Pharmacokinetics, safety and preliminary pharmacodynamic evaluation of DARE-VVA1: a soft gelatin capsule containing tamoxifen for the treatment of vulvovaginal atrophy

OBJECTIVE

This study aimed to measure safety, systemic pharmacokinetics and preliminary efficacy of a vaginal tamoxifen capsule (DARE-VVA1) among postmenopausal women with moderate-to-severe vulvovaginal atrophy.

METHODS

This was a randomized, placebo-controlled, double-blind, phase 1/2 study of DARE-VVA1, in four doses (1, 5, 10 and 20 mg).

RESULTS

Seventeen women were enrolled and 14 completed the 8-week treatment. DARE-VVA1 was safe. All adverse events were of mild or moderate severity and distributed similarly among active and placebo groups. Plasma tamoxifen concentrations were highest among women using DARE-VVA1 20 mg, but the maximum mean (standard deviation) plasma tamoxifen concentrations on day 1 (2.66 ± 0.85 ng/ml) and day 56 (5.69 ± 1.87 ng/ml) were <14% of those measured after one oral tamoxifen dose. Active study product users had significant decreases from pre-treatment baseline in vaginal pH and proportion of vaginal parabasal cells (p = 0.04 for both endpoints), with women randomized to the 10 mg or 20 mg dose experiencing the largest treatment impact. The severity of vaginal dryness and dyspareunia decreased significantly from baseline with active study product use (p = 0.02 for both endpoints).

CONCLUSIONS

DARE-VVA1 is safe and results in minimal systemic exposure to tamoxifen. Preliminary efficacy data support further development of this product.

Pre-service Military-related and Mental Disorder Factors Associated with Leaving the UK Armed Forces

Background: The UK Armed Forces (UKAF) have a substantial manning deficit as more personnel leave than join. This article identified pre-service, military, and mental health factors giving rise to leaving the UKAF and estimated the contributions to leaving of those factors which are potentially amenable to modification. Methods: This study utilized data from a three-phase cohort study (2004-2006, 2007-2009 and 2014-2016), commencing while respondents were serving in the UKAF (n = 10,836; 6,046 (55.8%) had left service). Associations between leaving the services and socio-demographics, military career and experiences, and mental health were determined using Cox regression. Contribution to leaving was based on population attributable fractions (PAF) from Cox regression. Analyses were stratified by rank due to the different career structures of Commissioned Officers and enlisted personnel. Results: Leaving the UKAF was associated with joining when older, being a woman with a child/children, Army service, combat role, lower education level, and poor mental health. Factors contributing a significant proportion of leaving among enlisted personnel were joining over the age of 17, history of externalizing behavior, being female, common mental disorders, and alcohol misuse. Among Commissioned Officers only age at joining and sex contributed significant proportions to leaving. Conclusions: The key factors for leaving are education and higher age at recruitment. These are not amenable to intervention, for policy, equity, and legal reasons. Heavy drinking and common mental disorder symptoms may be more amenable to modification and hence reduce rates of leaving the UKAF. Women are more likely to leave due to childbearing.

Preventing secondary exposure to women from men applying a novel nestorone/testosterone contraceptive gel

BACKGROUND

Testosterone (T)/Nestorone (NES) combination gel is a potential transdermal male contraceptive that suppresses gonadotropins and spermatogenesis. Transfer of transdermal T from men to women can be prevented by washing or covering application sites with clothing.

OBJECTIVES

We hypothesized that showering or wearing a shirt over gel application sites would prevent secondary exposure of T and NES to a woman after close skin contact.

MATERIALS AND METHODS

Twelve healthy male and 12 healthy female participants were recruited. Men applied T/NES 62 mg/8 mg gel to their shoulders and upper arms. Two hours after application, female partners rubbed the application site for 15 min. Exposure in the female partner was assessed under three conditions: a shirt covered the application site; the man showered prior to skin contact; or without intervention to reduce transfer. Serum T and NES concentrations were measured by LC-MS/MS in serial blood samples for 24 h after gel exposure.

MAIN OUTCOMES

Change in female serum T and NES levels as measured by average concentration over 24 h (C_avg ).

RESULTS

Median female serum T C_avg was 23.9 ng/dL (interquartile range, 19.3, 33.9) with the shirt barrier and 26.7 ng/dL (20.7, 33.9) after showering, which was higher than baseline 20.9 ng/dL (16.7, 25.0), both p < 0.03) but lower than without intervention (58.2 ng/dL [30.9, 89.1], both p < 0.01). Female serum NES C_avg and maximum concentration were below the lower limit of quantification with the shirt barrier and after showering, but increased without intervention in six of 12 women (maximum concentration <60 pg/mL). Men had lower average serum NES levels after showering (47 pg/ml [20, 94] compared to no intervention (153.3 pg/mL [51, 241], p < 0.02).

CONCLUSION

Secondary transfer of T and NES occurs after intensive skin contact with the gel application site. Secondary transfer is decreased by a shirt barrier or showering before contact.

Accurate measurement of androgen after androgen esters: problems created by ex vivo esterase effects and LC-MS/MS interference

Background

Ex vivo androgen prodrug conversion by blood esterases after oral androgen ester administration may result in an overestimation of the measured blood androgens.

Objective

We investigated whether blood collection tubes with esterase inhibitors decreased the conversion of testosterone undecanoate (TU) and dimethandrolone undecanoate (DMAU) to their active metabolites, testosterone (T), and dimethandrolone (DMA), providing a more accurate assessment of circulating T/DMA levels.

Methods

Blood was collected in tubes with/without esterase inhibitors from: (i) four healthy and four hypogonadal men receiving no androgens and spiked ex vivo with TU/DMAU; (ii) four men taking oral TU (Andriol^®); and (iii) eight hypogonadal men dosed with oral 316 mg TU and 15 healthy men with 200 mg DMAU. T/DMA levels were measured by LC‐MS/MS.

Results

Sodium fluoride (NaF, an esterase inhibitor) decreased measured T levels by 14.2% in men not receiving TU. Increasing amounts of TU/DMAU added to blood collected into plain tubes resulted in a concentration‐dependent overestimation of T/DMA that was reduced by collecting blood into NaF tubes (by 30–85%), and keeping samples at 4 °C and minimizing time prior to centrifugation. After oral TU/DMAU administration to men, when TU/DMAU levels were >15/10 ng/mL, respectively, blood collected in NaF tubes yielded lower measured T concentrations by 15–30% and DMA by 22% due to an additional inhibitory effect of NaF on blood esterases.

Conclusion

NaF directly lowers plasma T/DMA levels measured by LC‐MS/MS and also inhibits blood esterase activity. Overestimation of T/DMA in blood collected in tubes without NaF after oral TU/DMAU administration is important for pharmacokinetics studies in drug development clinical trials but may have limited impact in clinical practice/utilization because the differences between measured and true androgen values are modest and the wide therapeutic androgen efficacy ranges obviate the need for highly accurate androgen measurements during therapy.

Trajectories of alcohol use in the UK military and associations with mental health

INTRODUCTION

There are higher levels of alcohol misuse in the military compared to the general population. Yet there is a dearth of research in military populations on the longitudinal patterns of alcohol use. This study aims to identify group trajectories of alcohol consumption in the UK military and to identify associations with childhood adversity, deployment history and mental disorder.

