Infect Immun, 1997 Mar, 65(3), 909 - 15 Oral immunization with the saliva-binding region of Streptococcus mutans AgI/II genetically coupled to the cholera toxin B subunit elicits T-helper-cell responses in gut-associated lymphoid tissues; Toida N et al.; Mice immunized intragastrically (i.g.) with a genetically constructed chimeric protein consisting of the saliva-binding region (SBR) of Streptococcus mutans AgI/II coupled to cholera toxin (CT) A2 and B subunits (CTA2/B) develop serum immunoglobulin G (IgG) and mucosal IgA antibody responses against AgI/II that are enhanced by the coadministration of CT as an adjuvant . To investigate the development of antigen-specific T cells in the gut-associated lymphoid tissues, mice were immunized i.g . with SBR, SBR-CTA2/B, or SBR-CTA2/B plus CT . AgI/II-specific T cells in Peyer's patches (PP), mesenteric lymph nodes (MLN), and spleen were assayed by lymphoproliferation and flow cytometry for the expression of T-cell surface markers, and cytokine mRNA expression was evaluated by reverse transcription-PCR . T-cell responses were consistent with antibody responses but were detectable after the first immunization . Proliferative responses of PP and MLN cells upon stimulation with AgI/II in vitro were low and delayed in mice given SBR alone, and these cells displayed a mixed type 1 and 2 (or Th0) pattern of cytokine expression . Immunization with SBR-CTA2/B resulted in greater AgI/II-specific proliferative responses in PP cells and an increase in the proportion of CD4+ T cells . Coadministration of CT with SBR-CTA2/B led to greater proliferative responses especially in the MLN cells, which then showed an increase in CD4+ cells . Immunization with SBR-CTA2/B (with or without CT) skewed the cytokine expression pattern in PP and MLN cells toward Th2 . The results indicate that T helper cells were induced in gut-associated lymphoid tissues by i.g . immunization with SBR-CTA2/B, concomitantly with and prior to the appearance of circulating and mucosal antibodies. Tidsskr Nor Laegeforen, 1997 Feb 28, 117(6), 815 - 7 {Pneumococcal endocarditis of the tricuspid valve . A case report with review of the literature}; Holm AM et al.; The incidence of invasive infections caused by Streptococcus pneumoniae has increased dramatically in Norway the last 5-10 years . We describe a patient with a pneumococcal endocarditis of the tricuspic valve who illustrates some of the diagnostic and therapeutic problems often connected with right-sided endocarditis . We also review literature on pneumococcal endocarditis . Since the introduction of antibiotics, the incidence of pneumococcal endocarditis has decreased significantly . The most important predisposition still seems to be alcoholism . Cases of pneumococcal endocarditis require prolonged and consistent antibiotic treatment . Rapid destruction of the valves is typical, and often demands surgical intervention at an early stage . So far no multiresistant pneumococci have been observed in Norway . The increased incidence of serious pneumococcal infections has recently made it necessary to recommend that pneumococcal vaccine be given on wider indications. Biochem Biophys Res Commun, 1997 Feb 24, 231(3), 839 - 43 A 13-kDa protein with a helix-turn-helix motif is encoded by bacterial operons related to the SRP pathway; Samuelsson T et al.; We have identified a 13 kDa protein (p13) in Mycoplasma mycoides subsp . mycoides that is encoded immediately downstream of a protein homologous to E . coli FtsY, a protein taking part in the bacterial signal recognition particle (SRP) pathway . The same organisation of the p13 and FtsY genes occurs in Mycoplasma pneumoniae . PCR analysis of different mycoplasma strains revealed the same organisation in strains belonging to the Mycoplasma mycoides cluster of the mycoplasma phylogenetic tree . Searches in sequence databases identified homologues to p13 in Bacillus subtilis and Streptococcus mutans . In these bacteria the p13 protein is encoded by the same operon as a protein homologous to the 54 kDa subunit of SRP . These findings suggest that there is a functional relationship between the p13 protein and the SRP pathway . Sequence analysis of the p13 proteins strongly suggest that they have a helix-turn-helix (HTH) motif, indicating that they are gene regulatory proteins. Presse Med, 1997 Feb 22, 26(5), 243 - 7 {Pneumococcal infections in patients with HIV infections}; Lesprit P et al.; VERY HIGH INCIDENCE: Streptococcus pneumoniae is the most frequent causal agent of bacterial pneumonia in HIV-positive patients . SPECIFIC COURSE: Clinical manifestations are similar to those in normal hosts except for increased rates of bacteremia and recurrent disease, but mortality from pneumococcal disease is substantial in patients with AIDS . THERAPEUTIC MANAGEMENT: Although the independent influence of HIV infection has not been well assessed, antibiotics effective against penicillin-resistant strains such as the amoxicillin-clavulanic acid combination or cephalosporines (cefatoxime, ceftriaxone) must be considered in the empirical treatment of HIV-infected patients with pneumococcal disease . PROPHYLAXIS: Since the effectiveness of pneumococcal vaccine has not been demonstrated, clinical trials of vaccination performed early in the course of HIV infection are warranted. FEMS Microbiol Lett, 1997 Feb 15, 147(2), 245 - 50 Description of an albumin binding activity for Streptococcus suis serotype 2; Quessy S et al.; This study was undertaken to investigate the binding activity of Streptococcus suis serotype 2 to albumin . Using flow cytometry we observed a binding activity of S . suis to albumin for virulent as well as for avirulent isolates . Western immunoblots analysis revealed that a 39-kDa S . suis protein was responsible, at least in part, for this binding activity . This protein showed high N-terminal homology (95.6% for the first 23 residues) with a group A Streptococcus glyceraldehyde-3-phosphate dehydrogenase . Furthermore, the addition of albumin to the culture broth resulted in an increase in the virulence of S . suis strains in mice . These results suggest that an interaction with albumin could play a role in the pathogenesis of S . suis serotype 2 infections. Dtsch Med Wochenschr, 1997 Feb 7, 122(6), 156 - 60 {Septic myocardial aneurysm in mitral valve endocarditis . Clinical and pathological-anatomical findings}; Omran H et al.; HISTORY AND CLINICAL FINDINGS: A 68-year-old woman was hospitalized because of fever and tiredness for 3 months . Her general condition was clearly impaired . She had a mild fever of 38.5 degrees C and on auscultation a 3/6 systolic murmur, maximal parasternally in the 3rd intercostal space, transmitted to the apex . There were distant rales over both lungs, the neck veins were distended and there was ankle oedema . INVESTIGATIONS: C-reactive protein was raised to 17.3 mg/dl (normal up to 0.9 mg/dl), WBC count 19,300/microliter . beta-haemolysing streptococcus (S . agalactiae) was grown in the blood culture . The ECG showed sinus tachycardia (rate of 98/min) and transthoracic echocardiography demonstrated a small pericardial, enlarged ventricles, marked mitral regurgitation and a large vegetation on the posterior mitral leaflet, as well as a 3 x 4 cm mass in the posterior wall of the ventricle, originating from the posterior mitral valve ring and communicating with the vegetation on the mitral valve . The posterior mitral leaflet was perforated . TREATMENT AND COURSE: As endocarditis of the mitral valve with a complicated course was suspected-abscess of the posterior mitral valve ring and septic myocardial aneurysm with associated pericarditis and haemodynamically insignificant effusion-she was transferred to the intensive care unit where she died suddenly of circulatory arrest only 30 min after transfer . Autopsy confirmed the echocardiographic findings . CONCLUSION: Paravalvular abscess in the course of mitral valve endocarditis is rare, but should be looked for at transthoracic echocardiography so that any necessary surgical intervention can be undertaken early. Ugeskr Laeger, 1997 Feb 3, 159(6), 732 - 5 {Group B streptococcal infection in adults}; Laursen SB et al.; Three cases of infection with Streptococcus agalactiae, or Lancefield group B beta-haemolytic streptococcus (GBS), in adults are described and the literature is reviewed . During a period of 14 years the incidence of GBS-disease in adults aged above 15 years has increased in Denmark . The most common clinical presentations of GBS-disease in adults are puerpural fever, bacteraemia without evident focus, skin or soft-tissue infection, pneumonia, urosepsis and meningitis, preceded by a few days of influenza-like symptoms . The features of this fulminant disease include rapid development of multiple organ dysfunction syndrome (MODS) with renal impairment, adult respiratory distress syndrome (ARDS) and, in many patients, also cardiovascular instability . The therapy includes parenteral antibiotics, usually with high doses of benzylpenicillin, and symptomatic treatment . GBS-disease in both infants and adults may be prevented by the development of effective GBS-vaccines. G Ital Cardiol, 1997 Feb, 27(2), 141 - 5 {Replacement of the aortic valve with a pulmonary autograft: experience at the University of Verona}; Santini F et al.; BACKGROUND: Early and long term results after surgical replacement of the aortic valve depend to a large degree on the type of valve substitute used . Pulmonary autograft offers many theoretical advantages, particularly in young patients . METHODS: Between July 1994 and August 1996, 15 patients (12 male) with a mean age of 28 +/- 6 years (range 14 to 36 years) were selected for aortic valve replacement with a pulmonary autograft . The aortic valve disease was isolated insufficiency in 7 cases (47%), stenosis in 3 (20%) and mixed lesion in 5 (33%) . One patient in the last group had bacterial endocarditis (Streptococcus mitis) . Seven patients (47%) had a bicuspid aortic valve . In 3 cases (20%) the autograft was inserted as a scalloped subcoronary implant . Twelve patients (80%) had total aortic root replacement with re-implantation of the coronary ostia . The right ventricular outflow tract was reconstructed with a cryopreserved homograft (13 pulmonary; 2 aortic) . The aortic cross-clamp time was 156 +/- 18 minutes with a total bypass time of 221 +/- 26 minutes . RESULTS: All patients survived the operation . Three postoperative bleeding (20%) necessitated re-exploration . Mean post-operative hospital stay was 10 +/- 2 days . All patients were discharged on aspirin for the period of three months . One patient (7%) with moderate neo-aortic valve insufficiency died suddenly 11 months post-operatively . All survivors are asymptomatic, in NYHA FC 1 at a mean follow-up time of 15.7 months . Freedom from reoperation, valve related complication and endocarditis is 100% . Two-dimensional (2-D) echocardiography six months postoperatively showed a mean left ventricular outflow gradient of 13 +/- 4 mmHg with no evidence of aortic regurgitation in 11 cases (78.5%) and trivial in 3 (21.5%) . CONCLUSIONS: Although the Ross operation is technically more challenging and requires a longer operating time than standard procedures, this does not seem to affect early mortality and morbidity . Clinical and haemodynamic results appear to be gratifying . Continued patients evaluation particularly with regard to evidence of valve degeneration and arrhythmias in the long term is warranted. J Endod, 1997 Feb, 23(2), 115 - 20 Defense responses of dentin/pulp complex to experimentally induced caries in rat molars: an immunohistochemical study on kinetics of pulpal Ia antigen-expressing cells and macrophages; Kamal AM et al.; Experimental caries was induced in rats that were inoculated orally with Streptococcus mutants and maintained on a cariogenic diet . During the caries process, kinetics of the pulpal la antigen-expressing cells and macrophages was monitored immunohistochemically and was correlated with caries depth and the status of reparative dentin formation . Initial pulpal response was characterized by a localized accumulation of la antigen-expressing cells beneath the dentinal tubules communicating with the superficial caries . This was followed by a caries-depth related increase of la antigen-expressing cells and macrophages in the coronal pulp . The accumulation of these cells under the dentin was most apparent when the caries had progressed into the reparative dentin . These findings suggest that the response of la antigen-expressing cells to carious irritants triggers the defense reactions of the pulp . The intensity of the defense reactions may be correlated with the permeability of carious dentin. Mol Pathol, 1997 Feb, 50(1), 45 - 50 Determination of penicillin susceptibility of Streptococcus pneumoniae using the polymerase chain reaction; Jalal H et al.; AIM: To develop a polymerase chain reaction (PCR) based method to detect penicillin susceptibility in isolates of Streptococcus pneumoniae (SP) . METHOD: PCR primers were designed to amplify differential nucleotide sequences of the penicillin-binding protein (PBP) genes 2b, 2x, and 1a in penicillin susceptible and resistant strains of SP . Primers derived from the PBP 2x and 2b genes were designed to amplify products from penicillin susceptible S pneumoniae (PSSP), whereas primers derived from the PBP 1a gene were designed to amplify gene sequences of penicillin resistant S pneumoniae (PRSP) . RESULTS: Two hundred and thirty clinical isolates of SP from the USA, UK, Kenya, Romania, and the Kingdom of Saudi Arabia were tested . Of the isolates, 116 were penicillin susceptible, 65 were intermediately resistant, and 49 were highly resistant . PCR identified 108 (93%) of 116 of PSSP isolates, 55 (85%) of 65 intermediately resistant isolates, and all of the 49 highly resistant isolates