BACKGROUND:It is unclear whether a short-term change in circulating androgens is associated with changes in the transcriptome of the peripheral blood mononuclear cells (PBMC). AIMS AND METHODS:To explore the effect of hCG stimulation on the PBMC transcriptome, 12 boys with a median age (range) of 0.7 years (0.3, 11.2) who received intramuscular hCG 1500u on 3 consecutive days as part of their investigations underwent transcriptomic array analysis on RNA extracted from peripheral blood mononuclear cells before and after hCG stimulation. RESULTS:Median pre- and post-hCG testosterone for the overall group was 0.7 nmol/L (<0.5, 6) and 7.9 nmol/L (<0.5, 31.5), respectively. Of the 12 boys, 3 (25%) did not respond to hCG stimulation with a pre and post median serum testosterone of <0.5 nmol/L and <0.5 nmol/L, respectively. When corrected for gene expression changes in the non-responders to exclude hCG effects, all 9 of the hCG responders consistently demonstrated a 20% or greater increase in the expression of piR-37153 and piR-39248, non-coding PIWI-interacting RNAs (piRNAs). In addition, of the 9 responders, 8, 6 and 4 demonstrated a 30, 40 and 50% rise, respectively, in a total of 2 further piRNAs. In addition, 3 of the responders showed a 50% or greater rise in the expression of another small RNA, SNORD5. On comparing fold-change in serum testosterone with fold-change in the above transcripts, a positive correlation was detected for SNORD5 (P = 0.01). CONCLUSIONS:The identification of a dynamic and androgen-responsive PBMC transcriptome extends the potential value of the hCG test for the assessment of androgen sufficiency.

Background: In boys with suspected partial androgen insensitivity syndrome (PAIS), systematic evidence that supports the long-term prognostic value of identifying a mutation in the androgen receptor gene (AR) is lacking.Objective: To assess the clinical characteristics and long-term outcomes in young men with suspected PAIS in relation to the results of AR analysis.Methods: Through the International Disorders of Sex Development Registry, clinical information was gathered on young men suspected of having PAIS (n = 52) who presented before the age of 16 years and had genetic analysis of AR.Results: The median ages at presentation and at the time of the study were 1 month (range, 1 day to 16 years) and 22 years (range, 16 to 52 years), respectively. Of the cohort, 29 men (56%) had 20 different AR mutations reported. At diagnosis, the median external masculinization scores were 7 and 6 in cases with and without AR mutation, respectively (P =.9), and median current external masculinization scores were 9 and 10, respectively (P =.28). Thirty-five men (67%) required at least one surgical procedure, and those with a mutation were more likely to require multiple surgeries for hypospadias (P =.004). All cases with an AR mutation had gynecomastia, compared to 9% of those without an AR mutation. Of the six men who had a mastectomy, five (83%) had an AR mutation.Conclusions: Boys with genetically confirmed PAIS are likely to have a poorer clinical outcome than those with XY DSD, with normal T synthesis, and without an identifiable AR mutation. Routine genetic analysis of AR to confirm PAIS informs long-term prognosis and management.

