The effect of intrathecal bupivacaine/morphine on quality of recovery in robot-assisted radical prostatectomy: a randomised controlled trial.

Robot-assisted radical prostatectomy causes discomfort in the immediate postoperative period. This randomised controlled trial investigated if intrathecal bupivacaine/morphine, in addition to general anaesthesia, could be beneficial for the postoperative quality of recovery. One hundred and fifty-five patients were randomly allocated to an intervention group that received intrathecal 12.5 mg bupivacaine/300 µg morphine (20% dose reduction in patients > 75 years) or a control group receiving a subcutaneous sham injection and an intravenous loading dose of 0.1 mg.kg-1 morphine. Both groups received standardised general anaesthesia and the same postoperative analgesic regimen. The primary outcome was a decrease in the Quality of Recovery-15 (QoR-15) questionnaire score on postoperative day 1. The intervention group (n = 76) had less reduction in QoR-15 on postoperative day 1; median (IQR [range]) 10% (1-8 [-60% to 50%]) vs. 13% (5-24 [-6% to 50%]), p = 0.019, and used less morphine during the admission; 2 mg (1-7 [0-41 mg]) vs. 15 mg (12-20 [8-61 mg]), p < 0.001. Furthermore, they perceived lower pain scores during exertion; numeric rating scale (NRS) 3 (1-6 [0-9]) vs. 5 (3-7 [0-9]), p = 0.001; less bladder spasms (NRS 1 (0-2 [0-10]) vs. 2 (0-5 [0-10]), p = 0.001 and less sedation; NRS 2 (0-3 [0-10]) vs. 3 (2-6 [0-10]), p = 0.005. Moreover, the intervention group used less rescue medication. Pruritus was more severe in the intervention group; NRS 4 (1-7 [0-10]) vs. 0 (0-1 [0-10]), p = 0.000. We conclude that despite a modest increase in the incidence of pruritus, multimodal pain management with intrathecal bupivacaine/morphine remains a viable option for robot-assisted radical prostatectomy.

Effect of hyperextension of the neck (rose position) on cerebral blood oxygenation in patients who underwent cleft palate reconstructive surgery: prospective cohort study using near-infrared spectroscopy.

OBJECTIVES: To facilitate the best approach during cleft palate surgery, children are positioned with hyperextension of the neck. Extensive head extension may induce intraoperative cerebral ischemia if collateral flow is insufficient. To evaluate and monitor the effect of cerebral blood flow on cerebral tissue oxygenation, near-infrared spectroscopy has proved to be a valuable method. The aim of this study was to evaluate and quantify whether hyperextension affects the cerebral tissue oxygenation in children during cleft palate surgery. MATERIALS AND METHODS: This prospective study included children (ASA 1 and 2) under the age of 3 years old who underwent cleft palate repair at the Wilhelmina Children's Hospital, in The Netherlands. Data were collected for date of birth, cleft type, date of cleft repair, and physiological parameters (MAP, saturation, heart rate, expiratory CO2 and O2, temperature, and cerebral blood oxygenation) during surgery. The cerebral blood oxygenation was measured with NIRS. RESULTS: Thirty-four children were included in this study. The majority of the population was male (61.8%, n = 21). The mixed model analyses showed a significant drop at time of Rose position of - 4.25 (69-74 95% CI; p < 0.001) and - 4.39 (69-74 95% CI; p < 0.001). Postoperatively, none of the children displayed any neurological disturbance. CONCLUSION: This study suggests that hyperextension of the head during cleft palate surgery leads to a significant decrease in cerebral oxygenation. Severe cerebral desaturation events during surgery were uncommon and do not seem to be of clinical relevance in ASA 1 and 2 children. CLINICAL RELEVANCE: There was a significant drop in cerebral oxygenation after positioning however it is not clear whether this drop is truly significant physiologically in ASA 1 and 2 patients.

Differences in Blood Pressure in Infants After General Anesthesia Compared to Awake Regional Anesthesia (GAS Study-A Prospective Randomized Trial).

