Patients, carers and healthcare providers' perspectives on a patient-owned surveillance system for diabetic foot ulcer care: A qualitative study.

Objective: Digital health has recently gained a foothold in monitoring and improving diabetes care. We aim to explore the views of patients, carers and healthcare providers (HCPs) regarding the use of a novel patient-owned wound surveillance application as part of outpatient management of patients with diabetic foot ulcers (DFUs). Methods: Semi-structured online interviews were conducted with patients, carers and HCPs in wound care for DFUs. The participants were recruited from a primary care polyclinic network and two tertiary hospitals in Singapore, within the same healthcare cluster. Purposive maximum variation sampling was used to select participants with differing attributes to ensure heterogeneity. Common themes relating to the wound imaging app were captured. Results: A total of 20 patients, 5 carers and 20 HCPs participated in the qualitative study. None of the participants have used a wound imaging app before. Regarding a patient-owned wound surveillance app, all were open and receptive to the system and workflow for use in DFU care. Four major themes emerged from patients and carers: (1) technology, (2) application features and usability, (3) feasibility of using the wound imaging application and (4) logistics of care. Four major themes were identified from HCPs: (1) attitudes towards wound imaging app, (2) preferences regarding functionality, (3) perceived challenges for patients/carers and (4) perceived barriers for HCPs. Conclusion: Our study highlighted several barriers and facilitators from patients, carers and HCPs regarding the use of a patient-owned wound surveillance app. These findings demonstrate the potential of digital health and areas to improve and tailor a DFU wound app suitable for implementation in the local population.

Expression of Interleukin-1ß and Histological Changes of the Three-Dimensional Oral Mucosal Model in Response to Yttria-Stabilized Nanozirconia.

Over the years, advancement in ceramic-based dental restorative materials has led to the development of monolithic zirconia with increased translucency. The monolithic zirconia fabricated from nano-sized zirconia powders is shown to be superior in physical properties and more translucent for anterior dental restorations. Most in vitro studies on monolithic zirconia have focused mainly on the effect of surface treatment or the wear of the material, while the nanotoxicity of this material is yet to be explored. Hence, this research aimed to assess the biocompatibility of yttria-stabilized nanozirconia (3-YZP) on the three-dimensional oral mucosal models (3D-OMM). The 3D-OMMs were constructed using human gingival fibroblast (HGF) and immortalized human oral keratinocyte cell line (OKF6/TERT-2), co-cultured on an acellular dermal matrix. On day 12, the tissue models were exposed to 3-YZP (test) and inCoris TZI (IC) (reference material). The growth media were collected at 24 and 48 h of exposure to materials and assessed for IL-1ß released. The 3D-OMMs were fixed with 10% formalin for the histopathological assessments. The concentration of the IL-1ß was not statistically different between the two materials for 24 and 48 h of exposure (p = 0.892). Histologically, stratification of epithelial cells was formed without evidence of cytotoxic damage and the epithelial thickness measured was the same for all model tissues. The excellent biocompatibility of nanozirconia, as evidenced by the multiple endpoint analyses of the 3D-OMM, may indicate the potential of its clinical application as a restorative material.

Assessment of gingival thickness in multi-ethnic subjects with different gingival pigmentation levels.

AIM: Assessment of the thickness of gingival tissues using the probe visibility test is regarded as the method of choice during routine examinations. However, the probe visibility test has not been validated for patients with gingival pigmentation and its accuracy in populations with physiological gingival pigmentation is yet unknown. This study aims to evaluate different methods for the clinical assessment of gingival thickness in participants with varying levels of gingival pigmentation. MATERIALS AND METHODS: Buccal mucosa of the maxillary right central incisor teeth of 171 participants was evaluated using four methods, which were direct measurements using calliper, transgingival probing method using an endodontic probe, and probe visibility method using Colorvue biotype probe (CBP) and UNC-15 probe. The pigmentation of the gingiva was assessed using the Dummett-Gupta oral pigmentation lesion index. RESULTS: The average gingival thickness of the selected population was 1.22 ± 0.38 mm with a distribution of 70% thick and 30% thin gingiva. Transgingival and calliper methods showed good agreement and significant correlation (r = 0.229; p = .003). Visual assessment using CBP and UNC-15 probe showed poor agreement with the direct measurement methods. Gingival pigmentation significantly affected the probe visibility assessment, reducing the visibility of both the CBP (odds ratio [OR] = 4.00; 95% confidence interval [CI], 1.83-8.74) and UNC-15 probe (OR = 1.84; 95% CI, 1.05-3.23) while controlling for thickness of the gingiva. CONCLUSION: The probe visibility method using either CBP or the UNC-15 probe is affected by the degree of gingival pigmentation. Direct measurements using either a calliper or transgingival probing are recommended as methods to measure the gingival thickness in populations with gingival pigmentation.

