[Efficacy of bioregulative drugs in the treatment of otitis media with effusion associated with rhinosinusitis and adenoiditis]. / Effektivnost' preparatov bioregulyatsionnoi meditsiny pri lechenii ekssudativnogo srednego otita, sopryazhennogo s rinosinusitom i adenoiditom.

PURPOSE: Improving of otitis media with effusion (OME) with rhinosinusitis (RS) and adenoiditis treatment effectiveness. MATERIALS AND METHODS: The study included 112 patients 12-18 y.o. with otitis media with effusion, who were divided into 2 groups depending on the treatment scheme. The Group I (the main group) patients treatment included Traumeel S and Euphorbium compositum Nasentropfen S in addition to the standard treatment, and the Group II (comparison), children were prescribed standard therapy. Patients of both groups were divided into 3 subgroups depending on the upper respiratory tract inflammation symptoms: A - patients with adenoiditis; B - with rhinosinusitis and C - combination of adenoiditis and rhinosinusitis. The comparison group (groups IIB and IIC) treatment scheme (children with rhinosinusitis) included topical corticosteroids and the main group patients didn't receive corticosteroids. All patients went through complaints and anamnesis collection, routine otorhinolaryngological and instrumental examination before and after treatment. RESULTS: Analysis of treatment results demonstrated high efficacy of multicomponent drugs with low doses of active ingredients in the therapy of patients with OME, regardless of comorbid pathology. Significantly better results were obtained in the patients treated with bioregulatory drugs when comparing the outcomes of OME therapy in combination with adenoiditis (groups IA and IIA). Comparable efficacy results were obtained in the treatment group of patients with OME associated with RS (in groups IB and IIB as well as in groups IC and IIC), where GCS was received in the comparison group. The high efficacy and safety of bioregulatory drugs makes the use of these agents a promising treatment for patients with OME, RS and adenoiditis.

Septin 9 Methylation in Nasopharyngeal Swabs: A Potential Minimally Invasive Biomarker for the Early Detection of Nasopharyngeal Carcinoma.

Nasopharyngeal carcinoma (NPC) is highly prevalent in Southeast Asia, and an unfavorable outcome is usually attributed to advanced stage NPC. Current methods for the early diagnosis of NPC have limitations in clinical practice. The aim of this study was to investigate the diagnostic ability of Septin 9 methylation for NPC. A quantitative methylation-sensitive PCR (qMS-PCR) assay was developed to measure the methylation status and levels of Septin 9 in nasopharyngeal tissues and paired swabs from patients with NPC, chronic nasopharyngitis, and healthy donors. Methylated Septin 9 was detected in 92% (23/25) of NPC tissues and 25% (4/16) of nasopharyngitis controls (p < 0.05). High-frequency hypermethylation with decreased mRNA expression of Septin 9 in NPC was also identified. Further, Septin 9 methylation was identified in 90.5% (19/21) of NPC biopsies and 71.4% (15/21) of paired swabs, indicating a good concordance between the two sample types. In addition, methylated Septin 9 was found in 16 (72.7%) nasal swabs from 22 NPC patients, 2 of 19 (10.5%) nasopharyngitis, but not in any of the healthy controls (p < 0.01). The methylation score in nasal swabs of the NPC group was also significantly higher than that of non-NPC controls (p < 0.001). Moreover, receiver operating characteristic (ROC) curve analysis showed an area under the curve (AUC) of 0.882 of Septin 9 methylation tests to discriminate NPC from non-NPC subjects. Our study demonstrated that frequent methylation of Septin 9 was present in NPC. Its detection in nasopharyngeal swabs may provide a minimally invasive and informative method for identifying early NPC cases.

Oral roxadustat three times weekly in ESA-naïve and ESA-converted patients with anemia of chronic kidney disease on hemodialysis: Results from two phase 3 studies.

