Testicular Trauma Research Articles

Fertility preservation after bilateral severe testicular trauma

Fertility preservation after bilateral severe testicular trauma

Male fertility and varicocoele: role of immune factors

The role of antisperm antibodies (ASA) in the aetiopathogenesis of varicocoele-related male infertility remains unclear. The objective of this study was to determine whether varicocoele is associated with antisperm immune response and whether this factor provides additional affect on male fertility. We performed a multicentral, prospective study that included the clinical examination of 1639 male subjects from infertile couples and 90 fertile men, the evaluation of the absolute and relative risks of immune infertility associated with varicocoele and the impact of the autoimmune response on the semen quality. The methods used were as follows: standard examination of seminal fluid according to WHO criteria; ASA detection in seminal fluid using mixed antiglobulin reaction (MAR) and direct flow cytometry; measurement of spontaneous and ionophore-induced acrosome reactions; oxidative stress evaluation with luminal-dependent chemiluminescence method and evaluation of DNA fragmentation by sperm chromatin dispersion. The prevalence of varicocoele-related immune infertility is about 15% and does not depend on the grade of vein dilatation both in primary and secondary fertility disorders. Varicocoele is not an immediate cause of autoimmune reactions against spermatozoa, but is a cofactor increasing ASA risk; the OR of immune infertility after a testicular trauma in varicocoele patients increases twofold. In varicocoele patients, the autoimmune antisperm reaction is accompanied by a more significant decrease in the semen quality (concentration and number of progressively motile and morphologically normal spermatozoa in the ejaculate), acrosome reaction disorders (presence of pre-term spontaneous and lack of induced reactions) and an increase in the proportion of spermatozoa with DNA fragmentation. These disorders correlate with the level of sperm oxidative stress; reactive oxygen species (ROS) production in ASA-positive varicocoele patients is 2.8 and 3.5 times higher than in ASA-negative varicocoele patients and fertile men respectively. We did not find correlation between the grade of spermatic cord vein dilatation and ROS production.

Frequency and nature of testicular and paratesticular lesions in forensic autopsies

The aim of our study was to determine the frequency and nature of testicular and paratesticular lesions in forensic autopsies. A retrospective study was carried out on 495 adult male cases that underwent forensic autopsy from January 2008 to December 2011 in our Department. For each case, the following parameters were reported: age, body mass index, nature of testicular and paratesticular lesions, associated lesions in external genitalia, testicle weight, cause of death, manner of death, resuscitation attempts and prior medical history. Mean age of the studied population was 47.8 years (range 18-96). Mean body mass index was 25.3 kg/m(2) (range 15-46.2). Testicular lesions and/or paratesticular were found in 16.4% of the cases (n = 81). The most frequent lesions were, respectively, testicular atrophy (n = 38) and trauma (n = 28). In three cases showing traumatic lesions, associated traumatic lesions were found in external genitalia. Most frequent cause of death was blunt trauma (19.9% of the cases). Manner of death most frequently associated with testicular trauma was, respectively, road traffic accident (n = 11) and suicidal fall (n = 6). Mean testicular weight was, respectively, 17.9 g for the right and 20.8 g for the left (range 2-38). Atrophy was associated with testicular weight less than 10 g. A significant association between testicular atrophy and age was found, the risk of atrophy increasing quite linearly with age. No significant statistical link between prior medical history and testicular pathology was found. There was also no influence of body mass index. Resuscitation attempts were not statistically associated with testicular traumatic lesions.