of SP . The susceptibility of 16 (7%) isolates could not be determined using PCR . All of these 16 isolates had a minimum inhibitory concentration (MIC) of penicillin < 1 mg/l . None of the highly resistant isolates was identified as penicillin susceptible by PCR, although two of the isolates with intermediate resistance (MIC = 0.125 mg/l) were . CONCLUSION: Using primers that differentially identify the genotypes of susceptible and resistant strains of SP, PCR provides a rapid method for determining the penicillin susceptibility of SP isolates and could potentially be used for testing clinical samples. Am J Ophthalmol, 1997 Feb, 123(2), 260 - 1 Endogenous endophthalmitis caused by Streptococcus mitis; Harrison SA et al.; PURPOSE: To report endogenous endophthalmitis caused by Streptococcus mitis . METHODS: A 3-year-old girl was hospitalized for possible retinoblastoma after she suddenly developed a red and sensitive left eye . After administration of anesthesia, we examined the patient and obtained samples of aqueous, vitreous, and blood for culture . RESULTS: Blood and vitreous cultures grew S mitis . Intravenous and intravitreal injections of antibiotics were used to treat the infection . CONCLUSIONS: Streptococcus mitis should be considered a cause of endogenous endophthalmitis. An Esp Pediatr, 1997 Feb, 46(2), 189 - 94 {Neonatal meningitis: study of 56 cases}; Olmedo Diaz I et al.; OBJECTIVE: The objective of this study was to know the most common organisms causing neonatal meningitis in a defined region of southern Madrid, the developmental outcome of these babies and the risk factors associated with the prognosis . PATIENTS AND METHODS: This was an observational study of 56 cases of meningitis diagnosed in our Neonatal Service between 1988 and 1994 . In order to study the handicaps of these babies, only those who were born before May 1993 were considered so that they had a corrected age of at least 2 years when the neurological evaluations were done . RESULTS: The most common causative organisms were group B Streptococcus (27%), E . coli (11%) and enteroviruses (9%) . In the premature infants the leading organisms were E . coli and Candida albicans . The age at diagnosis was 8 +/- 6 days in the group of preterm infants (p = 0.002) . The mortality was associated with the prematurity (risk ratio: 17.8), the isolation of a gram-negative organism in the cerebral fluid (RR: 3.3) and the presence of abnormal findings in cerebral ultrasound studies (RR: 12.7) . Sequelae were associated with the presence of abnormal findings in cerebral ultrasound studies (RR: 24.7) or in the neurologic examination (R: 7) and with the presence of previous cerebral lesions (RR: 5.7) . CONCLUSIONS: Neonatal ultrasound examination, as well as the gestational age, the causative organisms, the presence of a previous cerebral lesion and the neurological examination, seem to be very important in predicting the prognosis of these babies. Mol Microbiol, 1997 Feb, 23(4), 719 - 28 Bacteriophage T12 of Streptococcus pyogenes integrates into the gene encoding a serine tRNA; McShan WM et al.; The region of temperate bacteriophage T12 responsible for integration into the chromosome of Streptococcus pyogenes has been identified . The integrase gene (int) and the phage attachment site (attP) are found immediately upstream of the gene for speA, the latter of which is known to be responsible for the production of erythrogenic toxin A (also known as pyrogenic exotoxin A) . The integrase gene has a coding capacity for a protein of 41457 Da, and the C-terminus of the deduced protein is similar to other conserved C-terminal regions typical of phage integrases . Upstream of int is a second open reading frame, which is capable of encoding an acidic protein of 72 amino acids (8744 Da); the position of this region in relation to int suggests it to be the phage excisionase gene (xis) . The arms flanking the integrated prophage (attL and attR) were identified, allowing determination of the sequences of the phage (attP) and bacterial (attB) attachment sites . A fragment containing the integrase gene and attP was cloned into a streptococcal suicide vector; when introduced into S . pyogenes by electrotransformation, this plasmid stably integrated into the bacterial chromosome at attB . The insertion site for the phage into the S . pyogenes chromosome was found to be in the anticodon loop of a putative type II gene for a serine tRNA . attP and attB share a region of identity that is 96 bp in length; this region of identity corresponds to the 3' end of the tRNA gene such that the coding sequence remains intact after integration of the prophage . The symmetry of the core region of att may set this region apart from previously described phage attachment sites (Campbell, 1992), and may play a role in the biology of this medically important bacteriophage. Mol Microbiol, 1997 Feb, 23(4), 683 - 92 The com locus controls genetic transformation in Streptococcus pneumoniae; Cheng Q et al.; Genetic exchange by natural transformation in Streptococcus pneumoniae occurs in a cell-density dependent process and is initiated by a small extracellular signalling molecule, the competence-stimulating peptide (CSP) . comC, the gene for this peptide, has previously been identified and encodes a 44 amino acid pre-peptide that is apparently processed to an active molecule that consists of the C-terminal 17 amino acids . We have sequenced the region adjacent to comC and shown that it is the first gene of an operon, com, consisting of two downstream elements, comD and comE, which encode members of the two-component family of sensor regulators . Null mutants with defects in either comC or comD were transformation deficient and failed to respond to exogenous CSP . A comC mutant did not exhibit any detectable CSP activity, while a comD mutant that contained an intact comC produced minimal CSP activity . In mixed-culture experiments consisting of isogenic pairs of pneumococci (Csp+ and Csp-), we showed that induction of competence by quorum sensing was independent of CSP . Northern analysis showed that com was transcribed as a single polycistronic message, while analysis of strains with transcriptional fusions showed that com was constitutively expressed under conditions that both promoted or repressed the development of competence . Finally, we showed genetically and biochemically a CSP-dependent transcription of rec, a competence-induced locus, and that ComD and ComE are required for this CSP-dependent expression. Oral Microbiol Immunol, 1997 Feb, 12(1), 57 - 63 Age-related changes in salivary antibodies to commensal oral and gut biota; Percival RS et al.; The prevalence of mucosally derived infections appears to increase with age, suggesting dysfunction at the mucosal surfaces . The present investigation was undertaken to examine any age-related changes in secretion rates and concentrations of secretory antibodies in whole and parotid saliva in a healthy adult population . A total of 116 subjects were subdivided into the following age groups: 20-39 years, 40-59 years, 60-79 years and 80 years and over . Specific immunoglobulin A (IgA), IgG and IgM antibodies in whole and parotid saliva to Streptococcus mutans (serotype c), Actinomyces viscosus NCTC 10951, and Escherichia coli NCTC 10418 were quantified by enzyme-linked immunosorbent assay . IgA antibodies to all three organisms examined increased with age in both whole and parotid saliva, whereas IgG antibody levels to S . mutans in whole saliva were significantly decreased with age . IgG antibodies to E . coli in parotid saliva were reduced in older age groups . IgM antibody levels to S . mutans were reduced with age in both secretions, whereas IgM antibodies to A . viscosus were greatest in the oldest age groups . No significant changes with age were observed in salivary IgM antibody levels to E . coli . No significant reduction in the secretion rates of IgA antibodies were observed in parotid or whole saliva, whereas IgG and IgM antibody secretion rates to all three microorganisms were reduced in most age groups in both whole and parotid saliva . The results of this investigation have demonstrated age-related changes with salivary antibodies, but, whereas salivary IgG and IgM antibodies showed decreases, salivary IgA levels generally increased with age . This suggests that the ability to form IgA antibody responses is not impaired with increased age, and that secretion rates and functional properties of antibodies may be as important as concentrations in protection against mucosal infective diseases. Clin Infect Dis, 1997 Feb, 24 Suppl 2, S213 - 21 The challenge of penicillin-resistant Streptococcus pneumoniae meningitis: current antibiotic therapy in the 1990s; Bradley JS et al.; Bacterial meningitis caused by Streptococcus pneumoniae is an important cause of neurological morbidity and mortality in both children and adults . With increasing antibiotic resistance in pneumococci and documented microbiological failure in treatment of pneumococcal meningitis with cefotaxime and ceftriaxone, the need for alternative antibiotic therapy is critical . Of the currently available options, vancomycin has shown the most promise, particularly when used in combination with ceftriaxone or cefotaxime . Rifampin, also used in combination with either ceftriaxone or cefotaxime, has demonstrated encouraging preliminary results against antibiotic-resistant pneumococci as well . Chloramphenicol has unexpectedly yielded discouraging clinical results in children with infection caused by penicillin-resistant strains . Of the investigational antibiotics currently in clinical trials for the treatment of meningitis, meropenem, a carbapenem-class antibiotic, has demonstrated increased activity against penicillin-resistant pneumococci compared with that of other beta-lactam antibiotics, while having a safety profile similar to that of the cephalosporins. J Dairy Res, 1997 Feb, 64(1), 23 - 37 Patterns of clinical mastitis manifestations in Danish organic dairy herds; Vaarst M et al.; Danish organic dairy production is characterized by a low input of antibiotics for udder treatment and a high input of other mastitis control procedures . A study was conducted in 14 organic dairy herds with the objectives of obtaining a comprehensive description of clinical mastitis cases and identifying characteristic patterns in these results . Clinical signs, inflammatory reactions and microbiological identifications were obtained from 367 cases of clinical mastitis occurring over 18 months . Cow characteristics and preincident values such as milk yield and somatic cell count were obtained for each cow . Signs of previous udder inflammation were present in two-thirds of the clinical mastitis cases . Severe local inflammatory reactions were found in 21% of the cases and some indication of generalized signs such as fever and reduced appetite were found in 35% of the cases . Logistic regression analyses were performed based on the results of an initial (exploratory) multiple correspondence analysis . Coliform mastitis (6% of the cases) was rarely preceded by pathogen isolation or inflammatory reactions in the same quarter . Coliform mastitis cases usually occurred in one quarter only . Escherichia coli infections were typically (truly) acute cases . Bacteriologically negative mastitis (20% of the cases) showed strong similarities with clinical coliform mastitis . Staphylococcus aureus cases (18% of the cases) occurred most frequently in late lactation or around drying-off . Prior isolation of Staph . aureus and slight decreases in milk yield were two factors that interacted but both were strongly and positively related to clinical Staph . aureus . Staph . aureus mastitis typically had a subclinical debut, and increasing degrees and duration of inflammation decreased shedding of this pathogen . Streptococcus dysgalactiae (9% of the cases) mastitis was typically persistent virulent and manifest in periods of lower cow resistance . More patterns of subclinical and clinical Str . uberis mastitis (23% of the cases) seemed to be present. Nippon Ika Daigaku Zasshi, 1997 Feb, 64(1), 16 - 21 Infective endocarditis . Considerations for the timing of surgical intervention and type of infecting microorganism; Yamauchi S et al.; To determine the appropriate timing for surgical intervention in infective endocarditis (IE), we evaluated 24 patients (17 males, 6 females, with one included twice) who underwent surgical intervention for IE of native valves (NVE, n = 21) and prosthetic valves (PVE, n = 3) between January 1989 and September 1994 . The mean age was 41 +/- 13 years (range 6 to 64 years) . The most common infective organisms were Staphylococcus (33% of NVE) and Streptococcus (19% of NVE), with five NVE patients (24%) negative for blood culture . The PVE patients showed a different pattern of infecting organisms, with Enterococcus in one and Pseudomonas in another . From the resected valve culture and pathological findings, 12 patients were in the active stage at operation . Two in-hospital deaths occurred for a mortality rate of 8.7% (2/23) . Further, surgical interventions were performed earlier with Staphylococcal infections than with Streptococcal infections, because hemodynamic compromise presented more progressively in the former . Also resected valve cultures and the pathological findings showed that a persistent infectious process existed in many cases of Staphylococcal infection in spite of intensive antibiotic therapy . In conclusion, we suggest that internists make referrals for surgical intervention for patients with NVE or PVE as early as possible in the active stage of infection. Nihon Kyobu Shikkan Gakkai Zasshi, 1997 Feb, 35(2), 236 - 9 {Bronchial lipoma removed with bronchoscopic snaring forceps}; Takiguchi Y; A 62-year-old woman was admitted to the hospital because of dyspnea . A chest X-ray