Effect of helmet use on maxillofacial injuries due to bicycle and scooter accidents: a systematic literature review and meta-analysis

Maxillofacial injury is a common injury resulting from bicycle (including e-bike) and scooter accidents. With 80,000 admissions to emergency departments in 2019, bicycle accidents account for more than half of all traffic-related emergency department visits in the Netherlands. The United States reports approximately 130,000 injuries and 1000 fatalities related to cycling annually. This systematic review and meta-analysis was performed to examine the protective effect of helmets against maxillofacial injuries resulting from bicycle and scooter (including e-bike and e-scooter) accidents. After a systematic literature search, 14 studies were found to be eligible for this systematic review. Of these, 11 were included in the meta-analysis. None of the included studies focused on vehicles with motors (e-bikes and e-scooters); all focused only on non-motorized vehicles. All included studies were non-randomized, which could have led to bias in the pooled results. Data from the included studies were tested for heterogeneity using the binary random-effects model (DerSimonian-Laird method), and the odds ratio for the occurrence of maxillofacial injury in cyclists wearing a helmet versus those not wearing a helmet was calculated by random-effects meta-analysis. Patients who had worn a helmet suffered significantly fewer maxillofacial injuries than patients who had not, in bicycle accidents (odds ratio 0.682). In conclusion, wearing a helmet has a significant protective effect against maxillofacial injury, indicating the need for strict helmet legislation.

Long COVID: health symptoms, impact on health-related quality of life and mapping to disability weights

Introduction

Previous studies indicated that a significant share of COVID-19 patients experiences long lasting health complaints; a condition also referred to as “long COVID”. In order to assess the long term burden of disease of COVID-19, including long COVID, information is needed on health symptoms, health-related quality of life and duration of symptoms of long COVID patients. Therefore, the aim of this study was to assess health symptoms and health-related quality of life of long COVID in the general population of the Netherlands.

Methods

A total of 33,903 COVID-19 patients from the region South-Holland South (the Netherlands) whom tested positive between June 2020 and May 2021 at the municipal health services were invited to complete a web-based questionnaire on the presence, nature and consequences of long COVID and health-related quality of life, measured with the EQ-5D-5L.

Results

In total, 3,768 participants who completed the questionnaire experienced long COVID. Most commonly reporting symptoms were reduced physical condition (65.5%), fatigue (59.6%), problems concentrating (49.6%), loss of smell (41.2%) and shortness of breath (37.8%). 648 participants indicated that they experienced long COVID symptoms for 5 months or longer. Preliminary analysis showed that increasing number of symptoms was associated with a decrease in health-related quality of life.

Discussion and conclusions

Long COVID covers a range of health symptoms of varying severity and duration. This complicates the calculation of the non-fatal burden of disease of COVID-19, particularly because mapping of long COVID to existing disability weights is hampered.

Measuring health expectancy in the European Union

Background

Healthy life expectancy (HLE) is a population health measure that combines mortality and morbidity, which can be calculated using different methods. In this study, we aimed to assess the correlation, reliability and (dis)agreement between two estimates monitored in the European Union (EU), that is, the European Commission's HLE based on self-perceived health (SPH-HLE) and the Institute for Health Metrics and Evaluation's HLE based on disability weight (DW-HLE), by sex, and comparing these results with LE and proportion of life spent in good health (%GH).

Methods

We performed a retrospective study in the EU28 countries, between 2010 and 2017. The HLE methods differ in definition, measurement and valuation of health states. While SPH-HLE relies directly on one question, DW-HLE relies on epidemiological data adjusted for DW. Spearman's r, intraclass correlation coefficient, information-based measure of disagreement and Bland-Altman plots were used to assess reliability, correlation and disagreement in HLE resulting from both methods and in LE or %GH measured by both institutions.

Results

Correlation and reliability between SPH-HLE and DW-HLE were good (better for males), with low disagreement, and were even better for LE between both institutions. The HLE Bland-Altman plots suggest a variability range of approximately 6 years for both sexes, higher for females. There was also an increasing HLE difference between methods with higher average HLE for both sexes.

Conclusions

We showed wide variations between both methods with a clear and different high impact on female and male HLE, showing a tendency for countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

Acknowledgements: This presentation was supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia,I.P., within CINTESIS, R&D Unit (reference UIDP/4255/2020)

Key messages

• Different methods for evaluating health expectancy lead to significantly different results.

• There is a systematic tendency with countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

Reporting guidelines for burden of disease studies: why and how?

Background

The Disability Adjusted Life Year (DALY) is a frequently used metric to assess burden of disease (BoD). Many independent BoD studies have been performed across Europe, showing wide variations and inconsistencies in the application and reporting of DALY specific methods. The European Burden of Disease Network (burden-eu) aims to develop guidelines for reporting DALY calculation studies which may enhance transparency and comparability of BoD estimates across Europe and beyond.

Methods

A burden-eu working group of experts generated a list of potential reporting items based on existing literature, guidance for developing guidelines and consultations with BoD experts. To pilot the drafted product, we asked BoD experts and non-experts to apply it to existing BoD studies. We received feedback and we revised the guidelines accordingly.

Results

The guide for DALY calculation studies comprises about 25 items that should be reported in BoD studies. We included information about the study setting, data input sources including methods for data corrections, DALY-specific methods (e.g., YLL life table, YLD approach, disability weights etc), data analyses, and data limitations. We also included information on how users can compare their new estimates with previously available BoD estimates.

Conclusions

We introduced a reporting instrument for DALY calculations that can be used to document input data and methodological design choices in BoD studies. The application of such guidelines will enhance usability of BoD estimates for decision-makers as well as global, regional, and national health experts.

Key messages

Quantification of injury burden and barriers in maintaining quality data

For policy-makers, quantification of the burden of injury and the determination of the relative attributes of avoidable risk factors to this burden are vital tools for priority-setting purposes. This is particularly important in the case of a rapidly changing injury landscape due to effects of the COVID-19 pandemic. Following the 1996 Global Burden of Disease study the disability adjusted life year (DALY) is widely used to assess the burden of injury. The DALY is a population health metric that expresses health loss due mortality, morbidity and disability into a single number. This allows comparisons of distinct health outcomes across subgroups of a population and over time. In addition, cost-of-illness studies can be used to assess the societal burden of injury. Cost-of-illness studies may vary with regards to the time horizon that is used as well as the cost components, which may include intramural and extramural costs as well as productivity loss due work absenteeism due to injury. Essential for the calculation of injury DALYs and cost-of-illness is relevant data on the occurrence of injury, injury deaths, data on exposure to risk factors for injuries, health care consumption and return to work. However, each phase of the pandemic posed different barriers maintaining collection of quality data which may subsequently jeopardize accurate injury DALY calculations and determination of the relative attributes of avoidable risk factors during the COVID-19 pandemic.

