The Inferto-Sex Syndrome (ISS): sexual dysfunction in fertility care setting and assisted reproduction

PURPOSE

Infertility represents a peculiar social burden affecting more than 15% of couples, provoking it a real threat to the general quality of life and to the sexual health. The medicalization (diagnosis, therapy and follow up) of the lack of fertility is frequently a challenge in term of personal and couple's involvement. In particular, while the Assisted Reproductive Technology (ART) has allowed many infertile couples to achieve pregnancy, the therapeutic process faced by the couple bears a strong psychological stress that can affect the couple's quality of life, relationship and sexuality. Despite infertility affects both female and male sexual health, only recently the interest in the effects of ART on the couple's sexuality has grown, especially for women.

METHODS

A literature research on the sexual dysfunction in fertility care and particularly in ART setting was performed.

RESULTS

Literature largely found that intimacy and sexuality appear specifically impaired by intrusiveness of treatments and medical prescriptions. Moreover, there is a close relationship between emotional, psychological and sexual aspects, which can be integrated in the new concept of Inferto-Sex Syndrome (ISS) that can impair the ART treatment outcomes. Evidence demonstrates that the assessment of sexual function is necessary in couples undergoing diagnosis of infertility and ART.

CONCLUSION

A close relationship between infertility and sexuality, both in the female and male partners, was detected. ART treatments may heavily impact on the couple's psychosexual health. A couple-centred program for the integrated management of psychological and sexual dysfunction should be considered in the context of ART programs.

Application of targeted genome sequencing to brain metastasis from non-small cell lung carcinoma: Case report

Non-small cell lung cancer (NSCLC) is frequently associated with central nervous system metastases resulting in poor outcomes. As newer targeted therapies become available determining which patients can benefit from these therapies has remained challenging, and current molecular testing options rely on a panel of only a handful of known oncogenic drivers. Here, we demonstrate a targeted approach at uncovering clinically relevant variants in cancer-associated genes using genomic sequencing. Our patient underwent targeted sequencing of 212 cancer-associated genes, revealing mutations in six; two of which were in EGFR, an important target for therapy in NSCLC. A multidisciplinary approach involving surgical resection, radiation, and targeted therapy based on the genomic profile and tumor pathology ultimately lead to positive therapeutic response and stable disease. Our report provides a proof of principle for incorporating higher throughput genomic sequencing techniques directly into patient care. We also report an atypical response of an EGFR mutation positive metastatic tumor to immune checkpoint therapy, despite recent reports suggesting that these patients do not benefit from immune checkpoint inhibitors. A brief review of current literature is discussed here to explore links between EGFR mutations and PD-L1 expression, as well as response to targeted therapies.

Immunoprotection of Pancreatic Islet Grafts within Artificial Microcapsules

To circumvent pancreatic islet graft-directed immune destruction we enveloped porcine islets within highly biocompatible and selectively permeable algin/polyaminoacid microcapsules. These special microspheres were deposited between the inner (permeable) and the outer (impermeable) layers of an artificial, coaxial vascular prosthesis, directly anastomized to blood vessels. Five dogs with spontaneous, insulin-dependent diabetes received microencapsulated porcine islets in arterio-vein iliac prosthesis by-passes. One showed complete and the remainder partial, sustained reversal of hyperglycemia. Microencapsulation may be a potential solution to immunological problems related to islet transplantation.

Effects of Simulated Microgravity on the Morphology and Function of Neonatal Porcine Cell Clusters Cultured with and without Sertoli Cells

Human islet allografts are well known to induce full and sustained remission of hyperglycemia, with complete normalization of key metabolic parameters. Nevertheless, acquiring human islets, even from cadaveric human donor pancreases, remains a significant impediment to successful transplantation therapy for diabetes. To overcome this difficulty, neonatal porcine cell clusters (NPCCs) have been considered for human islet substitutes because they are easily obtained by collagenase digestion of the neonatal piglet pancreas. Currently, the major hurdle in using NPCCs for xenograft is the delay (time lag) in achieving the posttransplant normalization of blood glucose levels in animal diabetic recipients. The present work is the first attempt to evaluate whether incubation of NPCCs in simulated microgravity, in the presence or absence of Sertoli cells (SC), may reduce the maturation time lag of β-cells by differentiation acceleration in vitro, thereby expediting production, viability, and acquisition of functional competence of pretransplantation β-cell-enriched islets. Following a 3-day incubation period, NPCCs maintained in conventional culture, NPCCs incubated in simulated microgravity in the HARV biochamber, and NPCCs plus co-incubated SC in simulated microgravity were examined for viability, morphology, and insulin secretion. Results show that NPCCs grown alone in the HARV biochamber are superior in quality, both in terms of viability and functional competence, when compared to other culture pretreatment protocols. This finding strongly suggests that NPCC pretreatment in simulated microgravity may enhance the transplantation success of NPCCs in the diabetic recipient.