film showed a massive left pleural effusion . Thoracentesis was done and purulent fluid was found . Streptococcus intermedius was detected in the fluid . Chest drainage and administration of antibiotics were successful, but computed tomography of the chest revealed a mass in the left main bronchus . The mass was removed with transbronchial electrosurgical snaring forceps and was found to be a lipoma . This tumor had low CT numbers (from -70 HU to -140 HU), and this finding may be useful in the differential diagnosis of endobronchial tumors. Biol Chem, 1997 Feb, 378(2), 83 - 8 In vivo binding of the salivary glycoprotein EP-GP (identical to GCDFP-15) to oral and non-oral bacteria detection and identification of EP-GP binding species; Schenkels LC et al.; Extra Parotid Glycoprotein (EP-GP) is a glycoprotein isolated from human saliva, having homologues in several other body fluids . The biological role of EP-GP and its homologues is unknown . Recently, EP-GP was shown to bind in vitro to the bacterium Streptococcus salivarius HB . In contrast, no binding to a number of other oral microorganisms could be demonstrated . In the present study we have determined whether binding of EP-GP to bacteria occurs in vivo in saliva and in other EP-GP containing body fluids . Therefore the presence of EP-GP on bacteria in vivo was determined by analyzing oral, skin and ear floras by confocal fluoresence microscopy using specific antibodies . About 12% of the in vivo oral flora had EP-GP present on their surface, while approximately 5% of the bacteria from ear canal or skin was positive for EP-GP . IgA was detected on approximately 65% of the salivary bacteria, whereas the high-molecular weight mucin (MG1) and cystatin C were not detectable on any oral bacterium . Using a replica-plate assay, a number of EP-GP binding strains in saliva were isolated and identified as Gemella haemolysans, Gemella morbillorium, Streptococcus acidominimus, Streptococcus oralis, Streptococcus salivarius and Streptococcus parasanguis . Bacteria from the ear canal and skin bacteria were identified as Staphylococcus hominis . It is concluded that EP-GP is selectively bound in vivo to several oral and non-oral bacterial species. Eur J Oral Sci, 1997 Feb, 105(1), 81 - 5 Resin-modified glass ionomer cements: fluoride release and influence on Streptococcus mutans growth; Friedl KH et al.; The aims of the present study were to measure the fluoride release of 1 glass ionomer cement, 1 cermet, 3 resin-modified glass ionomer cements and 1 compomer, and to determine the influence of each material on bacterial growth . Test specimens were eluted in saline for 180 days . Every 2 days, the specimens were transferred into fresh saline and the fluoride content of the solution was measured . Furthermore, 48-h, 14-d, 90-d, and 180-d eluates were inoculated with Streptococcus mutans and bacterial growth was recorded nephelometrically . Fluoride release dropped significantly over time for each material with values between 6.2 (Ketac-Silver) and 29.3 (Photac-Fil) ppm after 48 h to values between 0.6 (Ketac-Silver) and 1.7 (Ketac-Fil, Vitremer) ppm after 180 days . Each material reduced bacterial growth at each time of examination, but the effect decreased significantly over time with a maximum growth of 71.7% (Ketac-Fil) to 85.6% (Ketac-Silver) after 48 h and 94.7 (Vitremer) to 99.0% (Ketac-Silver) after 180 days (growth control = 100%) . Both Ketac-Silver and Dyract showed a significantly lower inhibiting effect on bacterial growth than the other materials . The tested materials showed a good correlation between fluoride release and influence on bacterial growth . However, both effects dropped dramatically over the 180-days period. Am J Trop Med Hyg, 1997 Feb, 56(2), 211 - 5 Pneumococcal capsular antigen detection after enrichment culture: an alternative to culture methods in epidemiologic research; Lankinen KS et al.; Bacterial culture of Streptococcus pneumoniae followed by serotyping is not always feasible under field conditions . Antigen detection methods could be an alternative, but they are associated with sensitivity problems . In an effort to improve their sensitivity, we introduced an enrichment phase before antigen detection and compared the results with direct bacterial culture, using nasopharyngeal swabs from 95 children with symptoms of acute respiratory infection . Antigen detection was performed by latex agglutination and counterimmunoelectrophoresis . Streptococcus pneumoniae was found in 29 (30%) of the samples by culture, and in 42 (44%) by antigen detection after enrichment, an excess of 45% over culture findings . This excess was shown to represent true positive samples since pneumococcal DNA could be detected by polymerase chain reaction in all 15 antigen-positive, culture-negative samples . Two culture-positive samples were antigen-negative; in one of these the bacteria were nonencapsulated . We conclude that for type-specific demonstration of S . pneumoniae, detection of pneumococcal antigen after an enrichment step is a sensitive method that can be applied for epidemiologic study purposes, e.g., in vaccine trials, in areas without ready access to a good microbiology laboratory. Aust N Z J Med, 1997 Feb, 27(1), 29 - 34 The clinical spectrum of necrotising fasciitis . A review of 15 cases; Jarrett P et al.; BACKGROUND: Necrotising fasciitis represents a spectrum of disease which ranges from fulminant through acute to subacute varieties . While fulminating necrotising fasciitis is a well recognised entity the subacute variety is not . AIM: To assess six years' experience of necrotising fasciitis at Waikato Hospital . METHOD: Cases of necrotising fasciitis were identified from discharge statistics for the period 1990-1995 . Records were reviewed for clinical features, predisposing factors, microbiology, histology, treatment and outcome . RESULTS: Fifteen cases were identified of which ten were female . The average age was 55 years (range of 15-92 years) . One patient presented with fulminant, eight with acute and six with subacute necrotising fasciitis . Significant blister formation was noted in eight cases . Risk factors were identified in 14 patients including trauma, renal impairment, diabetes mellitus, and various drugs including diclofenac (four patients), naproxen (one patient) and prednisone (two patients) . Group A beta haemolytic streptococcus (GABHS) was identified in ten cases . Swab or tissue cultures had the highest yield for isolating the organism . Blood cultures grew GABHS in only three of 12 cases . Eight patients (53%) died . Of the survivors all but one patient required debridement and skin grafting . CONCLUSIONS: Necrotising fasciitis is a clinical spectrum of disease . It affects a wide age group and can have associated morbidities . It is often a fatal disease . Early recognition, high dose antibiotics and surgical debridement are important in the management of the entire spectrum of necrotising fasciitis. Aust N Z J Obstet Gynaecol, 1997 Feb, 37(1), 45 - 51 The role of Ureaplasma urealyticum in adverse pregnancy outcome; Knox CL et al.; We investigated Ureaplasma urealyticum genital tract colonization rates in an Australian population to determine whether colonization was associated with adverse pregnancy outcome . Women attending an antenatal clinic were evaluated for lower genital tract colonization at their first antenatal visit (162 women) and at 28 weeks' gestation (120 women) . Placentas from 92 women were cultured . U . urealyticum was the predominant isolate from the lower (57.4%) and upper (17.4%) genital tract in this population of pregnant women . U . urealyticum was a persistent colonizer during mid-trimester of pregnancy (in 88% of women colonized) whereas M . hominis, G . vaginalis, and Group B streptococcus were present as transient flora of the lower genital tract . Lower genital tract colonization during pregnancy was not directly associated with adverse pregnancy outcome . However preterm delivery in afebrile, asymptomatic women, could possibly be associated with chorioamnionitis (4 of 16 preterm births) . Screening of women with a history of preterm birth may prevent upper genital tract infections and preterm delivery. J Antimicrob Chemother, 1997 Feb, 39(2), 199 - 207 Experimental lobar pneumonia due to penicillin-susceptible and penicillin-resistant Streptococcus pneumoniae in immunocompetent and neutropenic rats: efficacy of penicillin and teicoplanin treatment; Candiani G et al.; Lobar pneumonia models were established in rats by intratracheal inoculation of either penicillin-susceptible (immunocompetent model) or penicillin-resistant (immunocompetent and neutropenic models) Streptococcus pneumoniae . Untreated animals maintained a relatively high bacterial load in the lungs but only occasionally developed bacteraemia or pleurisy . The infection was rarely fatal in immunocompetent rats, but immunocompromised rats frequently died . Treatment i.m . with 10,000 IU/kg of procaine penicillin G (12 h after infection then bid for 3 days) or with a single i.v . dose of 5 or 10 mg/kg of teicoplanin significantly reduced lung bacterial loads of rats infected with the penicillin-susceptible strain . Against the penicillin-resistant strain, teicoplanin displayed a significant activity regardless of the immununological status of the animals . Penicillin G significantly reduced lung bacterial load of the penicillin-resistant strain only in immunocompetent rats and at a higher dose than needed in treatment of the penicillin-susceptible infection . The experimental models described here could be suitable for studying the efficacy of antibacterial agents against pulmonary infections caused by penicillin-susceptible and penicillin-resistant S . pneumoniae strains. J Neurosci Nurs, 1997 Feb, 29(1), 4 - 8, 13-4 Multiple bilateral cerebral abscesses with hemorrhage; Baumann CK; Brain abscess with spontaneous hemorrhage is an uncommon illness . A rare case of multiple abscesses in both cerebral hemispheres complicated by hemorrhage is reported . Minimally invasive surgery utilizing magnetic resonance imaging (MRI) guidance was performed after extensive testing failed to yield a diagnosis . Streptococcus intermedius was isolated from cultures taken during surgery and intravenous antimicrobial therapy was instituted . Pathology other than metastatic neoplasms and subacute hemorrhage should be considered in cases of cerebral ring-enhancing masses with hemosiderin deposition. Vaccine, 1997 Feb, 15(2), 179 - 86 The synthesis of Streptococcus pneumoniae polysaccharide-tetanus toxoid conjugates and the effect of chain length on immunogenicity; Laferriere CA et al.; To study the relationship between length of pneumococcal polysaccharide and immunologic performance in rabbits we took well defined fragments of the capsular polysaccharides of S . pneumoniae types 3, 6A, 18C, 19F and 23F and pneumococcal C-polysaccharide and linked them terminally by reductive amination to tetanus toxoid . Contrary to other reports we found little variation in antibody titers with increasing length . In general the opsonophagocytic titers determined using activated HL60 cells and rabbit peritoneal cells correlated well with the antibody titers except for that of type 3, which despite the presence of high polysaccharide antibody titers gave unexpectedly low opsonophagocytic titers . The C-polysaccharide-conjugate was also immunogenic when injected in both rabbits and mice but gave low opsonophagocytic titers . It was demonstrated that opsonophagocytosis was solely dependent on the presence of phosphoryl choline-specific antibody and that the induction of these antibodies was species dependent. J Dent Res, 1997 Feb, 76(2), 665 - 72 Inhibition of Streptococcus mutans adsorption to hydroxyapatite by low-molecular-weight chitosans; Tarsi R et al.; The role of Streptococcus mutans in the initiation of dental caries has been recognized and attributed, at least in part, to its ability to colonize the tooth surface . Therefore, factors which prevent S . mutans attachment to hydroxyapatite (HA) are of considerable interest for the prophylaxis of this infectious disease . Chitosan, a chitin derivative by N-deacetylation, is an interesting candidate in this respect, since it stimulates the ordered regeneration of oral soft tissues, prevents the deleterious action of organic acid, and exhibits bactericidal action against several pathogens . In the present work, the efficacy of a low-molecular-weight chitosan (LMWC) and its derivatives N-carboxymethyl chitosan (NCMC) and imidazolyl chitosan (IMIC) in preventing S . mutans attachment to HA beads was assessed . The effects of chitosan on both sucrose-dependent and -independent adherence were evaluated . In both cases, when saliva-coated or uncoated HA beads were treated with any of the chitosans, a reduction in S . mutans adsorption ranging from 47 to 66% was observed . When HA beads were coated with saliva after the treatment with chitosan, neither carbohydrate caused a statistically significant reduction in S . mutans adsorption, suggesting that saliva deposition restores HA binding properties . Bacteria grown in the presence of chitosan subminimal inhibitory concentrations (sub-MICs) ranging from 12 to 500 micrograms mL-1 adsorbed poorly to HA and exhibited a lower affinity toward xylene than untreated controls . In the presence of chitosan sub-MICs up to 60 micrograms mL-1, an increase in the percentage of detached bacteria from two- to nine-fold was observed . The desorptive effect of chitosan was weaker when S . mutans had adhered to saliva-coated HA in the presence of sucrose . These results demonstrate that the presence of minor amounts of modified chitosans prevents S . mutans adsorption to HA and suggest that colonization of the tooth surface might be impaired by the use of toothpastes, mouthrinses, or chewing gums containing