Adolescent varicocele: Efficacy of indication-to-treat protocol and proposal of a grading system for postoperative hydroceles.

BACKGROUND: Varicocele is a common urologic anomaly in adolescent males; however, evidence-based treatment guidelines do not exist. Hydroceles are known to be a common complication after surgical therapy, with a wide variation in the reported incidence between 1 and 40%. AIM: This study aimed to introduce a standardized indication-to-treat protocol and prove its efficacy by analyzing the outcome of patients. Secondly, it aimed to better define postoperative hydroceles because the wide variation of reported incidence is attributed to a lack of definition. METHODS: Our standardized treatment protocol included an initial assessment with clinical grading of varicoceles, ultrasound evaluation of testicular volume, and calculation of the atrophy index. Indications for surgical treatment were testicular volume asymmetry >20%, discomfort and pain, or bilateral varicocele. The Palomo procedure (laparoscopically since 2005) was the standard procedure. Postoperative hydroceles were graded according to clinical findings and symptoms: Grade I, sonographic chance finding without clinical correlate; Grade II, palpable but clinically insignificant; Grade III, symptomatic. All patients treated according to the defined protocol were prospectively monitored between January 2001 and December 2015. RESULTS: A total of 129 patients with left varicocele were referred to our institution; 70 fulfilled the indication criteria for surgical treatment. Twenty-eight of these patients were treated for volume asymmetry, 26 of these showed catch-up growth. Forty-two patients were treated for discomfort and pain; the symptoms subsided in all of them. Postoperative hydroceles were detected in 36 patients (51%). In 29 patients this was a sonographic chance finding (Grade I). Three patients showed a palpable but clinically insignificant postoperative hydrocele (Grade II) and four patients (5.7%) showed symptomatic hydrocele (Grade III) where treatment was recommended. DISCUSSION: The treatment protocol allowed judicious indication for surgery and postoperative outcomes similar to previous reports. The high rate of catch-up growth in operated cases represents a proxy for successful treatment in cases where more precise parameters, like semen quality or paternity rate, were not yet detectable. The introduced grading system for postoperative hydroceles provs to be a valid and appropriate instrument, and promises to be a standardized method for comparing outcomes in future studies. CONCLUSION: The indication-to-treat protocol proved to be easily applicable, highly efficient, and have outcomes comparable to international literature. The necessity for a standardized grading of postoperative hydroceles was underscored in the data.

Defining the role of MRP-mediated efflux and glutathione in detoxification of oxaliplatin.

Albeit platinum complexes are widely used in cancer chemotherapy, their cellular processing has not been completely elucidated so far. In this study the effects of modulating multidrug resistance-associated protein (MRP)-mediated efflux and glutathione (GSH) depletion on the cytotoxicity of oxaliplatin were assessed in a human ileocecal colorectal adenocarcinoma cell line and its oxaliplatin-resistant variant. Upon oxaliplatin exposure, DNA platination was elevated by co-incubation with Gü83, a MRP1 and MRP2 inhibitor, but cytotoxicity was not increased. Addition of oxaliplatin did not alter the cellular GSH content. Following GSH depletion, platinum accumulation was unchanged but cytotoxicity was increased in oxaliplatin-sensitive cells. In conclusion, modulation of MRP-mediated efflux did not affect oxaliplatin cytotoxicity in the investigated cell lines. Intracellular GSH depletion seems to sensitize the cells but does not overcome resistance.

Survival and differentiation defects contribute to neutropenia in glucose-6-phosphatase-ß (G6PC3) deficiency in a model of mouse neutrophil granulocyte differentiation.

