The frequency of interleukin-1ß-producing monocytes is significantly associated with varicella-zoster responses of nursing home residents.

Previous studies have demonstrated that the status of the T cell compartment and inflammation-related factors are associated with the immunogenicity of the varicella-zoster virus (VZV) vaccine in older adults; however, little is known about the roles of other immune cell subsets known to influence the generation and maintenance of immunological memory. Responses to a live-attenuated VZV vaccine were studied in relation to peripheral blood mononuclear cell (PBMC) composition and function in a sample of 30 nursing home residents (aged 80-99 years). Interferon-gamma enzyme-linked immunospot (ELISPOT) was used to measure VZV responses at baseline and 6 weeks following vaccination, and associations were sought with the frequencies of monocytes and T, B and natural killer (NK) cells and the production and secretion of cytokines following their ex-vivo stimulation with different agents. While only the frequency of interleukin (IL)-6+ CD14+ monocytes was inversely associated with post-vaccination VZV response, amounts of IL-1ß, IL-10, IL-17A and tumour necrosis factor (TNF) secreted by PBMCs and the frequency of IL-1ß+ CD14+ monocytes was positively correlated with pre-vaccination VZV response. Furthermore, both bivariate correlation and causal mediation analyses supported the notion that IL-1ß+ CD14+ monocytes were significant mediators of the associations between IL-1ß and TNF secretion by PBMCs and pre-vaccination VZV responses. Our findings implicate a strong cytokine response mediated by inflammatory IL-1ß+ monocytes in coordinating responses of long-lived VZV-reactive memory T cells, but with an opposing effect of IL-6+ CD14+ monocytes. Whether monocyte status promotes or inhibits the induction and/or maintenance of these memory T cells later in life has yet to be determined.

The Impact of Prior Season Vaccination on Subsequent Influenza Vaccine Effectiveness to Prevent Influenza-related Hospitalizations Over 4 Influenza Seasons in Canada.

BACKGROUND: Recent studies have demonstrated the possibility of negative associations between prior influenza vaccines and subsequent influenza vaccine effectiveness (VE), depending on season and strain. We investigated this association over 4 consecutive influenza seasons (2011-2012 through 2014-2015) in Canada. METHODS: Using a matched test-negative design, laboratory-confirmed influenza cases and matched test-negative controls admitted to hospitals were enrolled. Patients were stratified into 4 groups according to influenza vaccine history (not vaccinated current and prior season [referent], vaccinated prior season only, vaccinated current season only, and vaccinated both current and prior season). Conditional logistic regression was used to estimate VE; prior vaccine impact was assessed each season for overall effect and effect stratified by age (<65 years, ≥65 years) and type/subtype (A/H1N1, A/H3N2, influenza B). RESULTS: Overall, mainly nonsignificant associations were observed. Trends of nonsignificant decreased VE among patients repeatedly vaccinated in both prior and current season relative to the current season only were observed in the A/H3N2-dominant seasons of 2012-2013 and 2014-2015. Conversely, in 2011-2012, during which B viruses circulated, and in 2013-2014, when A/H1N1 circulated, being vaccinated in both seasons tended to result in a high VE in the current season against the dominant circulating subtype. CONCLUSIONS: Prior vaccine impact on subsequent VE among Canadian inpatients was mainly nonsignificant. Even in circumstances where we observed a trend of negative impact, being repeatedly vaccinated was still more effective than not receiving the current season's vaccine. These findings favor continuation of annual influenza vaccination recommendations, particularly in older adults. CLINICAL TRIALS REGISTRATION: NCT01517191.

A new species of Anchoviella (Clupeiformes: Engraulidae) from the western Amazon River in Peru, with comments on congeners in the Peruvian Amazon River.

Anchoviella hernanni sp. nov. is described from the upper Amazon River basin, in tributaries of the Marañon, Ucayali and Madre de Dios river drainages that drain the Peruvian Andes. The new taxon can be distinguished from all congeners except Anchoviella jamesi, Anchoviella manamensis and Anchoviella perezi, by having 12-15 gill rakers in the lower branch of the first gill arch (v·16-35) and from those species by the distance between verticals through the posterior margin of the orbit to the posterior margin of the upper jaw 9·5-14·8% head length; LH (v. up to 6·0% LH ). An updated identification key of all freshwater species of Anchoviella and morphological comparisons between all species of the genus occurring in Peru are provided.

