Evaluation of plasma membrane integrity of donkey spermatozoa.

The aim of the study was to develop a hypo-osmotic swelling test (HOS-test) for evaluating plasma membrane integrity in donkey spermatozoa. In the first study, six different hypo-osmotic solutions (fructose or fructose/sodium citrate, 75 or 150 mOsm, or bi-distilled water at 1 : 10 semen : solution ratio, or bi-distilled water at 1 : 3) were compared. The 75 mOsm fructose solution (1 : 10) and bi-distilled water (1 : 3) were chosen for study 2, where two incubation times (5 or 45 min) were tested. Bi-distilled water showed a significantly higher proportion of plasma membrane intact spermatozoa than the fructose solution (p < 0.05), it was thus concluded that the simple incubation for 5 or 45 min at 37 degrees C of one part of semen with three parts of bi-distilled water is an applicable HOS-test in the semen analysis of donkey spermatozoa. Regression analyses showed a significant correspondence of the latest method with Sybr 14- propidium iodide staining.

Prevalence of substance-related disorders in heart transplantation candidates.

Substance abuse cessation is one of the leading factors in determining the eligibility for the heart transplantation waiting list, as noncompliance with this issue may seriously endanger posttransplantation outcomes. Yet, the prevalence of substance-related disorders among candidates for heart transplantation has not been evaluated enough. Eighty three heart transplantation candidates were assessed for prior or current substance-related disorders through the Structured Clinical Interview for mental disorders according to DSM-IV. A prior history of at least one substance-related disorder was found in 64% of patients, with nicotine dependence as the most prevalent diagnosis (61.4% of the sample). Ten subjects were currently smokers, despite heart failure. A prior history of alcohol abuse and caffeine intoxication was found in 9.6% and 2.4% of patients, respectively. Substance abuse or dependence behaviors should be monitored during all the phases of heart transplantation program. Early identification of current substance-related disorders may allow better allocation of organ resources and proper lifestyle modification programs provision. A prior history of substance-related disorders should alert physicians to assess patients for possible relapse, especially after transplantation. The inclusion of a specialist in the assessment and treatment of substance-related disorders in the heart transplantation unit may reduce the risk of unsuccessful outcomes due to noncompliance with an adequate lifestyle.

Long-term safety and effectiveness of statins for heart transplant recipients in routine clinical practice.

BACKGROUND: Whereas the efficacy of statins after heart transplantation (HT) in controlled study settings has been clearly demonstrated, more extensive data are required on the safety and effectiveness of long-term treatment in routine clinical practice. METHODS: We analyzed the risks and benefits in clinical practice of treatment with statins in all patients who survived HT for at least a month from December 1985 through 2001. RESULTS: During a mean follow-up of 4.8+/-3.8 years, 186 patients were treated with statins (for a median duration [25th to 75th percentile] of 29 [12 to 54] months), while 48 received dietary therapy alone. Patients treated with statins (pravastatin, 48%; atorvastatin, 37%; simvastatin, 14%) presented linearized rates of rhabdomyolisis, myositis, and significant transaminase elevation of 0.37%, 0.74%, and 0.37% per year of treatment, respectively (no fatal event occurred). Low-density lipoprotein decreased after statins by 19% (P<.001). At multivariate analysis, treatment with statins was independently associated with reduced risk of cardiac allograft vasculopathy and overall mortality (P<.001). CONCLUSIONS: Our data provide necessary confirmation of the safety and effectiveness in routine clinical practice of appropriately monitored long-term administration of statins (particularly atorvastatin, pravastatin, and simvastatin) in the chronic post-HT phase. Strict follow-up is needed for HT recipients receiving high doses of statins with/without other medications potentially exacerbating the risk of adverse effects.

Combined heart and liver transplantation in four adults with familial amyloidosis: experience of a single center.

