Inflammatory bowel diseases (IBDs), including ulcerative colitis (UC) and Crohn’s disease (CD), are chronic intestinal diseases of unknown etiology that present with variable disease extents and outcomes. The use of biomarkers for the diagnosis and management of IBDs is considered beneficial. Palmitoleic acid (PO) is an adipose tissue-derived mono-unsaturated free fatty acid that potentially serves as a lipokine in metabolic and inflammatory diseases. The aim of this study was to investigate the significance of PO levels in the serum of patients with UC and CD. The study included patients with UC (n = 22), patients with CD (n = 35), and controls (n = 22). The levels of serum PO were analyzed using gas chromatography. The association of serum PO levels with the clinical features and disease outcomes in IBD was examined. Serum PO levels were significantly higher in patients with CD than in controls, whereas no difference in these levels was observed between patients with UC and controls. Serum PO levels were significantly associated with the CD activity index. Additionally, high serum PO levels were associated with an increased risk of surgical intervention requirement during follow-up. In a pilot study with a few patients, high PO levels were observed in the mesenteric tissue in the active disease site of patients with CD (n = 7) compared with those with colon cancer (n = 6). Elevated serum PO levels might serve as a marker for local inflammation and prognosis in patients with CD. Both diseases often require long-term treatments, including 5-aminosalicylic acid (5-ASA), immune-suppressor, and anti-tumor necrosis factor-alpha (TNF-α) administration. Failure to control flare ups and induce remission with drug therapy can necessitate surgical interventions, including colectomy, enterectomy, and abscess drainage2. The severity and persistence of IBD markedly vary among the patients; it is difficult to assess the prognosis of the disease, especially, the risk for surgical intervention. Therefore, identifying a potential biomarker for assessing the prognosis of IBDs is of clinical interest.Ulcerative colitis (UC) and Crohn’s disease (CD) are inflammatory bowel diseases (IBDs). They exhibit similar clinical manifestations; however, only the mucosal layer in the large intestine is affected in UC3. Luminal antigens induce abnormal immune responses, including intestinal inflammation, reactive oxygen species production, and circulation of inflammatory mediators, such as cytokines3. Inflammation localized in the intestine wall may radiate to the surrounding visceral adipose tissue, resulting in the proliferation and activation of adipocytes, especially in CD4. The activation of adipocytes releases subsets of fat-derived hormones, such as vaspin and adiponectin. These hormones influence gastrointestinal immune responses by modulating the expression of proinflammatory interleukins and adhesion factors, especially, TNF-α, which plays a crucial role in the pathogenesis of IBD5.The etiology of UC and CD is still unknown; however, microbial agents, immune dysfunction, genetic susceptibility, and environmental factors, such as diet, are implicated as pathogenic factors9.Lipids are increasingly recognized as key components of multiple signal transduction cascades, including those associated with the regulation of inflammation. The levels of free fatty acids, especially poly-unsaturated fatty acids (PUFAs), are dysregulated in the serum of patients with IBD. The levels of n-3 and n-6 PUFAs, precursors of eicosanoids that are critical in modulating inflammation, are positively correlated with disease severity and pro-inflammatory cytokine levels14. The role of PO in immunity remains largely unexplored; however, several studies have shown that PO mainly influences anti-inflammatory responses. Incubation with PO has been reported to reverse the expression of proinflammatory factors and secretion of cytokines during proinflammatory polarization in bone marrow-derived macrophages obtained from high-fat diet-fed mice15. PO reduces nuclear factor-kappa B phosphorylation and downregulates interleukin (IL)-6 and tumor necrosis factor (TNF)-α expression in hepatocytes and inflammatory cells16. Nevertheless, Wang et al. used cross-phenotype analysis of genome-wide association studies to show that high serum PA levels could be associated with an increased risk of developing CD. They also showed that PO tended to increase neutrophil recruitment in 2,4,6-trinitrobenezene sulfonic acid-induced colitis in zebrafish17. High serum PO levels have been observed in diseases involving metabolic dysregulation and inflammation, such as non-alcoholic steatohepatitis, hypertension, and heart failure18. Thus, PO could be a potential clinical marker for inflammatory diseases.Palmitoleic acid (PO) is a non-essential omega-7 monounsaturated free fatty acid. It is the third most common unsaturated free fatty acid in the human serum, after oleic acid (OA) and palmitic acid (PA). PO is an adipose tissue-derived lipid hormone (lipokine) that improves insulin sensitivityThere is a growing interest in the role of fatty acids in metabolic and inflammatory diseases; however, the association between serum PO levels and IBD severity and prognosis remains unexplored. In this study, we aimed to elucidate the role of PO levels in the serum of patients with IBD and its potential for use as a clinical biomarker for IBD.The patient characteristics are summarized in Table Disease status and treatment at the time of sample collection are shown in Table Serum PO levels in the UC, CD, and control groups are shown in Fig. Based on these results, we assessed the factors that might affect PO level in patients with CD. Age, BMI, and C-reactive protein (CRP) levels did not have a significant correlation with PO levels, whereas the CDAI, which reflects disease severity, showed a moderate positive correlation with PO levels Fig. . OngoingNext, we assessed whether PO levels are related to IBD prognosis. This assessment involved patients who underwent surgical intervention after sample collection for multivariate Cox regression modeling Table . Of the p < 0.0224, Fig. To investigate the potential source of serum PO, the levels of PO in the mesenteric adipose tissue (MAT) was studied in patients with IBD in a pilot study; patients with colon cancer (non-tumor area) were included in the control group. PO levels in the site of active disease in patients with CD were significantly higher than those in the MAT of patients with colon cancer p < 0.022, Fig. 4AIn this study, we found serum PO levels to be significantly higher in patients with CD than in healthy controls; serum PO levels were positively correlated with disease activity in patients with CD but were not correlated with BMI or elemental diet, which are the possible factors besides disease activity that can affect PO levels. Elevated serum PO levels were associated with an increased risk of requiring surgical intervention.19. Studies have indicated that circulating PO levels are associated with multiple metabolic risk factors and inflammatory diseases but in mixed directions, perhaps related to diversified lifestyle determinants or an endogenous source of fatty acids in humans20.PO has garnered attention in recent years because of its potential role as an adipokine21. A high ratio of PO to linoleic acid levels has been reported in children with CD3; its relevance to the clinical severity and course of CD in adults is poorly understood. To the best of our knowledge, the present study is among the first to analyze the detailed relationship between PO levels and IBD, with reference to disease activity and prognosis.The lipid profile is altered in both the serum and adipose tissue in patients with IBDsWe observed elevated serum PO levels only in patients with CD, in comparison with its levels in the control subjects. The other two major free fatty acids, PA and OA, remained stable in the serum of patients with CD; therefore, PO could be a potential biomarker reflecting the disease status in CD. In addition, PO levels did not exhibit an association with BMI or elemental diet; therefore, PO levels do not merely reflect the nutritional status of the patients. Interestingly, circulating PO levels were associated with the CDAI as well as levels of CRP, which is a general inflammation marker. These results suggest that PO serves as an optimal biomarker for determining the clinical severity of CD. The CDAI score includes the severity of abdominal pain and incidence of diarrhea, the occurrence of which in patients must be recorded for 1 week. In addition, data comprising BMI and blood hematocrit levels are necessary, and physicians are required to confirm the absence or presence of abdominal mass. Therefore, serum PO level may be beneficial to estimate the inflammation state in patients with CD when the collection of necessary information is challenging. In addition, our study showed that PO levels serve as a significant indicator for the need of later surgical procedures, which might be helpful in identifying high-risk cases that are prone to drug therapy failure. Thus, PO levels could alert physicians regarding the risk of complicated CD, thereby aiding in deciding the extent of treatment and follow-up intervals.22. Accumulating evidence suggests adipose tissue in the mesentery might play a highly active role in the pathogenesis of CD23. For example, mesenteric adipocytes in patients with CD have been shown to secrete both proinflammatory mediators  and anti-inflammatory cytokines 25. In CD, a high visceral to subcutaneous fat area has been reported as a biomarker for complications of CD including fistula and luminal stricture, which are often the indicators of surgery requirement. Our pilot study conducted using abdominal MAT samples from a small number of patients indicated a tendency of PO levels to increase in the active disease site of CD compared with that in patients with UC and controls. These findings suggest that PO may be released from the MAT. The possible explanation for the differential PO levels between patients with UC and CD is that inflammation caused by CD often affects the entire wall of the digestive system, which causes fat wrapping of the mesenchymal tissue as a defense mechanism in the active disease site26. A study in a larger population, including the other potential sources of PO, such as the liver and subcutaneous fat, could substantiate our hypothesis.The main sources of serum free fatty acids, including palmitoleate, include the adipose tissue, the liver, and dietary intakeLimitations of this study include the relatively small number of individuals studied