Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Inactivation kinetics of Salmonella enterica serovar Typhimurium NCTC 12023 in Chokanan mango (Mangifera indica L.) fruit juice by aqueous ozone treatment

Food processing industries worldwide focus on maintaining and enhancing food quality and security, particularly microbial food safety, to fulfil customer requirements. This study examined the efficacy of aqueous ozone on the inactivation of Salmonella enterica serovar Typhimurium NCTC 12023 in Chokanan mango juice (MJ) diluted with distilled water (DW) ratios (100MJ:0DW, 75MJ:25DW, and 50MJ:50DW). The inoculated MJ samples were treated at 10, 20, 30, and 40 mins with ozone doses 0.33, 0.67, 1.00, and 1.33 mg/mL. The results showed that the Bx values and mango pulp presence in the various MJ samples interfered with the S. enterica ser. Typhimurium disinfection activity by ozone. The S. enterica ser. Typhimurium inactivation and the survival curves’ concavity are more reliably measured in the kinetic Weibull model. Validation of the Weibull model produced coefficient determination (R 2 ) of 0.94–0.99, RSME of 0.1 to 0.4, bias and accuracy factor of 0.7 to 1.4, and shape parameter p<1. A fast inactivation rate for 5-log reduction of S. enterica ser. Typhimurium was observed in 50MJ:50DW sample (24.82 mins, 0.82 mg/mL) and in 75MJ:25DW sample (28.39 mins, 0.95 mg/mL), respectively. However, in the 100MJ:0DW sample, the 5-log reduction was achieved at 36.39 min with an ozone dose of 1.20 mg/mL. Nevertheless, this study’s ozone dose range from 0.33 mg/mL to 1.33 mg/mL with a treatment time of 10 to 40 mins has proven to lower and achieved a 5-log reduction of S. enterica ser. Typhimurium in all MJ samples

Localization and Mechanical Transmission of Tomato Brown Rugose Fruit Virus in Tomato Seeds

Tomato brown rugose fruit virus (ToBRFV), belonging to the genus Tobamovirus, is a highly virulent emerging virus, causing disease outbreaks and significant crop losses worldwide. The growing number of ToBRFV epidemic episodes prompted the investigation of the role of seeds in the dissemination of the virus as an important aspect in the overall disease management. Therefore, the objectives of this study were to determine the localization of ToBRFV within tomato seeds and to evaluate its seed transmission characteristics. Seeds extracted from naturally ToBRFV-infected tomato fruits were tested for the presence of the virus using serological, molecular, and biological assays. Three immunolocalization techniques were used to determine the localization and distribution of ToBRFV within the different tissues and parts of tomato seeds. To evaluate seed transmission of ToBRFV, two grow-out experiments were conducted to assess the rate of both vertical (seeds to progeny seedlings) and possible horizontal transmission (plant to plant) based on serological and molecular assays. Seeds extracted from ToBRFV-infected fruits had a 100% contamination rate. The localization of ToBRFV in tomato seeds is only external on the seed coat (testa). Seed transmission rate from seeds to their seedlings was very low (0.08%), while no transmission was recorded from plants to plants in a small-scale greenhouse experimental setup. In conclusion, ToBRFV is a seedborne virus located externally on tomato seed coat and transmitted mechanically from ToBRFV-contaminated tomato seeds to seedlings, which could initiate a disease foci and eventually drive further dissemination and spread of the disease in a new growing area.

Tracheomalacia after thyroidectomy for retrosternal goitres requiring sternotomy- a myth or reality?

INTRODUCTION

Tracheomalacia after thyroidectomy is not well understood. Reports on tracheomalacia are conflicting, with some suggesting a high rate and other large cohorts in which no tracheomalacia is reported. The aim of our study was to assess the incidence and factors associated with tracheomalacia after thyroidectomy in patients with retrosternal goitres requiring sternotomy at a high-volume tertiary care referral centre.

