Prevalence and distribution of beta-lactamase coding genes in third-generation cephalosporin-resistant Enterobacteriaceae from bloodstream infections in Cambodia.

Resistance to third-generation cephalosporins in Gram-negative bacteria is emerging in Asia. We report the prevalence and distribution of extended-spectrum beta-lactamase (ESBL), AmpC beta-lactamase and carbapenemase-coding genes in cefotaxime-resistant Enterobacteriaceae isolates from bloodstream infections (BSI) in Cambodia. All Enterobacteriaceae isolated from BSI in adult patients at Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia (2007-2010) were assessed. Antimicrobial susceptibility testing was carried out by disc diffusion and MicroScan according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Screening for ESBL, plasmidic AmpC and carbapenemase-coding genes was performed by multiplex polymerase chain reaction (PCR) sequencing assays. Identification of the ST131 clone was performed in all CTX-M-positive Escherichia coli, using PCR targeting the papB gene. Out of 183 Enterobacteriaceae, 91 (49.7 %) isolates (84 BSI episodes) were cefotaxime-resistant: E. coli (n = 68), Klebsiella pneumoniae (n = 17) and Enterobacter spp. (n = 6). Most episodes were community-acquired (66/84; 78.3 %). ESBLs were present in 89/91 (97.8 %) cefotaxime-resistant isolates: 86 (96.6 %) were CTX-M, mainly CTX-M-15 (n = 41) and CTX-M-14 (n = 21). CTX-M of group 1 were frequently associated with TEM and/or OXA-1/30 coding genes and with phenotypic combined resistance to ciprofloxacin, sulphamethoxazole-trimethoprim and gentamicin (39/50, 78.0 %). Plasmidic AmpC (CMY-2 and DHA-1 types) were found alone (n = 2) or in combination with ESBL (n = 4). Eighteen E. coli isolates were identified as B2-ST131-O25B: 11 (61.1 %) carried CTX-M-14. No carbapenemase-coding genes were detected. ESBL among Enterobacteriaceae from BSI in Cambodia is common, mainly associated with CTX-M-15 and CTX-M-14. These findings warrant urgent action for the containment of antibiotic resistance in Cambodia.

Lactating dairy cows adapt quickly to being milked by an automatic milking system.

Transitioning a dairy herd to an automatic milking system (AMS) from a conventional parlor system may be stressful for the cow, as many changes occur during this process. Chronic stress may affect the welfare of the cow, and acute stress during milking can decrease milk yield. Therefore, it is important to quantify if and how long stress during adaptation to an AMS might persist. Seventy-seven cows with acceptable udder and teat conformation that would not interfere with adaptation to the AMS and that were lactating n = 18, early [0 to 100 d in milk (DIM)]; n = 27, mid (100 to 200 DIM); and n = 32, late (200+ DIM) for the full duration of the project were chosen for observation. All cows had been milked previously in a double-6 herringbone milking parlor. Four stress-related behaviors [step-kick behavior both before and after attachment of teat cups, elimination (urination and defecation instances), and vocalization] were recorded during milking by trained observers, whereas milk yield was automatically recorded by the AMS. Data were collected for 24-h periods beginning on the day the cows transitioned to milking in the AMS (d 0), and on d 1, 2, 4, 8, 16, and 32 thereafter. Instances of elimination and vocalization were greater on d 0 compared with all other days (elimination: d 0 = 3.1 ± 0.09, d 1 = 0.6 ± 0.07, and 0 ± 0 instances thereafter; vocalization: d 0 = 1.7 ± 0.07, d 1 = 0.05 ± 0.04, and 0 ± 0 instances thereafter). Milk yield increased between d 0 (18.3 ± 1.7 kg) and d 1 (30.9 ± 1.7 kg). Primiparous cows (n=28) were more likely than multiparous cows (n = 49) to display step-kick behaviors both before (8.3 ± 2.5; 5.5 ± 0.6, respectively) and after (15.6 ± 2.4; 13.3 ± 1.3, respectively) teat cup attachment during milking. Eight days after introducing the cows to the AMS, over 60% of the herd was milking voluntarily and 95% of the herd was milking voluntarily within a month, which suggests that cows did not find the AMS aversive. Greater elimination and vocalization behavior and lower milk yield on d 0 relative to subsequent days indicated initial stress and discomfort with the milking process in the new system; however, the cows appeared to adapt within 24h.