and the lack of functional studies of PO.27. PO blocks the inflammatory cascade triggered by endotoxins by downregulating the expression of Toll like receptor-4 (TLR-4) and nuclear factor-kappa B (NF-κB) and decreasing the production of pro-inflammatory cytokines in cultured primary macrophages28. PO treatment has been reported to be beneficial for patients with UC; however, there are no data on its use in patients with CD29. A previous study showed that the occurrence of SNPs near fatty acid desaturase 1 and glucokinase regulator was related to both increased serum PO levels and enhanced risk of CD in humans, thus indicating that high PO levels may be associated with an increased risk of CD. Our result is consistent with that of a previous study; it indicates that serum PO levels may also affect disease outcomes17.In general, PO supplementation is beneficial in suppressing inflammation, such as atherosclerosis in mice, where it prevents the activation of endoplasmic stress and inflammasomesIn conclusion, our data indicate altered PO metabolism in CD and its role in identifying disease activity. PO has the potential to serve as a disease activity marker for local inflammation, as well as a prognostic factor, in CD.The protocol of this retrospective study was approved by the medical ethics committee of Nagasaki University Hospital Clinical Research Ethics Committee . Patients who did not provide informed consent were excluded from the study. For subjects under 18 years of age, informed consent was obtained from their parents and/or legal guardian. This study was performed in accordance with the ethical guidelines of the Declaration of Helsinki. The serum study group consisted of 57 patients with IBD (35 patients with CD and 22 with UC) from April 2010 to March 2011. Twenty-two healthy volunteers were recruited as controls. The diagnosis of UC or CD was confirmed according to standardized criteria by prior clinical assessment, endoscopy, and histology. Omental fat specimens were obtained from 6 patients with CD and 4 with UC and were compared with those from 7 patients with colon cancer who underwent surgical resection between April 2013 and November 2014. The clinical records of the patients were then investigated from the time of sample collection until September 2020. Baseline data collected included those for sex, age, disease duration, surgical history, concomitant medications, CRP level, CAI, and CDAI. The dates of all surgical intervention procedures, including colectomy, enterectomy, and abscess drainage during the follow-up, were recorded for patients with IBD.Serum samples were collected from all patients with IBD and healthy volunteers in ethylenediaminetetraacetic acid tubes and preserved at − 80 °C until use. The MAT was collected during the colectomy. All surgeries were performed because of clinically necessary reasons. The MAT samples were stored at − 80 °C until use. Samples were homogenized in a Fast Prep System with Lysing Matrix D . The homogenates were extracted using a mixture of methanol, chloroform, and purified water. The extracts were concentrated to complete dryness by blowing nitrogen. After transmethylation with HCl-methanol (3 h at 70 °C), the fatty acid composition was analyzed by gas chromatography  using a GC flame ionization detector system  equipped with a capillary column  by TORAY Research Center . Methyl stearate was used as the internal standard for free fatty acid analysis. The injector temperature was 250 °C, and the detector temperature was 270 °C. Initially, the column temperature was set to 50 °C for 1 min, and then ramped up to 270 °C at a rate of 8 °C/min. Helium was used as carrier gas at a flow rate of 30 cm/s. The concentration of fatty acids was assessed through a comparison with the standard Supelco 37 FAME component .Statistical analyses were performed by a statistician (HK). Differences in quantitative values between two groups were assessed using the Wilcoxon rank-sum test. Differences in values among three or more groups were assessed using the Steel–Dwass test. A Cox proportional hazards model with person-days as the underlying metric was employed to estimate hazard ratios for surgical interventions for CD using the PHREG procedures in the SAS software package . The AUC and cut-off value of PO levels for surgical interventions were calculated using the LOGISTIC procedure with the SAS software package. All statistical tests were two-sided, and results with p < 0.05 were considered statistically significant.This study was performed in accordance with the ethical guidelines of the Declaration of Helsinki.Written informed consent was obtained from each patient.


The practice of human organ transplantation studies is shot through with questions concerning the concepts of selfhood and identity that continually reach out towards transmigration, displacement and haunting. In particular, heart transplantation is the site at which the parameters of human life and death are tested to their limits, not simply for the recipient but for the donor too. In conventional biomedicine, the definition and therefore the moment of death is a matter of ongoing and disturbing dispute between two major channels of thought. Should we understand life to end at the point of cessation of cardiac function, or alternatively that of the brainstem? That whole logic is predicated, however, on the familiar binary of life/death that fails to address urgent concerns in three arenas: social-cultural imaginaries, postmodernist philosophy and increasingly exploratory bioscience. If there is always something about death that is uncanny, that exceeds rationalist thought, then we need to queer the concept and ask whether there are more sensitive ways of thinking the process of dying. The very concept of extended life for the recipient is no simple outcome, and the question of whose life has been prolonged is far from clear. My contribution touches on the idea of thinking transplantation in the mode of parasitism but will suggest an alternative Deleuzian way forward. The field of human organ transplantation studies is shot through with questions concerning the concepts of selfhood and identity that continually reach out towards transmigration, displacement and haunting. Most particularly, heart transplantation is the site at which the parameters of human life and death are tested to their limits, not simply for the recipient but for the donor too. In conventional biomedicine, the definition and therefore the moment of death is a matter of ongoing and disturbing dispute between two major channels of thought. Should we understand life to end at the cessation of cardiac function, or alternatively that of the brainstem? The distinction is no trivial matter but is strongly tied to which utilitarian consequences are in play, and how interventions like the removal of organs for transplant should be operationalised. The whole issue is predicated, however, on the familiar Western binary of life/death that fails to address urgent concerns in three arenas: social-cultural imaginaries, postmodernist philosophy, and exploratory bioscience in which microchimerism defies a simple temporal cut. If there is always something about death that is uncanny, that exceeds rationalist thought, then we need to queer the concept and ask whether there are more sensitive ways of thinking the process of deceased donation. The very concept of extended life for the recipient is no simple outcome, and the question of whose life has been prolonged is far from clear. My approach touches on the idea of thinking transplantation in the mode of parasitism but will suggest an alternative Deleuzian way forward.should not be living. Certainly life and death intrude on one another, but the prevailing psychosocial imaginary of the global North remains confident that the entanglement can be resolved into a familiar binary difference. What would it mean then to think not about death as a bounded category but as irreducibly entangled in the processes of life? Jacques Derrida is perhaps exemplary in his exhortation to live well with the dead and to accept the hauntological dimensions of all existence—by which he refers to those elements which are neither present nor absent, neither dead nor alive—while Gilles Deleuze provides a way of challenging the normative temporalities of death. I want to start, however, by looking at the implications of some more mundane considerations arising from the biomedical understanding of death and dying, particularly in relation to heart transplantation, and by reflecting on some empirical data as they illuminate my theorisation of the issues involved.In the era of biopolitical thought and its concern with what constitutes the parameters of life, the emphasis has been firmly on the management of the living in every register of existence—social, political, ontological—without fully engaging with what, if anything, constitutes death as an irrecoverable endpoint. We understand that the dead still contribute as data as Process of Incorporating a Transplanted Heart (PITH) initiated in 2007, which from 2011 segued into The gift of life: A critical visual exploration of donor families’ responses to organ donation (GOLA).display no doubts about the moment at which ‘natural’ death has occurred and it would appear appropriate to terminate any life support technology. Donor families are far less certain and may feel acute distress, not only in being asked to rapidly consent during a time of shock and often disbelief, but also in frequently questioning if the person before them is really dead.Over several years, I have collaborated on two major qualitative research projects in Canada: the In all but certain unusual cases, the normative split between dead and alive prevails, and where donor families do refuse consent it is often for reasons other than a questioning of death itself. Yet there are some disturbing and highly visible anomalies that trouble the distinction. For example, even after the machinery that prolongs respiration and heart beat has been disconnected, a putatively brain dead body may show strong signs of animation, as in the so-called Lazarus sign . This ofare forms of rudimentary communication. A review by Even in the face of growing research, the implications of such considerations remain speculative, but my misgivings become clearer in the recent historical context of what constitutes death for a prospective heart donor. Up until the 1960s death was defined as the failure of the cardiorespiratory system, with the permanent cessation of breathing being the unquestioned mark of death. With the invention of the artificial ventilator, however, a