Implementation of nutritional care in hospitals: A qualitative study of barriers and facilitators using implementation theory

BACKGROUND

Disease-related malnutrition is prevalent among hospitalised patients, but not all patients achieve the needed nutritional care. At a Danish University Hospital, focus has been on implementing nutritional practices based on clinical guidelines, but there is continuously variation between the wards regarding the quality of nutritional care.

AIM

The aim of this study was to identify the potential barriers and facilitators for implementation of the clinical guidelines for nutritional practices and to recommend suggestions for development of nutritional practices, using a theoretical implementation strategy.

METHOD

The design was a qualitative interview study of employees at a Danish University Hospital, using a semi-structured interview guide. The participants were nurses, nurse's assistant, nurse nutrition expert, head nurse and dieticians. We recruited 11 employees, representing eight different wards.

FINDINGS

The analysis identified six themes: (1) clear allocation of responsibilities and committed management enhances nutrition practices, (2) leadership support is essential, (3) physical settings and tools affect possibilities for action, (4) selection of equivalent staff is core, (5) teaching promotes the knowledge and skills and (6) a dietitian in the ward facilitates implementation of nutritional care. Barriers and facilitators among the themes were identified and has led to suggestions to strengthen nutritional care, based on implementation theory.

CONCLUSION

Various factors were identified as having impact on the implementation of nutrition practices and different suggestions have emerged to accommodate those factors, as well as to apply an implementation strategy to facilitate change in practice.

Patient safety incidents involving transdermal opioids: data from the Danish Patient Safety Database

Background Transdermal opioids are widely used among elderly adults with chronic pain. However, transdermal patches may be involved in a significant proportion of opioid-related patient safety incidents, as the application process includes several subprocesses, each associated with an individual risk of error. Objective The aim was to obtain specific knowledge on patient safety incidents related to transdermal opioid treatment within both the primary care sector and the hospital sector in Denmark. Setting The study is descriptive with data provided by the Danish Patient Safety Database. Methods We manually retrieved all patient safety incidents concerning transdermal opioids reported for 2018 from (1) the hospital sector and (2) the primary care sector. Study data were collected and managed using REDCap electronic data capture tools. Main outcome measure The available information for each incident was sorted into the following categories: location, medication process, type of problem, outcome at time of reporting, and outcome classification. Results A total of 866 patient safety incidents involving transdermal opioids were reported to the Danish Patient Safety Database in 2018. No fatal incidents were present in the database. In 386 cases, the incidents were reported as harmful, and these 386 cases were analysed. Most reports came from the primary care sector (nursing home, home care or social housing). The majority of incidents were related to the administration of the patch in the medication process, and the most prevalent problem was the omission of doses. Conclusion This study has demonstrated that the administration of transdermal opioids is challenging and may cause harm, particularly in the primary care sector. To improve patient safety, optimized systems, including guidelines on drug management and the continuing education of healthcare personnel in transdermal opioid management, are necessary. These guidelines should preferably incorporate reminders and checklists, since the omission of doses was the most reported problem.

Contaminating viral sequences in high-throughput sequencing viromics: a linkage study of 700 sequencing libraries

OBJECTIVES

Sample preparation for high-throughput sequencing (HTS) includes treatment with various laboratory components, potentially carrying viral nucleic acids, the extent of which has not been thoroughly investigated. Our aim was to systematically examine a diverse repertoire of laboratory components used to prepare samples for HTS in order to identify contaminating viral sequences.

METHODS

A total of 322 samples of mainly human origin were analysed using eight protocols, applying a wide variety of laboratory components. Several samples (60% of human specimens) were processed using different protocols. In total, 712 sequencing libraries were investigated for viral sequence contamination.

RESULTS

Among sequences showing similarity to viruses, 493 were significantly associated with the use of laboratory components. Each of these viral sequences had sporadic appearance, only being identified in a subset of the samples treated with the linked laboratory component, and some were not identified in the non-template control samples. Remarkably, more than 65% of all viral sequences identified were within viral clusters linked to the use of laboratory components.

CONCLUSIONS

We show that high prevalence of contaminating viral sequences can be expected in HTS-based virome data and provide an extensive list of novel contaminating viral sequences that can be used for evaluation of viral findings in future virome and metagenome studies. Moreover, we show that detection can be problematic due to stochastic appearance and limited non-template controls. Although the exact origin of these viral sequences requires further research, our results support laboratory-component-linked viral sequence contamination of both biological and synthetic origin.

Epstein-Barr virus early antigen diffuse (EBV-EA/D)-directed immunoglobulin A antibodies in systemic lupus erythematosus patients

OBJECTIVE

We sought to determine whether the serological response towards lytic cycle antigens of Epstein-Barr virus (EBV) is altered in systemic lupus erythematosus (SLE) patients.

METHOD

We used enzyme-linked immunosorbent assay (ELISA) to investigate the prevalence of EBV early antigen diffuse (EBV-EA/D) antibodies in sera from 60 patients with SLE, 40 with scleroderma (SSc), 20 with primary Sjögren's syndrome (pSS), 20 with rheumatoid arthritis (RA), 20 healthy controls, and also subjects with various circulating autoantibodies. Samples from patients were obtained from clinics specialized within the diseases in Denmark and Sweden and samples from healthy controls were obtained from volunteers.

RESULTS

A significant elevated titre of immunoglobulin (Ig)A, IgG, and IgM EBV-EA/D antibodies was found in SLE patients compared to healthy controls, a finding not explained by immunosuppressive treatment or disease activity. The largest difference was observed for IgA EBV-EA/D antibodies (p = 0.0013) with a seropositive rate of 58% in SLE patients and 0% in healthy controls. RA and SSc patients and individuals seropositive for anti-Scl-70 were additionally found to have elevated titres of IgA EBV-EA/D antibodies (40%, p = 0.014; 60%, p = 0.015; and 38.5%, p = 0.045, respectively). However, the titres were generally lower than in SLE patients.

CONCLUSION

Our findings support an association between EBV and SLE. The elevated titre of EBV-EA/D-directed IgA antibodies found in SLE patients could suggest reactivation of EBV in epithelial cells or reinfection of epithelial cells after reactivation in B cells, indicating lack of control of the latent infection.

