Clinico-epidemiological presentations and management of Nipah virus infection during the outbreak in Kozhikode district, Kerala state, India 2023

India experienced its sixth Nipah virus (NiV) outbreak in September 2023 in the Kozhikode district of Kerala state. The NiV is primarily transmitted by spillover events from infected bats followed by human-to-human transmission. The clinical specimens were screened using real-time RT-PCR, and positive specimens were further characterized using next-generation sequencing. We describe here an in-depth clinical presentation and management of NiV-confirmed cases and outbreak containment activities. The current outbreak reported a total of six cases with two deaths, with a case fatality ratio of 33.33%. The cases had a mixed presentation of acute respiratory distress syndrome and encephalitis syndrome. Fever was a persistent presentation in all the cases. The Nipah viral RNA was detected in clinical specimens until the post-onset day of illness (POD) 14, with viral load in the range of 1.7-3.3 × 104 viral RNA copies/mL. The genomic analysis showed that the sequences from the current outbreak clustered into the Indian clade similar to the 2018 and 2019 outbreaks. This study highlights the vigilance of the health system to detect and effectively manage the clustering of cases with clinical presentations similar to NiV, which led to early detection and containment activities.

Mental Health Assessment of Health Care Providers of Bangladesh during Covid-19 Pandemic: A Cross-Sectional Web-Based Study

SARS COV 2 raised immense agony to everyone. As health care workers remains direct contact with patients, they are vulnerable to mental health disorder. The study was done to identify mental health status of health care providers of Bangladesh. It was a cross sectional web based survey among health care providers of bangladesh. A structured web based questionnaire was prepared both in Bangla and English version for better understanding. Total 2594 health care workers responded to online survey. Male were 1303(50.2%) and female were 1291(49.8%). Occupational demography shows 98.5% were physicians. Mean value of patient health questionnaire 9 (PHQ9) and generalized anxiety disorder (GAD) were 8.43±6.082 and 8.27±5.234 respectively among healthcare providers. To overcome anxiety and depression, 93.4% of HCW didn't receive any psychological material and 85.6% HCW didn't find physiological resources even through media. Despite many lacking, healthcare workers were resilient in our study.

Nipah Virus Outbreak in Kerala State, India Amidst of COVID-19 Pandemic

We report here a Nipah virus (NiV) outbreak in Kozhikode district of Kerala state, India, which had caused fatal encephalitis in a 12-year-old boy and the outbreak response, which led to the successful containment of the disease and the related investigations. Quantitative real-time reverse transcription (RT)-PCR, ELISA-based antibody detection, and whole genome sequencing (WGS) were performed to confirm the NiV infection. Contacts of the index case were traced and isolated based on risk categorization. Bats from the areas near the epicenter of the outbreak were sampled for throat swabs, rectal swabs, and blood samples for NiV screening by real-time RT-PCR and anti-NiV bat immunoglobulin G (IgG) ELISA. A plaque reduction neutralization test was performed for the detection of neutralizing antibodies. Nipah viral RNA could be detected from blood, bronchial wash, endotracheal (ET) secretion, and cerebrospinal fluid (CSF) and anti-NiV immunoglobulin M (IgM) antibodies from the serum sample of the index case. Rapid establishment of an onsite NiV diagnostic facility and contact tracing helped in quick containment of the outbreak. NiV sequences retrieved from the clinical specimen of the index case formed a sub-cluster with the earlier reported Nipah I genotype sequences from India with more than 95% similarity. Anti-NiV IgG positivity could be detected in 21% of Pteropus medius (P. medius) and 37.73% of Rousettus leschenaultia (R. leschenaultia). Neutralizing antibodies against NiV could be detected in P. medius. Stringent surveillance and awareness campaigns need to be implemented in the area to reduce human-bat interactions and minimize spillover events, which can lead to sporadic outbreaks of NiV.

Range of factors in the reduction of hyperhydricity associated with in vitro shoots of Salvia santolinifolia Bioss

Hyperhydricity is a serious physiological disorder and affects In vitro propagation of many plants and as well of Salvia santolinifolia. The donor material to initiate the in vitro culture was the callus taken from the in vitro shoots produced on Murashig and Skoogs (MS) medium at 4.0 mg/l BA. This callus formed numerous hyperhydric shoots on culturing upon the medium of the same composition. The aim was to systematically evaluate the effect of cytokinins (Benzyladnine (BA) and N6-(-2-isopentenyl) adenine (2iP), culture vessels magnitude, medium solidification, source of nitrogen and calcium chloride for the alleviation of hyperhydricity. In the tissue cultures of S. santolinifolia BA and 2iP induced severe hyperhydricity, when other factors i.e. culture vessels magnitude and a suitable concentration of agar, ammonium nitrate (NH4NO3), potassium nitrate (KNO3) & calcium chloride (CaCl2.2H2O) were not optimized. After 30 days' culture, we observed 83.82% hyperhydric shoots at increased level (1.5 mg/l 2iP) and 81.59% at decreased levels (1.0 mg/l 2iP). On the other hand, hyperhydricity percentage at decreased (0.4%) and at increased (0.8%) levels of agar were 72.37% and 39.08%, respectively. MS medium modification with NH4NO3 (412 mg/l), KNO3 (475 mg/l) and CaCl2.2H2O (880 mg/l) was found the best medium to reduced hyperhydricity (23.6%).

Mosquitocidal activities of Chenopodium botrys whole plant n-hexane extract against Culex quinquefasciatus

This research aimed to investigate various mosquitocidal activities of Chenopodium botrys whole- plant n-hexane extract against Culex quinquefasciatus. The extract showed remarkable larvicidal, pupicidal, adulticidal, oviposition deterrent and adult emergence inhibitory activities against Cx. quinquefasciatus. During the larvicidal and pupicidal activities, the 24-hour lethal concentration (LC50) of extract against 2nd instar larvae, 4th instar larvae and pupae were 324.6, 495.6 and 950.8 ppm, respectively. During the CDC (Centers for Disease Control and Prevention) bottle bioassay for adulticidal activity, the median knockdown times (KDT50) at 1.25% concentration was 123.4 minutes. During the filter paper impregnation bioassay for adulticidal activity, the KDT50 value at 0.138 mg/cm2 concentration was 48.6 minutes. The extract was fractionated into 14 fractions through silica gel column chromatography which were then combined into six fractions on the basis of similar retention factor (Rf) value. These fractions were screened for adulticidal activity by applying CDC bottle bioassay. The fraction obtained through 60:40 to 50:50% n-hexanes-chloroform mobile phase with 0.5 Rf value showed 100% adulticidal activity at 0.2% concentration. During oviposition deterrent activity, the highest concentration (1000 ppm) showed 71.3 ± 4.4% effective repellence and 0.6 ± 0.1 oviposition activity index. During adult emergence inhibition activity, the median emergence inhibition (EI50) value was 312.3 ppm. From the outcome of the present investigation, it is concluded that the n-hexane extract of C. botrys whole- plant possesses strong larvicidal, pupicidal, adulticidal, oviposition deterrent and adult emergence inhibitory activities against Cx. quinquefasciatus.

