The office evaluation of the infertile male involves a comprehensive history and physical structured to uncover all potential causes including congenital, medical, surgical, environmental, genetic, and psychosocial etiologies. The physical exam begins with the patient’s general appearance, body habitus, and progresses to the genital exam in which the testicles are examined for size, consistency, and location. Prior surgical scars, absence of the vas deferens, or the presence of varicoceles may be identifiable causes of infertility. The semen analysis is the cornerstone laboratory evaluation of the male undergoing an infertility workup. The semen is evaluated for several key parameters including volume as well as sperm concentration, number, motility, and form. An endocrine evaluation is indicated in men with oligospermia, azoospermia, or a history of physical examination findings suggestive of hormonal abnormalities including sexual dysfunction, decreased libido, or physical evidence of impair androgenization. Pending the initial workup genetic testing may be indicated.

Overview of respiratory complications such as hemoptysis, hiccups, laryngectomy and tracheostomy troubleshooting, airway obstruction, pneumonitis, and pleural effusion management

Overview of respiratory complications such as hemoptysis, hiccups, laryngectomy and tracheostomy troubleshooting, airway obstruction, pneumonitis, and pleural effusion management

Overview of respiratory complications such as hemoptysis, hiccups, laryngectomy and tracheostomy troubleshooting, airway obstruction, pneumonitis, and pleural effusion management

Overview of respiratory complications such as hemoptysis, hiccups, laryngectomy and tracheostomy troubleshooting, airway obstruction, pneumonitis, and pleural effusion management

Overview of respiratory complications such as hemoptysis, hiccups, laryngectomy and tracheostomy troubleshooting, airway obstruction, pneumonitis, and pleural effusion management

Overview of respiratory complications such as hemoptysis, hiccups, laryngectomy and tracheostomy troubleshooting, airway obstruction, pneumonitis, and pleural effusion management

Overview of respiratory complications such as hemoptysis, hiccups, laryngectomy and tracheostomy troubleshooting, airway obstruction, pneumonitis, and pleural effusion management

Overview of respiratory complications such as hemoptysis, hiccups, laryngectomy and tracheostomy troubleshooting, airway obstruction, pneumonitis, and pleural effusion management

Key Learning Points

1. 1. On an abdominal X-ray, the bowel is only visible when there is intraluminal gas or an air–fluid level, as the different densities are required to create contrast resolution so they can be perceived on a radiograph.

2. 2. The 3/6/9 rule refers to the maximum size of specific sections of the bowel.

3. 3. On an abdominal X-ray, the small bowel is normally central and valvulae conniventes can be seen. The colon, by contrast, is normally peripheral and has haustral folds which do not completely traverse the lumen.

4. 4. In the early stages of pancreatitis, no abnormalities may be seen on CT imaging.

5. 5. In cholecystitis, ultrasound is more sensitive than CT; however, CT is better at depicting complications such as perforation.

Although the term ‘tracheostomy’ simply means a hole entering the trachea, it can be usefully divided into tracheostomy (in which a hole is made between the anterior neck and the trachea, which remains otherwise intact) and laryngectomy (in which the larynx is removed and the trachea is joined to the neck as a blind-ending stoma). Both groups of patients have an increased risk of complications outside and within hospitals. Many of these are entirely avoidable by better knowledge and reliability of care. There is confusion about different types of tracheostomy and between management of complications of tracheostomy and laryngectomy stoma. There is a need for clear understanding of the differences and what represents good care of such patients and their airways. Complications include airway blockage and displacement. Harm may occur if airway emergencies are not managed promptly and in a structured manner. Standard operating procedures, algorithms and checklists have a role in improving reliability of care and approaches to emergencies. Recent evidence shows multidisciplinary teams using quality improvement principles can reduce complications, hasten decannulation and improve patient experience. The National Tracheostomy Safety Project and the Global Tracheostomy Collaborative have been established to improve education and safety of tracheostomy care.

All sperm accrue varying amounts of DNA damage during maturation and storage, a process that appears to be mediated through oxidative stress. The clinical significance of genetic damage in the male germ line depends upon severity and how that damage is distributed among the sperm population. In human reproduction, the embryo is capable of significant DNA repair, which occurs prior to the first cleavage event. However, when the magnitude of genomic damage reaches pathologic levels, reproductive outcomes begin to be affected. Evidence now exists linking excessive sperm DNA fragmentation with time to pregnancy for natural conception, pregnancy outcomes of intrauterine insemination and in vitro fertilization, and miscarriage rates when intracytoplasmic sperm injection is employed. This review will discuss the pathophysiology of sperm DNA damage, the studies linking it to impaired reproductive outcomes, and how clinicians may render treatment to optimize the chance of paternity for their patients.