Electronic real-time surveillance for influenza-like illness: experience from the 2009 influenza A(H1N1) pandemic in Denmark

To enhance surveillance for influenza-like illness (ILI) in Denmark, a year-round electronic reporting system was established in collaboration with the Danish medical on-call service (DMOS). In order to achieve real-time surveillance of ILI, a checkbox for ILI was inserted in the electronic health record and a system for daily transfer of data to the national surveillance centre was implemented. The weekly number of all consultations in DMOS was around 60,000, and activity of ILI peaked in week 46 of 2009 when 9.5% of 73,723 consultations were classified as ILI. The incidence of ILI reached a maximum on 16 November 2009 for individuals between five and 24 years of age, followed by peaks in children under five years, adults aged between 25 and 64 years and on 27 November in senior citizens (65 years old or older). In addition to the established influenza surveillance system, this novel system was useful because it was timelier than the sentinel surveillance system and allowed for a detailed situational analysis including subgroup analysis on a daily basis.

Electronic real-time surveillance for influenza-like illness: experience from the 2009 influenza A(H1N1) pandemic in Denmark

To enhance surveillance for influenza-like illness (ILI)in Denmark, a year-round electronic reporting system was established in collaboration with the Danish medical on-call service (DMOS). In order to achieve real-time surveillance of ILI, a checkbox for ILI was inserted in the electronic health record and a system for daily transfer of data to the national surveillance centre was implemented. The weekly number of all consultations in DMOS was around 60,000, and activity of ILI peaked in week 46 of 2009 when 9.5% of 73,723 consultations were classified as ILI. The incidence of ILI reached a maximum on 16 November 2009 for individuals between five and 24 years of age, followed by peaks in children under five years, adults aged between 25 and 64 years and on 27 November in senior citizens(65 years old or older). In addition to the established influenza surveillance system, this novel system was useful because it was timelier than the sentinel surveillance system and allowed for a detailed situational analysis including subgroup analysis on a daily basis.

Combined oxygen and nitrous oxide microsensor for denitrification studies

The construction of a microsensor which can be used to measure O(2) and N(2)O simultaneously is described. The microsensor exhibited a linear response to both O(2) and N(2)O, and the response to N(2)O was independent of the O(2) concentration and vice versa. The N(2)O detection limit of a microsensor with a tip diameter of 20 mum was around 1 mumol liter. The signals for O(2) and N(2)O were affected by hydrogen sulfide, but other interfering agents were not observed in the biofilms and sediments analyzed. Microprofiles of O(2) and N(2)O were measured in a biofilm which was exposed to acetylene to block the N(2)O reductase activity of denitrifying bacteria. O(2) penetrated about 0.5 mm into the biofilm and was not affected by acetylene, but the N(2)O concentration at 1.4 mm depth increased from 32 to 411 mumol liter after the addition of the inhibitor. The shape of the N(2)O profile after the addition of acetylene showed that denitrification (denitrifying activity) was detectable in all anoxic layers of the biofilm.

Oxygen Responses and Mat Formation by Beggiatoa spp

The behavioral response of single Beggiatoa sp. filaments moving on a gas-permeable membrane was studied by the combined use of microscopy and oxygen microelectrodes during controlled oscillations of oxygen tension. The bacteria reacted to increasing oxygen by reversing the direction of movement. The same step-up phobic response to oxygen was observed when a filament tip or loop glided into a stable microgradient of increasing oxygen. The response was sensitive to a change in oxygen tension of <5% of air saturation min. The response time was 20 to 50 s. Frequently, only part of the filament responded, which led to the formation of sharp bends, loops, and coils. This partial response facilitated the positioning of the long filaments within the narrow O(2)-H(2)S interface. The structure of whole Beggiatoa mats on sediment surfaces varied from loose to dense in relation to shallow or steep oxygen gradients in the 0.3- to 2-mm-thick, unstirred boundary layer. In an illuminated sediment Beggiatoa spp. lived together with photosynthetic organisms and migrated vertically in accordance with light/dark variations. The combined effect of phobic responses to light and oxygen can explain this migration.

Nitrification and denitrification in lake and estuarine sediments measured by the N dilution technique and isotope pairing

The transformation of nitrogen compounds in lake and estuarine sediments incubated in the dark was analyzed in a continuous-flowthrough system. The inflowing water contained NO(3), and by determination of the isotopic composition of the N(2), NO(3), and NH(4) pools in the outflowing water, it was possible to quantify the following reactions: total NO(3) uptake, denitrification based on NO(3) from the overlying water, nitrification, coupled nitrification-denitrification, and N mineralization. In sediment cores from both lake and estuarine environments, benthic microphytes assimilated NO(3) and NH(4) for a period of 25 to 60 h after darkening. Under steady-state conditions in the dark, denitrification of NO(3) originating from the overlying water accounted for 91 to 171 mumol m h in the lake sediments and for 131 to 182 mumol m h in the estuarine sediments, corresponding to approximately 100% of the total NO(3) uptake for both sediments. It seems that high NO(3) uptake by benthic microphytes in the initial dark period may have been misinterpreted in earlier investigations as dissimilatory reduction to ammonium. The rates of coupled nitrification-denitrification within the sediments contributed to 10% of the total denitrification at steady state in the dark, and total nitrification was only twice as high as the coupled process.

Serum eosinophil granule proteins predict asthma risk in allergic rhinitis

BACKGROUND

Allergic rhinitis is a common disease, in which some patients will deteriorate or develop asthma. It is important to characterize these patients, thereby offering the possibility for prevention. This study evaluated eosinophil parameters as potential indicators of deteriorating allergic airway disease.

METHODS

The subjects of the study included all patients who suffered seasonal allergic rhinitis and had participated in a study 6 years earlier, in which blood eosinophils, serum eosinophil cationic protein (ECP) serum eosinophil peroxidase (EPO), nasal lavage ECP and nasal lavage EPO levels were measured. Patients in the present study were interviewed on occurrence of rhinitis symptoms during the last season, rhinitis outside season, asthma-like symptoms and asthma diagnosis, and were skin-prick tested for common aeroallergens. Eosinophil parameters from the study 6 years earlier were then tested for the ability to predict occurrence of new allergies, worsening of rhinitis and occurrence of asthma.

RESULTS

Forty-four patients participated in the study. In four patients seasonal rhinitis symptoms had deteriorated, 10 had experienced perennial rhinitis symptoms, 14 reported asthma-like symptoms and seven had been diagnosed with asthma. Thirteen had developed additional sensitization. Patients developing asthma-like symptoms compared with patients with no such symptoms had significantly higher serum ECP (16.7 microg/l vs 8.2 microg/l; P < or = 0.01) and serum EPO (17.9 microg/l vs 8.8 microg/l; P < or = 0.05). Results were similar, considering patients diagnosed with asthma. Blood eosinophils and nasal lavage parameters were not related to development of asthma and asthma-like symptoms. No eosinophil parameter was related to deterioration of rhinitis or additional sensitization.