Validation of the Malay Oral Impacts on Daily Performances and Evaluation of Oral Health-Related Quality of Life in a Multi-Ethnic Urban Malaysian Population: A Cross-Sectional Study.

Oral Impacts on Daily Performances (OIDP) can be used as a generic or condition-specific oral health-related quality of life (OHRQoL) instrument. It offers different contexts on how dental conditions affect OHRQoL. This cross-sectional study aimed to validate a newly translated Malay OIDP (OIDP-M), compare OHRQoL, decayed, missing, or filled teeth (DMFT) in Malaysians, and investigate factors associated with OHRQoL. A total of 368 Malaysians were surveyed and examined for DMFT. Short-form oral health impact profile-Malaysia [S-OHIP(M)] and OIDP-M were used to measure OHRQoL. The OIDP-M was tested for reliability and validity. DMFT, S-OHIP(M), and OIDP-M between ethnicities were compared. Associations between ethnicity, DMFT, S-OHIP(M), and OIDP-M of Malays and Chinese were evaluated through partial correlation. Malays and Chinese had more filled teeth and DMFT compared with Indians. Malays reported worse OHRQoL through S-OHIP(M). Decayed teeth were positively associated with S-OHIP(M), physical, psychological, social disabilities, and handicap. For OIDP-M, decayed teeth were positively associated with OIDP-M, working, and sleeping. Missing teeth and ethnicity were positively associated with eating and speaking. Filled teeth were negatively associated with cleaning teeth. The OIDP-M was reliable and valid for evaluating OHRQoL. There were differences in DMFT and OHRQoL between ethnicities. Ethnicity affects OHRQoL, where Malays experienced worse OHRQoL due to dental problems.

Impact of psychological states on periodontitis severity and oral health-related quality of life.

PURPOSE: This cross-sectional study aimed to identify impacts of depression, anxiety and stress on periodontitis severity and oral health-related quality of life (OHRQoL). METHODS: A total of 141 periodontitis patients were recruited. Psychological states were assessed using the Malay short-form Depression, Anxiety and Stress Scales (MDASS-21). Subjects were grouped as positive for depression, anxiety or stress (DAS) (positive-DAS), without DAS (non-DAS), stress-only and anxiety-only. OHRQoL was evaluated using the Malay short-form Oral Health Impact Profile (S-OHIP[M]). RESULTS: OHRQoL was associated with MDASS-21, probing pocket depths, recession, clinical attachment levels, number of teeth present and number of teeth with mobility. S-OHIP(M) of positive-DAS subjects was associated with clinical attachment levels, number of teeth present and presence of anxiety. Anxiety-only subjects reported higher S-OHIP(M) scores compared to the non-DAS group. CONCLUSION: OHRQoL of all subjects was negatively impacted by periodontitis severity and tooth loss. Combinations of depression, anxiety or stress led to worse periodontal status and OHRQoL. Subjects with anxiety-only experienced poorer OHRQoL compared to those without depression, anxiety and stress regardless of periodontitis severity. Possible impacts of psychological states on periodontitis and OHRQoL highlights the importance of assessing and improving psychological factors as part of periodontal therapy and to enhance OHRQoL.

Long-Term Prognosis of Patients With Coronary Microvascular Disease Using Stress Perfusion Cardiac Magnetic Resonance.

