Role of exosomes in metastasis and therapeutic resistance in esophageal cancer

Esophageal cancer (EC) has a high incidence and mortality rate and is emerging as one of the most common health problems globally. Owing to the lack of sensitive detection methods, uncontrollable rapid metastasis, and pervasive treatment resistance, EC is often diagnosed in advanced stages and is susceptible to local recurrence. Exosomes are important components of intercellular communication and the exosome-mediated crosstalk between the cancer and surrounding cells within the tumor microenvironment plays a crucial role in the metastasis, progression, and therapeutic resistance of EC. Considering the critical role of exosomes in tumor pathogenesis, this review focused on elucidating the impact of exosomes on EC metastasis and therapeutic resistance. Here, we summarized the relevant signaling pathways involved in these processes. In addition, we discussed the potential clinical applications of exosomes for the early diagnosis, prognosis, and treatment of EC.

[Characteristics of fusion gene expression in acute lymphoblastic leukemia]

Objective: To analyze the genetic landscape of 52 fusion genes in patients with de novo acute lymphoblastic leukemia (ALL) and to investigate the characteristics of other laboratory results. Methods: The fusion gene expression was retrospectively analyzed in the 1 994 patients with de novo ALL diagnosed from September 2016 to December 2020. In addition, their mutational, immunophenotypical and karyotypical profiles were investigated. Results: In the 1 994 patients with ALL, the median age was 12 years (from 15 days to 89 years). In the panel of targeted genes, 15 different types of fusion genes were detected in 884 patients (44.33%) and demonstrated a Power law distribution. The frequency of detectable fusion genes in B-cell ALL was significantly higher than that in T-cell ALL (48.48% vs 18.71%), and fusion genes were almost exclusively expressed in B-cell ALL or T-cell ALL. The number of fusion genes showed peaks at<1 year, 3-5 years and 35-44 years, respectively. More fusion genes were identified in children than in adults. MLL-FG was most frequently seen in infants and TEL-AML1 was most commonly seen in children, while BCR-ABL1 was dominant in adults. The majority of fusion gene mutations involved signaling pathway and the most frequent mutations were observed in NRAS and KRAS genes. The expression of early-stage B-cell antigens varied in B-cell ALL patients. The complex karyotypes were more common in BCR-ABL1 positive patients than others. Conclusion: The distribution of fusion genes in ALL patients differs by ages and cell lineages. It also corresponds to various gene mutations, immunophenotypes, and karyotypes.

[Analysis of fusion gene expression in acute myeloid leukemia]

Objective: To analyze the genetic landscape of multiple fusion genes in patients with de novo acute myeloid leukemia (AML) and investigate the characteristics of immunophenotypes and mutations. Methods: The results of multiple fusion genes from 4192 patients with de novo AML were retrospectively analyzed from 2016 to 2020. In addition, the immunophenotypical data and the mutational results from high-through put method were statistically investigated and correlated as well. Results: ①Among the 52 targets, 29 different types of fusion genes were detected in 1948 patients (46.47%) with AML, which demonstrated an "exponential distribution" . ② As the age increased, the number of patients with fusion gene increased first and then decreased gradually. The total incidence rate of fusion genes and MLL rearrangment in children were significantly higher than those in adults (69.18% vs 44.76%, 15.35% vs 8.36%) . ③The mutations involving FLT3 and RAS signaling pathway contributed most in patients with MLL rearrangment. ④No specific immunophenotypic characteristics were found in AML patients with MLL or NUP98 rearrangements. Conclusion: Nearly half of AML patients were accompanied by specific fusion gene expression, the proportions of different fusion genes in pediatric and adults patients were different by multiple PCR. The gene mutations and immunophenotype of these AML patients have certain rules.

[Analysis of infection status and recombination types of norovirus in patients with acute gastroenteritis in the Ningxia Hui Autonomous Region from 2016 to 2017]

Objective: To analyze the infection status and recombination of Norovirus in patients with acute gastroenteritis in Ningxia. Methods: The specimens of 10 sentinel hospitals in Ningxia were collected from 2016 to 2017. Real-time quantitative PCR was used for nucleic acid detection. GⅡ-positive samples were amplified by RT-PCR for the RdRp and Capsid regions, then sequenced and genotyped. Evolution analysis was performed using software such as MEGA-X, and recombination analysis was performed using Simplot 3.5.1 and RDP4. Results: The age of the 2 334 cases was 1.42 (0.68, 7.69) years old, 1 133 cases in 2016 and 1 201 cases in 2017, 1 343 and 991 cases for males and females respectively. The positive rate of Norovirus GⅠ genogroup was 0.86% (20/2 334), and GⅡ genogroup was 14.82% (346/2 334). A total of 78 recombinant strains were sequenced and 12 recombinant types were found. GⅡ.Pe/GⅡ.4Sydney_2012 and GⅡ.P12/GⅡ.3 were the main epidemic strains, accounting for 35.90% (28 strains) and 32.05% (25 strain) respectively, followed by GⅡ.P16/GⅡ.2 accounting for 12.82% (10 strains). Among them,GⅡ.P7/GⅡ.6 (2 strains), GⅡ.P12/GⅡ.3 (6 strains), GⅡ.P16/GⅡ.1 (2 strains), GⅡ.P16/GⅡ.2 (5 strains), GⅡ.Pe/GⅡ.4 (7 strains) were detected for the first time in Ningxia. Recombinant strains were all intergenotype recombination, and the recombination breakpionts were all located within ORF1. Conclusion: Norovirus infection in Ningxia area was mainly in GⅡ genogroup from 2016 to 2017, and most of them were recombinant strains. GⅡ.Pe/GⅡ.4Sydney_2012 and GⅡ.P12/GⅡ.3 were the main epidemic strains, followed by GⅡ.P16/GⅡ. 2.

