A minority of women of childbearing potential are tested for pregnancy before chemoimmunotherapy: an Australian cancer centre experience

BACKGROUND

Chemotherapy is potentially harmful to a developing foetus, and there are limited data on the foetal impact of chemoimmunotherapy (CIT). Therefore, determining pregnancy status prior to initiation of CIT should be standard of care.

AIMS

To determine how many women of childbearing age are tested for pregnancy prior to immunochemotherapy administration.

METHODS

A retrospective chart review at a large Australian metropolitan cancer referral centre, including 304 women aged 18-51 years with a diagnosis of cancer receiving outpatient-based CIT between 1 May 2015 and 12 June 2020. We assessed the uptake of pregnancy screening and contraception counselling prior to and during first-line CIT.

RESULTS

Only 17.3% of CIT cycles (n = 416) screened patients for pregnancy no more than 90 days prior to administration, and the median time between pregnancy screening and treatment was approximately 3 weeks. One patient with early breast cancer had a spontaneous miscarriage estimated at 3-4 weeks' gestation, and neither the patient nor the treating oncologist was aware of this event. This was also the only patient who had a pregnancy test beyond the first cycle of CIT during their treatment.

CONCLUSIONS

Our results highlight a concerningly low rate of pregnancy screening in women of childbearing age receiving CIT. The implication of missing a positive pregnancy test in this group of women could result in foetal complications, accidental miscarriage, potential bleeding risks and avoidable psychosocial stress. This highlights the urgent need for guidelines to mandate pregnancy testing in women of childbearing age receiving CIT and evidence-based implementation tools.

Rates of Menstrual History-Taking and Counseling With Anticancer Treatments Are Low: People Who Menstruate Deserve Gender-Specific Cancer Care

BACKGROUND

Chemotherapy predisposes people who menstruate to abnormal uterine bleeding that can be life-threatening and may also damage ovaries, resulting in premature menopause. The purpose of this study was to explore the incidence of menstrual history documentation and counseling before, during, and after cancer treatment.

PATIENTS AND METHODS

The medical charts of 137 consecutive females (self-reported) aged 18 to 49 years receiving anticancer treatment at a major tertiary metropolitan hospital in Australia between 2017 and 2020 were reviewed. Data collected included primary diagnosis, stage of cancer, treatment(s) received, rates of remission or progression, documentation of involvement of a specialist gynecologist, reproductive history, menstrual disturbances, menstruation counseling or intervention offered, and diagnosis of early ovarian failure.

RESULTS

Only 16.1% of patients had their menstrual history documented at the initial consult, and 49.6% had their menstrual history documented at a subsequent consult with their treating oncologist or hematologist. Most (82.4%) patients with a menstrual history documented experienced menstrual disturbance posttreatment, most commonly amenorrhea (48.0%), followed by menopause or menopause symptoms (20.6%), irregular menstrual bleeding (16.7%), menorrhagia (13.7%), dysmenorrhea (3.9%), and iron deficiency from bleeding (2.9%). Menopause/Menopausal symptoms and iron deficiency were more likely to be treated than other disturbances.

CONCLUSIONS

Menstruation disturbance is a common side effect of cancer treatment. Menstrual care should be integral to cancer care for people who menstruate, and higher engagement could be achieved through education of medical and allied health staff, information technology systems automating prompts and referral pathways, regular audits to ensure compliance, better alliances between cancer and fertility specialists, and the creation of accessible patient information to promote awareness and facilitate discussion.

Circulating cell-free endometrial DNA level is unaltered during menstruation and in endometriosis

STUDY QUESTION

Is circulating cell-free DNA (cirDNA) from the endometrium elevated during menstruation and in endometriosis?

SUMMARY ANSWER

Endometrial cirDNA does not increase during menstruation and is not elevated in endometriosis.

WHAT IS KNOWN ALREADY

Changes in cirDNA associated with common benign conditions are a potential source of false positives in cancer diagnostic applications, but also present an opportunity for biomarker development for diseases such as endometriosis. Elevated cirDNA has been reported in endometriosis patients compared to healthy community controls, but no difference in total or endometrial cirDNA has been found between patients with endometriosis and patients with other gynaecological conditions. Likewise, menstruation is a potential driver of changes in cirDNA levels and tissue profile, but total and endothelial cirDNA do not increase during menstruation.

STUDY DESIGN, SIZE, DURATION

For endometriosis comparisons, 59 participants with surgically confirmed endometriosis and 27 laparoscopic patients without endometriosis (hospital controls) were prospectively recruited, while 25 healthy community participants (healthy controls) were recruited in a university setting. Total and endometrial cirDNA and cirDNA fragmentation were measured across the three groups. For menstrual comparisons, 36 matched non-menstruating and menstruating samples were collected from healthy women recruited within a university setting, and the endometrial cirDNA was compared between the two groups.

PARTICIPANTS/MATERIALS, SETTING, METHODS

cirDNA was extracted from venous blood plasma then quantitated by quantitative PCR of ALU repetitive element (115 bp) and TP53 gene sequence (105 bp) for total concentration. cirDNA derived from the endometrium was quantitated by methylation-specific droplet digital PCR of a FAM101A region (69 bp) after bisulfite conversion of the DNA. A cirDNA size fragmentation ratio was obtained by quantifying a long segment of ALU repetitive element (247 bp) and expressing the amount relative to the 115 bp ALU target.

