User acceptance of a multi-media software application to increase preparedness for caring problems

This paper presents verification data for a multimedia software application intended to enhance carers’ ability to respond to everyday difficulties and emergency situations. The program provides educational information about first aid, how to deal with everyday problems and a number of emergency situations such as bleeding, falling and choking. An evaluation plan was developed, including instruments for measuring and assessing usability. These included a questionnaire, scenarios and a pro-forma for user trials; a questionnaire for evaluation of the program; log diaries, field notes and technical diaries. User trials were carried out with both healthcare professionals and family carers. Casual users were encouraged to test the programs at the professional sites. Users’ views on usability were utilized for the development of further prototype of the software application.

Testosterone replacement-induced hyperprolactinaemia: case report and review of the literature

Half of all men with prolactin (PRL)-producing macroadenomas present with hypogonadism, decreased libido and impotence, and therefore require testosterone replacement. However, very little is known about the effect of testosterone on prolactinomas. We report a case of an 18-year-old obese man who presented with hypogonadism and hyperprolactinaemia and underwent a transphenoidal hypophysectomy after a computer tomography scan showed the presence of a suprasellar macroadenoma. On separate occasions, we documented a rise in PRL when testosterone replacement was started and a fall in PRL when testosterone replacement was stopped ( r=0.6090, P=0.0095). Furthermore, imaging studies suggested the possibility of tumour re-growth after testosterone therapy. We hypothesize that the exogenous testosterone was aromatized to oestradiol, which stimulated the release of PRL by the anterior pituitary. This was supported by the increase in oestradiol levels after testosterone replacement, although statistical significance was not achieved due to the availability of only a few data points. This case highlights the need to be aware of testosterone-replacement-induced hyperprolactinaemia, an under-recognized complication of androgen replacement in this setting. The use of aromatase inhibitors together with testosterone-replacement therapy or the use of non-aromatizable androgens might be indicated in such patients. Taken together, this report and previous studies show that dopamine agonists apparently do not suppress the hyperprolactinaemia induced by testosterone replacement.

Immunological and C-peptide studies of patients with diabetes in northern Ethiopia: existence of an unusual subgroup possibly related to malnutrition

AIMS/HYPOTHESIS

Surveys in northern Ethiopia have demonstrated that apparent type 1 diabetes occurs more frequently than elsewhere in Africa and, indeed, in other parts of the world. We therefore investigated in detail a cohort of diabetic patients from this region to clarify the nature of this type of diabetes.

METHODS

All patients attending the diabetic clinic at Mekelle Hospital in the Tigray region of northern Ethiopia were investigated over a 6 week period. Clinical, demographic and anthropometric data were collected, as well as measurements of HbA(1c), fasting lipid profile, fasting serum C-peptide and serum markers of beta cell autoimmunity, i.e. islet antigen-2 and GAD antibodies (GADA).

RESULTS

Of 105 patients seen, 69 (66%) were on insulin treatment and had been from or close to diagnosis. Their median age and diabetes duration were 30 and 5 years, respectively, with a male excess of 2:1. Median BMI was 20.6 kg/m². Despite these clinical characteristics suggestive of type 1 diabetes, only 42 of 69 (61%) patients were C-peptide-negative and 35% GADA-positive. Overall, 38 (36%) of the total group (n = 105) had immunological or C-peptide characteristics inconsistent with typical type 1 or type 2 diabetes. The clinical characteristics, local prevalence of undernutrition, and GADA and C-peptide heterogeneity suggest a malnutrition-related form of diabetes.

CONCLUSIONS/INTERPRETATION

Not all patients in northern Ethiopia with apparent type 1 diabetes appear to have the form of disease seen in Europids; their disease may, in fact, be related to malnutrition.

