Development of a standardized low-dose double-blind placebo-controlled challenge vehicle for the EuroPrevall project.

BACKGROUND: Double-blind placebo-controlled food challenge (DBPCFC) is the gold standard for diagnosing food allergy. Standardized materials and protocols are essential for comparing DBPCFC results for multicentre studies such as EuroPrevall. This required the development and piloting of a standardized vehicle and low-dose protocol for confirming food allergy and determination of minimum eliciting doses (MEDs). METHODS: A low-dose DBPCFC protocol was developed, with eight titrated protein doses from 3 µg to 1 g. This was delivered using a simple, microbiologically stable food base incorporating allergenic food ingredients manufactured at three sites and centrally distributed to clinical centres. Allergen blinding was assessed by a professional sensory testing panel using a triangle test. Homogeneity and allergen content were confirmed by ELISA and clinical efficacy was assessed in a pilot study, using celeriac and hazelnut as exemplars. RESULTS: Celeriac and hazelnut ingredients were sufficiently blinded in the dessert. The dessert meals were successfully piloted with hazelnut in allergy clinics in Spain, the Netherlands and Italy and with celeriac and hazelnut in Zurich. The challenges elicited a range of subjective and objective reactions ranging in severity from mild itching of the oral mucosa to bronchospasm. CONCLUSIONS: A standardized challenge vehicle proven to sufficiently blind processed, powdered hazelnut and celeriac ingredients and that can be reproducibly manufactured has been developed. This pilot study shows that the vehicle is promising for the confirmation of food allergy and determination of MEDs in adults and children with body weight >28.8 kg (approximately 7-11 years old).

Value of mental health first aid training of advisory and extension agents in supporting farmers in rural Queensland.

INTRODUCTION: This study was a pilot project responding to the increasing levels of stress, depression and other mental health issues in Australian rural areas resulting from prolonged drought and a changing economic and social environment. METHODS: Thirty-two Advisory and Extension Agents (AEAs) attended a training course held in 2007 and 2008 in Queensland, Australia. A year after the training, data was collected to determine its value. Interviews were conducted with course participants and their supervisors and focus groups were held with stakeholders (farmers, agency staff and health professionals). RESULTS: The findings show that Mental Health First Aid training improved the participants' confidence level and their knowledge of mental health issues and increased their empathy toward persons with mental health problems. Furthermore, providing training on mental health issues to AEAs was perceived by stakeholders to be beneficial to both farmers and AEAs. CONCLUSION: This study demonstrated that stakeholders and course participants see this type of training as very much needed and highly beneficial. Further, providing training in mental health issues to rural service providers can be very beneficial to their farmer clients and their social network.

Metabolism of testosterone in previable human fetuses.

Labeled testosterone was injected into the umbilical vein of each of 4 male and 3 female previable fetuses at the time of laparotomy. After leaving the circulation intact for 3 min, the fetal tissues of each fetus were removed and the labeled metabolites present in each tissue were extracted, separated and isolated. Aliquots of tissue extracts were used for the qualitative analysis of metabolites following which metabolites were reisolated quantitatively from other tissue aliquots with the aid of the corresponding 3-H-labeled recovery markers. Testosterone and 11beta-hydroxyandrostenedione-4 were isolated from the adrenals and 5beta-androstanedione, androstenedione, etiocholanolone, androsterone, 5alpha-androstanediol, 5beta-androstanediol and testosterone were isolated from the livers. In addition, etiocholanolone and 5beta-androstanediol were isolated from the sulfate and glucuronide fractions of the livers. A sex difference in fetal testosterone metabolism was observed in the liver where the amounts of unconjugated 5beta-androstanediol in the male livers with no overlap in values. This conclusion has to be viewed with caution as only 4 males and 3 female fetuses were examined in these studies.

The use of radionuclides in the investigation of conjoined twins.

