Wound Infection in Surgical Ward of a Tertiary Care Hospital in Dhaka City: The Identification of Organisms and Their Sensitivity Pattern

Wound infection is one of the most important causes of morbidity and mortality worldwide. The aim of this study was to identify the organisms and their sensitivity pattern from wound infection patients attending in a tertiary care hospital in Dhaka city. This cross-sectional study was carried out in a total of 240 aseptically collected wound swab samples from wound infection suspected patients visiting Bangladesh Medical College Hospital, Dhaka, Bangladesh were analyzed from July 2017 to June 2019. Bacteriological culture of the samples, colony morphology, Gram's staining, and biochemical tests were done following standard microbiological techniques. The antimicrobial susceptibility testing was performed by modified Kirby-Bauer disc diffusion technique following clinical and laboratory standards institute guidelines. Out of 240 wound swab samples from suspected patients of wound infection, 126(52.5%) showed bacterial growth whereas 114(47.5%) were culture negative. No sample yielded more than one organism. Among 126 culture positive cases 75(59.52%) were male and 51(40.48%) were female. The higher rate of bacterial infections 26.19% was noted in the age group of 21-30 years, followed by the age group of 31-40 years, 41-50 years, 51-60 years. Among 126 culture positive cases, 74.6% were Gram negative and 25.4% were Gram positive bacteria. Out of total 126 isolates, E. coli was the most prevalent pathogen 31(24.60%) followed by Staphylococcus aureus 29(23.01%); Pseudomonas 27(21.43%); Klebsiella 18(14.29%); Enterobacter 12(9.52%); Acinetobacter 4(3.17%), while Coagulase negative Staphylococcus 3(2.38%) and Proteus 2(1.59%) were least detected isolates in wound swab. Highly effective antibiotics against Staph aureus were vancomycin 100.0%; imipenem 100.0%; linezolid 100.0% and meropenem 89.65%. Amikacin; gentamicin; netilmicin; imipenem and meropenem showed higher sensitivity in E coli, Klebsiella and Enterobacter species. Colistin was 88.88% effective against Pseudominas spp. followed by imipenem 81.48%, piperacillin-tazobactam 77.78%, meropenem 70.37% and amikacin 51.85%. Acinetobacter spp. showed 75.0% and 50.0% sensitivity to netilmicin and colistin respectively. Injectable and reserve drugs were sensitive to bacterial populations among patients of wound infections in our hospital. It is a wake-up call for clinician to treat wound infections. To prevent the increase resistance to antibiotics, it is necessary to avoid the administration of uncontrolled and unnecessary antibiotics available.

Examining Feasibility, Acceptability, and Preliminary Outcomes of a Culturally Adapted Evidence-Based Postpartum Depression Preventive Intervention for Women in Doha, Qatar: Protocol for a Randomized Controlled Trial

BACKGROUND

Postpartum depression and anxiety are the 2 most common perinatal mental health disorders, with prevalence rates higher among women living in the Middle East than in most Western countries. The negative outcomes associated with postpartum depression and anxiety are profound and include less responsive parenting and compromised infant and young child development. Although interventions exist to prevent postpartum depression and anxiety, to date, there have been no studies that have attempted to prevent postpartum depression or anxiety among Arabic-speaking women in the Middle East, including Qatar.

OBJECTIVE

The purpose of this study is to conduct a randomized controlled trial (RCT) of an evidence-based postpartum depression preventive intervention-Mothers and Babies (MB)-culturally adapted for use with Arabic-speaking women in Doha, Qatar. MB is guided by a cognitive behavioral therapy framework that focuses on increasing pleasant activities, promoting healthy thought patterns, and increasing the type and frequency of personal contacts. MB is tailored to specific needs and issues related to pregnancy and the postpartum period.

METHODS

A multidisciplinary and multiethnic investigator team adapted MB to promote cultural and contextual fit for Arabic-speaking women. Intervention concepts were reviewed to ensure core content would be understood by Arabic-speaking women in Qatar. Subsequently, images, activities, and examples in the intervention manuals were adapted, as needed, to make the content more relevant to Arab culture. To deliver the adapted intervention, 30 Arabic-speaking individuals with mental health backgrounds were trained. The adapted intervention was subsequently pilot-tested with 10 pregnant women receiving prenatal care at Sidra Hospital in Doha. We are now conducting an RCT to examine the effectiveness of the adapted intervention. We plan to enroll 210 pregnant individuals who are Arabic-speaking, with 1:1 randomization to the MB intervention or usual prenatal care. Among the enrolled participants, a stratified subsample of 40 pregnant women with diabetes is being recruited. Data collection will take place at baseline and a 6-month follow-up. The primary outcomes are depressive and anxiety symptoms and perceived stress. Diabetes self-care is the exploratory outcome for the subsample of individuals with diabetes. Intervention implementation will be assessed via client and provider surveys during and after intervention delivery. Power and sample size were calculated using a 2-sided 5% effort rate and assumed analyses on the individual level, accounting for attrition of 20%.

RESULTS

The cultural adaptation and pilot study of the adapted MB intervention are completed. A total of 157 women have been enrolled in the RCT as of March 31, 2023.

CONCLUSIONS

This study is highly innovative, as it is the first study to our knowledge to examine the effectiveness of an evidence-based postpartum depression preventive intervention in the Middle East. Limitations include a single follow-up time point and a small subsample of individuals with diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04442529; https://www.clinicaltrials.gov/study/NCT04442529.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/11623.

A structural model examining racism, stress, and psychological symptoms among Arab American adolescents

OBJECTIVE

Previous minority stress scholarship has investigated racism as both a constituent to stress and as an independent psychosocial stressor. It is generally understood that experiences of racism operate differently to affect mental health outcomes compared to general life stress. Racism is consistently implicated in poor psychological health outcomes among Arab Americans. Experiences of racism may be particularly harmful among Arab American adolescents who are in a critical developmental period. This study tested a minority stress framework among Arab American adolescents by examining the association between racism and psychological symptoms both directly and indirectly via stress.

