A Novel Method for Intracavitary Cervical HDR Brachytherapy: Express Finger-Guided Implant Insertion at Simulation Table without Speculum, Cervical Dilatation, Sleeve, Anesthesia, or Sedation

PURPOSE/OBJECTIVE(S)

Our purpose is to develop a fast, effective, and independent intracavitary brachytherapy implant insertion method that does not need sleeve insertion, anesthesia or conscious sedation, and that can be performed at the front edge of the simulation table (CT or MRI), using finger guidance without a need for speculum or cervical dilatation.

MATERIALS/METHODS

From February 2022 to January 2023, we treated 27 locally advanced cervical cancer patients. In the last week of EBRT, we assessed patients with MRI and pelvic exam to determine their eligibility: 89% (24 patients) met the two inclusion criteria for the express insertion which are: the ability to cover any residual disease with intracavitary brachytherapy, and the accessibility of cervix external os. Each patient had 3 HDR express insertions (8Gy x3). A total of 72 consecutive express implant insertions were performed. Each insertion is evaluated for the success of procedure, number of attempts, and time taken. Patients started on laxative 3 days prior to the procedure, and paracetamol & Ibuprofen taken at home 2 hours before the procedure. On arrival, patients used the bathroom, and IM/SC morphine given. Patients were prepared at the front edge of the simulation table and topical lidocaine applied to the cervix. The external os identified with the index finger of one hand which also guided the tandem insertion using the other hand. No cervical dilatation was used. CT simulation was performed to confirm adequate implant placement and to contour and plan CTV-HR and OARs as per GEC-ESTRO/ABS guidelines.

RESULTS

The success rate was 100% in all the 72 express insertions. >90% (66 insertions) were smooth and fast, i.e., completed in 1 attempt that took <20 minutes. <10% (6 insertions) were challenging but successful, in 2 patients: one patient had an acute anteverted uterus for which suprapubic abdominal pressure facilitated the procedure that took <3 attempts and completed in <40 minutes, the other patient had an acute retroverted uterus which was associated with the most challenging procedure that took >3 attempts and completed in >40 minutes. The success rate was not affected by the type of applicator used. 85% of our applications used multichannel tandem and cylinder, 10% used tandem and ovoids, and 5% used tandem and ring applicators.

CONCLUSION

Express finger-guided intracavitary brachytherapy implant insertion at the simulation table without speculum, cervical dilatation, sleeve, anesthesia, or sedation is fast, effective, and an independent method that can be used in most cervical cancer patients to complete their planned brachytherapy treatment regardless of limited resources. Practice and dissemination of this innovative method is important especially when operative rooms and anesthesia support are limited (e.g., epidemics and closures) and in centers lacking such support. Further studies are warranted to optimize the procedure and to highlight its significant medical and socioeconomic benefits.

Prevention of mother-to-child transmission of hepatitis B virus: An observation of routine practice in a tertiary liver centre before and after the introduction of the global health sector strategy on viral hepatitis

INTRODUCTION

Worldwide, around 296 million people have hepatitis B virus (HBV) infection, most commonly transmitted from mother-to-child. Global Health Sector Strategy on Viral Hepatitis (GHSSVH) was introduced in May 2016, calling for elimination of viral hepatitis by 2030. This study aims to compare practice in a tertiary liver centre before and after GHSSVH introduction for prevention of mother-to-child transmission (MTCT).

MATERIALS AND METHODS

This retrospective cohort study was performed in a tertiary referral liver centre in Malaysia, using data from electronic medical record from January 2015 to December 2019. A total of 1457 medical records of female with HBV infection were screened. The inclusion criteria of the study were pregnant women with HBsAg positive or known to have HBV infection during the study period. We excluded patients with co-infections of other types of viral hepatitis or human immunodeficiency virus, concurrent liver diseases (e.g.: autoimmune hepatitis, Wilson’s disease), previous organ transplant and malignancy—except for hepatocellular carcinoma (HCC).

RESULTS

This study included 117 pregnancies and 21/117 (17.9%) were on antiviral therapy (AVT) for HBV. In 2017– 2019, 13/18 (72.2%) of those with HBV DNA >200,000IU/ml were on AVT, compared to 5/9 (55.6%) for 2015–2016, indicating 58% (95% CI −63% to 568%) higher odds of being on AVT in post GHSSVH group after accounting for HBV DNA.

CONCLUSION

Uptake of maternal AVT for the prevention of MTCT shows an increased trend since the introduction of GHSSVH, with room for improvement.