CONCLUSION

Serum ECP and EPO in patients with seasonal rhinitis demonstrated a high predictive ability for later development of asthma.

Detection and identification of Anaplasma phagocytophilum, Borrelia burgdorferi, and Rickettsia helvetica in Danish Ixodes ricinus ticks

Borreliosis is an endemic infection in Denmark. Recent serosurveys have indicated that human anaplasmosis may be equally common. The aim of this study was to look for Anaplasma phagocytophilum and related pathogens in Ixodes ricinus ticks and estimate their prevalence, compared to Borrelia, using PCR. Ticks were collected from three locations in Denmark: Jutland, Funen, and Bornholm. Ticks from Jutland and Funen were analysed individually, ticks from Bornholm were analysed in pools of 20. A. phagocytophilum was found in ticks from all areas. A. phagocytophilum was found in 23.6% of ticks from Jutland and Funen, while 11% were positive for Borrelia burgdorferi. The Borrelia genotype B. afzelii was most prevalent, followed by B. valaisiana, B. burgdorferi s.s. and B. garinii.A. phagocytophilum was found in 14.5% of nymphs and 40.5% of adult ticks, while Borrelia was found in 13% of nymphs and 8% of adult ticks. The difference in prevalence between Anaplasma and Borrelia in adult ticks supports the idea that their maintenance cycles in nature may be different. Ticks were also infected with Rickettsia helvetica. Our study indicates that A. phagocytophilum prevalence in ticks in Denmark is as high as Borrelia prevalence and that human anaplasmosis may be unrecognized.

Intranasal and inhaled fluticasone propionate for pollen-induced rhinitis and asthma

BACKGROUND

Studies suggest that nasal treatment might influence lower airway symptoms and function in patients with comorbid rhinitis and asthma. We investigated the effect of intranasal, inhaled corticosteroid or the combination of both in patients with both pollen-induced rhinitis and asthma.

METHODS

A total of 262 patients were randomized to 6 weeks' treatment with intranasal fluticasone propionate (INFP) 200 microg o.d., inhaled fluticasone propionate (IHFP) 250 microg b.i.d., their combination, or intranasal or inhaled placebo, in a multicentre, double-blind, parallel-group study. Treatment was started 2 weeks prior to the pollen season and patients recorded their nasal and bronchial symptoms twice daily. Before and after 4 and 6 weeks' treatment, the patients were assessed for lung function, methacholine responsiveness, and induced sputum cell counts.

RESULTS

Intranasal fluticasone propionate significantly increased the percentages of patients reporting no nasal blockage, sneezing, or rhinorrhoea during the pollen season, compared with IHFP or intranasal or inhaled placebo. In contrast, only IHFP significantly improved morning peak-flow, forced expiratory volume in 1 second (FEV1) and methacholine PD20, and the seasonal increase in the sputum eosinophils and methacholine responsiveness.

CONCLUSIONS

In patients with pollen-induced rhinitis and asthma, the combination of intranasal and IHFP is needed to control the seasonal increase in nasal and asthmatic symptoms.

Anaerobic ammonium oxidation by marine and freshwater planctomycete-like bacteria

Recently, two fresh water species, " Candidatus Brocadia anammoxidans" and " Candidatus Kuenenia stuttgartiensis", and one marine species, " Candidatus Scalindua sorokinii", of planctomycete anammox bacteria have been identified. " Candidatus Scalindua sorokinii" was discovered in the Black Sea, and contributed substantially to the loss of fixed nitrogen. All three species contain a unique organelle--the anammoxosome--in their cytoplasm. The anammoxosome contains the hydrazine/hydroxylamine oxidoreductase enzyme, and is thus the site of anammox catabolism. The anammoxosome is surrounded by a very dense membrane composed almost exclusively of linearly concatenated cyclobutane-containing lipids. These so-called 'ladderanes' are connected to the glycerol moiety via both ester and ether bonds. In natural and man-made ecosystems, anammox bacteria can cooperate with aerobic ammonium-oxidising bacteria, which protect them from harmful oxygen, and provide the necessary nitrite. The cooperation of these two groups of ammonium-oxidising bacteria is the microbial basis for a sustainable one reactor system, CANON (completely autotrophic nitrogen-removal over nitrite) to remove ammonia from high strength wastewater.

Effect of ciclesonide on allergen challenge in subjects with bronchial asthma

BACKGROUND

The aim of this clinical trial was to investigate whether repeated inhalation of the new inhaled steroid ciclesonide reduces the early-phase (EAR) and late-phase (LAR) reactions after allergen challenge in patients with mild allergic asthma. Also, this study provides further data on safety and tolerance of ciclesonide.

METHODS

The study was designed as a double-blind placebo-controlled randomized crossover trial. Following a baseline period, patients were randomized to either of two treatment sequences (ciclesonide/placebo, placebo/ciclesonide) each of which lasted for one week and were separated by 3-5 weeks from the alternate treatment sequence. Patients received 800 micro g ciclesonide twice daily by means of a Cyclohaler. At the end of each treatment patients were subjected to an allergen challenge.

RESULTS

Thirteen asthmatic patients (mean FEV1 of 91% predicted) who experienced an EAR and LAR after allergen challenge participated in the study. The time-average FEV1 decreases 0-2 h (2-12 h) after allergen challenge as measure of the EAR (LAR) were significantly reduced (P < 0.05, one-sided) from 0.426 L to 0.233 L (EAR) and from 0.443 L to 0.213 L (LAR), respectively. Thus, the study results suggest that ciclesonide significantly lowered the extent of EAR and LAR compared to placebo. Ciclesonide was well tolerated and no drug-related adverse events were reported. Cortisol excretion in 24-h urine showed no significant difference between ciclesonide and placebo.

CONCLUSIONS

The study supports the efficacy and safety of ciclesonide.

Intranasal corticosteroids for allergic rhinitis: superior relief?

