Correlation between Excessive Daytime Sleepiness (EDS) and self-reported and objective nasal characteristics.

BACKGROUND: The aim of the present study was to explore the relationship between excessive daytime sleepiness (EDS), Peak Nasal Inspiratory Flow (PNIF), and patient reported symptoms from the nose. METHOLOGY: Six hundred and fifty one consecutive patients referred to a hospital on suspicion of sleep related breathing disorder (SRBD) were included in the study. Daytime sleepiness was assessed by Epworth Sleepiness Scale (EpSS). Nasal airflow was measured with Peak Nasal Inspiratory Flow (PNIF). Symptoms of sino-nasal dysfunction and diseases were graded on Visual Analogue Scales (VAS). RESULTS: EpSS score was not correlated with nasal flow as measured by PNIF or nasal obstruction - VAS scores. There were significant associations between daytime sleepiness and patient-reported VAS-scores on nasal discharge, headache, coughing, general health and to some extent sneezing when age, gender, BMI and reported co-morbidity levels were adjusted for. CONCLUSION: A clinical implication of this is that patients with EDS may be evaluated and treated for sino-nasal disease, while medical and surgical measures to open the nose per se may not be effective therapeutic options. A scientific implication is that the relationship between SRBD and sino-nasal disease should be further investigated.

Prevalence and clinical correlates of insomnia in adults with attention-deficit hyperactivity disorder.

OBJECTIVE: To investigate the prevalence of insomnia in adults with Attention-deficit hyperactivity disorder (ADHD) and its association with clinical subtypes, current ADHD symptoms, and stimulant treatment. METHOD: We obtained diagnostic information, symptom rating scales and treatment history from clinically ascertained adult ADHD patients diagnosed according to DSM-IV criteria (n = 268, mean age 38.1 years) and randomly selected population controls (n = 202, mean age 36.5 years). The Bergen Insomnia Scale (BIS) was used to measure insomnia. ADHD symptom domains were self-rated using the Adult ADHD Self-Rating Scale. RESULTS: Insomnia was far more frequent among adults with ADHD (66.8%) than in the population controls (28.8%) (P < 0.001). Insomnia was more common in adults with the combined subtype than in those with the inattentive subtype (79.7% and 55.6%, respectively) (P = 0.003). For self-reported current ADHD symptoms, inattention was strongly correlated to insomnia. Patients currently using stimulant treatment for ADHD reported a lower total insomnia score compared to patients without medication (P < 0.05). CONCLUSION: Insomnia was highly prevalent among adults with ADHD. The lower insomnia score in patients on current stimulant treatment suggests that stimulant treatment is not associated with worsening of insomnia symptoms in adult ADHD patients.

Updating and prospective validation of a prognostic model for high sickness absence.

OBJECTIVES: To further develop and validate a Dutch prognostic model for high sickness absence (SA). METHODS: Three-wave longitudinal cohort study of 2,059 Norwegian nurses. The Dutch prognostic model was used to predict high SA among Norwegian nurses at wave 2. Subsequently, the model was updated by adding person-related (age, gender, marital status, children at home, and coping strategies), health-related (BMI, physical activity, smoking, and caffeine and alcohol intake), and work-related (job satisfaction, job demands, decision latitude, social support at work, and both work-to-family and family-to-work spillover) variables. The updated model was then prospectively validated for predictions at wave 3. RESULTS: 1,557 (77 %) nurses had complete data at wave 2 and 1,342 (65 %) at wave 3. The risk of high SA was under-estimated by the Dutch model, but discrimination between high-risk and low-risk nurses was fair after re-calibration to the Norwegian data. Gender, marital status, BMI, physical activity, smoking, alcohol intake, job satisfaction, job demands, decision latitude, support at the workplace, and work-to-family spillover were identified as potential predictors of high SA. However, these predictors did not improve the model's discriminative ability, which remained fair at wave 3. CONCLUSIONS: The prognostic model correctly identifies 73 % of Norwegian nurses at risk of high SA, although additional predictors are needed before the model can be used to screen working populations for risk of high SA.

No impact of early real-time PCR screening for respiratory viruses on length of stay and use of antibiotics in elderly patients hospitalized with symptoms of a respiratory tract infection in a single center in Norway.

