Acute heart failure and cardiogenic shock: a multidisciplinary practical guidance.

PURPOSE: Acute heart failure (AHF) causes high burden of mortality, morbidity, and repeated hospitalizations worldwide. This guidance paper describes the tailored treatment approaches of different clinical scenarios of AHF and CS, focusing on the needs of professionals working in intensive care settings. RESULTS: Tissue congestion and hypoperfusion are the two leading mechanisms of end-organ injury and dysfunction, which are associated with worse outcome in AHF. Diagnosis of AHF is based on clinical assessment, measurement of natriuretic peptides, and imaging modalities. Simultaneously, emphasis should be given in rapidly identifying the underlying trigger of AHF and assessing severity of AHF, as well as in recognizing end-organ injuries. Early initiation of effective treatment is associated with superior outcomes. Oxygen, diuretics, and vasodilators are the key therapies for the initial treatment of AHF. In case of respiratory distress, non-invasive ventilation with pressure support should be promptly started. In patients with severe forms of AHF with cardiogenic shock (CS), inotropes are recommended to achieve hemodynamic stability and restore tissue perfusion. In refractory CS, when hemodynamic stabilization is not achieved, the use of mechanical support with assist devices should be considered early, before the development of irreversible end-organ injuries. CONCLUSION: A multidisciplinary approach along the entire patient journey from pre-hospital care to hospital discharge is needed to ensure early recognition, risk stratification, and the benefit of available therapies. Medical management should be planned according to the underlying mechanisms of various clinical scenarios of AHF.

The role of cardiorenal biomarkers for risk stratification in the early follow-up after hospitalisation for acute heart failure.

CONTEXT: Cardiorenal biomarkers (CBs) predict outcome in acute heart failure (AHF). OBJECTIVE: To evaluate CBs in early follow-up prognostication. METHODS: In 124 AHF patients, levels of CystatinC, NT-proBNP and TroponinI measured five weeks from admission (W5) and relative change from day 2 (D2) were assessed for 6-month prognosis (mortality/HF hospitalization). RESULTS: The combined end-point occurred in 33 patients (27%). D2-, W5-cystatin≥ median, and lack of ≥30%decrease in NT-proBNP were independent predictors of outcome. Additionally, a risk score established from W5 CBs identified patients with very high event rate. CONCLUSIONS: CBs at early follow-up of AHF may guide risk stratification.

Cystatin C, NT-proBNP, and inflammatory markers in acute heart failure: insights into the cardiorenal syndrome.

BACKGROUND: Inflammation is thought to be a mediator in the pathophysiology of the cardiorenal syndrome. We evaluated the interactions between kidney function, cardiac stress, and various inflammatory cytokines in patients with acute heart failure (AHF). The effect on 1-year mortality was also assessed. METHODS AND RESULTS: Plasma levels of cystatin C, NT-proBNP, and inflammatory cytokines (interleukin [IL]-6, tumor necrosis factor-α [TNF-α], IL-10) were measured in consecutive patients (n = 465) hospitalized for AHF. After adjustment for demographic characteristics and comorbidities, TNF-α had the strongest relation with renal function (ß = 0.39, P < 0.0001). Elevated TNF-α levels were seen in patients with high cystatin C, irrespective of NT-proBNP. Levels of IL-6 (ß = 0.26, P < 0.0001) and IL-10 (ß = 0.15, P < 0.01), but not TNF-α, were associated with NT-proBNP. Moreover, the most elevated levels of IL-6 were seen in patients with combined high NT-proBNP and high cystatin C. Cox regression analysis found IL-6 above median to be independently predictive of mortality (hazard ratio 1.9; 95% CI 1.2-2.9, P = 0.003). TNF-α was not significantly associated with prognosis in the overall population after adjustment for multiple covariates, but improved risk stratification in the subgroup with low cystatin C and NT-proBNP. CONCLUSION: Levels of TNF-α in AHF are related to kidney function, but not to NT-proBNP. IL-6 seems to be more associated with cardiac stress. Patients with severe dual organ dysfunction have the highest levels of IL-6 and TNF-α. Different relations of inflammatory cytokines to renal function and cardiac stress need to be considered when evaluating heart--kidney interactions.

Dendritic cells in rheumatoid synovial membrane after total removal of the hyaline articular cartilage.

