Estimating the changing burden of disease attributable to alcohol use in South Africa for 2000, 2006 and 2012.

BACKGROUND: Alcohol use was one of the leading contributors to South Africa (SA)'s disease burden in 2000, accounting for 7% of deaths and disability-adjusted life years (DALYs) in the first South African Comparative Risk Assessment Study (SACRA1). Since then, patterns of alcohol use have changed, as has the epidemiological evidence pertaining to the role of alcohol as a risk factor for infectious diseases, most notably HIV/AIDS and tuberculosis (TB). OBJECTIVES: To estimate the burden of disease attributable to alcohol use by sex and age group in SA in 2000, 2006 and 2012. METHODS: The analysis follows the World Health Organization (WHO)'s comparative risk assessment methodology. Population attributable fractions (PAFs) were calculated from modelled exposure estimated from a systematic assessment and synthesis of 17 nationally representative surveys and relative risks based on the global review by the International Model of Alcohol Harms and Policies. PAFs were applied to the burden of disease estimates from the revised second South African National Burden of Disease Study (SANBD2) to calculate the alcohol-attributable burden for deaths and DALYs for 2000, 2006 and 2012. We quantified the uncertainty by observing the posterior distribution of the estimated prevalence of drinkers and mean use among adult drinkers (≥15 years old) in a Bayesian model. We assumed no uncertainty in the outcome measures. RESULTS: The alcohol-attributable disease burden decreased from 2000 to 2012 after peaking in 2006, owing to shifts in the disease burden, particularly infectious disease and injuries, and changes in drinking patterns. In 2012, alcohol-attributable harm accounted for an estimated 7.1% (95% uncertainty interval (UI) 6.6 - 7.6) of all deaths and 5.6% (95% UI 5.3 - 6.0) of all DALYs. Attributable deaths were split three ways fairly evenly across major disease categories: infectious diseases (36.4%), non-communicable diseases (32.4%) and injuries (31.2%). Top rankings for alcohol-attributable DALYs for specific causes were TB (22.6%), HIV/AIDS (16.0%), road traffic injuries (15.9%), interpersonal violence (12.8%), cardiovascular disease (11.1%), cancer and cirrhosis (both 4%). Alcohol remains an important contributor to the overall disease burden, ranking fifth in terms of deaths and DALYs. CONCLUSION: Although reducing overall alcohol use will decrease the burden of disease at a societal level, alcohol harm reduction strategies in SA should prioritise evidence-based interventions to change drinking patterns. Frequent heavy episodic (i.e. binge) drinking accounts for the unusually large share of injuries and infectious diseases in the alcohol-attributable burden of disease profile. Interventions should focus on the distal causes of heavy drinking by focusing on strategies recommended by the WHO's SAFER initiative.

PDGFRß promotes oncogenic progression via STAT3/STAT5 hyperactivation in anaplastic large cell lymphoma.

BACKGROUND: Anaplastic large cell lymphoma (ALCL) is an aggressive non-Hodgkin T cell lymphoma commonly driven by NPM-ALK. AP-1 transcription factors, cJUN and JUNb, act as downstream effectors of NPM-ALK and transcriptionally regulate PDGFRß. Blocking PDGFRß kinase activity with imatinib effectively reduces tumor burden and prolongs survival, although the downstream molecular mechanisms remain elusive. METHODS AND RESULTS: In a transgenic mouse model that mimics PDGFRß-driven human ALCL in vivo, we identify PDGFRß as a driver of aggressive tumor growth. Mechanistically, PDGFRß induces the pro-survival factor Bcl-xL and the growth-enhancing cytokine IL-10 via STAT5 activation. CRISPR/Cas9 deletion of both STAT5 gene products, STAT5A and STAT5B, results in the significant impairment of cell viability compared to deletion of STAT5A, STAT5B or STAT3 alone. Moreover, combined blockade of STAT3/5 activity with a selective SH2 domain inhibitor, AC-4-130, effectively obstructs tumor development in vivo. CONCLUSIONS: We therefore propose PDGFRß as a novel biomarker and introduce PDGFRß-STAT3/5 signaling as an important axis in aggressive ALCL. Furthermore, we suggest that inhibition of PDGFRß or STAT3/5 improve existing therapies for both previously untreated and relapsed/refractory ALK+ ALCL patients.

