OTC use of a topical nasal spray solution containing xylometazoline plus ipratropium in patients with common cold.

BACKGROUND: Combination of xylometazoline and ipratropium in a nasal spray provides fast, effective symptomatic relief of nasal congestion and rhinorrhea in adults with common cold. OBJECTIVES: To gather data in a non-prescription setting regarding the safety, pattern of use, patients' general assessment of treatment and suitability of making available without medical prescription of this topical combination nasal spray. DESIGN: Post-marketing, non-interventional, non-controlled study reflecting normal over-the-counter (OTC) use of the spray in adults with common cold (n = 1,019). Main outcome measures included pattern of use (patient-reported effectiveness, compliance with treatment) and safety (adverse drug reaction (ADR) reports). RESULTS: Over 92% of patients used the product for the intended indication, 81.4% used it 2 - 3 times/day and the median duration of treatment was 6 days. In total, 39.7% of patients reported 585 ADRs (mean 1.45 ADR/patient) while 60.3% reported no ADRs. Most common side effects were nasal dryness (12.4%), blood tinged mucus (9.3%), nasal discomfort (6.2%), epistaxis (4.2%), generally harmless and of mild severity. Patients who used the product outside the approved indication did not seem to have a higher risk of ADRs. Mean general impression score was 3.4, with 79% of patients rating treatment as "good" to "excellent". CONCLUSIONS: The topical combination nasal spray (xylometazoline plus ipratropium) for the symptomatic relief of nasal congestion and rhinorrhea in adults with common cold has a good safety profile and results in high patient satisfaction in an OTC setting. No reasons could be found to oppose the assertion that the combination spray is suitable for classification as a product not subject to medical prescription.

Biofilm formation by Propionibacterium acnes is a characteristic of invasive isolates.

Propionibacterium acnes is a common and probably underestimated cause of delayed joint prosthesis infection. Bacterial biofilm formation is central in the pathogenesis of infections related to foreign material, and P. acnes has been shown to form biofilm both in vitro and in vivo. Here, biofilm formation by 93 P. acnes isolates, either from invasive infections (n = 45) or from the skin of healthy people (n = 48), was analysed. The majority of isolates from deep infections produced biofilm in a microtitre model of biofilm formation, whereas the skin isolates were poor biofilm producers (p <0.001 for a difference). This indicates a role for biofilm formation in P. acnes virulence. The type distribution, as determined by sequencing of recA, was similar among isolates isolated from skin and from deep infections, demonstrating that P. acnes isolates with different genetic backgrounds have pathogenic potential. The biofilm formed on plastic and on bone cement was analysed by scanning electron microscopy (EM) and by transmission EM. The biofilm was seen as a 10-mum-thick layer covering the bacteria and was composed of filamentous as well as more amorphous structures. Interestingly, the presence of human plasma in solution or at the plastic surface inhibits biofilm formation, which could explain why P. acnes primarily infect plasma-poor environments of, for example, joint prostheses and cerebrospinal shunts. This work underlines the importance of biofilm formation in P. acnes pathogenesis, and shows that biofilm formation should be considered in the diagnosis and treatment of invasive P. acnes infections.

Bacterial vaginosis--a microbiological and immunological enigma.

The development of bacterial vaginosis (BV) among women of childbearing age and the resulting quantitative and qualitative shift from normally occurring lactobacilli in the vagina to a mixture of mainly anaerobic bacteria is a microbiological and immunological enigma that so far has precluded the formulation of a unifying generally accepted theory on the aetiology and clinical course of BV. This critical review highlights some of the more important aspects of BV research that could help in formulating new basic ideas respecting the biology of BV, not least the importance of the interleukin mediators of local inflammatory responses and the bacterial shift from the normally occurring lactobacilli species: L. crispatus, L. gasseri, L. jensenii, and L. iners to a mixed flora dominated by anaerobic bacteria.

Intrauterine infection may be a major cause of stillbirth in Sweden.

AIM OF THE STUDY: To investigate intrauterine infection as a cause for unexplained stillbirth. METHODS: Chorioamnionitis was studied in a material of stillbirths (117 subjects from the years 1985-1994) from a region in the south Sweden. Control material (126 alive and healthy newborns and with healthy mothers) was gathered from the same region. RESULTS: Chorioamnionitis was a common diagnosis both with stillbirths and 'healthy' deliveries (82 and 68%, respectively). Extension of the inflammation to decidua basalis was seven times more common among stillbirths than among controls (odds ratio 7.2, confidence interval 2.8-21.9). The most common bacteria found at cultures were Escherichia coli, Coagulase negative staphylococcus, Enterococcus faecalis and group B Streptococcus. The risk for stillbirth was doubled if both inflammation and bacteria were present (odds ratio 2.3, confidence interval 0.92-5.8). Meconium discharge was more common among stillbirths than controls (odds ratio=4.7, confidence interval 1.7-14). There were no differences in any respect regarding macerated and non-macerated stillbirths. Our findings are similar to the results from studies in developing countries except for the higher incidence of stillbirths in such countries. CONCLUSIONS: Thus, a large part of otherwise unexplained stillbirths might be due to ascending infections.