MAIN RESULTS AND THE ROLE OF CHANCE

No differences in cirDNA level were found in any comparison populations in this study. Mean total cirDNA was unchanged between healthy controls (ALU-115-3.31 ng/ml; TP53-2.73 ng/ml), hospital controls (ALU-115-3.47 ng/ml; TP53-2.83 ng/ml) and endometriosis patients (ALU-115-3.35 ng/ml; TP53-2.66 ng/ml). Likewise, endometrial cirDNA was unchanged between healthy controls (18.3 copies/ml), hospital controls (20.6 copies/ml) and endometriosis patients (22 copies/ml). Endometrial cirDNA did not change during menstruation (non-menstruating: 38 copies/ml; menstruating: 33 copies/ml). Irrespective of endometriosis diagnosis, blood from patients undergoing laparoscopy (hospital controls: 0.77; endometriosis patients: 0.79), had a significantly higher cirDNA size ratio than community-recruited healthy controls (0.64), indicating increased abundance of long cirDNA fragments.

LIMITATIONS, REASONS FOR CAUTION

It was not possible to completely match the age, BMI and parity between the three cohorts investigated, however of these, only age has been shown to influence circulating DNA levels and not within the age range of our cohort. Blood from community-recruited healthy women and women undergoing laparoscopy was collected via antecubital vein venepuncture (processed within 3 h) and with either peripheral cannula or venepuncture (processed within 6 h), respectively, which could potentially impact the size distribution of circulating DNA fragments. For the collection of non-menstruating phase blood samples, we did not differentiate between follicular phase, ovulation and luteal phase. Thus, only the mensturating samples were collected at a consistent phase, and any fluctuations in cirDNA that occur at the other phases may have obscured small changes during menstruation.

WIDER IMPLICATIONS OF THE FINDINGS

There is no evidence that cirDNA has potential as a diagnostic biomarker for endometriosis. Endometriosis, representing a common benign gynaecological condition, and menstruation, representing a normal physiological occurrence in women, should not affect methylation-based diagnostics in other disease areas, including oncology.

STUDY FUNDING/COMPETING INTEREST(S)

N.L.Y.: Australian Government Research Training Program (RTP) Stipend through The University of New South Wales, Translational Cancer Research Network PhD Scholarship Top-Up Award via the Cancer Institute NSW, Beth Yarrow Memorial Award in Medical Science, UNSW Completion Scholarship; C.E.H.: Gynaecological Oncology Fund of the Royal Hospital for Women; K.W.: Ovarian Cancer Research Foundation and CAMILLA AND MARC. C.E.F.: UNSW Women's Wellbeing Academy and the Australian Human Rights Institute. We declare the following competing interest: K.W. holds stock in Guardant Health, Exact Sciences and Epigenomics AG. No other authors have competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Comparison of total and endometrial circulating cell-free DNA in women with and without endometriosis

RESEARCH QUESTION

Do women with laparoscopically confirmed endometriosis have higher plasma concentrations of circulating cell-free DNA (cirDNA) than those without endometriosis?

DESIGN

Prospective study of women aged 18-45 years undergoing benign gynaecological laparoscopy at two tertiary hospitals. Venous blood was collected immediately before surgery, and women were allocated to the endometriosis or control groups based on surgical findings. Total plasma cirDNA and cirDNA integrity were measured by quantitative polymerase chain reaction (qPCR) targeting short (115 bases) and long (247 bases) ALU segments. Endometrial-derived cirDNA was measured by qPCR of bisulfite-treated cirDNA using primers selective for a FAM101A sequence uniquely unmethylated in endometrial tissue. Five cirDNA parameters were compared between the control and endometriosis cohorts: total cirDNA concentration, long-stranded cirDNA concentration, integrity ratio, endometrial cirDNA concentration and endometrial cirDNA proportion.

RESULTS

Twenty-eight endometriosis and 15 control samples were included. Women with and without endometriosis had cirDNA concentrations of 2.24 ± 0.89 ng/ml and 2.56 ± 0.92 ng/ml, respectively. Analysis by phenotype of endometriosis revealed a significantly higher endometrial cirDNA concentration in women with superficial disease (n = 10) compared with deep endometriosis (n = 18) (mean difference 0.14 ng/ml; 95% CI 0.15 to 0.26; P = 0.025), but not with controls.

CONCLUSIONS

No significant differences were found in any of the cirDNA parameters between women with and without endometriosis. The low statistical power and heterogenous pelvic pathology in the control group render it difficult to determine whether the negative results reflect a true lack of increase in cirDNA in endometriosis.

The effect of laparoscopic salpingectomy for ectopic pregnancy on ovarian reserve

BACKGROUND

Salpingectomy may damage ovarian reserve by direct vascular interruption to the ovary or thermal vascular injury from electrosurgery. It is plausible that this risk may increase in the context of salpingectomy conducted for ectopic pregnancy due to the distension of the fallopian tube and vascular changes associated with pregnancy.

AIM

To report anti-Müllerian hormone (AMH) concentrations before and after laparoscopic salpingectomy for ectopic pregnancy as an indicator of change in ovarian reserve.

MATERIALS AND METHODS

Women aged 18-44 years scheduled for salpingectomy for tubal ectopic pregnancy were prospectively recruited. Serum AMH concentrations were measured immediately prior to surgery, then repeated four months post-operatively. In all cases, salpingectomy was conducted laparoscopically using bipolar electrosurgery and mechanical scissors. A group of women scheduled for uterine curettage for first trimester miscarriage was recruited to ensure any observed change in AMH concentration in the women undergoing salpingectomy was secondary to surgery, rather than an effect of pregnancy.

