Microplastics and metals: Microplastics generated from biodegradable polylactic acid mulch reduce bioaccumulation of cadmium in earthworms compared to those generated from polyethylene.

Biodegradable polylactic acid (PLA) mulch has been developed to replace conventional polyethylene (PE) mulch in agriculture as a response to growing concerns about recalcitrant plastic pollution and the accumulation of microplastics (MPs) in soil. Cadmium is a significant soil pollutant in China. MPs have been shown to adsorb metals. In this study the earthworm Lumbricus terrestris was exposed to either Cd (1.0-100 mg / kg) or MPs (PE and PLA, 0.1-3 % w / w), or a combination of the two, for 28 days. Cd bioavailability significantly decreased in the presence of MPs. In particular, at the end of the experiment, PLA treatments had lower measured Cd concentrations in both earthworms (2.127-29.24 mg / kg) and pore water (below detection limits - 0.1384 mg /L) relative to PE treatments (2.720-33.77 mg / kg and below detection limits - 0.2489 mg / L). In our adsorption experiment PLA MPs adsorbed significantly more Cd than PE MPs with maximum adsorption capacities of 126.0 and 23.2 mg / kg respectively. These results suggest that the PLA MPs reduce earthworm exposure to Cd relative to PE by removing it from solution and reducing its bioavailability.

Adsorption of Pb and Zn from binary metal solutions and in the presence of dissolved organic carbon by DTPA-functionalised, silica-coated magnetic nanoparticles.

The ability of diethylenetriaminepentaacetic acid (DTPA)-functionalised, silica-coated magnetic nanoparticles to adsorb Pb and Zn from single and bi-metallic metal solutions and from solutions containing dissolved organic carbon was assessed. In all experiments 10 mL solutions containing 10 mg of nanoparticles were used. For single metal solutions (10 mg L-1 Pb or Zn) at pH 2 to 8, extraction efficiencies were typically >70%. In bi-metallic experiments, examining the effect of a background of either Zn or Pb (0.025 mmol L-1) on the adsorption of variable concentrations (0-0.045 mmol L-1) of the other metal (Pb or Zn, respectively) adsorption was well modelled by linear isotherms (R2 > 0.60; p ≤ 0.001) and Pb was preferentially adsorbed relative to Zn. In dissolved organic carbon experiments, the presence of fulvic acid (0, 2.1 and 21 mg DOC L-1) reduced Pb and Zn adsorption from 0.01, 0.1 and 1.0 mmol L-1 solutions. However, even at 21 mg DOC L-1 fulvic acid, extraction efficiencies from 0.01 to 0.1 mmol L-1 solutions remained >80% (Pb) and >50% (Zn). Decreases in extraction efficiency were significant between initial metal concentrations of 0.1 and 1.0 mmol L-1 indicating that at metal loadings between c. 100 mg kg-1 and 300 mg kg-1 occupancy of adsorption sites began to limit further adsorption. The nanoparticles have the potential to perform effectively as metal adsorbents in systems containing more than one metal and dissolved organic carbon at a range of pH values.

Renal diseases in adults with cystic fibrosis: a 40 year single centre experience.

BACKGROUND: There is a sizable literature describing renal disease in patients with cystic fibrosis. Previous studies have focused on single disease processes alone, most commonly renal stone disease or acute kidney injury. In this study we report for the first time on the prevalence of all forms of renal disease in a cystic fibrosis population. METHODS: A retrospective review of adult patients with cystic fibrosis attending the Adult Cystic Fibrosis Department at the Royal Brompton Hospital was carried out by searching the department's database to identify patients with renal problems and subsequently retrieving clinical information from medical notes. RESULTS: The prevalence of all renal diseases in our population was 5.1 %. The most commonly identified problem was renal stones. At 2.0 % the prevalence of renal stones in adult patients with cystic fibrosis was comparable to the general population. A range of other renal diseases were identified, the next most common being drug-induced acute kidney injury. CONCLUSIONS: A range of cystic fibrosis independent and attributable diseases has been identified but no cystic fibrosis specific disease. In contrast to other cystic fibrosis centres no increased prevalence of renal stones was found.

An energy budget agent-based model of earthworm populations and its application to study the effects of pesticides.

