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The effect of population growth and demographic transition on economic development has been well documented. The population growth in Iraqi Kurdistan is passing through a critical stage of demographic transition. It is, in fact, extremely likely that the region will fail to efficiently move through the demographic transition and will experience a long period in the demographic trap, i.e. the population will grow steadily and rapidly owing to the high fertility and low mortality rates. With correct government policies in terms of promoting family planning programmes, should the political context allow, demographic transition can pass smoothly through this critical stage. Furthermore, if demographic transition in Kurdistan moves to the next stage, it will provide an important window of opportunity for economic development. Proper exploitation of this demographic window through investment in education, on-the-job training and health services, in addition to proper and appropriate exploitation of economic resources and suitable and productive use of the labour force, will result in significant economic development over the next few decades. [ABSTRACT FROM AUTHOR]

Abstract Background As part of a comprehensive study on the primary health care system in Iraq, we sought to explore primary care providers’ perspectives about the main problems influencing the provision of primary care services and opportunities to improve the system. Methods A qualitative study based on four focus groups involving 40 primary care providers from 12 primary health care centres was conducted in Erbil governorate in the Iraqi Kurdistan region between July and October 2010. A topic guide was used to lead discussions and covered questions on positive aspects of and current problems with the primary care system in addition to the priority needs for its improvement. The discussions were fully transcribed and the qualitative data was analyzed by content analysis, followed by a thematic analysis. Results Problems facing the primary care system included inappropriate health service delivery (irrational use of health services, irrational treatment, poor referral system, poor infrastructure and poor hygiene), health workforce challenges (high number of specialists, uneven distribution of the health workforce, rapid turnover, lack of training and educational opportunities and discrepancies in the salary system), shortage in resources (shortage and low quality of medical supplies and shortage in financing), poor information technology and poor leadership/governance. The greatest emphasis was placed on poor organization of health services delivery, particularly the irrational use of health services and the related overcrowding and overload on primary care providers and health facilities. Suggestions for improving the system included application of a family medicine approach and ensuring effective planning and monitoring. Conclusions This study has provided a comprehensive understanding of the factors that negatively affect the primary care system in Iraq’s Kurdistan region from the perspective of primary care providers. From their experience, primary care providers have a role in informing the community and policy makers about the main problems affecting this system, though improvements to the health care system must be taken up at the national level and involve other key stakeholders.

Abstract Background Violence against women by intimate partners is still a public health problem. The study aims at finding out the prevalence of violence among women residing in Erbil city (Muslim culture) and in Ankawa sub-district (Christian culture), finding out the role of religion and culture on the prevalence, and finding out some other factors (like occupation of husband and wife, age at marriage, woman agreement for marriage, illegitimate relations of husband) that might be associated with violence. Methods A cross-sectional study was carried out in Erbil during the second half of the year 2011. Two groups were considered; group one (G1) included women residing in Ankawa sub-district (representing Christian culture), and group two (G2) included women residing in Erbil city (representing Muslim culture). A convenience method of sampling was used to collect the sample (250 women of each group). Questionnaire was designed to collect information about history of exposure to physical, sexual, and psychological violence, in addition to the related factors. These forms were distributed (by women of the Assyrian Women Union) in sealed envelopes to women attending the Mass in three churches located in Ankawa. Women of Erbil group were recruited from the maternity teaching hospital of Erbil. The same questionnaire was distributed to them by the same team. Binary logistic regression was used to show the independent effect of each factor on the prevalence of violence. Results Overall prevalence of violence (physical and/or sexual) in G2 (20.8%) was higher than that of G1 (18.8%). The prevalence of psychological violence was 40% in Erbil, which was significantly higher than the prevalence (24.8%) of Ankawa. The rates of physical and sexual violence were also higher in Erbil (18.4%, and 10.8% respectively) than rates of Ankawa (16.8% and 8% respectively). Factors found to be significantly associated with overall violence were: culture of Erbil, alcoholic husband, wife working as manual worker (compared with professionals), and having children. Conclusion Violence against women is a serious public health issue. There was significant role of culture on the prevalence of violence.

