Systematic Review of Tularemia During Pregnancy

BACKGROUND

Tularemia is caused by the gram-negative bacterium Francisella tularensis. Although rare, tularemia during pregnancy has been associated with pregnancy complications; data on efficacy of recommended antimicrobials for treatment are limited. We performed a systematic literature review to characterize clinical manifestations of tularemia during pregnancy and examine maternal, fetal, and neonatal outcomes with and without antimicrobial treatment.

METHODS

We searched 9 databases, including Medline, Embase, Global Health, and PubMed Central, using terms related to tularemia and pregnancy. Articles reporting cases of tularemia with ≥1 maternal or fetal outcome were included.

RESULTS

Of 5891 articles identified, 30 articles describing 52 cases of tularemia in pregnant patients met inclusion criteria. Cases were reported from 9 countries, and oropharyngeal and ulceroglandular tularemia were the most common presenting forms. A plurality (46%) of infections occurred in the second trimester. Six complications were observed: lymph node aspiration, lymph node excision, maternal bleeding, spontaneous abortion, intrauterine fetal demise, and preterm birth. No deaths among mothers were reported. Of 28 patients who received antimicrobial treatment, 1 pregnancy loss and 1 fetal death were reported. Among 24 untreated patients, 1 pregnancy loss and 3 fetal deaths were reported, including one where F. tularensis was detected in placental and fetal tissues.

CONCLUSIONS

Pregnancy loss and other complications have been reported among cases of tularemia during pregnancy. However, risk of adverse outcomes may be lower when antimicrobials known to be effective are used. Without treatment, transplacental transmission appears possible. These data underscore the importance of prompt recognition and treatment of tularemia during pregnancy.

Systematic Review: Clinical Features, Antimicrobial Treatment, and Outcomes of Human Tularemia, 1993-2023

BACKGROUND

Francisella tularensis, the causative agent of tularemia, is endemic throughout the Northern Hemisphere and requires as few as 10 organisms to cause disease, making this potential bioterrorism agent one of the most infectious bacterial pathogens known. Aminoglycosides, tetracyclines, and, more recently, fluoroquinolones are used for treatment of tularemia; however, data on the relative effectiveness of these and other antimicrobial classes are limited.

METHODS

Nine databases, including Medline, Global Health, and Embase, were systematically searched for articles containing terms related to tularemia. Articles with case-level data on tularemia diagnosis, antimicrobial treatment, and patient outcome were included. Patient demographics, clinical findings, antimicrobial administration, and outcome (eg, intubation, fatality) were abstracted using a standardized form.

RESULTS

Of the 8878 publications identified and screened, 410 articles describing 870 cases from 1993 to 2023 met inclusion criteria. Cases were reported from 35 countries; more than half were from the United States, Turkey, or Spain. The most common clinical forms were ulceroglandular, oropharyngeal, glandular, and pneumonic disease. Among patients treated with aminoglycosides (n = 452 [52%]), fluoroquinolones (n = 339 [39%]), or tetracyclines (n = 419 [48%]), the fatality rate was 0.7%, 0.9%, and 1.2%, respectively. Patients with pneumonic disease who received ciprofloxacin had no fatalities and the lowest rates of thoracentesis/pleural effusion drainage and intubation compared to those who received aminoglycosides and tetracyclines.

CONCLUSIONS

Aminoglycosides, fluoroquinolones, and tetracyclines are effective antimicrobials for treatment of tularemia, regardless of clinical manifestation. For pneumonic disease specifically, ciprofloxacin may have slight advantages compared to other antimicrobials.

