Validation, Deployment, and Real-World Implementation of a Modular Toolbox for Alzheimer's Disease Detection and Dementia Risk Reduction: The AD-RIDDLE Project

The Real-World Implementation, Deployment, and Validation of Early Detection Tools and Lifestyle Enhancement (AD-RIDDLE) project, recently launched with the support of the EU Innovative Health Initiative (IHI) public-private partnership and UK Research and Innovation (UKRI), aims to develop, test, and deploy a modular toolbox platform that can reduce existing barriers to the timely detection, and therapeutic approaches in Alzheimer's disease (AD), thus accelerating AD innovation. By focusing on health system and health worker practices, AD-RIDDLE seeks to improve and smooth AD management at and between each key step of the clinical pathway and across the disease continuum, from at-risk asymptomatic stages to early symptomatic ones. This includes innovation and improvement in AD awareness, risk reduction and prevention, detection, diagnosis, and intervention. The 24 partners in the AD-RIDDLE interdisciplinary consortium will develop and test the AD-RIDDLE toolbox platform and its components individually and in combination in six European countries. Expected results from this cross-sectoral research collaboration include tools for earlier detection and accurate diagnosis; validated, novel digital cognitive and blood-based biomarkers; and improved access to individualized preventative interventions (including multimodal interventions and symptomatic/disease-modifying therapies) across diverse populations, within the framework of precision medicine. Overall, AD-RIDDLE toolbox platform will advance management of AD, improving outcomes for patients and their families, and reducing costs.

The European Academy of Andrology (EAA) ultrasound study on healthy, fertile men: Scrotal ultrasound reference ranges and associations with clinical, seminal, and biochemical characteristics

BACKGROUND

Scrotal color Doppler ultrasound (CDUS) still suffers from lack of standardization. Hence, the European Academy of Andrology (EAA) has promoted a multicenter study to assess the CDUS characteristics of healthy fertile men (HFM) to obtain normative parameters.

OBJECTIVES

To report and discuss the scrotal organs CDUS reference ranges and characteristics in HFM and their associations with clinical, seminal, and biochemical parameters.

METHODS

A cohort of 248 HFM (35.3 ± 5.9years) was studied, evaluating, on the same day, clinical, biochemical, seminal, and scrotal CDUS following Standard Operating Procedures.

RESULTS

The CDUS reference range and characteristics of the scrotal organs of HFM are reported here. CDUS showed a higher accuracy than physical examination in detecting scrotal abnormalities. Prader orchidometer (PO)- and US-measured testicular volume (TV) were closely related. The US-assessed TV with the ellipsoid formula showed the best correlation with the PO-TV. The mean TV of HFM was ~ 17 ml. The lowest reference limit for right and left testis was 12 and 11 ml, thresholds defining testicular hypotrophy. The highest reference limit for epididymal head, tail, and vas deferens was 12, 6, and 4.5 mm, respectively. Mean TV was associated positively with sperm concentration and total count and negatively with gonadotropins levels and pulse pressure. Subjects with testicular inhomogeneity or calcifications showed lower sperm vitality and concentration, respectively, than the rest of the sample. Sperm normal morphology and progressive motility were positively associated with epididymal head size/vascularization and vas deferens size, respectively. Increased epididymis and vas deferens sizes were associated with MAR test positivity. Decreased epididymal tail homogeneity/vascularization were positively associated with waistline, which was negatively associated with intratesticular vascularization. CDUS varicocele was detected in 37.2% of men and was not associated with seminal or hormonal parameters. Scrotal CDUS parameters were not associated with time to pregnancy, number of children, history of miscarriage.

CONCLUSIONS

The present findings will help in better understanding male infertility pathophysiology, improving its management.

Immunolocalization of DMRTB1 in human testis with normal and impaired spermatogenesis

BACKGROUND

The transcription factor DMRTB1 plays a pivotal role in coordinating the transition between mitosis and meiosis in murine germ cells. No reliable data are available for human testis.

OBJECTIVES

The present study aims to examine the testicular expression pattern of DMRTB1 in men showing normal and impaired spermatogenesis.

MATERIALS AND METHODS

Immunohistochemistry was performed using 54 human testicular biopsy specimens and a commercial rabbit polyclonal anti-DMRTB1 primary antibody. RT-PCR complemented immunohistochemistry. To further characterize immunopositive cells and possible co-localization, the proliferation marker Ki-67, the tumor marker PLAP, and an anti-DMRT1 antibody were used.

