Manganese transport by Streptococcus sanguinis in acidic conditions and its impact on growth in vitro and in vivo.

Streptococcus sanguinis is an oral commensal and an etiological agent of infective endocarditis. Previous studies have identified the SsaACB manganese transporter as essential for endocarditis virulence; however, the significance of SsaACB in the oral environment has never been examined. Here we report that a ΔssaACB deletion mutant of strain SK36 exhibits reduced growth and manganese uptake under acidic conditions. Further studies revealed that these deficits resulted from the decreased activity of TmpA, shown in the accompanying paper to function as a ZIP-family manganese transporter. Transcriptomic analysis of fermentor-grown cultures of SK36 WT and ΔssaACB strains identified pH-dependent changes related to carbon catabolite repression in both strains, though their magnitude was generally greater in the mutant. In strain VMC66, which possesses a MntH transporter, loss of SsaACB did not significantly alter growth or cellular manganese levels under the same conditions. Interestingly, there were only modest differences between SK36 and its ΔssaACB mutant in competition with Streptococcus mutans in vitro and in a murine oral colonization model. Our results suggest that the heterogeneity of the oral environment may provide a rationale for the variety of manganese transporters found in S. sanguinis.

Testing of candidate probiotics to prevent dental caries induced by Streptococcus mutans in a mouse model.

AIMS: We evaluated two species of human oral commensal streptococci in protection against dental caries induced by Streptococcus mutans. METHODS AND RESULTS: Candidate probiotics, Streptococcus sp. A12, Streptococcus sanguinis BCC23 and an arginine deiminase mutant of BCC23 (∆arcADS) were tested for their ability to reduce S. mutans-induced caries in an established mouse model. Mice were colonized with a probiotic, challenged with S. mutans, then intermittently reinoculated with a probiotic strain. Oral colonization of each strain and autochthonous bacteria was assessed by quantitative polymerase chain reaction. Both BCC23 strains, but not A12, were associated with markedly reduced sulcal caries, persistently colonized mucosal and dental biofilms, and significantly lowered S. mutans counts. All three strains enhanced mucosal colonization of autochthonous bacteria. In a follow-up experiment, when S. mutans was established first, dental and mucosal colonization of S. mutans was unaltered by a subsequent challenge with either BCC23 strain. Results between BCC23 and BCC23 ∆arcADS were equivalent. CONCLUSIONS: BCC23 is a potential probiotic to treat patients at high caries risk. Its effectiveness is independent of ADS activity, but initial dental cleaning to enhance establishment in dental biofilms may be required. SIGNIFICANCE AND IMPACT OF THE STUDY: In vivo testing of candidate probiotics is highly informative, as effectiveness is not always reflected by genotype or in vitro behaviours.

Oxidized phosphatidylcholines induce multiple functional defects in airway epithelial cells.

Oxidative stress is a hallmark of numerous airway diseases, contributing to extensive cell and tissue damage. Cell membranes and the airway mucosal lining are rich in phospholipids that are particularly susceptible to oxidative attack, producing bioactive molecules including oxidized phosphatidylcholines (OxPCs). With the recent discovery of elevated OxPCs in patients with asthma after allergen challenge, we hypothesized that OxPCs directly contribute to disease by inducing airway epithelial cell dysfunction. We found that OxPCs induced concentration-dependent cell stress and loss of viability in BEAS-2B and Calu-3 cell lines and primary human epithelial cells. These responses corresponded with significant epithelial barrier dysfunction, which was further compounded when combining OxPCs with an epithelial wound. OxPCs inhibited DNA synthesis and migration required to reestablish barrier function, but cells recovered if OxPCs were washed off soon after treatment. OxPCs induced generation of reactive oxygen species, lipid peroxidation, and mitochondrial dysfunction, raising the possibility that OxPCs cause pathological lipid metabolism in a self-propagating cycle. The oxidative stress induced by OxPCs could not be abrogated by putative OxPC receptor blockers, but partial recovery of barrier function, proliferation, and lipid peroxidation could be achieved with the antioxidant N-acetyl cysteine. In summary, we have identified OxPCs as a group of bioactive molecules that significantly impair multiple facets of epithelial cell function, consistent with pathological features of asthma. Further characterization of the mechanisms by which OxPCs affect epithelial cells could yield new insights into how oxidative stress contributes to the pathogenesis of airway disease.

In Vivo Colonization with Candidate Oral Probiotics Attenuates Colonization and Virulence of Streptococcus mutans.

