Features Associated With Radiographic Pneumonia in Children with SARS-CoV-2

14% of children with SARS-CoV-2 infections had radiographic pneumonia. Hypoxemia, cough, higher temperature, and older age were associated with pneumonias. In children tested, SARS-CoV-2 test results were not associated with radiographic pneumonia.

Impact of SARS-CoV-2 Infection on the Association Between Laboratory Tests and Severe Outcomes Among Hospitalized Children

Background

To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations.

Methods

We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations.

Results

We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 109/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 109/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts.

Conclusions

Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.

Post-COVID-19 Conditions Among Children 90 Days After SARS-CoV-2 Infection

IMPORTANCE

Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children.

OBJECTIVES

To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls.

EXPOSURE

SARS-CoV-2 detected via nucleic acid testing.

MAIN OUTCOMES AND MEASURES

Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey.

RESULTS

Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference, 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; ≥7 symptoms: aOR, 4.59 [95% CI, 2.50-8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321 [2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391 [10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]).

CONCLUSIONS AND RELEVANCE

In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older.

Outcomes of SARS-CoV-2-Positive Youths Tested in Emergency Departments: The Global PERN-COVID-19 Study

IMPORTANCE

Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized.

OBJECTIVE

To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED).

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021.

EXPOSURES

Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing.

MAIN OUTCOMES AND MEASURES

Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death.

RESULTS

Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). Among a subgroup of 2510 participants discharged home from the ED after initial testing and who had complete follow-up, 50 (2.0%; 95% CI, 1.5%-2.6%) were eventually hospitalized and 12 (0.5%; 95% CI, 0.3%-0.8%) had severe outcomes. Compared with hospitalized SARS-CoV-2-negative youths, the risk of severe outcomes was higher among hospitalized SARS-CoV-2-positive youths (risk difference, 3.9%; 95% CI, 1.1%-6.9%).

CONCLUSIONS AND RELEVANCE

In this study, approximately 3% of SARS-CoV-2-positive youths tested in EDs experienced severe outcomes within 2 weeks of their ED visit. Among children discharged home from the ED, the risk was much lower. Risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions.

High success and low recurrence with shorter treatment regimen for multidrug-resistant TB in Nepal

SETTING:

Nine drug-resistant TB centres, some of them supported by Damien Foundation in Nepal where >80% of multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB) patients are treated.

OBJECTIVE:

To assess the uptake, effectiveness and safety of the 9–12-month shorter treatment regimen (STR) in MDR/RR-TB patients registered from January 2018 to December 2019.

DESIGN:

This was a cohort study involving secondary programme data.

RESULTS:

Of 631 patients, 301 (48.0%) started and continued STR. Key reasons for ineligibility to start/continue STR were baseline resistance or exposure to second-line drugs (62.0%), contact with extensively drug-resistant TB (XDR-TB) or pre-XDR-TB (7.0%) patients and unavailability of STR drugs (6.0%). Treatment success was 79.6%; unsuccessful outcomes were death (12.0%), lost to follow-up (5.3%), failure (2.7%) and not evaluated (0.7%). Unsuccessful outcomes were significantly associated with HIV positivity and patient age ⩾55 years, with adjusted relative risk of respectively 2.39 (95% CI 1.52–3.77) and 3.86 (95% CI 2.30–6.46). Post-treatment recurrence at 6 and 12 months was respectively 0.5% and 2.4%. Serious adverse events (SAEs) were seen in 15.3% patients — hepatotoxicity and ototoxicity were most common.

CONCLUSION:

STR had a modest uptake, high treatment success and low post-treatment recurrence. For proper detection and management of SAEs, improving pharmacovigilance might be considered. Availability of rapid diagnostic test for second-line drugs is crucial for correct patient management.

Belimumab for systemic lupus erythematosus

BACKGROUND

Belimumab, the first biologic approved for the treatment of systemic lupus erythematosus (SLE), has been shown to reduce autoantibody levels in people with SLE and help control disease activity.

OBJECTIVES

To assess the benefits and harms of belimumab (alone or in combination) in systematic lupus erythematosus.

SEARCH METHODS

An Information Specialist carried out the searches of CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, the World Health Organization (WHO) International Clinical Trials Registry Platform, and clinicaltrials.gov from inception to 25 September 2019. There were no language or date restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) or controlled clinical trials (CCTs) of belimumab (alone or in combination) compared to placebo/control treatment (immunosuppressive drugs, such as azathioprine, cyclosporine, mycophenolate mofetil or another biologic), in adults with SLE.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

Six RCTs (2917 participants) qualified for quantitative analyses. All included studies were multicenter, international or US-based. The age range of the included participants was 22 to 80 years; most were women; and study duration ranged from 84 days to 76 weeks. The risk of bias was generally low except for attrition bias, which was high in 67% of studies. Compared to placebo, more participants on belimumab 10 mg/kg (Food and Drug Administration (FDA)-approved dose) showed at least a 4-point improvement (reduction) in Safety of Estrogen in Lupus National Assessment (SELENA) - Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score, a validated SLE disease activity index: (risk ratio (RR) 1.33, 95% confidence interval (CI) 1.22 to 1.45; 829/1589 in belimumab group and 424/1077 in placebo; I²= 0%; 4 RCTs; high-certainty evidence). Change in health-related quality of life (HRQOL), assessed by Short Form-36 Physical Component Summary score improvement (range 0 to 100), showed there was probably little or no difference between groups (mean difference 1.6 points, 95% CI 0.30 to 2.90; 401 in belimumab group and 400 in placebo; I²= 0%; 2 RCTs; moderate-certainty evidence). The belimumab 10 mg/kg group showed greater improvement in glucocorticoid dose, with a higher proportion of participants reducing their dose by at least 50% compared to placebo (RR 1.59, 95% CI 1.17 to 2.15; 81/269 in belimumab group and 52/268 in placebo; I²= 0%; 2 RCTs; high-certainty evidence). The proportion of participants experiencing harm may not differ meaningfully between the belimumab 10 mg/kg and placebo groups: one or more serious adverse event (RR 0.87, 95% CI: 0.68 to 1.11; 238/1700 in belimumab group and 199/1190 in placebo; I²= 48%; 5 RCTs; low-certainty evidence; ); one or more serious infection (RR 1.01, 95% CI: 0.66 to 1.54; 44/1230 in belimumab group and 40/955 in placebo; I²= 0%; 4 RCTs; moderate-certainty evidence); and withdrawals due to adverse events (RR 0.82, 95% CI: 0.63 to 1.07; 113/1700 in belimumab group and 94/1190 in placebo; I²= 0%; 5 RCTs; moderate-certainty evidence). Mortality was rare, and may not differ between belimumab 10 mg/kg and placebo (Peto odds ratio 1.15, 95% CI 0.41 to 3.25; 9/1714 in belimumab group and 6/1203 in placebo; I²= 4%; 6 RCTs; low-certainty evidence).

AUTHORS' CONCLUSIONS

The six studies that provided evidence for benefits and harms of belimumab were well-designed, high-quality RCTs. At the FDA-approved dose of 10 mg/kg, based on moderate to high-certainty data, belimumab was probably associated with a clinically meaningful efficacy benefit compared to placebo in participants with SLE at 52 weeks. Evidence related to harms is inconclusive and mostly of moderate to low-certainty evidence. More data are needed for the longer-term efficacy of belimumab.

Bifurcation of the inferior dental nerve canal: an anatomical study

The aims of this study were to find the incidence of bifurcation of the inferior dental nerve (IDN) canal, to describe the characteristics of this variant, and to examine the sensitivity and specificity of dental panoramic tomography to identify it. We classified bifurcations by size and position relative to the main canal and the lower third molar using cone-beam computed tomography (CT) and dental panoramic tomography. In our study of 281 patients, 106 (38%) had bifurcations, and in one quarter, these were classified as large accessory canals. Bifurcations were most commonly found posterior to the lower third molar (n=64, 57%) or within 2mm of the roots of the third molar (n=40, 38%). The sensitivity and specificity of dental panoramic tomography to identify all bifurcations was 11% (95% CI: 5.67 to 17.97) and 91% (95% CI: 85.58 to 94.68), respectively; this was 33% (95% CI: 15.63 to 55.32) and 94% (95% CI: 90.34 to 96.50), respectively, for large bifurcations. Our use of cone-beam CT suggested an incidence of bifid canals of 38%, with a variation in size and distribution in relation to the lower third molar. It also showed that the sensitivity of panoramic radiography to identify them was poor.

