Human semen quality and environmental and occupational exposure to pollutants: A systematic review.

Background: The aim of the present systematic review was to evaluate the correlation between the exposure to environmental and/or occupational pollutants and possible alteration of semen quality, focalizing the attention on the studies performed using a biomonitoring approach. Methods: The review was conducted from inception to May 11 2023, according to the PRISMA Statement 2020 and using the following databases: Scopus, Pubmed and Web of Science. The protocol was registered on PROSPERO (CRD42023405607). Studies were considered eligible if they reported data about the association between exposure to environmental pollutants and alteration of semen quality using human biomonitoring. The quality assessment was carried out by the use of the Newcastle-Ottawa Quality Assessment Scale. Results: In total, 21 articles were included, conducted in several countries. The main matrices used for biomonitoring were urine and blood and the most sought-after contaminants were bisphenols, phthalates, pesticides, polychlorinated biphenyls, polycyclic aromatic hydrocarbons, heavy metals and other inorganic trace elements. The results of the studies demonstrated a significant positive correlation between the increase of the pollutants' levels in the biological matrices examined and some alterations of the semen quality indicators, such as a decrease in motility, concentration and morphology of the spermatozoa. Conclusions: Male fertility can be negatively affected by the exposure to environmental and/or occupational pollutants. Human biomonitoring programs may be considered a useful tool for specific surveillance programs devoted to early highlight subjects who are more exposed to environmental pollutants in order to reduce risk exposure.

MitraClip step by step; how to simplify the procedure.

The MitraClip system is a device for percutaneous edge-to-edge reconstruction of the mitral valve in patients with severe mitral regurgitation who are deemed at high risk for surgery. Studies have underlined the therapeutic benefit of the MitraClip system for patients at extreme and high risk for mitral valve surgery, suffering from either degenerative or functional mitral regurgitation. The MitraClip procedure shows low peri-procedural complication rates, and a significant reduction in mitral regurgitation, as well as an improvement in functional capacity and most importantly quality of life. It hereby widens the spectrum of mitral valve repair for the Heart Team. The current review underscores the efficacy of the procedure and describes the technique to simplify the procedure.

Successful lung transplantation in an HIV- and HBV-positive patient with cystic fibrosis.

Prior to the advent of highly active antiretroviral therapy (HAART), HIV-infected patients were usually not considered as transplant candidates because of the poor prognosis of their underlying disease and concerns regarding the potential detrimental effects of immunosuppression on viral load and immune status. However, with the significant HAART-associated improvements in morbidity and mortality, good short-term outcomes after liver and kidney transplantation for patients with HIV infection have been reported. Nevertheless, HIV infection is currently considered a contraindication to lung transplantation in most transplant centers worldwide. The results of a double lung transplant performed in an HIV and HBV co-infected patient with cystic fibrosis (CF) and end-stage respiratory failure (ESRF) are presented after a 2-year follow-up. Approval of and recommendations for the management of this patient were obtained from the Italian National Center for Transplantation as an extension of the ongoing Italian protocol for liver and kidney transplantation in HIV-infected individuals. The operation was successful and the patient recovered rapidly after surgery. A cautious infectious and immunosuppressive management allowed so far the avoidance of major infectious complications and rejection. To the best of our knowledge, this is the first report of lung transplantation in an HIV and HBV co-infected patient.

Regulation of lysophosphatidic acid receptor-stimulated response by G-protein-coupled receptor kinase-2 and beta-arrestin1 in FRTL-5 rat thyroid cells.

