The association of adolescents' smoking with the physical activity levels of their friends.

BACKGROUND: Smoking is inversely related to people's Physical Activity Level (PAL). As the behavior of friends may affect the choices and behavior of adolescents, having friends with a high PAL may potentially protect against adolescent smoking. This study aims to assess whether adolescents' smoking is associated with the PAL of their friends. METHODS: SILNE-R survey data of 11.918 adolescents from 55 different schools in 7 European cities was used to determine weekly smoking, individual PAL, PAL of friends, school PAL, and smoking of friends. Multilevel, multivariable logistic regression analysis were used to assess the association between the PAL of friends and weekly smoking. Several socio-demographic variables were included as covariates in the analysis. RESULTS: Our results indicated that 10.8% of the respondents was smoking weekly. Weekly smoking was most common among adolescents whose friends had a PAL of 0-42.0 min per day (14.5%). Respondents were significantly more likely to be smoking weekly if their friends were on average 0-42 min vs. 80-180 min physically active (OR 1.27 [95% CI 1.04-1.55]). This association existed independently of the individual PAL of respondents. Stratification for smoking of friends yielded equal results, although the association appeared to be somewhat stronger for those with smoking friends (OR 1.38 [95% CI 1.06-1.82]). CONCLUSION: Adolescents are less likely to smoke weekly if they associate with friends who spend >80 min per day on physical activity. Initiatives aimed at the prevention of smoking among adolescents may benefit from organizing group-based physical activity programs.

Nicotine dependence among adolescents in the European Union: How many and who are affected?

BACKGROUND: Nicotine dependence during adolescence increases the risk of continuing smoking into adulthood. The magnitude of nicotine dependence among adolescents in the European Union (EU) has not been established. We aimed to estimate the number of nicotine dependent 15-year-old adolescents in the EU, and identify high-risk groups. METHODS: The number of nicotine dependent 15-year-olds in the EU was derived combining: (i) total number of 15-year-olds in the EU (2013 Eurostat), (ii) smoking prevalence among 15-year-olds (2013/2014 HBSC survey) and (iii) proportion of nicotine dependent 15-year-olds in six EU countries (2013 SILNE survey). Logistic regression analyses identified high-risk groups in the SILNE dataset. RESULTS: We estimated 172 636 15-year-olds were moderately to highly nicotine dependent (3.2% of all 15 years old; 35.3% of daily smokers). In the total population, risk of nicotine dependence was higher in males, adolescents with poor academic achievement, and those with smoking parents or friends. Among daily smokers, only lower academic achievement and younger age of smoking onset were associated with nicotine dependence. CONCLUSION: According to our conservative estimates, more than 172 000 15-year-old EU adolescents were nicotine dependent in 2013. Prevention of smoking initiation, especially among adolescents with poor academic performance, is necessary to prevent a similar number of adolescents getting addicted to nicotine each consecutive year.

Treatment of psoriasis with non-registered fumaric acid esters in The Netherlands: a nationwide survey among Dutch dermatologists.

BACKGROUND: Psoriasis vulgaris is a T-cell mediated disease that affects 2-3% of the worldwide white-skinned population. Fumaric acid esters are mentioned as an effective therapy for moderate-to-severe psoriasis vulgaris in adult patients in the new guidelines for psoriasis treatment. OBJECTIVES: To obtain an insight into the use of fumaric acid esters by Dutch dermatologists in the Netherlands. METHODS: This was a cross-sectional postal survey. An anonymous survey was posted to all Dutch dermatologists. In this survey, data were collected on the extent of fumaric acid esters use, the reasons for use, the reasons for non- or limited use of fumaric acid esters, the perception of fumaric acid esters as a mono-therapy with regards to the effectiveness, the safety, the adverse events and the overall satisfaction of fumaric acid esters as a mono-therapy. RESULTS: Sixty-three per cent of the 300 responders indicated to prescribe fumaric acid esters for the treatment of psoriasis. About 37% of the dermatologists indicated (almost) never to prescribe it. Biologicals were considered as the most effective therapy. Fumaric acid esters were regarded as the safest therapy. They were generally well-tolerated by the patients similar to that for methotrexate according to the respondents. CONCLUSION: A large proportion of the dermatologists in our survey indicated to prescribe fumaric acid esters. It is considered to be effective, safe and without adverse events profile that is favourable in the practice, also as compared with other systemic therapies such as methotrexate and biologicals.