METHODS

Data on weekly alcohol consumption across an eight year period and three phases of a UK military cohort study (n=667) were examined using growth mixture modelling.

RESULTS

Five alcohol trajectory classes were identified: mid-average drinkers (55%), abstainers (4%), low level drinkers (19%), decreasing drinkers (3%) and heavy drinkers (19%). Alcohol consumption remained stable over the three periods in all classes, other than in the small decreasing trajectory class. Individuals in the heavy drinking class were more likely to have deployed to Iraq. Abstainers and heavy drinkers were more likely to report post-traumatic stress disorders at baseline compared to average drinkers.

CONCLUSIONS

Heavy drinkers in the UK military did not change their drinking pattern over a period of eight years. This highlights the need to develop effective preventive programmes to lessen the physical and psychological consequences of long-term heavy alcohol use. Individuals with a mental health problem appeared more likely to either be drinking at a high level or to be abstaining from use.

Comparison of the single dose pharmacokinetics, pharmacodynamics, and safety of two novel oral formulations of dimethandrolone undecanoate (DMAU): a potential oral, male contraceptive

Dimethandrolone (DMA, 7α,11β-dimethyl-19-nortestosterone) has both androgenic and progestational activities, ideal properties for a male hormonal contraceptive. In vivo, dimethandrolone undecanoate (DMAU) is hydrolyzed to DMA. We showed previously that single oral doses of DMAU powder in capsule taken with food are well tolerated and effective at suppressing both LH and testosterone (T), but absorption was low. We compared the pharmacokinetics and pharmacodynamics of two new formulations of DMAU, in castor oil and in self-emulsifying drug delivery systems (SEDDS), with the previously tested powder formulation. DMAU was dosed orally in healthy adult male volunteers at two academic medical centers. For each formulation tested in this double-blind, placebo-controlled study, 10 men received single, escalating, oral doses of DMAU (100, 200, and 400 mg) and two subjects received placebo. All doses were evaluated for both fasting and with a high fat meal. All three formulations were well tolerated without clinically significant changes in vital signs, blood counts, or serum chemistries. For all formulations, DMA and DMAU showed higher maximum (p < 0.007) and average concentrations (p < 0.002) at the 400 mg dose, compared with the 200 mg dose. The powder formulation resulted in a lower conversion of DMAU to DMA (p = 0.027) compared with both castor oil and SEDDS formulations. DMAU in SEDDS given fasting resulted in higher serum DMA and DMAU concentrations compared to the other two formulations. Serum LH and sex hormone concentrations were suppressed by all formulations of 200 and 400 mg DMAU when administered with food, but only the SEDDS formulation was effectively suppressed serum T when given fasting. We conclude that while all three formulations of oral DMAU are effective and well tolerated when administered with food, DMAU in oil and SEDDS increased conversion to DMA, and SEDDS may have some effectiveness when given fasting. These properties might be advantageous for the application of DMAU as a male contraceptive.

Are common mental disorders more prevalent in the UK serving military compared to the general working population?

BACKGROUND

Although the military is considered to be a stressful occupation, there are remarkably few studies that compare the prevalence of common mental disorder (CMD) between the military and the general population. This study examined the prevalence of probable CMD in a serving UK military sample compared to a general population sample of employed individuals.

METHOD

Data for the general population was from the 2003 and 2008 collections for the Health Survey for England (HSE) and for the serving military from phases 1 (2004-2006) and 2 (2007-2009) of the King's Centre for Military Health Research (KCMHR) cohort study. Probable CMD was assessed by the General Health Questionnaire (GHQ-12). The datasets were appended to calculate the odds of CMD in the military compared to the general population.

RESULTS

The odds of probable CMD was approximately double in the military, when comparing phase 1 of the military study to the 2003 HSE [odds ratio (OR) 2.4, 95% confidence interval (CI) 2.1-2.7], and phase 2 to the 2008 HSE (OR 2.3, 95% CI 2.0-2.6) after adjustment for sex, age, social class, education and marital status.

CONCLUSIONS

Serving military personnel are more likely to endorse symptoms of CMD compared to those selected from a general population study as employed in other occupations, even after accounting for demographic characteristics. This difference may be partly explained by the context of the military study, with evidence from previous research for higher reports of symptoms from the GHQ in occupational compared to population studies, in addition to the role of predisposing characteristics.

What explains post-traumatic stress disorder (PTSD) in UK service personnel: deployment or something else?

BACKGROUND

In previous studies an association between deployment to Iraq or Afghanistan and an overall increased risk for post-traumatic stress disorder (PTSD) in UK armed forces has not been found. The lack of a deployment effect might be explained by including, in the comparison group, personnel deployed on other operations or who have experienced traumatic stressors unrelated to deployment.

METHODS

The sample comprised 8261 regular UK armed forces personnel who deployed to Iraq, Afghanistan or other operational areas or were not deployed. Participants completed the PTSD CheckList-Civilian Version (PCL-C) and provided information about deployment history, demographic and service factors, serious accidents and childhood experiences.

RESULTS

Deployment to Iraq or Afghanistan [odds ratio (OR) 1.2, 95% confidence interval (CI) 0.6-2.2] or elsewhere (OR 1.1, 95% CI 0.6-2.0) was unrelated to PTSD although holding a combat role was associated with PTSD if deployed to Iraq or Afghanistan (OR 2.7, 95% CI 1.9-3.9). Childhood adversity (OR 3.3, 95% CI 2.1-5.0), having left service (OR 2.7, 95% CI 1.9-4.0) and serious accident (OR 2.1, 95% CI 1.4-3.0) were associated with PTSD whereas higher rank was protective (OR 0.3, 95% CI 0.12-0.76).

CONCLUSIONS

For the majority of UK armed forces personnel, deployment whether to Iraq, Afghanistan or elsewhere confers no greater risk for PTSD than service in the armed forces per se but holding a combat role in those deployed to Iraq or Afghanistan is associated with PTSD. Vulnerability factors such as lower rank, childhood adversity and leaving service, and having had a serious accident, may be at least as important as holding a combat role in predicting PTSD in UK armed forces personnel.

Violent behaviour in U.K. military personnel returning home after deployment

BACKGROUND

There is growing concern about an alleged rise in violent behaviour amongst military personnel returning from deployment to Iraq and Afghanistan. The aims of this study were to determine the prevalence of violence in a sample of U.K. military personnel following homecoming from deployment in Iraq and to examine the impact of deployment-related experiences, such as combat trauma, on violence, and the role of sociodemographics and pre-enlistment antisocial behaviour.

METHOD

This study used baseline data from a cohort study of a large randomly selected sample of U.K. Armed Forces personnel in service at the time of the Iraq war (2003). Regular personnel (n=4928) who had been deployed to Iraq were included. Data, collected by questionnaire, included information on deployment experiences, sociodemographic and military characteristics, pre-enlistment antisocial behaviour, post-deployment health outcomes and a self-report measure of physical violence in the weeks following return from deployment.