Study of knowledge, attitude and practice concerning aspects of torture.

The report presents the first attempt of the IMA-AKN Sinha Institute of continuing medical and health education and research to study the knowledge, attitude and practice of doctors regarding torture. Although, majority of the doctors in India are aware of various national and international human rights institutions, but they seem not to be aware of the human rights of the detainees. It is interesting to note that the doctors are aware of the long term physical and psychological effects of torture and also agreed that physical examination is not sufficient to detect torture sequelae. A large number of doctors have seen cases of torture, and were willing to treat them and felt reasonably competent. A significant number of doctors justified use of coercive technique and manhandling in dealing with detainees by law enforcement agencies. A small number of doctors expressed their unwillingness to get involved in the treatment of the victims of torture due to medicolegal consequence. The dissemination of information on human rights and medical ethics and incorporating them into the medical curriculum at undergraduate and postgraduate training was emphasised by majority of the respondents. Almost unanimous view was expressed by respondents on the importance of the role of medical ethics and the profession's responsibility to its members. An important finding of the study is the need for IMA to help establishing counselling and rehabilitation centres for treatment of torture victims and educate its members. A large number of doctors mentioned the need of initiating community action in case of rape, child abuse, dowry victims and sexual harassment. Further, a majority of respondents expressed the view that the medical association should take the responsibilities of protecting the doctors who fearlessly testify cases of torture besides disciplining doctors who facilitate torture. Respondents felt that the reasons for doctors' participation in torture need further study. It is encouraging that most of the responding physicians are willing to take up training and become counsellor for victims of torture to be able to provide treatment, counselling and rehabilitation.

Comparison of muscle sizes and moment arms of two rotator cuff muscles measured by ultrasonography and magnetic resonance imaging.

OBJECTIVE: The purpose was to investigate ultrasound (US) and anthropometry (AN) as valid alternatives to magnetic resonance imaging (MRI) regarding muscle size characteristics of two rotator cuff muscles. METHODS: Eight healthy females (age 27-54 yrs.) went through MRI and US scannings and AN measurements, where muscle thickness, cross-section area (CSA), moment arm, muscle length and width were measured on supraspinatus and infraspinatus muscle. RESULTS: The agreement between the methods was very satisfactory for CSA, and satisfactory for muscle thickness, moment arm, muscle length and width, with a mean difference below 2 mm in thickness and below 5 mm in muscle length and width. Volume could be estimated satisfactory in supraspinatus muscle, but not in infraspinatus muscle, where volume had to be calculated from thickness, length and width. As a significant relation was found in the MRI measurements between thickness and CSA, thickness measurements may replace CSA in inaccessible muscles. CONCLUSIONS: US was a valid method in measuring CSA, muscle thickness and moment arm. Combined with anthropometric measures of muscle length and width, volume can be calculated, which is important when defining the physiological cross-sectional area and muscle function. Further development and validation of the method is needed, however.

Calibration of the disk diffusion test for trovafloxacin susceptibility testing of four anaerobic species.

OBJECTIVES: To study trovafloxacin susceptibility among clinical isolates of four anaerobic bacterial species using minimum inhibitory concentrations (MIC) determinations, E test assays and disk diffusion test results and to calibrate the disk diffusion method for these species using single strain regression analysis (SRA). METHODS: One-hundred and eighty-seven clinical isolates of four anaerobic bacterial species were included. Trovafloxacin MIC determinations were performed using the agar dilution technique and MIC estimations using the E test. The disk diffusion test was performed according to Swedish Reference Group for Antibiotics standardization. NCCLS limits for susceptibility categories were applied. SRA was performed using 1, 3, 10, 30, and 100 microg trovafloxacin disk contents and ATCC control strains. The regression lines obtained permitted the calculation of zone equivalents to MIC limits as well as an evaluation of various disk potencies. RESULTS: Trovafloxacin susceptibility (S + I) was noted in 98.9, 100, 100, and 97% of Bacteroides fragilis, Bacteroides thetaiotaomicron, Clostridium perfringens, and Peptostreptococcus magnus strains, respectively, as judged by MIC determinations. Agar dilution and E test estimations gave the same results, but E test values were consistently lower than MIC values by the reference method. Regression lines calculated for the four species using SRA showed different equation constants indicating species-related differences. Interpretive zone diameter breakpoints were calculated for the four species and used for the interpretation of susceptibility. CONCLUSIONS: The disk diffusion test was successfully calibrated for trovafloxacin susceptibility testing of four anaerobic species using single strain regression analysis, SRA. There was a good agreement between the results of MIC-tests and disk testing. Interpretive errors of type I are prone to occur among Bacteroides isolates and might require species-related MIC limits. SRA calculations permitted the testing of the effect of different disk potencies on inhibition zones produced at the interpretive MIC limits. Criteria for the selection of a minimal disk content showed that 5 microg trovafloxacin is sufficient, but a 10 microg disk will safeguard against residual laboratory variation without producing too large inhibition zones for very susceptible strains.

