Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations.

BACKGROUND: Pre-hospital tracheal intubation success and complication rates vary considerably among provider categories. The purpose of this study was to estimate the success and complication rates of pre-hospital tracheal intubation performed by physician anaesthetist or nurse anaesthetist pre-hospital critical care teams. METHODS: Data were prospectively collected from critical care teams staffed with a physician anaesthetist or a nurse anaesthetist according to the Utstein template for pre-hospital advanced airway management. The patients served by six ambulance helicopters and six rapid response vehicles in Denmark, Finland, Norway, and Sweden from May 2015 to November 2016 were included. RESULTS: The critical care teams attended to 32 007 patients; 2028 (6.3%) required pre-hospital tracheal intubation. The overall success rate of pre-hospital tracheal intubation was 98.7% with a median intubation time of 25 s and an on-scene time of 25 min. The majority (67.0%) of the patients' tracheas were intubated by providers who had performed >2500 tracheal intubations. The success rate of tracheal intubation on the first attempt was 84.5%, and 95.9% of intubations were completed after two attempts. Complications related to pre-hospital tracheal intubation were recorded in 10.9% of the patients. Intubations after rapid sequence induction had a higher success rate compared with intubations without rapid sequence induction (99.4% vs 98.1%; P=0.02). Physicians had a higher tracheal intubation success rate than nurses (99.0% vs 97.6%; P=0.03). CONCLUSIONS: When performed by experienced physician anaesthetists and nurse anaesthetists, pre-hospital tracheal intubation was completed rapidly with high success rates and a low incidence of complications. CLINICAL TRIAL NUMBER: NCT 02450071.

Rapid typing of neonatal Staphylococcus epidermidis isolates using polymerase chain reaction for repeat regions in surface protein genes.

Staphylococcus epidermidis is a significant pathogen in neonatal sepsis and other nosocomial infections. For further investigations of the colonisation patterns and invasive pathways, typing methods that are applicable on large populations of bacterial isolates are warranted. In the present study, a genotyping method based on polymerase chain reaction (PCR) for the repeat regions of four genes (sdrG, sdrF, aap and sesE) that encode for bacterial surface proteins was developed and applied to a sample of well-characterised neonatal blood isolates of S. epidermidis (n = 49). The PCR products were visualised on agarose gel (sdrG, sdrF and sesE) or by fragment analysis (aap). The discriminatory index (D-index) for genotyping of the different genes was compared to genotyping by pulsed-field gel electrophoresis (PFGE). The highest D-index for the PCR-based typing methods was found for the combination of sdrF, sdrG and aap (D-index 0.94), whereas the optimal two-gene combination (sdrF and aap) resulted in a D-index of 0.92. We conclude that the described method can be used for the genotyping of large populations of S. epidermidis isolates with a sufficient discriminatory capacity, and we suggest that the combination of sdrF and aap is the most suitable to use.

Carbohydrate specificity of the Escherichia coli P-pilus papG protein is mediated by its N-terminal part.

The adherence of pyelonephritic Escherichia coli isolates to mammalian host cells is mediated by the P-pili structures on the bacterial surface. The protein constituting the distal part of the pili structure, papG, interacts with glycan receptors on the host cell. Variation in specificity for different glycoconjugates between the isolates, that may reflect variation in host tropism, has been correlated to three different classes of papG. Truncated variants of the class I, II and III papG adhesins were produced as fusion protein in E. coli and analysed for carbohydrate binding. The results showed that both carbohydrate binding and specificity of the papG adhesin resided in a linear part of the N-terminus of the protein.

Molecular cloning and tissue expression of the murine analog to human stratum corneum chymotryptic enzyme.