Cerebral hemodynamic response to unpleasant odors in the preterm newborn measured by near-infrared spectroscopy

Newborn infants in intensive care units are exposed to several unfamiliar smells, mostly related to the nosocomial environment. How the preterm baby perceives these olfactory stimulations remains unclear. Near-infrared spectroscopy can be performed noninvasively above the olfactory cortex to monitor changes of cerebral blood flow as an indicator of cortical activation. The aim of this study was to explore by near-infrared spectroscopy how odorous substances routinely used in the neonatal intensive care unit influence bilateral cortical hemodynamics in the olfactory region of the brains of preterm infants. Specifically, a detergent (Neomidil) and an adhesive remover (Remove) have been tested. Twenty preterm neonates of gestational age 30-37 wk (mean 33.7 +/- 2.3 SD) and postconceptional age 32-37.3 wk (mean 35.5 +/- 2.75 SD) were monitored by near-infrared spectroscopy. Two optode pairs were placed above the anterior orbitofrontal gyri, which is involved in olfactory processing, on each side of the skull. Fifteen babies were exposed to the smell of a disinfectant and five babies to that of a detergent, both applied to small cotton pads. Changes of oxygenated Hb and deoxygenated Hb were recorded before, during, and after a 10-s stimulus. In 17 out of 20 babies, there was a decrease in oxygenated Hb and total Hb after the exposure to the substances. The decrease was significantly greater in the right side than in the left side. This change was different from that observed in our previous study after exposure to colostrum and the pleasant smell of vanilla, which elicited an increase in blood oxygenation in the same region. The biologic significance of this finding is unknown. We conclude that cortical hemodynamic modifications occur in the preterm newborn after exposure to preparations commonly used in the neonatal intensive care unit. A lateralization seems to occur in processing unpleasant olfactory cues.

Activation of olfactory cortex in newborn infants after odor stimulation: a functional near-infrared spectroscopy study

In mammals, perception of smells during the first hours of life is an essential prerequisite for adaptation of the newborn to the new extrauterine world. Functional magnetic resonance studies have shown that olfactory impression is processed in the lateral and anterior orbito-frontal gyri of the frontal lobe. Near-infrared spectroscopy (NIRS) can detect changes in oxygenated [Hb O2], and deoxygenated [Hb H] Hb during cortical activation. The aim of this study was to assess by NIRS olfactory cortex activity in newborn infants receiving olfactory stimuli. Twelve males and 11 females were studied when awake at 6 h to 8 d after birth. NIRS monitoring was carried out using two optodes placed above the left anterior orbito-frontal gyri. Each newborn was exposed for 30 s to two different smell stimuli-mother's colostrum and vanilla-and to a negative control, distilled water. Changes in Hb concentration were measured over the orbitofrontal region. During exposure to vanilla, [Hb O2] increased significantly over the left orbito-frontal area in all babies. The magnitude of the [Hb O2] increase over the illuminated region during colostrum exposure was inversely related to postnatal age. We conclude that monitoring Hb changes by NIRS can be valuable in assessing olfactory responsiveness in infants.

Vaccination with FimH adhesin protects cynomolgus monkeys from colonization and infection by uropathogenic Escherichia coli

Escherichia coli FimH adhesin mediates binding to the bladder mucosa. In mice, a FimH vaccine protects against bacterial challenge. In this study, 4 monkeys were inoculated with 100 microgram of FimCH adhesin-chaperone complex mixed with MF59 adjuvant, and 4 monkeys were given adjuvant only intramuscularly. After 2 doses (day 0 and week 4), a booster at 48 weeks elicited a strong IgG antibody response to FimH in the vaccinated monkeys. All 8 monkeys were challenged with 1 mL of 108 E. coli cystitis isolate NU14. Three of the 4 vaccinated monkeys were protected from bacteruria and pyuria; all control monkeys were infected. These findings suggest that a vaccine based on the FimH adhesin of E. coli type 1 pili may have utility in preventing cystitis in humans.

Unique salience of maternal breast odors for newborn infants

Human infants are particularly responsive to olfactory cues emanating from their mother's nipple/areola region. Beginning within minutes after birth, maternal breast odors elicit preferential head orientation by neonates and help guide them to the nipple. Such odors also influence babies' general motor activity and arousal, which may contribute further to successful nipple localization and sucking. The role of maternal olfactory signals in the mediation of early breast-feeding is functionally analogous to that of nipple-search pheromone as described in nonhuman mammals. To some extent, the chemical profile of breast secretions overlaps with that of amniotic fluid. Therefore, early postnatal attraction to odors associated with the nipple/areola may reflect prenatal exposure and familiarization. Although newborns are generally attracted to breast odors produced by lactating women, breast-fed infants rapidly learn their mother's characteristic olfactory signature while sucking at her breasts and can subsequently recognize her by that unique scent alone. Early odor-based recognition may be an important factor in the development of the infant-mother bond.