METHOD

The sample included 223 Arab American adolescents whose ages ranged from 13 to 18 (M = 15.63, SD = 1.26; 51.1% boys; 49.3% Lebanese) drawn from the Detroit metropolitan area. Participants responded to measures of racism, stress, and internalizing and externalizing psychological symptoms.

RESULTS

The structural equation model provided good model fit to the data and indirect effects testing showed that the association between racism and psychological symptoms via general stress was statistically significant (z = 3.48, p < .001). Greater racism was associated with more psychological symptoms in the presence and absence of general stress. The magnitude of the association between racism and psychological symptoms was attenuated with stress included in the model. The association remained statistically significant and reasonably robust.

CONCLUSIONS

Findings support racism as both a unique construct and an adjunct to general stress that is positively correlated with psychological symptoms among Arab American adolescents. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Predictors of Psychological Distress in Health Care Staff in Qatar during COVID-19 Pandemic

Background & Objective

The Coronavirus disease 2019 (COVID-19) pandemic has caused widespread psychological distress. The aims of the study were a) to assess mental health symptoms experienced by expatriate hospital staff and b) to determine the impact of staff wellbeing interventions specific to pandemic related stress.

Methods

The study was conducted from June 2020 until August 2020. A 16-question survey was disseminated online via Survey Monkey to assess the mental health needs of hospital staff during the pandemic. Based on results, a virtual, tiered mental health support model was developed, and staff feedback was collected.

Results

Almost 46.2% of respondents (N: 1001) reported at least one mental health symptom in the initial survey. The most common symptoms were anxiety, low mood and feelings of isolation. Being single and in poor health status were predictors of developing mental health symptoms (P <0.01). Female gender was a predictor for experiencing fear of getting infected. Time constraints at work was the most common reason for not accessing mental health support.

Conclusions

As in other parts of the world, hospital staff in Qatar experienced mental health symptoms and significant fear related to the COVID-19 Pandemic. Being single and in poor health status were risk factors. Mental health interventions at work must take into account time constraints experienced by staff.

Omouma: a prospective mother and child cohort aiming to identify early biomarkers of pregnancy complications in women living in Qatar

BACKGROUND

Pregnancy is governed by multiple molecular and cellular processes, which might influence pregnancy health and outcomes. Failure to predict and understand the cause of pregnancy complications, adverse pregnancy outcomes, infant's morbidity and mortality, have limited effective interventions. Integrative multi-omics technologies provide an unbiased platform to explore the complex molecular interactions with an unprecedented depth. The objective of the present protocol is to build a longitudinal mother-baby cohort and use multi-omics technologies to help identify predictive biomarkers of adverse pregnancy outcomes, early life determinants and their effect on child health.

METHODS/DESIGN

One thousand pregnant women with a viable pregnancy in the first trimester (6-14 weeks of gestation) will be recruited from Sidra Medicine hospital. All the study participants will be monitored every trimester, at delivery, and one-year post-partum. Serial high-frequency sampling, including blood, stool, urine, saliva, skin, and vaginal swabs (mother only) from the pregnant women and their babies, will be collected. Maternal and neonatal health, including mental health and perinatal growth, will be recorded using a combination of questionnaires, interviews, and medical records. Downstream sample processing including microbial profiling, vaginal immune response, blood transcriptomics, epigenomics, and metabolomics will be performed.

DISCUSSION

It is expected that the present study will provide valuable insights into predicting pregnancy complications and neonatal health outcomes. Those include whether specific microbial and/or epigenomics signatures, immune profiles are associated with a healthy pregnancy and/or complicated pregnancy and poor neonatal health outcome. Moreover, this non-interventional cohort will also serve as a baseline dataset to understand how familial, socioeconomic, environmental and lifestyle factors interact with genetic determinants to influence health outcomes later in life. These findings will hold promise for the diagnosis and precision-medicine interventions.

The Relationship Between Acculturative Stress and Postmigration Mental Health in Iraqi Refugee Women Resettled in San Diego, California

Due to the lack of research on the adverse impact of acculturative stress on the mental health, the current study examined the associations between acculturative stress and post-migration mental health outcomes among 219 Iraqi refugee women resettled in San Diego, California. Mental illness, trauma history, and acculturative stress were measured and descriptive statistical analyses, and multivariate logistic regression analyses were conducted to determine the association between acculturative stress, depression, and anxiety among the refugee women.About half of the participants were categorized as having anxiety (45.6%) and depression (55.3%). The multivariate regression analysis found that the odds of a mental health outcome of depression and anxiety in relation to acculturative stress, increases by a factor of 1.056 and 1.076 respectively, for every point increase on the acculturative stress scale.The study's findings reflect a linear association of acculturative stress with depression and anxiety among Iraqi refugee mothers resettled in San Diego. The mental well-being of refugees does not always improve nor does their trauma disappear by resettling in a new country. Policy makers should consider extending the evaluation, follow-up, and support of Iraqi refugee mental health long beyond the current 90 post arrival policy.

Effect of incorporation of calcium lactate on physico-chemical, textural, and sensory properties of restructured buffalo meat loaves

AIM

The present study was conducted to develop a functional meat product by fortifying calcium (in the form of calcium lactate) with restructured buffalo meat loaf (RBML).

MATERIALS AND METHODS

Deboned buffalo meat obtained from the carcass of adult female buffalo within 5-6 h of slaughter and stored under frozen condition. Calcium fortified RBML were prepared by replacing the lean buffalo meat with calcium lactate powder at 0%, 1%, 1.25%, and 1.5% level through the pre-standardized procedure. The developed products were evaluated for physico-chemical properties, proximate composition, calcium concentration (mg/100 g), water activity (aw), Lovibond(®) tintometer color units, texture profile analysis (TPA), and sensory qualities as per-standard procedures.