any of the tested polysaccharides. FEMS Immunol Med Microbiol, 1997 Feb, 17(2), 121 - 9 Purification and partial characterization of a novel human platelet aggregation factor in the extracellular products of Streptococcus mitis, strain Nm-65; Ohkuni H et al.; A human blood platelet aggregation factor was purified from the extracellular products (ECP) of Streptococcus mitis, strain Nm-65 by sequential chromatography on DEAE-Sepharose CL-6B, hydroxyapatite and Superdex 75 columns . The purified factor (S . mitis-derived human platelet aggregation factor, Sm-hPAF) gave a single band with a molecular weight of 66 kDa on SDS-polyacrylamide gel electrophoresis (SDS-PAGE) . Sm-hPAF showed a peak absorption at 278 nm and an isoelectric point of around 8.5 . Chemical analyses revealed that Sm-hPAF contained no sugars and that its first 15 amino-terminal amino acid residues were H-DEQGNRPVETENIAR . Platelet aggregation activity of Sm-hPAF was abolished by heating at 45 degrees C for 10 min . Platelet aggregation by Sm-hPAF was accompanied by a release of prostaglandin E2 (PGE2) in a dose-dependent manner . The platelet aggregation was not inhibited by either prostaglandin E1 (PGE1) or Gly-Arg-Gly-Asp-Ser (GRGDS), that inhibit the platelet aggregation induced by collagen . Twenty (77%) platelet rich-plasma (PRP) specimens derived from 26 healthy volunteers were aggregated by Sm-hPAF, but the remaining 6 (23%) were not reactive . A preliminary study suggested the presence of an inhibitory factor against Sm-hPAF in the plasma from a non-reactive donor. J Dairy Sci, 1997 Feb, 80(2), 313 - 7 Comparison of success of antibiotic therapy during lactation and results of antimicrobial susceptibility tests for bovine mastitis; Owens WE et al.; Antimicrobial susceptibility testing was conducted on a variety of mastitis pathogens . The infected quarters were subsequently treated during lactation with a commercially available product containing penicillin and novobiocin that was designed for lactating cows . Cows were treated as per the recommendations of the product manufacturer, and cures were determined by the absence of bacteria in both sets of duplicate quarter milk samples that were collected at 28 d posttreatment . Comparisons were made between the susceptibility of the bacteria and the therapeutic success or failure . All isolates tested were considered to be susceptible to the penicillin and novobiocin combination . Bacteriologic cure rates for newly acquired Staphylococcus aureus intramammary infection (IMI) (< 2 wk in duration) at 28 d posttreatment were 70% . Cure rates for chronic Staph . aureus IMI (> 4 wk duration) were much lower (35%), reaffirming previous reports of the intractable nature of chronic Staph . aureus IMI . Cure rates for subclinical IMI caused by other organisms were 90% for Streptococcus agalactiae, 91% for Streptococcus uberis, 90% for Streptococcus dysgalactiae, 77% for other Streptococcus spp., and 71% for Staphylococcus spp . other than Staph . aureus . In vitro testing was considered to be a predictor of therapy outcome for IMI caused by Staphylococcus spp., newly acquired Staph . aureus, Strep . uberis, Strep . dysgalactiae, and Strep . agalactiae, but was not considered to be a useful predictor of efficacy for chronic IMI caused by Staph . aureus. J Dairy Sci, 1997 Feb, 80(2), 307 - 12 Prevalence and duration of intramammary infection in Danish heifers during the peripartum period; Aarestrup FM et al.; Milk samples were collected from 180 heifers from 20 herds around parturition to study the prevalence and persistence of intramammary infection (IMI) . A total of 3382 quarter milk samples was collected each week from 4 wk before parturition to 4 wk after parturition . Staphylococcus chromogenes, the most commonly found bacterial species before parturition, was isolated from 15% of all quarters . However, IMI with Staph . chromogenes decreased shortly after parturition to around 1% of quarters . Infectious with Staphylococcus simulans and Staphylococcus epidermidis occurred in 1 to 3% of quarters both before and after parturition . Infections with Staph . simulans persisted in the same quarter for several weeks, but IMI with Staph . epidermidis were transient . Streptococcus dysgalactiae was isolated from 4 to 6% of quarters before and immediately after parturition, but the prevalence of IMI with Strep . dysgalactiae decreased . A strong association existed between IMI with Strep . dysgalactiae before parturition and IMI with Strep . dysgalactiae after parturition, and, using DNA typing, the persistence of 9 IMI was confirmed . Infections with Staphylococcus aureus rarely occurred before parturition, but the rate of IMI with Staph . aureus greatly increased during the 1st wk after parturition . No association was found between bacterial status before parturition and IMI with Staph . aureus after parturition . Overall, the presence of bacterial IMI in a quarter before parturition increased the risk of IMI for the lactating cow . This study demonstrated that variability in prevalence and duration of IMI according to bacterial species occurred around first parturition. J Gen Intern Med, 1997 Feb, 12(2), 95 - 101 The effect of erythromycin on resolution of symptoms among adults with pharyngitis not caused by group A streptococcus; Petersen K et al.; OBJECTIVE: To determine the effect of treatment with erythromycin on the resolution of symptoms among adults with pharyngitis not caused by group A streptococcus (GAS) . DESIGN: Randomized, double-blind, placebo-controlled trial . SETTING: Ambulatory setting (hospital-based general internal medicine practices, walk-in clinic, employee health service, and university health service) . PATIENTS: One hundred and eighty-six adults who met eligibility criteria and whose chief complaint included sore throat . Patients with positive cultures for GAS were excluded . INTERVENTION: Ninety-three patients received erythromycin (333 mg three times daily for 10 days) and 93 control patients received placebo . MEASUREMENTS AND MAIN RESULTS: Major outcome measurements included time to improvement in sore throat, time to improvement in cough, time to improvement in activity level, and subjective sense of well-being . The average age of the patients studied was 26.6 years; 35% were men . Patients given erythromycin had more rapid resolution of sore throat symptoms (hazard ratio 1.43: 95% confidence interval {CI} 1.00, 2.03: p = .049) . Cough also resolved more rapidly in patients receiving erythromycin (hazard ratio 2.22: 95% CI 1.01, 4.88: p = .05) . There were no differences between the two treatment groups in improvement of activity level or how sick patients felt in general . Most of the benefit in resolution of sore throat was conferred on patients who sought medical care within 2 days of onset . CONCLUSIONS: Our results suggest that the benefit of erythromycin treatment for patients with non-GAS pharyngitis is small and of borderline statistical significance . Because of the small size of the effect and because widespread use of erythromycin could promote drug resistance, we do not recommend routine use of erythromycin in adult patients with this type of pharyngitis. J R Coll Surg Edinb, 1997 Feb, 42(1), 15 - 8 The surgical management of empyema thoracis; Galea JL et al.; Empyema thoracis remains a common thoracic problem with challenging management strategies . We analysed retrospectively 107 consecutive patients treated for empyema thoracic over a 5-year period . The majority of patients (75%) were male with a mean age of 51 years . Common presenting symptoms were cough, dyspnoea, chest pain and pyrexia . The mean duration of pre-admission symptoms was 7.5 weeks . The causes of empyema were pneumonia, malignancy, iatrogenic injury and trauma . The most frequently isolated organism was Streptococcus milleri . In 71% of patients there was an underlying systemic disorder . Forty-nine patients (46%) underwent an unsuccessful therapeutic procedure prior to admission to the surgical units . In the units, 24 patients received closed intercostal chest tube drainage, 14 of whom required further intervention . Two patients were treated with repeated thoracocentesis . The majority of patients underwent a surgical procedure in the first instance: rib resection and drainage (5), decortication (22), and more extensive procedures (9) with only two patients requiring further surgery . The mean post-operative stay was 16 days and the hospital mortality was 13% . We recommend early referral of all empyema patients to thoracic units, where assessment and definitive procedures can be performed with high chances of success and moderate risk of morbidity and mortality. Microbiology, 1997 Feb, 143 ( Pt 2), 523 - 6 Electrotransformation of Streptococcus pneumoniae: evidence for restriction of DNA on entry; Lefrancois J et al.; Electrotransformation is a method generally used in biotechnology to introduce recombinant DNA into a wide range of bacteria . However, the mechanism of DNA entry is poorly understood . We report that in Streptococcus pneumoniae, a naturally transformable species, electrotransformation efficiently introduces a plasmid replicon . DNA is strongly restricted by the restriction-modification systems DpnI and DpnII which degrade methylated and non-methylated DNA, respectively, at GATC sequences . This suggests that in electrotransformation double-stranded DNA penetrates into these bacteria without a single-stranded DNA step in contrast to natural transformation . Single-stranded DNA by itself is able to electrotransform very weakly and linearized double-stranded plasmid DNA yields barely detectable levels of transformants. J Pediatr, 1997 Feb, 130(2), 284 - 8 Repeated invasive pneumococcal infections in young children without apparent underlying immunodeficiency; Orlicek SL et al.; During a 30-month interval at LeBonheur Children's Medical Center, 394 patients had a blood or cerebrospinal fluid culture positive for Streptococcus pneumoniae . Sixteen of these episodes (4%) were repeated infections; 6 of these 16 patients had sickle cell disease . Six of the remaining 10 patients had immunologic evaluations of varying completeness; no immunodeficiency was identified by these tests or on follow-up . Nine of the ten previously healthy patients with repeated pneumococcal disease were less than 2 years of age . In our experience, repeated invasive pneumococcal infections in otherwise healthy young children were relatively common (10/394, or 2.5% of patients with invasive pneumococcal infections) and did not indicate the presence of an unsuspected immunodeficiency. J Allergy Clin Immunol, 1997 Feb, 99(2), S787 - 97 Otitis media and eustachian tube dysfunction: connection to allergic rhinitis; Fireman P; Otitis media and otitis media with effusion are among the most common childhood illnesses and contribute a great deal to health care costs . The cause of otitis media is multifactorial . Eustachian tube dysfunction, bacterial or viral infection of the middle ear, and nasal inflammation resulting from allergic rhinitis or upper respiratory infection are acknowledged contributing factors . Data from epidemiology studies indicate that 25% to 40% of upper respiratory infections in children younger than 3 years are accompanied by an episode of otitis media, 40% to 50% of children older than 3 years with chronic otitis media have confirmed allergic rhinitis . Studies of the pathogenesis of otitis media have identified interactions among infection, allergic reactions, and eustachian tube dysfunction . Nasal inflammation due to allergen challenge results in classic signs and symptoms of allergic rhinitis and eustachian tube dysfunction . Eustachian tube dysfunction leads to increased negative pressure in the middle ear and improper ventilation . Both viral upper respiratory infection and nasal allergic reaction provoke nasal inflammation, eustachian tube dysfunction, and enhanced nasal protein transudation and secretion, which is likely to be sustained and modulated by inflammatory mediators and cytokines . In a study of experimental infection with influenza A virus, histamine release increased from peripheral blood basophils of patients with allergic rhinitis . These data support an interaction between viral infection and nasal allergy in enhancing certain pathophysiologic responses . Viral upper respiratory infections may promote secondary bacterial infections by altering bacterial adherence, modulating host immune and inflammatory responses, and impairing eustachian tube function . In acute otitis media, bacteria are cultured front approximately 70% of middle ear effusions with Streptococcus pneumoniae being the most common organism . Initial management of otitis media consists of appropriate antimicrobial therapy . In the presence of allergic rhinitis, antiallergic therapies may be used to augment symptom resolution and therapeutic response . Surgical insertion of tympanostomy or ventilation tubes to promote drainage of unresolved effusions has become common . Further delineation of the pathogenesis of otitis media and otitis media with effusion will guide appropriate medical management and may decrease the need and frequency of surgical procedures. Epidemiol Infect, 1997 Feb, 118(1), 7 - 15 Epidemiology of invasive Streptococcus pneumoniae infections in adults in Finland; Sankilampi U et al.; Laboratory-based surveillance of invasive pneumococcal infections in adults in Finland from 1983 to 1992 identified 862 episodes of pneumococcal bacteraemia and 97 episodes of meningitis . The overall incidence of invasive pneumococcal infections was 9.1 per 100,000 for all adults per year, but 27.1, 35.8, and 44.5 per 100,000 in those aged 65 years or over, 75 years or over, and 85 years or over, respectively . Most (99.7%) of the pneumococcal strains were sensitive to penicillin . Ninety-five percent of the