Mechanical ventilation and the titer of antibodies as risk factors for the development of transfusion-related lung injury.

Purpose. Onset of transfusion-related acute lung injury (TRALI) is suggested to be a threshold-event. Data is lacking on the relation between titer of antibodies infused and onset of TRALI. We determined whether onset of TRALI is dependent on the titer of MHC-I antibodies infused in a combined model of ventilator-induced lung injury and antibody-induced TRALl. Methods. BALB/c mice were ventilated for five hours with low (7.5 ml/kg) or high (15 ml/kg) tidal volume. After three hours of MV, TRALI was induced by infusion of 0.5 mg/kg, 2.0 mg/kg or 4.5 mg/kg MHC-I antibodies. Control animals received vehicle. After five hours of MV, animals were sacrificed. Results. MV with high tidal volumes resulted in increased levels of all markers of lung injury compared to animals ventilated with low tidal MV. In ventilator-induced lung injury, infusion of 4.5 mg/kg of antibodies further increased pulmonary wet-to-dry ratio, pulmonary neutrophil influx and pulmonary KC levels, whereas infusion of lower dose of antibodies did not augment lung injury. In contrast, mice ventilated with low tidal volumes did not develop lung injury, irrespective of the dose of antibody used. Conclusions. In the presence of injurious MV, onset of TRALI depends on the titer of antibodies infused.

Hypomagnesaemia due to use of proton pump inhibitors--a review.

Magnesium homeostasis is essential for many intracellular processes and depends on the balance of intestinal absorption and renal excretion. Hypomagnesaemia may arise from various disorders. We review the literature on hypomagnesaemia due to the use of proton pump inhibitors, as illustrated by a case of a 76-year-old woman with muscle cramps and lethargy caused by hypomagnesaemia and hypocalcaemia with a low parathyroid hormone level while using esomeprazole, a proton pump inhibitor (PPI). After oral magnesium repletion both abnormalities resolved. Fractional magnesium excretion was low, excluding excessive renal loss. A causal relation with PPI use was supported by the recurrence of hypomagnesaemia after rechallenge. In the past decade our understanding of transcellular magnesium transport was enhanced by the discovery of several gene mutations i.e. transient receptor potential melastin (TR PM) 6 and 7. In this light we discuss the possible aetiology of proton pump inhibitor related hypomagnesaemia.

Survey among patients with basal cell carcinoma in The Netherlands.

This paper describes the findings of a survey distributed among Dutch patients with basal cell carcinoma (BCC). The questionnaire comprised a list of questions related to demographic characteristics, features of BCC, reason for consulting a dermatologist, anxiety, type of treatment and the satisfaction with this treatment and desired benefits of treatment. In total, 220 patients completed the survey. The age of these responders varied between 27 and 89 years (mean 64.6 years). Half of the patient group had already previously experienced a BCC. Most patients (52%) indicated that the diagnosis 'skin cancer' frightened them, but that they knew it could be treated. Accordingly, most patients (70%) indicated that BCC had no or hardly any influence on their quality of life. From the patient's perspective, efficacy, low recurrence rate and no or minor scarring are important features of a BCC treatment. Surgery was the most popular therapy. The number of BCC patients is growing, which will lead to a definite burden for dermatologists in the near future. Our survey demonstrated that patients are mostly interested in the efficacy, low recurrence rates and cosmetic outcome of their therapies. Newly efficacious and non-invasive therapies, such as the recently introduced photodynamic therapy or home treatment with imiquimod, can help to overcome these concerns.