Background: Between 1961-1971 vitamin D deficiency was recognized as a public health issue in the UK, because of the lack of effective sunlight and the population mix [1, 2]. In recent years, health care professionals have cited evidence suggesting a re-emergence of the vitamin D deficiency linked to a number of health consequences as a concern [3-6]. Evidence from observational studies has linked low vitamin D status with impairment in glucose homeostasis and immune dysfunction [7-9]. However, interventional studies, particularly those focused on paediatric populations, have been limited and inconsistent. There is a need for detailed studies, to clarify the therapeutic benefits of vitamin D in these important clinical areas. Objective: The aims of this PhD thesis were two-fold. Firstly, to perform preliminary work assessing the association between vitamin D deficiency and bone status, glucose homeostasis and immune function, and to explore any changes in these parameters following short term vitamin D3 replacement therapy. Secondly, to assess the effectiveness of an electronic surveillance system (ScotPSU) as a tool to determine the current incidence of hospital-based presentation of childhood vitamin D deficiency in Scotland. Methods: Active surveillance was performed for a period of two years as a part of an electronic web-based surveillance programme performed by the Scottish Paediatric Surveillance Unit (ScotPSU). The validity of the system was assessed by identifying cases with profound vitamin D deficiency (in Glasgow and Edinburgh) from the regional laboratory. All clinical details were checked against those identified using the surveillance system. Thirty-seven children aged 3 months to 10 years, who had been diagnosed with vitamin D deficiency, were recruited for the bone, glucose and immunity studies over a period of 24 months. Twenty-five samples were analysed for the glucose and bone studies; of these, 18 samples were further analysed for immune study. Treatment consisted of six weeks taking 5000 IU units cholecalciferol orally once a day. At baseline and after completion of treatment, 25 hydroxyvitamin D (25(OH)D), parathyroid hormone (PTH), alkaline phosphatase (ALP), collagen type 1 cross-linked C-telopeptide (CTX), osteocalcin (OCN), calcium, phosphate, insulin, glucose, homeostasis model assessment index, estimated insulin resistance (HOMA IR), glycated hemoglobin (HbA1c), sex hormone binding globulin (SHBG), lipids profiles, T helper 1 (Th1) cytokines (interleukin-2 ( IL-2), tumor necrosis factors-alpha (TNF-α), interferon-gamma (INF-γ)), T helper 2 (Th2) cytokines (interleukin-4 (IL-4), interleukin-5 (IL-5), interleukin-6 (IL-6)), T helper 17 (Th17) cytokine (interleukin-17 (IL-17)), Regulatory T (Treg) cytokine (interleukin-10 (IL-10)) and chemokines/cytokines, linked with Th1/Th2 subset balance and/or differentiation (interleukin-8 (IL-8), interleukin-12 (IL-12), eosinophil chemotactic protein ( EOTAXIN), macrophage inflammatory proteins-1beta (MIP-1β), interferon-gamma-induced protein-10 (IP-10), regulated on activation, normal T cell expressed and secreted (RANTES), monocyte chemoattractant protein-1(MCP-1)) were measured. Leukoocyte subset analysis was performed for T cells, B cells and T regulatory cells and a luminex assay was used to measure the cytokiens. Results: Between September 2009 and August 2011, 163 cases of vitamin D deficiency were brought to the attention of the ScotPSU, and the majority of cases (n = 82) were reported in Glasgow. The cross-validation checking in Glasgow and Edinburgh over a one-year period revealed only 3 (11%) cases of clearly symptomatic vitamin D deficiency, which had been missed by the ScotPSU survey in Glasgow. While 16 (67%) symptomatic cases had failed to be reported through the ScotPSU survey in Edinburgh. For the 23 children who are included in bone and glucose studies, 22 (96%) children had basal serum 25(OH)D in the deficiency range ( 50-75 nmol/l, 12 (52%) children reached a final serum 25(OH)D >75-150 nmol/l and finally 3 (13%) exceeded the normal reference range with a final 25(OH)D >150 nmol/l. Markers for remodelling ALP and PTH had significantly decreased (p = 0.001 and <0.0001 for ALP and PTH respectively). In 17 patients for whom insulin and HOMA IR data were available and enrolled in glucose study, significant improvements in insulin resistance (p = 0.04) with a trend toward a reduction in serum insulin (p = 0.05) was observed. Of those 14 children who had their cytokines profile data analysed and enrolled in the immunity study, insulin and HOMA IR data were missed in one child. A significant increase in the main Th2 secreted cytokine IL-4 (p = 0.001) and a tendency for significant increases in other Th2 secreted cytokines IL-5 (p = 0.05) and IL-6 (p = 0.05) was observed following vitamin D3 supplementation. Conclusion: An electronic surveillance system can provide data for studying the epidemiology of vitamin D deficiency. However, it may underestimate the number of positive cases. Improving vitamin D status in vitamin D deficient otherwise healthy children significantly improved their vitamin D deficient status, and was associated with an improvement in bone profile, improvements in insulin resistance and an alteration in main Th2 secreting cytokines.