Roxadustat is a hypoxia-inducible factor prolyl hydroxylase inhibitor approved in China for anemia of dialysis-dependent chronic kidney disease (CKD). Japanese hemodialysis patients with anemia of CKD previously naïve to, or converted from, erythropoiesis-stimulating agents (ESAs) were enrolled in two open-label, noncomparative studies of titrated oral roxadustat administered three times weekly. ESA-naïve patients (n = 75) were randomized to roxadustat (initial dose, 50 or 70 mg) for 24 weeks; ESA-converted patients (n = 164) were assigned to roxadustat (initial dose, 70 or 100 mg based on prior ESA dose) for 52 weeks. Efficacy outcomes included average hemoglobin (Hb, weeks 18-24 or 46-52), change of Hb from baseline to weeks 18 to 24 (ΔHb18-24 ) or weeks 46 to 52 (ΔHb46-52 ), and maintenance rate (proportion of patients who achieved average Hb of 10.0-12.0 g/dL for weeks 18-24 or weeks 46-52). Treatment-emergent adverse events (TEAEs) were monitored. Mean (SD) Hb was 10.93 (0.79) g/dL (weeks 18-24) (ESA-Naïve Study), and 10.93 (0.69; weeks 18-24) g/dL and 11.11 (0.67; weeks 46-52) g/dL (ESA-Converted Study). Mean (SD) ΔHb18-24 was 2.26 (1.02) g/dL (ESA-Naïve Study) and -0.03 (0.90) g/dL (ESA-Converted Study); mean (SD) ΔHb46-52 was 0.12 (0.83) g/dL (ESA-Converted Study). The overall maintenance rate was 73.0% (54/74) (ESA-Naïve Study) (weeks 18-24), and 79.1% (129/163; weeks 18-24) and 71.2% (116/163; weeks 46-52) (ESA-Converted Study). Nasopharyngitis was the most common TEAE. Two deaths, considered unrelated to roxadustat, occurred in the ESA-Converted Study. Roxadustat effectively corrected and maintained Hb, regardless of previous ESA treatment, in Japanese anemic CKD patients on hemodialysis.

Long-term safety and efficacy of delgocitinib ointment, a topical Janus kinase inhibitor, in adult patients with atopic dermatitis.

Previous studies demonstrated that delgocitinib ointment, a novel topical Janus kinase inhibitor, rapidly improved clinical signs and symptoms of atopic dermatitis (AD) in Japanese adult patients. We sought to evaluate the long-term safety and efficacy of delgocitinib 0.5% ointment in a 52-week study (QBA4-2). Japanese patients aged 16 years or older with AD received delgocitinib 0.5% ointment b.i.d. for up to 52 weeks. Topical corticosteroids for the treatment of worsening of AD could be used at the investigators' discretion during the treatment period. Safety end-points included the incidence and severity of adverse events (AEs). Pooled safety analyses included the data from the other long-term study (QBA4-1). Efficacy end-points included the percentage change from baseline in the modified Eczema Area and Severity Index (mEASI). A total of 506 patients were included in the pooled safety population. Overall, AEs were reported in 69.0% of patients; most AEs were mild and unrelated to delgocitinib ointment. The most common AE was nasopharyngitis, followed by contact dermatitis, acne, and application site folliculitis. No skin atrophy or telangiectasia was found at the application sites of delgocitinib ointment. Application site irritation symptoms were infrequent (<2%) and mild. The incidence of AEs did not increase over time, except for seasonal diseases. The improvement effects on AD as assessed by mEASI were maintained throughout the treatment period. Delgocitinib 0.5% ointment was well tolerated and effective when administrated to Japanese adult patients with AD for up to 52 weeks.

[Fungal adenoiditis and tonsillomycosis in children: features of diagnosis and therapy]. / Gribkovyi adenoidit i tonzillomikoz u detei: osobennosti diagnostiki i terapii.

The purpose of the work is to study the current state of the problem of diagnosing and treating fungal adenoiditis and tonsillomycosis in children. This article summarizes the literature data on the predisposing factors and characteristics of the occurrence of fungal infections of adenoid vegetations and tonsils in children. The works present modern approaches to the diagnosis and treatment of children with fungal adenoiditis and tonsillomycosis, depending on the selected genus and the type of fungus. Based on the conducted research, performed on the basis of "The Sverzhevskiy Otorhinolaryngology Healthcare Research Institute", we found that the incidence of fungal adenoiditis in children is 16.4%, and the incidence of tonsillomicosis in children with chronic tonsillitis is 21.5%. The most frequently detected strain in this pathology is C. albicans. In the presented study, a justification of the chosen treatment regimen was made on the basis of the data obtained during microbiological (bacteriological and mycological) studies.

Long-term safety and tolerability of valsartan in children aged 6 to 17 years with hypertension.

