Features of the metabolic syndrome in late adolescence are associated with impaired testicular function at 20 years of age

STUDY QUESTION

Are early signs of metabolic disorder in late adolescence associated with features of impaired testicular function many years before the majority seek parenthood?

SUMMARY ANSWER

Adolescents with features of metabolic disorder at 17 years, or insulin resistance (IR) at 20 years of age, show impaired testicular function and altered hormone levels compared to those without metabolic disorder.

WHAT IS KNOWN ALREADY

Controversial evidence suggests a recent decline in sperm production potentially linked to environmental influences, but its cause remains unclear. Concomitant increases in obesity and diabetes suggest that lifestyle factors may contribute to this decline in testicular function. Although obesity has been associated with adverse testicular function in some studies, it remains unclear whether poor testicular function merely reflects, or causes, poor metabolic health. If metabolic disorder were present in adolescence, prior to the onset of obesity, this may suggest that metabolic disorder maybe a precursor of impaired testicular function.

STUDY DESIGN, SIZE, DURATION

The Western Australian Pregnancy Cohort (Raine) Study is a longitudinal study of children born in 1989-1991 who have undergone detailed physical assessments since birth (1454 male infants born). At 17 years of age, 490 boys underwent a hepatic ultrasound examination, serum cytokine assessment (n = 520) and a metabolic assessment (n = 544). A further metabolic assessment was performed at 20 years (n = 608). Testicular assessment was performed at 20 years; 609 had reproductive hormones measured, 404 underwent a testicular ultrasound and 365 produced a semen sample.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Testicular volume was estimated by ultrasonography, and semen analysis was performed according to World Health Organization guidelines. Concentrations of LH, FSH and inhibin B (inhB) in serum were measured by immunoassay and total testosterone by liquid chromatography-mass spectrometry.At 17 years of age, a liver ultrasound examination was performed to determine the presence of non-alcoholic fatty liver disease (NAFLD), and serum analysed for the cytokines interleukin-18 and soluble tumour necrosis factor receptor 1 and 2 (sTNFR1, sTNFR2).At 17 and 20 years of age, fasting blood samples were analysed for serum liver enzymes, insulin, glucose, triglycerides (TG), total cholesterol, high density lipoprotein and low density lipoprotein cholesterol, high sensitivity C-reactive protein and uric acid. The homoeostatic model assessment (HOMA) was calculated and approximated IR was defined by a HOMA >4. Anthropometric data was collected and dual energy X-ray absorptiometry measurement performed for lean and total fat mass. As at this young age the prevalence of metabolic syndrome was expected to be low, a two-step cluster analysis was used using waist circumference, TGs, insulin, and systolic blood pressure to derive a distinct high-risk group with features consistent with the metabolic syndrome and increased cardiometabolic risk.

MAIN RESULTS AND THE ROLE OF CHANCE

Men at age 17 years with increased cardiometabolic risk had lower concentrations of serum testosterone (medians: 4.0 versus 4.9 ng/mL) and inhB (193.2 versus 221.9 pg/mL) (P < 0.001 for both) compared to those within the low risk metabolic cluster. Men with ultrasound evidence of NAFLD (n = 45, 9.8%) had reduced total sperm output (medians: 68.0 versus 126.00 million, P = 0.044), testosterone (4.0 versus 4.7 ng/mL, P = 0.005) and inhB (209.1 versus 218.4 pg/mL, P = 0.032) compared to men without NAFLD.Men with higher concentrations of sTNFR1 at 17 years of age had a lower sperm output and serum concentration of inhB, with an increase in LH and FSH (all P < 0.05 after adjustment for age, BMI, abstinence and a history of cryptorchidism, varicocele, cigarette smoking, alcohol and drug use), compared to those without an elevated sTNFR1. Multivariable regression analysis, adjusting for confounders, demonstrated that men in the high-risk metabolic cluster at 20 years had a lower serum testosterone and inhB (P = 0.003 and P = 0.001, respectively). A HOMA-IR > 4 was associated with a lower serum testosterone (P = <0.001) and inhB (P = 0.010) and an increase in serum FSH (P = 0.015).

LIMITATIONS, REASONS FOR CAUTION

This study is limited by the sample size and multiple comparisons, and causality cannot be proven from an observational study. Due to a 3-year interval between some metabolic assessments and assessment of testicular function, we cannot exclude the introduction of a bias into the study, as some of the participants and their testicular function will not have been fully mature at the 17-year assessment.