Three sets of thoraco-omphalopagous conjoined twins were investigated. The clinical findings indicated a complex shared heart in two sets, and separate cardiovascular systems in the other. These assessments were confirmed by dynamic imaging after bolus injection of Tc-99m(Sn)colloid or Tc-99m millimicrospheres. Static images were then used to establish the configurations of the shared livers. The results of these studies were in keeping with the angiographic and autopsy findings in the two sets with complex cardiac anomalies and with the surgical findings during successful separation of the third set.

Ovarian function in women immediately post partum.

Ovarian function in pregnant women at term was investigated by obtaining plasma samples from both ovarian veins simultaneously with a peripheral sample from the antecubital vein. All samples were analyzed by radioimmunoassay to determine the concentration of progesterone, estradiol, estrone, androstenedione, testosterone, and human chorionic gonadotropin. The corpus luteum was found to secrete progesterone and not significant amounts of estrogens or androgens. Extraluteal tissue secreted estrogens and androgens and also progesterone. No quantitative relationship was found between the concentrations of human chorionic gonadotropin and any ovarian steroid, and estradiol appeared to be produced from both estrone and testosterone.

Induction of multiple follicular growth in normally menstruating women with endogenous gonadotropin suppression.

Patients with normal menstrual rhythm and normal luteinizing hormone were treated with exogenous gonadotropins to induce multiple follicular development. This was effected in the absence (34 cycles in 12 patients) or with concurrent suppression of endogenous gonadotropin levels with a gonadotropin-releasing hormone analog (84 cycles in 18 patients). In the absence of the analog, "premature" luteinization occurred in 51% of cycles before the ultrasonic visualization of a follicle with a diameter of 20 mm. In the analog-treated cycles, premature luteinization was almost totally eliminated and progesterone elevations were delayed until after administration of human chorionic gonadotropin. Follicular estrogen production was unaffected by the analog treatment, compared with hypogonadal patients treated with exogenous gonadotropins. The characteristics of follicular development showed that two to three follicles of mature size were induced with this technique, and the capacity for the induction of a larger number of follicles was evident.

Luteal cysts and unexplained infertility: biochemical and ultrasonic evaluation.

A prospective, controlled study of ovarian function using ovarian ultrasound and daily plasma hormone estimations (estradiol, progesterone [P], follicle-stimulating hormone [FSH], luteinizing hormone [LH]) was carried out on 175 spontaneously cycling patients with unexplained infertility. Forty-one (23.4%) demonstrated luteal phase cyst formation. In 21 cycles the dominant follicle reduced in size after the LH peak (cystic corpus luteum cycles), and in 20 no shrinkage was seen (luteinized unruptured follicles). Progesterone concentrations in the early luteal phase were significantly reduced in the luteinized unruptured follicle cycles. Elevation in plasma FSH was seen in the early follicular and luteal phases of both cyst forming groups and may be due to disturbances in ovarian metabolism. Follicular rupture is important for efficient P release by the corpus luteum.

In vivo and in vitro maturation of human oocytes: effects on embryo development and polyspermic fertilization.

OBJECTIVE: To compare the effects of in vivo and in vitro maturation of human oocytes. DESIGN: Women (n = 60) undergoing follicular stimulation for in vitro fertilization, using long-course analog therapy to suppress endogenous luteinizing hormone (LH), were randomly allocated to a short (34 hour) or long (39 hour) delay between human chorionic gonadotropin (hCG) administration and oocyte retrieval. Each patient's oocytes were divided into two groups that were either inseminated immediately or after 5 hours. RESULTS: The incidence of polyspermic fertilization was highest in oocytes inseminated immediately after a short hCG/oocyte retrieval interval (17/100) and was significantly (P less than 0.05) reduced by preincubation and/or a long hGG/oocyte retrieval interval. Fertilization rates were higher with 39 hours than with 34 hours in vivo maturation (84.2% versus 76.8%; P less than 0.05). The incidence of delayed fertilization was reduced by extending the hCG/oocyte retrieval interval (short, 12.9%; long, 3.9%; P less than 0.001). CONCLUSIONS: Extension of the in vivo maturation time increased fertilization rates and eliminated the requirement for preinsemination incubation, allowing simplification of laboratory procedures.

Luteinization to oocyte retrieval delay in women in whom multiple follicular growth was induced as part of an in vitro fertilization/gamete intrafallopian transfer program.

