Comparison of two alcohol-based surgical scrub solutions with an iodine-based scrub brush for presurgical antiseptic effectiveness in a community hospital

The antiseptic effectiveness and acceptability of a commercial alcohol-based waterless (ABWL) and an alcohol-based water-aided (ABWA) scrub solution were compared with a brush-based iodine solution (BBIS) under conditions encountered in community hospital operating rooms. This randomized partially blinded study was based on guidelines from the American Society for Testing and Methods. The three scrub solutions were compared for antimicrobial efficacy, using criteria within the Food and Drug Administration's Tentative Final Monograph for Healthcare Antiseptic Products (FDA-TFM), and for participants' acceptance of the products. Volunteer surgical staff that worked daily in the same operating room for the entire duration of the study were enrolled. In total, 1126 surgical scrub procedures were performed over the duration of the study. Only the ABWL met all of the FDA-TFM criteria. The BBIS performed better than both of the alcohol-based solutions at the end of Day 1 (P=0.03), but the ABWL was more efficacious than the ABWA and the BBIS at the end of Days 2 and 5 (P=0.02 and 0.01, respectively). When colony-count reductions were compared over the entire duration of the study, there was no significant difference between the three solutions (P=0.2). The participants found the ABWL easiest to use (P<0.001), with the fewest adverse effects on skin (P=0.007), and it was their preferred product (P<0.001). Although both of the commercially available alcohol-based solutions may be considered as acceptable alternatives to the BBIS for presurgical antisepsis, the ABWL was found to have significantly higher user acceptability.

Patients with stage IV lung cancer lose 25% of their valuable time in the office visits and hospital stay

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Background: Patients with stage IV lung cancer have median survival of 4–6 months. Randomized trials have shown chemotherapy may have small but significant survival benefit. To achieve this small gain,patients may have to spend their last few days of life in the office visits and hospitalization. Last few days of person’s life need to be spent comfortably and most effective manner in accordance to their wishes, desires and priorties.We attempted to study the “Time Lost” in the stage IV lung cancer patients who either did not choose or were not offered the palliative care/Hospice. Methods: We retrospectively reviewed charts of patients diagnosed with stage IV lung cancer (at their initial presentation) from Jan 2002 to Dec 2005 at our institution. We calculated their inpatient and out patient visit hrs and hence “Time Lost” during the last few days of their life. Patients were divided into two groups—Group A (n = 12): Patients who opted to choose palliative/hospice care immediately after the diagnosis and GroupB (n = 46): Patients who either refused or were not offered palliative/hospice care. Results: The median age at diagnosis was similar in both groups (71 vs 69.5 yrs). The median survival was also similar in both groups (4 months vs 4 months). Patients in group B (non hospice) had 1 month “Lost Time” out of their median survival of 4 months. In comparison patients in group A (hospice) had median survival of 4 months with “No Lost Time”. Thus patients who were not offered hospice or refused hospice spent 25% of their precious time during last stages of their life in inpatient stays and outpatient visits. Conclusions: Patients with stage IV lung cancer should be actively offered palliative/Hospice care, though studies with large number of patients is further required.

[Table: see text]

No significant financial relationships to disclose.

Acquired angioedema secondary to hormone replacement therapy

Angioedema is a potentially life threatening condition and may be either inherited or acquired. The latter is rare with only a handful of cases reported in the world literature. Presenting complaints are often vague. Those most commonly described include swelling in the subcutaneous and submucosal tissues. Patients presenting with laryngeal edema have high mortality, and high clinical suspicion is necessary to avoid instrumentation, which can precipitate laryngeal spasm. We present a review of reported cases of hormonally induced hereditary angioedema, along with a report of a patient with acquired angioedema secondary to hormone replacement therapy. To the best of our knowledge, this case probably represents the first reported case of acquired angioedema secondary to hormone replacement therapy.

