Practical model to identify liver transplant recipients at low risk of postoperative haemorrhage, bile leakage and ascites

Background

This study aimed to identify a subgroup of recipients at low risk of haemorrhage, bile leakage and ascites following liver transplantation (LT).

Methods

Factors associated with significant postoperative ascites (more than 10 ml/kg on postoperative day 5), bile leakage and haemorrhage after LT were identified using three separate multivariable analyses in patients who had LT in 2010–2019. A model predicting the absence of all three outcomes was created and validated internally using bootstrap procedure.

Results

Overall, 944 recipients underwent LT. Rates of ascites, bile leakage and haemorrhage were 34.9, 7.7 and 6.0 per cent respectively. The 90-day mortality rate was 7.0 per cent. Partial liver graft (relative risk (RR) 1.31; P = 0.021), intraoperative ascites (more than 10 ml/kg suctioned after laparotomy) (RR 2.05; P = 0.001), malnutrition (RR 1.27; P = 0.006), portal vein thrombosis (RR 1.56; P = 0.024) and intraoperative blood loss greater than 1000 ml (RR 1.39; P = 0.003) were independently associated with postoperative ascites and/or bile leak and/or haemorrhage, and were introduced in the model. The model was well calibrated and predicted the absence of all three outcomes with an area under the curve of 0.76 (P = 0.001). Of the 944 patients, 218 (23.1 per cent) fulfilled the five criteria of the model, and 9.6 per cent experienced postoperative ascites (RR 0.22; P = 0.001), 1.8 per cent haemorrhage (RR 0.21; P = 0.033), 4.1 per cent bile leak (RR 0.54; P = 0.048), 40.4 per cent severe complications (RR 0.70; P = 0.001) and 1.4 per cent 90-day mortality (RR 0.13; P = 0.004).

Conclusion

A practical model has been provided to identify patients at low risk of ascites, bile leakage and haemorrhage after LT; these patients could potentially qualify for inclusion in non-abdominal drainage protocols.

Risk score to predict biliary leakage after elective liver resection

Background

Biliary leakage remains a major cause of morbidity after liver resection. Previous prognostic studies of posthepatectomy biliary leakage (PHBL) lacked power, population homogeneity, and model validation. The present study aimed to develop a risk score for predicting severe PHBL.

Methods

In this multicentre observational study, patients who underwent liver resection without hepaticojejunostomy in one of nine tertiary centres between 2012 and 2015 were randomly assigned to a development or validation cohort in a 2 : 1 ratio. A model predicting severe PHBL (International Study Group of Liver Surgery grade B/C) was developed and further validated.

Results

A total of 2218 procedures were included. PHBL of any severity and severe PHBL occurred in 141 (6·4 per cent) and 92 (4·1 per cent) patients respectively. In the development cohort (1475 patients), multivariable analysis identified blood loss of at least 500 ml, liver remnant ischaemia time 45 min or more, anatomical resection including segment VIII, transection along the right aspect of the left intersectional plane, and associating liver partition and portal vein ligation for staged hepatectomy as predictors of severe PHBL. A risk score (ranging from 0 to 5) was built using the development cohort (area under the receiver operating characteristic curve (AUROC) 0·79, 95 per cent c.i. 0·74 to 0·85) and tested successfully in the validation cohort (AUROC 0·70, 0·60 to 0·80). A score of at least 3 predicted an increase in severe PHBL (19·4 versus 2·6 per cent in the development cohort, P < 0·001; 15 versus 3·1 per cent in the validation cohort, P < 0·001).

Conclusion

The present risk score reliably predicts severe PHBL. It represents a multi-institutionally validated prognostic tool that can be used to identify a subset of patients at high risk of severe PHBL after elective hepatectomy.

Multibiomarker response in the earthworm Eisenia fetida as tool for assessing multi-walled carbon nanotube ecotoxicity

Carbon nanotubes have received a great attention in the last years thanks to their remarkable structural, electrical, and chemical properties. Nowadays carbon nanotubes are increasingly found in terrestrial and aquatic environment and potential harmful impacts of these nanoparticles on humans and wildlife are attracting increasing research and public attention. The effects of carbon nanotubes on aquatic organisms have been explored by several authors, but comparatively the information available on the impact of these particles on soil organisms is much less. Earthworms have traditionally been considered to be convenient indicators of land use impact and soil fertility. The aim of this work was to study the integrated response of a suite of biomarkers covering molecular to whole organism endpoints for the assessment of multi-walled carbon nanotube (MWCNTs) effects on earthworms (Eisenia fetida) exposed to spiked soil. Results showed that cellular and biochemical responses, such as immune cells morphometric alterations and lysosomal membrane destabilization, acetylcholinesterase inhibition and metallothionein tissue concentration changes, showed high sensitivity to MWCNTs exposure. They can improve our understanding and ability to predict chronic toxicity outcomes of MWCNTs exposure such as reproductive alterations. In this context although more investigation is needed to understand the mechanistic pathway relating the biochemical and cellular biomarker analyzed to reproductive alterations, the obtained results give an early contribution to the future development of an adverse outcomes pathways for MWCNTs exposure.