METHODS

A longitudinal cohort study was conducted from January 2011 to December 2019. All adult patients who underwent thyroidectomy with sternotomy were included. Tracheomalacia was considered when tracheal rings were soft compared with other parts (proximal or distal) of the trachea and required either tracheostomy or resection with anastomosis. The decision to perform a tracheostomy or to administer continuous or bilevel positive airway pressure postoperatively was made depending on the degree of tracheomalacia. Logistic regression analysis was used to assess factors associated with tracheomalacia.

RESULTS

We evaluated 40 patients who underwent thyroidectomy with sternotomy. The mean age of our cohort was 48.7 ± 11.3 years and the population was predominantly female (67.5%). One patient required tracheal resection with anastomosis, and two patients required tracheostomy. Multivariable logistic regression analysis did not reveal any patient- or thyroid-related factor significantly associated with the development of tracheomalacia in our cohort.

CONCLUSIONS

The incidence of tracheomalacia after thyroidectomy with sternotomy appears to be very low. However, the occurrence of tracheomalacia after thyroidectomy in cases of large goitre is possible and hence worrisome.

Pure posterior chordoid foramen magnum meningioma: A case report and review of literature

Introduction and importance

Meningiomas are extra-axial central nervous system (CNS) tumors that arise from the arachnoid cells of the dura mater. Only 1.8–3.2% of all meningiomas are located at foramen magnum (FM) and pure posterior FM meningioma are very rare. The diagnosis of malignancy in patients with meningiomas has been a controversial issue. Only a histological study can confirm this situation.

Case presentation

We report a case of A 52-year-old female presented with a history of neck pain with progressive spastic quadriparesis.

Clinical discussion

Magnetic resonance imaging MRI T1 and T2 weighted images revealed well-defied pure posterior foramen magnum Lesion. Although the lesion was very sticky to neurovascular components. Simpson grade I was achieved. Histopathology revealed Chordoid meningioma. The patient had a dramatic recovery.

Conclusion

Although choroid meningioma is usually well circumscribed, sticky tumors should be suspected. Recurrence of Chordoid meningioma should be suspected. Total excision should be achieved and routine follow-up should be informed. Reports about chordoid meningioma aren't common, but reports on choroid foramen magnum meningioma are very rare. The opportunity to give the patient a symptom-free and normal life should not be missed in such cases.

Complete resection of pure anterior foramen magnum meningioma without neurovascular injuries poses a big challenge: Case report

Introduction and importance

Meningiomas are common neoplasms representing 14.3–19% of all intracranial tumors. Among all the meningiomas, only 1.8–3.2% arises at the foramen magnum (FM) level.

Most of the lesions (68%–98%) arising anterolaterally, followed by postolateral, purely posterior and, more rarely, purely anterior.

Case presentation

We report a case of A 42-year-old female presented with a history of neck pain with progressive spastic hemiparesis.

Clinical Discussion

MRI revealed well-defied pure anterior and on both sides of vertebral artery, foramen magnum lesion. Through conservative transcondylar approach, Lesion was removed totally in a piecemeal fashion. Histopathology revealed meningothelial meningioma. The patient had a dramatic recovery.

Conclusion

The exposure allowed by the far-lateral retrocondylar or partial transcondylar approach is adequate for resecting even anterior intradural FMMs.

Reports about Foramen magnum meningioma aren't common, but reports on pure anterior foramen magnum meningioma are very rare. The prerequisite for treating FM meningiomas (FMMs) is the perfect knowledge of the surgical anatomy. The opportunity to give the patient a symptom-free and normal life should not be missed in such cases.

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Only 1.8–3.2% of all meningiomas are located at foramen magnum (FM).

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Foramen magnum meningiomas (FMMs) represent a common histological tumor in a rare and eloquent location.

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FMMs are one of the most surgically complex conditions in neuro-oncologic surgery.

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The transcondylar approach is a more advanced technique and the total removal of ventral lesion could be achieved.