RESULTS

Prevalence of violence was 12.6%. This was strongly associated with pre-enlistment antisocial behaviour [adjusted odds ratio (aOR) 3.6, 95% confidence interval (CI) 2.9-4.4]. After controlling for pre-enlistment antisocial behaviour, sociodemographics and military factors, violence was still strongly associated with holding a combat role (aOR 2.0, 95% CI 1.6-2.5) and having experienced multiple traumatic events on deployment (aOR for four or more traumatic events 3.7, 95% CI 2.5-5.5). Violence on homecoming was also associated with mental health problems such as post-traumatic stress disorder (aOR 4.8, 95% CI 3.2-7.2) and alcohol misuse (aOR 3.1, 95% CI 2.5-3.9).

CONCLUSIONS

Experiences of combat and trauma during deployment were significantly associated with violent behaviour following homecoming in U.K. military personnel. Post-deployment mental health problems and alcohol misuse are also associated with increased violence.

Steady-state pharmacokinetics of oral testosterone undecanoate with concomitant inhibition of 5α-reductase by finasteride

Oral testosterone undecanoate (TU) is used to treat testosterone deficiency; however, oral TU treatment elevates dihydrotestosterone (DHT), which may be associated with an increased risk of acne, male pattern baldness and prostate hyperplasia. Co-administration of 5α-reductase inhibitors with other formulations of oral testosterone suppresses DHT production and increases serum testosterone. We hypothesized that finasteride would increase serum testosterone and lower DHT during treatment with oral TU. Therefore, we studied the steady-state pharmacokinetics of oral TU, 200 mg equivalents of testosterone twice daily for 7 days, alone and with finasteride 0.5 and 1.0 mg po twice daily in an open-label, three-way crossover study in 11 young men with experimentally induced hypogonadism. On the seventh day of each dosing period, serum testosterone, DHT and oestradiol were measured at baseline and 1, 2, 4, 8, 12, 13, 14, 16, 20 and 24 h after the morning dose. Serum testosterone and DHT were significantly increased into and above their normal ranges similarly by all three treatments. Co-administration of finasteride at 0.5 and 1.0 mg po twice daily had no significant effect on either serum testosterone or DHT. Oral TU differs from other formulations of oral testosterone in its response to concomitant inhibition of 5α-reductase, perhaps because of its unique lymphatic route of absorption.

Smoking among males in the UK Armed Forces: changes over a seven year period

OBJECTIVES

We assessed socio-demographic and military factors associated with smoking among males in the UK Armed Forces; made comparisons with the general population; and, tested the hypothesis that smoking has declined in the Armed Forces.

METHODS

Using data from two cross-sectional studies (conducted in 1998 and 2004), we examined the patterns of smoking among regular male UK Service personnel aged 20-49 years and made comparisons with general population data from England, Scotland and Wales.

RESULTS

In 2004, the prevalence of smoking among military males aged 20-49 years was 30% (n=2276), compared to 33% within the general population. Among current smokers, the mean number of cigarettes smoked per day was 15 for the military and 14 for the general population. The prevalence of smoking has decreased in lower ranks between 1998 and 2004 by 5.1% in 20-24 year olds to 6.3% in 35-49 year olds. These decreases are similar to those seen within those in the routine, manual or intermediate socio-economic group.

CONCLUSIONS

Smoking among males in the UK military is associated with similar factors to those in the general population. As these factors are clustered in younger personnel, policies to decrease smoking should be targeted at younger recruits.

Symptoms of post-concussional syndrome are non-specifically related to mild traumatic brain injury in UK Armed Forces personnel on return from deployment in Iraq: an analysis of self-reported data

BACKGROUND

Mild traumatic brain injury (mTBI) is being claimed as the 'signature' injury of the Iraq war, and is believed to be the cause of long-term symptomatic ill health (post-concussional syndrome; PCS) in an unknown proportion of military personnel.

METHOD

We analysed cross-sectional data from a large, randomly selected cohort of UK military personnel deployed to Iraq (n=5869). Two markers of PCS were generated: 'PCS symptoms' (indicating the presence of mTBI-related symptoms: none, 1-2, 3+) and 'PCS symptom severity' (indicating the presence of mTBI-related symptoms at either a moderate or severe level of severity: none, 1-2, 3+).

RESULTS

PCS symptoms and PCS symptom severity were associated with self-reported exposure to blast whilst in a combat zone. However, the same symptoms were also associated with other in-theatre exposures such as potential exposure to depleted uranium and aiding the wounded. Strong associations were apparent between having PCS symptoms and other health outcomes, in particular being a post-traumatic stress disorder or General Health Questionnaire case.

CONCLUSIONS

PCS symptoms are common and some are related to exposures such as blast injury. However, this association is not specific, and the same symptom complex is also related to numerous other risk factors and exposures. Post-deployment screening for PCS and/or mTBI in the absence of contemporaneous recording of exposure is likely to be fraught with hazards.

Chronic fatigue syndrome and related disorders in UK veterans of the Gulf War 1990-1991: results from a two-phase cohort study

BACKGROUND

The aim was to determine the prevalence of chronic fatigue syndrome (CFS), chronic fatigue and fibromyalgia in UK military personnel after the Gulf War 1990-1991.

METHOD

A two-phase cohort study was used. Three randomly selected subsamples identified from a population-based cross-sectional postal survey of over 10,000 current and ex-service UK military personnel (Gulf veterans were those deployed to the Gulf War 1990-1991; non-Gulf veterans were Bosnia peacekeepers 1992-1997 and those on active duty during the Gulf War 1990-1991 but not deployed) were recruited. Their disability status was assessed using the Short Form 36 physical functioning scale; Gulf veterans who reported physical disability (n=111) were compared with non-Gulf (n=133) veterans who reported similar levels of physical disability. Screening for known medical and psychiatric conditions was conducted to exclude medical explanations for disability and symptomatic distress. Standardised criteria for CFS, chronic fatigue and fibromyalgia were used.

RESULTS

Disabled Gulf veterans were more likely to be overweight, have elevated gamma-glutamyl transferase levels and screen positive for hypertension. There were no other clinically significant differences in clinical markers for medically explainable conditions. Disabled Gulf veterans were more likely than similarly disabled Bosnia and Era veterans (adjusted odds ratio 7.8, 95% confidence interval 2.5-24.5) to meet the criteria for CFS. Rates for other medically unexplained conditions were not significantly increased.

CONCLUSIONS

Symptoms in keeping with CFS account for a significant part of the symptomatic distress in Gulf veterans.

Risk factors for post-traumatic stress disorder among UK Armed Forces personnel

BACKGROUND

There is considerable interest in understanding further the factors that increase the risk of post-traumatic stress disorder (PTSD) for military personnel. This study aimed to investigate the relative contribution of demographic variables; childhood adversity; the nature of exposure to traumatic events during deployment; appraisal of these experiences; and home-coming experiences in relation to the prevalence of PTSD 'caseness' as measured by a score of 50 on the PTSD Checklist (PCL) in UK Armed Forces personnel who have been deployed in Iraq since 2003.

METHOD

Data were drawn from the first stage of a retrospective cohort study comparing UK military personnel who were deployed to the 2003 Iraq War with personnel serving in the UK Armed Forces on 31 March 2003 but who were not deployed to the initial phase of war fighting. Participants were randomly selected and invited to participate. The response rate was 61%. We have limited these analyses to 4762 regular service individuals who responded to the survey and who have been deployed in Iraq since 2003.

