Prevention of legionella infections from toilet flushing cisterns

INTRODUCTION

Immunocompromised patients are at an increased risk of severe legionella infections. We present the results of an outbreak investigation initiated following a fatal case of hospital-acquired legionellosis linked to contaminated water from a toilet-flushing cistern. Additionally, we provide experimental data on the growth of Legionella spp. in flushing cisterns and propose a straightforward protocol for prevention.

METHODS

We monitored the growth of Legionella spp. in the building's hot- and cold-water systems using quantitative bacterial culture on selective agar. Molecular typing of Legionella pneumophila isolates from the infected patient and the water system was conducted through core-genome multi-locus sequence typing (cgMLST).

RESULTS

Legionella contamination in the hospital building's cold-water system was significantly higher than in the hot-water system and significantly higher in toilet flushing cistern's water compared with cold water from bathroom sinks and showers. Isolates from the patient and from the flushing cistern of the patient's bathroom were identical by cgMLST. In an experimental setting, daily toilet flushing for a period of 21 days resulted in a 67% reduction in the growth of Legionella spp. in the water of toilet flushing cisterns. Moreover, a one-time disinfection of cisterns with peracetic acid, followed by daily flushing, decreased legionella growth to less than 1% over a period of at least seven weeks in these setting.

CONCLUSIONS

One-time disinfection of highly contaminated cisterns with peracetic acid and daily toilet flushing as short-term measure can significantly reduce legionella contamination in flushing cisterns. These measures may aid in preventing legionella infection among immunocompromised patients.

[Traumatic brain injuries in winter sports : An overview based on the winter sports skiing, snowboarding and ice hockey]

In winter sports, skiers, snowboarders and ice hockey players have the highest risk of traumatic brain injuries (TBI). In skiing/snowboarding severe TBIs are of concern; in ice hockey, repetitive minor TBIs are frequent. The main causes of TBI in recreational skiing are collisions with trees; in professionals falls due to technical or tactical mistakes are the main causes. In ice hockey 10-15% of all injuries are due to a sports-related concussion (SRC), mostly caused by player-opponent contact. The pathomechanism in TBI is a combination of rotational and linear acceleration during head impact, which causes a diffuse axonal injury. Long-term complications such as neurodegenerative diseases and functional deficits are of relevance. Prevention by wearing helmets is effective, but less effective in TBI/SRC than in focal injuries.

Cavum septi pellucidi (CSP) ratio: a marker for partial agenesis of the fetal corpus callosum

OBJECTIVE

While complete agenesis of the corpus callosum is often suspected on fetal ultrasound due to absence of the cavum septi pellucidi (CSP), suspicion of partial agenesis of the corpus callosum (pACC) is a challenge since the CSP is almost always present. The aim of this study was to measure the length and width of the CSP and calculate the length-to-width ratio (CSP ratio), and compare these between fetuses with pACC and normal fetuses.

METHODS

In this retrospective case-control study, the length and width of the CSP were measured in the axial plane of the fetal head, and the CSP length-to-width ratio calculated, in 323 normal fetuses and in 20 fetuses with pACC between 20 and 34 weeks' gestation. From the normal population we constructed reference ranges in relation to biparietal diameter (BPD). For all fetuses we calculated Z-scores for the CSP ratio.

RESULTS

In the normal population, the length and width of the CSP increased with increasing BPD, while the CSP ratio decreased. The CSP was short (< 5^th centile) in 85% (17/20) of fetuses with pACC and wide (> 95^th centile) in 65% (13/20). The CSP ratio was small (< 5^th centile) in 95% (19/20) of pACC fetuses, with 16/20 (80%) having a ratio below an empirical cut-off of 1.5. Analysis of Z-scores showed that fetuses with pACC had a significantly smaller CSP ratio (P < 0.0001) compared with the normal population.

CONCLUSIONS

Fetuses with a normal-sized corpus callosum have a rectangular-shaped CSP, with a CSP ratio > 1.5 in the second half of gestation. Most fetuses with pACC have an abnormally shaped, wide and short CSP, with a decreased CSP ratio. This simple ratio has the potential to identify fetuses at high risk for pACC. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Frontal space distance in facial clefts and retrognathia at 11-13 weeks' gestation

OBJECTIVE

To examine the frontal space (FS) distance in first-trimester fetuses with bilateral, unilateral or median cleft lip and palate and in those with retrognathia.