Spontaneous migration of a falling bullet in the cerebellum reveals the importance of intraoperative skull X-ray

Cranial gunshot wounds (CGSWs) are the most lethal types of the cranial traumas and they are usually mortal. Falling bullets or gravitational bullets are the ones that move under the effect of the gravity force after the muzzle force diminished. CGSWs constitute a major clinical challenge for neurosurgeons dealing with trauma in both the military and civil experience. We report the case of a 21-year-old man with a falling bullet wound to the head. The decision of surgical treatment of a bullet injury is difficult if it is in close proximity to vital structures; removal of the bullet may cause significant neurological damage; however, migration can lead to a worsening of the neurological status of the patient. Before surgical removal of any intracranial bullet, as valuable information, it is recommended that a plain skull X-ray be obtained after final positioning of the head.

Effect of High-Pressure Processing (HPP) on composition, lactose and microstructure of goat milk

Thermal pasteurisation is an established method for milk processing. However, the high temperature could affect the micronutrients in the milk. High pressure processing (HPP) is a cold alternative to thermal pasteurisation that can maintain the fresh-like properties of liquid food. However, employing pressure could potentially affect the composition and microstructure of milk and milk products. Therefore, this study focusses on evaluating the effect of high pressure processing (HPP) towards the composition, lactose content and microstructure (in term of fat globules) of goat milk. The goat milk was subjected to HPP at a pressure range of 200 to 600 MPa and process holding time at 5 - 15 mins. There were insignificant differences in terms of fat, protein and carbohydrate, but significant changes observed for lactose content of pressurised goat milk (PGM). The lactose content of PGM was in the range of (2.540 – 2.986 g/mL), while 1.253±0.01 g/100 mL for untreated goat milk (UGM). A higher number of the small size of goat milk fat globules observed at 600 MPa compared to lower processing pressure (200 and 400 MPa) at the same pressure holding time (5 to 15 mins). The mean diameters of fat globules were in the range of 5.215 to 5.651 μm. This size reduction of milk fat globules is an advantage for cheese making or other dairy product making industries, because it can help to possess a smoother and more refined texture of milk products.

Proximate composition of Malaysian local sweet potatoes

Sweet potato (Ipomoea batatas (L.) Lam) is one of the main crops worldwide. However, systematic properties characterization of this crop is still required, particularly on the Malaysian local sweet potatoes. Hence, this study aims to determine the proximate composition and the energy value of five common varieties of local sweet potato (Anggun 1, Anggun 2, Anggun 3, White, and VitAto) in Malaysia. For each variety, three different parts of the tuberous root which were the skin, the cortex, and the mixture of cambium and parenchyma were characterized. The findings indicated that VitAto exhibited the highest starch (16.95% – 17.17%) and crude protein (0.86% – 1.15%) contents in all parts as compared to other varieties, hence reflecting its potentials to be further processed for a mass starch production. Among all the parts, the skin contained the highest crude protein, crude fat, ash and crude fibre, which can be further utilized to produce by-products such as animal feed. The findings in this study serve as a baseline for the future starch and byproducts production from local sweet potatoes.

Ultrasound-assisted extraction and gaseous ozone as preservation method for Roselle (Hibiscus sabdariffa L.) fruit juice

Ultrasound extraction and ozone treatment are promising non-thermal hurdle technologies which can increase the extraction yield while minimizing the loss of nutritional qualities of Roselle fruit juice. Response surface methodology (RSM) was used to investigate the effect of ultrasound time and temperature on juice yield. The optimized points were found at 4.4 min and 22°C, where the extraction yield of the Roselle fruit juice achieved a maximum of 80%, 12% higher than the control sample without ultrasound treatment. Roselle fruit juice (unfiltered and filtered) was then ozone-treated with processing variable of treatment time (0–30 mins). The effects of processing variables on physicochemical characteristics of Roselle fruit juice were determined and no significant differences (P>0.05) in pH and titratable acidity (TA) were observed. However, significant effect (P<0.05) was found in total colour difference (TCD), ascorbic acid (AA), total phenolic content (TPC), and total anthocyanin content (TAC) with increased ozone treatment time. Nevertheless, the degradation of AA was less than 50%, which showed that ozone has the potential to retain a high amount of AA in Roselle fruit juice. Thus, the synergistic effects of ultrasound and ozone treatment on Roselle fruit juice should be carefully considered by processors prior to its adoption as a preservation technique.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Physico-Chemical and Morphological Changes of Sayong Kaolinite Clay Treated with Sulphuric Acid for Enzyme Immobilization

