[Campylobacteriosis outbreaks in the state of Hesse, Germany, 2005-2011: raw milk yet again]

BACKGROUND

Campylobacter is the most frequently reported cause of acute infectious diarrhea in Germany. Campylobacter outbreaks are rare events. However, their investigation provides useful information on risks of infection and unused prevention potentials.

METHODS

We analyzed the Hessian database for notifiable diseases for cases of campylobacteriosis reported from 2005 through 2011. For campylobacter outbreaks including five or more cases we prospectively obtained additional information from local public health authorities.

RESULTS

From 2005 through 2011, 29,473 cases of campylobacteriosis were reported in Hesse, Germany (approx. 6 million inhabitants), yielding an annual incidence ranging from 53.4 to 81.4 cases per 100,000 inhabitants. Only 236 cases were part of 16 outbreaks with five or more cases. Among these, six outbreaks occurred among groups traveling outside Germany, four were associated with the consumption of raw milk. For eight outbreaks consumption of poultry was considered a probable or - based on the frequent consumption of poultry during group travel - possible vehicle of infection. Two of the raw-milk associated outbreaks were reported among two groups who visited the same farm within 18 days. Five of 14 members of several families and 77 of 117 students fell sick. The local public health authority was only informed when both groups had visited the farm.

CONCLUSION

The reported outbreaks can be attributed to known risk factors for campylobacteriosis - consumption of raw milk and poultry and international travel. This underlines that prevention possibilities are insufficiently used. These include avoiding the consumption of unpasteurized milk and milk products, the hygienically correct handling of raw poultry and timely identification and notification of outbreaks to public health authorities.

Secondary transmissions during the outbreak of Shiga toxin-producing Escherichia coli O104 in Hesse, Germany, 2011

During the recent outbreak of Shiga toxin-producing Escherichia coli (STEC) O104:H4 in Germany most cases notified in the State of Hesse (6 million inhabitants) were linked to satellite clusters or had travelled to the outbreak area in northern Germany. Intensified surveillance was introduced to rapidly identify cases not linked to known clusters or cases and thus to obtain timely information on possible further contaminated vehicles distributed in Hesse, as well to describe the risk of secondary transmission among known cases. As of 2 August 2011*, 56 cases of haemolytic uraemic syndrome (HUS) including two fatal cases, and 124 cases of STEC gastroenteritis meeting the national case definitions have been reported in Hesse. Among the 55 HUS and 81 STEC gastroenteritis cases that met the outbreak case definition, one HUS case and eight STEC gastroenteritis cases may have acquired their infection through secondary transmission. They include six possible transmissions within the family, two possible nosocomial and one possible laboratory transmission. Our results do not suggest an increased transmissibility of the outbreak strain compared to what is already known about E. coli O157 and other STEC serotypes.

Secondary transmissions during the outbreak of Shiga toxin-producing Escherichia coli O104 in Hesse, Germany, 2011

During the recent outbreak of Shiga toxin-producing Escherichia coli (STEC) O104:H4 in Germany most cases notified in the State of Hesse (6 million inhabitants) were linked to satellite clusters or had travelled to the outbreak area in northern Germany. Intensified surveillance was introduced to rapidly identify cases not linked to known clusters or cases and thus to obtain timely information on possible further contaminated vehicles distributed in Hesse, as well to describe the risk of secondary transmission among known cases. As of 2 August 2011* [corrected], 56 cases of haemolytic uraemic syndrome (HUS) including two fatal cases, and 124 cases of STEC gastroenteritis meeting the national case definitions have been reported in Hesse. Among the 55 HUS and 81 STEC gastroenteritis cases thatmet the outbreak case definition, one HUS case and eight STEC gastroenteritis cases may have acquired their infection through secondary transmission. They include six possible transmissions within the family, two possible nosocomial and one possible laboratory transmission. Our results do not suggest an increased transmissibility of the outbreak strain compared to what is already known about E. coli O157 and other STEC serotypes.