Dairy cow behavior affects the availability of an automatic milking system.

Facility design can affect the accessibility of an automatic milking system (AMS). In particular, gates and alleys positioned around the AMS may affect cow traffic and cow behavior, potentially affecting the duration of time the AMS is available for milking. Eighty-four Holstein cows of various parities and days in milk were randomly divided between 2 groups, each group having access to its own AMS. Cow locations and behaviors in the AMS entrance and exit areas, as well as in the adjacent holding area, were recorded continuously for 14 d. Cows receiving a "no-milking" decision (i.e., cow is rejected from the milking stall due to a recent milking event) took longer to exit the milking stall (18.2±1.33 s), and were more likely to circle and re-enter the AMS (0.8±0.15) compared with cows receiving a milking decision (16.2±1.09 s; 0.2±0.03). Cows exiting the AMS hesitated for long periods when another cow was near the exit gate (192.93±1.11 s) or in the general holding area (101.04±1.07 s). Cows in late lactation had a greater probability of hesitating in the exit alley for long periods (0.55±0.09) compared with cows in early lactation (0.15±0.07), regardless of whether cows were in the holding area. Primiparous cows were more likely to block other cows trying to exit (0.60±0.13) compared with multiparous cows (0.29±0.09). Occasionally, blocking events led to "back-up" events, in which the AMS became unavailable for new cow access due to a back up of cows through the exit alley into the milking stall. The AMS was empty (not occupied) for 10 and 18% (groups 1 and 2, respectively) of the day; therefore, it was possible that back-up events would simply reduce the amount of time the AMS was empty. The duration of back-up events and AMS empty events had a negative relationship in group 1 (r=-0.74), but no such relationship was observed in group 2. The differences in time budgets between the 2 groups suggest that the effect of back-up events on AMS availability may be dependent on group social dynamics.

Invited review: The impact of automatic milking systems on dairy cow management, behavior, health, and welfare.

Over the last 100 yr, the dairy industry has incorporated technology to maximize yield and profit. Pressure to maximize efficiency and lower inputs has resulted in novel approaches to managing and milking dairy herds, including implementation of automatic milking systems (AMS) to reduce labor associated with milking. Although AMS have been used for almost 20 yr in Europe, they have only recently become more popular in North America. Automatic milking systems have the potential to increase milk production by up to 12%, decrease labor by as much as 18%, and simultaneously improve dairy cow welfare by allowing cows to choose when to be milked. However, producers using AMS may not fully realize these anticipated benefits for a variety of reasons. For example, producers may not see a reduction in labor because some cows do not milk voluntarily or because they have not fully or efficiently incorporated the AMS into their management routines. Following the introduction of AMS on the market in the 1990s, research has been conducted examining AMS systems versus conventional parlors focusing primarily on cow health, milk yield, and milk quality, as well as on some of the economic and social factors related to AMS adoption. Additionally, because AMS rely on cows milking themselves voluntarily, research has also been conducted on the behavior of cows in AMS facilities, with particular attention paid to cow traffic around AMS, cow use of AMS, and cows' motivation to enter the milking stall. However, the sometimes contradictory findings resulting from different studies on the same aspect of AMS suggest that differences in management and farm-level variables may be more important to AMS efficiency and milk production than features of the milking system itself. Furthermore, some of the recommendations that have been made regarding AMS facility design and management should be scientifically tested to demonstrate their validity, as not all may work as intended. As updated AMS designs, such as the automatic rotary milking parlor, continue to be introduced to the dairy industry, research must continue to be conducted on AMS to understand the causes and consequences of differences between milking systems as well as the impacts of the different facilities and management systems that surround them on dairy cow behavior, health, and welfare.

Inappropriate drug donations: what has happened since the 1999 WHO guidelines?