This study analyzed the effects of sulphuric acid (H2SO4) treatment on pysico-chemical properties and morphological changes of clay obtained from Sg. Sayong, Perak. The clay was ground and sieved to <150μm and treated with different concentrations of H2SO4. The treatment was completed by refluxing the clay with different concentration of H2SO4 (1M, 5M and 10M ) at 100 °C for 4 hours and followed by calcination at 500 °C for 1 hour. The physic-chemical properties and morphological changes of the untreated and treated clay were compared using Surface Area Analyser, X-Ray Diffraction (XRD), Field Emission Scanning Electron Micrograph (FESEM), X-Ray Diffraction (XRD) and Fourier Transformed Infrared Spectroscopy (FTIR). The results showed that acid treatment of 5M increased the surface area from 25 m2/g to 75 m2/g and the pore volume increased from 0.1518 cc/g to 0.3546 cc/g. The nanopore size of the clay decreased from 24.8 nm to 19.4 nm after treated with acid. This can be explained due to the elimination of the exchangeable cations and generation of microporosity. The results of XRF showed SiO2 increased from 58.34% to 74.52% and Al2O3 reduced from 34.6% to 18.31%. The mineral oxides such as Fe2O3, MgO, CaO, K2O and TiO2 also reduced. This concluded that H2SO4 treatment has led to significant removal of octahedral Al3+, Fe3+ cations and other impurities. In conclusion, this study showed the physico-chemical properties and morphology of Sayong clay were improved once treated with H2SO4 and therefore suggests better supporting material for enzyme immobilization.

Anharmonic oscillation effect on the Davydov-Scott monomer in a thermal bath

The dynamics of Davydov-Scott monomer in a thermal bath with higher order amide-site's displacement leads to anharmonic oscillation effect is investigated using full-quantum approach and the Lindblad formulation of master equation. The specific heat is calculated based on the thermodynamic partition function using the path integral method. The temperature dependence of the specific heat is studied. In the model the specific heat anomaly as pointed out in recent works by Ingold [Phys. Rev. E 79, 061105 (2009)] is also observed. However, it is found that the anomaly occurs at high-temperature region, and the anharmonic oscillation restores the positivity of specific heat.

Low back pain and association with whole body vibration among military armoured vehicle drivers in Malaysia

A cross sectional study was conducted among military armoured vehicle drivers in the two largest mechanized battalions with the objective to determine the prevalence of low back pain (LBP), and its association with whole body vibration (WBV) and other associated factors. A self-administered questionnaire and Human Vibration Meter were used in this study. A total of 159 respondents participated in this study and 102 (64.2%) of them were subjected to WBV measurement. One-hundred-and-seventeen respondents complained of LBP for the past 12 months giving a prevalence of 73.6%. The prevalence of LBP among tracked armoured vehicle drivers was higher (81.7%) as compared to wheeled armoured vehicle drivers (67.0%). The mean acceleration at Z-axis in tracked armoured vehicles (1.09 +/- 0.26 ms(-2)) and wheeled armoured vehicles (0.33 +/- 0.07 ms) were the dominant vibration directions. The mean estimated vibration dose value (eVDV) for eight-hour daily exposure at Z-axis (19.86 +/- 4.72 ms(-1.75)) in tracked armoured vehicles showed the highest estimation. Based on the European Vibration Directive (2002), the mean eVDV at Z-axis in tracked armoured vehicles exceeded exposure action value (EAV) (> 9.1 ms(-1.75), but did not exceed exposure limit value (ELV) (<21.0 ms(-1.75)). Logistic regression analysis revealed that only driving in forward bending sitting posture (OR = 3.63, 95% CI 1.06-12.42) and WBV exposure at X-axis (OR = 1.94, 95% CI 1.02-3.69) were significant risk factors to LBP. Preventive measures should be implemented to minimize risk of WBV and to improve ergonomic postures among drivers.