Role of pharmaceutical care for self-administered pulmonary tuberculosis treatment in Thailand.

WHAT IS KNOWN AND OBJECTIVE: With resource constraints in Thailand, directly observed therapy (DOT) for treating tuberculosis (TB) may not be feasible to implement. To improve patients' adherence, hospitals either modify DOT or adopt different approaches: pharmaceutical care or home visit. Our objective was to assess pulmonary TB treatment success rate of pharmaceutical care compared to home visit and modified DOT in Thailand. METHODS: We conducted a retrospective cohort study using data collected in adult pulmonary TB patients starting treatment between October 2010 and September 2013 in three hospitals in Thailand. This study was approved by the Research Ethics Board at each of the participating hospitals. We built a propensity score matching to account for differences in patient baseline characteristics. RESULTS: Analysis included 1398 patients. Before matching, the treatment success rate for patients receiving pharmaceutical care was 94.9%, home visit 93.6% and modified DOT 90.1%. The propensity score-matched cohorts indicated that differences in the treatment success rate were not statistically significant when comparing pharmaceutical care with either home visit (success rate: 92.76% vs 94.74%, risk difference: 1.97%, 95% CI -3.64 to 7.59) or modified DOT (success rate 93.37% for both, risk difference: 0%, 95% CI -5.30 to 5.30). WHAT IS NEW AND CONCLUSION: Pharmaceutical care, home visit and modified DOT are all associated with high success rate for pulmonary TB treatment and exceeded the WHO target, in this retrospective analysis.

Identification of genetic variants associated with susceptibility to West Nile virus neuroinvasive disease.

West Nile virus (WNV) infection results in a diverse spectrum of outcomes, and host genetics are likely to influence susceptibility to neuroinvasive disease (West Nile neuroinvasive disease (WNND)). We performed whole-exome sequencing of 44 individuals with WNND and identified alleles associated with severe disease by variant filtration in cases, kernel association testing in cases and controls and single-nucleotide polymorphism (SNP) imputation into a larger cohort of WNND cases and seropositive controls followed by genome-wide association analysis. Variant filtration prioritized genes based on the enrichment of otherwise rare variants, but did not unambiguously implicate variants shared by a majority of cases. Kernel association demonstrated enrichment for risk and protective alleles in the human leukocyte antigen (HLA)-A and HLA-DQB1 loci that have well understood roles in antiviral immunity. Two loci, HERC5 and an intergenic region between CD83 and JARID2, were implicated by multiple imputed SNPs and exceeded genome-wide significance in a discovery cohort (n=862). SNPs at two additional loci, TFCP2L1 and CACNA1H, achieved genome-wide significance after association testing of directly genotyped and imputed SNPs in a discovery cohort (n=862) and a separate replication cohort (n=1387). The context of these loci suggests that immunoregulatory, ion channel and endothelial barrier functions may be important elements of the host response to WNV.

Interim estimates of 2013/14 influenza clinical severity and vaccine effectiveness in the prevention of laboratory-confirmed influenza-related hospitalisation, Canada, February 2014.

During the 2013/14 influenza season in Canada, 631 of 654 hospitalisations for laboratory-confirmed influenza enrolled in sentinel hospitals were due to Influenza A. Of the 375 with known subtype, influenza A(H1N1) accounted for 357. Interim unmatched vaccine effectiveness adjusted for age and presence of one or more medical comorbidities was determined by test-negative case-control design to be 58.5% (90% confidence interval (CI): 43.9-69.3%) overall and 57.9% (90% CI: 37.7-71.5) for confirmed influenza A(H1N1).

Aging, frailty and age-related diseases.

The concept of frailty as a medically distinct syndrome has evolved based on the clinical experience of geriatricians and is clinically well recognizable. Frailty is a nonspecific state of vulnerability, which reflects multisystem physiological change. These changes underlying frailty do not always achieve disease status, so some people, usually very elderly, are frail without a specific life threatening illness. Current thinking is that not only physical but also psychological, cognitive and social factors contribute to this syndrome and need to be taken into account in its definition and treatment. Together, these signs and symptoms seem to reflect a reduced functional reserve and consequent decrease in adaptation (resilience) to any sort of stressor and perhaps even in the absence of extrinsic stressors. The overall consequence is that frail elderly are at higher risk for accelerated physical and cognitive decline, disability and death. All these characteristics associated with frailty can easily be applied to the definition and characterization of the aging process per se and there is little consensus in the literature concerning the physiological/biological pathways associated with or determining frailty. It is probably true to say that a consensus view would implicate heightened chronic systemic inflammation as a major contributor to frailty. This review will focus on the relationship between aging, frailty and age-related diseases, and will highlight possible interventions to reduce the occurrence and effects of frailty in elderly people.