The impact of different biocompatible coated cardiopulmonary bypass circuits on inflammatory response and oxidative stress

This study was to compare the impact of different biocompatible coated circuits on inflammatory response and oxidative stress induced during cardiopulmonary bypass (CPB). Seventy-eight patients undergoing elective coronary artery bypass grafting (CABG) with CPB were randomly assigned to five groups with different biocompatible coated circuits: Trillium, Bioline, Phosphorylcholine, Polymethoxyethyl acrylate (PMEA), and the uncoated control group. Blood was drawn at three different time points: before CPB, 6 and 72 hours post CPB. Unlike the Trillium group, serum levels of TNF-α in the Bioline and Phosphorylcholine groups significantly increased only at 72 hours post CPB (p < 0.05). Serum levels of IL-6 significantly increased at 6 and 72 hours post CPB in all groups (p < 0.01). The Trillium group showed a significant increase of IL-10 compared to the control group at 72 hours post CPB (p < 0.05). Serum levels of NOx in the Phosphorylcholine group significantly decreased at 6 hours post CPB compared to baseline (p < 0.05). Both the Bioline and Phosphorylcholine groups showed statistical decreases in serum NOx levels compared with other groups at 6 hours post CPB (p < 0.05). A significant difference in NOx levels between the Bioline and the control group was also observed at 72 hours post CPB. Myeloperoxidase levels were significantly elevated at 6 and 72 hours post CPB in all groups (p < 0.05). Inflammatory response and oxidative stress are elevated during CABG with CPB. Heparin-coated and the Phosphorylcholine-coated circuits induce less inflammatory responses and oxidative stress compared to other circuits.

Osmolality revisited—Deriving and validating the best formula for calculated osmolality

OBJECTIVE

To derive a formula that can be used (i) to calculate osmolality in normal patients as well as those that are hyperglycemic and intoxicated, and (ii) to predict the presence of unexplained compounds with the osmol gap calculation in the presence and absence of ethanol. DESIGN AND EXPERIMENTS: We performed in vitro experiments to determine the relationship of serum osmolality with sodium, potassium, urea, glucose, ethanol, methanol, and ethylene glycol. Several formulas were then tested for their validity in predicting osmolality in normal individuals. Finally, we assessed whether these formulas would allow us to calculate the osmolality gap (OG) that may be indicative of the presence of other osmotically active compounds. The OG calculation was done both in the presence and absence of ethanol. In this way, the OG should be able to detect compounds like methanol and ethylene glycol even in the presence of ethanol which is easily measured and is very often present in the above-named poisonings.

RESULTS

Experimental results show that glucose, ethanol, methanol, and ethylene glycol need factors of 1.15, 1.20, 1.07, and 1.00, respectively, to accurately predict osmolality. The factors for glucose and ethanol were then validated in normal subjects as well as in a large patient database. The formulas below predicted osmolality very well in patients whether ethanol was present or not. All concentrations are expressed in mmol/L. The mean osmol gap for healthy subjects without ethanol present was 0.77 +/- 3.80 mosM/kg with the reference interval being -6.68 to 8.23 mosM/kg for formula 1 and -8.04 to 6.50 mosM/kg for formula 2. The mean osmol gap (OG) in patients who had ethanol present was 1.22 +/- 5.32 for formula 1 and -0.2 +/- 5.0 for formula 2.

CONCLUSIONS

This study shows that factors of 1.20 and 1.15 have to be applied to ethanol and glucose to allow for accurate calculation of osmolality and osmolality gap. There were insufficient patient data to verify the factors for methanol and ethylene glycol.

Intravenous pamidronate attenuates bone density loss after acute spinal cord injury

OBJECTIVE

To compare the effects of a 6-month treatment with intravenous pamidronate (30-mg infusion once per month) to conventional rehabilitation without pamidronate on bone density of the spine and leg bones and on the excretion rate of N-telopeptide, a urinary marker of bone catabolism, in acutely spinal cord injured patients.

DESIGN

A nonrandomized control trial in which 24 spinal cord injured subjects entered the study within 6 weeks of their injury. Fourteen subjects received pamidronate; 10 did not.

OUTCOME MEASURES

Bone density measurements by dual x-ray absorptiometry were performed before the initial treatment (within 6 weeks of the injury) and at 3, 6, and 12 months postinjury and was the primary efficacy parameter. Urine for N-telopeptide levels was the secondary efficacy parameter.

RESULTS

After acute spinal cord injury, patients treated with intravenous pamidronate had significantly less bone density loss compared with those who did not receive pamidronate (parametric ANOVA, p<.02). Also, ambulatory subjects had significantly less bone density loss over the study period (p<.05) than nonambulatory subjects. In general, a high excretion level of the urinary bone-breakdown product N-telopeptide was found before intravenous pamidronate treatment, followed by a dramatic reduction in excretion after pamidronate treatment. Ambulatory subjects excreted significantly less N-telopeptide than motor-complete subjects at all time points.