Biologics or tofacitinib for rheumatoid arthritis in incomplete responders to methotrexate or other traditional disease-modifying anti-rheumatic drugs: a systematic review and network meta-analysis

BACKGROUND

This is an update of the 2009 Cochrane overview and network meta-analysis (NMA) of biologics for rheumatoid arthritis (RA).

OBJECTIVES

To assess the benefits and harms of nine biologics (abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, tocilizumab) and small molecule tofacitinib, versus comparator (MTX, DMARD, placebo (PL), or a combination) in adults with rheumatoid arthritis who have failed to respond to methotrexate (MTX) or other disease-modifying anti-rheumatic drugs (DMARDs), i.e., MTX/DMARD incomplete responders (MTX/DMARD-IR).

METHODS

We searched for randomized controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (via The Cochrane Library Issue 6, June 2015), MEDLINE (via OVID 1946 to June 2015), and EMBASE (via OVID 1947 to June 2015). Data extraction, risk of bias and GRADE assessments were done in duplicate. We calculated both direct estimates using standard meta-analysis and used Bayesian mixed treatment comparisons approach for NMA estimates to calculate odds ratios (OR) and 95% credible intervals (CrI). We converted OR to risk ratios (RR) which are reported in the abstract for the ease of interpretation.

MAIN RESULTS

This update included 73 new RCTs for a total of 90 RCTs; 79 RCTs with 32,874 participants provided usable data. Few trials were at high risk of bias for blinding of assessors/participants (13% to 21%), selective reporting (4%) or major baseline imbalance (8%); a large number had unclear risk of bias for random sequence generation (68%) or allocation concealment (74%).Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with a statistically significant and clinically meaningful improvement in ACR50 versus comparator (RR 2.71 (95% confidence interval (CI) 2.36 to 3.10); absolute benefit 24% more patients (95% CI 19% to 29%), number needed to treat for an additional beneficial outcome (NNTB) = 5 (4 to 6). NMA estimates for ACR50 in tumor necrosis factor (TNF) biologic+MTX/DMARD (RR 3.23 (95% credible interval (Crl) 2.75 to 3.79), non-TNF biologic+MTX/DMARD (RR 2.99; 95% Crl 2.36 to 3.74), and anakinra + MTX/DMARD (RR 2.37 (95% Crl 1.00 to 4.70) were similar to the direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with a clinically and statistically important improvement in function measured by the Health Assessment Questionnaire (0 to 3 scale, higher = worse function) with a mean difference (MD) based on direct evidence of -0.25 (95% CI -0.28 to -0.22); absolute benefit of -8.3% (95% CI -9.3% to -7.3%), NNTB = 3 (95% CI 2 to 4). NMA estimates for TNF biologic+MTX/DMARD (absolute benefit, -10.3% (95% Crl -14% to -6.7%) and non-TNF biologic+MTX/DMARD (absolute benefit, -7.3% (95% Crl -13.6% to -0.67%) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with clinically and statistically significantly greater proportion of participants achieving remission in RA (defined by disease activity score DAS < 1.6 or DAS28 < 2.6) versus comparator (RR 2.81 (95% CI, 2.23 to 3.53); absolute benefit 18% more patients (95% CI 12% to 25%), NNTB = 6 (4 to 9)). NMA estimates for TNF biologic+MTX/DMARD (absolute improvement 17% (95% Crl 11% to 23%)) and non-TNF biologic+MTX/DMARD (absolute improvement 19% (95% Crl 12% to 28%) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), radiographic progression (scale 0 to 448) was statistically significantly reduced in those on biologics + MTX/DMARDs versus comparator, MD -2.61 (95% CI -4.08 to -1.14). The absolute reduction was small, -0.58% (95% CI -0.91% to -0.25%) and we are unsure of the clinical relevance of this reduction. NMA estimates of TNF biologic+MTX/DMARD (absolute reduction -0.67% (95% Crl -1.4% to -0.12%) and non-TNF biologic+MTX/DMARD (absolute reduction, -0.68% (95% Crl -2.36% to 0.92%)) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for imprecision), results for withdrawals due to adverse events were inconclusive, with wide confidence intervals encompassing the null effect and evidence of an important increase in withdrawals, RR 1.11 (95% CI 0.96 to 1.30). The NMA estimates of TNF biologic+MTX/DMARD (RR 1.24 (95% Crl 0.99 to 1.57)) and non-TNF biologic+MTX/DMARD (RR 1.20 (95% Crl 0.87 to 1.67)) were similarly inconclusive and downgraded to low for both imprecision and indirectness.Based on direct evidence of high quality, biologic+MTX/DMARD was associated with clinically significantly increased risk (statistically borderline significant) of serious adverse events on biologic+MTX/DMARD (Peto OR [can be interpreted as RR due to low event rate] 1.12 (95% CI 0.99 to 1.27); absolute risk 1% (0% to 2%), As well, the NMA estimate for TNF biologic+MTX/DMARD (Peto OR 1.20 (95% Crl 1.01 to 1.43)) showed moderate quality evidence of an increase in the risk of serious adverse events. The other two NMA estimates were downgraded to low quality due to imprecision and indirectness and had wide confidence intervals resulting in uncertainty around the estimates: non-TNF biologics + MTX/DMARD: 1.07 (95% Crl 0.89 to 1.29) and anakinra: RR 1.06 (95% Crl 0.65 to 1.75).Based on direct evidence of low quality (downgraded for serious imprecision), results were inconclusive for cancer (Peto OR 1.07 (95% CI 0.68 to 1.68) for all biologic+MTX/DMARD combinations. The NMA estimates of TNF biologic+MTX/DMARD (Peto OR 1.21 (95% Crl 0.63 to 2.38) and non-TNF biologic+MTX/DMARD (Peto OR 0.99 (95% Crl 0.58 to 1.78)) were similarly inconclusive and downgraded to low quality for both imprecision and indirectness.Main results text shows the results for tofacitinib and differences between medications.

AUTHORS' CONCLUSIONS

Based primarily on RCTs of 6 months' to 12 months' duration, there is moderate quality evidence that the use of biologic+MTX/DMARD in people with rheumatoid arthritis who have failed to respond to MTX or other DMARDs results in clinically important improvement in function and higher ACR50 and remission rates, and increased risk of serious adverse events than the comparator (MTX/DMARD/PL; high quality evidence). Radiographic progression is slowed but its clinical relevance is uncertain. Results were inconclusive for whether biologics + MTX/DMARDs are associated with an increased risk of cancer or withdrawals due to adverse events.

Brief advice on alcohol: as easy as A...B...I?

Alcohol is widely consumed by the majority of the UK population and alcohol-related harm is estimated to cost society £21 billion per year in healthcare, lost productivity costs, crime and antisocial behaviour. The dental setting offers an ideal opportunity to screen for harmful alcohol consumption; however, current emphasis is on the management of acute complications and risk associated in treating patients with excessive alcohol intake rather than screening and patient education. This article outlines ways in which dentists could improve their recognition of 'at risk' patients and then offer practical advice to help reduce the harmful effects of alcohol.

Phase II study of treatment of advanced ovarian cancer with folate-receptor-targeted therapeutic (vintafolide) and companion SPECT-based imaging agent (99mTc-etarfolatide)

BACKGROUND

This report examines (99m)Tc-etarfolatide imaging to identify the presence of folate receptor (FR) on tumors of women with recurrent/refractory ovarian or endometrial cancer and correlates expression with response to FR-targeted therapy (vintafolide).

PATIENTS AND METHODS

In this phase II, single-arm, multicenter study, patients with advanced ovarian cancer were imaged with (99m)Tc-etarfolatide before vintafolide treatment. Up to 10 target lesions (TLs) were selected based on Response Evaluation Criteria In Solid Tumors criteria using computed tomography scans. Single-photon emission computed tomography images of TLs were assessed for (99m)Tc-etarfolatide uptake as either FR positive or negative. Patients were categorized by percentage of TLs positive and grouped as FR(100%), FR(10%-90%), and FR(0%). Lesion and patient response were correlated with etarfolatide uptake.