[Complaints of back pain in childhood: find curable causes]. / Rugpijnklachten op de kinderleeftijd: behandelbare oorzaken opsporen.

Three children, a 13-year-old boy and a 3-year-old and 6-year-old girl, were presented to the hospital with back pain, caused by Scheuermann's disease, spondylodiscitis and sickle cell disease, respectively. The boy with Scheuermann's disease received exercise therapy, the spondylodiscitis was treated with antibiotic therapy and the girl with sickle cell disease was given hyperhydration and folic acid. Although back pain is a common problem in children and teenagers, it is infrequently reported in the clinic. In contrast to back pain in adults, the same complaint in childhood is more often caused by a serious disorder which should be treated. Various causes of back pain in children can be distinguished: mechanical problems, infections of the lumbar spine, neoplasia, inflammation, and other causes, such as sickle cell disease. A child or adolescent presenting to the clinic with complaints of back pain deserves a careful detailed evaluation of the history, appropriate physical examination and additional investigation. Alarm symptoms are an increase in back pain, age below 4 years, pain during the night, restriction in function, systemic complaints or neurological deficits.

Multiple doses of the antimuscarinic agent solifenacin do not affect the pharmacodynamics or pharmacokinetics of warfarin or the steady-state pharmacokinetics of digoxin in healthy subjects.

AIMS: Solifenacin succinate is used for the treatment of overactive bladder (OAB). The potential for pharmacokinetic and/or pharmacodynamic interactions between solifenacin and warfarin or digoxin was investigated. METHODS: The solifenacin-warfarin study was a two-period crossover trial conducted in healthy males. Subjects received warfarin on the 10th day of 16 days of dosing with either solifenacin or placebo. The solifenacin-digoxin study was an one-sequence crossover trial conducted in healthy males and females. Following a phase-in period for digoxin, solifenacin was administered concomitantly with the drug on days 9-18. RESULTS: The AUC(PT; 0-168 h) following a single dose of warfarin was unchanged in the presence of solifenacin [point estimate = 1.005; 90% confidence interval (CI) 0.98, 1.02)]. The AUC(0-infinity) values for both warfarin enantiomers were also unchanged. A small increase in the C(max) of digoxin was observed during treatment with solifenacin, but for AUC(ss,tau) and C(max) the 90% CI fell within the prespecified interval of 0.80-1.25. Combined administration of solifenacin and warfarin or digoxin was well tolerated. CONCLUSIONS: Since the pharmacokinetics and pharmacodynamics of a single dose of warfarin and the steady-state pharmacokinetics of digoxin were not affected by coadministration of solifenacin in healthy subjects, the need for dosing adjustments for digoxin and/or warfarin does not seem warranted.

Amoxicillin/clavulanic acid (875/125): bioequivalence of a novel Solutab tablet and rationale for a twice-daily dosing regimen.

A new amoxicillin/clavulanic acid tablet formulation (Solutab tablet, Forcid Solutab) containing amoxicillin/clavulanic acid (875/125) has been developed. The aim of the present study was to demonstrate bioequivalence between the new tablet formulation (test), taken as an intact tablet and after prior dispersal, versus the originator product viz. Augmentan film-coated tablet (875/125) used as reference. The study was performed in 48 healthy volunteers according to an open, single-dose, crossover design. Bioequivalence was demonstrated using Cmax and AUC(0-infinity) as primary parameters of evaluation for both amoxicillin and clavulanic acid with 90% confidence intervals of the ratios Solutab tablet/Augmentan within the range of 0.8-1.25. The duration of the plasma concentration exceeding the amoxicillin minimal inhibitory concentration (MICs) was calculated using individual plasma concentration-time curves and compartmental analysis. The data showed that the bioavailability characteristics of the test tablet, taken intact or in dispersed form, and the reference tablets were very similar. The analysis, moreover, also confirmed the appropriateness of using a b.i.d. dosage regimen for both formulations, taking into account the pharmacodynamic breakpoint values for some major pathogens.