Whether first-line pharmacological treatment of allergic rhinitis should be antihistamines or intranasal corticosteroids has been discussed for several years. First-generation antihistamines are rarely used in the treatment of allergic rhinitis, mainly because of sedative and anticholinergic adverse effects. On the basis of clinical evidence of efficacy, no second-generation antihistamine seems preferable to another. Similarly, comparisons of topical and oral antihistamines have been unable to demonstrate superior efficacy for one method of administration over the other. Current data documents no striking differences in efficacy and safety parameters between intranasal corticosteroids. When the efficacy of antihistamines and intranasal corticosteroids are compared in patients with allergic rhinitis, present data favours intranasal corticosteroids. Interestingly, data do not show antihistamines as superior for the treatment of conjunctivitis. Safety data from comparative studies in patients with allergic rhinitis do not indicate differences between antihistamines and intranasal corticosteroids. Combining antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis does not provide any additional effect to intranasal corticosteroids alone. On the basis of current data, intranasal corticosteroids seem to offer superior relief in allergic rhinitis than antihistamines.

Ecology of Thioploca spp.: nitrate and sulfur storage in relation to chemical microgradients and influence of Thioploca spp. on the sedimentary nitrogen cycle

Microsensors, including a recently developed NO3(-) biosensor, were applied to measure O(2) and NO3(-) profiles in marine sediments from the upwelling area off central Chile and to investigate the influence of Thioploca spp. on the sedimentary nitrogen metabolism. The studies were performed in undisturbed sediment cores incubated in a small laboratory flume to simulate the environmental conditions of low O(2), high NO3(-), and bottom water current. On addition of NO3(-) and NO2(-), Thioploca spp. exhibited positive chemotaxis and stretched out of the sediment into the flume water. In a core densely populated with Thioploca, the penetration depth of NO3(-) was only 0.5 mm and a sharp maximum of NO3(-) uptake was observed 0.5 mm above the sediment surface. In sediments with only few Thioploca spp., NO3(-) was detectable down to a depth of 2 mm and the maximum consumption rates were observed within the sediment. No chemotaxis toward nitrous oxide (N2O) was observed, which is consistent with the observation that Thioploca does not denitrify but reduces intracellular NO3(-) to NH(4)(+). Measurements of the intracellular NO3(-) and S(0) pools in Thioploca filaments from various depths in the sediment gave insights into possible differences in the migration behavior between the different species. Living filaments containing significant amounts of intracellular NO3(-) were found to a depth of at least 13 cm, providing final proof for the vertical shuttling of Thioploca spp. and nitrate transport into the sediment.

Mode of action of intranasal corticosteroids

The mode of action of intranasal corticosteroids (INCS) is complex. It is not known whether INCS penetrate the nasal mucosa or act on target cells; however, their low systemic activity supports the concept of local action on nasal mucosa. This local effect can nonetheless influence a variety of inflammatory cells and their mediators such as epithelial cells, lymphocytes, basophils, mast cells, and Langerhans cells. Corticosteroid-induced inhibition of immunoglobulin E-dependent release of histamine is a possible but unproven mode of action. Epithelial cells are an important target for corticosteroids, and INCS concentration is high at the epithelial surface. INCS may combine with the corticosteroid receptors in epithelial cells, which are then expelled into the airway lumen together with the dead epithelial cells or migrating inflammatory cells. A reduced influx of mediator cells may explain some of the effects of INCS on rhinitis symptoms, but it cannot explain all of the effects because INCS also reduce the early-phase sneezing and rhinorrhea after an allergen challenge outside the pollen season. In this situation, the number of surface mast cells/basophils is very low, as it is in the absence of allergic rhinitis. The mechanism by which INCS treatment of allergic rhinitis reduces itching, sneezing, and rhinorrhea, the characteristic symptoms of an early-phase response involving mast cell release of histamine, remains to be determined. Studies should be conducted to characterize the broad range of mechanisms by which INCS produce their therapeutic effects in allergic rhinitis.

Herpesvirus type 1-8 in sinus aspirates from HIV-infected patients and immunocompetent individuals

Sinusitis is frequently occurring in HIV-infected patients, but in a substantial number of cases the etiology is unknown. The purpose of this study was by PCR 1) to determine the prevalence of the eight human herpesviruses in sinus aspirates from 24 HIV-positive/AIDS patients with sinusitis 2) to relate the presence of herpesvirus DNA to clinical and immunological parameters and 3) to compare the prevalence of herpesvirus DNA in sinus aspirates from HIV-infected patients with the prevalence observed in 50 immunocompetent patients with sinusitis. DNA from HSV-1, EBV, CMV and HHV-8 was detected in 8 (33%) of the sinus aspirates from HIV-infected patients. In the immunocompetent patients, one of the herpesviruses, HHV-6, was found in one sinus aspirate. These data indicate that herpesviruses are frequently found in sinus aspirates from HIV-infected patients with sinusitis, whereas they do not seem to be related to clinical signs of sinusitis in immunocompetent individuals. The cause of these discrepancies may be due to uncontrolled reactivation of herpesviruses, which is known to occur in immunocompromised individuals. It remains to be established whether the herpesviruses play a pathogenic role in the development of sinusitis in HIV-infected patients.

Detection and subtyping (H5 and H7) of avian type A influenza virus by reverse transcription-PCR and PCR-ELISA

Avian influenza virus infections are a major cause of morbidity and rapid identification of the virus has important clinical, economical and epidemiological implications. We have developed a one-tube Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) for the rapid diagnosis of avian influenza A. A panel of reference influenza strains from various hosts including avian species, human, swine and horse were evaluated in a one tube RT-PCR using primers designed for the amplification of a 218 bp fragment of the NP gene. The PCR products were detected by PCR-ELISA by use of an internal catching probe confirming the NP influenza A origin. The PCR-ELISA was about 100 times more sensitive than detection of PCR products by agarose gel electrophoresis. RT-PCR and detection by PCR-ELISA is comparable in sensitivity to virus propagation in eggs. We also designed primers for the detection of the influenza. A subtypes H5 and H7 shown to have pathogenic potential in poultry. The H5 primers cover the cleavage site of the HA gene and specifically amplify influenza A subtype H5. The H7 primers also cover the HA cleavage site and detected all H7 reference strains investigated. In addition, the H7 primers also amplified very weak and/or additional bands on an agarose gel from other subtypes. However, the H7 origin and the pathogenic potential defined by the presence or absence of basic amino acids at the cleavage site can be determined by sequencing of the PCR product. As far as we know this is the first demonstration of RT-PCR detection on a panel of H7 strains using only one primer set.