OBJECTIVES: This study investigated the prognosis of coronary microvascular disease (CMD) as determined by stress perfusion cardiac magnetic resonance (CMR) in patients with ischemic symptoms but without significant coronary artery disease (CAD). BACKGROUND: Patients with CMD have poorer prognosis with various cardiac diseases. The myocardial perfusion reserve index (MPRI) derived from noninvasive stress perfusion CMR has been established to diagnose microvascular angina with a threshold MPRI <1.4. The prognosis of CMD as determined by MPRI is unknown. METHODS: Chest pain patients without epicardial CAD or myocardial disease from January 2009 to December 2017 were retrospectively included from 3 imaging centers in Hong Kong (HK). Stress perfusion CMR examinations were performed using either adenosine or adenosine triphosphate. Adequate stress was assessed by achieving splenic switch-off sign. Measurement of MPRI was performed in all stress perfusion CMR scans. Patients were followed for major adverse cardiovascular events defined as all-cause death, acute coronary syndrome (ACS), epicardial CAD development, heart failure hospitalization and non-fatal stroke. RESULTS: A total of 218 patients were studied (mean age 59 ± 12 years; 49.5% male) and the average MPRI of that cohort was 1.56 ± 0.33. Females and a history of hyperlipidemia were predictors of lower MPRI. Major adverse cardiovascular events (MACE) occurred in 15.6% of patients during a median follow-up of 5.5 years (interquartile range: 4.6 to 6.8 years). The optimal cutoff value of MPRI in predicting MACE was found with a threshold MPRI ≤1.47. Patients with MPRI ≤1.47 had three-fold increased risk of MACE compared with those with MPRI >1.47 (hazard ratio [HR]: 3.14; 95% confidence interval [CI]: 1.58 to 6.25; p = 0.001). Multivariate Cox regression after adjusting for age and hypertension demonstrated that MPRI was an independent predictor of MACE (HR: 0.10; 95% CI: 0.03 to 0.34; p < 0.001). CONCLUSIONS: Stress perfusion CMR-derived MPRI is an independent imaging marker that predicts MACE in patients with ischemic symptom and no overt CAD over the medium term.

Management of Bilateral Mandibular Fused Teeth.

Tooth fusion is a developmental dental anomaly that may affect both the deciduous and permanent dentition. Such anomalies may cause problems such as caries, periodontal disease or even esthetic impairments, which will require intervention. In the present case, a young patient was referred to the periodontal clinic for management of bilateral mandibular fused teeth as part of the orthodontic treatment. On the lower right, the teeth involved were incompletely fused involving only the cervical region. On the lower left, the two teeth were completely fused from the crown to the apex. A surgical resection was carried out on the fused teeth on the right, while the fused teeth on the left was undisturbed. Orthodontic treatment was later carried out to align both the upper and lower arch. The patient was satisfied with treatment outcome.

Excess fat in the abdomen but not general obesity is associated with poorer metabolic and cardiovascular health in premenopausal and postmenopausal Asian women.

OBJECTIVES: To examine the associations of various metabolites and hormones and hormone replacement therapy (HRT) with obesity. METHODS: This is a cross-sectional study of 1326 Singaporean women. A DXA-derived percent body fat (PBF) of ≥35% and percent abdominal fat (PAbdF) of >21.8% were used, respectively, to define women with general (GOb) and abdominal (AbdOb) obesity. RESULTS: Higher levels of insulin and glucose, lower levels of HDL, higher levels of TC/HDL and HOMA values, and different levels of some hormones were noted only in the women with abdominal, and not general obesity. The incidence of general and abdominal obesity was higher in postmenopausal women with or without HRT, except that those who were on conjugated estradiol-only HRT had no increase in the incidence of general obesity compared with premenopausal women. CONCLUSIONS: Abdominal obesity is associated with insulin resistance and with higher risks of metabolic syndrome and cardiovascular diseases, whereas general obesity is not. Abdominal obesity may predispose to a higher risk of diabetes. The onset of the menopause tends to increase the incidence of general and abdominal obesity, except that postmenopausal women on conjugated estradiol HRT appear to be relatively protected from general obesity.

Effects of a brief action and coping planning intervention on completion of preventive exercises prescribed by a physiotherapist among people with knee pain.

OBJECTIVES: The present study aimed to test the efficacy of action and coping planning in promoting engagement with preventive exercises among a sample of people with knee pain. DESIGN: Experimental trial. METHODS: Individuals who presented to a physiotherapist with knee pain (N=373, 57% female; M age=31.54, SD=10.06, age range=18-69 years) completed two assessments separated by 14 days. At baseline, participants completed measures of severity of problems associated with the knee (e.g., pain, symptoms) and past behavior. Subsequently, participants were randomly assigned to an action and coping planning or control group. Two weeks later, participants retrospectively reported their preventive exercise behavior over the past 14 days. Analyses revealed that the experimental group reported a higher number of preventive exercise sessions over the 14day period when compared with the control group. RESULTS: Participants who planned action and coping strategies reported a greater frequency of completed preventive exercises over a 2-week period than people who did not. CONCLUSIONS: The results of this study underscore the importance of action and coping planning for the enactment of preventive exercises that are designed to manage or prevent knee pain.