Diving accidents treated at a military hospital-based recompression chamber facility in Peninsular Malaysia

This paper describes the pattern of diving accidents treated in a military hospital-based recompression chamber facility in Peninsular Malaysia. A retrospective study was carried out to utilize secondary data from the respective hospital medical records from 1st January 1996 to 31st December 2004. A total of 179 cases categorized as diving accidents received treatment with an average of 20 cases per year. Out of 179 cases, 96.3% (n = 173) received recompression treatment. Majority were males (93.3%), civilians (87.2%) and non-Malaysian citizens (59.2%). Commercial diving activities contributed the highest percentage of diving accidents (48.0%), followed by recreational (39.2%) and military (12.8%). Diving accidents due to commercial diving (n = 86) were mainly contributed by underwater logging activities (87.2%). The most common cases sustained were decompression illness (DCI) (96.1%). Underwater logging and recreational diving activities which contribute to a significant number of diving accidents must be closely monitored. Notification, centralised data registration, medical surveillance as well as legislations related to diving activities in Malaysia are essential to ensure adequate monitoring of diving accidents in the future.

Decompression illness secondary to occupational diving: recommended management based current legistation and practice in Malaysia

Occupational divers are exposed to hazards which contribute to the risk of developing decompression illnesses (DCI). DCI consists of Type I decompression sickness (DCS), Type II DCS and arterial gas embolism (AGE), developed from formation of bubbles in the tissues or circulation as a result of inadequate elimination of inert gas (nitrogen) after a dive. In Malaysia, DCI is one of the significant contributions to mortality and permanent residual morbidity in diving accidents. This is a case of a diver who suffered from Type II DCS with neurological complications due to an occupational diving activity. This article mentions the clinical management of the case and makes several recommendations based on current legislations and practise implemented in Malaysia in order to educate medical and health practitioners on the current management of DCI from the occupational perspective. By following these recommendations, hopefully diving accidents mainly DCI and its sequalae among occupational divers can be minimized and prevented, while divers who become injured receive the proper compensation for their disabilities.

Development of underwater and hyperbaric medicine in Malaysia

Underwater and Hyperbaric Medicine is a treatment modality gaining recognition in Malaysia. It uses the hyperbaric oxygen therapy (HBOT) approach where patients are placed in recompression chambers and subjected to oxygen therapy under pressure. In Malaysia it was introduced as early as the 1960's by the Royal Malaysian Navy to treat their divers for decompression illness (DCI), arterial gas embolism (AGE) and barotraumas. Other sectors in the armed forces, universities and private health centres began developing this approach too in the late 1990's, for similar purposes. In 1996, Underwater and Hyperbaric Medicine began gaining its popularity when the Institute of Underwater and Hyperbaric Medicine at the Armed Forces Hospital in Lumut started treating specific clinical diseases such as diabetic foot ulcers, osteomyelitis, and carbon monoxide poisoning and other diseases using HBOT. This paper discusses the development of this interesting treatment modality, giving a brief historical overview to its current development, as well as provides some thought for its future development in Malaysia.

Pulmonary overinflation syndrome in an underwater logger

Pulmonary overinflation syndrome (POIS) is a group of barotrauma-related diseases caused by the expansion of gas trapped in the lung, or over-pressurization of the lung with subsequent over-expansion and rupture of the alveolar air sacs. This group of disorders includes arterial gas embolism, tension pneumothorax, mediastinal emphysema, subcutaneous emphysema and rarely pneumopericardium. In the case of diving activities, POIS is rarely reported and is frequently related to unsafe diving techniques. We report a classical case of POIS in an underwater logger while cutting trees for logs in Tasik Kenyir, Terengganu. The patient, a 24-year-old worker, made a rapid free ascent to the surface after his breathing equipment malfunctioned while he was working underwater. He suffered from bilateral tension pneumothoraces, arterial gas embolism giving rise to multiple cerebral and cerebellar infarcts, mediastinal and subcutaneous emphysema as well as pneumopericardium. He was treated in a recompression chamber with hyperbaric oxygen therapy and discharged with residual weakness in his right leg.