RESULTS

Paired pre- and post-operative serum AMH concentrations were obtained from 32 women with tubal ectopic pregnancy. The mean age of the women was 33.6 ± 4.6 years. There was no significant difference in the median pre- and post-operative AMH concentrations (13.00 pmol/L (range 5-67 pmol/L) vs 15.25 pmol/L (range 3-96 pmol/L), P = 0.575). Median AMH concentrations also remained stable in women experiencing a first trimester miscarriage (10.40 pmol/L (range 3.9-37.8 pmol/L) vs 13.67 pmol/L (range 2.8-30.5 pmol/L), P = 0.185).

CONCLUSION

Laparoscopic salpingectomy using electrosurgery and mechanical scissors does not damage ovarian reserve. AMH concentrations do not fluctuate from baseline in the first trimester of pregnancy.

Clinical case presentation: life threatening Group A sepsis secondary to HyCoSy

Hysterosalpingo contrast sonography (HyCoSy) is a commonly performed procedure in the investigation of infertility. Infection is an uncommon complication of this procedure. Should it occur, it is generally mild and amenable to outpatient treatment with oral antibiotics. We present a case of an immunosuppressed woman who underwent HyCoSy for investigation of secondary infertility and developed life‐threatening sepsis with Group A streptococcus.

Borderline personality disorder and mental healthcare service use among adolescents

Borderline personality disorder (BPD) is believed to be frequent among adolescents. While several prospective studies have assessed the use of mental health services among adults who suffer from BPD, few studies have provided adolescent data. This paper presents findings from the first assessment point of the European Research Network on Borderline Personality Disorder (EURNET BPD) study. In this study, we describe lifetime treatment utilization for 85 adolescents with BPD (Mean age: 16.3 years old). In line with adult findings, adolescents with BPD reported greater mental healthcare service use (outpatient: 98%; inpatient: 79%) compared to controls. Phenothiazine, a sedative neuroleptic, was the most frequently prescribed treatment. 47% of patients had received psychotherapy; in one our of three cases this was psychodynamic therapy. Patients who had received psychotherapy did not differ on any psychopathological variables from those who did not receive psychotherapy; however, psychotherapy was more frequent among females.

[The impact of exposure to images of ideally thin models on body dissatisfaction in young French and Italian women]

AIMS

The thin-ideal of feminine beauty has a strong impact on body image and plays a central part in eating disorders. This ideal is widely promoted by the media images that flood western societies. Although the harmful effects of exposure to thin-ideal media images have been repeatedly demonstrated experimentally in English-speaking western countries, no such studies exist in southern Europe. There is evidence to suggest that the use of average-size models could reduce these negative effects. This study investigates body image amongst French and Italian students following exposure to media images of thin or average-size models, with a neutral or supportive slogan.

METHODS

The data were gathered in three locations: the psychology departments of the Universities of Padua, Italy, and Toulouse, France, and lastly high schools in the Toulouse area. A total of 299 girls took part in the study; their average age was 19.9 years old (S.D.=2.54) In order to investigate the effects of media images, we created three fake advertisements, allegedly promoting body-cream. The first advertisement displayed an ideally-thin model accompanied by a neutral slogan. In the second, the model was average-size with the same neutral slogan. The last advertisement also contained the average-size model, but with a supportive slogan designed to convey acceptance of deviations from the social norms of thinness. The participants first graded themselves on a VAS of body dissatisfaction (0 to 10). On the basis of this score, we created a first group containing girls reporting body dissatisfaction (VAS>or=5), the second with those reporting no body dissatisfaction (VAS<5). Participants were then randomly exposed to one of the three advertisements, after which they filled in the body dissatisfaction sub-scale of the Eating Disorders Inventory (EDI-2).

RESULTS

The results showed that girls with initial body dissatisfaction reported higher body dissatisfaction after being exposed to images of ideally thin models than images of average-size models (F(1.32)=4.64, p=0.039). However, there was no significant difference between body dissatisfaction scores reported after exposure to images of average-size models accompanied by neutral or supportive slogans (F(1.39)=0.093, p=0.76).

CONCLUSIONS

This study illustrates the negative effects of exposure to thin-ideal media images among students with body dissatisfaction. The use of average-size models in the media and advertising might help reduce these effects. No improvement was obtained via the use of a supportive slogan. These results highlight the importance of media literacy campaigns in the prevention of eating disorders.

420. The effect of maternal dietary protein on the expression of genes involved in TGF-β superfamily bioavailability in the bovine ovarian cortex of female offspring

Although numerous familial studies have indicated a genetic component to polycystic ovary syndrome (PCOS), a consistent and repeatable association with any particular gene has not been definitively established. However, one genetic marker, the microsatellite D19S884, has shown repeatable and consistent association with PCOS. D19S884 maps to intron 55 of the fibrillin-3 gene. The family of fibrillin extracellular matrix proteins includes the family of latent TGF-β binding proteins which are known to have roles in ovarian function. These provide structural support to tissues and regulate TGF-β bioavailability and are candidates for involvement in clinical manifestation of PCOS. Many of the risk factors associated with PCOS including type II diabetes, heart disease, and obesity are also known to be affected by in utero experience. In addition, although diet has not been examined in the PCOS outcome of offspring, some fetal experiences including androgen exposure have been linked to PCOS outcome. We therefore investigated the effect of protein content of maternal diet on expression of fibrillins-1, –2, and –3 and LTBPs-1 and –2 in the tunica albuginea of ovaries from female offspring by QRT–PCR. Diets were either high (13% protein per total dry weight) or a low protein (5%) during the first two trimesters. All three fibrillins were expressed in the tunica albuginea with the highest level of expression observed for fibrillin-1 followed by fibrillin-2, with low levels of expression of fibrillin-3. Both LTBP-1 and LTBP-2 were expressed, with the highest expression observed for LTBP-2. No significant (P > 0.05) effects of diet upon gene expression were observed. Expression levels of all three fibrillins were positively correlated with each other, and fibrillins-1 and 2 were positively correlated with LTBP-2. This is the first demonstration of the expression of fibrillins and LTBPs in the ovary, however these were unaffected by the maternal diets examined.