Islet transplantation versus stem cells for the cell therapy of type 1 diabetes mellitus

Pancreatic islet cell transplantation has represented the mainstay of cell therapy for the potential, final cure of type 1 diabetes mellitus (T1D), along the past two decades. Unfortunately, the restricted availability of cadaveric human donor pancreases coupled with heavy side effects of the recipient's general immunosuppression, have severely crippled progress of this approach into clinical trials. Only a few excellence centers, worldwide, have thus far accrued still quite marginal clinical success. In an attempt to overcome the limits of islet transplantation new technologies for use of several stem cell lineages are being under investigation, with initial experimental evidence of success. Essentially, the actual lines of research involve attempts to either activate native endogenous stem cells that replace diseased/dead cells, by a cell regeneration process, or condition other stem cells to acquire the functional properties of the targeted cells to be substituted (i.e., beta-cell-like elements associated with insulin secretory competence). A wide array of stem cells may fulfill this task, from embryonic (whose use still faces strong ethical barriers), to adult, to induced pluripotent stem cells. Mesenchymal adult stem cells, retrievable from many different sites, including adipose tissue, bone marrow and post-partum umbilical cord Wharton Jelly, seem to couple plastic to immunoregulatory properties that might greatly help progress for the disease cure.

Xenograft of microencapsulated Sertoli cells for the cell therapy of type 2 diabetes mellitus in spontaneously diabetic nonhuman primates: preliminary data

Insulin resistance in type 2 diabetes mellitus (T2DM) may be due to a chronic inflammation of the visceral adipose tissue (VAT) leading to local and systemic increases in proinflammatory cytokines. Microencapsulated porcine Sertoli cells (MC-pSC), by provision of immunomodulatory and trophic factors, have been successfully used to reduce such inflammation in rodent animal models of type 1 diabetes with no complications or deleterious side effects. Herein, we have begun to investigate this novel and safe therapeutic approach in the spontaneously obese nonhuman primate with spontaneous, insulin-dependent T2DM. After MC-pSC intraperitoneal injection we have evaluated, throughout a 6-month follow-up period, daily ad libitum fed glucose levels, daily exogenous insulin supplementation, biweekly body weight measurements, periodic fasting blood glucose concentrations, glycated hemoglobin (HbA1c) levels, glucose tolerance tests (GTT), and fluorescence-activated cell sorting cytometry (FACS) assessment of peripheral blood mononuclear cells. Very preliminarily, we have observed a slight reduction in fasting (FPG) and mean nonfasting (NF) plasma glucose levels. We found minimal changes, only in 1 animal, in daily exogenous insulin requirements and HbA1c levels. Flow cytometric analysis was associated with decrease in CD8(+) cells only in 1 recipient with a reduction in mean regulatory T Cells (Treg), whereas interestingly, decrease of B lymphocytes was observed in both animals. These results may suggest that this novel MC-SC-based transplantation protocol might possibly impact the metabolic status of T2DM in higher mammals that are close to humans.

Toxicity of cadmium on Sertoli cell functional competence: an in vitro study

Cadmium (Cd), an ubiquitous environmental metal, mainly used for industrial purposes, may be toxic at level of the reproductive system. Testis tubular-based Sertoli cells (SC), play a major role in constituting the blood-testis barrier and provide a unique microenvironment for the genesis and differentiation of germ cells. Hence SC strictly control sperm qualitative and quantitative parameters. We aimed to assess whether exposure to Cd would adversely affect superior mammal SC viability and function. We isolated and purified SC from pre-pubertal pig testes according to our method and incubated the retrieved cells with three different Cadmium chloride concentrations (5-10-15 microM). Parameters of SC function such as inhibin B and anti-Mullerian hormone (AMH) were depressed by Cd exposure, contrary to what observed in untreated controls. No impairment of the FSH receptor integrity on the SC, as assessed by 17-beta-estradiol production, upon stimulation with FSH, was observed in either 5 microM Cd-treated or untreated controls. Differences, on the contrary, were observed for higher Cd concentrations (10 and 15 mM), in terms of FSH receptor integrity, that was altered, as compared to untreated controls, in terms of lower production of 17-beta-estradiol. In addition, the apoptotic test showed a significant increase of early (ANNEXIN V-/Propidium Iodide+) (AV-/PI+) and late apoptotic cells (AV+/ PI+) in all Cd -treated SC conditions as compared to controls. In conclusion, the Cd -related toxicity on SC, clearly demonstrated by our study, even at low concentrations, is expected to damage spermatogenesis that directly is dependent upon retention of SC viability and function.

Rapid and easy assessment of insulin resistance contributes to early detection of polycystic ovary syndrome

AIMS

Polycystic ovary syndrome (PCOS) is frequently observed in women of reproductive age, and is associated with disturbances in both reproductive and metabolic function. Insulin resistance (IR) is key to the pathophysiology of PCOS, and early detection may improve outcomes in this patient group. Rapid and straightforward laboratory tests may contribute towards early detection.

METHODS

A retrospective chart review of 185 women presenting for the first time to a gynecology clinic was carried out. Of this group, 77 met the inclusion criteria. The sample was divided according to insulin sensitivity (IS) given by the Matsuda Index, and the two groups were compared using correlation analysis. Furthermore, the sensitivity and specificity of the Matsuda, homeostasis model assessment of IR (HOMA-IR) and quantitative insulin sensitivity check index (QUICKI) indexes were compared.

RESULTS

Although bodu mass index (BMI) was higher in the insulin resistant group than the insulin sensitive group, the mean age of the IR group was actually lower. HOMA-IR and QUICKI correlated well with the Matsuda index in both groups. The HOMA-IR test showed the highest sensitivity and specificity in the detection of IR when compared to the Matsuda Index, and no added benefit was derived from using a combination of both QUICKI and HOMA- 1R.

CONCLUSIONS

In a group of 77 women diagnosed with PCOS, 49 (63.6%) had IR according to the Matsuda index. The HOMA-IR index, which is based on fasting serum insulin and glucose, correlated closely with the Matsuda index, indicating it may be a reliable substitute in the detection and subsequent early intervention required to improve outcomes in PCOS.