OBJECTIVE: To investigate the effect of total removal of the hyaline articular cartilage on dendritic cells in synovial membrane in rheumatoid arthritis (RA) or ankylosing spondylitis (AS). PATIENTS AND METHODS: Immunohistochemical staining for two dendritic cell markers, CD35 and RFD1, was carried out on synovial membrane specimens from arthritis patients undergoing primary (n=10) or revision (n=8) total hip replacement (THR). The results are expressed as the number (mean+/-standard deviation) of positive cells per 1000 total cells. RESULTS: CD35-(112+/-9) and RFD1-(27+/-5) positive cells were found in all primary RA synovial membrane, while only two out of eight synovial membrane samples from revision THR contained CD35-positive follicular dendritic cells (nine and 12 cells), and no revision samples contained any RFD1-positive interdigitating dendritic cells. CONCLUSION: Removal of the hyaline articular cartilage reduces the infiltration and functional differentiation of dendritic cells in synovial membrane. Our findings suggest that the antigen driving chronic arthritis/synovitis is contained in the hyaline articular cartilage.

Anatomical reconstruction of ruptured lateral ligaments of upper ankle joint.

BACKGROUND AND AIMS: It seems that a certain patient population after conservatively treated ankle distorsions later develops chronic symptoms such as instability, pain and swelling. MATERIAL AND METHODS: The present study comprised 20 such patients, who underwent an anatomical reconstruction of ruptured ankle ligament(s) (FC, FTA and/or FTP). Patients were followed in average for 22 months postoperatively. RESULTS: Sixteen of them had excellent or good results. Clinically 5 and radiologically 4 patients had instability of the operatively treated ankle joint at the follow-up. Instability and subjective patient satisfaction did not correlate at all. CONCLUSION: Anatomical reconstruction of ruptured ankle ligaments in chronic posttraumatic instability syndrome is technically possible to perform in almost all cases. The present method of anatomical ligament reconstruction usually results in good stability, diminishes symptoms and in most cases leads into a normal functional capacity.

Acid attack and cathepsin K in bone resorption around total hip replacement prosthesis.

Normal bone remodeling and pathological bone destruction have been considered to be osteoclast-driven. Osteoclasts are able to attach to bare bone surface and produce an acidic subcellular space. This leads to acid dissolution of hydroxyapatite, allowing cathepsin K to degrade the organic type I collagen-rich osteoid matrix under the acidic condition prevailing in Howship lacunae. Using a sting pH electrode, the interface membrane around a loosened total hip replacement prosthesis was found to be acidic. Confocal laser scanning disclosed irregular demineralization of the bone surface in contact with the acidic interface. Cathepsin K, an acidic collagenolytic enzyme, was found in interface tissue macrophages/giant cells and pseudosynovial fluid. Tissue extracts contained high levels of cathepsin K messenger RNA (mRNA) and protein. These observations suggest the presence of an acid- and cathepsin K-driven pathological mechanism of bone resorption, mediated not by osteoclasts in subosteoclastic space, but rather by the uncontrolled activity of macrophages in extracellular space.

Removal of hyaline articular cartilage reduces lymphocyte infiltration and activation in rheumatoid synovial membrane.

OBJECTIVE: To analyze the effect of removal of hyaline articular cartilage on synovial membrane pathology in chronic arthritis. METHODS: Synovial membrane samples were obtained from patients with rheumatoid arthritis or ankylosing spondylitis in association with total hip arthroplasty, either primary or revision surgery. Synovial membrane histopathology was assessed by immunochemical staining and morphometry. RESULTS: CD68 positive macrophages were common in revision synovial membranes. In contrast, T lymphocytes were much more common in primary rheumatoid synovial membranes (p < 0.001). Many T lymphocytes in primary synovial membrane were HLA-D/DR positive (p < 0.001) and interleukin 2 receptor (IL-2R) positive (p < 0.001) and contained interferon-gamma(IFN-gamma; p < 0.001) and tumor necrosis factor-beta (TNF-beta; p < 0.001). In contrast, revision synovial membranes from patients with chronic arthritis contained only a few HLA-D/DR positive T cells and practically no IL-2R, IFN-gamma, or TNF-beta positive activated T lymphocytes. CONCLUSION: The components of hyaline articular cartilage may be the source of autoantigen responsible for perpetuation of chronic arthritides.

No lymphokines in T-cells around loosened hip prostheses.

