Availability and Access to Medications for Puberty Induction and Maintenance in Adolescents with Hypogonadism in the Arab Region.

Background: Inducing puberty in hypogonadal patients enables achieving normal final adult height and healthy bone mass accrual and improves fertility potential. Reliable availability and access to medicines remain a challenge around the world, particularly in low-income countries. Aim: We aimed to describe the availability/access to medications used for inducing and maintaining puberty in centers within the Arab region. Method: A cross-sectional survey was conducted using a link to an online questionnaire, which was emailed to paediatric endocrinologists in the Arab region. The questionnaire consisted of three questions related to the availability of various forms of sex hormones. Results: 99 physicians from 16 countries participated in the study. The commonest available form of estrogen was conjugated estrogen (29% of centers), followed by ethinylestradiol (26%). Depot estradiol was available in 11 centers, while topical estrogen preparations of gel and patches were available in 6 and 10 centers, respectively. Medroxy progesterone was available in 26% of the centers, followed by norethisterone (24%). The combined forms of oral and transdermal patches of estrogen/progesterone were available in 35% and 9% of centers, respectively. Intramuscular testosterone (Sustanon) was the most commonly available preparation of testosterone, followed by the depot injection (Nebido), oral testosterone, and testosterone gel and cream. Conclusions: We report the first available data on medications used for puberty induction and maintenance in paediatric hypogonadism in the Arab region. Recommended preparations for this purpose are not widely available. Creating an essential list of medications used in paediatric endocrinology disorders might improve availability, access, and consequently practice.

EFFECT OF INDOMETHACIN AND ITS COMPLEXES ON REPRODUCTIVE PERFORMANCE AND OXIDATIVE STRESS IN TESTIS AND STOMACH OF MALE ALBINO RATS WITH REFERENCE TO THEIR CHEMICAL CHARACTERIZATIONS.

Four new complexes of Hg (II), Pb (II), Sn (II) and Bi (III) with indomethacin drug ligand (IMC) were synthesized and characterized by using infrared, electronic, 1H-NMR spectral, thermogravimetric and conductivity measurements. The IMC was found to act as bidentate chelating agent. IMC complexes coordinate through the oxygen of the carboxyl group. The molar ratio chelation is 1:2 (M2+:IMC) with general formula [M (IMC) 2], nH2O for Hg (II), Pb(II) and Sn(II), but 1:3 for Bi(III) ions. Antibacterial screening of these heavy metal complexes against Escherichia coli (Gram-ve), Bacillus subtilis (Gram +ve) and anti-fungi (Asperagillus oryzae, Asperagillus niger, Asperagillus Flavus) were investigated. In the present study, we found evidence suggesting that Bi+3/IMC possesses the capacity to protect the stomach, sperm, testes, cellular ATP, cellular NAD, INSL3, PGD2, PGE2 and antioxidant enzymes from deleterious actions of IMC.

Assessment of serum acylated ghrelin in children and adolescents with chronic liver diseases: relation to nutritional status.

Because ghrelin is one of the key hormones in regulating feeding behavior and caloric status, it was suggested that ghrelin behavior might be closely associated with malnutrition state of patients with chronic liver disease (CLD). Thus, we aimed to assess serum ghrelin levels in children with CLD and its relation to anthropometric parameters and severity of CLD. Forty CLD patients were studied in comparison to 40 controls. All subjects were subjected to history, anthropometric, and laboratory assessment of liver functions and serum acylated ghrelin. Ghrelin was higher in patients than controls being higher with progress of Child's grade and with deterioration of liver functions. Hyperghrelinemia was detected in 62.5% of cases. Ghrelin correlated negatively with body mass index standard deviation score (BMISDS (r = -0.95, P < 0.001)), triceps skin fold thickness (TSFT (r = -0.88, P < 0.001)), and subscapular skin fold thickness (SSFT (r = 0.83, P < 0.001)) percentiles. In conclusion, hyperghrelinemia may represent a compensatory mechanism trying to overcome malnutrition state complicating CLD and can be used as a parameter for early detection and assessment of the severity of malnutrition in children with CLD.

Avascular Necrosis of the Femoral Head Following Intramedullary Nailing of a Femoral Shaft Fracture in a Skeletally Mature Adult: A Case Report.