We tested the hypothesis that the results of real-time polymerase chain reaction (PCR) analyses for respiratory viruses would reduce antibiotic treatment and length of stay in elderly patients hospitalized with respiratory infections. Within 24 h of hospital admission, a total of 922 patients aged ≥60 years were interviewed for symptoms of ongoing respiratory tract infection. Symptomatic patients were swabbed for oropharyngeal/nasopharyngeal presence of viral pathogens immediately by members of the study group. During a 2-month period, non-symptomatic volunteers among interviewed patients were swabbed as well (controls). Oropharyngeal/nasopharyngeal swabs were analyzed with real-time PCR for nine common respiratory viruses. A total of 147 out of 173 symptomatic patients and 56 non-symptomatic patients (controls) agreed to participate in the study. The patients were allocated to three cohorts: (1) symptomatic and PCR-positive (S/PCR+), (2) symptomatic and PCR-negative (S/PCR-), or (3) non-symptomatic and PCR-negative (control). There were no non-symptomatic patients with a positive PCR result. A non-significant difference in the frequency of empiric antibiotic administration was found when comparing the S/PCR+ to the S/PCR- cohort; 16/19 (84 %) vs. 99/128 (77 %) (χ(2) = 0.49). Antibiotic treatment was withdrawn in only two patients in the S/PCR+ cohort after receiving a positive viral diagnosis. The length of stay did not significantly differ between the S/PCR+ and the S/PCR- groups. We conclude that, at least in our general hospital setting, access to early viral diagnosis by real-time PCR had little impact on the antimicrobial treatment or length of hospitalization of elderly patients.

A comparison of nasopharyngeal and oropharyngeal swabbing for the detection of influenza virus by real-time PCR.

We tested the hypothesis that swabs from the nasopharynx carry a higher viral load than swabs from the oropharynx in patients with real-time polymerase chain reaction (PCR)-confirmed influenza infection. Using flocked swabs, oropharyngeal and nasopharyngeal samples were harvested from hospital-admitted influenza patients no later than 3 days after the initial detection of influenza virus. Comparison of cycle threshold (CT) values was performed to assess differences in viral load in the specimens. Seventeen patients were diagnosed with influenza B, 14 patients with influenza A(H1N1)pdm09, and one patient with influenza A(H3N2). Nasopharyngeal samples were positive at a lower CT value than the oropharyngeal samples [mean difference in CT 5.75, 95 % confidence interval (CI) 3.8-7.7, p < 0.01], suggesting that, on average, the calculated viral load of the nasopharyngeal samples was 54 times higher (95 % CI 13.7-210.8) than those of the oropharyngeal samples. The corresponding difference in the calculated viral load for influenza A(H1N1)pdm09 virus was 23 times (95 % CI 3.8-136.2, p < 0.01) and for influenza B virus, it was 80 times (95 % CI 9.3-694.6, p < 0.01). In patients with acute influenza, nasopharyngeal swabbing was clearly superior to oropharyngeal swabbing in terms of diagnostic yield by real-time PCR.

Sick leave during pregnancy: a longitudinal study of rates and risk factors in a Norwegian population.

OBJECTIVE: To describe the prevalence of, reasons given for, and factors associated with sick leave during pregnancy. DESIGN: Longitudinal, population-based descriptive study. SETTING: Akershus University Hospital, Norway. POPULATION: All women scheduled to give birth at the hospital (November 2008 to April 2010). METHODS: Consenting women were handed a questionnaire at the routine ultrasound check at 17 weeks of gestation. Women returning this questionnaire received a second questionnaire at 32 weeks of gestation. Multiple logistic regression analyses were performed to examine associations with somatic, psychiatric and social factors. MAIN OUTCOME MEASURES: Rates and duration of sick leave. RESULTS: By 32 weeks of gestation, 63.2% of the 2918 women included were on sick leave, and 75.3% had been on sick leave at some point during their pregnancy. Pelvic girdle pain and fatigue/sleep problems were the main reasons given for sick leave. Being on sick leave in all trimesters was strongly associated with hyperemesis, exercising less than weekly, chronic pain before or during pregnancy, infertility treatment (all P < 0.001); younger maternal age, conflicts in the workplace (both P < 0.01); multiparity, previous depression, insomnia and lower education (all P < 0.05). Sick leave was associated with elective caesarean section and higher infant birthweight (P < 0.01). Adjustment of the work situation was associated with 1 week shorter duration of sick leave. CONCLUSIONS: Most women receive sick leave during pregnancy, but sick leave might not be caused by pregnancy alone. Previous medical and psychiatric history, work conditions and socio-economic factors need to be addressed to understand sick leave during pregnancy.