A collection of 113 Streptococcus strains from supragingival dental plaque of caries-free individuals were recently tested in vitro for direct antagonism of the dental caries pathogen Streptococcus mutans, and for their capacity for arginine catabolism via the arginine deiminase system (ADS). To advance their evaluation as potential probiotics, twelve strains of commensal oral streptococci with various antagonistic and ADS potentials were assessed in a mouse model for oral (i.e., oral mucosal pellicles and saliva) and dental colonization under four diets (healthy or high-sucrose, with or without prebiotic arginine). Colonization by autochthonous bacteria was also monitored. One strain failed to colonize, whereas oral colonization by the other eleven strains varied by 3 log units. Dental colonization was high for five strains regardless of diet, six strains increased colonization with at least one high-sucrose diet, and added dietary arginine decreased dental colonization of two strains. Streptococcus sp. A12 (high in vitro ADS activity and antagonism) and two engineered mutants lacking the ADS (ΔarcADS) or pyruvate oxidase-mediated H2O2 production (ΔspxB) were tested for competition against S. mutans UA159. A12 wild type and ΔarcADS colonized only transiently, whereas ΔspxB persisted, but without altering oral or dental colonization by S. mutans In testing four additional candidates, S. sanguinis BCC23 markedly attenuated S. mutans' oral and dental colonization, enhanced colonization of autochthonous bacteria, and decreased severity of smooth surface caries under highly cariogenic conditions. Results demonstrate the utility of the mouse model to evaluate potential probiotics, revealing little correlation between in vitro antagonism and competitiveness against S. mutans in vivo IMPORTANCE Our results demonstrate in vivo testing of potential oral probiotics can be accomplished and can yield information to facilitate the ultimate design and optimization of novel anti-caries probiotics. We show human oral commensals associated with dental health are an important source of potential probiotics that may be used to colonize patients under dietary conditions of highly varying cariogenicity. Assessment of competitiveness against dental caries pathogen Streptococcus mutans and impact on caries identified strains or genetic elements for further study. Results also uncovered strains that enhanced oral and dental colonization by autochthonous bacteria when challenged with S. mutans, suggesting cooperative interactions for future elucidation. Distinguishing a rare strain that effectively compete with S. mutans under conditions that promote caries further validates our systematic approach to more critically evaluate probiotics for use in humans.

Leucine and branched-chain amino acid metabolism contribute to the growth of bone sarcomas by regulating AMPK and mTORC1 signaling.

Osteosarcoma and chondrosarcoma are sarcomas of the bone and the cartilage that are primarily treated by surgical intervention combined with high toxicity chemotherapy. In search of alternative metabolic approaches to address the challenges in treating bone sarcomas, we assessed the growth dependence of these cancers on leucine, one of the branched-chain amino acids (BCAAs), and BCAA metabolism. Tumor biopsies from bone sarcoma patients revealed differential expression of BCAA metabolic enzymes. The cytosolic branched-chain aminotransferase (BCATc) that is commonly overexpressed in cancer cells, was down-regulated in chondrosarcoma (SW1353) in contrast with osteosarcoma (143B) cells that expressed both BCATc and its mitochondrial isoform BCATm. Treating SW1353 cells with gabapentin, a selective inhibitor of BCATc, further revealed that these cells failed to respond to gabapentin. Application of the structural analog of leucine, N-acetyl-leucine amide (NALA) to disrupt leucine uptake, indicated that all bone sarcoma cells used leucine to support their energy metabolism and biosynthetic demands. This was evident from the increased activity of the energy sensor AMP-activated protein kinase (AMPK), down-regulation of complex 1 of the mammalian target of rapamycin (mTORC1), and reduced cell viability in response to NALA. The observed changes were most profound in the 143B cells, which appeared highly dependent on cytosolic and mitochondrial BCAA metabolism. This study thus demonstrates that bone sarcomas rely on leucine and BCAA metabolism for energy and growth; however, the differential expression of BCAA enzymes and the presence of other carbon sources may dictate how efficiently these cancer cells take advantage of BCAA metabolism.

How should continence and incontinence after radical prostatectomy be evaluated? A prospective study of patient ratings and changes with time.

PURPOSE: We examined prevalence rates, and changes in continence and incontinence before and after radical prostatectomy for prostate cancer by comparing different definitions. We also studied the descriptive validity of the grading system of Ellison et al for post-prostatectomy incontinence and baseline predictors of post-prostatectomy incontinence at 12 months. MATERIALS AND METHODS: This national prospective study included 844 patients treated with radical prostatectomy between 2005 and 2009. Adverse effects, including urinary dysfunction and bother, were reported by 735 patients (88%) using the EPIC-50 and UCLA-PCI validated questionnaires at baseline and 12-month followup. Linear regression analysis was done to examine baseline predictors and the degree of post-prostatectomy incontinence at followup. RESULTS: At 12 months after radical prostatectomy 74% of patients reported post-prostatectomy incontinence, of whom 40% used pads daily, 34% reported occasional dribbling without pads and 26% had total urinary control. When defined as total incontinence/no urinary control, severe post-prostatectomy incontinence was reported by 3% of the men but 25% had severe post-prostatectomy incontinence according to the stratification of Ellison et al. Of patients with preoperative incontinence 14% improved postoperatively. Predictors of post-prostatectomy incontinence were age 65 years or greater, not working, sexual dysfunction and incontinence preoperatively. The latter 2 remained the strongest predictors on multivariate analysis. Prostate cancer related variables were not associated with post-prostatectomy incontinence. CONCLUSIONS: The prevalence of post-prostatectomy incontinence varied considerably according to the definition applied. In our opinion incontinence may be reported as any leakage and not only as pad use with grading done on a symptom scale. Preoperative sexual dysfunction and urinary incontinence were the strongest predictors of post-prostatectomy incontinence at 12-month followup.