[Results of a primary health care study on alcohol: 17 per cent of men, 8 per cent of women were probable heavy consumers]

A questionnaire study designed to elicit an impression of the proportion of heavy drinkers among primary care patients, carried out at five primary facilities in Västerbotten County, showed 12 per cent of the patients (17% of the men, 8% of the women) to be probable heavy alcohol consumers. This emphasises the strategically advantageous position of primary care facilities with a view to early intervention. Age was found to be a significant determinant of alcohol consumption, but not place of residence or the reason for consulting.

Soothing effect of amniotic fluid smell in newborn infants

Newborn young of several mammalian species are attracted to the odor of amniotic fluid (AF); these chemical cues also appear to calm neonates and help them adapt to their novel postnatal environment. AF odor likewise elicits positive (head orientation) responses by human infants. The present study systematically examined whether the odors of AF and mother's breasts influence the crying of the newborn infant, when separated from its mother. The total crying time from 31-90 min postnatal was registered on tapes in 47 healthy fullterm newborns, allocated to one of three conditions; exposure to either AF or breast odor or no exposure (controls). Babies exposed to AF smell cried significantly less (median 29 s) than babies in the two other groups (breast odor--301 s, controls--135 s). The data are consistent with the hypothesis that the fetus may become familiar with chemical cues present in the intrauterine environment. Our data provide new evidence of the human baby's fine olfactory discrimination capacity, and add to the growing body of evidence indicating that naturally occurring odors play an important role in the mediation of infants' early behavior.

Olfaction and human neonatal behaviour: clinical implications

About 1-2% of the human genome is allocated to production of receptors for the olfactory epithelium--a hint as to the possible importance of this chemical sense, which includes two anatomically distinct systems: the main olfactory system with sensory cells located in the upper part of the nasal cavity, and the vomero-nasal organ with sensory cells on the nasal septum. In adults, individual odours may influence mate preferences and a growing body of evidence indicates that naturally occurring odours play an important role in the mediation of the infant's behaviour. Even foetal olfactory learning seems to occur and breast odours from the mother exert a pheromone-like effect at the newborn's first attempt to locate the nipple. Newborns are generally responsive to breast odours produced by lactating women. Olfactory recognition may be implicated in the early stages of the mother-infant attachment process, when the newborns learn to recognize the own mother's unique odour signature--a process possibly facilitated by the high norepinephrine release and the arousal of the locus coeruleus at birth. New knowledge about human odour physiology may have diagnostic and therapeutic implications--the initiation and stabilization of breastfeeding and termination of apnoeic spells are mentioned as examples.

Natural odour preferences of newborn infants change over time

At their first sucking contact, neonates prefer an unwashed breast to a washed one, but an amniotic fluid (AF)- treated breast over a "natural odour" breast. We examined the development of these neonatal olfactory preferences. On days 3-4 significantly more babies still selected their mother's unwashed breast (n = 21) than the washed alternative (n = 8). Preferences for natural breast odours were more pronounced for girls than boys. In a subsequent experiment comprising another 28 babies, the number of babies who selected a naturally scented (n = 9) vs an AF-treated breast (n = 19) on days 2-5 were not reliably different. However, babies who selected the natural breast had longer pre-test maternal contact and had spent more time breastfeeding. Ten babies who chose the AF breast in the latter experiment were tested in the same manner several days later; all preferred the naturally smelling breast. While preferences for AF fade after birth, responsiveness to natural breast odours may be enhanced by postnatal experience.