Swabbing for respiratory viral infections in older patients: a comparison of rayon and nylon flocked swabs.

The purpose of this study was to compare the sampling efficacy of rayon swabs and nylon flocked swabs, and of oropharyngeal and nasopharyngeal specimens for the detection of respiratory viruses in elderly patients. Samples were obtained from patients 60 years of age or above who were newly admitted to Sorlandet Hospital Arendal, Norway. The patients were interviewed for current symptoms of a respiratory tract infection. Using rayon swabs and nylon flocked swabs, comparable sets of mucosal samples were harvested from the nasopharynx and the oropharynx. The samples were analysed using real-time polymerase chain reaction (PCR) methods. A total of 223 patients (mean age 74.9 years, standard deviation [SD] 9.0 years) were swabbed and a virus was recovered from 11% of the symptomatic patients. Regardless of the sampling site, a calculated 4.8 times higher viral load (95% confidence interval [CI] 1.3-17, p = 0.017) was obtained using the nylon flocked swabs as compared to the rayon swabs. Also, regardless of the type of swab, a calculated 19 times higher viral load was found in the samples from the nasopharynx as compared to the oropharynx (95% CI 5.4-67.4, p < 0.001). When swabbing for respiratory viruses in elderly patients, nasopharyngeal rather than oropharyngeal samples should be obtained. Nylon flocked swabs appear to be more efficient than rayon swabs.

Subjective and objective sleep among depressed and non-depressed postnatal women.

OBJECTIVE: Women sleep less in the postnatal period and it has been suggested that mothers diagnosed with depression alternatively could be suffering from the effects of chronic sleep deprivation. METHOD: From a population-based study, we recruited 42 women, of whom 21 scored >or=10 on the Edinburgh Postnatal Depression Scale. Sleep was registered by the Pittsburgh Sleep Quality Index (PSQI), sleep diaries and actigraphy 2 months after delivery. RESULTS: There were significant differences in subjective sleep measured retrospectively by the PSQI between depressed and non-depressed women. In contrast, there were no significant differences in sleep measured prospectively by sleep diaries and actigraphy. Both depressed and non-depressed women had impaired sleep efficiency (82%) and were awake for about 1.5 h during the night. Primipara had worse sleep, measured by actigraphy, compared with multipara. CONCLUSION: Measured objectively and prospectively, women with depression did not have worse sleep than non-depressed women.

The effect of OSAS on sick leave and work disability.

The objective of the present study was to examine the independent contribution of symptoms of obstructive sleep apnoea syndrome (OSAS) to long-term sick leave and permanent work disability. Using a historical cohort design with 4 yrs of follow-up, information on sick leave and disability benefit recipiency were merged with health information from the Hordaland Health Study, carried out in western Norway during 1997-1999. Persons aged 40-45 yrs (n = 7,028) were assessed for self-reported symptoms of OSAS (snoring, breathing cessations and daytime sleepiness), body mass index, somatic conditions and other potential confounders. The outcomes, cumulative sick leave of > or =8 weeks and permanent work disability, were identified in records from the National Insurance Administration. After excluding participants with work disability at baseline, symptoms of OSAS were found to be a significant predictor of both subsequent long-term sick leave and permanent work disability. These effects remained significant after adjustment for a range of possible confounding factors. Daytime sleepiness showed the greatest explanatory power, followed by breathing cessations and snoring. It is concluded that self-reported symptoms of obstructive sleep apnoea syndrome are an independent risk factor for subsequent long-term sick leave and permanent work disability. These findings need to be replicated using objective measures of obstructive sleep apnoea syndrome.

Serotonin and the sleep/wake cycle: special emphasis on microdialysis studies.