Synthesis of dihydropyrazole sulphonamide derivatives that act as anti-cancer agents through COX-2 inhibition

COX-2 has long been exploited in the treatment of inflammation and relief of pain; however, research increasingly suggests COX-2 inhibitors might possess potential benefits to thwart tumour processes. In the present study, we designed a series of novel COX-2 inhibitors based on analysis of known inhibitors combined with an in silico scaffold modification strategy. A docking simulation combined with a primary screen in vitro were performed to filter for the lead compound, which was then substituted, synthesized and evaluated by a variety of bioassays. Derivative 4d was identified as a potent COX-2 enzyme inhibitor and exerted an anticancer effect through COX-2 inhibition. Further investigation confirmed that 4d could induce A549 cell apoptosis and arrest the cell cycle at the G2/M phase. Moreover, treatment with 4d reduced A549 cell adhesive ability and COX-2 expression. The morphological variation of treated cells was also visualized by confocal microscopy. Overall, the biological profile of 4d suggests that this compound may be developed as a potential anticancer agent.

Dihydropyrazoles containing morpholine: design, synthesis and bioassay testing as potent antimicrobial agents

A series of dihydropyrazole derivatives were designed and synthesized as antimicrobial agents. In both docking simulation and bioassay tests, these compounds showed potent S. aureus TyrRS enzyme inhibition activity.

Analysis of drug pharmacology towards predicting drug behavior by expression profiling using high-density oligonucleotide arrays

An important aspect of the drug development process is prediction of efficacious and toxic side effects. Profiling of mRNA expression is a powerful approach to analyze the molecular phenotype of cells under various conditions, for example, in response to stimulation by compounds. We attempt to explore the approach of using expression profiling to identify patterns or fingerprints that are correlated with specific drug properties or behaviors. Identification of such expression patterns may also lead to revelation of the potential action mechanism of drugs and fingerprints indicative of certain drug efficacy or side effects. We describe here a strategy that was used to identify a set of genes whose differential expression pattern correlates with activation mode and target specificity of a specific group of drug compounds.

Subunit structure of vacuolar proton-pyrophosphatase as determined by radiation inactivation

Vacuolar proton-pyrophosphatase (H(+)-PPase) of mung bean seedlings contains a single kind of polypeptide with a molecular mass of approx. 73 kDa. However, in this study, a molecular mass of approx. 140 kDa was obtained for the purified vacuolar H(+)-PPase by size-exclusion gel-filtration chromatography, suggesting that the solubilized form of this enzyme is a dimer. Radiation inactivation analysis of tonoplast vesicles yielded functional masses of 141.5 +/- 10.8 and 158.4 +/- 19.5 kDa for PP1 hydrolysis activity and its supported proton translocation respectively. These results confirmed the in situ dimeric structure of the membrane-bound H(+)-PPase of plant vacuoles. Further target-size analysis showed that the functional unit of purified vacuolar H(+)-PPase was 71.1 +/- 6.7 kDa, indicating that only one subunit of the purified dimeric complex would sufficiently display its enzymic reaction. Moreover, in the presence of valinomycin and KCl, the functional size of membrane-bound H(+)-PPase was decreased to approx. 63.4 +/- 6.3 kDa. A working model was proposed to elucidate the structure of native H(+)-PPase on vacuolar membrane as a functional dimer. Factors that would disturb the membrane, e.g. membrane solubilization and the addition of valinomycin and KCl, may induce an alteration in its enzyme structure, subsequently resulting in a different functional size.

Serum response element associated transcription factors in mouse embryos: serum response factor, YY1, and PEA3 factor

Many mammalian transcription factors, including human and mouse serum response factors (SRFs), are post-translationally modified with O-linked N-acetylglucosamine monosaccharides on multiple serine and/or threonine residues. Nuclear extracts were prepared from 9.5 to 19 days postcoitum mouse embryos and subsequently were fractionated by wheat germ agglutinin (WGA)-agarose affinity chromatography. SRF binds WGA-agarose and apparently is O-glycosylated. On the other hand, the low molecular weight serum response element (SRE)-binding proteins, including the previously named band I and band II factors, did not bind WGA-agarose. Furthermore, we showed that the fastest migrating complex contains the Yin-Yang 1 (YY1) factor. YY1 binds to the c-fos SRE and skeletal alpha-actin muscle regulatory element (MRE), but not the cardiac alpha-actin MRE. Nuclear extracts from NIH/3T3 fibroblasts contain similar, if not identical, SRE-binding complexes. Besides these SRE-binding factors, mouse PEA3-binding factor, presumably an ETS domain-containing protein, was found to bind SRF protein. This physical interaction, between SRF and ETS domain proteins, was shown to involve the DNA-binding domain-containing region of SRF and not the carboxyl-terminal transactivation domain.

Muscle homeodomain protein MHox inhibits ternary complex formation at the c-fos serum response element

The Serum Response Element in the c-fos promoter is the target of growth factor-regulated signal transduction pathways. The ternary complex of Serum Response Element-binding protein Serum Response Factor and its accessory protein Ternary Complex Factor are important for transcriptional stimulation of the c-fos promoter in fibroblasts. However, this promoter is repressed in differentiating muscle cells. We discovered that MHox, a muscle homeodomain protein, was capable of inhibiting formation of the ternary complex by direct physical interaction between MHox and Serum Response Factor accessory protein-1 (SAP-1), one member of the Ternary Complex Factor family of proteins. Furthermore, exogenous MHox protein inhibited serum-inducibility of a Serum Response Element-dependent reporter gene in permeabilized fibroblasts. Taken together, these results imply that MHox is involved in blocking mitogenic signals during myogenesis.