Induction of protective immunity after escherichia coli bladder infection in primates. Dependence of the globoside-specific P-fimbrial tip adhesin and its cognate receptor

Clinical observations suggest that immune mechanisms affect etiology and course of recurrent cystitis. A primate infection model was used to show that primary bladder infection with a uropathogenic P-fimbriated strain (binding to globoside present in the bladder wall) protects against rechallenge with homologous as well as heterologous Escherichia coli strains for up to 5-6 mo. In contrast, mutant derivatives producing P-fimbriae either lacking the tip adhesin protein or carrying an adhesin for which no bladder receptor was present, were unable to induce protection, even though they generated bladder infections of similar duration as the wild type. Therefore, the protective effect mediated by the adhesin seemed to depend upon the presence of its cognate receptor. Since the wild strain also mediated protection against mutants that lacked the adhesin, our data suggest that the globoside-binding PapG adhesin acts as an adjuvant during infection to enhance a specific response against other bacterial antigens. In fact, the globoside-binding strain DS17, but not the mutant DS17-1, unable to bind to membrane-bound globoside, elicited a secretory IgA response to LPS in urine. These in vivo findings suggest that bacterial adhesin-ligand interactions may have signaling functions of importance for the immune response.

Molecular evidence for pap-G specific adhesion of Escherichia coli to human renal cells

PURPOSE

To study the interaction between class II G-adhesin of Escherichia coli and human urogenital cells.

MATERIAL AND METHODS

The adherence of two wild type P-fimbriated E. coli strains, both carrying a class II G-adhesion, and two constructed mutants (one class II G-adhesion knock-out mutant and one class switch mutant in which the papG gene was exchanged with a prsJ96 allele which is a representative of the class III G-adhesin) to human urogenital cells were examined by light microscopy and flow cytometry.

RESULTS

The wild type E. coli strains adhered avidly to proximal tubular cells, but the isogenic mutant strains did only adhere in one of the experiments. A soluble receptor analogue inhibited bacterial attachment.

CONCLUSIONS

These experiments strongly suggest that the papG class II tip adhesin of P-fimbriae is essential in the pathogenesis of human kidney infection.

Attractiveness of amniotic fluid odor: evidence of prenatal olfactory learning?

Human infants are responsive to maternal odors beginning shortly after birth. In several non-human mammals, the fetus is capable of olfactory learning and in some species neonates are attracted to the odor of amniotic fluid (AF). The present study examined the responses of newborn babies to AF in a biologically relevant context, i.e. during their initial attempt to locate the mother's nipple/areola. We observed newborns' spontaneous choice between a breast with the nipple/areola moistened with AF and an untreated breast; 23 of 30 infants chose the AF-treated breast. All babies had been washed before the observations, and only 12/30 sucked their hands/fingers prior to approaching the nipple/ areola. In a previous study with unwashed newborns, the corresponding proportion was 27/30 (p < 0.001). We tentatively suggest that the observed attraction to AF odor may reflect fetal exposure to that substance (i.e. prenatal olfactory learning). Because of the salience of biological odors for neonates, products that eliminate or mask such cues should be avoided during the perinatal period.

Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route

The aim of this study was to find out whether the hormonal patterns of oxytocin, prolactin and cortisol differed between women delivered by emergency section or by the vaginal route and if these patterns show any relation to the duration of breastfeeding. Seventeen mothers with emergency section (C.S.) and 20 mothers with normal vaginal deliver (V.D.) were blood sampled in connection with breastfeeding on day 2 post partum for oxytocin, prolactin and cortisol. The number of oxytocin pulses as calculated with the PULSAR program occurring during the first 10 min of the breastfeeding session varied between 0 and 5. The V.D. mothers had significantly more pulses than the C.S. ones. Furthermore the C.S. women lacked a significant rise in prolactin levels at 20-30 min after the onset of breastfeeding. Logistic regression analysis revealed mode of delivery and infant's age at first breastfeed to be the most important, independent variables showing a relation to the release pattern of oxytocin on day 2. Correlations between oxytocin pulsatility on day 2 and the duration of the exclusive breastfeeding period in the V.D. group suggest that development of an early pulsatile oxytocin pattern is of importance for breastfeeding.