A tissue-bioengineering strategy for modeling rare human kidney diseases in vivo.

The lack of animal models for some human diseases precludes our understanding of disease mechanisms and our ability to test prospective therapies in vivo. Generation of kidney organoids from Tuberous Sclerosis Complex (TSC) patient-derived-hiPSCs allows us to recapitulate a rare kidney tumor called angiomyolipoma (AML). Organoids derived from TSC2-/- hiPSCs but not from isogenic TSC2+/- or TSC2+/+ hiPSCs share a common transcriptional signature and a myomelanocytic cell phenotype with kidney AMLs, and develop epithelial cysts, replicating two major TSC-associated kidney lesions driven by genetic mechanisms that cannot be consistently recapitulated with transgenic mice. Transplantation of multiple TSC2-/- renal organoids into the kidneys of immunodeficient rats allows us to model AML in vivo for the study of tumor mechanisms, and to test the efficacy of rapamycin-loaded nanoparticles as an approach to rapidly ablate AMLs. Collectively, our experimental approaches represent an innovative and scalable tissue-bioengineering strategy for modeling rare kidney disease in vivo.

Traumatic events and psychotic experiences: a nationally representative study in Thailand.

AIMS: Most research exploring the link between traumatic events and psychotic experiences has focused on either Australia, Europe or North America. In this study, we expand the existing knowledge to Thailand and investigate the impact of the type and the number of traumatic events on psychotic experiences in Thailand. METHODS: We used data from the nationally representative 2013 Thai National Mental Health Survey (TNMHS), including questions on traumatic events and psychotic experiences. We regressed the lifetime experience of hallucinations or delusions against the following independent variables: the experience of any traumatic event during lifetime (dichotomous; hypothesis 1); the experience of either no traumatic event, one interpersonal, one unintentional or both interpersonal and unintentional traumatic events (categorical; hypothesis 2) and the number of traumatic events experienced during lifetime (categorical; hypothesis 3). We adjusted the regression models for sociodemographic indicators and psychiatric disorders, and considered survey weights. RESULTS: About 6% (95% confidence interval: 4.9-7.0) of the respondents stated that they had either hallucinatory or delusional experiences during their lifetime. The risk of reporting such experiences was more than doubled as high among respondents who had experienced at least one traumatic event during their lifetime than among those who had not yet experienced one, with higher risks for interpersonal or multiple traumatic events. Our results further indicated an increase in the risk of psychotic experiences as the number of traumatic events increased, with up to an eight-fold higher risk for people exposed to five or more traumatic events in their lifetime, compared to those with no traumatic events. CONCLUSIONS: Individuals reporting interpersonal or multiple traumatic events face much higher risk of psychotic experiences. Effective and widely accessible secondary prevention programmes for people having experienced interpersonal or multiple traumatic events constitute a key intervention option.

A sensitive and specific assay for the serological diagnosis of antilaminin 332 mucous membrane pemphigoid.

BACKGROUND: Antilaminin 332 mucous membrane pemphigoid (MMP) is an autoimmune subepidermal blistering disease with predominant mucosal involvement and autoantibodies against laminin 332. Malignancies have been associated with this disease; however, no standardized detection system for antilaminin 332 serum antibodies is widely available. OBJECTIVES: Development of a sensitive and specific assay for the detection of antilaminin 332 antibodies. METHODS: An indirect immunofluorescence (IF) assay using recombinant laminin 332 was developed and probed with a large number of antilaminin 332 MMP patient sera (n = 93), as well as sera from patients with antilaminin 332-negative MMP (n = 153), bullous pemphigoid (n = 20), pemphigus vulgaris (n = 20) and noninflammatory dermatoses (n = 22), and healthy blood donors (n = 100). RESULTS: In the novel IF assay, sensitivities with the laminin 332 heterotrimer and the individual α3, ß3 and γ2 chains were 77%, 43%, 41% and 13%, respectively, with specificities of 100% for each substrate. The sensitivity for the heterotrimer increased when an anti-IgG4 enriched antitotal IgG conjugate was applied. Antilaminin 332 reactivity paralleled disease activity and was associated with malignancies in 25% of patients with antilaminin 332 MMP. CONCLUSIONS: The novel IF-based assay will facilitate the serological diagnosis of antilaminin 332 MMP and may help to identify patients at risk of a malignancy.