External fixation with standard AO-plates: technique, indications, and results in 31 cases.

The standard AO-plate was used as an external fixator in 31 patients with an infected nonunion or open fracture mainly of the upper extremity. With the use of this technique, good stability can be achieved with an inexpensive and relatively simple construction. The low profile of the frame is an advantage for the patient.

Conditions influencing the in vitro antifungal activity of lactoferrin combined with antimycotics against clinical isolates of Candida. Impact on the development of buccal preparations of lactoferrin.

Lactoferrin, an iron-binding glycoprotein, is a potential agent for the treatment of oropharyngeal Candidiasis. The aim of the present study was to test the capability of lactoferrin, combined or not combined with conventional antifungal agents, to inhibit the growth of different Candida species under various experimental conditions to be of guidance in the development of a suitable pharmaceutical formulation containing lactoferrin. The anti-Candida activities of lactoferrin were considerably higher using RPMI instead of SLM as assay medium. They were moreover increased by raising the medium pH from 5.6 to 7.5. With the 'standard' antifungal agent fluconazole similar results were found as for lactoferrin, but the medium type and pH did not affect MIC values of amphotericin B. The addition of saliva to medium did not reduce the antifungal activities of the individual compounds. Synergistic inhibitory effects on Candida growth were found for combinations of lactoferrin and fluconazole or amphotericin B, irrespective of the medium type and pH, or the addition of saliva. This indicates that for treatment of oral Candidiasis a formulation containing lactoferrin seems appropriate; results may be optimized if the formulation is provided with buffer capacity to attain pH 7.5 in the mucosal fluid. The synergistic effects between lactoferrin and 'standard' antifungals indicate that combinations should be considered in such a formulation.

On the determination of the angular orientation of a vertebra.

In this paper we consider the spatial orientation of vertebrae. We take the view that, in determining their rotation angles from X-rays, the procedure applied by Drerup yields the most reliable empirical results, viz. the three angles through which a vertebra rotates about its own symmetry axes in a specific sequence. With a view to the further use of this information to analyze deformations or the motion of a spine we recommend that the Drerup angles be converted into the well-known Eulerian angles. How this can be done is the subject of this report.

The metabolic fate of the Anti-HIV active drug carrier succinylated human serum albumin after intravenous administration in rats.

The pharmacokinetics and metabolic fate of the intrinsically active (anti-HIV) drug carrier succinylated human serum albumin (Suc-HSA) was studied in rats. Suc-HSA was prepared by derivatizing HSA with 1,4-[14C]-succinic anhydride, a modification by which all available epsilon NH2-groups in HSA were converted into carboxylic groups. After i.v. injections of 0.3, 1.0, 3.0 and 10.0 mg/kg in freely moving rats, Suc-HSA showed a dose dependent elimination pattern, indicating a saturable elimination pathway. The Michaelis-Menten parameters Vmax and Km were 98.7 micrograms.min-1.kg-1 and 8.5 micrograms.ml-1 respectively. The kinetics of Suc-HSA was influenced by anaesthesia. In anaesthetised animals, Vmax and Km were found to be 26.9 micrograms.min-1.kg-1 and 0.26 microgram.ml-1, respectively. This implies an intrinsic clearance of 100 ml.min-1.kg-1, which is about 10-fold higher as compared to 12 ml.min-1.kg-1 in freely moving animals. Intravenous administration of a sub-saturable dose of 3.0 mg.kg-1 1,4-[14C]-Suc-HSA to freely moving rats resulted in a biphasic elimination with an initial t 1/2 of 20 min and a terminal t 1/2 of 40 hrs. Excretion of metabolites in urine and faeces lasted for at least 48 hours. About 70% of the radioactive dose was excreted in urine, whereas maximally 2% was detected in faeces. Suc-HSA was degraded to its individual amino acids including succinylated lysine (the only radioactive product formed). Succinylated lysine was not further metabolised and mainly excreted via the urine. Immunohistochemical staining showed that even after 48 hrs Suc-HSA could be detected in livers. Together with the urinary excretion patterns, this points to a gradual degradation of Suc-HSA.