OBJECTIVE: The present study aimed to assess the long-term safety and tolerability of valsartan in hypertensive children aged 6-17 years, with or without chronic kidney disease (CKD). METHODS: This was an 18-month, open-label, multicentre, prospective study conducted in 150 patients with history of hypertension with or without CKD. The primary endpoint was long-term safety and tolerability of valsartan and valsartan-based treatments, assessed in terms of adverse events (AEs), serious AEs, laboratory measurements, estimated glomerular filtration rate (eGFR), urinalysis and electrocardiogram. RESULTS: Of 150 enrolled patients, 117 (78%) completed the study. At week 78, a clinically and statistically significant reduction in mean sitting systolic and diastolic blood pressures was observed in all patients (- 14.9 mmHg and - 10.6 mmHg, respectively). Within the first 3 months of treatment, mean urine albumin creatinine ratio decreased in CKD population, which was sustained. A higher percentage of CKD patients had at least one AE compared to non-CKD patients (85.3% vs. 73.3%, respectively). The majority of AEs were mild (50.7%) or moderate (18.7%) in severity. As expected, in patients with underlying CKD, increases in serum potassium, creatinine and blood urea nitrogen were more commonly reported compared to non-CKD patients. A > 25% decrease in Schwartz eGFR was observed in 28.4% of CKD patients and 13.5% of non-CKD patients. CONCLUSIONS: Valsartan was generally well tolerated, with an AE profile consistent with angiotensin receptor blockers in the overall population and in patients with underlying CKD. Long-term efficacy was maintained and a beneficial effect on proteinuria was observed.

Nasopharyngeal linguatulosis or halzoun syndrome: clinical diagnosis and treatment.

OBJECTIVE: Halzoun syndrome, also known as nasopharyngeal linguatulosis, is a rare entity that is mostly prevalent in Eastern Mediterranean countries. The consumption of raw ovine liver and lymph nodes infested with Linguatula serrata nymphs remains a major cause of the nasopharyngeal symptoms and discomfort associated with the disease. Halzoun syndrome is a clinical diagnosis based on history and presentation. METHODS: Treatment of this disease is still debated; however, our experience reveals that alcohol gargle can be a good option. Proper counselling on the hazards of eating raw liver in endemic areas is needed. RESULTS: Moreover, physicians should be aware of the sequence of events in the disease in order not to delay or miss the diagnosis. CONCLUSIONS: This communication presents a rare Lebanese case of Halzoun syndrome that offers medical implications in the clinical diagnosis and treatment of the nasopharyngeal symptoms of this syndrome, with a review of the literature.

Nasopharyngeal linguatulosis or halzoun syndrome: clinical diagnosis and treatment

SUMMARY Halzoun syndrome, also known as nasopharyngeal linguatulosis, is a rare entity that is mostly prevalent in Eastern Mediterranean countries. The consumption of raw ovine liver and lymph nodes infested with Linguatula serrata nymphs remains a major cause of the nasopharyngeal symptoms and discomfort associated with the disease. Halzoun syndrome is a clinical diagnosis based on history and presentation. Treatment of this disease is still debated; however, our experience reveals that alcohol gargle can be a good option. Proper counselling on the hazards of eating raw liver in endemic areas is needed. Moreover, physicians should be aware of the sequence of events in the disease in order not to delay or miss the diagnosis. This communication presents a rare Lebanese case of Halzoun syndrome that offers medical implications in the clinical diagnosis and treatment of the nasopharyngeal symptoms of this syndrome, with a review of the literature.

RESUMO Esta comunicação apresenta um caso libanês raro de síndrome de Halzoun que oferece implicações médicas no diagnóstico clínico e no tratamento dos sintomas nasofaríngeos desta síndrome, com uma revisão da literatura. A síndrome de Halzoun, também conhecida como linguatulose nasofaríngea, é uma entidade rara predominante nos países do Mediterrâneo Oriental. O consumo de linfonodos ovinos e linfáticos ovinos infestados com ninfas Linguatula serrata continua a ser uma das principais causas dos sintomas nasofaríngeos e do desconforto associado à doença. A síndrome de Halzoun é um diagnóstico clínico baseado na história e na apresentação. O tratamento dessa doença ainda é debatido; no entanto, nossos resultados revelam que o gargarismo de álcool pode ser uma boa opção. É necessário um aconselhamento adequado sobre os perigos de comer fígado cru em áreas endêmicas. Além disso, os médicos devem estar cientes da sequência de eventos na doença, a fim de não atrasar ou perder o diagnóstico.