Identification of the flotillin-1/2 heterocomplex as a target of autoantibodies in bona fide multiple sclerosis.

BACKGROUND: Autoantibodies, in particular those against aquaporin-4 and myelin-oligodendrocyte glycoprotein (MOG), aid as biomarkers in the differential diagnosis of demyelination. Here, we report on discovery of autoantibodies against flotillin in patients with multiple sclerosis (MS). METHODS: The target antigen was identified by histo-immunoprecipitation using the patients' sera and cryosections of rat or pig cerebellum combined with mass spectrometrical analysis. Correct identification was ascertained by indirect immunofluorescence and neutralization tests using the target antigens recombinantly expressed in HEK293 cells. RESULTS: Serum and CSF of the index patient produced a fine-granular IgG indirect immunofluorescence staining of the hippocampal and cerebellar molecular layers. Flotillin-1 and flotillin-2 were identified as target autoantigens. They also reacted with recombinant human flotillin-1/2 co-expressed in HEK293 cells, but not with the individual flotillins in fixed- and live-cell assays. Moreover, neutralization using flotillin-1/2, but not the single flotillins, abolished the tissue reactivity of patient serum. Screening of 521 patients, for whom anti-aquaporin-4 testing was requested and negative, revealed 8 additional patients with anti-flotillin-1/2 autoantibodies. All eight were negative for anti-MOG. Six patients ex post fulfilled the revised McDonald criteria for MS. Vice versa, screening of 538 MS sera revealed anti-flotillin-1/2 autoantibodies in eight patients. The autoantibodies were not found in a cohort of 67 patients with other neural autoantibody-associated syndromes and in 444 healthy blood donors. CONCLUSIONS: Autoantibodies against the flotillin-1/2 heterocomplex, a peripheral membrane protein that is involved in axon outgrowth and regeneration of the optic nerve, are present in 1-2% of patients with bona fide MS.

Injuries to the upper extremities in polytrauma: limited effect on outcome more than ten years after injury - a cohort study in 629 patients.

AIMS: To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients. PATIENTS AND METHODS: A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients' injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion. RESULTS: In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC. CONCLUSION: Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255-60.

Utilizing a Human Factors Nursing Worksystem Improvement Framework to Increase Nurses' Time at the Bedside and Enhance Safety.

OBJECTIVE: The aim of this study is to increase nurses' time for direct patient care and improve safety via a novel human factors framework for nursing worksystem improvement. BACKGROUND: Time available for direct patient care influences outcomes, yet worksystem barriers prevent nurses adequate time at the bedside. METHODS: A novel human factors framework was developed for worksystem improvement in 3 units at 2 facilities. Objectives included improving nurse efficiency as measured by time-and-motion studies, reducing missing medications and subsequent trips to medication rooms and improving medication safety. RESULTS: Worksystem improvement resulted in time savings of 16% to 32% per nurse per 12-hour shift. Requests for missing medications dropped from 3.2 to 1.3 per day. Nurse medication room trips were reduced by 30% and nurse-reported medication errors fell from a range of 1.2 to 0.8 and 6.3 to 4.0 per month. CONCLUSIONS: An innovative human factors framework for nursing worksystem improvement provided practical and high priority targets for interventions that significantly improved the nursing worksystem.

THE EFFECT OF AN OPTIMIZED IMAGING FLOW CYTOMETRY ANALYSIS TEMPLATE ON SAMPLE THROUGHPUT IN THE REDUCED CULTURE CYTOKINESIS-BLOCK MICRONUCLEUS ASSAY.