Protective effects of Zizyphus oxyphyla on liver and kidney related serum biomarkers in (CCl4) intoxicate rabbits

The study was aimed to evaluate the therapeutic effects of Zizyphus oxyphyla leaves methanolic (ZOX-LME), on serum liver, kidney and hematology along with other serum parameters in Carbon tetrachloride (CCl4) intoxicated rabbits. Experimental animals were divided into five groups, six rabbits in each. These were: group NC (normal control), group, TC (toxic control) and group ST i.e. silymarine administered group at dose rate (50) mg/kg body weight (BW). Group ET1 and group ET2 treated with (ZOX-LME) at dose 200 mg/kg BW and 400 mg/kg BW. CCl4 administration caused significant (P> 0.05) impairment in serum liver enzymes, blood factors and other serum indices. Treatment with (ZOX-LME) significantly (P<0.05) reduced and normalized the levels of serum alanine transaminase (ALT) aspartate transaminase (AST) and alkaline phosphatase (ALP) and hematological indices. Also significant (P< 0.05) reduction was observed in creatinine, urea, uric acid, blood urea nitrogen (BUN), and albumin and glucose concentrations. The altered levels of lipid profile and serum electrolytes (Ca, Mg, Cl, Na, K, and P) were significantly (P<0.05) change toward normal levels with (ZOX-LME) feeding. In addition (ZOX-LME) ingestion caused significant improvement in GSH, GST and CAT levels, while reducing the TBARS levels, exhibited antioxidant capacity. Also (ZOX-LME) showed increase inhibition against percent scavenging of 2, 2-diphenile-1-picrylehydrazyle (DPPH) free radical. Significant (P<0.05) normalizing effects were observed with high dose 400 mg/kg BW of (ZOX-LME and were equivalent to silymarine administered groups. The histological study of liver supported the hepatoprotective and renal curative activity of (ZOX-LME).

Pelatihan Pembuatan Media Pembelajaran Matematika di SD Negeri Jatimekar 02

In general, elementary school age children (SD) are experiencing development at their thinking level, elementary school children's thinking stages are still not formal and are still concrete in nature. Therefore, the teacher must present material that is real so that elementary students can understand the concept completely. Based on the results of interviews with several mathematics teachers and principals, information was obtained that mathematics learning is carried out very rarely using media, especially in the form of props or other innovative media. Regarding the above problems, we are interested in conducting training through a community service program entitled "PKM Training on Making Mathematics Learning Media at SDN Jatimekar 02." This PKM is carried out in the form of three meetings training. The training participants were a number of teachers at SDN Jatimekar 02 Pagi. The presentation material in this service activity is: (1) The concept of learning media that is in accordance with the characteristics of Mathematics subjects along with examples of implementation in learning (2) Making learning implementation plans (RPP) with appropriate learning media (3) Simulation of implementing cooperative learning media in learning, and (4) assessment of learning using instructional media. Based on the results of the evaluation, 28 out of 32 participants understood the concept of learning media well, 25 participants were able to develop plans for implementing learning using media, and 30 participants were able to use media when learning in class.

Clinical and Radiological Study of Serum Fluoride in Relation to Knee Osteoarthritis

Introduction

Fluorosis has been associated with an increased risk of degenerative changes in the knee. Multiple studies have found an association between arthritis and elevated fluoride levels. We aim to delineate if elevated fluoride level has any direct correlation with the degree of radiological grading and clinical symptoms in knee arthritis.

Materials and Methods

A cross-sectional study of 80 knee arthritis patients was conducted from February 2017 to April 2018. Serum fluoride levels were measured and patient's pain scores, WOMAC scores and radiological grading were correlated with the elevated fluoride levels.

Results

In our study, 30 out of 80 patients had increased serum fluoride level. Statistically significant differences were noted in VAS score, WOMAC score and Kellgren and Lawrence radiological grades between patients with normal serum fluoride level and those with elevated fluoride level.

Conclusion

There is an increased risk of knee arthritis in patients with elevated blood fluoride levels and patients with increased fluoride levels are associated with more severe symptoms and radiographic disease.

Small group discussions as an effective teaching-learning methodology for learning the principles of family medicine among 2nd-year MBBS students

Teaching methodology has a great impact on the learning outcomes in an undergraduate's education.

P860 Multimodality imaging of multiple recurrent myxomas: the role of three dimensional echocardiography

A 33-year-old lady who underwent left atrial myxoma resection was found to have on a 3 years follow up transthoracic echocardiography (E) a multilobular mass in the right atrium.

A 2D transesophageal echocardiogram (TEE) was performed. Two Multi-lobulated masses were seen in the right atrium(RA); one bigger attached by a peduncle to the atrial wall in between the interatrial septum (IAS) and the superior vena cava and one smaller attached to the inferior RA wall; a remnant likely a suture was seen on the right side of the fossa ovalis; another small mass was noted on the left atrial (LA) side of the IAS; a small mass attached close to the posteromedial commissure and P3 scallop of the mitral valve was also detected. The RA mass was partially protruding into the tricuspid valve during diastole with no significant obstruction to flow.

Three dimensional TEE allows an anatomical imaging able to identify the peduncles of two right atrial masses and three LA masses that were confirmed at surgery and consistent with cardiac myxoma at histopathology : one close the previous resection area, one at the opening of the LAA (panel A, white arrow) and one close to the posterior commissure of mitral valve (panel B, yellow arrow) and that were not seen by 2D. Magnetic resonance imaging (MRI) with contrast identified and showed opacification of : two masses in the RA with the pedicles ; - one mass on the LA side of interatrial septum; - one mass close to mitral valve posterior commissure ; however it was not able to detect the small mass close to the LAA.