Several areas in the brainstem and forebrain are important for the modulation and expression of the sleep/wake cycle. Even if the first observations of biochemical events in relation to sleep were made only 40 years ago, it is now well established that several neurotransmitters, neuropeptides, and neurohormones are involved in the modulation of the sleep/wake cycle. Serotonin has been known for many years to play a role in the modulation of sleep, however, it is still very controversial how and where serotonin may operate this modulation. Early studies suggested that serotonin is necessary to obtain and maintain behavioral sleep (permissive role on sleep). However, more recent microdialysis experiments provide evidence that the level of serotonin during W is higher in most cortical and subcortical areas receiving serotonergic projections. In this view the level of extracellular serotonin would be consistent with the pattern of discharge of the DRN serotonergic neurons which show the highest firing rate during W, followed by a decrease in slow wave sleep and by virtual electrical silence during REM sleep. This suggests that during waking serotonin may complement the action of noradrenaline and acetylcholine in promoting cortical responsiveness and participate to the inhibition of REM-sleep effector neurons in the brainstem (inhibitory role on REM sleep). The apparent inconsistency between an inhibitory and a facilitatory role played by serotonin on sleep has at least two possible explanations. On the one hand serotonergic modulation on the sleep/wake cycle takes place through a multitude of post-synaptic receptors which mediate different or even opposite responses; on the other hand the achievement of a behavioral state depends on the complex interaction between the serotonergic and other neurotransmitter systems. The main aim of this commentary is to review the role of brain serotonin in relation to the sleep/wake cycle. In particular we highlight the importance of microdialysis for on-line monitoring of the level of serotonin in different areas of the brain across the sleep/wake cycle.

Tx-discs--no effect against subjective health complaints: a randomised controlled study.

BACKGROUND: Dowsers claim unhealthy effects of 'earth rays', and the producer of TX-discs claims that these discs may shield a person from the influence of 'earth rays', thereby relieving most illness in the person shielded. OBJECTIVES: To compare the effects of the TX-disc versus a placebo disc in patients with longstanding muscular-skeletal complaints. SETTING: Self-recruited community living persons in the Bergen area, Western Norway. PATIENTS: 67 women and 13 men with longstanding muscular-skeletal complaints, recruited by advertisements in local newspapers. DESIGN: A randomised and double-blinded controlled trial with a 6 months follow-up period. MAIN OUTCOME MEASUREMENT: The Subjective Health Complaints (SHC) questionnaire. RESULTS: We found a substantial reduction on the mean SHC sub-scale scores of muscular-skeletal, pseudo-neurological, gastro-intestinal, and allergic complaints, mainly occurring from baseline to 6 weeks (28-45%, P < 0.05-0.001). There were however no statistically significant differences for these variables between the TX group and the placebo group at any time point. IMPLICATIONS: TX-discs used in accordance with the instructions had no clinically or statistically significant effect on muscular-skeletal pain, pseudo-neurological complaints, gastro-intestinal, or allergic complaints during this study.

Changes in sleep and wakefulness following 5-HT1A ligands given systemically and locally in different brain regions.

Serotonin (5-HT) has been implicated in the regulation of vigilance, but whether 5-HT is important for sleep or waking processes remains controversial. This review addresses the role of 5-HT1A receptors in sleep and wakefulness. Systemic administration of 5-HT1A agonists consistently increases wakefulness, whereas slow wave sleep (SWS) and REM (rapid-eye movement) sleep are reduced. However, systemic 5-HT1A agonists also produce a delayed increase in deep slow wave sleep, or an increase in slow wave activity. Intrathecal administration of a selective 5-HT1A agonist produces an increase in SWS, whereas wakefulness is reduced, presumably by stimulating 5-HT1A receptors located presynaptically on primary afferents in the spinal cord. Microinjection of serotonin into the region of the cholinergic basalis neurons produces an increase in slow wave activity, presumably by stimulating 5-HT1A receptors. Microdialysis perfusion of a selective 5-HT1A agonist into the dorsal Raphe nucleus causes an increase in REM sleep, whereas the other sleep/wake stages are unaltered. The REM sleep increase is likely due to a decrease in 5-HT neuronal activity, and thereby reduced 5-HT neurotransmission in projection areas, e.g. the laterodorsal and pedunculopontine tegmental nuclei. Direct injection of a selective 5-HT1A agonist into the pedunculopontine tegmental nuclei reduces REM sleep, consistent with such a hypothesis. These complex sleep/wake data of 5-HT1A ligands suggest that 5-HT1A receptor activation may increase waking, increase slow wave sleep or increase REM sleep depending on where the 5-HT1A receptors are located within the central nervous system.

On-line detection of extracellular levels of serotonin in dorsal raphe nucleus and frontal cortex over the sleep/wake cycle in the freely moving rat.