Fusidic acid disk diffusion testing of clostridium difficile can be calibrated using single-strain regression analysis.

Single-strain regression analysis (SRA) was employed to calibrate the disk diffusion antibiotic susceptibility test for fusidic acid and Clostridium difficile. MIC determinations of 40 clinical isolates of C. difficile were performed with the E-test. The disk diffusion test was standardized according to the Swedish Reference Group for Antibiotics (SRGA). Disks used for SRA contained 1.5, 5, 15, 50 and 150 microg fusidic acid and the routine disk contained 50 microg fusidic acid. A control strain, ATCC 9689, was also tested. SRA constants A and B of the regression lines were calculated. This permitted the determination of zone breakpoints for C. difficile. When applying the pharmacological MIC S and R limits set by SRGA to the E-test results I strain of C. difficile was interpreted as resistant. Zone breakpoints corresponding to the pharmacological MIC limits and calculated using the mean SRA constants for the 40 clinical isolates lead to all strains being interpreted as susceptible. SRA calculations enable laboratories to set up calibrated disk tests with species-related and laboratory-specific interpretations.

Dexamethasone differentially regulates cytokine transcription and translation in macrophages responding to bacteria or okadaic acid.

Many microorganisms and microbial products induce expression of pro-inflammatory cytokines such as interleukin-1 (IL-1alpha/beta) and tumour necrosis factor-alpha (TNF-alpha) in macrophages, primarily by transcriptional activation. We show here, by using mouse macrophages in primary culture, that pre-treatment with dexamethasone inhibits bacteria-induced IL-1beta expression as mRNA and cellular pro-IL-1beta in parallel, consistent with an effect primarily on transcriptional activation. In contrast, the expression of TNF-alpha mRNA was only partly inhibited despite virtually complete inhibition of TNF-alpha protein formation. Furthermore, the selective induction of primarily cell-associated 26,000 M, pro-TNF-alpha by the protein phosphatase inhibitor okadaic acid also was partly inhibited at the mRNA level by dexamethasone, whereas additional translational inhibition appeared to be lacking. This latter finding is reminiscent of earlier findings regarding signalling to activation of cytosolic phospholipase A2, which is sensitive to dexamethasone when elicited by bacteria, but not when elicited by okadaic acid. The present results raise the possibility that the inhibitory effect of dexamethasone on TNF-alpha translation, but not on transcriptional activation, is mediated by one or more okadaic acid-sensitive protein phosphatases.

Tonsillar microbial flora: comparison of recurrent tonsillitis and normal tonsils.

Tonsillar microbial flora was studied in cultures of tonsillar core specimens from 34 patients tonsillectomized due to recurrent group A streptococcal pharyngotonsillitis (n = 17) or sleep apnoea (n = 17). Patients in the sleep apnoea subgroup, who had no history of recurrent tonsillitis and manifested no tonsillar hypertrophy at ENT examination, served as controls. Tonsillar core specimens were cultured for semi-quantitative estimation of growth of aerobic, anaerobic and facultative organisms. The recurrent tonsillitis and apnoea subgroups did not differ significantly in the mean number of isolates per patient, either of aerobic spp. (3.8 vs. 4.3) or anaerobic spp. (5.2 vs. 4.7). Nor did the two subgroups differ significantly in the proportion of patients whose specimens manifested beta-lactamase producers (71% vs. 59%), in the isolation frequency of viridans (alpha) streptococci, or in the occurrence of semi-quantitative growth estimates of 3-4+ for aerobic, anaerobic or beta-lactamase-producing spp. Thus, the study provided no support for the hypothesis that inactivation of penicillin V by beta-lactamase-producing bacteria in oral or throat flora, or the eradication of viridans streptococci with their GAS-inhibitory capacity, is an important factor with regard to recurrent group A streptococcal tonsillitis. Other possible explanations, such as poor antibiotic penetration at the site of infection, are discussed.