RESULTS

Of the various product quality parameters evaluated, cooking yield (%), product pH, moisture (%), protein (%), fat (%), and water activity (aw) decreases significantly with increasing level of calcium lactate. Calcium content of fortified functional RBMLs was 135.02, 165.73, and 203.85 mg/100 g as compared to 6.48 mg/100 g in control. Most of the sensory scores at 1% and 1.25% levels of calcium lactate in treatment products remained comparable among themselves and control product, with a gradual decline.

CONCLUSIONS

The present study concluded that 1.25% calcium lactate was the optimum level for the fortification of calcium in RBML without affecting the textural and sensory properties which could meet out 15% of recommended dietary allowance for calcium.

A structural model of racial discrimination, acculturative stress, and cultural resources among Arab American adolescents

Despite evidence towards the risk for discrimination and acculturative stress that Arab American adolescents may face, the link between socio-cultural adversities and psychological well-being in this population has not been established. This study examined the role of socio-cultural adversities (discrimination and acculturative stress) and cultural resources (ethnic identity, religious support and religious coping) in terms of their direct impact on psychological distress. Using structural equation modeling, the proposed model was tested with 240 Arab American adolescents. The results indicated a strong positive relationship between socio-cultural adversities and psychological distress. Furthermore, this study supported a promotive model of cultural resources, where a negative association between cultural resources and psychological distress was found. Understanding the manner in which socio-cultural adversities and resources are linked to psychological distress can inform the development of culturally appropriate interventions that can effectively mitigate mental health concerns for understudied and vulnerable populations.

Intimate partner violence and maternal depression during the perinatal period: a longitudinal investigation of Latinas

This study assessed the course of perinatal depression among 210 Latinas who were and were not affected by intimate partner violence (IPV) and identified associated psychosocial factors. Peak depression prevalence occurred prenatally among 45.7% of IPV-exposed and 24.6% of non-IPV-exposed Latinas. At each assessment, depression was significantly higher for IPV-exposed compared to non-IPV-exposed mothers. Mastery and social support were associated with lower depression, whereas history of IPV, perceived stress, and avoidant coping behaviors were associated with higher depression. Findings support recommendations for routine depression and IPV screening of Latinas in perinatal clinical settings.

Intimate partner violence and community service needs among pregnant and postpartum Latina women

Health care providers are advised to refer abused women to needed community services. However, little is known about abused women's perceived need for services, particularly among Latina women. We examined the relationship between intimate partner violence (IPV) and perceived needs for legal, social, and job services among a prospective cohort of 210 pregnant Latinas. IPV was associated with needing social and legal services at most time points. Women with recent IPV experiences reported greater service needs than women with more remote IPV experiences, who in turn reported greater need than women without IPV experiences. We conclude that IPV may be associated with ongoing perceived needs for social and legal services among Latina perinatal patients.

COMMUNITY VIOLENCE AND EXTERNALIZING PROBLEMS: MODERATING EFFECTS OF RACE AND RELIGIOSITY IN EMERGING ADULTHOOD

The present study examined racial differences in the relationship between exposure to community violence and public and private religiosity in predicting externalizing problems among at-risk emerging adults. Participants were 178 African American and 163 European American emerging adults at risk for exposure to community violence. Exposure to community violence related to more externalizing problems. Greater public religious affiliation buffered the relationship between community violence and substance abuse, for both African American and European emerging adults. In addition, more privately religious African American emerging adults engaged in less deviant behavior when exposed to higher levels of community violence. European Americans were not protected by private religiosity.

Human saphenous vein and coronary bypass surgery: ultrastructural aspects of conventional and "no-touch" vein graft preparations

Coronary artery bypass graft surgery (CABG) is routinely used to restore blood flow to diseased cardiac muscle due to coronary artery disease. The patency of conventional grafts decreases with time, which is due to thrombosis and formation of neointima. A primary cause of graft failure is the mechanical damage inflicted to the graft during harvesting, including removal of surrounding tissue accompanied by high pressure saline distension to overcome vasospasm (both causing considerable mechanical trauma). The aim of this study was to compare the ultrastructural features of human saphenous vein (SV) grafts harvested conventionally and grafts prepared using an atraumatic 'no-touch' harvesting technique introduced by Souza (1996). The results of this study showed a better preservation of the lumenal endothelium and medial vascular smooth muscle (SM) in 'no-touch' versus conventional grafts. A 'fast' (within 30 min) response of SM cells to conventional harvesting was noted where features of both SM cell division and apoptosis were observed. It is concluded that the 'preserved' nature of the 'no-touch' aortocoronary SV grafts renders them less susceptible to thrombotic and atherosclerotic factors than grafts harvested conventionally. These features are suggested to contribute to the improved early patency rate described using the no-touch technique of SV harvesting.

External hydrocephalus in primary hypomagnesaemia: a new finding

This paper reports a new finding in two siblings with primary hypomagnesaemia as a result of renal magnesium wasting, namely, rapidly increasing head size. External hydrocephalus and brain shrinkage in primary hypomagnesaemia seen on computed tomography of the brain with reversibility after magnesium treatment has not been reported previously.