Sources of viral respiratory infections in Canadian acute care hospital healthcare personnel.

BACKGROUND: Viral respiratory illnesses are common causes of outbreaks and can be fatal to some patients. AIM: To investigate the association between laboratory-confirmed viral respiratory infections and potential sources of exposure during the previous 7 days. METHODS: In this nested case-control analysis, healthcare personnel from nine Canadian hospitals who developed acute respiratory illnesses during the winters of 2010/11-2013/14 submitted swabs that were tested for viral pathogens. Associated illness diaries and the weekly diaries of non-ill participants provided information on contact with people displaying symptoms of acute respiratory illness in the previous week. Conditional logistic regression assessed the association between cases, who were matched by study week and site with controls with no respiratory symptoms. FINDINGS: There were 814 laboratory-confirmed viral respiratory illnesses. The adjusted odds ratio (aOR) of a viral illness was higher for healthcare personnel reporting exposures to ill household members [7.0, 95% confidence interval (CI) 5.4-9.1], co-workers (3.4, 95% CI 2.4-4.7) or other social contacts (5.1, 95% CI 3.6-7.1). Exposures to patients with respiratory illness were not associated with infection (aOR 0.9, 95% CI 0.7-1.2); however, healthcare personnel with direct patient contact did have higher odds (aOR 1.3, 95% CI 1.1-1.6). The aORs for exposure and for direct patient contact were similar for illnesses caused by influenza. CONCLUSION: Community and co-worker contacts are important sources of viral respiratory illness in healthcare personnel, while exposure to patients with recognized respiratory infections is not associated. The comparatively low risk associated with direct patient contact may reflect transmission related to asymptomatic patients or unrecognized infections.

Validation of the Seegene RV15 multiplex PCR for the detection of influenza A subtypes and influenza B lineages during national influenza surveillance in hospitalized adults.

Background. The Serious Outcomes Surveillance Network of the Canadian Immunization Research Network (CIRN SOS) has been performing active influenza surveillance since 2009 (ClinicalTrials.gov identifier: NCT01517191). Influenza A and B viruses are identified and characterized using real-time reverse-transcriptase polymerase chain reaction (RT-PCR), and multiplex testing has been performed on a subset of patients to identify other respiratory virus aetiologies. Since both methods can identify influenza A and B, a direct comparison was performed.Methods. Validated real-time RT-PCRs from the World Health Organization (WHO) to identify influenza A and B viruses, characterize influenza A viruses into the H1N1 or H3N2 subtypes and describe influenza B viruses belonging to the Yamagata or Victoria lineages. In a subset of patients, the Seeplex RV15 One-Step ACE Detection assay (RV15) kit was also used for the detection of other respiratory viruses.Results. In total, 1111 nasopharyngeal swabs were tested by RV15 and real-time RT-PCRs for influenza A and B identification and characterization. For influenza A, RV15 showed 98.0 % sensitivity, 100 % specificity and 99.7 % accuracy. The performance characteristics of RV15 were similar for influenza A subtypes H1N1 and H3N2. For influenza B, RV15 had 99.2 % sensitivity, 100 % specificity and 99.8 % accuracy, with similar assay performance being shown for both the Yamagata and Victoria lineages.Conclusions. Overall, the detection of circulating subtypes of influenza A and lineages of influenza B by RV15 was similar to detection by real-time RT-PCR. Multiplex testing with RV15 allows for a more comprehensive respiratory virus surveillance in hospitalized adults, without significantly compromising the reliability of influenza A or B virus detection.

Larval testes of the tobacco budworm: a new source of insect ecdysteroids.