Efficacy and Safety of Toreforant, a Selective Histamine H4 Receptor Antagonist, for the Treatment of Moderate-to-Severe Plaque Psoriasis: Results from a Phase 2 Multicenter, Randomized, Double-blind, Placebo-controlled Trial.

BACKGROUND: Toreforant is a selective histamine H4 receptor antagonist. H4 receptor activation may play a role in immune-mediated inflammation in psoriasis. OBJECTIVE: To evaluate Toreforant efficacy and safety in patients with moderate-to-severe psoriasis. METHODS: Biologic-naïve patients were to be treated (30, 60, or 3 mg Toreforant or placebo) for 12 weeks and followed through week 16. In this adaptive-design study, assignments were guided by interim analyses. Primary and major secondary efficacy endpoints, evaluated using Bayesian analyses, were the proportions of patients achieving ≥75% improvement in Psoriasis Area and Severity Index (PASI) from baseline and achieving Investigator's Global Assessment (IGA) of cleared (0) or minimal (1), respectively, at week 12. RESULTS: Per interim analyses results, patients were randomized to 30 (n = 30) or 60 mg (n = 26) Toreforant or placebo (n = 6). The estimated mean difference in the PASI 75 response rate at week 12 from the posterior distributions compared to placebo was 14.1% (95% credible interval [CI], -0.1% to 30.9%) and 8.9% (95% CI, -5.0% to 24.3%) with 30 and 60 mg Toreforant, respectively. The posterior probabilities of 30 and 60 mg Toreforant inducing a greater response rate than placebo were 97.4% and 90.3%, respectively; neither met the 97.5% predefined success criterion. Results for the IGA 0/1 endpoint were similar. Toreforant was generally safe and well tolerated. No deaths, serious or opportunistic infections, active tuberculosis, or malignancies were reported. CONCLUSIONS: Toreforant efficacy at 30 and 60 mg was greater than placebo but did not meet predefined success criterion. J Drugs Dermatol. 2018;17(8):873-879.

Characterization of the nasopharyngeal and middle ear microbiota in gastroesophageal reflux-prone versus gastroesophageal reflux non-prone children.

Otitis media (OM) is one of the most common pediatric infections worldwide, but the complex microbiology associated with OM is poorly understood. Previous studies have shown an association between OM and gastroesophageal reflux (GER) in children. Therefore, in order to bridge the gap in our current understanding of the interaction between GER and OM, we investigated the nasopharyngeal and middle ear microbiota of children suffering from GER-associated OM and OM only, using culture-independent 16S rRNA gene sequencing. Middle ear fluid, nasopharyngeal swabs, and clinical data were collected as part of a prospective pilot study conducted at the Department of Otorhinolaryngology of the Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands. A total of 30 children up to 12 years of age who suffered from recurrent acute otitis media (AOM) (5), chronic otitis media with effusion (OME) (23), or both (2), and who were listed for tympanostomy tube placement, were included in the study. Nine children were included in the GER-associated OM cohort and 21 in the OM-only cohort. We found no obvious effect of GER on the nasopharyngeal and middle ear microbiota between the two groups of children. However, our results highlight the need to assess the true role of Alloiococcus spp. and Turicella spp. in children presenting with a high prevalence of recurrent AOM and chronic OME.

Paediatric nasopharyngeal cytology: a new diagnostic opportunity?