dying patient could be resuscitated or stabilised so that the heart would go on beating for an indefinite period. Given that the 1960s were also the point at which organ transplantation became feasible, this technological intervention clearly created a conundrum in that it could no longer be certain that the patient had died. Partly in response to this, the biomedical definition of death—in Westernised societies at least—was shifted in 1967 to brain death which it was felt could be accurately assessed even though the body was warm, breathing and oxygenated.That disparity underpins the immediate scenario of donation and retrieval of the organ where the codification of passing time is at its most acute and conflicted, as our qualitative study of 22 Canadian donor families shows. All consented to the donation of one or, more usually, several organs once brain dead had been established, yet the clinicians’ desire for a speedy procedure gave little time for bereaved relations to examine their own feelings and doubts. While none of our interviewees overtly questioned the distinction between cardiac and brain death, the sight of a still breathing, at least minimally reactive body was extremely disturbing for many. As Kathleen Fenton puts it, ‘society as a whole is not completely comfortable with the idea that a warm, pink patient is actually a corpse’ , 2056. AGOLA project—which was an art, social sciences, humanities and medical sciences collaboration—had agreed to donation whatever their misgivings. For just a few, it was a seamless transaction that scarcely raised any ontological anxieties and provoked only minimal speculation on the meaning and temporality of death. One robust 80-year-old retired professor (D20) who donated her husband’s organs told the interviewers, “I looked down at him and said that’s not my husband…the body is just cells…they’re not the person,” while the parents (D6) of a deceased daughter remarked, “We were a little bit on pins and needles to make sure it [donation] happened.” Most commonly, clinical staff were praised for their sensitive approach, but they could not, nevertheless, cover over the strangeness of the situation. As one mother (D18) puts it, they “were very professional and personal at the same time,” but “in the back of my mind I kept wondering was he really gone.” The majority of respondents, however, experienced the short process of gaining consent as highly disturbing—“like a pushy used car salesman,” said two bereaved sisters (D3) who had witnessed their “dead” brother’s legs still twitching and a tear falling from his face; or “like seagulls circling” as one bereaved husband (D1) described the clinical staff. A mother (D8) who still felt traumatised 36 months later told us that the time of her daughter dying was unbelievably bad because “she looked like she was just asleep,” so “I just wanted to punch them in the face…That’s your child being carved up to be doled out to other people.” Another mother (D16), this time of an adult son described 3 days of emotional turmoil when “you listen but you don’t hear…it’s gut wrenching.” Her profound doubts following consent pervaded her dreams: “I was having nightmares…when they were removing his heart and eyes, he was screaming.” Another (D2) said of the same period: “I felt some-one was surgically removing my heart.”All the donor proxies interviewed for the him to live on through them. The father, however, had wanted to be sure and resisted consent, leading to an 8-day gap between the declaration of brain death and donation.The provision of life support that is necessary during the quasi-death period to maintain the functionality of organs clearly creates an epistemological quagmire for those who are asked for consent, which does not end once the transplantations have been completed. This can be illustrated with reference to a particular case of a young First Nations man who had drowned but been temporarily revived. This was an especially lengthy and harrowing story in that the estranged non-indigenous mother (D14) was interviewed separately from her indigenous husband and daughter (D9). Everyone was in agreement that the deceased man, Eric,both Eric and the recipients would be enabled to live on through donation. Each parent and his sister talked about Eric actively saving five lives through the distribution of his organs and somewhat unusually they saw his continued being-in-the-world as a matter of everything being connected and sustained. The father’s raw grief at his loss was mediated by a sense of Eric’s continuing presence in his life and he stressed how he would like to ask the heart recipient if he ever wanted to ride a horse or climb mountains as his son did. For the family, Eric is both part of the recipients and may guide their behaviour, but he is also everywhere, beyond any specific temporal location. As the mother said about the interview, “I love talking about Eric…I hope he hears me,” while the father and the sister are certain they are still in communication. A spirit guide from another indigenous group had even contacted them with a message from Eric which they are inclined to accept at face value.During that period he attended a drumming ceremony at the lake where Eric drowned, and felt that he was given certain signs from the natural world that convinced him that donation should go ahead: two loons on the lake that spoke to the calmness of Eric’s spirit, a crow that flew up overhead in response to a prayer for a sign from Mother Earth, and finally coming across a seemingly dead, but still sprouting tree which signalled the intertwining of life and death. For the father, living on did devolve on his son but in two conflicting ways. On the one hand his First Nations beliefs were opposed to donation because the body is cherished (as a gift in itself), the self is transcendent, and not least because Eric’s eyes were needed to show him the way to the spirit world. On the other hand he firmly believed that The specific indigenous imaginaryand to the donor. In some magical sense the necessary death of the donor is negated and she is not so much reincarnated in an other as she occupies a new location where aspects of the self can endure. As the mother (D2) of a teenage donor puts it, “I haven’t lost him – I know exactly where he is…he’s still giving,” or a daughter (D17) speaking of her father, “He lives on, he got to share himself with strangers.” There are perhaps some hints of parasitism in the strange alliance between the deceased donor and the recipient, where one of the organisms benefits at the expense of another, but given the marked emphasis on altruism it may better be thought of as a hauntological relation or symbiotic entanglement.What does all this mean to donor families reflecting on their decisions to assent to the transplantation process? The question of living on is central to their thinking, although the grief experienced may overwhelm other affects. The narrative favoured by OPOs clearly promotes the transplant organ as the so-called gift of life that offers the hope of survival to recipients, with the associated benefit to donor proxies that they have engaged in an altruistic act. There is recognition too that altruism is not entirely disinterested in that giving has therapeutic effects in introducing something positive into the scenario of loss. As one woman (D4) puts it, “I had to believe in something good. It was the most awful thing,” while an upbeat couple (D6) whose daughter died in a Road Traffic Accident stressed, “Do the recipients know how happy we are?” “Do they know we are on their team?” What is less acknowledged is that many proxies are more or less invested in the belief that through donation it is not only the recipient but also their dead loved one who will live on. It is certainly the case that donor proxies may express a deep concern for recipients and say that they would be devastated again should the recipient fail to flourish, but as our interviews revealed it is rarely that simple. As the father (D8) of young woman killed in a light aircraft crash told us, “we don’t need any more grief,” while his wife adds, “Ruth [the recipient] is a little piece of Lisa [their daughter]…if something happened to her, it would be another death for Lisa.” The empirical data show that the majority of donor families go on referring to transplanted hearts as still belonging to their own loved one, and as having an agency independent of the recipient, who in turn habitually experiences the transplanted organ as not fully incorporated to the self, but rather as a living reminder of the deceased donor. Typically as one respondent (D13) puts it, “There’s my sister’s heart beating away in someone else, bringing them joy,” and she thinks of the donated organs as “keeping them alive, that’s what they’re doing, they’re keeping others alive with their organs.” It is difficult to escape the conclusion that living on refers both to the survival of the recipient The whole procedure is greatly complicated where anonymity between recipients and proxies is enforced, although that requirement is breached with some frequency. In many jurisdictions—including in the geographical area of my own research—anonymity is legally mandated between transplant recipients and organ donors or their proxies. Any communication between donor families and heart recipients is vetted, depersonalised and anonymised prior to being shared, such that no one should know the identity of the giver and the receiver of ‘gifted’ organs. Despite the widespread terminology of the ‘gift of life’ to describe the transplanted organ, which implies an intimacy in the relation between the donor and the recipient, anonymity has been central to biomedical, psychosocial and societal practices and discourses around the process. The result is an inevitable disjunct between significant evidence that both individual recipients and donor families may be emotionally troubled by the prohibition, and the wider biopolitical context of transplantation procedures which operate through a systemic de-individualisation of donors and serve to endorse the commodification of their bodies. The practice of anonymous donation is deemed a public good—mediated by the biomedical community—in which the gift is not personal at all, but becomes an expression of community cohesion rather than an enactment between individuals. The bitter irony, nevertheless, is that those most intimately concerned are simultaneously encouraged to celebrate the individual ‘gift’ relationship and denied knowledge of their counterparts as either recipients or donors. Either way, anonymity intends to effect a profound depersonalisation that