CONCLUSION

Intravenous pamidronate treatment and ambulatory ability in the first 6 months after an acute spinal cord injury prevents bone density loss.

Transcutaneous bilirubinometry: its role in the assessment of neonatal jaundice

OBJECTIVE

To review the literature on transcutaneous bilirubinometry so that its exact role in the prevention of kernicterus or bilirubin encephalopathy could be determined.

DESIGN AND METHODS

Literature searches were done in Medline and Current Contents.

RESULTS

It is estimated that about 50% of newborns have an episode of jaundice in the first few days of life. Six percent of newborns may develop hyperbilirubinemia (> 220 mumol/L), which can potentially cause bilirubin encephalopathy or kernicterus, a severe neonatal disease. In the past, serum bilirubin (SB) has been the preferred method of detecting hyperbilirubinemia in newborns. The ordering of SB in neonates is based on visual evaluation by either physicians or nursing staff. Skin puncture collection of blood exposes the neonate to trauma and risk of infection. A noninvasive device for predicting serum bilirubin levels in newborns diminishes the need to do skin punctures. One such device that has been very extensively studied is the Minolta AirShields Jaundice Meter. It is a portable light-weight instrument that uses reflectance measurements on the skin to determine the amount of yellow color present in the skin, namely transcutaneous bilirubin (TcB). Although the TcB measurements correlate well with serum bilirubin (SB) levels, they cannot accurately predict serum bilirubin because of error related to a variety of factors.

CONCLUSIONS

TcB cannot be used directly to make decisions about transfusions or phototherapy in neonates. It is a good tool for screening neonates to determine when a laboratory measurement of serum bilirubin is needed. Such a practice requires careful selection of the decision level so that false-negative TcB values do not prevent appropriate serum bilirubin tests from being done.

Clinical impact of transcutaneous bilirubinometry as an adjunctive screen for hyperbilirubinemia

OBJECTIVE

To determine what the clinical impact would be of implementing a jaundice meter for use in a busy neonatal service as an adjunctive screening tool for hyperbilirubinemia.

DESIGN AND METHODS

Test utilization data was collected for a 6-month period to determine how neonatal bilirubin was utilized in this hospital. The jaundice meter was evaluated in a study population of healthy term infants. The performance characteristics of the meter and the test utilization data were used to predict the clinical impact a meter could have on screening for hyperbilirubinemia.

RESULTS

Utilization data indicated that about 60% of all single bilirubin neonatal testing (i.e., bilirubin only ordered) was done by normal nurseries. A jaundice meter cutoff decision reading of 17 was shown to have a sensitivity of 100% and a specificity of 68% for hyperbilirubinemia (> 260 mumol/L) in a study population of healthy term infants. From this data, it was estimated that use of a jaundice meter could eliminate 43% of the single (i.e., not combined with other tests) bilirubin tests done on healthy term neonates with no prior exposure to phototherapy. This constitutes an overall 20% reduction in bilirubin testing in normal nurseries when testing done on babies exposed to phototherapy and combined bilirubin testing are taken into consideration. Additionally, it was shown that there would be an improvement of 9% in the prediction of hyperbilirubinemia without loss of 100% sensitivity.

CONCLUSION

Use of a jaundice meter in normal nurseries as an adjunctive screening tool enhances patient care by reducing the overall blood procurement rate in normal nurseries by 20% and increasing screening efficiency for significant hyperbilirubinemia by 5%.

Diagnostic ophthalmology. Retinal degeneration

Images

Falsely elevated enzyme-multiplied immunoassay serum valproic acid results in 12 patients

A split sample study of 69 patients' serum for valproic acid analysis by enzyme-multiplied immunoassay technique (EMIT) and by gas-liquid chromatography revealed falsely elevated EMIT values in 12 patients. Of the 69 serum samples, 28 were also assayed by fluorescence polarization immunoassay and all results agreed with those of gas-liquid chromatography. Five of the 12 patients with elevated EMIT values were included in this subgroup. The unidentified interfering substance appears to be a heat-labile, high-molecular-weight compound, possibly a protein complex that can persist in blood for several months following discontinuation of the drug.