BACKGROUND The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the UK and worldwide. Before the onset of T2DM, there are two conditions characterised by blood glucose levels that are above normal but below the threshold for diabetes. If screening for T2DM in introduced, many people with impaired glucose tolerance (IGT) will be found and it is necessary to consider how they should be treated. The number would depend on what screening test was used and what cut-offs were chosen. OBJECTIVE To review the clinical effectiveness and cost-effectiveness of non-pharmacological interventions, including diet and physical activity, for the prevention of T2DM in people with intermediate hyperglycaemia. DATA SOURCES Electronic databases, MEDLINE (1996-2011), EMBASE (1980-2011) and all sections of The Cochrane Library, were searched for systematic reviews, randomised controlled trials (RCTs) and other relevant literature on the effectiveness of diet and/or physical activity in preventing, or delaying, progression to T2DM.The databases were also searched for studies on the cost-effectiveness of interventions. REVIEW METHODS The review of clinical effectiveness was based mainly on RCTs, which were critically appraised. Subjects were people with intermediate hyperglycaemia, mainly with IGT. Interventions could be diet alone, physical activity alone, or the combination. For cost-effectiveness analysis, we updated the Sheffield economic model of T2DM. Modelling based on RCTs may not reflect what happens in routine care so we created a 'real-life' modelling scenario wherein people would try lifestyle change but switch to metformin after 1 year if they failed. RESULTS Nine RCTs compared lifestyle interventions (predominantly dietary and physical activity advice, with regular reinforcement and frequent follow-up) with standard care. The primary outcome was progression to diabetes. In most trials, progression was reduced, by over half in some trials. The best effects were seen in participants who adhered best to the lifestyle changes; a scenario of a trial of lifestyle change but a switch to metformin after 1 year in those who did not adhere sufficiently appeared to be the most cost-effective option. LIMITATIONS Participants in the RCTs were volunteers and their results may have been better than in general populations. Even among the volunteers, many did not adhere. Some studies were not long enough to show whether the interventions reduced cardiovascular mortality as well as diabetes. The main problem is that we know what people should do to reduce progression, but not how to persuade most to do it. CONCLUSION In people with IGT, dietary change to ensure weight loss, coupled with physical activity, is clinically effective and cost-effective in reducing progression to diabetes. FUNDING The National Institute for Health Research Health Technology Assessment programme.

Background: Early warning scores (EWS) are widely used to allow early recognition of the deteriorating patient. We aimed to test their ability to predict major deterioration in medical patients.Methods: Two cohorts were prospectively identified who were admitted to an acute medical admissions unit and to the respiratory unit but not admitted to the intensive care unit (ICU): medical-non ICU and respiratory-non ICU groups. Two further cohorts were retrospectively identified that required ICU admission from these units (medical-ICU and respiratory-ICU groups). Discriminant analysis and receiver operating characteristic curves were used to discriminate between groups, and time relationships were analysed.Results: Heart rate (HR), respiratory rate (RR) and oxygen saturation (SaO(2)) were significantly higher in the medical-ICU group than the medical-non ICU group and significantly higher in the respiratory-ICU group than in the respiratory-non ICU group. Discriminant functions incorporating HR, RR and SaO(2) performed at least as well as existing EWS systems in predicting ICU admission.Conclusions: Commonly used physiological parameters and existing EWS systems are useful at identifying sick patients. The discriminant functions described here appear to have a role in this setting but require validation in future studies.

Aims Studies of children with diabetes up to the age of 15 years report deteriorating glycaemic control in the early teenage years. The aim was to investigate glycaemia and body mass index in older teenagers and young adults.Method A Scottish, regional, population-based, cross-sectional study of 255 young people (117 female, 138 male) with Type 1 diabetes, aged 15-25 years (mean +/- SD 19.8 +/- 2.8 years, diabetes duration: 8.8 +/- 5.4 years) registered on a diabetes database. Glycaemic control, body mass index (BMI) and insulin regimens were assessed in three age groups [group 1 (n = 96) 15-18 years; group 2 (n = 74) 18.1-22 years; and group 3 (n = 85) 22.1-25 years].Results Subjects in the oldest age group had a significantly lower mean HbA(1c) than those in the youngest age group (8.8 +/- 1.7 vs. 9.9 +/- 1.9%; P < 0.001). Mean BMI was higher in group 3 (25.2 +/- 3.4 kg/m(2)) compared with group 1 (23.9 +/- 3.1 kg/m(2); P < 0.001). HbA(1c) levels were higher in the younger subjects and women. Lower HbA(1c) levels were associated with a higher BMI (r = -0.324, P < 0.001) in men only. Overall, 74% took three or more injections a day, of whom 60% were on basal/bolus therapy. The proportion on basal/bolus insulin therapy increased with age and duration of diabetes.Conclusion Compared with adolescents, young adults with Type 1 diabetes have better glycaemic control and higher BMI. This was associated with lower insulin requirements.

