Effect of live and inactivated Lactobacillus rhamnosus GG on experimentally induced rhinovirus colds: randomised, double blind, placebo-controlled pilot trial.

The aim of this work was to investigate the usability of an experimental rhinovirus model in probiotic trials aiming to assess effectiveness in viral infections, and to provide preliminary data of live and inactivated probiotic Lactobacillus rhamnosus GG for larger-scale trials utilising the model. 59 subjects were randomised to receive 100 ml of fruit juice supplemented with 10(9) cfu of live or heat-inactivated (by spray-drying) L. rhamnosus GG or control juice daily for six weeks. After three weeks subjects were intranasally inoculated with experimental rhinovirus. Infection rate (at least one positive culture for challenge virus on five days following inoculation or at least four-fold rise in antibody response to challenge virus) was 14/19 in the group receiving live probiotic strain and 18/20 both in the group receiving heat-inactivated probiotic strain and in the control group (P=0.36). The occurrence and severity of cold symptoms on the five days following the inoculation was lowest in the group receiving live probiotic strain (P=0.45). This trial was the first one dedicated to the investigation of the effect of probiotics using the experimental rhinovirus model. The model showed potential for demonstration of efficacy of probiotics in controlled respiratory viral infections. Occurrence and severity of cold symptoms and number of subjects with rhinovirus infection was lowest in the group receiving live L. rhamnosus GG, but differences were not statistically significant. Further large-scale studies are needed to demonstrate the efficacy of L. rhamnosus GG in respiratory infections.

B cell infiltration and lymphonodular hyperplasia in bladder submucosa of patients with persistent bacteriuria and recurrent urinary tract infections.

PURPOSE: We defined chronic inflammatory cell types in bladder submucosa and the presence of umbrella cells on the surface of bladder epithelium in patients 5 to 21 years old with persistent bacteriuria due to neurogenic bladder and recurrent urinary tract infections associated with vesicoureteral reflux. MATERIALS AND METHODS: Bladder mucosa biopsies from 12 patients and 6 controls were fixed in Carnoy's solution and examined for T cells (CD3, CD4, CD8), B cells (CD79) and plasma cells (CD138). The number of cells in a defined area of submucosa was determined by counting all nuclei in the area. A contiguous section was also stained for uroplakin expression with a monoclonal antibody against uroplakin III to ascertain the integrity of bladder umbrella cells. RESULTS: B cells, plasma cells and lymphoid nodules were found only in patient biopsies. T cell expression was evident in patient and control biopsies. Uroplakin staining of surface epithelium was uniform from control biopsies but spotty or entirely absent from patient biopsies. CONCLUSIONS: Patients with persistent bacteriuria or recurrent urinary tract infections had significant B cell infiltration in the submucosa, including lymphoid nodules. These inflammatory changes are likely due to antigenic stimulation from repeated exposure to bacteria. These changes are associated with frequent absence of uroplakin on surface epithelium.

Rhinovirus contamination of surfaces in homes of adults with natural colds: transfer of virus to fingertips during normal daily activities.

Multiple surfaces contaminated with rhinovirus were detected in hotel rooms by reverse transcriptase-polymerase chain reaction (RT-PCR) following occupancy by a cold sufferer. Whether infectious rhinovirus contaminates surfaces in homes and is transferred from surfaces to fingertips through normal activities is not known. Nasal secretions from 30 subjects with new colds were tested for rhinovirus genome by RT-PCR; infectious rhinovirus was sought with tissue cultures. Each subject identified 10 sites in their home touched during the preceding 24 hr. Samples from sites were tested for rhinovirus by RT-PCR and cell culture. Later, each subject's mucus (stored at -70°C) was deposited on surfaces for testing transfer to fingertips through daily life activities such as flipping a light switch, touching the telephone keypad, and holding the telephone handset. Nasal secretions from 16/30 subjects were positive for rhinovirus by RT-PCR; 66 (41%) of 160 surfaces in homes were positive. Contaminated surfaces included doorknobs (6 positive/18 tested), refrigerator door handles (8/14), TV remote controls (5/10), and bathroom faucets (8/10). Five (19%) of 26 RT-PCR positive sites from culture positive subjects were positive in cell culture. Nasal mucus from six culture positive subjects was deposited on objects. Infectious rhinovirus was detected on 22% of fingertips following contact with objects contaminated for 1 hr; transfer dropped to 3% after 24 hr of contamination, and 0% after 48 hr. Infectious rhinovirus found on surfaces in homes of people with colds can be transferred to fingertips, but infectivity of virus in mucus declines by 24 hr after deposition.

