Identifying viable regulatory and innovation pathways for regenerative medicine: a case study of cultured red blood cells

The creation of red blood cells for the blood transfusion markets represents a highly innovative application of regenerative medicine with a medium term (5-10 year) prospect for first clinical studies. This article describes a case study analysis of a project to derive red blood cells from human embryonic stem cells, including the systemic challenges arising from (i) the selection of appropriate and viable regulatory protocols and (ii) technological constraints related to stem cell manufacture and scale up to clinical Good Manufacturing Practice (GMP) standard. The method used for case study analysis (Analysis of Life Science Innovation Systems (ALSIS)) is also innovative, demonstrating a new approach to social and natural science collaboration to foresight product development pathways. Issues arising along the development pathway include cell manufacture and scale-up challenges, affected by regulatory demands emerging from the innovation ecosystem (preclinical testing and clinical trials). Our discussion reflects on the efforts being made by regulators to adapt the current pharmaceuticals-based regulatory model to an allogeneic regenerative medicine product and the broader lessons from this case study for successful innovation and translation of regenerative medicine therapies, including the role of methodological and regulatory innovation in future development in the field.

Review article: 2014 UK consensus guidelines - hepatitis C management and direct-acting anti-viral therapy

BACKGROUND

Therapeutic options for the management of hepatitis C virus (HCV) infection have evolved rapidly over the past two decades, with a consequent improvement in cure rates. Novel therapeutic agents are an area of great interest in the research community, with a number of these agents showing promise in the clinical setting.

AIMS

To assess and present the available evidence for the use of novel therapeutic agents for the treatment of HCV, updating previous guidelines.

METHODS

All Phase 2 and 3 studies, as well as abstract presentations from international Hepatology meetings were identified and reviewed for suitable inclusion, based on studies of new therapies in HCV. Treatment-naïve and experienced individuals, as well as cirrhotic and co-infected individuals were included.

RESULTS

Sofosbuvir, simeprevir and faldaprevir, along with pegylated interferon and ribavirin, have a role in the treatment of chronic HCV infection. The precise regimens are largely dependent on the patient characteristics, patient and physician preferences, and cost implication.

CONCLUSIONS

Therapies for chronic HCV have evolved dramatically in recent years. Interferon-free regimens are now possible without compromise in the rate of sustained viral response. The decision as to which regimen is most appropriate is multifactorial, and based on efficacy, safety and cost.

Dangling conversations: reflections on the process of creating digital stories during a workshop with people with early-stage dementia

Care and compassion are key features of the NHS Constitution. Recent reports have identified a lack of compassion in the care and treatment of older people. Nurses draw on aesthetic knowledge, developed through engagement with the experience of others, when providing compassionate care. Patient Voices reflective digital stories are used in healthcare education to facilitate student engagement with the patient experience. Digital stories were made with seven people with early-stage dementia as part of a learning package for student nurses. In this paper the authors reflect on their experience and observations from facilitating the 4-day digital story-making workshop. Social theories of dementia provide a theoretical framework for understanding these reflections. Despite considerable challenges in developing a story, and anxiety about using the technology, reading and speaking, all participants engaged in creating their own digital stories. Positive changes in the participants' interactions were observed. These improvements appeared to be the product of the person-centred facilitation and the creative process which supported self-expression and a sense of identity. Nurses working in this way could facilitate ability of the person with dementia to participate in their care, and improve their sense of well-being by supporting self-expression.

Intravenous drug use: not a barrier to achieving a sustained virological response in HCV infection

Hepatitis C virus (HCV) is commonly transmitted by intravenous drug use (IDU) but drug users are under represented in many treatment cohorts, this is because of the assumption of lowered treatment success. We assessed HCV treatment outcomes in active intravenous drug users and patients on opiate substitution therapy. The Tayside HCV treatment database was retrospectively analysed for consecutively treated patients based on risk factor for acquisition of HCV. Primary end point was sustained virological response (SVR). Two hundred and ninety-one consecutively treated patients were assessed. The overall SVR rate was 55.3%. The SVR rates by risk factor were; Non-IDU 61.4%, Ex-IDU 54.8% and Active IDU 47.1% (P = n/s). In the groups G1 patients SVR was; Non-IDU 52.7%, Ex-IDU 30.7% and active IDU 35.4% (P = n/s). In the non-G1 patients: non-IDU 65.1%, Ex-IDU 76.7% and active IDU 53.5%. Ex-IDU had a significantly better SVR than active IDU, other differences were not significant. Our results demonstrate that SVR rates in the active drug users and those on opiate substitution therapy can be achieved which are comparable with non-IDU infected individuals. Intravenous drug use in those engaged with treatment services should not be seen as a barrier to treatment of HCV.