BACKGROUNDIn preliminary data in Portugal, we found that African babies of migrant mothers were heavier than White Portuguese babies born in Lisbon. We investigate whether this pattern is replicated in the national data, and in addition the trends in birth weight in these groups.METHODSDESIGN AND SETTINGBirths registered between 1995 and 2002 classified by reported nationality of mothers.PARTICIPANTS849,595 Portuguese births ('Portuguese' nationality, predominantly of European descent) and 22,463 African births ('Angola', 'Cape Verde', or 'Guinea Bissau, Republic of Guinea or Equatorial Guinea' nationality, predominantly of African origin).RESULTSAmong Portuguese births, there was a decline in births to teenaged mothers and an increase to mothers aged >or=35 years, with >9 years of education or in a non-manual class, but among African births there was an increase in births to teenaged mothers and a decline to mothers from advantaged socioeconomic backgrounds. Using the Wilcox-Russell method, overall mean birth weights of term Portuguese (3,303, SD 424 g) and African (3297, SD 441 g) babies were not different but the percentage of small preterm births was higher among African (4.7%) than among Portuguese (2.9%) births. Between 1995 and 2002, mean birth weight of term Portuguese babies declined by 58 g (3,334-3,276 g) and of African babies by 57 g (3,341-3,284 g). The left shift of the birth weight distributions was independent of maternal age, parity, and social factors among Portuguese babies, but among African babies the decrease appeared to be associated with socioeconomic advantage.CONCLUSIONThere has been a downward trend in birth weights in Portugal among both Portuguese and African term births, but average birth weights of the two groups were similar.

Modulators of P-glycoprotein (P-gp) can enhance or limit the permeability of a number of therapeutic agents that are considered substrates of this efflux pump protein. The modulatory effect of amlodipine (4-dihydropyridine calcium antagonist) on P-gp efflux activity has not been fully elucidated. We have studied the concentration dependency of its modulatory effect and compared it qualitatively with tamoxifen (a non-esteroid anti-estrogen). The investigation was conducted on transmembrane efflux of doxorubicin at a fixed concentration of 5 microM across a Caco-2 monolayer in the presence of various concentrations of amlodipine or tamoxifen. The maximum flux of doxorubicin from basolateral to apical (ba) occurred at 4.5 microM amlodipine and at 0.02 microM tamoxifen. At higher concentrations, the apical to basolateral (ab) flux and the net flux of doxorubicin (ba - ab) declined steadily in a concentration-dependent manner. We analysed the observed net flux data by fitting different mathematical models to the data. A composite sigmoidal Emax/Imax (stimulatory/inhibitory) model was found to be the most appropriate to define the system. The observed and calculated parameters supported the modulatory role of both compounds and clearly indicated that the stimulation and inhibition of transmembrane efflux occurred simultaneously in the presence of amlodipine or tamoxifen. It was concluded that amlodipine, similar to tamoxifen, modulated the transporter-dependent transmembrane flux of the P-gp substrate in a concentration-dependent manner.

