Immunodeficiencies, pathogens and sex in upper respiratory diseases

In the first part of this thesis the association of different forms of sinonasal diseases and plasma concentrations of C3, C4, immunoglobulins, immunoglobulin G subclasses, C4A and C4B gene numbers were studied in 287 adult patients and 150 sex-matched adult controls. Patients were well characterized and stratified into groups using strict clinical criteria and females and males were also studied as separate groups. Severe primary antibody antibody deficiencies were rare in patients coming to sinonasal operations. Female patients had more recurrent sinusitis and other mucosal infections and males had more nasal polyposis. Upregulation of complement activity was seen in acute rhinosinusitis patients (high levels of plasma C3, C4, and complement classical pathway activity CH50) and male patients coming to sinonasal operations (high levels of plasma C3 and C4). In females, total and partial C4B deficiencies and lower levels of IgG1 and IgG3 were associated with rhinosinusitis leading to sinonasal operations. C4A deficiencies were found to predispose to severe chronic rhinosinusitis in females and males. In female patients with chronic or recurrent rhinosinusitis with nasal polyposis C4B deficiencies seem to predispose to the disease, but in males with a similar disease C4B deficiencies seem to be protective. This suggests a different pathophysiology between sexes in this form of sinonasal disease. In the second part of this thesis work 213 children coming to elective tonsillectomy were studied and compared with 155 randomly selected school children. An association with recurrent upper respiratory tract infections and hypersensitivity disorders was seen especially in children under 7 years of age. However, this association was not seen in levels of specific IgE to respiratory allergens in the same age group. Both symptomatic respiratory allergy and specific IgE to respiratory allergens became more common in boys than girls over 7 years of age. We were able to show that although both rhinoviruses and bacterial pathogens were found in the tonsils, no association between their presence and clinical forms of tonsillar disease was seen. The ability of GAS to bind complement regulators FH and C4BP did not differ between strains causing tonsillar diseases or septicemia, suggesting that other virulence mechanisms of the bacteria are more important.

Probiotics and prebiotics in the primary prevention of allergic diseases

The rapid increase in allergic diseases in developed, high-income countries during recent decades is attributed to several changes in the environment such as urbanization and improved hygiene. This relative lack of microbial stimulation is connected to a delay in maturation of the infantile immune system and seems to predispose especially genetically prone infants to allergic diseases. Probiotics, which are live ingestible health-promoting microbes, may compensate for the lack of microbial stimulation of the developing gut immune system and may thus be beneficial in prevention of allergies. Prebiotics, which are indigestible nutrients by us, promote the growth and activity of a number of bacterial strains considered beneficial for the gut. In a large cohort of 1 223 infants at hereditary risk for allergies we studied in a double-blind placebo-controlled manner whether probiotics administered in early life prevent allergic diseases from developing. We also evaluated their safety and their effects on common childhood infections, vaccine antibody responses, and intestinal immune markers. Pregnant mothers used a mixture of four probiotic bacteria or a placebo, from their 36th week of gestation. Their infants received the same probiotics plus prebiotic galacto-oligosaccharides for 6 months. The 2-year follow-up consisted of clinical examinations and allergy tests, fecal and blood sampling, and regular questionnaires. Among the 925 infants participating in the 2-year follow-up the cumulative incidence of any allergic disease (food allergy, eczema, asthma, rhinitis) was comparable in the probiotic (32%) and the placebo (35%) group. However, eczema, which was the most common manifestation (88%) of all allergic diseases, occurred less frequently in the probiotic (26%) than in the placebo group (32%). The preventive effect was more pronounced against atopic (IgE-associated) eczema which, of all atopic diseases, accounted for 92%. The relative risk reduction of eczema was 26% and of atopic eczema 34%. To prevent one case of eczema, the number of mother-infant pairs needed to treat was 16. Probiotic treatment was safe without any undesirable outcome for neonatal morbidity, feeding-related behavior, serious adverse events, growth, or for vaccine-induced antibody responses. Fewer infants in the probiotic than in the placebo group received antibiotics during their first 6 months of life and thereafter to age 2 years suffered from fewer respiratory tract infections. As a novel finding, we discovered that high fecal immunoglobulin A (IgA) concentrations at age 6 months associated with reduced risk for atopic (IgE-associated) diseases by age 2 years. In conclusion, although feeding probiotics to high-risk newborn infants showed no preventive effect on the cumulative incidence of any allergic diseases by age 2, they apparently prevented eczema. This probiotic effect was more pronounced among IgE-sensitized infants. The treatment was safe and seemed to stimulate maturation of the immune system as indicated by increased resistance to respiratory infections and improved vaccine antibody responses.