WIDER IMPLICATIONS OF THE FINDINGS

Irrespective of a proven causation, our study findings are important in that a significant minority of the men, prior to seeking parenthood, presented co-existent features of metabolic disorder and signs of testicular impairment. Of particular note is that the presence of NAFLD at 17 years of age, although only present in a minority of men, was associated with an almost 50% reduction in sperm output at 20 years of age, and that the presence of IR at 20 years was associated with a 20% reduction in testicular volume.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by Australian NHMRC (Grant Numbers 634457, 35351417 and 403981) and received support from the Raine Medical Research Foundation, The Telethon Kids Institute, University of Western Australia, Women and Infants Research Foundation, Curtin University and Edith Cowan University. D.A.D., J.E.D., N.M., L.A.A., R.-C.H., T.A.M., J.K.O., L.J.B. have nothing to declare. R.J.H. is Medical Director of Fertility Specialists of Western Australia, has equity interests in Western IVF, and has received grant support from MSD, Merck-Serono and Ferring Pharmaceuticals. RMcL has equity interests in the Monash IVF Group. R.J.N. has equity interests in FertilitySA, and has received grant support from Merck Serono and Ferring Pharmaceuticals. D.J.H. has received institutional grant funding (but no personal income) for investigator-initiated testosterone pharmacology studies from Lawley and Besins Healthcare and has provided expert testimony to anti-doping tribunals and for testosterone litigation.This abstract was awarded the Fertility Society of Australia clinical exchange award for the oral presentation at ESHRE, Barcelona, in 2018.

Decrease in semen quality and Leydig cell function in infertile men: a longitudinal study

STUDY QUESTION

Are infertile men with reduced semen quality at risk of a further decrease in testicular function?

SUMMARY ANSWER

Infertile men with severely reduced semen quality risk further deterioration of semen quality 15 years after treatment for infertility, and a lower baseline sperm concentration was associated with a more pronounced increase in LH and decrease in testosterone/LH ratio at follow-up.

WHAT IS KNOWN ALREADY

Male factors account for up to 50% of human infertility. The most common finding is spermatogenic failure (SgF) yet the life course of semen quality and testosterone production in such men has not been described.

STUDY DESIGN, SIZE, DURATION

A follow-up study of men with SgF was performed 15 years after the initial infertility assessment between January 1995 and December 2000.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Hospital records were used to identify potential participants in the study. A total of 137 men with primary male infertility due to SgF and 70 controls with good semen quality from couples with female factor infertility who attended a tertiary referral centre were included: the participation rate was 31% and 26%, respectively. The men provided semen samples and underwent a physical examination. Blood samples were taken to measure levels of reproductive hormones (FSH, LH, testosterone, sex hormone-binding globulin, estradiol and inhibin B). Current results were compared with results from the initial assessments.

MAIN RESULTS AND THE ROLE OF CHANCE

At the time of follow up the SgF men had significantly lower Leydig cell capacity than the control group as well as much lower semen quality. For the SgF men, between baseline sampling and follow up, the median sperm concentration decreased from 1.9 to 0.6 mill/ml and total sperm count from 7.7 to 2.0 million (P = 0.019 and 0.012, respectively), and 10% developed azoospermia. Calculated free testosterone (cFT), but not total testosterone (tT) decreased in the SgF group by ~0.6% (95% CI 0.1-1.2%) per year. In the SgF group, LH increased by 1.6% (CI 0.9-2.3%) annually, and consequently tT/LH and cFT/LH ratios had decreased by 1.3% (CI 0.5-2.1) and 2.1% (CI 1.2-3.0%), respectively. The increase in LH and the decreases in tT/LH and cFT/LH ratios were more pronounced in men with lower baseline sperm concentrations.

LIMITATIONS, REASONS FOR CAUTION

We consider the case group as representative of infertile men not in need of testosterone treatment at baseline investigation, but do not have information on those that chose not to participate in the follow-up study. There were alterations in some hormone analysis methods during the follow-up period that may introduce uncertainty in interpretation of long-term changes in hormone levels despite rigorous quality control. The validity of the control group suffers from a lack of hormone values at baseline. Also, at follow-up, for practical reasons only one semen sample could be obtained, which makes the effect estimate more uncertain and there is a risk of non-differential misclassification.

WIDER IMPLICATIONS OF THE FINDINGS

Without being able to predict individual outcomes, it is prudent to consider sperm cryopreservation or advise not to postpone fertility treatment when men present with infertility due to impaired semen quality. Whether partly compensated Leydig cell insufficiency in men with SgF will eventually develop into overt testosterone deficiency cannot be determined from our study.

STUDY FUNDING/COMPETING INTEREST(s)

Aase and Einar Danielsen (Grant no. 10-001053), Nordic Research Committee (Grant no. 5109), The Kirsten and Freddie Johansen Fund, and Rigshospitalet's Research Fund (grant no. R24-A812). There are no competing interests.

The effect of intraoperative fluid administration on outcomes of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Background

Determine the effect of intraoperative fluids (IOFs) administered during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) on postoperative patient outcomes.

Methods

Retrospective cohort study of patients that underwent CRS/HIPEC from February 2010 to June 2017.