Earthworms are important organisms in soil communities and so are used as model organisms in environmental risk assessments of chemicals. However current risk assessments of soil invertebrates are based on short-term laboratory studies, of limited ecological relevance, supplemented if necessary by site-specific field trials, which sometimes are challenging to apply across the whole agricultural landscape. Here, we investigate whether population responses to environmental stressors and pesticide exposure can be accurately predicted by combining energy budget and agent-based models (ABMs), based on knowledge of how individuals respond to their local circumstances. A simple energy budget model was implemented within each earthworm Eisenia fetida in the ABM, based on a priori parameter estimates. From broadly accepted physiological principles, simple algorithms specify how energy acquisition and expenditure drive life cycle processes. Each individual allocates energy between maintenance, growth and/or reproduction under varying conditions of food density, soil temperature and soil moisture. When simulating published experiments, good model fits were obtained to experimental data on individual growth, reproduction and starvation. Using the energy budget model as a platform we developed methods to identify which of the physiological parameters in the energy budget model (rates of ingestion, maintenance, growth or reproduction) are primarily affected by pesticide applications, producing four hypotheses about how toxicity acts. We tested these hypotheses by comparing model outputs with published toxicity data on the effects of copper oxychloride and chlorpyrifos on E. fetida. Both growth and reproduction were directly affected in experiments in which sufficient food was provided, whilst maintenance was targeted under food limitation. Although we only incorporate toxic effects at the individual level we show how ABMs can readily extrapolate to larger scales by providing good model fits to field population data. The ability of the presented model to fit the available field and laboratory data for E. fetida demonstrates the promise of the agent-based approach in ecology, by showing how biological knowledge can be used to make ecological inferences. Further work is required to extend the approach to populations of more ecologically relevant species studied at the field scale. Such a model could help extrapolate from laboratory to field conditions and from one set of field conditions to another or from species to species.

A retrospective analysis of the impact of azithromycin maintenance therapy on adults attending a UK cystic fibrosis clinic.

BACKGROUND: Azithromycin is widely used as an immunomodulatory agent in the treatment of cystic fibrosis with previous literature documenting improvements in lung function and a reduction in infective exacerbations. The maximal study period in adults has been six months. METHODS: 81 adult patients taking continuous azithromycin were retrospectively identified. Percentage predicted FEV(1) and courses of intravenous antibiotics were examined at yearly intervals two years prior to and two years after azithromycin initiation. RESULTS: FEV(1) deteriorated in the two years before starting azithromycin by a mean of 2.02% per year. In the year following initiation, FEV(1) increased by 1.15% (P=0.01). However, a mean 2.58% reduction was observed in year two. There was no statistically significant effect on courses of intravenous antibiotics. CONCLUSIONS: Azithromycin resulted in an improved FEV(1) at year one. This effect was not sustained beyond the first year of treatment.

The outcome of pregnancies in women with cystic fibrosis--single centre experience 1998-2011.

OBJECTIVE: To describe the maternal and fetal outcomes of pregnancies in women with cystic fibrosis. DESIGN: Retrospective study. SETTING: Single obstetric hospital and adult cystic fibrosis centre. METHODS: Retrospective case-note review of pregnant women with cystic fibrosis referred for antenatal care and delivery. MAIN OUTCOME MEASURES: Maternal and fetal outcomes, mode of delivery, lung function and pregnancy complications. RESULTS: Forty-eight pregnancies were studied in 41 women. There were two miscarriages, 44 singleton pregnancies and two sets of twins. All babies were liveborn and survived. The mean gestational age at delivery was 35.9 ± 3.3 weeks. There were no fetal abnormalities or terminations of pregnancy. The median birthweight centile was 31.9 (interquartile range 14.9-55.6). Twenty-five (52.1%) of the women had pancreatic insufficiency and 17 (35.4%) required insulin. There was a positive correlation between booking predicted forced expiratory volume in 1 second (FEV(1) ) and gestational age at delivery (P < 0.01). Women with FEV(1) ≤60% were more likely to deliver earlier and by caesarean section compared with women with FEV(1) >60% (35.0 ± 3.2 weeks versus 37.1 ± 3.0 weeks; P = 0.02 and 75.0% versus 25.0%; P = 0.01). Three of the seven women with an FEV(1) <40% died within 18 months of delivery. Four of the eight women with FEV(1) 40-50% died between 2 and 8 years after delivery. CONCLUSION: Pregnancy for women with cystic fibrosis is possible and results in favourable maternal and fetal outcomes, but the incidence of preterm delivery and caesarean section is increased. Women with pre-existing poor lung function should be counselled antenatally to ensure that they understand the implications of their shortened life-expectancy and parenthood.

