Microsurgical vasovasostomy for the treatment of intractable chronic scrotal pain after vasectomy

Dear Editor, We present herein two rare cases of intractable chronic scrotal pain after vasectomy. The patients were effectively treated with microsurgical vasovasostomy (MVV). We also discuss the possible aetiologies of the pain and other surgical options. Vasectomy was once the most common method of permanent contraception for men in both China and worldwide. One particularly distressing complication after vasectomy is chronic scrotal pain, which is defined as intermittent or constant, unilateral or bilateral scrotal pain for o3 months. The pain is intense enough to interfere with the patient's daily activities and prompts him to seek medical attention. 1 Although its aetiology remains unclear, epididymal congestion, painful sperm granulomas, vascular stasis and nerve impingement have been postulated as possible aetiologic factors. 2 Non-surgical options have been used successfully to treat chronic scrotal pain after vasectomy, including scrotal support, thermal therapy, limiting activity, non-steroidal anti-inflammatory drugs, narcotic analgesics, antibiotics, neuroleptics, spermatic cord nerve block, biofeedback and psychiatric evaluation. Surgical options include reversal of the vasectomy, microsurgical spermatic cord denervation, granuloma excision, epididymectomy and orchidectomy. The microsurgical techniques used for vasectomy reversal have changed significantly in the past decade, culminating in the standard surgical procedures used today, and its indications include a desire to have more children (remarriage or after the death of a child), treatment of post-vasectomy pain and treatment of obstructive azoospermia due to traumatic or iatrogenic injury of vas deferens. 3 To our knowledge, we report the first cases of the use of MVV for the treatment of intractable chronic scrotal pain after vasectomy in a Chinese hospital. The 72-year-old and 49-year-old men presented with a more than 20-year history of intractable, chronic scrotal pain after vasectomy. They had consulted various urologists and had undergone numerous attempted therapies in other hospitals. They reported a history of vasectomy more than 30 years and 20 years previously, respectively. They did not have any histories of haematuria, haematospermia, lower urinary tract symptoms, epididymitis, prostatitis or testicular trauma. Their physical examination was unremarkable, and both the secondary sexual characteristics and genital examination were normal. The testes were descended bilaterally and normal in size and consistency. The caput epididymides exhibited dilatation and tenderness. The vasa deferentia were palpated for painful lumps at the vasectomy sites. Digital rectal examination was unremarkable for prostatic abnormalities. Each patient underwent Doppler ultrasonography of the testes and urinary tract, urinalysis, urine culture and spermiogram to exclude primary or secondary causes of pain, including intratesticular infection, tumours and ureteral lithiasis. At our initial consultation, the patients were asked to complete a pain and psychological questionnaire, which included pain, depression and anxiety scores. The pain score (Visual Analogue Scale) was in the form of an 11-point numerical rating score with 0 representing 'no pain' and 10 representing the 'worst possible pain'. The patients' preoperative pain scores were 5 and 6 points, respectively. The depression scores (Self-rating Depression Scale) were in the form of an 80-point numerical rating score; a score less than 50 indicated 'normal', and a score greater than 50 indicated 'depression'. The depression scores of the two patients were 35 and 38 points, respectively. The anxiety scores (Self-rating Anxiety Scale) were in the form of an 80-point numerical rating score; scores less than 50 were considered to indicate 'normal', whereas scores greater than 50 indicated 'anxiety'. The anxiety scores of the two patients were 33 and 32 points, respectively. Spermatic cord block was performed once for each patient with 6 ml of 1% lidocaine and 1 ml of methylprednisolone (40 mg). The patients had 3 and 7 days of complete pain relief after the blockade, respectively. The study protocol was approved by the Ethical Committee of the First Affiliated Hospital of Sun Yat-Sen University, and informed consent was signed by the patients. The patients were offered MVV as a more permanent solution in March and July 2012, respectively. Scrotal exploration was performed with the patients under combined spinal-epidural anaesthesia. The left-side incision (3 cm) of the scrotum through the tunica vaginalis was made, and the left vas deferens was delivered through this incision. The painful lumps and nerveimpinging tissue at the vasectomy site were thoroughly resected by electrocautery. Distal patency was confirmed by infusing diluted methylene blue through the abdominal side of the vas deferens, resulting in blue colouring of the urine. A 123 to 153 operating microscope (Leica Microsystems (Schweiz) AG, Heerbrugg, Switzerland) was use

Impaired Thymic Export and Apoptosis Contribute to Regulatory T-Cell Defects in Patients with Chronic Heart Failure