Modelling monthly NH3 emissions from dairy in 12 Ecoregions of Canada

Sheppard, S. C., Bittman, S., Swift, M. L. and Tait, J. 2011. Modelling monthly NH 3 emissions from dairy in 12 Ecoregions of Canada. Can. J. Anim. Sci. 91: 649–661. Ammonia (NH3) from livestock manure is emitted from barns, storages and manured land, and is a loss to the farm operations, while atmospheric NH3 has potential impacts beyond the farm, including human health and ecological damage. Models are used to estimate the intensity and spatial extent of NH3 emissions, and this paper reports a recent model developed for quantifying emissions from the dairy sector in Canada. The estimated overall average emission to the atmosphere in Canada in 2006 was 42.4±9.0 kg NH3 cow−1 yr−1 from a lactating cow, and total emission from the Canadian dairy sector was 56000 t NH3. On many farms the NH3 emissions may have been a significant portion of the N requirements of their crops. The emission estimates in the 12 Ecoregions were proportional to the animal census. Emissions generally peaked in May, mainly because of landspreading of manure. There were also differences in emissions per animal among the Ecoregions related to the specific practices, such as amount of grazing and injection of slurry. The sensitivity analysis suggested that a shift from the present 14% injection of slurry manure into soil to 80% may be effective overall, potentially decreasing annual emissions by 13% and emissions in May by 27%.

Farm practices survey and modelling to estimate monthly NH3 emissions from swine production in 12 Ecoregions of Canada

The swine industry in Canada has undergone rapid growth in some areas, but has also been restricted by a variety of environmental issues. Ammonia (NH3) emissions are seldom mentioned among these issues, but emissions do occur and atmospheric NH3 causes a number of impacts including contributing to odour, deposition into sensitive ecosystems and formation of secondary particulate matter, which is a health concern in some regions of North America. This paper describes a new model to estimate NH3 emissions from the swine sector, relying heavily on a recent survey of swine producers to determine the present N and manure management practices. The key hypothesis was that NH3 emission rates vary across Ecoregions and over time in a way that affects the degree of impact. The survey showed many differences across Ecoregions, most importantly related to feed crude protein and landspreading practices. The model estimated that grower pigs (>20 kg to market size) excreted on average about 8.5 kg total ammoniacal N (TAN) per (occupied) pig place per year, and based on the national average farm practices, 25% of this TAN was emitted from barns, 5.3% was emitted from manure storage, and 17% was emitted during landspreading for a total of 4.8 kg NH3 pig-place-1 yr-1. The total loss for grower pigs ranged from 40 to 53% of excreted TAN across the 12 Ecoregions. Nursing sows emitted over twice as much per pig. Regions varied in reliance on homegrown feeds, which affected crude protein feeding and TAN excretion rates. Western regions had relatively low emissions from land application of slurry because of more extensive use of injectors. Emissions from grower pigs in winter were about 0.2 kg NH3 pig-place-1 month-1, mostly from barns, to as high as 0.7 kg NH3 pig-place-1 month-1 in May, mostly from landspreading. Total emission for all of Canada in 2006 was 73 × 106 kg NH3 or about 13% of agricultural emissions in Canada. The results indicate that emission reductions can be achieved with greater use of low-emission application methods and reduced crude protein in feed. The emissions model can be used in future to assess the impacts from changes in feeding regimes and barn designs, and changes in practices such as animal density and increased access to outdoor spaces.Key words: Swine, ammonia, nitrogen, manure, emissions

Sonographic study of the decidua basalis in the first trimester of pregnancy

OBJECTIVES

To describe the sonographic appearance of the decidua basalis and its changes in the first trimester of pregnancy.

METHODS

We reviewed images from 159 first-trimester ultrasound examinations in 105 women with uncomplicated pregnancies who later delivered at term. The appearance of the decidua basalis layer and the sonographic changes that it underwent, including in echogenicity and thickness, were analyzed with respect to gestational age.