Results

A total of 335 patients formed the cohort study. Patients who received higher IOFs had longer hospital length of stay (LOS) (34 vs. 22.5 days; P<0.001), extended intensive care unit (ICU) admission (5.3 vs. 3.2 days; P<0.001) and a 12% increase in grade 3/4 complications (P<0.001). Greater amounts of blood product transfusion were associated with longer hospital LOS (33.7 vs. 23 days; P<0.001), and ICU admission (5 vs. 3.4 days; P<0.001) and 12% increase in grade 3/4 complications (P<0.001). When corrected for weight and peritoneal cancer index (PCI), increased transfusion of blood products still resulted in longer hospital LOS (31.2 vs. 25.2 days; P=0.04) and longer ICU admission (4.7 vs. 3.6 days; P=0.03). On multivariable analysis, less blood product transfusions demonstrated a decreased LOS in hospital by 4.8 days (P=0.01) and fewer grade 3/4 complications (OR 0.59; 95% CI, 0.35-0.99; P=0.05).

Conclusions

Greater IOF administration is associated with an increase in postoperative morbidity, including hospital LOS, ICU admission and grade 3/4 complications, in patients undergoing CRS/HIPEC.

Associations between major dietary patterns and testicular function in a population-based cohort of young men: results from the Western Australian Pregnancy Cohort (Raine) Study

BACKGROUND

Controversial speculation suggestions that dietary intake may affect semen quality and testicular function, however, there are limited comprehensive studies observing dietary patterns.

OBJECTIVE

To study associations between major dietary patterns and markers of testicular function in adulthood.

MATERIAL AND METHODS

Observational cross-sectional study of two hundred and ninety men with an average age of 20 years, from the Western Australian Pregnancy Cohort (Raine) Study. Usual dietary intake assessed using a semi-quantitative food frequency questionnaire at 20 years of age. Two dietary patterns previously identified using exploratory factor analysis ("Healthy" or "Western") and participants received z-scores for each dietary pattern. Primary endpoints were testicular volume, total sperm per ejaculate, morning serum testosterone concentration. Secondary endpoints were semen sample parameters, inhibin B and sex steroids (DHT: 3α-diol, 3β-diol; LH; FSH; DHEA; estradiol; estrone).

RESULT(S)

Participants were on average 20.0 ± 0.4 years old, had a median of 2 days sexual abstinence and a body mass index of 24.1 ± 3.9 kg/m² , 13% were smokers, 52% were 'moderate' alcohol drinkers, 23% frequently used recreational drugs and 68% reported 'high' physical activity levels. Sperm concentration and DHT 3α-diol were negatively associated with a greater z-score for the "Western" dietary pattern (p = 0.007 and; p = 0.044, respectively), and serum estradiol concentration was positively associated with a "Western" dietary pattern (p = 0.007) after adjustment for BMI, varicocele, cryptorchidism and sexual abstinence.

DISCUSSION

Despite associations between greater intake of the "Western" dietary pattern and a decreased male reproductive health markers, our lack of consistent associations of either a "Healthy" or a "Western" dietary pattern, limit clinical or biological significance in isolation.

CONCLUSIONS

A potential negative association of a "Western" dietary pattern with male reproductive health was detected and should be studied further in population-based studies.

Osteitic bone: a surrogate marker of eosinophilia in chronic rhinosinusitis

BACKGROUND

Causes of osteitis in chronic rhinosinusitis (CRS) other than previous surgery are poorly defined. Patients with eosinophilic CRS (ECRS) have more severe disease and poorer outcomes despite repeated surgery. Associations between osteitis and markers of ECRS are not well described.

METHODS

A cross-sectional study of CRS patients undergoing sinus surgery was conducted. Osteitis was scored radiologically using previously published measures. Associations between osteitis and histopathology, symptoms, endoscopy, CT mucosal score and seromarkers were analyzed.

RESULTS

Eighty-eight patients were assessed of whom forty-five had osteitis. Patients undergoing revision surgery recorded higher osteitis scores. Patients with mucosal eosinophilia had higher osteitis score than those without. Patients with osteitis had higher serum eosinophil. Similar relationships were also found in primary surgery. Osteitis was associated with endoscopic and radiologic, but not symptomatic disease severity.

CONCLUSIONS

Osteitis is associated with tissue and serum eosinophilia in both patients with and without prior surgery. Patients with these features may benefit from post-operative corticosteroid therapy to prevent osteitis.