Human stratum corneum chymotryptic enzyme (SCCE) may play a central part in epidermal homeostasis. Its proposed function is to catalyze the degradation of intercellular structures, including desmosomes, in the stratum corneum as part of the desquamation process. In order to facilitate physiologic and pathophysiologic studies on SCCE we have looked for the corresponding murine enzyme. A cDNA obtained by reverse transcription-polymerase chain reaction with total RNA prepared from mouse tails as starting material was cloned, and the expression of the corresponding mRNA studied. The murine cDNA showed 77% homology to human SCCE cDNA. It had an open-reading frame encoding a protein comprising 249 amino acids with 82% amino acid sequence homology to human SCCE including the conserved sequences of the catalytic traid of mammalian serine proteases. The murine protein was deduced to have a 21 amino acid signal peptide and a four amino acid propeptide ending with a tryptic cleavage site, followed by a sequence motif identical to the N-terminal amino acid sequence of native active human SCCE. As in human SCCE the P2 position of the propeptide was occupied by an acidic amino acid residue, and the position corresponding to the suggested bottom of the primary substrate specificity pouch occupied by an asparagine residue. Analyses of mouse tissues by reverse transcriptase-polymerase chain reaction showed high expression in the skin, low expression in lung, kidney, brain, heart, and spleen, and no expression in liver or skeletal muscle. In situ hybridization of mouse skin showed expression in high suprabasal keratinocytes and in the luminal parts of hair follicles. Our results strongly suggest that we have cloned the murine analog of human SCCE cDNA.

A series of wide-host-range low-copy-number vectors that allow direct screening for recombinants.

A series of controlled expression vectors was constructed based on the wide-host-range plasmid pMMB66EH. Some of these new vectors code for the alpha-peptide of beta-galactosidase and allow the direct screening of recombinant clones by inactivation of alpha-complementation. The bla gene was replaced in some plasmids by the cat gene of Tn9 coding for chloramphenicol resistance, extending the use into beta-lactam-resistant strains. They all feature either the tac or taclac (tac-lac UV5 in tandem) promoters in front of a polylinker followed by the rrnB transcriptional stop point. These vectors were tested by subcloning the xylE gene coding for the Pseudomonas putida catechol 2,3-oxygenase and the Escherichia coli lamB gene coding for the lambda receptor. The expression of these genes in E. coli indicated that the tac promoter is five times stronger than the taclac promoter and that both were tightly regulated. The tac promoter in Pseudomonas syringae pv glycinea and Xanthomonas campestris pv vesicatoria had a strength similar to that in E. coli, while the taclac promoter was much weaker, reaching only 6.5 and 3% of the level of expression of the tac promoter, respectively. The taclac promoter, however, proved to be useful for the cloning in E. coli of DNA fragments that were unstable in vectors with stronger promoters and higher copy number. Expression of the lamB gene in Vibrio cholerae strain TRH7000 was not sufficient to permit cosmid transduction. Two subunits of the E. coli mannose permease, coded by the ptsP and ptsM genes, are also required for cosmid DNA penetration into the recipient cells.

Characterization of the bone-resorptive effect of interleukin-11 in cultured mouse calvarial bones.

Interleukin-11 (IL-11) is a stromal cell-derived cytokine that can enhance osteoclast formation and stimulate bone resorption. In the present study, the characteristics of the resorptive effect of IL-11 in mouse calvarial bones were investigated. Both recombinant mouse IL-11 and human IL-11 caused concentration- and time-dependent stimulations of (45)Ca release from prelabeled mouse calvariae. Half-maximal responses were obtained at 0.7 ng/mL (approximately 40 pmol/L). Mouse and human IL-11 also stimulated release of (3)H from [(3)H]-proline-labeled bones. The magnitude of the (45)Ca and (3)H release (1.4-1.6-fold) caused by a maximally effective concentration of IL-11 was less than the stimulation (2.5-4.0-fold) elicited by a maximum concentration of parathyroid hormone (PTH). Release of (45)Ca by IL-11 was unaffected by the mitotic inhibitors, hydroxyurea and aphidicolin. In addition to resorption of bone, IL-11 caused a small (1.5-2.0-fold) enhancement of prostaglandin E(2) (PGE(2)) biosynthesis in calvariae, but had no effect on the mRNA expression of cyclooxygenase-1 and -2, or cytosolic phospholipase A(2). Indomethacin and flurbiprofen abolished the formation of PGE(2) and partially reduced (45)Ca release stimulated by IL-11. When either mouse interleukin-4 (IL-4) or interleukin-13 (IL-13) was added to calvariae treated with IL-11, (45)Ca release was inhibited. Resorption caused by IL-11 was also inhibited by both anti-mouse glycoprotein 130 (gp130) and an antibody neutralizing IL-11, but these agents had no effect on (45)Ca release caused by PTH or 1,25(OH)(2)vitamin D(3) (D(3)). Real-time, quantitative polymerase chain reaction (PCR) analysis (TaqMan PCR) and semiquantitative reverse transcription-polymerase chain reaction (RT-PCR) demonstrated that IL-11 caused concentration-dependent enhancements of receptor activator of nuclear factor-kappaB ligand (RANKL) and osteoprotegerin (OPG) mRNA, without affecting the mRNA expression of RANK. Mouse RANKL stimulated (45)Ca release in the calvarial bones. The stimulatory effects of RANKL and IL-11 were inhibited by mouse OPG. These data demonstrate that IL-11 stimulates osteoclastic resorption in mouse calvariae by mechanisms that are independent of cell proliferation; partially dependent on prostaglandin biosynthesis; sensitive to inhibition by IL-4, IL-13, and OPG; and associated with enhanced expression of RANKL and OPG. In addition, IL-11 was not found to play an essential role in resorption stimulated by other calciotropic agents in calvariae.