Aging and bone health in Singaporean Chinese pre-menopausal and postmenopausal women.

OBJECTIVE: The study evaluated relationships between menopausal statuses, hormone replacement therapy (HRT), body mass index (BMI), percent body fat (PBF), and exercise with osteoporosis and bone mineral density (BMD) in Singaporean women. STUDY DESIGN: This is a cross-sectional study. MAIN OUTCOME MEASURES: The spine BMD, and femoral neck BMD as well as the prevalence of osteoporosis are the main outcome measures studied. RESULTS: Age, BMI, PBF and exercise intensity were independently associated with spine and femoral neck BMD. Women with higher BMI and lower PBF had higher BMD and lower prevalence of osteoporosis. Postmenopausal women without HRT had lower BMD and higher prevalence of osteoporosis while those on HRT had similar BMD and prevalence of osteoporosis as premenopausal women. CONCLUSION: This study shows that BMI and PBF are powerful predictors of BMD. Osteoporosis is site-specific in the Singapore population, being higher in the femoral neck than in the lumbar spine. The bone status after menopause may not be worse than that dictated by age alone and both ERT and E/PRT could sustain the BMD to levels corresponding to those of women a decade younger. A strategy to improve bone health should include dieting and physical exercise program that focuses on selectively reducing fat mass and increasing lean mass.

Impact of dentine hypersensitivity on oral health-related quality of life in individuals receiving supportive periodontal care.

AIM: To determine the prevalence and impact of dentine hypersensitivity (DH) on oral health-related quality of life (OHRQoL) in individuals receiving supportive periodontal care (SPC). MATERIALS AND METHODS: One hundred and two adults receiving SPC were recruited for a cross-sectional study. Subjects were categorized into those who self-reported DH (DH1) or did not (DH0). Impact of DH on OHRQoL was assessed using the Chinese Condition-Specific Oral Impact on Daily Performance questionnaire (CS-OIDP). Evaluation of DH included tactile-stimulation followed by air-blast, and recorded using a Visual Analogue Scale (VAS). RESULTS: Sixty-one (59.8%) subjects self-reported DH with mean air-blast VAS score of 29.4 ± 21.3 mm and mean tactile-stimulation VAS score of 10.9 ± 14.7 mm. Fifty (49%) subjects reported impact on OHRQoL (mean CS-OIDP score = 4.7 ± 6.3). The most affected performance was cleaning the mouth (35.3%). Positive expression of DH and worse OHRQoL were associated with higher air-blast and tactile-stimulation VAS scores, and use of desensitizing agents. The minimally important difference (MID) in CS-OIDP scores was 2.0 points. Approximately 30% of the subjects reported CS-OIDP scores above the MID. CONCLUSIONS: Dentine hypersensitivity affects OHRQoL in patients undergoing SPC. The extent of impact was associated with severity of DH.

Association of general and abdominal obesity with age, endocrine and metabolic factors in Asian men.

OBJECTIVE: This study made use of the percent abdominal fat to define abdominal obesity (AbO) and examined the differential associations of general obesity (GOb) and AbO with age, metabolic and endocrine factors. METHODS: Metabolic, endocrine and anthropometric factors and body composition were measured in 481 Asian men. RESULTS: A DEXA-derived ≥25% abdominal fat (PAbdF) was used to define men with AbO. Age was directly associated with PAbdF and percent total body fat (PBF). Exercise intensity was negatively associated with PBF. Both PBF and PAbdF were associated with HDL and LDL, but have opposite correlation with triglyceride. Furthermore, both PBF and PAbdF were associated with the number of metabolic syndrome (MetS) risk factors. Men with GOb had lower levels of percent lean mass (PLM), testosterone and bioavailable testosterone, and higher insulin and glucose levels. Men with AbO had lower arm and leg fat, higher insulin levels and triglycerides. CONCLUSIONS: Men with GOb and AbO had different pattern of body composition. Age may be a contributory factor in AbO and a sedentary lifestyle may contribute to GOb. Both GOb and AbO are associated with an increased risk of MetS, with GOb more predispose to risk of diabetes, while AbO more at risk for cardiovascular diseases.

