Characterizing Microbiota from Sjögren's Syndrome Patients.

OBJECTIVE: To compare the oral microbiota of Sjögren's syndrome (SS) with that of healthy subjects (HS). METHODS: Supragingival and subgingival biofilm samples were collected from the mesial-buccal tooth surfaces of SS patients (n = 57) and age- and sex-matched HS (n = 53). Unstimulated saliva and 8 oral tissue samples were taken using a buccal brush. Caries and periodontal measures were recorded. All supragingival samples and a subgroup of 24 SS and 28 HS subgingival samples, as well as 32 SS and 11 HS saliva and oral tissue samples, were analyzed for their content of 41 bacterial species using checkerboard DNA-DNA hybridization. Mean levels (×105 ± SEM) and percentage of DNA probe counts of each species were determined for each sample site and averaged within subjects in the 2 clinical groups. Kruskal-Wallis tests, adjusting for multiple comparisons and cluster analysis, were used for soft tissue and microbial analysis, and the Mann-Whitney test was used to compare caries and periodontal measures. RESULTS: Mean (×105 ± SEM) total DNA probe counts in supragingival samples were significantly lower (P < 0.001) in the SS (13.3 ± .7) compared to the HS (44.1 ± 6.8) group. In supragingival samples, Veillonella parvula, Fusobacterium nucleatum ss vincenti, and Propionibacterium acnes were markedly elevated in the SS compared to the HS group in both mean (×105 ± SEM) and mean (± SEM) percentage DNA probe counts (P < 0.001). In subgingival samples of SS, V. parvula was significantly different compared to HS (P < 0.05). SS was characterized by high levels of purple and low levels of orange and red complexes. Cluster analysis of oral tissues and saliva demonstrated that the mean microbial profiles for SS patients and the HS group clustered separately. Active root caries (P < 0.003) and attachment loss were significantly higher (P < 0.029) in the SS group compared to the HS group. CONCLUSION: These findings indicate that saliva is a major controlling factor of intraoral biofilm. V. parvula may be a unique microbial biomarker for Sjögren's syndrome. KNOWLEDGE TRANSFER STATEMENT: The microbiome characterized for Sjögren's syndrome in salivary hypofunction is shown to be under stress and reduced. Veillonella parvula can be a possible identification of a biomarker for Sjögren's syndrome.

Comparison of microbial changes in early redeveloping biofilms on natural teeth and dentures.

BACKGROUND: Surfaces and fluids can affect oral bacterial colonization. The aim of this study is to compare redeveloping biofilms on natural teeth and dentures. METHODS: Supragingival plaque samples were taken from 55 dentate individuals and the denture teeth of 62 edentulous individuals before and after professional cleaning. Also, samples from seven "teeth" (samples included dentures) in randomly selected quadrants were collected after 1, 2, 4, and 7 days of no oral hygiene. Samples were analyzed using checkerboard DNA-DNA hybridization. Counts and proportions of 41 bacterial taxa were determined at each time point, and significant differences were determined using the Mann-Whitney U test. Ecological succession was determined using a modified moving window analysis. RESULTS: Mean total DNA probe counts were similar precleaning but were higher in dentate individuals at all post-cleaning visits (P <0.01). Precleaning edentate biofilms had higher counts and proportions of Streptococcus mitis, Streptococcus oralis, and Streptococcus mutans, whereas dentate individuals had higher proportions of Tannerella forsythia, Selenomonas noxia, and Neisseria mucosa. By day 2, mean counts of all taxa were higher in natural teeth, and most remained higher at day 7 (P <0.01). Succession was more rapid and complex in dentate individuals. Both groups demonstrated increased proportions of S. mitis and S. oralis by day 1. N. mucosa, Veillonella parvula, and Eikenella corrodens increased in both groups, but later in samples from edentate individuals. CONCLUSIONS: "Mature" natural and denture teeth biofilms have similar total numbers of bacteria but different species proportions. Post-cleaning biofilm redevelopment is more rapid and more complex on natural teeth than on denture teeth.

Early microbial succession in redeveloping dental biofilms in periodontal health and disease.