A systematic literature review of burden of disease studies in Europe: next steps and implications for researchers

Facing the considerable variation in the computation of disability-adjusted life years (DALY), the European Burden of Disease Network (burden-eu) launched a series of systematic literature reviews (SLR) to explore the key variations in the assumptions used in the European burden of disease (BoD) assessments. The studies were evaluated in terms of pre-defined criteria, focusing on data sources used and on specific methodological and normative choices to assess BoD. Preliminary results show a wide variety in methodological assumptions used to quantify DALYs, but also important inconsistencies in the reporting of methods and particular assumptions. For instance, the quantification of uncertainties is not a common practice, even though most authors seem to be aware of the uncertainty in their DALY estimates and discuss uncertainties as an important study limitation. When uncertainties were quantified, different approaches were used, and described using inconsistent nomenclature. The results of the SLR show that there is a clear need for standardized reporting guidelines for DALY estimates. Such a tool could be based on quality assessment checklists already in place for clinical trials and observational studies (PRISMA, STROBE, CRD), and would require inclusion of the DALY's key methodological and normative choices. Standardized DALY reporting guidelines could serve multiple purposes. First and foremost, they would allow to increase the quality of reporting, thereby increasing the transparency and comparability of BoD studies. As a reference document, such guidelines would also help to harmonize nomenclature, which would further increase transparency and comparability. Last but not least, it would also serve as a capacity building tool, supporting researchers in understanding which methods and assumptions underlie the DALY metric. To address this need, the burden-eu network aims to play a driving role in the development of standardized DALY reporting guidelines.

A systematic literature review of studies estimating the risk factor attributable burden in Europe

Along with the computation of disability-adjusted life years (DALY), the Global Burden of Disease (GBD) study uses the comparative risk assessment method to estimate the burden attributable to risk factors (RF). The methodology used for GBD studies has undergone continuous improvements through the years and across many independent studies. The European burden of disease network launched a series of systematic literature reviews (SLR) to explore key assumptions used in the European burden of disease (BoD) assessments. The SLR will give an overview of existing studies, including those estimating the BoD attributable to RF and focus on the different computational approaches. The SLR will also help to identify ways to harmonize computational procedures to enhance the comparability of RF attributable burden. The SLR involved four parallel reviews: non-communicable diseases, communicable diseases, injuries and RF. For the latter, we used a search strategy with terms describing the population (GBD area “European region”) and terms specifically used in comparative risk assessments (comparative risk assessment [CRA], attributable mortality/burden/risk). Studies published between January 1990 and April 2020 were included, without language restrictions. The search strategy was run in PubMed, Web of Science, Cochrane, and Embase. OpenGrey, OAIster, CABDirect, WHO, and targeted public health agency websites were screened for indexed grey literature. In addition, burden-eu members were asked to supplement the list of publications with any material available in their national public health institutes. The title, abstract, and full-text screening resulted in the final inclusion of 114 publications. The list of publications includes peer-reviewed articles and reports showing a variability in CRA analysis (e.g. use of exposure-response function, relative risks) and other methodological choices. Further data extraction and analysis is in process and will be presented during the workshop.

The state of health in the European Union in 2019

Background

The European Union (EU) faces many health-related challenges. Accurate and timely data on mortality and morbidity from diseases and injuries and their trends over time are essential for health planning and priority setting.

Methods

We use the GBD 2019 study estimates and 95% uncertainty intervals for the whole EU and each country to evaluate age-standardized death, YLL, YLD and DALY rates for Level 2 causes. We evaluate trends by comparing estimates for the year 2019 with those for the year 2010.

Results

In 2019, the age-standardized death and DALY rates in the EU were 465.8 and 20 251.0 per 100 000 inhabitants, respectively. Between 2010 and 2019, there were significant decreases for age-standardized, death and YLL rates across EU countries. However, YLD rates remained mainly unchanged, with increases in the Netherlands and the ‘. The largest decreases in age-standardized DALY rates were observed for HIV/AIDS and sexually transmitted diseases and transport injuries (both -19%). On the other hand, only diabetes and kidney diseases showed a significant increase for age-standardized DALY rates in the EU (3.5%). Mental disorders showed an increasing age-standardized YLD rate, as well.

Conclusions

Overall, there was a visible trend of improvement in the health status in the EU with substantial differences between countries. EU health policy makers need to tackle incidence of diseases and injuries, with specific attention to causes such as mental disorders. There are many opportunities for mutual learning among otherwise similar countries with different patterns of disease.

Inequalities in non-communicable diseases across the European Union: current state and trends from 2000 to 2019

Background

Non-communicable diseases (NCDs) remain the leading cause of disease burden in the European Union (EU). However, this burden varies across Member States, driven by the socioeconomic and demographic structure of the populations, as well as health care and social support systems in each country. This geographical gradient in the burden of NCDs represents health inequalities that may have expanded as a result of population ageing, migration, and economic crisis, and historic backgrounds.

Methods

Using data from the GBD 2019 study, we quantify the inequality gap between EU countries, characterize the geographical gradient of total and individual NCDs, and analyze the trends over the last 20 years.

Results

A considerable gap exists in the rates of NCD-related DALYs between the country with the lowest burden (Slovenia in 2019) and the highest (Bulgaria in 2019), with a constant (p-trend > 0.05) ratio of 1.6 (95%CI, 1.57; 1.64) since the year 2000. The largest inequality was observed for the burden of stroke between the lowest (France in 2019) and the highest (Bulgaria in 2019) with a ratio of 7.47 (6.78; 8.24) Increasing steadily (p-trend < 0.001) since 2000. Using the relative index of inequality to characterize the gradient of inequalities across the EU, a decreasing trend (p < 0.001) can be observed for NCD-related DALYs rates from 1.56 (1.44; 1.7) in 2000 to in 1.42 (1.33; 1.52) 2019.

Conclusions

Despite overall improvements in health, spatial disparities related to NCDs in the EU persist. Our estimates provide a baseline to inform future equitable health policies.

Burden of diseases and injuries attributable to risk factors in the European Union in 2019

Background

In addition to information on mortality and morbidity from diseases and injuries, it is important to identify the attributable burden of risk factors to allow for health planning and prioritization.

Methods

For the whole EU and each country, using estimates and 95% uncertainty intervals from the GBD 2019 study, we report attributable (all-cause and by level 2 risk factors) age-standardized death and DALY rates, as well as summary exposure values (SEV). We evaluate trends by comparing estimates for the year 2019 with those for the year 2010.

Results

Age-standardized death and DALY rates attributable to risk factors declined by 10.7% (95%UI 13.8%-7.6%) and 9.1% (95%UI 12.0%-6.3%), between 2010 and 2019 in the EU. While there was a decreasing trend for both age-standardized death and DALY rates for almost all risk factors, some showed an increasing trend on SEV, including low physical activity and intimate partner violence.

Conclusions

Despite the improvement of health metrics attributable to risk factors, several modifiable behavioral and metabolic risk factors remain unchanged over the years. It is crucial to ensure a swift implementation of evidence-based policies and interventions in EU member states to achieve the targets of the Sustainable Development Goals.