A cadaveric study of the endoscopic endonasal transclival approach to the basilar artery

The anterior transclival route to basilar artery aneurysms is not widely performed. The objective of this study was to carry out a feasibility assessment of the transclival approach to basilar aneurysms with advanced endonasal techniques on 11 cadaver heads. Clival dura was exposed from the sella to the foramen magnum between the paraclival segments of the internal carotid arteries (ICA) laterally. An inverted dural "U" flap was reflected inferiorly to expose the basilar artery. The maximal dimensions from operative measurements were recorded. Surgical manoeuvrability of multiple instruments and the proficiency to place proximal and distal vascular clips were evaluated. The mean operative depth (± standard deviation), measured from the anterior choanae to the basilar artery, was 110±6mm. The lateral corridors were limited distally by the medial pterygoids (mean width 21±2mm) and paraclival ICA (mean width 20±2mm). The mean transclival craniectomy dimensions were 19±2mm (width) and 23±4mm (height). Exposure of the basilar-anterior inferior cerebellar artery junction, superior cerebellar artery, and the basilar caput were possible in 100%, 91%, and 64% of instances, respectively. Placements of proximal and distal aneurysm clips were achieved in all instances. Based on our findings, the transclival endoscopic endonasal surgery approach provides excellent visualisation of the basilar artery. Clip application and manoeuvrability of instruments was considered adequate for basilar aneurysm surgery. Surgical skills and instrumentation to control significant haemorrhage can potentially limit the clinical applicability of this technique.

Clinical severity and epithelial endotypes in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous disease defined by epithelial inflammation. The link between measures of traditional disease severity and markers of epithelial inflammation is poorly understood as prior research has focused on presence of polyps or degree of eosinophilia. The expression of 3 epithelial derived cytokines implicated in initiation of T-helper 2 (Th2) inflammation and an eosinophil chemoattractant were compared with clinical measures used in CRS.

METHODS

Sinus mucosal samples from CRS patients undergoing sinus surgery were analyzed for interleukin-25 (IL-25), IL-33, thymic stromal lymphopoietin (TSLP), and eotaxin-3 messenger RNA (mRNA) expression by quantitative polymerase chain reaction (PCR). Tumor patients undergoing surgery transnasally with normal sinus mucosa were controls. Gene expression was compared with symptom, radiology, and endoscopy scores, serological markers, presence of reactive airways disease (RAD), and atopy.

RESULTS

Thirty-seven patients (38% female, mean age 48 ± 15 years), 12 CRS with nasal polyps (CRSwNP), 18 CRS without nasal polyps (CRSsNP), and 7 controls were recruited. CRSwNP phenotype predicted elevated IL-25, IL-33, and eotaxin-3 levels. Increased eotaxin-3 correlated with poorer computed tomography (CT) (p = 0.004) and endoscopic scores (p = 0.049). Increased IL-25 correlated with poorer CT scores (p = 0.012) and raised serum eosinophils (p = 0.006). No associations with RAD, atopy, and symptom measures were found. No associations for IL-33 and TSLP were found.

CONCLUSION

Inflammatory mediators of the epithelium in CRS has some correlation with traditional measures of disease burden. Certain epithelial profiles may predict highly dysfunctional epithelial barriers and prospective evaluation of the clinical outcomes from interventions is required. Future endotyping of the epithelium in CRS may be able to provide prognostic information.

Phenotypic variation within European carriers of the Y-chromosomal gr/gr deletion is independent of Y-chromosomal background

BACKGROUND

Previous studies have compared sperm phenotypes between men with partial deletions within the AZFc region of the Y chromosome and non-carriers, with variable results. In this study, a separate question was investigated, the basis of the variation in sperm phenotype within gr/gr deletion carriers, which ranges from normozoospermia to azoospermia. Differences in the genes removed by independent gr/gr deletions, the occurrence of subsequent duplications or the presence of linked modifying variants elsewhere on the chromosome have been suggested as possible causal factors. This study set out to test these possibilities in a large sample of gr/gr deletion carriers with known phenotypes spanning the complete range.

RESULTS

In total, 169 men diagnosed with gr/gr deletions from six centres in Europe and one in Australia were studied. The DAZ and CDY1 copies retained, the presence or absence of duplications and the Y-chromosomal haplogroup were characterised. Although the study had good power to detect factors that accounted for >or=5.5% of the variation in sperm concentration, no such factor was found. A negative effect of gr/gr deletions followed by b2/b4 duplication was found within the normospermic group, which remains to be further explored in a larger study population. Finally, significant geographical differences in the frequency of different subtypes of gr/gr deletions were found, which may have relevance for the interpretation of case control studies dealing with admixed populations.

CONCLUSIONS

The phenotypic variation of gr/gr carriers in men of European origin is largely independent of the Y-chromosomal background.

Activin receptor subunits in normal and dysfunctional adult human testis

BACKGROUND

The cellular sites of activin action and its regulation in the normal and dysfunctional adult human testis are unknown.

METHODS

Activin type I (ALK2 and ALK4) and type II (ActRIIA and ActRIIB) receptors were detected using immunohistochemistry on Bouins fixed sections of normal, carcinoma in situ (CIS), seminoma, non-seminoma and gonadotropin-deprived human testis. ActRIIA mRNA was localized by in situ hybridization.