RESULTS

In men with normal spermatogenesis, a strong immunoreactivity was detectable in a subset of spermatogonia (38.34 ± 2.14%). Some spermatocytes showed a weak immunostaining. Adjacent Sertoli cells were immunonegative. Compared with a hematoxylin and eosin overview staining, these immunopositive cells were almost exclusively identified as A_pale and B spermatogonia and primary spermatocytes in (pre-)leptotene, zygotene, and pachytene stages. In patients with spermatogenic arrest at spermatogonial level, an altered staining pattern was found. No immunoreactivity was detected in Sertoli cells in Sertoli cell-only syndrome. In germ cell neoplasia in situ (GCNIS) tubules, except for a few (0.4 ± 0.03%), pre-invasive tumor cells were immunonegative. Seminoma cells showed no immunostaining.

DISCUSSION

According to previous findings in mice, it seems reasonable that DMRTB1 is expressed in these normal germ cell populations. Moreover, altered staining pattern in spermatogenic arrest at spermatogonial stage suggests a correlation with mitosis and transformation into B spermatogonia. The absence of DMRTB1 in GCNIS cells and tumor cells might be associated with uncontrolled neoplastic cell proliferation and progression into invasive germ cell tumors. Further research is required to elucidate, for example, the role of DMRTB1 in the malignant transformation of human germ cells.

CONCLUSION

Our data indicate a relevant role for DMRTB1 regarding the entry of spermatogonia into meiosis in men.

Expression patterns of HENMT1 and PIWIL1 in human testis: implications for transposon expression

This study aimed to define the expression patterns of HENMT1 and PIWI proteins in human testis and investigate their association with transposon expression, infertility sub-type or development of testicular germ cell tumours (TGCTs). Testis biopsies showing normal spermatogenesis were used to identify normal localisation patterns of HENMT1 and PIWIL1 by immunolocalisation and RT-PCR after laser microdissection. 222 testis biopsies representing normal spermatogenesis, hypospermatogenesis, spermatogenic arrests, Sertoli cell-only (SCO) tumours and TGCTs were analysed by RT-qPCR for expression of HENMT1/PIWIL1/PIWIL2/PIWIL3/PIWIL4 and LINE-1 Additionally, HENMT1-overexpressing TCam2 seminoma cell lines were analysed for the same parameters by RT-qPCR. We found that HENMT1 and PIWIL1 are coexpressed in pachytene spermatocytes and spermatids. Expression of HENMT1, PIWIL1 and PIWIL2 was mainly dependent on germ cell content but low levels of expression were also detected in some SCO samples. Levels of HENMT1, PIWIL1 and PIWIL2 expression were low in TGCT. Samples with HENMT1, PIWIL2 and PIWIL4 expression showed significantly (P < 0.05) lower transposon expression compared to samples without expression in the same histological group. HENMT1-overexpressing TCam2 cells showed lower LINE-1 expression than empty vector-transfected control lines. Our findings support that the transposon-regulating function of the piRNA pathway found in the mouse is conserved in adult human testis. HENMT1 and PIWI proteins are expressed in a germ-cell-specific manner and required for transposon control.

[German validation of the Acute Cystitis Symptom Score]

BACKGROUND

The Uzbek version of the Acute Cystitis Symptom Score (ACSS) was developed as a simple self-reporting questionnaire to improve diagnosis and therapy of women with acute cystitis (AC). The purpose of this work was to validate the ACSS in the German language.

MATERIALS AND METHODS

The ACSS consists of 18 questions in four subscales: (1) typical symptoms, (2) differential diagnosis, (3) quality of life, and (4) additional circumstances. Translation of the ACSS into German was performed according to international guidelines. For the validation process 36 German-speaking women (age: 18-90 years), with and without symptoms of AC, were included in the study. Classification of participants into two groups (patients or controls) was based on the presence or absence of typical symptoms and significant bacteriuria (≥ 10(3) CFU/ml). Statistical evaluations of reliability, validity, and predictive ability were performed. ROC curve analysis was performed to assess sensitivity and specificity of ACSS and its subscales. The Mann-Whitney's U test and t-test were used to compare the scores of the groups.