Differentiation of neutrophil granulocytes (neutrophils) occurs through several steps in the bone marrow and requires a coordinate regulation of factors determining survival and lineage-specific development. A number of genes are known whose deficiency disrupts neutrophil generation in humans and in mice. One of the proteins encoded by these genes, glucose-6-phosphatase-ß (G6PC3), is involved in glucose metabolism. G6PC3 deficiency causes neutropenia in humans and in mice, linked to enhanced apoptosis and ER stress. We used a model of conditional Hoxb8 expression to test molecular and functional differentiation as well as survival defects in neutrophils from G6PC3(-/-) mice. Progenitor lines were established and differentiated into neutrophils when Hoxb8 was turned off. G6PC3(-/-) progenitor cells underwent substantial apoptosis when differentiation was started. Transgenic expression of Bcl-XL rescued survival; however, Bcl-XL-protected differentiated cells showed reduced proliferation, immaturity and functional deficiency such as altered MAP kinase signaling and reduced cytokine secretion. Impaired glucose utilization was found and was associated with ER stress and apoptosis, associated with the upregulation of Bim and Bax; downregulation of Bim protected against apoptosis during differentiation. ER-stress further caused a profound loss of expression and secretion of the main neutrophil product neutrophil elastase during differentiation. Transplantation of wild-type Hoxb8-progenitor cells into irradiated mice allowed differentiation into neutrophils in the bone marrow in vivo. Transplantation of G6PC3(-/-) cells yielded few mature neutrophils in bone marrow and peripheral blood. Transgenic Bcl-XL permitted differentiation of G6PC3(-/-) cells in vivo. However, functional deficiencies and differentiation abnormalities remained. Differentiation of macrophages from Hoxb8-dependent progenitors was only slightly disturbed. A combination of defects in differentiation and survival thus underlies neutropenia in G6PC3(-/-) deficiency, both originating from a reduced ability to utilize glucose. Hoxb8-dependent cells are a model to study differentiation and survival of the neutrophil lineage.

Molecular analysis of neutrophil spontaneous apoptosis reveals a strong role for the pro-apoptotic BH3-only protein Noxa.

Neutrophils enter the peripheral blood from the bone marrow and die after a short time. Molecular analysis of spontaneous neutrophil apoptosis is difficult as these cells die rapidly and cannot be easily manipulated. We use conditional Hoxb8 expression to generate mouse neutrophils and test the regulation of apoptosis by extensive manipulation of B-cell lymphoma protein 2 (Bcl-2)-family proteins. Spontaneous apoptosis was preceded by downregulation of anti-apoptotic Bcl-2 proteins. Loss of the pro-apoptotic Bcl-2 homology domain (BH3)-only protein Bcl-2-interacting mediator of cell death (Bim) gave some protection, but only neutrophils deficient in both BH3-only proteins, Bim and Noxa, were strongly protected against apoptosis. Function of Noxa was at least in part neutralization of induced myeloid leukemia cell differentiation protein (Mcl-1) in neutrophils and progenitors. Loss of Bim and Noxa preserved neutrophil function in culture, and apoptosis-resistant cells remained in circulation in mice. Apoptosis regulated by Bim- and Noxa-driven loss of Mcl-1 is thus the final step in neutrophil differentiation, required for the termination of neutrophil function and neutrophil-dependent inflammation.

Pseudoaneurysm rupture after liver injury in a 14-year-old boy.

Today, haemodynamically stable children with blunt liver trauma are treated conservatively and can be discharged from hospital within one week. We report on a 14-year-old boy with a blunt hepatic trauma grade III, who showed a pseudoaneurysm with active bleeding into the abdominal cavity after mobilisation on day 9. Supraselective angiography of the right hepatic artery was performed and 2 titanium coils and gelatine sponge particles were placed for embolisation. In view of this complication, we suggest carrying out colour Doppler sonographic imaging to rule out pseudoaneurysm in children with blunt hepatic trauma before they are discharged from hospital.

Laser induced photoreceptor damage and recovery in the high numerical aperture eye of the garter snake.