Disruption of white matter integrity and its relationship with cognitive function in non-severe traumatic brain injury

Background

Impairment in cognitive function is a recognized outcome of traumatic brain injury (TBI). However, the degree of impairment has variable relationship with TBI severity and time post injury. The underlying pathology is often due to diffuse axonal injury that has been found even in mild TBI. In this study, we examine the state of white matter putative connectivity in patients with non-severe TBI in the subacute phase, i.e., within 10 weeks of injury and determine its relationship with neuropsychological scores.

Methods

We conducted a case-control prospective study involving 11 male adult patients with non-severe TBI and an age-matched control group of 11 adult male volunteers. Diffusion MRI scanning and neuropsychological tests were administered within 10 weeks post injury. The difference in fractional anisotropy (FA) values between the patient and control groups was examined using tract-based spatial statistics. The FA values that were significantly different between patients and controls were then correlated with neuropsychological tests in the patient group.

Results

Several clusters with peak voxels of significant FA reductions (p < 0.05) in the white matter skeleton were seen in patients compared to the control group. These clusters were located in the superior fronto-occipital fasciculus, superior longitudinal fasciculus, uncinate fasciculus, and cingulum, as well as white matter fibers in the area of genu of corpus callosum, anterior corona radiata, superior corona radiata, anterior thalamic radiation and part of inferior frontal gyrus. Mean global FA magnitude correlated significantly with MAVLT immediate recall scores while matrix reasoning scores correlated positively with FA values in the area of right superior fronto-occipital fasciculus and left anterior corona radiata.

Conclusion

The non-severe TBI patients had abnormally reduced FA values in multiple regions compared to controls that correlated with several measures of executive function during the sub-acute phase of TBI.

Harmonized-Multinational qEEG norms (HarMNqEEG)

This paper extends frequency domain quantitative electroencephalography (qEEG) methods pursuing higher sensitivity to detect Brain Developmental Disorders. Prior qEEG work lacked integration of cross-spectral information omitting important functional connectivity descriptors. Lack of geographical diversity precluded accounting for site-specific variance, increasing qEEG nuisance variance. We ameliorate these weaknesses. (i) Create lifespan Riemannian multinational qEEG norms for cross-spectral tensors. These norms result from the HarMNqEEG project fostered by the Global Brain Consortium. We calculate the norms with data from 9 countries, 12 devices, and 14 studies, including 1564 subjects. Instead of raw data, only anonymized metadata and EEG cross-spectral tensors were shared. After visual and automatic quality control, developmental equations for the mean and standard deviation of qEEG traditional and Riemannian DPs were calculated using additive mixed-effects models. We demonstrate qEEG "batch effects" and provide methods to calculate harmonized z-scores. (ii) We also show that harmonized Riemannian norms produce z-scores with increased diagnostic accuracy predicting brain dysfunction produced by malnutrition in the first year of life and detecting COVID induced brain dysfunction. (iii) We offer open code and data to calculate different individual z-scores from the HarMNqEEG dataset. These results contribute to developing bias-free, low-cost neuroimaging technologies applicable in various health settings.

Alteration in the Functional Organization of the Default Mode Network Following Closed Non-severe Traumatic Brain Injury

The debilitating effect of traumatic brain injury (TBI) extends years after the initial injury and hampers the recovery process and quality of life. In this study, we explore the functional reorganization of the default mode network (DMN) of those affected with non-severe TBI. Traumatic brain injury (TBI) is a wide-spectrum disease that has heterogeneous effects on its victims and impacts everyday functioning. The functional disruption of the default mode network (DMN) after TBI has been established, but its link to causal effective connectivity remains to be explored. This study investigated the differences in the DMN between healthy participants and mild and moderate TBI, in terms of functional and effective connectivity using resting-state functional magnetic resonance imaging (fMRI). Nineteen non-severe TBI (mean age 30.84 ± 14.56) and twenty-two healthy (HC; mean age 27.23 ± 6.32) participants were recruited for this study. Resting-state fMRI data were obtained at the subacute phase (mean days 40.63 ± 10.14) and analyzed for functional activation and connectivity, independent component analysis, and effective connectivity within and between the DMN. Neuropsychological tests were also performed to assess the cognitive and memory domains. Compared to the HC, the TBI group exhibited lower activation in the thalamus, as well as significant functional hypoconnectivity between DMN and LN. Within the DMN nodes, decreased activations were detected in the left inferior parietal lobule, precuneus, and right superior frontal gyrus. Altered effective connectivities were also observed in the TBI group and were linked to the diminished activation in the left parietal region and precuneus. With regard to intra-DMN connectivity within the TBI group, positive correlations were found in verbal and visual memory with the language network, while a negative correlation was found in the cognitive domain with the visual network. Our results suggested that aberrant activities and functional connectivities within the DMN and with other RSNs were accompanied by the altered effective connectivities in the TBI group. These alterations were associated with impaired cognitive and memory domains in the TBI group, in particular within the language domain. These findings may provide insight for future TBI observational and interventional research.