enables organs to be translocated in the service of utilitarian ethics. Although OPOs are not unaware of the strength of negative feeling about imposed anonymity, they go to some lengths to cover over identities, ostensibly for the protection of both donor proxies and recipients. There may, of course, some sense to this,Throughout the pretransplant and post-transplant process, the donor is disembodied and effectively stripped of identity, seen only as the source of spare body parts precisely because in conventional biomedicine the heart is regarded merely as a pump, and transplantation as a technically mediated medical intervention with no metaphysical or ontological connotations.Right from the start with the original PITH project and subsequently with the GOLA research, our own study has been guided by a very different approach that initially referenced the philosophy of are strongly encouraged to write anonymised letters, with at least an expression of gratitude, although donor proxies—longing for some indication of the location of the gifted organ—may initiate the correspondence. Given that any identifying text—gender, ethnicity, names of pets, age, employment categories—is redacted at source, it is hardly surprising that the quasi-obligation to engage in a wholly anonymised exchange does not often provide the resolution that is sought, but becomes a focal point of overt disturbance for givers and receivers alike.What is really at stake in this seemingly uncaring approach opens up another dimension of anonymity in organ procurement and donation that I will touch on just briefly. While it is ethically routine to decry the international trade in scarce organs, the commodification of the body parts that it evokes is not confined to illicit activity. It is fundamental to the operation of transplantation as both enhancing life and seeking death. The thanatopolitics of transplantation is not simply an aberrant side effect. Once the human body is thought of as an object of commodification in the Marxist sense, its specific fragmentation in the transplant scenario ultimately renders the organs of the deceased donor as objects, with a use-value, shaped by quality, quantity and utility, and determined through consumption. Evoking commodity fetishism, should not be known, there is in both a hauntological dimension that finds resonance in the concept of ‘living on’ that is the counterpart of deceased donation.In the context of anonymity, the gift rhetoric that is the common currency of any communication unintentionally flirts with danger by encouraging donor proxies to look for a return on their supposed altruism when nothing substantial can be offered. At an unproblematised level, the implicit demand for reciprocity can collapse into ‘the tyranny of the gift’ for both parties.All forms of organ and tissue donation might be expected to evoke the absent presence of the other, but throughout our interview material, which often touches on other forms of donation, it is invariably the heart, with all its cultural baggage, that is the centre of attention. All the respondents spoke of donors who were the source of multiple organ and tissue transplants, but no other organ had the power to disturb the normative teleology of life and death, that was attributed to the heart. One bereaved mother (D16) expressed something of this breakdown: “I miss him, I miss him, I carry him in my heart for ever. You carry him for 9 months, to grow up, to have a normal progression,” and unusually she saw the trope of ‘living on’ as extending to herself. Imagining what she would tell the recipient, she says, “Take care of the heart and it will look after you for the rest of your life,” adding “I hope he’d look after his heart. After all I created that heart…(I hope) he’s a good man.” In that context, it is no surprise that the death of a recipient—if it is known—can come as another personally felt death. As one mother told us, “We need to know that they lived.” A single respondent (D12) cited the spare parts model of transplantation—“it’s like taking an engine out of a car”—and a couple more referred to the heart as a pump, but for the majority there is nothing impersonal about the transfer. Against the clinical metaphor of replaceable machine parts, the counternarratives of the gift of life and donor altruism promoted by OPOs are the ones that make most intuitive sense to donor families. Where for the clinical professionals the success or failure of the procedure is a matter of objective biomedical measures, the longer term emotional impact of the decision on the lives of donor families and recipients alike tells another story in which the clear distinction between life and death is lost.is seen as an exchange that grounds an intimate and ongoing relation between self and other. Yet, as With regard to living on, however, the approved notion is supposed to be purely symbolic, or at least referencing only the recovering recipient. The authorised discourses stop short at a template of a dying, and then deceased, donor superseded by the putatively restored life proper to the recipient alone. Despite the keen beliefs of donor proxies, indicated in the quotes above, there is nothing in official models to disturb the succession of singular selves. In the biomedical imaginary—which constrains but does not wholly suppress the intimations of donor families—if only inanimate material is transferred then no ontological anxieties should arise. At present, the imposition of anonymity matters both positively and, more often, negatively precisely because transplantation Before pursuing that different theoretical—and in the end more affective approach—I want to quickly mark that the biology of transplantation is far less straightforward than it purports to be. I have already outlined the difficulty of making a biomedically coherent cut between life and death once a donor body is maintained in a perfused state and the ontological anxiety that invokes in donor proxies, but there is an even more complicating factor. The phenomenon of microchimerism in which a single body may host two or more entirely separate sets of DNA has long been acknowledged as a feature of maternal-fetal interchange in pregnancy and subsequently, and more controversially, since the early 1990s as a potential outcome of transplantation (Starzl et al. 1992; At this point in time, the existence and persistence of microchimerism are no longer doubted, but its cause—transplantation is just one of several possible sources—and its effect remain highly disputed in the bioscience of immunology. The major controversy revolves around the question of whether it should be regarded as pathological or beneficial, or perhaps both in different contexts. Biomedicine aside, the implications of microchimerism have become an arena of deep fascination for biophilosophy, particularly with reference to the notion of immunity, but also for the instability it brings to questions of self and other and life and death . If micris marked by discrete episodes such as pregnancy, transplantation or dying that effect radical changes or transformations for that specific person, in another sense, those modes also transcend any singular form of embodiment and can be understood as intangible and atemporal forces and points of intensity. The Deleuzian approach rejects the modernist and very Western imaginary of an atomistic and sovereign subject, and celebrates instead not sustained and independent ‘being’—the enduring sense of self—but a material and processual state of becoming in which any individuality is provisional and always in the course of unravelling (As a philosopher concerned with experiential states, I have long felt highly ambivalent about organ transplantation, initially from witnessing the ongoing disruption of recipients (which I have scarcely touched on hereavelling . In shorongoing and fluid project that encompasses both the recipient and the deceased donor.As Deleuze sets out, each of us is entangled in what he calls assemblages, those fields of energy reliant on multiple and shifting networks of interconnections, both organic and inorganic, that constitute life itself. In such heterogeneous orders, what matters are the mutual interactions and the irreducible hybridity of form that exceeds the unique experiences and singular embodiment of the individual . In placThe medical humanities to date have a limited appreciation of the Deleuzian intervention into modernist ontology and epistemology, but assemblages are highly significant in enabling us to reconsider the nature of embodiment, not least in transplantation . DeleuzeAt the present time, the sociocultural imaginary of the global North remains dominated by quasi-Cartesian conceptions of the body, and by the separation of self and other, both modes that facilitate the surgical onslaught of heart transplantation through the machine model and at the same time generate deep anxieties when that model fails to correspond with lived experience. The research I have outlined attempts to think beyond transplantation as a heroic intervention that defies death, and to recognise that organ donation generates a disturbing and potentially painful awareness that the boundaries of the self are no longer certain. It suggests two new registers of thought: first, if the personal event of dying were seen simultaneously as the recomposition of life under new relations of sustainability, then mortality itself would not be a failure; and second we might reimagine existence not in terms of a recovered self, but through dynamic incorporeal coexistence and forms of assemblage. In contradistinction to modernist societies that regulate what is deemed appropriate to any given body, the Deleuzian approach advocates pushing to the limits of what is possible, embracing uncertainty and radical change, and sustaining becoming, however that plays out. The task is surely to begin to change the sociocultural imaginary. One step might be to push the authoritative discourse of biomedicine to give up its investment in mastery and chrononormativity and openly explore what lies beyond the wound of the sutured body. It requires a paradigm shift on the part not just of clinicians, but all of us, to bring the threads together. Revisiting the case of the First Nations family, it is apparent that beyond the Western mindset there are already more positive ways of thinking death that can speak to a wider atemporal vitalism. We cannot deny the immediate pain or grief of individual demise, but it can be mitigated through an open encounter with another dimension where living and dying, self and other, absence and presence are irreducibly entangled.