BACKGROUND: The General Anesthesia compared to Spinal anesthesia (GAS) study is a prospective randomized, controlled, multisite, trial designed to assess the influence of general anesthesia (GA) on neurodevelopment at 5 years of age. A secondary aim obtained from the blood pressure data of the GAS trial is to compare rates of intraoperative hypotension after anesthesia and to identify risk factors for intraoperative hypotension. METHODS: A total of 722 infants ≤60 weeks postmenstrual age undergoing inguinal herniorrhaphy were randomized to either bupivacaine regional anesthesia (RA) or sevoflurane GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born at <26 weeks of gestation. Moderate hypotension was defined as mean arterial pressure measurement of <35 mm Hg. Any hypotension was defined as mean arterial pressure of <45 mm Hg. Epochs were defined as 5-minute measurement periods. The primary outcome was any measured hypotension <35 mm Hg from start of anesthesia to leaving the operating room. This analysis is reported primarily as intention to treat (ITT) and secondarily as per protocol. RESULTS: The relative risk of GA compared with RA predicting any measured hypotension of <35 mm Hg from the start of anesthesia to leaving the operating room was 2.8 (confidence interval [CI], 2.0-4.1; P < .001) by ITT analysis and 4.5 (CI, 2.7-7.4, P < .001) as per protocol analysis. In the GA group, 87% and 49%, and in the RA group, 41% and 16%, exhibited any or moderate hypotension by ITT, respectively. In multivariable modeling, group assignment (GA versus RA), weight at the time of surgery, and minimal intraoperative temperature were risk factors for hypotension. Interventions for hypotension occurred more commonly in the GA group compared with the RA group (relative risk, 2.8, 95% CI, 1.7-4.4 by ITT). CONCLUSIONS: RA reduces the incidence of hypotension and the chance of intervention to treat it compared with sevoflurane anesthesia in young infants undergoing inguinal hernia repair.

Maternal fatty acid levels during pregnancy, childhood lung function and atopic diseases. The Generation R Study.

BACKGROUND: Maternal fatty acid status during pregnancy might influence foetal immunological development and subsequently the risk of childhood atopic diseases. OBJECTIVE: To examine the associations of maternal fatty acid levels during pregnancy with airway resistance and inflammation, asthma and eczema, in school-age children. METHODS: This study among 4976 subjects was embedded in a population-based prospective cohort study. We measured maternal plasma glycerophospholipid fatty acid levels by gas chromatography during the second trimester of pregnancy (mean gestational age: 20.7 (± 1.1) weeks). At the age of 6 years, airway resistance and inflammation were measured by interrupter technique (Rint) and fractional exhaled nitric oxide (FeNO), and current physician-diagnosed asthma and eczema were assessed by ISAAC-based questionnaires. Multiple linear and logistic regression models were adjusted for socio-demographic, lifestyle and anthropometric factors. RESULTS: We did not observe consistent associations of maternal total polyunsaturated fatty acid (PUFA), total n-6 PUFA, total n-3 PUFA levels and n-6/n-3 PUFA ratio during pregnancy with child's Rint and FeNO. Higher maternal total PUFA and total n-6 PUFA levels were associated with a decreased risk of childhood asthma (odds ratios (95% confidence interval): 0.76 (0.60, 0.97) and 0.71 (0.52, 0.96) per standard deviation score (SDS) increase of total PUFA and total n-6 PUFA levels, respectively) and with an increased risk of childhood eczema (1.16 (1.05, 1.28) and 1.21 (1.07, 1.37)). The observed associations were partly explained by Linoleic acid (LA, C18:2n-6) levels. Maternal total n-3 PUFA levels and n-6/n-3 PUFA ratio were not associated with current asthma and eczema. The observed associations were not explained by child's PUFA intake. CONCLUSIONS AND CLINICAL RELEVANCE: Higher maternal total PUFA and total n-6 PUFA levels during pregnancy seem to influence the risk of atopic diseases in childhood. The underlying mechanisms need to be further explored.

Perioperative hospital mortality at a tertiary paediatric institution.