French survey of the first three-years of liver transplantation activity from uncontrolled donors deceased after cardiac death

OBJECTIVE

To assess the first three years of French activity related to liver transplantation from uncontrolled donation after cardiac death (uDCD).

STUDY DESIGN

Prospective and observational study in the three active centres authorized by the French Biomedicine Agency.

PATIENTS AND METHODS

All patients deceased between 2010 and 2012 after an uncontrolled cardiac arrest admitted to one of three centres (Pitié-Salpêtrière, Saint-Louis or Bicêtre hospitals, AP-HP, Paris, France) and potentially eligible for liver recovery were included. Abdominal normothermic oxygenated recirculation (ANOR) was used for graft preservation.

RESULTS

One hundred twenty-six potential uDCD donors were identified as eligible for liver recovery after hospital admission. The main causes of organ recovery failure were technical failure related to ANOR (29 patients, 23%), refusal of consent (39 patients, 31% of potential uDCD donors and 40% of asked relatives) and abnormal hepatic transaminases up to 200 UI.L(-1) during ANOR (24 patients, 19%). Finally, 11 livers were transplanted. Process efficiency was 9% [95% CI: 4-15%]. One-year recipient survival was 82%, [95% CI: 48-98%] and one-year graft survival was 64% [95% CI: 31-89%].

CONCLUSION

Liver transplantation from uDCD donors is achievable in France, despite low process efficiency.

Liver resection in transplanted patients: a single-center Western experience

BACKGROUND

Liver resection (LR) in liver transplant (OLT) recipients, an extremely rare situation, who performed on 8 recipients.

METHODS

This retrospective analysis of prospectively collected data concerned 8 (0.66%) 1198 LR cases among OLT performed from 1997 to 2011. We analyzed demographic data, surgical indications, and postoperative courses.

RESULTS

The indications were resectable recurrent hepatocellular carcinomas (HCC, n = 3), persistent fistula from a posterior sectorial duct (n = 1), recurrent cholangitis due to anastomotic stricture on the posterior sectorial duct (n = l), hydatid cyst (n = l), left arterial hepatic thrombosis with secondary ischemic cholangitis (n = 1), and a large symptomatic biliary cyst (n = 1). The mean interval time to liver resection was 23.7 months (range, 5-47). LR included right hepatectomy (n = 1), right posterior hepatectomy (n = 1), left lobectomy (n = 4), pericystectomy (n = 1), or biliary fenestration (n = 1). Which there was no postoperative mortality, the global morbidity rate was 62% (5/8). The mean follow-up after LR was 92 months (range, 11-156). No patients required retransplantation. None of the 3 patients who underwent LR for HCC showed a recurrence.

CONCLUSIONS

LR in OLT recipients is safe, but associated with a high morbidity rate. This procedure can avoid retransplantation in highly selected patients, presenting a possible option particularly for transplanted patients with a resectable, recurrent HCC.

Fatal Escherichia coli skin and soft tissue infections in liver transplant recipients: report of three cases

Gram-negative bacilli are unusual agents of skin and soft tissue infections. Most previous cases have been reported in cirrhotic or immunocompromised patients, including a single case in a liver transplant recipient. The present report describes 3 cases of fatal skin or soft tissue infections caused by Escherichia coli that occurred in the postoperative course of liver transplantation. The 3 patients were profoundly immunosuppressed as a result of pre-transplant cirrhosis and the postoperative administration of a potent immunosuppressive therapy. Skin and soft tissue infections developed within the first week after liver transplantation, while graft liver function was satisfactory. The 3 patients presented with fever and skin lesions with or without bullae. Despite prompt appropriate antibiotic therapy and surgical debridement, the outcome was rapidly fatal (24 h on average). E. coli was isolated from subcutaneous tissues in 2 cases and from several blood cultures in the third one. The 3 isolates belonged to distinct phylogenetic groups, and did not harbor most of the virulence factors usually reported in extraintestinal pathogenic E. coli isolates. Our report suggests that E. coli can cause severe skin or soft tissue infection in the postoperative course of liver transplantation. The onset of infection is very early and the outcome is extremely poor, despite prompt adapted medical and surgical treatment. Host factors, rather than E. coli bacterial virulence potential, appear to be the major determinants of severity in these patients.

Simultaneous surgical repair for combined biliary and arterial stenoses after liver transplantation

After orthotopic liver transplantation (OLT), hepatic artery stenoses (HAS) and biliary strictures (BS) are frequent. These complications remain a significant cause of graft loss and patient death. The present study reported a group of 7 patients in whom both HAS and BS were identified and treated surgically in the same surgical session. The median times to diagnosis were 42 (range, 5-120) and 84 (range, 15-280) days after OLT for biliary and arterial stenosis, respectively. The mortality was nil. Two patients (28%) developed postoperative complications. The median hospital stay was 16 days (range, 10-42). All patients are alive; there was no graft loss. With a median of 76 months' follow-up (range, 38-132), only 1 patient (14%) developed recurrence of both BS and HAS. In patients with coincident biliary and artery stenosis, concomitant surgical repair is feasible, offering good long-term results.