Index of Suspicion

A 5-year-old previously healthy boy presents to the emergency department (ED) with a 2-week history of intermittent left groin pain, usually occurring later in the day. Pain is not related to eating, movement, urination, or stooling. There is no report of trauma or precipitating event. He screams and refuses to stand up during pain episodes, which occur suddenly and last approximately 1 to 2 hours at a time. He otherwise has normal gait and activity when pain free. He does not wake up at night in pain. No recent illnesses or fevers are reported. Review of systems and his examination findings are unremarkable. Two days prior, he was evaluated in the ED for the same issue and had normal urinalysis, urine culture, and scrotal ultrasonogram results. The consulting urologist did not suspect a urologic process. He was discharged home with pain medication. Today, he returns to the ED because of the intense pain. The patient is admitted for further evaluation and pain management. Complete blood cell (CBC) count, C-reactive protein level, urinalysis results, and plain radiographs of the hips are unremarkable. Computed tomography of the abdomen and pelvis reveals a trace amount of nonspecific free fluid in the pelvis. His pain appears to be alleviated with ibuprofen and bed rest. The following day, he has another episode of intense groin pain after returning from the play room. Physical examination at this time demonstrates only point tenderness on palpation over his symphysis pubis area. No swelling, erythema, or increased warmth was noted in that area. An additional imaging study reveals the diagnosis. A 15-year-old girl presents to the clinic with an itchy rash, fever, headache, nausea, and dizziness. A few days earlier she was evaluated for rash on her back and low-grade fevers. She was prescribed amoxicillin clavulanate for suspected streptococcal …

US in the assessment of acute scrotum

BackgroundThe acute scrotum is a medical emergency . The acute scrotum is defined as scrotal pain, swelling, and redness of acute onset. Scrotal abnormalities can be divided into three groups , which are extra-testicular lesion, intra-testicular lesion and trauma. This is a retrospective analysis of 164 ultrasound examination performed in patient arriving in the emergency room for scrotal pain.The objective of this article is to familiarize the reader with the US features of the most common and some of the least common scrotal lesions.MethodsBetween January 2008 and January 2010, 164 patients aged few month and older with scrotal symptoms, who underwent scrotal ultrasonography (US), were retrospectively reviewed. The clinical presentation, outcome, and US results were analyzed. The presentation symptoms including scrotal pain, painless scrotal mass or swelling, and trauma.ResultsOf 164 patients, 125 (76%) presented with scrotal pain, 31 (19%) had painless scrotal mass or swelling and 8 (5%) had trauma. Of the 125 patients with scrotal pain, 72 had infection,10 had testicular torsion, 8 had testicular trauma, 18 had varicocele, 20 had hydrocele, 5 had cryptorchidism, 5 had scrotal sac and groin metastases, and 2 had unremarkable results. In the 8 patients who had history of scrotal trauma, US detected testicular rupture in 1 patients, scrotal haematomas in 2 patients .Of the 19 patients who presented with painless scrotal mass or swelling, 1 6 had extra-testicular lesions and 3 had intra-testicular lesions. All the extra-testicular lesions were benign. Of the 3 intra-testicular lesions, one was due to tuberculosis epididymo-orchitis, one was non-Hodgkin’s lymphoma, and one was metastasis from liposarcomaConclusionsUS provides excellent anatomic detail; when color Doppler and Power Doppler imaging are added, testicular perfusion can be assessed

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

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

Recovery from azoospermia caused by a testicular injury: a case report

Some cases of testicular trauma cause infertility especially when the injured testes are not removed. However, only a few long-term follow-up studies investigating endocrinological and semen parameters in patients who had testicular trauma have been conducted. Herein, we report an interesting case of a patient who spontaneously recovered from azoospermia due to a traffic injury and present in detail the results of the hormonal examination and semen analysis. The patient was a 22-year-old man with a history of left testicular injury and bilateral orchidopexy. Four months after the injury, the semen parameters improved but azoospermia occurred 1year later. However, spermatogenesis spontaneously recovered without any treatment or without undergoing orchiectomy 6months after the testicular injury.

Testicular Torsion Masked by Painful Abdomen

We would like to add a few comments to the excellent review article by Gunther and Rubben. In our opinion it seems worth mentioning that testicular torsion may be masked by a painful abdomen. We review 10 patients with testicular torsion who presented with abdominal pain as their leading symptom. For this reason we recommend mandatory genital examination in the clinical assessment of boys with abdominal pain. Particular attention should go to boys with reduced sensitivity of the lower half of the body—for example, in patients with meningomyelocele. When operating a patient with an incarcerated inguinal hernia we advise to visualize the ipsilateral testis since an incarceration can substantially compromise testis perfusion. Testicular trauma is not only an important differential diagnosis in acute scrotum but in itself presents a risk factor for testicular torsion (e21 in the article). The literature encompasses some 50 cases of ipsilateral testicular torsion after orchidopexy (1). Thus we suggest the modified technique for testicular fixation reported by Gesino and Bachmann de Santos (2). A full blood count, C-reactive protein concentration, and the analysis of urine sediment are listed as components of the diagnostic approach. With the exception of leukemia, which hardly ever needs to be considered, none of the differential diagnoses has a definitive laboratory constellation. Studies investigating predictive variables in acute pediatric scrotum mostly do not even consider laboratory variables from the outset (for example, e21 and 3). Furthermore, ascertaining the above-mentioned parameters may delay the definitive diagnosis. The decisive issue is timely presentation in institutions that can perform the required surgical measures immediately. For this reason we think that the diagnostic evaluation listed above can be dispensed when assessing a boy for testicular torsion.