Testes of last-instar larvae of the tobacco budworm release five times more ecdysteroid into incubation medium (judged by radioimmunoassay) in 2.5 hours than is found in testis homogenates. Incubation of testicular components indicates that the testis sheath may be the site of ecdysteroid synthesis. Fractionation of hemalymph, testis homogenate, and incubation medium by high-performance liquid chromatography produces a distinct ecdysteroid pattern in each case. Thus, released testis ecdysteroids are probably converted to other forms for use, sequestration, or general circulation. Their functions are unknown.

Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak.

OBJECTIVE: To assess factors associated with adherence to recommended barrier precautions among healthcare workers (HCWs) providing care to critically ill patients with severe acute respiratory syndrome (SARS). SETTING: Fifteen acute care hospitals in Ontario, Canada. DESIGN: Retrospective cohort study. PATIENTS: All patients with SARS who required intubation during the Toronto SARS outbreak in 2003. PARTICIPANTS: HCWs who provided care to or entered the room of a SARS patient during the period from 24 hours before intubation until 4 hours after intubation. METHODS: Standardized interviews were conducted with eligible HCWs to assess their interactions with the SARS patient, their use of barrier precautions, their practices for removing personal protective equipment, and the infection control training they received. RESULTS: Of 879 eligible HCWs, 795 (90%) participated. In multivariate analysis, the following predictors of consistent adherence to recommended barrier precautions were identified: recognition of the patient as a SARS case (odds ratio [OR], 2.5 [95% confidence interval {CI}, 1.5-4.5); recent infection control training (OR for interactive training, 2.7 [95% CI, 1.7-4.4]; OR for passive training, 1.7 [95% CI, 1.0-3.0]), and working in a SARS unit (OR, 4.0 [95% CI, 1.8-8.9]) or intensive care unit (OR, 4.3 [95% CI, 2.0-9.0]). Two factors were associated with significantly lower rates of consistent adherence: the provision of care for patients with higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (OR for score APACHE II of 20 or greater, 0.4 [95% CI, 0.28-0.68]) and work on shifts that required more frequent room entry (OR for 6 or more entries per shift, 0.5 [95% CI, 0.32-0.86]). CONCLUSIONS: There were significant deficits in knowledge about self-protection that were partially corrected by education programs during the SARS outbreak. HCWs' adherence to self-protection guidelines was most closely associated with whether they provided care to patients who had received a definite diagnosis of SARS.

Point prevalence survey for healthcare-associated infections within Canadian adult acute-care hospitals.

A survey of adult patients 19 years of age and older was conducted in February 2002 in hospitals across Canada to estimate the prevalence of healthcare-associated infections (HAIs). A total of 5750 adults were surveyed; 601 of these had 667 HAIs, giving a prevalence of 10.5% infected patients and 11.6% HAIs. Urinary tract infections (UTI) were the most frequent HAI, shown by 194 (3.4%) of the patients surveyed. Pneumonia was found in 175 (3.0%) of the patients, surgical site infections (SSI) in 146 (2.5%), bloodstream infections (BSI) in 93 (1.6%) and Clostridium difficile-associated diarrhoea (CDAD) in 59 (1%). In this first national point prevalence study in Canada, the prevalence of HAI was found to be similar to that reported by other industrialized countries.

Accuracy of healthcare worker recall and medical record review for identifying infectious exposures to hospitalized patients.

OBJECTIVE: To determine the validity of using healthcare worker (HCW) recall of patient interactions and medical record review for contact tracing in a critical care setting. DESIGN: Trained observers recorded the interactions of nurses, respiratory therapists, and service assistants with study patients in a medical-surgical intensive care unit. These observers' records were used as the reference standard to test the criterion validity of using HCW recall data or medical record review data to identify exposure characteristics. We assessed the effects of previous quarantine of the HCW (because of possible exposure) and the availability of patients' medical records for use as memory aids on the accuracy of HCW recall. SETTING: A 10-bed medical-surgical intensive care unit at Mount Sinai Hospital in Toronto, Ontario. PATIENTS: Thirty-six HCWs observed caring for 16 patients, for a total of 55 healthcare worker shifts. RESULTS: Recall accuracy was better among HCWs who were provided with patient medical records as memory aids (P<.01). However, HCWs tended to overestimate exposures when they used patient medical records as memory aids. For 6 of 26 procedures or care activities, this tendency to overestimate was statistically significant (P<.05). Most HCWs with true exposures were identified by means of this technique, despite the overestimations. Documentation of the activities of the 4 service assistants could not be found in any of the patients' medical records. Similarly, the interactions between 6 (19%) of 32 other patient-HCW pairs were not recorded in patients' medical records. CONCLUSIONS: Data collected from follow-up interviews with HCWs in which they are provided with patient medical records as memory aids should be adequate for contact tracing and for determining exposure histories. Neither follow-up interviews nor medical record review alone provide sufficient data for these purposes.