In cases of overexposure to ionizing radiation, the cytokinesis-block micronucleus (CBMN) assay can be performed in order to estimate the dose of radiation to an exposed individual. However, in the event of a large-scale radiation accident with many potentially exposed casualties, the assay must be able to generate accurate dose estimates to within ±0.5 Gy as quickly as possible. The assay has been adapted to, validated and optimized on the ImageStreamX imaging flow cytometer. The ease of running this automated version of the CBMN assay allowed investigation into the accuracy of dose estimates after reducing the volume of whole blood cultured to 200 µl and reducing the culture time to 48 h. The data analysis template used to identify binucleated lymphocyte cells (BNCs) and micronuclei (MN) has since been optimized to improve the sensitivity and specificity of BNC and MN detection. This paper presents a re-analysis of existing data using this optimized analysis template to demonstrate that dose estimations from blinded samples can be obtained to the same level of accuracy in a shorter data collection time. Here, we show that dose estimates from blinded samples were obtained to within ±0.5 Gy of the delivered dose when data collection time was reduced by 30 min at standard culture conditions and by 15 min at reduced culture conditions. Reducing data collection time while retaining the same level of accuracy in our imaging flow cytometry-based version of the CBMN assay results in higher throughput and further increases the relevancy of the CBMN assay as a radiation biodosimeter.

Optimized automated data analysis for the cytokinesis-block micronucleus assay using imaging flow cytometry for high throughput radiation biodosimetry.

The cytokinesis-block micronucleus (CBMN) assay is a well-established technique that can be employed in triage radiation biodosimetry to estimate whole body doses of radiation to potentially exposed individuals through quantitation of the frequency of micronuclei (MN) in binucleated lymphocyte cells (BNCs). The assay has been partially automated using traditional microscope-based methods and most recently has been modified for application on the ImageStream(X) (IS(X) ) imaging flow cytometer. This modification has allowed for a similar number of BNCs to be automatically scored as compared to traditional microscopy in a much shorter time period. However, the MN frequency measured was much lower than both manual and automated slide-based methods of performing the assay. This work describes the optimized analysis template which implements newly developed functions in the IDEAS(®) data analysis software for the IS(X) that enhances specificity for BNCs and increases the frequency of scored MN. A new dose response calibration curve is presented in which the average rate of MN per BNC is of similar magnitude to those presented in the literature using automated CBMN slide scoring methods. In addition, dose estimates were generated for nine irradiated, blinded samples and were found to be within ±0.5 Gy of the delivered dose. Results demonstrate that the improved identification accuracy for MN and BNCs in the IS(X) -based version of the CBMN assay will translate to increased accuracy when estimating unknown radiation doses received by exposed individuals following large-scale radiological or nuclear emergencies. © 2016 The Authors. Cytometry Part A published by Wiley Periodicals, Inc. on behalf of ISAC.

[Pain assessment of severely injured patients 2 years after trauma]. / Bestandsaufnahme der Schmerzsituation von Schwerstverletzten zwei Jahre nach Trauma.

BACKGROUND AND OBJECTIVES: Trauma patients often suffer from persisting pain even years after injury, and data on long-term pain management is lacking. The aim of this study was to evaluate the frequency of persisting pain and health-related quality of life (HrQoL) among trauma victims 2 years after injury. Furthermore, the frequency of pain specialist consultation and the quality of outpatient pain management, including phamacological management, was assessed. MATERIALS AND METHODS: We analyzed prospectively collected data on severely injured adult patients treated between 2008-2011 at the Cologne Merheim Medical Center (CMMC)/Germany.  Data included the 'Polytrauma Outcome Profile' and a standardized questionnaire on outpatient pain management. Exclusion criteria were death, inability to answer the questionnaire due to cognitive disabilities and lack of language knowledge. RESULTS AND CONCLUSIONS: 207/391 (53 %) data sets were available for analysis, presenting a typical trauma collective with injury severity of ISS 19, predominantly male and a mean age of 44 years. 2 years after trauma 59 % still reported that they suffered from severe persisting pain; 53 % of these patients were under pharmacological pain medication. Only 1/5 of the patients with severe persisting pain was treated by a pain specialist. Successful treatment options do exist; improvement of treatment is required.

[Current standard of care for initial management of open fractures in emergency departments : A nationwide survey in German trauma centers]. / Realität initialer Versorgung offener Frakturen in deutschen Notaufnahmen : Eine Umfrage aus der Sektion NIS der DGU.