Avascular necrosis (AVN) of the femoral head is a well-documented complication that occurs following femoral neck fractures in both adults and pediatrics. Incidence of AVN following intramedullary nailing (IMN) for femoral shaft fractures is relatively rare. We are reporting an exceptional case of a 28-year-old skeletally mature adult, with no risk factors, who developed stage 3 AVN following trochanteric entry-point IMN for a traumatic femur shaft fracture. Our case contributes to the existing literature by adding to the limited number of reported cases available. In addition, it emphasizes the importance of observation and anticipation for such complications and shows the need for further studies to understand the relationship between this modality of treatment and the development of AVN of the femoral head.

Utility of the Paris System in Urine Cytology for Improved Screening of High-Grade Urothelial Carcinoma in Bahrain.

BACKGROUND: Urothelial carcinoma, a prevalent and aggressive urological malignancy, necessitates early detection for improved prognosis. Urine cytology serves as a cost-effective screening tool, but inconsistencies in reporting due to the lack of standardized criteria limit its efficacy. The Paris System for reporting urinary cytology (TPS) was introduced to address this issue, aiming to improve diagnostic accuracy. This retrospective study investigates the effectiveness of urine cytology in detecting high-grade urothelial carcinoma (HGUC) using TPS classification, specifically focusing on atypical urothelial cells (AUC) categorized as TPS-III and suspicious for high-grade urothelial carcinoma (SHGUC) categorized as TPS-IV. METHODS: We reviewed 470 urine cytology samples collected over two years at a tertiary healthcare center in Bahrain. All samples were re-evaluated using TPS classification by two independent consultant cytopathologists blinded to the original cytology report. The analysis included only samples categorized as TPS-III or TPS-IV with corresponding histopathology reports from confirmatory biopsies performed within four months of urine collection. Biopsy results were categorized as either benign/low-grade urothelial carcinoma (non-HGUC) or malignant (HGUC). The positive predictive value (PPV) of urine cytology for HGUC detection was calculated for both TPS-III and TPS-IV categories. Statistical significance was assessed using Fisher's exact test. RESULTS: Among the 470 urine cytology samples, 40 (8.5%) were classified as TPS-III or TPS-IV. Within this subset, 16 patients underwent confirmatory biopsies. Histopathological analysis revealed HGUC in 12 (75%) patients and non-HGUC (benign or low-grade) in 4 (25%) patients. The PPV of TPS-III for HGUC was 50%, while TPS-IV demonstrated a higher PPV of 90%. However, the difference between these values was not statistically significant (p = 0.25). This study explored the utility of TPS classification in urine cytology for HGUC detection. While SHGUC (TPS-IV) exhibited a numerically higher PPV compared to AUC (TPS-III), the lack of statistical significance necessitates further investigation. Our findings highlight the potential of TPS to improve the accuracy of urine cytology. TPS implementation has been shown to reduce the number of inconclusive "atypical" diagnoses, leading to more targeted investigations. CONCLUSION: Our study suggests that SHGUC (TPS-IV) within TPS classification framework might hold promise as a more specific indicator for HGUC compared to AUC (TPS-III). However, further research with larger cohorts is necessary to definitively establish the clinical significance of this observation. This investigation paves the way for future studies exploring the potential of TPS, particularly the SHGUC category, as a reliable screening tool for HGUC, potentially leading to earlier diagnoses and improved patient outcomes.

Surgical and functional outcomes of sigmoid vaginoplasty among patients with variants of disorders of sex development.

PURPOSE: To assess the use of sigmoid colon in vaginal reconstruction of some patients with disorders of sex development. MATERIALS AND METHODS: The study included 31 patients with disorders of sex development of various causes. All were reared as females. Female gender was decided for all cases after complete medical assessment. All patients underwent sigmoid vaginoplasty. Assessment of surgical and functional outcomes was carried out in a follow-up period of up to 6 years. RESULTS: The preoperative diagnoses included mullerian aplasia (16 cases), androgen insensitivity syndrome (12 cases) and previous failed vaginoplasty (3 cases). Associated surgical procedures were gonadectomy in 5 cases and gonadectomy combined with clitoroplasty and vulvoplasty in 7 cases. No intra-operative or early postoperative complications occurred. A cosmetic neovagina with adequate size was achieved in all cases. Long term follow-up showed introital stenosis in 4 cases (12.9 %). Two of them responded to vaginal dilatation. The third one needed y-v plasty while the fourth one presented by acute abdomen secondary to ruptured vagina and was submitted to urgent laparotomy. Mucosal prolapse occurred in 1 case (3.2 %). Reoperation rate was 9.6 %. Sexual satisfaction was achieved among 9 sexually active cases. The subjective satisfaction score of the surgical outcome was 8.03. CONCLUSIONS: For patients with disorders of sex development of various etiologies, sigmoid vaginoplasty is the preferred technique for vaginal replacement. It is a safe technique that provides the patient with a cosmetic neovagina of adequate caliber and a satisfactory functional outcome.