Release of a special fraction of the outer membrane from both growing and phage T4-infected Escherichia coli B.

Growing Escherichia coli release envelope material into the medium. Upon infection with T4 phage increased amounts of this material are released and at a greater rate. In order to determine whether both inner and outer membranes are present in this material, and whether the material released by growing cells differs from that released by infected cells, we have examined the protein composition of envelope released by growing and T4-infected E. coli B. Our results show: (a) the protein composition of envelope released from growing or infected cells is similar, (b) the proteins present are representative of the outer membrane, (c) the major outer membrane protein of E. coli B, protein II, is deficient in the released material. We therefore conclude that the envelope material released from growing or infected E. coli represents a special fraction of the outer membrane. This finding is discussed in relation to outer membrane structure and function. In addition, data are presented on the differing outer membrane protein composition of substrains of E. coli B obtained from different laboratories.

Lipopolysaccharide interferes with the staining of lipoprotein on polyacrylamide gels.

After electrophoresis of total membrane preparations of Escherichia coli B on sodium dodecyl sulfate polyacrylamide gels, and subsequent staining with Coomassie Brilliant blue, a band corresponding to the Braun lipoprotein fails to appear. This is in contrast to similar preparations of E. coli K-12 which do display the lipoprotein upon staining. Experiments described below indicate that failure to observe this protein in E. coli B is due to interference in the staining reaction by the lipopolysaccharide present in the membrane preparations.

Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.

BACKGROUND: Little is known about the risk factors, outcome, and impact of pneumonia and other lower respiratory tract infections (LRTIs) in residents of long-term care facilities. OBJECTIVE: To determine the risk factors and the effect of these infections on functional status and clinical course. METHODS: Active surveillance for these infections was conducted for 475 residents in 5 nursing homes from July 1, 1993, through June 30, 1996. Information regarding potential risk factors for these infections, functional status, transfers to hospital, and death was also obtained. RESULTS: Two hundred seventy-two episodes of pneumonia and other LRTIs occurred in 170 residents during 228 757 days of surveillance for an incidence of 1.2 episodes per 1000 resident-days. Multivariable analysis revealed that older age (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.6 per 10-year interval; P = .01), male sex (OR, 1.9; 95% CI, 1.1-3.5; P = .03), swallowing difficulty (OR, 2.0; 95% CI, 1.2-3.3; P = .01), and the inability to take oral medications (OR, 8.3; 95% CI, 1.4-50.3; P = .02) were significant risk factors for pneumonia; receipt of influenza vaccine (OR, 0.4; 95% CI, 0.3-0.5; P = .01) was protective. Age (OR, 1.6 [95% CI, 1.0-2.5] per 10-year interval; P = .05) and immobility (OR, 2.6; 95% CI, 1.8-3.8; P = .01) were significant risk factors for other LRTIs, and influenza vaccination was protective (OR, 0.3; 95% CI, 0.2-0.4; P = .01). Residents with pneumonia (OR, 0.7; 95% CI, 0.3-1.4; P = .31) or with other LRTIs (OR, 0.5; 95% CI, 0.2-1.1; P = .43) were no more likely to have a deterioration in functional status than individuals in whom infection did not develop. CONCLUSIONS: Swallowing difficulty and lack of influenza vaccination are important, modifiable risks for pneumonia and other LRTIs in elderly residents of long-term care facilities. Our findings challenge the commonly held belief that pneumonia leads to long-term decline in functional status in this population.

Postoperative radiotherapy in breast cancer--long-term results from the Oslo study.

The long-term results of a randomized clinical trial evaluating the effect of postoperative radiotherapy as an adjuvant to radical mastectomy are presented. There were 1115 patients including 27 protocol deviants. The follow-up time is 11-20 years. In the first part a conventional roentgen unit was used, and in the second part a 60Co unit, with considerably increased dosage and altered treatment plan. Both types of radiation techniques lowered the incidence of loco-regional recurrences significantly, but had no significant influence on the overall survival. The relapse-free survival was significantly improved by 60Co radiation in Stage II patients, but was unaffected by radiation in the other subgroups. Regarding survival, Stage II patients with medially located tumors seemed to benefit more from 60Co radiation than those with lateral tumors. A significant increase in the number of deaths caused by myocardial infarction was observed in Stage I patients having 60Co radiation, indicating that the radiation dose to the heart is of significance.

