The Role of Endoplasmic Reticulum Stress Response in Male Reproductive Physiology and Pathology: A Review

Endoplasmic reticulum (ER) stress, defined as prolonged disturbances in protein folding and accumulation of unfolded proteins in the ER. Perturbation of the ER, such as distribution of oxidative stress, iron imbalance, Ca²⁺ leakage, protein overload, and hypoxia, can cause ER stress. The cell reacts to ER stress by activating protective pathways, called the unfolded protein response (UPR), which is comprised of cellular mechanisms aimed for maintaining cellular homeostasis or, in case of excessively severe stress, at the initiation of cellular apoptosis. The three UPR signaling pathways from the ER stress sensors are initiated by activating transcription factor 6, inositol requiring enzyme 1, and protein kinase RNA-activated-like ER kinase. A number of physiological and pathological conditions, environmental toxicants and variety of pharmacological agents showed disruption of proper ER functions and thereby cause ER stress in male reproductive organ in rat model. The present review summarizes the existing data concerning the molecular and biological mechanism of ER stress in male reproduction and male infertility. ER stress initiated cell death pathway has been related to several diseases, including hypoxia, heath disease, diabetes, and Parkinson's disease. Although there is not enough evidence to prove the relationship between ER stress and male infertility in human, most studies in this review found that ER stress was correlated with male reproduction and infertility in animal models. The ER stress could be novel signaling pathway of regulating male reproductive cellular apoptosis. Infertility might be a result of disturbing the ER stress response during the process of male reproduction.

Prediction of difficult airway management in traumatic cervical spine injury: influence of retropharyngeal space extension

Background

Retropharyngeal hematoma following cervical spine trauma may lead to life-threatening upper airway obstruction and difficult airway management. This retrospective study was performed to investigate whether the extension of retropharyngeal space (RPS) was associated with difficult intubation by direct laryngoscopy in traumatic cervical spine injury.

Patients and methods

Sixty-two patients who had undergone direct endotracheal intubation under general anesthesia for cervical spine surgery were retrospectively identified. Laryngoscopic grade by Cormack–Lehane (C-L) classification was collected; grade 1 or 2 was categorized as easy laryngoscopy, whereas grade 3 or 4 was categorized as difficult laryngoscopy. In these patients, RPS thickness and the proportions of RPS to the vertebral bodies were measured at the 2nd, 5th and 7th cervical spine levels using magnetic resonance imaging (MRI) of the cervical spine. Measures of RPS were compared between easy and difficult laryngoscopy. Relationships between measures of RPS and difficult laryngoscopy were analyzed with logistic regression analysis.

Results

RPS thickness at C2 was significantly greater in difficult laryngoscopy (median 14.29 mm, IQR: 9.75–18.04) than easy laryngoscopy (median 5.10, IQR: 4.33–5.94, p<0.001). Proportion of RPS to the C2 vertebral body were significantly higher in difficult laryngoscopy than in easy laryngoscopy (p<0.001). RPS thickness and the proportion of RPS to the vertebral body were significantly associated with difficult laryngoscopy (OR=2.13, 95% CI: 1.38–3.30; p<0.001 and OR=1.13, 95% CI: 1.05–1.21; p<0.001, respectively).

Conclusion

RPS extension at the upper cervical spine level is associated with difficult direct laryngoscopy in traumatic cervical spine injury.

Friction underwear for ease of pulling down in elderly patients with overactive bladder: A prospective randomized control trial

Purpose

Friction underwear was developed by adding small silicon dots in front of the underwear to decrease the time for pulling down underwear in elderly patients with urge incontinence. We studied about the effects of the friction underwear for elderly overactive bladder (OAB) patients.

Materials and Methods

Male patients over 60 years of age diagnosed with OAB were prospectively enrolled and randomized to either the friction underwear first group (measuring for the time taken to pull down the friction underwear first and the non-friction underwear second) or the friction underwear later group (non-friction underwear first and the friction underwear second). An investigator measured the time to pulling down the underwear. And we measured the coefficient of friction of underwear.

Results

A total of 56 male patients were randomly divided into two groups using a random number table envelope method. There were no significant differences in demographics and clinical characteristics between the two groups. Of the total 56 patients, the time taken to pull down underwear for the friction underwear (3.79±0.15 seconds) was found significantly shorter than that for the non-friction underwear (4.10±0.17 seconds) (p=0.03). The static and dynamic coefficients of friction of the friction were 4.21 and 2.88, respectively, while those of the non-friction underwear were 0.64 and 0.45, respectively.