BACKGROUND: Limiting the morbidity of open fractures requires highly specific initial treatment. In addition to a stringent surgical strategy, correct antibiotic prophylaxis seems to be associated with an improved outcome. In the current literature, the duration and type of antibiotic prophylaxis are under discussion. The aim of the study was to survey the current initial treatment regimes for open fractures in German emergency departments. MATERIAL AND METHODS: With an online-based anonymous 16-item questionnaire all 3006 members of the German Trauma Society were surveyed. A total of 585 questionnaires (19.5 %) were returned completed. This article presents a descriptive analysis of the current state of treatment. RESULTS: Mainly specialists (35 %), senior physicians (30 %) and chief physicians (17 %) answered as well as interns (8 %) and out-patient practitioners (10 %). Of the participants 65 % did not accept the classification of emergency services; however, 93 % carried out urgent or emergency surgery, 84 % started an antibiotic prophylaxis in the emergency department and 63 % used a standard operating procedure (SOP). A total of 60 % used 1 antibiotic drug, 25 % used 2 and 15 % used 3 or more substances. An antibiotic treatment for more than 3 days was performed by 60 % of participants. CONCLUSION: The early initiation of antibiotic prophylaxis seems to be the standard practice in German emergency departments as well as early surgery. Strategies to improve the communication between prehospital and in-hospital teams, as well as graded antibiotic prophylaxis depending on the severity of soft tissue damage are needed.

Human factors engineering approaches to patient identification armband design.

The task of patient identification is performed many times each day by nurses and other members of the care team. Armbands are used for both direct verification and barcode scanning during patient identification. Armbands and information layout are critical to reducing patient identification errors and dangerous workarounds. We report the effort at two large, integrated healthcare systems that employed human factors engineering approaches to the information layout design of new patient identification armbands. The different methods used illustrate potential pathways to obtain standardized armbands across healthcare systems that incorporate human factors principles. By extension, how the designs have been adopted provides examples of how to incorporate human factors engineering into key clinical processes.

[P.A.R.T.Y. An initiative for more risk awareness among young road users]. / P.A.R.T.Y. Eine Initiative für mehr Risikobewusstsein bei Jugendlichen.

BACKGROUND AND OBJECTIVES: Accident prevention strategies aim to inform young people about risk-taking behavior and the consequences of trauma. The Prevent Alcohol and Risk-related Trauma in Youth (P.A.R.T.Y.) program is an accident prevention program that focuses on the prevention of road traffic accidents among young road users. Initial results of the program were evaluated to find out if the implementation of this prevention program is feasible in Germany. MATERIAL AND METHODS: During a 1-day interactive course young road users were introduced to the work carried out in an accident trauma unit and were informed about injury mechanisms and about the consequences of trauma. A systematic evaluation was made by all participants. The results were analyzed to find out whether it is possible to implement the program and the impressions gained by the participants of the program in order to be able to make further adjustments. RESULTS: A total of 219 young road users participated in the P.A.R.T.Y. program between 2011 and 2013. All participants reviewed the structure of the program with the help of school grades. Of the participants 59 % (n = 129) rated the program as "very good" and 41 % gave the rating of "good". Overall, 70 % of all participants advocated that all people of the same age should participate in the program. The structure was described as being well-balanced with respect to the theoretical and practical stations. CONCLUSION: The P.A.R.T.Y. program is a standardized and well-established concept that can also contribute to accident prevention in Germany. It provides the possibility to implement an accident awareness program throughout Germany. Initial results show that the program can be implemented in German hospitals and that the program appeals to the target group of young road users.

Patterns of early resuscitation associated with mortality after penetrating injuries.

BACKGROUND: Penetrating injuries are rare in European populations so their management represents a particular challenge. The aim was to assess early therapeutic aspects that are associated with favourable outcomes in patients with penetrating trauma. METHODS: Patients with penetrating injuries documented from 2009 to 2013 in the TraumaRegister DGU® were analysed. Patients with a primary admission and an Injury Severity Score (ISS) of at least 9 were included. The Revised Injury Severity Classification (RISC) II score was used for mortality prediction, and a standardized mortality ratio (SMR) calculated per hospital. Hospitals with favourable outcome (SMR below 1) were compared with those with poor outcome (SMR 1 or more). RESULTS: A total of 50 centres had favourable outcome (1242 patients; observed mortality rate 15.7 per cent) and 34 centres had poor outcome (918 patients; observed mortality rate 24.4 per cent). Predicted mortality rates according to RISC-II were 20.4 and 20.5 per cent respectively. Mean(s.d.) ISS values were 22(14) versus 21(14) (P = 0.121). Patients in the favourable outcome group had a significantly shorter time before admission to hospital and a lower intubation rate. They received smaller quantities of intravenous fluids on admission to the emergency room, but larger amounts of fresh frozen plasma, and were more likely to receive haemostatic agents. A higher proportion of patients in the favourable outcome group were treated in a level I trauma centre. Independent risk factors for hospital death following penetrating trauma identified by multivariable analysis included gunshot injury mechanism and treatment in non-level I centres. CONCLUSION: Among penetrating traumas, gunshot injuries pose an independent risk of death. Treatment of penetrating trauma in a level I trauma centre was significantly and independently associated with lower hospital mortality.