Research results have been contradictory about the role of lymphocytes and immune response in aseptic loosening of total hip replacement (THR). Conclusive evidence is still lacking in spite of extensive in vivo and in vitro studies. Our study was designed to check whether T-cells were activated and if they produced lymphokines in synovial membrane-like interface tissue around loosened THRs. Tissue sections were stabilized and permeabilized to allow the cytokine-specific antibodies to penetrate through the cell membrane and the membranes of intracellular organelles. This technique, combined with computer-assisted image analysis, permits the detection and quantitation of lymphokine-producing cells. We found that the number of T-cells was low, and none of the T-cells was activated, as shown by the absence of interleukin-2 receptor (IL-2R) immunoreactivity. There was no cell producing lymphokines, such as interleukin-2 (IL-2), interferon-gamma (IFN-gamma), and tumor necrosis factor-beta (TNF-beta). Our results suggest that T-cell-mediated immune response is not actively involved in aseptic loosening of THR.

Hyaluronan synthases, hyaluronan, and its CD44 receptor in tissue around loosened total hip prostheses.

Aseptic loosening of prosthetic components, the most common long-term complication after total hip replacement (THR), is characterized by the formation of a synovial membrane-like interface tissue (SMLIT). It was hypothesized that the hyaluronan synthase (HAS)/hyaluronan (HA)/HA receptor CD44 signalling system is responsible for the synovial-like differentiation of the interface membrane. SMLIT was therefore compared with osteoarthritis (OA) synovial membrane by using reverse transcriptase polymerase chain reaction (RT-PCR) of HAS 1, 2 and 3, histochemical HA assay, and immunohistochemistry of CD44 and its non-HA ligands. All three isoforms of HAS were found in these samples. HA and CD44 were most abundant in the lining, but the signal was actually stronger in aseptic loosening than in OA (p<0.01). The non-HA CD44 ligands, collagen type VI, fibronectin, osteopontin, and MCP-1, had a similar distribution pattern in both tissues. These results confirm the synovial-like structure of the interface tissue lining. The pressure waves and movement of the HA-rich pseudosynovial fluid seem to drive HA into the implant-to-host interface, which itself also produces HA. HA may be responsible for the induction of a synovial-like lining at the interface through HA-CD44 signalling.

Distribution of tenascin-X in different synovial samples and synovial membrane-like interface tissue from aseptic loosening of total hip replacement.

The distribution of tenascin-X (Tn-X) was investigated in synovial samples from rheumatoid arthritis (RA), osteoarthritis (OA) and knee injuries, and in synovial membrane-like interface tissue (SMLIT) from aseptic loosening of total hip replacement (THR). An affinity purified rabbit antiserum against Tn-X was applied in avidin-biotin-peroxidase complex method. Double immunofluorescence labeling was used to assess the spatial relationship of Tn-X and Tn-C. All samples showed Tn-X immunoreactivity. Strong staining appeared in the lining and lining-like layers of RA and SMLIT samples, respectively. An intensive immunoreactivity was also found in pannus tissue in RA, and around multinucleate giant cells and polyethylene wear debris in SMLIT. Staining intensity/extent varied significantly in different samples in the following rank order: SMLIT, RA, OA, knee synovium membrane. Double labeling revealed two patterns of Tn-X/Tn-C distribution, reciprocal and co-localization. Our results suggest that Tn-X is an essential component of normal synovial membrane, and that inflammatory mediators may increase local Tn-X production. Tn-X distribution is not always reciprocal to that of Tn-C.

Increased interleukin-8 (IL-8) expression is related to aseptic loosening of total hip replacement.

Aseptic loosening is an increasing problem in total hip replacement (THR). Chronic inflammatory reaction against implant wear particle results in collageno- and osteolysis, leading to loosening of the implant. Cytokines are known to play a major role in this particular inflammatory process. The aim of the present study was to examine interleukin-8 (IL-8) in the synovial-like interface membrane (SLIM) and pseudocapsular tissue of THRs and to compare it to normal knee synovial membrane. Eleven patients suffering from aseptically loosened THRs were included. All the SLIM and pseudocapsular tissue samples were obtained during revision operations. Ten control samples of normal synovium were collected per arthroscopy from the superior recessus of the knee. For immunohistochemical IL-8 detection, polyclonal mouse anti-human immunoglobulin (Ig)G1 IL-8-primary antibody was used with the alkaline phosphatase anti-alkaline phosphatase (APAAP) method. Results were quantitated using the Vidas image analysis system. The highest count levels (mean +/- SEM) were detected in SLIM tissue (386+/-82 cells/mm2). The difference was statistically significant compared with pseudocapsular tissue (193+/-36 cells/mm2) and control samples (18+/-5 cells/mm2). Count levels in control tissue were on average 5% of the SLIM tissues values. The present study determines for the first time the cellular origin of IL-8 in aseptically loosened THRs and also quantitates the IL-8-producing cells in the periprosthetic tissue. The results reveal a high rise in IL-8 concentration in SLIM and in synovial tissues. This finding moves us one step forward in solving the complex network of multiple factors affecting loosening of hip implants.