strains belonged to serogroups/types present in the 23-valent pneumococcal polysaccharide vaccine . Group/type distribution was different in patients aged 16-64 years compared to those 65 years or over (P < 0.001), in bacteraemia compared to meningitis (P < 0.001), and in the years 1983-7 compared to 1988-92 (P < 0.05). Pediatr Infect Dis J, 1997 Feb, 16(2), 195 - 9 Changing epidemiology of invasive Streptococcus pyogenes infections in southern Israel: differences between two ethnic population groups; Chiobotaru P et al.; BACKGROUND: Two ethnic populations (westernized Jews and Bedouins in transition from semi-nomadic to sedentary life conditions) living in Southern Israel and receiving inpatient services in the only medical facility of the region . OBJECTIVE: To determine whether the incidence and severity of Streptococcus pyogenes infections among Jewish and Bedouin children have changed over the years . STUDY DESIGN: Retrospective (1980 to 1994), population-based . Medical charts of children younger than 15 years of age hospitalized with S . pyogenes bacteremia and/or severe invasive infection were reviewed . Incidence rates of bacteremia among Jewish and Bedouin children were calculated separately . RESULTS: The incidence of S . pyogenes bacteremia was 2.82/100,000 between 1980 and 1984, was 2.58/100,000 between 1985 and 1989 and rose significantly during 1990 through 1994 to 4.82/100,000 (P < 0.01) . The observed increment was the result of a significant increase among the Jews, whereas the incidence among the Bedouin population remained relatively stable . Streptococcal toxic shock syndrome was diagnosed in three Jewish patients between 1992 and 1994 . No predominance of any particular streptococcal M-type was observed . CONCLUSIONS: The incidence of pediatric S . pyogenes bacteremia has increased in Southern Israel in recent years . This increase has occurred among the Jewish population, among which the first cases of streptococcal toxic shock syndrome have recently occurred . The increased incidence observed is not the result of dissemination of a single virulent streptococcal clone. J Thorac Cardiovasc Surg, 1997 Feb, 113(2), 285 - 91 Results of allograft aortic valve replacement for complex endocarditis; Dearani JA et al.; METHODS: Between November 1985 and July 1995, 36 patients underwent allograft aortic valve replacement for endocarditis . The mean age of the 29 men and seven women was 53 years (range 25 to 79 years) . Previous procedures included mechanical (n = 9), bioprosthetic (n = 5), and allograft (n = 2) aortic valve replacement, aortic valvotomy (n = 1), and orthotopic heart transplantation (n = 1) . Infecting organisms were Staphylococcus and Streptococcus species in 69% of patients and fungi in 6% . Intraoperative findings demonstrated valvular vegetations (n = 25), annular abscesses (n = 25), and cusp destruction (n = 13) . Complex reconstruction of the aortic anulus was required in 25 patients, and associated procedures included mitral valve repair (n = 2), mitral valve replacement (n = 3), coronary artery bypass grafting (n = 8), repair of ventricular septal defect (n = 4), left ventricular aneurysmectomy (n = 1), and repair of atrial septal defect (n = 1) . Allograft valve insertion was performed by the scalloped technique in seven, intraaortic cylinder technique in 19, and allograft aortic root replacement in 10 . RESULTS: Follow-up was 100% complete at a mean of 2.6 +/- 2.8 years after valve replacement . Operative mortality was 13.8% . Complications included low cardiac output (n = 10), bleeding (n = 2), myocardial infarction (n = 1), stroke (n = 1), renal insufficiency (n = 2), respiratory insufficiency (n = 3), and heart block (n = 8) . Late echocardiogram (mean 2.6 +/- 1.8 years) demonstrated grade III/IV aortic regurgitation in five patients . There were seven late deaths (five cardiac, not valve-related; two noncardiac) . No patient has had recurrence of endocarditis . Actuarial survival at 5 years was 53.1% +/- 11.5% . Univariate analysis demonstrated prosthetic valve endocarditis to adversely affect late survival (p = 0.04) . Cumulative risk of reoperation at 5 years was 8.0% +/- 5.6% . CONCLUSION: Allograft aortic valve replacement facilitated reconstruction of complex aortic valve endocarditis with a low reoperation rate and no recurrent endocarditis in this series. J Rheumatol, 1997 Feb, 24(2), 337 - 40 Acute rheumatic fever in adults: a resurgence in the Hasidic Jewish community; Feuer J et al.; OBJECTIVE: To describe a series of adults diagnosed with acute rheumatic fever (ARF) . METHODS: Retrospective chart review of 14 patients age > 18 years with suspected ARF between 1990 and 1994 in a private rheumatology practice setting . Four additional patients treated at our medical center were included in the study . RESULTS: Twelve patients met Jones criteria for rheumatic fever and were included in the study . Of these, only 3 had a childhood history of rheumatic fever . All had recent onset of arthritis and a history of antecedent sore throat . Only 4 patients, however, had throat cultures positive for B-hemolytic streptococcus . Nine patients were Hasidic Jews . Four patients had carditis . One patient had erythema marginatum, while chorea and subcutaneous nodules were not seen . Nine patients improved taking nonsteroidal antiinflammatory drugs or acetylsalicylic acid; 3 required steroid treatment to control severe arthritis . CONCLUSION: Our clinical experience suggests that ARF occurs frequently, especially among Hasidic Jewish adults . Due to the disabling nature of the arthritis and the significant incidence (33%) of carditis, strict adherence to penicillin prophylaxis guidelines is indicated. Am J Respir Crit Care Med, 1997 Feb, 155(2), 603 - 8 Passive immunization against tumor necrosis factor-alpha impairs host defense during pneumococcal pneumonia in mice; van der Poll T et al.; Streptococcus pneumoniae is the most frequent cause of community-acquired pneumonia . We sought to determine the role of tumor necrosis factor-alpha (TNF) in the pathogenesis of pneumococcal pneumonia . Induction of pneumonia in C57B1/6 mice by intranasal inoculation with 10(6) colony-forming units (cfu) S . pneumoniae resulted in a sustained increase in TNF activity in lung homogenates reaching a plateau between 12 and 72 h (72 h: 185.49 +/- 54.41 ng/g), while plasma TNF activity remained low or undetectable . Treatment with a neutralizing anti-TNF monoclonal antibody 2 h before inoculation strongly reduced lung TNF activity, but only modestly diminished lung interleukin (IL)-1beta levels, and did not significantly influence lung IL-6, IL-10, and interferon-gamma concentrations . Anti-TNF-treated mice had fourfold more S . pneumoniae cfu isolated from lungs than control mice 40 h after inoculation (p < 0.05), although lung myeloperoxidase activities were similar in both treatment groups . Anti-TNF-treated mice died significantly earlier from pneumococcal pneumonia than control mice (p < 0.05) . Endogenously produced TNF is important for host defense during pneumococcal pneumonia. Can J Surg, 1997 Feb, 40(1), 18 - 25 Group A Streptococcus invasive infections: a review; Weiss KA et al.; The incidence of group A Streptococcus (GAS) invasive infections has been increasing worldwide, and there is no obvious explanation for this phenomenon . In 1993, a working group on severe GAS infections was established to define accurately what constitutes an invasive infection . Three types of infection are particularly feared: necrotizing fasciitis, myositis and a newly defined entity, named streptococcal toxic shock syndrome (STSS) because of a certain analogy with its staphylococcal counterpart . GAS produces many toxins responsible for its clinical manifestations . Some of them, labelled streptococcal pyrogenic exotoxins, have been characterized as superantigens . These proteins play a key role in initiating the immune response to GAS and are mostly responsible for the precipitous course of invasive infections . Death rates are high in streptococcal invasive infections, ranging from about 20% for necrotizing fasciitis to almost 100% for myositis . Therapy consists mainly of high doses of antibiotic combinations, aggressive surgery, and intravenous administration of immunoglobulins for STSS. Pediatrics, 1997 Feb, 99(2), 289 - 99 Therapy for children with invasive pneumococcal infections . American Academy of Pediatrics Committee on Infectious Diseases; Hydrogen peroxide in acute otitis media in guinea pigs; Division of Pediatric Otolaryngology--Head and Neck Surgery, Babies and Children's Hospital of New York, New York, 10032, USAEvidence has emerged that oxygen free radicals contribute to middle-ear mucosa damage in acute otitis media (AOM) . Streptococcus pneumoniae is the most common pathogen in AOM and produces hydrogen peroxide, a free radical intermediate, as it grows . To better characterize the mechanism of free radical damage in AOM, an experiment was conducted to examine the production of hydrogen peroxide . Thirty-two guinea pigs were injected transtympanically with bacteria in the left (infected) middle ear and sterile saline into the right (control) middle ear . Middle-ear fluid was removed and analyzed for quantity of hydrogen peroxide . Results indicated significantly greater hydrogen peroxide levels in infected versus control middle-ear fluid at 6, 12, and 24 h . Likely sources of hydrogen peroxide include both the neutrophil response to infection and pneumococcal growth and death. J Clin Invest, 1997 Feb 1, 99(3), 526 - 33 Neutrophil margination, sequestration, and emigration in the lungs of L-selectin-deficient mice; Doyle NA et al.; These studies tested the hypothesis that L-selectin plays a role in neutrophil traffic in the lungs, particularly in neutrophil margination, sequestration, and emigration, using L-selectin-deficient mice . No defect in neutrophil margination within either capillaries or arterioles and venules was observed in uninflamed lungs of L-selectin-deficient mice . The initial rapid sequestration of neutrophils within the pulmonary capillaries 1 min after intravascular injection of complement fragments was not prevented . In contrast, L-selectin did contribute to the prolonged neutrophil sequestration (> or = 5 min) . Interestingly, neutrophil accumulation within noncapillary microvessels required L-selectin at both 1 and 5 min after complement injection . During bacterial pneumonias, L-selectin played a role in neutrophil accumulation within noncapillary microvessels in response to either Escherichia coli or Streptococcus pneumoniae and within capillaries in response to E . coli but not S . pneumoniae . However, L-selectin was not required for emigration of neutrophils or edema in response to either organism . These studies demonstrate a role for L-selectin in the prolonged sequestration of neutrophils in response to intravascular complement fragments, in the intracapillary accumulation of neutrophils during E . coli-induced pneumonia, and in the accumulation of neutrophils within noncapillary microvessels when induced by either intravascular complement fragments or Antimicrob Agents Chemother, 1997 Feb, 41(2), 478 - 80 Trovafloxacin, a new fluoroquinolone with potent activity against Streptococcus pneumoniae; Thomson KS et al.; An in vitro study of the activity of 15 antibacterial agents against 202 recent pediatric isolates of Streptococcus pneumoniae from urban and rural Nebraska and rural Kentucky identified trovafloxacin, ofloxacin, clindamycin, and vancomycin as the most active agents and equally active against both penicillin-susceptible and--resistant strains . In contrast, six beta-lactams, three macrolides, and trimethoprim-sulfamethoxazole were less active overall, especially against penicillin-intermediate and--resistant strains . Trovafloxacin inhibited all strains at a concentration of < or = 0.25 micrograms/ml and was 8- to 16-fold more potent than ofloxacin or ciprofloxacin. Antimicrob Agents Chemother, 1997 Feb, 41(2), 471 - 4 Targeting of DNA gyrase in Streptococcus pneumoniae by sparfloxacin: selective targeting of gyrase or topoisomerase IV by quinolones; Pan XS et al.; gyrA and parC mutations have been identified inn Streptococcus pneumoniae mutants stepwise selected for resistance to sparfloxacin, an antipneumococcal fluoroquinolone . GyrA mutations (at the position equivalent to resistance hot spot Ser-83 in Escherichia coli GyrA) were found in all 17 first-step mutants examined and preceded DNA topoisomerase IV parC mutations (at Ser-79 or Glu-83), which appeared only in second-step mutants . The targeting of gyrase by sparfloxacin in S . pneumoniae but of topoisomerase IV by ciprofloxacin indicates that target preference can be altered by changes in quinolone structure. Obstet Gynecol, 1997 Feb, 89(2), 257 - 60 Group B streptococcus colonization in pregnant diabetic women; Ramos E et al.; OBJECTIVE: To evaluate the influence of maternal diabetes on the risk of group B streptococcus colonization during pregnancy . METHODS: We prospectively analyzed data on 105 pregnant women with diabetes mellitus, both pregestational and gestational, and a control group of 300 pregnant women without carbohydrate intolerance . All had singleton gestations, negative tests for human immunodeficiency virus, and intact membranes at enrollment . Culture specimens for group B streptococcus were obtained from the lower vaginal walls and rectum . Two-tailed unpaired Student t test, Mann-Whitney U test, and chi 2 test were used as appropriate . Multiple logistic regression analyses were performed to evaluate the independent influence of maternal diabetes on the rate of group B streptococcus colonization . RESULTS: Compared to controls, diabetic women had a higher colonization rate (43.8 versus 22.7%, odds ratio {OR} 2.56, 95% confidence interval {CI} 1.6, 4.1) . The prevalence of group