Conclusions

Our study demonstrates that friction underwear significantly shortened the time to pull down underwear. This functional underwear may be effective in preventing the underwear from getting wet in patients who suffer from urge incontinence.

Failed dural puncture during needle-through-needle combined spinal-epidural anesthesia: a case series

Objective

Combined spinal-epidural (CSE) anesthesia is a widely used neuraxial anesthetic technique. In clinical practice, failed dural puncture during needle-through-needle technique occasionally occurs, with incidence of 5%-29%. We radiologically evaluated four cases of failed dural puncture during needle-through-needle CSE anesthesia.

Case series

Four patients received CSE anesthesia for elective orthopedic surgery. CSE procedures were performed in the same manner using a CSE device for needle-through-needle technique. An epidural needle was inserted in midline at L4/5 interspaces using loss of resistance to air whilst patients lay in the lateral decubitus position. The spinal needle was then inserted through the epidural needle for subarachnoid block, however, negative cerebrospinal flow was identified. Subsequently, radiographic imaging using C-arm fluoroscopy was performed to evaluate the status of needles. We found that epidural needles were considerably deviated from the midline, while spinal needles exited epidural needles, not through back holes, but through the Tuohy curve in three patients. In one patient, when the spinal needle was inserted to 12 mm, the anesthesiologist felt the needle touching the bony structure. The spinal needle was in contact with the superior articular process of the fifth lumbar vertebra, which was confirmed by C-arm radiography.

Conclusion

Excessive paramedian deviation of the epidural needle may affect dural puncture during needle-through-needle CSE technique. Moreover, wrong passage of the spinal needle through Tuohy curve instead of the back hole, may contribute to failure of dural puncture.

Effect of preoperative urethral dilatation on preventing urethral stricture after holmium laser enucleation of the prostate: A randomized controlled study

INTRODUCTION

We aimed to evaluate the effect of preoperative urethral dilatation during holmium laser enucleation of the prostate (HoLEP) on the prevention of urethral stricture.

METHODS

A total of 72 patients without urethral stricture underwent HoLEP for benign prostatic hyperplasia (BPH). Recruited patients were randomly divided into two groups (groups A and B). Patients in group A (36 patients, experimental group) received preoperative urethral dilatation and patients in group B (36 patients, control group) did not. Each patient was evaluated at four weeks, 12 weeks, and 24 weeks after surgery. The effectiveness of preoperative urethral dilatation was evaluated based on the International Prostate Symptom Score (IPSS), peak urine flow rate (Qmax), voided volume, and post-void residual (PVR) volume. To diagnose urethral stricture, Qmax <10 mL/s, as assessed using uroflowmetry and findings of visualization through retrograde urethrography and urethroscopy, were used.

RESULTS

Among 72 initial participants, 33 patients in group A and 31 patients in group B completed the experiment. Preoperative characteristics were well-balanced between groups. At each postoperative visit, there was no significant difference in voiding symptoms between groups. Two patients (6.06%) in group A and five patients (15.15%) in group B showed a Qmax <10 mL/s on uroflowmetry (p=0.013). On urethroscopy, no patient in group A (0%) and two patients in group B (6.45%) (p=0.021) showed urethral stricture after HoLEP.

CONCLUSIONS

Preoperative urethral dilatation during HoLEP decreased the incidence of urethral stricture. This procedure could be useful to reduce the risk of urethral stricture after transurethral prostate surgery. One limitation of the current study is the single-centre design. Also, we sought to determine the efficacy of preoperative urethral dilatation for the prevention of urethral stricture after transurethral prostate surgery within a short time period, which could be another limitation of the study. Despite these limitations, to the best of our knowledge, the present study is the first reported prospective, randomized trial analyzing the safety and efficacy of preoperative urethral dilatation for the prevention of urethral stricture after transurethral prostate surgery.

Penile skin preservation technique for reconstruction surgery of penile paraffinoma

Purpose

Penile resurfacing with various scrotal flaps is a simple, effective, and reliable reconstructive armamentarium to treat penile paraffinoma. However, scrotal flaps often result in heavy hair-bearing penile skin causing dyspareunia or shortening of penile length. We introduce a new penile skin preservation technique for reconstruction surgery of penile paraffinoma.