Genosubtyping by sequencing group A, B and C meningococci; a tool for epidemiological studies of epidemics, clusters and sporadic cases.

Genosubtyping, by sequencing variable regions (VRs) 1, 2 and 3 of the porA gene, was evaluated as a tool to detect clonality of isolates in meningococcal epidemics in Africa and clusters of disease in Sweden. All 63 examined meningococcal isolates were successfully genosubtyped. The isolates belonging to group A type 4 with genosubtype P1.20,9,35a showed little heterogeneity in African epidemics in 1988 and onwards. In Sweden, two meningococcal clones of group B type 15, with genosubtypes P1.7,16,35 and P1.7,16f,35, dominated during two clusters of meningococcal disease in 1995-96 and in sporadic cases thereafter. The characterisation of group C meningococci isolated during 1992 in Sweden indicated a cluster (type 2a with genosubtype P1.5a,10d,36b) connected with a discotheque visit. Two variants of VR2 (10p and 25b), not previously described, were found among the examined isolates. Nucleotide sequence analysis of VRs in the porA gene proved a valuable epidemiological tool since almost all isolates could be genosubtyped, in contrast to the phenotypic methods presently used.

Quantification of Bordetella pertussis in clinical samples by colorimetric detection of competitive PCR products.

Quantification of microorganisms is an important part of the normal diagnostic work of a clinical microbiology laboratory. Traditionally the diagnosis of pertussis is subject to a yes or no approach with no quantitative dimension. This can, however, be of interest as a factor when judging the risk of a patient spreading the bacterium and as a research tool. The aim of the present study was to develop a PCR-based quantitative assay for Bordetella pertussis DNA in clinical nasopharyngeal aspirates by combining a quantitative PCR with a colorimetric detection principle, DIANA (detection of immobilised amplified nucleic acid). A competitor to the PCR target sequence in IS-481, containing a lac-operator, was constructed and calibrated, and a test protocol prepared. A total of 46 clinical nasopharyngeal aspirates, previously diagnosed using a standard nested PCR assay and quantified by culture, were analysed by the quantitative PCR. The method showed acceptable precision and accuracy considering that it estimates the total number of bacterial genomes while culture detects viable bacteria. Recognised advantages were the simple colorimetric detection, the inborn indication of a working PCR assay, and the possibility of obtaining results even when partial inhibition of the PCR assay was seen. In addition, the quantitative PCR result can be obtained within one day compared to 3-10 days for culture. The present results and the qualities of the quantitative PCR suggest that this assay will be a useful complement in routine diagnostics and in research.

Osteitis after newborn vaccination with three different Bacillus Calmette-Guérin vaccines: twenty-nine years of experience.

Newborns in Finland have been vaccinated with Bacillus Calmette-Guérin (BCG) since the 1950s. Until the end of 1970 the vaccine was made from BCG strain Gothenburg by the Swedish BCG laboratory in Gothenburg and from 1971 on from the same strain in Copenhagen, Denmark. It was replaced by the Glaxo vaccine in 1978. Complications caused by BCG vaccination have been under follow-up, and the data have been collected from nationwide registers. In this study we analyzed the incidence rates of BCG osteitis between the years 1960 and 1988. From 1960 to 1970 the incidence rate was from 2.7 to 13.0/100,000 BCG-vaccinated infants (mean, 7.3; median, 6.9). The incidence increased during the years 1971 to 1978 when it varied between 15.3 and 72.9/100,000 BCG-vaccinated infants (mean, 36.9; median, 30.4). Since 1978 the incidence has varied between 1.7 and 10.1/100,000 BCG-vaccinated infants (mean, 6.4; median, 7.2). In Britain no reports of BCG osteitis have been published despite the use of the same Glaxo vaccine. Our results indicate that the incidence of BCG osteitis in a given population depends on the BCG vaccine used. The follow-up of BCG complications is an essential part of BCG vaccination program.