RESULTS

A distinct decidual layer could be identified consistently at 5-6 weeks' gestation and its thickness peaked at 6-7 weeks. It was seen inconsistently at 8-9 weeks and was not identifiable by 10 weeks. Its appearance changed over time, from a uniformly echogenic layer at 5-6 weeks to a heterogeneous echogenic layer at 7 weeks, corresponding to the histological evidence of trophoblast penetration. The layer then became less echogenic with time until it became unidentifiable.

CONCLUSIONS

There is a window of opportunity in the first trimester for sonographic examination of the decidua. This may allow screening, at an early stage, for conditions that affect the decidua during pregnancy.

Examination of the secondary palate on stored 3D ultrasound volumes of the fetal face

OBJECTIVES

To examine the use of oblique planes from stored three-dimensional (3D) ultrasound volumes of the fetal face for viewing the secondary palate at various gestational ages.

METHODS

3D ultrasound volumes of the fetal face acquired with surface rendering at 15-35 weeks' gestation in 31 fetuses with confirmed normal secondary palates were reviewed. The secondary palate was viewed in three oblique planes targeted at the uvula: the oblique axial, the oblique sagittal and the reverse face view. The detection and appearance of the secondary palate, including the soft palate, with these views at various gestational ages were compared.

RESULTS

The various surfaces of the secondary palate could be viewed in all 31 fetuses in the oblique axial and the reverse face views, and in all except two fetuses in the oblique sagittal view. Both of these were < 19 weeks' gestation, at which age the uvula could not be identified clearly in this plane.

CONCLUSIONS

The oblique axial, the oblique sagittal and the reverse face view targeted at the uvula allow visualization of the various aspects of the fetal secondary palate on 3D ultrasound in the second and third trimesters of pregnancy. The uvula could be used as a landmark for viewing the soft palate, but was not always easily identifiable before 19 weeks' gestation.

Monthly NH3 emissions from poultry in 12 Ecoregions of Canada

Management of ammonia (NH3) is a multi faceted issue for farmers. It is simultaneously a toxicant that can affect farm worker and animal health, a volatile plant nutrient that is expensive to replace if lost, and a potential contributor to environmental degradation. The environmental implications have important spatial and temporal dimensions, beyond the farm. This paper describes a model developed to estimate NH3 emissions from poultry (broiler, layer and turkey) production in 2780 mapping units across Canada on a monthly time scale. It includes estimates of daily emission peaks within critical months. The results will contribute to estimates of haze and atmospheric aerosol production, as well as contributions to other potential impacts such as eutrophication of sensitive ecosystems. The model is based on a detailed survey of farm practices. Emissions vary strongly throughout the year, and in many regions there are peak emissions in early spring and late fall, associated with landspreading of manure. There are also markedly different nitrogen excretion rates among regions, and these and bird populations are the key factors controlling emissions. On average, 22% of excreted uric acid or ammoniacal N is emitted from barns, 2% from storage and 26% from landspreading, resulting in a total loss of 50%. Key words: Ammonia, PM2.5, acid rain, nitrogen

A case of amyoplasia in a monochorionic twin pregnancy: a sequela from twin-twin transfusion syndrome?

OBJECTIVE

To present and discuss the sonographic and clinical findings in one twin of a monochorionic pair affected by amyoplasia.

METHODS

On ultrasound examination at 21 weeks in a monochorionic twin pregnancy, twin I was smaller, hydropic, with multiple contractures consistent with amyoplasia and oligohydramnios. Twin II was anatomically normal with polyhydramnios.

RESULTS

The twins were delivered at 28 weeks' gestation. The clinical findings were consistent with twin-twin transfusion syndrome (TTTS).

CONCLUSION

It is postulated that TTTS may be a causative factor in the excessive incidence of amyoplasia in monozygotic twin pregnancy.

Mapping the future dynamics of disease transmission: risk analysis in the United Kingdom Foresight Programme on the detection and identification of infectious diseases

This paper reflects on the qualitative risk analysis framework developed for a Foresight study on the Detection and Identification of Infectious Diseases, which was coordinated in 2005 by the United Kingdom (UK) under what is now the Government Office for Science, Department for Innovation, Universities and Skills. The risk assessment covered human, plant and animal diseases in the UK and Africa in the years 2015 and 2030. Through engaging a diverse pool of experts, we developed a model conceptualising disease spread as the outcome of interactions among sources, pathways and drivers. We then used this model to conduct a Delphi survey of experts. The factors perceived most likely to contribute to infectious disease spread in 2015 and 2030 included geographic extension of existing pathogens (partially due to climate change), over-use of antibiotics/antivirals/pesticides leading to drug resistance, and zoonoses. Our methodology provides a framework for those who need to integrate a wide range of perspectives and factors into their planning and analyses.