RESULTS

Of the 36 German-speaking women (age: 40 ± 19 years), 19 were diagnosed with AC (patient group), while 17 women served as controls. Cronbach's α for the German ACSS total scale was 0.87. A threshold score of ≥ 6 points in category 1 (typical symptoms) significantly predicted AC (sensitivity 94.7%, specificity 82.4%). There were no significant differences in ACSS scores in patients and controls compared to the original Uzbek version of the ACSS.

CONCLUSION

The German version of the ACSS showed a high reliability and validity. Therefore, the German version of the ACSS can be reliably used in clinical practice and research for diagnosis and therapeutic monitoring of patients suffering from AC.

[Operative therapy of Pyronie's disease]

The operative therapy of Pyronie's disease (penile induration) follows a staged scheme. If the deviation is > 45° a complex operative treatment in the sense of plaque incision and excision with subsequent defect coverage is necessary. This operation should be carried out under optical magnification to safeguard the vessel-nerve bundle. Defect coverage can currently be carried out using a collagen fleece with excellent outcome but alternative patches are also still available. The focus in patient management is on a realistic preoperative estimation of the situation in order to avoid any unrealistic preconceptions and expectations by the patient.

[Fractal geometry in the objective grading of prostate carcinoma]

BACKGROUND

A possible approach to objectively classify complex patterns in tumor tissue is a mathematical and statistical investigation of the distribution of cell nuclei as a geometric representation of cancer cells by fractal dimensions. Both the existence and changes in the fractal structure of tumor tissue have important consequences for the objective system of tumor grading. In addition, the complexity of growth in different carcinomas or their intercellular interactions can be compared to each other.

RESULTS

We present a theoretical introduction into fractal geometry as well as in the computer algorithms based upon the Rényi family of fractal dimensions. Finally, a geometric model of prostate cancer is introduced and the relationship between geometric patterns of prostate tumor and the fractal dimensions of the Rényi family are explained.

[Objective grading of prostate carcinoma based on fractal dimensions: Gleason 3 + 4= 7a ≠ Gleason 4 + 3 =7b]

BACKGROUND

Significant intra- and interobserver variability ranging between 40 and 80% is observed in tumor grading of prostate carcinoma. By combining geometric and statistical methods, an objective system of grading can be designed.

MATERIAL AND METHODS

The distributions of cell nuclei in two-dimensional patterns of prostate cancer classified subjectively as Gleason score 3+3, 3+4, 4+3, 4+4, 4+5, 5+4, and 5+5 were analyzed with algorithms measuring the global fractal dimensions of the Rényi family and with the algorithm for the local connected fractal dimension (LCFD).

RESULTS

The dimensions for global fractal capacity, information, and correlation (standard deviation) were 1.470 (045), 1.528 (046), and 1.582 (099) for homogenous Gleason grade 3 (n = 16), 1.642 (034), 1.678 (041), and 1.673 (084) for homogenous Gleason grade 4 (n=18), and 1.797 (042), 1.791 (026), and 1.854 (031) for homogenous Gleason grade 5 (n=12), respectively. The LCFD algorithm can be used to distinguish both qualitatively and quantitatively between mixed and heterogeneous patterns, such as Gleason score 3+4=7a (intermediate risk cancer) and Gleason score 4+3=7b (high-risk cancer). Sensitivity of the method is 89.3%, and specificity 84.3%.

CONCLUSION

The method of fractal geometry enables both an objective and quantitative grading of prostate cancer.

The use of proton pump inhibitors and the spectrum and number of biliary pathogens in patients with acute cholangitis

BACKGROUND

Knowledge of the bacterial spectrum for acute cholangitis is essential for adequate empiric antibiotic treatment.

AIM

To analyse the relation of proton pump inhibitors (PPI) with biliary pathogens in patients with acute cholangitis.

METHODS

This retrospective study identified 278 patients with 318 acute cholangitis episodes using an endoscopic database. The relationship between PPI and microbiological outcomes was assessed by logistic and poisson regression analysis for binary and count data.