Animal studies suggest that regulatory T (T(reg)) cells play a beneficial role in ventricular remodeling and our previous data have demonstrated defects of T(reg) cells in patients with chronic heart failure (CHF). However, the mechanisms behind T(reg-)cell defects remained unknown. We here sought to elucidate the mechanism of T(reg-)cell defects in CHF patients.We performed flow cytometry analysis and demonstrated reduced numbers of peripheral blood CD4(+)CD25(+)FOXP3(+)CD45RO(-)CD45RA(+) naïve T(reg) (nT(reg)) cells and CD4(+)CD25(+)FOXP3(+)CD45RO(+)CD45RA(-) memory T(reg) (mT(reg)) cells in CHF patients as compared with non-CHF controls. Moreover, the nT(reg)/mT(reg) ratio (p<0.01), CD4(+)CD25(+)FOXP3(+)CD45RO(-) CD45RA(+)CD31(+) recent thymic emigrant T(reg) cell (RTE-T(reg)) frequency (p<0.01), and T-cell receptor excision circle levels in T(reg) cells (p<0.01) were lower in CHF patients than in non-CHF controls. Combined annexin-V and 7-AAD staining showed that peripheral T(reg) cells from CHF patients exhibited increased spontaneous apoptosis and were more prone to interleukin (IL)-2 deprivation- and CD95 ligand-mediated apoptosis than those from non-CHF individuals. Furthermore, analyses by both flow cytometry and real-time polymerase chain reaction showed that T(reg)-cell frequency in the mediastinal lymph nodes or Foxp3 expression in hearts of CHF patients was no higher than that of the non-CHF controls.Our data suggested that the T(reg)-cell defects of CHF patients were likely caused by decreased thymic output of nascent T(reg) cells and increased susceptibility to apoptosis in the periphery

Synthetic strategies to nanostructured photocatalysts for CO2 reduction to solar fuels and chemicals

Artificial photosynthesis represents one of the great scientific challenges of the 21st century, offering the possibility of clean energy through water photolysis and renewable chemicals through CO2 utilisation as a sustainable feedstock. Catalysis will undoubtedly play a key role in delivering technologies able to meet these goals, mediating solar energy via excited generate charge carriers to selectively activate molecular bonds under ambient conditions. This review describes recent synthetic approaches adopted to engineer nanostructured photocatalytic materials for efficient light harnessing, charge separation and the photoreduction of CO2 to higher hydrocarbons such as methane, methanol and even olefins

Muon reconstruction and identification efficiency in ATLAS using the full Run 2 pp collision data set at \sqrt{s}=13 TeV

This article documents the muon reconstruction and identification efficiency obtained by the ATLAS experiment for 139 \hbox {fb}^{-1} of pp collision data at \sqrt{s}=13 TeV collected between 2015 and 2018 during Run 2 of the LHC. The increased instantaneous luminosity delivered by the LHC over this period required a reoptimisation of the criteria for the identification of prompt muons. Improved and newly developed algorithms were deployed to preserve high muon identification efficiency with a low misidentification rate and good momentum resolution. The availability of large samples of Z\rightarrow \mu \mu and J/\psi \rightarrow \mu \mu decays, and the minimisation of systematic uncertainties, allows the efficiencies of criteria for muon identification, primary vertex association, and isolation to be measured with an accuracy at the per-mille level in the bulk of the phase space, and up to the percent level in complex kinematic configurations. Excellent performance is achieved over a range of transverse momenta from 3 GeV to several hundred GeV, and across the full muon detector acceptance of |\eta |<2.7

Dijet Resonance Search with Weak Supervision Using root S=13 TeV pp Collisions in the ATLAS Detector

This Letter describes a search for narrowly resonant new physics using a machine-learning anomaly detection procedure that does not rely on signal simulations for developing the analysis selection. Weakly supervised learning is used to train classifiers directly on data to enhance potential signals. The targeted topology is dijet events and the features used for machine learning are the masses of the two jets. The resulting analysis is essentially a three-dimensional search A → BC, for mA ∼ OðTeVÞ, mB; mC ∼ Oð100 GeVÞ and B, C are reconstructed as large-radius jets, without paying a penalty associated with a large trials factor in the scan of the masses of the two jets. The full run 2 ffiffi s p ¼ 13 TeV pp collision dataset of 139 fb−1 recorded by the ATLAS detector at the Large Hadron Collider is used for the search. There is no significant evidence of a localized excess in the dijet invariant mass spectrum between 1.8 and 8.2 TeV. Cross-section limits for narrow-width A, B, and C particles vary with mA, mB, and mC. For example, when mA ¼ 3 TeV and mB ≳ 200 GeV, a production cross section between 1 and 5 fb is excluded at 95% confidence level, depending on mC. For certain masses, these limits are up to 10 times more sensitive than those obtained by the inclusive dijet search. These results are complementary to the dedicated searches for the case that B and C are standard model boson