The purpose of this investigation was to describe the first application of nasopharyngeal cytology (NPC), a new cytological technique to collect cellular material from the nasopharyngeal surface non-invasively in children with chronic adenoiditis associated with recurrent acute otitis media and/or otitis media with effusion. Cellular material was collected transorally using an extra-thin flexible wire nasopharyngeal swab and then examined under a light microscope. The diagnostic accuracy of NPC in detecting the presence of allergy and pathogens (compared to microbiological evaluation of nasopharyngeal aspirates, NPAs) was assessed. NPC was performed on 121 children (mean age 69.4 ± 15.5 months). Inflammatory cells and pathogens were detected in 61.1 % and 44.2 % of patients, respectively. The specificity of nasopharyngeal eosinophils in detecting allergy was good (91.9 %), as was the specificity of mast cells, but the sensitivities were less. The NPAs revealed bacterial colonisation in 84.7 % of the patients, and Streptococcus pneumoniae was the most frequently isolated (60.0 %). NPC revealed the presence of bacteria in 94.9 % of patients, including bacillary species in 33.9 %. NPC was highly sensitive in detecting pathogens (96.0 %). Its specificity in detecting bacillary species was fairly good (75.0 %), but the corresponding values of the specificity of NPC in detecting pathogens and its sensitivity in detecting bacillary species were poor. Our findings suggest the need for more structured studies that can test the real effectiveness and usefulness of NPC in defining nasopharyngeal cytological patterns in children with chronic nasopharyngeal diseases by comparing it with established diagnostic techniques.

Epstein-Barr virus mir-bart1-5p detection via nasopharyngeal brush sampling is effective for diagnosing nasopharyngeal carcinoma.

Epstein-Barr virus (EBV)-encoded microRNAs (miRNAs) are highly expressed in nasopharyngeal carcinoma (NPC) cases in high-risk areas, and may be involved in tumorigenesis. Using quantitative RT-PCR, we detected four EBV-encoded BamHI A rightward transcript (BART) miRNAs (mir-bart1-5p, mir-bart5, mir-bart6-5p and mir-bart17-5p) exclusively in 53 NPC biopsies as compared to 69 controls. In a larger patient group, that included 215 NPC cases and 209 controls, significantly higher levels of all four EBV miRNAs were detected in tumor cells harvested directly from the nasopharynx using a less invasive nasopharyngeal (NP) brush than in the controls (p < 0.001). One EBV miRNA, mir-bart1-5p, holds particular promise for use as a diagnostic indicator of NPC (with 93.5% sensitivity and 100% specificity), and its relative expression level was reflective of disease progression. Detection of this miRNA was effective for diagnosing early-stage NPC, even in cases that were falsely diagnosed as negative based on histopathological analysis, plasma EBV DNA load, and VCA-IgA and EA-IgA titers. EBV-encoded mir-bart1-5p detection via NP brush sampling could act as an efficient and less invasive method assisting clinical diagnosis of NPC.

Expression and clinical significance of LRRC4 in benign and malignant nasopharyngeal diseases.

The aim of this study was to investigate the expression of LRRC4 in nasopharyngeal carcinomas, nasopharyngeal precancerous lesions, and nasopharyngitis as well as the clinical significance of LRRC4. Fifty patients with nasopharyngeal carcinoma were selected as study subjects; 28 patients with chronic nasopharyngitis and 22 patients with nasopharyngeal precancerous lesions served as controls. Immunohistochemical analysis was used to study protein expression of LRRC4; the relation between LRRC4 expression and the clinical stage and histopathological features of nasopharyngeal carcinoma was also analyzed. The LRRC4 expression manifested itself as yellow staining in the cytoplasm or nucleus. LRRC4 was strongly expressed in nasopharyngeal epithelial tissues of patients with chronic nasopharyngitis and in nasopharyngeal precancerous lesions; the rates of positive results were 82.1 and 81.8%, respectively. LRRC4 was weakly expressed in nasopharyngeal carcinoma tissues, at a rate of 10% positive results (P< 0.001); there was no significant difference in the expression of LRRC4 among different clinical stages and pathological grades. Therefore, disappearance of LRRC4 expression is a major feature of nasopharyngeal carcinoma.

Association of laryngeal and nasopharyngeal tuberculosis: a case report.

INTRODUCTION: To the best of our knowledge, the association of nasopharyngeal and laryngeal tuberculosis has never been described before in the literature. We report here a first observation. CASE PRESENTATION: We report the case of a 38-year-old Arab man who presented with an isolated hoarseness. Radiological and endoscopic examinations showed a thickening of the left lateral wall of his nasopharynx and the left vocal cord. Pathology revealed the diagnosis of tuberculosis of both localizations. He received a 6-month antituberculous chemotherapy with a satisfying uneventful evolution. CONCLUSIONS: Tuberculosis should be considered in the differential diagnosis of soft tissue masses of the head and neck, particularly when the imaging findings and clinical presentation are atypical. The diagnosis of tuberculosis is mainly based on histopathological and/or bacteriological examination.