Crying in separated and non-separated newborns: sound spectrographic analysis

During the first 1-2 h after birth crying occurs during separation from the mother and stops on reunion. In rats, such "separation distress calls" have distinct phonetic properties. We examined this early crying by sound spectrography in 29 healthy, full-term, vaginally delivered babies, randomly assigned either to be kept in a cot or to be placed in body contact with the mother during the 90 min following birth. The former babies cried almost 10 times more than the latter ones. The duration of the cry signal (the smallest element of a cry analysed by spectrography) in both groups was 0.8-09s; the melody contour was flat or slightly rising--falling with a fundamental frequency of around 500 hertz. The cry is provisionally characterized as a discomfort cry, elicited mainly by separation from the mother.

The PapG-adhesin at the tip of P-fimbriae provides Escherichia coli with a competitive edge in experimental bladder infections of cynomolgus monkeys

Human urinary tract infection is an infectious disease that depends on a series of host-microbial interactions. The bacteria first colonize the colon and then the periurethral/vaginal areas; they ascend to and infect first the bladder and then the kidneys. Expression of Escherichia coli P-fimbriae constitutes the strongest correlation to renal pathogenicity, but is also related to first-time cystitis in children. The role of P-fimbriae in the preceding steps in the infectious process is unknown. To examine this, we constructed, from a P-fimbriated E. coli strain with a class II G-adhesin preferentially binding to globoside, one isogenic mutant lacking the G-adhesin and another isogenic mutant in which we replaced the papG class II allele with a class III adhesin preferentially binding to the Forssman antigen. We report here the comparison of the adhesin knockout mutant (DS17-8) and the class-switch mutant (DS17-1) with the wild-type (DS17) for in vivo colonization of the gut, vagina, and bladder of cynomolgus monkeys. It was recently shown that the class II tip G-adhesin is a prerequisite for acute pyelonephritis to occur in the monkey model in the absence of other kidney-specific adhesins or obstruction of the urinary flow. Here we show that it is not required for bladder infection but gives a competitive advantage in mixed infections. In the vagina and colon, the G-adhesin gives no competitive advantage.

Separation distress call in the human neonate in the absence of maternal body contact

Few studies have used the baby's cry as a means of evaluating the quality of neonatal care. In this randomized trial the newborn's cry was registered during the first 90 min after birth when infants were cared for either: (a) skin-to-skin with the mother; (b) in a cot; or (c) in a cot for the first 45 min of the 90-min observation period and then skin-to-skin with the mother. The results suggested that human infants recognize physical separation from their mothers and start to cry in pulses. Crying stops at reunion. The observed postnatal cry may be a human counterpart to the "separation distress call" which is a general phenomenon among several mammalian species, and serves to restore proximity to the mother. Our results suggest that in human newborns this cry is not dependent on earlier social experience and may be a genetically encoded reaction to separation. The findings are compatible with the opinion that the most appropriate position of the healthy full-term newborn baby after birth is in close body contact with the mother.

The Gal(alpha 1-4)Gal-specific tip adhesin of Escherichia coli P-fimbriae is needed for pyelonephritis to occur in the normal urinary tract

Nonobstructive acute pyelonephritis in humans is most often caused by P-fimbriated Escherichia coli. P-fimbriae are heteropolymeric fibers carrying a Gal(alpha 1-4)Gal-specific PapG adhesin at its distal end. The pyelonephritic strain DS17 expresses P-fimbriae from a single gene cluster. A mutant strain, DS17-8, which expresses P-fimbriae tacking the PapG adhesin, was constructed by allelic replacement introducing a 1-bp deletion early in the papG gene. In cynomolgus monkeys, DS17 and DS17-8 were equally able to cause bladder infection, whereas only the wild-type strain DS17 could cause pyelonephritis as monitored by bacteriological, functional, and histopathological criteria. Since DS17, but not DS17-8, adheres to renal tissue, these data underscore the critical role of microbial adherence to host tissues in infectious disease and strongly suggest that the PapG tip adhesin of P-fimbriae is essential in the pathogenesis of human kidney infection.

Does the newborn baby find the nipple by smell?

We studied the involvement of naturally occurring odours in guiding the baby to the nipple. One breast of each participating mother was washed immediately after delivery. The newborn infant was placed prone between the breasts. Of 30 infants, 22 spontaneously selected the unwashed breast. The washing procedure had no effect on breast temperature. We concluded that the infants responded to olfactory differences between the washed and unwashed breasts.