Childhood otitis media - risk factors and surgical management

Background: Otitis media (OM) is one of the most common childhood diseases. Approximately every third child suffers from recurrent acute otitis media (RAOM), and 5% of all children have persistent middle ear effusion for months during their childhood. Despite numerous studies on the prevention and treatment of OM during the past decades, its management remains challenging and controversial. In this study, the effect of adenoidectomy on the risk for OM, the potential risk factors influencing the development of OM and the frequency of asthma among otitis-prone children were investigated. Subjects and methods: One prospective randomized trial and two retrospective studies were conducted. In the prospective trial, 217 children with RAOM or chronic otitis media with effusion (COME) were randomized to have tympanostomy with or without adenoidectomy. The age of the children at recruitment was between 1 and 4 years. RAOM was defined as having at least 3 episodes of AOM during the last 6 months or at least 5 episodes of AOM during the last 12 months. COME was defined as having persistent middle ear effusion for 2-3 months. The children were followed up for one year. In the first retrospective study, the frequency of childhood infections and allergy was evaluated by a questionnaire among 819 individuals. In the second retrospective study, data of asthma diagnosis were analysed from hospital discharge records of 1616 children who underwent adenoidectomy or had probing of the nasolacrimal duct. Results: In the prospective randomized study, adenoidectomy had no beneficial effect on the prevention of subsequent episodes of AOM. Parental smoking was found to be a significant risk factor for OM even after the insertion of tympanostomy tubes. The frequencies of exposure to tobacco smoke and day-care attendance at the time of randomization were similar among children with RAOM and COME. However, the frequencies of allergy to animal dust and pollen and parental asthma were lower among children with COME than those with RAOM. The questionnaire survey and the hospital discharge data revealed that children who had frequent episodes of OM had an increased risk for asthma. Conclusions: The first surgical intervention to treat an otitis-prone child younger than 4 years should not include adenoidectomy. Interventions to stop parental smoking could significantly reduce the risk for childhood RAOM. Whether an otitis-prone child develops COME or RAOM, seems to be influenced by genetic predisposition more strongly than by environmental risk factors. Children who suffer from repeated upper respiratory tract infections, like OM, may be at increased risk for developing asthma.

2,1,3-Bentsoksadiatsolirakenteiset molekyylit antibakteerisina ja antiparasiittisina yhdisteinä