Improved survival at low lung function in cystic fibrosis: cohort study from 1990 to 2007.

OBJECTIVES: To evaluate the survival of patients with cystic fibrosis whose lung function has deteriorated to a forced expiratory volume in one second (FEV(1)) below 30% predicted in the recent treatment era and to explore factors associated with any change in survival. Design Cohort study. SETTING: Adult cystic fibrosis unit in London. PARTICIPANTS: 276 patients (147 (53%) male) whose FEV(1) was first observed to be less than 30% predicted between 1 January 1990 and 31 December 2003. MAIN OUTCOME MEASURE: Survival during follow-up to 31 December 2007 in two year sub-cohorts. RESULTS: Median survival improved from 1.2 years in the 1990-1 group to 5.3 years in the 2002-3 group, with a marked improvement in survival from 1994. The use of nebulised recombinant human DNase was significantly associated with a reduced risk of death (hazard ratio 0.59, 95% confidence interval 0.44 to 0.79). Significantly increased risks were associated with a body mass index under 19 (hazard ratio 1.52, 1.10 to 2.10), long term oxygen therapy (3.52, 2.49 to 4.99), and nebulised antibiotics (1.84, 1.05 to 3.22). CONCLUSION: A marked improvement has occurred in the survival of patients with cystic fibrosis with an FEV(1) less than 30% predicted. Secondary analyses suggest that some of this improvement may be due to use of recombinant human DNase.

Cystic fibrosis and survival to 40 years: a study of cystic fibrosis transmembrane conductance regulator function.

Significant survival heterogeneity exists in cystic fibrosis. Our aim was to determine whether residual function of the cystic fibrosis transmembrane conductance regulator (CFTR) is present in long-term survivors with severe mutations. Nasal potential difference (PD) and sweat chloride were measured in 34 long-term survivors (aged ≥ 40 yrs) and compared with young patients (18-23 yrs) with severe (n = 30) and mild (n = 31) lung disease. Baseline PD was not significantly different across the three groups (long-term survivors, -42.8 (range -71.0- -20.5) mV; young/mild, -40.5 (-58.8- -19.5) mV; young/severe,-46.3 (-74.0- -20.0) mV). Response to amiloride (ΔAmil) was significantly different across the three groups (p = 0.01); long-term survivors had values (27.8 (range 8.5-46) mV) which were not different to either young group, but the young/severe group had significantly higher values (29.5 (11-47) mV) than those in the young/mild group (22.0 (7-39) mV; p<0.01). Baseline PD and ΔAmil were associated with forced expiratory volume in 1 s (FEV1) (co-efficient (95% CI) -0.13 (-0.23- -0.03); p = 0.009 and -0.12 (-0.20- -0.04); p = 0.003, respectively). Sweat chloride was lowest (p <0.05) in the young/severe group (93.5 (74-111) mmol·L⁻¹ versus 98.8 (76.5-116.0) mmol·L⁻¹; long-term survivors; and 99.5 (80.0-113.5) mmol·L⁻¹; young/mild). Δ Amil is associated with FEV1 but our findings indicate that long-term survival cannot be explained by residual CFTR function when measurements are taken in later life.

Twice vs three-times daily antibiotics in the treatment of pulmonary exacerbations of cystic fibrosis.

BACKGROUND: Once daily dosing of aminoglycosides is widely used but is limited by the inconvenience of the slow infusion it requires and the associated three-times daily infusion of a beta-lactam. Twice daily tobramycin can be given as a slow IV bolus and may be more convenient. This study compares twice with three-times daily dosing of both tobramycin and ceftazidime. METHODS: This was a randomised, open-label, parallel group trial. CF patients presenting with an infective exacerbation were randomised to either twice or three-times daily ceftazidime and tobramycin. Markers of treatment efficacy and safety were measured in the two groups. The primary outcome measure was improvement in FEV1. RESULTS: 146 patients were randomised into the study. There was no significant difference in the two groups for improvement in FEV1% predicted (9.93% and 7.98% for twice daily and three-times daily respectively) and similar times to next exacerbation. There were no differences in the incidence of treatment failure, nephrotoxicity and ototoxicity. DISCUSSION: This study confirms that twice daily dosing of both tobramycin and ceftazidime is safe and effective and may be considered more convenient than current dosing schedules.