Methane microprofiles in a sewage biofilm determined with a microscale biosensor

Microprofiles of the methane concentration in a 3.5-mm-thick sewage outlet biofilm were measured at high spatial and temporal resolution using a microscale biosensor for methane. In the freshly collected biofilm, methane was building up to a concentration of 175 mumol l-1 at 3 mm depth with a total methanogenesis of 0.14 mumol m-2 s-1, as compared to an aerobic respiration (including methane oxidation) of 0.80 mumol m-2 s-1. A model biofilm was established by homogenisation of an in situ biofilm and 12 days of incubation with surplus sodium acetate. The homogenised biofilm was able to maintain 50% of the methanogenic activity in the absence of external electron donor. Oxygen had only a minor effect on the methane production, but aerobic respiration consumed a substantial part of the produced methane and was thus an important control on methane export from the biofilm. A concentration of 2 mmol l-1 nitrate was shown to inhibit methanogenesis only in the upper layer of the biofilm, whereas a further addition of 2 mmol l-1 sulphate inhibited methanogenesis in the entire biofilm. The study demonstrated the power of the methane microsensor in the study of microhabitats with concurrent production and consumption of methane.

Respiratory tract infections in cytomegalovirus-excreting and nonexcreting infants

BACKGROUND

There is evidence of an immunosuppressive effect of cytomegalovirus (CMV), and CMV has been claimed to be a copathogen in respiratory tract infections (RTI). We therefore studied the significance of CMV viral load in infants with RTI, compared the frequency of infection with respiratory viruses and followed the course of RTI in CMV-excreting vs. nonexcreting infants.

METHODS

We examined 201 infants consecutively admitted to the Department of Pediatrics for RTI. At admission nasopharyngeal aspirates, throat swabs and urine were examined for CMV, and nasopharyngeal aspirates were examined for respiratory viruses.

RESULTS

In these patients 23.3% had CMV in the urine, 15.3% had CMV in the throat and 10.9% had CMV in the nasopharynx; 26.2% excreted CMV in at least one site. No relationship was found between CMV viral load and clinical symptoms. Infection with respiratory viruses was as common in infants excreting CMV as in nonexcreting infants. Symptoms and the course of infection were not different in the two groups except that CMV-excreting infants had a significantly higher frequency of rhonchi at admission (P = 0.007) and a tendency for longer duration of cough (P = 0.06).

CONCLUSION

CMV viral load was not related to clinical symptoms. The frequency of infection with common respiratory viruses in infants was independent of CMV excretion. The course of infection was not more complicated in infants excreting CMV; however, a higher frequency of rhonchi was demonstrated in patients with CMV.

Therapeutic ratio of inhaled corticosteroids in adult asthma. A dose-range comparison between fluticasone propionate and budesonide, measuring their effect on bronchial hyperresponsiveness and adrenal cortex function

Inhaled corticosteroids have become the mainstay treatment of bronchial asthma. However, simultaneous evaluations of efficacy and side effects are few. This study aimed to compare the relative effect of fluticasone propionate (FP) and budesonide (BUD) on bronchial responsiveness and endogenous cortisol secretion in adults with asthma. The study was double-blind and included 66 adults with asthma, who were randomized to FP (n = 33) or BUD (n = 33). Prestudy, all participants were clinically stable, using inhaled corticosteroids and hyperresponsive to methacholine. Eligible patients were randomized to three consecutive 2-wk periods with either FP 250 microg twice daily, FP 500 microg twice daily, and FP 1,000 microg twice daily, or BUD 400 microg twice daily, BUD 800 microg twice daily, and BUD 1,600 microg twice daily, delivered by Diskhaler and Turbuhaler, respectively. Before randomization and at the end of each treatment, bronchial methacholine PD(20), 24-h urinary cortisol excretion (24-h UC), plasma cortisol, serum osteocalcin, and blood eosinophils were determined. The relative PD(20) potency between FP and BUD was 2.51 (95% CI, 1.05-5.99; p < 0. 05), while the relative 24-h UC potency was 0.60 (95% CI, 0.44-0.83; p < 0.01). The differential therapeutic ratio (FP/BUD) based on PD(20) potency and 24-h UC was 4.18 (95% CI, 1.16-15.03; p < 0.05). The difference in systemic potency was also seen for plasma cortisol, serum osteocalcin, and blood eosinophils. Therapeutic ratio over a wide dose range, determined by impact on bronchial responsiveness and endogenous corticosteroid production, seems to favor FP.

Regulated exocytosis in immune function: are SNARE-proteins involved?

Inflammation is an important feature in the pathogenesis of most chronic lung diseases. It is characterized by tissue infiltration with various inflammatory cells, including eosinophils, mast cells, basophils, macrophages, neutrophils, T- and B-lymphocytes and dendritic cells (1). In the tissue granulocytes release their toxic granule proteins after being stimulated by soluble mediators released by other inflammatory cells (2). Therefore, it is important to characterize the intracellular mechanisms regulating the transport of the granule contents in inflammatory cells. Intracellular vesicle-traffic in mammalian cells is mediated by transport vesicles that emerge from donor compartments and are specifically targeted to acceptor compartments where they deliver their contents after membrane fusion (3). This traffic leads to three types of fusion: vesicle-intracellular membranes, vesicle-vesicle or vesicle-plasma membrane. The process leading to fusion of vesicle-plasma membrane is called exocytosis, and it delivers proteins to the cell surface (receptors e.g. CD11b, CD18) and exports soluble molecules (mediators e.g. ECP) from the cell. A number of key proteins involved in regulated exocytosis have been identified from inflammatory cells. This review is a brief summary of these proteins and it includes recent results from studies on regulated exocytosis in inflammatory cells.

Salmeterol reduces the need for inhaled corticosteroid in steroid-dependent asthmatics

Previous results have demonstrated addition of long-acting beta2-adrenergic agonists to be beneficial in asthma patients already receiving inhaled corticosteroid. The purpose of this study was to determine, qualitatively as well as quantitatively, the steroid-sparing properties of salmeterol in stable asthma patients receiving maintenance inhaled corticosteroids (800-1600 microg day(-1)). In these patients, the daily dose of beclomethasone dipropionate was reduced by 200 microg each week until asthma deteriorated, with the minimal acceptable dose (MAD) being defined as the dose one step above deterioration (sensitivity period). Following this, patients received three times the MAD for 2 weeks. Patients were randomized to receive either salmeterol 50 microg twice daily or placebo and the MAD was again determined (treatment period). Forced expiratory volume in 1 sec (FEV1) was measured each week. Morning and evening peak expiratory flow (PEF), symptom score and use of bronchodilator were recorded each day. Fifteen patients received salmeterol and 19 placebo. The MAD was significantly lower in the salmeterol group compared with placebo during the treatment period (P<0.01). A 50% reduction of the MAD was achieved by more patients treated with salmeterol than placebo (P = 0.001). Salmeterol caused a significantly greater reduction in daytime symptom score and use of as-needed beta2-agoinist therapy between sensitivity and treatment periods compared with placebo (P<0.05 for both). The results demonstrate, that the addition of salmeterol to corticosteroid treatment offers a clinically relevant potential for reduction of inhaled corticosteroid dose in steroid sensitive asthmatics.