Materials and Methods

From March 2007 to April 2018, 23 patients underwent excision of paraffinoma with the penile skin preservation technique. Complete removal of the subcutaneous tissue was done, including paraffinoma. No. 10 surgical blades were used to peel off the skin as thin as possible in order to get paraffinoma-free skin. The preserved penile skin was given an end to end anastomosis to the circumferential incision site. Multiple anchoring fixation sutures of the penile skin were made on the underlying tissue. Dressing of chopped gauze soaked with antibiotic saline solution was done on the skin to help preserve it and keep it fixed on the penis.

Results

The skin survived completely without necrosis in 19 patients (82.6%), with the mean duration of healing being 21.9 days. The penis after the operation looked natural in color and shape. Partial necrosis after the operation was shown on 4 patients (17.4%), whom were all later treated with the scrotal skin free graft. The final results were successful without any cosmetic or functional complications, such as skin contracture.

Conclusions

Penile resurfacing with the penile skin preservation technique is a new effective reliable method for skin-intact paraffinoma which produces good functional and cosmetic results.

Protective effect of MOTILIPERM in varicocele-induced oxidative injury in rat testis by activating phosphorylated inositol requiring kinase 1α (p-IRE1α) and phosphorylated c-Jun N-terminal kinase (p-JNK) pathways

CONTEXT

MOTILIPERM was prepared as a mixture of extracts of three medicinal herbs [roots of Morinda officinalis How (Rubiaceae), outer scales of Allium cepa L. (Liliaceae) and seeds of Cuscuta chinensis Lamark (Convolvulaceae)].

OBJECTIVE

To investigate the role of reactive oxygen species (ROS)-based endoplasmic reticulum (ER) stress in a rat model of varicocele and the therapeutic efficacy of MOTILIPERM in this model.

MATERIALS AND METHODS

Sixty male rats were divided into five experimental groups: a normal control group (CTR + vehicle), a control group administered MOTILIPERM 200 mg/kg (CTR + M 200), a varicocele-induced control group (VC + vehicle) and two varicocele-induced groups administered MOTILIPERM 100 (VC + M 100) or 200 (VC + M 200) mg/kg for 4 weeks. Testis weights were recorded and serums were assayed for hormone concentrations. Tissues were subjected to semen analysis, histopathology, analyses of ER response protein expression levels and oxidative stress were assessed by measuring ROS, reactive nitrogen species (RNS), malondialdehyde (MDA) level and ratios of total glutathione (GSH)/oxidized GSH (GSSG).

RESULTS

MOTILIPERM treatment of varicocele-induced groups significantly increased left testis weight, testosterone level, sperm motility, count and spermatogenic cell density. ER-response protein expression levels were dose-dependently decreased in VC + M 200 group compared with VC + vehicle group. MOTILIPERM treatment also decreased MDA and ROS/RNS level but increased GSH/GSSG ratio.

DISCUSSION AND CONCLUSIONS

This study suggests that ROS-related ER stress may play a major role in varicocele-induced infertility and MOTILIPERM, a novel compound targeting ROS-based ER stress, may be therapeutically useful in treatment of varicocele, or as a supplement for the treatment of infertility.

Landscape of Elderly Suicide in South Korea: Its Trend According to Age, Gender, and Educational Attainment

South Korea has one of the highest suicide rates in the world, and the most alarming suicide rate is among its elders. This study aims to understand the social, historical, and cultural context of the Korean older adults and examine suicide trends based on that understanding. The results show that the suicide risk increases with age, the male suicide rate outweighs that of females, and the suicide rate decreases with educational attainment. In addition, several suggestions for reducing elderly suicide rate are addressed, including differentiating the existing social services for elders by age and expanding suicide prevention programs beyond schools to communities so that all people in need can access them.

Seven-year Follow-up of Resin Infiltration Treatment on Noncavitated Proximal Caries

The purpose of this case report is to present success and failure outcomes of seven-year follow-up of resin infiltration treatment (RIT) used for the proximal caries of maxillary premolars. Although resin infiltration can be a good option for micro-invasive treatment, long-term follow-up data are not sufficient, and the outcome of this technique can be affected by factors such as technique sensitivity of procedure, patient's caries risk, and depth of caries progression. Therefore, careful case selection, application, and follow-up are needed.