The garter snake provides a unique model for in-vivo imaging of photoreceptor damage induced by laser retinal exposure. Laser thermal/mechanical retinal injury induced alterations in photoreceptor structure and leukocyte cellular behavior. Photoreceptors turned white, lost mode structure, and swelled; leukocyte activity was observed in the vicinity of photoreceptor cells. Non-thermal alterations were identified with a bio-tag for oxidative stress. Mechanisms of photoreceptor recovery and replacement were observed and evaluated for active cytoskeletal systems by using an anti-actin tag that could detect the presence of active cytoskeletal systems resident in photoreceptors as well as other retinal systems.

Cystic colon duplication as differential diagnosis to ovarian cyst.

OBJECTIVE: We report the case of a female fetus with a single spherical anechoic cyst on the right side of the lower abdomen first diagnosed at 22 weeks of pregnancy. METHODS: Serial ultrasound monitoring and needle aspiration of the cyst were performed. RESULTS: The cyst grew during pregnancy up to 8 cm diameter. Needle aspiration was performed at 33 and 36 weeks. At 38 weeks labor was induced and a girl was delivered spontaneously. Postnatally the child showed abdominal distention, vomiting, and an obstruction of venous return of the right leg. To improve venous circulation, another needle aspiration of the cyst was performed. Laparoscopy revealed cystic colon duplication. CONCLUSIONS: Prenatal differentiation of a single round anechoic cyst in the pelvis of a female fetus can be difficult. As a rare abnormality cystic colon duplication has to be considered.

Human TLR9 confers responsiveness to bacterial DNA via species-specific CpG motif recognition.

The Toll-like receptor (TLR) family consists of phylogenetically conserved transmembrane proteins, which function as mediators of innate immunity for recognition of pathogen-derived ligands and subsequent cell activation via the Toll/IL-1R signal pathway. Here, we show that human TLR9 (hTLR9) expression in human immune cells correlates with responsiveness to bacterial deoxycytidylate-phosphate-deoxyguanylate (CpG)-DNA. Notably "gain of function" to immunostimulatory CpG-DNA is achieved by expressing TLR9 in human nonresponder cells. Transfection of either human or murine TLR9 conferred responsiveness in a CD14- and MD2-independent manner, yet required species-specific CpG-DNA motifs for initiation of the Toll/IL-1R signal pathway via MyD88. The optimal CpG motif for hTLR9 was GTCGTT, whereas the optimal murine sequence was GACGTT. Overall, these data suggest that hTLR9 conveys CpG-DNA responsiveness to human cells by directly engaging immunostimulating CpG-DNA.

Endocytosed HSP60s use toll-like receptor 2 (TLR2) and TLR4 to activate the toll/interleukin-1 receptor signaling pathway in innate immune cells.

Heat shock proteins (HSPs) require no adjuvant to confer immunogenicity to bound peptides, as if they possessed an intrinsic "danger" signature. To understand the proinflammatory nature of HSP, we analyzed signaling induced by human and chlamydial HSP60. We show that both HSP60s activate the stress-activated protein kinases p38 and JNK1/2, the mitogen-activated protein kinases ERK1/2, and the I-kappaB kinase (IKK). Activation of JNK and IKK proceeds via the Toll/IL-1 receptor signaling pathway involving MyD88 and TRAF6. Human fibroblasts transfected with TLR2 or TLR4 plus MD-2 gain responsiveness to HSP60, while TLR2- or TLR4-defective cells display impaired responses. Initiation of signaling requires endocytosis of HSP60 that is effectively inhibited by serum component(s). The results revealed that adjuvanticity of HSP60 operates similar to that of classical pathogen-derived ligands.

Laser resection of posterior urethral valves.

Laser resection (LR) of posterior urethral valves during infancy as early as possible after diagnosis appears to represent a safe and reliable method. In contrast to other procedures, LR allows valve ablation with thin cystoscopes and carries little risk, even in premature and newborn infants. Its application in seven children in the course of 2 years principally confirmed its suitability for use: it could be applied in all cases without any problems and led to extensive resection of the valve tissue and removal of the obstruction in all patients. The encouraging clinical findings were confirmed by control cystoscopies and micturating cystourethrograms. Complications arising from the method were not observed.