RESULTS

Post-traumatic stress symptoms were associated with lower rank, being unmarried, having low educational attainment and a history of childhood adversity. Exposure to potentially traumatizing events, in particular being deployed to a 'forward' area in close contact with the enemy, was associated with post-traumatic stress symptoms. Appraisals of the experience as involving threat to one's own life and a perception that work in theatre was above an individual's trade and experience were strongly associated with post-traumatic stress symptoms. Low morale and poor social support within the unit and non-receipt of a home-coming brief (psycho-education) were associated with greater risk of post-traumatic stress symptoms.

CONCLUSIONS

Personal appraisal of threat to life during the trauma emerged as the most important predictor of post-traumatic stress symptoms. These results also raise the possibility that there are important modifiable occupational factors such as unit morale, leadership, preparing combatants for their role in theatre which may influence an individual's risk of post-traumatic stress symptoms. Therefore interventions focused on systematic preparation of personnel for the extreme stress of combat may help to lessen the psychological impact of deployment.

Urinary isotopic analysis in the UK Armed Forces: no evidence of depleted uranium absorption in combat and other personnel in Iraq

OBJECTIVES

To assess the distribution and risk factors of depleted uranium uptake in military personnel who had taken part in the invasion of Iraq in 2003.

METHODS

Sector field inductively coupled plasma-mass spectrometry (SF-ICP-MS) was used to determine the uranium concentration and (238)U/(235)U isotopic ratio in spot urine samples. The authors collected urine samples from four groups identified a priori as having different potential for exposure to depleted uranium. These groups were: combat personnel (n = 199); non-combat personnel (n = 96); medical personnel (n = 22); and "clean-up" personnel (n = 24) who had been involved in the maintenance, repair or clearance of potentially contaminated vehicles in Iraq. A short questionnaire was used to ascertain individual experience of circumstances in which depleted uranium exposure might have occurred.

RESULTS

There was no statistically significant difference in the (238)U/(235)U ratio between groups. Mean ratios by group varied from 138.0 (95% CI 137.3 to 138.7) for clean-up personnel to 138.2 (95% CI 138.0 to 138.5) for combat personnel, and were close to the ratio of 137.9 for natural uranium. The two highest individual ratios (146.9 and 147.7) were retested using more accurate, multiple collector inductively coupled plasma-mass spectrometry (MC-ICP-MS) and found to be within measurement of error of that for natural uranium. There were no significant differences in isotope ratio between participants according to self-reported circumstances of potential depleted uranium exposure.

CONCLUSIONS

Based on measurements using a SF-ICP-MS apparatus, this study provides reassurance following concern for potential widespread depleted uranium uptake in the UK military. The rare occurrence of elevated ratios may reflect the limits of accuracy of the SF-ICP-MS apparatus and not a real increase from the natural proportions of the isotopes. Any uptake of depleted uranium among participants in this study sample would be very unlikely to have any implications for health.

Sublethal effects of chronic exposure to tebufenozide on the development, survival, and reproduction of the tufted apple bud moth (Lepidoptera: Tortricidae)

The lethal and sublethal effects of tebufenozide on the survival, development, and reproduction of a field strain of tufted apple bud moth, Platynota idaeusalis (Walker) (Lepidoptera: Tortricidae), were assessed by feeding first and third instars tebufenozide-treated diet until pupation. Larval mortality was 27.4 and 44.7% at 0.1 and 0.2 ppm for first instars and 21.9 and 57.8% at 0.2 and 0.4 ppm for third instars, respectively. Treated larvae exhibited higher pupal mortalities, lower pupal weights, and generally more deformed adults than untreated larvae. Larval development was not affected by tebufenozide when neonates were exposed, but development was accelerated slightly at 0.4 ppm for both males and females when third instars were exposed. All treatments produced sex ratios biased toward males. When paired with either treated or untreated males, females resulting from neonates treated at 0.2 ppm and from third instars treated at both 0.2 and 0.4 ppm laid from 37 to 65% fewer eggs. A reduction in fertility was only found when third instars were treated at the higher 0.4 ppm rate. These results suggest that tebufenozide can exhibit a significant effect on the population dynamics of the tufted apple bud moth.

Evaluation of neuromuscular symptoms in UK Gulf War veterans: A controlled study

OBJECTIVES

To determine whether Gulf War veterans with neuromuscular symptoms that included weakness and fatigue had either 1) objective correlates for muscle weakness or fatigue; or 2) any etiologic explanation for such symptoms; and if so, 3) whether such objective measures or etiologic mechanisms were specific to Gulf War service.

METHODS

Forty-nine ill Gulf War veterans with more than four neuromuscular symptoms (Gulf-ill) were compared with 26 Gulf-well veterans, 13 symptomatic Bosnian veterans (Bosnia-ill), and 22 symptomatic troops who were not deployed to the Gulf (Era-ill). Quantitative myometry was used to objectively measure weakness and fatigue. Subjects had an ischemic forearm exercise test, a subanaerobic bicycle exercise test, and a muscle biopsy.

RESULTS

Quantitative strength and fatigue measures did not correlate with self-perception of weakness or fatigue for any of our groups. No specific muscle biopsy abnormalities were found. There was no defect of adenylate deaminase or glycogenolysis found. Gulf-ill subjects did find the subanaerobic bicycle exercise more effortful and generated significantly higher plasma lactate concentrations compared with Gulf-well subjects.

CONCLUSION

Because complaints of weakness and fatigue in unwell servicemen do not correlate with actual weakness or fatigue, explanations for these symptoms must lie outside of the neuromuscular system. Increased lactate production during subanaerobic bicycle exercise reflects mitochondrial inefficiency, but it is unclear whether this reflects mitochondrial damage sustained during Gulf War service or inactivity secondary to ill health.

Liquid based cytology: examination of its potential in a chlamydia screening programme

OBJECTIVE

To assess the feasibility of testing for chlamydia directly on a single liquid based specimen (ThinPrep test) collected for cervical screening.

METHOD

Cervical smears were taken using a Cervex spatula and rinsed in the liquid based cytology collection vial. Following this, the conventional sample for chlamydia testing was taken from the endocervix using an Abbott Collection kit. Cytological specimens were prepared using an automated slide processor. Residual cellular material and the conventional samples were sent to the laboratory where both were tested for chlamydia by ligase chain reaction (LCR). The manufacturer's protocol for LCR urine testing was modified to substitute 1 ml of PreservCyt suspension.

RESULTS

581 women had both swab and cytology suspension tested for Chlamydia trachomatis with LCR. There were 19 concordant positive and 562 concordant negative reports. The stability of chlamydia in the cytology suspension was maintained for at least 5 months.

CONCLUSION

The findings lead us to conclude that samples collected for liquid based cytology using the ThinPrep test collection vial provide a potential platform for chlamydia screening, though the study established several issues to be addressed to make this a practical proposition.

Screening for depleted uranium in the United Kingdom armed forces: who wants it and why?

BACKGROUND

Depleted uranium (DU) use has been implicated in the poor health of many service personnel who have served in the Gulf and the Balkans. Although the health related risks are thought to be small the UK government has offered to set up a voluntary screening programme for service personnel. This study aimed to find out the characteristics and possible exposures to DU for those personnel who desire DU screening.