Integration of biochemical, histochemical and toxicogenomic indices for the assessment of health status of mussels from the Tamar Estuary, U.K

The aim of this study was to examine whether a combination of biochemical, histopathological and toxicogenomic data could be used as a valuable tool for the assessment of biological risk associated with pollutants within the Tamar River and Estuary, S.W. England, U.K. Accordingly, biochemical and histopathological biomarkers (protein carbonyls, lipofuscin, neutral lipids, lysosomal stability [N-acetyl-β-hexosaminidase and neutral red], lysosomal volume, ferric reducing antioxidant power [FRAP] and malonaldehyde [MDA]) and gene expression profiles were assessed in 5 sites from the Tamar River and Estuary (Neal Point, Town Quay, Wilcove, Cremyll Ferry and Whitsand; and a reference site, Trebarwith Strand, N. Cornwall). PAHs were measured in mussel tissue and sediment and metals were measured in mussel tissue only. Data from the biomarkers was integrated into a Mussel Expert System (MES) model to produce a simple assessment of mussel stress. Clear gradients of mussel toxicity were identified by the biomarkers (with the exception of neutral lipids) with the highest impacted animals found furthest up the Tamar, whilst the MES was unable to identify a gradient of effect. Gene expression profiles also indicated a gradient of stress with the greatest number of significantly up- or down- regulated genes found at the uppermost 2 sites. The MES did, however, determine that mussels from all sites, except the reference site, were highly stressed; a conclusion that could not be inferred from the biomarker data alone. It is concluded that the MES is a valuable tool that permits integration and interpretation of complex sets of biomarker data by identifying the biological meaning of biomarker changes.

Molecular epidemiology of Escherichia coli bacteremia in liver transplant recipients

The characteristics of Escherichia coli strains causing bacteremia in profoundly immunosuppressed patients such as transplant recipients are undefined. The phylogenetic group and the virulence genotype of 57 distinct E. coli strains that caused bacteremia in 53 liver transplant recipients were investigated, and the association of these characteristics with host factors and in-hospital mortality was examined. Phylogenetic groups A, B1, B2, and D accounted for 39%, 10%, 25%, and 26% of the isolates, respectively. The most prevalent virulence genes were fyuA (yersiniabactin system: 70%) and iutA (aerobactin system: 63%), whereas hlyA (alpha-hemolysin) and cnf1 (cytotoxic necrotizing factor 1) occurred in only 14% and 12% of isolates, respectively. Most virulence genes were significantly more prevalent among group B2 and D isolates, vs. group A and B1 isolates. The overall rate of in-hospital mortality after E. coli bacteremia was 20%. Predictors of mortality included onset of bacteremia within 30 days of transplantation or during the intensive care unit stay, and non-urinary source and cutaneous source, but not E. coli phylogenetic group or virulence profile. Compared with historical E. coli bloodstream isolates from non-transplant patients, those from liver transplant recipients are characterized by a higher prevalence of groups A and B1 isolates and reduced virulence gene content. This finding can be explained by the severely immunocompromised status of the patients and the predominance of abdominal-source bacteremic episodes. Time of onset and source of bacteremia, not bacterial characteristics, predict mortality.

Microbiological findings of culture-positive preservation fluid in liver transplantation

Bacterial and fungal infections are the leading cause of mortality in liver transplant (LT) recipients. Few studies have examined the incidence of culture-positive preservation fluid (PF) and the outcome of related recipients. The aim of this study was to determine the incidence and the microbiologic findings of PF positive cultures, and to evaluate the impact on morbidity and mortality of LT recipients. A retrospective analysis of PF cultures performed after 477 LTs from cadaveric grafts between January 2001 and February 2008 was conducted. Forty-five (9.5%) PFs were found to be positive with 1 or 2 pathogens. The demographic profiles of recipients of PF with positive or negative cultures were similar. Enterobacteriaceae species were the most frequent organisms (n = 30), followed by Staphylococcus aureus (n = 5), coagulase-negative staphylococci (n = 5), enterococci (n = 4), and yeasts (n = 3). Mortality rate at 1 month was not significantly different in recipients with positive or sterile PF cultures (88.1% vs. 87.7%, respectively). The rate of bacteremia among LT recipients with positive or negative PF cultures was not statistically different. Systemic infections caused by the pathogen cultured from the PF occurred in 8 (18%) of the 45 recipients, including bacteremia (4/8) or intra-abdominal sepsis (5/8). Causative organisms were Enterobacteriaceae species (n = 5), Candida species (n = 2), and Enterococcus faecium (n = 1). Among the 8 patients who developed infection with the PF organism, 4 (50%) died in the intensive care unit (ICU) vs. an ICU mortality rate of 8% (3/37) in those who did not develop infection with the PF organism (P < 0.05). Infection occurred less frequently in recipients who received antimicrobial therapy with activity against the PF isolate than in those without appropriate treatment (41% vs. 3.8%, P < 0.005). Those who develop infection with organisms recovered from PF cultures appear to have high early mortality rates; therefore, appropriate antimicrobial therapy against organisms cultured from PF should be given.