Aikaisemman tutkimuksen perusteella tiedettiin tiettyjen 2,1,3-bentsoksadiatsolirakenteisten molekyylien olevan aktiivisia Chlamydia pneumoniae –bakteeria vastaan. Tutkimusta lähdettiin jatkamaan ja 2,1,3-bentsoksadiatsolimolekyylien rakenne-aktiivisuusuhteista haluttiin saada lisätietoa. Tarkoituksena oli kehittää 2,1,3-bentsoksadiatsolimolekyyleille ja sen avulla muodostaa molekyylikirjasto. Syntetisoidut molekyylit haluttiin testata sekä Chlamydia pneumoniae -bakteeria että Leishmania donovani –parasiittia vastaan. Chlamydia pneumoniae –bakteeri aiheuttaa akuutteja ylä- ja alahengitystieinfektiota, kuten keuhkoputkentulehdusta. Akuutissa tulehduksessa oireet vaihtelevat huomattavasti. Chlamydia pneumoniae –bakteerilla on myös taipumus aiheuttaa kroonisia tulehduksia. Nämä ovat useissa tutkimuksissa yhdistetty kansantaloudellisesti merkittäviin sairauksiin, kuten ateroskleroosiin ja astmaan. Leishmanioosi on toiseksi yleisin loissairaus ihmisellä malarian jälkeen. Leishmania donovani –parasiitti voi aiheuttaa tappavaa viskeraalista leishmanioosia. Vuodessa leishmanioosiin kuolee yli 50 000 ihmistä. Viime vuosina leishmanioosin lääkehoidossa on esiintynyt monenlaisia ongelmia. Osat lääkkeistä ovat menettäneet tehonsa ja osalla esiintyy vakavia haittavaikutuksia. 2,1,3-Bentsoksadiatsolirakenteisille yhdisteille saatiin kehitettyä toimiva synteesireitti. Lähtöaineena käytettiin 4-amino-2-nitrobentsoehappoa, josta saatiin hapettavalla renkaansulkeutumisreaktiolla 2,1,3-bentsoksadiatsoli-5-karboksyylihappoa. Karboksyylihaposta syntetisoitiin amidi-välituotteen kautta 2,1,3-bentsoksadiatsoli-5-karbonitriiliä. Hydroksyyliamiini hydrokloridin avulla 2,1,3-bentsoksadiatsoli-5-karbonitriilistä muodostettiin vastaavaa karboksimidamidia, joka oli synteesireitin yhteinen välituote kaikille molekyyleille. Viimeisessä vaiheessa N´-hydroksidi-2,1,3-bentsoksadiatsoli-5-karboksimidamidin annettiin reagoida joko fenyyli-isosyanaatin tai fenyyli-isotiosyanaatin kanssa, jolloin saatiin lopputuotetta. Synteesireitin kehittäminen osoittautui haastavaksi ja loppujen lopuksi saatiin ainoastaan kolme lopputuotetta syntetisoitua. Yksi lopputuotteista testattiin C. pneumoniae –bakteeria vastaan Åbo akademissa Turussa. Testattavaa yhdiste ei sisältänyt 2,1,3-bentsoksadiatsoliarengasta ja bioaktiivisuuskokeen tulos oli odotusten mukainen. Yhdiste ei ollut aktiivinen C. pneumoniae –bakteeria vastaan alhaisilla konsentraatioilla ja tuloksesta voitiin todeta 2,1,3-bentsoksadiatsolirengaan olevan tärkeä aktiivisuuden kannalta. Kaksi lopputuotetta saatiin testaukseen Leishamania donovani –parasiittia vastaan Israeliin. Ainoastaan toinen molekyyleistä sisälsi 2,1,3-bentsoksadiatsolirakenteen. Bioaktiivisuuskokeiden tulokset olivat erittäin rohkaisevia. Yhdisteet olivat aktiivisia parasiittia vastaan jo alhaisilla konsentraatioilla. Kuitenkin 2,1,3-bentsoksadiatsolirakenteinen molekyyli oli aktiivisempi, joten tämäkin aktiivisuuskokeen perusteella huomattiin rengasrakenteen olevan tärkeä aktiivisuuden kannalta.

Excreção urinária de glicosaminoglicanos em crianças com bexiga neurogênica secundária a mielomeningocele