Management of primary vesico-ureteric reflux in children--operation ineffective in preventing progressive renal damage

Four studies comprising 606 children and with a follow-up of 4-5 years have shown that operation and long-term antibiotic prophylaxis are equally ineffective in preventing post-infectious, progressive renal damage in children with grade III-IV reflux. To consider only the grade of reflux in the choice of management is too simple an approach. Other aspects of the complex biology of UTI should also be considered. Another important aspect concerns the organization of the care. Efficient and robust routines for a thorough follow-up and measures to guarantee immediate diagnosis and treatment of recurrent infections in children known to be at risk may be more important for the preservation of the kidneys than a stereotyped policy of operation or "endless" antibiotic prophylaxis. Specialized teams should be used as in the treatment of other long-term diseases. Parents should be educated and made active participants in the supervision of children at risk. Controlled multicentre studies are powerful scientific instruments, but appear to have too little impact on clinical practice. The responsibility of clinical scientists to make important results known and understood among those concerned is discussed from the ethical point of view.

Pathogenesis of urinary tract infection--experimental studies of vaginal resistance to colonization

The review summarizes studies of vaginal colonization resistance against Escherichia coli in a primate model. The genital flora surrounding the urethral orifice exerts a strong colonization resistance. Amoxicillin profoundly disturbs the normal vaginal microflora, reduces its adherence to vaginal epithelial cells in vivo and promotes a persistent vaginal E. coli colonization. Certain cephalosporins may have a similar effect. The induced ecological changes mimic those seen in patients with recurrent urinary tract infections (UTI). Amoxicillin also promotes the spread of E. coli from rectum to vagina, which may be of clinical significance. Trimethoprim and nitrofurantoin do not have these effects. The natural colonization resistance could not clearly be correlated with the presence of lactobacilli, which were only transiently reduced by amoxicillin. The colonization resistance against E. coli could only partly be restored by vaginal instillation of lactobacilli, but was fully restored by flushing of the whole vaginal flora from a healthy monkey. Clinical observations suggest that accumulation of E. coli around the urethral orifice increases the risk of UTI. We conclude that antibiotics and other compounds that interfere with the normal genital flora may increase the risk of UTI. This should influence the choice of antibiotics in the treatment of UTI.

Cephadroxil promotes vaginal colonization with Escherichia coli

The aim of this study was to examine whether a vaginal Escherichia coli colonization, mimicking the one seen in UTI-prone females, could be induced by local cephadroxil administration. When five adult cynomolgus monkeys were given a vaginal flush with a P-fimbriated E. coli strain, none became persistently colonized. When such colonization attempts were preceded by cephadroxil administration a persistent colonization occurred in 9/10 experiments. Cephadroxil also promoted a spread of fecal E. coli strains to the vagina. Reduction of the anaerobic vaginal flora can explain the breakdown of the colonization resistance. Clinical observations suggest that accumulation of E. coli around the urethral orifice increases the risk of UTI. Therefore antibiotics which promote such colonization may increase the risk for UTI in susceptible patients. From this point of view antibiotics such as cephadroxil may be less suitable for treatment of UTI-susceptible patients.

Lower body temperatures in infants delivered by caesarean section than in vaginally delivered infants

Clinical experience suggests that infants delivered by caesarean section have difficulties maintaining normal body temperature during the first hours after birth. To test this hypothesis, body and skin temperatures were measured and compared in healthy full-term caesarean section and vaginally delivered newborn infants. The babies were studied during the first 90 min after birth. Axillary and skin temperatures were significantly higher in the vaginally delivered group than in infants delivered by caesarean section. Infants born by non-elective caesarean section were slightly warmer during the first 90 min after birth compared to infants born by elective caesarean section. There were no significant differences in temperatures between infants cared for in a cot as compared to those cared for in an incubator. An incubator creates a physical barrier between babies and parents and incubator care might cause parental anxiety. Thus the routine of putting healthy, full-term caesarean section infants in incubators can be abandoned from a thermoregulatory point of view.