Percutaneous vertebroplasty: an experience of 31 procedures

A prospective study of 31 percutaneous vertebroplasty procedures (PVP) in 22 patients treated during January 2000 to December 2001 is presented. PVP was performed using polymethylmethacrylate (PMMA) to treat vertebral collapse due to osteoporosis and vertebral metastasis, to obtain analgesia and spinal stabilization. We analyze the efficacy and complications related to the procedure. PVP is a safe, effective and a daycare surgery. It can be performed under local anesthesia and has minimal and manageable complications.

Phenobarbital-induced alterations in the sexual differentiation of the female rat: reversal by hydroxyurea and cycloheximide

The possible mechanism of action of phenobarbital in prenatal female rats has been studied using different inhibitors of protein/DNA/RNA synthesis. Administration of phenobarbital (40 mg/kg/day) subcutaneously from day 17 to day 20 of pregnancy resulted in a delay of the onset of puberty, disorders of estrous cycle, infertility, and high estrogen levels in the female offspring. Cycloheximide (60 microg/kg/day)--a protein synthesis inhibitor and hydroxyurea (160 mg/kg/day)--a DNA synthesis inhibitor when combined with phenobarbital, significantly reduced the incidence of reproductive dysfunctions listed above. Alpha-amanitin (15 microg/kg/day), an inhibitor of m-RNA synthesis, produced reproductive disorders in the female offspring when administered alone to pregnant rats and also failed to reverse the PB-induced reproductive alterations. Cycloheximide and hydroxyurea produced no effect upon reproductive function when administered alone. Cycloheximide administration resulted in low body weight at birth and delayed eye opening. These results suggest that prenatal administration of phenobarbital produces its effect via new protein synthesis and that cycloheximide and hydroxyurea protect the offspring from phenobarbital-induced toxic effects by inhibiting its biochemical action.

Surgical emphysema--an unusual finding in spontaneous neonatal gastric perforation

A neonate presented with extensive surgical emphysema of the abdominal wall and a spontaneous gastric perforation. This clinical presentation is very rare. Early diagnosis and treatment improve the clinical outcome.

The role of estrogen receptor, androgen receptor and growth factors in diethylstilbestrol-induced programming of prostate differentiation

Recently, others and we have demonstrated that prenatal exposure to an extremely low dose of diethylstilbestrol (DES) and other estrogenic compounds produces a significant effect on mouse prostate development in vivo and in vitro in the presence and absence of androgen. In this study, we investigated the mechanism by which DES produces this effect and determined the role of its estrogenic activity on the growth and branching, induced by DES in the 17-day-old fetal prostate in culture. Additionally, we investigated whether the androgen receptor (AR) plays a role and whether any of the growth factors, namely, EGF and IGF-1 which are known to modulate the estrogen receptor (ER) and androgen receptor (AR)-dependent process, mediate the DES-induced effects. Using the organ culture bioassay of prostate development, we demonstrate that DES enhanced the growth and branching of the prostate at both 0.1 and 0.5 pg/ml dosages, thus, confirming a previous report of ours. An anti-estrogen, ICI164,387 blocked both of the effect of DES, suggesting that both of these two effects are ER dependent. Anti-androgen, flutamide also blocked both branching and prostatic growth induced by DES, while cyproterone acetate blocked only the branching effect, suggesting a role for AR in the DES-induced effects. Depletion of EGF by anti-EGF antibody blocked the DES-induced effects and this was reversed following EGF replacement in the organ culture system. Anti-IGF-1 antibody, on the other hand, only blocked the branching effect, but produced no effect on the prostatic growth, induced by DES. Estrogenic chemicals, bisphenol A and DES enhanced EGF-mRNA level of the cultured prostates. Taken together, it appears that DES-induced prostatic enlargement involves enhancement of ER-dependent EGF and IGF-1 synthesis, mediating prostatic enlargement and androgen action.