A Chinese lady with Carney's complex

A young Chinese lady with ACTH-independent Cushing's Syndrome was reported. Her clinical features was compatible with the recently described Carney's complex. Bilateral adrenalectomy was then performed. The diagnosis of bilateral pigmented nodular adrenocortical dysplasia was microscopically confirmed.

The carboxyl-terminal transactivation domain of human serum response factor contains DNA-activated protein kinase phosphorylation sites

The serum response factor (SRF) is a 67-kDa phosphoprotein that, together with auxiliary factors, modulates transcription of immediate early genes containing serum response elements in their promoters. Here we show that the carboxyl-terminal domain of human SRF is phosphorylated in vivo and is recognized in vitro by the double-stranded DNA-activated serine/threonine-specific protein kinase, DNA-PK. SRF phosphorylation by DNA-PK was stimulated by its cognate binding site. Protein microsequence analysis of a 22-amino acid synthetic SRF peptide and phosphopeptide analysis of genetically altered glutathione S-transferase-SRF fusion proteins identified Ser-435 and Ser-446 of human SRF as sites phosphorylated by DNA-PK. Both serines are followed by glutamine. Changing Gln-436 and Gln-447 to other residues reduced or eliminated phosphorylation by DNA-PK, confirming that these glutamines are important determinants for kinase recognition. The carboxyl-terminal transcription activation domain was mapped within a 71-amino acid region that contains both DNA-PK phosphorylation sites. Amino acid substitutions that interfered with phosphorylation by DNA-PK at Ser-435/446 in GAL4-SRF fusion proteins were reduced in transactivation potency. From these data we suggest that DNA-PK phosphorylation may modulate SRF activity in vivo.

Functional size analysis of F-ATPase from Escherichia coli by radiation inactivation

A radiation inactivation technique was employed to determine the functional size of adenosine triphosphatase from Escherichia coli (EF0EF1-ATPase). Functional units of the membrane-bound and the soluble ATPases were estimated to be 300 +/- 39 and 295 +/- 32 kDa, respectively. The presence of the free radical scavenger dithiothreitol was crucial in measuring the radiation inactivation size of ATPase. When gramicidin and carbonyl cyanide p-trifluoromethoxyphenylhydrazone were added, an increase in the functional mass of membrane-bound ATPase was observed. In contrast, valinomycin and KCl had hardly any effect on the functional size of ATPase. We also determined a functional unit of 355 +/- 33 kDa for proton translocation by a fluorescence quenching technique. A reconstitution study using irradiated coupling factor 1 (EF1)-depleted membrane revealed that the functional mass of the proton channel was 96 +/- 11 kDa. A similar functional size for ATP-Pi exchange and ATP hydrolysis implies that both reactions might utilize identical machinery. Furthermore, functional units of soluble EF1 for unisite (nonsteady state) and multisite (steady state) ATP hydrolysis were calculated as 200 +/- 32 and 298 +/- 32 kDa, respectively. A working hypothesis was proposed from radiation inactivation analysis to elucidate the structure and mechanism of F1-ATPase.

[A study of transpial migration of implanted serotonergic neurons in rat spinal cord]

Transpial migration of implanted 5-HT neurons from the subarachnoid space into the spinal cord was studied in adult Wistar rats. Embryonic raphe tissue or cell suspension containing 5-HT cells was used as grafts. The implanted 5-HT cells were monitored by 5-HT immunohistochemical method. The results are as follows: (1) 10 d after cutting the spinal cord at lower thoracic level, 5-HT fibers disappeared in the transected spinal cord. (2) Raphe tissue was implanted into the subarachnoid space of the thoracic lumbar segment after the spinal cord was cut. One month later, 5-HT positive cells could be found in the transected spinal cord with fibers extending into both the grey and the white matters. (3) If the raphe cell suspension instead was implanted, a number of 5-HT positive cells appeared in the grey matter near the implanted region and the distribution of these cells in the grey matter was quite consistent with the implanted range of the cell suspension in the subarachnoid space. The 5-HT positive cells which had entered into the spinal cord sent out fibers and reestablished a new fiber network in the grey matter. (4) After implantation, the number of the 5-HT positive fibers in the transected grey matter became more and more sparsely distributed with increasing distance from the cell bodies and the 5-HT positive fibers reappeared in the white matter were much less than that in the grey matter. Present results show that the implanted 5-HT neurons are able to migrate transpially from the subarachnoid space into the spinal cord.

[Guiding effect of embryonic fimbria graft on cholinergic fiber growth in hippocampus of adult rats]

In view of the fact that in embryonic and neonatal central nervous system (CNS), the pathway of developing fiber tracts is capable of guiding the axonal growth, it would be interesting to know whether a similar effect exists on the axonal growth in adult CNS. Embryonic fimbria was grafted into the hippocampus of the adult rat. Two weeks later, the grafts were examined for cholinergic fibers with AChE histochemical method. It was found that a lot of cholinergic fibers appeared in the embryonic graft, but none of them in the adult fimbria graft as control. If the fimbria-fornix was transected at the time of grafting, no cholinergic fibers could subsequently be detected in both the embryonic graft and the host hippocampus. If a suspension of embryonic fimbria was used as a graft, only a few of long cholinergic fibers could be found in the grafted area. However, if tissue fragments of embryonic fimbria adhered to a strip of nitrocellulose filter were grafted as previously, numerous cholinergic fibers from the host hippocampus were found to be attracted around the strip and grow along the surface of the filter. The results seem to indicate that grafted embryonic fimbria or its tissue fragments are able to guide cholinergic fiber growth in adult hippocampus. It is possible that embryonic fimbria and other pathways of developing CNS fiber tracts provide a natural substrate for guiding axonal growth in adult CNS.