BACKGROUND AND OBJECTIVE: The development of dental biofilms after professional plaque removal is very rapid. However, it is not clear whether most bacterial species return at similar rates in periodontally healthy and periodontitis subjects or if there are differences in bacterial recolonization between supragingival and subgingival biofilms in periodontal health and disease. MATERIAL AND METHODS: Supragingival and subgingival plaque samples were taken separately from 28 teeth in 38 healthy and 17 periodontitis subjects immediately after professional cleaning. Samples were taken again from seven teeth in randomly selected quadrants after 1, 2, 4 and 7 d of no oral hygiene and analyzed using checkerboard DNA-DNA hybridization. The percentage of DNA probe counts were averaged within subjects at each time-point. Ecological succession was determined using a modified moving-window analysis. RESULTS: Succession in supragingival biofilms from subjects with periodontitis and from healthy individuals was similar. At 1 d, Streptococcus mitis and Neisseria mucosa showed increased proportions, followed by Capnocytophaga gingivalis, Eikenella corrodens, Veillonella parvula and Streptococcus oralis at 1-4 d. At 4-7 d, Campylobacter rectus, Campylobacter showae, Prevotella melaninogenica and Prevotella nigrescens became elevated. Subgingival plaque redevelopment was slower and very different from supragingival plaque redevelopment. Increased proportions were first observed for S. mitis, followed by V. parvula and C. gingivalis and, at 7 d, by Capnocytophaga sputigena and P. nigrescens. No significant increase in the proportions of periodontal pathogens was observed in any of the clinical groups or locations. CONCLUSION: There is a defined order in bacterial species succession in early supragingival and subgingival biofilm redevelopment after professional cleaning.

The efficacy of demineralized bone matrix and cancellous bone chips for maxillary sinus augmentation.

Demineralized bone matrix and cancellous bone chips in a reverse-phase medium carrier (DynaBlast, Keystone Dental) were used to augment the maxillary sinuses in 8 patients requiring 10 sinus augmentations. Clinical reentry after 6 to 7 months (mean, 6.2 months) and computed tomographic scan evaluation at 5 months demonstrated new bone formation as well as sufficient radiopaque volume to place implants in all sites. Microcomputed tomographic evaluation and histomorphometric analysis of sinus core biopsies confirmed the formation of new bone and demonstrated three distinctive mineralization patterns that have been previously described. DynaBlast can be considered a viable alternative to the use of autogenous bone or other types of grafting materials.

Initial subgingival colonization of 'pristine' pockets.

The treatment of periodontitis/peri-implantitis involves the reduction/eradication of periopathogens. After therapy, beneficial and pathogenic species recolonize the subgingival area. The dynamics of recolonization and especially the role of the supragingival environment in this process are still not well-understood. This prospective, split-mouth study followed the early colonization of 'pristine' pockets created during implant surgery (16 partially edentulous patients), to record the time needed before a complex subgingival flora could be established with the supragingival area as the single source. Four subgingival plaque samples were taken from shallow and medium pockets around implants (test), and neighboring teeth (undisturbed microbiota as reference) 1, 2, and 4 wks after abutment connection. Checkerboard DNA-DNA hybridization and culture data revealed a complex microbiota (including several pathogenic species) in the pristine pockets within a wk, with a minimal increase in counts up to 4 wks. Analysis of these data demonstrated that, even with the supragingival environment as the single source for colonizing bacteria, a complex subgingival microbiota can develop within 1 wk.

Use of checkerboard DNA-DNA hybridization to study complex microbial ecosystems.

It has been difficult to conduct large scale studies of microbiologically complex ecosystems using conventional microbiological techniques. Molecular identification techniques in new probe-target formats, such as checkerboard DNA-DNA hybridization, permit enumeration of large numbers of species in very large numbers of samples. Digoxigenin-labeled whole genomic probes to 40 common subgingival species were tested in a checkerboard hydridization format. Chemifluorescent signals resulting from the hybridization reactions were quantified using a Fluorimager and used to evaluate sensitivity and specificity of the probes. Sensitivity of the DNA probes was adjusted to detect 10(4) cells. In all, 93.5% of potential cross-reactions to 80 cultivable species exhibited signals <5% of that detected for the homologous probe signal. Competitive hybridization and probes prepared by subtraction hybridization and polymerase chain reaction were effective in minimizing cross-reactions for closely related taxa. To demonstrate utility, the technique was used to evaluate 8887 subgingival plaque samples from 79 periodontally healthy and 272 chronic periodontitis subjects and 8126 samples from 166 subjects taken prior to and after periodontal therapy. Significant differences were detected for many taxa for mean counts, proportion of total sample, and percentage of sites colonized between samples from periodontally healthy and periodontitis subjects. Further, significant reductions were observed post therapy for many subgingival species including periodontal pathogens. DNA probes used in the checkerboard DNA-DNA format provide a useful tool for the enumeration of bacterial species in microbiologically complex systems.