There are few reports of combined heart and liver transplantation (CHLT) for familial amyloidotic polyneuropathy (FAP). The technique for the operation remains to be defined. Four CHLTs were performed for amyloidogenic transthyretin-related (variant Glu89Gln-ATTR Glu89Gln) cardiomyopathy in our center. Patients 1 and 4 had no serious involvement of other organs, whereas patients 2 and 3 had evident peripheral neuropathy and gastrointestinal motility alterations. Patient 3 also had high-grade orthostatic hypotension. All four patients underwent cardiac and sequential hepatic transplantation with organs procured from the same donor. Venovenous bypass was used in patients 1 and 4 who experienced uncomplicated procedures. The amyloidotic liver of patient 4 was successfully utilized for a domino procedure to treat a patient with hepatocellular carcinoma on cirrhosis. The cardiac performance of patients 1 and 4 remains normal; there has been no progression of amyloidosis at 42 and 1 months after transplantation. Patient 2 had no intraoperative complications but experienced postoperative bleeding, renal failure, sepsis, and heart failure, and finally died of multiorgan failure 2 months after transplant. In patient 3, right hemicolectomy was required intraoperatively due to intestinal ischemia, without significant hemodynamic instability, while extracardiac symptoms of amyloidosis gradually worsened postoperatively. In conclusion, CHLT for ATTR Glu89Gln may be performed even in patients with advanced disease. However, the most compromised patients are more likely to display intraoperative risks, postoperative complications, and worsening of extracardiac, extrahepatic symptoms.

Folate supplementation after heart transplantation: effects on homocysteine plasma levels and allograft vascular disease.

BACKGROUND AND AIMS: After heart transplantation, the effects of folate supplementation on total homocysteine plasma levels (THcy) and heart allograft vascular disease (AVD) remain unclear. METHODS: Accordingly, we prospectively analyzed 48 heart transplant receipients referred for routine follow-up from July to September 1998 (age 54+/-11 years, 75% male, 35+/-27 months from transplant). Among these patients, 17 were treated with folate supplementation for 12 months (Group F), while 31 cross-matched for age, gender, serum creatinine and time from transplant (P>0.3 vs Group F for all) did not assume folate supplementation (Group NF). Routine coronary angiography for AVD detection was routinely obtained in every patient. RESULTS: THcy overall increased during the study period (from 16.6+/-6.5 to 19.4+/-7.6 micromol/l, P<0.001), and a strong trend toward higher THcy was observed in patients presenting AVD (22.4+/-8.7 vs 17.6+/-6.8 micromol/l, P=0.051). After 12 months THcy was lower in Group F as compared to Group NF (16.2+/-5.6 vs 21.1+/-8.1 micromol/l, respectively, P=0.033). CONCLUSIONS: Our results demonstrate that THcy increases over time in heart transplant recipients, and a strong trend toward higher THcy is observed in the presence of AVD. Since folate supplementation appears to positively influence THcy, a favorable effect of folate on AVD can be hypothesized.

Interplay between methylenetetrahydrofolate reductase gene polymorphism 677C-->T and serum folate levels in determining hyperhomocysteinemia in heart transplant recipients.

BACKGROUND: Homocysteine metabolism is often impaired in heart transplant recipients, and increased total homocysteine plasma levels may constitute a risk factor for the development of heart allograft vascular disease. Although 677C-->T transition in methylenetetrahydrofolate reductase (MTHFR) is associated with increased homocysteine levels in the general population, it is unclear whether MTHFR polymorphism influences homocysteine metabolism after heart transplant. METHODS: Homocysteine, serum folate, renal function, concentrations of cyclosporine and its metabolites, and MTHFR genotype were determined in 57 heart transplant recipients (age, 55 +/- 11 yr; 21% women; time from transplant, 48 +/- 42 months). RESULTS: Forty nine percent of the study population presented with hyperhomocysteinemia. Homocysteine was 17.1 +/- 5.9 micromol/liter, 19.4 +/- 4.9 micromol/liter, and 26.3 +/- 14.2 micromol/liter for genotypes CC, CT, and TT, respectively (p = 0.028, Kruskal-Wallis test). At multivariate analysis, MTHFR genotype was independently associated with homocysteine (p = 0.005). When the study population was divided into 2 groups accordingly to serum folate levels (above/below the median value of 6.1 ng/ml), MTHFR genotype remained a significant predictor of homocysteine only in patients with low serum folate (p = 0.048). CONCLUSIONS: This study demonstrates that hyperhomocysteinemia is frequent in heart transplant recipients and that the 677C-->T transition in the MTHFR gene independently and unfavorably influences homocysteine metabolism in this group of patients. Adequate folate intake may overcome genetic predisposition to hyperhomocysteinemia.

Arrhythmogenic right ventricular cardiomyopathy: clinicopathologic correlation based on a revised definition of pathologic patterns.