An overview of burden of disease studies in Europe

Facing the considerable variation in the computation of disability-adjusted life years (DALY) in the numerous updates of the Global Burden of Disease (GBD) study and many independent studies, the European burden of disease network (burden-eu) launched a series of systematic literature reviews (SLR) to explore the key assumptions used in the European burden of disease (BoD) studies. The SLR will provide an overview of the existing BoD studies and the computational variations used and will also help identifying ways to harmonize the approaches enhancing the comparability of BoD estimates. The SLR was split in four parallel reviews: non-communicable diseases (NCDs), communicable diseases (CDs), injuries and risk factors. For the first three, the search strategy included terms describing the population (GBD area “European region”) and the BoD measures (years lived with disability, years of life lost, and DALYs). We included studies published between January 1990 and April 2020, without language restrictions. The search strategy was run in PubMed, Web of Science, Cochrane, and Embase. OpenGrey, OAIster, CABDirect, WHO and targeted public health agency websites were screened for grey literature. In addition, burden-eu members were asked to supplement the list of publications with any material available within their national public health institutes. Data extraction focused on methodological information. The title, abstract and full-text screening resulted in the final inclusion of 165 papers regarding NCDs, 189 with CDs, and 124 papers regarding injuries. The final list includes peer-reviewed articles and reports showing a variability in data sources used (e.g. patient medical records, disease registries, insurance claims sources) and model assumptions (e.g. use of multi-morbidity adjustments, use of disability weights). Further data extraction and analysis is in process, and will be presented during the workshop.

The relation between EQ-5D and fatigue in a Dutch general population sample: an explorative study

Background

Fatigue negatively influences health-related quality of life. It is questionable whether fatigue is sufficiently covered by the EQ-5D. This study investigated whether fatigue is covered by the existing domains of the EQ-5D.

Methods

A Dutch general population sample completed the EQ-5D (3L and 5L version) and the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), of which the fatigue item was used. Outcomes were compared between participants with and without a chronic health condition. Convergent validity was assessed, and multivariate regression analyses was used to predict the RPQ fatigue item from the EQ-5D-3L and EQ-5D-5L domains separately.

Results

3027 people completed the survey, of whom 52% had ≥ 1 chronic health condition. Fatigue was reported by 48% of the participants. Fatigue was moderately correlated to the EQ-5D domains ‘pain/discomfort’, ‘usual activities’, and ‘anxiety/depression’ for the 3L (r = 0.379–0.426) and 5L version (r = 0.411–0.469). For the 5L, also a moderate correlation with ‘mobility’ (r = 0.335) was observed. The remaining correlations were weak. All EQ-5D-3L and 5L domains except for ‘mobility’ were significantly associated with the RPQ fatigue item (unstandardized Beta = − 0.20–0.67; p < 0.01 to p = 0.04). Comparable outcomes were found for participants with and without ≥ 1 chronic health condition.

Conclusions

The extent to which fatigue is covered by the EQ-5D domains is small to moderate, with the EQ-5D-5L being slightly more sensitive to capture fatigue compared to the EQ-5D-3L. An extra fatigue item for the EQ-5D may add value, as fatigue is not fully captured by the existing domains, both in people with and without a chronic health condition.

The added value of extending the EQ-5D-5L with an itching item for the assessment of health-related quality of life of burn patients: an explorative study

INTRODUCTION

Health-related quality of life (HRQL) is an important outcome in burn care and research. An advantage of a generic HRQL instrument, like the EQ-5D, is that it enables comparison of outcomes with other conditions and the general population. However, the downside is that it does not include burn specific domains, like scar issues or itching. Adding extra items to a generic instrument might overcome this issue. This study explored the potential and added value of extending the EQ-5D-5L with a burn-specific item, using a itching item as an example.

METHODS

The EQ-5D-5L and the Patient and Observer Scar Assessment Scale (POSAS) was completed by adult patients 5-7 years after injury. A separate POSAS itching item was used to study the added value of an itching item for the EQ-5D-5L. The EQ-5D-5L + Itching was created by adding the POSAS itching item to the EQ-5D-5L. Five psychometric properties were compared between EQ-5D-5L and EQ-5D-5L + Itching: distribution (e.g. ceiling), informativity cf. Shannon's indices, convergent validity, dimension dependency, and explanatory power respectively.

RESULTS

A total of 243 patients were included, of whom 49% reported any itching on the POSAS. Adding an itching item to the EQ-5D-5L decreased the ceiling effect, and resulted in increased absolute informativity (H' = 4.76 vs. H' = 3.64) and relative informativity (J' = 0.34 vs. J' = 0.31). The extra itching item decreased the convergent validity (Spearman's rank correlation coefficient = -0.51 vs. -0.59). Mutual dependency of dimensions existed, showing that all other items were dominant over the itching item. Adding the itching item to the standard EQ-5D-5L barely improved explanatory power (49.3% vs. 49.0%).

CONCLUSIONS

PThe present study showed adding a burn-specific item to the EQ-5D-5L is possible and has potential. However, 5 to 7 years after injury, adding an itching item to the EQ-5D-5L provides little additional information; the gain in terms of added value is relatively small. Apart from instances where itching information is specifically needed, a strong case is not present for adding an itching item to the EQ-5D-5L for long-term (>5 yr after burns) HRQL assessment in burn patients. In early time periods after burn, the added value might be greater and we recommend exploring this potential in future studies, ideally on multiple timepoints after burn.

Data inputs and assumptions in calculating the non-fatal burden in burden of disease studies

Years Lived with Disability (YLD) is a component of the Disability-Adjusted Life Year (DALY), and measures the healthy time that is lost because of living with a disease or disability. YLDs are calculated by multiplying the prevalence and/or incidence of a disorder by the short- or long-term loss of health associated with that disability (the disability weight) and disease severity (severity distribution).

The process of calculating a YLD involves several components and in this presentation each step will be highlighted through a sequential walk through for each step in the YLD calculation, including counting disease occurrencethe relationship between disability weights, health states and severity distributionsadjusting for comorbiditiesdealing with uncertainty

The aim of this presentation is to provide a simple step by step guide on the key components in the YLD calculation. Using the real-life example of cerebrovascular disease, the presentation will outline the key choices and assumptions that underline each data input in the YLD calculation. Participants in this session will also be provided with links to resources to help facilitate this decision-making process. The workshop will end with an interactive session where the presenters will discuss the implications of the different methodological choices with the audience.

Unscattering the burden of disease landscape: supporting interaction between existing burden of disease efforts

The burden of disease landscape in Europe is currently scattered with experts from diverse professional backgrounds, ranging from experts in infectious diseases, non-communicable diseases, injuries and risk factors, to experts in more comprehensive national, regional and global burden of disease studies. Currently there is little interaction between these experts and existing burden of disease efforts. The European burden of disease network (burden-eu) COST Action aims to bring together expertise across different domains and professional backgrounds. During the course of the burden-eu COST Action, several steps will be taken to facilitate interaction between existing burden of disease efforts. First, a survey has been sent around to all members of the EU burden of disease network to map burden of disease studies that have been carried out in their country. Apart from general details about the year of the study and cause of disease categories, items of the survey included data sources, methodological approach and collaborations with institutes of other countries. In the first month, the survey has been completed for over 70 studies that have been carried out in twelve countries. Second, comparison of existing burden of disease initiatives allows for the identification of the various domains for which burden of disease has been assessed, highlight methodological differences as well as similarities, and

facilitate improvements and harmonization of methods and approaches. Furthermore, the data collected from the survey will be included in a continuously updated burden of disease database that lists all past and current burden of disease activities. Lastly, burden-eu will facilitate regular meetings and workshops. Each of these steps will make it possible to move beyond the currently scattered burden of disease landscape and increase interaction between professionals and burden of disease efforts.