B streptococcus colonization in pregestational diabetic women was 54.1% and in women with gestational diabetes it was 35.1% (P = .05) . Among women with pregestational diabetes, the prevalence of group B streptococcus colonization was 59.1% in class B and 50.0% in class C to R (P = not significant) . After we adjusted for maternal age, race, and obesity, diabetic women continued to be at increased risk of group B streptococcus colonization (OR 3.1, 95% CI 1.8, 5.2) . CONCLUSION: Carbohydrate intolerance appears to be an independent risk factor for group B streptococcus colonization during pregnancy. Infect Immun, 1997 Feb, 65(2), 794 - 7 Identification of a frameshift mutation resulting in premature termination and loss of cell wall anchoring of the PAc antigen of Streptococcus mutans GS-5; Murakami Y et al.; Most strains of Streptococcus mutans possess a 190-kDa protein antigen (PAc) on their cell surfaces, while strain GS-5 produces extracellularly a 155-kDa PAc protein . The pac gene of strain GS-5 consists of 3,477 bp and codes for a protein of 1,158 amino acids . One insertion of an adenine into the 3,469th, 3,470th, or 3,471st position from the start codon results in a frameshift mutation at codon 1157 with subsequent termination after 3 additional codons. Infect Immun, 1997 Feb, 65(2), 640 - 4 Oral immunization with PspA elicits protective humoral immunity against Streptococcus pneumoniae infection; Yamamoto M et al.; Streptococcus pneumoniae is a major respiratory mucosal pathogen affecting infants and children . Although a polysaccharide-based vaccine has been useful in adult populations, it does not elicit protective immunity in infants and young children . Pneumococcal surface protein A (PspA) is a highly immunogenic surface protein produced by all strains of Streptococcus pneumoniae . Previous studies have shown that systemic immunization of mice with PspA can elicit protective immunity against fatal pneumococcal infection . In this study, we demonstrated that oral immunization with PspA could elicit protective immune responses against pneumococcal infection . When mice were orally immunized with PspA alone, low levels of PspA-specific immunoglobulin G (IgG) responses were induced in serum; none was induced in secretion . On the other hand, when PspA was given orally with the mucosal adjuvant cholera toxin (CT), significant levels of IgG and IgA anti-PspA responses were induced in serum . The major IgG subclass was IgG1, followed by IgG2b, a profile of antibody response supported by Th2-type cells . In addition, all mice orally immunized with PspA and CT were protected from the lethal challenge with capsular serotype 3 S . pneumoniae A66 . These results suggested that an oral PspA vaccine may be a useful means of preventing pneumococcal disease. Infect Immun, 1997 Feb, 65(2), 484 - 7 Localization by site-directed mutagenesis of the site in human complement factor H that binds to Streptococcus pyogenes M protein; Sharma AK et al.; M-protein receptors located on Streptococcus pyogenes cells are known to bind human plasma protein factor H . Human factor H is composed of 20 short consensus repeat (SCR) domains containing approximately 60 amino acids each . Factor H controls the activation of the alternative pathway of complement in plasma . We have scanned the entire human factor H molecule by site-directed deletion mutagenesis, expressed the recombinant proteins in insect cells using the baculovirus system, and measured the binding of different purified mutant proteins to three strains of S . pyogenes . These studies have revealed that recombinant factor H lacking SCR domains 6 to 10 does not bind to wild-type M+ S . pyogenes JRS4 . Experiments performed with S . pyogenes JRS251, in which both C-repeat domains of M protein were deleted, demonstrated that all of the factor H mutant proteins bound weakly to these cells except those lacking the SCR region from domains 6 to 10 . Neither human factor H nor any of the recombinant proteins bound to the M- strain JRS145 . Our results indicate that the only binding site on human factor H that interacts with streptococcus M protein is located in SCR domains 6 to 10 of factor H and that regions of M protein outside the C-repeat domains are involved in binding factor H. Infect Immun, 1997 Feb, 65(2), 466 - 71 Role of coagulase in a murine model of hematogenous pulmonary infection induced by intravenous injection of Staphylococcus aureus enmeshed in agar beads; Sawai T et al.; We describe a novel mouse model of acute staphylococcal pneumonia induced by intravenous injection of Staphylococcus aureus enmeshed in agar beads . For comparison, we also used various strains of bacteria, including three strains of S . aureus, two strains of Staphylococcus epidermidis, one strain of Streptococcus pyogenes, three strains of Pseudomonas aeruginosa, and one strain of Klebsiella pneumoniae . All except two strains of S . aureus were cleared rapidly from the lungs . When S . aureus NUMR1 enmeshed in agar beads was injected intravenously, the organisms concentrated and remained in the lung for a period longer than several weeks . Multiple lung abscesses were evident macroscopically, and histological examination of the infected lung showed multiple lung abscesses around the pulmonary arterioles, consisting of bacterial colonies encircled with fibrin filaments and surrounded by inflammatory cells of neutrophils and macrophages . When 14 strains of clinically isolated S . aureus were injected intravenously, the number of bacteria recovered from the lung tissue 7 days after infection correlated with the titer of staphylocoagulase (P < 0.01) but not with the titer of clumping factor . Injection of coagulase-deficient mutant strain DU5843 was associated with a markedly reduced number of viable bacteria isolated from the lung, compared with its coagulase-positive parental strain DU5789 . Our results suggest that coagulase may play a role in the development of blood-borne staphylococcal pneumonia in our model . Our animal model is simple and reproducible and resembles blood-borne staphylococcal pneumonia in humans, and it could be useful for investigating the pathogenicity or treatment of staphylococcal pulmonary infection, including infections with methicillin-resistant S . aureus. J Bacteriol, 1997 Feb, 179(3), 650 - 5 Role of the citrate pathway in glutamate biosynthesis by Streptococcus mutans; Cvitkovitch DG et al.; In work previously reported (J . A . Gutierrez, P . J . Crowley, D . P . Brown, J . D . Hillman, P . Youngman, and A . S . Bleiweis, J . Bacteriol . 178:4166-4175, 1996), a Tn917 transposon-generated mutant of Streptococcus mutans JH1005 unable to synthesize glutamate anaerobically was isolated and the insertion point of the transposon was determined to be in the icd gene encoding isocitrate dehydrogenase (ICDH) . The intact icd gene of S . mutans has now been isolated from an S . mutans genomic plasmid library by complementation of an icd mutation in Escherichia coli host strain EB106 . Genetic analysis of the complementing plasmid pJG400 revealed an open reading frame (ORF) of 1,182 nucleotides which encoded an enzyme of 393 amino acids with a predicted molecular mass of 43 kDa . The nucleotide sequence contained regions of high (60 to 72%) homology with icd genes from three other bacterial species . Immediately 5' of the icd gene, we discovered an ORF of 1,119 nucleotides in length, designated citZ, encoding a homolog of known citrate synthase genes from other bacteria . This ORF encoded a predicted protein of 372 amino acids with a molecular mass of 43 kDa . Furthermore, plasmid pJG400 was also able to complement a citrate synthase (gltA) mutation of E . coli W620 . The enzyme activities of both ICDH, found to be NAD+ dependent, and citrate synthase were measured in cell extracts of wild-type S . mutans and E . coli mutants harboring plasmid pJG400 . The region 5' from the citZ gene also revealed a partial ORF encoding 264 carboxy-terminal amino acids of a putative aconitase gene . The genetic and biochemical evidence indicates that S . mutans possesses the enzymes required to convert acetyl coenzyme A and oxalacetate to alpha-ketoglutarate, which is necessary for the synthesis of glutamic acid . Indeed, S . mutans JH1005 was shown to assimilate ammonia as a sole source of nitrogen in minimal medium devoid of organic nitrogen sources. Vet Rec, 1997 Jan 25, 140(4), 84 - 90 Naturally occurring persistent and asymptomatic infection of the guttural pouches of horses with Streptococcus equi; Newton JR et al.; During an outbreak of strangles on a farm with approximately 1500 horses, the spread of Streptococcus equi infection was monitored by repeated nasopharyngeal swabbing and culture . In order to control the infection and prevent new introductions of strangles on to the premises, a system of quarantine and swabbing of cases and all incoming animals was instituted . Long-term carriage of the organism was detected in four clinically healthy convalescent animals, and in two of 350 new ponies; it persisted for between seven and 39 months, but it was detected only intermittently by the culture of swabs which was a much less sensitive method than the culture of guttural pouch lavages taken by endoscopy (45 per cent v 88 per cent sensitivity, respectively, for any single sample) . Repeated swabs were often negative for several weeks between positive samples . Nonetheless, in all but one of the long-term carriers, S equi was detected by culture of repeated swabs taken over a period of less than two to three months . Infection was detected unilaterally in the guttural pouches of five of the carriers and was accompanied by large numbers of neutrophils in the lavage samples whether or not there was empyema . Abnormalities of the affected guttural pouches were detectable by radiography but only after the instillation of contrast medium . The study indicated that clinically healthy long-term carriers of S equi present a serious risk of spreading strangles, particularly because they may be detected only by repeated nasopharyngeal swabbing over two to three months. Tidsskr Nor Laegeforen, 1997 Jan 10, 117(1), 32 - 5 {Serious streptococcal infections of the head and neck region}; Kongelf E et al.; This article describes the four cases of serious infections caused by Streptococcus pyogenes in the head and neck . Three patients presented with invasive infections of the soft tissues in the neck and one with epiglottitis . Two patients fulfilled the criteria for toxic streptococcal shock syndrome . The incidence of severe streptococcal disease is increasing in Norway, which emphasizes the importance of an aggressive attitude when diagnosing and treating atypical throat infections. Int J Pediatr Otorhinolaryngol, 1997 Jan 3, 38(3), 263 - 71 Pediatric deep space neck infections: the Medical College of Wisconsin experience; Flanary VA et al.; A retrospective review was performed on 39 patients with deep space neck infection admitted to the Children's Hospital of Wisconsin over a nine year period . The signs and symptoms as well as issues of diagnosis and treatment were reviewed with attention to the use of computed tomography (CT) scans . Beta hemolytic streptococcus was the most commonly cultured organism followed by alpha hemolytic streptococcus . Sixteen patients underwent CT scans . Twelve were diagnosed with an abscess by CT scan . An abscess was confirmed in ten patients . Necrotic lymph nodes mimicked abscesses on CT scans and resulted in negative surgical findings . Airway obstruction occurred in 30% of the children in the study . Children under the age of 36 months had a significantly higher rate of airway obstruction upon presentation compared to older children (P < 0.05) . There should be a high index of suspicion of upper airway compromise in children under the age of 36 months with a deep neck infection. Biochem Biophys Res Commun, 1997 Jan 3, 230(1), 13 - 5 Purification of streptodornase from Streptococcus equisimilis and its DNA-induced conformational change; Lee M et al.; Extracellular streptodornase was purified from fermentation media of Streptococcus equisimilis by stepwise carboxymethyl-Sepharose column chromatography . The active enzyme fraction was eluted with phosphate buffer containing 0.2 M NaCl . The purified enzyme showed a homogeneity on SDS-PAGE and had a subunit molecular weight of 35 kDa . Conformational change of streptodornase by binding to calf thymus DNA was examined by circular dichroism (CD) . CD study clearly showed a DNA-induced conformational change in the secondary structure of streptodornase, resulting in a decrease of alpha-helical content of the enzyme. Am J Chin Med, 1997, 25(2), 175 - 80 Studies on the antimicrobial activity of juglans regia; Alkhawajah AM; Juglans regia L . bark is used in some countries as a toothbrush and as a dye for coloring the lips for cosmetic purposes . Its extract showed a broad spectrum antimicrobial activity in a dose dependent manner . It inhibited the growth of several species of pathogenic micro-organisms representing Gram-positive bacteria (Staphylococcus aureus and Streptococcus mutans), Gram-negative bacteria (Esherichia coli and Pseudomonas aeruginosa) and a pathogenic yeast (Candida albicans) . The extract has either synergistic or additive action when tested with a wide range of antibacterial drugs . It also increased the pH of saliva . Thus, brushing the teeth with this bark may improve oral hygiene, prevent plaque and caries formation, and reduce the incidence of gingival and periodontal infections. Acta Otolaryngol Suppl, 1997, 529, 212 - 4 Identification of Streptococcus pyogenes on tonsillar epithelium during infection; Stenfors LE et al.; Epithelial cells were swabbed from the tonsillar surfaces of 5 patients with acute tonsillitis culture-positive for Streptococcus pyogenes . By using 10 nm gold particles conjugated to