RESULTS

In total, 882 pathogens were isolated, of which, 120 cholangitis episodes occurred with PPI; 198 cholangitis episodes without PPI. Multivariate poisson regression analysis showed that PPI use resulted in a 23% increase in the number of biliary pathogens [3.14 vs. 2.55 (Δ = 0.59), P < 0.01], whereas stent therapy, previous interventional procedures (endoscopic retrograde cholangiography/percutaneous transhepatic cholangiography), genesis, age and sex showed no significant association with the number of biliary pathogens. Significantly, more cholangitis episodes with more than one pathogen isolated occurred during PPI treatment [103/120 (86%) vs. 151/198 (76%), P = 0.04]. Analysis of intrinsic anti-microbial resistance patterns was performed: Anti-microbial combination therapies were significantly more required to cover all isolated pathogens in cholangitis episodes with PPI than in cholangitis episodes without PPI (44/120 vs. 46/198, P = 0.01). Additionally, PPI use was associated with a significantly higher incidence of oropharyngeal flora in the biliary tract (53/120 vs. 61/198, P = 0.02).

CONCLUSIONS

Proton pump inhibitors seem to influence biliary pathogens by increasing the number and broadening the spectrum of biliary pathogens. However, the findings of this hypothesis-generating study need to be tested by confirmatory studies.

[Urinary tract infections]

Urinary tract infections (UTI) are amongst the most frequent bacterial infections and therefore responsible for a great amount of antibiotic administration. UTI may present as benign, uncomplicated cystitis or severe, life-threatening urosepsis. Due to the heterogeneity of UTI the European Section of Infections in Urology (ESIU) has introduced a phenotypical classification, based upon the clinical presentation, the risk factors and the antibiotic susceptibility of the causative pathogens. Antibiotic treatment of the UTI varies accordingly. In uncomplicated cystitis antibiotics with low potential for collateral damage are recommended, which are mainly indicated for these infections. In uncomplicated pyelonephritis fluoroquinolones and 3rd generation cephalosporines are recommended. Antibiotic treatment regimens of complicated UTI depend very much on the antibiotic susceptibility according to regional resistance statistics. In urosepsis an early diagnosis and therapy is mandatory. In this regard a procalcitonin level > 0.25 µg/l has a good sensitivity and acceptable specificity in predicting bacteremia. Apart from the early antibiotic therapy successful decompression of the obstructed urinary tract is a predictor of survival. In children UTI are also amongst the most important bacterial infections, although symptoms are frequently not characteristic. The correct sampling of urine for microbiological investigations is critical. Due to the increasing fluoroquinolone resistance, infectious complications after transrectal prostate biopsy are becoming more frequent. Strategies to decrease complications encompass, amongst others, microbiological screening of the faecal flora for fluoroquinolone resistance, administration of alternative antibiotics for prophylaxis and alternative techniques for biopsy, such as perineal prostate biopsy.

Experimental Escherichia coli epididymitis in rats: assessment of testicular involvement in a long-term follow-up

The objective of this study was to investigate spermatogenesis and testicular inflammation in a rat model of unilateral Escherichia coli epididymitis in a long-term follow-up. Unilateral epididymitis was induced in 30 Sprague-Dawley rats by injecting E. coli into the right ductus deferens. Oral antimicrobial treatment with sparfloxacin (50 mg kg(-1) body weight/7 days) was administered in half of the animals 24 h after infection. Five treated and five untreated rats were killed at 2 weeks, 3 months and 6 months after infection. Spermatogenesis was investigated using a histological semi-quantitative score. The presence of inflammatory cells (B- and T lymphocytes, macrophages and granulocytes) in the testicular tissues was evaluated by immunohistochemistry. The testes were sterile at all times. Over the course of 6 months, spermatogenesis underwent significant incremental impairment on the inoculated side as compared to the contralateral side (P < 0.001). However, overall spermatogenesis scores were not significantly different between treated and untreated animals (P > 0.3 at each time point). Finally, loss of testicular architecture on the inoculated side was not associated with any cellular inflammatory response. Thus, adjuvant therapies need to be studied, and research is necessary on how to prevent deterioration of testicular function in bacterial epididymitis.

[Infection and sepsis prevention in prostate biopsy]

Prostate biopsy is currently the gold standard in the diagnosis of carcinoma of the prostate. An estimated one million prostate biopsies are performed every year in Europe. Worldwide the most frequent form is the transrectal prostate biopsy using preoperative fluoroquinolone prophylaxis. In recent years an increasing rate of infectious complications after prostate biopsy has been observed. The main causative factor is fecal fluoroquinolone-resistant bacteria. This review aims to present the current evidence regarding infectious complications after prostate biopsy and strategies to reduce symptomatic infections and urosepsis.