Prospective evaluation of long-term safety of dual-release hydrocortisone replacement administered once daily in patients with adrenal insufficiency.

OBJECTIVE: The objective was to assess the long-term safety profile of dual-release hydrocortisone (DR-HC) in patients with adrenal insufficiency (AI). DESIGN: Randomised, open-label, crossover trial of DR-HC or thrice-daily hydrocortisone for 3 months each (stage 1) followed by two consecutive, prospective, open-label studies of DR-HC for 6 months (stage 2) and 18 months (stage 3) at five university clinics in Sweden. METHODS: Sixty-four adults with primary AI started stage 1, and an additional 16 entered stage 3. Patients received DR-HC 20-40 mg once daily and hydrocortisone 20-40 mg divided into three daily doses (stage 1 only). Main outcome measures were adverse events (AEs) and intercurrent illness (self-reported hydrocortisone use during illness). RESULTS: In stage 1, patients had a median 1.5 (range, 1-9) intercurrent illness events with DR-HC and 1.0 (1-8) with thrice-daily hydrocortisone. AEs during stage 1 were not related to the cortisol exposure-time profile. The percentage of patients with one or more AEs during stage 1 (73.4% with DR-HC; 65.6% with thrice-daily hydrocortisone) decreased during stage 2, when all patients received DR-HC (51% in the first 3 months; 54% in the second 3 months). In stages 1-3 combined, 19 patients experienced 27 serious AEs, equating to 18.6 serious AEs/100 patient-years of DR-HC exposure. CONCLUSIONS: This long-term prospective trial is the first to document the safety of DR-HC in patients with primary AI and demonstrates that such treatment is well tolerated during 24 consecutive months of therapy.

Adenoids in children: Advances in immunology, diagnosis, and surgery.

Adenoids are strategically located for mediating local and regional immune functions as they are exposed to antigens from both the outside air and the alimentary tract. Recurrent or chronic respiratory infections can induce histomorphological and functional changes in the adenoidal immunological barrier, sometimes making surgical treatment necessary. Our aim in this review is to summarize the crucial points about not only the immunological histopathology of adenoidal tissue, especially in patients with adenoid hypertrophy, but also the most common and useful diagnostic techniques and surgical options.

Over-prescribing of antibiotics and imaging in the management of uncomplicated URIs in emergency departments.

BACKGROUND: Unnecessary use of resources for common illnesses has substantial effect on patient care and costs. Evidence-based guidelines do not recommend antibiotics or imaging for uncomplicated upper respiratory infections (URIs). The objective of the current study was to examine medical care providers' compliance with guidelines in treating uncomplicated URIs in emergency departments (EDs) in the US. METHODS: Nationally representative data from the NHAMCS 2007 and 2008 were used. Uncomplicated URIs were identified through ICD-9 codes of nasopharyngitis, laryngitis, bronchitis, URI not otherwise specified and influenza involving upper respiratory tract. Exclusion criteria were concurrent comorbidities, follow-up visits, and age < 18 or >64 years. Most frequently prescribed classes of antibiotics were identified. Multivariate analyses were conducted to identify the factors associated with the prescribing of antibiotics and use of imaging studies. RESULTS: In 2007 and 2008, there were 2.2 million adult uncomplicated URI visits without any other concurrent diagnoses in EDs in the US. Approximately 52% were given antibiotic prescriptions, over one-third of which were macrolides, and nearly half of the visits performed imaging studies. About 51% had a diagnosis of bronchitis, 35% URI NOS, 9% nasopharyngitis, laryngitis or influenza, and 4% multiple URI diagnoses. The diagnosis of bronchitis, fever at presentation, older ages, male gender, longer waiting time, and metropolitan areas were associated with a greater likelihood of prescribing antibiotics or imaging studies, controlling for confounding factors. CONCLUSION: Despite the recommendations and campaign efforts by the CDC and many medical associations, the prescribing of antibiotics in treating uncomplicated URIs in the EDs remains prevalent. Furthermore, overutilization of imaging studies is prevalent. Changes at levels of health care system and hospitals are needed to avoid unnecessary resource utilization. In addition, further patient education about antibiotic use in the community may greatly facilitate the transition out of an antibiotic-dependent consumer culture.