Absence of bacterial reservoirs in the bladder epithelium of patients with chronic bacteriuria due to neurogenic bladder.

PURPOSE: Bacteriuria is common in patients with neurogenic bladder who are on clean intermittent catheterization for bladder emptying. In a longitudinal study patients carried 1 or 2 clones of Escherichia coli in the urine during months of surveillance. An explanation for persistent bacteriuria in this population could be that periurethral E. coli inoculated during clean intermittent catheterization would attach via type I adhesin, invade superficial bladder epithelial cells and establish reservoirs. Resurgence of bacteria from these reservoirs in bladder epithelium could later reenter the urine and establish a recurrent episode of bacteriuria. We investigated whether bacterial reservoirs were present in the superficial epithelium of patients with neurogenic bladder and chronic bacteriuria. MATERIALS AND METHODS: Bladder biopsies were obtained from patients with neurogenic bladder and a history of chronic recurrent bacteriuria. Biopsies were fixed in Carnoy's solution to preserve the material overlying the luminal surface of the superficial bladder epithelium. Following fixation biopsies were stained with hematoxylin and eosin to detect intracellular bacterial reservoirs and with periodic acid-Schiff for exopolysaccharide of biofilm. Fluorescence in situ hybridization was done to visualize individual bacteria. RESULTS: No evidence of bacterial reservoirs was found in the superficial bladder epithelium of 9 patients with neurogenic bladder. On hematoxylin and eosin staining epithelium with an intact luminal surface had no intracellular bacterial pods. On periodic acid-Schiff staining no biofilm or collection of exopolysaccharide surrounding bacterial communities was found. No collections or individual bacteria were seen on fluorescence in situ hybridization stained sections examined at 1,000x magnification with oil immersion. CONCLUSIONS: Bacterial reservoirs do not appear to be an important source of bacteriuria in patients with chronic recurrent bacteriuria due to neurogenic bladder.

Radiopaque contrast dye in nasopharynx reaches the middle ear during swallowing and/or yawning.

CONCLUSION: Contrast dye in the nasopharynx reaches the middle ear during swallowing and yawning in normal adults. This suggests that displacement of bacteria in nasopharyngeal secretion to the middle ear may occur frequently during sleep. OBJECTIVE: The middle ear is sterile under normal conditions. The purpose of this study was to examine by means of CT whether radiopaque contrast dye in the nasopharynx would reflux into the middle ear of normal adults during swallowing and/or yawning. MATERIAL AND METHODS: Six normal adult volunteers were studied. Contrast dye was kept at the orifices of the Eustachian tube during swallowing and/or yawning by placing volunteers in either a head-down or lateral decubitus position. Reflux was determined by the presence of contrast dye in the middle ear on CT scanning of the temporal bone. RESULTS: Two of the three volunteers in each group (four out of six in total) had contrast material detected in one or both middle ear cavities.

Effect of a phosphate supplement on urine pH in patients with neurogenic bladder receiving intermittent catheterization.

STUDY DESIGN: Pilot study; prospective design. SETTING: University Hospital, Virginia, USA. OBJECTIVE: To examine a phosphorus supplement as a urine-acidifying agent in patients with neurogenic bladder on clean intermittent catheterization. METHODS: Seven patients were followed for 4 weeks. For the first week of study urine pH was measured three times a day: first morning urine sample, afternoon sample, evening sample. For the second and third weeks urine pH was measured and the patients drank a phosphorus supplement three times a day. For the fourth week of study the patients did not take the phosphorus supplement but the measurement of urine pH was continued. The patients were visited in their homes twice a week. During each visit a sample of urine was collected for culture. A supplement container count was performed and urine pH recordings were checked. RESULTS: There was no significant change in urine pH during the 2-week period when a patient was on phosphorus supplementation compared to when the patient was off supplementation. In addition, urine acidification was not achieved over the time period when urine pH was monitored. CONCLUSION: Phosphate supplementation had no effect on urine pH in patients with neurogenic bladder.

Bladder epithelium is abnormal in patients with neurogenic bladder due to myelomeningocele.