Reference values for testicular volume, epididymal head size and peak systolic velocity of the testicular artery in adult males measured by ultrasonography

PURPOSE

To obtain ultrasonography-based reference values for testicular volume, epididymal head size and peak systolic velocity (PSV) of the testicular artery in adult males of all ages.

MATERIALS AND METHODS

Between 2009 and 2011, 306 Caucasian adult males (median age: 51 years; range: 18-88 years) without scrotal pathology underwent prospective scrotal ultrasonography. The testicular volume was calculated from the length (L), width (W), and height (H) using three formulas: a) 0.52 × L × W × H, b) 0.52 × L × W², and c) 0.71 × L × W × H. Thickness and height of the epididymal head and PSV of the testicular artery were measured.

RESULTS

The median testicular volumes on the right (left) side were 13.9 (12.7) ml, 18.1 (16.5) ml, and 18.9 (17.3) ml for formula a), b), and c) respectively, and thus significantly different (p < 0.01 for all). The left testes were significantly smaller than the right testes (p < 0.01). The thickness and height of the right (left) epididymal head measured 7.5 (7.7) mm and 11.6 (11.3) mm, respectively. Median PSV of the right (left) testicular artery was 8.7 (8.6) cm/sec. No significant side-specific differences were documented with respect to epididymal size and PSV.

CONCLUSION

It was possible to obtain virtually age-independent reference values for testicular volume, epididymal head size and PSV of the testicular artery in adults. With regard to testicular volumetry, it is essential to consider which formula has been used, since the calculated volumes differ significantly from formula to formula.

Validation of RiskCheck Bladder Cancer ©, version 5.0 for risk-adapted screening of bladder cancer

INTRODUCTION

The aim of the study was to assess the strength of the online tool RiskCheck Bladder Cancer©, version 5.0 (RCBC) for early detection of bladder cancer (BC).

MATERIALS AND METHODS

RCBC was evaluated retrospectively based on the data of 241 patients, of which 141 were suffering from BC. Statistical analysis was performed by descriptive statistics, nonparametric group comparison, classification tree analysis and ROC analysis.

RESULTS

ROC analysis of the risk classification showed a sensitivity of 71.6%, a specificity of 56.5%, a positive predictive value of 67.8%, a negative predictive value of 52% and an accuracy of 63.5%. BC risk factors ranked by importance are time of smoking (p < 0.0001), gender (within the nonsmoking group: p < 0.009), occupational toxin exposure (within the group <35 years of smoking: p < 0.048) and amount of consumed cigarettes resulting in a 95% association with BC (within the group >35 years of smoking: p < 0.0001).

CONCLUSIONS

The high predictive power of RCBC for the identification of asymptomatic patients living under risk could be demonstrated.

Prostatitis and andrological implications

AIM

The prostatitis syndrome is a frequent disease affecting men in their reproductive age. The prostatitis syndrome is classified according to the National Institutes of Health (NIH) definition. Andrological implications of the prostatitis syndrome might encompass fertility issues, sexual dysfunctions and endocrinological alterations and influences.

METHODS

A medline query using the terms prostatitis AND andrological implication, fertility, sexual dysfunction or endocrinology was performed.

RESULTS

Acute bacterial prostatitis and andrological implications have not been adequately addressed. Patients with chronic bacterial prostatitis and chronic pelvic pain syndrome have been investigated evaluating sperm parameters. Some studies showed impaired sperm parameters. In chronic bacterial prostatitis, half of the patients reveal significant bacteriospermia with still debatable deleterious effects on sperm quality. Few interventional studies have addressed fertility issues in those patients. Anti-inflammatory treatment perhaps could have a positive impact on sperm parameters. Sexual dysfunction can be described by different components such as erectile, ejaculatory, orgasmic and sexual desire dysfunctions. Sexual dysfunction in chronic prostatitis adds to the number of positive symptom phenotypes and correlates therefore with increasing symptom scores in patients with chronic prostatitis syndromes. However, prospective interventional studies on the role of sexual dysfunctions are missing. Hormones have been found to modulate the inflammatory response via different receptors, particularly via estrogen receptor alpha. This evidence, however, is mainly limited to pre-clinical studies currently.