Neural alterations in working memory of mild-moderate TBI: An fMRI study in Malaysia

Working memory (WM) encompasses crucial cognitive processes or abilities to retain and manipulate temporary information for immediate execution of complex cognitive tasks in daily functioning such as reasoning and decision-making. The WM of individuals sustaining traumatic brain injury (TBI) was commonly compromised, especially in the domain of WM. The current study investigated the brain responses of WM in a group of participants with mild-moderate TBI compared to their healthy counterparts employing functional magnetic resonance imaging. All consented participants (healthy: n = 26 and TBI: n = 15) performed two variations of the n-back WM task with four load conditions (0-, 1-, 2-, and 3-back). The respective within-group effects showed a right hemisphere-dominance activation and slower reaction in performance for the TBI group. Random-effects analysis revealed activation difference between the two groups in the right occipital lobe in the guided n-back with cues, and in the bilateral occipital lobe, superior parietal region, and cingulate cortices in the n-back without cues. The left middle frontal gyrus was implicated in the load-dependent processing of WM in both groups. Further group analysis identified that the notable activation changes in the frontal gyri and anterior cingulate cortex are according to low and high loads. Though relatively smaller in scale, this study was eminent as it clarified the neural alterations in WM in the mild-moderate TBI group compared to healthy controls. It confirmed the robustness of the phenomenon in TBI with the reproducibility of the results in a heterogeneous non-Western sample.

Enteral myiasis causing acute dysentery: A case report

Enteral myiasis or intestinal myiasis is acquired by ingesting food or water contaminated with dipteran fly eggs or larvae. Here, we describe a patient with intestinal myiasis presenting with acute dysentery caused by the larva of Hermetia illucens. The larva was identified morphologically, and its species confirmed through molecular analysis using polymerase chain reaction and sequencing based on mitochondrial cytochrome c oxidase subunit I gene (COI).

Brain responses to high frequencies (270 Hz-480 Hz) changes due to vibratory stimulation of human fingertips: An fMRI study

This fMRI study investigated the effects of vibratory stimulation on somatosensory areas during high-frequencies stimulation using a piezoelectric finger stimulation system during an fMRI scan. Twelve healthy right-handed subjects were stimulated at 270 Hz-480 Hz and the fMRI dataset was analysed to generate the activated regions due to the high-frequencies stimulation. The activated regions were identified and thresholded at Puncorrected<0.001 for multiple comparisons. The average effect of frequencies revealed significant activation in the left thalamus, right inferior parietal gyrus, right medial frontal gyrus, and right precuneus whereas the main effect of frequencies revealed significant activation in the left thalamus. The positive effect of frequencies displayed significant activation in the left pallidum, right amygdala, right superior temporal gyrus, right medial temporal gyrus. The vibratory stimulation at a frequency of 330 Hz and 360 Hz (330 Hz<360 Hz) revealed a significant difference in the left thalamus. Findings indicated the role of the secondary somatosensory areas processing and transporting sensory information to perform the perceptual and cognitive function.

Brain responses to frequency changes due to vibratory stimulation of human fingertips: An fMRI study

Vibratory (e.g., piezoelectric) devices can stimulate cortical responses from the somatosensory area during functional magnetic resonance imaging. Twelve healthy, right-handed subjects (7 males and 5 females) were scanned with a 3.0 T magnetic resonance imaging scanner and stimulated at 30-240 Hz using a piezoelectric vibrator attached to the subjects’ index fingers. The functional images were analysed to determine the brain activation region by performing random effects analyses at the group level. One-way analysis of variance was used to measure changes in frequency on brain activity. The activated regions were identified with WFU PickAtlas software, and the images were thresholded at Puncorrected < 0.001 for multiple comparisons. The average effect of frequency revealed significant activations in the right insula and right middle frontal gyrus; the corresponding region in the somatosensory area may act as a top-down control signal to improve sensory targets. Results revealed significant differences between frequencies; 90 Hz > 120 Hz activated right inferior parietal gyrus, 120 Hz > 150 Hz activated right cerebellum, and 60 Hz > 90 Hz activated right supramarginal gyrus and bilateral inferior frontal gyrus pars triangularis. Findings indicated the role of secondary somatosensory areas and the cerebellum in performing higher-order functions and discriminating various frequencies during vibratory stimulation. Increasing the patient sample size and testing higher frequencies in future experiments will contribute to furthering brain mapping of somatosensory areas.

