Safety and Efficacy of Prolonged Use of Dalbavancin in Bone and Joint Infections.

Dalbavancin is a lipoglycopeptide with potent activity against Gram-positive microorganisms, a long half-life, a favorable safety profile, and a high concentration in bone, which makes it an interesting alternative for treatment of osteoarticular infections. We performed a multicentric retrospective study of all patients with an osteoarticular infection (septic arthritis, spondylodiscitis, osteomyelitis, or orthopedic implant-related infection) treated with at least one dose of dalbavancin between 2016 and 2017 in 30 institutions in Spain. In order to evaluate the response, patients with or without an orthopedic implant were separated. A total of 64 patients were included. Staphylococcus epidermidis and Staphylococcus aureus were the most frequent microorganisms. The reasons for switching to dalbavancin were simplification (53.1%), adverse events (25%), or failure (21.9%). There were 7 adverse events, and no patient had to discontinue dalbavancin. In 45 cases, infection was related to an orthopedic implant. The implant material was retained in 23 cases, including that in 15 (65.2%) patients that were classified as cured and 8 (34.8%) that presented improvement. In 21 cases, the implants were removed, including those in 16 (76.2%) cases that were considered successes, 4 (19%) cases were considered improved, and 1 (4.8%) case that was considered a failure. Among the 19 cases without implants, 14 (73.7%) were considered cured, 3 (15.8%) were considered improved, and 2 (10.5%) were considered failures. The results show that dalbavancin is a well-tolerated antibiotic, even when >2 doses are administered, and is associated with a high cure rate. These are preliminary data with a short follow-up; therefore, it is necessary to gain more experience and, in the future, to establish the most appropriate dose and frequency.

Fertility preservation in female oncology patients: the influence of the type of cancer on ovarian stimulation response.

STUDY QUESTION: Does the type of cancer influence on the ovarian response to stimulation for fertility preservation (FP) in female oncology patients? SUMMARY ANSWER: Patients with gynaecological cancer have less number of retrieved mature oocytes compared with haematological and breast cancer patients. WHAT IS KNOWN ALREADY: Concerns about the impact of cancer therapy on future fertility have been raised and FP has become an important component in cancer management. Previous studies analysing FP results in cancer patients have shown conflicting findings. STUDY DESIGN, SIZE, DURATION: This was a retrospective analytical study performed in the Centre for Reproductive Medicine, at St Bartholomew's Hospital, between January 2000 and December 2014. The aim of this study was to analyse the response to ovarian stimulation in cancer patients before undergoing cancer treatment and to determine whether any difference can be attributed to underlying cancer diagnosis. We also report the pregnancy outcomes. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 531 female patients recently diagnosed with cancer were referred for counselling on FP. A total of 306 patients underwent ovarian stimulation for oocyte or embryo cryopreservation. We compared the baseline characteristics and ovarian response in five main subgroups: breast cancer, haematological cancer, gynaecological cancer, gastrointestinal cancer and others. The primary outcome was the total number of mature oocytes retrieved and pregnancy outcomes. MAIN RESULTS AND THE ROLE OF CHANCE: The main cancer diagnosis was breast cancer with 145 patients (47.4%); 79 patients (25.8%) had haematological malignancies; 42 (13.7%) had gynaecological malignancies; 20 (6.5%) had gastrointestinal cancer and 20 (6.5%) had other types of cancer. Patients with breast cancer were older (P < 0.001). Patients with haematological malignancies had higher number of mature oocytes retrieved (P = 0.003). The number of mature oocytes retrieved was lower in patients with gynaecological malignancy compared with haematological and breast cancer patients (P = 0.005 and P = 0.045, respectively). The fertilization rate and the number of cycles cancelled were comparable between all the groups. Thirty-two embryo transfer cycles have been done in 22 patients who have returned to attempt pregnancy. Pregnancy rate per transfer cycle was 43.75%, and cumulative pregnancy rate per patient was 54.5%. Live birth rate per patient was 22.72%. LIMITATIONS, REASONS FOR CAUTION: Apart from the retrospective nature of the study, patients were included over the period of 15 years, and over that time technology has changed and protocols have evolved. The results obtained from subcategory analyses should be interpreted with caution, as in each subgroup there are different types of malignancies with different number of patients in different age groups. Different ovarian stimulation protocols were applied. Only a few patients have come back to attempt pregnancy after being cured from their disease. We do not have follow-up data on these patients; as a result, we are not able to report the survival rate and the reason for non-return for embryo transfer. In addition, we cannot report information on spontaneous conceptions and births. Slow freezing used for embryo cryopreservation, high miscarriage rate and low live birth rate per transfer are other limitations of this study. WIDER IMPLICATIONS OF THE FINDINGS: The current study is the largest series analysing each group of cancer separately and showing pregnancy outcomes in oncology patients undergoing FP. These results provide valuable information about the success of this technique in oncology patients. STUDY FUNDING/COMPETING INTEREST(S): The authors have not received any funding to support this study. There are no conflicts of interest to declare.