METHODS

This was a retrospective study using stored two-dimensional ultrasound images of fetal profiles that were recorded at the time of the nuchal translucency (NT) scan at three prenatal medical centers. Images of 300 normal fetuses and 53 fetuses with facial defects were obtained. To measure the FS distance, a line was drawn between the anterior edge of the mental protuberance of the mandible and anterior edge of the maxilla (MM line) and extended upwards in front of the forehead. The perpendicular distance (FS distance) between the MM line and the skin at the point of largest excursion of the fetal forehead was measured. In cases in which the MM line was located anteriorly to the forehead, the distance was measured in the same fashion but was multiplied by -1. Two operators measured the FS distance twice, independently of each other. FS distances were transformed into Z-scores based on the linear relationship with crown-rump length (CRL) in normal fetuses. The distribution of FS distances in fetuses with bilateral, unilateral or median cleft lip and palate and those with retrognathia were compared with that in the normal group using Student's t-test.

RESULTS

A search of the centers' databases identified 53 abnormal cases including 20, nine and eight with a bilateral, unilateral and median cleft lip and palate, respectively, and 16 cases of retrognathia. In fetuses with bilateral, unilateral and median clefts and those with retrognathia, median delta NT was 1.00 mm, 0.37 mm, 4.00 mm and 0.26 mm, respectively. Among these affected groups, 12 (60.0%), six (66.7%), two (25.0%) and eight (50.0%) fetuses had an abnormal karyotype. In the normal population, FS distance was dependent on CRL measurement (FS = 6.62 - (0.08 × CRL); r = -0.539; P < 0.0001). In fetuses with a bilateral and median cleft and in those with retrognathia, FS distance was significantly different from that in the normal population (all P < 0.0001), however, the difference was not significant in fetuses with unilateral clefts (P = 0.103). The respective Z-scores of FS distance for fetuses with bilateral, unilateral and median clefts and retrognathia were -9.7 ± 2.0, -3.1 ± 5.1, 8.2 ± 3.4 and -7.3 ± 2.3. Measurements were ≥ 99(th) and ≤ 1(st) centiles in all but one (98.1%) case.

CONCLUSION

The FS distance appears to be a helpful tool in the detection of facial clefts at 11-13 weeks' gestation. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

[Identification and economic evaluation of anesthesiologic secondary diagnoses on the basis of intraoperative medication]

BACKGROUND

Complications and comorbidities are encodable in the German diagnosis related groups (G-DRG) system and can improve revenues. In this study, secondary diagnoses were identified through drug administrations during anaesthesia and were economically evaluated by regrouping these cases.

METHODS

All intraoperative drug administrations from 2008 were extracted from a database. After exclusion of synonyms and procedure-specific drug administrations, all remaining drugs were matched to explicit secondary diagnoses. All cases were regrouped with their newly defined secondary diagnoses by G‑DRG grouper software, and changes in cost weight were evaluated.

RESULTS

A total of 29 drugs could be assigned to 18 secondary diagnoses. From 22,440 anaesthesia the § 21 data record could be extracted in 1,929 cases and was regrouped with 2,976 secondary diagnoses, according to additional proceeds of 125,330.25 € in 2008 and 103,542.35 € in 2014. Intraoperative secondary diagnoses influence cost weight only in small parts. The average increase in revenue in this study could have been about 50 € per case. From 2008 to 2014 secondary diagnoses were continuously devaluated, although some of them, e. g. afibrinogenemia, have were revaluated.

DISCUSSION

Our retrospective method of making a diagnosis and assuming a correct indication of drug administration is inapplicable to daily routine. The anaesthesiologic documentation has to make drug administration and thereby the secondary diagnosis plausible.