Hyperglycemia produced in mice by administration of acetazolamide and diphenylhydantoin.

Isolated mouse islets exposed to 3mM glucose released an increased amount of insulin in the presence of acetazolamide (AZM) (10 mM) and diphenylhydantoin (DPH) (0.35 or 3.5 mM), whereas insulin secretion due to 20 mM glucose was decreased in the presence of AZM (10 mM) and DPH (0.35, 0.70 or 3.5 mM). The serum insulin concentration was increased 1 h after AZM injection, but was not significantly altered 1 h after combined administration of AZM and DPH. A moderate transient hyperglycemia was found 1 and 2 h after DPH injection (100 mg/kg b.w.) in fed mice, and a slight, transient hyperglycemic response was observed 24 h after administration of AZM (1.5 g/kg b.w.) to fed mice. A steadily increasing, marked hyperglycemia was seen in both fed and starved mice when AZM was given shortly before or after DPH. All animals subjected to this kind of treatment died within 48 h after the injections. Ketones were found in urine and serum of the hyperglycemic animals, and the hyperglycemia was abolished and the survival of the animals was prolonged by insulin administration, suggesting that ketoacidosis contributed to the death. Light microscopy disclosed degeneration and necrosis of some B-cells, and occasionally insulitis after combined treatment with AZM and DPH. Pretreatment with AZM inhibited the hyperglycemic response to p-hydroxymercuribenzoate in fed mice, but did not affect the hyperglycemic response of fed mice to D-mannoheptulose. The findings indicate that AZM and DPH, when given to mice in combination and in sufficient amount, cause impaired B-cell function with an inhibited glucose-induced insulin release and a severe, fatal hyperglycemia. The B-cell changes are believed to be due to intracellular ionic alterations.

PCR assay or culture for diagnosis of Bordetella pertussis in the routine diagnostic laboratory?

A nested PCR method was compared with culture for the detection of Bordetella pertussis in a routine clinical diagnostic laboratory. A total of 241 clinical nasopharyngeal aspirates were examined in parallel in the laboratory. Both methods were positive for 75 samples (31%), eight samples were positive by nested PCR only (3.3%), and one sample was positive by culture only (0.4%). The mean time actually required in the clinical laboratory (not operating with pertussis diagnosis during weekends) from the day of arrival to the diagnosis of a positive or negative sample by the nested PCR assay was 1.8 +/- 1.3 days (mean +/- SD), for positive culture 4.5 +/- 1.4 days and for negative culture 10.5 +/- 1.0 days. The hands-on time in the laboratory to perform the nested PCR was 2 h, for a positive culture 25 min, and for a negative culture 15 min. The cost analysis of the methods, when running one sample at a time, showed that the laboratory cost for PCR was six times higher than culture. When running four samples together the cost for PCR was three times higher than culture. In conclusion, the nested PCR is the more rapid and sensitive method compared to culture. With the present design, the PCR-protocol involves higher material expenditure and claims more hands-on time.

Plant odor analysis of apple: antennal response of codling moth females to apple volatiles during phenological development.

Volatile compounds were collected from apple branches (Malus domestica) at different developmental stages, and the antennal response of codling moth females (Cydia pomonella) to these compounds was recorded by electroantennography coupled to gas chromatography. Presence of a range of terpenoid compounds, many of which had antennal activity, was characteristic for volatile collections from branches with leaves, and from small green apples. Nine compounds from branches with leaves and green fruit consistently elicited an antennal response: methyl salicylate, (E)-beta-farnesene, beta-caryophyllene, 4,8-dimethyl-1,3(E),7-nonatriene, (Z)3-hexenol, (Z,E)-alpha-farnesene, linalool, germacrene D, and (E,E)-alpha-farnesene. The bouquet emitted from flowering branches contained in addition several benzenoid compounds which were not found after bloom. Small green apples, which are the main target of codling moth oviposition during the first seasonal flight period, released very few esters. In comparison, fully grown apples released a large number of esters, but fewer terpenoids. The study of apple volatiles eliciting an antennal response, together with a survey of the seasonal change in the release of these compounds, is the first step toward the identification of volatiles mediating host-finding and oviposition in codling moth females.