Exploring the relation between the EQ-5D-5L pain/discomfort and pain and itching in a sample of burn patients

BACKGROUND

The EQ-5D domain pain/discomfort (PD) uses one item to capture pain and other aspects of discomfort, like itching. This study explored how pain, itching and the EQ-5D-5L PD domain relate to each other in a sample of burn patients.

METHODS

Adult burn patients completed the EQ-5D-5L and the Patient and Observer Scar Assessment Scale (POSAS) 5-7 years after sustaining their injury. The POSAS includes a separate pain and an itching item. Spearman's correlation coefficient established the association between the EQ-5D-5L PD and the POSAS pain and itching item. With multivariable regression analysis the linear association between the POSAS pain and itching item and EQ-5D-5L PD domain was tested.

RESULTS

Data from 245 patients were included. Mean EQ-5D-5L index value was 0.87 and 39.2% reported at least slight problems on the EQ-5D-5L PD domain. Most patients gave corresponding answers on the EQ-5D-5L PD domain and on the POSAS pain (73%) and itching (70%) item. Spearman correlation coefficients of the EQ-5D-5L PD domain with the POSAS pain and itching were 0.468 (p < 0.001) and 0.473 (p < 0.001), respectively. Among respondents with pain and without itching and respondents with itching and without pain, Spearman correlation coefficients were 0.585 (p = 0.076) and 0.408 (p = 0.001), respectively. POSAS pain (unstandardized Beta = 0.14) and POSAS itching (unstandardized Beta = 0.08) were significantly associated with EQ-5D-5L PD domain (p < 0.001).

CONCLUSIONS

Our findings indicate that, in a sample of burn patients, pain and itching are captured by the broader EQ-5D-5L PD domain. The EQ-5D-5L PD domain can thus be used to assess pain and itching in relation to HRQL, but the POSAS pain and itching items are more sensitive. The EQ-5D-5L is, however, no replacement of the POSAS when the POSAS is used for its primary aim; assessment of scar quality.

TRIAL REGISTRATION

Netherlands Trial Register (NTR6407).

Evaluation of Measurement Properties of Patient-Reported Outcome Measures After Rhinoplasty: A Systematic Review

Importance

The number of available rhinoplasty outcome measurement instruments has increased rapidly over the past years. A large heterogeneity of instruments of different quality now exists, causing difficulty in pooling and comparing outcome data.

Objective

To critically appraise, summarize, and compare the measurement properties of all patient-reported outcome measures (PROMs) that measure functional or aesthetic symptoms of patients undergoing rhinoplasty, using consensus-based methodology and guidelines. This facilitates an evidence-based recommendation on the most suitable instrument to measure rhinoplasty outcomes and identifies promising instruments worthy of further research.

Evidence Review

A systematic literature search of Embase, Medline, and Web of Science was conducted from the databases' respective inception dates to May 18, 2018. Thirty-three articles evaluating 1 or more measurement properties of instruments measuring symptoms related to nasal breathing or satisfaction with nasal appearance in patients who had undergone septoplasty and/or rhinoplasty were included. Measurement properties were graded according to the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines for systematic reviews of PROMs.

Findings

The search strategy identified 33 studies that used 12 different measurement instruments. In general, high-quality studies on measurement properties of instruments measuring aesthetic and/or functional symptom-specific outcome of rhinoplasty are scarce. The Nasal Obstruction Symptom Evaluation (NOSE) scale demonstrated high-quality evidence for sufficient structural validity, internal consistency, reliability, construct validity, and responsiveness, along with favorable interpretability and feasibility aspects, and was therefore selected as the most suitable instrument to measure functional outcome. Among instruments measuring aesthetic outcome, the FACE-Q and Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) aesthetic subscale are recommended for further study. Future studies on the measurement properties of the identified PROMs, in particular content validity studies, are necessary.

Conclusions and Relevance

Three instruments with high potential for further use were identified in a systematic review of rhinoplasty outcome instruments using a standardized, consensus-based methodology: the NOSE, FACE-Q, and SCHNOS. These findings may contribute to standardized collection of outcome data in rhinoplasty.

Correspondence of directly reported and recalled health-related quality of life in a large heterogeneous sample of trauma patients

Purpose

To evaluate the correspondence of directly reported and recalled health-related quality of life (HRQL) in a heterogeneous sample of trauma patients.

Methods

Adult trauma patients who attended the Emergency Department and were admitted between 03/2016 and 11/2016 were invited to participate. Postal surveys were sent 1 week (T1), 3 months (T2), and 12 months (T3) post-trauma. The EQ-5D-3L and Visual Analogue Scale (EQ-VAS) were used to assess directly reported and recalled HRQL.

Results

The EQ-5D was completed by 446 patients at T1, T2, and T3. Directly reported mean T1 EQ-5D summary score was 0.482, whereas recalled T1 EQ-5D summary score was 0.453 (p < 0.05) at T2 and 0.363 (p < 0.001) at T3. Directly reported mean T2 EQ-5D summary score was 0.737 and mean recalled T2 EQ-5D summary score was 0.713 (p < 0.05) at T3. Directly reported mean T1 EQ-VAS was 56.3, whereas mean recalled T1 EQ-VAS at T2 and T3 was 55.4 (p = 0.304) and 53.3 (p < 0.05), respectively. Directly reported mean T2 EQ-VAS was 72.5 and recalled T2 EQ-VAS at T3 was 68.0 (p < 0.001). The correspondence between all directly reported and recalled HRQL (both EQ-5D summary and EQ-VAS) was fair (ICC = 0.518–0.598). Lowest correspondence was seen in patients with major trauma (injury severity score ≥ 16) and in patients with middle-level education.

Conclusions

Recalled HRQL measured by the EQ-5D-3L and EQ-VAS was systematically lower compared to the directly reported HRQL. Patient characteristics, injury severity, subjectivity of the dimension, and time interval appear to influence correspondence between directly reported and recalled HRQL.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02256-z) contains supplementary material, which is available to authorized users.

Validation and reliability of the Abbreviated World Health Organization Quality of Life Instrument (WHOQOL-BREF) in the hospitalized trauma population

INTRODUCTION

While the number of trauma patients surviving their injury increase, it is important to measure Quality of Life (QoL). The Abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire can be used to assess QoL. However, its psychometric properties in trauma patients are unknown and therefore, we aimed to investigate the validity and reliability of the WHOQOL-BREF for the hospitalized trauma population.

METHODS

Data were derived from the Brabant Injury Outcome Surveillance. Floor and ceiling effects and missing values of the WHOQOL-BREF were examined. Confirmatory factor analysis (CFA) was performed to examine the underlying 4 dimensions (i.e. physical, psychological, social and environmental) of the questionnaire. Cronbach's alpha (CA) was calculated to determine internal consistency. In total, 42 hypotheses were formulated to determine construct validity and 6 hypotheses were created to determine discriminant validity. To determine construct validity, Spearman's correlations were calculated between the WHOQOL-BREF and the EuroQol-five-dimension-3-level questionnaire, the Health Utility Index Mark 2 and 3, the Hospital Anxiety and Depression Scale and the Impact of Event Scale. Discriminant validity between patients with minor injuries (i.e. Injury Severity Score (ISS)≤8) and moderate/severe injuries (i.e. ISS ≥ 9) was examined by conducting Mann-Whitney-U-tests.