Abstract Background Medical education in Iraq is poorly assessed and there is a general lack of documented knowledge about the challenges facing this field and the needs for its development. This study aimed to assess the existing teaching methods in the Hawler College of Medicine, Iraq from teaching staff perspectives and assess the knowledge of the teaching staff about student-centred learning. Methods A qualitative study based on a self-administered questionnaire survey of a purposive sample of 83 teaching staff in Hawler Medical University was conducted. The questionnaire addressed the participants’ view on the positive aspects and problems of the current teaching methods and priorities to change it. The qualitative data analysis comprised thematic analysis. Results The study revealed significant problems facing the existing teaching methods including having large number of students in the lecture hall (45.0 %), having focus on teacher-centred teaching (45.0 %) and lack of infrastructures and facilities suitable for proper teaching (26.7 %). The priorities for improving the quality of teaching methods included adoption of small group teaching strategy in all study years (34.6 %), improving the infrastructure and facilities for teaching in the college (34.6 %) and provision of continuous academic development programs for the teaching staff (24.3 %). Conclusions The existing medical education system face significant problems and it needs important and comprehensive improvements in different areas. There is a need for further research in this field to explore the identified problems in a more in-depth manner in order to better understand of the problems and needs of this important area of education.

Abstract Background The views of medical professionals on efficiency of health system and needs for any changes are very critical and constitute a cornerstone for any health system improvement. This is particularly relevant to Iraqi Kurdistan case as the events of the last few decades have significantly devastated the national Iraqi health system while the necessity for adopting a new health care system is increasingly recognized since 2004. This study aims to examine the regional health system in Iraqi Kurdistan from medical professionals' perspectives and try to define its problems and priorities for improvement. Methods A survey questionnaire was developed and administered to a convenience sample of 250 medical professionals in Erbil governorate. The questionnaire included four items; rating of the quality of services and availability of resources in the health institutions, view on different aspects of the health system, the perceived priority needs for health system improvement and gender and professional characteristics of the respondents. Results The response rate to the survey was 83.6%. A high proportion of respondents rated the different aspects of services and resources in the health institutions as weak or very weak including the availability of the required quantity and quality of medicines (68.7%), the availability of sufficient medical equipment and investigation tools (68.7%), and the quality of offered services (65.3%). Around 72% of respondents had a rather negative view on the overall health system. The weak role of medical research, the weak role of professional associations in controlling the system and the inefficient health education were identified as important problems in the current health system (87.9%, 87.1% and 84.9%, respectively). The priority needs of health system improvement included adoption of social insurance for medical care of the poor (82%), enhancing the role of family medicine (77.2%), adopting health insurance system (76.1%) and periodic scientific evaluation of physicians and other health staff (69.8%). Conclusion Medical professionals were generally unsatisfied with the different aspects of the health system in Iraqi Kurdistan region. A number of problems and different priority needs for health system improvement have been recognized that require to be studied in more details.

Background and Aims: The family size plays an important role in fulfilling the primary needs of each family member and providing a quality life for them. This research studies the association of family size with various socioeconomic and demographic factors and the lifetime fertility patterns of previous decades., Methods: This cross-sectional study was conducted at the Maternity Teaching Hospital in Erbil, Kurdistan Region of Iraq (KRI). The data was collected from December 11, 2023, to April 15, 2024, after the ethics committee of the Kurdistan Higher Council for Medical Specialties approved the proposal. A convenience sample of 400 women aged 45-74 years who had completed their families were directly interviewed. The data was analyzed using IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States)., Results: The prevalence of large family size (seven members and above) was 78.5%. The lifetime fertility rate of the women was 6.78 live births per woman. Large family size is significantly (p < 0.001) associated with age <18 years at marriage, short birth spacing interval, and unplanned pregnancies. The majority (91.7%) of the participants were grand multipara. The Cesarean section (CS) rate was 7.3%, 60.2% of the births were delivered at home, and 46.6% of the live births were delivered with a preceding birth interval of less than two years. The majority (82.2%) of the pregnancies were unplanned., Conclusions: Large family size is highly prevalent among women who have completed their families in Erbil. Many demographic and socioeconomic factors are associated with large family sizes, such as rural residency, age <18 years at marriage, low socioeconomic status (SES), short birth spacing interval, and unplanned pregnancies. For a more desired family size, it is recommended that young females be empowered by encouraging their education and providing occupation opportunities. In addition to that, prohibiting early marriage and providing/strengthening premarital programs focusing on the importance of family planning including birth spacing and utilizing contraceptive methods properly play a great role., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Kurdistan Higher Council of Medical Specialties Ethics Committee issued approval 1974 on 28.11.2023. According to the authority given to us in the decree of the Ministry of Higher Education and Scientific Research No. 4573 dated April 8, 2010, and referring to the minutes of meeting No. 9 on November 26, 2023, on the sidelines of the Ethics Committee of Medical Research, we decided to approve the change of title and research protocol of trainee Halbeen Abdulrazzaq Adil, in community medicine specialty, referring to our administrative order number 885 on April 13, 2022, from the research title "Pattern of Pregnancies and Their Outcomes in a Group of Married Women Aged More Than 45 Years, in Erbil" to the research title "Family Size and Past Obstetric History of Married Women Aged 45 Years and Older in Erbil.". Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Adil et al.)