CONTEXT: Drug donations to developing countries may be part of medical relief operations in acute emergencies, development aid in non-emergency situations, or a corporate donations programme. After a number of documented inappropriate drug donations, the World Health Organization developed the 'Guidelines for Drug Donations', with the second and final version published in 1999. OBJECTIVES: We reviewed the medical literature on drug donations since the Guidelines publication in 1999. DESIGN: Literature was retrieved from PubMed and other on-line databases as well as from relevant websites providing medical literature for use in developing countries. We considered the following donations to be inappropriate: (i) essential drugs in excessive quantities; (ii) mixed unused drugs (unsorted medicines and free samples); and (iii) drug dumping (large quantities of useless medicines). RESULTS: We retrieved 25 publications dated after 1999, including 20 and 5 from the scientific literature and 'grey' literature (technical reports, working papers), respectively. New information concerned emergencies in East Timor, Mozambique, El Salvador, Gujarat State (India), Aceh (Indonesia) and Sri Lanka. Except for East Timor and Gujarat, inappropriate donations still occurred, accounting for 85%, 37%, 70% and 80% of donations in Mozambique, El Salvador, Aceh and Sri Lanka, respectively. Very little information was found on drug donations in non-emergency situations. CONCLUSION: There are few recent reports on the compliance of drug donations with the World Health Organization guidelines. For emergency situations, there is still room for improvement. Drug donations in non-emergency situations need to be evaluated. A reform of drug donations policy is needed.

Effect of synbiotics on thyroid hormones, intestinal histomorphology, and heat shock protein 70 expression in broiler chickens reared under cyclic heat stress.

This study examined effect of a dietary synbiotic supplement on the concentrations of plasma thyroid hormones, expressions of heat shock protein 70 (HSP70), and intestinal histomorphology in broiler chickens exposed to cyclic heat stress (HS). Three hundred and sixty day old male Ross 708 broiler chicks were randomly distributed among 3 dietary treatments containing a synbiotic (PoultryStar meUS) at 0 (control), 0.5 (0.5×), and 1.0 (1.0×) g/kg. Each treatment contained 8 replicates of 15 birds each housed in floor pens in a temperature and lighting controlled room. Heat stimulation was established from days 15 to 42 at 32°C for 9 h daily. The results indicated that under the HS condition, both synbiotic fed groups had lower liver and hypothalamus HSP70 levels (P < 0.001) compared to control group; however, HSP70 mRNA expression was not different among treatments (P > 0.05). There were no treatment effects on the levels of triiodothyronine (T3) and thyroxine (T4) as well as T3/T4 ratio (P > 0.05). Compared to controls, 1.0× HS broilers had greater villus height in the duodenum (P < 0.01), and greater villus height and villus height:crypt depth ratios in the ileum (P < 0.01). There were no differences among treatments on the measured intestinal parameters in the jejunum (P > 0.05). The results suggest that the synbiotic may ameliorate the negative effects of HS on chicken health as indicated by the changes in the intestinal architecture and the levels of HSP70. Dietary synbiotic supplement could be a feasible nutritive strategy for the poultry industry to improve the health and welfare of chickens when exposed to hot environmental temperature.

Effect of a synbiotic supplement on cecal microbial ecology, antioxidant status, and immune response of broiler chickens reared under heat stress.

The aim of this study was to examine the effect of a dietary synbiotic supplement on the cecal microflora, antioxidant status, and immune response of broiler chickens under heat stress (HS). A total of 360 one-day-old male Ross 708 broiler chicks were randomly distributed among 3 dietary treatments containing a synbiotic (PoultryStar consists of Bifidobacterium animalis, Enterococcus faecium, Lactobacillus reuteri, Pediococcus acidilactici, and fructooligosaccharides) at 0 (control), 0.5 (0.5X), and 1.0 (1.0X) g/kg. Each treatment contained 8 replicates of 15 birds each housed in floor pens. Heat stimulation was at 32°C for 9 h daily from day 15 to 42. Heat stress-induced changes of cecal bacteria were detected using bacteria-specific agars, and spleen protein concentration and mRNA expression of interleukins and antioxidants were examined using ELISA and real-time PCR, respectively. Under the HS condition, synbiotic fed broilers regardless of dose had lower cecal enumerations of Escherichia coli and coliforms, and a lower heterophil/lymphocyte (H/L) ratio (P < 0.05) compared to controls. 1.0X group also had higher cecal enumerations of Bifidobacterium spp. and Lactobacillus spp., spleen glutathione peroxidase (GPx), and plasma nuclear factor erythroid 2-related factor 2 (Nrf-2), and a lower H/L ratio compared to both control and 0.5X groups (P < 0.05). However, there were no treatment effects on the levels of Enterococcus spp., the circulating monocytes, eosinophils, and basophils, Toll like receptor-4 (TLR-4), interleukin-6 (IL-6), interlukin-10 (IL-10), and their mRNA expression, as well as plasma Kelch-like ECH-associated protein 1 (Keap-1) (P > 0.05). These results suggest that the synbiotic could inhibit the negative effects of HS on broiler health through the reduction of cecal pathogens, regulation of stress reactions, and improvement of antioxidant status.