Long-term survival after portal vein arterialization for portal vein thrombosis in orthotopic liver transplantation

Portal vein thrombosis is a relatively common finding during liver transplantation. The management of portal vein thrombosis during liver transplantation is technically demanding and ensures adequate portal flow to the liver graft. Eversion thromboendovenectomy and bypass using a patent splanchnic vein and cavoportal hemitransposition are the most often used procedures to treat portal vein thrombosis. There have been anecdotal reports of portal vein arterialization. We report a case of portal vein arterialization during orthotopic liver transplantation for decompensated cirrhosis. When thromboendovenectomy failed to restore sufficient portal flow and completion of arterial anastomosis between the recipient hepatic artery and the donor celiac trunk, a calibrated end-to-side anastomosis between the donor splenic artery and the donor portal vein was performed. With a 6-year follow-up, there are no symptoms related to portal hypertension, liver function is normal. However, an aneurismal dilatation of the portal branches has progressively developed. Calibrated portal vein arterialization is a possible option for portal vein thrombosis in liver transplantation, allowing long-term patient and graft survival.

Use of partial liver resection according to carcinologic procedures as an alternative to liver transplantation for HCC

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Background: There are some arguments showing that anatomic resection, anterior approach and preoperative transarterial chemoembolization (TACE) with portal vein embolization (PVE) before major resection improves long term survival after partial liver resection for HCC. This oncologic approach could compete with liver transplantation (LT) which remains poorly accessible in western countries and inaccessible in the greatest part of the world.The aim of this study was to evaluate in patients with good liver function.the result of partial liver resection with an intended carcinologic approach. Methods: Between 1998 and 2007, among 210 patients resected for HCC, we selected a subgroup of 36 patients with single and small HCC (< 6 cm) developed on chronic liver disease (CLD) who underwent anatomic partial resection and anterior approach and TACE and PVE in case of major resection. Results: These 36 patients aged 37 to 76 years included 26 males (72%). Underlying CLD included hepatitis C in 16 (44%); hepatitis B in 8 (22%); alcohol in 9 (25%) and other in 3 ( 8%). The mean size of the tumor was 5.2 cm and 86% (n=31) had major resection. Operative mortality was 2.7% (n=1) and the overall 1-, 3- and 5-year survival rate were 92%,85%,73% while the disease free 1-, 3-, 5-year survival was 80%, 74%, 58%. Tumor recurrence occurred in 16 cases( 44%) after a mean delay of 21 months (ranging from 5 to 58 months). Recurrence was located out of the resected location in 6 cases. Conclusions: Partial liver resection for small tumors in patients with good liver function according to carcinologic procedures allow an excellent overall and disease free survival which can challenge LT. In the case of single HCC <6cm on chronic liver disease, this surgical approach may therefore be considered as a valuable alternative to LT within a curative intent.

No significant financial relationships to disclose.

A biomonitoring study assessing the residual biological effects of pollution caused by the HAVEN wreck on marine organisms in the Ligurian Sea (Italy)

Residual biological effects of the 1991 HAVEN oil spill off the Ligurian (Arenzano) coast were assessed in this study. Samples of the fish species Boops boops, Mullus barbatus, and Uranoscupus scaber were collected from two polluted sites near the HAVEN wreck and from an uncontaminated area. In addition to this, mussels were caged along the coast affected by the HAVEN disaster. The physiological status of fish and mussels was assessed using a battery of stress and exposure biomarkers. The PAH content of mussel and fish tissues was also analyzed. Significant biological responses were observed in lysosomal membrane stability, neutral lipid and lipofuscin accumulation and micronucleus frequency for mussels caged at two sites close to the HAVEN wreck. Chemical analyses indicated, however, that these effects are not caused by aromatic hydrocarbons. For this reason, we suggest that the aftermath of the HAVEN disaster contributes very little to coastal ecosystem pollution. This was also confirmed by the few biological effects observed in fish specimens (Boops boops) collected from surface waters. Nevertheless, it is important to point out that benthic fish displayed a stress syndrome potentially caused by aromatic hydrocarbons released from the oil tanker, as witnessed by an enhanced EROD activity and increased lipofuscin and neutral lipid lysosomal contents.