MRI measurement of residual cervical length after radical trachelectomy for cervical cancer and the risk of adverse pregnancy outcomes: a blinded imaging analysis.

OBJECTIVE: To determine the association between the residual cervix measured on postoperative MRI after radical vaginal trachelectomy (RVT) and adverse obstetrical outcomes. DESIGN: Observational study. SETTING: Referral Cancer centre. POPULATION: Women who conceived after RVT for cervical cancer at the Royal Marsden Hospital, London, between 1995 and 2015. METHODS: Postoperative MRI scans were analysed by three researchers. The agreement between researchers was assessed by Pearson's correlation coefficient and Bland-Altman plot. Patients were divided into two groups (<10 and ≥10 mm residual cervix) for the analysis of adverse obstetrical outcomes. MAIN OUTCOME MEASURES: Late miscarriage, premature delivery, premature rupture of membranes (PROM) and chorioamnionitis. RESULTS: Thirty-one MRI scans were available; 29 of these women had a pregnancy that progressed beyond the first trimester. There was a strong reproducibility of the measurement of residual cervix (P < 0.001). Nineteen women (65.5%) had <10 mm residual cervix and 10 (34.5%) had ≥10 mm. Among women with <10 mm residual cervix, seven (36.8%) experienced PROM and ten (66.7%) had a preterm birth; No women with ≥10 mm residual cervix had PROM and two (22.2%) had a preterm birth (P = 0.028 and P = 0.035, respectively). Overall, there were nine (16.7%) first-trimester miscarriages, six (11.1%) late fetal losses, 12 (31.6%) preterm births and 36 (66.7%) live births. After a mean follow up of 78.1 months, 36 women were disease-free and one woman had died. CONCLUSIONS: MRI measurements of the residual cervix are reproducible between observers. The incidence of PROM and premature delivery is higher when the residual cervix after RVT is <10 mm. TWEETABLE ABSTRACT: The risk of prematurity after RVT can be predicted from measurements of residual cervical length on postoperative MRI scan.

[Impact of Staphylococcus aureus bacteremia in COVID-19 patients]. / Impacto de la bacteriemia por Staphylococcus aureus en pacientes con COVID-19.

OBJECTIVE: The disease caused by SARS-CoV-2 (COVID-19) has been a challenge for healthcare professionals since its appearance. Staphylococcus aureus has been described as one of the main pathogens causing bacterial infections in viral pandemics. However, co- infection with S. aureus causing bacteremia in patients with COVID-19 has yet to be well studied. METHODS: We performed a e study of S. aureus bacteremia (SAB) at Hospital Miguel Servet (Zaragoza) from March 2020 to February 2021. The clinical characteristics, mortality and risk factors of adults hospitalized patients with BSA associated COVID-19 compared to patients without COVID-19. RESULTS: A total of 95 patients with SAB were identified. 27.3% were positive for SARS-CoV-2. SAB represented 9.9% of bacteremia, being the second agent in frequency after E. coli. Nosocomial bacteremia was more frequent in the group of COVID-19 patients. The most frequent source of BSA in these patients was the respiratory source (26.9% vs 0%; P<0.001) followed by the skin (15.5% vs 15.9%; P=1). The development of sepsis was more frequent in COVID-19 patients (61,5% vs 7,8%; P=0,336) and among them, who received dexamethasone at doses > 6 mg/day (62.5% vs. 37.5%, P<0.05). CONCLUSIONS: Our data suggest that BSA has a negative impact on the evolution of patients with COVID-19. However, further and preferably prospective studies are required to obtain solid data on the impact of BSA on coronavirus patients.