Generic daclatasvir plus sofosbuvir, with or without ribavirin, in treatment of chronic hepatitis C: real-world results from 18 378 patients in Egypt

BACKGROUND

Treatment of chronic hepatitis C using combination of sofosbuvir (SOF) and daclatasvir (DCV) was used in several clinical trials and multicentre studies, which were somewhat limited to genotypes 1-3. The national program in Egypt is using SOF-DCV combination for large scale treatment.

AIM

To assess the efficacy and safety of combined SOF-DCV in treating patients with HCV-G4 in a real-world setting.

METHODS

Data and outcome of chronic HCV patients who were treated for 12 weeks with generic medications: DCV 60 mg plus SOF 400 mg ± ribavirin (RBV) within the national hepatitis C treatment program in Egypt are presented. Treatment-naïve patients without cirrhosis were treated without RBV, and those who had cirrhosis or were treatment-experienced (interferon experienced or SOF experienced) received RBV. Efficacy and safety were assessed, and baseline factors associated with sustained virological response at post-treatment week 12 (SVR12) were explored.

RESULTS

During the first 2 months of the programme, 18 378 patients with HCV-G4 started treatment with SOF-DCV with or without RBV. Overall, 95.1% achieved SVR12 (95.4% among patients treated without RBV and 94.7% for patients treated with RBV, P = .32). Treatment was prematurely discontinued in only 1.5% of patients. The most common events leading to discontinuation were patient withdrawal (n = 76) and pregnancy (n = 5). Five deaths occurred within this group.

CONCLUSIONS

Real-world experience of generic SOF-DCV in patients with chronic HCV-G4 proved to be safe and associated with a high SVR12 rate, in patients with different stages of fibrosis.

Poor outcome of adenovirus infections in adult hematopoietic stem cell transplant patients with sustained adenovirus viremia

The outcome of adenovirus (ADV) infections in adult hematopoietic stem cell transplant (HSCT) patients remains poorly characterized. We studied 14 adults and 3 children, who had undergone HSCT and had developed ADV viremia. Peak ADV DNA levels were significantly higher in patients with ADV diseases than in those without (P=0.03). All children survived the ADV infections. Among the 14 adult HSCT patients, 11 were treated with cidofovir, 2 with ribavirin, and 1 did not receive antiviral treatment. Six of the 13 (46%) treated patients developed ADV diseases and 3 of them (23%) died of ADV infections. Sustained viremia (≥3 positive polymerase chain reaction assays during follow-up) was detected in all patients who finally died of ADV infections. However, 2 adults having had transient ADV viremia either survived or died of diseases other than ADV infections. Our study indicates that the outcome of adult HSCT patients with sustained ADV viremia may be poor, even for those who have received anti-ADV treatment.

Study the effect of beryllium reflector poisoning on the Syrian MNSR

Neutron interactions with beryllium lead to formation of (3)H and strong neutron absorbers (3)He and (6)Li in the reflector (so called beryllium poisoning). After the reactor shutdown, the concentration of (3)He increases in time due to tritium decay. This paper illustrates the impact of poisoning accumulation in the beryllium reflectors on reactivity for the Syrian MNSR research reactor. The prediction of (6)Li and (3)He poison concentrations, initiated by the 9Be(n,α) reaction, in the beryllium reflectors of the MNSR was also presented. The results were based on MCNP Monte Carlo calculations and solutions to the differential equations which describe the time dependent poison concentrations as a function of reactor operation time and shutdown periods. The whole reactor history was taken into account to predict reliable values of parasitic isotope concentrations. It was found that the (3)He and (6)Li accumulations in the beryllium reflectors during the actual working history decreased the excess reactivity by about 28%. While, the effect became more significant at the reactor life's end and the reactor became subcritical after 25,000 h operation. The results contained in this paper could be used in assess the safety analysis of the MNSR reactor.

Allogeneic haematopoietic stem-cell transplantation with reduced intensity conditioning for advanced stage Hodgkin's lymphoma in Sweden: high incidence of post transplant lymphoproliferative disorder

Allogeneic transplantation after reduced intensity conditioning (allo-RIC) is a treatment option for patients with Hodgkin's lymphoma (HL) relapsing after autologous transplantation. In all, 23 adult patients with HL underwent allo-RIC in Sweden between 2000 and 2007. The median number of previous treatment lines was five and 20 patients (87%) were previously autografted. TRM at 100 days and at 1 year was 13 and 22% respectively. Acute GVHD grades II-IV developed in 7 out of 23 patients (30%) and chronic GVHD in 10 out of 20 patients at risk (50%). The OS and EFS at three years was 59 and 27%, respectively. Four patients (17%) developed post transplant lymphoproliferative disease (PTLD) after a median time of 55 days (range 38-95); two of these patients later died. The study confirmed that allo-RIC is feasible, but associated with a substantial relapse rate: only 20% of the patients were still alive 7 years after the transplant. A finding of high incidence of PTLD needs to be confirmed in a larger trial that includes patients with non-HL and CLL.