Finasteride and Erectile Dysfunction in Patients with Benign Prostatic Hyperplasia or Male Androgenetic Alopecia

Finasteride is primarily used to treat benign prostatic hyperplasia (BPH) and male androgenetic alopecia (MAA). Five-alpha reductase inhibitors (5α-RIs) could induce male sexual dysfunction due to their effects on testosterone and dihydrotestosterone. There is evidence suggesting that 5α-RIs may independently increase the risk of erectile dysfunction (ED). However, many investigators believe that side effects of 5α-RIs will disappear with continuous treatment. Considerable controversy exists regarding the severity and persistence of side effects of finasteride on ED. The aim of this review was to summarize current research studies on finasteride associated with ED. The search strategy used each term of finasteride and ED against PubMed database to identify related studies. ED data reported from available trials for finasteride were summarized and reviewed. Although there is not enough evidence to prove the relationship between finasteride and ED, most studies in this review found that finasteride for BPH was correlated with ED. However, most studies included in this review revealed that finasteride for MAA was not correlated with ED. On the other hand, some studies reported side effects of finasteride associated with sexual dysfunction, including ED, male infertility, ejaculation problem, and loss of libido, even in MAA patients. Well-designed randomized controlled trials are needed to further determine the mechanism and effects of finasteride on ED. However, physicians should discuss with their patients possible long-term effects of finasteride on sexual function, although we do not have evidence showing that adverse events of sexual dysfunction are absolutely associated with 5α-RIs.

Clinical significance of anatomical urethral length on stress urinary incontinence women

Objective

To evaluate the association between the length of the female urethra and urodynamic study (UDS) parameters in patients presenting with stress urinary incontinence (SUI).

Patients and methods

We retrospectively enrolled 391 women who underwent a transobturator adjustable tape sling implantation for the management of SUI between April 2009 and March 2016. All patients underwent a physical examination and UDS. Filling cystometry data that were evaluated included the Valsalva leak point pressure, and the cough leak point pressure. The maximal urethral closure pressure, the functional urethral length (FUL), and the length of the continence zone (LCZ) were measured using the urethral profile obtained from the UDS. The anatomical urethral length (AUL) was measured intraoperatively using a Foley catheter. We calculated the LCZ/FUL ratio to determine the anatomical continence length for this study.

Results

We noted that 299 patients completed the study. The mean AUL was 26.25±3.59 mm. The mean FUL and LCZ were 41.37±15.05 mm and 24.15±13.90 mm, respectively. The mean LCZ/FUL was 0.57±0.19. Using the Pearson correlation coefficient, we observed that the AUL showed a correlation with the FUL (0.168, P=0.034), the LCZ (0.212, P=0.007), the LCZ/FUL ratio (0.190, P=0.016), the Valsalva leak point pressure (0.223, P=0.005), the cough leak point pressure (0.215, P=0.006), and the maximal urethral closure pressure (0.178, P=0.043).

Conclusion

Our results show that the AUL in women is associated with UDS parameters relating to SUI.

Radiation-induced neuropathic pain successfully treated with systemic lidocaine administration

Radiation-induced neuropathic pain is a rare but devastating complication following cancer treatment. It is often progressive, refractory to conservative treatment, and sometimes irreversible. The exact mechanism of radiation-induced neuropathic pain is unknown, but it is associated with perineural fibrosis, atrophy, and ischemia. Systemic administration of local anesthetics is known to be effective for various acute and chronic painful diseases, such as neuropathic pain, as well as inflammatory and nociceptive pains. We report a patient with generalized radiation-induced neuropathic pain successfully treated with systemic lidocaine administration.

Neutrophil autophagy and extracellular DNA traps contribute to airway inflammation in severe asthma

BACKGROUND

Autophagy and neutrophil extracellular DNA traps (NETs) are implicated in asthma; however, their roles in asthma pathogenesis have not been elucidated.

OBJECTIVES

We compared autophagy and NET production levels from peripheral blood neutrophils (PBNs) of patients with severe asthma (SA) and non-severe asthma (NSA). Additionally, we investigated the inflammatory effects of NETs on human airway epithelial cells (AECs) and peripheral blood eosinophils (PBEs).

METHODS

Peripheral blood neutrophils from patients with SA (n = 30) and NSA (n = 38) were treated with interleukin (IL)-8 (100 ng/mL). Autophagy (light chain 3-II expression) and NET production levels were evaluated by Western blot, immunofluorescence microscopy, and PicoGreen assay. The effects of NETs on AECs were assessed by investigating cell death, cell detachment, expression of occludin and claudin-1, and IL-8 production; the effects of NETs on PBEs were examined by investigating the activation and release of eosinophil cationic protein (ECP) and eosinophil-derived neurotoxin (EDN).