antiserum to S . pyogenes it was possible to trace the actual microorganisms when examined in a transmission electron microscope . The S . pyogenes bacteria, usually in pairs, were attached to the epithelial surface by their pili . The bacteria often formed a hollow in the epithelial cell surface . Coccus-shaped bacteria expressing positive affinity to immunogold-labelled antiserum were intermingled with bacteria, often rods, having no affinity whatsoever to the antiserum . With the immunocytological technique outlined in this study it is possible to study more closely cellular/bacterial adhesion mechanisms. Acta Otolaryngol Suppl, 1997, 529, 158 - 61 Immunoglobulin-coated bacteria in effusions obtained during chronic maxillary sinusitis; Rantala H et al.; Local protection of the maxillary sinuses against bacterial invasion takes both specific and non-specific forms . The present study is intended to evaluate the participation of the specific protective factors, immunoglobulins IgG, secretory IgA, IgM and complement, in protecting the maxillary sinuses during chronic maxillary sinusitis (CMS) . We collected 47 sinus effusion samples from 37 patients (17 male, 20 female) with current CMS of at least 3 months' duration . Patients' ages ranged from 3 to 80 years . The effusion material was subjected to qualitative and quantitative bacteriological analyses, while bacterial coating with IgG, SIgA, IgM and C3b was determined using an immunofluorescence technique . Detectable bacteria were harboured by 55% of the samples, the most common species being Moraxella catarrhalis, Streptococcus pneumoniae and Staphylococcus aureus . The bacterial counts ranged from 0 to 10(9) per ml effusion . Half of the samples hosting detectable bacteria showed microorganisms coated with protective immunoglobulins . Antibacterial factors had completely eradicated the microorganisms in 45% of the CMS cases and coated the organisms with specific immunoglobulins in a further 28%. Acta Otolaryngol Suppl, 1997, 529, 137 - 9 Ciliary ultrastructure in experimental sinusitis; Toskala E et al.; Ultrastructure of respiratory cilia was observed in experimental sinusitis of rabbit maxillary sinuses . Sinus mucosa of 15 rabbits was inoculated with Streptococcus pneumonia bacteria and of 16 rabbits with Bacteroides fragilis bacteria . Specimens were taken during 12 weeks' observation time and they were studied by transmission electron microscopy from the cross-sections . A special emphasis was paid to the number of cilia, the ciliary orientation, the tubular anomalies, the presence of dynein arms and the compound cilia . It seems likely that pneumococcal sinusitis is a more toxic infection to the epithelium causing loss of ciliated cells and cilia than B . fragilis infection . In anaerobic infection ciliary ultrastructure remains normal and dynein arms as well as normal tubular ultrastructure were seen even after 12 weeks' infection. Caries Res, 1997, 31(5), 373 - 8 Effect of low levels of fluoride on proton excretion and intracellular pH in glycolysing streptococcal cells under strictly anaerobic conditions; Guha-Chowdhury N et al.; The effect of low levels of fluoride on intracellular acid production and proton excretion in Streptococcus mutans NCTC 10449 at different growth and extracellular pH (pHo) levels was monitored under strictly anaerobic conditions . The sensitivity of S . mutans to fluoride increased as pHo decreased . Cells grown under acidic (pH 6.0 and 5.5) conditions were more resistant to fluoride than cells grown at a neutral pH . Under acidic extracellular conditions (pHo = 5.0), 0.025 mM fluoride inhibited proton excretion by approximately 50% in cells grown at pH 7.0 . Slightly higher levels of fluoride (0.05-0.07 mM) were required for 50% or more inhibition in cells exposed to alkaline extracellular conditions or cells grown at acidic pH . Such levels of fluoride are about 10-20 times lower than that reported previously . Therefore, it is possible that as pH falls during initial bacterial glycolysis, sufficient amounts of anionic fluoride may be released, from its bound form in plaque, to cause significant inhibition of net proton movement out of the bacterial cell during further glycolysis, especially under the anaerobic environment of the deep layers of plaque . In addition to proton excretion, fluoride was also found to inhibit intracellular acid production. Microbios, 1997, 89(360-361), 171 - 85 Immunochemical localization of CAMP factor (protein B) in Streptococcus agalactiae; Takaisi-Kikuni NB et al.; Biochemical and immunochemical investigations were used in order to study the quantitative and qualitative localization of CAMP factor (protein B) in the cell fractions of Streptococcus agalactiae during the logarithmic growth phase . The dynamic quantitative distribution of CAMP factor activity showed that higher concentrations of CAMP factor were found in the cytoplasm than in the cell envelopes . A maximal intracellular accumulation of CAMP factor activity was observed in the late log phase . Immunoblotting analysis using specific anti-CAMP-IgG showed that CAMP factor could be detected in the different cell fractions of S . agalactiae . During the early log phase, CAMP factor was present as a single 25 kD protein band in the cytoplasm; white it was found together with its 26 and 24 kD satellite proteins in the cytoplasmic membrane and the cell wall as well as in all the cell fractions in the mid- and late log phases . Intracellular CAMP factor exhibited the same antigenic and amphiphilic behaviour as the extracellular species . Additionally, a newly discovered amphiphilic protein of approximately 54 kD which exhibited similar antigenicity with the CAMP factor was present in all the cell fractions . Immunoelectron microscopic examinations using ferritin-labelled antibodies revealed that CAMP factor was mainly found in the cytoplasm, whereas it was associated to a minor extent with the cell envelopes . Interestingly, an accumulation of CAMP factor was also localized either at the sites of cross-wall initiation or at the cell surfaces where the cell wall became autolysed. Respiration, 1997, 64(4), 313 - 5 Primary purulent mediastinitis due to Streptococcus milleri; Shishido H et al.; Streptococcus milleri mediastinitis had resolved in a 44-year-old male after 3 weeks of combined parenteral antibiotic therapy including clindamycin, which showed the greatest in vitro activity against S . milleri isolated from this patient, and surgical drainage . This case demonstrates that primary purulent mediastinitis may be caused by a strain of S . milleri with or without other bacterial species, and suggests that S . milleri should be added to the list of causative organisms of purulent mediastinitis even when the patient has not undergone a surgical procedure. Scand J Infect Dis, 1997, 29(3), 255 - 7 Choice of an oral beta-lactam antibiotic for infections due to penicillin-resistant Streptococcus pneumoniae; Goldstein FW; The activity, pharmacokinetic and pharmacodynamic parameters of 5 oral beta-lactams have been compared against 400 penicillin-resistant Streptococcus pneumoniae (PRSP) isolated in 9 European countries . All the data have been calculated for the highest recommended oral dosage in France . Amoxicillin was by far the most effective antibiotic when considering its intrinsic activity (96% of the PRSP inhibited at 2 mg/l), the inhibitory quotient (100% of the PRSP > 1 vs 69.2% for cefuroxime) or a time above MIC > 40% which best correlates with clinical results (96% for amoxicillin vs < 25% for the cephalosporins). Scand J Infect Dis, 1997, 29(3), 251 - 4 Antimicrobial resistance of invasive Streptococcus pneumoniae in Slovenia, 1993-1995 . The Slovenian Meningitis Study Group; Cizman M et al.; The susceptibility of 108 Streptococcus pneumoniae strains isolated from normally sterile body sites during 1993-1995 in Slovenia has been studied . Overall resistance to penicillin, erythromycin, trimethoprim-sulfamethoxazole, cefuroxime, cefaclor and chloramphenicol was 16.6, 0.9, 26.8, 0, 4.5 and 4.6%, respectively . All penicillin-resistant isolates (intermediate resistance) were susceptible to cefotaxime, ceftriaxone and vancomycin . Isolates less susceptible to penicillin were also significantly less sensitive to chloramphenicol, cefaclor and trimethoprim-sulfamethoxazole than penicillin-sensitive strains . Pneumococci isolated in children were significantly (p < 0.05) more resistant to trimethoprim-sulfamethoxazole than those isolated in adults . The study demonstrated moderate resistance rate of S . pneumoniae to penicillin and trimethoprim-sulfamethoxazole and a low-level resistance rate to erythromycin, cefaclor and chloramphenicol . No straightforward correlation between overall consumption of antibiotics and antimicrobial resistance was found. Immunol Res, 1997, 16(2), 127 - 36 C-reactive protein: structural biology, gene expression, and host defense function; Szalai AJ et al.; Over the past few years substantial insight was gained into the biology and biochemistry of human C-reactive protein (CRP) . X-ray crystallography in conjunction with mutational analyses, generated the three-dimensional structure of the protein and indicated the topology and structure of ligand-binding sites . Using human CRP transgenic mice infected with Streptococcus pneumoniae, we obtained data that clearly established CRP as an important host defense molecule . Studies using the same mice revealed a previously unknown testosterone-dependence of constitutive expression of human CRP . In this article we provide a brief overview of these recent findings. J Cardiol, 1997, 29 Suppl 2, 125 - 8 {A patient with mitral stenosis due to infective endocarditis}; Nakajima Y et al.; A 51-year-old woman presented with mild stenosis of the mitral valve which had become thickened and rigid due to infective endocarditis, manifesting as persistent fever of up to 40 degrees C and general fatigue of a few days' duration . A harsh systolic murmur was heard . Multiple blood cultures revealed alpha-streptococcus . Echocardiography disclosed asymmetric septal hypertrophy (interventricular septal thickness/posterior wall thickness, 19/14 mm) and systolic anterior wall motion of the mitral valve . Continuous wave Doppler ultrasonography showed a peak left ventricular outflow tract pressure gradient of 170 mmHg . Transesophageal echocardiography revealed vegetations on the anterior mitral leaflet, aortic valve and interventricular septum along the left ventricular outflow tract . In particular, the anterior mitral leaflet was thickened and moved poorly . The calculated mitral valve areas was 1.5 cm2 and peak diastolic left atrium-left ventricle pressure gradient was 7 mmHg . A specimen of the mitral valve did not reveal commissural adhesion, but the anterior mitral leaflet showed marked fibrous thickening caused by scarred vegetation . Based on these findings, the diagnosis was hypertrophic obstructive cardiomyopathy complicated by infective endocarditis and "mitral stenosis" . Valvular regurgitation is a common complication of active and healed infective endocarditis . In contrast, infective endocarditis rarely causes valvular stenosis except for stenosis caused by large fungus vegetation. Int Rev Immunol, 1997, 14(1), 21 - 32 The role of heat shock protein, microbial and autoimmune agents in the aetiology of Behçet's disease; Lehner T; Investigation of the aetiology of Behcet's disease (BD) has focused predominantly on herpes simplex virus immunopathology, autoimmunity to oral mucosa or cross-reactive microbial antigens, and streptococcal infection . These aetiological factors might have a common denominator in microbial heat shock protein (HSP) which shows significant homology with the human mitochondrial HSP . Indeed, the uncommon serotypes of Streptococcus sanguis found in BD cross-react with the 65 kD HSP which also shares antigenicity with an oral mucosal antigen . T cell epitope mapping has identified 4 peptides derived from the sequence of the 65 kD HSP which stimulate specifically TCR gamma delta + lymphocytes from patients with BD . These peptides (111-125, 154-172, 219-233 and 311-325) show significant homology with the corresponding peptides derived from the human 60 kD HSP . The specific proliferative response of TCR gamma delta + lymphocytes elicited by the 4 peptides can be used as a laboratory test for the diagnosis of BD . The pathogenic significance of these peptides has been established by inducing uveitis in rats. Ciba Found Symp, 1997, 207, 93 - 105; discussion 105-11 The antibiotic selective process: concentration-specific amplification of low-level resistant populations; Baquero F et al.; The biochemistry and genetics of antibiotic resistance are far better known than the equally important events underlying the selection of resistant populations . The hidden selection of low-level resistant variants may be a key process in the emergence of high-level antibiotic resistance . Different low-level resistant bacterial subpopulations may be specifically selected by different low antibiotic concentrations . The space in the environment (human body) where a given selective concentration exists represents the selective compartment . For pharmacokinetic reasons, low antibiotic concentrations occur in a larger selective compartment and persist longer than high antibiotic concentrations . The specific selection of low-level variants by low concentrations of antibiotic can be reproduced in experimental in vitro models using mixtures of susceptible and low-level resistant populations . We demonstrated this in Escherichia coli strains harbouring TEM-1, TEM-12 and TEM-10 beta-lactamases challenged by cefotaxime, and also Streptococcus pneumoniae strains with various levels of penicillin resistance challenged by amoxicillin or cefotaxime . In both cases, four hours of antibiotic challenge