Lysophosphatidic acid (LPA) is a naturally occurring phospholipid that activates a variety of biological activities including cell proliferation. Three mammalian LPA receptor (LPAr) subtypes have been identified by molecular cloning, named lp(A1), lp(A2) and lp(A3), that are coupled to heterotrimeric G-proteins for signal transduction. The LPAr are endogenously expressed in the rat thyroid cell line FRTL-5 and we used the FRTL-5 cells permanently transfected to obtain moderate overexpression of G-protein-coupled receptor kinase-2 (GRK2) or beta-arrestin1 to study whether GRK2 and beta-arrestin1 desensitise LPAr-mediated signalling and regulate LPA-stimulated functional effects. Using RT-PCR we documented that lp(A1), lp(A2) and lp(A3) receptors are all expressed in FRTL-5 cells. We then analysed the signal transduction of the LPAr in FRTL-5 cells. Exposure to LPA did not stimulate inositol phosphate formation nor cAMP accumulation but reduced forskolin-stimulated cAMP. LPA was also able to stimulate MAP kinase activation and this effect was abolished by pertussis toxin pretreatment. These results suggest that LPAr are mainly coupled to a pertussis toxin-sensitive G-protein in FRTL-5 cells. In order to investigate whether GRKs and arrestins are involved in the regulation of LPAr-mediated signalling, we used the FRTL-5 cell line permanently transfected to overexpress GRK2 (named L5GRK2 cells) or beta-arrestin1 (L5betaarr1 cells). The ability of LPA to inhibit forskolin-stimulated cAMP accumulation was blunted in L5GRK2 and more markedly in L5betaarr1. The MAP kinase activation was also blunted in L5GRK2 and in L5betaarr1B cells. Exposure to 20 microM LPA increased the phosphorylation of extracellular signal-regulated kinases ERK1/2 by approximately 3-fold in L5pBJI cells (FRTL-5 cells transfected with the empty vector pBJI) while it induced a modest increase in L5betaarr1 and was ineffective in L5GRK2. We measured [3H]thymidine uptake in L5betaarr1B and in L5 GRK2 cells to test whether GRK2 and beta-arrestin1 could have a role in the regulation of LPAr-mediated cell proliferation. The mitogenic response induced by 35 microM LPA was substantially blunted in L5betaarr1 (-69+/-6%) and in L5GRK2 (-69.8+/-4.5%) cells as compared with L5pBJI. Our findings document that the receptor-mediated responses elicited by LPA are regulated by GRK2 and beta-arrestin1 in FRTL-5 cells and indicate that this mechanism is potentially important for the control of the LPA-stimulated proliferative response.

Use of the Internet by patients before and after cardiac surgery: telephone survey.

BACKGROUND: Little is known about to what extent patients who underwent medical treatment access the Internet and whether they benefit from consulting the Internet. OBJECTIVE: To understand if cardiopathic patients use the Internet for health-related information and whether they find retrieved information understandable and useful. METHODS: Telephone interviews, using a semi-structured questionnaire, were conducted with 82 patients who had undergone off-pump coronary-artery bypass grafting at the Center for Less Invasive and Robotic Heart Surgery in Buffalo, New York, USA. Study design was multidisciplinary, combining expertise of medical and communication science. Sources of medical information were identified (doctor, Internet, magazines, newspapers, television, radio, family members). Accessibility, quality, and readability of Internet medical information from the patients point of view were investigated. RESULTS: Out of 82 patients, 35 (35/82, 42.7%) were Internet users. Internet users had a significantly higher education level than Internet non-users (college education: 42.9% of users, 10.6% of non-users; P <.001). Among the Internet users, 18 (18/35, 51.4%) had used the Internet for retrieving medical information; 17 (17/35, 48.6%) had not. No statistically significant differences in demographic data were found when comparing these 2 sub-groups of patients. Family-members involvement was high (15/18, 83.3%). Internet medical information was rated helpful in most cases; readability was acceptable for only 3 patients (3/18, 16.7%). To improve on-line medical information, all patients interviewed suggested sites designed by their physicians. CONCLUSIONS: Although 1 in 5 patients in our sample has used the Internet to retrieve medical information, the majority of them experiences difficulties comprehending the information retrieved. Health-care providers should provide Internet medical information that is adequate for the non-medical public's needs.

Thyrotropin activates mitogen-activated protein kinase pathway in FRTL-5 by a cAMP-dependent protein kinase A-independent mechanism.