Production and Characterization of Alginate Microcapsules Produced by a Vibrational Encapsulation Device

The optimization, through a Design of Experiments (DoE) approach, of a microencapsulation procedure for isolated neonatal porcine islets (NPI) is described. The applied method is based on the generation of monodisperse droplets by a vibrational nozzle. An alginate/polyornithine encapsulation procedure, developed and validated in our laboratory for almost a decade, was used to embody pancreatic islets. We analyzed different experimental parameters including frequency of vibration, amplitude of vibration, polymer pumping rate, and distance between the nozzle and the gelling bath. We produced calcium—alginate gel microbeads with excellent morphological characteristics as well as a very narrow size distribution. The automatically produced microcapsules did not alter morphology, viability and functional properties of the enveloped NPI. The optimization of this automatic procedure may provide a novel approach to obtain a large number of batches possibly suitable for large scale production of immunoisolated NPI for in vivo cell transplantation procedures in humans.

Effects of poly-L-lysine and collagen on FH-B-TPN cell differentiation into endocrine cell phenotype

Pdx-1 genetically engineered FH-B-TPN cells might represent a source for insulin-secreting cells. We then have tested whether poly-L-lysine (PLL) and collagen (C) exposure in vitro promote three-dimensional particle formation and differentiation toward an endocrine cell phenotype. On these matrices, we observed that FH-B-TPN cells showed a tendency to either aggregate when seeded on PLL or to form uniform cell monolayers, but not to aggregate on C. While insulin was released in any condition, GSIR was only associated with PLL mainly at 24 and 72 hours of culture. Various culture matrices influenced the expression of glucose transporter type 2 and gluco kinase, being they expressed more intensively on PLL rather than C or in controls. mRNA expression for NeuroD/Beta2, Isl-1, Ras, Metalloproteinase-2 (MMP-2), -9 and -7 also were affected, with PLL inducing increased expression of NeuroD/Beta2 of Isl-1, and no difference between C and control. PLL, unlike C, strongly increased Ras through observation times. MPP-2 and -9 were decreased by both PLL and C, whereas MMP-7 was increased by PLL. PLL, usually employed to promote culture cell adhesion, has been proven capable to stimulate pancreatic endocrine function and cell aggregation and to stimulate gene expression of key markers for either insulin transcription or MMP-7.

Formulating the alginate–polyornithine biocapsule for prolonged stability: Evaluation of composition and manufacturing technique

Alginate encapsulation is one of the most widely used techniques for introducing cell-based therapeutics into the body. Numerous encapsulation methodologies exist, utilizing a variety of alginates, purification technologies, and unique polycationic membrane components. The stability of a conventional alginate formulation encapsulated using a commercially available technique and apparatus has been characterized extensively. The current study employs an encapsulation protocol and ultra-pure alginate pioneered at the University of Perugia. The enhanced microcapsules were produced, characterized, and implanted into the brain, peritoneal cavity, and subcutaneous space of Long-Evans rats. After 14, 28, 60, 90, 120, and 180 or 215 days, capsules were explanted and the surface was analyzed using Fourier-transform infrared spectroscopy (FTIR) and scanning electron microscopy (SEM). Image analysis was carried out to measure changes in diameter and wall thickness. FTIR peak analysis and surface morphology from SEM indicated that the enhanced encapsulation technique and formulation produced a stable biocapsule capable of survival in all sites, including the harsh peritoneal environment, for at least 215 days. Preimplant analysis showed a marked increase in the structural integrity of the enhanced formulation with improved elasticity and burst strength compared with the baseline formulation, which remained stable for less than 60 days. The enhanced microcapsule composition showed advantages in physical strength and longevity, indicating that small changes in encapsulation methodologies and materials selection can dramatically impact the stability and longevity of alginate microcapsules and their contents.

Standard technical procedures for microencapsulation of human islets for graft into nonimmunosuppressed patients with type 1 diabetes mellitus

To comply with regulatory restrictions, with regard to graft of human islets immunoprotected within artificial microcapsules, into patients with type 1 diabetes mellitus (T1DM) with no recipient immunosuppression, we have prepared standard protocols on: (1) sodium alginate purification (clinical grade) for microcapsule fabrication; (2) preparation of biocompatible and permselective microcapsules containing human islets; and (3) minimally invasive techniques for grafting of the encapsulated human islets into the recipients' peritoneal cavity. As to no. 1, starting from pharmaceutical grade, raw sodium alginate powder, we prepared a pyrogen- and endotoxin-free 1.6% alginate solution by means of dialysis, multiple filtrations, and dilution/osmolality adjustments. As to no. 2, we have selected human islet preparations associated with >80% purity/viability, which underwent careful functional quality control testing prior to encapsulation; namely, most capsules contained one islet. As for no. 3, we have devised a simple intraperitoneal injection method under abdominal echography guidance with only local anesthesia to deposit the encapsulated islets in saline within the peritoneal leaflets. These technical protocols were officially approved by the Italian Ministry of Health which has released permission to conduct a phase I, closed human trial in 10 patients using encapsulated human islet grafts into nonimmunosuppressed patients with T1DM.

Intraperitoneal alginate-encapsulated neonatal porcine islets in a placebo-controlled study with 16 diabetic cynomolgus primates

BACKGROUND

A nonhuman primate model of diabetes is valuable for assessing porcine pancreatic islet transplants that might have clinical benefits in humans.