We used in vivo microdialysis coupled with polygraphic recording to monitor 5-hydroxytryptamine levels in the dorsal raphe nucleus and frontal cortex across waking, slow-wave sleep and rapid eye-movement sleep. Male Sprague-Dawley rats were prepared with electroencephalogram and electromyogram electrodes. Microdialysis probes were placed in dorsal raphe nucleus and/or frontal cortex. Dialysate samples were manually collected during polygraphically-defined behavioural states and the level of serotonin was assayed by means of microbore high-performance liquid chromatography separation and electrochemical detection. Samples from microdialysis probes histologically localized to the dorsal raphe nucleus and frontal cortex showed different levels of extracellular 5-hydroxytryptamine in waking, slow-wave sleep and rapid eye-movement sleep. In dorsal raphe nucleus the extracellular level of serotonin was highest in waking, decreased in slow-wave sleep to 69% and in rapid eye-movement sleep to 39% of waking mean level (waking 3.2 +/- 0.9; slow-wave sleep 2.2 +/- 0.8; rapid eye-movement sleep 1.3 +/- 0.4 fmol/sample). Mean extracellular levels of serotonin in frontal cortex displayed a similar pattern (waking 1.7 +/- 0.4; slow-wave sleep 1.0 +/- 0.3; rapid eye-movement 0.5 +/- 0.05 fmol/sample). In frontal cortex, rapid eye-movement sleep samples were only obtained in three animals. Our findings are consistent with previous results in cats, and suggest that in rats also, extracellular 5-hydroxytryptamine levels in dorsal raphe nucleus and frontal cortex across the sleep/wake cycle might reflect serotonergic neuronal activity. The findings stress the importance of controlling for behavioural state when investigating neurochemical correlates of serotonergic function.

Effects of sleep deprivation on extracellular serotonin in hippocampus and frontal cortex of the rat.

Sleep deprivation improves the mood of depressed patients, but the exact mechanism behind this effect is unclear. An enhancement of serotonergic neurotransmission has been suggested. In this study, we used in vivo microdialysis to monitor extracellular serotonin in the hippocampus and the frontal cortex of rats during an 8 h sleep deprivation period. These brain regions were selected since both have been implicated in depression. The behavioral state of the animal was continuously monitored by polygraphic recordings during the experiment. Sleep deprivation produced a gradual decline in extracellular serotonin levels, both in the hippocampus and in the frontal cortex. In order to investigate whether the reduction in serotonin was due to other factors than sleep deprivation, i.e. time of day effect, another experiment was performed. Here animals were allowed to sleep during most of the recording period. This experiment showed the expected changes in extracellular serotonin levels: consistently higher levels in the awake, non-sleep deprived animals compared to during sleep, but no time of day effect. The reduction in extracellular serotonin during sleep deprivation may suggest that serotonin does not play a major role in the mood-elevating effect of sleep deprivation. However, since 5-HT levels are strongly behavioral state dependent, by eliminating sleep, there may be a net increase in serotonergic neurotransmission during the sleep deprivation period.

Sleep/waking and EEG power spectrum effects of a nonselective serotonin (5-HT) antagonist and a selective 5-HT reuptake inhibitor given alone and in combination.

Sleep/waking stages, electroencephalogram (EEG) power spectra and behavior were studied in rats for 8 hours following intraperitoneal administration of a nonselective serotonin (5-HT) antagonist (0.1 and 2.0 mg/kg methiothepin) and a selective 5-HT reuptake inhibitor (20 mg/kg zimeldine), given alone and in combination. Consistent with earlier studies, zimeldine gave a biphasic effect on sleep and waking. Waking was increased and slow wave sleep (SWS)-2 decreased initially, followed by an increase in SWS-2 in the second 2-hour period. Rapid eye movement (REM) sleep was reduced throughout the experiment. EEG power densities were generally reduced in the higher frequencies, but the effect differed somewhat in the different vigilance states and between the fronto-frontal and fronto-parietal EEG leads. Zimeldine did not change behavior. Methiothepin, at 0.1 mg/kg, gave only minor effects by itself, but it blocked the initial waking increase of zimeldine. So did 2.0 mg/kg methiothepin, but this dose markedly changed sleep/waking stages by itself: SWS-1 was profoundly increased, whereas waking, SWS-2 and REM sleep were reduced. Total SWS (TSWS) was markedly increased due to the SWS-1 increase. Because TSWS was increased while SWS-2 was decreased following 2.0 mg/kg methiothepin, it is concluded that spindle activity was facilitated, whereas slow wave activity was antagonized. Methiothepin, at 2.0 mg/kg, also markedly changed EEG power densities within TSWS and induced cataleptic behavior. It is concluded that the initial waking increase of zimeldine depends on simultaneous activation of several different 5-HT receptor subtypes. The other zimeldine effects were not consistently antagonized, thus the mechanisms behind these effects remain unclear.