Assessment of heavy metal contamination using real-time PCR analysis of mussel metallothionein mt10 and mt20 expression: a validation along the Tunisian coast

In mussel Mytilus galloprovincialis tissues, metallothionein belongs to two different gene classes, mt10 and mt20, showing differential expression at both basal conditions and under heavy metal challenge. In this study, a new more highly sensitive technique, expression analysis of mt10 and mt20 mRNA levels by quantitative reverse transcription polymerase chain reaction, was used to assess the effects of heavy metal contamination in the digestive glands of mussels caged along the Tunisian coast. To validate the new assay, total metallothionein protein, amount of heavy metals (zinc, copper, cadmium), and a biomarker of oxidative stress such as malondialdehyde content, were assessed in the same tissues. At the investigated sites, the molecular assay showed variations of mt20 relative gene expression levels within one or two orders of magnitude, with maximum values at two sites severely polluted with cadmium, Mahres (100-fold) and Menzel Jemile (165-fold). Changes in mt10 expression were recorded at all sites where copper had significantly accumulated, although fold induction levels were less pronounced than those of mt20. In this paper, gene expression data are discussed in relation to the studied biomarkers, demonstrating that the molecular technique based on the differential expression of mt10 and mt20 genes represents (i) a useful and robust tool for studying and monitoring heavy metal pollution under field conditions, and (ii) an improvement in the application of metallothionein as a biomarker of response to exposure to heavy metals in marine mussels.

Survival of micro-organisms in cryostorage of human sperm

The authors describe the clinical application of semen cryostorage, survival of micro-organism during cryostorage procedures and the risk of cross-contamination.

Cryopreservation and Sperm DNA Integrity

Cryopreservation of sperm is an extremely important issue in the field of male infertility as freezing can have detrimental effects on a variety of sperm functions, some of them not accessible to the traditional semen quality analysis. In this study, chromatin structure variations in human spermatozoa in semen were studied with the sperm chromatin structure assay (SCSA), both before and after cryopreservation. Samples were divided into two aliquots: the first was analysed without further treatment, while the second was stored in liquid nitrogen at -196 degrees C using standard cryopreservation techniques. The fresh and thawed aliquots were also assessed by light and fluorescence microscopy (after Acridine Orange staining, AO), and computer-assisted semen analysis (CASA) of motility. Overall sperm quality was found to deteriorate after cryopreservation. When thawed spermatozoa were subjected to an extra swim-up round, a general improvement in nuclear maturity was seen in post-rise spermatozoa.

Diagnosing erectile dysfunction: instruments for endocrine diagnosis

Endocrine factors represent an important and potentially treatable cause of sexual dysfunction. The availability of a correct endocrinological diagnosis allows correct identification of most cases of sexual dysfunction in which the endocrine apparatus is involved. Not only the most frequent causes of endocrine sexual dysfunction, such as hypogonadism and hyperprolactinaemia, but almost all extra-gonadal endocrinopathies (hyper-and hypothyroidism, hyper- and hypocortisolism, steroidal secreting tumours, etc.) may have importance to a greater or lesser extent in sexual function. It is, therefore, necessary that the diagnostic process for sexual dysfunctions of an endocrine nature be as integrated and wide as possible, especially as such pathologies are normally extremely responsive to medical or surgical therapy.

Presence of membrane and soluble forms of Fas ligand and of matrilysin (MMP-7) activity in normal and abnormal human semen

BACKGROUND

The aim of this study is to shed some light on the role of the Fas system in human semen, by investigating whether there is an association between the expression of the molecules regulating the Fas system [membrane-bound Fas ligand (mFasL), soluble Fas ligand (sFasL) and matrilysin, the metalloprotease cleaving mFasL to sFasL] and sperm parameters.

METHODS

We investigated, by flow cytometric analysis, the presence of FasL on spermatozoa from normozoospermic and teratozoospermic subjects and, by western blot, the presence of sFasL and matrilysin in the seminal plasma of the same samples as well as on samples from azoospermic subjects. The enzymatic activity of matrilysin was examined by gel zymography.

RESULTS

We observed that sperm cells expressed mFasL in 22% of normozoospermic men, whereas it was absent from spermatozoa from teratozoospermic patients. Higher levels of sFasL and augmented enzymatic activity of matrilysin were found in azoospermic samples.

CONCLUSIONS

The presence of mFasL on sperm from normozoospermic men and its absence in pathological samples emphasize the role of the Fas system in human semen. Moreover, the presence of both sFasL and matrilysin in seminal plasma implies a fine regulation of the function of the Fas system and, consequently, of the apoptotic process in the human genital tract.

Androgens and fertility

Androgens play a pivotal role in the development of the male reproductive tract. The spermatogenesis requires high levels of intratesticular testosterone secreted by the Leydig cells. Testosterone exerts its action through the androgen receptor (AR), which is located both in the cytoplasm and in the nucleus of cells in the target tissue. Severe defects of the AR may result in abnormal male sexual development, while more subtle modifications can be a potential cause of male infertility. Low circulating levels of testosterone can be found in 20-30% of infertile men, but administration of testosterone or gonadotropins does not result in improved sperm production. Abuse of anabolic steroids is a frequent cause of male infertility, and substances such as endocrine disruptors can alter male fertility through an anti androgenic action.

Might erectile dysfunction be due to the thermolabile variant of methylenetetrahydrofolate reductase?