High prevalence of undiagnosed diabetes among Chinese patients with ischaemic stroke

We reviewed the prevalence of diabetes mellitus, hypertension and cigarette smoking in 176 Chinese patients with acute stroke, classified, on computed tomographic findings, as intracerebral haemorrhage or cerebral infarction. In all patients with no known history of diabetes, a 75 g OGTT was done 3-6 months after ictus and interpreted using WHO criteria. The overall prevalence of diabetes and impaired glucose tolerance (IGT) was 33.5% and 21.0%, respectively, with a higher prevalence being found in patients with cerebral infarction (P less than 0.05). Forty percent of those with diabetes were previously undiagnosed - all but 2 had ischaemic stroke. Compared to reported findings in the general population, an increased prevalence of hypertension, and possibly also cigarette smoking was found in patients with both stroke categories. On the other hand, significant hypercholesterolaemia was not found in patients of either category. In view of the high prevalence of undiagnosed diabetes among these stroke patients and the increased morbidity and mortality associated with diabetes mellitus, screening for diabetes is recommended especially in those with ischaemic stroke. If a fasting plasma glucose of greater than or equal to 6 mmol/l was used for the initial screening of undiagnosed diabetes in this group of patients, the sensitivity and specificity values would have been 78% and 94%, respectively. Whether this cut-off value can be cost-effectively employed for mass screening remains to be confirmed by studies involving larger numbers of stroke patients.

Prediction of persistent carbohydrate intolerance in patients with gestational diabetes

A 12-month prospective study was carried out in 120 Chinese patients with gestational diabetes who were found to have persistent carbohydrate intolerance at 6 weeks postpartum. The 75 g OGTT and WHO diagnostic criteria were employed for both antepartum and postpartum assessment. By 12 months, persistent carbohydrate intolerance was found in 13.3% of the patients only, 6 patients were diabetic while 10 had impaired glucose tolerance. Of those whose carbohydrate tolerance reverted to normal, 85% did so within the first 6 months. The clinical variables were analysed by multiple discriminant analysis using the logistic model. Five prognostic variables which were predictive of persistent carbohydrate intolerance at 12 months were identified. In order of decreasing predictive value, these included a high fasting glucose during pregnancy and at the first postnatal visit, a high antepartum 2 h blood glucose, the requirement of insulin during pregnancy, and a high postpartum 2 h blood glucose. Macrosomia, gestational age at diagnosis and a family history of diabetes were not predictive of persistent carbohydrate intolerance. Multiparity, maternal age and body mass index were of marginal significance only. The fitted logistic model provides a mechanism to estimate the probability of persistent carbohydrate intolerance. Such information will be helpful in patient counselling and in the efficient planning of postpartum medical follow-up.

Functional size analysis of pyrophosphatase from Rhodospirillum rubrum determined by radiation inactivation

A radiation inactivation technique was employed to determine the functional size of pyrophosphatase (PPase) from the chromatophores of Rhodospirillum rubrum. The activities of hydrolysis and synthesis reactions of pyrophosphatase and its coupled proton translocation decayed in a simple exponential function with the increase of radiation dosages. D37 values of 5.2 +/- 0.7 and 5.8 +/- 0.8 Mrads were obtained for pyrophosphate hydrolysis and its associated proton translocation yielding molecular masses of 167.7 +/- 30.7 and 156.3 +/- 26.6 kDa, respectively. Similarly, a D37 value of 4.4 +/- 0.6 Mrads was measured for the acid-base induced pyrophosphate synthesis resulting in a radiation sensitive size of 196.3 +/- 31.9 kDa.

Comparison of captopril and enalapril in the treatment of hypertension in patients with non-insulin dependent diabetes mellitus and nephropathy

Eighteen patients with non-insulin dependent diabetes mellitus (NIDDM), hypertension and nephropathy were randomized to receive captopril or enalapril for 6 months. Two patients with serum creatinine of greater than 400 mumol/l had to be excluded from the study because of rapidly deteriorating renal function after starting treatment. Of the remaining patients, 7 received captopril and 9 received enalapril. Blood pressure control was achieved in about 50% of patients with either drug alone. Serum creatinine and creatinine clearance were unchanged in both groups but there was a greater tendency for the former to increase in patients with higher pretreatment values. Proteinuria was reduced at 1 month only in the enalapril group which also showed a significant elevation of serum potassium after treatment. Captopril and enalapril have only a modest antihypertensive action in patients with NIDDM and nephropathy. Their use in patients with renal insufficiency must be balanced against the risk of further aggravating the deterioration of renal function.

Hyperthyroidism during pregnancy due to coexistence of struma ovarii and Graves' disease

A patient with hyperthyroid Graves' disease and struma ovarii is described. She had pre-existing Graves' disease and positive thyrotrophin receptor antibody. She was treated with radioactive iodine 5 months before she became pregnant. Paripartum she had torsion of an ovarian cyst with histological evidence of a functional struma ovarii. Immediate exacerbation of her thyrotoxic state was observed after operation as a result of release of thyroid hormone from the tumour. It is postulated that the tumour was stimulated by circulating thyrotrophin receptor antibody.