Bedside Ultrasound in a Case of Blunt Scrotal Trauma

This case study describes a patient who suffered blunt force trauma to the scrotum. Use of bedside emergency ultrasound facilitated early diagnosis of a ruptured testicle and allowed for prompt urological consultation and timely surgical repair. The utility of bedside emergency ultrasound in the evaluation of testicular trauma, as well as the outcome of our case, is discussed here.

Diagnosis and Management of Testicular Injuries

Testicular injuries are seldom because of the mobility of the testes and their anatomical position between the thighs, which offers them protection. They represent only a small percentage of traumatic injuries of the genitourinary tract. Etiologically we can categorize testicular trauma in blunt or penetrating. Treatment can be conservative or surgical. Significant haematocele indicates rupture of the tunica vaginalis testis and should be treated with surgical exploration and repair. Treatment decision can be made with the help of real time ultrasonography or sometimes MRI and CT-scans of the testes. Hormonal function remains in most of the cases normal but hormone status should be controlled in complicated cases, which affect fertility and could require hormone replacement.

Role of laparoscopy in the management of impalpable testis in children: a study in Bangladesh

Introduction : Treatment of the cryptorchid testicle is justified due to the increased risk of infertility and malignancy as well as the risk of testicular trauma and psychological stigma on patients and their parents. Approximately 20% of cryptorchid testicles are impalpable. In these cases, the laparoscopic technique is the method of choice for diagnosis and treatment. Materials and Methods : From 1 April 2009 to 31 October 2010, 37 testicles of 30 patients were submitted to diagnostic laparoscopy for impalpable testes. This was a prospective study seeking the diagnostic accuracy and therapeutic outcomes of use of laparoscopy in impalpable testes. Age, operative techniques, complications, the cosmetic aspect and outcomes were also recorded. Results : Mean age was 6.64 ± 3.96 years and 23% cases were bilateral. Twenty-one cases had primary orchiopexy, 9 had 1st stage Fowler- Stephens (FS) procedure, 3 had 2nd stage FS, 13 cases needed inguinal exploration and there was one vanishing testicles. Average operating time was 40 min for diagnostic laparoscopy, 90 min for unilateral and 120 min for the bilateral cases. Two of the patients had late postoperative complications e.g. one uretereral obstruction and one recurrence. Conclusions : In pediatric age group, the laparoscopic approach is safe and feasible. The purpose of study is to see whether the laparoscopic procedure presents excellent results in terms of diagnosis and therapy of the impalpable testis. DOI: http://dx.doi.org/10.11593/bje.2013.0101.0005 Bangladesh Journal of Endosurgery Vol.1(1) January 2013: 16-20

Contrast-enhanced ultrasound performed under urgent conditions. Indications, review of the technique, clinical examples and limitations

Contrast-enhanced ultrasound (CEUS) is an imaging technique with various indications, most of which refer to scheduled examinations. However, CEUS can also be performed under urgent conditions for the investigation of many different clinical questions. This article reviews basic physics of ultrasound contrast agents and examines the commonest urgent clinical applications of CEUS. These include, among others, abdominal solid organ trauma and infarcts, scrotal and penile pathology and blood vessel imaging. Patients can be examined with a very short time delay at their bedside, without exposure to ionising radiation or risk of anaphylactic reaction and renal failure, while contraindications are minimal. CEUS technique is described for various urgent indications and imaging examples from our department’s experience are presented. Safety matters and limitations of CEUS are also mentioned. Teaching Points Contrast-enhanced ultrasound (CEUS) can be performed urgently for various clinical applications. Abdominal indications include solid organ trauma and infarcts. CEUS in abdominal organ trauma correlates well with CT and can replace it for patient follow-up. CEUS images testicular torsion, infection and infarction, as well as testicular and penile trauma. Blood vessels can be assessed with CEUS for obstruction, aneurysm, thrombosis and dissection.