275FOLLICULAR ATRESIA IN SMALL, NON-FSH-DEPENDENT BOVINE FOLLICLES IS ASSOCIATED WITH INCREASED DEVELOPMENTAL POTENTIAL OF OOCYTES FOLLOWING IVP

Oocytes from small, non-FSH-dependent follicles are associated with reduced developmental competence following in vitro embryo production (IVP) compared to oocytes from larger follicles. It has been suggested that, for small follicles, oocytes derived from atretic follicles are more developmentally competent than those from healthy follicles (Blondin P and Sirard MA, 1995 Mol. Reprod. Dev. 41, 54–62). Little is known of the characteristics of small follicles that support developmentally competent oocytes. Here we examine the development to blastocyst stage of oocytes collected from histologically-assessed bovine 2–5mm follicles. Ovaries were obtained at a local abattoir;; 4 follicles were dissected from each ovary and oocytes were recovered. A section of each follicle wall was taken and fixed in 2.5% glutaraldehyde for histological assessment of the follicle and characterization of the morphology of the follicular basal lamina by electron microscopy (Irving-Rodgers HF and Rodgers RJ, 2000 J. Reprod. Fert. 118, 221–228). Oocytes recovered from follicles underwent IVP utilizing a novel single IVP system. Oocytes were matured for 24h (10μL per COC) in TCM199, supplemented with FSH, hCG, FCS, cysteamine and pyruvate. Mature oocytes were inseminated with 1×106 sperm mL−1 for an additional 24h using Bovine Fertilization Medium (10μL per COC;; Cook, Australia). Following insemination, putative zygotes were stripped of remaining cells and placed within individual micro-wells prepared in 1% agar in Bovine Early Cleavage Medium, Cook, Australia. The agar (350μL) was prepared within wells of a 4-well plate and small plugs of agar were removed to form micro-wells. The agar was over-laid with 450μL of Early Cleavage Medium and 250μL mineral oil, and equilibrated overnight before putative zygotes were placed individually within micro-wells. Culture was performed under 7% O2, 6% CO2, and 87% N2 at 39°C. On Day 5 following insemination, fetal calf serum (final concentration 10% v/v) was added to facilitate blastocyst development. Blastocyst formation was assessed on Day 8. A total of 211 oocytes were cultured and 69% were from healthy follicles;; 67 oocytes (32%) had developed to the blastocyst stage by Day 8. Forty-three percent of oocytes recovered from atretic follicles (28/65) had developed to the blastocyst stage by Day 8, as compared to only 27% (39/146) oocytes recovered from healthy follicles, this difference was significant (P&lt;0.05, chi-square analysis). Seventy-eight percent (14/18) of oocytes from healthy follicles with additional follicular basal lamina material (Irging-Rodgers HF and Rodgers RJ, 2000 J. Reprod. Fert. 118, 221–228) failed to develop, whereas only 44% (4/9) of oocytes from healthy follicles with a normal basal lamina failed to develop (P&gt;0.08). The present study finds a direct association between the follicle morphology and oocyte maturational potential within non-FSH dependent follicles, revealing that high levels of development (&gt;40%) can be obtained from atretic follicles. Furthermore, differences between healthy follicles may also contribute to developmental variation.

Cholinergic system modulates growth, apoptosis, and secretion of cholangiocytes from bile duct-ligated rats

BACKGROUND & AIMS

To investigate the role of the cholinergic system in regulation of cholangiocyte functions, we evaluated the effects of vagotomy on cholangiocyte proliferation and secretion in rats that underwent bile duct ligation (BDL rats).

METHODS

After bile duct ligation (BDL), the vagus nerve was resected; 7 days later, expression of M3 acetylcholine receptor was evaluated. Cholangiocyte proliferation was assessed by morphometry and measurement of DNA synthesis. Apoptosis was evaluated by light microscopy and annexin-V staining. Ductal secretion was evaluated by measurement of secretin-induced choleresis, secretin receptor (SR) gene expression, and cyclic adenosine 3',5'-monophosphate (cAMP) levels.

RESULTS

Vagotomy decreased the expression of M3 acetylcholine receptors in cholangiocytes. DNA synthesis and ductal mass were markedly decreased, whereas cholangiocyte apoptosis was increased by vagotomy. Vagotomy decreased ductal secretion. Forskolin treatment prevented the decrease in cAMP levels induced by vagotomy, maintained cholangiocyte proliferation, and decreased cholangiocyte apoptosis caused by vagotomy in BDL rats. Cholangiocyte secretion was also maintained by forskolin.

CONCLUSIONS

Vagotomy impairs cholangiocyte proliferation and enhances apoptosis, leading to decreased ductal mass in response to BDL. Secretin-induced choleresis of BDL rats was virtually eliminated by vagotomy in association with decreased cholangiocyte cAMP levels. Maintenance of cAMP levels by forskolin administration prevents the effects of vagotomy on cholangiocyte proliferation, apoptosis, and secretion.