[Bilateral carotid artery dissection in a kite surfer by strangulation with the kite lines]. / Bilaterale Karotisdissektion eines Kitesurfers durch Strangulation mit Kiteleinen.

While a kite surfer was preparing the kite it was caught by a gust of wind, which blew it 10 m into the air and the cords became entangled around the neck of the kite surfer causing strangulation. After admittance to hospital, the diagnostics revealed multiple injuries including a bilateral dissection of the internal carotid arteries, cerebral edema and multiple fractures. As kitesurfing is gaining popularity severe injuries are becoming more frequent. Safety precautions, such as preparing the kite with two persons, wearing safety equipment and using bars with a safety leash can prevent severe injuries.

[Current practice in coagulation and transfusion therapy in multiple trauma patients: A German nation-wide online survey]. / Stand der Gerinnungs- und Transfusionstherapie beim Schwerverletzten : Eine deutschlandweite Online-Umfrage.

BACKGROUND: In recent years, the treatment of trauma-associated coagulopathy and bleeding has advanced enormously. The aim of this study was to assess the current practice of coagulation and transfusion management in Germany. PATIENTS AND METHODS: From October 2011 until January 2012 we conducted a survey via online-questionnaire that was sent per E-Mail to all members of the German Society for Trauma Surgery. It comprised 12 questions with respect to current treatment of coagulopathy and haemorrhage in trauma patients. RESULTS: The response rate was 145/3006 (5 %). The respondents had following specialties: 77.2 % trauma surgery 15.9 % anesthesiology, 6.9 % others. 64 % of respondents were employed by a Level 1 trauma centre, wheras 17 % worked in a local level 3 centre. The majority (94 %) claimed to treat hypothermia regularly. Only about half of the participants reported to follow a massive transfusion protocol in their institution. The potential components of these protocols were reported in varying rates, being it well-established components (e.g. FFP 78 %; Fibrinogen 75 %) or therapies with poor evidence in multiple trauma (Desmopressin 39 %, rFVIIa 47 %). Calcium was provided by only 48 % of respondents although generally recommended in all guidelines. CONCLUSION: The current study suggests that in Germany strategies and principles regarding management of trauma-associated coagulopathy are standardized only poorly. Level 1 centres appear to apply a more advanced approach, however to much variability exists with respect to the components of the transfusion protocols. The low response rate indicates that most German trauma surgeons consider coagulation and hemorrhage as "expert-topics" beyond their field of duty.

Why German farmers have their animals vaccinated against Bluetongue virus serotype 8: results of a questionnaire survey.

In response to the Bluetongue disease epidemic in 2006-2007, Germany started in 2008 a country-wide mandatory vaccination campaign. By 2009 the number of new outbreaks had decreased so that vaccination became voluntary in 2010. We conducted a questionnaire survey in cattle and sheep farms in three German federal states, namely North-Rhine Westphalia, Rhineland Palatinate and Saxony-Anhalt to estimate the vaccination uptake in 2010, the intention to vaccinate in 2011 and the main determinants of refusal or acceptance to do so. The results showed that 42.8% (40.6-45.1) of the cattle farmers and 33.8% (31.8-35.8) of the sheep farmers had their animals vaccinated in 2010, whereas 40.7% (38.5-43.0) of cattle and 37.93% (35.8-40.1) sheep farmers expressed their intention to vaccinate in 2011. The main reasons mentioned for having animals vaccinated against BTV-8 were ability to export animals, prevention of production losses, subsidized vaccination, and recommendation by the veterinarian. Motives for refusing vaccination were presumed low risk of infection, costs, absence of clinical BT symptoms, presumed negative cost-benefit ratio, and negative experience with previous vaccination events (side effects). We assume that in order to increase farmers' motivation to have their animals immunized against BTV-8, (1) the vaccination needs to be subsidized, (2) combined vaccines with several different BT serotypes or even other diseases should be available and (3) farmers need to be better informed about the safety and benefit of vaccination.