Long-term effects of megavoltage radiotherapy in acromegaly

The progress of 41 Chinese patients with acromegaly treated with megavoltage radiotherapy was reviewed after a mean follow-up of 4.5 (one-ten) years. Nine received prior surgery. Radiotherapy was delivered by a 3-field technique to a total of 4000-5000 cGy in 25 fractions. By life table analysis successful treatment of growth hormone (GH) hypersecretion, as defined by a mean GH concentration of less than or equal to 10 mu/L, could be expected in 6, 11, 26, 64 and 67% of the patients after one, two, five, eight and ten years respectively. Median intervals before achieving a mean GH level of less than or equal to 10 mu/L were 6.6 and 8.6 years following radiotherapy with the higher (4500-5000 cGy) and lower (4000 cGy) doses respectively, suggesting a tendency towards earlier response following radiotherapy with the higher dose. The prevalence of acquired hypopituitarism in patients followed up for over five years was 40% for gonadotrophins, 30% for TSH and 20% for ACTH deficiency respectively. In the majority of patients, acquired hypopituitarism was not apparent within five years after radiotherapy. No mortality or major side effects were noted following radiotherapy. In 34 patients on long-term bromocriptine treatment, mean GH concentrations were normalised in 26.5% of patients. We conclude that with judicious selection of patients and use of adjunctive medical therapy, megavoltage radiotherapy remains a safe and satisfactory form of treatment for acromegaly especially if expert transphenoidal surgery is not readily available.

Hyperglycemia is a stress response in acute stroke

To explore further the relation between admission glucose concentration and outcome in stroke, we measured glucose, fructosamine, and glycosylated hemoglobin concentrations on admission in 216 patients seen within 24 hours after the onset of their first stroke. Fructosamine concentration reflects the degree of glycemia in the preceding 4-6 weeks and glycosylated hemoglobin concentration reflects that in the preceding 3 months. Based on clinical, computed tomographic, and necropsy findings, strokes were classified as cortical infarction, lacunar infarction, or intracerebral hemorrhage. Analyses were done including and excluding 47 diabetic patients. No correlation between neurologic outcome as mortality and fructosamine or glycosylated hemoglobin concentration was found. Survival showed a significant correlation with admission glucose concentration only for patients with intracerebral hemorrhage. Our results suggest that hyperglycemia is unlikely to worsen the outcome of acute stroke and that hyperglycemia probably represents either a latent diabetic state or a stress response.

An assessment of drug information sheets for diabetic patients: only active involvement by patients is helpful

Insulin/sulphonylurea-treated diabetics attending a busy university diabetic clinic were studied to determine whether issuing drug information sheets and/or age influenced understanding and behaviour regarding their disease and its treatment, especially with respect to avoiding hypoglycaemia. Patients were each asked 10 basic questions (each correct answer scoring 1), stratified by age (20 were less than or equal to 45 years and 91 greater than 45 years). According to a single-blind randomised protocol, they were issued or not issued with drug information sheets (providing information to correctly answer all 10 questions). After 2-3 months, 107 (88 aged greater than 45 years) were retested and asked whether they recalled an information sheet, read it themselves or had it read to them. Whether or not patients received sheets, corresponding mean aggregate scores were very similar in both age groups and there was no correlation with age. Second test scores yielded clinically and statistically significant increments in both the sheet and no sheet groups, respective mean aggregate scores increasing from 4.48 to 5.80 and 5.14 to 6.27 (P less than 0.001). Among patients issued with sheets, 32 who recalled reading them achieved the greatest improvement in mean scores (4.53 to 6.16, P less than 0.001). Active interaction/communication (participation in first test, recall and reading of information sheet) had a favourable educational impact irrespective of age, but merely issuing drug information sheets had no benefit.

Primary hyperparathyroidism: its clinical pattern and results of surgical treatment in Hong Kong Chinese

Primary hyperparathyroidism has been increasingly diagnosed among whites since the advent of the biochemical autoanalyzer. However, the condition remains uncommon among Orientals. Our experience with 31 patients at the Queen Mary Hospital, University of Hong Kong, in the periods before and after we began to use the biochemical autoanalyzer was reviewed. The prevalence of primary hyperparathyroidism rose slightly from 3.1 to 3.7 per 100,000 hospital population. In both periods skeletal manifestation was the major clinical presentation, followed by hypercalcemic symptoms and urologic disease. Asymptomatic hypercalcemia occurred in three of 31 patients despite the use of the biochemical autoanalyzer. Preoperative localization was carried out in 27 patients and was helpful in nine (33.3%) of them. The surgeon explored all four parathyroids, removed the diseased gland(s), and examined a biopsy specimen of one normal-appearing gland. There were 27 adenomas, two carcinomas, one four-gland hyperplasia, and one sarcoidosis. Twenty-eight patients had transient hypocalcemia after parathyroidectomy and required calcium supplements for variable periods. Before and after we began to use the biochemical autoanalyzer, there was minimal change in the prevalence and clinical pattern of primary hyperparathyroidism seen in our hospital. In our experience, successful parathyroidectomy depends more on the surgeon's operative technique than on preoperative localization.

Strong association of HLA-DR3/DRw9 heterozygosity with early-onset insulin-dependent diabetes mellitus in Chinese

Studies of Caucasian and Japanese patients with insulin-dependent diabetes mellitus (IDDM) have shown that heterozygosity for certain HLA-DR antigens confers a high risk of developing the disease. The HLA antigens of 75 Chinese patients and 100 Chinese controls in Hong Kong were studied to investigate the role of HLA-DR heterozygosity in Chinese individuals. Some of the patients and controls were also tested for allotypic variation in the complement components C2, C4, and BF. Three alleles, Aw33, B17, and DR3, had increased frequencies in patients compared with controls and frequently occurred together in the same phenotype, which suggested their existence as a haplotype. There were no statistically significant differences in complement allotype frequencies between patients and controls, although the C4B null allele seemed to be associated with Aw33, B17, and DR3. No other HLA-DR antigen appeared to be associated with IDDM. However, when the patients were separated on the basis of age at onset, the frequency of DR3/DRw9 heterozygosity was markedly increased in patients presenting in the first decade of life, but there was no increase in patients presenting at greater than 20 yr of age. DRw9 is strongly associated with autoimmune disease in Chinese, whereas DR3 is not. We suggest that the major IDDM susceptibility locus in Chinese is associated with HLA-DR3 and that patients with HLA-DR3 and HLA-DRw9 have an added predisposition to autoimmune disease and therefore develop IDDM earlier than patients without DRw9.