Necrotizing infundibulo-hypophysitis: a unique syndrome of diabetes insipidus and hypopituitarism

Clinical, radiological, histological, and anatomical features in 2 patients with necrotizing infundibulo-hypophysitis are reported. The patients presented with a combination of diabetes insipidus and hypopituitarism. Each was found to have a sellar mass lesion with an abnormally thickened enlarged pituitary stalk that intensively enhanced on contrast magnetic resonance imaging. They were suspected to have pituitary tumors with suprasellar extension. However, tissue obtained at transphenoidal surgery revealed necrosis, fibrosis, and chronic inflammation; there was no evidence of infiltrative, infective, or neoplastic disease processes. Postoperatively, they continued to have diabetes insipidus and hypopituitarism despite radiological improvement and steroid therapy. Several clinical and anatomical features distinguish these 2 cases from classical lymphocytic hypophysitis, the most common entity in the differential diagnosis. Specifically, diabetes insipidus has not been observed preoperatively in 30 cases of lymphocytic hypophysitis, but was present in the 2 cases reported. Histological evidence of tissue necrosis present in these 2 cases is not a feature of lymphocytic hypophysitis. Pituitary stalk involvement on magnetic resonance imaging or computed tomographic scan present in these 2 cases is highly unusual in lymphocytic hypophysitis. Finally, 29 of 30 cases of lymphocytic hypophysitis were females, whereas the 2 cases reported are men. On the basis of these disparate findings, we suggest that these 2 cases represent a unique syndrome, which may be recognized clinically and radiologically.

Role of transforming growth factor-alpha (TGF-alpha) in basal and hormone-stimulated growth by estradiol, prolactin and progesterone in human and rat mammary tumor cells: studies using TGF-alpha and EGF receptor antibodies

The biological role of transforming growth factor-alpha (TGF-alpha) in basal and hormone-stimulated proliferation of primary human and rat mammary tumor cells was studied using antibodies against TGF-alpha and its receptor. A monoclonal antibody, MAb-425 against human EGF receptor was added to in vitro soft agar, clonogenic cultures of human breast carcinoma cells under basal and estradiol(E2)-stimulated conditions. The antibody had an antagonist effect on colony growth in 4 of 10 tumors and an agonist effect in 4 (72 and 153% of control). E2-stimulated colony growth in 5 tumors (167% of control) and the antibody blocked E2-stimulation in 3 of the 5. Inhibition of E2-stimulated growth in 3 and basal growth in 4 other tumors by the EGF receptor antibody suggest that endogenously secreted TGF-alpha has a role as an autocrine/paracrine growth factor in constitutive and E2-stimulated tumor cell proliferation in a majority of human tumors. A polyclonal antibody against TGF-alpha was used to study the role of TGF-alpha in E2-, prolactin(Prl)- and progesterone(Prog)-stimulated proliferation of NMU(nitrosomethylurea)-induced rat mammary tumor cells under similar culture conditions. TGF-alpha, E2, Prl and Prog stimulated colony growth equally to 176, 187, 168 and 181% of control. The antibody produced significant and similar inhibition of TGF-alpha and E2-stimulated growth (95 and 83%). In contrast, inhibition of Prl- and Prog-stimulated growth by the antibody was only 24 and 37%. The TGF-alpha ligand antibody did not have an agonist or antagonist effect when added alone. Thus, TGF-alpha seems to be a major stimulatory growth factor mediating E2-induced tumor cell proliferation in rat mammary tumors. It is less important in Prl- and Prog-induced tumor growth and not essential for basal growth in these tumors. We conclude that TGF-alpha is a biologically important autocrine/paracrine growth factor in primary human breast cancer cell proliferation and in E2-induced rat mammary tumor growth.

Long-term follow-up of low-dose external pituitary irradiation for Cushing's disease

Twenty-four patients (three male) with Cushing's disease, aged between 11 and 67 years, were treated with low-dose external pituitary irradiation (20 Gy in eight fractions over 10-12 days) and followed for between 13 and 171 months (median 93 months). Eleven patients (46%) went into remission 4-36 months after irradiation, but five subsequently relapsed. Two of these received no further active treatment, one underwent successful pituitary surgery, one underwent a second course of low-dose external irradiation (as yet unsuccessful) and one has been treated with metyrapone for a total of 75 months. One of the 13 patients who did not respond received a further course of low-dose pituitary irradiation with prompt remission and two have received metyrapone for 41 months and 15 years without ill effect. One patient died from cerebrovascular disease. The remaining nine patients underwent bilateral adrenalectomy (one after unsuccessful pituitary surgery) with rapid resolution of hypercortisolism. Five of these patients have developed hyperpigmentation and elevated ACTH levels (range 505-1150 ng/l). A pituitary microadenoma has been demonstrated on CT scan in three and successfully removed by microadenomectomy. In the present series, the low incidence of radiation-induced hypopituitarism and absence of other complications attributable to radiotherapy suggest that low-dose pituitary irradiation may be a useful treatment option in selected patients. However, long-term follow-up has demonstrated a high relapse rate and failure to prevent Nelson's syndrome in adrenalectomized patients, indicating that it should not be used as primary treatment in preference to selective adenomectomy.

Characterization and hormonal regulation of radioimmunoassayable IGF-I (insulin-like growth factor I) like activity and IGF-binding proteins secreted by human breast cancer cells

Insulin-like growth factor-I (IGF-I) is considered an important local mitogenic growth factor involved in autocrine/paracrine regulation of human breast cancer cell proliferation. We have characterized the IGF-I-like activity and studied its hormonal regulation by estradiol in the MCF-7 human breast cancer cell line. We found that the radioimmunoassayable IGF-I-like activity measured in conditioned medium (CM) is predominantly due to the presence of IGF-binding proteins (IGFBP). Acid chromatography demonstrated that most of the IGF-I-like activity eluted in the high molecular weight fractions and less than 10% co-eluted with authentic IGF-I (mol wt 7500). Binding protein activity measured by a 125I-IGF-I-ligand binding IGFBP-assay was present in these same high molecular weight fractions. SDS-polyacrylamide gel electrophoresis and 125I-IGF-I-ligand blot analysis of the CM showed the presence of two species of binding proteins of 29 kDa and 41 kDa molecular weight which demonstrated specific 125I-IGF-I binding activity. Estradiol did not stimulate IGFBP activity as assessed by the IGFBP-assay and as indirectly reflected by the IGF-I-like activity in the high molecular weight fractions. We conclude that the IGF-I-like activity in CM from human breast cancer cell cultures is predominantly due to the presence of IGFBP. Binding proteins of apparent molecular weight 29 kDa and 41 kDa are present in CM from MCF-7 cells. Assessment of their hormonal regulation showed that estradiol did not stimulate IGFBP. However, this needs to be assessed more stringently using better quantitative estimations for BP. The IGF-binding proteins may have an important role in the regulation of tumor cell growth by influencing the local concentrations and receptor mediated actions of IGF-I.