CONCLUSION

Andrological implications are heterogenous and frequently described in patients with chronic prostatitis syndrome. Nonetheless, andrological factors have not been routinely addressed as primary variables in the different studies, which makes further research necessary.

Prevention of recurrent urinary tract infections

Urinary tract infections (UTI) are among the most frequent bacterial infections in the community and health care setting. Mostly young and, to some extent, postmenopausal women are affected by recurrent UTI (rUTI) defined as ≥3 UTI/year or ≥2 UTI/half year. In contrast, rUTI is rare in healthy men. On the other hand, rUTI are frequently found in female and male patients with complicating urological factors, e.g. urinary catheters, infection stones. Remediable predisposing factors in uncomplicated rUTI in women are rare. In complicated rUTI the success depends mainly on the possibility to eliminate or at leastimprove the complicating risk factors. Continuous antibiotic prophylaxis or postcoital prophylaxis, if there is close correlation with sexual intercourse, are most effective to prevent rUTI. Nitrofurantoin, trimethoprim (or cotrimoxazole), and fosfomycin trometamol are available as first-line drugs. Oral cephalosporins and quinolones should be restricted to specific indications. Antibiotic prophylaxis reduces the number of uropathogens in the gut and/or vaginal flora and reduces bacterial "fitness". Given the correct indication, the recurrence rate of rUTI can be reduced by about 90%. Due to possible adverse events and the concern of selecting resistant pathogens, according to the guidelines of the European Association of Urology antimicrobial prophylaxis should be considered only after counselling, behavioural modification and non-antimicrobial measures have been attempted. In postmenopausal patients vaginal substitution of oestriol should be started first. Oral or parenteral immunoprophylaxis is another option in patients with rUTI. Other possibilities with varying scientific evidence are prophylaxis with cranberry products, specific plant combinations or probiotics. The prophylaxis of catheter-associated UTI should employ strategies which result in a reduction of frequency and duration of catheter drainage of the urinary tract. The currently available catheter materials have only little influence on reducing catheter-associated rUTI.

Clinical evaluation of human epididymis protein 4 as a biomarker for epididymitis

Aim: To evaluate HE4 as a potential biomarker for acute epididymitis. Materials & methods: HE4 levels in serum were measured in 62 patients with acute epididymitis and 62 age-matched male controls. Results: Both patients with epididymitis and the controls showed median HE4 values of 42 pmol/l (range: 10–560 pmol/l) and 34 pmol/l (range: 2–300 pmol/l), respectively (p = 0.3). Levels of HE4 did not change in the course of the treatment in patients with epididymitis. Regression analysis revealed no significant association between HE4 and any infection-linked variable. Multivariate analysis resulted in a number of factors associated with increased HE4 levels, which were renal dysfunction, cardiovascular diseases and malignancies. Conclusion: Although HE4 is not a biomarker for epididymitis and infection, it qualifies as a candidate for identifying patients with increased morbidity.

Presence of histone H3 acetylated at lysine 9 in male germ cells and its distribution pattern in the genome of human spermatozoa

During spermatogenesis, approximately 85% of histones are replaced by protamines. The remaining histones have been proposed to carry essential marks for the establishment of epigenetic information in the offspring. The aim of the present study was to analyse the expression pattern of histone H3 acetylated at lysine 9 (H3K9ac) during normal and impaired spermatogenesis and the binding pattern of H3K9ac to selected genes within ejaculates. Testicular biopsies, as well as semen samples, were used for immunohistochemistry. Chromatin immunoprecipitation was performed with ejaculated sperm chromatin. HeLa cells and prostate tissue served as controls. Binding of selected genes was evaluated by semiquantitative and real-time polymerase chain reaction. Immunohistochemistry of H3K9ac demonstrated positive signals in spermatogonia, spermatocytes, elongating spermatids and ejaculated spermatozoa of fertile and infertile men. H3K9ac was associated with gene promoters (CRAT, G6PD, MCF2L), exons (SOX2, GAPDH, STK11IP, FLNA, PLXNA3, SH3GLB2, CTSD) and intergenic regions (TH) in fertile men and revealed shifts of the distribution pattern in ejaculated spermatozoa of infertile men. In conclusion, H3K9ac is present in male germ cells and may play a role during the development of human spermatozoa. In addition, H3K9ac is associated with specific regions of the sperm genome defining an epigenetic code that may influence gene expression directly after fertilisation.