Mapping the future dynamics of disease transmission: risk analysis in the United Kingdom Foresight Programme on the detection and identification of infectious diseases

This paper reflects on the qualitative risk analysis framework developed for a Foresight study on the Detection and Identification of Infectious Diseases, which was coordinated in 2005 by the United Kingdom (UK) under what is now the Government Office for Science, Department for Innovation, Universities and Skills. The risk assessment covered human, plant and animal diseases in the UK and Africa in the years 2015 and 2030. Through engaging a diverse pool of experts, we developed a model conceptualising disease spread as the outcome of interactions among sources, pathways and drivers. We then used this model to conduct a Delphi survey of experts. The factors perceived most likely to contribute to infectious disease spread in 2015 and 2030 included geographic extension of existing pathogens (partially due to climate change), over-use of antibiotics/antivirals/pesticides leading to drug resistance, and zoonoses. Our methodology provides a framework for those who need to integrate a wide range of perspectives and factors into their planning and analyses.

Antenatal diagnosis of anophthalmia by three-dimensional ultrasound: a novel application of the reverse face view

The prenatal diagnosis of anophthalmia can be made on the demonstration of absent eye globe and lens on the affected side(s) on two-dimensional ultrasound examination, but when the fetal head position is unfavorable three-dimensional (3D) ultrasound may reveal additional diagnostic sonographic features, including sunken eyelids and small or hypoplastic orbit on the affected side(s). We present two cases of isolated anophthalmia diagnosed on prenatal ultrasound examination in which 3D ultrasound provided additional diagnostic information. The reverse face view provides valuable information about the orbits and the eyeballs for prenatal diagnosis and assessment of anophthalmia.

Primordial radionuclides in Canadian background sites: secular equilibrium and isotopic differences

A literature review and field sampling were done to obtain information on primordial (natural-series) radionuclide concentrations in terrestrial environments in diverse locations across Canada. Of special interest was the degree of secular equilibrium among members of decay series. The analytes measured in soils and plants were (nat)U by neutron activation-delayed neutron counting, (228)Th, (230)Th, (232)Th, (226)Ra and (210)Po by alpha spectroscopy, (210)Pb by gas flow proportional counting, (228)Ra by beta counting and (137)Cs by gamma spectroscopy. In addition, ICP-MS was used to obtain concentrations of about 50 analytes including elemental U, Pb, and Th. Samples were from seven representative background sites with a total of 162 plant samples from 38 different species. These data were supplemented by a review that gathered a large portion of the similar data from published sources. The sites chosen were semi-natural, far from any nuclear industry, although several were specifically located in areas with slightly elevated natural U concentrations. As might be expected, there were many cases of non-detectable concentrations. However, certain trends were evident. The activity ratio (210)Po/(210)Pb was unity in soils and non-annual plant tissues such as lichens. It was about 0.6 in annual plant tissues. These results are consistent with the time required for ingrowth of (210)Po to reach secular equilibrium. There was evidence from several sources that (210)Pb in plants came predominantly from deposition of (210)Pb from air after the decay of airborne (222)Rn. This was expected. Somewhat unexpected was the observation that (228)Th seemed to be much more plant available than (232)Th, even though both are in the same decay series and should be chemically similar. The difference was attributed to the combined effects of ingrowth from (228)Ra in the plant and effects of alpha recoil in mobilizing (228)Th in the soil. In general, the results of this study will benefit risk assessment, both in providing background concentrations, but also some indication of where isotope activity ratios can and cannot be used to estimate concentrations.

Photodynamic therapy for superficial basal cell carcinoma and Bowen's disease

Photodynamic therapy (PDT) is an effective treatment for superficial basal cell carcinoma (BCCs) and Bowen's disease. Several studies have reported complete response rates of 80-95% and an excellent cosmetic outcome. Bowen's disease and superficial basal cell carcinomas characteristically affect older patients who may also have associated difficulties with mobility. Using a portable PDT light source we were able to deliver PDT in a community setting with the aim of providing a more convenient service for patients. This randomised study confirmed that community delivered PDT is a viable treatment option and can be administered safely in the community by a trained dermatology nurse. The results from patient questionnaires suggest that community delivered PDT is more convenient to the patient, and also cost effective.