BACKGROUND: Research in postoperative mortality is scarce. Insight into mortality and cause of death might improve and innovate perioperative care. The objective for this study was to report the 24-hour and 30-day overall, and surgery and anaesthesia-related, in-hospital mortality at a tertiary paediatric hospital. METHODS: All patients <18 yr old who underwent anaesthesia with or without surgery between January 1, 2006, and December 31, 2012, at the Wilhelmina Children's Hospital, Utrecht, The Netherlands, were included in this retrospective cohort study. Causes of death within 30 days were identified and tabulated into four major categories according to principal cause. RESULTS: A total of 45,182 anaesthetics were administered during this 7-yr period. The all-cause 24-hour hospital mortality was 13.1 per 10,000 anaesthetics (95% CI: 9.9-16.8) and the all-cause 30-day in-hospital mortality was 41.6 per 10,000 anaesthetics (95% CI: 35.9-48.0). In total five patients were partially contributable to anaesthesia (30-day mortality: 1.1/10,000, 95% CI: 0.4-2.6) and four patients were partially contributable to surgery (30-day mortality: 0.9/10,000, 95% CI: 0.2-2.3). Mortality was higher in neonates and infants, children with ASA physical status III and IV, and emergency- and cardiothoracic surgery. CONCLUSIONS: Neonates and infants, children with ASA physical status III or poorer, and emergency- and cardiothoracic surgery are associated with a higher postoperative mortality. Anaesthesia- or surgery-related complications contribute to mortality in only a small amount of the deaths, indicating the relative safety of paediatric surgical and anaesthetic procedures.

Fertility treatment, twin births, and unplanned pregnancies in women with eating disorders: findings from a population-based birth cohort.

OBJECTIVE: To investigate fertility treatment, twin births, and unplanned pregnancies in pregnant women with eating disorders in a population-based sample. DESIGN: A longitudinal population-based birth cohort (Generation R). SETTING: Rotterdam, the Netherlands. SAMPLE: Women from the Generation R study who reported a history of (recent or past) anorexia nervosa (n = 160), bulimia nervosa (n = 265), or both (n = 130), and a history of psychiatric disorders other than eating disorders (n = 1396) were compared with women without psychiatric disorders (n = 4367). METHODS: Women were compared on the studied outcomes using logistic regression. We performed crude and adjusted analyses (adjusting for relevant confounding factors). MAIN OUTCOME MEASURES: Fertility treatment, twin births, unplanned pregnancies, and women's feelings towards unplanned pregnancies. RESULTS: Relative to women without psychiatric disorders, women with bulimia nervosa had increased odds (odds ratio, OR, 2.3; 95% confidence interval, 95% CI, 1.1-5.2) of having undergone fertility treatment. Women with all eating disorders had increased odds of twin births (anorexia nervosa, OR 2.7, 95% CI 1.0-7.7; bulimia nervosa, OR 2.7, 95% CI 1.1-6.6; anorexia and bulimia nervosa, OR 3.795% CI 1.3-10.7). Anorexia nervosa was associated with increased odds of unplanned pregnancies (OR 1.8, 95% CI 1.2-2.6) and mixed feelings about these pregnancies (adjusted OR 5.0, 95% CI 1.7-14.4). Pre-pregnancy body mass index did not explain the observed associations. CONCLUSIONS: Eating disorders are associated with increased odds of receiving fertility treatment and twin births. Women with anorexia nervosa were more likely to have an unplanned pregnancy and have mixed feelings about the unplanned pregnancy. Fertility treatment specialists should be aware that both active and past eating disorders (both anorexia nervosa and bulimia nervosa) might underlie fertility problems.

Near-infrared light to aid peripheral intravenous cannulation in children: a cluster randomised clinical trial of three devices.

Intravenous cannulation can be difficult in children. Recently, new devices using near-infrared light to make blood vessels visible have become available. We aimed to evaluate the effectiveness of three such devices in facilitating peripheral intravenous cannulation in children. In this cluster randomised clinical trial, daily operating rooms at a tertiary childrens' hospital were randomised to the use of the VeinViewer®, AccuVein® AV300, VascuLuminator Vision® or to a control group. We included 1913 children between birth and 18 years scheduled for elective surgery. Suitable veins for cannulation were more easily visible with the VeinViewer (307/322 (95.3%)) and AccuVein (239/254 (94.1%)) devices than with VascuLuminator (229/257 (89.1%)) (p = 0.03). However, success at the first attempt was not significantly different among groups, ranging from 73.1% to 75.3% (p = 0.93). We conclude that although vein visibility is enhanced, near-infrared devices do not improve cannulation.

Perinatal outcomes and gestational weight gain in women with eating disorders: a population-based cohort study.