Evaluation of a surveillance strategy for early detection of adenovirus by PCR of peripheral blood in hematopoietic SCT recipients: incidence and outcome

Adenoviruses (AdV) have emerged as important causes of morbidity and mortality in patients after hematopoietic SCT (HSCT). Early diagnosis of the infection by detection of viral DNA may improve the prognosis. A surveillance strategy was evaluated for detection of AdV DNA by PCR in a prospective study of unselected allogeneic HSCT recipients. In parallel with a routine CMV surveillance program, plasma from 20 children and 77 adults was analyzed by quantitative PCR for detection of AdV DNA. In addition, in 12 unselected patients, the presence of AdV-specific T cells were analyzed by enzyme-linked immunosorbent spot (ELISPOT) at 1 to 3 months after transplantation. A total of 5 of 97 (5%) patients had detectable AdV DNA in peripheral blood. Only one patient had high titers and none developed AdV disease. BM as a source of stem cells and myelodysplastic syndrome as the indication for transplantation were independently associated with higher risk of acquiring AdV infection. AdV-specific T cells were detected in 7 (58%) of 12 patients. Although AdV DNA was found in peripheral blood by quantitative PCR in 5% of patients undergoing allogeneic HSCT, the present surveillance program did not have a significant effect on the clinical outcome.

Targeted monitoring of patients at high risk of post-transplant lymphoproliferative disease by quantitative Epstein-Barr virus polymerase chain reaction

BACKGROUND

Epstein-Barr virus (EBV)-associated post-transplantation lymphoproliferative disease (PTLD) is a serious complication after allogeneic stem cell transplantation (SCT). The likelihood of PTLD is increased in the presence of specific risk factors. Monitoring of EBV DNA load and early administration of rituximab in patients with high EBV loads is recommended for high-risk patients.

METHODS

Patients at high risk of EBV-associated PTLD were defined as those showing an EBV serological mismatch between donor and recipient, those with lymphoma, those given cord blood grafts, and those with primary EBV disease before SCT. High-risk patients were prospectively monitored by weekly measurement of EBV DNA by quantitative polymerase chain reaction assay, and rituximab was given when the EBV load reached 10,000 copies/mL or symptoms were suggestive of EBV disease. During the study period (July 2005 to the end of June 2007) 131 patients underwent SCT, of whom 53 had high risk factors. A historical control group transplanted between January 2003 to the end of June 2005 was retrospectively used to evaluate the effect of the prospective monitoring strategy.

RESULTS

Of the patients, 30% were positive for EBV DNA at least once; 10% of patients with EBV DNAemia developed PTLD. Risk factors of EBV DNAemia were younger age (P=0.04), receiving transplants from mismatched family or unrelated donors (P=0.01), and acute graft-versus-host disease grades II-IV (P=0.001). The overall frequency of PTLD was 3%; 5.7% in the high-risk group and 1.3% in the standard-risk group. Previous splenectomy (P=0.046) was the only significant risk factor associated with PTLD. In the control group, 6 of 150 patients (4%) developed PTLD; 5/53 (9.4%) in the high-risk group and 1/97 (1%) in the standard-risk group. Human leukocyte antigen-mismatched donors (P<0.01) and EBV-positive donors/EBV-negative recipients (P=0.01) had a significant impact on the risk of PTLD.

CONCLUSION

A targeted monitoring strategy among patients at a high risk of EBV-associated PTLD might be helpful to decrease the risk of development of PTLD. However, larger prospective studies are needed to verify this hypothesis.

Multimodal sensory testing of the rectum and rectosigmoid: development and reproducibility of a new method

Evaluation of rectal and rectosigmoid sensation is important in basic, clinical and pharmacological studies. New methods to evoke and assess multimodal (electrical, thermal and mechanical) experimental pain of the upper gut activate distinct pathways and mimics clinical pain. The aims of the current study were to characterize the sensory response and reproducibility to multimodal stimulation of rectum and the rectosigmoid. A multimodal rectal probe was developed. Mucosal electrostimulation was delivered at the recto-sigmoid junction. In Rectum, impedance planimetry was used for measurement of cross-sectional area (CSA) during distension. Circulation of water within the bag at either 4 or 60 degrees C was applied for thermal stimulation. The method was tested in 12 healthy volunteers (six men mean age 32 years) on two subsequent days. Mechanical and sensory responses and referred pain areas were assessed. Stimulation with electrical, thermal and mechanical modalities resulted in different sensory perceptions. The relationship between stimulus intensity and sensory response was linear for all modalities. Sensory response to different modalities did not differ between investigation days (all P-values > 0.1). Approximately 75% of subjects felt referred pain in distinct skin locations. Between-days reproducibility was good for all modalities [intra-class correlation (ICC) > or = 0.6]. At sensory threshold, CSA showed best reproducibility (ICC > or = 0.9). At pain detection threshold stretch ratio, CSA and electrostimulation showed best reproducibility (ICC = 1.0; 0.9; 0.9). The present model was easily implemented, robust and showed good reproducibility. It can be used to study pathophysiology or pharmacological interventions in healthy controls and in patients with diseases involving the distal hindgut.