Charcot Foot Beaming with Subsequent Titanium Allergy: A Case Report.

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Long-term experience with surgical treatment of selected patients with bladder pain syndrome/interstitial cystitis.

OBJECTIVE: The role of major surgery in patients with bladder pain syndrome/interstitial cystitis (BPS/IC) is not fully established. This report presents a single-institution experience with major surgery in patients with disabling BPS/IC where conservative treatment had failed. MATERIAL AND METHODS: Forty-one patients (34 women, seven men) with BPS/IC refractory to conservative treatment underwent major surgery from 1983 to 2004. Surgical approach was determined on a case-by-case basis. Postoperative pain and satisfaction were assessed by a questionnaire. RESULTS: Cystectomy was the primary procedure in five patients. The remaining 36 patients were primarily operated on with subtotal cystectomy and bladder augmentation (n = 16) or supravesical urinary diversion with intact bladder (n = 20). Thirteen of these patients were later operated on with cystectomy due to persisting pain 12 (6-146) months after the primary procedure. The questionnaire was answered by 38 of 41 patients after a median follow-up of 66 (6-238) months. In total, 28 patients (74%) were free of pain, and 26 patients (68%) were satisfied with the end result. There was no difference in reported pain between cystectomized and non-cystectomized patients. When comparing patients who reported pain at follow-up with those who did not report pain, preoperative length of symptoms was significantly increased, with 12.1 compared to 5.4 years (p = 0.02). CONCLUSIONS: Major surgery is associated with good symptom relief in strictly selected patients with disabling BPS/IC, where conservative treatment has failed. Extended preoperative duration of symptoms may be a predictor for persisting pain after major surgery for BPS/IC.

[Sexual dysfunction in men]. / Seksuell dysfunksjon hos menn.

BACKGROUND: Sexuality is an important part of most men's quality of life. Reduced sexual function is common and can be treated. MATERIAL AND METHODS: The article is based on relevant publications retrieved from Medline, recent textbooks and the authors' clinical experience. RESULTS AND INTERPRETATION: Numerous aspects affect sexual function in men. The following is discussed; prevalence of sexual dysfunction in men, symptoms, diagnostic approaches and treatment options for premature ejaculation, delayed ejaculation, anejaculation, retrograde ejaculation, erectile dysfunction with organic cause, congenital penile curvature, Peyronie's disease, reduced sexual desire and hypogonadism. Medical doctors need to know about sexual medicine and to be able to communicate well with patients about these issues.

[Treatment of erectile dysfunction with penile implants]. / Behandling av ereksjonssvikt med penisimplantat.

BACKGROUND: Penile implants are the final step in the treatment of erectile dysfunction. The aim of this study was to evaluate patients treated with penile implants in our department. MATERIAL AND METHODS: From 1990 to 2002, 37 men with erectile dysfunction were treated with a three-component penile implant (AMS 700). In 2 patients the implant was removed; 2 patients were dead at the time of the study. The remaining group (n = 33) received a questionnaire concerning their penile implants, of whom 27 (82 %) responded. Mean observation time after surgery was 6 years. Mean age at surgery was 50 (27 - 68 years). RESULTS: Diabetes mellitus, trauma and venous insufficiency were the main reasons (68 %) for dysfunction in this patient group. Five patients had perioperative or early postoperative complications. Nineteen (51 %) were re-operated mainly because of dislocation (n = 5), perforation (n = 4) or mechanical failure (n = 4) of the implant. Twenty (74 %) patients were satisfied after surgery. There was no significant improvement in libido or in the relationship with partners. INTERPRETATION: Three out of four patients were pleased to have the penile implantation done despite the high reoperation rate.

Urostomy and health-related quality of life in patients with lower urinary tract dysfunction.