A excreção urinária de glicosaminoglicanos (GAG) está alterada em várias patologias do trato urinário; o padrão de excreção pode estar associado com o estado da doença. A excreção urinária de GAG em crianças com bexiga neurogênica (BN) secundária a mielomeningocele (MMC) pode também estar alterada, mas até a presente data não há detalhamento epidemiológico dos pacientes e não se correlacionou o padrão de excreção com grau de disfunção vesical. Analisamos a excreção urinária de um grupo bem definido de crianças com MMC e correlacionamos os resultados com escore cistométrico. As amostras de urina de 17 pacientes com MMC, 10 meninos e 7 meninas (média de idade DP de 4,6 2,9 anos) foram obtidas durante o exame cistométrico. As amostras do grupo controle foram obtidas de 18 crianças normais, 13 meninos e 5 meninas (6,9 2,2 anos). Todas as crianças não estavam com infecção urinária, tinham função renal normal e não estavam sob tratamento farmacológico. A quantificação do GAG urinário total foi expressa em μg de ácido hexurônico / mg de creatinina e a proporção dos diferentes tipos de GAGs sulfatados foi obtida por eletroforese em gel de agarose. A avaliação cistométrica foi realizada utilizando aparelho de urodinâmica Dynapack modelo MPX816 (Dynamed, São Paulo, Brasil), a partir da qual o escore cistométrico foi calculado de acordo com procedimento recente publicado. [14]. Não observamos diferença significativa na excreção urinária de GAG total entre meninos e meninas tanto no grupo com MMC ( 0,913 0,528 vs 0,867 0,434, p>0,05) como no grupo controle (0,546 0,240 vs 0,699 0,296, p>0,05). Os resultados mostraram também que a excreção de GAG urinário não se correlacionou com a idade tanto no grupo com MMC ( r = -0,28, p> 0,05) como no grupo controle (r = -0,40, p> 0,05). Entretanto, a comparação dos dois grupos mostrou que o grupo com MMC excretava 52% a mais de GAG total que o grupo controle (0,894 0,477 vs 0,588 0,257, p <0,04). Nesses pacientes a excreção de GAG total não se correlacionou com a complacência vesical isoladamente (r = -0,18, p> 0,05) mas foi significativa e negativamente correlacionada ao escore cistométrico (r= -0,56, p<0,05). Em média, os pacientes com piores escores (<9) excretaram 81% a mais de GAG que os pacientes com melhor escore (>9) (1,157 0,467 vs 0,639 0,133, p<0,04). O sulfato de condroitin foi o GAG sulfatado predominante nos grupos neurogênico e controles (92,5 7,6% vs 96,4 4,8%, respectivamente, p> 0,05), enquanto o sulfato do heparan estava presente em quantidades marcadamente menores; o dermatam sulfato não foi detectado. A excreção urinária de GAG em pacientes com MMC é significativamente maior que a excreção das crianças normais e os altos valores encontrados estão correlacionados a um maior compromentimento da função vesical. Evidências em modelos animais com MMC induzida sugerem que alterações no detrusor estão associadas a um elevado turnover da matriz extra celular (MEC) vesical, o que pode explicar a elevada excreção de GAG nos pacientes com MMC. Além disso, esses resultados indicam que a excreção urinária de GAG pode ser usada como fator adjuvante para a caracterização da disfunção vesical em pacientes com MMC.

Estudo quantitativo da matriz extracelular e células do músculo liso de bexigas urinária após traumatismo raquimedular

Lesões na inervação do trato urinário inferior ocasionado por traumatismo raquimedular afetam geralmente o músculo detrusor e o esfíncteres uretrais. Estas alterações acarretam problemas basicamente de incontinência urinária e aumento da pressão intravesical, decorrente deste traumatismo, trazendo consequências para o funcionamento do sistema urinário superior. Quantificar os elementos fibrosos da matriz extracelular e fibras musculares das bexigas neurogênicas hiper-reflexas comparando-as com bexigas normais. Foram utilizadas 6 amostras de bexigas neurogênicas de indivíduos que foram submetidos a cirurgia de reparação por cistoenteroplastia realizados pelo serviço de urologia do Hospital Municipal Souza Aguiar, estas amostras foram fixadas imediatamente em solução tamponada de formalina a 10%. O controle com amostras iguais as do estudo extraída de cadáveres cuja causa morte não relacionava-se ao sistema urogenital macroscópicamente. O material foi submetido as seguintes técnicas histoquímicas: H&E, van Gieson e Resorcina Fucsina resorcina de Weigert com prévia oxidação pela oxona. Imunohistoquímica: anti-elastina. A observação dos cortes corados pelo van Gieson demonstrou uma diminuição significativa do músculo liso de 13% e aumento do colágeno em 72% e as fibras do sistema elástico um aumento de 101%. Conclusão. Nas bexigas neurogênicas hiper-reflexas o músculo detrusor e os elementos fibrosos da matriz foram profundamente modificados. As fibras do sistema elástico foram as mais afetadas.