In our case 2D Echocardiography and MRI were able to identify 4 of the 5 recurrences found at surgery. 3D TEE was the only technique able to identify all 5 lesions. MRI is considered the gold standard for detecting cardiac tumor masses; however, even after careful review, it was not possible to identify the presence of the mass close to LAA. In particular 3D TEE was able to image the left atrial masses by an "en face view" of the left atrium from above. In addition, the unique 2D planes in unconventional views allow a more clear identifications of the peduncles of the masses in the right atrium. The identification of the peduncles is mainstay for the diagnosis of recurrent myxomas and exclude other tumors like metastasis or sarcomas. In fact multiple recurrence are very rare in particular if we consider that are in the two atria. Genetic tests for Carney complex were negative. The MRI allowed to confirm the vascularization of the contrast and to identify the peduncles of two masses in the right atrium.

A multimodality imaging is able to correctly detect recurrent myxomas by identifying the anatomical features and the vascularization and lead to the diagnosis ; 3DE was the only technique able to correctly identify all the recurrent myxomas and and its use has the potential for being considered the key adjunctive modality for the anatomy when advanced surgical plan is required.

Abstract P860 Figure.

Neurological complications in patients with Plasmodium vivax malaria from Karachi, Pakistan

BACKGROUND

Malaria remains an endemic disease in Pakistan with an estimated healthcare burden of 1.6 million cases annually, with Plasmodium vivax accounting for 67% of reported cases. P. vivax is the most common species causing malaria outside of Africa, with approximately 13.8 million reported cases worldwide.

METHOD

We report a series of P. vivax cases with cerebral involvement that presented at Aga Khan University Hospital, Karachi, Pakistan.

RESULTS

The majority of the patients presented with high-grade fever accompanied by projectile vomiting and abnormal behaviour, seizures, shock and unconsciousness. Seven of 801 patients with P. vivax monoinfection presented or developed cerebral complications. P. vivax infections were diagnosed based on peripheral smears and rapid diagnostic testing.

CONCLUSION

P. vivax infection can lead to severe complications, although not with the frequency of Plasmodium falciparum infection. Current cases highlight an increasing trend of cerebral complications caused by P. vivax.

Compliance to Antihypertensive Medication: A Tertiary Care Study

Hypertension is a global health problem and affects more than one billion people worldwide. Long term hypertension is associated with grave complications and therefore maintaining blood pressure within normal range is essential and ensuring patient's drug compliance is an important sector of patient care. Therefore, the purpose of our study was to find out the causes of poor compliance to antihypertensive medications. This cross sectional study was carried out in Medical Department of Ayub Teaching Hospital Abbottabad, Pakistan from 1st September 2017 to 30th October 2018. One hundred ninety three (193) patients were included through non probability consecutive sampling and were divided into two groups on the basis of compliance. The data was collected with the help of a structured questionnaire and analyzed using SPSS 20. Out of 193 hypertensive patients, 88(45.6%) were male while 105(54.4%) were females, with minimum age of 24 years and maximum age of 95 years and mean age of 61.98±12.81SD. Minimum duration of hypertension was 5 months and maximum was 30 years with mean duration of hypertension and standard deviation (SD) of 6.26±6.51 years. One hundred & Twenty (62.2%) patients were non-compliant, while 73(37.8%) were compliant to medication. Forgetfulness of medicine 85(70.8%) and non-affordability 62(52.5%) were the most common causes of noncompliance. This study documented a significantly higher proportion of medication non-adherence among hypertensive patients, with drug forgetfulness and affordability being found as the most common cause.

Effect of Tris-egg Yolk, Soya Milk, and Liposome-based Extenders on Sahiwal (Bos indicus) Sperm Quality during Pre- and Post-Cryopreservation Stages

BACKGROUND

Even though there are plenty of semen cryopreservation extenders available, their adoption is limited. Although normal tris-based egg yolk (EYC) extender is widely used, it leads to compromised post-thaw sperm quality.

OBJECTIVE

To find a standard semen extender, six different semen extenders were validated.

METHODS

In a split study, six aliquots of zebu cattle fresh semen ejaculate were cryopreserved in extenders containing egg yolk obtained from hen which was reared either in 1) normal, 2) omega-3 enriched, and 3) herbal enriched diet supplementation, and egg yolk free extenders such as 4) soya lecithin, 5) Bioxcell and 6) Optixcell.

RESULT

Significantly poor sperm quality and kinematics were observed in extender containing herbal egg yolk. However, omega-3 enriched egg yolk extender was on par with EYC. Among all extenders, soya lecithin and bioxcell have shown better sperm quality. Sperm motility was significantly higher in semen extended in liposome-based extender Optixcell.

CONCULSION

Optixcell can be considered as a standard extender for cattle semen cryopreservation to maintain adequate sperm quality required for artificial insemination.

Estimating microsatellite based genetic diversity in Rhode Island Red chicken

This study aimed to estimate microsatellite based genetic diversity in two lines (the selected RIR(S) and control line RIR(C)) of Rhode Island Red (RIR) chicken. Genomic DNA of 24 randomly selected birds maintained at Central Avian Research Institute (India) and 24 microsatellite markers were used. Microsatellite alleles were determined on 6% urea-PAGE, recorded using GelDoc system and the samples were genotyped. Nei's heterozygosity and Botstein's polymorphic information content (PIC) at each microsatellite locus were estimated. Wright's fixation indices and gene flow were estimated using POPGENE software. All the microsatellite loci were polymorphic and the estimated PIC ranged from 0.3648 (MCW0059) to 0.7819 (ADL0267) in RIR(S) and from 0.2392 (MCW0059) to 0.8620 (ADL0136) in RIR(C). Most of the loci were highly informative (PIC>0.50) in the both lines, except for five loci in RIR(S) and six loci in RIR(C) line. Nei's heterozygosity per locus ranged from 0.4800 (MCW0059) to 0.8056 (ADL0267) in RIR(S) and from 0.2778 (MCW0059) to 0.875 (ADL0136) in RIR(C). Out of 24 loci, 15 (62.5%) in RIR(S) and 14 loci (58.33%) in RIR(C) revealed moderate to high negative FIS index indicating heterozygote excess for these loci in corresponding lines, but the rest revealed positive FIS indicating heterozygosity deficiency. A mean FIS across the both lines indicated overall 10.77% heterozygosity deficit and a mean FIT indicated 17.19% inbreeding co-efficient favoring homozygosity over the two lines. The mean FST indicated that 10.18% of the microsatellite variation between the two lines was due to their genetic difference.