Excess serum osmolality gap after ingestion of methanol

Two cases of methanol ingestion and one case of combined methanol and ethylene glycol ingestion are presented to illustrate the large differences that exist between the serum osmolality gap and the measured methanol (plus ethylene glycol) concentration(s) before treatment of these poisonings. After treatment with intravenous ethanol and hemodialysis was initiated, the differences disappeared in all three cases. We speculate that one or more metabolites with osmotic activity are formed in cases of methanol intoxication where no ethanol has also been consumed. The possible identity of these compounds is discussed.

Excess serum osmolality gap after ingestion of methanol

Two cases of methanol ingestion and one case of combined methanol and ethylene glycol ingestion are presented to illustrate the large differences that exist between the serum osmolality gap and the measured methanol (plus ethylene glycol) concentration(s) before treatment of these poisonings. After treatment with intravenous ethanol and hemodialysis was initiated, the differences disappeared in all three cases. We speculate that one or more metabolites with osmotic activity are formed in cases of methanol intoxication where no ethanol has also been consumed. The possible identity of these compounds is discussed.

Comparison of screening methods in a diabetes prevalence survey among northern Indians

The use of medical records, fasting plasma glucose, 2-hour post-challenge glucose and glycosylated hemoglobin is compared in a population diabetes screening survey among Indians in northern Ontario and Manitoba. As expected, screening identified additional diabetics not previously known to the health care system. Glycosylated hemoglobin was highly correlated with fasting glucose and could discriminate between diabetics and non-diabetics, although not those with impaired glucose tolerance. In multiple regression models more significant predictors were identified and a larger proportion of the overall variance accounted for when log hemoglobin instead of log fasting glucose was used as the dependent variable. In a subsample of subjects, no additional diabetics were identified when both 2-hour and fasting criteria were used, compared to fasting plasma glucose alone.

Variables affecting resolution of lung phospholipids in one-dimensional thin-layer chromatography

Resolution of the confusion in the literature about the separation of lung phospholipids in thin-layer chromatographic systems has awaited a systematic study of the variables that potentially affect this separation. In this study I show that: incorporation of ammonium sulfate into silica gel "GHL" has a dramatic effect on separation of lung phospholipids; this effect is equally dramatic but different in activated and nonactivated gels; when it picks up moisture, ammonium sulfate-activated gel very rapidly loses its ability to resolve lecithin from phosphatidylinositol; in gel containing ammonium sulfate, small amounts of phosphatidylethanolamine are hydrolyzed to lyso-phosphatidylethanolamine.

Variables affecting resolution of lung phospholipids in one-dimensional thin-layer chromatography

Resolution of the confusion in the literature about the separation of lung phospholipids in thin-layer chromatographic systems has awaited a systematic study of the variables that potentially affect this separation. In this study I show that: incorporation of ammonium sulfate into silica gel "GHL" has a dramatic effect on separation of lung phospholipids; this effect is equally dramatic but different in activated and nonactivated gels; when it picks up moisture, ammonium sulfate-activated gel very rapidly loses its ability to resolve lecithin from phosphatidylinositol; in gel containing ammonium sulfate, small amounts of phosphatidylethanolamine are hydrolyzed to lyso-phosphatidylethanolamine.

Evaluation of the Dupont aca bromocresol purple albumin method

The bromocresol purple (BCP) albumin method on the DuPont aca was evaluated by determining the accuracy and precision of the method. A split sample comparison was performed against the electroimmunoassay (EIA) method as well as the bromocresol green (BCG) method on the DuPont aca and the Technicon SMA 12/60. The BCP method was found to have more than adequate precision and its accuracy is as good as the EIA method. The BCP method will give results which are approximately 9 g/L lower than end point BCG methods. Problems have been identified with some of the commercial materials that could be used to standardize the BCP method, since different commercial preparations of human serum albumin do not react in identical fashion in the BCP and EIA methods. For this reason caution should be exercised when standardizing the BCP method.

[A case of malignant hyperthermia unrelated to anaesthesia (author's transl)]

Narcots and muscle relaxants are proven causes of malignant hyperthermia. Alcohol and a large number of drugs are capable of inducing myopathic changes which resemble malignant hyperthermia. The case of a 47-year-old man is reported who presented with the clinical symptoms of maligant hyperthermia. The similarity in the course of the disturbance, the clinical and chemical findings and the changes in the morphological features of the muscle suggested that the abnormally high body temperature had been induced by psychotropic durgs in a pre-disposed patient with an history of chronic alcoholism.