Different luteinization-to-oocyte-retrieval delays were examined in 64 IVF/GIFT patients. Multiple follicular stimulation was induced with combined therapy of hMG and GnRH-a to create continuous pituitary suppression and thus eliminate endogenous gonadotropin fluctuations. The results demonstrated that with this induction regime, the time interval can be extended to 39 hours without preoperative ovulation and with improved oocyte maturity.

Absence of effect of adjuvant growth hormone therapy on follicular responses to exogenous gonadotropins in women: normal and poor responders.

OBJECTIVE: To examine the effects of growth hormone (GH) on ovarian responses to exogenous gonadotropins after pituitary desensitization in normal and poor responder patients undergoing in vitro fertilization. DESIGN: A prospective study with comparison of control and GH-treated cycles. PATIENTS: Poor responder patients (n = 10) required > 44 ampules of human menopausal gonadotropin (hMG) to achieve criteria for administration of human chorionic gonadotropin (hCG) on day 0 or cancellation in control cycles, and normal responder patients (n = 10) required < 45 ampules. MAIN OUTCOME MEASURES: Ovarian responses to hMG assessed by duration of stimulation required to achieve first significant estradiol (E2) response and hCG criteria. Total doses and duration of hMG, follicular development and E2 concentrations on day 0, and embryology were also assessed. RESULTS: Growth hormone showed no effect on any of the parameters studied in either patient group. CONCLUSION: Follicular recruitment, E2 secretion by mature follicles, and oocyte yield and quality were uninfluenced by GH treatment.

Growth factors in human ovarian follicle fluid and growth factor receptors in granulosa-luteal cells.

The levels of oestradiol (E2), progesterone (P4), transforming growth factor alpha (TGF alpha), transforming growth factor beta 2 (TGF beta 2), insulin-like growth factor I (IGF-I), platelet-derived growth factor AB (PDGF-AB) and epidermal growth factor (EGF) were measured in follicular fluids obtained from patients undergoing ovarian stimulation as part of an in vitro fertilisation program. Each of the substances was detected in all of the fluid samples tested, except TGF alpha (which was detected in 90% of samples tested), PDGF-AB (70%) and EGF (2%). Comparisons were made between each of these factors, follicular maturity, successful oocyte recovery and the outcome of fertilisation and embryo transfer. No statistically significant correlations were found. The presence of receptors for EGF, IGF-I and PDGF in extracts from granulosa-luteal cells isolated from follicular fluids was detected by means of Western blotting. The co-localisation of these growth factors and their receptors within the ovarian follicle suggests a likely role in control of follicular development.

Flexible bronchoscopy under 10 kg.

We report 35 bronchoscopies performed in 27 post-neonatal subjects weighing less than 10 kg using an Olympus BC3F20 (3.5 mm diameter) bronchoscope. Twenty-three procedures were performed primarily for investigation of airway anatomy and 12 primarily for broncho-alveolar lavage. Mild oxygen desaturation responsive to increased O2 administration was common. Major complications were infrequent with two children developing lower respiratory tract infection and one patient requiring ventilation overnight. The diagnostic yield was high with 76% of studies in children suspected of airway anomalies proving positive. We conclude that bronchoscopy in this age group is well tolerated and identifies a significant number of abnormalities.

Paediatricians' perception of the use of extracorporeal membrane oxygenation to treat meconium aspiration syndrome.

This questionnaire study was designed to determine how consultant paediatricians perceived the value of extracorporeal membrane oxygenation (ECMO) in the treatment of meconium aspiration syndrome (MAS). A significant number believed that the survival of infants with MAS who received ECMO was lower than reported. Early discussion with an ECMO centre will ensure appropriate timing of referral.

Three cases of smooth muscle tumours of the small intestine.

Three cases of rare primary smooth muscle tumours of the small intestine, two benign and one malignant, are presented. The two benign lesions produced melaena for thirty years and twelve years respectively while remaining undetected by repeated investigation; the third case presented more acutely with obstruction. All three tumours were excised curatively.