Treatment of infection and non-union after bilateral complicated proximal tibial fracture.

BACKGROUND AND AIMS: Complicated tibial fractures form a great challenge for orthopaedic surgeons. Non-unions and infections are more common in complicated than in closed fractures. In the present study, we describe a patient case treated for non-union combined to chronic osteomyelitis after bilateral open proximal tibial fractures. MATERIAL AND METHODS: A female patient born in 1946 was multi-traumatised, when a car hit her as a pedestrian. She went through multiple operations of both tibias due to bilateral complicated proximal fractures. Fractures were stabilised at first with internal fixation, which had to be changed to external fixation due to infection of both sides. During the last operative step a commercial bone graft based on hydroxyapatite and bovine type I fibrillar collagen/tricalcium phosphate ceramic (Collagraft) mixed with autogenous bone marrow was applied. RESULTS: Fractures united after 28 (right tibia) and 22 (left tibia) months of follow-up. At the final follow-up visit 55 months after the initial accident patient walked without any aid and showed no signs of an infection. CONCLUSIONS: The use of commercial mixed xeno-/autogenous-bone graft may provide a feasible alternative in complicated chronic non-unions of the tibia even when an infection is present, especially when autogenous bone is not easily available after previous attempts of bone grafting.

Studies of host response to orthopedic implants and biomaterials.

The use of implanted biomaterials in orthopedic surgery has increased rapidly during the past two decades. Total joint replacement of the hip or knee joint has become common treatment; at the same time, an increasing number of fractures are treated with osteosynthesis. The original Charnley low-friction arthroplasty of the hip is still widely used and gives in large series excellent results. Aseptic loosening of this arthroplasty has been thought to be due to wear debris of the methylmethacrylate used for fixation of the implants, or to debris generated from wear of the polyethylene socket. To date, many different materials have been tried in order to reduce wear and generation of macrophage irritating submicron sized particles, or to provide more biocompatible components. However, trials to improve the methylmethacrylate cement or to invent better polyethylenes have often failed. Diamond coating of the metallic components seems promising: there is less wear and diamond is very biocompatible in bulk and small particulate form. Biodegradable implants have also been found useful in treating fractures. Bioactive bioabsorbable materials may also make possible a tissue engineering approach and can be used as carriers for selected drugs and cytokines. Because many promising materials and designs have failed in clinical use, extensive theoretical and experimental testing is mandatory before introducing new materials and implants in a clinical setting.

A safe surgical technique for the partial resection of the ruptured spleen. A clinical report.

A consecutive series of 11 patients with an acute blunt splenic injury were treated with a 'safe resection' technique. 57% of the injured spleens (range 35-100%) were saved. None of the patients had any signs of secondary bleeding in control CT scan and the mortality was zero. No second-look laparotomies were performed. Follow-up time was at least two months (range 2 month-6 yr). Operation time was in average 120 min. Total mean peroperative bleeding was 1400 ml. Partial resection may offer patient a change for normal function of the injured spleen. However, it is not yet known what is the critical mass of spleen tissue needed for humans. The follow-up time of the present study is still too short to estimate this fact, but further studies may show the benefit of the present method in avoiding serious long term immunological complications of splenectomy. This present study introduces a novel technique for partial resection of injured spleen. Operation can be performed safely and quickly with a complication risk comparable to splenectomy. Resection is applicable even for multi-trauma patients.

Macrophage activation results in bone resorption.