METHODS

Neonatal porcine islets, microencapsulated in alginate-polyornithine-alginate, were injected intraperitoneally (10,000 IEQs/kg islets) into eight adult male cynomolgus monkeys rendered diabetic with streptozotocin. Eight diabetic controls were given an equivalent dose of empty placebo capsules. All subjects received a repeat transplant 3 months after the first.

RESULTS

The transplant was well tolerated and no adverse or hypoglycemic events occurred. There were two deaths from nontransplant treatment or diabetic complications unrelated to the transplants. After transplantation, the average insulin dose was reduced in the islet-treated group and increased in the control group. At 12 weeks after the first transplant there was a mean 36% (95% CI: 6% to 65%, P = .02) drop in daily insulin dose compared with the control group. After 24 weeks the difference increased to a mean of 43% (95% CI: 12% to 75%, P = .01) without significant differences in blood glucose values between the two groups. Individual responses after islet transplant varied and one monkey was weaned off insulin by 36 weeks. At terminal autopsy, organs appeared normal and there was no visible peritoneal reaction. No animal had polymerase chain reaction (PCR)-amplified signals of porcine endogenous retrovirus or exogenous virus infections in blood or tissues.

CONCLUSION

Repeated intraperitoneal transplantation of microencapsulated neonatal porcine islets is a safe procedure in diabetic primates. It was shown to result in a significant reduction in insulin dose requirement in the majority of animals studied, whereas insulin requirement increased in controls.

Transplantation of micro- and macroencapsulated piglet islets into mice and monkeys

Neonatal porcine islets within alginate microcapsules transplanted intraperitoneally (IP) or within semi-permeable macrocapsules (TheraCyte) and transplanted subcutaneously (SC) survive and reverse diabetes for up to 16 weeks in diabetic autoimmune nonobese diabetic (NOD) mice. The islets in microcapsules transplanted IP into nondiabetic cynomolgus monkeys survived for 8 weeks. Similar results were shown with islets transplanted in TheraCytes. Neither species showed adverse effects or evidence of infection with porcine endogenous retroviruses or other endemic pig viruses. Proof of principle is illustrated for successful xenotransplantation in humans.

Transdifferentiation molecular pathways of neonatal pig pancreatic duct cells into endocrine cell phenotypes

Restrictions in availability of cadaveric human donor pancreata have intensified the search for alternate sources of pancreatic endocrine tissue. We have undertaken to assess whether nonendocrine pancreatic tissue, with special regard to ducts, including epithelial cells, and retrieved from neonatal pig pancreata that are used for islet isolation, may under special in vitro culture conditions generate endocrine cell phenotypes. Special care was taken to identify the time-related appearance of molecular and biochemical markers associated with beta-cell specificity, in terms of glucose-sensing apparatus and insulin secretion. For this purpose, established ductal origin monolayer cell cultures were incubated with a battery of mono- or polyvalent growth factors. Morphological, immunocytochemical, molecular, and functional assays indicated that under special culture conditions ductal origin cells acquired an endocrine identity, based upon expression of key gene transcripts that govern the stimulus-coupled insulin secretory activity. Among factors eliciting transdifferentiation of ductal epithelial into endocrine cells, Sertoli cell (SC)-conditioned medium seemed to be the most powerful inducer of this process. In fact, the resulting cultures not only expressed beta-cell-oriented metabolic markers but also were associated with insulin and C-peptide output at equimolar ratios. This finding indicates that SC coincubation, more than other conditions, caused originally ductal cell cultures to gradually differentiate and mature into beta-cell-like elements. In vivo studies with this early cell differentiation product will test whether our approach may be suitable for correction of hyperglycemia in diabetic animal models.

Short-term Stimulation Studies on Neonatal Pig Pancreatic Duct-derived Cell Monolayers

Short-term stimulation with insulinotropic factors may induce morphologic and functional changes in primary ductal cell cultures as a potential source of stem cells. We sought to assess the capacity of hepatocyte growth factor (HGF) to induce expression and maturation of proteins--PDX-1 and GLUT-2--and the subsequent beta-cell secretory profiles. HGF, which is involved in pancreatic development, may induce islet beta-cell neogenesis. Primary ductal cell monolayers were cultured in Click's + FBS 10% at 37 degrees C until tissue confluence. The medium was enriched with HGF (10 ng/mL for different periods); controls were treated for similar times with normal culture medium. At the end of the study, three-dimensional islet-like cell aggregates were observed in both conditions. In all conditions immunostaining studies showed positivity for the major endocrine-phenotype cell markers: insulin, PDX-1, glucokinase, and GLUT-2. Furthermore, treatment with HGF for short periods induced the expression of a functionally active, phosphorylated isoform of PDX-1. Finally, we observed that under basal conditions the cells initially and progressively released proinsulin throughout 5 days in all settings. Thereafter proinsulin was gradually replaced by insulin in the culture medium, reflecting a maturation progress. This pattern of insulin maturation and release was more evident when the cells were continuously stimulated with HGF for 12 days. The employed stimuli seemed to differentiate the original ductal cell layers toward endocrine cell phenotypes that synthesize and release proinsulin and subsequently insulin. HGF seems to provide a more efficient differentiation.