Aging, lifestyle factors, hormones and bone health in Singaporean men.

PURPOSE: The present study examined how age, bodyweight, body fat, regular exercise and some endocrine factors are associated with osteoporosis, spine bone mineral density (Sbmd) and femoral neck bone mineral density (Fnbmd) in Singaporean men. METHODS: Body composition and bone scans of lumbar spine at L2-L4 and hip were carried out with duel-energy X-ray absorptiometry (DXA). Anthropometric parameters were measured and demographic data, medical history and exercise schedule were collected via a questionnaire. RESULTS: Osteoporosis prevalence was higher and Sbmd and Fnbmd were lower in men with high percent body fat (PBF) and conversely osteoporosis prevalence was lower and Sbmd and Fnbmd were higher in men with higher body mass index (BMI). Age was negatively associated with Fnbmd but not Sbmd. On the other hand, PBF and insulin levels were negatively associated with both Sbmd and Fnbmd. Body mass index and exercise intensity were positively associated with both Sbmd and Fnbmd. Sex hormones were significantly associated with only Sbmd but not Fnbmd. Both estradiol and DHEAS were positively, while testosterone was negatively associated with Sbmd. CONCLUSION: The study shows that the prevalence of osteoporosis and some of the determinants of bone mineral density (BMD) in Singaporean men was site-specific. Further, BMI and PBF are opposing predictors of BMD. Therefore, any strategy for improving bone health should include modalities that increase lean and bone mass and decrease fat mass. The bone health of Singaporean men is comparable to non-Hispanic whites and better than some other Asian men.

Endocrine factors, memory and perceptual capacities and aging in Asian men.

BACKGROUND: This cross-sectional study examined the associations of hormones and age with short-term memory and perceptual capacity in 472 healthy Asian men. METHODS: The symbol digit and digit span tests from the Swedish Performance Evaluation System were used to assess perceptual capacity and memory. Linear regression analyses with the stepwise method were carried out with the SPSS 21.0 package. RESULTS: Age was associated with lower dehydorepiandrosterone sulphate (DHEA/S), insulin growth factor-1 (IGF-1), thyroxine (T4), testosterone (T), bioavailable T (BioT) and error rate (Err) but higher glucose (GLU), sex hormone binding globulin (SHBG), estradiol (E2) and retention time (RT). High GLU was associated with higher error rate, longer RT of the perceptual capacity domain and shorter digit span (DSpan) of the short-term memory domain. Higher insulin-like growth factor binding protein-3 (BP3) was associated with longer DSpan. High cortisol (Cor) was associated with higher Err, while high DHEA/S was associated with shorter RT. All other hormones from the adrenal, somatotrophic and gonadal were not significantly associated with cognition. CONCLUSION: The findings suggest (1) a role for tighter control of blood glucose levels in cognitive decline with aging in men, (2) different hormones may be related to different parameters of cognition and "cognition" is not a unitary phenomenon and (3) further investigation of the potential for exogenous DHEA/S to slow cognitive decline in aging, especially as it relates to reaction time.

The association of metabolic syndrome and aging with cognition in Asian men.

BACKGROUND: The present cross-sectional study examined the associations of individual metabolic factors and age with the short-term memory and perceptual capacity in 472 healthy Asian men. METHODS: The symbol digit and digit span tests from the Swedish Performance Evaluation System were used to assess the perceptual capacity and memory cognitive domains. Linear regression with the stepwise method, and multivariate analyses of the General Linear Model with the Bonferroni correction for multiple comparisons were carried out with the SPSS 21.0 package. RESULTS: High blood pressure and HDL were not significantly associated with either short-term memory or perceptual capacity. Age and glucose level were negatively associated but regular physical exercise was positively associated with perceptual capacity. On the other hand, high triglyceride level (TG) was positively associated but high waist/height ratio was negatively associated with short-term memory. When men without any component of the metabolic syndrome (MetS) were compared with men with one, two or three or more components of MetS, no significant differences in cognitive performance were noted. CONCLUSION: Not all the metabolic factors were significantly associated with short-term memory or the perceptual capacity domains. Those that were did not show a sufficiently consistent pattern of association to support a role for MetS as a whole in cognitive decline with aging. It may not be meaningful to evaluate the association of MetS as a whole with cognition.