Hyperhomocysteinemia is considered one of the most important cardiovascular risk factors increasing considerably the risk of stroke and myocardial infarction. With respect to endothelial function, direct effects of hyperhomocysteinemia on vascular endothelial cells have been demonstrated through the reduction of endothelial nitric oxide production. In this paper, we report the case of a young man with homozygote genotype mutated with 5-methylenetetrahydrofolate reductase (MTHFR) thermolabile variant who, in the absence of relational stress, developed an erectile dysfunction (ED) refractory to the vasoactive type-V phosphodiesterase (PDE5) inhibitor therapy. After one month of treatment with 5 mg/day folic acid and 1000 microg/day cyanocobalamin, the patient restarted the assumption of 50 mg sildenafil, obtaining satisfying erections during sexual intercourse. We suggest that hyperhomocysteinemia may interfere with penile blood supply and, thus, be responsible for ED. If this relationship is confirmed, plasma levels and urinary homocysteine (HCy) should be evaluated in selected young patients with vascular ED. Furthermore, careful attention should be given to the risk of ED when dealing with this metabolic disturbance.

Full-term pregnancies achieved with ICSI despite high levels of sperm chromatin damage

BACKGROUND

Sperm DNA integrity is essential for the accurate transmission of genetic information. The clinical significance of this assessment lies in its association with not only natural conception rates, but also the success of assisted reproduction technology (ART). It has been reported that sperm chromatin structure assay (SCSA) identified thresholds for negative pregnancy outcome after ART when the DNA fragmentation index (DFI), previously known as COMPalphat, was >30%.

METHODS

In a prospective clinical study, we examined 34 male infertile patients, the husbands of women undergoing conventional IVF or ICSI. SCSA and ART were carried out on semen aliquots taken from the same ejaculate. Fertilization rate, embryo quality and pregnancy rates were correlated to SCSA parameters, DFI and highly DNA stainable (HDS) cells.

RESULTS

No differences were seen in SCSA parameter values between patients initiating pregnancies and not doing so in either ICSI or conventional IVF. Pregnancies and normal delivery were obtained even with high levels of DFI.

CONCLUSIONS

There is still controversy over whether analytical techniques currently in use are able to identify the level of damage to spermatozoa. Large-scale studies should be conducted in different clinical settings to determine the effects of sperm DNA damage on the outcome of ART.

Heat-shock protein 70 favours human liver recovery from ischaemia-reperfusion

BACKGROUND

Pringle's manoeuvre controls excessive bleeding, but results in ischaemia-reperfusion injury during liver surgery. Activation of the heat-shock protein system of cell defense has been demonstrated after ischaemia-reperfusion injury in animal tissues. The aim of the present study was to determine whether the ischaemia-reperfusion accompanying hepatic surgery induces heat-shock protein 70 (HSP70) in human liver and whether the induction of HSP70 is related to the recovery of liver function.

METHODS

Heat-shock protein 70 and gamma-actin mRNAs were assayed in the liver biopsies of 10 subjects undergoing partial hepatectomy for localized lesions. Measurements were performed before the Pringle's manoeuvre and at the end of the surgery. Transaminases and fibrinogen were measured before and at 12, 24 and 36 h following hepatectomy.

RESULTS

After an average 40 +/- 8-min period of warm ischaemia, a significant increase of HSP70 mRNA (187 +/- 67%, 2P < 0.05) was observed. The acute increase of HSP70 mRNA correlates with the decrease of transaminases (AST: rs -0.964, ALT: rs -0.891, P < 0.002) and the increase of fibrinogen (rs -0.7, P < 0.02) observed between 12 and 24 h following surgery.

CONCLUSIONS

Heat-shock protein 70 is induced by ischaemia-reperfusion injury in human liver. Its induction seems to have beneficial effects, including a prompt reduction of transaminases and a rapid recovery of fibrinogen synthesis.

Endocrinological diagnosis in sexology

Endocrine factors represent an important and potentially treatable cause of sexual dysfunction. The availability of a correct endocrinological diagnosis allows correct identification of most cases of sexual dysfunction in which the endocrine apparatus is involved. Not only the most frequent causes of endocrine sexual dysfunction, such as hypogonadism and hyperprolactinemia, but almost all extra-gonadal endocrinopathies (hyper- and hypothyroidism, hyper- and hypocortisolism, steroidal secreting tumors, etc.) may play a role to a greater or lesser extent in sexual function. It is therefore necessary that the diagnostic process for sexual dysfunctions of an endocrine nature be as integrated and wide as possible, especially as such pathologies are usually extremely responsive to medical or surgical therapy.

Polyunsaturated fatty acids of germ cell membranes, glutathione and blutathione-dependent enzyme-PHGPx: from basic to clinic

The lipid metabolism in sperm cells is important both for energy production and for cell structure. A special composition of membrane phospholipids, rich in polyunsaturated fatty acids (PUFA), and the different composition of sperm and immature germ cell membrane are described and discussed. Testis germ cells as well as epididymal maturing spermatozoa are endowed with enzymatic and non-enzymatic scavenger systems to prevent lipoperoxidative damage. Catalase, superoxide dismutase, and glutathione-dependent oxidoreductases are present in variable amounts in the different developmental stages. Phospholipid hydroperoxide glutathione peroxidase (PHGPx) activity and roles in caput and cauda epididymal sperm cells are discussed. Also seminal plasma has a highly specialized scavenger system that defends the sperm membrane against lipoperoxidation and the degree of PUFA insaturation acts to achieve the same goal. Systemic predisposition and a number of pathologies can lead to an anti-oxidant/pro-oxidant disequilibrium. Scavengers, such as glutathione can be used to treat these cases as they can restore the physiological constitution of PUFA in the cell membrane.