Muscle mass and function in thyrotoxic patients before and during medical treatment

OBJECTIVE

Development of muscle weakness and atrophy are well known complications of thyrotoxicosis, although little is known about its clinical course. The present longitudinal study was therefore undertaken to monitor muscle mass and strength before and during treatment of hyperthyroidism.

DESIGN AND PATIENTS

Five patients (2 male, 3 female; Age 41 +/- 6 years; BMI 22.2 +/- 1.1 kg/m2) with newly diagnosed hyperthyroidism were studied with respect to muscle area, muscle strength, body composition and substrate metabolism at baseline and after 1, 3, 6, 9 and 12 months of treatment.

MEASUREMENTS

Midthigh muscle areas were assessed by computed tomography (CT), while bioelectrical impedance analysis (BIA) was used for assessment of body composition. The isometric strength of the biceps brachialis and quadriceps muscles was assessed by means of a dynamometer and the maximal static ins- and ex-piratory mouth pressures were measured with a respiratory pressure module.

RESULTS

Prior to treatment thyrotoxic patients all displayed elevated levels of total and free T3 and T4 together with suppressed TSH. BMI, fat mass and lean body mass increased significantly during the treatment period, while energy expenditure (EE) decreased. Thigh muscle areas increased by 24% (101.5 +/- 11.5 vs. 125.3 +/- 13.1 cm2, P < 0.05) from entry to peak. Peak time was 9 +/- 0.9 months. During treatment a significant (P < 0.01) increase in muscle strength was observed; arm capacity increased by 48%, while leg capacity increased by 51%. Peak time (months) was: Right arm: 8 +/- 3, left arm: 7 +/- 2, right leg: 5 +/- 3, left leg: 9 +/- 2. Respiratory muscle strength, expressed as maximal ins- or ex-piratory mouth pressure, was significantly impaired among patients at entry. A significant increase in inspiratory and expiratory strength was found from entry to peak (P < 0.05), as inspiratory strength increased by 35% and expiratory by 19%. Inspiratory strength peaked after 7 +/- 1 months, expiratory muscle strength after 6 +/- 1 months.

CONCLUSIONS

In conclusion we find that in patients with thyrotoxicosis muscle mass is reduced by approximately 20% and muscle strength by approximately 40% and that between 5 and 9 months elapse before normal muscle mass and function are reestablished.

[Treatment of HIV infections and AIDS with protease inhibitor and two nucleoside analogs]

Until December 31st 1997, 163 HIV/AIDS patients were treated with HAART at the Department of Infectious Diseases, Aarhus University Hospital. The patients mainly received a combination of zidovudine, lamivudine and saquinavir. They were observed for an average period of 375 days. HAART was found to increase the amount of CD4 lymphocytes in peripheral blood and decrease the number of HIV-RNA copies. Both effects were seen to be more pronounced in patients naive to antiretroviral treatment. However, 64 patients had their protease inhibitor changed during the observation period, 53% due to failure of suppression of the viral load, 25% due to adverse events and 22% due to other reasons.

Phylogenetic relationships of a large marine Beggiatoa

Based upon 16S rRNA sequence and phenotypic similarities, a large, uncultured Beggiatoa sp. from the Bay of Concepción (Chile), is very closely related to the Chilean Thioploca species Thioploca araucae., whose filaments grow as sheathed bundles. The formation of sheathed filament bundles, the key character to distinguish the genus Thioploca from Beggiatoa, places closely related filamentous sulfur-oxidizing bacteria into two different genera, incongruent with 16S rRNA-defined clades.

Eosinophil markers in seasonal allergic rhinitis. Intranasal fluticasone propionate inhibits local and systemic increases during the pollen season

BACKGROUND

The purpose was to study activation markers of the eosinophil granulocytes in seasonal allergic rhinitis, and the impact of topical steroid therapy thereupon.

METHODS

Sixty-three rhinitis patients with monoallergy to grass were examined before and at peak pollen season. Blood eosinophil count, eosinophil cationic protein (ECP), and eosinophil peroxidase (EPO) in serum and nasal lavage fluid were measured. During the season, patients were randomized to treatment with intranasal fluticasone propionate 0.1 mg o.d. (n=26), 0.2 mg o.d. (n=25), or placebo (n=12). Six healthy persons served as controls.

RESULTS

During the season, all parameters, except nasal lavage ECP, increased in the placebo group (P<0.001-P<0.05). Significant differences were seen between the steroid groups and the placebo group for all parameters (P<0.001-P<0.05). Higher eosinophil count (P<0.05), serum EPO (P<0.02), and nasal lavage EPO (P<0.05) were found in patients before season than in controls. The following winter, 44 patients returned for repeated measurement. Lower levels of nasal lavage EPO were observed for patients than levels at the beginning of the season (P<0.0001).

CONCLUSIONS

Intranasal fluticasone propionate reduced inflammation of the nasal mucosa, demonstrated locally by nasal lavage ECP and EPO, and systemically by blood eosinophils, serum ECP, and serum EPO. EPO seemed more sensitive than ECP as indicator of allergic inflammation. EPO demonstrated some perennial eosinophil activity in hay fever patients, increasing locally during spring.

Effect of nasal inflammation and of intranasal anti-inflammatory treatment on bronchial asthma

It is logical to look upon the nose and the bronchi as integrated parts of one 'united airway' and we would like to advance the hypothesis that optimal management of airway disease, caused by inhaled allergens, may necessitate control of inflammation in all parts of the airways. Nasal inflammation can aggravate asthma symptoms, and there is a rationale for giving intranasal anti-inflammatory treatment to patients with asthma. (i) Inhaled allergens are predominantly deposited in the nose, whether a patient suffers from rhinitis, asthma or both. (ii) Antigen presentation consequently takes place in the nose, and the response of the airway immune system is thus initiated in the nasal mucous membrane. (iii) Antigen presentation in the nose may possibly induce cell recruitment and activation not only in the nasal mucosa but also in the lower airways. (iv) Suppression of nasal inflammation may therefore be necessary for optimal management of asthma.