Associations of physical exercise as a lifestyle habit with lean and fat body mass and handgrip strength and age in Asian men.

BACKGROUND: We evaluated how the intensity of physical exercise as a lifestyle habit is associated with age, body composition and handgrip strength. METHODS: Total body composition was analyzed using DEXA. Exercise scores were derived from an administered questionnaire and the scoring was calculated using the Metabolic Equivalent of Task (MET). Handgrip strength was measured using a dynamometer. RESULTS: Age, independent of exercise intensity, was associated with declining lean mass, and handgrip strength and with increasing total body fat. A regular physical exercise regime of intensity greater than 1230 MET-min/week was associated with higher total lean mass and lean mass in the limbs, and handgrip strength and lower fat mass in the limbs. DISCUSSION: We have shown that age was associated with lower lean mass especially in the limbs and handgrip strength and higher total fat mass. Regular physical exercise as a lifestyle habit of any type and of sufficient intensity could help improve muscle strength in the limbs.

The moderating impact of lifestyle factors on sex steroids, sexual activities and aging in Asian men.

The present study sought to evaluate the relative associations of exercise, sleep and other lifestyle habits with aging, sex hormones, percent body fat (%BF) and sexual activities in men living in the community. A better understanding of this complex interrelationship is important in helping the formulation of modalities for a holistic approach to the management of aging men. The results showed that age is a major determinant for many physiological parameters, including sleep, hormonal and metabolic parameters, some lifestyle factors and sexual activities. Testosterone (T), bioavailable testosterone (BioT) and dehydroepiandrosterone sulphate (DHEAS) concentrations decreased with age, while estradiol (E2), sex hormone-binding globulin (SHBG) and %BF increased with age. In addition, there exist intricate associations among hormonal and lifestyle factors, %BF and age. High-intensity exercise and longer duration of sleep were associated with higher concentrations of T and BioT. T was shown to be associated positively with men who were engaged in masturbation. DHEAS was associated with men wanting more sex and with good morning penile rigidity. Older Singaporean men tended to sleep for shorter duration, but exercised more intensely than younger men. Coital and masturbation frequencies decreased with age, and a significantly greater number of younger men were engaged in masturbation. Relationship between the partners is a key determinant of sexuality in men. It appears that T may have a limited, while dehydroepiandrosterone (DHEA) have a greater role than previously suggest, as a motivational signal for sexual function in men. Both biological and psychosocial factors interact with each other to influence sexual functions in men. Hence, a biopsychosocial approach may be more appropriate for a more lasting resolution to sexual dysfunctions in men.

Reexamination of testosterone, dihydrotestosterone, estradiol and estrone levels across the menstrual cycle and in postmenopausal women measured by liquid chromatography-tandem mass spectrometry.

Measuring serum androgen levels in women has been challenging due to limitations in method accuracy, precision sensitivity and specificity at low hormone levels. The clinical significance of changes in sex steroids across the menstrual cycle and lifespan has remained controversial, in part due to these limitations. We used validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) assays to determine testosterone (T) and dihydrotestosterone (DHT) along with estradiol (E2) and estrone (E1) levels across the menstrual cycle of 31 healthy premenopausal females and in 19 postmenopausal females. Samples were obtained in ovulatory women in the early follicular phase (EFP), midcycle and mid luteal phase (MLP). Overall, the levels of T, DHT, E2 and E1 in premenopausal women measured by LC-MS/MS were lower overall than previously reported with immunoassays. In premenopausal women, serum T, free T, E2, E1 and SHBG levels peaked at midcycle and remained higher in the MLP, whereas DHT did not change. In postmenopausal women, T, free T, SHBG and DHT were significantly lower than in premenopausal women, concomitant with declines in E2 and E1. These data support the hypothesis that the changes in T and DHT that occur across the cycle may reflect changes in SHBG and estrogen, whereas in menopause, androgen levels decrease. LC-MS/MS may provide more accurate and precise measurement of sex steroid hormones than prior immunoassay methods and can be useful to assess the clinical significance of changes in T, DHT, E2 and E1 levels in females.