Adult cystic fibrosis care in the 21st century.

Cystic fibrosis (CF) is the most common autosomal recessive inherited disease of Caucasian populations. As a result of a variety of diagnostic and therapeutic strategies there has been a dramatic increase in the life expectancy of patients with CF in the last decades and 50% of patients are now adults. This review will focus on the disease in adults and the provision of appropriate care. The complex care required to improve the survival and quality of life in the adult patients can best be provided in a dedicated adult cystic fibrosis unit. These units currently exist in many European countries, but more are needed in Italy.

Cystic fibrosis and survival to 40 years: a case-control study.

The clinical course of patients with cystic fibrosis (CF) is variable and probably determined by many interacting factors. We aimed to examine the influence of early social and clinical factors on long-term survival. A case-control study of adult CF patients was used to compare long-term survivors (aged ≥ 40 yrs) with patients who died before reaching 30 yrs of age. Each case (n = 78) was matched by birth date with at least one control (n = 152), after exclusion of "late diagnosis" patients. Probability-weighted logistic regression models were used to identify influences on survival. Factors resulting in increased probabilities of survival included high body mass index (OR 1.76, 95% CI 1.40-2.22), forced expiratory volume in 1 s (OR per 5% increase 1.54, 95% CI 1.32-1.80), and forced vital capacity (OR per 5% increase 1.54, 95% CI 1.33-1.78) at transfer to the adult clinic and the exclusive use of oral antibiotics (OR 8.31, 95% CI 3.02-22.88). Factors resulting in decreased probabilities of survival were Pseudomonas aeruginosa acquisition (OR 0.18, 95% 0.05-0.65) or pneumothorax before transfer to the adult clinic (OR 0.02, 95% CI 0.004-0.08) and referral from a paediatric clinic in a deprived area (OR 0.13, 95% CI 0.04-0.38). Long-term survival is associated with the clinical features present by the time of referral to an adult clinic. Even "early-diagnosis" disease appears to have different phenotypes, possibly independent of CF gene function, that have different survival patterns.

Beyond postural drainage and percussion: Airway clearance in people with cystic fibrosis.

BACKGROUND: Evidence indicates that there are no statistically significant differences in effectiveness among the airway clearance techniques (ACTs) of active cycle of breathing, autogenic drainage, positive expiratory pressure (PEP) or oscillating PEP in the short-term, but are there differences in the long-term (one year)? The objective of the study was to demonstrate non-inferiority in the long-term. METHODS: Seventy-five people with cystic fibrosis entered the prospective, randomised controlled trial of these five different ACTs. The primary outcome measure was forced expiratory volume in one second (FEV(1)). Secondary outcome measures included exercise capacity and health related quality of life. RESULTS: Using intention to treat, data were available on 65 subjects at the end of the study period. There were no statistically significant differences among the regimens in the primary outcome measurement of FEV(1) (p=0.35). CONCLUSION: In different countries either one or several airway clearance regimens are used. This study provides evidence in support of current practices.

Trends in pathogens colonising the respiratory tract of adult patients with cystic fibrosis, 1985-2005.

INTRODUCTION: The treatment of patients with CF has continued to evolve. We hypothesised that sputum microbiology may have changed as a result of this. METHOD: Retrospective analysis of sputum microbiology from adult CF patients (1985 to 2005) using the Royal Brompton Hospital CF database. RESULTS: Colonisation with Pseudomonas aeruginosa or Staphylococcus aureus between 1985 and 2005 remained stable (77 to 82%, p=0.159; 54 to 47%, p=0.108; respectively). Haemophilus influenzae (48 to 6%; p<0.001), Aspergillus species (18 to 9%; p=0.002) and Burkholderia cepacia complex (9 to 4%; p=0.041) prevalence decreased. Stenotrophomonas maltophilia and MRSA increased (1 to 4%, p=0.02; 1 to 6%, p=0.002, respectively). CONCLUSION: P. aeruginosa colonisation has remained stable; there has been a decline in B. cepacia complex, H. influenzae and Aspergillus sp., and only a small increase in S. maltophilia and MRSA. Intensive antibiotic strategies have been employed, which, so far, have not resulted in clinically significant emergence of new pathogens.