RESULTS

Untreated and IL-8-treated PBNs from the SA group produced higher autophagy and NET levels compared with those from the NSA group (P < 0.01). IL-8 increased autophagy and NET levels in PBNs from the SA group, but not from the NSA group. NET levels were correlated with autophagy levels in PBNs (P < 0.001). IL-8-induced NET production levels negatively were correlated with FEV1/FVC (r = -0.700, P = 0.016). NETs induced cell death, detachment, degradation of occludin and claudin-1, and IL-8 production from AECs. Higher levels of NET-induced ECP and EDN were released from PBEs in SA compared with NSA groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Neutrophil autophagy and NETs could enhance asthma severity by damaging airway epithelium and triggering inflammatory responses of AECs and PBEs. Modulating neutrophil autophagy and NET production may be a new target therapy for SA.

Protective effect of DA-9401 in finasteride-induced apoptosis in rat testis: inositol requiring kinase 1 and c-Jun N-terminal kinase pathway

Finasteride is used to treat male pattern baldness and benign prostatic hyperplasia. This study investigated the toxicity of finasteride and recovery by DA-9401 using Sprague Dawley (SD) rats. Forty adult male SD rats were assigned to four groups: control (CTR), finasteride 1 mg/kg/day (F), finasteride 1 mg/kg + DA-9401 100 mg/kg/day (F + DA 100) and finasteride 1 mg/kg + DA-9401 200 mg/kg/day (F + DA 200). Treatments were by oral delivery once daily for 90 consecutive days. The gross anatomical parameters assessed included: genital organ weight; vas deferens sperm count and sperm motility; testosterone, dihydrotestosterone (DHT) and malondialdehyde levels; and histological and terminal deoxynucleotidyl transferase enzyme mediated dUTP nick-end labeling (TUNEL) staining of testis for spermatogenic cell density, Johnsen’s score and apoptosis. Testicular tissue was also used for evaluating endoplasmic reticulum (ER) stress and apoptotic proteins. Epididymis weight, seminal vesicle weight, prostate weight, penile weight and vas deferens sperm motility showed significant differences between the F group and the CTR, F + DA 100 and F + DA 200 groups. There was no significant change in the testosterone level. DHT level decreased significantly in the F group compared with the CTR group. Testis tissue revealed significant changes in spermatogenic cell density, Johnsen’s score and apoptotic index. Western blot showed significant changes in the ER stress and apoptotic markers. Finasteride resulted in reduced fertility and increased ER stress and apoptotic markers, which were recovered by administration of DA-9401 in the SD rats.

Efficacy and safety of 0.75% ropivacaine instillation into subinguinal wound in patients after bilateral microsurgical varicocelectomy: a bi-center, randomized, double-blind, placebo-controlled trial

Objective

To evaluate the efficacy and safety of 0.75% ropivacaine instillation into inguinal wound in patients who have undergone bilateral microsurgical varicocelectomy.

Patients and methods

Eighty-five men who were screened for bilateral varicoceles from March 2015 to July 2016 were randomized for the treatment. All patients underwent inguinal varicocelectomy by general anesthesia. After ligation of the internal spermatic veins from the spermatic cord, additional delivery of testis through inguinal incision site was done to ligate external spermatic veins and gubernacular veins. Before repairing external oblique aponeurosis, 6 mL of 0.75% ropivacaine and 6 mL of normal saline were instilled under the fascia and around the funiculus (spermatic cord) by a randomized and double-blind method. Visual analog scale (VAS) pain score and Prince Henry Pain Score (PHPS) were used for evaluating operative sites at 1, 2, 4, and 8 hours and 7 days after surgery. Safety and tolerability were evaluated throughout the course of this study by assessing adverse events.

Results

A total of 55 men completed the study. Of these 55 men, 31 received instillation of ropivacaine on the left operative site, while 24 received instillation of ropivacaine on the right operative site. VAS pain scores and PHPS in the ropivacaine-instilled operative site were significantly lower compared to those obtained with placebo at 2, 4, and 8 hours after surgery. In general, instillation of ropivacaine was safe and well tolerated in patients.

Conclusion

Ropivacaine instillation into inguinal surgical site wound significantly reduced postoperative pain after microsurgical varicocelectomy.