Clinical and microbiological changes associated with the use of combined antimicrobial therapies to treat "refractory" periodontitis.

BACKGROUND: The present investigation examined clinical and microbial changes after a combined aggressive antimicrobial therapy in subjects identified as "refractory" to conventional periodontal therapy. METHOD: Fourteen subjects were identified as "refractory" based on full-mouth mean attachment loss and/or >3 sites with attachment loss > or =3 mm following scaling and root planing (SRP), periodontal surgery and systemic antibiotics. After baseline monitoring, subjects received SRP, locally delivered tetracycline at pockets > or =4 mm, systemically administered amoxicillin (500 mg, t.i.d. for 14 days)+metronidazole (250 mg, t.i.d. for 14 days) and professional removal of supragingival plaque weekly for 3 months. Subjects were monitored clinically every 3 months post-therapy for 2 years. Subgingival plaque samples were taken at the same time points from the mesial aspect of each tooth and the levels of 40 subgingival taxa were determined using checkerboard DNA-DNA hybridization. Mean levels of each species were averaged within a subject at each visit. Significance of changes in clinical and microbiological parameters over time were evaluated using the Friedman or Wilcoxon signed ranks test. RESULTS: On average, subjects showed significant improvements in all clinical parameters after therapy. Mean (+/-SEM) full-mouth pocket depth reduction was 0.83+/-0.13 mm and mean attachment level "gain" was 0.44+/-0.12 at 24 months. Clinical improvement was accompanied by major reductions in multiple subgingival species during the first 3 months of active therapy that were maintained for most species to the last monitoring visit. Reductions occurred for three Actinomyces species, "orange complex" species including Campylobacter showae, Eubacterium nodatum, three Fusobacterium nucleatum subspecies, Peptostreptococcus micros, Prevotella intermedia as well as the "Streptococcus milleri" group, Streptococcus anginosus, Streptococcus constellatus and Streptococcus intermedus. Subjects differed in their response to therapy; six modest response subjects exhibited less attachment level gain and were characterized by reductions in the microbiota from baseline to 3 months, but re-growth of many species thereafter. CONCLUSIONS: The combined antibacterial therapy was successful in controlling disease progression in 14 "refractory" periodontitis subjects for 2 years.

Relationship between periodontal pocket sulfide levels and subgingival species.

BACKGROUND: Many species implicated in the pathogenesis of periodontal disease produce volatile sulfur compounds (VSC). This investigation examined the relationship between levels of sulfide and subgingival bacterial species in the same periodontal pockets. MATERIAL AND METHODS: Twenty chronic periodontitis subjects were measured clinically at six sites per tooth for plaque, gingivitis, bleeding on probing, suppuration, pocket depth and attachment level. Subgingival plaque samples, taken from the mesial aspect of each tooth, were individually analyzed for their content of 40 bacterial species using checkerboard DNA-DNA hybridization. Sulfide levels were measured at the same sites using a Diamond Probe/Perio 2000 system. Clinical and microbiological data were averaged for sulfide-positive and -negative sites separately in each subject and then averaged across subjects. Significance differences in clinical and microbial parameters between sulfide-positive and -negative sites were sought using the Wilcoxon signed ranks test. RESULTS: Mean total DNA probe counts (x10(5), +/-SEM) at sulfide-negative and -positive sites were 44.0 +/- 9.9 and 65.0 +/- 13.3, respectively (p < 0.01). Seventeen species were found at significantly higher levels in sulfide-positive than -negative sites. These included abundant producers of VSC such as members of the genera Fusobacterium, Campylobacter, Prevotella, Treponema and Eubacterium, and Bacteriodes forsythus, Selenomonas noxia and Propionibacterium acnes. Prevotella intermedia, Bacteriodes forsythus, Prevotella nigrescens, Fusobacterium nucleatum ss vincentii and Treponema denticola exhibited the greatest difference in mean counts between sulfide-negative and -positive sites. Orange and red complex species were at higher counts at shallow (< 4 mm) sulfide-positive than shallow sulfide-negative sites. Although not statistically significant, mean clinical parameters were somewhat higher at sulfide-positive than sulfide-negative sites. CONCLUSIONS: Intra-pocket sulfide levels reflect the levels of sulfide-producing species and may provide useful diagnostic information.