Factors influencing vaginal fetal fibronectin concentrations during pregnancy.

In order to evaluate factors influencing fetal fibronectin concentrations during pregnancy a total of 312 vaginal samples for fetal fibronectin measurements and microbiological culture were collected and later included in a stepwise regression analysis. Preterm premature rupture of membranes, a modified Bishop score >/=6 (p < 0.0001), a low vaginal polymorphonuclear leukocyte count (p < 0. 002), the presence of Enterococcus faecalis (p < 0.0001), Prevotella species (p < 0.05), a bacterial vaginosis-associated flora (p < 0. 05), and a non-lactobacilli-dominated vaginal flora (p < 0.05) were associated with an elevated vaginal fetal fibronectin concentration.

Multiple C-terminal serine phosphorylation accompanies both protein kinase C-dependent and -independent activation of cytosolic 85 kDa phospholipase A2 in macrophages.

Exposure of mouse macrophages to either phorbol ester or certain bacteria was previously shown to cause increased phosphorylation of the cytosolic 85 kDa phospholipase A2 as well as a stable increase in its catalytic activity. We have now attempted to map the major phosphorylation sites on the enzyme in such cells. Phosphorylation occurred on serine residues without a detectable increase in either phosphothreonine or phosphotyrosine. After CNBr cleavage five fragments showed increased 32P labelling. Among those the most heavily labelled fragment was identified as the most C-terminal (residues 698-749), containing six serine residues. This was true whether phorbol ester or bacteria, causing protein kinase C-independent phospholipase A2 activation, was used as stimulus. The heavy phosphorylation of the most C-terminal fragment and an analysis of tryptic peptides derived from it suggested that more than one of the six serine residues became phosphorylated. Smaller increases also occurred in other CNBr-cleaved fragments from the C-terminal part of the protein, including that carrying Ser-505, a known target of the mitogen-activated protein kinase ERK-2 (extracellular-signal regulated kinase). Dexamethasone treatment (1-100 nM for 20 h), which was earlier shown to dose-dependently down-regulate the 85 kDa phospholipase A2 and its activation by phorbol ester and zymosan, was here shown also to counteract the protein kinase C-independent activation and arachidonate release elicited by bacteria. It remains to be determined whether all phosphorylation sites are equally affected under those conditions.

Fetal fibronectin and microorganisms in vaginal fluid of women with complicated pregnancies.

OBJECTIVES: To determine vaginal fetal fibronectin in women with pregnancies complicated by preterm labor (PTL), preterm premature rupture of the membranes (PPROM) or bleeding; to investigate possible relationships to the vaginal microflora; and to assess the ability to predict preterm delivery from these measures. MATERIAL AND METHODS: Group comparative study between women of the same gestational age with a normal pregnancy (n = 28) and consecutive women admitted with PTL (n = 63), PPROM (n = 18) and bleeding (n = 21). Samples of vaginal fluid were collected at the time of admission in complicated pregnancies and from the women with normal pregnancies. Fetal fibronectin was determined by enzyme immunoassay and quantitative aerobic and anaerobic microbiological cultures were performed. RESULTS: The number of positive (> or = 0.05 mg/L) vaginal fetal fibronectin values was higher among women with PTL, PPROM and bleeding compared to controls (p < 0.001). A positive fibronectin value was predictive of delivery < or = 34 weeks (sensitivity 64%, specificity 87%). The absence of hydrogen peroxide-producing lactobacilli was predictive for preterm delivery < 34 weeks (sensitivity of 100%, specificity 35%). CONCLUSIONS: The presence of vaginal fibronectin and the absence of hydrogen peroxide-producing lactobacilli was indicative of an increased risk for preterm delivery < 34 weeks.

Microorganisms in vaginal fluid from women in prolonged pregnancy.

In order to compare the vaginal microflora of women in prolonged pregnancy with that of women who delivered at term, samples for quantitative aerobic and anaerobic microbiological culture were collected from 100 women at 42 weeks of gestation and from 60 women at term. The occurrence of lactobacilli-dominated flora was similar in women at term and women with prolonged pregnancy. However, non-hydrogen-peroxide-producing lactobacilli (p < 0.01) were significantly more common and Peptostreptococci species (p < 0.05) significantly less common in postterm women as compared with term controls. In postterm women, Candida albicans was more common (p < 0.001) in microfloras dominated by non-hydrogen-peroxide-producing lactobacilli than in floras dominated by hydrogen-peroxide-producing lactobacilli. The ecosystem of the vagina in asymptomatic postterm women was disrupted concerning the composition of lactobacilli as compared with term controls.