[Clinical characteristics and prognosis of Staphylococcus aureus bacteremia]. / Características clínicas, pronóstico y factores asociados de la bacteriemia por Staphylococcus aureus en la actualidad.

OBJECTIVE: Staphylococcus aureus bacteremia patients characteristics at a tertiary hospital are described, and complications, mortality and associated factors are analyzed. METHODS: Data from patients with S. aureus bacteremia admitted between March 2020 and February2021 at Miguel Servet university hospital in Zaragoza were retrospectively analyzed. RESULTS: Results showed a 14 days mortality of 24.2% and an 30 days mortality of 40%. Overall survival decreased with complications appearance [HR 3.1 (1.2-8.05)] and age over 65 years [HR 3.1 (1.4-6.6)]. The adjusted analysis showed correlation between a higher mortality at 14 and 30 days with age over 65 years [OR 6.3 (1.7-23.1)], sepsis presence [OR 19.3 (5.4-68.7)] and number of positive (+) blood cultures ≥3 [OR 5.4 (0.8-34.1)]. Mortality at 14 days was associated with sepsis presence [OR 58.2 (5.7-592.9)], number of positive (+) blood cultures ≥3 [OR 14.1 (1.1-173.7)] and an older age [OR 1.1 (1.03-1.1)]. Analyzing time to positive blood cultures ≤12 hours and number of positive blood cultures ≥ 3 at the same time, frequency of sepsis increased [30 patients (66.6%) vs 15 patients (33.3%); OR 3.4 (IC95% 1.5-8)]. CONCLUSIONS: High 14- and 30-days mortality were found, as well as a worse evolution in older age patients, with sepsis presence, and with greater number of positive blood cultures and times to positive blood cultures ≤12 h.

[Utilization study in real clinical practice of ceftolozane/tazobactam vs aminoglycosides and/or colistin in the treatment of multirresistant or extremely resistant Pseudomonas aeruginosa]. / Estudio de utilización en práctica clínica real de ceftolozano/tazobactam frente a aminoglucósidos y/o colistina en el tratamiento de Pseudomonas aeruginosa.

OBJECTIVE: Comparative "real life" data on the effectiveness and safety of ceftolozane/tazobactam (C/T) versus other regimens (aminoglycosides/colistin/combination), in the treatment of multi-resistant (MDR) and extremely resistant (XDR) Pseudomonas aeruginosa (PA), are needed to establish positions. METHODS: Observational, retrospective study of patients with microbiological confirmation of MDR and XDR PA from July 2016 up to December 2018 in a tertiary hospital. Variables: age, sex, comorbidities, risk factors for multidrug resistance, variables related to infection, source of infection, microorganism and type of sample, antibiotic treatment, clinical cure, microbiological cure, recurrence, mortality on admission and 30 days post-discharge. Patients were classified according to received antibiotic treatment, C/T or aminoglycosides/colistin/combination. RESULTS: A total of 405 patients with PA MDR and XDR infection (73.1% men, mean age 63 ± 15 years) were studied. An 87.1% of PA XDR and a 12.9% MDR were observed. All patients received C/T as targeted therapy and in the aminoglycosides/colistin/combination group were 73.5%. Patients in the C/T group present worse prognostic factors: septic shock (30.0%) and catheterization (90.0%) (p<0.05). There were not statistically significant differences in microbiological cure (p=0.412), recurrence (p=0.880) and clinical cure (p=0.566). There were not statistically significant differences in mortality at admission (p=0.352) or at 30 days after discharge (p=0.231). A 17.2% of the patients with aminoglycosides/colistin/combination had acute kidney injury according to RIFLE criteria and 4.3% with C/T. CONCLUSIONS: The data obtained suggest that there have been no differences in effectiveness (clinical or microbiological cure) in favour of C/T, although, in the period studied, it was used in most cases in multitreated patients with a worse prognosis. Randomized and prospective studies would be needed to establish an adequate positioning.

Molecular characterization of calcitonin gene-related peptide (CGRP) related peptides (CGRP, amylin, adrenomedullin and adrenomedullin-2/intermedin) in goldfish (Carassius auratus): cloning and distribution.