Emergency testicular sperm extraction after scrotal trauma in a patient with a history of contralateral orchiopexy for cryptorchidism: case report and review of the literature

To report a case of successful testicular sperm extraction performed during an emergency scrotal exploration for trauma in a patient with a history of previous contralateral cryptorchidism. Case report. Clinica Urologica I, Università degli Studi di Milano, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Ca' Granda, Ospedale Maggiore Policlinico. A 28-year-old man with a history of right orchiopexy for cryptorchidism presenting with blunt trauma of the pelvis. Seminiferous tubules extraction. Successful sperm retrieval. Scrotal ultrasonography (US) showed a suspected rupture of the left tunica albuginea, and color Doppler examination evidenced testicular perfusion only in the region near the mediastinum testis. Twelve hours after scrotal exploration, the extracted testicular tissue was successfully processed, and seven vials of sperm were frozen. After testicular trauma in selected patients, such as individuals with a history of monorchism or cryptorchidism, emergency testicular sperm extraction (TESE) can be a useful option to preserve fertility.

Contrast-enhanced ultrasound in testicular trauma: role in directing exploration, debridement and organ salvage

We describe the use of contrast-enhanced ultrasound as an additional imaging technique during an ultrasound examination of a traumatised testis, allowing for confident testicular preserving surgery to be performed.

Race and Insurance Status are Risk Factors for Orchiectomy Due to Testicular Trauma

Race and insurance status independently predict outcome disparities after trauma. Black patients, Hispanic patients, uninsured patients and patients who live farther from trauma centers have a worse outcome after trauma than others. To our knowledge it is unknown whether these factors have a role in the testicular salvage rate after testicular trauma. We used NTDB (National Trauma Data Bank®) to investigate whether socioeconomic status, race and rural location predict testicular salvage. Patients who sustained testicular trauma were identified in NTDB, version 9.1. Procedure codes for orchiectomy vs testicular repair were used to determine the risk of testicular salvage. Rural location was determined by matching the injury with the urban influence code. Univariate analysis of the influence of patient age, injury severity, race, insurance status and rural location was performed. Multivariate longitudinal analysis was done to identify orchiectomy predictors. Of 635,013 trauma cases 980 (0.2%) involved testicular injury. Of these patients 108 (11.0%) underwent orchiectomy and 58 (5.9%) underwent testicular repair. Self-paying patients had a statistically higher rate of orchiectomy than those with private insurance (79.2% vs 48.0%, p = 0.006). Black patients had a statistically higher rate of orchiectomy than white patients (75.8% vs 53.7%, p = 0.009). No difference in the orchiectomy rate was seen between Hispanic and nonHispanic patients (68.0% vs 65.8%, p = 0.84). In terms of rurality the incidence location was similar for orchiectomy and testicular repair, including urban 46.3% and 39.7%, rural 6.5% and 3.5%, suburban 2.8% and 1.7%, and wilderness 0.9% and 3.5%, respectively (p = 0.55). No statistically significant differences were found in age (31 vs 29 years, p = 0.42), injury severity score (5.8 vs 5.8, p = 0.99), hospital stay (8.4 vs 6.7 days, p = 0.41), intensive care unit stay (14.4 vs 9.6 days, p = 0.41) or ventilator days (18.2 vs 10.2, p = 0.24) for orchiectomy and testicular repair cases. Although age, injury severity score, hospital stay, intensive care unit stay and days of ventilator support are similar for patients who underwent orchiectomy vs testicular repair, the orchiectomy rate was higher for uninsured and black patients. Further studies are needed to elucidate the reasons for this disparity. Standardized protocols to manage testicular injury may decrease these disparities.