Reproductive malformation of the male offspring following maternal exposure to estrogenic chemicals

Recently, significant concerns have been placed on the widespread use of chemicals with persistent estrogenic activity for their long-term effects on human health. In this communication, we investigated whether fetal exposure to some of these chemicals at doses consumed by people, has any long-term effect on the reproductive functions of the male offspring. Thus, time-pregnant CD-1 mice were fed diethylstilbestrol (DES), bisphenol A (BPA), and aroclor (aroclor 1016) at an average concentration of 100 ng/kg/day, 50 microg/kg/day, and 50 microg/kg/day, respectively, during Days 16-18 of gestation. A high dose of DES (200 microg/kg/day) was also tested to compare the results of the current study with those of others using the high dose only. The offspring were examined at Day 3, Day 21, and Day 60 following birth. We demonstrated that BPA, aroclor, and the lower dose of DES enhanced anogenital distance, increased prostate size, and decreased epididymal weight. No effect was found on the testicular weight or size. The chemicals also permanently increased androgen receptor (AR) binding activity of the prostate at this dosage. This is the first demonstration that environmental chemicals program AR function permanently at the dosage consumed by the general population. The higher dosage of DES, on the other hand, produced an opposite effect, decreasing prostate weight, prostate AR binding, and anogenital distance, thus confirming the previous reports. To investigate whether the above mentioned effects of the chemicals represent direct or indirect effects, we also tested the effect of the chemicals on prostate development in vitro. Thus fetal urogenital sinus (UGS), isolated at the 17th day of gestation was cultured with the chemicals in the presence and absence of testosterone (10 ng/ml) for 6 days, and prostate growth was monitored by determining the size and branching of the specimen following histology. Results showed that these chemicals induced prostate growth in the presence and absence of testosterone. They also increased androgen-binding activity. Thus, the results of the in vivo studies were reproduced in the in vitro experiments, suggesting a direct effect of these chemicals on the development of fetal reproductive organs. This is the first demonstration that estrogenic chemicals induce reproductive malformation by direct interference with the fetal reproductive organs and not by interfering with the maternal or fetal endocrine system. The chemicals are able to induce malformation even in the absence of fetal testosterone; however, they are more effective in the presence of testosterone.

Comparison of absorption rate and bioavailability of two brands of carbamazepine

OBJECTIVE

To assess the bioavailability of carbamazepine from two brands of carbamazepine--Tegretol 200 and Zen-200.

METHODS

A two-way randomised cross-over bioavailability of carbamazepine was carried out in twelve healthy male volunteers. Coded plasma samples were analysed for levels of carbamazepine by high performance liquid chromatography (HPLC) method. Tegretol 200 and Zen-200 were tested for in-vitro dissolution profiles.

RESULTS

The mean Cmax, Tmax and t1/2a for Tegretol 200 were: 2.17 +/- 0.42 mcg/mL, 11.67 +/- 6.37 h and 2.72 +/- 1.87 h; for Zen-200 were 3.10 +/- 0.05 mcg/mL, 3.50 +/- 2.11 h and 0.76 +/- 0.76 h respectively. These values were statistically significant. However AUC (0-96 h) value of 150.16 +/- 27.13 mcg/ml.h after Zen-200 was not statistically significant as compared to 128.68 +/- 20.22 mcg/ml.h after Tegretol 200. The in-vitro dissolution profiles of the two formulations were dissimilar. The fluctuations in CBZ levels after Tegretol 200 was significantly less as compared to Zen-200. The absorption profile as judged by parameter 'A' was 50.44 +/- 10.95 for Tegretol 200 and 42.49 +/- 18.89 for Zen-200.

CONCLUSION

Based on parameter 'A' and other pharmacokinetic parameters, the marketed generic carbamazepine product, Zen-200 is not bioequivalent to Tegretol 200.