Torsion of the testis is an urgent surgical condition that endangers the viability of the gonad and the fertility of the patient. Our aim was to assess potential autoimmune processes and hormonal abnormalities in boys operated on due to that illness.The authors evaluated the levels of antibodies against sperm and Leydig cells, concentrations of follicle-stimulating, luteinizing and anti-Müllerian hormone, testosterone, oestradiol and vascular endothelial growth factor in the serum in 28 boys operated on due to torsion of the testis. Patients’ sexual maturity was assessed according the Tanner scale .No antibodies against sperm or Leydig cells were found in the serum. Statistically significant differences in follicle-stimulating and anti-Müllerian hormone concentrations were observed in the G1, and they were higher in the study than in the control group. There were no statistically significant differences in luteinizing hormone, testosterone, oestradiol and vascular endothelial growth factor concentrations in the study group or control group. Testosterone concentration was unrelated to total testicular volume.Results did not confirm the autoimmune process in boys with torsion of the testis. The pituitary–testis axis seems to have sufficient compensation capabilities. However, study results suggest that primary gonadal dysfunction may predispose to torsion.Significant differences exist between the literature data and own results on the formation of antibodies and hormonal changes due to testicular torsion in boys.It is a novel, prospective study on antibodies against sperms and Leydig cells in the serum and on hormonal processes occurring as a result of the testicular torsion from the prenatal period to the adolescence with division into pubertal groups.The study has revealed sufficient compensation capabilities of the pituitary–testis axis and no autoimmune process in boys with torsion of the testis. The disease mainly affects boys in the neonatal–infant age and at puberty.7Torsion of the testis (TT) is an urgent surgical condition involving incomplete or complete and single or multiple rotation(s) of the spermatic cord around a long axis with impaired blood flow through the testis.10 This urgent surgical condition can be caused by injury to the scrotum, intense physical effort or strong spasm of the cremaster muscle.8Various anatomical abnormalities predispose to TT, such as incorrect attachment of the testis or epididymis in the scrotum, bell clapper deformity  and anomalies of the gubernaculum of the testis.7 Arap et al.5 and Lee et al.6 report that the operation for detorsion of the testis provides an opportunity to maintain the viability of the gonad within 6 h of the beginning of the torsion, assuming that it is complete (360° or more). If the torsion is not complete, this time is extended. According to research by Yang, 2 h after the beginning of the torsion, a haemorrhagic infarction of the testis develops, irreversible changes in the parenchyma occur after 6 h and total necrosis is seen after 24 h.2Rybkiewicz et al.,13 The second theory is that antibodies against sperm and testicular antigens are formed due to torsion in the serum and semen.17 The third theory is that twisted testis is damaged, including reproductive cells, by ischaemia–reperfusion syndrome, causing oxidative stress.9 Chakraborty9 also described the possibility of ischaemic lesions and neurotransmitter dysfunction in the contralateral healthy testis in response to pathological processes in the twisted testis.There are three different theories of disturbances of function of the testis after torsion and therefore spermatogenesis. The first theory is that testes have features of primary dysplasia with disordered spermatogenesis and abnormal fixation in the scrotum, which predisposes them to turn.20 Follicle-stimulating hormone (FSH), however, showed a tendency towards higher values and testosterone to normal or lower.TT also causes abnormal functioning of the endocrine pituitary–testes axis. In previous studies on patients after TT, the endocrine function of this axis was within the laboratory norms.25Vascular endothelial growth factor (VEGF) is one of the factors that are associated with autoimmune processes. This factor is necessary for the proper development of the testis. Its concentration is temporarily elevated in the case of transient tissue ischaemia and then returns to normal. In the case of an active autoimmune process, its level is sometimes constantly increased.Objectives of this study were: (1) assessment of potential autoimmune processes induced by TT and (2) determining of possible hormonal abnormalities in boys operated on due to TT.From 2012 to 2015, 80 boys were operated on at our department due to TT. They lived in the central-eastern part of Poland. To form the study group, we selected 28 boys, who were subjected to at least 1 year  of ambulatory observation.No diseases with a hormonal nor immunological background were reported in patients and their families. The age of boys at the time of surgery ranged from 1 day of life to 15 years. In 15 cases, the testis was detorted and preserved, but it was excised due to necrosis in 13 cases.Informed consent for the research was obtained from parents or legal guardians of boys and also from patients over 16 years of age due to the legal regulations in Poland.The research was approved by the Bioethics Commission of the Medical University of Lublin, Poland, No. KE-0254/11/2017.Patients from the study group gave a 4.9 ml venous blood sample at 11:00, from which, after centrifugation, 2 ml of serum was obtained. The hour of collection was determined by logistic factors in the hospital. The serum has been subjected to the following laboratory tests.The level of antibodies against sperm and antibodies against Leydig cells in the serum was determined. The indirect immunofluorescence technique and conjugates of IgG, IgA and IgM antibodies were applied .The levels of FSH, luteinizing hormone (LH), testosterone and oestradiol were determined using the chemiluminescence method . The levels of anti-Müllerian hormone (AMH) were determined by the immunoelectrochemiluminescence method . In order to determine AMH, due to the weakness of the method, we often had to use dilutions of the sample.Levels of VEGF were determined using Quantikine ELISA .The control group for the above determinations consisted of eight boys with normal sexual development, without health problems that could affect the levels of the tested hormones or growth factors, classified according to age in the amount proportional to the study group. These patients were hospitalised in the Paediatric Surgery Clinic of our hospital.For the purpose of comparative analysis, boys from the study group and control group were divided into three puberty groups: pre-pubertal G1 , pubertal G4  and pubertal G5 . Puberty of the patient was determined at the time of medical examination for this study.We have analysed 28 patients. The G1 group consisted of 11 patients, G4 group included 9 patients and G5 group 7 patients. One patient with stage 3 of puberty according to the Tanner scale was excluded from the analysis for statistical reasons.The pre-pubertal G1 control group consisted of four patients. Each puberty group (G4 and G5) consisted of two patients. Our pubertal grouping was designed to enable comparative analysis of hormonal profiles that had changed with degree of puberty.26 The statistical relationship between total testicular volume (TTV) and testosterone concentration was determined in patients from the G4 and G5 groups. TTV means the summed volume of both testes  or only of the contralateral one in case of orchiectomy.All patients from the study group underwent an ultrasound. Ultrasound examination of the testes was conducted with a Siemens Acuson S2000 apparatus with linear transducer 9–12 MHz. The length, width and thickness of the testis were measured, and then its volume was calculated (length × width × thickness in cm × 0.52).The achieved results were statistically analysed in the Department of Medical Informatics and Statistics with E-learning Lab of our university.X), standard deviation (SD) and median (Me). The normality of the distribution of the analysed parameters was evaluated using the Shapiro–Wilk test.The values of measurable parameters were characterised by the range of values, arithmetic mean  was used to compare two independent groups. The Kruskal–Wallis test  was used to compare many groups. The Spearman’s R correlation coefficient was used to assess the relationship between independent parameters. A significance level of p < 0.05 was set, indicating statistically significant differences or dependencies were accepted. The statistical analysis was conducted using the Statistica 13.0 software .The No antibodies against sperm nor Leydig cells were found in the serum of patients from the study and control groups.p = 0.005), while no significant differences between the study and control groups were found in groups G4 and G5 (p > 0.05) . There were no significant differences in FSH in other puberty groups (p > 0.05)  Table .Table 2Fp > 0.05)    Table .Table 11Statistical analysis showed no correlation between testosterone concentration and TTV in pubertal study groups G4 and G5 Table .Table 1217Conducting our research, we tried to answer the question “What are the risks for men who suffered from testicular torsion during the developmental period?”