Adrenal function in thalassemia major adolescents.

BACKGROUND: Several studies reported a significant prevalence of adrenal insufficiency, ranging from 18-45%, in patients with thalassemia. Evidence for dissociation of cortisol and adrenal androgen secretion in patients with beta-thalassemia was previously reported. AIM: We measured adrenal androgen response along with cortisol to the standard (250 mg) dose ACTH test. METHODS: Forty five beta-thalassemia major (TM) patients were enrolled. Their ages ranged between 12 and 20 years (14.9 ± 2.2 years). All patients underwent the 250 mg cosyntropin test in the morning before blood transfusion. Blood samples for total cortisol, dehdroepiandrosterone (DHEA) and androstendione (A) measurements were collected before and 60 min after IV injection of 250 mg cosyntropin. Adrenal insufficiency was observed in 7 of 45 (15.5%) patients. Adrenal androgen levels decreased significantly with advancing Tanner stage. No difference was noted between patients with and without adrenal insufficiency regarding anthropometric and laboratory parameters. CONCLUSION: Adrenal insufficiency is not a rare complication in thalassemia. Adrenal androgen production declines with advancing puberty in thalassemic adolescents and might explain the poor development of pubic and axillary hair observed in this condition.

Synergistic antioxidant capacities of vanillin and chitosan nanoparticles against reactive oxygen species, hepatotoxicity, and genotoxicity induced by aging in male Wistar rats.

This study aimed to evaluate the synergistic effects of both vanillin (V) and chitosan nanoparticles (CNPs) in alleviating hepatotoxicity, oxidative injury, and genotoxicity induced by d-galactose (DG) and resulted from aging in male albino rats. Male Wistar rats were divided into seven groups (10 rats/group) as follows: control group, (DG) group (100 mg/kg), (V) group (100 mg/kg), CNPs either (low dose (LD) or CNPs (high dose (HD) (140 mg/kg) and (280 mg/kg), and CNPs (LD and HD) dose with V- and DG plus V-treated groups. The CNPs were characterized by transmission electron microscopy (TEM), zeta potential, and size distribution of nanoparticles. After 60 consecutive days of exposure, some biochemical parameters were measured as hepatic aminotransferases enzymes, lipid profile, tumor necrosis factor alpha, interleukin-6 (IL-6), markers of inflammation, tissue damage lactate dehydrogenase, C-reactive protein (CRP), mitochondrial potential activities, myeloperoxidase, xanthine oxidase, CRP, succinate dehydrogenase, mitochondria membrane potential, malondialdehyde levels and antioxidant enzymes (superoxide dismutase, catalase, glutathione reductase, and glutathione S-transferase), and adenosine triphosphate content with histological, alkaline comet assay, and TEM examination of the hepatic tissues. CNPs showed that size distribution (polydispersity index) 0.350 nm and the zeta potential measurement of CNPs were found to be -14.9 mV which revealed the high stability of CNPs. DG induced biochemical and cellular alterations in the hepatic tissues. CNPs and V synergistically afforded protection against hepatic injury and oxidative stress resulting from aging that was induced by DG. Consequently, CNPs were an effective agent in the drug delivery in the hepatic diseases medications and act as a carrier for V and thus make synergistic effect between CNPs and V that achieved the high antioxidant capacities. CNPs and V improved the hepatic enzymes, which act as anti-inflammatory and antigenotoxicity, and improved the antioxidant capacities in the hepatic tissues.

Synthesis of N,N'-bis(1,5-dimethyl-2-phenyl-1,2-dihydro-3-oxopyrazol-4-yl) sebacamide that ameliorate osteoarthritis symptoms and improve bone marrow matrix structure and cartilage alterations induced by monoiodoacetate in the rat model: "Suggested potent anti-inflammatory agent against COVID-19".