Tuberculose endobronchique

Race and insurance status independently predict outcome disparities after trauma. Black patients, Hispanic patients, uninsured patients and patients who live farther from trauma centers have a worse outcome after trauma than others. To our knowledge it is unknown whether these factors have a role in the testicular salvage rate after testicular trauma. We used NTDB (National Trauma Data Bank®) to investigate whether socioeconomic status, race and rural location predict testicular salvage.Patients who sustained testicular trauma were identified in NTDB, version 9.1. Procedure codes for orchiectomy vs testicular repair were used to determine the risk of testicular salvage. Rural location was determined by matching the injury with the urban influence code. Univariate analysis of the influence of patient age, injury severity, race, insurance status and rural location was performed. Multivariate longitudinal analysis was done to identify orchiectomy predictors.Of 635,013 trauma cases 980 (0.2%) involved testicular injury. Of these patients 108 (11.0%) underwent orchiectomy and 58 (5.9%) underwent testicular repair. Self-paying patients had a statistically higher rate of orchiectomy than those with private insurance (79.2% vs 48.0%, p = 0.006). Black patients had a statistically higher rate of orchiectomy than white patients (75.8% vs 53.7%, p = 0.009). No difference in the orchiectomy rate was seen between Hispanic and nonHispanic patients (68.0% vs 65.8%, p = 0.84). In terms of rurality the incidence location was similar for orchiectomy and testicular repair, including urban 46.3% and 39.7%, rural 6.5% and 3.5%, suburban 2.8% and 1.7%, and wilderness 0.9% and 3.5%, respectively (p = 0.55). No statistically significant differences were found in age (31 vs 29 years, p = 0.42), injury severity score (5.8 vs 5.8, p = 0.99), hospital stay (8.4 vs 6.7 days, p = 0.41), intensive care unit stay (14.4 vs 9.6 days, p = 0.41) or ventilator days (18.2 vs 10.2, p = 0.24) for orchiectomy and testicular repair cases.Although age, injury severity score, hospital stay, intensive care unit stay and days of ventilator support are similar for patients who underwent orchiectomy vs testicular repair, the orchiectomy rate was higher for uninsured and black patients. Further studies are needed to elucidate the reasons for this disparity. Standardized protocols to manage testicular injury may decrease these disparities.

Etiology of acute scrotal pain in children and adolescent patients admitted in Ahvaz Educational Hospitals

Purpose Acute scrotum is an emergency condition requiring rapid intervention. The aim of this study was to evaluate the clinical and epidemiological specifications of acute scrotum. Patients and methods This retrospective study was carried out on patients less than 21 years admitted with a diagnosis of acute scrotum in the surgical and medical wards from 2009 to 2010. One hundred and thirty-nine patients were included in this study. Epi-info version 6.4 (CDC) was used for data analysis. Results The final diagnoses were as follows: spermatic cord torsion (n =57, 41.00%), incarcerated inguinal hernia (n =30, 21.60%), epididymo-orchitis (n= 28, 20.14%), missed torsion (n =15, 10.79%), testicular trauma (n=5, 3.60%), and torsion of the appendix of the testis (n= 4, 2.87%). The most common age groups in relation to the diagnoses were as follows: testicular torsion and missed torsion (10–15 years, 34.7%), torsion of appendix testis (10–15 years, 100%), epididymo-orchitis (15–21 years, 85.71%), and incarcerated inguinal hernia with two peaks of age ( <5 years, 46.7%). Fifty-eight patients (41.72%) visited the hospital less than 6 h after the onset of pain. Twenty-eight patients underwent orchiectomy or orchiopexy and 38 patients underwent detorsion and bilateral orchiopexy. A herniotomy was performed in 15 patients and herniorraphy in 10 patients. An appendectomy was performed in four patients. Other procedures were carried out in seven patients. Out of 72 patients diagnosed with torsion (57 patients) or missed torsion (15 patients), 38 patients (52.7%) underwent a testicular salvage surgery (detorsion and orchiopexy). Out of all patients (139 patients), 92 patients underwent surgery and the rest (47 patients) were treated conservatively. These 47 patients had epididymo-orchitis (n= 28), testicular trauma (n =4), incarcerated inguinal hernia (n= 5), and missed torsion and testicular torsion (n= 10). Out of 27 patients with abnormal urinary findings, 19 patients had epididymo-orchitis. Conclusion The most common important differential diagnosis for acute scrotum is spermatic cord torsion. Most of the abnormal urinary findings were observed in patients with epididymo-orchitis. Most of the patients underwent surgery less than 6 h of disease onset. In patients with spermatic cord torsion, the affected testis has to be evaluated and treated during the first 6 h of presentation. Keywords: epididymitis, epididymo-orchitis, herniotomy, hydrocele, inguinal hernia, orchiopexy, scrotum, testicular torsion, trauma