Effect of corticosteroids on nasal blockage in rhinitis measured by objective methods

This paper gives an overview of placebo-controlled studies of the effect of corticosteroid treatment on nasal blockage, based on objective measurements of nasal airway patency. A few studies of perennial rhinitis have indicated that pretreatment with an intranasal corticosteroid has a moderate effect on nasal hyperresponsiveness, measured as the histamine-induced increase of nasal blockage. Whereas the effect on allergen-induced early-phase symptoms is variable, the effect on the late-phase blockage is almost complete. In seasonal allergic rhinitis, a few studies have shown an effect of intranasal steroids on nasal airway resistance, nasal peak flow and on acoustic rhinometry, but there are no reports on the effect in adults with perennial rhinitis. In children with perennial disease, intranasal treatment results in increased nasal patency and, in one study, also in reduced mouth breathing and in an increased threshold for exercise-induced bronchoconstriction. In patients with nasal polyposis, intranasal steroids have an effect on nasal airway resistance and on nasal peak flow both before and after polypectomy. There is convincing evidence that intranasal corticosteroids provide a better effect than antihistamine on nasal blockage. Amazingly, there does not appear to be any report on the effect of systemic corticosteroid treatment on nasal airway patency, and it is therefore difficult to recommend this treatment in a rational dosage. In conclusion, there is a fairly good documentation in support of the efficacy of intranasal steroid treatment on nasal airway patency in rhinitis. An objective measurement of nasal airway patency ought to be the routine in controlled rhinitis trials.

A comparison of aqueous suspensions of budesonide nasal spray (128 micrograms and 256 micrograms once daily) and fluticasone propionate nasal spray (200 micrograms once daily) in the treatment of adult patients with seasonal allergic rhinitis

The efficacy of aqueous suspensions of budesonide nasal spray and fluticasone propionate nasal spray, in the treatment of seasonal allergic rhinitis, was compared in a large, placebo-controlled, two-center study. A 1-week baseline period was followed by a 4- to 6-week treatment period during which 635 adult patients, aged 18-72 years, were randomized to receive either placebo, budesonide 128 micrograms, or 256 micrograms once daily, or fluticasone propionate, 200 micrograms once daily. Nasal and eye symptoms, overall treatment efficacy and safety assessments were made during the study period. Combined, as well as individual, nasal symptoms were significantly improved in all three active treatment groups compared with placebo therapy. Treatment with 256 micrograms/day of budesonide was found to be significantly more effective in reducing the sneezing score compared with 200 micrograms/day of fluticasone propionate. Analysis of symptom scores on days when the pollen count was greater than 10 grains/m3 revealed 256 micrograms/day of budesonide therapy to be significantly more effective in reducing combined symptom scores as well as the individual scores for sneezing and runny nose, compared with 200 micrograms/day fluticasone propionate. The higher dose of budesonide (256 micrograms/day) was also more effective than the lower dose (128 micrograms/day) in reducing sneezing scores and statistical significance was almost reached for the reduction in combined symptom and runny nose scores. Substantial or total control of symptoms was achieved by 31.4%, 85.3%, 88.4%, and 81.9% of patients receiving placebo, 128 micrograms/day of budesonide, 256 micrograms/day of budesonide, and 200 micrograms/day of fluticasone propionate, respectively. The incidence of adverse events was low in all treatment groups. In conclusion, both budesonide and fluticasone propionate treatments were effective and well-tolerated in the treatment of seasonal allergic rhinitis. However, 256 micrograms/day of budesonide tended to be more effective than 200 micrograms/day of fluticasone propionate and 128 micrograms/day of budesonide, especially when patients were exposed to a higher pollen load.

Absence of entero- and cardioviral RNA in multiple sclerosis brain tissue

OBJECTIVES

Epidemiological evidence suggests that an infectious agent may be involved in the pathogenesis of multiple sclerosis (MS). Picornaviruses are possible candidates for an etiological agent, because of their neurotropic properties and ability to cause chronic infections.

MATERIALS AND METHODS

Autopsy brain tissue from 25 patients with clinically definite MS and 33 control patients without inflammatory neurological disease was tested with reverse transcription PCR specific for enteroviruses and cardioviruses.

RESULTS

All specimens were found negative.

CONCLUSION

These results do not support the theory of a persisting entero- or cardioviral infection as the cause of Ms as we found no evidence of the presence of entero- or cardioviral genomes in the brains from MS patients.

Assessment of the allergic reaction in seasonal rhinitis: acoustic rhinometry is a sensitive and objective method

BACKGROUND

Seasonal allergic rhinitis constitutes an excellent in vivo model of an allergic mucosal inflammatory reaction. This offers the opportunity of studying the fundamentals of allergic inflammation in addition to improvement of knowledge on the basal pathophysiological mechanisms of the disease. So far, monitoring methods of disease activity and treatment efficacy have mainly been based upon subjective assessments, illustrating the impact of introducing reliable objective methods.

OBJECTIVE

To investigate the allergic inflammatory reaction of seasonal rhinitis through different objective methods and evaluate these as indicators of disease activity and treatment efficacy.

METHODS

Functional parameters, i.e. acoustic rhinometry and nasal metacholine challenge, and biological markers, i.e. blood eosinophil count, eosinophil cationic protein in serum (s-ECP) and nasal lavage fluid (n-ECP), were assessed before and at peak pollen season in 27 patients with grass pollen induced rhinitis. Patients were randomized to either nasal corticosteroid or placebo treatment and recorded nasal symptom scores.

RESULTS

Acoustic rhinometry revealed a significant difference in favour of steroid treatment (P < 0.05) comparing nasal volumes before and during season. This difference primarily relied upon a decrease in the placebo group (P = 0.05). A reduction from baseline of s-ECP in the steroid group (P < 0.01) was obtained. N-ECP demonstrated a difference between treatment groups, although not significant. Symptom scores increased in all patients during the pollen season, although this was only significant in the placebo treated patients (P < 0.01). The remaining methods applied did not demonstrate further differences, either within or between treatment groups.