Functional role of M2 and M3 muscarinic receptors in the urinary bladder of rats in vitro and in vivo.

1. Urinary bladder smooth muscle is enriched with muscarinic receptors, the majority of which are of the M2 subtype whereas the remaining minority belong to the M3 subtype. The objective of the present study was to assess the functional role of M2 and M3 receptors in the urinary bladder of rat in vitro and in vivo by use of key discriminatory antagonists. 2. In the isolated bladder of rat, (+)-cis-dioxolane produced concentration-dependent contractions (pEC50 = 6.3) which were unaffected by tetrodotoxin (0.1 microM). These contractions were antagonized by muscarinic antagonists with the following rank order of affinity (pA2) estimates: atropine (9.1) > 4-diphenyl acetoxy-methyl piperidine methiodide (4-DAMP) (8.9) > darifenacin (8.5) > para fluoro hexahydrosiladifenidol (p-F-HHSiD) (7.4) > pirenzepine (6.8) > methoctramine (5.9). These pA2 estimates correlated most favourably (r = 0.99, P < 0.001) with the binding affinity (pKi) estimates of these compounds at human recombinant muscarinic m3 receptors expressed in Chinese hamster ovary cells, suggesting that the receptor mediating the direct contractile responses to (+)-cis-dioxolane equates with the pharmacologically defined M3 receptor. 3. As M2 receptors in smooth muscle are negatively coupled to adenylyl cyclase, we sought to determine whether a functional role of M2 receptors could be unmasked under conditions of elevated adenylyl cyclase activity (i.e., isoprenaline-induced relaxation of KCl pre-contracted tissues). Muscarinic M3 receptors were preferentially alkylated by exposing tissues to 4-DAMP mustard (40 nM, 1 h) in the presence of methoctramine (0.3 microM) to protect M2 receptors. Under these conditions, (+)-cis-dioxolane produced concentration-dependent reversal (re-contraction) of isoprenaline-induced relaxation (pEC50 = 5.8) but had marginal effects on pinacidil-induced, adenosine 3':5'-cyclic monophosphate (cyclic AMP)-independent, relaxation. The re-contractions were antagonized by methoctramine and darifenacin, yielding pA2 estimates of 6.8 and 7.6, respectively. These values are intermediate between those expected for these compounds at M2 and M3 receptors and were consistent with the involvement of both of these subtypes. 4. In urethane-anaesthetized rats, the cholinergic component (approximately 55%) of volume-induced bladder contractions was inhibited by muscarinic antagonists with the following rank order of potency (ID35%inh, nmol kg-1, i.v.): 4-DAMP (8.1) > atropine (20.7) > methoctramine (119.9) > darifenacin (283.3) > pirenzepine (369.1) > p-F-HHSiD (1053.8). These potency estimates correlated most favourably (r = 0.89, P = 0.04) with the pKi estimates of these compounds at human recombinant muscarinic m2 receptors. This is consistent with a major contribution of M2 receptors in the generation of volume-induced bladder contractions, although the modest potency of darifenacin does not exclude a role of M3 receptors. Pretreatment with propranolol (1 mg kg-1, i.v.) increased the ID35%inh of methoctramine significantly from 95.9 to 404.5 nmol kg-1 but had no significant effects on the inhibitory responses to darifenacin. These data suggest an obligatory role of beta-adrenoceptors in M2 receptor-mediated bladder contractions in vivo. 5. The findings of the present study suggest that both M2 and M3 receptors can cause contraction of the rat bladder in vitro and may also mediate reflex bladder contractions in vivo. It is proposed that muscarinic M3 receptor activation primarily causes direct contraction of the detrusor whereas M2 receptor activation can contract the bladder indirectly by reversing sympathetically (i.e. beta-adrenoceptor)-mediated relaxation. This dual mechanism may allow the parasympathetic nervous system, which is activated during voiding, to cause more efficient and complete emptying of the bladder.