Laboratory measurement of testosterone

Plasma testosterone concentrations in men, first quantified nearly half a century ago, are now measured routinely as a primary index of androgen status. Most clinical laboratories employ a multichannel, fully automated analyzer. Current evidence suggests that these analyzers are capable of satisfactorily quantifying the concentration of total plasma testosterone in men. Newer technology, in the form of tandem mass spectrometry, may, in the future, replace these automated platforms, providing a more specific estimate of testosterone concentration. When concentrations of plasma testosterone are found to be around the lower limit of normal ( 9.0 nmol/l; microg/l=nmol/lx0.288), some measure of bioactive testosterone should be sought. This may be a free (non-protein-bound) or bioavailable (free plus albumin-bound) testosterone and may be measured (laborious and time-consuming and therefore unsuited to routine clinical laboratories) or calculated using any one of a variety of mathematical expressions. Sampling for the estimation of plasma testosterone should be carried out in the morning, before 11:00 h, to obviate the effect of the marked diurnal variation in testosterone production. In samples found to have an equivocal concentration (7.0-12.5 nmol/l) at least one more estimate should be obtained to account for the possible significant intra-individual variability. Although it is generally accepted that the concentrations of total, free and bioavailable testosterone decline as men age, the majority of elderly men have testosterone levels in the young adult range (9.0-35 nmol/l) and some maintain a diurnal rhythm. Salivary testosterone offers a non-invasive estimate of free testosterone but there does not appear to be an immediate demand for a routine salivary testosterone service.

Non islet cell tumor hypoglycaemia in a metastatic Leydig cell tumor

Non islet cell tumour hypoglycaemia (NICTH) is a rare cause of hypoglycaemia associated with malignancy and can be considered as a paraneoplastic syndrome. The hormonal factor associated with this condition is big IGF II, which exerts negative feedback effect and decreases the production of growth hormone and insulin. Due to low growth hormone levels, hepatic production of IGFBP 3 (the main binding protein of IGF II) is impaired. Excess free big IGF II is thus available for binding with insulin receptors to cause hypoglycaemia. Treatment options are either surgical removal of the tumour, administration of growth hormone, glucocorticoids or combination of treatments. A case of metastatic Leydig cell tumour causing NICTH has been discussed and the mechanism of NICTH hypoglycaemia and the treatment is outlined.

Plasma insulin growth factor-1 and incident delirium in older people

BACKGROUND

A variety of demographic and clinical variables are acknowledged as risk factors for delirium; a syndrome thought to be mediated by abnormalities in a wide range of neurotransmitters. However, little research has been conducted in this field and the role of neuro-immunological factors as a mechanism of medication has received very little attention.

AIMS

To determine if low base line (on admission) IGF-1 levels (a protective cytokine released by brain cells in response to insult) is a risk factor for incident delirium in patients aged 75 and over admitted to an acute medical ward.

METHOD

Base line demographic and clinical variables and serum IGF-1 levels were measured in a consecutive series of 100 non-delirious subjects on inpatient admission. Subjects were assessed daily regarding the development of delirium during the inpatient episode.

RESULTS

Twelve patients developed incident delirium. IGF-1 (OR: 0.822, CI: 0.69, 0.97, p = 0.027), pre-admission cognitive deterioration (assessed by IQCODE) (OR; 3.26, CI: 1.18, 9.04, p = 0.023) and depression (GDS four item: cut-off score > or = 3) (OR; 8.99, CI 1.59,50.76, p = 0.013) were identified as risk factors for developing subsequent delirium.

CONCLUSIONS

Despite the small size of this study our findings suggest that low, pre-morbid IGF-1 is a risk factor for subsequent delirium in this population, emphasizing the potential protective role of this anabolic cytokine and the need for replication of these findings.

Usability of multimedia technology to help caregivers prepare for a crisis

The objective of the research was to evaluate the usability of a multimedia software application that provides information on coping with difficult situations, dealing with everyday caring problems, and first aid for emergency situations. Casual users (family caregivers, professional caregivers, and older people) were invited to use the software application and complete a questionnaire measuring quality and efficiency in utility and usability. Quantitative data were analyzed using the Statistical Package for the Social Sciences (SPSS) and qualitative data were analyzed by content analysis. Findings indicated the software application to have high global usability, correspond to user expectations, respond quickly, and be visually pleasant and easily understood. The authors conclude that software applications of this type have the potential to increase the quality of life of family caregivers, enhance their coping capacity, and enable them to continue for a longer period in their caring role.