RESULTS

Forty-nine patients were enrolled; 43 were available for analysis. One hundred thirty-nine lesions were (99m)Tc-etarfolatide evaluable: 110 FR positive and 29 FR negative. Lesion disease control rate (DCR = stable or response) was observed in 56.4% of FR-positive lesions versus 20.7% of FR-negative lesions (P < 0.001). Patient DCR was 57%, 36%, and 33% in FR(100%), FR(10%-90%), and FR(0%) patients, respectively. Median overall survival was 14.6, 9.6, and 3.0 months in FR(100%), FR(10%-90%), and FR(0%) patients, respectively.

CONCLUSIONS

Overall response to FR-targeted therapy and DCR correlate with FR positivity demonstrated by (99m)Tc-etarfolatide imaging.

CLINICAL TRIAL NUMBER

NCT00507741.

Phase II study of treatment of advanced ovarian cancer with folate-receptor-targeted therapeutic (vintafolide) and companion SPECT-based imaging agent (99mTc-etarfolatide)

BACKGROUND

This report examines (99m)Tc-etarfolatide imaging to identify the presence of folate receptor (FR) on tumors of women with recurrent/refractory ovarian or endometrial cancer and correlates expression with response to FR-targeted therapy (vintafolide).

PATIENTS AND METHODS

In this phase II, single-arm, multicenter study, patients with advanced ovarian cancer were imaged with (99m)Tc-etarfolatide before vintafolide treatment. Up to 10 target lesions (TLs) were selected based on Response Evaluation Criteria In Solid Tumors criteria using computed tomography scans. Single-photon emission computed tomography images of TLs were assessed for (99m)Tc-etarfolatide uptake as either FR positive or negative. Patients were categorized by percentage of TLs positive and grouped as FR(100%), FR(10%-90%), and FR(0%). Lesion and patient response were correlated with etarfolatide uptake.

RESULTS

Forty-nine patients were enrolled; 43 were available for analysis. One hundred thirty-nine lesions were (99m)Tc-etarfolatide evaluable: 110 FR positive and 29 FR negative. Lesion disease control rate (DCR = stable or response) was observed in 56.4% of FR-positive lesions versus 20.7% of FR-negative lesions (P < 0.001). Patient DCR was 57%, 36%, and 33% in FR(100%), FR(10%-90%), and FR(0%) patients, respectively. Median overall survival was 14.6, 9.6, and 3.0 months in FR(100%), FR(10%-90%), and FR(0%) patients, respectively.

CONCLUSIONS

Overall response to FR-targeted therapy and DCR correlate with FR positivity demonstrated by (99m)Tc-etarfolatide imaging.

CLINICAL TRIAL NUMBER

NCT00507741.

A phase 2 trial of ponatinib in Philadelphia chromosome-positive leukemias

BACKGROUND

Ponatinib is a potent oral tyrosine kinase inhibitor of unmutated and mutated BCR-ABL, including BCR-ABL with the tyrosine kinase inhibitor-refractory threonine-to-isoleucine mutation at position 315 (T315I). We conducted a phase 2 trial of ponatinib in patients with chronic myeloid leukemia (CML) or Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph-positive ALL).

METHODS

We enrolled 449 heavily pretreated patients who had CML or Ph-positive ALL with resistance to or unacceptable side effects from dasatinib or nilotinib or who had the BCR-ABL T315I mutation. Ponatinib was administered at an initial dose of 45 mg once daily. The median follow-up was 15 months.

RESULTS

Among 267 patients with chronic-phase CML, 56% had a major cytogenetic response (51% of patients with resistance to or unacceptable side effects from dasatinib or nilotinib and 70% of patients with the T315I mutation), 46% had a complete cytogenetic response (40% and 66% in the two subgroups, respectively), and 34% had a major molecular response (27% and 56% in the two subgroups, respectively). Responses were observed regardless of the baseline BCR-ABL kinase domain mutation status and were durable; the estimated rate of a sustained major cytogenetic response of at least 12 months was 91%. No single BCR-ABL mutation conferring resistance to ponatinib was detected. Among 83 patients with accelerated-phase CML, 55% had a major hematologic response and 39% had a major cytogenetic response. Among 62 patients with blast-phase CML, 31% had a major hematologic response and 23% had a major cytogenetic response. Among 32 patients with Ph-positive ALL, 41% had a major hematologic response and 47% had a major cytogenetic response. Common adverse events were thrombocytopenia (in 37% of patients), rash (in 34%), dry skin (in 32%), and abdominal pain (in 22%). Serious arterial thrombotic events were observed in 9% of patients; these events were considered to be treatment-related in 3%. A total of 12% of patients discontinued treatment because of an adverse event.

CONCLUSIONS

Ponatinib had significant antileukemic activity across categories of disease stage and mutation status. (Funded by Ariad Pharmaceuticals and others; PACE ClinicalTrials.gov number, NCT01207440 .).

The effect of NaCl substitution with KCl on Akawi cheese: chemical composition, proteolysis, angiotensin-converting enzyme-inhibitory activity, probiotic survival, texture profile, and sensory properties

The effect of partial substitution of NaCl with KCl on Akawi cheese with probiotic bacteria was investigated during 30 d of storage at 4 °C. Chemical composition, the survival of probiotic and lactic acid bacteria, proteolytic activity, and texture profile analysis were analyzed and sensory analysis was carried out to determine the effects of substitution. No significant differences were observed in moisture, protein, fat, and ash contents among the experimental Akawi cheeses at the same storage period. Significant differences were observed in water-soluble nitrogen and phosphotungstic-soluble nitrogen between experimental cheeses at the same of storage period. No significant difference was observed in the growth of Lactobacillus delbrueckii ssp. bulgaricus between experimental cheeses at the same storage period. However, the growth of Streptococcus thermophilus, Lactobacillus casei, and Lactobacillus acidophilus was significantly affected among experimental cheeses. A significant difference was observed in soluble Ca among experimental cheeses at the same storage period. In general, no significant differences existed in hardness and adhesiveness among experimental cheeses at the same storage period. No significant differences existed in sensory attributes, including creaminess, bitterness, saltiness, sour-acid, and vinegar taste among experimental Akawi cheeses at the same storage period.

The impact of NaCl substitution with KCl on proteinase activities cell-free extract and cell-free supernatant at different pH levels and salt concentrations: Lactobacillus delbrueckii ssp. bulgaricus and Streptococcus thermophilus

The effect of NaCl substitution with KCl at different pH levels (6.0, 5.5, and 5.0) and salt concentrations on proteinase activities of cell-free and supernatant of Lactobacillus delbrueckii ssp. bulgaricus 11824 (L. bulgaricus) and Streptococcus thermophilus MS (ST) was investigated. MRS broths were separately mixed with 4 salt treatments (NaCl only, 1NaCl:1KCl, 1NaCl:3KCl, and KCl only) at 2 different concentrations (5% and 10%) and incubated at 37 °C for 22 h. The cell pellets were used to prepare proteinase of cell-free extract and the cell-free supernatants were used as source of extracellular proteinases. The proteolytic activities and protein contents of both fractions were determined. The supernatants after incubation of both fractions with 3 milk caseins (α-, β-, κ-casein) were subjected to angiotensin-converting-enzyme inhibitory (ACE-inhibitory) activity and proteolytic activity by ortho-phthalaldehyde (OPA) method. Significant differences were observed in ACE-inhibitory activities and proteolytic (OPA) between salt treatments of cell-free extract and cell-free supernatant of L. bulgaricus and S. thermophilus at same salt concentration and same pH level. There was a significant effect of pH level and salt treatments interaction on ACE-inhibitory activity, OPA activity and azocasein activity.

PRACTICAL APPLICATION

To reduce sodium concentration in cheese by substituting of NaCl with KCl, it was important to study the effect on starter culture proteinases which play a vital role in ripening and texture profile of cheese.