OBJECTIVE: To describe the urothelium of the neurogenic bladder in patients with myelomeningocele on clean intermittent catheterization. SETTING: Outpatient practice. METHODS: Samples of bladder wall obtained from two groups of patients were examined for urothelium. The first group included 12 children and young adults with myelomeningocele and neurogenic bladder on intermittent catheterization for bladder emptying. The second group included eight children with vesicoureteral reflux and non-neurogenic bladder. Nine patients from the first group and four patients from the second group had urothelium. A contiguous section of each of the 13 samples with urothelium was stained for uroplakin expression, a marker of superficial bladder urothelium by immunohistochemistry. RESULTS: Samples from children with reflux revealed normal bladder epithelium and a uniform layer of umbrella cells (95% CI: 0-60%). In contrast, the epithelium from all patients with myelomeningocele was abnormal (95% CI: 66-100%). Epithelium from five patients (four children, one adult) revealed chronic inflammation. Three patients (two children, one adult) had squamous metaplasia. The apical surface of the epithelium in all patients with chronic inflammation had some reactivity with anti-uroplakin antibody, but the cells staining positive for uroplakin were scattered along the lumenal surface of the epithelium. The apical surface of patients with squamous metaplasia was negative for uroplakin. CONCLUSION: The urothelium of the neurogenic bladder in young patients with myelomeningocele is abnormal, with loss of uroplakin expression and altered urothelial proliferation.

Variation in frequency of the virulence-factor gene in Escherichia coli clones colonizing the stools and urinary tracts of healthy prepubertal girls.

To provide information on virulence expression of Escherichia coli in healthy hosts, stool, periurethral, and urine samples were collected weekly from healthy 3-6-year-old girls who lived in a small rural community. Dominant and nondominant clones were defined in stool specimens, and the expression of virulence factors was determined. We found that healthy girls commonly shared dominant clones. P adhesin, hemolysin, and type I adhesin were commonly found in clones in the stool and in clones in the urinary tract. In addition, expression of virulence factors, among both dominant and nondominant clones in the stool, changed from week to week. The presence of P adhesin was a marker for the persistence of a dominant clone in the stool and was associated with an increased likelihood that a nondominant clone would be detected in the urinary tract. Type I adhesin was ubiquitous among stool strains, with orientation of the fimbrial switch being both in the "off" position and in both the "on" and "off" positions. In summary, the intestinal flora of healthy girls is complex, with frequent changes in virulence expression.

Bacterial pathogens of otitis media and sinusitis: detection in the nasopharynx with selective agar media.

Carriage rates for the bacterial pathogens associated with otitis media (Streptococcus pneumoniae [SP], Hemophilus influenzae [HI], and Moraxella catarrhalis [MC]) are of interest. Culture on three selective agars was compared with culture on two standard agars to determine the more accurate method for detection of these species in the nasopharynx of healthy children. Weekly samples were obtained in winter from 18 healthy children (ages 1 through 9 years) as part of a longitudinal study. A 0.1-mL sample of 116 nasopharyngeal aspirate/washes was inoculated onto each of five agars. Two were standard (sheep blood and chocolate), and three were selective (blood with gentamicin for SP; chocolate with vancomycin, bacitracin, and clindamycin for HI; blood with amphotericin B, vancomycin, trimethoprim, and acetazolamide for MC). One technician read the standard plates and another the selective; both were blinded to the results of the other. SP was found in 44% of samples with selective agar versus 25% with standard agar; HI was found in 31% with selective versus 9% with standard; MC was found in 56% with selective versus 37% with standard. Overall, 80% of samples had one or more pathogens detected with selective agars as compared with 58% with standard agars (P =.0004). Selective agars were more accurate than standard agars for detecting otitis pathogens in the nasopharynx, where they are a common part of normal flora in healthy children.

Should we abandon standard microscopy when screening for urinary tract infections in young children?

Dipstick analysis is a screening test for urinary tract infection (UTI) in office practice. Standard urine microscopy is available offsite. We evaluated the usefulness of these tests on consecutive urine samples obtained by bladder catheterization in young children with a possible UTI. Thirty of 230 children had positive cultures. Dipstick analysis was specific (98%) but not sensitive (70%). Standard microscopy was not specific. Dipstick analysis and urine culture are useful tests for the diagnosis of UTI.

Effect of practice variation on resource utilization in infants hospitalized for viral lower respiratory illness.