CONCLUSION

Our results demonstrate acoustic rhinometry to be a sensitive and objective method of assessment of nasal obstruction. Furthermore, acoustic rhinometry and s-ECP reflect the impact of nasal steroid therapy on seasonal allergic rhinitis.

Human blood eosinophils produce and secrete interleukin 4

Interleukin 4 (Il-4) is an immunoregulatory cytokine which induces T-cell proliferation and differentiation into a Th2 phenotype, and is of particular importance for the induction of IgE synthesis. In the present study, the capability of human peripheral blood eosinophils from allergic and non-allergic donors to produce Il-4 was examined. Using reverse transcribed polymerase chain reaction (RT-PCR), it was shown that highly purified eosinophils from allergic patients express mRNA for Il-4. Resting eosinophils also gave specific immunoreactivity with anti-Il-4 antibodies, consistent with translation of Il-4 mRNA. Light and electron microscopic immunocytochemistry revealed that Il-4 was prestored in the eosinophilic granules. These results were confirmed by Il-4 specific ELISA which showed that Il-4 production could be upregulated in the eosinophils and released from the eosinophils following stimulation with the calcium ionophore A23187. These data indicate that eosinophils may be an important source of Il-4 at sites of allergic inflammation. Thus, eosinophils may act as immunomodulatory cells enhancing the allergic response through formation of Th2-cells and inducing the isotype switching to IgE in human B-cells.

No difference in enterotoxin production among Staphylococcus aureus strains isolated from blood compared with strains isolated from healthy carriers

The production of enterotoxin A, B, C and D by 196 Staphylococcus aureus strains isolated from blood cultures and 95 strains from nasal carriers was investigated. Half of the bacteraemia strains were from patients who died with or because of their infection, the other half from patients who survived. The nasal strains were selected to match the bacteraemia strains regarding phage types. Overall, 30.6% of the bacteraemia strains and 40.0% of the nasal strains produced enterotoxins; enterotoxins B and C were the toxins produced most frequently in both groups. A similar incidence and pattern of enterotoxin production was found among the bacteraemia strains of S. aureus regardless of acquisition of the infection, the portal of entry, presence or absence of endocarditis and outcome of the infection. Thus, the concept that the enterotoxins play an important role in staphylococcal infections, apart from the diseases caused by the toxins per se such as food poisoning and toxic shock syndrome, cannot be substantiated by the results of the present study.

Hepatitis A vaccine. A new convenient single-dose schedule with booster when long-term immunization is warranted

A total of 162 anti-HAV-negative healthy adults were immunized with a single high dose (1440 ELISA units = 1 ml) of inactivated hepatitis A vaccine and a booster was given at month 6. Antibodies were measured after modification of a commercial ELISA kit, enabling quantification of titres down to 6 mIU ml-1. After 14 days, 96% of vaccinees had positive anti-HAV titres (> 20 mIU ml-1), and after 30 days all vaccinees had seroconverted. The geometric mean titres were 150 mIU ml-1 and 380 mIU ml-1 respectively. The booster dose at month 6 elicited a dramatic (25-fold) increase in antibody titres from 125 to 3090 mIU ml-1. Thus a single dose may be a convenient alternative to immunoglobulin for inducing rapid seroprotection, with a booster dose at month 6 ensuring long-lasting protection.

Microscale Distribution of Nitrification Activity in Sediment Determined with a Shielded Microsensor for Nitrate

Microprofiles of O 2 and NO 3 - were measured simultaneously in freshwater sediment with microsensors which were completely free from electrical interference because of coaxial designs. Depth profiles of nitrification (NO 3 - production) and denitrification (NO 3 - consumption) were subsequently determined by computer simulation of the measured microprofiles. The nitrifying bacterial community responded very quickly to changes in environmental conditions, and new steady-state microprofiles of O 2 and NO 3 - were usually approached within a few hours after perturbation. Nitrification started quickly after introduction of O 2 in previously anoxic layers, suggesting prolonged survival of the nitrifiers during anaerobiosis. Changes in the availability of O 2 and NH 4 + greatly affected the nitrification profile, and there was a high rate of coupled nitrification-denitrification under conditions in which nitrification occurred right above the oxic-anoxic interface. Addition of C 2 H 2 rapidly removed the NO 3 - peaks, indicating that NO 3 - production was due mainly to autotrophic nitrification.

A comparison of three diuretic regimens in heart failure

Eight patients with mild heart failure were treated in random order for 1 week with 2 mg bumethanide at 0800 and 1200 (treatment 1) h, 1 mg bumethanide at 0800, 1200, 1800, 2200 (treatment 2) and 5 mg bendroflumethiazide at 0800 and 1800 (treatment 3) h. The 'quality of life' did not differ significantly between the three treatment periods. At the presumed trough of the diuretic effect the circulating blood volume was largest during treatment 1; it was 6.3% smaller during treatment 2 (P < 0.02) and 6.7% lower during treatment 3 (P < 0.05). In comparison with treatment 1, the maximal increase in rate-pressure product during physical exercise was 24.6% higher in treatment 3. Compared with treatment 1 the area under the curve (AUC) for plasma lactate during physical exercise was 14% lower during treatment 2 (P < 0.05) and 18% lower during treatment 3 (P < 0.01). These findings suggest that the type of program for diuretic therapy influences the magnitude of inevitable diurnal fluctuations in body fluids, the ability of the heart to work and the ability of the body to adjust to the oxygen demand.

Pathways of organic carbon oxidation in three continental margin sediments

We have combined several different methodologies to quantify rates of organic carbon mineralization by the various electron acceptors in sediments from the coast of Denmark and Norway. Rates of NH4+ and Sigma CO2 liberation sediment incubations were used with O2 penetration depths to conclude that O2 respiration accounted for only between 3.6-17.4% of the total organic carbon oxidation. Dentrification was limited to a narrow zone just below the depth of O2 penetration, and was not a major carbon oxidation pathway. The processes of Fe reduction, Mn reduction and sulfate reduction dominated organic carbon mineralization, but their relative significance varied depending on the sediment. Where high concentrations of Mn-oxide were found (3-4 wt% Mn), only Mn reduction occurred. With lower Mn oxide concentrations more typical of coastal sediments, Fe reduction and sulfate reduction were most important and of a similar magnitude. Overall, most of the measured O2 flux into the sediment was used to oxidized reduced inorganic species and not organic carbon. We suspect that the importance of O2 respiration in many coastal sediments has been overestimated, whereas metal oxide reduction (both Fe and Mn reduction) has probably been well underestimated.