Correlação entre a espessura da parede vesical e os achados urodinâmicos em pacientes com lesão medular traumática. Avaliação da influência das alterações morfológicas da bexiga nos resultados da injeção de toxina botulínica tipo-A no detrusor

Medir a espessura da parede vesical (EPV) através da ultrassonografia, correlacioná-la com os parâmetros urodinâmicos e avaliar o papel destes parâmetros para lesão do trato urinário superior. Avaliar também o papel das alterações da forma da bexiga nos resultados de injeção de toxina botulínica tipo-A (BTX-A) no detrusor em pacientes com lesão medular traumática (LMT). Trata-se de dois estudos. O primeiro é um estudo transversal de 272 pacientes com LMT submetidos à ultrassonografia renal e de bexiga e estudo urodinâmico. A parede anterior da bexiga foi medida e comparada com os dados urodinâmicos. A cistografia foi realizada em 57 pacientes. O segundo foi um estudo prospectivo avaliando os resultados da injeção de BTX-A no detrusor em 27 pacientes considerando os achados urodinâmicos (pré e pós procedimento) e as deformidades da bexiga (cistografia). A média da EPV foi de 3,94 mm e foi estatisticamente maior em pacientes com hiperatividade detrusora neurogênica associada à dissinergia vesicoesfincteriana (HDN/DVE), em comparação com aqueles sem DVE (p<0,001). Essa média também foi maior em pacientes com complacência < 20 mL/cmH2O, comparada aos pacientes com complacência ≥ 20 mL/cmH2O (p<0,001). A média da pressão detrusora máxima (Pdet Max) foi estatisticamente maior nos pacientes com refluxo vesicoureteral (RVU) em comparação com aqueles sem RVU (100,7 vs 61,2 cmH2O respectivamente, p=0,022). Pacientes com complacência < 20 mL/cmH2O apresentaram prevalência de hidronefrose 4,2 vezes maior, comparada aos pacientes com complacência ≥ 20 mL/cmH2O. Não houve associação estatística entre EPV e hidronefrose ou RVU. Vinte e sete pacientes foram submetidos à injeção de BTX-A no detrusor. A média de tempo de continência urinária foi de 8 meses. Nove pacientes (33,3%) tinham forma vesical alterada e 8 casos (29,6%) tinham divertículos. A capacidade cistométrica máxima, Pdet max, volume reflexo e complacência não apresentaram diferença significativa na presença de divertículos ou alteração da forma. O aumento da EPV está associado à complacência < 20 mL/cmH2O e HDN/DVE em pacientes com LMT. No entanto, não houve relação entre a EPV e hidronefrose ou RVU. Baixa complacência e HDN/DVE são os principais fatores de risco para dano ao trato urinário superior. A presença de divertículos ou alteração da forma vesical não influenciou nos resultados após injeção de BTX-A no detrusor.

Estudo do tempo de trânsito colônico em crianças e adolescentes com constipação intestinal crônica e disfunção do trato urinário inferior

