Male Circumcision

As part of a study designed to better understand the impact of forced migration on fertility, mortality, violence and traumatic stress among Sudanese nationals living in southern Sudan and Ugandan nationals and Sudanese refugees living in northern Uganda, we interviewed 3371 individuals from 1842 households in the Ugandan and Sudanese populations in the West Nile. Interviews were structured and were administered in the native languages of Lugbara or Juba Arabic. The study's design involved a multi-stage sampling design.
The full training of the interviewers took two months. The project objectives and the rationale behind the structure of the survey instrument as well as that of each question in the questionnaire were discussed in detail. Great attention was also paid to issues such as initial contacts, maintaining a professional attitude while in the field, avoiding influencing the respondent, and reducing interviewer and courtesy biases. The importance of collecting information by means of standardized questions so that the same question was asked to all respondents is stressed and questioning and probing skills were developed. Supervisors were instructed separately on data collection guidelines, their roles and their responsibility to ensure data quality. Keeping in mind the sensitive nature of some of the questions regarding violence and trauma and the fact that the team members were from the study population and probably had experiences similar to the respondents, a workshop on sexual and gender-based-violence was conducted by a consultant to the UNICEF office in Kampala, before the survey. The aim of this workshop was to increase awareness and sensitivity of the team towards respondents and their experiences. Another consultant to the project reviewed the team's interviewing skills and the project's data quality control measures just before the start of the survey. Problem areas were identified and remedied.
Data were complete and analyzed for N = 3179 respondents: 2,540 (75 %) of the respondents were women (15–50 years of age) and 831 (25%) were men (20–55 years of age). Details of the sampling, translation and assessment procedures, as well as the socio-demographic characteristics of the populations, have been described elsewhere [15 (link)].
Traumatic events were assessed using a checklist consisting of possible war and non-war related traumatic event types (i.e. witnessing or experiencing injury by a weapon or gun, beatings/torture, harassment by armed personnel, robbery/extortion, imprisonment, poisoning, rape or sexual abuse, beatings, abduction, child marriage, forced prostitution/sexual slavery, forced circumcision, etc.). The checklist was compiled after interviews with key informants (security personnel, doctors, community leaders, women's representatives) and 30 respondents from all three populations about their personal history of stressful events. Following these interviews, the single events obtained in these studies were rated as being potentially traumatic by experts. The following pilot checklist was pre-tested among further 44 Ugandans and Sudanese in areas not selected for the survey and modified according to the suggestions of the respondents. A primary item analysis based on inter-item correlations led to the exclusion of some events that were obviously not directly related to traumatic histories, e.g. the experiencing of witchcraft. Events included 19 experienced events and 12 witnessed events. Respondents were asked for each event type if they had experienced or witnessed such an event ever (i.e., lifetime experience) and if it happened in the past year. PTSD in respondents was assessed using the Posttraumatic Stress Diagnostic Scale (PDS), modified for assessment by trained lay interviewers [16 ]. The PDS is a self-report measure widely-used in industrialized countries as a screening instrument for the diagnosis and severity of PTSD based on DSM-IV Criteria.
Confidentiality was assured and it was explained that researchers were not working for any UN or Ugandan government organization. Informed consent was obtained using a standardized form explaining the potential risks of participation and explaining that no compensation would be provided. Informed consent forms were signed by the respondent and a witness; fingerprints were taken from illiterate respondents. No financial incentives were provided and respondents were informed that no improvements in living conditions were to be expected as a result of participating in the survey. Respondents were provided with referrals to counseling services provided by NGOs where available.