OBJECTIVE: To investigate adverse perinatal outcomes and gestational weight gain trajectories in women with lifetime (current/past) eating disorders (ED: anorexia nervosa [AN] and bulimia nervosa [BN]). DESIGN: A longitudinal population-based birth cohort. SETTING: Rotterdam, the Netherlands. SAMPLE: Women who enrolled prenatally, had complete information on exposure (lifetime ED), and gave birth to a live singleton (n = 5256). Four groups of exposed women: lifetime AN (n = 129), lifetime BN (n = 209), lifetime AN + BN (n = 100), other lifetime psychiatric disorder (n = 1002) were compared with unexposed women (n = 3816). METHODS: Perinatal outcomes and gestational weight gain were obtained from obstetric and midwifery records, self-report and objective measurements. Exposed women were compared with unexposed women within the cohort using linear, logistic regression and mixed models. MAIN OUTCOME MEASURES: Any pregnancy, delivery and postnatal complications. Birthweight adjusted for gestational age, prematurity (born <37 weeks), small-for-gestational age; maternal weight gain during pregnancy. RESULTS: Maternal AN was positively associated with suspected fetal distress. No differences were found in mean birthweight, prevalence of a small-for-gestational-age, or premature birth. Relative to unexposed women, women with AN had, on average, a lower body weight but a higher rate of weight gain subsequently; whereas women with BN had a higher body weight but a lower rate of weight gain. CONCLUSIONS: Maternal lifetime ED is associated with few adverse perinatal outcomes in this sample. Differential gestational weight gain patterns in women with AN and BN are consistent with possible biological compensatory mechanisms aimed at protecting the fetus.

Difficult arterial cannulation in children: is a near-infrared vascular imaging system the answer?

BACKGROUND: Arterial cannulation is a common anaesthetic procedure that can be challenging and time-consuming in small children. By visualizing the position of the radial artery, near-infrared vascular imaging systems (NIRVISs) might be of assistance in arterial cannulation. The present study evaluates the effectiveness of an NIRVIS in arterial cannulation in infants. METHODS: An observational study was conducted in patients up to 3 yr old, undergoing arterial cannulation before cardiothoracic surgery. Arterial cannulation was performed as usual in 38 patients, and subsequently with the NIRVIS in 39 patients. RESULTS: The time to successful cannulation was 547 s (171-1183) without and 464 s (174-996) with the NIRVIS (P=0.76) and the time to first flashback of blood was 171 s (96-522) and 219 s (59-447), respectively (P=0.38). There was a tendency in favour of the NIRVIS in success at first attempt: 12/38 and 7/39, respectively (P=0.29) and in the number of punctures: 6 (2-12) and 3 (1-7), respectively (P=0.10). CONCLUSIONS: The present study did not show a significant clinical improvement when NIR light was used during arterial cannulation in small children. There is a large difference between time to first flashback of blood and time to successful cannulation, indicating that inserting the cannula, and not localizing the artery, is the main difficulty in arterial cannulation in children.

Medication discontinuity errors in the perioperative period.

BACKGROUND: Inappropriate withdrawal or continuation of medication in the perioperative period is associated with an increased risk for adverse events. To reduce this risk, it is important that patients take their regular medication as prescribed. We evaluated this treatment objective by studying the frequency and reasons for errors related to medication discontinuity in the perioperative period. METHODS: Patients scheduled for non-cardiac surgery were included in this cross-sectional study. Perioperative medication intake was assessed at the holding area of the operation theatre complex and on the ward during the first 24 h after surgery. Medication intake data were obtained from medical records and by questioning patients and compared with pre-operative instructions. RESULTS: The study included 701 patients, of whom 485 (69%) used regular medication. Medication was incorrectly taken or discontinued before surgery in 27% of the patients. In 57% of these patients, the reason for incorrect intake was an unclear or a falsely understood instruction before surgery. Post-operative medication errors occurred in 26% of the patients. CONCLUSION: Medication errors occur frequently in the perioperative period, even in the era of an electronic medication file. Errors in prescription, administration and intake of medication are not easily solved because no single health care professional is responsible for adequate intake of medication in surgical patients. The anaesthesiologist should take on a more prominent role in regulating perioperative medication intake in surgical patients.

Routine pelvic lymphadenectomy in apparently early stage endometrial cancer.