Enhancing the biotransformation of isoflavones in soymilk supplemented with lactose using probiotic bacteria during extended fermentation

Soymilk (SM) lacks lactose; hence supplementation of SM with lactose is likely to enhance the growth of probiotic bacteria and biotransformation of isoflavone glycosides to isoflavone aglycones. In this study, 11 strains of probiotic bacteria including Lactobacillus rhamnosus, L. salivarius, L. plantarum, L. acidophilus, L. paracasei, HOWARU L. rhamnosus, L. delbrueckii subsp. bulgaricus, Bifidobacterium lactis type Bi-07, B. longum, HOWARU B. bifidum, and B lactis type Bi-04 were inoculated individually or as mixed cultures into SM and soymilk supplemented with lactose (SML). A total of 2% of lactose was added to 1 L of SM with the aim of improving the growth of probiotic organisms and promoting the biotransformation of isoflavone isomers to bioactive isoflavone aglycomes. Samples of SM were incubated at 37 degrees C and 10 mL aliquots of SM were taken at 0, 24, 48, and 72 h to monitor the growth of probiotic bacteria and changes in isoflavone contents using high-performance liquid chromatography (HPLC). Results indicated that SML fermented with probiotics had higher viable counts by >2.4 log CFU/mL than that in SM at the end of the 72 h fermentation period. Mixed cultures grew at different rates and in general Lactobacilius spp. had >1.02 log CFU/mL more cells than Bifidobacterium spp. at the end of the fermentation period. The total aglycone content in SM at 72 h of fermentation was 0.924 mg/100 mL, whereas that in SML was 1.623 mg/100 mL. Addition of lactose not only improved the growth of probiotic bacteria in SM but also enhanced the biotransformation of isoflavone glucosides to the more bioactive isoflavone aglycones. Mixed cultures did not improve the biotransformation of bioactive isoflavones when compared to single cultures.

Improving the stability of probiotic bacteria in model fruit juices using vitamins and antioxidants

This study examined the survival of probiotic bacteria in a model fruit juice system. Three different strains of probiotic bacteria were used in this study: HOWARU Lactobacillus rhamnosus HN001, HOWARU Bifidobacterium lactis HN001, and Lactobacillus paracasei LPC 37. The probiotic bacteria were inoculated into model juice with various vitamins and antioxidants, namely white grape seed extract, green tea extract, vitamin B2, vitamin B3, vitamin B6, vitamin C, and vitamin E. The model juice without any additives was used as a control. Their viability was assessed on a weekly basis using plate count method. The model juice was made with sucrose, sodium citrate, citric acid powder, and distilled water and was pasteurized before use. Our findings showed that probiotic bacteria did not survive well in the harsh environment of the model fruit juice. However, the model juice containing vitamin C, grape extract, and green tea extract showed better survival of probiotic bacteria. The model juice containing grape seed extract, green tea extract, and vitamin C had the same initial population of 8.32 log CFU/mL, and at the end of the 6-wk storage period it had an average viability of 4.29 log CFU/mL, 7.41 log CFU/mL, and 6.44 log CFU/mL, respectively. Juices containing all other ingredients tested had viable counts of <10 CFU/mL at the end of the 6-wk storage period.

Effect of exopolysaccharides on the proteolytic and angiotensin-I converting enzyme-inhibitory activities and textural and rheological properties of low-fat yogurt during refrigerated storage

The aim of this study was to examine the influence of using exopolysaccharide (EPS) producing strain of Streptococcus thermophilus on the viability of yogurt starters, their proteolytic and angiotensin-I converting enzyme-inhibitory activities, and on the textural and rheological properties of the low-fat yogurt during storage at 4 degrees C for 28 d. The use of an EPS-producing strain of S. thermophilus did not have influence on pH, lactic acid content, or the angiotensin-I converting enzyme-inhibition activity of low-fat yogurt. However, EPS showed a protective effect on the survival of Lactobacillus delbrueckii ssp. bulgaricus. Presence of EPS reduced the firmness, spontaneous whey separation, yield stress, and hysteresis loop area but not the consistency and flow behavior index of low-fat yogurt.

Influence of probiotic Lactobacillus acidophilus and L. helveticus on proteolysis, organic acid profiles, and ACE-inhibitory activity of cheddar cheeses ripened at 4, 8, and 12 degrees C

The influence of adjunct bacteria on composition of cheeses, organic acid profiles, proteolysis, and ACE-inhibitory activity during ripening at 4, 8, and 12 degrees C for 24 wk was investigated. cheddar cheeses were made with starter lactococci (control), Lactobacillus acidophilus L10, and starter lactococci (L10), and L. acidophilus L10, L. helveticus H100, and starter lactococci (H100). The counts of L. acidophilus in L10 cheeses remained at >10(6) colony forming units (CFU)/g after 24 wk of ripening at 4, 8, and 12 degrees C. Concentrations of lactic, acetic, and propionic acids of the L10 and H100 cheeses were significantly higher than those of the control cheeses after 24 wk of ripening (P < 0.05). Proteolysis of the cheeses was improved as the ripening temperature increased. Water-soluble nitrogen, trichloroacetic acid soluble nitrogen, and phosphotungstic acid soluble nitrogen of L10 and H100 cheeses were significantly higher than those of the control cheeses (P < 0.05). Increase in ripening temperature from 4 degrees C to 8 and 12 degrees C increased the percentage of ACE inhibition. The IC(50) value among cheeses ripened at 4, 8, and 12 degrees C, however, was not significantly different (P > 0.05). Hence, probiotic L. acidophilus L10 can be added into cheddar cheeses to improve proteolysis and ACE-inhibitory activity.

Discrimination of dairy industry isolates of the Lactobacillus casei group

Lactobacilli are a major part of the microflora of the gut and of many fermented dairy products, and are found in a variety of environments. Lactobacillus casei, Lactobacillus paracasei, Lactobacillus rhamnosus, and Lactobacillus zeae form a closely related taxonomic group within the facultatively heterofermentative lactobacilli. The classification and nomenclature of these bacteria are controversial. In this study, relationships between these species were investigated using type strains and dairy industry isolates examined with DNA-based techniques and conventional carbohydrate use tests. Carbohydrate use patterns gave poor discrimination of some species, but DNA PCR using specific primers targeted to sequences of the 16S rRNA gene discriminated 4 types consistent with the currently recognized species. Pulsed-field agarose gel electrophoresis of chromosomal NotI restriction fragments identified 18 different band patterns from 21 independent Lactobacillus isolates and confirmed the identity of L. casei strains from 2 culture collections (CSCC 5203 and ASCC 290), both representing the type strain of L. casei. Some isolates were reclassified as L. rhamnosus, suggesting that the prevalence of L. rhamnosus as a natural component of the microflora of dairy foods and dairy environments has previously been underestimated. These methods can provide a practical basis for discrimination of the species and identification of individual industrial strains.

Proteolytic profiles and angiotensin-I converting enzyme and alpha-glucosidase inhibitory activities of selected lactic acid bacteria

This study was conducted to examine the growth, proteolytic profiles as well as angiotensin-I converting enzyme (ACE) and alpha-glucosidase (alpha-glu) inhibitory potentials of selected strains of lactic acid bacteria (LAB). Two strains each of yogurt bacteria (Streptococcus thermophilus-1275 and 285, and Lactobacillus delbrueckii ssp. bulgaricus-1092 and 1368), and probiotics (L. acidophilus-4461 and 33200, and L. casei-2607 and 15286, and 1 strain of Bifidobacterium longum 5022), were cultivated in reconstituted skim milk (RSM) at 37 degrees C and their proteolytic profiles and ACE as well as alpha-glu inhibitory activities were determined. Among all the strains of lactic acid bacteria studied, yogurt bacteria grew very well, with the exception of L. delbrueckii ssp. bulgaricus 1368 which showed a slower growth during the initial 3 h of incubation. The growth pattern corresponded well with the decrease in pH for the organisms. All the organisms showed an increase in proteolysis with time. The variations in proteolytic capabilities translated into corresponding variations in ACE inhibitory potential of these organisms. Bifidobacterium longum 5022 showed the highest ACE inhibitory potential followed by L. delbrueckii ssp. bulgaricus 1368, L. casei 15286, S. thermophilus 1275, and L. acidophilus 4461. Organisms with high intracellular enzymatic activities grew well. Also, aminopeptidases of strains of L. acidophilus 4461 and S. thermophilus 1275 that could better utilize proline containing substrates showed enhanced ACE inhibitory potential. Lactic acid bacteria possessed the ability to inhibit alpha-glu activity, which endowed them an antidiabetic property as well.