Distribution and sequence variations of selected virulence genes among group A streptococcal isolates from western Norway.

In order to compare the distribution of selected virulence genes among group A streptococci recovered from invasive disease and superficial infections, 42 isolates were screened for mga, speB, speA, ssa and ska, by PCR. The isolates were predominantly of the sequence types emm1, emm3 and emm6, but also included a few of the types emm22, emm28, emm75 and emm78. The phage-mediated speA seemed to be prevalent in emm types 1 and 3, and its distribution was not related to disease severity. The other genes were present in all isolates. The mga, speB and speA were further studied by sequence analysis. Although allotypic associations with invasiveness were not found, allelic specificity to the emm sequence type was observed. In addition, the mga sequences indicated two lineages, related to opacity factor production. A possible recombination between these two main divergent mga genes was observed in isolates of the types emm22 and emm75. A logical nomenclature of the alleles of mga and speB is suggested.

Emm gene polymorphism among temporally clustered group A streptococcal isolates in western Norway.

Nineteen group A streptococcal isolates obtained in western Norway from patients with invasive disease during a period of high morbidity and mortality were examined for clonality and emm gene polymorphism. These isolates belonged to the prevalent serotypes during the outbreak, namely T1, T3 or T6. Restriction fragment length polymorphism and sequencing of the emm genes were used to compare these isolates with 14 isolates of the same serotype but from non-invasive infections. The restriction analysis did not identify specific invasive clones. The emm genes in three of the four T3 isolates from invasive disease had nucleotide substitutions inducing a charge difference in the N-terminal part of the M protein. The 4 T6 isolates had a longer emm amplicon when compared to 15 isolates from superficial infections and also showed nucleotide substitutions that could induce conformational changes in the hypervariable end of the M protein. Restriction analysis of the emm amplicon of the T6 isolates in order to estimate the number of A- and C-repeats is described. The emm gene sequence served as an epidemiological marker within the serotypes T3 and T6, but the significance of the emm polymorphism displayed by the isolates from invasive disease is uncertain at this stage.

Oligonucleotide gene probes may detect enterotoxigenic Escherichia coli directly in fecal smears.

Diarrhoeal stools from 86 Indian children were examined for the presence of enterotoxigenic Escherichia coli (ETEC) by DNA hybridization on bacterial colonies as well as directly on fecal smears. Colony hybridization showed that 8 of the samples contained ETEC. Only in three of these specimens were all the colonies tested positive for ETEC. These samples were correctly identified by the stool smear hybridization assay. The remaining 5 specimens produced enterotoxigenic as well as nonenterotoxigenic colonies. These samples were all negative by the stool smear hybridization technique. Methodological improvements of the stool smear assay may provide a substantially simplified method for the otherwise cumbersome identification of ETEC.

Mechanism of spontaneous loss of heat-stable toxin (STa) production in enterotoxigenic Escherichia coli.

Five strains of enterotoxigenic Escherichia coli (ETEC) showing spontaneous loss of heat-stable enterotoxin (STa) production were studied to elucidate the underlying genetic mechanisms. Southern blot analysis revealed that loss of STa production, and the corresponding lack of hybridization with the STa gene probes, were associated with deletions of DNA fragments harboring the relevant toxin genes rather than with loss of plasmids.

Genotypic and phenotypic markers in the differentiation of Neisseria gonorrhoeae strains.

Restriction enzyme (RE) patterns, using Hind III enzyme, were analysed on 101 urogenital strains of Neisseria gonorrhoeae. The strains were also analysed serologically, using monoclonal antibodies, and tested for nutritional requirements by auxotyping. In addition, testing susceptibility to doxycycline was performed by an agar-dilution method. The strains were distributed into 23 RE patterns, of which the five most common accounted for 67.3% of all isolates. The same strains were distributed into 17 serovars, of which the four most common accounted for 77.3% of all isolates. Eleven auxotypes were demonstrated, of which the four most common accounted for 85.1% of all isolates. When the methods were combined, 38 combinations of RE patterns and serovars, 25 combinations of RE patterns and auxotypes, and 31 combinations of serovars and auxotypes were seen. Combining all three methods, 40 combinations of RE patterns, serovars and auxotypes were found. Correlations were particularly seen between RE patterns and auxotypes. The strains were moderately sensitive to doxycycline, those with serological markers for WII/WIII being less sensitive than those with markers for WI.