Different morphologic features of arrhythmogenic right ventricular cardiomyopathy (ARVC) have been described. However, it is still unclear whether they correspond to distinct forms of the same disease. A pathologic study was performed on a series of ARVC (15 from heart transplant and 12 from autopsy) from 2 Italian referral university hospitals. Based on both myocellular features and the nature of myocardial replacement, hearts were divided into 2 groups: infiltrative, with a lacelike pattern of transmural fatty infiltration and strands of normal residual cardiomyocytes (n = 11); and cardiomyopathic, with massive myocardial replacement by fibro fatty tissue and cardiomyopathic changes (such as hypertrophy and myofibril loss) of residual cardiomyocytes (n = 16). Hearts from the infiltrative group were mostly obtained at autopsy of patients who died suddenly. Fatty substitution was limited almost exclusively to the right ventricle. Mitral valve dysplasia (prolapse or cleft) was frequently present. Hearts from the cardiomyopathic group came mainly from heart transplants for congestive heart failure. Fibro fatty replacement was more extensive, usually biventricular. Active myocarditis and features suggestive of myocardial transdifferentiation were also observed. Despite these differences in clinical outcome and morphologic features, patients from the 2 groups showed similar mean age, sex distribution, occurrence of threatening ventricular arrhythmias, and prevalence of family history of sudden death, arrhythmias, or cardiomyopathy. Infiltrative and cardiomyopathic patterns represent different clinical and pathologic subsets of ARVC. Myocellular features are an important clue in the distinction between the two entities. The differentiation between the 2 patterns is feasible on endomyocardial biopsy and could give important prognostic information.

[Familial predisposition to ischemic cardiopathy: role of homocysteine and genetic polymorphism of methylenetetrahydrofolate reductase]. / La predisposizione familiare alla cardiopatia ischemica: ruolo dell'omocisteina e del polimorfismo genetico della metilenetetraidrofolato reduttasi.

Homocysteine represents a risk factor for coronary artery disease determined not only by nutritional habits, but also by the genetic polymorphism of the enzymes involved in its metabolism (i.e. methylenetetrahydrofolate reductase - MTHFR). However, recent prospective studies questioned the initial evidence of a clear epidemiological and pathogenetic link between homocysteine levels and coronary artery disease. Moreover, the relationships between MTHFR polymorphism and coronary artery disease remain unclear. In this paper, the recent literature analyzing the role of homocysteine and MTHFR polymorphism as a risk factor for coronary artery disease has been reviewed.

Psychological evaluation after cardiac transplantation: the integration of different criteria.

BACKGROUND: The psychological evaluation of patients undergoing cardiac transplantation is currently based on DSM-IV criteria. An alternative diagnostic and conceptual framework has been proposed by an international group of psychosomatic investigators. The aim of this study was to compare these new criteria (Diagnostic Criteria for Psychosomatic Research, DCPR) with DSM-IV in a population where a high prevalence of psychological problems is expected (heart-transplanted patients). METHOD: 129 consecutive patients who underwent heart transplant surgery were assessed according to DSM-IV and DCPR criteria. RESULTS: The results showed a higher number of diagnoses made using the DCPR than with the use of the DSM-IV. At least one DCPR diagnosis was found in 85 (66%) patients, whereas at least one DSM diagnosis was present in 23 (18%) patients. The number of DCPR diagnoses was almost the triple of DSM criteria. While patients who were given a DSM diagnosis frequently had additional DCPR diagnoses, many patients with DCPR criteria did not fulfill any DSM criteria. Four DCPR syndromes appeared to be particularly frequent: demoralization, type A behavior, irritable mood and alexithymia. CONCLUSIONS: The joint use of DSM and DCPR criteria was found to improve the identification of psychological factors which could result in a worsening of quality of life in heart-transplanted patients.

Role of statins in the management of dyslipidemia after cardiac transplant: randomized controlled trial comparing the efficacy and the safety of atorvastatin with pravastatin.

BACKGROUND: Cardiac transplant patients are at increased risk of dyslipidemia, a known pathogenetic factor in chronic rejection. The aim of this study was to compare the efficacy and the safety of treatment with atorvastatin (AT) and treatment with pravastatin (PV) in a population of dyslipidemic transplant patients. METHODS: Thirty-nine transplant patients were randomized to receive a 4-month cycle of therapy with AT or PV, in a cross-over sequence. We analyzed the effects on their lipid profiles using Student t-test for paired data. RESULTS AND CONCLUSION: Atorvastatin was significantly more effective than PV in reducing total cholesterol (33% vs 21%, p < 0.001), LDL cholesterol (45% vs 30%, p = 0.001), and triglycerides (24% vs 7.7%, p < 0.001), at lower doses and with comparable tolerability and safety.