Background and Objectives: Improving maternal health is one of the World Health Organization's (WHO) key priorities, grounded in a human rights approach and linked to efforts on universal health coverage. This study aimed to assess maternal health experiences among refugees and displaced women in Iraq during the COVID-19 pandemic., Methods: A cross-sectional study was done on 1321 women of reproductive age living in four camps supervised by the Barzani Foundation Charity in the Kurdistan Region of Iraq from June to August 2021. Researchers developed a questionnaire, and the data was collected by four staff members working in the camps through direct interviews with women. The World Health Organization Brief (WHOQOL-BREF), generalized anxiety disorder seven-item (GAD-7), and Patient Health Questionnaire-9 (PHQ-9) scales were used to measure quality of life (QoL), anxiety, and depression. The frequency, percentage, percentile, and the Chi-square test were used for data analysis., Results:  The women's mean age (SD) was 31.9 (±7.7) years. Around two-thirds of women attended the camp's healthcare facilities, and 16.4% attended the private facilities. Women mentioned the following as barriers to seeking health services: COVID-19 (387/29.3%), transportation (351/26.6%), lack of someone watching children (300/22.7%), and language (242/18.3%). The rate of high-level QoL among currently pregnant women (8/8.7%) was significantly (p = 0.002) less than the rate among nonpregnant women (297/24.2%). More than half (734/55.6%) of the women had mild depression, 247/18.7% had major depression, and 50/3.8% had severe major depression. Regarding anxiety, 580/43.9% had minimal anxiety, 467/35.4% had mild anxiety, 173/13.1% had moderate anxiety, and only 101/7.6% had severe anxiety., Conclusions: Refugees and internal displaced women in Iraq have barriers to seeking maternal healthcare. They suffer from low QoL, depression, and anxiety. Factors affecting the quality and accessibility of maternal healthcare in the camps should be studied. Health policymakers have to consider its improvement., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethics Committee of College of Health Sciences, Hawler Medical University issued approval Sc.E.C.4. The Scientific and Ethics Committee of the College of Health Sciences, Hawler Medical University approved the study proposal. Informed verbal consent was obtained from the study sample, and participants were free to withdraw from the study during data collection. . Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mirkhan Ahmed et al.)

Background: Flavivirus infections pose a significant global health burden underscoring the need for the development of safe and effective vaccination strategies. Available flavivirus vaccines are from time to time concomitantly delivered to individuals. Co-administration of different vaccines saves time and visits to health care units and vaccine clinics. It serves to provide protection against multiple pathogens in a shorter time-span; e.g., for individuals travelling to different endemic areas. However, safety and immunogenicity-related responses have not been appropriately evaluated upon concomitant delivery of these vaccines. Therefore, we performed an open label, non-randomized clinical trial studying the safety and immunogenicity following concomitant delivery of the yellow fever virus (YFV) vaccine with tick-borne encephalitis virus (TBEV) and Japanese encephalitis virus (JE) virus vaccines., Methods and Findings: Following screening, healthy study participants were enrolled into different cohorts receiving either TBEV and YFV vaccines, JEV and YFV vaccines, or in control groups receiving only the TBEV, JEV, or YFV vaccine. Concomitant delivery was given in the same or different upper arms for comparison in the co-vaccination cohorts. Adverse effects were recorded throughout the study period and blood samples were taken before and at multiple time-points following vaccination to evaluate immunological responses to the vaccines. Adverse events were predominantly mild in the study groups. Four serious adverse events (SAE) were reported, none of them deemed related to vaccination. The development of neutralizing antibodies (nAbs) against TBEV, JEV, or YFV was not affected by the concomitant vaccination strategy. Concomitant vaccination in the same or different upper arms did not significantly affect safety or immunogenicity-related outcomes. Exploratory studies on immunological effects were additionally performed and included studies of lymphocyte activation, correlates associated with germinal center activation, and plasmablast expansion., Conclusions: Inactivated TBEV or JEV vaccines can be co-administered with the live attenuated YFV vaccine without an increased risk of adverse events and without reduced development of nAbs to the respective viruses. The vaccines can be delivered in the same upper arm without negative outcome. In a broader perspective, the results add valuable information for simultaneous administration of live and inactivated flavivirus vaccines in general., Trial Registration: Eudra CT 2017-002137-32., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Sandberg et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Substance use among adolescents, especially smoking and alcohol consumption, has become a public health concern in the Kurdistan Region, Iraq, in the past 10 years., Aims: This study aimed to determine the prevalence of substance use and certain associated factors among high school students in Erbil City, Kurdistan Region, Iraq., Methods: A cross-sectional study was conducted using a multistage cluster sampling technique to collect a sample of 3000 students. A modified version of the School Survey on Drug Use from the United Nations Office on Drugs and Crime was used for data collection. Binary logistic regression models were used to identify risk factors for substance use., Results: The lifetime prevalence rates of cigarettes smoking, waterpipe smoking and alcohol consumption were 27.6%, 23.6% and 3.7%, respectively. Male gender, age 17-19 years, smoker in the family, and easy accessibility of cigarettes were significantly associated with cigarette smoking. Factors significantly associated with waterpipe smoking were male gender, age 17-19 years, waterpipe smoker in the family, waterpipe smoker friend, and easy accessibility. Male gender, alcohol dependent in the family, alcohol-dependent friend, easy accessibility of alcohol, and low family income were significant predictors of alcohol consumption., Conclusions: The prevalence of cigarette smoking and waterpipe use was high in the studied sample. Possible explanations for this finding might be the use of flavoured tobacco associated with aromatic smell, and the misconception that waterpipe smoking is less toxic and addictive than cigarette smoking., (Copyright © World Health Organization (WHO) 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