Hypopituitarism following external radiotherapy for pituitary tumours in adults

The development of anterior pituitary hormone deficiencies has been studied in a group of 165 patients who underwent external radiotherapy for tumours of the pituitary or closely related anatomical sites, and who have been observed for up to 10 years. One hundred and forty had undergone pituitary surgery before radiotherapy. All patients received external radiotherapy by a three-field technique, giving 3750-4250 cGy in 15 or 16 fractions over 20-22 days. A combined test of anterior pituitary function using insulin hypoglycaemia or glucagon stimulation in conjunction with thyrotrophin and gonadotrophin releasing hormone tests and basal estimations of prolactin, thyroid hormones and testosterone or oestradiol was performed before radiotherapy. This was repeated six and 12 months later and subsequently annually. Before radiotherapy, 18 per cent of patients had normal growth hormone secretion, 21 per cent had normal gonadotrophin secretion, 57 per cent had normal corticotrophin reserve and 80 per cent had normal thyrotrophin secretion. Life table analysis demonstrated increasing incidences of all anterior pituitary hormone deficiencies with time: by five years all patients were growth hormone deficient, 91 per cent were gonadotrophin deficient, 77 per cent were corticotrophin deficient and 42 per cent were thyrotrophin deficient. At eight years, respective incidences of deficiencies were 100, 96, 84 and 49 per cent. Radiation-induced hyperprolactinaemia was seen in 73 patients; mean serum prolactin concentration rose from 227 +/- 11 mU/l to a peak of 369 +/- 60 mU/l at two years and subsequently declined towards the basal value. The primary diagnosis, patient age, sex, irradiated tissue volume and previous surgery were examined as variables that might influence the rate of development of anterior pituitary hormone deficiencies, but none of these factors had a significant effect. The radiation induced hyperprolactinaemia was however more marked in female patients. Although anterior pituitary hormone deficiencies most commonly developed in the order growth hormone, gonadotrophin, corticotrophin, thyrotrophin (61 per cent of patients), other sequences were evident. Most notably corticotrophin deficiency occurred before gonadotrophin deficiency. There is a high incidence of anterior pituitary hormone deficiencies in patients treated surgically for pituitary tumours and the incidence increases after external radiotherapy. Deficiencies may occur in an unpredictable sequence and endocrine testing is recommended on an annual basis.

Species-specificity of estradiol regulated growth factors in breast cancer

Recent evidence indicates that autocrine/paracrine mechanisms may mediate the mitogenic effect of estradiol (E2) both in human and experimental breast cancer. However, the species-specificity of E2-regulated growth factors with regard to their biologic action has not been evaluated. To test this issue, we examined, in the soft agar clonogenic assay, the colony-stimulating activity in human breast cancers of conditioned media obtained from rat mammary carcinomas exposed to E2 (rat E2-CM). Of 22 primary human breast cancers plated in soft agar in the absence of serum, 18 (82%) successfully grew with a mean colony number of 62.4 +/- 9.8 (S.E.M.) (range 14-193). Rat E2-CM significantly stimulated colony formation in 10/18 (56%) human breast cancers to 155 +/- 11% (S.E.M.) of control. E2 administration (10(-9) M) in these tumors had a virtually identical overall effect (154 +/- 13% of control colony number). In the remaining eight tumors (44%), neither rat E2-CM nor E2 had, in general, a significant colony-stimulating effect. The growth-promoting action of rat E2-CM and E2 was not influenced by the hormone receptor status of the tumor. These results suggest that E2-regulated growth factors may not be species-specific, at least with regard to their colony-stimulating effects in soft agar.

Role of polyamines in the growth of hormone-responsive experimental breast cancer in vivo

We have provided evidence for a critical role of polyamines in the growth of the hormone-responsive N-nitrosomethyl-urea (NMU)-induced rat mammary tumor in vitro. The present experiments were designed to test whether polyamines are involved in the growth of this experimental tumor in vivo. To test this hypothesis, groups of rats bearing NMU-induced mammary cancers were randomly allocated to receive no treatment or escalating doses of the polyamine biosynthesis inhibitor alpha-difluoromethyl-ornithine (DFMO) (0.5%, 1%, 2%, 3% in drinking water). DFMO inhibited tumor growth in a dose-dependent fashion and consistently reduced tumor putrescine level. To evaluate the time dependency of this effect, additional groups of rats received either no treatment or 2% DFMO for 3, 7, 14, and 21 days. At all times DFMO suppressed tumor putrescine level as well as spermidine to spermine ratio. Finally, exogenous administration of putrescine (200 mg/kg/i.p./day x 21 days) given concomitantly with DFMO restored tumor growth, partially repleted tumor putrescine level, and raised the spermidine to spermine ratio to control levels. Putrescine, given alone, had no significant effect on either tumor polyamine levels or tumor growth. Except for modest weight loss, no major toxicity was encountered. These results indicate that polyamines play an important role in the growth of the NMU rat mammary tumor in vivo. The interaction between polyamines and hormones in supporting NMU mammary tumor growth in vivo remains to be elucidated.