Plasma cholecystokinin concentrations after breast feeding in healthy 4 day old infants

The aim of the present study was to characterise plasma concentrations of cholecystokinin (CCK) after breast feeding in newborn infants. Fifty eight healthy full term exclusively breast fed infants were investigated at 4 (1) (2-6) days of age. Each infant contributed one blood sample collected just before, immediately after, or 10, 30, and 60 minutes after breast feeding. Plasma concentrations of CCK were measured with a technique consisting of high pressure liquid chromatography separation of gastrins and CCKs and consequent analysis with radioimmunoassay. Mean (SD) preprandial plasma concentrations of CCK (CCK8+CCK-33,39) were 68 (17) pmol/l. A significant increase was seen immediately after breast feeding, which was followed by a decline at 10 minutes and a secondary rise was seen at 30 and 60 minutes. The first peak is likely to be due to a suckling related activation of the vagal nerve and the second to a stimulatory effect of food on CCK-producing cells. An inverse relationship between basal concentrations of CCK and age of the infant was found. In rats peripheral injections of CCK reduce food intake and cause postprandial sedation and sleepiness via activation of an afferent vagal mechanism. CCK release in response to breast feeding may therefore in addition to exerting stimulatory effects on digestion and metabolism contribute to relaxation and sleepiness seen after breast feeding. The high CCK concentrations seen in younger infants may help the infant to remain satiated and calm despite receiving very little food during the first days of life.

Temperature, metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot

The aim of the present study was to compare temperatures, metabolic adaptation and crying behavior in 50 healthy, full-term, newborn infants who were randomized to be kept either skin-to-skin with the mother or next to the mother in a cot "separated". The babies were studied during the first 90 min after birth. Axillary and skin temperatures were significantly higher in the skin-to-skin group; at 90 min after birth blood glucose was also significantly higher and the return towards zero of the negative base-excess was more rapid as compared to the "separated" group. Babies kept in cots cried significantly more than those kept skin-to-skin with the mother. Keeping the baby skin-to-skin with the mother preserves energy and accelerates metabolic adaptation and may increase the well-being of the newborn.

Lack of effect of trimethoprim and nitrofurantoin on colonization resistance in the vagina of monkeys

The effects of trimethoprim and nitrofurantoin, two antibiotics often used for treatment and long-term prophylaxis of urinary tract infections, on colonization resistance in the vagina of monkeys were investigated. Female monkeys were flushed intravaginally with one of the antibiotics or buffered saline or amoxicillin (controls) for six days. During or after this antibiotic administration a pyelonephritogenic Escherichia coli, strain DS17, was flushed into the vagina. A persistent colonization was obtained in two of eight trimethoprim experiments and a transient colonization in one trimethoprim and two of seven nitrofurantoin experiments. These results did not differ significantly from those of the buffer control experiments. Neither the number of anaerobic bacteria nor the composition of the anaerobic microflora was much affected by these antibiotic agents, while amoxicillin both reduced the number of anaerobic bacteria and promoted E. coli colonization. We conclude that trimethoprim and nitrofurantoin exert a limited effect on the microecology and the colonization resistance in the vagina. From an ecological aspect both drugs seem to be good choices for treatment and prophylaxis of urinary tract infections.

The effect of amoxycillin on vaginal colonization resistance and normal vaginal flora in monkeys

Previous studies have shown that vaginal colonization resistance in monkeys can be eliminated by amoxycillin and restored by flushing vaginal flora from a healthy monkey into the vagina of a monkey colonized with Escherichia coli. The hypothesis that the effect of amoxycillin resulted from elimination of parts of the normal flora was tested in the present study. Nine monkeys were flushed vaginally with amoxycillin daily for six days. The number of anaerobic bacteria decreased during amoxycillin administration, as did the number of species isolated. The most obvious effects were observed among the genera Bacteroides and Peptostreptococcus, while Lactobacillus spp. were less affected. Restoration of the flora after amoxycillin administration was slow in most of the monkeys. During amoxycillin administration, all monkeys became colonized spontaneously with E. coli. This was not, however, associated with increased adherence in vitro. The colonization persisted throughout the study period (29 days). It was concluded that amoxycillin disturbs vaginal colonization resistance by eliminating at least part of the normal vaginal flora, thereby promoting periurethral colonization with enterobacteria.