Monocytes or macrophages from important accessory cells in the regulation of bone metabolism and destruction. Cells of the mononuclear phagocyte lineage form the precursor cells of the osteoclasts. Soluble products produced by activated macrophages regulate progenitor cell proliferation, recruitment, differentiation, and activity of osteoblasts and osteoclasts. After osteoclasts are removed from the resorption site, macrophages process bone surfaces and create a cement line before osteoblasts enter to form new bone. Although osteolysis associated with normal bone remodeling is seen as an osteoclast driven process, it may be that in chronic inflammation macrophage activation and vascular derangements lead to low pH, local bone demineralization (acid attack), and H+ mediated stimulation of the primary afferent nociceptive nerve fibers (bone pain). Osteoclasts are not able to attach to demineralized bone or to osteoid surfaces. However, if macrophages degrade the demineralized organic bone matrix, chemotactic factors and attachment sites for osteoclasts are produced. In such a scenario, the osteoclast-osteoblast mediated activation, resorption, and formation cycle would be secondarily activated. Such events may play a role in the most common orthopaedic problem related to macrophage activation, aseptic loosening of orthopaedic joint implants, which is secondary to a chronic foreign body reaction and to micromovement.

Production of platelet-derived growth factor in aseptic loosening of total hip replacement.

Aseptic loosening is the predominant cause of total hip implant failure. It has been assumed that a layer or membrane, containing macrophages, fibroblasts and vascular endothelial cells, of synovial-like tissue develops at the implant-to-bone interface almost invariably and, with time, somehow leads to loosening of the components from the surrounding bone. These cells produce a variety of cytokines and proteolytic enzymes which stimulate bone resorption. Platelet derived growth factor (PDGF) may be one of the cytokines which stimulate bone resorption and contribute to aseptic loosening in total hip replacement (THR). Synovial-like membrane from the implant or cement-to-bone interface (n = 10) and pseudocapsule (n = 10) were obtained from ten patients operated on for aseptic loosening of THR. As a control, nine samples of connective tissues were obtained from patients who had mandibular or maxillary fractures fixed with bone implant. The avidin-biotin-peroxidase complex (ABC) method with polyclonal rabbit anti-human IgG against the A-chain and B-chain of PDGF was used for staining. ABC-alkaline phosphatase-anti-alkaline-phosphatase double staining with monoclonal mouse anti-human fibroblast IgG1 and CD68 antibodies was used to ascertain the cellular origin of PDGF. Results of the PDGF staining were quantitated by a semi-automatic VIDAS image analysis system. The PDGF-A and PDGF-B chain containing cells were found in all periprosthetic tissues, in particular in macrophages with phagocytosed particulate debris, but to some extent also in fibroblasts and in endothelial cells. The numbers of PDGF-A and PDGF-B chain positive cells per mm 2 in synovial-like interface membrane (1881 +/- 486 and 1877 +/- 214) and pseudocapsule (1786 +/- 236 and 1676 +/- 152) were higher (P < 0.01) around loose THR than in control tissue (821 +/- 112 and 467 +/- 150), respectively. The results of the present study suggest that PDGF is preferably expressed by macrophages, which to an increased extent produce it in the synovial-like interface membrane and pseudocapsular synovial-like membrane. Because of its role in bone resorption, it may well play a role in periprosthetic bone loss and aseptic loosening and deserves more detailed study as a mediator and potential target in the modulation or prevention of loosening of THR.

Tumor necrosis factor-alpha (TNF-alpha) in loosening of total hip replacement (THR).

OBJECTIVE: The initially well-fixed implants of total hip replacement (THR) are in the long-term subject to aseptic loosening. Many cytokines can contribute to osteolysis due to osteoclast recruitment and/or activation. However, in this respect tumor necrosis factor-alpha (TNF-alpha) plays a pivotal role, because it upregulates interleukin-1 and 6 and granulocyte-macrophage colony stimulating factor. The aim of this study was to assess the eventual presence, cellular localization and extent of expression of TNF-alpha in the synovial-like membrane at the implant or at the cement to bone interface compared to control synovial membrane. METHODS: Twenty samples from the synovial-like membrane of the periprosthetic tissues were compared to control samples. TNF-alpha containing cells were visualized using an avidin-biotin-peroxidase complex (ABC) method and analyzed by light microscopy, double labelling and image analysis. RESULTS: TNF-alpha was found in the periprosthetic tissues in fibroblasts and vascular endothelial cells, but mainly in the macrophages was it found to coincide with areas containing implant-derived debris. TNF-alpha containing cells were more numerous in the synovial-like membrane in the interface tissue from the proximal stem area (2816 +/- 318 cells) than in the control synovial membrane (565 +/- 93 cells, p < 0.01). Interestingly, similarly high TNF-alpha expression (3452 +/- 582 cells) was also seen in the synovial-like membrane of the pseudocapsule. CONCLUSION: These findings suggest that the foreign body-type host reaction caused by THR is characterized by the high expression of TNF-alpha. Because such expression occurred in the interface tissue between the implant and surrounding bone, TNF-alpha, due to its pivotal direct and indirect role in the activation and recruitment of osteoclasts, may contribute to periprosthetic osteolysis and to the loosening of THR.