Eight years' experience of gastrostomy tube management

BACKGROUND AND STUDY AIMS

Increasingly, patients fed by gastrostomy tube are surviving the lifespan of the device. Data are scarce concerning the factors affecting the longevity and failure of gastrostomy tubes or the criteria for selection of replacement devices which leads to cost-effective patient management. The aims of the study were: to set criteria for selection of replacement gastrostomy tubes; to determine the causes of gastrostomy tube failure, and the factors affecting device longevity; and to examine the effect of initiating an educational programme for caregivers on resource utilization in long-term enteral nutrition patients.

MATERIALS AND METHODS

We analyzed the clinical gastrostomy tube database compiled prospectively over 8 years by the nutrition team at Ninewells Hospital, Dundee.

RESULTS

For 363 gastrostomy tubes inserted in 304 patients (160 women; median age 71), the median duration of gastrostomy tube use was 138 days. The total follow-up was 294 patient-years. Death occurred before the first gastrostomy tube replacement in 48 % of patients, but 20 % resumed oral nutrition. Tube failure mechanisms were: dislodgment, 28 %; perishing of tube material, 25 %; tube-related Candida albicans infection, 16 %; leakage, 7 %; and unspecified, 7 %. Of the balloon tubes and gastrostomy buttons, 8 % needed early replacement due to dislodgment and/or leakage. The cost per day for replacement percutaneous endoscopic gastrostomy (PEG) was Euro 2.12, for balloon tubes it was Euro 0.62, and for gastrostomy buttons Euro 1.80. Despite an increasing PEG insertion rate throughout the study period, yearly referrals for PEG-related problems dropped by 30 % between 1997 to 1999, coinciding with the initiation of an educational programme for caregivers.

CONCLUSION

Tube longevity is mainly limited by the patient's diagnosis and prognosis. The choice of replacement device should be based on clinical factors. The use of more durable materials in the manufacture of gastrostomy tubes may prolong tube life and reduce cost. Education of patients and caregivers by a multidisciplinary nutrition support team promotes independence and limits demand on the service.

Tamoxifen and breast cancer incidence among women with inherited mutations in BRCA1 and BRCA2: National Surgical Adjuvant Breast and Bowel Project (NSABP-P1) Breast Cancer Prevention Trial

CONTEXT

Among cancer-free women aged 35 years or older, tamoxifen reduced the incidence of estrogen receptor (ER)-positive but not ER-negative breast cancer. The effect of tamoxifen on breast cancer incidence among women at extremely high risk due to inherited BRCA1 or BRCA2 mutations is unknown.

OBJECTIVE

To evaluate the effect of tamoxifen on incidence of breast cancer among cancer-free women with inherited BRCA1 or BRCA2 mutations.

DESIGN, SETTING, AND PARTICIPANTS

Genomic analysis of BRCA1 and BRCA2 for 288 women who developed breast cancer after entry into the randomized, double-blind Breast Cancer Prevention Trial of the National Surgical Adjuvant Breast and Bowel Project (between April 1, 1992, and September 30, 1999).

MAIN OUTCOME MEASURE

Among women with BRCA1 or BRCA2 mutations, incidence of breast cancer among those who were receiving tamoxifen vs incidence of breast cancer among those receiving placebo.

RESULTS

Of the 288 breast cancer cases, 19 (6.6%) inherited disease-predisposing BRCA1 or BRCA2 mutations. Of 8 patients with BRCA1 mutations, 5 received tamoxifen and 3 received placebo (risk ratio, 1.67; 95% confidence interval, 0.32-10.70). Of 11 patients with BRCA2 mutations, 3 received tamoxifen and 8 received placebo (risk ratio, 0.38; 95% confidence interval, 0.06-1.56). From 10 studies, including this one, 83% of BRCA1 breast tumors were ER-negative, whereas 76% of BRCA2 breast tumors were ER-positive.

CONCLUSION

Tamoxifen reduced breast cancer incidence among healthy BRCA2 carriers by 62%, similar to the reduction in incidence of ER-positive breast cancer among all women in the Breast Cancer Prevention Trial. In contrast, tamoxifen use beginning at age 35 years or older did not reduce breast cancer incidence among healthy women with inherited BRCA1 mutations. Whether tamoxifen use at a younger age would reduce breast cancer incidence among healthy women with BRCA1 mutations remains unknown.