METHODS

This study looks at 2369 UK service personnel who were asked if they wanted to be screened for DU. Subjects were asked about their perceived exposure to deployment associated risks including DU and a number of psychological health measures.

RESULTS

The study found that 24% of the cohort wanted screening, a figure that if extrapolated to all those who have been offered screening would represent 36720 requests for screening. Those who wanted DU screening were younger, of lower rank, and more likely to be from the Royal Navy or Army rather than the Royal Air Force. Those requesting DU screening reported poorer health both subjectively and as measured by the GHQ-12 and a symptom checklist. They also reported more exposure to DU and to other deployment associated risks while in military service. Using combat exposure as a proxy for a significant risk of having been exposed to DU, there was a significant correlation.

CONCLUSIONS

This study found that the desire for DU screening is more closely linked to current health status rather than plausible exposure to DU.

Risk factors for continued illness among Gulf War veterans: a cohort study

BACKGROUND

There are no prospective cohort studies of prognostic factors on the outcome of Gulf War veterans. We aimed to test the hypotheses that Gulf War veterans who were older; had more severe symptoms; had more exposures during deployment; had increased psychological distress and believed they had 'Gulf War syndrome' would experience greater fatigue and poorer physical functioning at follow-up.

METHOD

Gulf War veterans who responded to an earlier retrospective cohort study were followed with a postal survey. More symptomatic individuals were oversampled. Outcome was measured on the Chalder fatigue questionnaire, the General Health Questionnaire and the Medical Outcome Study Short-Form 36.

RESULTS

Of those surveyed, 73.8% responded. We found some evidence for four of the five hypotheses. More self-reported exposures at baseline were not associated with poorer outcome, but older people, those with more severe symptoms at baseline, those with psychological distress and who believed they were suffering from 'Gulf War syndrome' had more fatigue at follow-up. Officer status was associated with a better outcome. A similar lack of association was found for exposures and physical functioning and GHQ-12 score. 'Gulf War syndrome' attribution was associated with a worse outcome for GHQ-12 and physical functioning even after controlling for severity of symptoms at baseline.

CONCLUSIONS

This study suggests that while multiple vaccination and military exposures are important risk factors for the onset of symptoms in Gulf War veterans, these are not important risk factors for persistence of such symptoms. Instead the severity of the initial symptoms; psychological distress and attributions may be more important determinants of outcome.

Stability of recall of military hazards over time. Evidence from the Persian Gulf War of 1991

BACKGROUND

War time traumatic events are related to subsequent psychological and physical health, but quantifying the association is problematic. Memory changes over time and is influenced by psychological status.

AIMS

To use a large, two-stage cohort study of members of the UK armed forces to study changes in recall of both traumatic and 'toxic' hazards.

METHOD

A questionnaire-based follow-up study assessed 2370 UK military personnel, repeating earlier questions about exposure to military hazards.

RESULTS

The k statistics for reporting of hazards were good for some exposures, but very low for others. Gulf veterans reported more exposures over time (no significant rise in the Bosnia cohort). In the Gulf cohort only, reporting new exposures was associated with worsening health perception, and forgetting previously reported exposures with improved perception. We found no association between physical health, psychological morbidity or post-traumatic stress disorder symptoms and endorsement or non-endorsement of exposures.

CONCLUSIONS

Reporting of military hazards after a conflict is not static, and is associated with current self-rated perception of health. Self-report of exposures associated with media publicity needs to be treated with caution.

The health effects of peace-keeping in the UK Armed Forces: Bosnia 1992-1996. Predictors of psychological symptoms

BACKGROUND

Peace-keeping duties are associated with unique stresses for military personnel. There have been few reports on the effects of peace-keeping on psychological health.

METHOD

We used data from a cross-sectional study originally established to examine health effects of service in the Gulf War, which included a control group who had been deployed in Bosnia (N= 2049). This group was examined to establish which demographic, occupational, and deployment-related risk factors were associated with psychological distress measured on the General Health Questionnaire (GHQ-12) and stress symptoms akin to a post-traumatic stress reactions.

RESULTS

The main risk factors for stress symptoms in the Bosnia group were--lower rank, being deployed early in the campaign, having more deployment-related exposures, and serving on staff duties. There was no protective effect of previous deployments to the Falklands or Northern Ireland, and time off following deployment was not protective. For GHQ-12 cases, the main risk factors were: female gender, lower rank, increased deployment-related exposures and serving on staff duties.

CONCLUSIONS

This study suggests that stress symptoms and GHQ-12 cases, are strongly predicted both by experiences during deployment and demographic factors.

Cognitive functioning and disturbances of mood in UK veterans of the Persian Gulf War: a comparative study

BACKGROUND

Complaints of poor memory and concentration are common in veterans of the 1991 Persian Gulf War as are other symptoms. Despite a large research effort, such symptoms remain largely unexplained.

METHOD

A comprehensive battery of neuropsychological tests and rating scales was administered to 341 UK servicemen who were returnees from the Gulf War and peace keeping duties in Bosnia, plus non-deployed military controls. All were drawn from a large randomized survey. Most were selected on the basis of impaired physical functioning defined operationally.

RESULTS

Group comparisons revealed an association between physical functioning and symptoms of depression, post-traumatic stress reactions, increased anger and subjective cognitive failures. Poorer performance on some general cognitive measures, sequencing and attention was also seen in association with being 'ill' but virtually all differences disappeared after adjusting for depressed mood or multiple comparisons. Deployment was also associated with symptoms of post-traumatic stress and subjective cognitive failures, independently of health status, as well as minor general cognitive and constructional impairment. The latter remained significantly poorer in the Gulf group even after adjusting for depressed mood.

CONCLUSIONS

Disturbances of mood are more prominent than quantifiable cognitive deficits in Gulf War veterans and probably lead to subjective underestimation of ability. Task performance deficits can themselves be explained by depressed mood although the direction of causality cannot be inferred confidently. Reduced constructional ability cannot be explained in this way and could be an effect of Gulf-specific exposures.

Antinuclear autoantibodies (ANA) in Gulf War-related illness and chronic fatigue syndrome (CFS) patients

It is established that veterans of the 1991 Gulf War have an increased frequency of experiencing multiple symptoms. The underlying mechanism of these ailments is unclear, although they do not correspond to any clearly defined syndrome. The most common symptoms overlap with those of chronic fatigue syndrome (CFS). CFS was recently associated with a novel subtype of antinuclear autoantibody (ANA) that reacts with nuclear envelope (NE) antigens. NE autoantibodies are not known to be linked with any distinct clinical condition, but have been observed in patients with unusual mixed chronic autoimmune disorders and connective tissue diseases. In this study we examined whether NE ANAs are a feature of patients with CFS and symptomatic Gulf War veterans (sGWV). We studied the prevalence of ANA in 130 sGWV, 90 well Gulf War veterans (wGWV), 128 symptomatic Bosnia and Era veterans (sBEV), 100 CFS patients, and 111 healthy control subjects matching for age and sex. We found no significant difference in the prevalence of ANAs between any of the groups. None of the patients/or veterans we studied had ANA of the NE type. Our results show that multisymptom illness due to CFS or related to Gulf War service is not associated with antinuclear autoimmunity.