Search for bottom-squark pair production in pp collision events at √s=13 TeV with hadronically decaying τ-leptons, b-jets, and missing transverse momentum using the ATLAS detector

A search for pair production of bottom squarks in events with hadronically decaying τ -leptons, b -tagged jets, and large missing transverse momentum is presented. The analyzed dataset is based on proton-proton collisions at √ s = 13     TeV delivered by the Large Hadron Collider and recorded by the ATLAS detector from 2015 to 2018, and corresponds to an integrated luminosity of 139     fb − 1 . The observed data are compatible with the expected Standard Model background. Results are interpreted in a simplified model where each bottom squark is assumed to decay into the second-lightest neutralino ˜ χ 0 2 and a bottom quark, with ˜ χ 0 2 decaying into a Higgs boson and the lightest neutralino ˜ χ 0 1 . The search focuses on final states where at least one Higgs boson decays into a pair of hadronically decaying τ -leptons. This allows the acceptance and thus the sensitivity to be significantly improved relative to the previous results at low masses of the ˜ χ 0 2 , where bottom-squark masses up to 850 GeV are excluded at the 95% confidence level, assuming a mass difference of 130 GeV between ˜ χ 0 2 and ˜ χ 0 1 . Model-independent upper limits are also set on the cross section of processes beyond the Standard Model

Measurements of differential cross-sections in four-lepton events in 13 TeV proton-proton collisions with the ATLAS detector

Measurements of four-lepton differential and integrated fiducial cross-sections in events with two same-flavour, opposite-charge electron or muon pairs are presented. The data correspond to 139 fb−1 of s√ = 13 TeV proton-proton collisions, collected by the ATLAS detector during Run 2 of the Large Hadron Collider (2015–2018). The final state has contributions from a number of interesting Standard Model processes that dominate in different four-lepton invariant mass regions, including single Z boson production, Higgs boson production and on-shell ZZ production, with a complex mix of interference terms, and possible contributions from physics beyond the Standard Model. The differential cross-sections include the four-lepton invariant mass inclusively, in slices of other kinematic variables, and in different lepton flavour categories. Also measured are dilepton invariant masses, transverse momenta, and angular correlation variables, in four regions of four-lepton invariant mass, each dominated by different processes. The measurements are corrected for detector effects and are compared with state-of-the-art Standard Model calculations, which are found to be consistent with the data. The Z → 4ℓ branching fraction is extracted, giving a value of (4.41 ± 0.30) × 10−6. Constraints on effective field theory parameters and a model based on a spontaneously broken B − L gauge symmetry are also evaluated. Further reinterpretations can be performed with the provided information

Pan-cancer analysis of whole genomes

Cancer is driven by genetic change, and the advent of massively parallel sequencing has enabled systematic documentation of this variation at the whole-genome scale(1-3). Here we report the integrative analysis of 2,658 whole-cancer genomes and their matching normal tissues across 38 tumour types from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA). We describe the generation of the PCAWG resource, facilitated by international data sharing using compute clouds. On average, cancer genomes contained 4-5 driver mutations when combining coding and non-coding genomic elements; however, in around 5% of cases no drivers were identified, suggesting that cancer driver discovery is not yet complete. Chromothripsis, in which many clustered structural variants arise in a single catastrophic event, is frequently an early event in tumour evolution; in acral melanoma, for example, these events precede most somatic point mutations and affect several cancer-associated genes simultaneously. Cancers with abnormal telomere maintenance often originate from tissues with low replicative activity and show several mechanisms of preventing telomere attrition to critical levels. Common and rare germline variants affect patterns of somatic mutation, including point mutations, structural variants and somatic retrotransposition. A collection of papers from the PCAWG Consortium describes non-coding mutations that drive cancer beyond those in the TERT promoter(4); identifies new signatures of mutational processes that cause base substitutions, small insertions and deletions and structural variation(5,6); analyses timings and patterns of tumour evolution(7); describes the diverse transcriptional consequences of somatic mutation on splicing, expression levels, fusion genes and promoter activity(8,9); and evaluates a range of more-specialized features of cancer genomes(8,10-18).Peer reviewe