Evaluation of laboratory tests in dehydrated children with acute gastroenteritis.

OBJECTIVE: The aim of the present study was to demonstrate the utility of laboratory tests in predicting dehydration severity. METHODOLOGY: We evaluated retrospectively 168 dehydrated children aged 1-21 months with acute gastroenteritis. The degree of dehydration in each patient was calculated as the percentage change in weight from admission to after rehydration. The associations between degree of dehydration, urea, bicarbonate and serum sodium were examined. RESULTS: Dehydration severity was significantly related to concentrations of urea (P < 0.00001) and bicarbonate (P = 0.01), but not to serum sodium or age. Children were divided into three groups on the basis of blood urea: (i) normal (< 6.7 mmol/L or < 40 mg/dL); (ii) intermediate (6.8-16.6 mmol/L); and (iii) high (>or=16.7 mmol/L or >or=100 mg/dL). Groups 1 and 3 had statistically significant associations with the degree of dehydration and combining the urea groups with plasma bicarbonate levels enhanced the accuracy of predictions. Group 1 had only mild to moderate dehydration, but if bicarbonate was 15 mmol/L or higher, there was a positive predictive value (PPV) of 93% for mild dehydration. Group 3 had moderate to severe dehydration, but if bicarbonate was 15 mmol/L or higher, moderate dehydration could be predicted (PPV 100%). Sixty per cent of mildly dehydrated children (32/53) had low bicarbonate, but only 7% (2/29) with bicarbonate 15 mmol/L or higher had severe dehydration. Serum sodium did not have any significant association with the degree of dehydration, or the levels of bicarbonate or urea. CONCLUSIONS: The results suggest that serum urea and bicarbonate concentrations can be helpful in the estimation of fluid deficit independently from serum sodium concentration, and may be considered to be adjuncts to clinical evaluation in assessing the degree of dehydration.

Efficacy of long duration resuscitation and magnesium sulphate treatment in amitriptyline poisoning.

A single dose of cyclic antidepressants leads to death in childhood. Myocardial depression and ventricular arrhythmia are the severe side effects in cyclic antidepressant overdose. A 23-month-old boy was brought to hospital because 36 mg/kg of amitriptyline had been taken. Cardiopulmonary resuscitation was applied for 70 minutes due to cardiac and respiratory arrest. Circulation was restored after resuscitative efforts. However, ventricular tachycardia was detected which did not respond to lidocaine, bicarbonate and cardioversion treatment. Magnesium sulphate treatment was started and cardiac rhythm normalized. No side effects were observed. The duration of resuscitation should be extended in cases of cardiopulmonary arrest secondary to tricyclic antidepressants intoxication. It should be continued at least for 1 hour. Magnesium sulphate was found to be extremely effective in a case of amitriptyline intoxication refractory to treatment.

Ceftriaxone-induced haemolytic anaemia in a child with no immune deficiency or haematological disease.

A 5-year-old girl, with no underlying immune deficiency or haematologic disease, was treated with ceftriaxone for a urinary tract infection. After receiving ceftriaxone intramuscularly, massive haemolytic anaemia developed. Laboratory studies showed the presence of an antibody against ceftriaxone, and the findings reflected immune complex type haemolysis. High-dose corticosteroids appeared to be effective therapeutically.

A rare cause of intracranial hemorrhage: factor X deficiency.