. One of them is the theory about specific antibodies against sperm and testicular antigens formed due to TT in the serum and semen that impair fertility.2 Rybkiewicz et al.7 and Fu et al.,17 while their presence in sperm was described by Arap et al.,5 Anderson and Williamson,12 Hagen et al.13 and Mastrogiacomo et al.14 Arap et al.5 indicated elevated titres of antibodies in the study groups (orchiectomy and orchidopexy), but without significant differences between groups. Neither do they describe the relationship between the titre of antibodies and the age at which torsion occurred nor its duration. The studies of Fraser et al.27 and Puri et al.28 did not show the presence of these antibodies.The results of studies on antibodies in patients after TT described in the literature are divergent. The occurrence of antibodies against sperm in serum was reported by Yang et al.,12 did not detect the presence of antibodies against testicular antigens in the serum. Zanchetta15 described antibodies against Leydig cells in a few percent of patients after TT.Anderson and Williamson2 and Arap et al.5 have been observing patients for the presence of antibodies for 5–10 years. In our material, the average observation period was 3 years. We believe that this was sufficient time for the development of an autoimmune response, both humoral and cellular. Of course our patients could developed antibodies only in the semen and they were sero-negative.No antibodies against sperm or Leydig cells were found in the serum in our study group or the control group. Yang et al.30 VEGF is a factor whose secretion is strongly stimulated in ischaemic tissues, and its elevated levels are found in many autoimmune processes.22 VEGF has been shown to be crucial for the sex-specific vascularisation of the testis.23 We know from the literature that both relay pathway inhibitors and excess isoforms for VEGF cause vascular development disorders in the testis and in the formation of the spermatic cord.31 An excess of VEGF causes infertility as a result of spermatogenesis retention and sex epithelium hypertrophy.31 However, mouse studies have shown that VEGF is not absolutely necessary for normal testicular development, although the development of vessels in this case may be delayed in the foetal period.25 This does not diminish the importance of VEGF for testicular function and fertility. In the study by Lu et al.25, the loss of VEGF isoforms in mice resulted in reduced sperm abundance and altered expression of genes that regulate undifferentiated spermatogonium. It also resulted in lower body weight, and a smaller epididymis and prostate. In the case of TT, in the mechanism of tissue hypoxia, we should deal with an increase in the concentration of VEGF the next after torsion. Co-existing autoimmune process should also result in increased concentration of this growth factor.When discussing the role of VEGF, it is worth noting that the lack of even one allele encoding VEGF causes the death of the foetus.Taking into account the role of VEGF in the proper development and functioning of testes and its elevated level in the serum in autoimmune processes, which has been widely described in the literature, we have evaluated the remote influence of TT on the secretion of that growth factor. We found that its concentrations in the study and control groups of our patients were comparable.Summarising the above considerations, it should be stated that the issue of the presence of specific antibodies and rise in VEGF levels in boys after an episode of TT require further research.13 The studies performed so far have shown that the concentration of gonadotropins was higher but within the limits of the norm in men who had TT, which caused damage to the testis or the necessity for orchiectomy, in comparison with healthy men.18 A study by Arap et al.5 shows that FSH concentrations are higher in patients who have undergone TT than in the control group, and patients treated with orchiectomy had higher gonadotropin concentrations than those treated with detorsion. Another study evaluating gonadotropin concentrations was the work of Romero et al.18 They measured gonadotropin concentrations before and after gonadoliberine stimulation; the values obtained were normal in all subjects and higher in the group treated with orchiectomy than with detorsion, but they were not compared to the control group. This study also shows that patients have lower concentrations of inhibin B after an episode of TT, which is considered to be a meaningful quantitative index of the function of Sertoli cells. The longer the duration of anoxia is, the greater the potential loss of functional weight of the testis and thus the number of Sertoli cells.32 This results in the reduced release of factors, such as inhibin B, from the testis. This process is responsible for the increased secretion of FSH.33 The increased secretory function of the pituitary gland is an indirect indicator of functional loss of testicular tissue.34Studies of hormones in our patients allowed us to refer to the theory of primary dysplasia.In our study, FSH concentrations were within normal limits in most cases; however, they were statistically significantly higher in the pre-pubertal G1 group compared to the control group. Analysing the G1 group, it was found that the concentration of FSH was the highest in patients whose testes were removed, lower in which they were preserved, and the lowest in the control group. In the remaining groups (G4 and G5), these concentrations were higher than in the control group; however, they did not show statistical significance. This is indirect proof of the lower mass of active testicular tissue, but it does not explain whether the lower mass is a secondary effect to the damage or a primary abnormality.35 In the study of Arap et al.5 higher concentrations of LH were found in patients treated with orchiectomy; however, similar to the study of Romero et al.18, these concentrations were within the limits of the norm.LH secreted from the pituitary gland regulates the function of Leydig cells producing testicular androgens, especially testosterone. Animal studies indicate that testicular ischaemia or poorer function of Leydig cells may adversely affect pulsed testosterone secretion.When evaluating LH concentration in our material, we did not show statistically significant differences between the study group and the control group.20 Turner et al.20 examined the concentration of testosterone in serum from the testicular vein. Experimental TT significantly reduced its concentration 3 and 30 days after the detorsion. Testosterone concentration was inversely proportional to reperfusion indexes after the operation on the twisted testis. In the study by Kurt et al.19 testosterone concentrations measured 3 and 30 days after the surgical intervention depended on the duration of torsion.19 All rats had their left testis removed, and groups were distinguished depending on the duration of the torsion . In the control group, the testis was not twisted. Testosterone concentrations in all groups were statistically significantly lower than in the control group on the third day after torsion. On the 30th day after the operation, an increase in testosterone concentration was observed in all groups. Only in the group of rats in which the torsion lasted for 5 h testosterone concentrations were significantly lower than in the control group. Our study showed that testosterone levels in patients after TT did not differ from the standards for age and puberty and were also comparable to the control group. Similar results were obtained by Arap et al.5 Romero et al.18 obtained a significant correlation between the amount of inhibin B secreted, testosterone concentration and TTV. Our study did not show any effect of TTV on testosterone secretion in pubertal groups G4 and G5. In our opinion, one testis has enough Leydig cells and is able to compensate for the damage to the second testis, so we believe that patients after TT are not at risk from symptoms of hypogonadism due to testosterone deficiency.Studies carried out on rats showed that TT impairs testicular steroidogenesis.36 It plays a key role in the differentiation of external and internal genital organs, by blocking the development of Müller’s ducts and consequently causing their atrophy, thereby preventing the development of female genital organs.32 It is also very important for the correct course of the testicular descent process. Low AMH values may reflect primary testicular dysfunction, .36 Serum AMH levels are highest in the pre-pubertal period.36AMH is a compound secreted by Sertoli cells. Its basic secretion is independent of gonadotropins or sex steroids, but FSH increases and testosterone inhibits AMH secretion.In