Race and insurance status are risk factors for orchiectomy due to testicular trauma

Purpose: Race and insurance status independently predict outcome disparities after trauma. Black patients, Hispanic patients, uninsured patients and patients who live farther from trauma centers have a worse outcome after trauma than others. To our knowledge it is unknown whether these factors have a role in the testicular salvage rate after testicular trauma. We used NTDB (National Trauma Data Bank®) to investigate whether socioeconomic status, race and rural location predict testicular salvage.Materials and Methods: Patients who sustained testicular trauma were identified in NTDB, version 9.1. Procedure codes for orchiectomy vs testicular repair were used to determine the risk of testicular salvage. Rural location was determined by matching the injury with the urban influence code. Univariate analysis of the influence of patient age, injury severity, race, insurance status and rural location was performed. Multivariate longitudinal analysis was done to identify orchiectomy predictors.Results: Of 635,013...

A Conservative Approach to Testicular Rupture in Adolescent Boys

Management for blunt trauma with breach of the renal capsule or bladder (extraperitoneal) has largely become nonsurgical since a conservative approach proved to be effective and safe. Currently the recommendation for managing testicular rupture is surgical exploration and débridement or orchiectomy. We report outcomes in boys diagnosed with testicular rupture and treated without surgical intervention. In the last year we conservatively treated 7 consecutive boys with delayed presentation of testicular rupture after blunt scrotal trauma. Patients were treated with scrotal support, antibiotics to prevent abscess, rest, analgesics and serial ultrasound. We report clinical information and outcomes. The 7 boys were 11 to 14 years old and presented 1 to 5 days after injury. Trauma was to the left testis in 3 cases and to the right testis in 4. Patients presented with mild to moderate pain and similar scrotal swelling. Ultrasound findings consistently revealed hematocele and increased echogenicity. Blood flow was present in the injured portion of the testes in 3 cases and to the remainder of the affected testicle in 6 of the 7 boys. In the remaining boy an adequate waveform was not seen in either testicle, which the radiologist thought was secondary to prepubertal status. Other findings included scrotal edema, irregular contour and seminiferous tubule extrusion. Followup was greater than 6 months in all cases. Five boys were seen at the office and the 2 remaining had telephone followup. In all cases hematocele resolved, testicular size stabilized without atrophy and echogenicity normalized in the 5 patients with followup ultrasound. One patient required surgical repair of hydrocele 4 months after trauma but no other patient needed surgical exploration. No abscess or infection developed. A conservative approach in a select group of adolescent boys with testicular rupture can result in resolution of the fracture and maintenance of testicular architectural integrity.

Factors affecting male infertility

Introduction: Infertility is commonly defined as the failure of conception after at least 12 months of unprotected intercourse. 1 Accurate assessment of the prevalence of infertility has always been difficult because of the large scale population based studies. 2 Male factor is the only cause of infertility in about 20 % of infertile couples, but it may be a contributing factor in as many as 30 % to 40 % of cases.3 Factors like diabetes, bronchiectasis, high grade fever, long term medication, urinary tract infection, sexually transmitted infection, epididymitis, testicular injury, un-descended testis,mumps, orchitis, excessive alcohol, smoking, exposure to heat and certain chemicals effect in the spermatogenesis. Impotence or erectile dysfunction remains one of the important contributors in the male infertility. Methods: This is a prospective descriptive study conducted during the health camps in Sindhupalchowk, Manang, Baitedi, Rauthat and Darchula districts of the Nepal. The objective of the study is to find out the factors contributing to male infertility. Couples who were unable to conceive after regular, unprotected coitus of at least one year were included in the study. Detail history, clinical examination and semen analysis was done. Results: There was limited facility of investigation and treatment of infertility in the health camps.The diagnosis was based only on history, examination and semen analysis. Various factors like mumps, chemical exposure like men working in carpet factory, testicular trauma and smoking were found as contributing factor of male infertility in these districts. Conclusions: Testicular trauma, mumps, smoking is common in all the districts. Exposure to chemicalssuch as dyes, used in carpet factories seems to be responsible for infertility in some men of Sindhupalchowk and Darchula.