AIMS: Controversial issues with respect to the treatment of patients with endometrial cancer include indications for lymphadenectomy and adjuvant radiotherapy. PATIENT AND METHODS: Between 1998 and 2004 all women with endometrial cancer stage I were included (n = 335). They all underwent total abdominal hysterectomy and bilateral salpingo-oöphorectomy. Two hundred and thirty-seven women also had a pelvic lymphadenectomy. When pelvic lymphadenectomy was performed, radiotherapy was administered only to patients with lymph-node metastases. Otherwise, adjuvant radiotherapy was based on the presence of risk factors. RESULTS: Eleven patients had lymph-node metastases. The overall absolute and relative survival-estimate at 5 years was 85.0 and 93.7%, respectively. Loco-regional recurrence was 8.5%. In the group with pelvic lymphadenectomy and negative lymph nodes these rates were 88.2, 93.9 and 5.6%, respectively. In 58 patients without any of the risk factors tumour grade III, deep myometrial invasion, or age > or =60 years, no lymph-node metastases were found. CONCLUSION: In patients with endometrial cancer FIGO stage I without risk-factors, a phenomenon which occurs in about 25% of patients with clinical stage I endometrial cancer, a lymphadenectomy can be omitted. In other patients, the debate regarding the optimal treatment will remain.

Comparison of OPS imaging and conventional capillary microscopy to study the human microcirculation.

Orthogonal polarization spectral (OPS) imaging is a new clinical technique for observation of the microcirculation of organ surfaces. For validation purposes, we compared OPS images of the nailfold skin with those obtained from conventional capillary microscopy at rest and during venous occlusion in 10 male volunteers. These images were computer analyzed to provide red blood cell velocity and capillary diameters of the same nailfold capillaries at rest and during venous occlusion. Results showed that OPS images provided similar values for red blood cell velocity and capillary diameter as those obtained from capillary microscopy images. OPS imaging, however, provided significantly better image quality, as shown by comparison of image contrast between OPS imaging and capillary microscopy. This made image analysis better and easier to perform. It is anticipated, therefore, that OPS imaging will become a new and powerful technique in the study of the human microcirculation in vivo because it can be used on human internal organs.

Treatment of Helicobacter pylori infections.

The available literature on the relationship between several diseases and Helicobacter pylori (H. pylori) is reviewed. Duodenal ulcer, gastric ulcer, complicated peptic ulcer, abdominal symptoms and gastroduodenal mucosal damage during the use of non-steroid anti-inflammatory drugs (NSAIDs), non-ulcer dyspepsia (NUD) and gastric malignancy are discussed. The case for and against eradication is critically discussed. Eradication of H. pylori should be pursued in all patients with peptic ulcer disease, whether they are using NSAIDs or not. Eradication of H. pylori in the treatment of NUD should be considered experimental. Treatment aimed at the eradication of H. pylori should be considered in all patients with low-grade malignant mucosa-associated lymphoid tissue (MALT) lymphoma and in all patients with Ménétrier's disease. Finally, this treatment should be considered in a subset of H. pylori-infected patients who possibly are at an increased risk of gastric cancer: patients with a strong family history of gastric carcinoma and patients in need of long-term treatment with a proton-pump inhibitor. In view of the importance of patient compliance, the risk of side-effects and the possibility of inducing metronidazole resistance when treatment with a metronidazole-containing regimen is used, treatment aimed at the eradication of H. pylori should be carefully implemented and monitored.

Human serum antibody response against iron-repressible outer membrane proteins of Helicobacter pylori.

In Helicobacter pylori, in vitro iron limitation induces the expression of several iron repressible outer membrane proteins (IROMPs), which are not expressed under normal growth conditions. To substantiate their proposed role in virulence of H. pylori, we determined whether these IROMPs are also expressed in vivo. Therefore, we tested whether sera of patients with H. pylori infection contained antibodies against IROMPs. All sera from 20 H. pylori positive patients showed a clear immune response against a 77 kDa heme-binding IROMP in an immunoblot assay. Antibody responses against the other IROMPs were also found, but with lower frequencies. Serum samples from 18 patients negative for H. pylori infection did not show any immunoreactivity with IROMPs. These results indicate that the IROMPs of H. pylori are immunogenic and are expressed in vivo.

Genomic DNA fingerprinting of clinical isolates of Helicobacter pylori by REP-PCR and restriction fragment end-labelling.