Changing trends in incidence and indications of caesarean section

Caesarean section is most frequently performed major operation in obstetrics. The rate of caesarean section has been increasing both in developed and developing countries in the past decade. This study was done to find out the change of sociodemographic condition of respondents, identify the different types & rate of caesarean section indications, the outcome of different indications, estimate the rate of caesarean section proportion of the elective & emergency indications and evaluate the complications of caesarean sections. This is a cross-sectional study of randomly selected 130 cases of lower caesarean section done at Sir Salimullah Medical College & Mitford Hospital, Dhaka from March 2006 to August 2006. In this study 80(61.5%) cases underwent emergency caesarean section and in 50(38.5%) cases elective caesarean section had done. Among indications of caesarean section repeat section scores the top of the list. No maternal mortality case recorded in this study. This study shows high incidence of caesarean section which does not reflect the picture of total population of Bangladesh.

Isolated ocular cutaneous involvement in antiphospholipid syndrome

BACKGROUND

Antiphospholipid syndrome (APS) is defined as the presence of venous or arterial thrombosis, and/or recurrent miscarriage with evidence of antiphospholipid antibodies (aPL). In both primary and secondary APS, ocular and neurophthalmic manifestations such as retinal arteritis, retinal venous occlusion, ischemic optic neuropathy, transient loss of vision - amaurosis fugax, diplopia have been reported.

MATERIALS AND METHODS

We present an unusual case of APS in a healthy 24-year old male who had isolated ocular presentation with recurrent right periocular oedema and non-healing ulceration of the biopsy site without systemic involvement. Ocular examinations and investigations including inflammatory markers were normal.

CONCLUSION

Atypical presentations of APS may result in initial difficulty in making diagnosis.

Unintentional injuries among children admitted in a tertiary care hospital in North Kerala

World Health Organization global disease update (2004) points out injuries as the sixth leading cause of morbidity and mortality in childhood. A descriptive hospital based study was conducted to find out the common types of unintentional injuries among children admitted for management of unintentional injuries in Pediatric Surgery department and Intensive Care Unit of a tertiary care hospital of North Kerala and to find out the contributing risk factors. A total of 400 children admitted during the study period of 6 months of 2009 constituted the study population. Mechanical injuries comprising of Road traffic accidents and accidental fall were the major cause of unintentional injuries (36%), followed by Poisoning (22.3%). A higher proportion of unintentional injuries were noted to occur among children of younger mothers, overactive child, children belonging to extended or joint families, child left alone or with friends, pre-school children, male child and from urban dwellings. The study highlights the need to identify the different types of unintentional injuries and the risk factors of childhood injuries which require hospitalisation. Identification of risk factors will help to formulate strategies aimed at risk reduction and prevention of childhood injuries.

The prevalence of vitamin D abnormalities in South Asians with type 2 diabetes mellitus in the UK

BACKGROUND

The high prevalence of both hypovitaminosis D and type 2 diabetes (T2DM) in the Asian community is well recognised, but the impact of diabetes on vitamin D status and vice versa, has not been well reported.

AIMS

To determine the prevalence of hypovitaminosis D in Asian patients with T2DM and its impact on glycaemic control.

METHODS

A cross-sectional study was conducted in a tertiary referral centre in the UK. Two hundred and ten Asian patients aged more than 40 years were included (170 with and 40 without T2DM). Each had a standard bone profile (serum calcium, phosphate and alkaline phosphatase), serum parathyroid hormone and 25-hydroxycholecalciferol.

RESULTS

The prevalence of low serum 25-hydroxyvitamin D (< 50 nmol/l) was high in the group as a whole (> 80%) and more common in diabetics compared with controls (83% vs. 70%; p = 0.07). This was particularly so in men (82.5% vs. 57.9%; p = 0.02). HbA1c was higher in women with vitamin D deficiency (< 12.5 nmol/l) (8.11 +/- 1.11% vs. 7.33 +/- 1.32%, p = 0.046). In logistic regression analysis, T2DM was an independent predictor of hypovitaminosis D. In linear regression analysis, vitamin D deficiency was independently related to HbA1c in women with T2DM.

CONCLUSIONS

Hypovitaminosis D remains a major public health issue in the Asian population and is exaggerated in patients with T2DM. The fact that vitamin D deficient women had higher HbA1c levels raises the possibility that vitamin D replacement may improve glycaemic control.

Effects of a continuous care model on perceived quality of life of spouses of haemodialysis patients

We carried out a semi-experimental study with simple randomized sampling to study the effects of applying a continuous care model on the quality of life of 36 spouses of haemodialysis patients in Hamedan, Islamic Republic of Iran. Participants took part in group discussions and training on the continuous care approach and completed the Perceived Quality Of Life (PQOL) questionnaire before and after the intervention. Mean scores on the physical, social and cognitive dimensions, as well as happiness and total scores significantly increased after the intervention. Applying a continuous care model has positive effects on the caregivers of chronic patients.

Measurements of natural radioactivity and radon exhalation rates from different brands of cement used in Pakistan

The measurement of activity due to the naturally occurring radionuclide has been carried out in different brands of cement available in Pakistan. The gamma spectra of the collected samples were obtained using high-purity germanium detector and analysed for the presence of 232Th, 238U and 40K. The assessment of radiological hazards due to these radionuclides has also been made. The studies concerning the determination of radon-exhalation rates from these samples of cement were also carried out using CR-39 based NRPB radon dosimeters. The range of activity concentrations were found for 226Ra (from 25.10 +/- 1.55 to 52.60 +/- 3.20 Bq kg(-1)), 232Th (from 10.30 +/- 0.65 to 30.40 +/- 1.70 Bq kg(-1)) and 40K (from 17.25 +/- 1.55 to 292.95 +/- 23.05 Bq kg(-1)). The estimated value of radium equivalent concentration was from 11.16 +/- 2.60 to 114.98 +/- 7.11 Bq kg(-1). The calculated absorbed dose rate in air and the annual effective dose were in the range from 18.54 +/- 1.17 to 52.90 +/- 3.31 nGy h(-1) and 0.09 +/- 0.01 to 0.26 +/- 0.02 mSv, respectively. The external and internal hazard indices were in the range from 0.11 +/- 0.01 to 0.31 +/- 0.02 and 0.18 +/- 0.01 to 0.45 +/- 0.03, respectively. The radon exhalation rates from different brands of cement were found in the range from 3.3 +/- 0.7 to 8.1 +/- 1.7 mBq kg(-1) h(-1).