To assess the chondroprotective effect and influence of N,N'-bis(1,5-dimethyl-2-phenyl-1,2-dihydro-3-oxopyrazol-4-yl) sebacamide (dpdo) that was synthesized through the reaction of phenazone with sebacoyl chloride and screened for its biological activity especially as anti-arthritic and anti-inflammatory agent in a monoiodoacetate (MA)-induced experimental osteoarthritis (OA) model. Thirty male albino rats weighing "190-200 g" were divided randomly into three groups (10 each): control, MA-induced OA, and MA-induced OA + dpdo. In MA-induced OA rat, the tumor necrosis factor alpha, interleukin 6, C-reactive protein, rheumatoid factors, reactive oxygen species, as well as all the mitochondrial markers such as mitochondria membrane potential, swelling mitochondria, cytochrome c oxidase (complex IV), and serum oxidative/antioxidant status (malondialdehyde level and activities of myeloperoxidase and xanthine oxidase) are elevated. Also, the activity of succinate dehydrogenase (complex II), levels of ATP, the level of glutathione (GSH), and thiol were markedly diminished in the MA-induced OA group compared to the normal control rats. These findings showed that mitochondrial function is associated with OA pathophysiological alterations and high gene expressions of (IL-6, TNF-a, and IL-1b) and suggests a promising use of dpdo as potential ameliorative agents in the animal model of OA and could act as anti-inflammatory agent in case of severe infection with COVID-19. It is clearly appeared in improving the bone cortex and bone marrow in the treated group with the novel compound in histological and transmission electron microscopic sections which is a very important issue today in fighting severe infections that have significant effects on the blood indices and declining of blood corpuscles like COVID-19, in addition to declining the genotoxicity and inflammation induced by MA in male rats. The novel synthesized compound was highly effective in improving all the above mentioned parameters.

Physician Preparedness in Response to the Coronavirus Disease 2019 Pandemic: A Cross-Sectional Study From a Developing Country.

Background December 2019 marked the inception of a global pandemic, with cases being reported worldwide. In the developing nations with scarce healthcare resources, the reliance on healthcare workers who are amply prepared to withstand the prevailing scenario is indispensable. Our study aimed to assess the level of preparedness of doctors working in various hospitals across Pakistan to combat coronavirus disease 2019 (COVID-19). Methods We conducted an online questionnaire-based survey in May 2020 to estimate the level of preparedness of doctors working in various departments of various private and public hospitals across Pakistan. The survey comprised 36 questions, with items evaluating the provision of adequate protective equipment, training, mental health resources, and sound collaboration between healthcare workers and the hospital management during the COVID-19 crisis. Results A total of 346 doctors responded to the survey, among whom 56.4% were working in public sector hospitals and 46.5% were working more than five days per week. Of those included, 87.6% were being provided with disposable gloves, but 72.8% and 43.4% of respondents professed to having no access to eye protective equipment and gowns, respectively. Only 35.3% of respondents claimed to be trained regarding the use of personal protective equipment and 28.95% were being tested. Of the physicians, 43.4% claimed to have no proper triage system for the suspected patients and 98.3% were concerned about transmitting the disease to their family members. Of the doctors, 53.5% reported that there was sound collaboration between the hospital management and healthcare staff. Conclusion The survey provided evidence of inadequate delivery of personal protective equipment and training to doctors working in various hospitals across Pakistan. A sound collaboration between the hospital management and departments needs to be addressed.

[Radiological protocol of large scale mammographic screeening for breast cancer in Ariana area of Tunisia]. / Protocole radiologique du dépistage mammographique du cancer du sein au gouvernorat de l'Ariana en Tunisie.

We present the radiological protocol of the breast cancer screening program of Ariana state in Tunisia. Specifications of this protocol are largely inspired from the french model adapted to the socioeconomic Tunisian conditions. We explain the guidelines of the mammograph specifications, quality insurance of all the process, mammography procedure, double reading, complementary views and ultrasound indications and final results management.

[Lesions classified ACR3 with the breast cancer screening mammography program of the Ariana area: features and problems encountered]. / Lésions classées ACR3 dans le programme de dépistage mammographique du cancer du sein du gouvernorat de l'Ariana: profil et difficultés de prise en charge.