OBJECTIVE: Hospital care for children with viral lower respiratory illness (VLRI) is highly variable, and its relationship to severity and impact on outcome is unclear. Using the Pediatric Comprehensive Severity Index, we analyzed the correlation of institutional practice variation with severity and resource utilization in 10 children's medical centers. METHODS: Demographics, clinical information, laboratory results, interventions, and outcomes were extracted from the charts of consecutive infants with VLRI from 10 children's medical centers. Pediatric Component of the Comprehensive Severity Index scoring was performed at admission and at maximum during hospitalization. The correlation of patient variables, interventions, and resource utilization at the patient level was compared with their correlation at the aggregate institutional level. RESULTS: Of 601 patients, 1 died, 6 were discharged to home health care, 4 were discharged to rehabilitative care, and 2 were discharged to chronic nursing care. Individual patient admission severity score correlated positively with patient hospital costs (r = 0.48), but institutional average patient severity was negatively correlated with average institutional costs (r = -0.26). Maximal severity score correlated well with costs (r = 0.66) and length of stay (LOS; r = 0.64) at the patient level but poorly at the institutional level (r = 0.07 costs; r = 0.40 LOS). The institutional intensity of therapy was negatively correlated with admission severity (r = -0.03) but strongly correlated with costs (r = 0.84) and LOS (r = 0.83). CONCLUSIONS: Institutional differences in care practices for children with VLRI were not explained by differences in patient severity and did not affect the children's recovery but correlated significantly with hospital costs and LOS.

Lactoferrin and eosinophilic cationic protein in nasal secretions of patients with experimental rhinovirus colds, natural colds, and presumed acute community-acquired bacterial sinusitis.

To distinguish sinusitis from uncomplicated "colds," we examined lactoferrin and eosinophilic cationic protein (ECP) in nasal secretions. Lactoferrin titers were >/=1:400 in 4% of persons with uncomplicated colds and controls but in 79% of persons with sinusitis or purulent sputa. ECP levels were >200 ng/ml in 61% of persons with colds and >3,000 ng/ml in 62% of persons with sinusitis. Nasal lactoferrin helps distinguish sinusitis from colds.

Nose blowing propels nasal fluid into the paranasal sinuses.

Intranasal pressures were measured in adults during nose blowing, sneezing, and coughing and were used for fluid dynamic modeling. Sinus CT scans were performed after instillation of radiopaque contrast medium into the nasopharynx followed by nose blowing, sneezing, and coughing. The mean (+/-SD) maximal intranasal pressure was 66 (+/-14) mm Hg during 35 nose blows, 4.6 (+/-3.8) mm Hg during 13 sneezes, and 6.6 (+/-3.8) mm Hg during 18 coughing bouts. A single nose blow can propel up to 1 mL of viscous fluid in the middle meatus into the maxillary sinus. Sneezing and coughing do not generate sufficient pressure to propel viscous fluid into the sinus. Contrast medium from the nasopharynx appeared in >/=1 sinuses in 4 of 4 subjects after a nose blow but not after sneezing or coughing.

Expression of virulence factors among Escherichia coli isolated from the periurethra and urine of children with neurogenic bladder on intermittent catheterization.

BACKGROUND: Patients with neurogenic bladder caused by spinal cord injury or myelomeningocele empty their bladder several times a day by intermittent catheterization. Bacteriuria without symptoms of infection is frequently present in these patients. Occasionally a clone of Escherichia coli that has been carried for weeks without symptoms causes a symptomatic urinary tract infection. Virulence factors are commonly expressed among E. coli causing infection in patients with normal urinary tracts. However, it is unknown whether expression of virulence factors by an E. coli clone colonizing the neurogenic bladder increases the risk of subsequent infection. In this study we examined the prevalence of virulence factor expression among E. coli isolated from the periurethra and urine of patients with neurogenic bladder. METHODS: The prevalence of virulence factors was examined among E. coli isolated from the periurethra and urine in patients with neurogenic bladder who received intermittent catheterization and were followed for 6 months. Representative isolates from the 37 clonal types of E. coli detected in the periurethra and urine of children with neurogenic bladder were assessed for O antigen, hemolysin, aerobactin, serum resistance and type I and P-adhesin. RESULTS: All clones were serum-resistant and expressed type I adhesin, none expressed aerobactin and two expressed hemolysin. The presence of P-adhesin was not unique to clones associated with symptomatic infection. The presence of P-adhesin carried for weeks in a clone did not predict subsequent infection in the neurogenic bladder. CONCLUSION: Bacterial virulence factors did not predict infection of the neurogenic bladder.