RESULTS

ALK2, ALK4 and ActRIIB proteins were observed in Sertoli cells, spermatogonia and some spermatocytes within normal and gonadotropin-suppressed adult human testis; all three receptor subunits were also detected in CIS, seminoma and non-seminoma cells. ActRIIA immunoreactivity was faint to absent in the normal testis and in CIS and non-seminoma cells, whereas some seminoma cells displayed a strong signal. Also in contrast to the normal testis, a majority of spermatogonia and Sertoli cells in gonadotropin-deprived samples exhibited a strong ActRIIA immunohistochemical and in situ hybridization signal.

CONCLUSIONS

Spermatogonia and Sertoli cells appear as the primary targets of activin action in the adult human testis. Changes in testicular function associated with altered hormone levels may enhance ActRIIA mRNA and protein synthesis, thus modifying signalling by activin or other TGFbeta ligands within specific cells of the seminiferous epithelium.

Genetic follow-up of male offspring born by ICSI, using a multiplex fluorescent PCR-based test for Yq deletions

De-novo deletions involving AZFa, b, c and d are one of the most common chromosomal aberrations in man resulting in defective spermatogenesis and male infertility. Currently, Yq deletion screening involves either single or multiplex PCR using Y-specific sequence tagged site markers and the subsequent analysis of the amplification products on ethidium bromide-stained agarose gels. To improve the practicality of routine and high throughput Yq testing, we have developed a more sensitive multiplex fluorescent (FL)-PCR screening system using genomic DNA extracted from cheek buccal cells as a readily available PCR template. For genetic follow-up studies of ICSI-conceived children, we also developed a DNA fingerprinting system based on the co-amplification of four highly polymorphic markers to validate family samples and detect any potential extraneous DNA contamination that could cause a misdiagnosis. Multiplex FL-PCR analysis of buccal cell DNA from two infertile men who conceived three sons by ICSI demonstrated that their Yq deletions were vertically transmitted. Fine mapping with additional Yq markers revealed identical deletion endpoints involving the loss of AZFdc sequences. This firstly indicates that the extent of the Yq deletion was unchanged on ICSI transmission and secondly supports the view that AZFdc deletions may arise by a common de-novo event. Analysis of paternal, maternal and sibling DNA fingerprints showed the co-inheritance of parental alleles by each male child and confirmed the expected relationship between each family member. The application of these new FL-PCR based screening tests in genetic follow-up studies will assist in confirming transmission of specific genetic defects to male offspring conceived by ICSI and provide a basis for genetic counselling and potential treatment options as these boys approach sexual maturity.

Reproductive status in long-term bone marrow transplant survivors receiving busulfan-cyclophosphamide (120 mg/kg)

There are few published data on the recovery of fertility after 'little' Bu-Cy (busulfan 16 mg/kg, cyclophosphamide 120 mg/kg) conditioning for BMT. To address this, we identified 19 females aged less than 40 years at transplant and 47 males from a single centre who were alive a minimum of 2 years after BMT with little Bu-Cy as conditioning and who were evaluable for testing. FSH, LH, testosterone and inhibin B levels were measured in males. Twenty-six also had semen analysis, a median of 5 years post transplant; 21 had detectable sperm, with 11 having counts >20 x 10(6)/ml. There was an association between prolonged chronic graft-versus-host disease and low sperm counts. FSH and inhibin B levels correlated with sperm counts but not to the extent that they could reliably predict counts in individual patients. An additional six of seven males attempting to father children did so, a median of 3.2 years post transplant. Low testosterone levels were noted in 12% of males, most of whom had symptoms consistent with androgen deficiency. FSH, LH and oestradiol levels in the absence of hormone replacement therapy were measured in females; all remained amenorrheic with endocrine evidence of ovarian failure. These results have implications for fertility counselling and hormone replacement therapy both pre- and post BMT.

Y chromosome analysis of infertile men and their sons conceived through intracytoplasmic sperm injection: vertical transmission of deletions and rarity of de novo deletions

OBJECTIVE

To determine the prevalence and type of Yq microdeletions in 86 consecutive men that fathered 99 sons by intracytoplasmic sperm injection (ICSI) and to determine the incidence of vertical transmission and de novo deletions in these boys.

DESIGN

Prospective clinical observational study.

SETTING

Genetics laboratory associated with a university IVF unit.

PATIENT(S)

Eighty-six consecutive infertile men presenting to an IVF clinic and their 99 ICSI-conceived sons. Fifty of the 86 men (58%) had idiopathic seminiferous tubule failure (STF); the remainder had a variety of other clinical indications for ICSI.

INTERVENTION(S)

Collection of peripheral and cord blood samples.

MAIN OUTCOME MEASURE(S)

The Yq genetic status of fathers who underwent ICSI and of their sons by the presence or absence of 22 Y-specific markers covering the four azoospermia factor (AZF) subregions.

RESULT(S)

Yq deletions of the AZFd/c region were detected in two (6.9%) of 29 azoo- or severely oligospermic men with STF. Identical deletions were found in their respective sons. No de novo deletions were detected in the remaining 97 sons conceived by men without deletions.