Effect of dietary synbiotic supplement on behavioral patterns and growth performance of broiler chickens reared under heat stress.

This study examined the effects of a dietary synbiotic supplement on the behavioral patterns and growth performance of broiler chickens exposed to heat stress (HS). Three hundred sixty 1-day-old male Ross 708 broiler chicks were distributed among 24 floor pens (15 chicks per pen); each pen was randomly assigned to one of 3 dietary treatments containing a synbiotic at 0 (control), 0.5 (0.5X) and 1.0 (1.0X) g/kg. From d 15 to 42, birds were exposed to HS at 32°C daily from 08:00 to 17:00. Five broiler chickens were randomly marked in each pen for behavioral observation. Instantaneous scan sampling was used to record the birds' behavioral patterns. Performance parameters were measured on d 7, 14, 28 and 42. The synbiotic fed birds exhibited more standing, sitting, walking, feeding, preening and less wing spreading and panting behaviors (P < 0.05) compared to birds fed the control diet. The synbiotic group also had higher BW, BW gain and feed intake on d 7, 14 and 42 (P < 0.05), and higher BW, feed intake and feed conversion ratio at d 28 (P < 0.01). There were no treatment effects on drinking behavior, BW gain on d 28 and feed conversion ratio on d 42 (P > 0.05). There were few dose-related differences of the synbiotic on production performance; namely, the 1.0X concentration resulted in the highest BW and feed intake on d 14 and 42 (P < 0.05), while BW gain was higher compared to the control group only on d 42 (P < 0.05). The results suggest that the synbiotic supplement may prove to be an important management tool for the broiler industry to diminish the negative effects of HS, potentially safeguarding the welfare and production of broiler chickens, particularly in areas that experience hot climates.

Tinea incognito due to Trichophytom rubrum after local steroid therapy.

The term "tinea incognito" refers to dermatophyte infections with clinical presentations that have been modified by the administration of corticosteroids. We describe a patient who had pustular inflammatory skin lesions due to Trichophyton rubrum after receiving treatment with potent topical corticosteroid creams.

Correlation of leukocyte esterase detection by reagent strips and the presence of neutrophils: a study in BAL fluid.

STUDY OBJECTIVE: In the present study, we evaluated the leukocyte esterase (LE) area of a reagent strip designed for urinalysis for the semiquantitative measurement of the percentage of polymorphonuclear neutrophils (PMNs) in BAL fluid. DESIGN: Prospective. The relative PMN counts (obtained by conventional microscopy and expressed as a percentage of a 500 cell count) of consecutive BAL fluid samples were compared with the corresponding LE categories as read with a urine chemistry reader. LE categories were graded as follows: negative, trace, +, + +, and + + +. RESULTS: A total of 153 BAL fluid samples were included. The mean PMN counts of the negative LE category (4.1 +/- 4.3%; n = 43) and the + + + category (81.8 +/- 16.3%; n = 37) differed significantly from each other and from the mean PMN counts of the other categories. Within the trace, +, and + + categories, a considerable overlap of PMN counts was noted. Assignment of a BAL fluid to the negative LE category consistently predicted a PMN count < 20%. At a threshold value of 50% PMNs, the + + + LE category predicted the BAL fluid samples to the correct group (PMNs > 50% vs < 50%) with a sensitivity of 70.8% and a specificity of 97.1%. CONCLUSIONS: The reagent strips proved to be useful as a rapid test for semiquantitative measurement of the relative PMN counts in BAL fluid. However, the low predictive value for the exclusion of a high PMN count may limit their application.

Streptococcus anginosus, Streptococcus constellatus and Streptococcus intermedius. Clinical relevance, hemolytic and serologic characteristics.

A collection of 518 "Streptococcus milleri" isolates recovered from clinical specimens was identified to the species level according to recently established criteria. Streptococcus anginosus was the most frequently isolated species (59.3%), followed by S constellatus (30.3%) and S intermedius (10.4%). One third (34%) of all isolates were beta-hemolytic. The majority of S anginosus isolates were nonhemolytic, carried Lancefield group F, or were nongroupable. Most of the S constellatus isolates were beta-hemolytic, as well as 16.6% of S intermedius strains. Streptococcus anginosus was recovered more often from the genital and urinary tracts and S constellatus was recovered from the thorax. Streptococcus intermedius was mostly found in the head and neck area, but was also isolated from the abdomen and the skin, bone, and soft tissue. Streptococcus intermedius and nonhemolytic isolates were recovered most often from abscess-related specimens.