Fermentation of calcium-fortified soymilk with Lactobacillus: effects on calcium solubility, isoflavone conversion, and production of organic acids

The objective of this study was to enhance calcium solubility and bioavailability from calcium-fortified soymilk by fermentation with 7 strains of Lactobacillus, namely, L. acidophilus ATCC 4962, ATCC33200, ATCC 4356, ATCC 4461, L. casei ASCC 290, L. plantarum ASCC 276, and L. fermentum VRI-003. The parameters that were used are viability, pH, calcium solubility, organic acid, and biologically active isoflavone aglycone content. Calcium-fortified soymilk made from soy protein isolate was inoculated with these probiotic strains, incubated for 24 h at 37 degrees C, then stored for 14 d at 4 degrees C. Soluble calcium was measured using atomic absorption spectrophotometry (AA). Organic acids and bioactive isoflavone aglycones, including diadzein, genistein, and glycetein, were measured using HPLC. Viability of the strains in the fermented calcium-fortified soymilk was > 8.5 log(10) CFU/g after 24 h fermentation and this was maintained for 14-d storage at 4 degrees C. After 24 h, there was a significant increase (P < 0.05) in soluble calcium. L. acidophilus ATCC 4962 and L. casei ASCC 290 demonstrated the highest increase with 89.3% and 87.0% soluble calcium after 24 h, respectively. The increase in calcium solubility observed was related to lowered pH associated with production of lactic and acetic acids. Fermentation significantly increased (P < 0.05) the level of conversion of isoflavones into biologically active aglycones, including diadzein, genistein, and glycetein. Our results show that fermenting calcium-fortified soymilk with the selected probiotics can potentially enhance the calcium bioavailability of calcium-fortified soymilk due to increased calcium solubility and bioactive isoflavone aglycone enrichment.

Acid, bile, and heat tolerance of free and microencapsulated probiotic bacteria

Eight strains of probiotic bacteria, including Lactobacillus rhamnosus, Bifidobacterium longum, L. salivarius, L. plantarum, L. acidophilus, L. paracasei, B. lactis type Bl-O4, and B. lactis type Bi-07, were studied for their acid, bile, and heat tolerance. Microencapsulation in alginate matrix was used to enhance survival of the bacteria in acid and bile as well as a brief exposure to heat. Free probiotic organisms were used as a control. The acid tolerance of probiotic organisms was tested using HCl in MRS broth over a 2-h incubation period. Bile tolerance was tested using 2 types of bile salts, oxgall and taurocholic acid, over an 8-h incubation period. Heat tolerance was tested by exposing the probiotic organisms to 65 degrees C for up to 1 h. Results indicated microencapsulated probiotic bacteria survived better (P < 0.05) than free probiotic bacteria in MRS containing HCl. When free probiotic bacteria were exposed to oxgall, viability was reduced by 6.51-log CFU/mL, whereas only 3.36-log CFU/mL was lost in microencapsulated strains. At 30 min of heat treatment, microencapsulated probiotic bacteria survived with an average loss of only 4.17-log CFU/mL, compared to 6.74-log CFU/mL loss with free probiotic bacteria. However, after 1 h of heating both free and microencapsulated probiotic strains showed similar losses in viability. Overall microencapsulation improved the survival of probiotic bacteria when exposed to acidic conditions, bile salts, and mild heat treatment.

Rheological properties and sensory characteristics of set-type soy yogurt

The study examined chemical composition and rheological and sensory properties of probiotic soy yogurt during 28 day storage at 4 degrees C. Soymilk supplemented with 2% (w/v) inulin or 1% (w/v) each of raffinose and glucose was used as a base for soy yogurt manufacture. Viability of probiotic organisms and their metabolic activity measured as production of organic acids and aldehyde content responsible for beany flavor, as well as rheological and sensory properties of soy yogurt, were examined. Inulin or raffinose/glucose supplementation in soymilk increased the bacterial population by one log cycle and the amount of lactic acid. Probiotic bacteria metabolized more aldehyde than yogurt culture and substantially reduced the beaniness in soy yogurt as determined by sensory evaluation. The probiotic soy yogurts showed more viscous and pseudoplastic properties than the control soy yogurts, but the sensory evaluation results showed preference for the control soy yogurts which were slightly less viscous. Control soy yogurt provided better mouth feel than probiotic soy yogurts.

Endogenous β-glucosidase and β-galactosidase activities from selected probiotic micro-organisms and their role in isoflavone biotransformation in soymilk

AIM

To compare endogenous beta-glucosidases and beta-galactosidases for hydrolysis of the predominant isoflavone glycosides into isoflavone aglycones in order to improve biological activity of soymilk.

METHODS AND RESULTS

beta-glucosidase and beta-galactosidase activities of probiotic organisms including Lactobacillus acidophilus ATCC 4461, Lactobacillus casei 2607 and Bifidobacterium animalis ssp. lactis Bb12 in soymilk were evaluated and correlated with the increase in concentration of isoflavone aglycones during fermentation. The concentrations of isoflavone compounds in soymilk were monitored using a Varian model high-performance liquid chromatography (HPLC) with an amperometric electrochemical detector. In all micro-organisms, beta-glucosidase activity was found greater than that of beta-galactosidase. There was an increase in the aglycone concentration with incubation time because of the apparent hydrolytic action on isoflavone glycosides. Aglycone concentration in the soymilk with L. acidophilus 4461, L. casei 2607 and B. animalis ssp. lactis Bb12, increased by 5.37-, 5.52- and 6.10-fold, respectively, after 15 h of fermentation at 37 degrees C. The maximum hydrolytic potential was also observed at 15 h of fermentation for the three micro-organims coinciding with peak activities of the two enzymes.

CONCLUSIONS

beta-glucosidase activity was more than 15 times higher than beta-galactosidase activity in soymilk for each of the micro-organisms during fermentation. beta-glucosidase played a greater role in isoflavone glycoside hydrolysis.

SIGNIFICANCE AND IMPACT OF THE STUDY

Screening for beta-glucosidase and beta-galactosidase activities among probiotics in soymilk is important for the improvement of biological activity of soymilk and in the selection of micro-organisms for use in the growing industry of functional foods and beverages.

Invited Review: Advances in Starter Cultures and Cultured Foods

With 2005 retail sales close to $4.8 million, cultured dairy products are driving the growth of dairy foods consumption. Starter cultures are of great industrial significance in that they play a vital role in the manufacturing, flavor, and texture development of fermented dairy foods. Furthermore, additional interest in starter bacteria has been generated because of the data accumulating on the potential health benefits of these organisms. Today, starter cultures for fermented foods are developed mainly by design rather than by the traditional screening methods and trial and error. Advances in genetics and molecular biology have provided opportunities for genomic studies of these economically significant organisms and engineering of cultures that focuses on rational improvement of the industrially useful strain. Furthermore, much research has been published on the health benefits associated with ingesting cultured dairy foods and probiotics, particularly their role in modulating immune function. The aim of this review is to describe some of the major scientific advances made in starter and non-starter lactic acid bacteria during the past 10 yr, including genomic studies on dairy starter cultures, engineering of culture attributes, advances in phage control, developments in methods to enumerate lactic acid bacteria and probiotics in dairy foods, and the potential role of cultured dairy foods in modulation of immune function.

A comparison of changes in the transformation of isoflavones in soymilk using varying concentrations of exogenous and probiotic-derived endogenous ?-glucosidases

AIMS

To compare endogenous and exogenous beta-glucosidases for the hydrolysis of the predominant isoflavone glucosides in soymilk in order to improve the biological activity.