Acute carbon tetrachloride feeding induces damage of large but not small cholangiocytes from BDL rat liver

Bile duct damage and/or loss is limited to a range of duct sizes in cholangiopathies. We tested the hypothesis that CCl4 damages only large ducts. CCl4 or mineral oil was given to bile duct-ligated (BDL) rats, and 1, 2, and 7 days later small and large cholangiocytes were purified and evaluated for apoptosis, proliferation, and secretion. In situ, we measured apoptosis by morphometric and TUNEL analysis and the number of small and large ducts by morphometry. Two days after CCl4 administration, we found an increased number of small ducts and reduced number of large ducts. In vitro apoptosis was observed only in large cholangiocytes, and this was accompanied by loss of proliferation and secretion in large cholangiocytes and loss of choleretic effect of secretin. Small cholangiocytes de novo express the secretin receptor gene and secretin-induced cAMP response. Consistent with damage of large ducts, we detected cytochrome P-4502E1 (which CCl4 converts to its radicals) only in large cholangiocytes. CCl4 induces selective apoptosis of large ducts associated with loss of large cholangiocyte proliferation and secretion.

Acute carbon tetrachloride feeding selectively damages large, but not small, cholangiocytes from normal rat liver

The aim of this study was to develop a model of selective duct damage restricted to hormone-responsive segments corresponding to the ducts damaged in primary biliary cirrhosis (PBC). Carbon tetrachloride (CCl4) was fed by gavage to rats, and 2, 7, 14, and 28 days later, small and large cholangiocytes were isolated. Apoptosis was determined in situ by morphology and in purified cholangiocytes by assessment of nuclear fragmentation by 4, 6-diamidino-2-phenylindole (DAPI) staining. Cholangiocyte proliferation was evaluated in situ by morphometry of liver sections stained for cytokeratin-19 (CK-19) and by proliferating cellular nuclear antigen (PCNA) staining in liver sections and in purified cholangiocytes by PCNA gene expression. Ductal secretion was assessed by measurement of secretin receptor (SR) gene expression and secretin-induced cyclic adenosine 3',5'-monophosphate (cAMP) synthesis and secretin-induced choleresis. Two days after CCl4 administration, there was an increased number of small ducts, but a reduction of large ducts. Apoptosis, observed only in large ducts, was associated with decreased DNA synthesis and ductal secretion. Conversely, small cholangiocytes expressed de novo the SR gene and secretin-stimulated cAMP synthesis 2 days after CCl4 treatment. Proliferation of large cholangiocytes was delayed until 7 days, which was associated with a transient increase in ductal secretion in vivo. CCl4 effects on cholangiocytes were reversed by day 28. CCl4 treatment causes a decrease in large duct mass as a result of a higher rate of apoptosis and absence of initial proliferation in large cholangiocytes. These processes were concomitant with a decrease of ductal secretion in large cholangiocytes. Small cholangiocytes appear resistant to CCl4-induced apoptosis, and proliferate and transiently compensate for loss of proliferative and secretory activity of large cholangiocytes.

Bile acid feeding induces cholangiocyte proliferation and secretion: evidence for bile acid-regulated ductal secretion

BACKGROUND & AIMS

We have shown that taurocholate (TC) and taurolithocholate (TLC) interact in vitro with normal cholangiocytes, increasing DNA synthesis, secretin receptor (SR) gene expression, and adenosine 3',5'-cyclic monophosphate (cAMP) synthesis. To further extend these in vitro studies, we tested the hypothesis that bile acids (BAs) directly stimulate cholangiocyte proliferation and secretion in vivo.

METHODS

After feeding with TC or TLC (1% for 1-4 weeks), we assessed the following in vivo: (1) ductal proliferation by both morphometry and immunohistochemistry for proliferating cell nuclear antigen (PCNA) and measurement of [3H]thymidine incorporation; and (2) the effect of secretin on bile secretion and bicarbonate secretion in vivo. Genetic expression of H3-histone and SR and intracellular cAMP levels were measured in isolated cholangiocytes.

RESULTS

After BA feeding, there was an increased number of PCNA-positive cholangiocytes and an increased number of ducts compared with control rats. [3H]Thymidine incorporation, absent in control cholangiocytes, was increased in cholangiocytes from BA-fed rats. In BA-fed rats, there was increased SR gene expression (approximately 2.5-fold) and secretin-induced cAMP levels (approximately 3.0-fold) in cholangiocytes, which was associated with de novo secretin-stimulated bile flow and bicarbonate secretion.

CONCLUSIONS

These data indicate that elevated BA levels stimulate ductal secretion and cholangiocyte proliferation.

Functional expression of the apical Na+-dependent bile acid transporter in large but not small rat cholangiocytes

BACKGROUND & AIMS

Bile acids interact with cholangiocytes, resulting in cholangiocyte proliferation and increases in ductal bile secretion in large but not small cholangiocytes. It was proposed that for bile acids to exert these effects on cholangiocytes, a specific uptake mechanism must be present in cholangiocytes. The aim of this study was to show the expression of a bile acid transporter in cholangiocytes.

METHODS

Small and large cholangiocytes or intrahepatic bile duct units (IBDUs) were isolated from normal rats, and gene expression for the apical Na+-dependent bile acid transporter (ABAT) and the 14-kilodalton ileal cytosolic binding protein (IBABP) was assessed by ribonuclease-protection assays. Tissue and subcellular distribution of bile acid transporters was also studied. [14C]-Taurocholate uptake into cholangiocytes was determined.

