (1.5 - 5 mL)
* Sperm density (>20 million/mL)
* Sperm motility (>50%)
* Sperm morphology (>30% normal forms)
* Leukocyte density (<1 million/mL)
* Need at least 2 S/As (because parameters are highly variable)
* S/A is not a measure of fertility but fertility potential

In Vitro Maturation of Germ Cells
* Spermatogenesis: orderly differentiation of immature germ cells to mature spermatozoa
* 1. Mitotic phase
* 2. Meiotic phase
* 3. Spermiogenesis
Two separate events observed in vitro
1. Spermatid differentiation (round to elongated)
2. Meiotic progression (spermatocyte to spermatid)
In Vitro Maturation of Germ Cells:
* Sperm head defects
* Sperm mid-piece defects
* Sperm tail defects
Semen Analysis: Critical Review
* Evaluated 765 infertile men and 696 fertile controls to
* determine semen parameter thresholds that best
* discriminate between fertile and infertile men.
* Infertile couples
* Fertile controls
* Methods:
2 semen samples were collected from each patient.
Technicians from the 9 centers were trained at a central site.
Stained sperm smears were sent to a central site for
strict morphology assessment (by a single technician).
* Statistical Analysis:
Classification-and-regression-tree (CART) analysis was
used to define thresholds for classifying infertility
Receiver-operating-characteristic (ROC) curves were used
to test the discriminatory power of each variable

* Results:
* Conclusions:
Abnormal Morphology
Sperm DNA Integrity
Why examine sperm DNA integrity?
Fertilization Pregnancy
Human Sperm DNA: Characteristics
Sperm DNA Packaging
Evolution During Epididymal Transit
Human Sperm DNA Damage: Etiology
Potential causes of DNA fragmentation
Antisperm Antibodies (ASAs)
Etiology & Incidence
Antisperm Antibodies: Testing
Hypo-Osmotic Swelling Test (HOST)
Hormonal Evaluation
Azoospermia: Normal semen volume
Genetic Evaluation
Non-Obstructive Azoospermia (NOA):
Management Options
Micro-Testicular Dissection
Obstructive Azoospermia (OA):
Clinical features
Management Options

* Male infertility is multifactorial
* Hormones, physiology, environment, anatomy and DNA all play a role
* It is the delicate balance of all of these factors that must be weighed in order to optimize male fertility
* Every evaluation is different and every treatment strategy is geared toward the individual patient and circumstance and must always take into account the female partner

Male Infertility.ppt

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