The role of a single free beta-human chorionic gonadotrophin measurement in the diagnosis of early pregnancy failure and the prognosis of fetal viability

The prospective controlled study investigated the concentrations of free beta-human chorionic gonadotrophin (HCG) subunit in 554 women with a singleton intrauterine or tubal pregnancy. They presented with vaginal bleeding and/or abdominal pain in the first 18 weeks of pregnancy. The control group comprised 156 women with musculoskeletal pain and no vaginal bleeding. Their pregnancies continued to term. The study group comprised 398 women (141 threatened-continuing pregnancies, 37 threatened-miscarriages, 185 non-continuing pregnancies and 35 tubal pregnancies). Free beta-HCG concentrations were significantly lower in the non-continuing, threatened-miscarriage and tubal pregnancy groups [mean 4.62, 6.50 and 4.27 ng/ml respectively; 95% confidence interval (CI) 3.75-5.69, 4.46-9.48 and 2.92-6.2 respectively] than in the control and threatened-continuing groups (mean 41.61 and 48.22 ng/ml respectively; 95% CI 34.53-50.13 and 42.03-55.32 respectively) (P < 0.001 in all cases). A cut-off value at 20 ng/ml was found to differentiate between the 'viable' (control and threatened-continuing) and the 'abnormal' (non-continuing, threatened-miscarriage and tubal) pregnancies, with 88.3% sensitivity and 82.6% positive predictive value. An excellent diagnostic and prognostic usability of free beta HCG was confirmed by a receiver operating characteristic curve plot. In conclusion, a single serum free beta-HCG measurement taken in early pregnancy is valuable in the immediate diagnosis of early pregnancy failure and the long-term prognosis of viability.

The role of a single progesterone measurement in the diagnosis of early pregnancy failure and the prognosis of fetal viability

OBJECTIVE

To assess the role of a single maternal serum progesterone measurement in the immediate diagnosis of early pregnancy failure and in the long term prognosis of fetal viability.

DESIGN

A prospective comparative study of women presenting with vaginal bleeding and abdominal pain in early pregnancy. The comparison group was defined retrospectively as women who presented with abdominal pain without history of, or the subsequent occurrence of, vaginal bleeding and whose pregnancies continued to viability. The study groups were defined retrospectively as threatened-continuing, non-continuing (including blighted ovum, missed abortion, incomplete and complete abortion) and tubal pregnancy groups, according to the outcome of the pregnancies.

SETTING

The emergency room at the gynaecology department of a teaching hospital.

SUBJECTS

Four hundred and eighty-nine women presenting with singleton pregnancy, vaginal bleeding and/or abdominal pain in the first 18 weeks of pregnancy. The comparison group comprised 131 women without vaginal bleeding whose pregnancies continued to viability. The study group comprised 358 women with 148 threatened-continuing pregnancies, 175 non-continuing and 35 tubal pregnancies.

INTERVENTIONS

A 10 ml blood sample was taken and pelvic ultrasonography was performed at presentation. Otherwise, conventional management was used.

MAIN OUTCOME MEASURES

Progesterone levels were interpreted in accordance with the outcome of the pregnancy: comparison, threatened-continuing, non-continuing or tubal. Viability was defined as 28 weeks or more weeks of gestation.

RESULTS

Progesterone levels were significantly lower in the non-continuing and tubal pregnancy groups than in the comparison and threatened-continuing groups (P < 0.001 in all cases). A cut-off level at 45 nmol/1 was found to differentiate between the viable (comparison and threatened-continuing) pregnancies and the abnormal (non-continuing and tubal) pregnancies with 87.6% sensitivity and 87.5% specificity.

CONCLUSIONS

A single serum progesterone measurement taken in early pregnancy is valuable in the immediate diagnosis of early pregnancy failure and the long term prognosis of viability.

Basic fibroblastic growth factor stimulates prolactin secretion from human anterior pituitary adenomas without affecting adenoma cell proliferation