To further characterize the structure and function of calcitonin gene-related peptide (CGRP) related peptides in fish, we have cloned cDNA sequences for CGRP, amylin, adrenomedullin (AM) and adrenomedullin-2/intermedin (IMD) in goldfish (Carassius auratus) and examined their tissue distribution. CGRP, amylin, AM and IMD cDNAs were isolated by reverse transcription (RT) and rapid amplification of cDNA ends (RACE). The cloned sequences contain the complete four mature peptides, which present a high degree of identity with mature peptide sequences from other fish. Phylogenetic analyses show that goldfish AM and IMD form a sub-family within the CGRP-related peptides that is distinct from the CGRP/amylin sub-family. The distribution of goldfish CGRP-like peptides mRNA expression in different tissues and within the brain was studied by RT-PCR. CGRP, IMD and AM are detected throughout the brain, in pituitary and in most peripheral tissues examined. Amylin mRNA is mostly expressed in the brain, in particular posterior brain, optic tectum and hypothalamus, but is also present in pituitary, gonad, kidney and muscle. Our results suggest that goldfish CGRP, amylin, AM and IMD are conserved peptides that show the typical structure characteristics present in their mammalian counterparts. The widespread distributions of CGRP, AM and IMD suggest that these peptides could be involved in the regulation of many diverse physiological functions in fish. Amylin mRNA distribution suggests possible new roles for this peptide in teleosts, including the control of reproduction.

Molecular cloning and characterization of recombinant parasite antigens for immunodiagnosis of onchocerciasis.

Immunological cross-reactivity among nematodes has hampered the development of specific serodiagnostic assays for onchocerciasis. In the present study, an Onchocerca volvulus adult worm complementary DNA expression library was differentially screened with human sera from patients infected with O. volvulus and with an omnibus anti-nematode serum pool comprised of sera from patients infected with Brugia malayi, Loa loa, Wuchereria bancrofti, Mansonella perstans, Strongyloides stercoralis, Ancylostoma duodenale, Ascaris lumbricoides, and Dracunculus medinensis. Seven Onchocerca-specific clones were identified and screened with individual onchocerciasis patient sera. Additional studies were performed to characterize the most immunoreactive clones, OC 3.6 and OC 9.3. OC 3.6 produced a 152-kD beta-galactosidase fusion protein that was recognized in dot-immunoblots by 54 of 55 sera from onchocerciasis patients (98%). The OC 3.6 DNA insert is 996 bp long with an open reading frame of 627 bp and a 369-bp untranslated 3' end. OC 3.6 is closely related to a previously reported clone (OV 33-3), but it differs from that clone at both the 5' and 3' ends. OC 9.3 contained a novel 565-bp insert and produced a 138-kD fusion protein that was recognized by 46 of 55 sera from onchocerciasis patients (83%). Additional studies are in progress to develop and evaluate immunodiagnostic tests for onchocerciasis based on measurement of antibodies to these promising recombinant antigens.

Differential characteristics of bacteraemias according to age in a community hospital. / Características diferenciales en las bacteriemias según la edad en un hospital comunitario.

OBJECTIVE: To describe the characteristics of bacteraemias, according to age, in a community hospital. MATERIAL AND METHOD: A prospective study of bacteraemias was conducted in 2011. The patients were classified into 3 age groups: younger than 65 years, 65 to 79, and 80 or older. The study collected variables on the patients and episodes. RESULTS: The study analysed 233 bacteraemias in 227 patients (23.8% in those younger than 65 years; 38.3% in the 65 to 79 age group; and 37.9% in the 80 years or older group). The most common underlying disease in all the groups was diabetes mellitus. In the most elderly patients, the Charlson index was highest, there was a lower proportion of exogenous factors, and almost 25% were severely dependent (Barthel index<20). Escherichia coli was the most common germ, and the main focus was urological. The patients aged 80 years or older had predominantly healthcare-associated infections, less severe symptoms (sepsis) (66.3%) and higher mortality (29.1%) compared with the younger patients. CONCLUSIONS: The very elderly patients with bacteraemia presented fewer exogenous factors, greater comorbidity and a poorer functional situation. The most common focus was urological and the origin was healthcare related. Despite their less severe clinical presentation, these patients' mortality was greater, and their degree of dependence was a highly relevant independent risk factor.

[Anticholinesterases in the treatment of Alzheimer's disease]. / Anticolinesterásicos en el tratamiento de la enfermedad de Alzheimer.

