Eric Belzile

Sperm DNA damage is associated with an increased risk of pregnancy loss after IVF and ICSI: systematic review and meta-analysis

BACKGROUND Sperm DNA damage is common amongst infertile men and may adversely impact natural reproduction, IUI-assisted reproduction and to a lesser degree IVF pregnancy. The aim of this study was to examine the influence of sperm DNA damage on the risk of spontaneous pregnancy loss after IVF and ICSI. METHODS We conducted a systematic review and meta-analysis of studies on sperm DNA damage and pregnancy loss after an IVF and/or ICSI pregnancy. RESULTS Two by two tables were constructed and odds ratios (ORs) were derived from 11 estimates of pregnancy loss (five IVF and six ICSI studies from seven reports). These 11 studies involved 1549 cycles of treatment (808 IVF and 741 ICSI cycles) with 640 pregnancies (345 IVF and 295 ICSI) and 122 pregnancy losses. The combined OR of 2.48 (95% CI 1.52, 4.04, P < 0.0001) indicates that sperm DNA damage is predictive of pregnancy loss after IVF and ICSI. CONCLUSIONS In conclusion, sperm DNA damage is associated with a significantly increased risk of pregnancy loss after IVF and ICSI. These data provide a clinical indication for the evaluation of sperm DNA damage prior to IVF or ICSI and a rationale for further investigating the association between sperm DNA damage and pregnancy loss.

Recognition of Depression by Non-psychiatric Physicians—A Systematic Literature Review and Meta-analysis

BACKGROUNDDepression, with up to 11.9% prevalence in the general population, is a common disorder strongly associated with increased morbidity. The accuracy of non-psychiatric physicians in recognizing depression may influence the outcome of the illness, as unrecognized patients are not offered treatment for depression.OBJECTIVESTo describe and quantitatively summarize the existing data on recognition of depression by non-psychiatric physicians.METHODSWe searched the following databases: MEDLINE (1966–2005), Psych INFO (1967–2005) and CINAHL (1982–2005). To summarize data presented in the papers reviewed, we calculated the Summary receiver operating characteristic (ROC) and the summary sensitivity, specificity and odds ratios (ORs) of recognition, and their 95% confidence intervals using the random effects model.MEASUREMENTS AND MAIN RESULTSThe summary sensitivity, specificity, and OR of recognition using the random effects model were: 36.4% (95% CI: 27.9–44.8), 83.7% (95% CI: 77.5–90.0), and 4.0 (95% CI: 3.2–4.9), respectively. We also calculated the Summary ROC. We performed a metaregression analysis, which showed that the method of documentation of recognition, the age of the sample, and the date of study publication have significant effect on the summary sensitivity and the odds of recognition, in the univariate model. Only the method of documentation had a significant effect on summary sensitivity, when the age of the sample and the date of publication were added to the model.CONCLUSIONThe accuracy of depression recognition by non-psychiatrist physicians is low. Further research should focus on developing standardized methods of documenting non-psychiatric physicians’ recognition of depression.

The Course of Delirium in Older Medical Inpatients: A Prospective Study

AbstractOBJECTIVES: To describe the clinical course and outcomes of delirium up to 12 months after diagnosis, the relationship between the in-hospital clinical course and post-discharge outcomes, and the role of dementia in both the clinical course and outcomes of delirium. DESIGN: Prospective cohort study. SETTING: Medical wards of a 400-bed, university-affiliated, primary acute care hospital in Montreal. PATIENTS: Cohort of 193 medical inpatients aged 65 and over with delirium diagnosed at admission or during the first week in hospital, who were discharged alive from hospital. MEASUREMENTS AND MAIN RESULTS: Study outcomes included cognitive impairment and activities of daily living (standardized, face-to-face clinical instruments at 1-, 2-, 6-, and 12-month follow-up), and mortality. Dementia, severity of illness, comorbidity, and sociodemographic variables were measured at time of diagnosis. Several measures of the inhospital course of delirium were constructed. The mean numbers of symptoms of delirium at diagnosis and 12-month follow-up, respectively, were 4.5 and 3.5 in the subgroup of patients with dementia and 3.4 and 2.2 among those without dementia. Inattention, disorientation, and impaired memory were the most persistent symptoms in both subgroups. In multivariate analyses, pre-morbid and admission level of function, nursing home residence, and slower recovery during the initial hospitalization were associated with worse cognitive and functional outcomes but not mortality. CONCLUSIONS: Among patients with and without dementia, symptoms of delirium persist up to 12 months after diagnosis. Quicker in-hospital recovery is associated with better outcomes.

Does delirium increase hospital stay

Objectives: To determine the effects of prevalent and incident delirium on length of hospital stay.

Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair.