Pooling of sera for human immunodeficiency virus (HIV) testing: an economical method for use in developing countries.

To determine whether donated blood samples in African countries could be pooled, then tested for the presence of human immunodeficiency virus (HIV) antibodies with a single test without loss of accuracy, a single test on five pooled samples was used, followed by individual testing of positive pools. This resulted in no loss of either sensitivity or specificity. Pooling 10 samples resulted in a loss of sensitivity for low antibody titre specimens. Pooling reduced the costs of screening by 70% and time needed for analysis. It is concluded that pooling of five samples for HIV screening may result in a substantial reduction in costs; in countries where the prevalence of HIV is higher than the 2-3% found in Zimbabwean donors, however, savings may not be as great.

PIP: The pooling of donated blood samples, followed by a single test for the presence of human immunodeficiency virus (HIV), has the potential of saving both time and money in developing countries; however, it is essential that such a procedure not compromise accuracy. To evaluate this possibility, a single test on 5 pooled samples from Zimbabwe was used, followed by individual testing of positive pools. This exercise was performed on 440 sera, or 88 pools of 5 and 44 pools of 10 sera. 17 positive results were identified through the individual testing of all sera. All 17 positive sera were also identified in the pools of 5, but 2 specimens were missed in the pools of 10 due to the loss of sensitivity for low antibody titer specimens. In addition to reducing the time needed for laboratory analysis, pooling reduces the costs of screening by 5% in settings where seroprevalence is 15% and by 70% when seroprevalence is 2%. In Zimbabwe, the cost of screening kits with this technique is 1/3 of what it would be if sera were tested individually. In general, the technique of pooling 5 sera seems cost-effective only when the prevalence of HIV seropositivity is 10% or less. The ability to declare specimens seronegative in lots of 5 also reduces the time that must be spent on record keeping as well as screening.

Viridans streptococci isolated from the bloodstream. Relevance of species identification.

Over a 4-year-period, 104 isolates belonging to the viridans streptococci were recovered from the blood and identified to the species according to Beighton and co-workers. Streptococcus oralis was the species most frequently recovered from patients in the hematology unit [29 of 39 (74%)]. Streptococcus mitis ranked second [seven of 39 (18%)]. Both species were associated with oromucositis. Isolates presently identified as S. oralis are mainly those previously identified as S. mitis or Streptococcus sanguis II. Streptococcus milleri was most frequently isolated in the patients from the general hospital population [28 of 65 (43%) isolates]: Streptococcus anginosus (n = 20), Streptococcus constellatus (n = 4), and Streptococcus intermedius (n = 4). In 14 episodes from the general hospital population, clinical significance was judged questionable. From this part of the laboratory, clinical significance could not be predicted from the number of blood cultures grown, nor from the delay of growth detection. The Rapid ID 32 Strep system agreed well with the identifications according to the scheme of Beighton et al., whereas the API 20 Strep system did not.

Haemolytic activity of the Streptococcus milleri group' and relationship between haemolysis restricted to human red blood cells and pathogenicity in S. intermedius.

A collection of 297 clinically documented 'Streptococcus milleri' strains, identified to the genotype level by 16S rRNA gene hydridisation, was screened for haemolysis of human and animal red blood cells. Forty-nine strains (65%) of the S. intermedius genotype displayed haemolysis restricted to human blood; they were named 'exclusive human haemolytic' (EHH) S. intermedius strains. The 26 remaining S. intermedius strains were named S. intermedius non-EHH strains. Quantitative studies on the haemolysis indicated that intermedilysin was the factor involved. The S. intermedius EHH strains represented the S. intermedius phenotype, whereas the S. intermedius non-EHH strains were phenotypically characteristic of S. constellatus. The complete 16S rRNA sequences of the S. intermedius EHH strains exhibited identity with S. intermedius strains ATCC 27335 (= NCDO 2227, NCTC 11324); the 16S rRNA sequences of the S. intermedius non-EHH strains were identical to S. constellatus strain ATCC 27823 (= NCDO 2226, NCTC 11325) except for positions 228 and 229 that carried an S. intermedius sequence signature. The 16S sequence similarities between the non-EHH strains and the S. constellatus and the S. intermedius type strains were 99.5% and 98.6%, respectively. Hybridisations of the complete 16S rRNA genes with oligonucleotide probes indicated a 16S rRNA homogeneity within the S. intermedius EHH and the non-EHH strains respectively. The S. intermedius EHH strains were isolated most frequently from infection- and abscess-related specimens. The present data emphasise the genetic variability within the S. constellatus species and redefine the S. intermedius species as a homogeneous group at the 16S rRNA level.