Resection of hepatocellular carcinoma: a European experience on 328 cases

BACKGROUND/AIMS

Surgical liver resection has been demonstrated in Asian countries to be the best therapeutic option in patients with hepatocellular carcinoma. Because the value of this treatment is still debated in Western countries, the aim of this paper was to report a European experience of resection for hepatocellular carcinoma.

METHODOLOGY

From 1990 to 1999, 239 men and 61 women aged from 15 to 77 years old underwent 328 resections including major resection in 138 (42%) cases. Normal liver was present in 53 patients (17%) and chronic liver disease was present in 247 including 152 (50%) with cirrhosis.

RESULTS

In-hospital mortality was 6.4% and was significantly influenced by the presence of chronic liver disease (1.7% vs. 7.4%). Mortality after resection in alcoholic patients (14%), in patients with hepatitis C (9%) was significantly higher than in patients chronic hepatitis B (1%) (P < 0.05). The overall survival rates were 81%, 57%, 37%, and 13% at 1, 3, 5 and 10 years. Five-year survival rate was significantly higher (P < 0.05) in patients with normal liver as compared to chronic liver disease (50% vs. 34%). In patients with chronic liver disease parameters, which significantly influenced survival rate, were vascular invasion, tumor differentiation and the extent of resection.

CONCLUSIONS

In this European study with varied profile of etiologies associated with hepatocellular carcinoma we showed that a five-year survival rate of 40% can be expected after resection and that chronic liver disease is a major factor influencing short and long-term prognosis.

Antisperm immunity in natural and assisted reproduction

Research conducted in the last 40 years has provided evidence that antisperm antibodies (ASA) can impair the fertilizing capacity of human spermatozoa. It is established that ASA can be present at different sites, can act against different antigens and can impair fertility in various ways. In fact, in the past it was amply demonstrated that ASA can act negatively on sperm motility and on cervical mucus penetration. In recent years, owing to the improvement and spreading of IVF techniques, it has been possible to demonstrate the effect of antibody-bound spermatozoa at the level of in-vitro gamete interaction. The literature demonstrates that the various previously used treatments for immunological infertility, i.e. medical therapy, intrauterine insemination with husband's spermatozoa (AIH) and IVF, usually had poor success. The primary choice of treatment in immunological infertility, especially in the most severe cases and when the sperm head is involved, is ICSI. ASA evaluation in all couples who undergo the various techniques of insemination or IVF is imperative.

A new objective method for scoring human sperm hyperactivation based on head axis angle deviation

The aims of the present study were, first to develop a new method for evaluating sperm hyperactivation (HA) based on sperm head axis angle deviation, and second to apply this method in scoring selected sperm populations during capacitation. This was made possible by improving our original superimposed image analysis system (SIAS). The new option on the system enables us to determine the real angular deviation of the entire head in successive superimposed frames. The entire procedure for each spermatozoon requires 10-20 sec, according to the frame/rate utilized. A clear cut-off between the values of hyperactivated, transitional and non-hyperactivated spermatozoa was found at 11 and 21 frames/sec. However, at 6 frames/sec, a partial overlap between the three classes was found. We defined sperm activity as follows. At 11 frames/sec, hyperactivated: angle sum > or = 405 degrees; transitional: 200 degrees < or = angle sum < 405 degrees. At 21 frames/sec, hyperactivated: angle sum > or = 760 degrees; transitional: 350 degrees < or = angle sum < 760 degrees. The results, in agreement with previous research, show the peaks of activity at 3 h, dropping to a minimum at 6 h. This phenomenon was significantly more evident in fertile compared with subfertile semen samples.

Improved human sperm recovery using superoxide dismutase and catalase supplementation in semen cryopreservation procedure