CONTEXT Varicocele is a common condition, found in many men who present for infertility evaluation. OBJECTIVE To assess the effect of varicocelectomy on male infertility. EVIDENCE ACQUISITION A literature search was performed using Embase and Medline. Literature reviewed included meta-analyses and randomized and nonrandomized prospective (controlled and noncontrolled) studies. In addition, a new meta-analysis was performed. EVIDENCE SYNTHESIS Four randomized controlled trials reporting on pregnancy outcome after repair of clinical varicoceles in oligozoospermic men were identified. Using the random effect model, the combined odds ratio was 2.23 (95% confidence interval [CI], 0.86-5.78; p=0.091), indicating that varicocelectomy is moderately superior to observation, but the effect is not statistically significant. We identified 22, 17, and 5 prospective studies reporting on sperm concentration, total motility, and progressive motility, respectively, before and after repair of clinical varicocele. The random effect model combined improvement in sperm concentration was 12.32 million sperm per milliliter (95% CI, 9.45-15.19; p<0.0001). The random effect model combined improvement in sperm total and progressive motility were 10.86% (95% CI, 7.07-14.65; p<0.0001) and 9.69% (95% CI, 4.86-14.52; p=0.003), respectively. These results indicate that varicocelectomy is associated with a significant increase in sperm concentration as well as total and progressive motility. Prospective studies also show that varicocelectomy reduces seminal oxidative stress and sperm DNA damage as well as improving sperm ultramorphology. Studies indicate that a microsurgical approach to a varicocele repair results in less recurrence and fewer complications than other techniques. CONCLUSIONS Although there is no conclusive evidence that a varicocele repair improves spontaneous pregnancy rates, varicocelectomy improves sperm parameters (count and total and progressive motility), reduces sperm DNA damage and seminal oxidative stress, and improves sperm ultramorphology. The various methods of repair are all viable options, but microsurgical repair seems to be associated with better outcomes.

Rapid Emergency Department Intervention for Older People Reduces Risk of Functional Decline: Results of a Multicenter Randomized Trial

To determine the effectiveness of a two‐stage (screening and nursing assessment) intervention for older patients in the emergency department (ED) who are at increased risk of functional decline and other adverse outcomes.

Persistent delirium in older hospital patients: a systematic review of frequency and prognosis

BACKGROUND one explanation for the poor prognosis of delirium among older hospital patients may be that many of these patients do not recover from delirium. We sought to determine the frequency and prognosis of persistent delirium (PerD) in older hospital patients by systematically reviewing original research on this topic. METHODS MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews were searched for potentially relevant articles. The bibliographies of relevant articles were searched for additional references. Eighteen reports (involving 1,322 patients with delirium) met the following seven inclusion criteria: original research published in English or French, prospective study design, study population of at least 20 hospital patients, patients aged 50 years or more, follow-up of at least 1 week, acceptable definition of delirium at enrollment and included at least one assessment for PerD at discharge or later. The methods of each study were assessed according to the six criteria for prognostic studies described by the Evidence-Based Medicine Working Group. Information about the sample origin and size, age, proportion with dementia, criteria for delirium, timing of follow-up assessments, criteria for PerD, proportion with PerD and prognosis of PerD was systematically abstracted from each report, tabulated and combined using standard meta-analysis techniques. RESULTS the combined proportions with PerD at discharge, 1, 3 and 6 months were 44.7% (95% CI 26.8%, 63.7%), 32.8% (95% CI 18.4%, 47.2%), 25.6% (95% CI 7.9%, 43.4%) and 21% (95% CI 1.4%, 40.6%), respectively. The outcomes (mortality, nursing home placement, function, cognition) of patients with PerD were consistently worse than the outcomes of patients who had recovered from delirium. CONCLUSION PerD in older hospital patients is frequent, appears to be associated with adverse outcomes and may account for the poor prognosis of delirium in this population. These findings have potentially important implications for clinical practice and research.

The identification of seniors at risk screening tool: further evidence of concurrent and predictive validity.

Objectives: To evaluate the validity of the Identification of Seniors at Risk (ISAR) screening tool for detecting severe functional impairment and depression and predicting increased depressive symptoms and increased utilization of health services.

The delirium index, a measure of the severity of delirium: new findings on reliability, validity, and responsiveness.

Objectives: To assess the reliability, validity, and responsiveness of an instrument for measuring the severity of delirium, the Delirium Index (DI).

Rapid Two-stage Emergency Department Intervention for Seniors: Impact on Continuity of Care

OBJECTIVES A two-stage intervention comprising screening and a brief standardized nursing assessment and referral, for emergency department (ED) patients aged 65 years and over, reduced the rate of functional decline four months after the visit, without increasing societal costs. In this study, the authors investigated the effects of the intervention on the process of care at, and during the month after, the ED visit. METHODS Patients at four Montreal hospital EDs were randomized by day of visit to the intervention or to usual care. Patients admitted to the hospital were excluded. Measures of process of care included: referrals and visits to the primary physician and to the local community health center, for home care or other services, and return ED visits. Data sources included hospital charts, patient questionnaires, and provincial administrative databases. RESULTS The study sample included 166 intervention and 179 control group patients ready for discharge from the ED. Intervention group patients were more likely to have a chart-documented referral to their local community health center [adjusted odds ratio (OR) 4.0, 95% confidence interval (95% CI) = 1.7 to 9.5] and their primary physician [adjusted OR 1.9, 95% CI = 1.0 to 3.4], and to have received home care services one month after the ED visit [adjusted OR 2.3, 95% CI = 1.1 to 5.1]. Unexpectedly, they were also more likely to make a return visit to the ED [adjusted OR 1.6, 95% CI = 1.0 to 2.6]. CONCLUSIONS The beneficial outcomes of the intervention appear to result primarily from the early provision of home care rather than early contact with the primary physician.