A constipação intestinal e a disfunção do trato urinário inferior são condições associadas e bastante prevalentes na infância e adolescência. Existem múltiplas teorias para explicar essa associação, como: o efeito mecânico do reto cheio sobre a parede e o colo vesical; estimulo de reflexos sacrais a partir do reto distendido, e mais recentemente, a associação entre a bexiga e o reto no sistema nervoso central. Muitas destas crianças e adolescentes apresentam constipação refratária. Esse fato chama a atenção para a possibilidade de existência de uma desordem neuromuscular comum envolvendo o cólon e o trato urinário inferior. O objetivo desse estudo foi avaliar o trânsito colônico de crianças e adolescentes com constipação crônica refratária e sintomas do trato urinário inferior. Foi realizado um estudo observacional com análise transversal, no qual foram incluídos 16 indivíduos com constipação refratária e sintomas do trato urinário inferior, com idades entre sete e 14 anos (média de idade de 9,67 anos). Os participantes foram avaliados utilizando anamnese padrão; exame físico; diário miccional e das evacuações; escala de Bristol; Disfunctional Voiding Scoring System com versão validada para o português; ultrassonografia renal, de vias urinárias e medida de diâmetro retal; urodinâmica, estudo de trânsito colônico com marcadores radiopacos e manometria anorretal. O estudo de trânsito foi normal em três (18,75%) crianças, dez (62,5%) apresentaram constipação de trânsito lento e três (18,75%) obstrução de via de saída. A avaliação urodinâmica estava alterada em 14 das 16 crianças estudadas: dez (76,9%) apresentaram hiperatividade detrusora associada à disfunção miccional, três (23,1%) hiperatividade vesical isolada e um (6,25%) disfunção miccional sem hiperatividade vesical. Ao compararmos constipação de trânsito lento e disfunção do trato urinário inferior, dez (100%) sujeitos com constipação de trânsito lento e três (50%) sem constipação de trânsito lento apresentavam hiperatividade vesical (p=0,036). Sete (70%) sujeitos com constipação de trânsito lento e quatro (66,7%) sem constipação de trânsito lento apresentavam disfunção miccional (p=0,65). Ao compararmos constipação de trânsito lento e a presença de incontinência urinária, esta estava presente em nove (90%) participantes com constipação de trânsito lento e em um (16,7%) sem constipação de trânsito lento (p = 0,008). Quanto à urgência urinária, estava presente em 10 (100%) e três (50%) respectivamente (p = 0,036). O escore do Disfunctional Voiding Scoring System variou de 6 a 21. O subgrupo com constipação de trânsito lento mostrou um escore de Disfunctional Voiding Scoring System significativamente maior que o subgrupo sem constipação de trânsito lento. O presente estudo demonstrou alta prevalência de constipação de trânsito lento em crianças e adolescentes com constipação refratária e sintomas do trato urinário inferior. Este estudo foi pioneiro em demonstrar a associação entre hiperatividade vesical e constipação de trânsito lento e coloca em voga a possibilidade de uma desordem neuromuscular comum, responsável pela dismotilidade vesical e colônica. Futuros estudos envolvendo a motilidade intestinal e vesical são necessários para melhor compreensão do tema e desenvolvimento de novas modalidades terapêuticas.

Maternal Effects of Respiratory Syncytial Virus Infection during Pregnancy.

Given the illness and deaths caused by respiratory syncytial virus (RSV) infection during the first year of life, preventing infant RSV infections through maternal vaccination is intriguing. However, little is known about the extent and maternal effects of RSV infection during pregnancy. We describe 3 cases of maternal RSV infection diagnosed at a US center during winter 2014. Case-patient 1 (26 years old, week 33 of gestation) received a diagnosis of RSV infection and required mechanical ventilation. Case-patient 2 (27 years old, week 34 of gestation) received a diagnosis of infection with influenza A(H1N1) virus and RSV and required mechanical ventilation. Case-patient 3 (21 years old, week 32 of gestation) received a diagnosis of group A streptococcus pharyngitis and RSV infection and was monitored as an outpatient. Clarifying the effects of maternal RSV infection could yield valuable insights into potential maternal and fetal benefits of an effective RSV vaccination program.