Increasing plasma homocysteine during follow-up in heart transplant recipients: effects of folate and renal function.

BACKGROUND: Hyperhomocysteinemia is a common finding in heart transplant recipients and may represent a risk factor for graft failure. However, the time-course, determinants and effects of medical therapy on total homocysteine plasma levels after heart transplantation remain undetermined. The aim of this study was to prospectively analyze 1) the time-course of total homocysteine in heart transplant recipients; 2) the effects of folate supplements and cyclosporine A on total homocysteine; 3) the relation among renal function, serum vitamin levels, and total homocysteine. METHODS: Fifty-two heart transplant recipients consecutively evaluated for routine follow-up during 1998 were included in the study (mean age 54 +/- 12 years; 28% female). Among the 52 patients, 10 patients were treated with folate for the entire period of the study (Group F), while 26 patients never received folate (Group NF). The remaining 16 patients who did not take folate on a regular basis were excluded from subgroup analysis. Total homocysteine and creatinine plasma levels were assayed at entry into the study (time 0) and at the end of the study, 12 months later (time 12). RESULTS: Homocysteinemia increased significantly from time 0 to time 12 (p < 0.001), regardless of creatinine plasma levels (p = 0.03) and folate intake (p < 0.01). However, total homocysteine levels were lower in Group F compared to Group NF at time 0 and time 12 (p < 0.02). On multivariate analysis, time of follow-up, serum creatinine and lack of folate intake were positive independent predictors of total homocysteine. CONCLUSIONS: Homocysteinemia increased over time in heart transplant recipients, regardless of renal function and folate administration. Lower total homocysteine levels were associated with folate intake, suggesting that folate supplements may play a role in the prevention of vascular allograft disease.

Delayed acquisition of high-avidity anti-cytomegalovirus antibody is correlated with prolonged antigenemia in solid organ transplant recipients.

Previous studies have demonstrated that maturation of cytomegalovirus (CMV)-specific antibodies in solid organ transplant recipients is delayed after primary CMV infection. To investigate the clinical significance of this finding, the avidity indices of anti-CMV antibody were determined in parallel with other serologic and virologic parameters in serial serum samples from 24 solid organ transplant recipients who had primary CMV infection that began during the first 3 months after transplantation. The data obtained show that a delay in antibody maturation is significantly correlated with a long persistence of positive antigenemia.

Cyclosporin-A-induced gingival overgrowth in heart transplant patients. A cross-sectional study.

The incidence of gingival overgrowth secondary to the administration of cyclosporine A (CsA) is widely reported in renal transplant recipients, while there is no information about periodontal conditions in heart transplant patients. In the present cross-sectional investigation the relationship between clinical periodontal conditions and pharmacological profiles of CsA was determined in 39 patients (31 male and 8 female, aged 18-63 years, mean 45.6 +/- 15.2 years) who possessed their 6 upper and 6 lower anterior teeth. All patients had been on a CsA-based immunosoppression regimen for at least 6 months (6-101, mean 39.3 +/- 30.1). 2 periodontal parameters (recorded on the 12 anterior teeth only) relating to gingival overgrowth were considered: hyperplastic index and % of sites with probing depth > 3 mm. These parameters were always recorded by the same observer at first appointment and 2 months after an oral hygiene programme. Both non parametric statistical analysis (Kruskal-Wallis one-way analysis by rank, Wicoxon signed rank-test and Mann Whitney U-test) and parametric analysis (stepwise multiple regression analysis, one-sample and two-sample t-test) were used to investigate the relationship between the periodontal parameters (dependent variables) and a series of independent variables: age, sex, plaque index (PI), gingival index (GI), CsA dose, CsA blood level, duration of therapy (months since allograft). Results failed to demonstrate any significant correlation between gingival overgrowth and age, sex, CsA dose or CsA blood level, PI. A positive significant correlation was found between periodontal conditions and GI and a significant inverse correlation between periodontal conditions and duration of therapy, suggesting that the relation between CsA therapy and gingival overgrowth in heart-transplant patients could be time-related and the negative influence of the drug on the periodontal status could spontaneously decrease over time.