The involvement of mitogen-activated protein (MAP) kinases in the mitogenic effect of thyrotropin (TSH) is not fully elucidated. In FRTL-5 cells, we found that the MAP kinase kinase (MEK) inhibitors UO126 and PD98059 substantially decreased TSH-induced DNA synthesis, indicating that MAP kinases are involved in the TSH-stimulated proliferative response. Accordingly, TSH, forskolin (FSK) and 8-bromo-cAMP induced a rapid (3 min) and transient activation of ERK1/2, as assessed by phosphorylation of myelin basic protein and ERK1/2. This effect was cAMP-dependent and protein kinase A (PKA)-independent. The activation of Rap1 and B-Raf was involved in the mechanism of MAP kinase stimulation by TSH. TSH induced rapid (3 min) GDP/GTP exchange and activation of Rap1. After a 3-min exposure to FSK, B-Raf was recruited to a vesicular compartment, where it colocalized with Rap1. Both activation of Rap1 and translocation of B-Raf were PKA-independent. The Rap1 dominant negative Rap1N17 significantly reduced TSH-stimulated but not insulin-like growth factor 1-stimulated ERK1/2 phosphorylation, whereas the Ras dominant negative RasN17 inhibited the effect of both agonists. In conclusion, our results document that TSH increases intracellular cAMP, which rapidly stimulates MAP kinase cascade independent of PKA. This novel mechanism could integrate other pathways involved in TSH-stimulated proliferative response.

Coronary artery exposure in off-pump cabg: a word of caution.

Coronary exposure and stabilization have focal importance in off-pump coronary surgery. Off-pump complete myocardial revascularization can be performed safely in the majority of the patients whenever strict surgical protocols are followed. Although new devices may be used to facilitate the performance of this demanding operation, technical pitfalls should be recognized to ensure the success of the procedure. We herein report our timely experience with the Xpose device (Guidant Corp., Cupertino, CA).

Reoperative coronary artery bypass grafting with and without cardiopulmonary bypass: determinants of perioperative morbidity and mortality.

BACKGROUND: This retrospective study evaluates perioperative results of reoperative coronary artery bypass grafting (CABG) with and without cardiopulmonary bypass (CPB). METHODS: From January 1995 to March 1999 reoperative CABG was performed on 581 patients: 307 (52.84%) patients were operated upon on-CPB and 274 (47.16%) off-CPB. Median sternotomy was used in all patients on-CPB. Median sternotomy or alternative surgical approaches were used in the off-CPB group. Data was retrospectively reviewed. To identify the variables independently related to perioperative mortality and adverse outcome, multivariate analysis was performed in the overall population of 581 patients. RESULTS: Preoperative risk factors were comparable in the two groups. Critical lesions of the right and left circumflex coronary artery were more common in the on-CPB group (p < 0.005). A total of 2.7 grafts/patient was performed in the on-CPB group versus 1.3 grafts/patient in the off-CPB group (p = NS). Freedom from postoperative complications was higher in the off-CPB group (72% versus 90.9%, p < 0.005). Perioperative stroke and respiratory failure rates were more common in the on-CPB group (3.9% versus 0.7% and 5.9% versus 2.2% respectively, p < 0.005). Actual mortality was 5.9% in the on-CPB group and 3.6% in the off-CPB group (p = NS). Risk adjusted mortality was 2.2% and 1.3% in the on-CPB and off-CPB groups respectively. Although CPB was found to be independently related to adverse outcome (odds ratio (OR) = 2.89, p-value < 0.005), no correlation was found between mortality and CPB. CONCLUSIONS: Avoidance of CPB independently reduces adverse outcomes in reoperative CABG without affecting mortality rate.

Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery?

BACKGROUND: The adverse effects of diabetes mellitus on the coronary circulation and the higher incidence of cardiovascular events in diabetic patients are well documented [Johnson 1982]. Improvements in myocardial protection, revascularization techniques, and anesthetic management have had favorable impacts on coronary artery bypass grafting (CABG) outcome in diabetic patients. Despite that, diabetic patients are significantly more likely to have a prior history of myocardial infarction, congestive heart failure, peripheral vascular disease, and hypertension, as well as having a significantly greater baseline serum creatinine. The aim of our study was to record, compare, and analyze the stroke rate among patients with a history of preoperative diabetes undergoing "off-pump" CABG (OPCAB) with conventional cardiopulmonary bypass (CPB) CABG to determine whether the stroke rate in this higher risk population could be decreased by off-pump techniques. METHODS: The records of 1,227 patients with a pre-operative history of diabetes undergoing conventional CABG (973 patients, 79.3%) using cardiopulmonary bypass and off-pump CABG 254 (20.7%) were analyzed from 1995 through 1999. There were no differences in age, sex, or elective/urgent status of patients. Preoperative risk factors (gender distribution, carotid disease, ejection fraction, CHF, hypertension, previous MI) were identical in both groups. The goal of the operations were complete revascularization, which was achieved via median sternotomy in both groups. RESULTS: Our reported series reveals a stroke rate of 3.6% in the CPB group and 1.2% in the off-pump group. This evidence alone was not statistically significant, but two other high-risk criteria for stroke, re-do CABG and calcified aortas, revealed that the off-pump series had a higher percentage of each (26.4% redos in off-pump vs. 8.7% CPB redos, p < 0.005; 7.1% calcified aorta cases in the off-pump group vs. 2.9% in the CPB group, p < 0.004). The threefold reduction in stroke may be clinically significant in light of the higher-risk profile of the off-pump group. The limitations of this study are that it was retrospective, there were a small number of events, and different surgeons were involved in the two different approaches to these patients. CONCLUSIONS: Improvements in myocardial protection, revascularization techniques, and anesthetic management have made significant, favorable impacts on CABG outcome in diabetic patients. New diagnostic and therapeutic strategies must be developed to lessen the medical and economic implications of stroke. A larger series or a more effective way of analyzing preoperative risk may well have shown a statistically significant difference in the stroke incidence given the differences in preoperative risk factors/stroke predictors. Until such advances occur, a threefold reduction of stroke incidence using OPCAB certainly makes this technique a favorable one for high-risk diabetics requiring coronary revascularization.