METHODS AND RESULTS

beta-glucosidase activity of probiotic organisms, including Bifidobacterium animalis ssp. lactis Bb12, Lactobacillus acidophilus ATCC 4461 and Lactobacillus casei 2607 in soymilk, was evaluated and was related to the increase in the concentration of isoflavone aglycones during fermentation. The concentrations of isoflavone compounds in soymilk were monitored using a Varian model HPLC with an Amperometric electrochemical detector. The aglycone composition, also known as aglycone equivalent ratio, has been considered to be important for the delivery of health benefits of isoflavones, and was monitored during the fermentation of soymilk. Comparison of the hydrolytic effectiveness of both exogenous and endogenous enzyme during 4-h incubation in soymilk was conducted using the Otieno-Shah (O-S) index. Results showed that exogenous enzyme exhibited faster rate of isoflavone glucoside hydrolysis than that by endogenous enzyme. Highest O-S indices were obtained after 4, 3 and 2 h of incubation with enzyme solution having beta-glucosidase activity of 0.288 U ml(-1), 0.359 U ml(-1) and 0.575 U ml(-1), resulting into aglycone concentration increments of 5.87-, 6.07- and 5.94-fold, respectively. Conversely, aglycone concentration in the soymilk with B. animalis ssp. lactis Bb12, L. casei 2607 and L. acidophilus 4461 increased by 3.43-, 2.72- and 3.03-fold, respectively, after 4 h of fermentation at 37 degrees C. In addition, the O-S index of endogenous enzyme was much lower than that of the exogenous enzyme over the same 4-h incubation period. Optimum aglycone equivalent ratios coincided with highest O-S indices and highest aglycone concentrations in soymilk hydrolysed with exogenous enzyme. The same correlation of O-S indices and highest aglycone concentrations occurred for endogenous enzyme during the 24 h of fermentation.

CONCLUSIONS

Obtaining highest aglycone concentration and optimum aglycone equivalent ratio could provide a critical beginning point in clinical trials for the realization of unique health benefits of soy isoflavones.

SIGNIFICANCE AND IMPACT OF THE STUDY

Screening for beta-glucosidase activities of probiotics in soymilk and comparing their hydrolytic potentials with that of exogenous beta-glucosidase could find wide applications in the development of different aglycone-rich functional soy beverages.

Isoflavone phytoestrogen degradation in fermented soymilk with selected β-glucosidase producing L. acidophilus strains during storage at different temperatures

Soymilk fermented with 3 selected Lactobacillus acidophilus strains were stored at various temperatures (-80 degrees C, 4 degrees C, 25 degrees C and 37 degrees C) for 8 weeks and the concentration of isoflavones determined weekly using RP-HPLC. The decreasing concentration of isoflavones in soymilk during storage due to degradation was found to fit the first order kinetics model. Isoflavone aglycones as well as isoflavone glucosides largely appeared to be stable during storage (P<0.01). Interestingly, the aglycone forms showed much smaller degradation as compared to glucoside forms at all the storage temperatures studied. Of the isoflavone aglycones, daidzein was found to be the most stable followed by genistein, while glycitein was least stable. Isoflavone aglycones such as glycitein, daidzein and genistein showed smaller degradation constants in fermented soymilk at lower storage temperatures (-80 degrees C and 4 degrees C) and higher degradation constants at higher storage temperatures (25 degrees C and 37 degrees C) with each strain. In contrast, glucosides glycitin and daidzin showed higher degradation at lower storage temperatures (-80 degrees C and 4 degrees C) and lower degradation at higher storage temperatures (25 degrees C and 37 degrees C). Storage temperature was therefore found to be very important in regulating the rate of degradation soy isoflavones in fermented soymilk.

Occurrence of overlooked zoonotic tuberculosis: detection of Mycobacterium bovis in human cerebrospinal fluid

The paucibacillary nature of the cerebrospinal fluid (CSF) has been a major obstacle in the diagnosis of human tuberculous meningitis (TBM). This study shows that with molecular techniques direct precise determination to the species level of mycobacterial pathogens can be made. The present report describes the utility of a nested PCR (N-PCR) assay (A. Mishra, A. Singhal, D. S. Chauhan, V. M. Katoch, K. Srivastava, S. S. Thakral, S. S. Bharadwaj, V. Sreenivas, and H. K. Prasad, J. Clin. Microbiol. 43:5670-5678, 2005) in detecting M. tuberculosis and M. bovis in human CSF. In 2.8% (6/212) of the samples, M. tuberculosis was detected, and in 17% (36/212), M. bovis was detected. Mixed infection was observed in 22 samples. Comparative analysis of clinical diagnosis, smear microscopy, and N-PCR in 69 patients (TBM, 25; non-TBM, 44) showed that the sensitivity of N-PCR (61.5%) was greater than that of smear microscopy (38.4%). Determination to the species level is important from the viewpoint of determining the prevalence of these mycobacteria in a community and would influence strategies currently adopted for the prevention of tuberculosis.

Urinary excretion of equol by postmenopausal women consuming soymilk fermented by probiotic bifidobacteria

OBJECTIVE

To study the effects of consuming isoflavone aglycone-enriched soymilk fermented by bifidobacteria on urinary excretion of equol with respect to fermentation, daidzein dose, supplementation duration and background diet.

DESIGN

Double-blind crossover pilot study comprising three 14-day supplementation periods separated by a washout.

SETTING

Victoria University, Melbourne, Australia.

SUBJECTS

Sixteen postmenopausal women.

INTERVENTION

SUBJECTS randomized into two groups consuming either fermented (FS) or non-fermented soymilk (NFS), ingested three daily dosages of daidzein via soymilk and collected pooled urine specimens. Daidzein and equol were quantified using high-performance liquid chromatography.

RESULTS

After 14-days supplementation six women (38%) excreted equol (>1 micromol equol/day), including four from the FS group, two of whom were classified as non-producers at day 4. Bifidobacteria ingestion, composition of daidzein and its glucosides, and carbohydrate intake appeared to influence equol formation among equol producers.

CONCLUSIONS

Pilot-study group mean urinary equol excretion results provided insufficient evidence (P>0.05) that FS consumption instigates equol production in women predetermined as non-producers.

Effects of a Lactobacillus casei Synbiotic on Serum Lipoprotein, Intestinal Microflora, and Organic Acids in Rats

The main aim of this study was to evaluate the effectiveness of 3 synbiotic diets: 1) containing Lactobacillus casei ASCC 292 and fructooligosaccharides (LF diet); 2) containing L. casei ASCC 292 and maltodextrin (LM diet); and 3) containing L. casei ASCC 292, fructooligosaccharide, and maltodextrin (LFM diet) to reduce serum cholesterol in male Wistar rats. The effect of the synbiotic diets on intestinal microflora, concentration of organic acids, and the possibility of translocation of lactobacilli were also investigated. The LFM diet lowered serum total cholesterol and triglyceride levels, whereas the LM diet increased serum high-density lipoprotein cholesterol level. However, synbiotic diets did not contribute to a change in low-density lipoprotein cholesterol level compared with the control diet. There was a decrease in the population of staphylococci, bacteroides, Escherichia coli, and total coliforms in most bowel regions with the LFM diet compared with the control (which did not contain any synbiotic). In general, the LFM diet contributed to a higher concentration of lactic acid that may have contributed to the decrease in the population of pathogenic microorganisms compared with the control. Fructooligosaccharide was the preferred substrate for production of acetic acid. Results from this study showed that the synbiotic diet that contained L. casei ASCC 292, fructooligosaccharide, and maltodextrin beneficially altered cholesterol levels and produced a healthier bowel microbial population without translocation of lactobacilli to other organs.

Production of organic acids from fermentation of mannitol, fructooligosaccharide and inulin by a cholesterol removing Lactobacillus acidophilus strain

AIMS

Assessment of individual production of organic acids by Lactobacillus acidophilus ATCC 4962 in the presence of mannitol, fructooligosaccharide (FOS) and inulin.

METHODS AND RESULTS

The production patterns of individual organic acids by L. acidophilus ATCC 4962 were assessed using the experimental region for optimum cholesterol removal from the interaction between L. acidophilus ATCC 4962 and prebiotics selected in our previous study. The production of acetic and formic acids was growth associated and was greatly influenced by the inoculum size of the organism and the concentration of mannitol. The growth of the organism was repressed with the fermentation end products of FOS and inulin, which subsequently exhibited repressed production of acetic and formic acids as well. The inoculum size, mannitol and FOS linearly affected the formation of butyric acid and the response surface generated showed a correlation between butyric acid and acetic acid. The experimental regions with increased production of lactic acid showed cessation of growth of the organism, indicating inhibition of growth at high concentration of lactic acid.

CONCLUSIONS

The production of individual organic acids was dependent on growth and the fermentability of prebiotics. Mannitol, FOS and inulin favoured the production of formic, lactic and butyric acids respectively.