Simultaneously detected aberrant p53 tumor suppressor protein and HPV-DNA localize mostly in separate keratinocytes in anogenital and common warts.

The E6 oncoprotein of human papillomavirus (HPV) is known to inactivate the control function on cell cycle exerted by p53 tumor suppressor protein in vitro by binding to p53 and thus facilitating the degradation of p53. We have applied a simultaneous in situ demonstration method for detecting p53 protein and HPV-DNA on formalin-fixed tissue sections, and investigated the in vivo interrelationship of p53 protein and HPV-DNA. Immunohistochemical staining for p53 protein with polyclonal and monoclonal antibodies, recognizing both wild-type (wt) and mutated p53 protein, was performed first and in situ DNA hybridization (ISH) for HPV types 6/11 or 16/18 with digoxigenin-labelled probes thereafter. 47% (25/53) of 48 histologically confirmed primary or recurrent condylomata acuminata (CA), 2 Bowenoid papulosis (BP) and 3 common wart (CW) biopsies, positive for HPV 6/11 or HPV 16/18 DNA, showed keratinocytes immunopositive for p53 protein. Of these, 11 lesions with abundant numbers of p53-positive cells were further analyzed with the double method. Signals for abnormal p53 protein and HPV-DNA were detected in separate cell nuclei in all biopsies and, additionally, in the same cell nuclei in 3 biopsies (1 BP, 1 CA, 1 CW). Usually the p53 positivity localized more basally in the epidermis than HPV-DNA, although p53- and HPV-positive keratinocytes were always located closely. The findings were similar for HPV-types 6/11 and 16/18. Our finding of both p53 and HPV-6/11 signals in the same cell nuclei may indicate complexing of p53 and low-risk HPV's without degradation of p53. Our results show abnormal p53 expression in HPV-infected skin lesions, and suggest that p53 protein is susceptible to aberrations even in the cells in the vicinity of productive HPV infection. However, it is not yet fully understood how HPV interferes with p53 protein in these cells.

Relation of p53 tumor suppressor protein expression to human papillomavirus (HPV) DNA and to cellular atypia in male genital warts and in premalignant lesions.

Functional disturbance of p53 tumor suppressor protein contributes to uncontrolled cell growth. Human papillomavirus (HPV) E6 oncoproteins bind to wild-type p53 and abrogate its function. Our objective was to elucidate the relation of aberrant p53 protein expression to HPV DNA and cellular atypia in male genital warts and premalignant lesions. Immunohistochemically detectable p53 protein expression was studied in 35 male anogenital warts with low-level or no keratinocyte atypia (histologically confirmed condylomata acuminata), in 25 lesions with bowenoid papulosis (BP; carcinoma in situ) histology, and in 10 non-condyloma lesions using immunostaining with three established antibodies recognizing full-length wild-type accumulated p53 protein, or its conformational mutants. HPV DNA specific for HPV 6/11, 16/18, or 31/33/35 was identified by in situ hybridization or by polymerase chain reaction (PCR) - based amplification. Both nuclear and cytoplasmic keratinocyte immunostaining for p53 protein was detected in 41% of condylomata with no keratinocyte atypia and in 42% of condylomata with slight nuclear atypia or with bowenoid papulosis histology. No association of aberrant p53 expression with any specific HPV type or with HPV DNA was observed. Normal skin and some other penile dermatoses were negative for p53 immunostaining. In the follow-up biopsies of 16 BP patients, treated with CO2 laser, recurrence of atypia was seen exclusively in lesions initially positive for both HPV DNA and p53 protein. Our results show that a few cells in male genital warts even with no cellular atypia may express abnormally sequestered or loss-of-function p53 protein, and that concomitant presence of any type of HPV DNA is associated with recurrencies or progression of premalignant changes.