Protein PAB, an albumin-binding bacterial surface protein promoting growth and virulence.

The anaerobic bacterium Peptostreptococcus magnus is a human commensal and pathogen. Previous work has shown that strains of P. magnus isolated from patients with gynecological disease (vaginosis) frequently express an immunoglobulin (Ig) light chain-binding protein called protein L. Here we report that strains isolated from localized suppurative infections bind human serum albumin (HSA), whereas commensal isolates bind neither Ig nor HSA. The HSA-binding protein PAB was extracted from the bacterial surface or isolated from the culture supernatant of the P. magnus strain ALB8. Protein PAB was shown to have two homologous HSA-binding domains, GA and uGA. GA is absent in the sequence of a related protein from another P. magnus strain and shows a high degree of homology to the HSA-binding domains of streptococcal protein G. Therefore GA is believed to have recently been shuffled as a module from genes of other bacterial species into the protein PAB gene. This GA module was shown to exhibit a much higher affinity for HSA than uGA and was also found to be present in all of the isolates tested from localized suppurative infections, indicating a role in virulence. Moreover, when peptostreptococci or streptococci expressing the GA module were grown in the presence of HSA, the growth rate was substantially increased. Thus, the HSA binding activity of the GA module adds selective advantages to the bacteria, which increases their virulence in the case of P. magnus strains.

The bacterial flora of the genitourinary tract in healthy fertile men.

The clinical significance of microorganisms in semen is unclear, as they may signify contamination rather than infection. Specimens from six locations in 97 healthy men scheduled for vasectomy were analyzed. Totally 1033 strains, aerobic or anaerobic, were isolated. Of 61 intraoperatively obtained vas deferens cultures, only one was positive. Of the 97 semen samples, 83% contained bacteria, 140 aerobes and 113 anaerobes; 44% of the strains found in semen and 58% of those in prostatic secretion were also identified in the urethra. The finding that 71% of the strains colonizing the coronal sulcus were present in the urethra indicates that the distal part of the urethra is colonized by a bacterial flora similar to that in the sulcus. The urethral flora may then contaminate semen and prostatic secretion. Presence of multiple bacterial species in semen was not associated with abnormal sperm function.

Fetal fibronectin and microorganisms in vaginal fluid of healthy pregnant women.

OBJECTIVE: To determine fetal fibronectin in vaginal fluid from healthy women during uncomplicated pregnancy and to investigate possible relationships to gestational age and the vaginal microflora. MATERIALS AND METHODS: Samples of vaginal fluid were collected for fetal fibronectin determination and for quantitative aerobic and anaerobic microbiological culture from 22 women followed longitudinally at 12, 28 and 37 weeks gestation cross-sectionally in women at 12 weeks (n = 10), 28 weeks (n = 10), 37 weeks (n = 10), and 39 weeks (n = 30) gestation, respectively. Fetal fibronectin was determined by a quantitative enzyme immunoassay (Adeza Biomedical). RESULTS: There were no significant differences between the concentrations of fetal fibronectin in vaginal secretions at any of the four measurement points (12, 28, 37 and 39 weeks gestation). Women with elevated fetal fibronectin concentration (> or = 0.05 mg/L) had less often hydrogen peroxide-producing facultative lactobacilli (p < 0.0001), and more often bacterial vaginosis (p < 0.02) and Peptostreptococcus species (p < 0.002). Bacterial vaginosis (p < 0.01) and Candida albicans (p < 0.01) were more frequently found in women lacking hydrogen peroxide-producing lactobacilli. CONCLUSION: Fetal fibronectin in vaginal fluid was more associated with the vaginal microflora than with the gestational age of the pregnancy. Presence of hydrogen peroxide-producing lactobacilli seems to be the most important factor for a stable vaginal microflora.

Protein shift and antigenic variation in the S-layer of Campylobacter fetus subsp. venerealis during bovine infection accompanied by genomic rearrangement of sapA homologs.

Campylobacter fetus subsp. venerealis isolated from a case of human vaginosis was inoculated into the uterus of a C. fetus-negative heifer. Isolates obtained weekly from the vaginal mucus exhibited variations in high-molecular-mass-protein profiles from that of the original inoculum, which had a dominant 110-kDa S-layer protein. Immunoblots of the weekly isolates with monoclonal antibody probes against the 110-kDa S-layer protein and other C. fetus S-layer proteins demonstrated antigenic shifts. Genomic digests of the isolates probed with a 75-mer oligonucleotide of the conserved sapA region also indicated that antigenic variation of the S-layer is accompanied by DNA rearrangement.