The ATLS(®) classification of hypovolaemic shock: a well established teaching tool on the edge?

Uncontrolled bleeding is the leading cause of shock in trauma patients and delays in recognition and treatment have been linked to adverse outcomes. For prompt detection and management of hypovolaemic shock, ATLS(®) suggests four shock classes based upon vital signs and an estimated blood loss in percent. Although this classification has been widely implemented over the past decades, there is still no clear prospective evidence to fully support this classification. In contrast, it has recently been shown that this classification may be associated with substantial deficits. A retrospective analysis of data derived from the TraumaRegister DGU(®) indicated that only 9.3% of all trauma patients could be allocated into one of the ATLS(®) shock classes when a combination of the three vital signs heart rate, systolic blood pressure and Glasgow Coma Scale was assessed. Consequently, more than 90% of all trauma patients could not be classified according to the ATLS(®) classification of hypovolaemic shock. Further analyses including also data from the UK-based TARN registry suggested that ATLS(®) may overestimate the degree of tachycardia associated with hypotension and underestimate mental disability in the presence of hypovolaemic shock. This finding was independent from pre-hospital treatment as well as from the presence or absence of a severe traumatic brain injury. Interestingly, even the underlying trauma mechanism (blunt or penetrating) had no influence on the number of patients who could be allocated adequately. Considering these potential deficits associated with the ATLS(®) classification of hypovolaemic shock, an online survey among 383 European ATLS(®) course instructors and directors was performed to assess the actual appreciation and confidence in this tool during daily clinical trauma care. Interestingly, less than half (48%) of all respondents declared that they would assess a potential circulatory depletion within the primary survey according to the ATLS(®) classification of hypovolaemic shock. Based on these observations, a critical reappraisal of the current ATLS(®) classification of hypovolaemic seems warranted.

Diversity of aflatoxin-producing fungi and their impact on food safety in sub-Saharan Africa.

Crops frequently contaminated by aflatoxins are important sources of revenue and daily nourishment in many portions of sub-Saharan Africa. In recent years, reports have associated aflatoxins with diminished human health and export opportunities in many African Nations. Aflatoxins are highly carcinogenic metabolites mainly produced by members of Aspergillus sect. Flavi. The current study examined aflatoxin-producing fungi associated with maize grain intended for human consumption in 18 sub-Saharan African countries. 4469 Aspergillus sect. Flavi isolates were obtained from 339 samples. The majority (75%) of isolates belonged to the L strain morphotype of A. flavus. Minor percentages were A. tamarii (6%), A. parasiticus (1%), and isolates with S strain morphology (3%). No A. bombycis or A. nomius isolates were detected. Phylogenetic analyses of partial sequences of the nitrate reductase gene (niaD, 1.3kb) and the aflatoxin pathway transcription factor gene (aflR, 1.7kb) were used to verify isolate assignments into species and lineages. Phylogenetics resolved S strain isolates producing only B aflatoxins into two lineages fully supported by sizes of deletions in the gene region spanning the aflatoxin biosynthesis genes cypA (aflU) and norB (aflF). One lineage was the A. flavus S strain with either 0.9 or 1.5kb deletions. The second lineage, recently described from Kenya, has a 2.2kb deletion. Taxa with S strain morphology differed in distribution with strain SBG limited to West Africa and both A. minisclerotigenes and the new lineage from Kenya in Central and East Africa. African A. flavus L strain isolates formed a single clade with L strain isolates from other continents. The sampled maize frequently tested positive for aflatoxins (65%), fumonisins (81%), and deoxynivalenol (40%) indicating the presence of fungi capable of producing the respective toxins. Percentage of samples exceeding US limits for total aflatoxins (regulatory limit), fumonisins (advisory limit), and deoxynivalenol (advisory limit) were 47%, 49%, 4%, respectively.