Calcipotriol cream in the morning and ointment in the evening: a novel regimen to improve compliance.

BACKGROUND: Calcipotriol ointment and calcipotriol cream have both been shown to be effective in the treatment of psoriasis. AIM: To find out the patient compliance, efficacy and tolerance to a regimen of a calcipotriol cream application in the morning and a calcipotriol ointment application in the evening. METHODS: In order to obtain data relevant to daily practice, information was obtained from patients and dermatologists on the treatment of psoriasis with a combination of calcipotriol ointment and calcipotriol cream. In total, three assessments were carried out: at the beginning, after 3 weeks and after 8 weeks. The first assessment comprised general demographics, localization of the lesions, the percentage body surface involved, and details on other antipsoriatic medications. The second and third assessments were an evaluation of compliance and efficacy in comparison with calcipotriol ointment monotherapy, provided that the patients had experience with this treatment. In total, 976 patients were included by 170 dermatologists in The Netherlands and Belgium. RESULTS: Compliance with the combined use of calcipotriol cream in the morning and calcipotriol ointment in the evening was optimal in 60-70% of the patients. The highest compliance was shown at the second visit but dropped at the third visit. Those patients with previous experience of calcipotriol ointment indicated that the calcipotriol cream/ointment regimen was a better principle. Response to the calcipotriol cream/ointment regimen was considered good in 67-76% of the patients. CONCLUSION: The present study indicates that the combined use of calcipotriol cream in the morning and ointment in the evening is useful as a principle for mild to severe psoriasis. A total of 67-68% of the patients stated that this regimen was the most preferred topical treatment of psoriasis.

Patient compliance and disease management in the treatment of psoriasis in the Netherlands.

BACKGROUND: Compliance behaviour and disease management are important issues in chronic skin diseases. Psoriasis patients are 'experts by experience' because of many years of treatment. Therefore, it is relevant to gather data from patients on the actual use of antipsoriatic treatments. OBJECTIVE: The following questions are addressed: (1) What is the present mode of prescription and actual use of antipsoriatic treatments, including topical treatments, photo(chemo)therapy and systemic treatments? (2) What information do patients expect from their doctor, and do they actually receive this information. METHODS: To answer these questions, a questionnaire survey was mailed to the subscribers of Psoriasis, the journal of the Dutch Psoriasis Patients' Organisation. RESULTS: (1) Major issues in the treatment of psoriasis are (a) long-term management, (b) control of mild, moderate but also extensive psoriasis and (c) control of psoriasis on difficult localisations. Patients perceive itch, scaliness and visibility as major criteria for efficacy. (2) Topical treatment is the mainstay in the management of psoriasis. Calcipotriol is the most prescribed drug. Photo(chemo)therapy has an intermediate position between topical and systemic treatments. UVB is prescribed more than twice as frequently as PUVA and 10% of the patients on photo(chemo)therapy proved to be treated with UVB at home. Only 16% of the patients were on a systemic treatment; methotrexate and acitretin were the most frequently used systemic treatments. (3) More than 70% of the patients indicated that they had taken part in the selection of a treatment. In general, the patients were satisfied about the contact with their dermatologist and general practitioner. Compliance with the duration of treatment is limited, especially with regard to topical treatment. Patient compliance with the dose of the treatment is better. Again compliance is the worst in topical treatments. (4) Patients have a strong preference for an effective treatment which is safe for long-term use. Only a minority of patients wants a fast clearing treatment. CONCLUSION: Itch, scaliness and visibility provide the most relevant information on the severity of psoriasis, as the patients perceive themselves. Treatment duration is often unrestricted, especially with regard to topical treatments, which implies that the cumulative toxicity potential of these treatments may have a serious impact on their safety profile. Patients regard it of importance to have a vote in the selection of the treatment and regard safety as more important than fast clearing.