Myocardial revascularization on the beating heart after recent onset of acute myocardial infarction.

OBJECTIVE: Coronary artery bypass grafting (CABG) after the recent onset of acute myocardial infarction (AMI) is associated with high morbidity and mortality. Myocardial revascularization without cardiopulmonary bypass (CPB) has been proposed as an alternative technique to treat these patients in an attempt to decrease the operative risks. METHODS: From January 1995 to June 1999, 518 patients underwent CABG after the recent onset of AMI (1-20 days): 421 patients were revascularized on-CPB and 97 patients off-CPB. Preoperative risk factors (redo operations, congestive heart failure, stroke, extensive calcification of the aorta, and dialysis) were significantly higher in the off-CPB group (p-value < 0.05). Preoperative use of intra-aortic balloon pump (IABP) (off-CPB 5.2% versus on-CPB 2.4%, p-value = NS) and emergent operations (off-CPB 5.2% versus on-CPB 2.6%, p-value = NS) were similar in both groups. Mean number of grafts per patient was 3.46 in the on-CPB group versus 1.82 in the off-CPB group (p-value < 0.005). RESULTS: Actual mortality was 2.9% in the on-CPB group versus 6.2% in the off-CPB group (p-value = NS). Morbidity was comparable in the two groups. Multivariate analysis showed that advanced age, preoperative hemodynamic instability, and left ventricular hypertrophy were independent risk factors for death. Global ischemic time and preoperative hypertension were independently related to postoperative AMI. At univariate and multivariate analysis, CPB was not related to mortality or major postoperative complications. CONCLUSION: Multivariate analysis demonstrates that CABG can be performed safely with or without CPB in patients with recent AMI. CPB is not independently related to mortality or major adverse outcomes.

Robotically assisted video-enhanced-endoscopic coronary artery bypass graft surgery.

Since 1988, through fierce industry-driven competition and patients' preference for minimally invasive procedures, widely diffused through the media, laparoscopic cholecystectomy was universally adopted and rapidly became the "gold standard" for symptomatic cholelithiasis. Robotically assisted video enhanced-endoscopic coronary artery bypass surgery (RAVE-CABG) will most likely follow suit with its similar developmental processes for symptomatic coronary artery disease. Since 1998, there are currently two surgical robotic systems that have been used in a clinical setting for endoscopic coronary artery bypass (ECABG): the da Vinci and the ZEUS system. Although each has separate learning curves to overcome, as with any new technology, both offer the promise to contribute in the interests of reduced hospital days, earlier return to normal activity, less pain, better cosmesis, and the rethinking of surgical dogma such as wide exposure.

Redo left anterior descending artery grafting via left anterior small thoracotomy: an alternative approach.

Reoperative left anterior descending artery (LAD) revascularization can be performed through a left anterior small thoracotomy (LAST approach) in patients requiring isolated LAD revascularization. If the left internal mammary artery has been previously used, however, the operation is generally performed either through a median sternotomy or through a full posterolateral thoracotomy for the necessity of connecting the vein graft to the ascending aorta or to the descending thoracic aorta, thus losing the advantages of a minimally invasive approach. In the case reported herein, we describe a technique in which reoperative revascularization of the LAD is accomplished through the LAST approach, using the stump of the left internal mammary artery as the inflow site of a saphenous vein coronary graft to the LAD.