RESULTS

In total, 202 patients (median 63y) participated in this study with a median of 32 days (interquartile range 29-37) post-trauma. The WHOQOL-BREF showed no problematic floor and ceiling effects. The CFA revealed a moderate model fit. The domains showed good internal consistency, with the exception of the social domain. All individual items and domain scores of the WHOQOL-BREF showed nearly symmetrical distributions since mean scores were close to median scores, except of the 'general health' item. The highest percentage of missing values was found on the 'sexual activity' item (i.e. 19.3%). The WHOQOL-BREF showed moderate construct and discriminant validity since in both cases, 67% of the hypotheses were confirmed.

CONCLUSION

The present study provides support for using the WHOQOL-BREF for the hospitalized trauma population since the questionnaire appears to be valid and reliable. The WHOQOL-BREF can be used to assess QoL in a heterogeneous group of hospitalized trauma patients accurately.

TRAIL REGISTRATION

ClinicalTrials.gov identifier: NCT02508675.

Mapping EQ-5D utilities to GBD 2010 and GBD 2013 disability weights: results of two pilot studies in Belgium

Background

Utilities and disability weights (DWs) are metrics used for calculating Quality-Adjusted Life Years and Disability-Adjusted Life Years (DALYs), respectively. Utilities can be obtained with multi-attribute instruments such as the EuroQol 5 dimensions questionnaire (EQ-5D). In 2010 and 2013, Salomon et al. proposed a set of DWs for 220 and 183 health states, respectively. The objective of this study is to develop an approach for mapping EQ-5D utilities to existing GBD 2010 and GBD 2013 DWs, allowing to predict new GBD 2010/2013 DWs based on EQ-5D utilities.

Methods

We conducted two pilot studies including respectively four and twenty-seven health states selected from the 220 DWs of the GBD 2010 study. In the first study, each participant evaluated four health conditions using the standard written EQ-5D-5 L questionnaire. In the second study, each participant evaluated four health conditions randomly selected among the twenty-seven health states using a previously developed web-based EQ-5D-5 L questionnaire. The EQ-5D responses were translated into utilities using the model developed by Cleemput et al. A loess regression allowed to map EQ-5D utilities to logit transformed DWs.

Results

Overall, 81 and 393 respondents completed the first and the second survey, respectively. In the first study, a monotonic relationship between derived utilities and predicted GBD 2010/2013 DWs was observed, but not in the second study. There were some important differences in ranking of health states based on utilities versus GBD 2010/2013 DWs. The participants of the current study attributed a relatively higher severity level to musculoskeletal disorders such as ‘Amputation of both legs’ and a relatively lower severity level to non-functional disorders such as ‘Headache migraine’ compared to the participants of the GBD 2010/2013 studies.

Conclusion

This study suggests the possibility to translate any utility derived from EQ-5D scores into a DW, but also highlights important caveats. We observed a satisfactory result of this methodology when utilities were derived from a population of public health students, a written questionnaire and a small number of health states in the presence of a study leader. However the results were unsatisfactory when utilities were derived from a sample of the general population, using a web-based questionnaire. We recommend to repeat the study in a larger and more diverse sample to obtain a more representative distribution of educational level and age.

Electronic supplementary material

The online version of this article (doi:10.1186/s13690-017-0174-z) contains supplementary material, which is available to authorized users.

[The effects of severe and very severe injuries]

- The effects of severe injuries can be charted using the International Classification of Functioning, Disability and Health (ICF) model and the burden of disease model, in which the burden of disease is expressed in 'disability-adjusted life years' (DALYs). - Severe accidents cause 10 DALYs per 1000 people, which is comparable with the burden of disease of mood disorders and lung cancer.- In the Netherlands, severe injury victims are often males aged < 40 years, who are often injured in road traffic accidents. - The average hospital stay after a severe injury is one month, after which almost 75% of the patients are discharged home, while one quarter subsequently stay in rehabilitation facilities for 3-6 months. More than half return to their original employment. - Patients with thoracic and abdominal injuries recover relatively well, whereas injuries of the lower extremities, brain and spinal cord give a relatively poor prognosis. Comorbidity increases the chance of a less good recovery. Older people who survive an accident recover relatively well.

Comorbidities and factors associated with central nervous system infections and death in non-perinatal listeriosis: a clinical case series

Background

Listeriosis is a rare disease caused by the bacterium Listeria monocytogenes and mainly affects at risk people. Listeriosis can lead to sepsis, central nervous system (CNS) infections and death. The objectives of this study were to describe and quantify comorbidities and neurological sequelae underlying non-perinatal listeriosis cases and to describe the factors associated with death and CNS infections in non-perinatal listeriosis.

Methods

We retrospectively collected clinical data through computerized, paper or microfilmed medical records in two Belgian university hospitals. Logistic regression models and likelihood ratio tests allowed identifying factors associated with death and CNS infections.

Results

Sixty-four cases of non-perinatal listeriosis were included in the clinical case series and 84 % were affected by at least one comorbid condition. The main comorbidities were cancer, renal and severe cardio-vascular diseases. Twenty-nine patients (45 %) suffered from a CNS infection and 14 patients (22 %) died during hospitalization, among whom six (43 %) had a CNS involvement. Among surviving patients, eleven suffered from neurological sequelae (22 %) at hospital discharge; all had CNS infection. Five of these patients (45 %) still suffered of their neurological sequelae after a median follow-up of one year (range: 0.08–19). The factor associated with death during the hospitalization was the presence of a severe cardiovascular disease (OR = 4.72, p = 0.015). Two factors inversely related with CNS infections were antibiotic monotherapy (OR = 0.28, p = 0.04) and the presence of renal disease (OR = 0.18, p = 0.02).

Conclusions

In a public health context these results could be a starting point for future burden of listeriosis studies taking into account comorbidity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1602-3) contains supplementary material, which is available to authorized users.

Health-related quality of life after mild, moderate and severe traumatic brain injury: patterns and predictors of suboptimal functioning during the first year after injury

BACKGROUND

The Glasgow Outcome Scale Extended (GOSE) is the established functional outcome scale to assess disability following traumatic brain injury (TBI), however does not capture the patient's subjective perspective. Health-related quality of life (HRQL) does capture the individual's perception of disability after TBI, and has therefore been recognized as an important outcome in TBI. In contrast to GOSE, HRQL enables comparison of health outcome across various disease states and with healthy individuals. We aimed to assess functional outcome, HRQL, recovery, and predictors of 6 and 12-month outcome in a comprehensive sample of patients with mild, moderate or severe TBI, and to examine the relationship between functional impairment (GOSE) and HRQL.

METHODS

A prospective cohort study was conducted among a sample of 2066 adult TBI patients who attended the emergency department (ED). GOSE was determined through questionnaires or structured interviews. Questionnaires 6 and 12 months after ED treatment included socio-demographic information and HRQL measured with Short-Form Health Survey (SF-36; reflecting physical, mental and social functioning) and Perceived Quality of Life Scale (PQoL; measuring degree of satisfaction with functioning).