Severe postcardiac-transplant rejection associated with recurrence of giant cell myocarditis.

Giant cell myocarditis is a disease of unknown etiology with several controversial aspects: clinical course, therapeutic management, recurring risk after heart transplantation, and histopathological factors. We report a case of giant cell myocarditis that recurred after orthotopic heart transplantation and an uneventful postoperative period. The myocardial inflammatory process in this patient showed various evolutive phases: an acute onset of diffuse giant cell myocarditis, an evolution into a granulomatous form of inflammation within the explanted heart, and a recurrence with multiple giant cell inflammatory infiltrates in the transplanted heart. Moreover, the patient presented a severe clinical course after surgery with precocious and continuous acute rejections despite the repeated immunosuppressive treatments. In this article we discuss the morphological aspects of the disease and the postoperative course of this case in relation to the possible immune dysregulation of patients affected by myocarditis before heart transplantation.

Neurocirculatory asthenia: a reassessment using modern psychosomatic criteria.

The purpose of this study was to assess the prevalence of mental illness and to evaluate the quality of life of patients with neurocirculatory asthenia. A consecutive series of 80 patients who satisfied the diagnostic criteria developed by Kannel et al. for neurocirculatory asthenia was included in this study. Patients underwent a psychiatric diagnostic research interview and extensive psychometric evaluation, with both observer and self-rated scales for depression, anxiety, phobic symptoms, quality of life and abnormal illness behavior. In 47 patients (59%), a psychiatric diagnosis (mainly an anxiety disorder) antedated the onset of neurocirculatory asthenia, which was thus defined as secondary, also because cardiorespiratory symptoms were part of the mental symptoms. In the remaining 33 patients (41%) neurocirculatory asthenia was the primary disorder. Patients with secondary neurocirculatory asthenia reported significantly higher levels of anxiety, depression, social phobia, abnormal illness behavior and an impaired quality of life compared with patients with primary neurocirculatory asthenia. This latter did not significantly differ in these variables (except for depression) from healthy control subjects matched for sociodemographic variables. At a 1-year follow-up, patients with primary neurocirculatory asthenia had a much better prognosis than those with secondary neurocirculatory asthenia. The results indicate the feasibility of the primary/secondary distinction based on the time of onset of mental and cardiorespiratory symptoms in neurocirculatory asthenia. Since only about one quarter of the patients were found to suffer from decreased energy and fatigue according to specified criteria, the terms neurocirculatory asthenia and effort syndrome should probably be discarded.

[Vasodilator agents: the lesson from large clinical trials]. / I farmaci vasodilatatori: l'insegnamento dei grandi trial.

The results of trials of vasodilators in patients with chronic heart failure showed improved survival by adding ACE-inhibitors or a combination of isosorbide dinitrate and hydralazine to the usual therapy with digoxin and diuretics. However, the mean prolongation of life is unsatisfactory (10-17 months) and very small effects are observed on the various measures of quality of life. In patients with asymptomatic left ventricular dysfunction, the treatment with ACE-inhibitors reduces the progression to the clinical phase of heart failure but not in all patients. Therefore is attractive to evaluate new agents to improve the results of the present therapeutic strategies. The attempts to combine new vasodilators to regimens including ACE-inhibitors have been inconclusive or even deleterious. The identification of subgroups of patients with different clinical, hemodynamic and neurohormonal characteristics may allow a more appropriate use of the new therapeutic resources.

Tranexamic acid as a mouthwash in anticoagulant-treated patients undergoing oral surgery. An alternative method to discontinuing anticoagulant therapy.

A double-blind randomized study was carried out to evaluate the clinical hemostatic effect of tranexamic acid mouthwash after dental extraction in 30 patients who received anticoagulant agents. Surgery was performed with a reduction in the level of anticoagulant therapy in the control group and with no change in the level of anticoagulant therapy in the group who received the tranexamic acid. After the extraction the surgical field was irrigated with a 5% solution of tranexamic acid in the group of 15 patients whose anticoagulant treatment had not been discontinued and with a placebo solution in the group of 15 patients for whom the anticoagulant therapy was reduced. Patients were instructed to rinse their mouths with 10 ml of the assigned solution for 2 minutes four times a day for 7 days. There was no significant difference between the two treatment groups in the bleeding incidence after oral surgery. We conclude that the anticoagulant treatment does not need to be withdrawn before oral surgery provided that local antifibrinolytic therapy is instituted.