Prevention of hypoglycaemia in a patient with pancreatic microadenomatosis by a long-acting somatostatin analogue SMS 201-995

Acute suppression of insulin secretion from pancreatic insulinomas by long-acting somatostatin analogue SMS 201-995 has been documented. We report the chronic use of the drug in a patient with persistent hypoglycaemia due to benign pancreatic microadenomatosis with satisfactory control of plasma glucose level and reduction of insulin production. There was no tachyphylaxis or untoward side-effect noted during the 6-month treatment period.

Long-term treatment of hyperprolactinaemia with bromocriptine: effect of drug withdrawal

Fifty-one patients with hyperprolactinaemia (23 with macroadenoma, 23 with microadenoma, and five with idiopathic hyperprolactinaemia) were treated with bromocriptine for 2-12 years (4.9 +/- 2.9 years, mean +/- SD). During therapy, the serum PRL levels were suppressed into the normal range in all but five patients. In these five patients, despite the high circulating PRL, gonadal function returned to normal in three, while in the other two gonadotrophin reserve was impaired even before therapy. Gel chromatography showed that one of these patients had a high proportion of a large molecular weight form of PRL. Twenty-four patients received bromocriptine as the sole method of treatment for over 2 years (3.4 +/- 2.3 years). In five out of the 24 subjects (21%), serum PRL remained normal with no clinical symptoms after prolonged drug withdrawal (1-4 years). Twenty-one patients received radiotherapy in conjunction with bromocriptine therapy. Of these 11 had prior surgery. After a follow-up of 6.0 +/- 3.0 years after radiotherapy, serum PRL remained within the normal range in 6 out of 21 subjects (29%), 1-4 years after bromocriptine withdrawal. One of the patients had impaired GH response to insulin hypoglycaemia developing after radiotherapy. We conclude that prolonged bromocriptine treatment is an effective treatment for prolactinomas.

Symptomatic hypothalamic-pituitary dysfunction in nasopharyngeal carcinoma patients following radiation therapy: a retrospective study

Endocrine assessment was performed in 32 relapse-free southern Chinese patients (21 males and 11 females, aged 27-50 years at the time of assessment) 5-17 years following radiation therapy (RT) alone for early nasopharyngeal carcinoma (NPC). Initial screening was done using questionnaires emphasizing on impaired sexual function and menstrual disturbance plus measurement of serum levels of thyroxine, free thyroxine index, thyrotropic hormone, prolactin, and additionally testosterone for males only. Those showing abnormalities were subjected to detailed pituitary function tests. Hypothalamic-pituitary dysfunction was found in 7 female patients and only 1 male patient. A delayed TSH response to thyrotropin releasing hormone suggesting a hypothalamic disorder was seen in 6 of the affected female patients, and hyperprolactinaemia in also 6. None of the patients had evidence of diabetes insipidus. Hypopituitarism became symptomatic 2-5 years after RT with a mean latent interval of 3.8 years. A practical protocol for regular endocrine assessment for NPC patients after RT has been proposed. Multiple linear regression analysis of the radiotherapeutic data from the 11 female patients indicates that the likelihood of late occurrence of symptomatic hypothalamic-pituitary dysfunction following RT is dependent on the TDF of the target dose to the nasopharyngeal region and the height of the upper margin of the opposed lateral facial fields above the diaphragma sellae (coefficient of multiple correlation = 0.9025). Except when the sphenoid sinus or the middle cranial fossa is involved, it is advisable to set the height of the upper margin of the lateral facial field at a level no higher than the diaphragma sellae. The hypothalamus and possibly the pituitary stalk as well may sustain permanent damage by doses of radiation within the conventional radiotherapeutic range for carcinomas.

Myopathy in acute hypothyroidism

Hypothyroid myopathy has so far been reported in long standing cases of hypothyroidism. We describe two adult patients with myopathy associated with acute transient hypothyroidism. Both presented with severe muscle aches and cramps, stiffness and spasms. Muscle enzymes were markedly elevated and electromyography in one patient showed myopathic features. Histological changes were absent in muscle biopsy, probably because of the short duration of metabolic disturbance. The myopathy subsided promptly when the hypothyroid state was reversed.

Dystrophia myotonica and pregnancy--an instructive case

Two cases of dystrophia myotonica, a mother and her newborn child, are reported. The diagnosis in the mother was only made after seven years and two eventful deliveries. The obstetrical and anaesthetic complications, as well as the neonatal form of dystrophia myotonica, are reviewed.

Strong association between HLA DRw9 and Hashimoto's thyroiditis in southern Chinese

The distribution of HLA-A, -B, and -DR antigens in 53 Southern Chinese patients with Hashimoto's thyroiditis including 33 with goitre and 20 without goitre was compared with the distribution in 100 Southern Chinese controls. There was a significantly increased prevalence of HLA Bw46 in the nongoiterous patients and of HLA DRw9 in both groups of patients, but only for HLA DRw9 in the goiterous group was the increase significant after adjustment for the number of antigens studied. Based on these findings and those in other autoimmune diseases it is considered that the haplotype Bw46, DRw9 in Chinese takes the place of B8, DR3 in Caucasians in carrying genes which predispose to the development of auto-immune disease.