Reported chemical sensitivities in a health survey of United Kingdom military personnel

OBJECTIVE

To report the prevalence of self reported chemical sensitivities in three cohorts of United Kingdom service personnel.

METHOD

Cross sectional postal survey of three cohorts of United Kingdom military personnel comprising Gulf veterans (n=3531), those who had served in Bosnia (n=2050), and those serving during the Gulf war but not deployed there (Era cohort, n=2614).

RESULTS

Sensitivity to at least one everyday chemical was reported by a considerable proportion of all three cohorts, and particularly by veterans of the Gulf war (Era: 14%; Bosnia: 13%; Gulf: 28%).

CONCLUSION

Reported chemical sensitivities were common in all three military cohorts. Our understanding of chemical sensitivities remains limited and objective evidence for a causal link between low level exposures to chemicals and reported symptoms is lacking. Given their frequency in the population, further work in this area is necessary.

The utility of plasma CRH as a predictor of preterm delivery

It has been suggested that CRH is a placental clock that controls the duration of pregnancy and that the timing of the rise in CRH may permit prediction of the onset of labor. We have performed a prospective longitudinal study, in 297 women, to examine the utility of a single second-trimester plasma CRH measurement to predict preterm delivery. Venous blood samples were taken at 4-weekly intervals, beginning at 16-20 wk gestation, until delivery for CRH and its binding protein. A time point at which a single plasma CRH test might give optimal data to predict preterm delivery was determined. Thirty-one subjects delivered prematurely (10.4%). Sampling for plasma CRH at 26 wk gestation seemed the optimal time point to maximize sensitivity and specificity of the test. The mean (+/- SD) plasma CRH in women at this gestation who eventually delivered after spontaneous labor within 1 wk of their due date (39-41 wk, n = 127) was 34.7 +/- 27.0 pM. A plasma CRH of more than 90 pM at 26 wk gestation had a sensitivity of 45% and a specificity of 94% for prediction of preterm delivery. The positive predictive value was 46.7%. Calculation of free CRH did not improve these figures. In conclusion, a single measurement of plasma CRH, toward the end of the second trimester, may identify a group at risk for preterm delivery, but over 50% of such deliveries will be unpredicted. These data do not support the routine clinical use of plasma CRH as a predictor of preterm labor.

Prevalence of Gulf war veterans who believe they have Gulf war syndrome: questionnaire study

OBJECTIVES

To determine how many veterans in a random sample of British veterans who served in the Gulf war believe they have "Gulf war syndrome," to examine factors associated with the presence of this belief, and to compare the health status of those who believe they have Gulf war syndrome with those who do not.

DESIGN

Questionnaire study asking British Gulf war veterans whether they believe they have Gulf war syndrome and about symptoms, fatigue, psychological distress, post-traumatic stress, physical functioning, and their perception of health.

PARTICIPANTS

2961 respondents to questionnaires sent out to a random sample of 4250 Gulf war veterans (69.7%).

MAIN OUTCOME MEASURE

The proportion of veterans who believe they have Gulf war syndrome.

RESULTS

Overall, 17.3% (95% confidence interval 15.9 to 18.7) of the respondents believed they had Gulf war syndrome. The belief was associated with the veteran having poor health, not serving in the army when responding to the questionnaire, and having received a high number of vaccinations before deployment to the Gulf. The strongest association was knowing another person who also thought they had Gulf war syndrome.

CONCLUSIONS

Substantial numbers of British Gulf war veterans believe they have Gulf war syndrome, which is associated with psychological distress, a high number of symptoms, and some reduction in activity levels. A combination of biological, psychological, and sociological factors are associated with the belief, and these factors should be addressed in clinical practice.

Multiple chemical sensitivity and chronic fatigue syndrome in British Gulf War veterans

The objective of this study was to measure the prevalence of multiple chemical sensitivity (MCS) and chronic fatigue syndrome (CFS) in British Gulf War veterans and to investigate their association with reported exposures and psychologic morbidity. In 1997--1998, the authors undertook a cross-sectional survey of three cohorts of British military personnel comprising Gulf veterans (n = 3,531), those who had served in Bosnia (n = 2,050), and those serving during the Gulf War but not deployed there (Era cohort, n = 2,614). MCS and CFS were defined according to operational criteria. The prevalence of MCS in the Gulf, Bosnia, and Era cohorts was 1.3%, 0.3%, and 0.2%, respectively. For CFS, the prevalence was 2.1% (Gulf cohort), 0.7% (Bosnia cohort), and 1.8% (Era cohort). In Gulf veterans, MCS was strongly associated with exposure to pesticides (adjusted odds ratio = 12.3, 95% confidence interval: 5.1, 30.0). Both syndromes were associated with high levels of psychologic morbidity. These findings suggest that CFS and MCS account for some of the medically unexplained illnesses reported by veterans after deployment to the Gulf. MCS was particularly associated with Gulf deployment and self-reported exposure to pesticides, findings that merit further exploration given the controversial status of this diagnosis and the potential for recall bias in a questionnaire survey.

Occupational risk factors for ill health in Gulf veterans of the United Kingdom

OBJECTIVES

To study the association between occupational factors specific to the Armed Forces (rank, functional roles, Service, regular or reservist status and deployment factors) and symptomatic health problems in Gulf veterans, after sociodemographic and lifestyle factors have been accounted for.

DESIGN

A postal cross sectional survey of randomly selected UK Gulf veterans was conducted six to seven years after the Gulf conflict. Physical ill health was measured using the Fatigue Questionnaire and a measure of the Centers for Disease Control and Prevention (CDC) multi-symptom syndrome. Psychological ill health was measured using the General Health Questionnaire and a post-traumatic stress measure.

SETTING

Population of servicemen who were serving in the UK Armed Forces during the Gulf conflict between 1 September 1990 and 30 June 1991.

PARTICIPANTS

3297 Gulf veterans.

MAIN RESULTS

In multivariate logistic regression, there was an inverse relation between higher rank and psychological and physical ill health (test of trend: General Health Questionnaire, p=0.004; post-traumatic stress, p=0.002; fatigue, p=0.015; CDC case, p=0.002). Having left the Armed Forces was associated with a two to three times increase in reporting ill health. Of the deployment factors, there was a weak association between being deployed as an individual reinforcement in a combat role and post-traumatic stress but there was no association between receiving pre-deployment training or post-deployment leave and ill health. Marital status and smoking were associated with psychological and physical ill health.

CONCLUSIONS

Rank was the main occupational factor associated with both psychological and physical ill health in Gulf veterans. This may parallel the associations between socioeconomic status and morbidity in civilian populations. Ill health seems to be greater in those who return to civilian life. Sociodemographic factors also seem to be important in ill health in Gulf veterans.

Role of vaccinations as risk factors for ill health in veterans of the Gulf war: cross sectional study

OBJECTIVES

To explore the relation between ill health after the Gulf war and vaccines received before or during the conflict. To test the hypothesis that such ill health is limited to military personnel who received multiple vaccines during deployment and that pesticide use modifies any effect.

DESIGN

Cross sectional study of Gulf war veterans followed for six to eight years after deployment.

SETTING

UK armed forces.

PARTICIPANTS

Military personnel who served in the Gulf and who still had their vaccine records.

MAIN OUTCOME MEASURES

Multisymptom illness as classified by the Centers for Disease Control and Prevention; fatigue; psychological distress; post-traumatic stress reaction; health perception; and physical functioning.