SIGNIFICANCE AND IMPACT OF THE STUDY

The fermentability of prebiotics to produce metabolites has been a controversial issue. Information gathered in this study provides a better understanding on the production of organic acids from fermentation of mannitol, FOS and inulin by L. acidophilus ATCC 4962, and on changes in their production as a response from interaction of factors.

Scintigraphic Evaluation of Intrathecal Infusion Systems: Selection of Patients for Surgical or Medical Management

PURPOSE

Continuous intrathecal medication through a surgically implanted infusion system is an established method for treating intractable spasticity or pain. To determine if imaging can guide surgical or medical management in patients with suspected infusion system malfunction, we reviewed our experience in evaluating the functional status of these systems with indium-111 DTPA scintigraphy.

METHODS

We retrospectively reviewed 23 indium-111 DTPA studies in 19 patients (7 female, 12 male; ages 20-83 years, average age 47 years). Indications included intractable spasticity or increasing pain. Infusion systems were classified scintigraphically as either functioning or malfunctioning; malfunctions were further classified as either mechanical or catheter-related. Imaging findings were correlated with subsequent clinical management.

RESULTS

Fifteen of 23 (65%) studies demonstrated functioning infusion systems; these patients were all treated medically. Eight of 23 (35%) studies demonstrated malfunctioning systems; 6 of 8 were subsequently treated surgically and 2 of 8 medically.

CONCLUSION

Indium-111 DTPA scintigraphy can differentiate between functioning and malfunctioning infusion systems, guiding appropriate medical or surgical management.

Bovine tuberculosis in India: potential basis for zoonosis

Our laboratory has designed a specific nested-PCR (N-PCR) assay, based on the hupB gene of Mycobacterium tuberculosis (Rv2986c) and Mycobacterium bovis (Mb3010c) as a method to differentiate these closely related species. The present paper deciphers the utility of this assay for identification of pathogenic Mycobacteria in clinical samples. Extra-pulmonary clinical samples obtained from cattle and humans were investigated. Pre-dominance of M. tuberculosis (15.7%) and M. bovis (26.8%) was seen in humans and cattle, respectively. However, more importantly, both mycobacterial pathogens (mixed infection) were identified in a number of samples. In humans 8.7% of the samples and 35.7% in cattle were classified as mixed infection. The detection of mixed infection with the mycobacterial pathogenic duo in humans and bovines denotes the prospect of potential transmission of these pathogens from humans to cattle (zoonosis) and vice versa (reverse zoonosis).

Optimization of cholesterol removal by probiotics in the presence of prebiotics by using a response surface method

Lactobacillus casei ASCC 292 was grown in the presence of six prebiotics, namely, sorbitol, mannitol, maltodextrin, high-amylose maize, fructooligosaccharide (FOS), and inulin, in order to determine the combination of probiotic and prebiotics that would remove the highest level of cholesterol. A first-order model showed that the combination of L. casei ASCC 292, FOS, and maltodextrin was the most efficient for the removal of cholesterol, and the optimum experimental region was developed by using the steepest ascent. This led to the middle points of probiotic (1.70% [wt/vol]), FOS (4.80% [wt/vol]), and maltodextrin (6.80% [wt/vol]) for the development of a central composite design for optimization. Perturbation plot, response surface, and coefficient estimates showed that all three factors had significant quadratic effects on cholesterol removal, with FOS showing the most conspicuous quadratic change. A second-order polynomial regression model estimated that the optimum condition of the factors for cholesterol removal by L. casei ASCC 292 is 1.71% (wt/vol) probiotic, 4.95% (wt/vol) FOS, and 6.62% (wt/vol) maltodextrin. Validation experiments showed that the predicted optimum conditions were more efficient than the high and low levels of the factors and the center points. A response surface method proved reliable for developing the model, optimizing factors, and analyzing interaction effects. Analyses of growth, substrate utilization, growth yield, mean doubling time, and short-chain fatty acid (SCFA) production by the use of quadratic models indicated that cholesterol removal was growth associated. The concentration of L. casei ASCC 292 had the most significant quadratic effect on all responses studied, except for substrate utilization and SCFA production, which were significantly (P < 0.05) influenced by the interactions between the probiotic and both prebiotics, indicating that they were closely associated with the uptake of prebiotics.

Low-Fat Mozzarella as Influenced by Microbial Exopolysaccharides, Preacidification, and Whey Protein Concentrate

Low-fat Mozzarella cheeses containing 6% fat were made by preacidification of milk, preacidification combined with exopolysaccharide- (EPS-) producing starter, used independently or as a coculture with non-EPS starter, and preacidification combined with whey protein concentrate (WPC) and EPS. The impact of these treatments on moisture retention, changes in texture profile analysis, cheese melt, stretch, and on pizza bake performance were investigated over 45 d of storage at 4 degrees C. Preacidified cheeses without EPS (control) had the lowest moisture content (53.75%). These cheeses were hardest and exhibited greatest springiness and chewiness. The meltability and stretchability of these cheeses increased most during the first 28 d of storage. The moisture content in cheeses increased to 55.08, 54.79, and 55.82% with EPS starter (containing 41.18 mg/g of EPS), coculturing (containing 28.61 mg/g of EPS), and WPC (containing 44.23 mg/g of EPS), respectively. Exopolysaccharide reduced hardness, springiness, and chewiness of low-fat cheeses made with preacidified milk in general and such cheeses exhibited an increase in cohesiveness and meltability. Although stretch distance was similar in all cheeses, those containing EPS were softer than the control. Cocultured cheeses exhibited the greatest meltability. Cheeses containing WPC were softest in general; however, hardness remained unchanged over 45 d. Cheeses made with WPC had the least increase in meltability over time. Incorporation of WPC did not reduce surface scorching or increase shred fusion of cheese shreds during pizza baking; however, there was an improvement in these properties between d 7 and 45. Coating of the cheese shreds with oil was necessary for adequate browning, melt, and flow characteristics in all cheese types.

Optimization of cholesterol removal, growth and fermentation patterns of Lactobacillus acidophilus ATCC 4962 in the presence of mannitol, fructo-oligosaccharide and inulin: a response surface methodology approach

AIMS

To optimize cholesterol removal by Lactobacillus acidophilus ATCC 4962 in the presence of prebiotics, and study the growth and fermentation patterns of the prebiotics.

METHODS AND RESULTS

Lactobacillus acidophilus ATCC 4962 was screened in the presence of six prebiotics, namely sorbitol, mannitol, maltodextrin, hi-amylose maize, fructo-oligosaccharide (FOS) and inulin in order to determine the best combination for highest level of cholesterol removal. The first-order model showed that the combination of inoculum size, mannitol, FOS and inulin was best for removal of cholesterol. The second-order polynomial regression model estimated the optimum condition of the factors for cholesterol removal by L. acidophilus ATCC 4962 to be 2.64% w/v inoculum size, 4.13% w/v mannitol, 3.29% w/v FOS and 5.81% w/v inulin. Analyses of growth, mean doubling time and short-chain fatty acid (SCFA) production using quadratic models indicated that cholesterol removal and the production of SCFA were growth associated.

CONCLUSIONS

Optimum cholesterol removal was obtained from the fermentation of L. acidophilus ATCC 4962 in the presence of mannitol, FOS and inulin. Cholesterol removal and the production of SCFA appeared to be growth associated and highly influenced by the prebiotics.

SIGNIFICANCE AND IMPACT OF THE STUDY

Response surface methodology proved reliable in developing the model, optimizing factors and analysing interaction effects. The results provide better understanding on the interactions between probiotic and prebiotics for the removal of cholesterol.