Quantification of adenovirus DNA in unrelated donor hematopoietic stem cell transplant recipients

BACKGROUND

Adenovirus (AdV) infection is a life threatening condition in immunosuppressed patients. Quantitative AdV assays can improve the clinical management of these patients.

OBJECTIVES

To evaluate quantitative measurement of AdV DNA with PCR in blood from hematopoietic stem cell transplant (HSCT) recipients.

STUDY DESIGN

Quantitative PCR was used to measure viral DNA levels of AdV in consecutive blood samples from 40 HSCT recipients (27 adults and 13 children) during a 1-year post-engraftment period. All patients received grafts from unrelated donors and were given anti-T-cell antibodies in the conditioning regimen.

RESULTS

In the group of 40 patients, six (15%) had detectable AdV DNA in blood for different lengths of time. None of these six patients suffered from severe graft-versus-host disease. In three of the patients a high AdV viral load (>10,000 copies/mL) was detected, one of whom also had high viral load of EBV and CMV and one of EBV only. These three patients died within 2 months after detection of ADV viremia. A low AdV viral load (<500 copies/mL) was detected in three surviving patients and they did not have concomitant high viral load of neither CMV nor EBV.

CONCLUSIONS

AdV viremia was present in 15% of the HSCT recipients and a high AdV viral load was associated with fatal outcome. Screening for AdV DNA with quantitative PCR in blood may be of clinical importance in allogeneic HSCT recipients in order to prevent severe clinical virological complications.

Kinetics of cell growth and cyclosporin A production by Tolypocladium inflatum when scaling up from shake flask to bioreactor

The kinetics of cell growth and Cyclosporin A (Cyc A) production by Tolypocladium inflatum were studied in shake flasks and bioreactors under controlled and uncontrolled pH conditions. In the case of the shake flask, the production time was extended to 226 h and the maximal antibiotic concentration was 76 mg/l. When scaling up the cultivation process to a bioreactor level, the production time was reduced to only 70 h with a significant increase in both the cell growth and the antibiotic production. The maximal dry cell weights in the case of the controlled pH and uncontrolled pH cultures in the bioreactor were 22.4 g/l and 14.2 g/l, respectively. The corresponding maximal dry cell weight values did not exceed 7.25 g/l with the shake flask cultures. The maximal values for Cyc A production were 144.72 and 131.4 mg/l for the controlled and uncontrolled pH cultures, respectively. It is also worth noting that a significant reduction was observed in both the dry cell mass and the antibiotic concentration after the Cyc A production phase, whereas the highest rate of antibiotic degradation was observed in the stirred tank bioreactor with an uncontrolled pH. Morphological characterization of the micromorphological cell growth (mycelial/pellet forms) was also performed during cultivation in the bioreactor.

Detecting and treating depression among adolescents presenting for reproductive care: realizing opportunities

This article reviews typical symptoms of depression presented by adolescents in the reproductive care practice setting, provides an overview of the assessment process, and offers options for referral and/or treatment of this common, yet often unrecognized, mood disorder. Because females have a two-fold higher prevalence rate of depressive disorders as compared to males of the same age and because reproductive care providers have exceptional access to females during the early reproductive years, these physicians have a unique, but often unrealized, opportunity to detect and initiate treatment and/or referrals for depression in adolescent patients. Indeed, adolescents often discuss symptoms of depression with their reproductive care provider with an expectation that they will serve as a "first responder" in terms of assisting in the management of the depression. Thus, it is important that the provider have an understanding of the disorder, its symptoms, and possible treatment modalities. Reproductive care providers are uniquely qualified to identify, assess, and treat many types of mood disorders in adolescent females.