The effects of human recombinant basic fibroblastic growth factor (bFGF) on the secretion and/or proliferation of 26 human anterior pituitary adenomas secreting PRL alone (6 tumors), PRL and GH (18 tumors), or GH alone (2 tumors) were examined. Secretory studies were performed over 4 h, 4 days, and 21 days, and proliferation studies over 4 days. The acute effect of bFGF on secretion over 4 h was examined in 10 tumors. bFGF (10 nmol/L) increased PRL compared to that in controls (100%) in 2 tumors (126% and 290%; P < 0.05) and PRL and GH in a third tumor (183% and 133%, respectively; P < 0.05), whereas 7 tumors remained unaffected. Fourteen tumors were studied over 4 days. bFGF (10 nmol/L) increased PRL secretion in 9 of 11 tumors (117-525%; P < 0.05) cosecreting PRL and GH and in all 3 tumors secreting PRL alone (156%, 183%, and 691%; P < 0.01). Dose-response curves with 0.1, 1, and 10 nmol/L bFGF in 2 of these tumors cosecreting GH and PRL showed that stimulation was achieved with all 3 concentrations. bFGF (10 nmol/L) stimulated GH secretion in 2 of 11 mixed tumors (159% and 196%, respectively; P < 0.05). In 2 tumors studied over 3 weeks, 5 nmol/L bFGF stimulated PRL secretion progressively without affecting GH secretion (106% and 207%; P < 0.05). Tissue proliferation was determined by double immunostaining after bromodeoxyuridine incorporation for 1 h in 7 tumors after 4 days. The labeling index did not exceed 1.2% in any tumor, and there was no effect of 10 nmol/L bFGF on the proliferation of adenoma cells. These results suggest that bFGF may have a paracrine role in the stimulatory regulation of PRL secretion in human pituitary adenomas, and these effects are most likely due to increased hormonal synthesis. An in vitro cell culture system can be used to study proliferative potential. However, bFGF is not mitogenic for human anterior pituitary adenomas secreting PRL and PRL plus GH in vitro.

The effect of clomiphene citrate treatment on cervical mucus and plasma estradiol and progesterone levels

OBJECTIVES

To study the relationship between cervical mucus (CM) quality, postcoital test (PCT) results and plasma estradiol (E2) in clomiphene citrate (CC)-treated women. A subsidiary aim was to study the relationship between CM quality and plasma progesterone (P).

DESIGN

Untreated women were compared with oligo-ovulatory patients given CC.

SETTING

Infertility Clinic, Fazakerley Hospital, United Kingdom.

PATIENTS, PARTICIPANTS

Fifty-one untreated patients and 31 women given CC.

INTERVENTIONS

The treated women were given 50 mg/d CC from days 2 to 6 of their cycle.

MAIN OUTCOME MEASURES

A CM assessment, a PCT, plasma E2, and P were performed at the anticipated time of ovulation based on at least two previous basal body temperature charts and menstrual patterns.

RESULTS

In untreated women there was a very strong tendency for CM quality to improve with rising plasma E2 levels and to worsen with rising plasma P levels. There was a significant association between CM quality and PCT results. Similar results were found in CC-treated women, except that plasma E2 was very significantly higher and there was a significant inverse relationship between plasma E2 and CM quality.

CONCLUSION

High plasma E2 in the periovulatory phase in CC-treated women is a marker for increased sensitivity to and continuing action of the antiestrogen. This impairs the quality of the CM.

Pituitary apoplexy and sudden blindness following the administration of gonadotrophin releasing hormone

Pituitary apoplexy has been reported as a rare complication of combined tests and of TRH administration in prolactinomas. A 54-year-old man with a pituitary macroadenoma had a single injection of 100 micrograms GnRH. Twenty minutes later he complained of increasing headache and vomited. These symptoms settled spontaneously and were attributed to the pharmacological effects of GnRH. Five hours later he was found to be blind and disorientated without spontaneous complaint. Emergency CT showed a large adenoma with central necrosis, consistent with pituitary apoplexy. An urgent surgical decompression was carried out and necrotic haemorrhagic debris removed. Baseline bloods revealed non-pulsatile FSH of 40 U/l with LH 0.3 U/l with no hormonal response to GnRH administration, but the sequence of events strongly suggests a causal relationship between this and pituitary apoplexy. To our knowledge this is the first time that GnRH administration has been associated with pituitary apoplexy of a glycoprotein secreting pituitary adenoma.

Lack of effect of bromocriptine on ACTH levels in patients with bilateral adrenalectomy for pituitary-dependent Cushing's syndrome

Bromocriptine lowers plasma ACTH levels in patients with pituitary-dependent Cushing's syndrome. It seemed possible that the drug would also be effective in patients who had been adrenalectomised for the disease. The effect of 5.0 mg of bromocriptine on plasma ACTH and prolactin levels in 13 patients, bilaterally adrenalectomised for pituitary-dependent Cushing's syndrome, was therefore studied. In only one patient was a fall in plasma ACTH observed. This may be of doubtful significance since marked spontaneous fluctuation in plasma ACTH levels were found in the five patients tested. Bromocriptine lowered the plasma prolactin in all of the patients, including two with hyperprolactinaemia.