Agglutination of "Streptococcus milleri" by lectins.

The agglutination of 218 clinical isolates and three ATCC type strains of "Streptococcus milleri" was tested with 25 different lectins from plants and fungi. An agglutination reaction with one or more lectins was observed with 42 isolates when the cells were untreated. After trypsinisation of the bacteria, 109 strains yielded a positive reaction and after boiling the bacterial cells at pH2, 218 isolates were agglutinated. As an overall result of our experiments with untreated, trypsinised and boiled cells, 17, 37 and 45 different agglutination patterns, respectively, were obtained. The lectins from Datura stramonium, Robinia pseudoacacia and Dolichos biflorus agglutinated isolates belonging only to Lancefield group C, being non-reactive with other isolates. These lectins were also found to be specific for "large colony type" streptococci of group C. The use of lectin agglutination in epidemiological and ecological studies of "S. milleri" is discussed.

The agglutination of beta-haemolytic streptococci by lectins.

The ability of 25 lectins, isolated from different plants and fungi, to agglutinate 95 clinical isolates of beta-haemolytic streptococci was examined. Cell suspensions were untreated, trypsin-treated or boiled at pH 2.0. None of the 95 untreated cell suspensions gave a visible reaction with any of the lectins. When the cells were trypsinised, 42 strains were agglutinated with one or more lectin and after boiling at pH 2, all the strains were agglutinated. After treatment with trypsin, 20 different agglutination patterns were observed, and after boiling, 19 patterns, four of which were similar. A correlation was found between Lancefield group C and some of these patterns. Some lectins reacted specifically with group C streptococci; DBA and WFA, both specific for D-GalNAc, DSA, a GlcNAc-specific lectin, and RPA, which showed a complex specificity, reacted only with group C strains. Furthermore, the lectin of Maackia amurensis reacted with 50% of group B streptococci only. Agglutination assays with lectins were reproducible, easy to perform, relatively inexpensive and, therefore, applicable to studies of cell-wall structure and epidemiology of beta-haemolytic streptococci.

Infection due to a contaminated thoracic drainage system.

Infection and colonization of the pleural space in three patients was traced to contaminated thoracic drain equipment. The organisms implicated were Bacillus cereus, Staphylococcus aureus and various non-fermenting Gram-negative bacteria. A careful examination of cleaning and decontamination procedures revealed delay in replacing the drainage bottle jar to be the main factor responsible for the contamination of the drainage unit and the pleural space. Recent technical adaptation of the drainage apparatus had removed the need for daily changing of this jar. These findings confirm that thoracic drainage systems may be a potential source of contamination for the patient. We emphasize that technical improvements to existing operating apparatus should necessitate the adaptation of recommendations governing their use in accordance with approved hospital hygiene standards.

Do endocrines play an etiological role in diabetic and nondiabetic sexual dysfunctions?

Sexually dysfunctional diabetic and nondiabetic males were compared with a group of normal controls using different endocrinological, psychophysiological, and psychological parameters. One hundred male subjects participated in this study: 47 diabetics with sexual dysfunction (DD), 31 nondiabetics with sexual dysfunction (NDD), and 22 normal controls (C). They were evaluated by an internist (physical examination and medical history), a psychologist (psychological and sexual functioning tests), a psychiatrist (psychiatric history and mental status examination), a urologist (genitourinary physical examination), and an endocrine biochemist (evaluation of endocrine factors). Additionally, subjects were evaluated for nocturnal penile tumescence (NPT) during three nights in the sleep laboratory to obtain a differential diagnosis of impotence, that is, psychogenic vs. organic. Both sexually dysfunctional groups showed significant differences on several measures in the psychological and psychophysiological evaluations. There were also significant differences between these two groups and the control group. Plasma levels of total testosterone and serum levels of prolactin, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) showed no significant differences among the three groups, but there were some significant correlations between the endocrine and psychological measures. No significant correlations were found between the endocrine and psychophysiological measures.