Early effects of cranial irradiation on hypothalamic-pituitary function

Hypothalamic-pituitary function was studied in 31 patients before and after cranial irradiation for nasopharyngeal carcinoma. The estimated radiotherapy (RT) doses to the hypothalamus and pituitary were 3979 +/- 78 (+/- SD) and 6167 +/- 122 centiGrays, respectively. All patients had normal pituitary function before RT. One year after RT, there was a significant decrease in the integrated serum GH response to insulin-induced hypoglycemia. In the male patients, basal serum FSH significantly increased, while basal serum LH and testosterone did not change. Moreover, in response to LHRH, the integrated FSH response was increased while that of LH was decreased. Such discordant changes in FSH and LH may be explained by a defect in LHRH pulsatile release involving predominantly a decrease in pulse frequency. The peak serum TSH response to TRH became delayed in 28 patients, suggesting a defect in TRH release. Twenty-one patients were reassessed 2 yr after RT. Their mean basal serum T4 and plasma cortisol levels had significantly decreased. Hyperprolactinemia associated with oligomenorrhoea was found in 3 women. Further impairment in the secretion of GH, FSH, LH, TSH, and ACTH had occurred, and 4 patients had hypopituitarism. Thus, progressive impairment in hypothalamic-pituitary function occurs after cranial irradiation and can be demonstrated as early as 1 yr after RT.

Glucose and lipid metabolism with triphasic oral contraceptives in women with history of gestational diabetes

The glucose and lipid metabolism in a group of women with previous history of gestational diabetes were evaluated before and after 6 months treatment with a low-dose triphasic oral contraceptives pill (TP). This group was compared with a control group of women, also with history of gestational diabetes, using intrauterine devices (IUD). In the TP group, 26.7% of the women developed impaired glucose tolerance which reverted to normal in all but one after cessation of the TP. The IUD group showed no change in glucose tolerance. The integrated insulin response to a 75g OGTT in the TP group increased by 48.3% at 6 months compared with an increase of 23.4% for the same period in the IUD group. In the TP group there was a significant decrease in serum total cholesterol without changes in HDL-cholesterol and triglycerides level. We conclude that even low-dose triphasic oral contraceptive pills can cause glucose intolerance in women with previous gestational diabetes mellitus.

Fifty cases of primary hyperaldosteronism in Hong Kong Chinese with a high frequency of periodic paralysis. Evaluation of techniques for tumour localisation

Fifty consecutive Chinese patients with primary hyperaldosteronism were studied. All were considered to have an adrenal cortical adenoma, this being proven by surgery in 46 cases. In contrast to other reports, periodic paralysis was a presenting feature in 42 per cent of patients. Other notable symptoms were palpitations (30 per cent) and syncope (12 per cent). Vascular complications were present in 20 per cent of cases. Mean serum potassium level at presentation was 2.1 +/- 0.1 (mean +/- SEM) and sodium 145.0 +/- 0.1 mmol/l. Serum potassium was significantly lower and plasma aldosterone higher in patients with periodic paralysis. Adrenal venography in order to localise the tumour was unreliable and was misleading in two cases. Adrenal venous sampling for steroid analysis was much more helpful, despite the difficulty of obtaining right adrenal venous blood. The side of the adenoma could be predicted in 97 per cent of cases from measurements of left adrenal venous and vena caval aldosterone levels. The use of high resolution CT gave 100 per cent accuracy in all 18 patients who underwent surgery, the smallest detected tumour being 0.8 cm in diameter. Surgery corrected hypokalaemia in all cases, and 37 of the 46 patients required no further antihypertensive treatment.

Disseminated zygomycosis masquerading as cerebral lupus erythematosus

Zygomycosis often occurs in patients with an underlying disease, e.g., diabetes mellitus, leukemia, and lymphoma, or an immunocompromised state. This report discusses a case of a 21-year-old woman with systemic lupus erythematosus complicated by uremia, acidosis, steroid therapy, prolonged antimicrobial therapy, and disseminated zygomycosis.

Hypothalamic defects in two adult patients with septo-optic dysplasia

Two adult patients with unilateral hypoplastic optic nerves, absent septa pellucida and hypopituitarism are described. Patient 1, aged 20, presented with diabetes insipidus due to partial vasopressin deficiency. Patients 2, aged 29, presented with focal epilepsy. Both had short stature. They showed absent growth hormone (GH) response to insulin-hypoglycaemia or glucagon, but responded to 100 micrograms growth hormone releasing factor (GRF-44) with a rise in circulating GH, suggesting a hypothalamic defect in GH release though a co-existing pituitary defect cannot be excluded. Other hypothalamic-pituitary functions were normal. These two patients probably represent the milder form of the clinical spectrum of septo-optic dysplasia which, with the extensive use of CT brain scans, will be increasingly encountered by physicians attending adult patients.

Sustained improvement in diabetic control on long-term self-monitoring of blood glucose

The benefits of self-monitoring of blood glucose (SMBG) were assessed in 38 Chinese adults on conventional insulin regimens who had been performing SMBG for a mean duration of 26 months (range 15-40). For analysis patients were divided into 2 groups. Group A consisted of 27 insulin-requiring patients who were referred for SMBG because of poor control or young age (less than or equal to 35 years). Group B consisted of 11 IDDM patients who were on SMBG from diagnosis. Mean age and duration of SMBG were similar in the 2 groups though group A had longer duration of disease. In group A, mean haemoglobin A1 (HbA1) decreased from 12.4 +/- 0.5% before SMBG to 10.9 +/- 0.5% at 6 months (P less than 0.005), 10.7 +/- 0.5% at 12 months (P less than 0.005) and 10.3 +/- 0.4% after long-term SMBG. This was accompanied by a significant reduction in insulin requirement from 0.82 +/- 0.07 U/kg/day to 0.72 +/- 0.07 U/kg/day (P less than 0.05). In group B, insulin requirement progressively decreased in the first 6 months. At 12 months, mean HbA1 was 9.0 +/- 0.5% and insulin requirement was 0.58 +/- 0.08 U/kg/day. No significant change in HbA1 or insulin requirement was observed beyond the first year. After long-term SMBG, 82% of patients in group B had good control (HbA1 less than or equal to 10%) compared to 45% only in group A (P less than 0.05). Long-term SMBG is associated with sustained improvement in diabetic control and is particularly beneficial if introduced to diabetic patients right from diagnosis.