OBJECTIVE: This retrospective work is related to ACR3 mammograms of the program "Feasibility of breast cancer screening by mammography in Ariana Governorate" in order to evaluate the efficiency and short-term quality control of these probably benign lesions. MATERIALS AND METHODS: Mammograms classified ACR3 raised the indication of further examination, futher mammogram (profile, expanded or compression). The monitoring and control period are explained to the patient by the radiologist. RESULTS: 6.6% mammograms were classified as ACR 3 with 71.3% under the age of 50 years. Breast is very dense in 20.5% of cases, and transparent in 6% of cases. Further exams has been performed in 94. 5% of cases with a profile in 52% of cases, enlarged in 22.1%, compression in 24.9% and ultrasound in 82.5%. The surveillance protocol was insufficient for 126 women lost to the 1st control, 32 women lost for the 2nd control and 19 women were lost to the 3rd control. After two years monitoring, 219 women were reclassified as ACR2 with a negative test. In 2 patients, we found an invasive ductal carcinoma at 4 months control. CONCLUSION: ACR 3 mammograms are the most important operator dependent category. The diagnosis of probably benign lesion dependant of the analysis of images and requires a great experience of the radiologist and a comprehensive complementary examination. In this study, this assessment was often heavy in relation to the frequency of dense breasts itself in connection with the young age of patients. In addition, for this particular category, the need of training is important and in terms of public health cost, the management of ACR3 mammograms increases difficulties and cost of screening.

[Retrospective results of ultrasonographically-guided biopsy the breast cancer screening program of the Ariana area of Tunisia]. / Etude rétrospective des résultats des cytoponctions et des microbiopsies mammaires écho-guidées du programme du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To report the results of breast ultrasonographically-guided fine needle aspirations and needle biopsies within the breast cancer screening program of L'Ariana state in Tunisia. MATERIAL AND METHODS: Our retrospective study include 143 patients, with mammographically detected lesions, which underwent a diagnostic percutanous ultrasonographically guided procedures. 57 patients underwent a fine needle aspiration, 25 underwent a needle biopsy and 61 patients underwent both procedures. RESULTS: Sensitivity and specificity of fine needle aspiration are of 84.2% and 98.5%. We report 13.5% of non contributive results. The needle biopsy have a sensitivity of 97.3% and a specificity of 100% with one false negative corresponding to an atypical ductal hyperplasia at the excisional biopsy. CONCLUSION: Fine needle aspiration is a reliable method of accurately establishing a diagnosis. Needle biopsy is recommended for a preoperative lesion characterisation before adequate treatment.

Diphenoxylate-atropine (Lomotil) Toxicity in Infantile Diarrhea: A Case Report of Therapeutic Failure.

Diphenoxylate-atropine (Lomotil) intoxication incidence was significantly high in the past, but seeing such cases in the present day of modern and advanced medicine, hints about the gaps in the practice of medicine. In our case, a general physician maltreated an infant for diarrhea with an adult dose of diphenoxylate-atropine (Lomotil), a Food and Drug Administration (FDA) unapproved drug, which caused labored breathing and pinpoint pupils. After being maltreated, at the time of presentation to the emergency room (ER), she was being misdiagnosed as a case of dehydration until doctors noticed miosis and reached the diagnosis of diphenoxylate-atropine (Lomotil) toxicity. Her condition completely reversed with a single dose of naloxone. Hence, this case highlights the need for basic knowledge about the dosage of drugs for different age groups, especially infants, along with the importance of adherence to the evaluation protocols for accurate management.

The beneficial effects of l-cysteine on brain antioxidants of rats affected by sodium valproate.

Oxidative stress caused by sodium valproate (SV) is known to play a key role in the pathogenesis of brain tissue. The present study was designed to evaluate the protective effect of l-cysteine (LC) on the antioxidants of brain tissue of rats. The animals were divided into six groups: control group 1 was treated with saline as vehicle, groups 2 and 3 were treated with low and high doses of SV (100 and 500 mg/kg, respectively), group 4 was treated with LC (100 mg/kg), and groups 5 and 6 were treated with low-dose SV + LC and high-dose SV + LC, respectively. All the groups were treated orally by gastric tube for 30 successive days. Some antioxidant parameters were determined. Brain tissue (cerebral cortex) of SV-treated animals showed an increase in lipid peroxidation (LPO) and reduction in activity of enzymatic antioxidant and total antioxidant levels. Histopathological examination of cerebral cortex of SV rats showed astrocytic swelling, inflammation, and necrosis. After 4 weeks of the combination treatment of SV and LC daily, results showed significant improvement in the activity of cathepsin marker enzymes and restored the structure of the brain. LC was able to ameliorate oxidative stress deficits observed in SV rats. LC decreased LPO level and was also able to restore the activity of antioxidant enzymes as well as structural deficits observed in the brain of SV animals. The protective effect of LC in SV-treated rats is mediated through attenuation of oxidative stress, suggesting a therapeutic role for LC in individuals treated with SV.