CONCLUSION(S)

The detection of Yq deletions only in men with severe STF is consistent with previous studies, with the AZFd/c region being most commonly affected. This study demonstrates the vertical transmission of these Yq deletions through the use of ICSI and supports the notion that, in most cases, Yq deletions will be inherited by male offspring. The absence of de novo Yq deletions in the male offspring indicates that these events are rare following ICSI in men with both STF and other common male factor indications.

Psychosis after resection of ganglioglioma or DNET: evidence for an association

PURPOSE

David Taylor and Murray Falconer suggested that some patients may develop a psychotic illness after resection of a ganglioglioma that led to intractable seizures. They implied that the mechanism of this association remained unclear. This concept is currently not universally accepted (M. Trimble, personal communication).

METHODS

We studied six children or young adults from four centers who developed psychosis after resection of a ganglioglioma or dysembryoplastic neuroepithelioma (DNET).

RESULTS

All patients were operated on because of intractable epilepsy. The lesions involved mainly the temporal lobe. Patients had good outcomes for seizure control. In none of the six was potentially psychogenic medication used nor were the psychotic symptoms postictal in nature. The psychosis was schizophreniform with paranoid features and prominent depressive symptoms. Although some behavioral abnormalities were described preoperatively, none had been psychotic before operation. This type of psychotic reaction was not encountered in the four centers in a comparable period after resection of other types of lesions. This complication is rare; it occurred in only one of 39 patients who had such a lesion resected.

CONCLUSIONS

Psychotic illness may rarely occur after resection of a ganglioglioma or DNET for treatment of intractable epilepsy. This does not seem to occur after removal of other types of lesions. Because the patients had good outcomes for seizures, the mechanism may be related to "forced normalization." The original observations of Taylor and Falconer are confirmed by this study; the reasons for the selective occurrence, however, remain speculative.

Azoospermia associated with a mutation in the ligand-binding domain of an androgen receptor displaying normal ligand binding, but defective trans-activation

Although male infertility affects a significant proportion of couples trying to conceive, the cause of defective spermatogenesis is not known in a large number of cases. Ligand binding studies indicate that a number of these subjects may have defects of the androgen receptor (AR). Genetic screening in subjects with defective spermatogenesis and in 110 fertile controls identified an azoospermic (no sperm in any ejaculates) patient with an amino acid substitution (Gln-->Glu) in residue 798 of the AR gene. This germline mutation was pathogenic because it was not observed in fertile controls, was associated with features of minimal androgen insensitivity in our patient, has been related to more severe grades of androgen insensitivity, and caused a subtle, but significant, decrease in receptor trans-activation function in vitro that is consistent with the phenotype. Despite being located in the middle of the ligand-binding domain of the receptor, the Q798E mutation did not cause any ligand binding defect, indicating that this highly conserved residue has a trans-activation function but does not directly form part of the ligand binding pocket of the receptor. The trans-activation defect of the mutant receptor can be rectified in vitro with the androgenic drug, fluoxymesterone, but not with mesterolone or nortestosterone. Further studies are required to determine the therapeutic relevance of this finding.

Outcome assessment in epilepsy: comparative responsiveness of quality of life and psychosocial instruments

PURPOSE

Few data exist on the ability of instruments to detect within-patient change over time in epilepsy, a property referred to as responsiveness. Our aim was to compare the responsiveness of three instruments [i.e., Epilepsy Surgery Inventory-55 (ESI-55) and Washington Psychosocial Inventory (WPSI), both epilepsy specific, and Symptom Checklist-90-Revised (SCL-90-R), non-epilepsy specific].

METHODS

Instruments were administered at baseline and at 1 year in a prospective cohort of surgically (43) and medically (14) treated patients with temporal lobe epilepsy. Coefficient of Responsiveness and relative efficiency were computed for each scale and for the dimensions of mental health, physical health, and role function.

RESULTS

The ESI-55 contained the most responsive scales, whereas SCL-90-R contained the largest number of scales with moderate responsiveness. The largest number of scales with low responsiveness belonged to the WPSI. Sensitivity to between-treatment differences in change was highest for ESI-55 and SCL-90-R. The most efficient scales in detecting differences between treatment groups in the mental, physical, and role-function dimensions were ESI-55 emotional well-being, ESI-55 health perceptions, and SCL-90-R hostility, respectively.

CONCLUSIONS

Our results support the responsiveness of ESI-55 scales and suggest that SCL-90-R is a responsive tool for the assessment of psychologic function and distress in epilepsy. Comparatively, WPSI is relatively unresponsive to small or medium-size changes.