Optimized parameters for microencapsulation of pancreatic islet cells: an in vitro study clueing on islet graft immunoprotection in type 1 diabetes mellitus

Alginate (AG)-based microcapsules may provide a selective permeable and biocompatible physical barrier to prevent islet graft (TX)-directed immune destruction. However, extent of the achieved immunoprotection will continue to be variable and unpredictable until the role of the individual mechanisms involved with TX-related inflammatory cell and immune reactivity are clarified. Macrophages (M) are believed to play a pivotal role in controlling the host/TX interaction and its consequences. We then have studied the effects of isolated rat M and their secretory products on allogeneic islets enveloped in variably sized and configured microcapsules, within in vitro mixed islet-M cocultures. In particular, we aimed to determine the sequence of immune or not immune specific cascade of early events that derive from such on interaction. One of the specific aims was to assess whether the membrane's physical intactness and conversely its even minimal rupture, along with the microcapsules' size (i.e., large vs. small) would significantly impact M reactivity and, thereby, the encapsulated islet viability and function. Special care was taken to evaluate extent of the elicited reactivity by meticulously monitoring cytokine, N2 derivative, and other proinflammatory protein curve profiles during the early M activation process. The study has preliminarily shown that, for equally formulated microcapsules, the capsular size and membrane's morphologic thoroughness are key to prevent M reactivity and possibly avoid the intracapsular islet cell damage. While elucidation of pathways involved with the encapsulated islet TX-directed host's responsiveness actually is in progress, it has clearly emerged that microcapsules should comply with well-defined physical properties and formulation specifications in order to obviate the primum movens of the inflammatory reaction process.

Neonatal pig pancreatic duct–derived insulin-producing cells: preliminary in vitro studies

Neonatal pig pancreata could represent an ideal tissue resource for donor islets for transplantation trials. Because functional islet beta-cells could derive from precursors situated in the ductal system, and neonatal animals are better suitable than adults for recovering such elements, we have examined whether isolated neonatal pancreatic ducts (NPD) could form insulin-producing cells. NPD, retrieved from the pancreas by collagenase digestion, were cultured for 2 weeks. A compact tissue monolayer detached by trypsin was re-incubated to form upon culture. The primary tissue monolayer was plated, yielding secondary monolayers that were supplemented in culture with the following factors: insulin transferrin selenium, niacinamide, keratinocyte growth factor, and high glucose, which promoted formation of islet cell-like clusters during 30 days of culture. Upon reaching 50 to 100 microm in diameter, the cell clusters were subjected to morphologic examination (assessment of viability by staining with ethidium bromide+fluorescein diacetate [EB+FD]; staining for insulin with diphenylthiocarbazone [DTZ]); DNA assay; insulin radioimmunoassay both in the basal state and after in vitro static incubation with high glucose; immunolabeling with anti-insulin fluorescent antibodies. Of the cell clusters, 80% were composed of viable cells that faintly showed DTZ staining. Basal insulin was 16.7 microU/mL, but no insulin response was elicited by stimulation with high glucose. Acid-ethanol extraction showed high insulin levels in the clusters. Finally, immunofluorescence for insulin was positive, indicating the presence of beta-cell-like committed elements. In conclusion, NPD may differentiate into insulin-producing cells, which are at a very early stage when the glucose-sensing apparatus is still immature.

Sertoli cell-induced adult rat islet beta-cell mitogenesis: causative pathways

We have previously observed that in vitro co-incubation of rat pre-pubertal Sertoli cells (SC), or their dialyzed/concentrated secretory products with homologous islets, resulted in significant stimulation of the islet beta-cell mitotic index. Aim of the present work was to assess both the specificity and nature of the mechanisms underlying this phenomenon. For this purpose, first we tested astrocytes (AA), separated and purified from the rat brain cortex, where they are known to release a number of growth factors and neurotrophic cytokines, for co-incubation with the islets. However, under the same experimental conditions used for SC, AA did not induce any changes in the beta-cell life cycle, thereby confirming specificity of SC, with respect to induction of beta-cell mitogenicity. For the second purpose, we examined the products of PD-1, a gene located in the cytoplasm of SC, where it promotes spermatogenesis. By blocking the protein encoded by PD-1, under appropriate culture conditions, we observed that the SC-induced increase in beta-cell mitotic activity lost its statistical significance, which suggested a role of PD-1 with respect to SC-related mitogenic properties on beta-cells. These findings corroborate the idea that SC, by either direct contact, or by means of their secretory products, clearly affect the islet beta-cell mitotic rate. Preliminarily, PD-1 gene, located in the cytoplasm of SC, might be one of the factors involved with the induction of beta-cell mitotic activity. In conclusion, SC-induced beta-cell mitotic activity is specific, seemingly mediated by humoral factors whose acting mechanisms have started being unfolded.

RNA expression bcl-w, a new related protein Bcl-2 family, and caspase-3 in isolated sertoli cells from pre-pubertal rat testes

Apoptosis has a major role in molding the embryo, in the maintenance of tissue homeostasis, and in the defense against pathogens, while its disgregulation is strongly implicated in cancer as well as in autoimmune and degenerative diseases. The opposite action of anti-apoptotic proteins (Bcl-2 family) and pro-apoptotic proteins (p53, Bax, Bak) regulates the activation of caspases that are the effectors proteases of the cell suicide. Bcl-W is a pro-survival protein, recently discovered, related to the Bcl-2 family. The presence of Bcl-W is fundamental for spermatogenesis in rats. Caspases are cysteine-dependent aspartate-specific proteases, and their over-expression can result in apoptotic cell death. Normally, caspases exist in cells as inactive pro-enzymes and can be activated by 2 distinct mechanisms: the FADD/caspase 8 cascade, and the Apaf-1/caspase 9 cascade. These 2 mechanisms are used extensively by cells for the activation of the effectors caspases: caspase 3, caspase 6, and/or caspase 7. Bcl-W and caspases might have a pivotal role in maintenance of Sertoli cells integrity. In this study, we demonstrate that both Bcl-W mRNA and caspase 3 mRNA are expressed in isolated Sertoli cells of pre-puberal rat testes. This finding might be crucial in clarifying whether Sertoli cells die by an apoptotic mechanism. Further studies are required to understand whether the expression of Bcl-W and caspases is different before and after puberty in rat testis and/or in pathological conditions, that lead to an increased cell apoptosis.