Evaluating your employees - Who, what to use, when, and how to deal with this sensitive topic to achieve results

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Compensating your associate--does pay for performance work for both associate and owner?

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Are Web sites for veterinary practices worthwhile?

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Apoptosis: the importance of nuclear medicine

Apoptosis is a genetically controlled, energy-dependent process which removes unwanted cells from the body. Because of its orderly progression, apoptosis is also known as programmed cell death or cell suicide. Once initiated, apoptosis is characterized by a series of biochemical and morphological changes involving the cytoplasm, nucleus and cell membrane. Cytoplasmic changes include cytoskeletal disruption, cytoplasmic shrinkage and condensation; prominent changes in the nucleus include peripheral chromatin clumping and inter-nucleosomal DNA cleavage (DNA ladder formation); and membrane changes include the expression of phosphatidylserine on the outer surface of the cell membrane and blebbing (resulting in the formation of cell membrane-bound vesicles or apoptotic bodies). These events allow the cell to digest and package itself into membrane-bound packets containing autodigested cytoplasm and DNA, which can then be easily absorbed by adjacent cells or phagocytes. An endogenous human protein, annexin V (molecular weight approximately 35,000), has an affinity of about 10(-9) M for phosphatidylserine exposed on the surface of apoptotic cells. Annexin V can be labelled with radionuclides such as iodine or technetium, or positron emitting agents. Experimental studies in cells confirm that fluorescence and 99Tc(m)-labelled annexin have comparable affinity for apoptotic cells. In vivo studies with 99Tc(m)-labelled annexin confirm that radiolabelled annexin V can be used to image apoptotic cells/tissues in vivo. In this article, we review experimental data using annexin V imaging and discuss its possible future use to identify apoptosis in vivo.

The results of tubal surgery in the treatment of infertility in Wellington 1986-90

AIMS

To audit the outcome of tubal surgery performed in Wellington between 1986-90. To establish the appropriate indications for tubal surgery in terms of likely benefit. To compare benefit with other treatment modalities namely in vitro fertilisation.

METHODS

Data obtained from hospital patient notes, theatre records and personal communication.

RESULTS

There were 71 patients, 67 of whom had been adequately followed up. The total pregnancy rate was 41.8% with an overall term pregnancy rate of 29.8%. The success rate was highest with proximal tubal occlusion and worst for distal disease and endometriosis.

CONCLUSION

The outcome of the audit is consistent with results worldwide. Tubal surgery allows for natural conception and more than one pregnancy can be conceived as a result. It should be considered the first line treatment for proximal tubal disease and fimbrial adhesions. In vitro fertilisation however should be offered to those with severe distal disease and severe endometriosis.

Segmental dilatation of the small bowel: report of three cases and literature review

Segmental dilatation of the small bowel is a rare congenital abnormality that occurs mainly in children and produces significant nonspecific symptoms. The authors reviewed 33 cases reported in the literature and present three new cases in which the lesion was demonstrated on radiographs obtained before laparotomy. These cases showed the spectrum of symptoms and characteristic radiologic features of this condition in both plain abdominal radiographs and barium studies. Plain radiographs of the abdomen may show an isolated loop of bowel containing an air-fluid level. The characteristic finding in barium studies of the small bowel is a localized dilatation of the small bowel lumen with afferent and efferent loops. In the absence of a complication or coexistent cause of obstruction, the transit time of contrast medium through the small bowel is not delayed. The radiologic examination is useful in diagnosis, and the condition is cured with surgery.

Urethral syndrome (abacterial cystitis)--search for a pathogen

Thirty-one women with the recurrent urethral syndrome (abacterial cystitis) had extensive microbiological, cytological and histological investigations. A Streptococcus species was isolated from the bladder aspirate of one patient, a wall-deficient Streptococcus species from two others and both a Lactobacillus species and Ureaplasma urealyticum from another. A possible microbiological cause was therefore identified in the bladder in only 4 of the 31 patients. A Lactobacillus species was isolated from the bladder aspirate of one control subject. Lactobacilli were grown in the voided urine of the majority of patients and in seven of the eight control subjects. Chlamydia trachomatis and Herpes simplex were isolated from the cervix and the urethra of one patient. Urethral cytology was normal in all patients. Trigonitis was noted at cystoscopy in 26 of the 31 patients. Bladder biopsies showed squamous metaplasia in 15 and lymphocytic infiltration of the lamina propria in 29, giving support to an inflammatory aetiology of this enigmatic syndrome.