The aim of this work was to evaluate the effects of ROS scavenger supplementation in human semen samples undergoing cryopreservation procedures.After screening out andrological pathologies, we selected 25 male partners of infertile couples with the following semen profile: volume >/= 2.0 ml, normal viscosity, sperm count >/=20 x 10(6)/ml, straight progressive motility (classes 1 and 2) >/= 40% (Mazzilli, Rossi, Delfino and Nofroni (1999) Andrologia 31: 187-194), atypical forms </= 70%, WBCs < 1.0 times 10(6)/ml.After liquefaction, standard semen analysis and the Hypoosmotic Viability Test (HVT) were carried out; the samples were then divided into 4 aliquots. The first was untreated as a control; 200 U/ml of superoxide dismutase (SOD) was added to the second, 200 U/ml of catalase to the third and both SOD (100 U/ml) and catalase (100 U/ml) were added to the fourth aliquot. Each aliquot was mixed (v/v) with TEST yolk buffer freezing medium (Irvine Scientific) and then frozen at -196 degrees C. The percent recovery of progressive motile and swollen spermatozoa was evaluated after thawing.No significant variation in the recovery of progressive motility was seen in the aliquots with added SOD or catalase alone, compared to the control group. On the other hand, a significant improvement in sperm parameter recovery was seen in the aliquot with both SOD and catalase supplementation; perhaps because of their combined and simultaneous action on superoxide anion and hydrogen peroxide. These results suggest that, in some selected cases, SOD and catalase supplementation can contribute greatly to the prevention of sperm membrane lipid peroxidation by ROS and thus allow good sperm parameter recovery after freezing-thawing procedures.

Chromosomal alterations and male infertility

Reduced male fertility can be caused by genetic factors affecting gamete formation or function; in particular, chromosome abnormalities are a possible cause of male subfertility as shown by their higher frequency in infertile men than in the general male population. Meiotic studies in a number of these males have shown spermatogenesis breakdown, often related to alterations in the process of chromosome synapsis. Indeed, any condition that can interfere with X-Y bivalent formation and X-chromosome inactivation is critical to the meiotic process; furthermore, asynapsed regions may themselves represent a signal for the meiotic checkpoint that eliminates spermatocytes with synaptic errors. We performed cytogenetic, hormonal and seminal studies in 333 infertile patients selected because azoospermic, severely oligozoospermic or normozoospermic with failure to fertilize the partner's oocytes in an in vitro fertilization (IVF) program. Our findings: 1) confirm the high incidence of chromosomal anomalies among infertile males; 2) highlight the relevance in male infertility of quantitative/positional modifications of the constitutive heterochromatin; and 3) underline the relevance of cooperation between andrologists and cytogenetists prior to every kind of assisted reproduction, above all prior to intracytoplasmic sperm injection, in which selective hurdles eliminating abnormal germ cells are bypassed.

Myth and reality of the decline in semen quality: an example of the relativity of data interpretation

Many hypotheses have been put forward to explain a suspected decline in semen quality. Up to now many sources of data were used but conflicting results are present in the literature. To study whether modifications of sperm parameters actually exist we used data from two groups of patients checked and two small groups of sperm bank donors selected at the beginning '80s and '90s. We tried to reduce bias to a minimum: all the semen analyses were carried out by the same biologist, using the same methods, groups were clinically evaluated by the same andrological team, the study groups were homogeneous for age, geographic-ethnic origin, residence, monthly-seasonal distribution and abstinence period. Comparing patients from the '80s and the '90s, sperm concentration and motility showed a significant reduction. Furthermore, the decrease in concentration and motility was mainly due to the higher age classes. In donors, no decline was observed. These results seem to indicate that sperm donors remain unaffected, while patients with lower levels of semen quality are experiencing a real decline. Unfortunately, many confounding variables, analyzed in detail in this review, still remain despite efforts at standardization.

Psychosocial factors and male seminal parameters

The relationships between (a) alexithymia, (b) extroversion (E), neuroticism (N), psychoticism (P), (c) coping style towards stressors, and seminal parameters, were assessed in 132 males on their first seminal fluid examination by means of a multivariate approach. They were given the TAS-20, the EPQ, and the Coping Inventory for Stressful Situations (CISS). Seminal parameters were: (1) sperm concentration; (2) total sperm count; (3) forward motility; (4) atypical forms. Multiple regressions considering quantitative parameters of seminal status as criterion showed a negative relationship with P, difficulty describing feelings (DDF), while a positive relationship was found for N, and emotion-oriented coping. A discriminant analysis also showed that P, N and DDF distinguished between two groups of normozoospermic and oligozoospermic subjects with a high probability of correct classifications. Results confirm the hypothesis that biological and psychological variables are not completely independent or randomly related in people with an impaired seminal status, although the correlations between psychosocial and biological data are not very strong.

Study of apoptotic DNA fragmentation in human spermatozoa

The aim of our work was to define and better understand apoptosis in the spermatozoa of normal subjects, infertile patients and patients affected by specific tumoral diseases employing the method of the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling and confirming the results by electron microscopy. We studied 23 healthy, normozoospermic subjects (group A), 29 oligoasthenoteratozoospermic patients, affected by various andrological pathologies (group B), 28 patients with Hodgkin's disease (C1) and 30 patients with testicular cancer (C2). Our data demonstrate that the percentage of apoptosis in normozoospermic subjects (group A) is significantly lower than in all the other groups (B, C1, C2) (P < 0.001). This confirms that high DNA fragmentation is one of the characteristics of spermatogenetic failure. The induction of apoptosis, which can also be a basic response to neoplastic disease, can even act right up to the mature male gamete. Our results suggest that apoptosis could be the final result of various pathologies and of a deregulation of spermatogenesis control systems.