Cellular support systems for alginate microcapsules containing islets, as composite bioartificial pancreas

To improve the functional performance of microencapsulated islets, we examined the effects of putative cellular support systems, consisting of rat purified Sertoli cells (SC) and astrocytes (AA), on coenveloped allogeneic islets. Coincubation of islets with SC but not AA, resulted in significant stimulation of beta cell mitogenesis, coupled with a significant increase in in vitro glucose-stimulated insulin release. Preliminarily, the xenotransplantation of coencapsulated rat islets and homologous SC significantly prolonged remission of hyperglycemia in diabetic mice.

Improved function of rat islets upon co-microencapsulation with Sertoli's cells in alginate/poly-L-ornithine

The purpose of this study was to assess whether Sertoli's cells would improve functional performance of homologous pancreatic islets within microcapsules. Purified rat Sertoli's cells were co-enveloped with islets in microcapsules that had been fabricated with alginic acid and poly-L-ornithine. Confocal laser microscopy was used to determine any mitogenic effects of Sertoli's cells on islets beta-cells. Insulin secretion from islets, with or without Sertoli's cells, was examined, and grafts of Sertoli's cells with islets in microcapsules into diabetic mice were carried out. Co-incubation of Sertoli's cells with islets resulted in a significant increase in the islet beta-cell mitotic rate, which was coupled with significantly higher insulin release under glucose stimulation, as compared to controls. Grafts of co-microencapsulated Sertoli's cells with islets resulted in prolongation of the achieved normoglycemia in the animals receiving Sertoli's cells with islets as compared to controls that received islets only. Sertoli's cells do promote mitogenic activities upon in vitro co-incubation with islets, whose in vitro functional and in vivo post-transplant consequences were evident. Sertoli's cells could, therefore, be co-microencapsulated with islets for transplantation in diabetic recipients.

Effects of anti-oxidizing vitamins on in vitro cultured porcine neonatal pancreatic islet cells

Oxidative stress may cause severe cellular damage to both allo- and xeno-transplanted islets, additional to islet graft-directed immunity, in diabetic patients. We thus aimed to examine the effects of antioxidants on in vitro culture-maintained, neonatal porcine cell clusters (NPCCs). NPCCs were treated with antioxidants (vitamins D3 and E) by a certain time of their maturation and differentiation process. Insulin recovery showed that both vitamins D3 and E, unlike untreated controls, resulted in preservation of the islet function for significantly long periods of time. Such effects were also confirmed during NPCCs in vitro static incubation with high glucose. Furthermore, morphologic examination of NPCCs demonstrated that at 16 days of cell culture beta-cell clusters were significantly larger and more intact when exposed to the vitamins as compared to controls. According to these preliminary results, because the employed vitamins, known to retain anti-oxidizing properties, seemed to clearly improve NPCCs morphology and function, they may represent a potentially useful tool for islet culture maintenance in the pre-transplant time period.

Sertoli cell-induced reversal of adult rat pancreatic islet beta-cells into fetal-like status: potential implications for islet transplantation in type I diabetes mellitus

BACKGROUND

Clinical success of pancreatic islet allograft (TX) for the therapy of diabetes mellitus is hampered by several pitfalls, primarily including the restricted availability of donor tissue and the immune- and/or non-immune-related TX's early loss, with the latter not necessarily being prevented by the host's general immunosuppression. Finally, adult islet beta-cells normally exhibit minimal proliferation capacity, which would not permit restoration of an eventually declining TX mass.

METHODS

To address the limited beta-cell growth capacity, we have examined whether in vitro co-culturing adult rat islets (I) with prepubertal homologous Sertoli cells (SC) would stimulate I beta-cell expansion. SC-derived effects on the islets were studied in vitro, both morphologically (confocal laser microscopy) and functionally (glucose-stimulated insulin release). We have also preliminarily examined the in vivo impact of microencapsulated SC + I co-cultures on TX in diabetic mice.

RESULTS

In vitro, we observed that SCs promoted significant beta-cell replication, as I beta-cell mitotic activity increased from 1% to greater than 8%, which coincided with the adult elements reversing into fetal-like status. This finding was coupled with significantly greater insulin release either in basal or in response to glucose, as compared with controls.

CONCLUSIONS

Addition of SC to islets promotes reversal of the adult beta-cell elements into fetal-like conditions, thereby providing a new, potentially powerful tool that could significantly enhance the functional performance of islet TX in diabetic recipients.