An unusual case of complete ptosis and failure of elevation due to severe facial trauma

The authors describe the case of 49-year-old female teacher who had sustained severe facial lacerations following a minor fall on the kerb. The severe shearing force by which the flap was ripped off the forehead caused complete ptosis and complete failure of elevation of the left eye, which was presumed to be due to mechanical damage to the superior rectus and levator complex. The management by a multidisciplinary approach and clinical course of the patient are described with documentary photographs. This presentation is meant to highlight an unusual case of severe facial trauma resulting from a minor injury, and its successful management with gratifying results for both patient and the surgeon.

Placebo controlled trial of methotrexate in systemic sclerosis

Eighteen adult patients of systemic sclerosis were included in this prospective study from Rheumatology Clinic of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka during the period of July 1997 to December 1999 to observe the effectiveness of treatment with methotrexate (MTX) versus placebo. Among the eighteen patients 9 patients were randomly assigned to MTX and 9 to placebo therapy. Nine patients were dropped out (6 in placebo and 3 in the MTX group), because of toxicity and non-compliance. Clinical improvement following treatment was observed in 33.33% of the patient in MTX group but none in placebo group, but this difference was not statistically significant. Anorexia, nausea and occasional vomiting were common side effects in MTX group and subsided in most cases with the passage of time despite the continuation of therapy.

Vitamin A deficiency in Afghanistan

PURPOSE

To evaluate children 6 years old and younger, lactating mothers, and women of childbearing age for vitamin A deficiency in the districts of Kabul City, Afghanistan.

METHODS

A set number of patients selected randomly in all 13 districts of the city limits were examined between August and September 2000 for ocular signs of vitamin A deficiency.

RESULTS

Night blindness, Bitot's spot, corneal ulceration, and corneal scars were seen in increased amounts as defined by the World Health Organization among the sampled population.

CONCLUSIONS

Vitamin A deficiency is a moderate to severe public health problem in children and lactating mothers in Kabul City, Afghanistan.

Reduced toxicity of F-deficient Sendai virus vector in the mouse fetus

Current concerns over insertional mutagenesis by retroviral vectors mitigate investigations into alternative, potentially persistent gene therapy vector systems not dependent on genomic integration, such as Sendai virus vectors (SeVV). Prenatal gene therapy requires efficient gene delivery to several tissues, which may not be achievable by somatic gene transfer to the adult. Initially, to test the potential and tropism of the SeVV for gene delivery to fetal tissues, first-generation (replication- and propagation-competent) recombinant SeVV, expressing beta-galactosidase was introduced into late gestation immunocompetent mice via the amniotic and peritoneal cavities and the yolk sac vessels. At 2 days, this resulted in very high levels of expression particularly in the airway epithelium, mesothelium and vascular endothelium, respectively. However, as expected, substantial vector toxicity was observed. The efficiency of gene transfer and the level of gene expression were then examined using a second-generation SeVV. The second generation was developed to be still capable of cytoplasmic RNA replication and therefore high-level gene expression, but incapable of vector spread due to lack of the gene for viral F-protein. Vector was introduced into the fetal amniotic and peritoneal cavities, intravascularly, intramuscularly and intraspinally; at 2 days, expression was observed in the airway epithelia, peritoneal mesothelia, unidentified cells in the gut wall, locally at the site of muscle injection and in the dorsal root ganglia, respectively. Mortality was dramatically diminished compared with the first-generation vector.

The impact of irradiation on growth hormone responsiveness to provocative agents is stimulus dependent: results in 161 individuals with radiation damage to the somatotropic axis

GH provocative tests remain the mainstay for the diagnosis of GH deficiency and at present the insulin tolerance test (ITT) is the gold standard. There are, however, a variety of other stimulation tests used in clinical practice. Each necessitates the use of a specific cut-off derived from normative data, but there remains a widely held view that the implications from a "failed" test are independent of the nature of the stimulus. We sought to examine whether this is the case in individuals with evidence of radiation damage to the somatotropic axis. One hundred and sixty-one nonacromegalic patients were identified who had undergone an arginine stimulation test (AST) and an ITT within a 3-month period as part of routine testing between 1975 and 1999. They were divided into those tested before (n = 81; 48 males) and those tested after (n = 80; 36 males) completion of growth and puberty. Patients were considered for inclusion in the study if they had a history of cranial irradiation and a GH response to one provocative test of less than 8 microg/L, taken as indicating that some damage to the GH axis may have occurred. The patients were compared with 2 control groups. The first comprised 35 adults (18 males) and the second consisted of 16 prepubertal children (10 males). The median peak (range) GH response to the ITT was significantly greater (P < 0.0001) than that to the AST in the adult controls: 24.9 (4.1--76.9) vs. 12.2 (0.88--35.0) microg/L, respectively. However, in the patients the GH responses were similar (P = 0.28): 2.2 (0.2--25.7) vs. 1.4 (0.2--12.8) microg/L to the ITT and AST, respectively. In contrast to the pattern seen in the adult controls, the response to an ITT in childhood controls was of similar magnitude (P = 0.5) to that to the AST: 17.5 (8.1--40.0) vs. 19.4 (7.3--53.8) microg/L, respectively. However in the patients, the GH response to the AST was greater than that to the ITT (P < 0.0001): 4.3 (0.7--17.2) vs. 3.0 (0.4--18.1) microg/L, respectively. In summary, we have shown that the impact of irradiation on GH responsiveness to provocative agents is stimulus dependent. The GH response to an AST appears to be more resistant to the effects of irradiation than that to the ITT. When investigating the impact of irradiation on GH secretory status, the GH response to an AST may be a less sensitive guide to the functional ability of the GH axis.