Evaluation of a poly(vinyl pyrollidone)-coated biomaterial for urological use

The associated problems of bacterial biofilm formation and encrustation that may cause obstruction or blockage of urethral catheters and ureteral stents often hinders the effective use of biomaterials within the urinary tract. In this in vitro study, we have investigated the surface properties of a hydrophilic polyvinyl pyrollidone) (PVP)-coating applied to polyurethane and determined its suitability for use as a urinary tract biomaterial by comparing its lubricity and ability to resist bacterial adherence and encrustation with that of uncoated polyurethane and silicone. The PVP-coated polyurethane was significantly more hydrophilic and more lubricious than either uncoated polyurethane or silicone. Adherence of a hydrophilic Escherichia coli isolate to PVP-coated polyurethane and uncoated polyurethane was similar but significantly less than adherence to silicone. Adherence of a hydrophobic Enterococcus faecalis isolate to PVP-coated polyurethane and silicone was similar but was significantly less than adherence to uncoated polyurethane. Struvite encrustation was similar on the PVP-coated polyurethane and silicone but significantly less than on uncoated polyurethane. Furthermore, hydroxyapatite encrustation was significantly less on the PVP-coated polyurethane than on either uncoated polyurethane or silicone. The results suggest that the PVP-coating could be useful in preventing complications caused by bacterial biofilm formation and the deposition of encrustation on biomaterials implanted in the urinary tract and, therefore, warrants further evaluation. (C) 2002 Elsevier Science Ltd. All rights reserved.

Electrical methods of controlling bacterial adhesion and biofilm on device surfaces.

This review will summarize the significant body of research within the field of electrical methods of controlling the growth of microorganisms. We examine the progress from early work using current to kill bacteria in static fluids to more realistic treatment scenarios such as flow-through systems designed to imitate the human urinary tract. Additionally, the electrical enhancement of biocide and antibiotic efficacy will be examined alongside recent innovations including the biological applications of acoustic energy systems to prevent bacterial surface adherence. Particular attention will be paid to the electrical engineering aspects of previous work, such as electrode composition, quantitative electrical parameters and the conductive medium used. Scrutiny of published systems from an electrical engineering perspective will help to facilitate improved understanding of the methods, devices and mechanisms that have been effective in controlling bacteria, as well as providing insights and strategies to improve the performance of such systems and develop the next generation of antimicrobial bioelectric materials.

COMPARISON OF THE GROWTH INHIBITORY AND BACTERIOCIDAL EFFECTS OF TAUROLIDINE AND TAURULTAM ON A CLINICAL ISOLATE OF ESCHERICHIA-COLI

To investigate the mode of action of Taurolin, an antimicrobial preparation, the growth inhibitory and bacteriocidal effects of taurolidine and taurultam solutions on Escherichia coli isolated from a diagnosed urinary tract infection were examined at 37-degrees-C. The inhibitory effects of taurolidine solutions were observed to be greater than those of taurultam solutions at comparative concentrations; however, the presence of sublethal concentrations of formaldehyde (methylene glycol) associated with taurolidine was sufficient to account for this. The bacteriocidal activity of taurolidine (2.0% w/v) was greater than that of taurultam (4.5% w/v). Both compounds produced biphasic death rates with dissimilar initial slopes, suggested to be due to the presence of formaldehyde in taurolidine solutions. These observations indicate that the growth inhibitory and bacteriocidal effects of Taurolin solutions are primarily due to taurultam, however, the presence of sublethal concentrations of formaldehyde is significant in the expression of this activity.

Chronic cough in children: bronchoalveolar lavage findings

Isolated chronic cough in childhood is a common complaint. Although the symptom cough is included in the definition of clildhood asthma, there is debate as to whether the majoritv of these children have asthma. The authors studied children with isolated chronic cough looking for evidence of airway inflammation typical of asthma, with increased numbers of airway eosinophils as assessed from bronchoalveolar lavage (BAL).

The investigations were carried out on 23 children (median age: 6.7 yrs; range: 1.7-12.75 yrs), attending the Royal Belfast Hospital for Sick Children for elective surgery, who also had a chronic unexplained cough. Written informed consent was obtained from the parent(s) and a nonbronchoscopic BAL was performed. BAL samples were analysed for total and differential white cell counts and also for the inflammatory mediators, eosinophil cationic protein (ECP) and histamine. Results were compared with a group of normal nonatopic children and also a group of atopic asthmatic children, who had been recruited for other studies on airway inflammation.