Transdermal testosterone therapy in the treatment of male hypogonadism

Five hypogonadal men were treated with transdermal testosterone therapy, using a testosterone patch applied to the scrotal skin. Daily application of the patch, which contained 10 mg testosterone, produced an increase in serum testosterone concentrations from a pretreatment value of 45 +/- 12 (+/- SE; 1.5 +/- 0.4) to 436 +/- 80 ng/dL (15.1 +/- 2.8 nmol/L; P less than 0.001) after 4 weeks of treatment. Normal serum testosterone concentrations were achieved in all men after 6-8 weeks of therapy and were maintained during continued long term therapy for 9-12 months with a patch containing 15 mg testosterone. All men reported a subjective increase in libido and sexual function during therapy, and three men preferred it to testosterone injections. The serum testosterone and estradiol levels did not rise above the normal adult male range at any time during therapy. However, elevated serum dihydrotestosterone (DHT) concentrations occurred during treatment; the pretreatment DHT concentration was 95 +/- 3 ng/dL (3.3 +/- 0.1 nmol/L), and it increased to 228 +/- 40 ng/dL (7.8 +/- 1.4 nmol/L) after 4 weeks of treatment and remained elevated thereafter. The individual mean DHT to testosterone ratio increased from a pretreatment value of 0.2 (range, 0.1-0.3) to 0.6 (range, 0.4-0.7) after 2 weeks of therapy and remained high thereafter. Comparison of the serum DHT levels in patients during therapy with those in normal men who had similar testosterone concentrations [531 +/- 62 vs. 566 +/- 72 ng/dL (18.4 +/- 2.1 vs. 19.6 +/- 2.5 nmol/L); P greater than 0.05] revealed that the mean serum DHT concentration was significantly higher in the patients [315 +/- 69 vs. 87 +/- 6 ng/dL (10.8 +/- 2.4 vs. 2.9 +/- 0.2 nmol/L); P less than 0.001], as was the mean DHT to testosterone ratio [0.6 (range, 0.25- 1.1) vs. 0.16 (range, 0.09- 0.24); P less than 0.001]. The high serum DHT levels presumably were due to increased metabolism of testosterone to DHT by the 5 alpha-reductase in the scrotal skin. Serum 3 alpha-androstanediol glucuronide levels were not elevated in the patients. We conclude that transdermal testosterone therapy is an effective long term treatment for hypogonadism in men. It is, however, associated with high serum DHT levels, whose potential long term effects on the prostate and other tissues need to be investigated.

Role of polyamines in the synthesis of prolactin-regulated growth factors by experimental breast cancer in culture

The present experiments were designed to test whether polyamines play an essential role in the synthesis of growth factors induced by ovine prolactin (oPRL), using the N-nitrosomethylurea (NMU)-induced rat mammary tumor cultured in the soft agar clonogenic assay. Conditioned media (CM) obtained from tumors treated with oPRL and the polyamine biosynthesis inhibitor alpha-difluoromethylornithine (DFMO) (1 mM) no longer exerted the colony-stimulating effect which was observed with oPRL-CM. Such growth-promoting activity was restored with conditioned media obtained from tumors treated with oPRL, DFMO, and increasing concentrations of spermidine from 1 to 500 microM. The colony-stimulating effect of the CM employed could not be accounted for by the contaminating presence in the media of oPRL, DFMO, and polyamines. These results indicate that in our system polyamines play an important role in the synthesis of oPRL-regulated growth factors.

Effects of progestins on growth of experimental breast cancer in culture: interaction with estradiol and prolactin and involvement of the polyamine pathway

The role of progesterone either alone or in combination with other hormones in breast cancer growth is not well established. In these experiments, using the hormone-responsive N-nitrosomethylurea-induced rat mammary tumor grown in the soft agar clonogenic assay, we tested the colony-stimulating effect of progesterone and the synthetic progestin R5020 over a wide range of physiological and pharmacological concentrations (from 0.1 nM to 10 microM). Both progesterone and R5020 were found to have a significant colony-stimulating effect which was more pronounced in the absence of serum. The action of progesterone appeared to plateau at concentrations of 10 or 100 nM, whereas R5020 was maximally effective at lower concentrations (approximately 1 nM). A biphasic dose-dependent effect was occasionally seen both with progesterone and R5020 with a loss of colony-stimulating effect at high concentrations. The combined administration of varying doses of progesterone (0.1, 1, 10, and 100 nM) and estradiol (10(-10) M and 10(-9) M) was found at times to potentiate and at times to decrease colony formation over that observed with the individual treatments. The former effect, when present, was usually seen with low doses of progesterone, while the latter was frequently observed with high concentrations (100 nM). No major potentiation or suppression of colony formation over individual treatments was observed when varying doses of progesterone (1, 10, and 100 nM) were added together with prolactin (50 ng/ml). The administration of the polyamine biosynthesis inhibitor alpha-difluoromethylornithine completely blocked the colony-stimulating effect of progesterone. The inhibitory effect of alpha-difluoromethylornithine was completely reversed in a dose-dependent fashion by exogenous administration of spermidine, thus implying a critical involvement of the polyamine pathway in progesterone action.

Testosterone and gonadotrophin profiles in patients on daily or monthly LHRH analogue ICI 118630 (Zoladex) compared with orchiectomy

Diurnal profiles of circulating gonadotrophins and testosterone have been measured in patients with prostatic carcinoma on long-term treatment with the LHRH agonist analogue ICI 118630, which was administered either by subcutaneous daily injection or monthly injection of the depot preparation. These have been compared with profiles in patients who had undergone orchiectomy. Daily injection of the analogue induced a significant rise in the level of LH but this was not associated with a significant rise in circulating testosterone. There was no diurnal variation of LH or testosterone concentration in patients receiving the depot preparation and this did not differ in patients who were "mid-cycle" compared with those who were "end-cycle". The depot preparation did, however, induce significantly lower circulating levels of testosterone than did daily injection of the analogue and the levels were comparable with those achieved after orchiectomy.