[New concepts for varicolele treatment in male infertility: the current situation]

There is no question that therapy for a varicocele in cases of male infertility improves the ejaculate quality. New data provide hints for an additional influence on the pregnancy rates in infertile partnerships.

[News from andrology. Infertility, erectile dysfunction, and hypogonadism]

This contribution discusses new aspects in andrology focusing on infertility, erectile dysfunction (ED), and hypogonadism. Topics such as prostatitis and detection of Chlamydia, idiopathic infertility and PDE5 inhibitors, and ED after GreenLight laser treatment are addressed.

[Removal of andrology from the specialty training programme in urology: a step forward or backward: initial assessment]

Andrology as a medical discipline has developed only recently. In the educational programme of residents in urology knowledge and skills of andrology are well established. But only since 2003 can urologists can become certified subspecialists in andrology. This made andrology much more visible to neighbouring disciplines, e.g. reproductive medicine, as well as to patients searching for well-educated specialist doctors in men's health. Andrology comprises more than infertility; it includes male endocrine disorders, dysfunctions of ejaculation and erections, questions of family planning and the andrological aspects of senescence. These aspects are included in the curriculum for andrology. There are a number of prerequisites of knowledge and skills established that have to be fulfilled by urologists, dermatologists or endocrinologists. Surgical andrological procedures are not included in the German educational programme, but are part of the European curriculum established by consensus of the European Academy of Andrology and the European Association of Andrological Urology of the European Association of Urology (EAU) in 2010. The educational programme is open to urologists and endocrinologists and covers a period of 18 months both in Germany and at the European level, with 6 months acceptable from the training for urology.The relevance of andrologists in IVF centres has been defined since 2006, with andrologists required to be included in the medical setting. According to the data of the General Medical Council of Germany altogether 1,474 andrologists are listed that had finished their certification by the end of 2010. Altogether 124 andrologists are licensed for training. Thus the first result of the subspecialisation of andrology can be evaluated positively. However, ensuring qualified andrological postgraduate training is the duty and the chance for the future of the urological community to maintain and further develop this field of subspecialisation.

Validation of reference genes in human testis and ejaculate

Beta-actin (ACTB), glyceraldehyde-3-phosphate-dehydrogenase (GAPD), Heat Shock Protein 1, beta (HSPCB) and Adenosine Triphosphate subunit 5 beta (ATP5B) with distinct functional characteristics and expression patterns were investigated as suitable references for gene expression studies. We determined the expression stability of the four reference genes in ejaculates, cryopreserved as well as fixed and paraffin-embedded testicular tissue (from fertile and subfertile men) applying real-time qRT-PCR and statistical analysis. The mean gene expressions (mean Ct value) were compared for each gene between the fertile and subfertile donors by using the Wilcoxon-Mann-Whitney test. We did not observe significant statistical differences between variability of genes. To detect random effects, we used the two-way analysis of variance with a hierarchical model. The results show no significant statistical differences between proband and repetition within the probands. Taken together, we concluded that ACTB, GAPD, HSPCB and ATP5B have a variable expression within these samples, but this variability is not statistically significant. This finding demonstrated that all these genes could be appropriated for further studies on gene expression in ejaculate and testis tissue. Therefore, the selection of the suitable reference genes is highly specific for a particular experimental model and validation for each situation, on an individual basis, is a crucial requirement.

Protamine-1 represents a sperm specific gene transcript: a study in Callithrix jacchus and Bos taurus

Spermatozoa are transcriptionally inactive cells, but contain acetylated histones, normally a characteristic of transcriptionally active cells. Acetylgroups are thought to represent epigenetic marks that are transmitted to the oocyte and are involved in starting gene expression in the zygote and in regulating gene expression during early embryogenesis. We performed reverse transcription polymerase chain reaction (RT-PCR) in the common marmoset monkey (Callithrix jacchus) and in bovine spermatozoa, oocytes, zygotes, two- and four-cell embryos to evaluate the presence of specific transcripts known to play a role during fertilisation and early embryo development, namely protamine-1 (PRM1), protamine-2 (PRM2), histone H1 (H1), histone H3 (H3), histone H4 (H4), cAMP-responsive element modulator (CREM), DNA methyltransferase-1 (DNMT1), TATA box-binding protein (TBP). All transcripts tested were present in spermatozoa of the common marmoset, while bull spermatozoa lack PRM2. Marmoset oocytes exhibited transcripts for H1, H3, H4 and TBP, whereas bovine oocytes revealed H1, H3, H4, CREM, DNMT and TBP mRNAs. In zygotes, we amplified H1, H4, TBP (marmoset) and PRM1, H1, H3, H4, CREM, DNMT1 and TBP (bovine). Two-cell embryos showed PCR products for H1, H3 and TBP in the marmoset. In the bovine, all transcripts could be observed except PRM2. In four-cell embryos, PCR signals were obtained for PRM1, H1, H3, H4 and TBP in the marmoset. In the bovine, all transcripts were detected except PRM2. Our data suggest that, in both C. jacchus and Bos taurus, PRM1 transcripts are delivered by the spermatozoon to the oocyte.