OPCAB therapy survey: off-pump clopidogrel, aspirin or both therapy survey.

BACKGROUND: Standards for heparinization during off-pump coronary artery bypass (OPCAB) are lacking. Similarly, there are no established standards for antiplatelet therapy before or after OPCAB. The aim of this study was to determine current practices and standards for both antiplatelet and heparin therapy in OPCAB. METHODS: A postal, multiple-choice survey questionnaire was sent to 800 randomly chosen cardiothoracic surgeons in the United States and Canada. Responses were tabulated and analyzed. RESULTS: The overall response rate was 38% (304 surgeons). The respondents performed CABG in centers with an overall volume between 240 and 1,250 procedures per year (average 380 procedures per year). OPCAB procedures within the same institutions ranged from 20 and 375 cases per year. Sixteen percent (48) of the respondents routinely administer antiplatelet therapy preoperatively; of these, 18% (9) use clopidogrel (Plavix) and 65% (31) aspirin. Eighty-eight percent (267) of the respondents routinely administer antiplatelet therapy after OPCAB. Of these, 24% (65) use clopidogrel and 74% (197) aspirin. Anticoagulation protocols during OPCAB were more variable with 28% (85) administering full dose of heparin, 54% (164) administering half dose heparin, and 13% (40) administering 1/3 dose of heparin during construction of coronary anastomoses. Although 10% (30) maintain an activated clotting time (ACT) above 400 seconds, 70% (213) are content with an ACT above 300 seconds and less than 400 seconds, and 20% (61) responded as "other". The average blood shed postoperatively was 600 ml (range 300 ml and 1 liter). Forty percent (122) administer protamine at half dose, and 60% (182) administer a full dose. CONCLUSION: Although the vast majority of surgeons use antiplatelet therapy postoperatively, a minority administer preoperative antiplatelet agents for OPCAB. The majority of surgeons use a half dose of heparin during OPCAB with ACT maintained above 300 seconds (> 80%). Prospective studies are necessary to determine the short and intermediate effects of antiplatelet therapy and heparinization doses in OPCAB surgery.

Myocardial revascularization of the beating heart in high-risk patients.

OBJECTIVE: Myocardial revascularization without cardiopulmonary bypass (CPB) has been proposed as an alternative technique in patients at high risk for conventional coronary artery bypass grafting (CABG). The purpose of this article is to evaluate the potential benefit of such an approach. METHODS: We retrospectively evaluated the perioperative results of off-pump CABG (OPCAB) performed from January 1995 to December 1999. Patients were divided into three groups on the basis of their preoperative risk factors: age greater than 80 years, reoperative CABG, and left ventricular ejection fraction percentage (LVEF%) less than 40%. The three subgroups were compared with patients operated on-CPB (ONCAB) during the same period of time. A total of 172 octogenarians had ONCAB versus 97 OPCAB, 307 reoperations were ONCAB versus 274 OPCAB, and 514 patients with LVEF% less than 40% were operated ONCAB versus 220 OPCAB. RESULTS: Preoperative comorbidities were homogeneously distributed in the OPCAB and ONCAB groups. More extensive coronary artery disease was found in the ONCAB groups. A trend for a lower number of perioperative complications was reported in the OPCAB groups. Freedom from overall complications was significantly higher (p < 0.005) in the OPCAB group. Actual mortality rates in the OPCAB and ONCAB groups were comparable (p = NS). CONCLUSIONS: CABG can be performed safely without CPB in patients with a high preoperative risk profile. Freedom from perioperative complications is markedly higher when the OPCAB approach is utilized.

Technical tips and pitfalls in OPCAB surgery: the buffalo experience.

The Center for Minimally Invasive and Robotic Heart Surgery has performed more than 1,500 off-pump coronary artery bypass (OPCAB) procedures since 1995. The operation has changed significantly based on experience and development of new tools. These improvements have made the operations safer and applicable to more patients. No patients are presently scheduled for on-pump bypass surgery in our center. The purpose of this paper is to describe some of the problems and pitfalls we have experienced and how to avoid them.