A new hormonal therapy for prostatic cancer: long-term clinical and hormonal response

Twenty-four patients with advanced prostatic cancer were treated with daily injections of the LHRH analogue ICI 118630 (Zoladex) for up to 2 1/2 years. Successful long-term suppression of LH (luteinising hormone) and testosterone was observed without any escape of testosterone. Immunoreactive LH concentrations rose significantly following the daily injection of LHRH analogue but there was no corresponding rise in testosterone concentrations, suggesting altered bioactivity of the LH. A long-term clinical response was obtained in 10 patients (41.6%) and the median duration of response in these patients was 25 months. Eight of the 10 had well to moderately differentiated tumours. The actuarial median survival of all patients was 22 months.

Discordant responses of prolactinoma to two different dopamine agonists

A 19-year-old woman presented with headaches, temporal lobe epilepsy and primary amenorrhoea. There was a family history of multiple endocrine adenomatosis. Investigation revealed normal visual fields and acuity, hyperprolactinaemia (48 000 mU/l) and a very large pituitary tumour with extrasellar spread. Treatment with bromocriptine reduced the tumour size and the prolactin level to 2440 mU/l. Six months after the start of therapy, resistance to bromocriptine developed and the prolactin concentration progressively rose to pretreatment levels, despite increasing the dose of bromocriptine to 40 mg/d. At this stage treatment with a second dopamine agonist, pergolide, was effective in reducing the prolactin concentration to normal within four months. Serial CT scans at 1, 6 and 12 months on dopamine agonist therapy showed a progressive decrease in tumour size, which seemed to be maintained even during the period of rising prolactin concentrations due to bromocriptine resistance. This case illustrates that during dopamine agonist therapy a discrepancy may exist in the clinical response as judged by reduction in tumour size and decrease in the circulating prolactin level. Furthermore, in patients with prolactinomas, pergolide may induce a response when resistance to bromocriptine develops.

The effects of cranial irradiation on growth hormone secretion

Growth hormone (GH) secretion has been studied under physiological conditions and in response to standard pharmacological stimuli in 14 children, who had previously received cranial irradiation between two and fourteen years earlier. All fourteen showed a blunted GH response to insulin hypoglycaemia and, in twelve, the GH response to arginine stimulation was also subnormal. Physiological GH secretion was studied by measuring integrated GH concentrations in 30 min blood samples collected over a 24 hour period by a continuous withdrawal pump. Compared to normal controls (n = 5), the irradiated patients showed a significant reduction in the mean integrated GH concentration (2.2: 8.8 mU/l; p less than 0.002), the total 24 hour GH output (mean 105.7 mU vs. 391.7 mU; p less than 0.002) and the mean GH output during the first six hours of sleep (mean 48.2 mU vs. 226 mU; p less than 0.002). There was no significant correlation between the maximum peak GH response to either pharmacological test and the total 24 hour GH output. Conventionally most short children undergo two provocative tests of GH release and if the GH response to one of the two tests is normal, it is usually assumed that GH production is adequate. Adopting these criteria in this study it would have been assumed incorrectly that GH production was normal in two children. Nonetheless all 14 children showed a blunted GH response to an ITT as well as a reduced total 24 hour GH output.(ABSTRACT TRUNCATED AT 250 WORDS)

Torsion of the gallbladder. A case report

A case of torsion of the gallbladder with gangrene in a 75-year-old woman is described. The diagnosis was established at laparotomy. The clinical features were suggestive of intestinal obstruction, while abdominal radiographs aroused suspicion of appendicitis and appendicular abscess; difficulty in preoperative diagnosis is emphasized.

Volvulus of the stomach. A case report

A case of gastric volvulus with atypical clinical features is reported. The predisposing aetiological factors and the mechanism of genesis of this very rare condition are discussed. The diagnosis was established by barium meal examination after an unsuccessful gastroscopy. The patient was successfully treated by emergency surgery.

Gonadal damage due to radioactive iodine (I131) treatment for thyroid carcinoma

Papillary carcinoma of the thyroid is the most common type of thyroid cancer and is associated with a good prognosis. Complications of treatment with surgery and radioiodine are uncommon. We report the case of a 13 year old boy who developed testicular damage following treatment with radioactive iodine 350 mCi for a papillary carcinoma of the thyroid. Four years after radioiodine treatment there has been no suggestion of recovery of spermatogenesis. Detailed follow-up studies of similarly treated young patients are required to define the incidence of this complication and to determine its reversibility.

Preliminary report on use of depot formulation of LHRH analogue ICI 118630 (Zoladex) in patients with prostatic cancer

A study was conducted of the response of the pituitary-testicular axis to two different methods of administration of the luteinising hormone releasing hormone (LHRH) analogue ICI 118630 (Zoladex) in patients with prostatic cancer. The analogue was given by continuous infusion to four previously untreated patients with prostatic cancer for 60 days (group 1). Subsequently a further four patients were given a depot formulation of the same analogue by subcutaneous injection once every 28 days (group 2). Both methods of administration produced similar, successful suppression of luteinising hormone (LH) associated with a reduction of testosterone to castrate concentrations. The median basal testosterone concentrations before treatment in groups 1 and 2 were 20.6 and 14.1 nmol/l (5.94 and 4.07 ng/ml) respectively; these were reduced to 1.4 and 1.1 nmol/l (0.40 and 0.32 ng/ml) within four weeks of the start of treatment. The median basal LH concentration in groups 1 and 2 were 7.9 and 16.6 IU/1 respectively, which were suppressed to 2.6 and 2.4 IU/1 by four weeks. The suppression of LH and testosterone was maintained with continuous subcutaneous infusion for up to 60 days in group 1, and by subsequent injections of the depot every 28 days in group 2. The use of depot preparation of an LHRH analogue to suppress gonadotrophin and sex hormone secretion offers the convenience of once monthly injections when LHRH analogues are required for the long term treatment of elderly patients with prostatic cancer and children with precocious puberty.