There is compelling in-vitro evidence that the evaluation of doxorubicin or epirubicin pharmacokinetics based solely on plasma concentration may not fully elucidate the differences between the two drugs. Both compounds bind to erythrocytes and their different binding to haemoglobin may influence their disposition in the body. The purpose of the present study was to compare the pharmacokinetics and metabolism of doxorubicin and epirubicin based on the plasma concentration, amount associated with blood cells and simultaneous monitoring of biliary and urinary elimination of unchanged drug and metabolites after single- and multiple-dose injections. The level of sarcoplasmic reticulum Ca(2+)ATPase in the heart was also measured as a biomarker of cardiotoxicity. Male Sprague-Dawley rats were treated in a parallel design with doxorubicin or epirubicin on a multiple-dosing basis (4 mg kg(-1) per week) or as a single dose injection (20 mg kg(-1)). Blood, urine and bile samples were collected periodically after each dose in the multiple-dosing regimen and the single dose injection, and at the end of each experiment the hearts were removed. The concentrations of each drug in plasma, blood cells, bile and urine samples were determined, and by simultaneous curve-fitting of plasma and bile data according to compartmental analysis, the pharmacokinetic parameters and constants were estimated. The concentration of drug associated with blood cells was analysed according to non-compartmental analysis. The bile and urine samples provided the in-vivo metabolic data. The level of Ca(2+)ATPase in the heart, determined by Western blotting, was used as the toxicodynamic parameter to correlate with the kinetic data. Multiple-dosing regimens reduced the total plasma clearance and increased the area under the plasma concentration-time curve of both drugs. Also, the area under the curve of doxorubicin associated with blood cells increased with the weekly doses, and the related mean residence time (MRT) and apparent volume of distribution (Vd(ss)) were steadily reduced. ln contrast to doxorubicin, the MRT and Vd(ss) of epirubicin increased significantly. Metabolic data indicated significant differences in the level of alcohol and aglycones metabolites. Doxorubicinol and doxorubicin aglycones were significantly greater than epirubicinol and epirubicin aglycone, whereas epirubicinol aglycone was greater than doxorubicinol aglycone. The area under the blood cells concentration-time curve correlated linearly with the changes in Ca(2+)ATPase net intensity. The results of this study demonstrate the importance of the kinetics of epirubicin and doxorubicin associated with blood cells. Linear correlation between the reduction of net intensity of the biomarker with the area under the curve of doxorubicin associated with blood cells confirms that the differences between the two compounds are related to their interaction with blood cells. This observation together with the observed differences in metabolism may underline a significant role for blood cells in distribution and metabolism of doxorubicin and epirubicin.

The molecular structure and anti-tumour activity of doxorubicin and epirubicin are similar. However, the incidence of their cardiotoxicity occurs at different cumulative dose concentrations. The purpose of this study was to investigate the in-vitro interaction of these two drugs with different blood components, namely intact erythrocytes, haemoglobin and erythrocyte ghosts. Plasma protein binding was also evaluated. The intended goal was to identify the most relevant samples among total blood, plasma or blood cells for pharmacokinetic analysis. The methodology involved the incubation of each of the blood components (the intact erythrocytes, erythrocyte ghosts, haemoglobin and plasma proteins) at physiological pH and temperature with different concentrations of each drug, followed by measurement by HPLC and fluorometry at excitation and emission wavelengths of 480 and 580 nm, respectively. The results indicated that the binding of doxorubicin and epirubicin to plasma proteins, erythrocyte ghosts and intact erythrocytes was essentially the same. However, the binding of both compounds to intact erythrocytes was significantly different from erythrocyte ghosts, which indicates that haemoglobin plays an important role in the binding to and uptake by erythrocytes. The isotherms of binding to haemoglobin revealed that the maximum binding of doxorubicin was approximately 0.42 microg mg(-1) haemoglobin; for epirubicin this value was ten times greater than for doxorubicin. The Scatchard plot of binding of both drugs to haemoglobin exhibited two distinct binding sites for each drug. The constant of association of high affinity and low capacity binding sites was significantly greater for epirubicin, whereas the constant of association of low affinity and high capacity binding sites was significantly higher for doxorubicin. The number of high affinity binding sites per mg of haemoglobin was estimated to be 0.072 for doxorubcin and 0.030 for epirubicin. The number of low affinity binding sites was significantly greater for epirubicin (1.963) than for doxorubicin (0.305). Since the combined number of binding sites for epirubicin was more than doxorubicin, and the total uptake by erythrocytes remained the same for both drugs, it was concluded that epirubicin, being a more lipophilic compound, may diffuse more freely into the cells. Therefore, it binds more to haemoglobin, whereas doxorubicin remains more adsorbed on the surface of the cells due to its self-association property. It was concluded that the interaction of both drugs with erythrocytes, although it appears to be similar, is significantly different due to the interaction with haemoglobin. The difference in this interaction is expected to influence the disposition of both drugs in-vivo.