[MRI findings in neuro-Behcet's disease]. / Aspect en IRM du neuro-Behcet.

PURPOSE: Describe the patterns and location of lesions seen on MR imaging in neuro-Behçet's disease. OBSERVATIONS: 33 patients with neuro-Behçet's disease (mean age: 27 years) imaged by MRI were reviewed. Most common neurologic symptoms included headaches and pyramidal signs. MRI examinations (Siemens Magnetom Impact 1 Tesla) included the following sequences: T1wi, T2wi, Flair, MPR-3D and MRA sequences. RESULTS: Parenchymal lesions were identified in 21 patients. Brainstem, internal capsule, cerebral white matter, basal ganglia were involved respectively in 14, 10, 7, and 5 cases. Vascular thrombosis (venous: n=7; arterial: n=1) were observed in eight. MRI was normal in four patients. CONCLUSION: This study shows the value of MR imaging for the exploration of parenchymal lesions of neuro-Behçet's and confirms the frequency of brainstem involvement.

[Osteoid osteoma of the coccyx: a case report]. / Ostéome ostéoïde du coccyx: à propos d'un cas.

The spine is a rare localization of osteoid osteoma and the coccyx even more exceptional. We report a case of osteoid osteoma of the coccyx in a young man who consulted for sacrococcygeal pain partially relieved with salicylates. Computed tomography of the region demonstrated a typical osteoid osteoma lesion. CT-guided localization enabled complete resection of the nidus as demonstrated by the CT of the operative specimen Pathology confirmed the diagnosis of osteoid osteoma. Outcome has been quite favorable at two years.

Uroplakin II gene is expressed in transitional cell carcinoma but not in bilharzial bladder squamous cell carcinoma: alternative pathways of bladder epithelial differentiation and tumor formation.

Uroplakins (UPs) are integral membrane proteins that are synthesized as the major differentiation products of mammalian urothelium. We have cloned the human UP-II gene and localized it on chromosome 11q23. A survey of 50 transitional cell carcinomas (TCCs) revealed a UP-II polymorphism but no tumor-specific mutations. Immunohistochemical staining using rabbit antisera against a synthetic peptide of UP-II and against total UPs showed UP reactivity in 39.5% (17 of 43 cases) of conventional TCCs, 12.8% (5 of 39) of bilharzial-related TCCs, and 2.7% (1 of 36) of bilharzial-related squamous cell carcinomas (SCCs). The finding that fewer bilharzial TCCs express UPs than conventional TCCs (12.8 versus 40%) raised the possibility that the former are heterogeneous, expressing SCC features to varying degrees. Our data strongly support the hypothesis that urothelium can undergo at least three pathways of differentiation: (a) urothelium-type pathway; (b) epidermis-type pathway; and (c) glandular-type pathway, characterized by the production of UPs, K1/K10 keratins, and secreted glycoproteins, respectively. Vitamin A deficiency and mesenchymal factors may play a role in determining the relative contributions of these pathways to urothelial differentiation as well as to the formation of TCC, SCC, and adenocarcinoma, or a mixture thereof.

Expression of cyclin D1, but not cyclins E and A, is related to progression in bilharzial bladder cancer.