Application of factorial experimental designs for optimization of cyclosporin. A production by Tolypocladium inflatum in submerged culture

A sequential optimization strategy based on statistical experimental designs was employed to enhance the production of cyclosporin A (CyA) by Tolypocladium inflatum DSMZ 915 in a submerged culture. A 2-level Plackett-Burman design was used to screen the bioprocess parameters significantly influencing CyA production. Among the 11 variables tested, sucrose, ammonium sulfate, and soluble starch were selected, owing to their significant positive effect on CyA production. A response surface methodology (RSM) involving a 3-level Box-Behnken design was adopted to acquire the best process conditions. Thus, a polynomial model was created to correlate the relationship between the three variables and the CyA yield, and the optimal combination of the major media constituents for cyclosporin A production, evaluated using the nonlinear optimization algorithm of EXCEL-Solver, was as follows (g/l): sucrose, 20; starch, 20; and ammonium sulfate, 10. The predicted optimum CyA yield was 113 mg/l, which was 2-fold the amount obtained with the basal medium. Experimental verification of the predicted model resulted in a CyA yield of 110 mg/l, representing 97% of the theoretically calculated yield.

Kiss and tell: what do we know about pre- and early adolescent females who report dating? A pilot study

STUDY OBJECTIVE

To evaluate the implications of dating in pre- and early adolescent females.

DESIGN

Cross-sectional survey.

SETTING

Child psychiatry clinic; pediatric clinic; family clinic.

PARTICIPANTS

Pre- and early adolescent females (n = 80) aged 11-14 and their parents.

INTERVENTION

Pre- and early adolescent females aged 11-14 and a parent were recruited during a regular clinic visit. Pre- and early adolescent females completed a survey that included measures of dating; sensation seeking; lifetime individual and peer drug use; Attention Deficit Hyperactive Disorder, Oppositional Defiant Disorder and Conduct Disorder symptoms; and onset of menses. Parents were asked similar questions about their child's dating behaviors and peer relationships.

MAIN OUTCOME MEASURE

Association of early dating with individual and peer drug use, sensation seeking, aggressive behavior, and onset of menses.

RESULTS

In pre- and early adolescent females, dating regularly is associated with nicotine and alcohol use, sensation seeking, and aggressive behavior. Dating regularly is also associated with onset of menses and a younger age of onset of menses in those who had started menstruating. Parents under-report their child's dating practices and associated high-risk behaviors.

CONCLUSION

Early dating is associated with nicotine and alcohol use, sensation seeking, aggressive behavior, and early onset of menses in adolescent females. Questions about early dating are a simple and efficient way to open inquiry of both parents and children about high-risk behaviors in the clinic setting.

The reproductive conditions and lipid profile in females with epilepsy

OBJECTIVE

To explore the reproductive conditions in women with epilepsy.

METHODS

Eighty-eight women were included; 37.5% and 62.5% had generalized and partial epilepsies, respectively. Ovarian sonogram, reproductive hormone and lipid profiles were assessed.

RESULTS

Compared with the control group and in accordance with our laboratory reference values, irregular menses and polycystic ovaries (PCO(s)) were reported in 70.5% and 39.8% versus 21.7% and 16.7% of controls. Abnormalities in leutinizing hormone (LH), follicle-stimulating hormone (FSH), LH-to-FSH ratio, testosterone (T) and prolactin (PRL) were identified. High values of FSH, LH and FSH-to-LH ratio were common with carbamazepine while that of T and PRL were common in untreated patients and with valproate. Low levels of high-density lipoprotein cholesterol was identified in approximately 59% but neither associated with duration and type of antiepileptic drugs nor patients' age, hormonal profile or PCO(s). Significant correlation was identified between menatrual irregularities, T, PRL, hormonal, lipid profile alterations, PCO(s) and seizure frequency but neither with epilepsy type nor focus.

CONCLUSION

This is the first study in our country that aimed at evaluation of reproductive conditions in women with epilepsy. This study indicates that reproductive dysfunction is common, hence, characterization of seizure-associated neuroendocrine adverse effects is important while managing women particularly during choice of antiepileptic medications as initial step and during patients' follow-up.

Oxidative hemolysis of erythrocytes induced by various vitamins

Hemolytic effect of some water-soluble vitamins (niacin B5, pyridoxine B6, thiamine B1 and ascorbic and acid C) on erythrocytes was studied spectrophotometrically at relatively high concentration. The oxidation mechanism of hemoglobin was the same for the used vitamins. Vitamin C was the strongest hemolytic agent in comparison with the other vitamins, while vitamin B1 is the weakest one. The results were confirmed by studying the variation in conductivity of erythrocytes with temperature in the range 20-40°C for the used vitamins at a concentration of 2 mM and after two hours from adding each vitamin to the erythrocytes suspension. The conductivity measurements show that the conductivity for the used vitamins is lower than that for control (without adding vitamin) due to hemoglobin oxidation, also may be due to the electrical reorganization of the erythrocyte membrane after the interaction of the used vitamin with it. The obtained results insure the oxidizing effect of the used vitamins on hemoglobin and consequently their hemolytic effect on erythrocytes.