RESULTS

The response rate for the original survey was 70.4% (n=3284). Of these, 28% (923) had vaccine records. Receipt of multiple vaccines before deployment was associated with only one of the six health outcomes (post-traumatic stress reaction). By contrast five of the six outcomes (all but post-traumatic stress reaction) were associated with multiple vaccines received during deployment. The strongest association was for the multisymptom illness (odds ratio 5.0; 95% confidence interval 2.5 to 9.8).

CONCLUSION

Among veterans of the Gulf war there is a specific relation between multiple vaccinations given during deployment and later ill health. Multiple vaccinations in themselves do not seem to be harmful but combined with the "stress" of deployment they may be associated with adverse health outcomes. These results imply that every effort should be made to maintain routine vaccines during peacetime.

Pharmacokinetics of transdermal testosterone gel in hypogonadal men: application of gel at one site versus four sites: a General Clinical Research Center Study

Testosterone (T) in a hydroalcoholic gel has been developed as an effective and convenient open system for transdermal delivery of the hormone to men. Because the gel can be applied either to small or large areas of skin, it was important to assess whether the skin surface area on which the gel was applied was an important determinant of serum T levels. To answer this question, the pharmacokinetics of a transdermal 1% hydroalcoholic gel preparation of T was studied in nine hypogonadal men. The subjects applied in random order a 25-mg metered dose of T gel either four times at one site (left arm/shoulder) or at four different sites (left and right arms/shoulders and left and right abdomen) once daily (6-8 min) for 7 consecutive days. After 7 days of washout, each subject was then crossed over to the opposite regimen for another 7 days of treatment. Serum samples were collected for measurements of T, 5alpha dihydrotestosterone (DHT), and estradiol before, during (days 1, 2, 3, 5, and 7), and after (days 8, 9, 11, 13, and 15) application of T gel. Multiple blood samples were drawn on the 1st and 7th day after gel application; single samples were obtained just before the next T gel application on other days (24 h after the previous gel application). The T gel dried in less than 5 min, left no residue, and produced no skin irritation in any of the subjects. Mean serum T levels, irrespective of application at one site or four sites followed the same pattern: rising to 2- to 3- and 4- to 5-fold above baseline at 0.5 and 24 h after first application, respectively. Thereafter, serum T levels reached steady state and remained at 4- to 5-fold above baseline (at the upper limit of the normal adult range) for the duration of gel application and returned to baseline within 4 days after stopping application. The application of T gel at four sites (application skin area approximately four times that of one site) resulted in a mean area under the curve (AUC0-24h) for serum T levels on the 7th day (868 +/- 72 nmol*h/L, mean +/- SEM), which was 23% higher but not significantly different (P = 0.06) than repeated application at one site (706 +/- 59 nmol*h/L). This could be due to the limited number of subjects studied (n = 9). Mean serum DHT levels followed the same pattern as serum T, achieving steady-state levels by 2 days. The mean concentration of serum DHT on the 7th day was significantly higher after application at four sites (9.15 +/- 1.26 nmol/L, P < 0.05) than at one site (6.9 +/- 0.77 nmol/L). These serum DHT levels were at or above the normal adult male range. Serum DHT:T ratio was not significantly altered by T gel application. Serum estradiol levels followed the same pattern as serum T and showed no significant difference between the one- or four-site application. We conclude that transdermal daily application of 100 mg T gel resulted in similar steady levels of serum T. The surface area of the skin to which the gel was applied had only a modest impact on serum T and DHT levels. Mean serum levels of T and DHT was higher by 23% and 33%, respectively, despite application of the gel to four times the skin area in the four sites compared with the one site group. Because of the greater dosage flexibility provided, hydroalcoholic T gel application over multiple sites seems to be an effective and nonskin-irritating method of transdermal T delivery for hypogonadal men. Dose-ranging studies are required to determine dosage regimens for T gel application as a replacement therapy in hypogonadal men.

Is there a Gulf War syndrome?

BACKGROUND

UK veterans of the Gulf War report more ill health than servicemen who were not deployed to the Gulf War. We investigated whether the pattern of symptom reporting by veterans of the Gulf War differed from that in active servicemen who had not fought in the Gulf War or who had fought in other conflicts.

METHODS

We used a population-based cross-sectional design. We sent a standardised survey that asked about 50 physical symptoms to three UK military cohorts; men who had served in the Gulf War, those who had served in the Bosnia conflict, and men who had been in active service but not deployed to the Gulf War (Era cohort). We used exploratory factor analysis to identify underlying factors and describe the factor structure of the symptoms reported in the Gulf War cohort. Confirmatory factor analysis was used to test the fit of this factor structure in the Bosnia and Era cohorts.

FINDINGS

Three factors in the Gulf War cohort together accounted for about 20% of the common variance. We labelled the factors mood, respiratory system, and peripheral nervous system, according to the symptoms that loaded on to them. In the confirmatory factor analysis, the factor structure identified in the Gulf War cohort fitted reasonably well in the Bosnia and Era cohorts.

INTERPRETATION

Although results from complex modelling procedures need to be interpreted with caution, our findings do not support a unique Gulf War syndrome. The mechanisms behind increased self-reporting of symptoms need further investigation.

Health of UK servicemen who served in Persian Gulf War

BACKGROUND

Various symptoms in military personnel in the Persian Gulf War 1990-91 have caused international speculation and concern. We investigated UK servicemen.

METHODS

We did a cross-sectional postal survey on a random sample of Gulf War veterans (Gulf War cohort, n=4248) and, stratified for age and rank, servicemen deployed to the Bosnia conflict (Bosnia cohort, n=4250) and those serving during the Gulf War but not deployed there (Era cohort, n=4246). We asked about deployment, exposures, symptoms, and illnesses. We analysed men only. Our outcome measures were physical health, functional capacity (SF-36), the general health questionnaire, the Centers for Disease Control and Prevention (CDC) multisymptom criteria for Gulf War illness, and post-traumatic stress reactions.

FINDINGS

There were 8195 (65.1%) valid responses. The Gulf War cohort reported symptoms and disorders significantly more frequently than those in the Bosnia and Era cohorts, which were similar. Perception of physical health and ability were significantly worse in the Gulf War cohort than in the other cohorts, even after adjustment for confounders. Gulf War veterans were more likely than the Bosnia cohort to have substantial fatigue (odds ratio 2.2 [95% CI 1.9-2.6]), symptoms of post-traumatic stress (2.6 [1.9-3.4]), and psychological distress (1.6 [1.4-1.8]), and were nearly twice as likely to reach the CDC case definition (2.5 [2.2-2.8]). In the Gulf War, Bosnia, and Era cohorts, respectively, 61.9%, 36.8%, and 36.4% met the CDC criteria, which fell to 25.3%, 11.8%, and 12.2% for severe symptoms. Potentially harmful exposures were reported most frequently by the Gulf War cohort. All exposures showed associations with all of the outcome measures in the three cohorts. Exposures specific to the Gulf were associated with all outcomes. Vaccination against biological warfare and multiple routine vaccinations were associated with the CDC multisymptom syndrome in the Gulf War cohort.