The present study was conducted to analyze the alterations affecting cyclins D1, E, and A in bilharzial bladder cancer and to assess their potential clinical significance. A total of 125 cases were examined. Histopathological subtypes included 68 squamous cell carcinomas, 55 transitional cell carcinomas, and 2 adenocarcinomas. Immunohistochemical analyses were performed using a panel of well-characterized antibodies. The results were correlated with proliferative index, as assessed by Ki67 antigen expression. The cyclin D1-positive phenotype, defined as the identification of positive immunoreactivity in the nuclei of >/=20% of tumor cells, was found in 33 of 107 (31%) evaluable cases. A significant association was observed between the cyclin D1-positive phenotype and deep muscle invasion (P = 0.02), high tumor grade (P = 0.02), and Ki67 high proliferative index (P = 0.03). The cyclin E-positive phenotype, defined as per cyclin D1, was found in 79 of 106 (75%) evaluable cases. The cyclin A-positive phenotype, defined using the above criteria, was identified in 60 of 108 (56%) evaluable cases. No statistically significant association was found between cyclins E or A and clinicopathological parameters or proliferative index. However, there was a strong association between the expression of cyclin D1 and the coexpression of cyclins A and/or E (P = 0.05). Ki67 proliferative index was considered high when >/=20% of tumor cells displayed positive nuclear staining, a phenotype that was observed in 99 of 115 (86%) cases. These data support the hypothesis that cyclin D1 activation determines the evolution of a particular subset of aggressive bladder tumors. In addition, cyclins E and A seem to follow an unscheduled pattern of expression, based on the high frequency of identifying a positive phenotype for these cyclins and the lack of correlation between their expression and Ki67 high proliferative index. It may be postulated that the expression of G1 cyclin genes is deregulated in bilharzial bladder cancer, and that cyclin D1 acts as an oncogenic event in these neoplasms. Moreover, the moderate number of tumors displaying the cyclin D1-positive phenotype (31%) versus the high frequency observed for both cyclins E (75%) and A (56%), suggests a short G1 disbalanced by a long S phase and a rapid transversal of the cell cycle, as evidenced by a high Ki67 index observed in 86% of these cases. This imbalance in the cell cycle, together with alterations reported on the p53 pathway, might underline the accumulation of DNA damage and the aggressive clinical course of bilharzial bladder cancer.

Alterations affecting the p53 control pathway in bilharzial-related bladder cancer.

Bilharzial-related bladder carcinoma (BBC) is the most common malignant neoplasm in Egypt, also occurring with a high incidence in other regions of the Middle East and East Africa. The clinical and pathological features of BBC are different than those described for the conventional transitional cell carcinoma of the bladder, including the high incidence of squamous cell carcinoma reported in BBC and the fact that over 90% of BBC cases at presentation are advanced-stage tumors (P3 and P4). This study was conducted to better define the phenotypic alterations associated with BBC affecting the p53 cell cycle control pathway, including altered patterns of expression of downstream effector proteins such as mdm2 and p21/WAF1. A well-characterized cohort of 125 patients affected with bilharzial-related bladder tumors was studied. Tumors were classified as squamous carcinomas (n = 68), transitional cell carcinomas (n = 55), or adenocarcinomas (n = 2). The products encoded by TP53, mdm2, and p21/WAF1 genes were analyzed by immunohistochemistry. Furthermore, the patterns of expression of these molecules were correlated with the Ki67 proliferative index. In addition, the microanatomical distribution of programmed cell death was assessed in a subset of tumors, using the so-called terminal deoxynucleotidyl transferase-mediated nick end labeling method. p53 nuclear overexpression was identified in 25 (20%) of 125 cases. Nuclear overexpression of mdm2 was detected in 74 (59.2%) of 125 cases. There was a statistically significant association between coexpression of both p53 and mdm2 and detection of lymph node metastases (P = 0.04). p21/WAF1 expression was detected in 87 (72%) of 121 evaluable cases. A high Ki67 proliferative index was observed in 99 (86%) of 115 evaluable cases. There was a statistically significant association between high Ki67 proliferative index and mdm2-positive phenotype (P = 0.005) and deep muscle invasion (P3b; P = 0.026) as well as lymph node metastases (P = 0.039). Apoptosis was observed in terminally differentiated tumor cells identified in the superficial layers of well-differentiated squamous carcinoma or exfoliating cells in transitional lesions. However, only rare apoptotic tumor cells were found in basal or suprabasal layers as well as in the invasive elements of the neoplasms studied. These results suggest that the frequency of p53 nuclear overexpression in BBC is lower than that reported for conventional transitional cell carcinoma. Nevertheless, tumors with p53 alterations have a greater propensity to progress. The prominent number of cases displaying an mdm2-positive phenotype suggests that this may be an early incident in BBC and should be regarded as a potential oncogenic phenomenon. This is supported by the significant correlation between high Ki67 proliferative index and mdm2 overexpression. The association of an aggressive clinical course with the coexpression of both p53 and mdm2 products might be viewed as a cooperative effect that develops in tumor progression.