RESULTS

996 TBI survivors with mild, moderate or severe TBI completed the 6-month questionnaire. Functional outcome and HRQL after moderate or severe TBI was significantly lower than after mild TBI. Patients with moderate TBI showed greatest improvement. After one year, the mild TBI group reached outcomes comparable to population norms. TBI of all severities highly affected SF-36 domains physical and social functioning, and physical and emotional role functioning. GOSE scores were highly related to all SF-36 domains and PQoL scores. Female gender, older age, co-morbidity and high ISS were strongest independent predictors of decreased HRQL at 6 and 12 months after TBI.

CONCLUSIONS

HRQL and recovery patterns differ for mild, moderate and severe TBI. This study indicates that GOSE, although clinically relevant, fails to capture the subjective perspective of TBI patients, which endorses the use of HRQL as valuable addition to established instruments in assessing disability following TBI. Influence of TBI severity on recovery, together with female gender, older age, co-morbidity and high ISS should be considered in long-term follow-up and intervention programs.

Health-related quality of life after upper extremity injuries and predictors for suboptimal outcome

PURPOSE

The purpose of this study was to examine the impact of upper extremity injuries (UEIs) on health-related quality of life (HRQoL) in adult patients compared with victims of other types of injuries and with the general population, in order to establish recovery patterns of different types of UEIs and determine predictors for suboptimal outcome in the long term.

METHODS

Data were obtained from the Dutch Injury Surveillance System, from the National Hospital Discharge Registry, and from a patient follow-up survey. A total of 608 patients (aged ≥18 years) with an UEI were included. The main outcome measure was HRQoL measured at 2.5, 5, 9 and 24 months after UEI according to the EuroQol-5D (EQ-5D). The predictors for the suboptimal outcome were examined by multivariate linear regression analyses.

RESULTS

For non-hospitalized UEI patients, a substantial loss in HRQoL was observed after 2.5 months which improved to the level of the general population norms by 24 months. For hospitalized UEI patients, HRQoL improved from 2.5 to 24 months but remained far below population norms. The more proximal UEI had a lower HRQoL and a slower recovery of HRQoL than distal injuries. At all time points, the proportion of UEI patients with limitations on the health domains self-care, usual activities and complaints of pain and/or discomfort was higher than in the group of all injuries. Female gender, higher age, low educational level, co-morbidity, shoulder or upper arm injury, multiple injuries and hospitalization are independent predictors for long-term loss in HRQoL.

CONCLUSIONS

The impact of UEI exceeds the health consequences of the group with all injuries, for both non-hospitalized and hospitalized patients. The presence of UEI substantially reduces HRQoL in the short and long term, mainly due to limitations on the health domains self-care, usual activities and complaints of pain and/or discomfort.

CLINICAL RELEVANCE

The impact of UEIs on HRQoL exceeds the health consequences of the group with all injuries. Proximal UEIs had a lower HRQoL and slower recovery than distal injuries. The predictors for the outcome on specific UEIs need to be further investigated in clinical studies, to understand how these differences affect patient-reported outcome measures. These data provide additional insight into treatment outcome and are needed to improve quality of care.

A systematic review on the influence of pre-existing disability on sustaining injury

OBJECTIVE

To systematically review studies measuring the influence of pre-existing disability on the risk of sustaining an injury.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases searched included Medline (Pubmed), ProQuest, Ovid and EMBASE.

INCLUSION CRITERIA

Studies (1990-2010) in international peer-reviewed journals were identified with main inclusion criteria being that the study assessed involvement of injury sustained by persons with and without pre-existing disability.

METHODS

Studies were collated by design and methods, and evaluation of results.

RESULTS

Twenty-two studies met the inclusion criteria of our review. All studies found that persons with disabilities were at a significantly higher risk of sustaining injuries than those without. Persons with disability had a 30-450% increased odds (odds ratio 1.3-5.5) of sustaining injury compared to persons without disability. Among persons with pre-existing disability, the high risk groups of sustaining an injury are children and elderly.

CONCLUSIONS

People with disabilities experience a higher risk to sustain an injury in comparison to the healthy population. There is a high need for large epidemiological studies of injury among persons with disability, to better address these unique risk profiles in order to prevent additional disability or secondary conditions.

Epidemiological burden of minor, major and fatal trauma in a national injury pyramid

BACKGROUND

The impact of trauma on population health is underestimated because comprehensive overviews of the entire severity spectrum of injuries are scarce. The aim of this study was to measure the total health impact of fatal and non-fatal unintentional injury in the Netherlands.

METHODS

Epidemiological data for the four levels of the injury pyramid (general practitioner (GP) registry, emergency department (ED) registers, hospital discharge and mortality data) were obtained for the whole country. For all levels, the incidence and years of life lost (YLL) owing to premature death, years lived with disability (YLD) and disability-adjusted life-years (DALYs) were calculated.

RESULTS

Unintentional injury resulted in 67 547 YLL and 161 775 YLD respectively, amounting to 229 322 DALYs (14.1 per 1000 inhabitants). Home and leisure, and traffic injuries caused most DALYs. Minor injury (GP and ED treatment) contributed 37.3 per cent (85 504 DALYs; 5.2 per 1000) to the total burden of injury, whereas injuries requiring hospital admission contributed 33.3 per cent (76 271 DALYs; 4.7 per 1000) and fatalities contributed 29.5 per cent (67 547 DALYs; 4.1 per 1000). Men aged 15-65 years had the greatest burden of injury, resulting in a share of 39.6 per cent for total DALYs owing to unintentional injury. The highest individual burden resulted from death (19 DALYs per patient).

CONCLUSION

Trauma causes a major burden to society. For priority setting in public health and the identification of opportunities for prevention it is important that burden-of-injury estimates cover the entire spectrum of injuries, ranging from minor injury to death.

Improved and standardized method for assessing years lived with disability after injury

OBJECTIVE

To develop a standardized method for calculating years lived with disability (YLD) after injury.

METHODS

The method developed consists of obtaining data on injury cases seen in emergency departments as well as injury-related hospital admissions, using the EUROCOST system to link the injury cases to disability information and employing empirical data to describe functional outcomes in injured patients.

FINDINGS

Overall, 87 weights and proportions for 27 injury diagnoses involving lifelong consequences were included in the method. Almost all of the injuries investigated (96-100%) could be assigned to EUROCOST categories. The mean number of YLD per case of injury varied with the country studied. Use of the novel method resulted in estimated burdens of injury that were 3 to 8 times higher, in terms of YLD, than the corresponding estimates produced using the conventional methods employed in global burden of disease studies, which employ disability-adjusted life years.

CONCLUSION

The novel method for calculating YLD after injury can be applied in different settings, overcomes some limitations of the method used to calculate the global burden of disease, and allows more accurate estimates of the population burden of injury.

A comparison of the potency of several Brucella allergens used to detect brucellosis in cattle

The potency of Brucella allergens prepared from a smooth Brucella abortus strain S-99, mucoid strain Leewarden, rough strain 45/20, and rough Brucella melitensis strain B-115 was assessed. The potency of these allergens was compared with that of a standard allergen prepared from smooth Brucella abortus S-99 that efficiently detected bovine brucellosis in other studies. Eight cattle experimentally inoculated with Brucella abortus 544 were tested with the allergens 4 and 10 weeks after infection, and again 8 months after infection. All the allergens effectively detected infection but there was a clear distinction in the mean skin reactions 48 and 72 h after injection of the allergens. The skin reactions provoked by the allergens prepared from smooth or mucoid strains of Brucella were most pronounced 48 h after injection. Skin reactions provoked by allergens prepared from rough strains of Brucella were strongest 72 h after injection. Allergens prepared from smooth or mucoid Brucella strains were more potent in detecting brucellosis than those prepared from rough strains of Brucella.