Transplantation of pancreatic islets contained in minimal volume microcapsules in diabetic high mammalians

To minimize technical problems relating to excessive size (600-800 mu in diameter) of standard alginate microcapsules (CSM) for pancreatic islet graft immunoisolation, we have developed two novel minimal volume, chemically identical, capsule prototypes (MVC): 1) coherent microcapsules (CM), and 2) medium-size microcapsules (300-400 mu, MSM). CM, which envelop each individual islet within a thin alginate hydrogel cast, are prepared by emulsification, whereas MSM are made by atomizing the islet-alginate suspension through a special microdroplet generator. Upon graft into diabetic rodents, CM have shown to immunoprotect both allo- and xenogeneic nondiscordant islets, and restored normoglycemia. In higher mammals, at subtherapeutic doses, CM fully immunoprotected islet allografts (pig-->pig), but only temporarily xenografts (dog-->pig). We then used MSM to immunoisolate canine islet allografts in the peritoneal cavity of dogs with spontaneous insulin-dependent diabetes. Of three grafted dogs, two showed full remission of hyperglycemia with insulin withdrawal. MSM could represent an intermediate solution between CSM and CM for peritoneal immunoisolated islet transplants.

Perspectives in pancreatic and islet cell transplantation for the therapy of IDDM

Endocrine pancreas transplantation could provide an ideal solution to the problem posed by IDDM. Although preliminary clinical success achieved over the past few years has been considerably higher with whole pancreatic transplant than with isolated islet grafts, both approaches remain experimental. Islet grafts might gain, over time, increasing credibility and might eventually provide an easier alternative in terms of grafting procedures and patient management, as compared with the more "traumatizing" whole-pancreas transplantation, but only if the pending technical problems are fully surmounted. Combined pancreas/kidney (either simultaneous pancreas/kidney [SPK] or pancreas after kidney [PAK]) transplantation, under general immunosuppression, in IDDM patients also suffering from end-stage renal disease (ESRD) is a procedure that may be worth pursuing in selected cases. However, there are still quite serious reservations about the scaled-up applicability of pancreas transplant alone (PTA) in patients with "brittle" IDDM; major restrictions are not only the necessity of pharmacological immunosuppression, but also the lower functional performance of PTA, especially as compared with SPK grafting. In terms of islets, as problems of human islet yield and purity are gradually being overcome, the problem of islet graft-directed immune destruction hampers the success of ongoing clinical trials in IDDM patients. The invariable requirement of general immunosuppression affects pancreatic as much as islet grafts, although a number of alternative, yet experimental, immunoprotection strategies in progress might suit islets better than they would whole organs. Another issue concerns the relative inadequacy of cadaveric donor organ availability, the requirements of which are more stringent for islets because of the persistent variability of islet cell yield per organ. Tremendous experimental efforts are in progress to create xenogeneic porcine/bovine islets and, perhaps over a longer period of time, human/nonhuman engineered insulin-producing cells suitable for graft within special immunoisolation barrier membranes.

A rapid qualitative method to assess in vitro immunobarrier competence of pancreatic islets containing alginate/polyaminoacidic microcapsules

A quick method for the qualitative evaluation of immunoisolatory properties associated with islet-containing alginate/poly-L-ornithine (AG/PLO) microcapsules is described. In particular, we examined a new AG/PLO coherent microcapsule (CM) prototype that was recently developed in our laboratory, although the procedure could be applicable to other capsule types as well. We observed no binding of immunoglobulins (Ig) contained in islet cell antibody (ICA)-positive human sera (> 60 Juvenile Diabetes Foundation units, JDT U) to pig islets, enveloped within AG/PLO CM, under indirect immunofluorescence examination. Also, CM were shown to inhibit human lymphocyte proliferative capacity fully, as assessed by the 3H-thymidine incorporation rate, in in vitro mixed xenogeneic pig islet/human lymphocyte co-cultures. These results provided us with a preliminary method to attempt standardization of basic physical/chemical properties which should be associated with an immunoisolatory membrane for islet allo/xenograft immunoprotection.

Ultrastructural examination of pancreatic islet containing alginate/polyaminoacidic coherent microcapsules

We ultrastructurally examined pancreatic islet containing alginate/poly-L-ornithine (AG/PLO) coherent microcapsules (CM) which we had previously developed in our laboratory. Specific issues, such as extent of CM coherency as well as morphologic integrity, and viability of the encapsulated islet subcellular organelles were addressed. We preliminarily demonstrated, both at scanning (SEM) and transmission (TEM) electron microscopy analysis, that CM seem to provide for structurally intact and functional, artificial microbarriers, enveloping each individual islet. These findings, additional to CM immunobarrier competence and biocompatibility, previously shown by our studies, might foster progress of CM into islet graft immunoisolation experimental and ultimately clinical trials.

Culture maintenance of isolated adult porcine pancreatic islets in three-dimensional gel matrices: morphologic and functional results

Adult porcine pancreatic islets are attractive for morphological and functional investigations but are difficult to obtain and use. In particular, the islet isolation and purification process is hampered by the lack of an outer capsule membrane, with predisposition to fragmentation. Attempts to culture maintain pig islets and preserve viability and functional competence have also been difficult. We found that placement of isolated porcine islets in biocompatible three-dimensional hydrogel matrices, made of calcium alginate and poly-L-ornithine, would improve morphology, as well as secretory responses to rapid glucose concentration changes.

Method for mass retrieval, morphologic, and functional characterization of adult porcine islets of Langerhans: a potential nonhuman pancreatic tissue resource for xenotransplantation in insulin-dependent diabetes mellitus

BACKGROUND

We aimed to implement and expand an original technique for mass procurement, maintenance, and study of adult porcine pancreatic islets (PPIs), which had been previously developed in our laboratory.