Leydig cell damage after testicular irradiation for lymphoblastic leukaemia

The effect of testicular irradiation on Leydig cell function has been studied in a group of boys irradiated between 1 and 5 years earlier for a testicular relapse of acute lymphoblastic leukaemia. Six of the seven boys irradiated during prepubertal life had an absent testosterone response to HCG stimulation. Two of the four boys irradiated during puberty had an appropriate basal testosterone level, but the testosterone response to HCG stimulation was subnormal in three of the four. Abnormalities in gonadotrophin secretion consistent with testicular damage were noted in nine of the 11 boys. Evidence of severe Leydig cell damage was present irrespective of whether the boys were studied within 1 year or between 3 and 5 years after irradiation, suggesting that recovery is unlikely. Androgen replacement therapy has been started in four boys and will be required by the majority of the remainder to undergo normal pubertal development.

Hypothalamic growth hormone releasing factor deficiency following cranial irradiation

The effect of synthetic human pancreatic tumour GH releasing factor (hp GRF1-44) on GH release has been studied in 10 patients with radiation-induced GH deficiency and four normal subjects. All 10 patients showed subnormal GH responses to both an ITT (median peak GH 3.2 mU/l) and to arginine stimulation (median peak GH 2.9 mU/l), although the remainder of pituitary function was intact. Following an acute intravenous bolus (100 micrograms) of hp GRF1-44, there was no GH response in two patients and a subnormal but definite GH response in a further four. The remaining four patients showed a significant GH response (median peak GH level 29 mU/l; range 22-57 mU/l) to hp GRF1-44, similar in magnitude and timing to that seen in the four normals. This strongly suggests that in these four subjects, the discrepancy in GH responses to hp GRF1-44, ITT and to arginine was a result of radiation-induced hypothalamic damage leading to a deficiency of endogenous GRF. The availability of synthetic hp GRF capable of stimulating GH secretion means that the distinction between hypothalamic and pituitary causes of GH deficiency will be of considerable therapeutic importance in the future.

Treatment of Cushing's disease with low dose radiation therapy

Nineteen patients with Cushing's disease were treated with low dose external pituitary irradiation (20 Gy (2000 rad) in eight fractions over 10 days). While awaiting the effects of pituitary irradiation all patients were treated with metyrapone. Seven patients had a complete remission of their disease within six to 12 months of irradiation. They did not require any further treatment and were followed up for a mean of three and a half (range one to eight) years. Another patient had a complete remission after a second course of pituitary irradiation. A further two patients showed a significant biochemical improvement after irradiation, although they were not rendered eucorticoid. There were no complications after this dose of irradiation. These results compare favourably with those reported after pituitary irradiation at conventional doses (40-50 Gy (4000-5000 rad) over four or five weeks) but were not associated with any complications. It is therefore recommended that low dose external pituitary irradiation be used as definitive first line treatment for Cushing's disease.

Primary gonadal damage following treatment of brain tumors in childhood

Gonadal function was studied in two groups of children previously treated for medulloblastoma with surgery followed by postoperative craniospinal irradiation. In group 1 but not in group 2, the children also received adjuvant chemotherapy for one to two years. All children in group 1 received a nitrosourea (BCNU or CCNU), plus vincristine in four and procarbazine in three patients. The nine children in group 1 showed clinical and biochemical evidence of gonadal damage with elevated serum FSH concentrations and, in the boys, small testes for their stage of pubertal development. In group 2 (n = 8), each child had completed pubertal development normally, the boys had adult sized testes and the girls regular menses. Gonadotropin values were normal in all eight children. We conclude that nitrosoureas were responsible for the gonadal damage in the children in group 1, with procarbazine also contributing to the damage in the three children who received this drug. In view of the limited proved value of adjuvant chemotherapy with nitrosoureas in the treatment of medulloblastoma, recognition of this serious complication of cytotoxic drug therapy may necessitate reassessing in which subgroups of children with medulloblastoma the benefits of adjuvant chemotherapy outweight the complications.

Human chorionic gonadotrophin secreting pineal germinoma and precocious puberty

A 10 1/2 year old boy presented with raised intracranial pressure and precocious puberty caused by a human chorionic gonadotrophin (HCG) secreting pineal germinoma. After craniospinal irradiation he improved clinically and his HCG concentration fell to an undetectable value. Two years later he remains well. Pineal germinomas are highly radiosensitive obviating the need for difficult surgery associated with high mortality.

Treatment of advanced prostatic cancer with LHRH analogue ICI 118630: clinical response and hormonal mechanisms

9 of 12 patients with advanced metastatic carcinoma of the prostate treated with luteinising-hormone-releasing-hormone (LHRH) analogue ICI 118630 for a mean period of 6 months showed objective evidence of response to treatment. Of 8 patients with bone pain, 7 obtained relief. After 6 weeks of treatment testosterone concentrations were reduced to castrate levels (range less than 2 to 5.5 nmol/l) from a pretreatment mean value of 15.7 nmol/l (range 10.3-24 nmol/l). Basal gonadotropin levels and gonadotropin responses to acute LHRH stimulation were suppressed within 2 weeks of treatment. However, the testosterone response to stimulation with human chorionic gonadotropin was unimpaired 4 weeks after the start of treatment. Therefore suppression of the basal testosterone concentration by ICI 118630 was due to inhibition of pituitary luteinising-hormone secretion rather than direct inhibition of testicular Leydig-cell function. ICI 118630 offers an alternative treatment to orchidectomy and oestrogen therapy.

Colorimetric Alpha-Amylase, Falling Number, and Amylograph Assays of Sprouted Wheat: Collaborative Study

Results are reported of a collaborative study on the determination of sprout damage in wheat. Methods of analysis included falling number, amylograph, and a colorimetric α-amylase assay. Data for the 3 methods were linearly interrelated. Primary source of error for each method was lack of agreement among collaborators. The 3 tests adequately differentiated among sprout damage levels within a single laboratory. The colorimetric test was the most sensitive to change in α-amylase content and appeared to have greater potential for standardization than the other 2 methods