Genetic diversity of 32 Helicobacter pylori strains isolated from patients with gastritis, gastric or duodenal ulcer, carcinoma, or lymphoma was determined by repetitive sequence element polymerase chain reaction (REP-PCR), and by the new typing method restriction fragment end-labelling (RFEL). Furthermore, these two methods were used to investigate a possible correlation between clinical symptoms and the genetic background of Helicobacter pylori. Both REP-PCR and RFEL revealed 31 different patterns for the 32 strains tested, but the pair of isolates with identical REP-PCR patterns was not the same as the pair of isolates with identical RFEL patterns. Computer-assisted analysis of the DNA fingerprints was used to determine similarity coefficients. This analysis revealed no clustering of disease-specific strains by any of the two methods.

Novobiocin resistance and virulence of strains of Staphylococcus saprophyticus isolated from urine and skin.

A method was developed to study virulence of coagulase-negative staphylococci. Our results showed that coagulase-negative staphylococci injected into adult mice by the intracerebral route did not give rise to lethal infections, whereas mice aged 2 days were much more susceptible. Novobiocin-resistant strains of Staphylococcus saprophyticus were more virulent than strains of Staphylococcus epidermidis. Strains of S. saprophyticus biotype 3 of Baird-Parker's classification varied in virulence according to novobiocin sensitivity. In the classification of Kloos and Schleifer, S. saprophyticus biotype 3 can be subdivided into four distinct staphylococcal species, namely S. saprophyticus , S.cohnii, S.haemolyticus and S.warneri. S. chonii and S. saprophyticus were equally virulent for mice aged 2 days, but novobiocinsensitive S. haemolyticus was less virulent. On epidemiological grounds, however, it would seem that S. saprophyticus has some undefined advantage in invading the urinary tract.

Histopathological changes in the hind foot of the mouse induced by black-pigmented Bacteroides strains.

The pathogenic potential of black-pigmented Bacteroides strains was studied in an animal model in which the effect on bone tissue could be determined. Bacteria suspended in agar were injected subcutaneously in the left hind paw of a mouse. After 3-5 days, B. gingivalis strain HG 66 had caused a massive infiltration with polymorphonuclear cells, destruction of the periosteum on the metatarsals and bone resorption by osteoclasts. After 7 days only a few osteoclasts remained and reactive bone formation was observed. In a comparative study with strains of several black-pigmented Bacteroides species, differences in bone resorbing potential were seen. B. gingivalis strains caused severe inflammation which resulted in bone resorption. Strains of B. asaccharolyticus, B. endodontalis, B. intermedius, B. melaninogenicus and B. loeschei caused less inflammation and less bone resorption. Killed bacteria or agar alone caused a relatively mild inflammation and no bone resorption.

The role of neuraminidase in haemagglutination and adherence to colon WiDr cells by Bacteroides fragilis.

The role of neuraminidase in haemagglutination and adherence to colon WiDr cells by eight strains of Bacteroides fragilis and four strains of oral black-pigmented gram-negative anaerobes was studied. Neuraminidase treatment resulted in a very small increase of haemagglutination by some of the strains but had no effect on adherence to WiDr cells by all bacterial strains tested except one strain of Prevotella intermedia (HG 110). Inhibition of neuraminidase had no effect on haemagglutination or adherence, nor was any correlation found between haemagglutinating ability and neuraminidase activity in the B. fragilis strain. The results indicated that haemagglutination and adherence of B. fragilis to WiDr cells were not mediated by neuraminidase.

Comparison of three molecular typing methods in studies of transmission of Porphyromonas gingivalis.

Porphyromonas gingivalis is associated strongly with severe periodontitis, but little information is available on possible transmission routes of this species. This study evaluated three DNA-based molecular typing methods for use in epidemiological surveys of P. gingivalis. In total, 32 isolates from eight married couples were investigated by: (i) restriction endonuclease analysis (REA) of whole chromosomal DNA; (ii) hybridisation of DNA fragments with ribosomal DNA (ribotyping); and (iii) amplification of DNA by the polymerase chain reaction with arbitrary primers (AP-PCR). The data obtained with the three methods were in broad agreement: in six of the eight couples, the isolates from husband and wife were indistinguishable, but isolates from unrelated individuals showed distinct types with all three methods. For some isolates, minor differences in REA pattern were obtained which could not be correlated with differences in ribotype or AP-PCR type. Ribotyping showed differences between isolates from one individual, which were indistinguishable with the other two methods. The patterns obtained with ribotyping or AP-PCR were simple in comparison to the relatively complex REA patterns. Although all three methods were concordant, AP-PCR was found to be the least time-consuming method. The data support the suggestion that P. gingivalis can be transmitted between spouses.