RESULTS

Both ABAT and IBABP messenger RNAs were detected in large but not small cholangiocytes. By immunohistochemistry, ABAT was present in large but not small cholangiocytes. Immunofluorescence showed ABAT to be present in the apical membrane of large IBDUs. A Na+-dependent saturable uptake of taurocholate was present in large but not small cholangiocytes.

CONCLUSIONS

These proteins may mediate bile acid uptake from the duct lumen in large ducts, resulting in modification of canalicular bile secretion and modulation of ductal bile secretion and growth.

An evaluation of a nurse-led ear care service in primary care: benefits and costs

BACKGROUND

Nurses trained in ear care provide a new model for the provision of services in general practice, with the aim of cost-effective treatment of minor ear and hearing problems that affect well-being and quality of life.

AIM

To compare a prospective observational cohort study measuring health outcomes and resource use for patients with ear or hearing problems treated by nurses trained in ear care with similar patients treated by standard practice.

METHOD

A total of 438 Rotherham and 196 Barnsley patients aged 16 years or over received two self-completion questionnaires: questionnaire 1 (Q1) on the day of consultation and questionnaire 2 (Q2) after three weeks. Primary measured outcomes were changes in discomfort and pain; secondary outcomes included the effect on normal life, health status, patient satisfaction, and resources used.

RESULTS

After adjusting for differences at Q1, by Q2 there was no statistical evidence of a difference in discomfort and pain reduction, or differential change in health status between areas. Satisfaction with treatment was significantly higher (P = 0.0001) in Rotherham (91%) than in Barnsley (82%). Average total general practitioner (GP) consultations were lower in Rotherham at 0.4 per patient with an average cost of 6.28 Pounds compared with Barnsley at 1.4 per patient and an average cost of 22.53 Pounds (P = 0.04). Barnsley GPs prescribed more drugs per case (6% of total costs compared with 1.5%) and used more systemic antibiotics (P = 0.001).

CONCLUSIONS

Nurses trained in ear care reduce costs, GP workload, and the use of systemic antibiotics, while increasing patient satisfaction with care. With understanding and support from GPs, such nurses are an example of how expanded nursing roles bring benefits to general practice. Nurses trained in ear care reduce treatment costs, reduce the use of antibiotics, educate patients in ear care, increase patient satisfaction, and raise ear awareness.

Lid imbrication syndrome. Diagnosis with rose bengal staining

BACKGROUND

Lid imbrication syndrome is an abnormality of lid apposition in which the upper lid overlies the lower lid. Patients often complain of irritation, tearing, and foreign body sensation. The condition may be difficult to diagnose.

METHOD

Twenty-one patients with suspected lid imbrication syndrome were compared with 21 age-matched controls. All patients were given 0.5% topical rose bengal.

RESULTS

The diagnosis of lid imbrication syndrome was confirmed by the presence of rose bengal staining of the tarsal conjunctiva of the upper lid margin. The amount of rose bengal staining correlated with the severity of lid imbrication. Eighteen of 21 patients had received a diagnosis previously of dry eye syndrome. Four patients had persistent epithelial defects.

CONCLUSIONS

Rose bengal staining of the superior lid margin tarsal conjunctiva offers an extremely reliable aid for diagnosing lid imbrication syndrome. The condition commonly presents as a dry eye or persistent epithelial defect. Treatment ranges from viscous tear substitutes to horizontal lid shortening of the upper lid.

Ventricular loading is coupled with DNA synthesis in adult cardiac myocytes after acute and chronic myocardial infarction in rats

To determine whether the overload associated with myocardial infarction and ventricular failure in rats is coupled with activation of DNA synthesis in the remaining left and right ventricular myocytes, flow cytometric analysis was performed on myocyte nuclei prepared from both ventricles 7 and 30 days after coronary occlusion. In addition, oral captopril was administered in separate groups of control and experimental rats to establish whether a relation existed between attenuation of ventricular loading and magnitude of DNA synthesis in myocytes. Results demonstrated that left ventricular failure and right ventricular dysfunction at 7 days after infarction were biventricularly associated with marked increases in the number of myocyte nuclei in the G2M phase of the cell cycle. In contrast, the fraction of nuclei in the G0+G1 phase decreased. In comparison with the earlier time point, the 30-day interval was characterized by a significant magnitude of cardiac hypertrophy, a moderate amelioration of ventricular pump function, and a decrease in the percentage of myocyte nuclei in the G2M phase in both ventricles. However, 30 days after infarction, the number of right ventricular myocyte nuclei in the S and G2M phases remained elevated with respect to control animals. Captopril therapy reduced the extent of ventricular loading and the population of myocyte nuclei in the cell cycle at 7 days. In conclusion, DNA synthesis in myocyte nuclei may represent an important adaptive component of the myocardial response to infarction.