Long-term prognosis of post-infectious renal scarring in relation to radiological findings in childhood--a 27-year follow-up

In a previous report the long-term prognosis of 30 patients with renal scarring after pyelonephritis in childhood was described. In this study, we have related the extent of renal scarring present in childhood to the conditions in early adulthood. A radiological progression of scarring from childhood to adulthood was seen in one-third of the kidneys. The 7 patients with bilateral scarring in childhood had a smaller renal area, lower glomerular filtration rate and higher plasma vasopressin at follow-up than 13 healthy controls. The 20 patients who had unilateral scarring in childhood had a smaller renal area, lower glomerular filtration rate, higher diastolic blood pressure and higher plasma renin at follow-up than controls; 4 had hypertension. The most important finding was that children with unilateral disease are at risk of serious long-term complications. Filtration fraction at follow-up was higher in patients with extensive renal scarring in childhood compared with those with a normal renal area or small scars in childhood (r = -0.43, P less than 0.05). This may indicate glomerular hyperfiltration by remnant glomeruli. This paper emphasizes t the potential seriousness of childhood urinary tract infections especially when early infantile infections are overlooked. A follow-up of more than 4 decades may be necessary before the ultimate prognosis can be established, especially in patients with unilateral renal disease. It is advised that most patients with post-infectious renal scars are followed as high-risk patients, and that treatment continuity is established between paediatricians, nephrologists and, when required, obstetricians.

Short-term effects of early suckling and touch of the nipple on maternal behaviour

The objective was to evaluate the effects of suckling within 30 min after birth when skin-to-skin body contact for mothers and infants was held constant in both cases (n = 32) and control groups (n = 25). Mother-infant interaction during breast-feeding, infants' time spent in nursery and different aspects of breast-feeding were evaluated. Prolactin and gastrin were measured in maternal serum before and after breast-feeding on day 4 post partum. The aim to evaluate effects of early post delivery suckling failed since only six of the 32 case infants did suck at this time. In spite of this, we found three significant differences among cases and controls. In the case group where all infants had touched or licked the areola and nipple, the mothers left the infants in the nursery for a significantly shorter time and significantly more mothers talked to their infants during the short breast-feeding observation. Median gastrin levels were significantly lower in cases than in controls both before (P less than 0.01) and after (P less than 0.03) breast-feeding. In conclusion, the infant's early touch of the mother's areola and nipple seemed to have positively influenced the mother/infant relationship during the first four days after birth. It was also associated with lower maternal gastrin levels which suggests that maternal neuroendocrine functions were also influenced. Ten months after birth, we found no differences between cases and controls.

Oxytocin and prolactin levels in breast-feeding women. Correlation with milk yield and duration of breast-feeding

The aim of the present study was to examine suckling-related plasma levels of oxytocin and prolactin in early and established lactation and to correlate hormone profiles to success of lactation performance. Fifty-five primiparous women participated in the study. From each, 18 blood samples were drawn in connection with breast-feeding on day 4 post partum and after 3-4 months. Oxytocin and prolactin levels were determined with radio-immunoassay. Basal levels of both hormones were significantly higher 4 days post partum than 3-4 months later and after weaning. Basal prolactin levels fell significantly within 24 h of weaning. Oxytocin and prolactin levels rose in response to breast-feeding--an effect which persisted during the lactation period. The suckling-induced release of prolactin--but not that of oxytocin--was related to basal hormone levels. Basal as well as stimulated oxytocin levels obtained 4 days and 3-4 months post partum correlated significantly, indicating that each woman has an individual, characteristic level of this hormone. Milk yield did not correlate with oxytocin or prolactin levels, but prolactin levels recorded 3-4 months post partum did correlate with the remaining period of breast-feeding. In addition, mothers who breast-fed exclusively 3-4 months post partum had significantly higher oxytocin and prolactin levels than those who gave supplementary feed. There was a significant correlation between oxytocin levels at 4 days and birth weight of the infant.