MCs were isolated from human foreskin tissue as previously described [51 (link)]. Each mast cell preparation/culture originated from several (2–10) donors to achieve sufficient cell numbers, as routinely performed in our lab [52 (link),53 (link),57 (link),88 (link),89 (link)]. The skin was obtained from circumcisions, with written, informed consent of the patients or legal guardians and approval by the university ethics committee (protocol code EA1/204/10, 9 March 2018). The experiments were conducted according to the Declaration of Helsinki Principles. Briefly, the skin was cut into strips and treated with dispase (26.5 mL per preparation, activity: 3.8 U/mL; Boehringer-Mannheim, Mannheim, Germany) at 4 °C overnight, the epidermis was removed, the dermis was finely chopped and then digested with 2.29 mg/mL collagenase (activity: 255 U/mg; Worthington, Lakewood, NJ, USA), 0.75 mg/mL hyaluronidase (activity: 1000 U/mg; Sigma, Deisenhofen, Germany) and DNase I at 10 µg/mL (Roche, Basel, Switzerland). Cells were filtered stepwise from the resulting suspension (100 and 40 µm strainers, Fisher Scientific, Berlin, Germany). MC purification was achieved by anti-human c-Kit microbeads (#130-091-332) and an Auto-MACS separation device (both from Miltenyi-Biotec, Bergisch Gladbach, Germany), giving rise to 98–100% pure preparations (FACS double staining of KIT/FcεRI (anti-FcεRI eBiosciene #11-5899-42), Fisher Scientific; anti-CD117 Miltenyi-Biotec # 130-111-593) and acidic toluidine blue (Sigma) staining, 0.1% in 0.5 N HCl (Fisher Scientific), as described previously [90 (link),91 (link)].
MCs were cultured in the presence of SCF, and IL-4 was freshly provided twice weekly when cultures were re-adjusted to 5 × 10⁵/mL. MCs were automatically counted by CASY-TTC (Innovatis/Casy Technology, Reutlingen, Germany) [88 (link),92 (link)].
Experiments were performed 3–4 d after the last addition of growth factors. For inhibition studies, cells were pre-incubated with 666-15 (CREB inhibitor; 5 µM unless otherwise stated; from Merck Chemicals, Darmstadt, Germany) or SCH772984 (ERK1/2 inhibitor; 10 µM), Pictilisib (PI3K inhibitor; 10 µM), Trametinib (MEK1/2 inhibitor; 10 µM), SB203580 (p38 inhibitor; 10 µM), SP600125 (JNK inhibitor; 10 µM), Pimozide (STAT5 inhibitor; 10 µM) and STAT3-IN (STAT3 inhibitor; 10 µM), all from Enzo Life Sciences, Germany, or imatinib-mesylate (Gleevec, KIT inhibitor; 10 µM, from Biozol Diagnostica, Eching, Germany) or KT 5720 (PKA inhibitor; 2 µM, from Bio-Techne, Wiesbaden, Germany) for 15 min, then stimulated (or not) by SCF (100 ng/mL). IL-33 was purchased from PeproTech (Hamburg, Germany) and applied in a concentration of 20 ng/mL, as described previously [52 (link)].

We identified 368 children who had undergone open pyeloplasty between January 2008 and February 2022 at our department (full member of ERN eUROGEN). A total of 185 children (50.3%) were under 1 year of age at the time of surgery. Patients with other cause of hydronephrosis than ureteropelvic junction obstruction were excluded (e.g., secondary stenosis due to primary megaureter), or patients who underwent other surgery in the same term (e.g., pyeloplasty and circumcision). We also excluded patients with skin incision other than described below. A total of 162 children met the inclusion parameters, 124 boys (76.7%) and 38 girls (23.3%).
The medical records were retrospectively reviewed in terms of demographic data, operation time, level of experience of the surgeon, length of hospital stay, duration of stent placement, febrile urinary tract infection during ureteral stenting, ultrasound findings (grade of hydronephrosis according to a consensus group pediatric nephrology working society [18 (link)], anteroposterior pelvic diameter (APD), parenchyma thickness) before and after surgery in a standardized follow-up, separate renal function (SRF) in MAG3 as well as analgesia during hospital stay, intraoperative and postoperative complications according to Clavien–Dindo (CD), and inpatient readmission within 30 days. We also examined the need of a redo pyeloplasty.
Complications were regarded as any deviation from the expected postoperative course according to the five-grade Clavien–Dindo classification [19 (link)].
In the second part of this study, a nonvalidated self-designed questionnaire (in German language) was sent in September 2022 to all included patients by mail to evaluate the postoperative course from the parents’ point of view, as well as the satisfaction in the long-term course. Additionally, they were asked to take a photo of the scar alongside a metric ruler to obtain scar length values. The parents were asked to return the completed questionnaire and the photo of the scar either by mail (prepaid envelope enclosed) or by e-mail within 4 weeks (Supplementary Data Figure S1).
In the third part, these photos were independently categorized by 2 experienced surgeons using a modified Vancouver Scar Scale [20 (link)]. The scale was modified for usage on photographs and linear scars. Instead of measuring the height, it was described as flat, slightly raised, fairly raised, bulging, and sunken. Pliability was left out as it is not representable on photographs. The higher the scoring, the worse the cosmesis, whereby the maximum score of 9 reflects the worst imaginable scar. The lowest scores (0–2) reflect the best imaginable scar or almost normal skin (Supplementary Data Figure S2).