Enlarged adrenal glands as a prenatal marker of congenital adrenal hyperplasia: a report of two cases

We report the prenatal findings of congenital adrenal hyperplasia (CAH) in two consecutive fetuses of one family. The first pregnancy was terminated at 23 weeks' gestation due to the presence of a complex heart anomaly. The adrenal glands appeared enlarged on prenatal ultrasound examination and autopsy confirmed CAH. The parents were subsequently examined and were found to be heterozygous for nucleotide 656 of the CYP21B gene. In a subsequent pregnancy, chorionic villus sampling at 11 weeks confirmed CAH in the male fetus. At this gestational age, mild body edema was present and the nuchal translucency measured 2.1 mm. From 14 weeks onwards, enlargement of the adrenal glands was the only sign of CAH. These findings suggest that enlarged adrenal glands may be a prenatal sign for CAH. In fetal medicine, when a pregnancy is terminated due to fetal malformations, autopsy should be performed because it can provide additional information that is helpful in counseling women with regard to subsequent pregnancies.

[Chronic anemia protects against gastric damage by alcohol and aspirin. The role of the toxic radicals and lipid peroxidation]

The effects of chronic anemia on gastric damage induced by ethanol or aspirin have been investigated in rats. The role of free radicals and lipid peroxidation in that circumstance was also assessed. Chronic anemia was induced by replacement of 1.5 ml of blood by a plasma expander during 5 days. Under anesthesia, the stomach was perfused with 100% ethanol or acidified aspirin during 30 minutes. Thereafter, the rats were sacrificed, the stomachs removed and analyzed planimetrically for macroscopic damage. In addition, gastric tissue was collected and homogenized for assessment of toxic free radicals generation by chemoluminicense and lipid peroxidation by measuring reactive species of thiobarbituric acid (TBA-RS). Chronic anemia significantly protected against damage induced by ethanol or aspirin. The rate of toxic free radicals and the TBA-RS in the gastric mucosa was significantly reduced by anemia, either under ethanol or aspirin injury. It is concluded that anemia offers a general protection against gastric mucosal damage and that this protection is in part mediated by limitations on lipid peroxidation and toxic free radicals generation.

Recognition of tetramethylenedisulfotetramine and related sulfamides by the brain GABA-gated chloride channel and a cyclodiene-sensitive monoclonal antibody

Aldrin and many other cyclodiene and polychlorocycloalkane insecticides interact with both the [35S]-tert-butylbicyclophosphorothionate ([35S]TBPS) binding site of the mammalian brain gamma-aminobutyric acid (GABA) gated chloride channel and several cyclodiene monoclonal antibodies (MAbs) at concentrations ranging from 0.06 to 8.7 microM. A survey of other classes of GABAA receptor antagonists (including picrotoxinin and several trioxabicyclooctanes) for possible interactions with the cyclodiene MAbs revealed only one potent inhibitor, the heteroadamantane tetramethylenedisulfotetramine (TETS) [mouse intraperitoneal LD50 0.24 mg/kg; TBPS binding site IC50 0.5 microM as a competitive inhibitor (Scatchard analysis); cyclodiene MAb IC50 3 microM]. These findings prompted comparative studies on the structure-activity relationships of other sulfamides as they apply to both the ligand-nerve and ligand-MAb interactions. TETS is active on only one (MAb 8H11) of four cyclodiene MAbs. Several hetero(homo)adamantanes were synthesized and compared with TETS for neurotoxicity and recognition by the TETS-sensitive cyclodiene MAb. The toxicity to mice and/or houseflies decreases in the following order: TETS much greater than the heterotetracyclic compound hexamethylenetrisulfohexamine (HEXS) and two TETS analogues in which one sulfamide group is replaced with o-phenylenediamine or 1,1-dimethyl-1,2-diaminoethane much greater than seven other hetero(homo)adamantanes. The TETS-sensitive cyclodiene MAb recognizes HEXS (IC50 0.4 microM) and, to a lesser extent, two related sulfamides. However, the cross-reactivity noted for the cyclodiene insecticides and TETS relative to the GABA-gated chloride channel (inhibition of TBPS binding) and the cyclodiene MAb does not extend to several TETS analogues including HEXS.(ABSTRACT TRUNCATED AT 250 WORDS)