produced selective peaks of low-level resistant variant populations at low-level antibiotic concentrations . We conclude that variants with small decreases in antibiotic susceptibility may be fully selectable under in vivo circumstances; on the other hand, low-level antibiotic concentrations may have a considerable selective effect on the emergence of antibiotic resistance. Am J Ophthalmol, 1997 Jan, 123(1), 133 - 5 Penicillin-resistant Streptococcus pneumoniae endophthalmitis; Cid M et al.; PURPOSE: To report a case of trabeculectomy-associated endophthalmitis caused by penicillin-resistant Streptococcus pneumoniae . METHOD: Case report . RESULTS: The patient developed endophthalmitis 1 month after an uncomplicated trabeculectomy for primary open-angle glaucoma . Vitreous cultures grew abundant, highly penicillin-resistant S pneumoniae . Despite aggressive treatment with vitrectomy and intravitreal injections of vancomycin hydrochloride and amikacin sulfate, the patient had a poor visual outcome . CONCLUSION: Penicillin-resistant S pneumoniae can cause endophthalmitis after trabeculectomy. Res Vet Sci, 1997 Jan-Feb, 62(1), 74 - 8 Phagocytosis of Streptococcus uberis by bovine mammary gland macrophages; Grant RG et al.; The ability of macrophages isolated from the bovine mammary gland to phagocytose and kill Streptococcus uberis was investigated . The strains of S uberis used were selected on the basis of their known resistance (C197C) or sensitivity (EF20) to phagocytosis by bovine peripheral blood neutrophils in the same assay system . Macrophages isolated from mammary secretions collected during the mid-dry period were capable of phagocytosing both strains of S uberis in the presence of serum and skimmed milk . The removal of complement from serum by heat-inactivation did not influence the opsonization of S uberis for phagocytosis by mammary macrophages and both IgG1 and IgG2 isotypes were found to opsonise both strains . The uptake of S uberis into the cells was confirmed by electron microscopy . Potential mechanisms by which S uberis could resist phagocytosis by neutrophils but not by macrophages are discussed. Br J Ophthalmol, 1997 Jan, 81(1), 37 - 40 Bacteriology of lacrimal duct obstruction in adults; Hartikainen J et al.; AIMS: To determine the current bacteriology of lacrimal duct obstruction (LDO) and to relate the bacteriological findings to the type of symptoms . METHODS: 127 samples were obtained from the lacrimal sac in 118 consecutive adult patients with LDO, including nine bilateral cases . RESULTS: Altogether, 156 isolates were recovered from the 127 samples cultured . Cultures were positive from 84% of the samples . Gram positive bacteria were isolated in 79 (62%) samples . The most frequently cultured bacterial species was Staphylococcus epidermidis, representing 27% of the isolates . Gram negative bacteria were recovered from 26 (20%) samples, and these bacteria were statistically significantly more common in cases with copious discharge than in cases with minor discharge (p = 0.000) . Cases with simple stenosis of the lacrimal duct (SSLD) showed significantly less Streptococcus sp (p = 0.004) and Gram negative organisms (p = 0.004) than those with chronic dacryocystitis . CONCLUSION: The bacteriology of SSLD resembles that of normal conjunctival flora . Chronic dacryocystitis in adults is associated with an increased proportion of Gram negative bacteria which may be a reservoir for postoperative intraocular infection . They should also be taken into account in selecting antimicrobial prophylaxis in lacrimal drainage surgery. J Pept Res, 1997 Jan, 49(1), 59 - 66 Synthesis and antibacterial action of cecropin and proline-arginine-rich peptides from pig intestine; Vunnam S et al.; Two antimicrobial peptides, cecropin P1 (CP1), with a C-terminal carboxyl group, and PR-39, with an amidated, C-terminus, are found in the small intestine of the pig . Each is active against both Gram-positive and Gram-negative bacteria . We have synthesized these peptides and several analogs, including the D-enantiomers and the retro sequences, each with a free or acetylated amino terminus . The CP1 amide was also prepared . The retro CP1 peptides were much less active than the parent CP1 peptide, confirming the importance of sequence or the amide bond and helix dipole direction, and the N alpha-acetyl peptides were also less active, indicating that a free amino terminus is essential for high activity . The ratio of the lethal concentration of L/D isomers of CP1 is less than 1 for Gram-negative, but greater than 1 for Gram-positive bacteria . PR-39 showed no significant chiral selectivity toward Escherichia coli, Bacillus subtilis and Streptococcus pyogenes, but the L/D ratio was high for Pseudomonas aeruginosa (66), and very high for Staphylococcus aureus (> 1000) . In the latter case the lethal concentration for the D-isomer was 0.57 microM, whereas this organism was quite resistant to the L-isomer (> 600 microM) . Thus the enantiomers of CP1 and PR-39 are not equally active for all species . In a plate assay with a very small log-phase inoculum of Staph aureus, D-PR-39 produced a clear zone of killing surrounded by a zone of stimulated growth . After prolonged incubation the two zones became one clear zone . Addition of D-PR-39 to the wells of a dense turbid plate of growing cells showed a cleared zone for each of the test organisms, indicating that PR-39 lyses the bacteria rather than simply inhibiting their multiplication. J Cancer Res Clin Oncol, 1997, 123(3), 173 - 9 Soluble E-selectin in cancer patients as a marker of the therapeutic efficacy of CM101, a tumor-inhibiting anti-neovascularization agent, evaluated in phase I clinical trail; Wamil BD et al.; A polysaccharide toxin, GBS toxin, is produced by group B Streptococcus (GBS) isolates from neonates who died of "early-onset disease" . GBS toxin, named CM101 in the clinic, was hypothesized, on the basis of our previous in vivo studies, to induce inflammation in pulmonary neovasculature in neonates by cross-linking of embryonic receptors still expressed after birth and in tumor neovasculature in adults . Immunohisto chemical in vitro analysis of human biopsies showed that tumor neovasculature is indeed a binding site for CM101 . In vivo studies in mice have demonstrated that CM101 induced inflammatory responses in neoplastic tumor neovasculature causing inhibition of tumor growth and tumor cell necrosis . These experimental observations warranted a phase I clinical trial for CM101 as an anti-neovascularization agent in human cancer therapy . Cancer patients received one cycle of therapy consisting of three treatments during 1 week . CM101 was administered over 15 min by i.v . infusion . Dosages of 7.5 micrograms/kg (1 U/kg), n = 3; 15 micrograms/kg (2 U/kg), n = 6; 24.75 micrograms/kg (3.3 U/kg), n = 3; and 37.5 micrograms/kg (5 U/kg), n = 3 were used . Enzyme-linked immunosorbent sandwich assays (ELISA) of the patients sera showed a marked elevation of soluble E-selectin with a peak concentration observed at 8-12 h after each CM101 infusion . The average baseline value for soluble E-selectin prior to the first treatment was 97.3 +/- 23.4 ng/ml (mean +/- SEM, n = 15) and the average peak level at 8 h was 441.6 +/- 62.4 (mean +/- SEM, n = 15; P < 0.001) . Subsequent treatments gave average maximum soluble E-selectin levels again at 8 h of 466.9 +/- 87.6 and 412.0 +/- 67.8 ng/ml, for treatments 2 and 3 respectively . Baseline values for treatments 2 and 3 were 192.3 +/- 26.4 and 226.4 +/- 26.1 ng/ml respectively (p < 0.01 versus treatment 1) . Out of 15 patients, 5 showed tumor reduction or stabilization and were given additional cycles of therapy . CM101 induced an increase in soluble E-selectin levels, which remained elevated over baseline at the start of the following treatment cycles . The baseline remained elevated for several weeks after the final treatment, i.e., P < 0.01 for levels before treatment 1 compared to those at week 4 after treatment . Elevated soluble E-selectin is considered proof of endothelial engagement in an inflammatory process . Our data support the contention that the inflammatory response observed in these cancer patients is targeting the tumor neovasculature and that measurement of soluble E-selectin levels in patients treated with CM101 can provide important information on the magnitude of CM101-mediated neovascular endothelial activation and tumor cell damage in cancer of endothelial origin, or cancer with a major neo-angiogenic component. Caries Res, 1997, 31(2), 155 - 60 Fluoride and pilocarpine reduce the risk of caries produced by chronic clomipramine treatment in rats; Martinez-Gomis J et al.; The effects of chronic clomipramine treatment on the incidence of caries in the rat and their prevention by fluoride and pilocarpine were investigated . One hundred and twenty male Wistar rats were divided into six groups, five experimental groups, one control group and treated with 50 mg/kg/day of clomipramine, 10 ppm fluoride in drinking water, and 5 mg/kg/day of pilocarpine . All animals were infected with Streptococcus sobrinus 6715 and fed a cariogenic diet ad libitum for 42 days . Water and food consumption, weight gain, salivary flow rate, amylase activity, protein and fluoride concentration in saliva, and caries scores were determined in all animals . Whereas clomipramine significantly increased the fluoride and protein concentration in saliva, pilocarpine only decreased fluoride concentration . Animals treated with clomipramine developed 40% more sulcal caries than nontreated animals . Administration of fluoride (10 ppm) in drinking water and chronic oral administration of pilocarpine prevented the increased risk of developing caries associated with chronic treatment with clomipramine. Alaska Med, 1997 Jan-Mar, 39(1), 3 - 7 Measurement of antimicrobial susceptibility among invasive isolates of Streptococcus pneumoniae: comparison of the Etest with the standard agar dilution method; Fitzgerald MA et al.; High rates of invasive disease caused by Streptococcus pneumoniae occur in the Alaska Native population . Because of the wide use of empiric antibiotics to treat infection in rural regions of Alaska and concern over the emergence of pneumococcal strains now resistant to an increasing number of antibiotics we compared a simple strip system (Etest) for the measurement of antibiotic susceptibilities to the standard agar dilution method . Eighty-two pneumococcal isolates were tested by both methods . Overall, the Etest MICs of 91% of the isolates agreed within one log2 of the agar dilution, and 99.3% agreed within 2 log2 dilutions . There were no very major or major interpretative category discrepancies with the Etest for any antibiotic tested . There were 4.1% minor interpretative errors with the Etest, which generally occurred at the breakpoint between susceptible and intermediate resistance . The results indicated that the Etest was comparable to the agar dilution method for the measurement of antibiotic MICs for Streptococcus pneumoniae. Scand J Infect Dis, 1997, 29(1), 71 - 5 Septic shock in bacteremic patients: risk factors, features and prognosis; Leibovici L et al.; Of 4,289 episodes of bacteremia detected in 3,631 patients, septic shock was diagnosed in 453 episodes (10.5%) . In 56% of shock episodes, septic shock developed more than 24 h after the first positive blood culture was taken . In a logistic regression analysis, variables predictive of septic shock were: advanced age {odds ratio (OR) of 1.015 for an increment of 1 year}; renal failure as an underlying disorder (OR = 1.47); neutropenia (OR of 2.26); curtailed functional capacity (OR of 1.54 for an increment of 1 category); unknown source of infection (OR = 1.66); anaerobic (OR = 2.86), polymicrobial bacteremia (OR = 1.54), or pathogens other than Streptococcus viridans (OR = 0.08 for Streptococcus viridans) . The in-hospital mortality associated with septic shock was 80% vs 21% in episodes of bacteremia without shock, and shock episodes accounted for 31% of all deaths . The fatality rate in shock patients given appropriate empiric antibiotic treatment was 74.9% vs 84.7% in patients given inappropriate treatment (p = 0.01) . Judging by the present results, host factors are more important determinants for development of septic shock in bacteremic patients than the type of pathogen . Even in patients with shock, appropriate empiric antibiotic treatment was associated with an improved chance of survival. Acad Emerg Med, 1997 Jan, 4(1), 44 - 51 A pilot study of the predictive value of plasma tumor necrosis factor alpha and interleukin 1 beta for Streptococcus pneumoniae bacteremia in febrile children; Strait RT et al.; OBJECTIVE: To determine the value of tumor necrosis factor alpha (TNF) and interleukin 1 beta (IL1) levels in predicting Streptococcus pneumoniae bacteremia in nontoxic-appearing, febrile children who do not have a bacterial source for their fever on physical examination . METHODS: A prospective, nested case-control study was conducted in a children's hospital ED . All febrile children < 3 years old who were believed to be immunocompetent and not in shock, had no obvious bacterial source for their fever on physical examination, and had a blood culture obtained were eligible . Plasma obtained at the time of the blood culture was available for analysis by enzyme-linked immunosorbent assays for TNF and IL1 . Children who had positive blood cultures for Streptococcus pneumoniae were the cases . The controls were selected from children who had negative blood cultures . RESULTS: During a 1-year period, 12 cases and 65 controls were identified . There was no significant difference in age, height or duration of fever, or illness acuity between the groups . The following were used as threshold values for positive test: white blood cell (WBC) count > 15.0 x 10(9) cells/L,