The diagnosis of growth hormone deficiency (GHD) in successfully treated acromegalic patients

Due to persistent qualitative abnormalities in GH secretion following treatment, and lack of a sensitive marker of GHD in mid-adult life it is extremely difficult to diagnose GHD in treated acromegalic patients. The diagnosis of GHD in patients with pituitary disease relies on provocative tests of GH reserve. Arginine releases GH by reducing somatostatin inhibition of GH release, whereas GH secretagogues (GHS) affect GH release by direct stimulation of the GHS receptor, though an intact GH releasing hormone (GHRH) axis is a prerequisite. The peak GH response to insulin-induced hypoglycaemia and arginine in acromegalic patients, in whom basal serum GH levels of less than 5 mU/l have been achieved, is greatly diminished in those treated by hypothalamo-pituitary irradiation. We aimed to study the response of successfully treated acromegalic patients to the growth hormone secretagogue hexarelin in view of its different putative mechanism of action, and in addition, to determine whether it has any value in the diagnosis of GH deficiency in this subset of patients. Nineteen acromegalic patients, in whom mean serum GH levels below 5 mU/l have been achieved through treatment, were recruited. Eight of the patients had been treated by surgery alone (Group A) and 11 had received primary or postoperative irradiation (Group B). All patients underwent 20 min blood sampling to provide a 24-h GH profile. Serum IGF-I was measured from a sample drawn between 0900 h and 1000 h. On a second visit arginine 20 g/m2 was infused over 30 min, blood samples were taken before commencing the infusion and at 30-min intervals thereafter for 180 min. At the final visit hexarelin 1.5 mcg/kg was administered as an intravenous bolus at t = 0. Blood was drawn at 15-min intervals from - 30 to 180 min. All patients in group A showed an increment in serum GH following hexarelin (DeltaGHHEX) > 20 mU/l, a normal response to arginine, and a mean 24-h GH > 0.5 mU/l. In group B only 4/11 achieved a DeltaGHHEX > 20 mU/l, 5/11 producing a response of < 2 mU/l. Four of the five patients with a DeltaGHHEX < 2 mU/l were also demonstrated to have a mean 24-h GH of < 0.5 mU/l and serum IGF-I SDS < + 0.5. All four patients in Group B who achieved a DeltaGHHEX > 20 mU/l, were observed to show an absent or minimal GH response to arginine. Despite loss of the GH response to arginine, the DeltaGHHEX is retained in a proportion of those patients in whom "safe" GH levels were achieved following irradiation. From the putative mechanisms of action of these provocative agents a plausible explanation would be that the GHRH axis is more resilient than endogenous somatostatin-secreting neurones to radiation-induced damage. Furthermore, GH secretagogues may have a role, in combination with serum IGF-I levels, in the diagnosis of GH deficiency in treated acromegaly.

Cancer incidence in Karachi, Pakistan: first results from Karachi Cancer Registry

No cancer incidence data from Pakistan have been published in the 5 decades since independence. Incidence data for the period 1995-1997 from the population of the Karachi South district (1.7 million) are presented here. A total of 4,268 new cancer cases were registered during this period: 2,160 cases in males and 2,108 cases in females. Overall, 95.3% of the incident cases were microscopically verified. The incidence rates for all cancers combined were 80.5 per 100,000 (crude) and 136.7 per 100,000 (age- standardised rates [ASR]) for males and 91.8 (crude) and 163.2 per 100,000 (ASR) for females. In males, lung cancer (ASR 20.3) was the most frequently recorded malignancy followed by oral cavity (ASR 13.8) and larynx cancer (ASR 8.6). In females, breast was the most common site of cancer, accounting for one third of female cancers (ASR 51.7), followed by oral cavity (ASR 14.1) and ovarian cancer (ASR 10.2). Karachi reports the highest incidence of breast cancer for any Asian population, except Jews in Israel. Tobacco smoking is estimated to be responsible for 40% of cancers in males and tobacco chewing for a further substantial proportion of head and neck cancers.

Survivors of childhood cancer: long-term endocrine and metabolic problems dwarf the growth disturbance

The long-term effects of radiotherapy and chemotherapy are becoming increasingly recognized as the cure rates of certain childhood malignancies improve. The endocrine system is particularly sensitive to cancer therapies. Long-term survivors of childhood cancer who received cranial irradiation have been shown to have lower than predicted height, an increased prevalence of obesity and reductions in strength, exercise tolerance, bone mineral density, quality of life and academic achievement. Growth hormone deficiency (GHD) is the most frequent endocrine deficiency observed following cranial irradiation. Adults with GHD resulting from primary hypothalamic-pituitary disease during childhood have been shown to exhibit a clinical picture similar to that described in long-term survivors of childhood cancer: increased fat mass and reduced lean mass, strength, exercise tolerance, bone mineral density and quality of life. This review considers the possible contribution of GHD to the adverse sequelae observed in long-term survivors of childhood malignancy and includes our preliminary experience in treating 14 adults with GHD resulting from the treatment of childhood malignancies.

How many tests are required to diagnose growth hormone (GH) deficiency in adults?

OBJECTIVE

The diagnosis of GH deficiency in adults relies on the results of GH provocative testing. Whilst in some patients the testing strategy is clear, this is not the case in all patients. The objective of this study was to further examine the concordance between the GH responses to two different provocative stimuli, to correlate this with the number of additional pituitary hormone deficits, and to produce guidelines as to which patients require two GH provocative tests and which require only one.

STUDY DESIGN AND PATIENTS

The results of GH provocative tests were reviewed in 103 patients (mean age 28 years, 48 male), with documented or potential hypothalamic-pituitary disease and 35 normal volunteers (mean age 21 years, 18 male). All patients and normal volunteers underwent an insulin tolerance test (ITT) and an arginine stimulation test (AST). Severe GH deficiency was defined as a GH response to an ITT of < 5 mU/l and a GH response to an AST of < 2 mU/l, utilizing data from previous studies in this unit. Patients were divided into four groups according to the number of anterior pituitary hormone deficits present other than possible GH deficiency: no other pituitary hormone deficits (GHD0) or one, two or three other hormone deficits (GHD1, GHD2 or GHD3).

RESULTS

The 103 patients were divided between the four groups as follows: 69 (67%) in GHD0, 15 (14. 6%) in GHD1, six (5.8%) in GHD2, and 13 (12.6%) in GHD3. There was a significant decline in the median GH peak to both the ITT and the AST with increasing numbers of other pituitary hormone deficits (P < 0.0001). If the magnitude of the difference between each individual's GH response to the ITT and AST is plotted against the mean GH value a clear trend is seen (Spearmans rank correlation = 0. 88, P < 0.0001) indicating that the magnitude of the difference between the GH responses to an ITT and AST increases with the underlying mean GH value. These data allow the estimation of the median ITT/AST ratio as 1.17 (CI 0.98, 1.39). None of the control subjects and 14.1% (10), 26.7% (four), 83% (five) and 92.3% (12) of groups GHD0, 1, 2 and 3, respectively, had severe GHD. The concordance between the AST and ITT (percent of patients in whom both tests confirmed or refuted the biochemical diagnosis of severe GHD) was 100%, 76.8%, 66.6%, 83.3%, and 92.3% in the controls, GHD0, 1, 2, and 3, respectively. Thus, 16/69 GHD0, 5/15 GHD1, 1/6 GHD2 and 1/13 GHD3 patients were misclassified by one or other test.