Modulation of androgen receptor (AR)-mediated transcriptional activity by EGF in the developing mouse reproductive tract primary cells

Recently, a role for epidermal growth factor in male sexual differentiation was reported from different laboratories. We demonstrated that androgen receptor (AR) mediates the EGF-induced effects. The mechanism, by which EGF modulates AR mediated activity, is not known and the current studies were designed to investigate the role of AR. Using mesenchymal cell preparation from the 18-day fetal reproductive tract, first, we determined whether EGF induced sexual differentiation by enhancing AR gene expression. Thus, AR mRNA and AR protein levels were measured in response to EGF-treatment using RT-PCR based analysis of AR mRNA and Western blot analysis of AR protein level respectively. Both of these analysis detected presence of AR gene expression in this cell preparation, however no effect of EGF was observed in AR protein or AR mRNA expression. Next, we examined whether EGF enhanced AR mediated transcriptional activity in the developing tract. Using the mesenchymal cells, co-transfected with AR expression vector (pSV-AR) and androgen response element linked to luciferase reporter vector (pMAMneoLUC) we assessed AR-mediated transcriptional activity in response to EGF treatment in the presence and absence of testosterone. The results showed that androgen stimulated the luciferase activity in a dose dependent manner, as expected. EGF also enhanced such activity; however, the response was significantly lower than that by androgen. EGF, however, produced striking enhancement of the androgen-induced transcriptional activity when used with androgen. EGF and testosterone produced no stimulation of the luciferase activity either alone or in combination in the cells lacking AR expression vector, suggesting a role for AR in the effect of EGF and testosterone. Flutamide, an AR antagonist, also blocked the enhancement of luciferase activity induced by EGF and testosterone, further confirming the role of AR in the effect of EGF and testosterone. Thus, it appears that EGF-modulation of sexual differentiation involves enhancement of AR-mediated transcriptional activity and not enhancement of AR gene expression. Additionally, it appears that EGF modulates sexual differentiation in the presence of testosterone possibly by potentiating the testosterone-effect.

Munchausen's syndrome: a case report

Munchausen syndrome, a chronic factitious disorder with physical symptoms, also called hospital hoboes or hospital addiction, is an uncommon psychiatric disorder, usually presents as an emergency. The correct recognition of the syndrome is important in medical practice. A brief review with an interesting case report is presented.

Cellular localization of immunoreactive epidermal growth factor during Wolffian duct differentiation of the fetal mouse

Previous studies from this laboratory indicated a role for epidermal growth factor (EGF) in androgen-dependent male reproductive tract differentiation of the fetal mouse. Expression of an EGF-like protein during Wolffian duct differentiation was indicated from the determinations by radioimmunoassay (RIA) and radioreceptor assay. To further characterize the protein and to assess its role in male sexual differentiation, expression of the protein has been analyzed by Western blot assay and its tissue-specific cellular expression has been determined by immunocytochemical assay in the present study. Western blot analysis of the 18-day fetal male reproductive tract detected an immunoreactive band of the predicted 6-kDa size. Immunocytochemical analysis also detected EGF-specific immunostaining in the Wolffian duct derivatives. At day 18 of gestation, the staining was localized predominantly in the epithelial nuclei of the Wolffian duct derivatives whereas at days 14 and 16 of gestation, the staining was equally distributed in the mesenchymal and epithelial sites of the Wolffian duct derivative. The intensity of the staining increased with progression of differentiation during the 14th-18th days of gestation. Prenatal exposure to the antiandrogen flutamide significantly reduced the immunostaining of the duct. Thus, a role for EGF in Wolffian duct differentiation is indicated.