Novel glycolipids of Mycobacterium avium and related M. paratuberculosis strains of relevance to AIDS and Crohn's disease

The polar glycolipid fractions of several mycobacterial strains of the closely related species M. avium and M. paratuberculosis have been analysed by thin layer chromatography (TLC), high pH anion exchange chromatography (HPAEC), gas-liquid chromatography (GC) and nuclear magnetic resonance (NMR) spectroscopy. The upper phase of a Folch partitioning (rather than the lower phase analysed by others) was subjected to TLC in solvent system chloroform-methanol-water 50:40:10 v/v/v. A major band was purified from each mycobacterial strain. Monosaccharide analysis of that from M. avium A14 (from an AIDS patient) contained Glc, Ara, Man, Gal in ratios 7:4:3:2. whereas one strain of M. paratuberculosis (316F) had low levels of Ara, Gal and Man with major monosaccharides being Glc and two unidentified monosaccharides. A second M. paratuberculosis strain (J10) had a single TLC band containing only Glc. These known strains were compared to two slow growing mycobacterial isolates, one from a Crohn's patient and one isolated from armadillo. These were similar to J10 in only having Glc present: the former also had a similar NMR spectrum to J10, whereas the latter had a different NMR spectrum from any of the other strains analysed. The results therefore indicate that M. paratuberculosis strain 316F is more closely related to M. avium (from an AIDS patient) than it is to the classical M. paratuberculosis strain J10 and a Crohn's isolate.

Production of Brucella allergens and evaluation of their biological activity in a guinea-pig bio-assay

A study was conducted to evaluate the biological activity of Brucella allergens extracted with hydrochloride or trichloroacetic acid. Smooth and mucoid Brucella abortus cells and the medium in which brucellae were propagated were used to prepare the allergens. The biological activity of the allergens was estimated in guinea-pigs sensitized with Brucella abortus strain 544. The guinea-pigs were intradermally injected with several allergen dilutions. The dilutions were coded and randomized for site of injection so that none of the dilution was injected twice on the same site. Variance analysis using incomplete Latin square was used for the statistical calculation of the results. The calculated biological activity of the allergens was compared with the biological activity of a 'standard' allergen that has proved effective in detecting cattle brucellosis. The skin erythema diameter was best when recorded 32 h after allergen injection. Statistical analysis of the skin erythema diameters showed a great variation in biological activity (12-105%) between the allergens. Only the allergen extracted from the medium in which a mucoid Brucella strain was propagated was as potent as the standard. The use of the incomplete Latin square for variance analysis resulted in the estimation of the biological activity of nine batches of allergen in only 27 guinea-pigs.

Use of various genetic markers in differentiation of Mycobacterium bovis strains from animals and humans and for studying epidemiology of bovine tuberculosis

One hundred fifty-three Mycobacterium bovis strains from cattle, various animal species from zoos and wild parks, and humans were analyzed for three different genetic markers for use in the epidemiology of bovine tuberculosis. M. bovis strains isolated from cattle were found to carry a single IS6110 element, whereas the majority of strains from other animals such as antelopes, monkeys, and seals harbored multiple IS6110 elements, suggesting that the reservoirs in cattle and wild animals are separated. Because the single IS6110 element in cattle strains is located at the same chromosomal position, strain differentiation by insertion sequence fingerprinting was hampered. Therefore, we investigated the usefulness of the direct repeat and polymorphic GC-rich repeat elements for strain differentiation. Both markers allowed sufficient strain discrimination for epidemiological purposes. Evidence is presented that in Argentina, most human M. bovis infections are due to transmission from cattle, whereas M. bovis infections among humans in the Netherlands are mainly contracted from animals other than cattle. Various outbreaks of M. bovis among animals and humans are described, including a small one which likely involved transmission from human to human.

Production of Apx toxins by field strains of Actinobacillus pleuropneumoniae and Actinobacillus suis

The three Apx toxins of Actinobacillus pleuropneumoniae have potential value for use in vaccines and diagnostic tests which will be species specific instead of serotype specific, provided that the Apx toxins are species specific and all field strains produce these toxins. We examined 114 A. pleuropneumoniae field strains and found that they secreted either ApxI, ApxII, ApxI and ApxII, or ApxII and ApxIII and secreted no other cytolytic activities. However, proteins similar to ApxI and ApxII were also produced by Actinobacillus suis.

An outbreak of tuberculosis in a captive herd of Arabian oryx (Oryx leucoryx): diagnosis and monitoring

An outbreak of tuberculosis induced a mortality of 25 per cent in a captive herd of Arabian oryx (Oryx leucoryx). The diagnostic screening tests used on live animals included the comparative skin test, indirect and comparative ELISA tests and lymphocyte transformation tests. Difficulties in the interpretation of these tests stemmed principally from the facts that false negatives and false positives were encountered and that the threshold of positivity was difficult to establish with the ELISA test. The presence of other mycobacterial infections in the environment was almost certainly a complicating factor.

Specificity of the skin delayed-type hypersensitivity test in brucellosis free cattle tested with a Brucella allergen

A study was conducted to determine possible nonspecific skin delayed-type hypersensitivity (SDTH) test reactions in cattle tested with a Brucella allergen. Cattle (n = 14) experimentally inoculated with microorganisms known serologically to cross-react with Brucella and cattle (n = 549) from Brucella free herds were tested serologically and with the SDTH test. The increase in skinfold thickness at the injection site of the allergen was measured to the nearest mm with calipers 48 hours after injection. The results show that none of the SDTH test reactions in cattle experimentally inoculated with microorganisms other than Brucella exceeded 2.0 mm. This indicates that an increase in skinfold thickness > or = 2.0 mm can be considered a positive SDTH test reaction. When this norm was applied to cattle in Brucella free herds 11/549 (2%) cattle showed an increase > or = 2.0. It is concluded that infections with microorganisms other than Brucella are unlikely to cause sensitization that interferes with the SDTH test when used to detect brucellosis. Therefore, the SDTH test can be used to verify positive serologic tests results that might have been caused by microorganisms that serologically cross-react with Brucella.

[An outbreak of bovine tuberculosis on a dairy farm]

An outbreak of bovine tuberculosis on a dairy farm is described. Following intradermal tuberculination 84 animals out of 111 animals older than 6 weeks had a positive reaction. Of the 34 adult sheep one gave a positive reaction. All animals on the farm were taken over for destruction by the Animal Health Centre. The source of the infection could not be established although there was a strong suspicion that the importation of three older dairy cows had introduced the infection on the farm. A further investigation was done on 45 farms. Two of these farms were infected by buying animals from the dairy farm in question. During the investigations the possible transmission of the infections to people who were in close contact to the infected animals was also investigated. From 35 examined persons 5 had a positive Mantoux-reaction. The outbreak coincided with a political discussion concerning the abolishment of the periodical tuberculination on dairy farms. Since 1 January 1993 the surveillance of bovine tuberculosis in the Netherlands is done by import control and findings in slaughter-houses combined with a good identification system. It is stressed that the examinations of the lymph glands in the slaughter-houses require the necessary attention.