Hepadnaviral hepatocarcinogenesis: in situ visualization of viral antigens, cytoplasmic compartmentation, enzymic patterns, and cellular proliferation in preneoplastic hepatocellular lineages in woodchucks.

BACKGROUND/AIMS: Hepadnaviral hepatocarcinogenesis induced in woodchucks with and without dietary aflatoxin B1 has been established as an appropriate animal model for studying the pathogenesis of human hepatocellular carcinoma in high-risk areas. Our aim in this study was the elucidation of phenotypic cellular changes in early stages of this process. METHODS: Woodchucks were inoculated as newborns with woodchuck hepatitis virus (WHV), and partly also exposed to aflatoxin B1. Sequential hepatocellular changes in the expression of viral antigens, ultrastructural organization, cellular proliferation and apoptosis were studied in situ by electron microscopy, enzyme and immunohistochemistry. RESULTS: A characteristic finding in WHV-infected animals (with and without aflatoxin B1) was proliferative areas of minimal structural deviation, which predominated periportally, comprised glycogen-rich, amphophilic, and ground-glass hepatocytes, and expressed the woodchuck hepatitis core and surface antigens. Two main types of proliferative foci emerged from minimal deviation areas, glycogenotic clear cell foci and amphophilic cell foci (being poor in glycogen but rich in mitochondria), giving rise to the glycogenotic-basophilic and the amphophilic preneoplastic hepatocellular lineages. A gradual loss in the expression of viral antigens appeared in both lineages, particularly early in the glycogenotic-basophilic cell lineage. Whereas glycogenosis was associated with an enzymic pattern suggesting an early activation of the insulin-signaling pathway, amphophilic cells showed changes in enzyme activities mimicking a response of the hepatocytes to thyroid hormone, which may also result from early changes in signal transduction. CONCLUSION: Preneoplastic hepatocellular lineages in hepadnaviral and chemical hepatocarcinognesis show striking phenotypic similarities, indicating concordant and possibly synergistic early changes in signaling.

Immune cell activation by bacterial CpG-DNA through myeloid differentiation marker 88 and tumor necrosis factor receptor-associated factor (TRAF)6.

Transition of immature antigen presenting cells (APCs) to the state of professional APCs is essential for initiation of cell-mediated immune responses to pathogens. Signal transduction via molecules of the Toll-like receptor (TLR)/interleukin 1 receptor (IL-1R) pathway is critical for activation of APCs either by pathogen-derived pattern ligands like lipopolysaccharides (LPS) or by CD40 ligation through T helper cells. The capacity of bacterial DNA (CpG-DNA) to induce APCs to differentiate into professional APCs represents an interesting discovery. However, the signaling pathways involved are poorly understood. Here we show that CpG-DNA activates the TLR/IL-1R signaling pathway via the molecules myeloid differentiation marker 88 (MyD88) and tumor necrosis factor receptor-associated factor 6 (TRAF6), leading to activation of kinases of the IkappaB kinase complex and the c-jun NH(2)-terminal kinases. Moreover, cells of TLR2- and TLR4-deficient mice are activated by CpG-DNA, whereas cells of MyD88-deficient mice do not respond. The data suggest that CpG-DNA initiates signaling via the TLR/IL-1R pathway in APCs in a manner similar to LPS and to T helper cell-mediated CD40 ligation. Activation of the TLR/IL-1R signaling pathway by foreign bacterial DNA may be one way to initiate innate defense mechanisms against infectious pathogens in vivo.

Matching two imagined clocks: the functional anatomy of spatial analysis in the absence of visual stimulation.