Activation of androgen receptor in epidermal growth factor modulation of fetal mouse sexual differentiation

Previous studies from this laboratory indicated a role for epidermal growth factor (EGF) in androgen-dependent male sexual differentiation. The mechanism by which EGF modulates male sexual differentiation has not been determined and investigation has been made to assess the role for androgen receptor (AR) in mediating the EGF-induced effect. We report that EGF, like androgen, stabilized the Wolffian duct in the 13-day female specimen, grown in organ culture. Anti-AR, flutamide and cyproterone acetate blocked the Wolffian duct-stabilizing effect of EGF. EGF also induced cell proliferation of the fetal reproductive tract in a dose-dependent manner and a combination of physiological dosages of EGF and androgen-induced cell proliferation synergistically, suggesting an interactive effect of these two drugs. Cyproterone acetate blocked both EGF-induced normal cell proliferation and the synergistic cell proliferation induced by combination of EGF and androgen suggesting a role of AR in the effects of EGF. The role of AR was further assessed by determining the effect of EGF on AR binding directly. It was shown that EGF stimulated androgen binding activity of the male fetal reproductive tract cells significantly by increasing the number of binding sites by 3-fold with slight decrease in binding affinity. Thus, it appears that AR plays a role in mediating EGF-modulation of sexual differentiation.

The role of growth hormone in fetal mouse reproductive tract differentiation

Although GH plays a key role in postnatal growth and differentiation, its role in fetal differentiation is not clear at the present. The aim of the present study was to investigate whether GH plays a role in fetal sexual differentiation, and we used in vitro organ culture assay of sexual differentiation to determine this. The results showed that anti-rGH antibody blocked Wolffian duct differentiation specifically in the presence of fetal testes. Exogenous GH supplemented in the above experiment reversed the blocking effect of anti-GH. Among the other related products, insulin-like growth factor I was highly effective in reversing the anti-GH effect, insulin-like growth factor II was partially effective, but PRL was unable to reverse the anti-GH effect. GH itself was found to produce some masculinizing effect, as demonstrated by its ability to stabilize the Wolffian duct in female fetuses. The role of GH was further demonstrated by the observation that GH-immunoreactive material of the size of authentic GH was detected in the 18-day fetal reproductive tract, and the concentration of this material increased in response to progression of sexual differentiation. Determination of androgen-binding activity using Scatchard analysis on the cells isolated from the 18-day fetal reproductive tract indicated that androgen-binding activity increased after GH treatment of the cells. Thus, it may be concluded that GH influences male sexual differentiation and alters the androgen-binding activity of the fetal reproductive tract.

The role of epidermal growth factor receptor (EGFR) in male reproductive tract differentiation: stimulation of EGFR expression and inhibition of Wolffian duct differentiation with anti-EGFR antibody

We have shown previously that epidermal growth factor (EGF) plays a role in testosterone-dependent fetal Wolffian duct differentiation. To assess the role of EGF further, we examined EGF receptor (EGFR) expression during Wolffian duct differentiation and determined whether inhibition of EGFR results in inhibition of Wolffian duct differentiation. Using a polyclonal anti-EGFR antibody in the Western blot analysis, we have detected an immunoreactive band at the expected 180-kDa size, the molecular size for the EGFR protein, in the 18-day fetal male reproductive tract. The mouse 3T3 cell line, used as a positive control, also produced an immunospecific band at the same region. The intensity of the immunoreactive 180-kDa band in the 18-day male reproductive tract significantly decreased after pretreatment of the antibody with the 3T3 cell extract. Nonimmune serum produced no band at the 180- kDa region, suggesting EGFR specificity of the 180-kDa band. The level of the 180-kDa EGFR protein was found to be higher in the 18-day male than in the female reproductive tract. Testosterone increased expression of the EGFR level in the 18-day masculinized female reproductive tract, and it induced Wolffian duct morphogenesis. Under in vitro culture conditions, the anti-EGFR antibody prevented Wolffian duct differentiation, induced by the fetal testis, suggesting a direct role of EGFR in male reproductive tract differentiation. No such effect was found when tested with nonimmune serum. Anti-EGFR also blocked the development of the Wolffian duct in the female explant, induced by exogenous EGF. Thus, a role of EGFR mediating the effect of EGF during male reproductive tract differentiation is demonstrated.