Apoptotic gene expression in potentially fertile and subfertile men

Human sperm contain similar amounts of protamine-1 (P1) and protamine-2 (P2). Although an aberrant protamine ratio have been observed in subfertile men, functional evidence is provided by protamine knockout mice exhibiting male infertility. As sperm DNA integrity is known to be linked with DNA fragmentation and apoptosis, we investigated whether the DNA fragmentation factor 40 (DFF40) ratio or caspase (Casp4, Casp6) and tumor necrosis factor superfamily member 10 (TNFSF10) ratio together with the P1/P2 ratio represents a reliable biomarker to discriminate between fertile and subfertile men. Real-time quantitative RT-PCR was used for amplification of P1, P2 and DFF40 in 49 testicular biopsies. Casp4, Casp6 and TNFSF10 have been selected from a PCR apoptosis array and were further investigated in another group of testicular biopsies (22 subfertile men versus 11 potentially fertile men). Using Spearman's rank correlation coefficient analysis, we did not find a correlation between DFF40 and P1, P2, P1/P2, score, fertilization rate and age. In addition, logistic regression analysis demonstrated no statistically significant effect of the analyzed variables on pregnancy. A two-way analysis of variance with repeated measures of relative expression of Casp4, Casp6 and TNFSF10 versus P1 or P2 in potentially fertile men and subfertile patients demonstrated statistically significant differences between both groups, all tested gene combinations and the interaction between two genes and both groups in all cases analyzed. Furthermore, significant differences in the expression of Casp4 and TNFSF10 between the groups of potentially fertile and subfertile men could be demonstrated. In addition, the means of differences of selected gene combinations revealed that the protamine to apoptotic gene ratio is statistically different between both groups. Our data suggest that Casp4, Casp 6 and TNFSF10 are differentially expressed in potentially fertile and subfertile men and represent useful biomarkers for predicting male fertility in combination with P1 and P2.

[Andrology: varicocele: an update]

Varicocele is a common finding in approximately 20% of adolescents and adult men and in about 40% of infertile patients. Although numerous theories addressing the deteriorating impact on the testis are known, the direct connection between varicocele and infertility is not clear. It is well known that after operative therapies an improvement in sperm quality is found. However, the impact on pregnancy in an infertile coupleship is controversial. While the most recent meta-analysis found an increased pregnancy rate after therapy, the Cochrane Reviews with the last update in 2009 did not. In summary, operative therapy seems justified in selected patients with infertility.

[Uncomplicated urinary tract infection and treatment]

Urinary tract infections (UTI) are frequent infections in the outpatient and hospital setting. With respect to treatment options, UTI can generally be stratified into uncomplicated and complicated / nosocomial infections. Uncomplicated UTI are represented by the acute uncomplicated cystitis and the uncomplicated pyelonephritis. They are mainly caused by E. coli. There are, however, also increasing resistance rates found in uncomplicated UTI, e. g., against aminopenicillins, cotrimoxazole and increasingly also fluoroquinolones. This development has called for a new evaluation of the treatment recommendations in uncomplicated UTI. As an empirical therapy for uncomplicated cystitis fosfomycin trometamol, nitrofurantoin or pivmecillinam are recommended as first-line agents. As the oral first line therapy for uncomplicated pyelonephritis fluroquinolones in high dosages are recommended. The frequent asymptomatic bacteriuria does not need to be treated, with only a few exceptions. Due to the increasing antibiotic resistance and the emergence of multiresistant uropathogens, empirical antibiotic treatment becomes more difficult. Therefore the results of susceptibility testing should be awaited whenever possible.