OBJECTIVE: Urinary diversion may be an option in patients with disabling lower urinary tract dysfunction (DLUTD), refractory to conservative and minor invasive treatment. The aim of this study was to evaluate whether urostomy improves quality of life and cost of surgery, in terms of complications, loss of kidney function and hospital stay, in these patients. MATERIAL AND METHODS: This prospective study included 52 consecutive patients (nine men and 43 women) with various benign disorders. Twenty-six patients received an ileal conduit and 26 a continent cutaneous diversion. The patients completed the general health-related quality of life instrument WHOQOL-BREF and a urinary problem-specific quality of life instrument preoperatively and 6 and 12 months after surgery. Length of hospital stay and complications were registered. Intravenous urography and determination of glomerular filtration rate (GFR) were performed preoperatively and 12 months postoperatively. RESULTS: Disease-specific and health-related quality of life improved significantly (p < 0.0005 and p < 0.05) in all domains except for social relationship, from preoperative to 12 months after surgery. There was no difference in improvement between patients with continent and those with incontinent diversion. Mean hospital stay was 14 days. Early and late complications required open surgery in 12 patients (23%). GFR was unchanged postoperatively. CONCLUSIONS: Urinary diversion improves health-related and disease-specific quality of life in patients with DLUTD refractory to conservative and minor invasive treatments. The burden of surgery is acceptable. Urinary diversion could be recommended more often in such patients.

Severe postprostatectomy incontinence: Is there an association between preoperative urodynamic findings and outcome of incontinence surgery?

OBJECTIVE: This study investigated urodynamic findings in prostate cancer patients with self-reported persistent severe postprostatectomy urinary incontinence (PPI) as well as the outcome of incontinence surgery. The main aim was to evaluate the ability of preoperative urodynamic dysfunctions to predict the outcome of incontinence surgery. The hypothesis was that preoperative bladder dysfunction was predictive of an unsuccessful surgical outcome. MATERIALS AND METHODS: Based on patient-reported adverse effects after radical prostatectomy (RP) in 2005-2009, 94 men with persistent severe PPI were invited in 2011 to a clinical examination including urodynamics. When indicated, surgery for PPI was offered, and by January 2014, 46 patients had been operated on with either an artificial urinary sphincter or a sling. The outcome of PPI surgery was evaluated with a follow-up questionnaire. Successful outcome was defined in two ways: patient-reported satisfaction and using one or fewer pads/day. RESULTS: Of the 94 men with severe PPI more than 12 months after RP, 76 patients (81% response rate) met for clinical examination. Among them, 99% had intrinsic sphincter deficiency, in 67% coexisting with urodynamic bladder dysfunction. The presence of preoperative bladder dysfunction was not predictive of the outcome of PPI surgery. Preoperative use of fewer pads, less severe PPI, and a longer interval between RP and PPI surgery were associated with the successful outcome of one or fewer pads/day. Longer duration from RP to PPI surgery was the only preoperative factor associated with the successful outcome of satisfaction. CONCLUSIONS: The hypothesis was not supported as the presence of preoperative urodynamic bladder dysfunction was not predictive of the outcome of PPI surgery in this study.

[Expandable penile implants in patients with erectile dysfunction]. / Penisimplantat ved ereksjonssvikt.

Modern medical treatment can restore normal sexual function in the majority of men with erectile dysfunction, but some men will not obtain an erection sufficient for sexual intercourse. In some of these men, with a strong desire to have an active sexual life including intercourse, it is possible to restore the function by the use of a penile implant. We describe the indications, the surgical procedure and the results with an expandable penile implant.

Sacral neuromodulation in Norway: clinical experience of the first three years.

We present our first three years' experience of sacral neromodulation as first line therapy in patients with a non-neurogenic refractory urge incontinence. In 53 patients, 45 women and 8 men with a mean age of 54 years (range 17-76 years), tested by subacute percutan nerve evaluation, 19 patients were declared as responders according to our programme. Fourteen patients, twelve women and two men with a mean age of 47 years (range 33-73 years), agreed to implantation of a neuroprosthesis (Medtronic Interstim Model 3031), which was placed in a subcutaneous buttock pocket in 12 patients. In the first two patients, the device was implanted subcutaneously corresponding to the lower quadrants of the abdominal wall. In two patients, the lead was repositioned from S:4 to S:3 six to twelve months after the primary implantation. In one woman with sensory urgency, the neuroprosthesis was removed six months after it was implanted because of failure. The patients were followed every six months using voiding diary, uroflowmetry, residual urine and cystometry. Eight patients reported total continence, and five declared >50% improvement. One woman has chronic bacteriuria and intermittently symptomatic urinary tract infection, which reduce the response to the chronic sacral nerve stimulation. Because of residual urine, four women are following an individual self-catheterisation programme. In conclusion, we have documented that sacral neuromodulation is an effective and safe procedure in patients with refractory urge incontinence depending on detrusor overactivity. We confirm the clinical results reported by other centres with long experience of sacral neuromodulation.