The sexual and reproductive health in men with generalized epilepsy: a multidisciplinary evaluation

This study was specifically aimed to evaluate the sexual and reproductive health in a group of men with generalized epilepsy. In total, 44 men with generalized epilepsy were included in this study, their ages between 18 and 48 years (29.2+/-9.9) and duration of illness between 2 and 35 years (11.2+/-7.4); 34 patients were treated with conventional antiepileptic drugs (AEDs). Sexological and psychological interviews together with serum total testosterone, E(2), FSH, LH and prolactin were determined. Hyposexuality was diagnosed in 61.4%. Erectile dysfunction (ED) and premature ejaculation represented 70.4 and 66.7%, respectively. Variables such as hyposexuality, seizure duration and its poor control on AEDs were significantly associated with depressive symptoms. Compared to the normal control group, all patients reported elevated E(2) levels (P<0.001), 10 had FSH (n=4) and LH (n=6) levels exceeding that of the normal range for controls and two had hyperprolactinemia. Although the patients' mean value of total testosterone remained within the normal range, but it was significantly lower in hyposexual men compared to nonhyposexual (P<0.002), only two epileptic patients had markedly reduced level of total testosterone beyond normal control levels. This study strongly supports that: (1) The risk of hyposexuality and reproductive disturbances is high in epileptic patients with GTC convulsions despite the AEDs utilized. The risk for SD is further increased by poor seizure control and the frequently accompanied depressive manifestations. (2) It is possible that elevated E2 could increase the risk of SD by reducing active testosterone through negative feedback and the reduction of active testosterone could increase seizure intractability to antiepileptic medications.

Allozyme polymorphisms and heavy metal levels in the green-lipped mussel Perna viridis (Linnaeus) collected from contaminated and uncontaminated sites in Malaysia

It has been widely reported that heavy metal contamination in coastal waters can modify the allozyme profiles of marine organisms. Previous studies have recorded elevated metal concentrations in sediments and mussel tissues off Peninsular Malaysia. In the present study, horizontal starch gel electrophoresis was carried out to estimate the levels of allelic variation of the green-lipped mussel, Perna viridis, collected from one contaminated and three relatively uncontaminated sites off Peninsular Malaysia. Fourteen polymorphic loci were observed. In addition, the concentrations of cadmium, copper, lead, mercury and zinc were determined in the sediments and in the soft tissues of the mussels. Mussels from contaminated site, evidenced by high metal pollution indices (MPI) of the sediment and the mussel tissues, showed the highest percentage of polymorphic loci (78.6%), while those collected from the uncontaminated sites had lower MPI of the sediment and mussel tissue, and exhibited lower percentages of polymorphic loci (35.7-57.1%). The population from the contaminated site showed the highest excess of heterozygosity (0.289) when compared to that of the populations from the three uncontaminated sites (0.108-0.149). Allozyme frequencies at the phosphoglucomutase (PGM; E.C. 2.7.5.1) locus also differed between the contaminated and uncontaminated populations. Previous studies have shown that exposure to heavy metals can select or counter-select for particular alleles at this locus. The present results suggest that allozyme polymorphism in P. viridis is a potential biomonitoring tool for heavy metal contamination but further validation is required.

Toxicities and tolerances of Cd, Cu, Pb and Zn in a primary producer (Isochrysis galbana) and in a primary consumer (Perna viridis)

Studies on toxicities and tolerances of cadmium (Cd), copper (Cu), lead (Pb) and zinc (Zn) in the brown alga Isochrysis galbana and in the green-lipped mussel Perna viridis were conducted by short-term bioassays using endpoints growth production and mortality, respectively. The 5-day EC(50) and 24-h LC(50) of these heavy metals were determined in the brown alga and mussel, respectively. The EC(50) values calculated for the alga were 0.74 mg/l for Cd, 0.91 mg/l for Cu, 1.40 mg/l for Pb and 0.60 mg/l for Zn. The LC(50) values for the mussels were 1.53 mg/l for Cd, 0.25 mg/l for Cu, 4.12 mg/l for Pb and 3.20 mg/l for Zn. These LC(50) values were within the concentration ranges as reported by other authors who used P. viridis as the test organism. Based on these EC(50) and LC(50) values, the alga was most sensitive to Zn, followed by Cd, Cu and Pb while the mussel was most sensitive to Cu, followed by Cd, Zn and Pb. Differences in the trophic levels, metal handling strategies, biology and ecology of the primary producer (brown alga) and the primary consumer (mussel) are believed to be the plausible causes for the different toxicities and tolerances of the metals studied.