Regulation of expression of the genes encoding steroidogenic enzymes

In recent years it has become apparent that tropic hormones involved in steroidogenesis act to regulate the expression of the enzymes involved in the various steroidogenic pathways. This is particularly evident in the ovary where the episodic secretion of steroids throughout the ovarian cycle is regulated largely by changes in the levels of the particular enzymes involved in each step of the steroid biosynthetic pathways. Recently, the genes for the various cytochrome P450 species involved in ovarian steroidogenesis, namely cholesterol side-chain cleavage P450 (P450SCC), 17 alpha-hydroxylase P450 (P450(17 alpha], and aromatase cytochrome P450 (P450AROM) have been isolated and characterized, making it possible to study the regulation of expression at the molecular level. To this end, a series of chimeric constructs have been prepared in which fragments of the 5'-untranslated region of bovine P450(17 alpha) and P450SCC have been inserted upstream of the chloramphenicol acetyl transferase (CAT) and beta-globin reporter genes. These constructs have been used to transfect primary cultures of bovine luteal and thecal cells. The results indicate that cAMP responsiveness lies within defined regions of genes which do not contain a classical CRE, similar to previous results utilizing adrenal cells in culture. Furthermore, although constructs containing both the P450(17 alpha) and P450SCC 5'-upstream regions are expressed in both luteal and thecal cell cultures, only those containing the P450SCC sequences are expressed in luteal cells. Studies on the expression of P450AROM indicate that the promoter which is responsible for its expression in human placenta is not operative in the corpus luteum. Thus estrogen biosynthesis may be regulated by the differential use of tissue specific promoters, thus accounting for the complexity and multifactorial nature of the expression of this activity.

Effect of selection intensity and population size on percent oil in maize, Zea mays L

The effect of selection intensity and population size on the response to selection for percent oil in the grain of maize (Zea mays L.) was evaluated in a replicated experiment over ten cycles of selection. An open-pollinated variety, Armel's Reid Yellow Dent, was divided into subpopulations of 6,10 and 50 plants. Selection proportions of 17% and 5% were imposed upon each subpopulation. Selection was based on the percentage of oil in individual kernels as determined by wide-line nuclear magnetic resonance spectroscopy. As expected, total response to selection increased with larger population sizes and selection intensities. The concave shape of the response curves suggested that an appreciable part of the genetic variance can be attributed to additive genes at high initial frequencies, dominance genes at low initial frequencies, or to the generation of negative linkage disequilibrium due to selection. The consistently greater loss of vigor experienced by the more intensely selected populations reflects the enhancement of inbreeding due to artificial selection, an effect that increases with the intensity of selection. The results indicate that combined selection, based on kernels and using within- and amongfamily information, will be more efficient than other conventional selection procedures, including the normal combined scheme where selection is based on plants.

Ocular involvement in congenital leukemia

Congenital leukemia, a rare disease with distinct features, was diagnosed in a 5-week-old girl. The infant was tachypneic and tachycardic, with intercostal retractions, distended abdomen, and multiple hematomas. Despite aggressive treatment, the child died. Histologic examination of tissue obtained at autopsy disclosed leukemic infiltrates in the ocular muscles, conjunctiva, uveal tract, and optic nerve.

The use of a computer in a hand clinic

We have developed a computerised system for the storage, retrieval and analysis of the workload of a hand clinic. In a study of 800 patients we have found it superior to a punched card system collecting similar information. The computer system functioned reliably and achieved its user specification. It should prove a useful tool in helping a surgeon in matters of audit, research and disease or accident prevention but its long term performance in this regard requires evaluation.

Ultrasound-accelerated immunoassay, as exemplified by enzyme immunoassay of choriogonadotropin

The rate-limiting step in many solid-phase immunoassays is associated with the slow kinetics of binding of macro-molecular antigen and conjugate to the immobilized phase. We demonstrate that the use of ultrasonic energy to enhance mass transport across liquid/solid interfaces can dramatically accelerate antigen binding to immobilized antibodies. We use an ultrasound-accelerated procedure with an enzyme-channelling test strip containing glucose oxidase and specific antibody to the alpha-subunit of human choriogonadotropin (HCG) co-immobilized onto a cellulose support. A horseradish peroxidase conjugate of monospecific antibody to the beta-subunit of HCG is used in the liquid phase to complete the immune "sandwich." Use of ultrasound to accelerate binding and of enzyme channelling to eliminate wash steps result in a simple two-incubation protocol by which 25 int. units of urinary HCG per liter can be detected visually in less than 20 min of assay time.

Ultrasound-accelerated immunoassay, as exemplified by enzyme immunoassay of choriogonadotropin

The rate-limiting step in many solid-phase immunoassays is associated with the slow kinetics of binding of macro-molecular antigen and conjugate to the immobilized phase. We demonstrate that the use of ultrasonic energy to enhance mass transport across liquid/solid interfaces can dramatically accelerate antigen binding to immobilized antibodies. We use an ultrasound-accelerated procedure with an enzyme-channelling test strip containing glucose oxidase and specific antibody to the alpha-subunit of human choriogonadotropin (HCG) co-immobilized onto a cellulose support. A horseradish peroxidase conjugate of monospecific antibody to the beta-subunit of HCG is used in the liquid phase to complete the immune "sandwich." Use of ultrasound to accelerate binding and of enzyme channelling to eliminate wash steps result in a simple two-incubation protocol by which 25 int. units of urinary HCG per liter can be detected visually in less than 20 min of assay time.