There was a small but statistically significant increase in BAL percentage eosinophils in the children with chronic cough compared with nonasthmatic controls (0.28% versus 0.10%, p=0.03). However, the children with cough had lower percentage eosinophils than the atopic asthmatic controls (0.28% versus 0.66%, p=0.01). Three out of 23 children with chronic cough had BAL eosinophils greater than the normal upper 95% reference interval in BAL. There was a small but statistically significant increase in percentage neutrophils in the children with cough compared with the nonasthmatic controls (5.85% versus 3.21%, p=0.03). Four out of the 23 children had BAL neutrophils greater than the normal upper 95% reference interval in BAL.

The authors conclude that only a minority of children with chronic unexplained cough have asthmatic-type airway inflammation. It is speculated that the increased percentage neutrophils in bronchoalveolar lavage from children with cough could relate to underlying persistent airways infection.

Use of adhesion counts to help predict symptomatic infection and the ability of fluoroquinolones to penetrate bacterial biofilms on the bladder cells of spinal cord injured patients

There were three objectives to the present study: (1) compare the bladder infection rate and extent of biofilm formation for seven untreated spinal cord injured (SCI) patients and seven given prophylactic co-trimoxazole, (2) identify a level of bacterial adhesion to bladder cells which could be used to help predict symptomatic infection, and (3) determine from in vivo and in vitro studies whether fluoroquinolones were effective at penetrating bacterial biofilms. The results showed that the infection rate had not changed with the introduction of prophylaxis. However, the uropathogenic population had altered subsequent to the introduction of prophylaxis with E. coli being replaced by E. faecalis as the most common cause of infection. In 63% of the specimens from asymptomatic patients, the bacterial counts per cell were <20, while 81% of specimens from patients with at least one sign and one symptom of urinary tract infection (UTI) had > 20 adherent bacteria per bladder cell. Therefore, it is proposed that counts of > 20 bacteria adherent to sediment transitional epithelial bladder cells may be predictive of symptomatic UTI. Clinical data showed that fluoroquinolone therapy reduced the adhesion counts to <20 per cell in 63% of cases, while trimethoprim-sulfamethoxazole only did so in 44%. Further in vitro testing showed that ciprofloxacin (0.1, 0.5 and 1.0 micrograms/ml) partially or completely eradicated adherent biofilms from 92% of spinal cord injured patients' bladder cells, while ofloxacin did so in 71% cases and norfloxacin in 56%. These findings have important implications for the detection and treatment of bacteriuria in spinal cord injured patients.

Which patients with renal colic should be referred?

Around 1-2 people per thousand present with an acute episode of pain caused by renal stones each year. Renal colic is classically sudden in onset, unilateral, and radiates from loin to groin. Renal pelvic or upper ureteric stones usually cause more flank pain and tenderness while lower ureteric stones cause pain radiating towards the ipsilateral testicle or labia. Other common symptoms include nausea and vomiting, haematuria and irritative LUTS. A febrile patient with renal colic requires immediate hospital admission. Symptoms suggestive of renal colic along with a positive dipstick for haematuria have a reported sensitivity of 84% and specificity of 99% but it is important to consider other differential diagnoses. An NSAID is preferred over an opiate drug as an initial analgesic choice as the NSAID can help reduce ureteric spasm. Diclofenac has the best evidence base for this class of analgesic. About 90% of stones will pass spontaneously and thus it is often appropriate to manage renal colic at home. Patients with signs of peritonitis, systemic infection, septic shock as well as those whose diagnosis is unclear should be referred urgently to hospital. Patients who are systemically unwell with renal stones are more likely to have an infected and obstructed urinary tract system that needs urgent imaging and possible drainage. All patients who are managed at home should have renal tract imaging within a week by fast track referral to radiology or as an urgent urology outpatient referral as per local guidelines to rule out an obstructed urinary system. Patients with recurrent stones should be advised to maintain a copious fluid intake (>2 L/day) to reduce the concentration of the urine. A reduction in salt intake (ideally