Hypothalamic hypopituitarism following cranial irradiation for nasopharyngeal carcinoma

Eight patients, one male and seven females, with no pre-existing hypothalamic-pituitary disease, who developed symptoms of hypopituitarism following cranial irradiation for nasopharyngeal carcinoma were studied 5 years or more after radiotherapy. All were GH deficient. Four of the patients with no GH response during insulin tolerance tests (ITT) showed increased GH in response to synthetic human growth hormone releasing factor (GRF-44). Four patients had impaired cortisol responses to ITT, and gradual but diminished cortisol responses to ovine corticotrophin releasing factor (CRF-41). There was no significant difference between mean peak increments in response to ITT and those in response to CRF-41. TSH responses to TRH were delayed in five and absent in two patients; four of these had low free T4 index. Prolactin was raised in all seven women and increased further in response to TRH. Two patients had impaired gonadotrophin responses to LHRH. None of the patients had clinical or biochemical evidence of diabetes insipidus. These data suggest that post-irradiation hypopituitarism in these patients results from radiation damage to the hypothalamus leading to varying degrees of deficiency of the hypothalamic releasing or inhibitory factors.

HLA antigens and acetylcholine receptor antibody in the subclassification of myasthenia gravis in Hong Kong Chinese

Thirty seven Chinese adults and 23 children in Hong Kong with myasthenia gravis were tested for HLA-A and -B antigens and acetylcholine receptor (AChR) antibody. HLA BW46 had a significantly increased prevalence in patients with juvenile onset ocular myasthenia gravis. Only one third of the juvenile ocular patients had AChR antibodies and the titres were generally low. In the adult patients taken as a whole there was a non-significant increase in the prevalence of HLA B5 and HLA B15. HLA BW46 was more prevalent in adult patients without AChR antibody and less prevalent in patients with AChR antibody but the findings were not statistically significant. It is suggested that ocular myasthenia gravis is determined by a pathological mechanism for which susceptibility is determined by HLA BW46. There was a strong correlation between ocular myasthenia gravis and Graves' disease in the adult patients. The possibility that ocular myasthenia gravis is accentuated by a BW46-associated predisposition to ocular Graves' disease is considered.

Analysis of linkage between HLA haplotype and susceptibility to Graves' disease in multiple-case Chinese families in Hong Kong

Data from 10 Chinese families in Hong Kong with multiple cases of thyrotoxic Graves' disease were analysed to determine whether genes predisposing to Graves' disease are linked to the HLA region. No evidence was obtained in favour of either dominant or recessive inheritance of HLA-linked susceptibility to Graves' disease. Six of 10 affected parent-offspring combinations had haplotypes containing HLA Bw46 which is more than would be expected from the antigen frequency of Bw46 in normal controls. It is concluded that HLA-associated genes play a role in determining disease susceptibility but that other factors are involved in determining disease expression.

Association of HLA antigens with thyrotoxic Graves' disease and periodic paralysis in Hong Kong Chinese

The HLA-A and -B antigen distribution in 132 Hong Kong Chinese patients with Graves' disease, including 24 with thyrotoxic periodic paralysis, was compared with that in 110 controls. The HLA-DR antigen distribution in 68 patients was compared with that in 47 controls. The prevalence of Bw46 was significantly increased in patients with Graves' disease and with periodic paralysis. The prevalence of DRw9 was also slightly increased but not at a statistically significant level. The high prevalence of Bw46 related to patients with early age at onset whereas patients with later age at onset had a significantly increased prevalence of HLA B5. It is suggested that Graves' disease in Chinese is due to two HLA-associated mechanisms in which early-onset disease is associated with Bw46 and late-onset disease with B5.

Primary hypothyroidism and essential hypernatremia in a patient with histiocytosis X

A 27 year old woman with histiocytosis X had an unusual initial presentation with features of primary hypothyroidism and a goitre. Diagnosis was made by lung and thyroid biopsies. Endocrine tests showed the presence of hypopituitarism and a discrete suprasellar mass, consistent with hypothalamic histiocytosis X, was demonstrated by computerised tomography. Radiotherapy and chemotherapy arrested the clinical progression of the disease.

The diagnosis of primary hyperaldosteronism

An aldosterone-suppression test based on a simple method of extracellular-fluid volume expansion over three days reliably discriminated between patients with aldosterone-producing adenomas, idiopathic adrenal hyperplasia, and essential benign hypertension. In patients with primary hyperaldosteronism adrenal-vein plasma aldosterone/cortisol concentration ratios successfully lateralised all 21 adenomas. In patients with an adenoma the contralateral adrenal gland was always suppressed, as indicated by a ratio which was less than that seen in the lower inferior vena cava, whereas in patients with hyperplasia the adrenal-vein aldosterone/cortisol concentration ratio from each adrenal was always greater than that seen in the lower inferior vena cava. Thus adrenal-vein sampling not only lateralises solitary adenomas but also discriminates between patients with an adenoma or hyperplasia. However, in view of the diagnostic reliability of the suppression test, it is suggested that adrenal-vein sampling is unnecessary in hyperaldosteronism due to adrenal hyperplasia.