Contrast enhancement in atherosclerosis development in a mouse model: in vivo results at 2 Tesla

To develop an MRI method for the evaluation of contrast enhancement in early atherosclerotic plaque development in the abdominal aorta of a mouse model. Male apoE-/- mice from three groups, respectively 4 (n = 6), 8 (n = 11) and 16 (n = 4) weeks were included. Axial T1 spin echo images of the abdominal aorta were obtained above and below the renal arteries (90 microm spatial resolution) before and over 1 h after the injection of a macromolecular contrast agent. Signal enhancement was measured in the vessel wall and compared to histological features. Maximal arterial wall signal enhancement was obtained from 16 to 32 min post injection. During this time, the signal-to-noise ratio increased by a factor up to 1.7 in 16 week mice and 2.7 and 2.4 in 8 and 4 weeks mice, respectively. The enhancement of the arterial wall appeared less pronounced in the oldest mice, 16 weeks old, exhibiting more advanced lesions. Using a macromolecular gadolinium agent, contrast uptake in atherogenesis varies with lesion stage and may be related to vessel-wall permeability. Dynamic contrast-enhanced MRI may be useful to evaluate the atherosclerotic plaque activity in mice.

First documented outbreak of hepatitis E virus transmission in Java, Indonesia

A suspected hepatitis outbreak occurred in Bondowoso District, East Java Province, Indonesia, in March-May 1998. An investigation was initiated in April 1998, involving a retrospective review of hospital records, a community-based cross-sectional study, and a health service-based case detection and household follow-up. Sera and epidemiological information were collected from 962 individuals: 235 from 3 outbreak-affected communities along the same rural stretch of river, 101 from community controls living distant from the river, 151 cases detected in health centres, 141 family members of the cases, and 334 subjects from neighbouring families. The prevalence of acute hepatitis E virus (HEV), based on anti-HEV IgM, total antibody (Ig) to HEV and polymerase chain reaction (PCR), was significantly (P < 0.00001) higher (52.4%) among the outbreak communities than among the community controls (3%). The background prevalence of HEV, based on anti-HEV IgG, was also significantly (P < 0.00001) higher (47%) among the outbreak communities than among the community controls (3%). None of the 476 sera screened for anti-HAV (hepatitis A virus) IgM was positive. These results indicate that HEV was the aetiological agent responsible for the outbreak. The overall attack rate (AR) for the 3 outbreak-affected communities surveyed was 19%, with AR determined on the basis of clinically recognized, acute jaundice illness. The usage of river water as primary source for bathing, human-waste disposal, and drinking purposes differed significantly (P < 0.00001) between the communities in outbreak areas and those in non-outbreak areas. There is no significant influence attributed to 'boiling water' on acute HEV. No climatic influences (flooding or drought) predisposed this instance of epidemic HEV transmission. This outbreak represents the first documented evidence of epidemic HEV transmission in Java, Indonesia.

The use of India ink and 51Cr-labeled microspheres in examining the function of the yolk stalk as a passageway between the yolk sac and intestine in posthatch broiler chicks

India ink and radioactive 51Cr-labeled microspheres were used in separate trials to examine the role of the yolk stalk lumen as a distinct pathway between the yolk sac and gut through the first 5 d of posthatch growth in broiler chicks. Throughout this period, India ink was able to pass from the yolk sac through the yolk stalk and into the intestine, but was not able to pass from the intestine into the yolk stalk or yolk sac. Furthermore, labeled microspheres moved from the yolk sac via the yolk stalk into the gut; which caused the total counts per minute of the intestine, yolk stalk, and excreta to progressively increase. It was concluded that India ink and 51Cr-labeled microspheres were useful materials in establishing that the yolk stalk provides a direct one-way passage by which material in the yolk sac may move into the intestine of broiler chicks during the first 5 d after hatching.