Implementation of European standards of care for cystic fibrosis - provision of care.

BACKGROUND: Several guidelines for cystic fibrosis (CF) caregivers exist, but information about their implementation is lacking. METHODS: Adherence to European Consensus Guidelines for CF was studied by sending surveys to named healthcare professionals in 487 CF centres/units. Data were analysed qualitatively. RESULTS: Data were obtained from 177 CF clinics, providing care for 21,177 patients (33% response rate). Access to specialist healthcare professionals was good according to 80% of respondents, although only 59% reported access to specialist pharmacists. Of the respondents, 16% reported unlimited access to inpatient CF beds, however 22% reported a lack of availability of immediate care. Most respondents (84%) reviewed their patients quarterly as outpatients. Shared-care models were used by 84% of respondents. Availability and adequacy of funding presented an issue for many, although 8% of respondents indicated that key funding was derived from CF charities. CONCLUSIONS: The respondents demonstrated a high degree of implementation of European Consensus Guidelines. However, areas for improvement include shared care, access to care and funding inequalities.

Implementation of European standards of care for cystic fibrosis--control and treatment of infection.

BACKGROUND: Several guidelines on infection control and treatment of infection exist for cystic fibrosis (CF) caregivers, although the extent of implementation is variable. METHODS: Adherence to European Consensus Guidelines for CF was studied by sending surveys to named healthcare professionals in 487 European CF centres/units. Qualitative data analysis was performed. RESULTS: A total of 177/547 (32%) surveys were returned. Infection control policies were implemented by most (77%) respondents. Separation of patients with Burkholderia cepacia was more common in adults (95%) than children (9%), and was implemented by 53% of respondents for Pseudomonas aeruginosa. Nebulised colistin plus oral ciprofloxacin was the most common (43%) therapy for P. aeruginosa infection. First infections of P. aeruginosa were usually treated with inhaled tobramycin; 41% of repondents did not intervene until lung function deteriorated. Most exacerbations were treated for less than the recommended period. CONCLUSIONS: European Consensus Guidelines are widely adhered to. Areas for improvement include: initiating therapy for exacerbations early, separating infected patients and optimising duration of antibiotic therapy.

Dornase alfa is well tolerated: data from the epidemiologic registry of cystic fibrosis.

After closure of the Epidemiologic Registry of Cystic Fibrosis (ERCF), a comprehensive safety analysis of dornase alfa was performed. A planned subanalysis focused on children under 5 years old. Reported serious adverse events (SAEs) were assigned a preferred term and ascribed to a specific organ system. Possible serious adverse reactions to dornase alfa (SADRs) were identified by reporting clinics. Twenty-eight of 15,865 SAEs (0.18%), occurring in 26 of 6,829 patients ever treated with dornase alfa (0.38%), and no deaths were reported as possible SADRs: most were typical complications of cystic fibrosis (CF). There was no evidence of any unrecognized risk of treatment. During 24,586 patient-years of follow-up (FU) of ever-treated patients, SAEs (mostly typical respiratory complications of CF) were more frequent on-treatment (0.4999/patient-year; 95% CI 0.4921-0.5076) than off-treatment (0.3889; 0.3787-0.3992). This was likely caused by within-patient prescription bias. During 655 patient-years of FU in 328 ever-treated patients under 5 years old, SAEs (mostly pulmonary exacerbations of CF) were slightly less frequent during treatment: 0.2911 (0.2367-0.3455) versus 0.3563 (0.3086-0.4040; ns). Results confirm the safety of dornase alfa in CF patients of all ages. Children under 5 years old tolerate dornase alfa at least as well as older patients.

Case-control study of Stenotrophomonas maltophilia acquisition in cystic fibrosis patients.