INTRODUCTION: Among the numerous pathophysiological theories that attempt to explain the development of Alzheimer's disease (AD) there are two facts that stand out above the rest: on the one hand, the formation of neurofibrillary tangles inside cells and, on the other, the extra-cellular deposition of beta-amyloid protein. These two mechanisms lead to neurodegeneration and the death of cells by means of a process called 'apoptosis' or 'programmed cell death'. In the early stages of this neurodegenerative process it is more pronounced in cholinergic-type brain centres. This led to the formulation of the so-called cholinergic theory of Alzheimer, which provides the rationale behind the use of the drugs that are currently available to treat this disease, namely, acetylcholine esterase (AChE) inhibitors (rivastigmine, donepezil and galanthamine). DEVELOPMENT AND CONCLUSIONS: We review the possible pharmacological approaches that could help to prevent or delay cell death, and which act on the mechanisms involved in the production of neurofibrillary tangles or the deposition of beta-amyloid protein. We also review the main characteristics of cholinergic neurotransmission, which will help us to understand the therapeutic approaches that have been applied in an attempt to enhance deficient cholinergic neurotransmission. One of the most notable of these is the amount of attention recently being paid to the enzyme AChE, which increases the bioavailability of the neurotransmitter in the cholinergic synapses by preventing the hydrolysis of acetylcholine; these are the only drugs currently available for the symptomatic treatment of this disease.

Use of Iodogen and sulfosuccinimidobiotin to identify and isolate cuticular proteins of the filarial parasite Brugia malayi.

The cuticle of filarial nematodes is a dynamic structure which may be an important target for protective host immune responses. Prior studies have employed radioiodination of intact parasites to demonstrate that the collagenous cuticle of filariids contains relatively few exposed proteins, some of which are stage and/or species-specific. In the present study, we have used sulfo-NHS-biotin to label and affinity purify cuticular components of living adult Brugia malayi. Results obtained by this method were compared with the widely used Iodogen method of surface radioiodination by SDS-PAGE analysis of detergent-solubilized worms and by ultrastructural analysis. Both labeling methods produced very similar electrophoretic patterns with major doublets at 70 and 100 kDa, a major band at 25 kDa, and minor bands between 60-200 kDa. Ultrastructural analysis showed that both methods labeled components throughout all levels of the parasite cuticle; underlying somatic tissues were not labeled. The biotinylated components were isolated from the total parasite extract by affinity chromatography on an avidin matrix. Further characterization of these surface-associated proteins may lead to improved methods for the control of filariasis.

Identification of paramyosin as a potential protective antigen against Brugia malayi infection in jirds.

Vaccination of jirds with irradiated infective larvae of Brugia malayi has been reported to provide partial immunity to larval challenge. In the present study, we found that sera from vaccinated animals recognized larval antigens with apparent molecular weights of 97, 55-60, and 10 kDa that were not recognized by sera from infected animals. A B. malayi cDNA expression library in lambda gt11 was screened to identify clones that were preferentially recognized by sera from immunized animals. One of these clones (BM-5) was chosen for further study. BM-5 contains a 2.1 kb DNA insert and produces a fusion protein with a molecular weight of 185 kDa. Antibody, affinity-purified with the BM-5 fusion protein, binds to a 97 kDa native B. malayi antigen. Immunological studies and partial DNA sequence data confirm that BM-5 encodes paramyosin. Recombinant B. malayi paramyosin is strongly recognized by antibodies in sera from jirds that have been immunized either by injection with irradiated larvae or by chemotherapy-abbreviated infection. Most sera from infected jirds do not contain antibody to paramyosin. Additional studies are needed to determine whether paramyosin is actually protective in this filariasis model.

Calcium signals in cell lines derived from the cerebral cortex of normal and trisomy 16 mice.

We established two immortalized cell lines from cerebral cortex of normal (CNh) and trisomy 16 (CTb) mouse fetuses, an animal model of human trisomy 21. Those cells loaded with the fluorescent Ca2+ dyes, Indo-1 and Fluo-3, exhibited increments of intracellular Ca2+ ([Ca2+]i) in response to external glutamate, NMDA, AMPA and kainate. CTb cells exhibited higher basal Ca2+ concentrations and had higher amplitude and slower time-dependent kinetics in the decay than CNh cells, suggesting an impaired Ca2+ buffering capacity in the trisomy 16-derived cell line. Nicotine also induced increments of [Ca2+]i. The CTb cell line could represent a model for studying cellular alterations related to Down syndrome.