Background and Aims: Substance use among adolescents especially smoking, is becoming a public health problem in the Kurdistan region of Iraq. School-based health education is an appropriate approach for improving students' knowledge regarding substance use in an attempt to prevent or reduce such problem The purpose of the study was to examine the effect of an educational intervention for high school students to improve their knowledge for substance use and its negative consequences, which will, in turn, motivate students to take protective measures against substance use., Methods: This quasi-experimental (one group; pre, and post-test) design was carried out in Erbil city from January 2017 to June 2017. A random sampling technique was employed to collect a sample of 280 students amongst four high schools in Erbil city which is the capital of Kurdistan Region-Iraq. A self- administered questionnaire on knowledge assessment regarding substance use was developed and validated by the experts regarding the relevance of the items. A structured teaching program for imparting knowledge on various aspects of substance use was developed based on extensive review of literature and experts' opinion. The intervention program consisted of a series of 4 education modules. These modules were mainly taught by "Rabers" over a period of four weeks (one session per week). SPSS version 21 was used for data entry and analysis. Data was analyzed through descriptive and inferential statistics (McNemar tests, paired t-test, and Chi-square test)., Results: Out of 280 students, a total of 270 students completed a pre and post-intervention survey. Of the 270 students, 124 (45.9%) were males and 146 (54.1%) were females. The mean age ± SD of the participants was 16.59 ± 0.784 years, ranging from 15-18 years. The study reveals a statistically significant improvement in the mean score of knowledge of students following the implementation of a health education program from 15.959 ± 3.25 to 20.633 ± 3.26 (p < 0.001). Moreover, no one of the students remained with poor knowledge, and relatively more than half (50.2%) of the students have upgraded to good knowledge level., Conclusion: Implementing a health education program about substance use on high school students in Erbil city had improved the knowledge of students about this topic., Competing Interests: The authors have declared that no competing interests exist.

Background: Kinetic oscillation stimulation in the nasal cavity (KOS) has been shown to have positive symptomatic effects in subjects with non-allergic rhinitis and in patients with migraine., Methods: To evaluate the effect of KOS on autonomic function, we assessed heart rate variability (HRV) in this small exploratory study in 12 healthy subjects. KOS treatment was performed using a minimally invasive system with a single-use catheter inserted into the nasal cavity. During treatment, the tip was inflated and oscillated with a mean pressure of 95 millibar and amplitude of the oscillations of 100 millibar at a frequency of 68 Hz. Treatment was given for 15 minutes sequentially on each side. Heart rate variability was assessed during five 30-minutes periods before, during and immediately after KOS treatment and 3.5 hours thereafter. KOS resulted in a substantial reduction of HRV., Results: As compared to baseline recorded during 30 minutes preceding treatment, VLF was reduced by 65%, LF by 55%, the ratio LF/HF by 44%, with somewhat smaller observed effects in the time domain; SDNN and RMSDD were reduced by of 36% and 18%, respectively. Heart rate remained stable during treatment with minimal mean changes from 68 ± 7 bpm before to 68 ± 9 and 69 ± 9 bpm during and after treatment. Reduction of HRV parameters was consistently seen in all subjects, with rapid onset and return towards baseline values during post-treatment observation periods., Conclusions: KOS has an effect on the autonomic balance with pronounced heart-rate independent reduction on HRV., (© 2017 The Authors Annals of Noninvasive Electrocardiology Published by Wiley Periodicals, Inc.)