INTERPRETATION

Service in the Gulf War was associated with various health problems over and above those associated with deployment to an unfamiliar hostile environment. Since associations of ill health with adverse events and exposures were found in all cohorts, however, they may not be unique and causally implicated in Gulf-War-related illness. A specific mechanism may link vaccination against biological warfare agents and later ill health, but the risks of illness must be considered against the protection of servicemen.

Effect of increased scrotal temperature on sperm production in normal men

OBJECTIVE

To determine whether application of polyester-lined athletic supports to bring the testes closer to the abdomen increases scrotal temperature and decreases sperm production.

DESIGN

Prospective clinical study.

SETTING

University academic medical center.

PATIENT(S)

Twenty-one healthy male volunteers.

INTERVENTION(S)

The study consisted of a pretreatment period of 6 weeks, a treatment phase of 52 weeks, and a recovery phase until return to normal sperm production. During the treatment phase, the men wore polyester-lined athletic supports (single layer, double layer, or double layer impregnated with aluminum) throughout the day.

MAIN OUTCOME MEASURE(S)

Semen parameters and sperm function tests.

RESULT(S)

In all three groups of subjects, scrotal temperature was consistently increased by 0.8 to 1 degree C while the subjects were wearing the athletic supports. Mean sperm concentration; sperm motility, morphology, and viability; sperm hyperactivation; and ability of spermatozoa to penetrate zone-free hamster oocytes were not affected by the increase in scrotal temperature.

CONCLUSION(S)

The increase in scrotal temperature induced by polyester-lined athletic supports was insufficient to cause significant suppression of spermatogenesis or alteration of sperm function.

Testosterone replacement therapy improves mood in hypogonadal men--a clinical research center study

The effect of testosterone (T) replacement on changes in mood was studied for 60 days in 51 hypogonadal men. All patients were withdrawn from their prior T replacement for at least 6 weeks before enrollment. Of these patients, 18 received T enanthate 200 mg im every 20 days, 16 received sublingual T cyclodextrin (SLT) at a dose of 2.5 mg three times daily, and 17 received SLT at a dose of 5.0 mg three times daily. The total treatment period was 60 days. The patients were asked to respond to a questionnaire on 7 consecutive days before the start of treatment and on 7 consecutive days before their visits to the clinic on days 21, 41, and 60 of treatment. The following mood parameters were assessed using a 7-point Likert rating scale: angry, alert, irritable, full of pep (energy), sad/blue, tired, friendly, nervous, and well/good. When compared with the baseline period, T replacement led to significant decreases in anger (P = 0.0045), irritability (P = 0.0009), sadness (P = 0.0033), tiredness (P = 0.0035), and nervousness (P = 0.0291), and significant improvement in energy level (P = 0.0020), friendliness (P = 0.0072), and sense of well-being (P = 0.024) in all subjects as a group. Analyses of the area under the curve (AUC) of baseline serum T levels before T replacement showed significant positive correlations between serum T (AUC) and friendliness (r = 0.29, P < 0.05) and sense of well-being (r = 0.27, P < 0.05), and significant negative correlations with nervousness (r = -0.27, P < 0.05), irritability (r = -0.29, P < 0.05) and tiredness (r = -0.28, P < 0.05). Similar correlations were found between serum dihydrotestosterone (DHT) and some of the mood parameters. After T replacement in the hypogonadal men, these correlations between AUC of serum T levels and the positive and negative mood scores disappeared. These results were corroborated in a subsequent study in which 30 hypogonadal men were supplemented with SLT 5 mg three times daily for 6 months. The patients were less nervous (P = 0.0025) and more alert (P = 0.0004), friendly (P = 0.042), and energetic (P = 0.0001) during the 6-month treatment period compared with baseline. We conclude that T replacement therapy in hypogonadal men improved their positive mood parameters, such as energy, well/good feelings, and friendliness and decreased negative mood parameters including anger, nervousness, and irritability, and direct correlations between serum T and DHT with mood scores were only observed in the baseline period when serum androgen levels were below the normal range. The latter observation suggests that once a minimally adequate serum T/DHT level was achieved by T replacement therapy, further increases in serum T/DHT levels did not further contribute to the improvement in mood variables.

The beta 2-microglobulin dissociation rate is an accurate measure of the stability of MHC class I heterotrimers and depends on which peptide is bound

Stable, recombinant, water-soluble complexes of HLA-A2 and HLA-B27 were reconstituted from 125I-labeled beta 2-microglobulin (beta 2m), a synthetic peptide, and HLA H chain fragments expressed as inclusion bodies in the Escherichia coli cytoplasm. Using this system, we were able to show: 1) the t1/2 of beta 2m dissociation from HLA complexes at 37 degrees C varied from approximately 40 h to less than 1 h, depending on the peptide employed for reconstitution. Peptide length and composition were found to be critical factors in determining the beta 2m dissociation rate. Endogenous peptides form complexes that are about as stable as those formed with typical antigenic peptides. 2) Peptide exchange reactions, in which an exogenous peptide replaces the peptide that is already bound by the class I molecule, proceed readily for complexes that have rapid beta 2m dissociation rates. Thus, difficulties in demonstrating peptide binding to complexes that contain endogenous peptides can be attributed to the stability of the endogenous peptide/class I molecule complex. 3) The peptide exchange reaction does not require concomitant beta 2m dissociation. 4) Distal parts of the class I molecule, which are not directly involved in peptide binding or beta 2m binding, have a major impact on the stability of class I molecules. Thus, these studies show that the dissociation rate of beta 2m is an excellent measure of how tightly a given peptide binds to class I MHC molecules, that the ability to bind peptide is tightly coupled to the binding of beta 2m and vice versa, and that regions of the molecule distal from the binding site influence the stability of peptide binding.

The beta 2-microglobulin dissociation rate is an accurate measure of the stability of MHC class I heterotrimers and depends on which peptide is bound

Stable, recombinant, water-soluble complexes of HLA-A2 and HLA-B27 were reconstituted from 125I-labeled beta 2-microglobulin (beta 2m), a synthetic peptide, and HLA H chain fragments expressed as inclusion bodies in the Escherichia coli cytoplasm. Using this system, we were able to show: 1) the t1/2 of beta 2m dissociation from HLA complexes at 37 degrees C varied from approximately 40 h to less than 1 h, depending on the peptide employed for reconstitution. Peptide length and composition were found to be critical factors in determining the beta 2m dissociation rate. Endogenous peptides form complexes that are about as stable as those formed with typical antigenic peptides. 2) Peptide exchange reactions, in which an exogenous peptide replaces the peptide that is already bound by the class I molecule, proceed readily for complexes that have rapid beta 2m dissociation rates. Thus, difficulties in demonstrating peptide binding to complexes that contain endogenous peptides can be attributed to the stability of the endogenous peptide/class I molecule complex. 3) The peptide exchange reaction does not require concomitant beta 2m dissociation. 4) Distal parts of the class I molecule, which are not directly involved in peptide binding or beta 2m binding, have a major impact on the stability of class I molecules. Thus, these studies show that the dissociation rate of beta 2m is an excellent measure of how tightly a given peptide binds to class I MHC molecules, that the ability to bind peptide is tightly coupled to the binding of beta 2m and vice versa, and that regions of the molecule distal from the binding site influence the stability of peptide binding.