Ethnicity, socioeconomic status, transfusions and risk of hepatitis B and hepatitis C infection

This study identifies the risk factors for hepatitis B virus (HBV) and hepatitis C virus (HCV) and measures the prevalence of hepatitis B surface antigen (HBsAg) and antibody to hepatitis C (anti-HCV) in the general population of Jakarta. A population-based sample of 985 people aged 15 and above was surveyed. Risk factors were identified through questionnaires and home visits. Serum was analysed for HBsAg, antibody to hepatitis B surface antigen (anti-HBs), anti-HCV, aspartate aminotransferase (AST) and alanine aminotransferase (ALT). The seroprevalence was: 4.0% (39/985) for HBsAg, 17.2% (170/985) for anti-HBs, and 3.9% (38/985) for anti-HCV. The risk factors for hepatitis B and hepatitis C infection had little in common. Low socioeconomic status was a strong risk factor for HBsAg (adjusted odds ratio (OR) 18.09; 95% confidence interval (CI) 2.35-139.50). In addition, the Chinese group has 2.97 higher risk of having HBV infection compared with the Malayan ethnic group (adjusted OR 2.97; 95% CI 1.22-7.83). There was moderate positive trend between family size and risk of HBsAg positivity (P = 0.130). Age over 50 (adjusted OR 14.72; 95% CI 4.35-49.89) and history of transfusion were significant risk factors for hepatitis C (adjusted OR 3.03; 95% CI 1.25-7.33). Hepatitis B and hepatitis C infections have different risk factors in Jakarta, a high risk in population for both diseases. Hepatitis B transmission is associated with low socioeconomic status, Chinese ethnic group and large family size, while hepatitis C is associated with an older age and a history of transfusions.

Short report: evidence of worldwide transmission of hepatitis G virus

Hepatitis G virus (HGV) has been recently documented in the Americas, Europe, and Australia. Distinct risk populations from North Africa, South America, and Southeast Asia were screened for HGV, in addition to hepatitis B and C viruses. First time recognition of HGV is described from Egypt and Indonesia. Notable is the high proportion of HGV positive individuals among multiply transfused children, ranging from 24% of those sampled from Egypt to 32% in Indonesia. Also, data from Peru suggest the likely association of HGV infection with progressive liver disease. Hepatitis G virus should be considered a world-wide health concern.

Cockroaches from urban human dwellings: isolation of bacterial pathogens and control

A study was carried out to determine the distribution of cockroaches in two different housing areas with central sewerage or individual septic tanks in an urban area in Kuala Lumpur, Malaysia. Six species of cockroaches were present and of these Periplaneta americana and Periplaneta brunnea were found in greater abundance. Seventeen species of bacteria were isolated and of these Escherichia coli and Klebsiella p. pneumoniae were isolated in greatest numbers. Control measures carried out using lambda cyhalothrin showed that there was no significant difference between treated and control sites.

Serological investigation of enterococcal infections using western blot

To assess the usefulness of Western blot in the diagnosis of enterococcal infections, a pilot study was conducted with a newly developed Western blot using sera from patients with confirmed enterococcal infections. Sera from 17 of 19 patients with enterococcal endocarditis reacted strongly to enterococcal antigens on the Western blot, and most produced specific bands at molecular weights 98 kDa and 54 kDa. Sera from patients with bacteremic cholangitis and pyelonephritis reacted frequently as well, but the pattern of bands was different from that observed with endocarditis. Eighty-five percent of 26 sera tested from patients with bacteremia and associated deep-seated infections (endocarditis, cholangitis, and pyelonephritis) were positive on Western blot, compared to 30% of sera from bacteremic patients with no clinically determined deep focus of infection (p < 0.001).

Hepatitis C virus RNA detection and HCV genotype in patients with chronic non-A, non-B hepatitis in Jakarta

Antibody response in HCV infection may be variable and the variability of the serological response could be due to the differences in HCV strains. Since the distribution of hepatitis C virus genotype has been found to be geographically dependent, it is important to determine the distribution of HCV genotype in various countries with high prevalence of chronic non-A, non-B hepatitis. In this study, serum HCV RNA was examined in 53 patients suspected of chronic non-A, non-B hepatitis with an anti-HCV test as determined by currently available assay. HCV viremia was detected in 48 patients (90.6%). These patients had elevated serum ALT level at the time of HCV RNA determination. Using specific genotype probes, all isolates were classified into three different genotypes. Double and triple infections were also noted. HCV genotype 1b is the predominant genotype found in chronic hepatitis C patients in Jakarta.