Acid and bile tolerance and cholesterol removal ability of lactobacilli strains

Eleven strains of lactobacilli were studied for their acid and bile tolerance. Possible mechanisms of cholesterol removal by strains of lactobacilli were examined. Cholesterol assimilation as determined by the difference in cholesterol content in the medium before and after the incubation period showed that all lactobacilli strains were able to assimilate cholesterol at varying levels ranging from 12.03 to 32.25 microg/mL. Cholesterol removal was associated with growth of cultures. Binding of cholesterol to lactobacilli cells was determined using growing, heat-killed, and resting cells in phosphate buffer. Cholesterol removed by dead and resting cells ranged from 0.79 to 3.82 mg/g of dry weight compared with growing cells, which ranged from 4.53 to 16.03 mg/g of dry weight. Fatty acid methyl esters, as quantified using gas chromatography, showed changes in lipid profiles in cells grown in the presence of cholesterol compared with those grown without cholesterol. Fatty acid profiles, especially of hexadecanoic, octadecanoic, total saturated, and unsaturated acids suggested that cholesterol from the medium was incorporated into the cellular membrane. These findings suggest that strains of lactobacilli could remove cholesterol via various mechanisms and may be promising candidates for use as a dietary adjunct to lower serum cholesterol in vivo.

Acute pyogenic iliopsoas abscess in children in Nepal

We describe a prospective study of twenty-four cases of acute pyogenic abscess of the iliopsoas in children treated conservatively and operatively. Eight patients were managed conservatively with antibiotics alone while sixteen others were managed operatively by open drainage. All made a complete recovery.

Effects of pH, Temperature, Supplementation with Whey Protein Concentrate, and Adjunct Cultures on the Production of Exopolysaccharides by Streptococcus thermophilus 1275

Effects of pH, temperature, supplementation with whey protein concentrate (WPC), and non-EPS culture on the exopolysaccharide (EPS) production by Streptococcus thermophilus 1275 were studied. The organism was grown in 10% reconstituted skim milk (RSM) in a Biostat B fermenter for 24 h at various pH (4.5, 5.5 and 6.5) and temperatures (30, 37, 40, and 42 degrees C), and supplementation with WPC 392, and non-EPS producing S. thermophilus 1303 and the amount of EPS produced were determined. Bacterial counts were enumerated and the concentrations of lactic acid, lactose, glucose, and galactose were also determined. A maximum of 406 mg/L of EPS was produced in RSM at 37 degrees C after 24 h of fermentation at pH 4.08 when the pH was not controlled. A pH of 5.5 and temperature of 40 degrees C were found to be optimal for EPS production by S. thermophilus 1275, yielding 458 mg/L. The EPS production increased when RSM was supplemented with WPC 392. At optimum pH and at 37 degrees C with WPC supplementation, the level of EPS increased to 1029 mg/L. Co-culturing S. thermophilus 1275 with non-EPS S. thermophilus 1303 increased EPS production at 37 degrees C and pH 5.5 to 832 mg/L. High temperature (42 degrees C) reduced the amount of EPS production, and EPS production ceased at pH 4.5 when maintained constantly at this pH. The level of lactose utilization and lactic acid production depended on growth conditions of the organism. No glucose was detected, while galactose was found to accumulate in the medium.

Selective enumeration of Lactobacillus delbrueckii ssp. bulgaricus, Streptococcus thermophilus, Lactobacillus acidophilus, bifidobacteria, Lactobacillus casei, Lactobacillus rhamnosus, and propionibacteria

Nineteen bacteriological media were evaluated to assess their suitability to selectively enumerate Lactobacillus delbrueckii ssp. bulgaricus, Streptococcus thermophilus, Lactobacillus casei, Lactobacillus rhamnosus, Lactobacillus acidophilus, bifidobacteria, and propionibacteria. Bacteriological media evaluated included Streptococcus thermophilus agar, pH modified MRS agar, MRS-vancomycine agar, MRS-bile agar, MRS-NaCl agar, MRS-lithium chloride agar, MRS-NNLP (nalidixic acid, neomycin sulfate, lithium chloride and paramomycine sulfate) agar, reinforced clostridial agar, sugar-based (such as maltose, galactose, sorbitol, manitol, esculin) media, sodium lactate agar, arabinose agar, raffinose agar, xylose agar, and L. casei agar. Incubations were carried out under aerobic and anaerobic conditions at 27, 30, 37, 43, and 45 degrees C for 24, 72 h, and 7 to 9 d. S. thermophilus agar and aerobic incubation at 37 degrees C for 24 h were suitable for S. thermophilus. L. delbrueckii ssp. bulgaricus could be enumerated using MRS agar (pH 4.58 or pH 5.20) and under anaerobic incubation at 45 degrees C for 72 h. MRS-vancomycine agar and anaerobic incubation at 43 degrees C for 72 h were suitable to enumerate L. rhamnosus. MRS-vancomycine agar and anaerobic incubation at 37 degrees C for 72 h were selective for L. casei. To estimate the counts of L. casei by subtraction method, counts of L. rhamnosus on MRS-vancomycine agar at 43 degrees C for 72 h under anaerobic incubation could be subtracted from total counts of L. casei and L. rhamnosus enumerated on MRS-vancomycine agar at 37 degrees C for 72 h under anaerobic incubation. L. acidophilus could be enumerated using MRS-agar at 43 degrees C for 72 h or Basal agar-maltose agar at 43 degrees C for 72 h or BA-sorbitol agar at 37 degrees C for 72 h, under anaerobic incubation. Bifidobacteria could be enumerated on MRS-NNLP agar under anaerobic incubation at 37 degrees C for 72 h. Propionibacteria could be enumerated on sodium lactate agar under anaerobic incubation at 30 degrees C for 7 to 9 d. A subtraction method was most suitable for counting propionibacteria in the presence of other lactic acid bacteria from a product. For this method, counts of lactic bacteria at d 3 on sodium lactate agar under anaerobic incubation at 30 degrees C were subtracted from counts at d 7 of lactic bacteria and propionibacteria.

Effects of milk-derived bioactives: an overview

Milk contains various components with physiological functionality. Peptides derived from caseins and whey proteins including opioid peptides, antihypertensive peptides, casein phosphopeptides, alpha- and beta-lactorphins and albutensin have been shown to possess various bioactive properties. This review considers an overview of the bioactive components in milk proteins and whey and their physiological function.

Probiotic bacteria: selective enumeration and survival in dairy foods

A number of health benefits have been claimed for probiotic bacteria such as Lactobacillus acidophilus, Bifidobacterium spp., and Lactobacillus casei. Because of the potential health benefits, these organisms are increasingly incorporated into dairy foods. However, studies have shown low viability of probiotics in market preparations. In order to assess viability of probiotic bacteria, it is important to have a working method for selective enumeration of these probiotic bacteria. Viability of probiotic bacteria is important in order to provide health benefits. Viability of probiotic bacteria can be improved by appropriate selection of acid and bile resistant strains, use of oxygen impermeable containers, two-step fermentation, micro-encapsulation, stress adaptation, incorporation of micronutrients such as peptides and amino acids and by sonication of yogurt bacteria. This review will cover selective enumeration and survival of probiotic bacteria in dairy foods.

Ingredient supplementation effects on viability of probiotic bacteria in yogurt

The present investigation studied the effects of cysteine, whey powder, whey protein concentrate, acid casein hydrolysates, or tryptone on the viability of Streptococcus thermophilus, Lactobacillus acidophilus, and bifidobacteria. Changes in pH, titratable acidity, redox potential, and viability of bacteria were monitored during 24 h of fermentation and refrigerated storage (4 degrees C) of yogurt for 35 d. The incubation time that was needed to reach pH 4.5 was considerably affected by the added ingredients. Also, the drop in pH or the increase in acidity and redox potential was dependent on the added ingredients. The addition of cysteine, whey protein concentrate, acid casein hydrolysates, or tryptone improved the viability of bifidobacteria to a variable extent, but whey powder failed to improve their viability. The morphology of S. thermophilus, as shown by electron microscopy, was affected by cysteine at 500 mg/L, possibly as a result of reduced redox potential. Sodium dodecyl sulfate-PAGE and amino acid analyses suggested that the nitrogen source in the form of peptides and amino acids improved the viability of bifidobacteria in yogurt made with a commercial ABT (Lactobacillus acidophilus, bifidobacteria, and Streptococcus thermophilus) starter culture, which showed a dramatic decline in the counts of this organism in previous studies.

Multiple supernumerary teeth in two brothers: a case report

Supernumerary teeth (hyperdontia) are relatively common in the general population and occur more frequently in patients with a family history of such teeth. Supernumerary teeth have been reported in many genetic syndromes, but multiple supernumerary teeth occurring as an isolated non-syndromic trait are rare. This article describes a rare non-syndromic variety of multiple impacted supernumerary teeth in two brothers.