The aims of this case-control study were to describe the characteristics of cystic fibrosis (CF) patients who isolated Stenotrophomonas maltophilia in sputum, to determine risk factors for acquisition, to assess persistence of the organism and clinical outcomes postacquisition. Data were collected from 1991-1999. CF patients and controls (who had never isolated S. maltophilia) were matched for age (+/- 1 yr), sex and forced expiratory volume in one second (+/- 10%). Data were collected from the year prior and for 2 yrs postacquisition of S. maltophilia. The prevalence of S. maltophilia increased from 3.3% to 15%. Factors associated with S. maltophilia acquisition were more than two courses of intravenous antibiotics, isolation of Aspergillus fumigatus in sputum and oral steroid use. The effect of A. fumigatus was independent of steroid use. Clinical status did not change postacquisition. The majority of patients cleared the organism from the sputum. Long-term infection or an accelerated deterioration in lung function or nutrition is not likely post-Stenotrophomonas maltophilia acquisition in cystic fibrosis. This is the first documentation of an association between Aspergillus fumigatus isolation and Stenotrophomonas maltophilia acquisition in cystic fibrosis, independently of steroid therapy.

Dornase alfa in the treatment of cystic fibrosis in Europe: a report from the Epidemiologic Registry of Cystic Fibrosis.

Dornase alfa (Pulmozyme) treatment for patients with cystic fibrosis (CF) has been shown to improve pulmonary function and reduce exacerbations of infection in a number of placebo-controlled double-blind studies. Data in the Epidemiologic Registry of Cystic Fibrosis (ERCF) in November 1998 were used to assess the long-term effectiveness in routine clinical practice of dornase alfa in terms of pulmonary function and frequency of acute pulmonary exacerbations in CF. At that time, the ERCF contained data on 13,684 CF patients, with a mean observation period of 2.3 years. To be included in the analysis, patients had to have 2 years of data in the Registry in appropriate detail. Overall, untreated patients showed a decline in forced expiratory volume in 1 sec over a 2-year period of -2.3% predicted, but treated patients were stable, showing a change of 0.3% predicted, i.e., a treatment benefit of 2.5%. Compared to untreated patients, there were 25 fewer exacerbations per 100 treated patients per year. The analysis suggested that younger patients were likely to benefit more from treatment. The findings of randomized clinical trials were supported by the data collected in routine clinical practice.

The psychosocial and psychiatric side of cystic fibrosis in adolescents and adults.

Increasing numbers of cystic fibrosis (CF) patients are surviving into adulthood. An understanding of the psychiatric and psychosocial aspects of CF in adults and adolescents is therefore more important than ever. There is a large body of evidence indicating that the psychological and psychosocial functioning of people with CF is similar to that of well people, until the disease becomes severe. However, there is also evidence that patients do suffer an increased likelihood of psychiatric problems, such as depression, and of scoring poorly on physical functioning measures of quality of life. Studies have found conflicting evidence as to any association between degree of respiratory impairment and psychological functioning. Coping styles seem to have a large effect upon the quality of life of CF patients. People with cystic fibrosis can have problems with sexuality, platonic relationships and independence. Families of patients also suffer problems, which can affect the patients themselves. Non-compliance is a complicated problem with many patients. New treatments for people with CF are emerging, such as lobe transplants from live donors and gene therapy, with possible new psychosocial problems resulting. Furthermore, older studies are becoming increasingly inapplicable as treatment and prognosis changes. Therefore, more research is needed in this field.

A randomised clinical trial of nebulised tobramycin or colistin in cystic fibrosis.

Chronic infection with Pseudomonas aeruginosa is associated with progressive deterioration in lung function in cystic fibrosis (CF) patients. The purpose of this trial was to assess the efficacy and safety of tobramycin nebuliser solution (TNS) and nebulised colistin in CF patients chronically infected with P. aeruginosa. One-hundred and fifteen patients, aged > or = 6 yrs, were randomised to receive either TNS or colistin, twice daily for 4 weeks. The primary end point was an evaluation of the relative change in lung function from baseline, as measured by forced expiratory volume in one second % predicted. Secondary end points included changes in sputum P. aeruginosa density, tobramycin/colistin minimum inhibitory concentrations and safety assessments. TNS produced a mean 6.7% improvement in lung function (p=0.006), whilst there was no significant improvement in the colistin-treated patients (mean change 0.37%). Both nebulised antibiotic regimens produced a significant decrease in the sputum P. aeruginosa density, and there was no development of highly resistant strains over the course of the study. The safety profile for both nebulised antibiotics was good. Tobramycin nebuliser solution significantly improved lung function of patients with cystic fibrosis chronically infected with Pseudomonas aeruginosa, but colistin did not, in this study of 1-month's duration. Both treatments reduced the bacterial load.