our study, AMH levels were statistically significantly higher in the control group than in the pre-pubertal G1 group. However, it is worth noting that several boys in the pre-pubertal group had significantly lower AMH concentrations than other boys. Serum concentrations in five boys aged 2 to 7 years ranged from 31.3 to 50 ng/ml , while they were >100 ng/ml in the control group. Moreover it is important that in four patients who had testes removed in this group, AMH concentrations were comparable to the control group. This may indicate a certain dysfunction of gonads in patients with lower AMH concentrations. It is possible that it has its primary character.37 He determined the influence of insuline-like factor 3 (INSL3) on the descending process of testes, their mobility, macroscopic structure, as well as the influence on the spermatic cord and its predisposition to torsion. In this study, three groups of mice with different expression of the gene responsible for the production of INSL3 were identified: INSL3 wild type (INSL3+/+), heterozygous (INSL3+/−) and knockout (INSL−/−). INSL3+/+ mice had correctly descended testes and formed spermatic cords. In the case of INSL3−/− mice had bilateral cryptorchidism, incorrectly formed and often twisted spermatic cords. INSL3+/− mice had descended testes or cryptorchidism, the structure of spermatic cords was better than in INSL3 knockout ones, but they were often twisted. TT occurred in a part of mice. There are many papers on cryptorchidism and hormonal factors. The Sozubir’s study suggests that the same factors are involved in cryptorchidism and TT, but in the case of TT this has not been so well documented. In terms of dysgenesis, these two disease entities are based on an abnormal process of descending and anchoring the testes in the scrotum. In addition to primary dysplasia, it should be mentioned of the so-called endocrinological disruptors, environmental pollution and food pollution, which have oestrogenic activity. They may favour TT, but this requires further research.The primary dysplasia, which in combination with anatomical disorders of the testicular region may predispose to its torsion, is described in Selami Sozubir’s experimental study.39 If there is an excess of endogenous oestradiol, it can also affect the occurrence of TT, especially in the youngest age groups. Oestradiol levels in our patients from the study group did not differ from the control group.However oestradiol is a hormone responsible for normal spermatogenesis, it reduces the volume of spermatogenic tubules and impairs testicular function when present in excess.In the case of G1 boys with reduced AMH levels, the cause of TT may be the same as for cryptorchidism. However, the diversity of the G1 group seems to confirm the multitude of potential predisposing and causative factors among younger boys. In the older groups, G4 and G5, higher FSH concentrations seem to be rather due to damage to testicular tissue. In these patients, too, could the primary dysplasia have affected the occurrence of TT? We cannot go back to the past and check their hormone profiles in the first years of life. However, indirectly, looking at the compensation for testosterone concentrations, this seems to contradict the high gonadal dysfunction in these patients. Patients with severe hypogonadism are unable to produce enough testosterone, even though two testes are present. A broader and unambiguous picture would be whether there is impaired fertility of these men as a result of TT. In the case of normal fertility, the theory of gonadal dysplasia in TT at an older age could be rejected.40To sum up, the fertility disorders in patients after TT should be mentioned. Subfertility generally describes any form of reduced fertility with prolonged time of unwanted non-conception.5, there are no statistically significant differences in sperm count and sperm mobility between a group of patients after orchiectomy and a group after detorsion of the testis due to TT and a control group. In none of the groups the sperm had an average normal morphology according to WHO criteria. The Puri’s publication describes correct results of sperm analysis only in 77% of men after TT in terms of sperm volume, number and mobility of spermatozoa.28 Jacobsen et al.41 present a meta-analysis of studies on the sperm in patients treated for TT, concluding that the mobility of spermatozoa is decreasing in most of them and that the number of spermatozoa is falling below 20 mln/ml. This fulfils the conditions of the WHO concept of “subfertile”.According to Arap et al.42 children were born in relationships to 56% of men after an orchiectomy because of TT and as many as 81% of men who had a testicular detorsion. Zhang et al.,43 on the other hand, analysed the percentage of children born by comparing the type of operation in the case of testicular torsion (relationship: orchiectomy/detorsion) and the age at which the man was operated on. They stated that the most favourable dependence (93%/100%) was in cases of operations under 14 years old .The problem of fertility in terms of pregnancy is discussed in two publications. According to Mäkelä’s study,Results of our study did not confirm the autoimmune process in boys operated on due to TT. The pituitary–testis axis seems to have sufficient compensation capabilities. However, study results suggest that primary gonadal dysplasia may predispose to testicular torsion.


Psychotic disorders are common and disabling mental conditions. The relative importance of immune-related mechanisms in psychotic disorders remains subject of debate. Here, we present a large-scale retrospective study of blood and cerebrospinal fluid (CSF) immune cell profiles of psychosis spectrum patients. We performed basic CSF analysis and multi-dimensional flow cytometry of CSF and blood cells from 59 patients with primary psychotic disorders  in comparison to inflammatory (49 RRMS and 16 NMDARE patients) and non-inflammatory controls (52 IIH patients). We replicated the known expansion of monocytes in the blood of psychosis spectrum patients, that we identified to preferentially affect classical monocytes. In the CSF, we found a relative shift from lymphocytes to monocytes, increased protein levels, and evidence of blood–brain barrier disruption in psychosis. In fact, these CSF features confidently distinguished autoimmune encephalitis from psychosis despite similar  clinical features. We then constructed machine learning models incorporating blood and CSF parameters and demonstrated their superior ability to differentiate psychosis from non-inflammatory controls compared to individual parameters. Multi-dimensional and multi-compartment immune cell signatures can thus support the diagnosis of psychosis spectrum disorders with the potential to accelerate diagnosis and initiation of therapy. Psychosis spectrum disorders (henceforth termed psychotic disorders or psychosis for simplicity) are a heterogenous clinical entity associated with altered thoughts, perceptions, mood, and behavior . HalluciThe etiology of psychotic disorders is thought to be multifactorial with both genetic and environmental factors contributing. However the exact pathophysiological mechanisms remain poorly understood –8. One oC4A, C4B) , delusional disorders , acute and transient psychotic disorders , and schizoaffective disorders ) were included and are henceforth collectively referred to as the F2x or psychosis group (Table n = 52), RRMS (n = 49), and NMDARE (n = 16) served as non-inflammatory and inflammatory controls (Methods). NMDARE can cause symptoms similar to primary psychosis [In total, 59 patients  –42 and wWe assessed basic CSF parameters  and found that total CSF cell counts, Ig synthesis, and ocbs were significantly higher in the RRMS and NMDARE groups compared to the IIH and F2x groups Fig. . These cAvailable mFC studies from psychosis spectrum patients remain limited to the peripheral blood (PB)  and lackPlotting parameters individually confirmed significant alterations in the proportion of monocytes and in the composition of monocyte subsets in PB of F2x patients as well as an elevated proportion of NK cells Fig. . CompareAs  clinical presentation of NMDARE can resemble primary psychotic disorders  we focusWe next translated our mFC approach to the CSF. We integrated basic CSF parameters with mFC-derived CSF parameters from all patients in our study and again performed PCA. In this analysis, NMDARE patients clearly separated from F2x and IIH patients and showed an overlap with RRMS patients Fig. . The maiPlotting individual parameters Fig.  emphasizWe next investigated potential immunological determinants of the severity of psychosis. We therefore tested for correlations between psychosis severity, quantified by the Global Assessment of Functioning (GAF) scale, and all collected blood and CSF parameters. We found that the proportions of CSF ncMono, PB T cells and PB CD8+ lymphocytes negatively correlated and NK cells in PB positively correlated with the GAF Fig. . Low GAFNMDARE may initially present with psychosis  emphasizWe next combined