Do spatial operations on mental images and those on visually presented material share the same neural substrate? We used the high spatial resolution of functional magnetic resonance imaging to determine whether areas in the parietal lobe that have been implicated in the spatial transformation of visual percepts are also activated during the generation and spatial analysis of imagined objects. Using a behaviourally controlled mental imagery paradigm, which did not involve any visual stimulation, we found robust activation in posterior parietal cortex in both hemispheres. We could thus identify the subset of spatial analysis-related activity that is involved in spatial operations on mental images in the absence of external visual input. This result clarifies the nature of top-down processes in the dorsal stream of the human cerebral cortex and provides evidence for a specific convergence of the pathways of imagery and visual perception within the parietal lobes.

Hepatocellular alterations after intraportal transplantation of ovarian tissue in ovariectomized rats.

The mechanisms of hepatocarcinogenesis by certain synthetic estrogens seem to involve both nongenotoxic and indirect genotoxic effects. However, the natural estrogen estradiol did not exert any carcinogenic effects in established experimental protocols. To elucidate specific long-term effects of natural estrogens on hepatocytes, small pieces of ovarian tissue were transplanted via the portal vein into the livers of ovariectomized female rats. One week, 3 weeks, and 3 months after transplantation the transplants were found to proliferate and to secrete estradiol. Three weeks after transplantation the hepatocytes of the liver acini downstream of the stimulated transplants already showed a remarkable loss of glycogen, distinct cytoplasmic amphophilia, enlargement of their nuclei, a strong increase in the number and size of peroxisomes, an increase in proliferative activity and apoptotic elimination, and changes in the activity of certain key enzymes of energy metabolism. All hepatocellular alterations could be inhibited by the estrogen receptor antagonist toremifene and are, therefore, attributed to specific effects of estradiol produced by the transplants. The observed alterations resemble in some respects amphophilic preneoplastic liver foci, which particularly occur after long-term administration of nongenotoxic hepatocarcinogens, including the adrenal steroid hormone dehydroepiandrosterone. In a preliminary experiment three of six animals exhibited a hepatocellular carcinoma, and another animal developed a hepatocellular adenoma 18 months after intrahepatic ovarian tissue transplantation.

Paroxysmal nocturnal haemoglobinuria: a replacement of haematopoietic tissue?

Acquired somatic mutations of the PIG-A gene lead to deficient expression of glycosyl-phosphatidyl-inositol-anchored proteins (GPI-AP) by haematopoietic cells and play a causative role in the pathogenesis of paroxysmal nocturnal haemoglobinuria (PNH). However, PIG-A mutations do not explain how the defective PNH clone can expand. It was hypothesized that a selection process conferring a relative advantage to the GPI-AP-deficient population is required. Since GPI-AP-deficient cells are also detectable in a substantial proportion of patients with otherwise typical aplastic anaemia (AA), the mechanisms inducing bone marrow failure might selectively spare the GPI-deficient cells. In order to examine the growth characteristics of GPI-AP-deficient cells in more detail, we performed repeated analyses of GPI-AP expression on peripheral blood cells in 41 patients with AA. We observed four patterns of the course of GPI-AP-deficient populations: (1) 13 patients showed normal expression of GPI-AP in the first analysis and in at least two follow-up studies at a median time of 709 days after the first analysis. (2) Secondary evolution of a GPI-AP-deficient population was a rare event. Only 4 patients with initially normal GPI-AP expression developed a GPI-AP-deficient population during follow up after immunosuppressive treatment. (3) Persistence of GPI-AP-deficient cells was observed in 16 patients during a median follow-up time of 774 days. However, in some patients, the size of the GPI-AP-deficient population increased substantially. (4) Disappearance of a GPI-AP-deficient population was observed in 8 patients. The time course of GPI-AP expression in relation to the treatment suggests that therapeutic interventions might modulate the ratio of normal versus GPI-AP-deficient haematopoiesis. Overall, these data argue against an 'absolute growth advantage' of GPI-AP-deficient cells. Our data are consistent with the hypothesis that haematopoietic failure caused by damage to normal haematopoiesis allows the outgrowth of a GPI-AP-deficient population. Thus, in at least some patients GPI-AP-deficient cells might pre-exist at a very low percentage and replace haematopoiesis after an insult to the normal cells.