Congenital factor X deficiency is a rare inherited coagulation disorder, characterized by prolonged prothrombin time and partial thromboplastin time. For the definite diagnosis, specific factor X level should be investigated. We describe a patient with factor X deficiency who had intracranial hemorrhage. Hematologic tests showed prolonged prothrombin time, partial thromboplastin time, and a factor X level of 5%. The patient's hemorrhage resolved with fresh frozen plasma replacement. In this article, we discuss the clinical features and management of factor X deficiency.

Bacterial nosocomial infections in mechanically ventilated children.

Of 480 patients admitted to the Pediatric Intensive Care Unit of the Institute of Child Health Children's Hospital in Istanbul, 97 required mechanical ventilation (MV). Sixty of these children were included in a retrospective analysis aiming to determine the frequency of and factors contributing to the development of nosocomial infections (NI). NI rate was 45 percent, ventilator-associated pneumonia (VAP) accounted for the greater part (66.7%) of the NI, followed by urinary tract infections (16.7%), septicemia (13.3%), and meningitis (3.3). Pseudomonas aeruginosa was the most frequent cause of VAP. The duration of the MV and invasive interventions were important risk factors for the development of VAP.

Acute childhood hemiplegia associated with chickenpox.

Although primary varicella-associated central nervous system complications and herpes zoster ophthalmicus with delayed hemiplegia are well known, and chickenpox is a common infection, cerebral vasculopathy associated with chickenpox has only been described recently. We report the case of an 18-month-old girl who developed a right hemiplegia 10 days after the onset of a primary varicella infection. She has the shortest latent interval in the literature. Cranial computed tomography and magnetic resonance imaging suggest an infarction involving the left putamen and internal capsule. Magnetic resonance angiography is normal. Possible causes of acute infantile hemiplegia are excluded. Neurologic signs gradually improve without any specific treatment. A review of the literature is also presented.

Ten steps for successful breast-feeding: assessment of hospital performance, its determinants and planning for improvement.

This paper discusses results from a project which aims to document the maternity hospital practices in istanbul within the context of Ten Steps for Successful Breastfeeding. Instruments developed for use in hospital level implementation of the WHO/UNICEF baby friendly hospital initiative were used in five hospitals (two public and three private). No hospital was implementing all Ten Steps. A core hospital team on lactation management and a sufficient number of health personnel skillful in breastfeeding counselling and adequate delivery room conditions are required to implement the Ten Steps. It is very difficult to provide these conditions in public hospitals with an excessive patient load. On the other hand, the fee for service system and the policy of changing practices according to the wishes of the clients can also become barriers to successful breastfeeding, as may occur in some private hospitals.

Analysis of patients admitted to the emergency unit of a university children's hospital in Turkey.

A retrospective analysis of the computerized data of patients admitted to our Emergency Unit Inpatient Service in 1991 was conducted to obtain data about age, sex, referred sources, admission period, monthly admission rates, diagnoses and eventual outcome. More than 47% of patients were younger than one year of age. The most common causes for hospital admission were infectious, respiratory and neurological diseases. The mean hospitalization period was 3.26 days. More than 60% of patients were treated by the Emergency Unit staff. The net mortality rate was 2.9%, infectious diseases being the most common cause of mortality. We conclude that demographic and diagnostic data regarding admissions to the Emergency Unit can be utilized to develop new strategies for patient care and to reorganize education programs for pediatric residents.

Analysis of measles cases in a university pediatric hospital during 1988 and 1993 outbreaks.

In Turkey, a mass measles immunization campaign was initiated in 1985, and the decision was made to administer the first of the measles vaccinations at nine months of age instead of 12-15 months. Following the campaign there was a decrease in the number of measles cases seen in the Outpatient Department of Istanbul University Children's Hospital in 1986 and 1987; however, after 1987 an increase was observed in measles cases, which continued until 1993. In order to investigate the current measles epidemics, we reevaluated the measles cases seen in our Outpatient Department from 1986 to 1993. We also investigated the vaccination status and the hospitalization and mortality rates of measles cases in the epidemics of 1988 and 1993. Since 1988 (except 1989) a significant increase (412-1375 percent) has been observed in measles cases, and between 1986 and 1993 more than half of all measles cases were in children older than four years of age. In 1988 and 1993 we found that most vaccinated measles cases were also in this age group, but the rate of complications and hospitalization among the vaccinated cases was lower compared to those who were not vaccinated.