Levamisole in primary breast cancer. A controlled study in conjunction with l-phenylalanine mustard

Between September 1976 and May 1980, 135 patients with operable breast cancer and positive axillary nodes received l-phenylalanine mustard, adjunct to surgery, 0.15 mg/kg for five days, six weekly, and were randomised prospectively to levamisole 150 mg for three days, two weekly, or a placebo. Treatment was continued for two years or until evidence of treatment failure, whichever was the sooner. At 4 1/2 years, for all patients, there was no significant difference between the two groups (P = 0.09), but in a subgroup of women less than or equal to 50 with 1-3 positive nodes, levamisole had a negative effect (P = 0.05). Although an analysis of the same age group, independent of the nodal status, did not reach significance, there was a trend in favor of placebo (P = 0.08) which was also apparent in premenopausal women (P = 0.15). In postmenopausal patients, however, and in those with more advanced disease with four or more positive nodes, although the results also failed to reach significance the trend in these subgroups favored levamisole. The results of this study suggest that levamisole has no place in the primary therapy of breast cancer in younger women and those with more favorable disease. The value of this agent in older patients and those with more advanced primary disease, remains unproven, but the favorable trends are in accord with a number of other studies with levamisole in metastatic breast and resectable lung cancer. Retrospective analysis confined to those women who received 75% or more of the total dose of l-phenylalanine mustard showed no evidence for a dose-responsive effect of adjuvant chemotherapy on the described pattern of results.

Airway obstruction due to inhalation of ammonia

Ammonia is an important chemical in industry. Accidental inhalation of ammonia has resulted in upper airway and bronchoalveolar injury, and even fatal inhalation of anhydrous ammonia has occurred. We present herein a 5-year follow-up on a patient who had no prior history of smoking or pulmonary symptoms and had overwhelming exposure to ammonia which resulted in acute respiratory failure with diffuse lung parenchymal and airway involvement. The extreme inflammation and desquamation of the mucosa of the central bronchial tree, as observed bronchoscopically, have apparently resulted in a hyperreactive bronchoconstrictive component. Because our patient had never smoked and had no history of pulmonary symptoms or wheezing, we speculate that both the central and the peripheral residual airway obstructions were a result of his inhalation injury. In addition, peripheral airway disease, suggested by the postbronchodilator flow-volume curves present during the first year of follow-up, has gradually cleared even though there is evidence of parenchymal scarring.

Dyphylline aerosol attenuates antigen-induced bronchoconstriction in experimental canine asthma

This study compared the bronchodilator effect in experimental canine asthma of dyphylline administered by aerosol and intravenous routes in doses producing equivalent concentrations of the drug in the plasma. Pulmonary resistance (RL) was calculated from simultaneous measurements of pressure and flow during fixed-volume controlled ventilation at the same peak flow and corrected for elastic recoil pressure. Dynamic compliance (Cdyn) was calculated by dividing tidal volume by the change in pressure measured between points of zero flow. Concentrations of dyphylline in the plasma were measured using high-performance liquid chromatographic techniques. Rates of infusion of dyphylline were determined from values for clearance observed in preliminary experiments with intravenous injection. Prior to exposure to antigen, RL and Cdyn were not significantly different in control and dyphylline-treated dogs. Following challenge, with antigen RL increased by 8.3 +/- 2.6 times (mean +/- SE) in untreated dogs but only by 2.4 +/- 0.4 times in dyphylline treated dogs. Levels of dyphylline in the plasma averaged 4.2 micrograms/ml +/- 0.6 micrograms/ml at the end of the ten-minute period of aerosol administration and remained at that level for 60 minutes. At equivalent plasma levels (4.3 micrograms/ml +/- 0.3 micrograms/ml), infusion of dyphylline did not significantly after the response to Ascaris antigen, whereas dyphylline administered by the aerosol route markedly attenuated the response.

Utilization of intravenous dihydroxypropyl theophylline (dyphylline) in an aminophylline-sensitive patient, and its pharmacokinetic comparison with theophylline

The pharmacokinetics and urinary excretion of intravenously administered 7-(2,3-dihydroxypropyl) theophylline (dyphylline), were studied in a 37-yr-old asthmatic woman with ethylene diamine sensitivity who manifested intolerance to intravenous aminophylline on three separate occasions. In this subject, intravenously administered dyphylline was tolerated very well and was effective in the subsequent management of acute bronchospastic episodes. Dyphylline was significantly concentrated in the urine. This, coupled with its rapid clearance, suggests potential clinical application in patients with hepatic dysfunction. Though aminophylline sensitivity is rare, ethylene diamine sensitivity should be considered in untoward reactions to this drug.

Homogeneous enzyme immunoassay for cannabinoids in urine

We describe a homogeneous enzyme immunoassay for measurement of cannabinoid metabolites, as well as delta9-tetrahydrocannabinol (I) in urine. Malate dehydrogenase from pig heart mitochondria was labeled with a derivative of I. The compound used to calibrate the assay was the I metabolite, 11-nor-delta9-tetrahydrocannabinol-9-carboxylic acid (II). With 15 microgram of II per liter of urine as the cutoff concentration, the assay can detect 25 microgram of II per liter with greater than 95% confidence. A positive response was obtained for urine specimens assayed within 30 min after exposure to cannabinoids. However, the persistence of metabolites of I in urine indicates that assay of this fluid is useful as an indicator of cannabinoid use but not as an indicator of intoxication.

Homogeneous enzyme immunoassay for cannabinoids in urine

We describe a homogeneous enzyme immunoassay for measurement of cannabinoid metabolites, as well as delta9-tetrahydrocannabinol (I) in urine. Malate dehydrogenase from pig heart mitochondria was labeled with a derivative of I. The compound used to calibrate the assay was the I metabolite, 11-nor-delta9-tetrahydrocannabinol-9-carboxylic acid (II). With 15 microgram of II per liter of urine as the cutoff concentration, the assay can detect 25 microgram of II per liter with greater than 95% confidence. A positive response was obtained for urine specimens assayed within 30 min after exposure to cannabinoids. However, the persistence of metabolites of I in urine indicates that assay of this fluid is useful as an indicator of cannabinoid use but not as an indicator of intoxication.