Background: Reference tissue-based quantification of brain PET data does not typically include correction for signal originating from blood vessels, which is known to result in biased outcome measures. The bias extent depends on the amount of radioactivity in the blood vessels. In this study, we seek to revisit the well-established Logan plot and derive alternative formulations that provide estimation of distribution volume ratios (DVRs) that are corrected for the signal originating from the vasculature., Results: New expressions for the Logan plot based on arterial input function and reference tissue were derived, which included explicit terms for whole blood radioactivity. The new methods were evaluated using PET data acquired using [ 11 C]raclopride and [ 18 F]MNI-659. The two-tissue compartment model (2TCM), with which signal originating from blood can be explicitly modeled, was used as a gold standard. DVR values obtained for [ 11 C]raclopride using the either blood-based or reference tissue-based Logan plot were systematically underestimated compared to 2TCM, and for [ 18 F]MNI-659, a proportionality bias was observed, i.e., the bias varied across regions. The biases disappeared when optimal blood-signal correction was used for respective tracer, although for the case of [ 18 F]MNI-659 a small but systematic overestimation of DVR was still observed., Conclusions: The new method appears to remove the bias introduced due to absence of correction for blood volume in regular graphical analysis and can be considered in clinical studies. Further studies are however required to derive a generic mapping between plasma and whole-blood radioactivity levels.

Background: Acellular pertussis vaccines do not control pertussis. A new approach to offer protection to infants is necessary. BPZE1, a genetically modified Bordetella pertussis strain, was developed as a live attenuated nasal pertussis vaccine by genetically eliminating or detoxifying 3 toxins., Methods: We performed a double-blind, placebo-controlled, dose-escalating study of BPZE1 given intranasally for the first time to human volunteers, the first trial of a live attenuated bacterial vaccine specifically designed for the respiratory tract. 12 subjects per dose group received 10³, 10⁵ or 10⁷ colony-forming units as droplets with half of the dose in each nostril. 12 controls received the diluent. Local and systemic safety and immune responses were assessed during 6 months, and nasopharyngeal colonization with BPZE1 was determined with repeated cultures during the first 4 weeks after vaccination., Results: Colonization was seen in one subject in the low dose, one in the medium dose and five in the high dose group. Significant increases in immune responses against pertussis antigens were seen in all colonized subjects. There was one serious adverse event not related to the vaccine. Other adverse events were trivial and occurred with similar frequency in the placebo and vaccine groups., Conclusions: BPZE1 is safe in healthy adults and able to transiently colonize the nasopharynx. It induces immune responses in all colonized individuals. BPZE1 can thus undergo further clinical development, including dose optimization and trials in younger age groups., Trial Registration: ClinicalTrials.gov NCT01188512.

We studied the prevalence and factors associated with overweight and obesity among 200 non-pregnant Iraqi women (> 18 years) attending 2 outpatient clinics in Baghdad. The women were interviewed using a questionnaire and had their body mass index (BMI) and waist-to-hip ratio (WHR) calculated. Only 24% of the women were normal weight: 39%, 25% and 12% were overweight (BMI 25-29.9 kg/m2), obese (> or =30 kg/m2) and morbidly obese (> or = 40 kg/m2) respectively. While the mean WHR was normal, the mean waist circumference was higher than normal. Factors significantly associated with overweight and obesity were older age, history of previous laparotomy and type of clothing worn (gown) inside the home.

Some internet communications have addressed the link between antiperspirant use and breast cancer. We studied the possible association between the use of antiperspirants and some other factors with the development of breast cancer in Al-Kadhmia teaching hospital. Thus, 54 cases of breast cancer and 50 controls were interviewed. We found 82.0% of the controls used antiperspirants compared with 51.8% of cases (P< 0.05). The use of antiperspirants had no association with the risk of breast cancer, while family history and oral contraceptives use were found to be associated.