Rapid detection and identification of Mycobacterium avium by amplification of 16S rRNA sequences

An assay that is based on the amplification of 16S rRNA sequences and that was initially developed to detect Mycobacterium paratuberculosis in cattle was used to test 20 serotypes of the Mycobacterium avium complex (MAC) and atypical mycobacterial species not belonging to MAC. Only serotypes 1 to 6 and 8 to 11, designated M. avium, were detected by the assay, indicating that it can be used for the rapid detection and identification of M. avium. The results of the assay for clinical samples from animals suspected of having mycobacterial infections indicated that it can also be used directly on clinical samples.

Paratuberculosis in farmed red deer (Cervus elaphus) in Ireland

Paratuberculosis was diagnosed in one 18-month-old and two 30-month-old hinds in a herd of 70 red deer (Cervus elaphus) in Ireland. Loss of condition and intermittent diarrhoea were the main clinical findings. Clumps of acid-fast organisms were found in the faeces of the three deer. Post mortem examination of one deer showed a slight swelling and pallor of the intestinal tract and associated lymph nodes. Histopathology showed a severe, granulomatous enteritis and lymphadenitis, with extensive cellular infiltration, notably with epithelioid macrophages containing numerous acid-fast organisms. Mycobacterium paratuberculosis was isolated from intestinal and lymph node samples. Paratuberculosis was also confirmed in one of nine clinically normal, yearling stags, sampled at slaughter. Complement fixation tests and enzyme-linked immunosorbent assays gave higher readings for clinically affected deer than healthy ones. Acid soil on the farm was believed to be a contributory cause.

Epidemiology and control of rabies in bats in The Netherlands

The first case of bat rabies in the Netherlands was recorded in 1987. Since then, 2,540 bats have been examined. In total, 186 bats belonging to two species were found positive for rabies: 182 Eptesicus serotinus and 4 Myotis dasycneme. The virus isolates from the two species were found to be different. Approximately 20% of the E. serotinus bats sent for examination were found positive. The epidemiological findings suggest a stable situation of infection north of the Rhine and the Meuse. A total of 174 humans received post-exposure treatment after direct contact with a positive or suspected bat. The public has been warned not to touch bats and, if contact does occur, to send the bat for rabies examination. The authorities also advise post-exposure treatment for dogs and cats which have had contact with a rabies-positive bat.

Amplification of 16S rRNA sequences to detect Mycobacterium paratuberculosis

A probe based on 16S ribosomal RNA (rRNA) sequences was developed to detect Mycobacterium paratuberculosis, the causative agent of Johne's disease in cattle. Three universal primers were used to sequence the amplified fragments of the 16S rRNA gene of various species of mycobacteria. When the nucleotide sequences were analysed, a deletion was detected in the sequence of the fast-growing species. An oligonucleotide probe (P) directed to this region was synthesised and hybridised directly with total RNA of various mycobacterial strains in a dot-spot assay. The probe detected M. paratuberculosis, some other slow-growing mycobacteria of the M. avium-intracellulare (MAI) complex, and one atypical strain, M. gordonae. To increase the sensitivity of the probe, a 413-bp fragment of the 16S rRNA gene of M. paratuberculosis between P and a second oligonucleotide primer was amplified and hybridised with a M. paratuberculosis/M. avium-specific probe. When faecal samples of cattle were tested, all culture-positive samples were positive in the PCR assay.

Evaluation of the abilities of three diagnostic tests based on the polymerase chain reaction to detect Mycobacterium paratuberculosis in cattle: application in a control program

Three assays for the specific detection of Mycobacterium paratuberculosis by dot spot hybridization of polymerase chain reaction products were applied to fecal samples of dairy cattle. The first two tests used polymerase chain reaction primers and a DNA probe derived from M. paratuberculosis-specific sequences of the 16S rRNA gene and insertion element IS900, respectively. These two tests were carried out on spiked fecal samples to determine the detection limits. The 16S rRNA test was able to detect 10(7) bacteria per g of feces, and the IS900 test detected 10(4) to 10(5) per g of feces. Next, we studied the usefulness of these tests in a control program for paratuberculosis. Therefore, the tests and a third, commercially available, test (IDEXX Corp.) were used twice with an interval of 3 months on fecal samples of 87 cows from two dairy herds with a history of Johne's disease. We compared the results of these tests with those of culturing. This showed that the tests are specific but that the sensitivity ranged from 3 to 23%. Further improvement of the sensitivity is needed before the tests can be used in a control program to eradicate Johne's disease.

[Mortality of cattle following feeding of moldy flower bulbs]

Five of eight meat cattle died suddenly without showing prior symptoms of disease. The sudden death occurred in connection with the feeding of mouldy tulip bulbs. A short review is given of the use of flower bulbs as cattle feed, the use of herbicides/fungicides in bulb cultivation, and the relevant legislation. Several toxicological aspects that should be taken into consideration when flower bulbs are used as cattle feed are discussed. Both the Central Veterinary Institute and the State Institute for Public Health and Environmental Hygiene showed, in experiments with mice, the presence of a toxin in extracts of the mouldy tulip bulbs. This toxin is probably produced by moulds present in the tulip bulbs. The death of the animals was probably caused by an as yet unidentified mycotoxin.

Pathogenic anaerobic bacteria and the environment

The distribution of pathogenic anaerobes in the environment and the relationship with diseases in animals are discussed. A distinction between the spore-bearing anaerobes (clostridia) and the Gram-negative non-spore-forming anaerobes is necessary. The main habitat of clostridia is the soil but they are also found in dust, sewage, rivers, lakes, sea water, milk, vegetables, fresh meat, fish, insects and the intestinal tract. The Gram-negative non-spore-forming anaerobic bacteria are also widely distributed among animals, principally on mucous membranes of the alimentary tract. After a general introduction and a section on the isolation of anaerobes, the various diseases caused by clostridia (botulism, tetanus, blackleg, malignant oedema, infectious necrotic hepatitis, enterotoxaemia and gas gangrene) and Gram-negative anaerobes (infections due to Fusobacterium and Bacteroides spp., such as diphtheria, footrot, etc.) are discussed. In particular, information concerning the reservoir of the causative agent and the mode of transmission is presented.

[Botulism in cattle, a review]

Botulism in cattle is reviewed in the present paper. General information concerning the aetiology and symptomatology of the disease is followed by a discussion of the epidemiological situation in the Netherlands. Since 1975 several outbreaks of botulism type C or D have occurred. Poultry litter in which toxic carcasses were present, was the most important source of the toxin. An increasing number of cases of botulism type D was reported in recent years, which was probably due to the fact that poultry is not susceptible to toxin type D and therefore the presence of type D toxin is difficult to recognise timely. In addition, atypical cases of type B botulism occurred in the Netherlands during the period from 1977 to 1978, which were caused by supplementary feeding of brewer's grains. Finally, the diagnostic problems, differential diagnosis, prevention, treatment and public health aspects are discussed.