The management of male subfertility by in vitro fertilisation techniques

Although IVF was developed for the treatment of tubal infertility, it is clear that it has a significant application in treatment of couples where the problem is one of male subfertility. This is particularly relevant because, despite the developments in reproductive medicine, in most males there is no identifiable cause for the poor semen quality. Therefore, for these men there is no efficacious method of treatment. Varicocele ligation and the use of agents such as clomiphene citrate, mesterolone empirical antibiotic therapy, and anabolic steroids have not been show to be beneficial when subject to controlled trials. The concept of improving the chance of fertilisation by taking the oocytes to the sperm in vitro is therefore the first feasible therapeutic option available to these subfertile couples. However, these possibilities should not obviate the need for a thorough assessment of the subfertile male and continuing research into the basis of male infertility. During the past decade new methods of sperm preparation, modified methods of insemination, and the use of microinjection have been developed. IVF is now a realistic option for couples if the male is subfertile. It has been suggested by some critics of these techniques that the brunt of the discomfort and risk has to be borne by the women where the problem appears to be solely with the male partner. Nevertheless, as having children is a 'couple' decision, prospective couples need to consider whether such procedures are acceptable to them.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary Sjögren's syndrome and gamma heavy chain disease

We describe a patient who has primary Sjögren's syndrome associated with asymptomatic gamma heavy chain disease and a tubulointerstitial nephritis. Sjögren's syndrome is known to be complicated by lymphoproliferative disorders and tubulointerstitial nephritis but gamma heavy chain disease is rare (approximately 100 cases described). There is one previously reported case of gamma heavy chain disease associated with primary Sjögren's syndrome and 2 cases associated with secondary Sjögren's syndrome. Our patient and the 3 other patients described in the literature did not have evidence of an underlying lymphoproliferative disorder.

Plasma intestinal alkaline phosphatase isoenzymes in neonates with bowel necrosis

AIM

To determine if the intestinal isoenzymes of alkaline phosphatase (ALP) are biochemical markers of bowel necrosis in neonates.

METHODS

Plasma ALP isoenzymes were measured in 22 babies with bowel necrosis, histologically confirmed, and in 22 matched controls. The isoenzymes were also measured in 16 infants with signs of necrotising enterocolitis, who recovered without histological confirmation of bowel necrosis. The isoenzymes were separated by polyacrylamide gel electrophoresis. Auxiliary tests for identification included neuraminidase digestion and treatment with monoclonal and polyclonal antiplacental antibodies.

RESULTS

Intestinal ALP was detected in 16 infants with bowel necrosis--13 had fetal intestinal ALP (FI-ALP) and three had adult intestinal ALP (AI-ALP). FI-ALP was detected in nine of the controls. In the babies with bowel necrosis intestinal ALP was found over all gestations, but in the controls only in those less than 34 weeks. The percentages of total ALP activity due to intestinal ALP were significantly higher in those with bowel necrosis compared with matched controls (p = 0.028). In babies of all gestations diagnostic sensitivity for the presence of intestinal ALP as a marker of bowel necrosis was 73% and diagnostic specificity 59%. In babies greater than 34 weeks' gestation, diagnostic sensitivity fell to 60% but the test became completely specific. In two babies FI-ALP increased from zero/trace to high activity coincident with the episode of bowel necrosis. In 16 babies with signs of necrotising enterocolitis but unconfirmed bowel necrosis FI-ALP was detected in four.

CONCLUSION

Intestinal ALP seems to be released into the circulation in some babies with bowel necrosis, but its detection does not have the diagnostic sensitivity and specificity to be a reliable biochemical marker of the condition.

Is IgD Myeloma a Separate Clinical Entity? Report of Six Cases Investigated by Isoelectric Focusing

Six IgD myeloma patients whose monoclonal components were identified by isoelectric focusing are presented. They represented 4% of all patients with myeloma seen at our institute between 1982 and 1986. The patients did not display many of the features described as typical for IgD myeloma: in particular younger age group, decreased survival and increased incidence of lymphadenopathy, hepatosplenomegaly, extraosseous disease, anemia, renal failure and hypercalcemia. However males predominated, the concentrations of circulating monoclonal IgD were low and concentrations of serum and urinary monoclonal free light chains were high, findings previously reported in IgD myeloma. The concentrations of circulating IgD were at the lower end of ranges reported previously. The hypothesis that our patients represent the malignant equivalent of the normal "low secretory phenotype", possibly associated with improved survival, is discussed. The belief that IgD myeloma is a separate clinical entity is questioned. The sensitive, high-resolution technique of isoelectric focusing is recommended as the investigation of choice for the detection of monoclonal gammopathies in body fluids.

Monoclonal immunoglobulins: affinity blotting for low concentrations in serum

I describe a simple, economical technique for identifying low concentrations of monoclonal immunoglobulins in the presence of excessive amounts of immunoglobulins of other classes. The technique involves binding of specific antibody to nitrocellulose, separating proteins by isoelectric focusing or zone electrophoresis in agarose gels, using capillary transfer to bind proteins to the nitrocellulose via their antibody affinity, and then detecting transferred proteins with enzyme-labeled antibody. A monoclonal immunoglobulin can be completely characterized in 2 h. No expensive equipment is required. Affinity blotting is about 10-fold as sensitive as native blotting, 100-fold as sensitive as silver staining.