In this pilot study, 14 patients with different symptoms and signs in relation to orthopedic implants were compared with 12 asymptomatic patients to determine the in vitro lymphocyte response to nickel sulfate. We conclude that nickel allergy may explain some, but not most, of the local and generalized symptoms associated with orthopedic implants.

Peripheral blood lymphocytes from 31 patients with a positive patch test to potassium dichromate (K2Cr2O7) and from 24 healthy controls were stimulated with various concentrations of chromium chloride (CrCl3) and/or chromium basic sulphate (Cr4(SO4)5(OH)2), sodium chromate (Na2CrO4) or K2Cr2O7 on various days of culture. Both trivalent and hexavalent chromium compounds could induce lymphocyte transformation, as measured by increased DNA synthesis. The response occurred in the T-enriched population and was monocyte dependent. Lymphocytes from 11 of these patients could not be stimulated with the chromium compounds in vitro, whereas the in vivo serial dilution test (SDT) was positive in 4 and negative in 7 of them. Lymphocytes from 2 patients with a negative in vivo SDT showed a positive response in vitro. The strength of the in vivo SDT results did not correlate well with the height of in vitro responses. The DNA synthesis test seems to be a reliable in vitro method to aid in the diagnosis of chromium sensitivity.

Peripheral blood lymphocytes from 16 patients with a positive patch test to 2.5% nickel sulphate (NiSO4) and 18 healthy controls were tested by the lymphocyte transformation technique where NiSO4 in six different concentrations was used and tested after various days of culture. Lymphocytes from all except one of the patients showed a significantly greater response than that of the controls. Lymphocyte transformation as measured by increased DNA synthesis seems to be a valuable tool for investigating the problems arising from false-positive or false-negative patch tests. With these data we have defined certain criteria for in vitro reactivity that should be fulfilled. Lymphocytes from controls responded non-specifically to high concentrations of NiSO4. Cord blood lymphocytes from 4 newborn infants could also be activated by NiSO4, thus confirming the assumption that NiSO4 is a weak mitogen.

Forty-three nickel-allergic patients (40 females and 3 males) participated in this study which was designed to elucidate the correlation between quantitative in vivo and in vitro responses. All were patch-tested with various concentrations of nickel-sulphate serial-diluted in water. The lowest concentration eliciting a cutaneous reaction (indicating the severity of the allergy) was recorded for each individual and compared with the in vitro lymphocyte response, using the lymphocyte transformation test. The best correlation coefficients obtained were 0.42 and 0.46, tested for linear and logarithmic correlation respectively. However, there were individuals who showed a weak cutaneous response and high lymphocyte reactivity. The converse situation was also found, however, indicating that other mechanisms than those mediated via lymphocytes may be of significance in the patch test response.

Peripheral blood lymphocytes from 45 patients with a positive patch test to cobalt chloride (CoCl2) and 37 controls were stimulated with various concentrations of CoCl2 and/or cobalt sulphate (CoSO4) or cobalt nitrate (Co(NO3)2) or cobalt acetate [CH3COO)2Co) for various days in culture. Lymphocytes from 35 of these patients showed a significantly greater response than that of the controls. The response occurred in the T enriched population and was monocyte dependent. The strength of the in vivo serial dilution test results did not correlate well with the height of in vitro responses. Lymphocytes from 3 nickel and/or chromium sensitive patients failed to respond to stimulation with cobalt compounds thus confirming the specificity of the reaction. The DNA synthesis test seems to be a reliable in vitro method to aid in the diagnosis of cobalt sensitivity.

Thirty healthy cashiers continuously exposed to nickel in coins were tested in vivo and in vitro for the presence of metal contact allergy. A traditional epicutaneous test and lymphocyte transformation test were used. We tested for nickel, cobalt and chromium sensitivity. Seven of the 30 cashiers were patch test positive and 3 were in vitro positive to nickel sulphate. Two were in vivo positive to cobalt and only one in vitro positive. None was chromium allergic. There was no correlation between the exposure time and the lymphocyte response towards nickel. The presence of pierced and non-pierced ear lobes was noted with and without eczema in conjunction with the wearing of ear-rings containing nickel. The lymphocyte reactivity showed no significant difference between these groups. Only 5 out of the 12 with ear lobe dermatitis were patch test positive towards nickel. The data suggest that nickel as test substance or released from nickel-containing jewellery can evoke a cutaneous response which is not always associated with allergy.