all blood and CSF parameters and applied machine learning approaches to identify the most powerful discriminatory parameters based on the AUC value. We applied feature selection methods, such as RFE or inherent feature selection mechanism of the algorithm, to reduce the numbers of predictors to make the model less complex and more interpretable. This represents an unbiased approach to select the most relevant features of the models (Methods).The elastic net approach achieved the highest AUC value (0.88) when distinguishing between F2x and IIH , we attempted to avoid overfitting despite low sample size. Nonetheless, a larger independent test cohort would be necessary to validate the models. Patient numbers were too low to benchmark models to discriminate between F2x and NMDARE. We also used statistical approaches to account for patient heterogeneity and potential confounders which substantiated our main findings. We were unable to include purely healthy controls because of ethical concerns in performing an invasive lumbar puncture for only scientific reasons. Beyond that, F2x patients with elevated CSF cell counts were excluded to rule out secondary (infectious) causes of psychosis which could potentially bias our results. Due to the retrospective design, only the GAF was available as a surrogate of clinical functioning and psychosis severity. The lack of other clinical scores  and inflammatory  controls. Alterations in peripheral and intrathecal myeloid compartments hint towards a contribution of the Further information and requests for resources, anonymized clinical and flow cytometry data should be directed to and will be fulfilled by the Lead Contact, Gerd Meyer zu Hörste (gerd.meyerzuhoerste@ukmuenster.de).Supplementary figuresSupplementary tables


The predictive role of retinol-binding protein 4 (RBP4) in the adverse prognosis of patients with stable coronary artery disease (CAD) has not been well-defined. We thus conducted this cohort study to investigate the association between circulating RBP4 level and major adverse cardiovascular events (MACEs) in Chinese patients with stable CAD.Patients with stable CAD and serum RBP4 concentration measurement at admission between July 2012 and January 2015 were included. The primary outcome in this study was incident MACEs, which included acute coronary syndrome, heart failure, stroke, peripheral vascular disease, and cardiovascular death. Cox proportional hazards regression was adopted to investigate the association between RBP4 and the incidence of MACEs.A total of 840 patients with stable CAD were analyzed. The mean age of patients was 61.2 ± 15.9 years, and 56.1% of them were men. After a median follow-up of 2.3 years, 129 MACEs were observed. Compared to participants exposed to the first quartile of serum RBP4 level, those in the second, the third, and the fourth quartiles had associated hazard ratios (HRs) of 2.38 [95% confidence interval (CI): 1.33–4.26], 2.35 (95% CI: 1.31–4.21), and 2.27 (95% CI: 1.28–4.04) after adjusted for confounders, respectively. Every 5 μg/ml increment in serum RBP4 concentration was associated with an adjusted HR of 1.13 (95% CI: 1.05–1.22) for the occurrence of MACEs. Subgroup analyses suggested no significant modifying effects of baseline characteristics for the association between RBP4 and MACEs in patients with stable CAD.Our finding suggested that the higher circulating RBP4 level was significantly associated with an increased risk of MACEs in patients with stable CAD. Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide, and nearly 330 million Chinese population were affected in 2019 .Retinol-binding protein 4 (RBP4) is an adipokine, which is mainly synthesized and secreted in the liver and adipose tissue . In adipTherefore, we conducted this cohort study to examine the association between circulating RBP4 level and major adverse cardiovascular events (MACEs) in Chinese patients with stable CAD.n = 1,356) in our center from July 2012 to January 2015 were retrospectively screened. The exclusion criteria were as follows: (1) without available data for RBP4 concentration (n = 272); (2) prior history of cancer (n = 8); (3) infectious disease (n = 55); (4) heart failure (HF) (n = 93); and (5) refusing participation (n = 71). Furthermore, 17 patients were further excluded due to loss to follow-up. As a result, a total of 840 patients were included in the final analysis. The flowchart of patients' selection was shown in All consecutive patients diagnosed with stable CAD  in all available samples, according to the manufacturer's protocol, and compared with purified human RBP4 standards. The minimum detection limit was 1 ng/ml. All samples were analyzed in duplicate. The average intra-assay and interassay coefficients of variation were 2.32–8.77 and 2.95–9.27%, respectively.2) = body weight (kg)/height squared (m2). We recorded comorbid conditions, such as hypertension, diabetes mellitus, and chronic kidney disease (CKD), given that they were potentially related to circulating RBP4 level  with participants wearing light indoor clothing and no shoes. Body mass index (BMI) was calculated according to the following equation: BMI  to explore the relationship between RBP4 and the risk of MACEs in patients with stable CAD. Three models were developed, namely, Model 1 was adjusted for age (years), sex , BMI , and smoking (yes or no); Model 2 further adjusted for hypertension (yes or no), diabetes mellitus (yes or no), and CKD (yes or no); and Model 3 comprised Model 2 plus further adjustment for medicine use, including beta-blocker (yes or no), statins (yes or no), or ACEI/ARB (yes or no). Subgroup analyses were conducted with stratification by age, sex, BMI, smoking, hypertension, diabetes mellitus, and CKD to examine the robustness of the association between circulating RBP4 level and MACEs in patients with stable CAD.All statistical analyses were conducted using R 3.3.2 , and two-sided p = 0.020) and had a higher level of BMI  and RBP4 . Moreover, they were more likely to have a history of STEMI and CKD but take less statins or ACEI/ARB , while 44.3% of patients had a history of non-ST-segment elevation myocardial infarction (NSTEMI), and 8.6% of patients had unstable angina. Regarding prior invasive treatment, 70.2 and 5.0% of patients ever received the percutaneous coronary intervention and coronary artery bypass grafting (CABG), respectively. The comparisons of general characteristics between patients in different quartiles of circulating RBP4 concentrations are presented in ACEI/ARB .The relationship between serum RBP4 level and MACEs in patients with stable CAD is presented in Pinteraction = 0.758), sex (Pinteraction = 0.180), BMI (Pinteraction = 0.749), smoking (Pinteraction = 0.708), hypertension (Pinteraction = 0.893), diabetes mellitus (Pinteraction = 0.625), and CKD (Pinteraction = 0.490) for the association between RBP4 and MACEs in patients with stable CAD.In this cohort study, we first found that elevated circulating RBP4 level was significantly associated with an increased risk of MACEs in patients with stable CAD. This association remained after the adjustment of covariates and kept consistent among different subgroup analyses. We also assessed the specified association of RBP4 and individual components of MACEs and found that HF may primarily drive the positive association.Epidemiological studies suggested that RBP4 might be involved in the pathogenesis of atherosclerosis. Elevated circulating RBP4 levels have been observed in subjects with previous clinical arteriosclerosis , subclinThe RBP4 was initially discovered as an adipocytokine, which is specifically bound to vitamin A (retinol) . RBP4 isA few limitations of the study analysis are worth discussing. First, this analysis was a single-center study and only performed in Chinese population, and the findings should be cautiously generalized and further validated in other cohorts. Second, the study patients were all presented with stable CAD rather than acute coronary syndrome, and the sample size might be unable to reach statistical power, especially in subgroup analyses. Third, the observational finding of the associations between RBP4 and the prognosis in patients with stable CAD makes it impossible for us to investigate the causal relationship. Even though some confounders have been considered, we cannot rule out the possibility that unmeasured factors contribute to the observed associations.The higher circulating RBP4 levels were significantly associated with MACEs in patients with stable CAD. The finding should be further verified in multicenter studies with a larger sample.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee Liyang People's Hospital. The identify information was removed before the data being released. The patients/participants provided their written informed consent to participate in this study.KQ: conceptualization and project administration. XY: formal analysis. CX and YF: investigation. CX: methodology. YF: validation. KQ and XY: writing—original draft. MM: writing—review and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.