Agrobacterium-mediated transformation of Amaranthus hypochondriacus: light- and tissue-specific expression of a pea chlorophyll a/b-binding protein promoter.

Mature embryos of Amaranthus hypochondriacus (amaranth) were used to develop an in vitro culture system for plant regeneration and genetic transformation. Plants were regenerated from embryo-derived callus cultivated on Murashige and Skoog medium supplemented with 10 µM 2,4-dichlorophenoxyacetic acid or 3,6-dichloro-2-methoxybenzoic acid and 10% coconut liquid endosperm. Transgenic plants were obtained by inoculation of mature embryo explants with a disarmed Agrobacterium strain containing the plasmid pGV2260(pEsc4), which carried the genes encoding neomycin phosphotransferase type II and ß-glucuronidase. The presence of transgenes in the genome of transformed amaranth plants and their progeny was demonstrated by Southern blot hybridization. Tissue specific and light-inducible expression directed by a pea chlorophyll a/b-binding protein promoter was observed in transgenic amaranth plants and their progeny.

Procedures for preventing the transmission of foot-and-mouth disease virus to pigs and sheep by personnel in contact with infected pigs.

The most effective method of containing an outbreak of foot-and-mouth disease (FMD) is by the culling of livestock. However, qualified people must diagnose the disease before the culling can begin, and they must avoid susceptible animals after having been in contact with infected premises, to prevent them from transmitting the virus. To test the effectiveness of biosecurity procedures in preventing the transmission of FMD virus (O/UK/35/2001) investigators contacted and sampled pigs inoculated with FMD virus for approximately 45 minutes and then contacted and sampled sentinel pigs and sheep after either using no biosecurity procedures, or washing their hands and donning clean outerwear, or showering and donning clean outerwear. The virus was detected in the nasal secretions of one investigator immediately after the postmortem investigation of the inoculated pigs but was not detected in samples collected between approximately 12 and 84 hours later. After the contaminated personnel had showered and changed into clean outerwear they did not transmit the strain of FMD virus to susceptible pigs and sheep.

Vibrational and theoretical studies of N-(fluorosulfonyl)imidosulfurous difluoride, FSO2N=SF2.

The Raman spectrum of liquid N-(fluorosulfonyl)imidosulfurous difluoride FSO2N = SF2 and the IR spectrum of its vapour phase were recorded. The observed features in combination with the theoretical studies indicate the existence at room temperature of only one conformer. In accord with previous results obtained by electron-diffraction analysis, this single conformer possesses C1 symmetry in which the SF2 group is oriented syn with respect to the N-S single bond. Theoretical vibrational spectra were also determined using ab initio and density functional theory (DFT) calculations at different levels of approximation. For all except one of the torsional modes, experimental wavenumbers were obtained. A subsequent normal coordinate analysis was performed using a torsional wavenumber calculated by theoretical methods.

[Rheumatic manifestations associated with infection by the hepatitis C virus]. / Manifestaciones reumáticas asociadas a la infección por el virus de la hepatitis C.

The development in the past few years of laboratory test for hepatitis C virus allow us to associate it with a broad range of autoimmune manifestations such as cryoglobulinemia and Sjögren syndrome. As in other virus' infections, rheumatic manifestations have been described during VHC infection, but there are no large studies enough to know their true frequency and characteristic. The three reported patients in this issue presented and HCV related arthropathy once clinical picture, laboratory test and following, allowed us to exclude other diagnostics. Clinical manifestations ranged from arthralgias and intermittent arthritis to symmetric polyarthritis without any kind of join damage.

[Pneumonia by Rhodococcus equi in patients with HIV infection]. / Neumonía por Rhodococcus equi en pacientes con infección por VIH.

We present the case of a patient with AIDS who developed abscessified pneumonia by Rhodococcus equi. We publish this case given the rare frequency of presentation of this opportunistic infection in this type of patient and given its good clinical evolution, on the contrary of other cases described so far in the literature. The good evolution of the patient may be due to an early diagnosis, less than one month, and the combined medical therapy with rifampicine and tetracyclines.