CONCLUSION

We have demonstrated that a constant ratio links the GH response to an ITT and AST in an individual, rather than a constant difference, and that the difference between the GH responses to two provocative stimuli is greater in those patients with milder degrees of GH deficiency or insufficiency. These patients tend to have one or no additional pituitary hormone deficits and may be misclassified if a single GH provocative test is performed. We suggest that whilst a single GH provocative test can be used with confidence in patients with two or three additional pituitary hormone deficits, in patients with suspected isolated GH deficiency or with only one additional pituitary hormone deficit, two GH provocative tests should be performed.

Influences on quality of life in GH deficient adults and their effect on response to treatment

OBJECTIVE

Studies of the effect of GH on quality of life (QOL) in growth hormone deficient (GHD) adults have reported conflicting results. Recently, however, we have demonstrated that by selecting only those patients with impaired QOL the efficacy of GH replacement on QOL can be greatly improved. The improvement in QOL was observed to correlate significantly with that recorded before commencing GH therapy. This study aims to assess if demographic variables affect QOL in untreated GHD adults or the improvement in QOL following GH therapy.

DESIGN

An open study of GH replacement, initiating treatment with a dose of 0.8 IU/day and titrating the dose by 0.4 IU increments to normalize the IGF-I SDS between - 2.0 and + 2.0 SD of the age related normal range.

PATIENTS

65 severely GHD patients (peak GH < 9 mU/l to provocative testing), mean age 38.7 (range 17-72) years. Inclusion criterion was that of subjectively poor quality of life on clinical interview.

MEASUREMENTS

Blood was taken for insulin-like growth factor 1 (IGF-I). The Psychological General Well-Being Schedule (PGWB) and Adult Growth Hormone Deficiency Assessment (AGHDA) self-rating questionnaires were used to assess quality of life at baseline, three and eight months after commencing GH.

RESULTS

The patients were subgrouped on the basis of gender, age of onset of GHD, pathology and presence of additional pituitary hormone deficits. The cohort consisted of 40 females and 25 males, 45 of adult-onset (AO) and 20 of childhood-onset (CO). GH deficiency resulted from a hypothalamo-pituitary pathology, or treatment thereof, in 36 patients and as a result of cranial irradiation for a primary brain tumour or prophylaxis in acute lymphoblastic leukaemia in 29 patients. Isolated GH deficiency (IGHD) was present in 25 patients, and 32 patients were demonstrated to have at least two additional pituitary hormone deficits (MPHD). No significant difference was detected between baseline PGWB scores of the subgroups. Multiple linear regression analysis revealed the age of onset of GHD to be a significant determinant of both the baseline PGWB (P = 0.05) and AGHDA (P = 0.025) scores, AO patients perceiving the greater distress. A significant improvement, from baseline, in both QOL scores was observed in all subgroups at three months, and in all subgroups at eight months except IGHD, where a trend towards improvement in the AGHDA score was observed but failed to reach significance. The mean improvement in the PGWB following GH therapy was not significantly different between subgroups. Multiple linear regression analysis confirmed baseline PGWB and AGHDA scores to be the most important variable in prediction of the level of improvement in respective scores following GH therapy. Age of onset was also observed to be a significant determinant of the PGWB scores following GH therapy (P = 0.02), the CO cohort experiencing the greater improvement. A similar relationship between age of onset and AGHDA scores was not observed (P = 0.22).

CONCLUSIONS

Baseline QOL as assessed by self-rating questionnaires is influenced by the age of onset of the GH deficiency, adult onset patients expressing the greater distress. Improvements in QOL scores are influenced by both baseline score and to a lesser extent the age of onset of GHD, the greater improvement being observed in childhood onset patients. The degree of improvement was observed to be independent of gender, pathology and number of pituitary hormone deficits. In a cohort selected by subjectively impaired QOL, we have demonstrated childhood onset GHD patients perceive themselves to have less impairment of QOL pretreatment. In contrast to previous data in unselected cohorts, however, we have shown that those childhood onset GHD patients in whom QOL is significantly reduced, show a capacity for improvement that is equal to, if not greater, than that seen in adult onset-GHD patients.

The pattern of malignancies in Karachi (1995 to 1996)

OBJECTIVE

To determine the cancer pattern of the city of Karachi for the years 1995-1996.

METHODS

The Karachi Cancer Registry, established in 1995 by the Government of Sindh, in collaboration with the IARC is an active registry. The staff collect the data pertaining to cancer patients and record it on the registry forms. Hospitals in Karachi, district south as well as some of the hospitals in other districts of the city, where patients are likely to go for treatment or diagnosis are visited. People residing in the district for more than six months prior to the onset of the malignancy were considered "residents". All the cases diagnosed on or after 1st January 1995 till 31st December 1996 were considered for analysis.

RESULTS

In the years 1995-96, the most common cancer sites among males were cancers of the lung, oral cavity and lymph nodes. For females, breast cancer ranked first, followed by cancer of the oral cavity and ovary. The age standardized rate for all cancers was 96.3 per 100,000 in males and 96.9 per 100,000 in females. At this early stage of registration we assume that the registry has a missing rate of approximately 20-25%.

CONCLUSION

The pattern of malignancies in Karachi is similar to the western countries, with lung and breast being the commonest tumors amongst the males and females respectively. The Asian countries have stomach/lung/oral cavity/liver as the commonest tumors amongst the males and cervix/breast amongst the females. Pakistan being a Muslim country, the incidence of cervical cancer showed an expected low figure.

Dose titration and patient selection increases the efficacy of GH replacement in severely GH deficient adults

OBJECTIVE

Previous studies of GH replacement in adults have used unselected cohorts of GH deficient (GHD) adults and weight-based dosing regimens resulting in supraphysiological serum IGF-I levels and a high frequency of side-effects and withdrawal from these studies. By choosing patients with a high level of morbidity at baseline and using a low dose GH titration regimen we aimed to avoid over-replacement and increase the efficacy of treatment.

DESIGN

An open study of GH replacement, initiating treatment with a dose of 0. 8 U/day and titrating the dose by 0.4 U increments to normalize the IGF-I SDS between - 2.0 and + 2.0 SD of the age-related normal range.