Monoclonal immunoglobulins: affinity blotting for low concentrations in serum

I describe a simple, economical technique for identifying low concentrations of monoclonal immunoglobulins in the presence of excessive amounts of immunoglobulins of other classes. The technique involves binding of specific antibody to nitrocellulose, separating proteins by isoelectric focusing or zone electrophoresis in agarose gels, using capillary transfer to bind proteins to the nitrocellulose via their antibody affinity, and then detecting transferred proteins with enzyme-labeled antibody. A monoclonal immunoglobulin can be completely characterized in 2 h. No expensive equipment is required. Affinity blotting is about 10-fold as sensitive as native blotting, 100-fold as sensitive as silver staining.

Demonstration of monoclonal IgE by isoelectric focusing: first reported case of IgE myeloma in Australia

A 56-year-old man who presented with back pain was diagnosed with multiple myeloma. Serum protein analysis by isoelectric focusing identified a monoclonal IgE lambda of unique spectrotype compared with other monoclonal immunoglobulins. The similarity of the spectrotype of this monoclonal IgE to that of two purified monoclonal IgEs suggests that these proteins have a characteristic spectrotype, sufficiently different from those of other immunoglobulin classes to allow its recognition.

Demonstration of monoclonal IgE by isoelectric focusing: first reported case of IgE myeloma in Australia

A 56-year-old man who presented with back pain was diagnosed with multiple myeloma. Serum protein analysis by isoelectric focusing identified a monoclonal IgE lambda of unique spectrotype compared with other monoclonal immunoglobulins. The similarity of the spectrotype of this monoclonal IgE to that of two purified monoclonal IgEs suggests that these proteins have a characteristic spectrotype, sufficiently different from those of other immunoglobulin classes to allow its recognition.

The medical and psychological investigation of psychogenic polydipsia: a case study

The case of a 17 year-old female with psychogenic polydipsia is reported; 13 out of 18 members of her maternal family were known to have had polydipsia and polyuria, but only two had undergone endocrine investigations--one had diabetes insipidus and one also had psychogenic polydipsia. There are probable contributions of non-genetic family factors including imitation and identification to the development of this patient's condition. Detailed family and developmental histories may be of particular assistance in the understanding of the psychogenesis of the disorder in some patients.

Chronic lymphatic leukemia developing in a patient with multiple myeloma: immunologic demonstration of a clonally distinct second malignancy

A patient with multiple myeloma who subsequently developed chronic lymphocytic leukemia is reported. Initial studies demonstrated clinical and hematological features of multiple myeloma with an IgM lambda paraprotein. Skeletal disease was a significant presenting feature, although relapse occurred in extraosseous sites, particularly the pleura. He developed chronic lymphatic leukemia 31 months later and immunological studies showed the malignant lymphocytes to have kappa (Kappa) light chain surface immunoglobulin, demonstrating separate clonal origin of this patient's two B-cell malignancies.

Monoclonal antibodies to murine cell surface antigens. I. Lyt-1.1

The production and properties of a monoclonal anti-Lyt-1.1 antibody are described. The monoclonal antibody is of the IgG2a subclass, is cytotoxic, and reacts with Staphylococcal protein A. The tissue culture supernatant has the same activity (titer on thymus > 1/1000) as an anti-Lyt-1.1 produced by a standard immunization procedure, and after in vivo passage of the hybridoma cell line, the serum titer was > 1:10(6). The monoclonal antibody has the same strain and tissue distribution as the conventional antibody, including reactions on Lyt-1 congenic strains, and it precipitates a cell surface molecule of m.w. approximately 67,000. In nonprimed mice, there were similar numbers of Thy-1+ and Lyt-1+ cells in spleen, lymph node, and thymus. By using the monoclonal reagent, T-helper and T-killer cells in an allogenic system were shown to be Lyt-1.1.

Monoclonal antibodies to murine cell surface antigens. I. Lyt-1.1

The production and properties of a monoclonal anti-Lyt-1.1 antibody are described. The monoclonal antibody is of the IgG2a subclass, is cytotoxic, and reacts with Staphylococcal protein A. The tissue culture supernatant has the same activity (titer on thymus &gt; 1/1000) as an anti-Lyt-1.1 produced by a standard immunization procedure, and after in vivo passage of the hybridoma cell line, the serum titer was &gt; 1:10(6). The monoclonal antibody has the same strain and tissue distribution as the conventional antibody, including reactions on Lyt-1 congenic strains, and it precipitates a cell surface molecule of m.w. approximately 67,000. In nonprimed mice, there were similar numbers of Thy-1+ and Lyt-1+ cells in spleen, lymph node, and thymus. By using the monoclonal reagent, T-helper and T-killer cells in an allogenic system were shown to be Lyt-1.1.