Effect of cranberry juice on bacteriuria in children with neurogenic bladder receiving intermittent catheterization.

OBJECTIVE: To determine the effect of cranberry prophylaxis on rates of bacteriuria and symptomatic urinary tract infection in children with neurogenic bladder receiving clean intermittent catheterization. DESIGN: Double-blind, placebo-controlled, crossover study of 15 children receiving cranberry concentrate or placebo concentrate for 6 months (3 months receiving one concentrate, followed by 3 months of the other). Weekly home visits were made. During each visit, a sample of bladder urine was obtained by intermittent catheterization. Signs and symptoms of urinary tract infection and all medications were recorded, and juice containers were counted. RESULTS: During consumption of cranberry concentrate, the frequency of bacteriuria remained high. Cultures of 75% (114 of 151) of the 151 samples obtained during consumption of placebo were positive for a pathogen (>/=10(4) colony-forming units/mL) compared with 75% (120 of 160) of the 160 samples obtained during consumption of cranberry concentrate. Escherichia coli remained the most common pathogen during placebo and cranberry periods. Three symptomatic infections each occurred during the placebo and cranberry periods. No significant difference was observed in the acidification of urine in the placebo group versus the cranberry group (median, 5.5 and 6.0, respectively). CONCLUSION: The frequency of bacteriuria in patients with neurogenic bladder receiving intermittent catheterization is 70%; cranberry concentrate had no effect on bacteriuria in this population.

Clinical virology of rhinoviruses.

Rhinoviruses cause more infections in humans than any other micro-organism. These acid-sensitive picornaviruses infect epithelial cells following inoculation onto the nasal mucosa and are detected reliably in nasopharyngeal secretions. Rhinovirus colds occur year round, with a peak of illness in the fall. Type-specific serum antibody correlates with protection against infection. The fact that there are at least 100 different immunotypes makes development of an effective vaccine unlikely. Nasopharyngeal secretions must be sampled for detection of rhinovirus by culture or RT-PCR. Efficient isolation of virus requires inoculation into two different types of sensitive cell cultures (i.e., fibroblasts and HeLa cells). RT of conserved sequences in the 5' noncoding region of the viral RNA to produce cDNA for PCR amplification has been coupled with detection of amplimers either by gel electrophoresis after nested PCR or by hybridization with labeled oligonucleotide probes to detect one viral genome in samples. In two studies in which both RT-PCR and cell cultures were used, virtually all of the positives were identified with RT-PCR; culture in two cell lines identified 75-80% of the positives. In year-round surveillance, 50% of colds in adults and children were rhinovirus positive. The symptoms occurring during rhinovirus colds are caused by the host's response to the virus, not by the virus itself. Elaboration of cytokines by infected epithelial cells is central to symptom pathogenesis.

Cat-scratch disease encephalopathy: a cause of status epilepticus in school-aged children.

We describe 6 school-aged patients who presented with status epilepticus (SE) secondary to cat-scratch disease (CSD) encephalopathy to alert clinicians to this distinctive clinical entity. The hospital database for admissions during 1 year was reviewed for patients presenting with SE; 4 of 5 previously healthy school-aged children with SE had CSD encephalopathy based on elevated indirect fluorescent antibody titers to Bartonella henselae. CSD encephalopathy should be included in the differential diagnosis of school-aged children presenting with SE.

Correlation of periurethral bacterial flora with bacteriuria and urinary tract infection in children with neurogenic bladder receiving intermittent catheterization.

Periurethral bacteria are inoculated daily into the urine of children with neurogenic bladder during clean intermittent catheterization (CIC). We examined how frequently periurethral bacterial species produced bacteriuria in children followed longitudinally. When Escherichia coli was detected on the periurethra, bacteriuria was also present 93% of the time. When Klebsiella, Pseudomonas, or Enterococcus species or nonpathogens were detected on the periurethra, bacteriuria was present 80%, 40%, 40%, and 25% of the time, respectively. Clonal typing of multiple colonies of E. coli from each periurethral and urine culture revealed that children carried only one or two E. coli clones in their urinary tracts over months of surveillance. When E. coli was detected in the urine, the identical clone was on the periurethra. E. coli persisted for weeks in the urine without causing symptoms. Occasionally the same E. coli clone carried for weeks caused a urinary tract infection. Bacteriuria frequently occurs after inoculation of periurethral E. coli into the urine during CIC.