PATIENTS

65 severely GHD patients (peak GH < 9 mU/l to provocative testing), 25 males, of mixed adult and childhood-onset and mean age 38.7 (range 17-72) years. Inclusion criterion was that of subjectively poor quality of life on clinical interview.

MEASUREMENTS

Height, weight, waist and hip circumference were measured to allow calculation of body mass index (BMI) and waist-hip ratio (WHR). Bone mineral density (BMD) was measured by dual X-ray absorptiometry (DEXA). Serum haemoglobin A1C (HbA1C), lipid profile and insulin like growth factor 1 (IGF-I) were measured. The Psychological General Well-Being Schedule (PGWB) and Adult Growth Hormone Deficiency Assessment (AGHDA) self-rating questionnaires (SRQ) were used to assess quality of life.

RESULTS

Baseline characteristics were consistent with those previously described in severely GHD adults; mean IGF-I SDS - 2.4 (+/- 2.7), BMI 28.8 (+/- 5. 4) kg/m2, total cholesterol 6.17 (+/- 1.2) mmol/l, reduced BMD z-scores at the lumbar spine (- 0.8 +/- 1.2) and femoral neck (- 0. 44 +/- 1.4), and SRQ scores considerably lower than reported in previous studies of GH deficient adults and normal controls. Following initiation of GH serum IGF-I SDS was increased significantly from baseline to a mean level of 0.15 +/- 2.7 (P < 0. 001) and 0.31 +/- 2.0 (P < 0.001) at three and eight months, respectively. The mean PGWB score increased from 59.7 +/- 19.9 to 75. 8 +/- 15.0 (P < 0.001) and 73.7 +/- 19.5 (P = 0.001) at three and eight months, respectively. An increase of 14 points represents the largest improvement in quality of life, using this index, that has been reported in GHD adults. The mean AGHDA score also demonstrated considerable improvement, falling from 15.3 +/- 6.0 to 10.4 +/- 6.2 (P < 0.001) and 9.8 +/- 6.5 (P < 0.001) at three and eight months, respectively. The changes observed in both the PGWB and AGHDA scores between baseline and at both three and eight months were shown to correlate significantly with the respective baseline score. A significantly greater improvement was observed in the PGWB following GH replacement in those with a baseline PGWB score of < 60 than in those with a score > 60. This observation was significant at both three (27.1 vs 6.7, P = 0.0001) and eight (25.6 vs 3.3, P = 0.0003) months. All PGWB subscales showed significant improvement though that of vitality was of greatest magnitude. A strong correlation was observed between the generic and disease-specific SRQ (r = - 0.73, P < 0.001).

CONCLUSIONS

The observed improvement in quality of life in GH deficient adults is proportional to the degree of impairment before commencing therapy. The use of low-dose titration and selection of a population with greater morbidity reduces the occurrence of over-replacement and increases the efficacy of treatment. This allows direction of resources to those in greatest need.

Reduced bone mineral density in young adults following cure of acute lymphoblastic leukaemia in childhood

Bone mineral density (BMD), serum osteocalcin and type I collagen C-telopeptide (ICTP) were assessed in a cohort of 31 (16 males) adults who had received cranial irradiation in childhood as part of their treatment for acute lymphoblastic leukaemia (ALL). Markers of bone turnover were compared with those of 35 age and body mass index (BMI) matched young adults (18 male). Growth hormone status had previously been determined using an insulin tolerance test and arginine stimulation test. Eight patients were classified as severe growth hormone deficiency (group 1), 12 patients as growth hormone insufficient (group 2) and 11 patients as normal (group 3). Vertebral trabecular BMD, lumbar spine and femoral neck integral BMD and forearm cortical bone mineral content (BMC) was measured 17.8 (6.8-28.6) years after cranial irradiation and was expressed as Z (standard deviation) scores. There was a significant reduction in vertebral trabecular BMD (median Z score -1.25, P < 0.001), in lumbar spine integral BMD (median Z score -0.74, P = 0.001), in forearm cortical BMC (median Z score -1.35, P < 0.001), and less so in femoral neck integral BMD (median Z score -0.43, P = 0.03). There was no difference among the growth hormone status groups for the following BMD measurements: vertebral trabecular BMD, lumbar spine integral BMD or femoral neck integral BMD (P = 0.8, P = 0.96 and P = 0.4 respectively). There was only a marginal significant difference for BMD at the wrist between growth hormone status groups (P = 0.04). There was no correlation between the BMD measurements with time since or age at diagnosis and no difference in markers of bone turnover between patients and controls; median serum osteocalcin 13.3 and 12.0 ng ml (P = 0.7), respectively, and for ICTP 5.0 and 4.9 microg L (P = 0.67) respectively. In conclusion, there is a highly significant reduction in BMD in young adults following treatment for ALL in childhood. The reduction in BMD affects both trabecular and cortical bone but did not seem to be related to time since diagnosis, age at diagnosis, or current growth hormone status. Possible explanations include a direct effect of chemotherapy, steroids or both on bone during childhood and hence an effect on the accretion of bone mass. In view of the risk of fractures in patients with osteopenia, adults treated for ALL in childhood may be at an increased risk of bone fractures later in life irrespective of the underlying cause of the osteopenia and thus intervention should be considered.

Selective lack of growth hormone (GH) response to the GH-releasing peptide hexarelin in patients with GH-releasing hormone receptor deficiency

The mechanism of the synergistic relationship between GH-releasing peptide (GHRP) and GHRH with respect to GH secretion is poorly understood. We report the response to hexarelin, a potent GHRP, in patients affected with a homozygous mutation in the GHRH receptor gene, with consequent GHRH resistance and GH-deficient dwarfism. This newly described syndrome is the human homolog of the little (lit/lit) mouse. Intravenous administration of hexarelin (2 microg/kg) to four male adult patients (dwarfs of Sindh) resulted in a complete lack of elevation in plasma GH levels (< 1 ng/mL), an at least 50- to 100-fold deviation from the normal response. In contrast, plasma PRL, ACTH, and cortisol levels rose in a normal manner in response to hexarelin. We conclude that an intact GHRH signaling system is critical for GHRPs to exert their effect on GH release, but that the GHRH system is not necessary for the effect of GHRP on PRL and ACTH secretion. Hexarelin (and probably other GHRPs) are not effective agents for the treatment of patients with GHRH resistance due to GHRH receptor deficiency.