Targeting of superoxide dismutase to the liver results in anti-inflammatory effects in rats with fibrotic livers.

BACKGROUND/AIMS: The rapid clearance from plasma and the limited uptake of superoxide dismutase (SOD) in the liver hampers the effectiveness of this enzyme in liver diseases. We therefore compared the pharmacokinetics and in vivo efficacy of SOD with two modified forms of this protein: SOD coupled to the copolymer DIVEMA and mannosylated-SOD. METHODS: Reactive oxygen scavenging activity of SOD conjugates was tested in livers of bile duct ligated rats. Intrahepatic production of reactive oxygen species (ROS) and neutrophil infiltration were studied immunohistochemically and related to the organ and cellular distribution of radiolabeled SOD conjugates. RESULTS: Native SOD was rapidly cleared from the circulation and accumulated in renal tubuli. The enzyme had no effect on the intrahepatic ROS production. Covalent attachment of SOD to DIVEMA yielded a polyanionic conjugate with a prolonged elimination half-life compared to native SOD. In contrast to native SOD, DIVEMA-SOD was taken up by the liver via scavenger receptors. Mannosylation of SOD (Man-SOD) resulted in a conjugate that was rapidly cleared from the blood. This Man-SOD was taken up by non-parenchymal liver cells. The pharmacokinetics of SOD and its derivatives were similar in normal and bile duct ligated rats. Efficacy studies with Man-SOD revealed only a slight decrease in intrahepatic ROS production. However, DIVEMA-SOD exhibited a potent inhibitory effect on ROS production in the liver. Nearly complete ROS-scavenging activity was observed in the portal areas. CONCLUSIONS: Considering the prolonged half-life, the increased delivery of SOD to the target cells, and the concomitant increased effectiveness, application of DIVEMA-SOD seems a promising new approach to attenuate intrahepatic inflammatory processes.

Resistance of the human immunodeficiency virus to the inhibitory action of negatively charged albumins on virus binding to CD4.

Negatively charged albumins (NCAs) have been identified as potent inhibitors of HIV-1 replication in vitro. Time of addition studies suggest that succinylated and aconitylated human serum albumin (Suc-HSA and Aco-HSA) act at an early stage of the virus life cycle, and surface plasmon resonance (BIAcore) experiments have confirmed a direct interaction of NCAs with HIV-1 gp120. Resistance to Suc-HSA and Aco-HSA was analyzed by characterizing HIV-1 variants that were selected in cell culture after serial passage of the NL4-3 strain in the presence of the compounds. After 24 passages (126 days) we isolated variants that were resistant to Suc-HSA (>27-fold) and Aco-HSA (37-fold), as compared with the wild-type NL4-3 virus. The binding of the NCA-resistant HIV strains to CD4+ MT-4 cells could no longer be inhibited by either Suc- or Aco-HSA. The emergence of mutations in the envelope gp120 of the resistant virus paralleled the emergence of the resistant phenotype. The Suc-HSA-resistant strain was 100-fold cross-resistant to the G quartet-containing oligonucleotide AR177 (Zintevir, an HIV-binding inhibitor), and partially cross-resistant to dextran sulfate, but remained sensitive to the bicyclam AMD3100 and the chemokine SDF-1alpha, which block HIV replication by interaction with the chemokine receptor CXCR4. Furthermore, neither Suc-HSA nor Aco-HSA inhibited the binding of monoclonal antibodies 12G5 and 2D7 (directed to CXCR4 and CCR5, respectively) in SUPT-1 cells or THP-1 cells. These results confirm that NCAs bind primarily to gp120 and do not interact directly with the HIV chemokine receptor but block the binding of the virus particles (through gp120) with CD4+ cells.