METHODS

By screening through specific criteria for pig donor strain selection, we acquired new leads for separation of large, intact islets from the whole pancreas. Accomplishment of this goal also was permitted by adjusting, and or replacing physical/chemical parameters of the pancreatic digestion process.

RESULTS

High yield isolation and purification of large and intact PPIs was thoroughly associated with full retention of islet morphologic integrity, as proven by accurate assessment of islet cell structure and ultra-structure, as well as viability and functional competence, in vitro and in vivo. In particular, we observed that isolated PPIs may retain capability of synthesizing insulin "de novo," and regulate this property on glucose stimulation. We also began to explore new approaches for in vitro, long-term PPI culture maintenance.

CONCLUSION

We found that a graft of PPI containing algin/polyaminoacidic microcapsules, in nonimmunosuppressed diabetic rodents, was associated preliminary with remission of hyperglycemia, providing further insight into the physiologic competence of these islets.

Preventive effects of azathioprine (AZA) on the onset of diabetes mellitus in NOD mice

We have studied the effects of long-term treatment with azathioprine (AZA) vs cyclosporin A (CSA) vs placebo (PL), in three groups of 10 week old, prediabetic NOD mice. One of 8 AZA, none of 8 CSA and 7 of 11 PL treated mice developed overt diabetes (IDDM). Quantitative morphometric analysis conducted on mouse pancreatic histologic sections documented that extent and degree of islet beta-cell damage were incomparably less severe in the mice that received AZA or CSA compared to those treated with PL. Since early and prolonged treatment with AZA seems to prevent the onset of DM in NOD mice as nearly effectively as CSA, AZA, which is significantly safer than CSA, could replace the latter as a potential approach for the immunotherapy of IDDM.

Pancreatic beta-cell destruction in non-obese diabetic mice

We determined the natural history of the widespread pancreatic islet beta-cell destruction that precedes the onset of spontaneous putative autoimmune diabetes mellitus in NOD mice. For this purpose, we performed both histological and immunocytochemical examinations of pancreata retrieved from mice at 2 through 30 weeks of age. An overexpression of la antigens was identified on islet beta cells at 4 weeks of age, without evidence of mononuclear cell infiltration. The abnormal expression of la antigens was age-related and was associated with hyperexpression of class I antigens and progressive islet cell histologic damage after 17 weeks of age. Immunocytochemical examination of islet cell infiltrate showed that the number of macrophages did not increase during the early phase of islet cell damage in these mice. The L3T4/Lyt-2 ratio increased after 7 weeks of age, but was 1:1 in the late stage of insulitis. These findings suggest that widespread islet beta-cell destruction is a process that begins primarily with derangements of the pancreatic beta-cell immune pattern, which may trigger a mononuclear cell reaction.

Transplantation of microencapsulated pancreatic human islets for therapy of diabetes mellitus. A preliminary report

To circumvent immune destruction of pancreatic islet grafts, human islets were deposited, enveloped within algin-polyaminoacidic microcapsules, in artificial prostheses directly anastomosed to blood vessels. Three dogs and two patients with insulin-dependent diabetes received transplantations with microencapsulated human islets embodied in arterial or AV prosthesis bypasses without any pharmacologic immunosuppression. Graft function was documented in all recipients by significative production and sustenance of serum C-peptide levels, although insulin independence was consistently achieved in only one of three dogs and, transiently, in one of two patients. On retrieval of grafted prostheses, viable human islets were found in microcapsules, most of which were freely dispersed in the vascular chambers. Vascular prostheses may represent a suitable site of implantation for large numbers of human islets, immunoprotected in semipermeable and biocompatible microcapsules, and be a novel strategy for therapy of insulin-dependent diabetes mellitus (IDDM).

Xenotransplantation of microencapsulated pancreatic islets contained in a vascular prosthesis: preliminary results

Porcine and human pancreatic islets were microencapsulated in an alginate-polylysine biomembrane and put in a chamber of a new vascular prosthesis composed of an inner tubing of Dacron mesh and an outer tubing of expanded polytetrafluorethylene material. The vascular prosthesis was anastomized between the iliac artery and the contralateral vein of diabetic dogs. The recipients did not receive any immunosuppressive therapy. Function of porcine and human islets was monitored by measuring serum glucose levels and human C-peptide concentrations. After transplantation, serum glucose levels were maintained at values lower than 200 mg/dl, and C-peptide concentrations were between 0.8 and 3.2 ng/ml. Injected insulin requirements decreased by 50%-60%. Four to 8 weeks after transplantation, histologic examination showed well-preserved and functioning islets in the majority of intact microcapsules. Fibrin and inflammatory cells were not observed in the chamber. These data suggest long-term survival and function of microencapsulated pancreatic islets in the vascular prosthesis.

Immunoprotection of pancreatic islet grafts within artificial microcapsules

To circumvent pancreatic islet graft-directed immune destruction we enveloped porcine islets within highly biocompatible and selectively permeable algin/polyaminoacid microcapsules. These special microspheres were deposited between the inner (permeable) and the outer (impermeable) layers of an artificial, coaxial vascular prosthesis, directly anastomized to blood vessels. Five dogs with spontaneous, insulin-dependent diabetes received microencapsulated porcine islets in arterio-vein iliac prosthesis by-passes. One showed complete and the remainder partial, sustained reversal of hyperglycemia. Microencapsulation may be a potential solution to immunological problems related to islet transplantation.