Homing of negatively charged albumins to the lymphatic system: general implications for drug targeting to peripheral tissues and viral reservoirs.

The present study shows the lymphatic distribution of the negatively charged anti-HIV-1 agents succinylated or aconytilated human serum albumins (HSAs) in rats. Quantitation of blood and lymphatic concentrations of these proteins was performed through fluorescence detection of the fluorescein isothiocyanate (FITC)-labeled proteins. At several time points after i.v. injection, samples were taken from the cannulated thoracic duct and the carotid artery. Distribution of the negatively charged albumins (NCAs) to lymph was much more rapid than that of albumin itself and was dependent on the total net negative charge added to the protein: the half-life times of lymphatic equilibration were 15, 30, and 120 min for FITC-labeled aconytilated HSA, FITC-labeled succinylated HSA, and FITC-labeled HSA, respectively. Lymph to blood concentration ratios of the studied compounds obtained at steady state approached unity. In addition, the fluorescence in both body fluids was shown to represent unchanged labeled proteins. It was therefore inferred that the NCAs efficiently passed the endothelial barrier from blood to the interstitial compartment. Subsequently, we studied whether a specialized process was involved in the endothelial passage of the NCAs to the lymph. The following observations supported such a mechanism: a) preinjection of the scavenger receptor blockers polyinosinic- and formaldehyde-treated HSA reduced the transport from blood to the lymphatic compartment of FITC-labeled aconytilated HSA by more than 90%; b) the rate of lymphatic distribution was largely reduced when the body temperature of the rat was lowered to 28 degrees; and c) pre-administration of chloroquine resulted in a significant reduction in the lymphatic distribution of the NCAs. These data collectively indicate that a scavenger receptor-mediated process is involved in the transendothelial transport of NCAs. In situ localization in lymph nodes of the rat showed that FITC-labeled aconytilated and succinylated HSA are mainly present in the germinal center and parafollicular zones. The efficient distribution of these anionized proteins to the lymphatic system is of particular interest for HIV therapy, taking into account that replication of HIV mainly takes place in the lymphoid system. The observation that macromolecules, through charge modification, can extravasate through a receptor-mediated transcytotic process is potentially of major importance for the delivery of drugs with macromolecular carriers to cells not directly in contact with the blood.

Synergistic fungistatic effects of lactoferrin in combination with antifungal drugs against clinical Candida isolates.

Because of the rising incidence of failures in the treatment of oropharyngeal candidosis in the case of severely immunosuppressed patients (mostly human immunodeficiency virus [HIV]-infected patients), there is need for the development of new, more effective agents and/or compounds that support the activity of the common antifungal agents. Since lactoferrin is one of the nonspecific host defense factors present in saliva that exhibit antifungal activity, we studied the antifungal effects of human, bovine, and iron-depleted lactoferrin in combination with fluconazole, amphotericin B, and 5-fluorocytosine in vitro against clinical isolates of Candida species. Distinct antifungal activities of lactoferrin were observed against clinical isolates of Candida. The MICs generally were determined to be in the range of 0.5 to 100 mg. ml(-1). Interestingly, in the combination experiments we observed pronounced cooperative activity against the growth of Candida by using lactoferrin and the three antifungals tested. Only in a limited concentration range was minor antagonism detected. The use of lactoferrin and fluconazole appeared to be the most successful combination. Significant reductions in the minimal effective concentrations of fluconazole were found when it was combined with a relatively low lactoferrin concentration (1 mg/ml). Such combinations still resulted in complete growth inhibition, while synergy of up to 50% against several Candida species was observed. It is concluded that the combined use of lactoferrin and antifungals against severe infections with Candida is an attractive therapeutic option. Since fluconazole-resistant Candida species have frequently been reported, especially in HIV-infected patients, the addition of lactoferrin to the existing fluconazole therapy could postpone the occurrence of species resistance against fluconazole. Clinical studies to further elucidate the potential utility of this combination therapy have been initiated.