Health survey of professional drivers.

A cross-sectional health survey comprising 633 male drivers showed that the frequencies of some complaints, for instance, pain in the shoulders and in the back of the neck, increased in older age groups. The frequencies of elevated blood pressure and electrocardiographic findings, on the other hand, tended to decrease among the older drivers. The percentage of drivers who had met with some kind of accident decreased among drivers aged 45-54 years. It was assumed that the results point toward health-based selection. The rate of turnover and its causes were studied in a cohort of 1,597 drivers. The results of the turnover study supported the findings of the health survey.

Turnover of professional drivers.

The aspects of turnover were studied in a cohort of 1,597 male drivers who had joined the trade union between 1967 and 1969 and who lived in six urban municipalities in different parts of the country. The retrospective study comprised the period from 1969 to 1979. At the end of this period, 1.5% of the cohort could not be traced, 3% were living abroad, and 5% were dead. An inquiry concerning occupation since 1969 was sent to 1,453 drivers (91% of the cohort). In all, 1,156 drivers responded (80%). A total of 69% of the subjects who answered the questions was still employed as drivers in 1979, 24% had turned to some other trade, 7% had retired, and less than 1% reported that they were out of work. The changes within the trade favored bus driving. The most common reasons for changing work were salary, the heaviness and irregularity of the work, and health. The major cause of death was accidents and other external causes, as could be expected in view of the drivers' comparatively young age in 1969 (mean age 29 years).

A health survey of granite workers in Finland: radiographic findings, respiratory function, hearing, electric sensory thresholds of the fingers and subjective symptoms.

Results from a health survey of 777 granite workers, exposed to quartz dust, noise and/or machine vibration, and 122 unexposed "controls" are reported. The survey included chest X-rays, pulmonary function tests, a hearing examination, the determination of the electric sensory thresholds of the fingers, and questionnaires on the subjective symptoms of the respiratory system and upper limbs. The exposed workers' radiographic findings (except for a 2.6 % rate of silicosis), respiratory functions, and sensory thresholds did not differ significantly from those of the controls. Granite drillers had a high prevalence of hearing defects. Respiratory symptoms were common among drillers and sandblasters, and subjective symptoms of the upper limbs due to vibration occurred among the granite dressing workers who used pneumatic hammers. Both primary and secondary measures of prevention are strongly recommended for the granite industry, primarlily for quartz dust exposure and its health effects.

Mortality, disability and changes in occupation among aging municipal employees.

During a four-year follow-up period the indicators of work load, individual factors, and stress reactions predicting mortality, disability, and change of occupation were studied. In 1981, 6257 active workers aged 44-58 years answered a questionnaire. The study was repeated in 1985 when 1% of the subjects had died, 9% had become disabled, and 5% had changed their occupation. These changes had occurred the most often in occupations which included muscular work, poor work postures, and a poor physical environment. The highest mortality rate was observed for the male installation and auxiliary workers who had reported the presence of cardiovascular, but no musculoskeletal, disease four years earlier. The highest disability rate was well predicted by a poor index of work ability. Major diseases leading to disability included malignant tumor, coronary artery disease, congestive heart failure, rheumatoid arthritis, bronchitis or bronchial asthma, and mental disease. Work-related stress reactions were associated with both mortality and disability.

Wegener's granulomatosis in childhood. A clinical report based on 3 cases.

Wegener's granulomatosis is a very rare disease in children; only 10 cases have been reported in the literature. The present report describes 3 cases where Wegener's granulomatosis developed at an early stage, beginning with upper respiratory tract symptoms. All the 3 children have been successfully treated with a combination of azathioprine and corticosteroids.

Cytotoxic leukocyte reaction.

Blood samples from 49 subjects were submitted to cytotoxic leukocyte tests, which were read double-blind by two laboratory technicians. The results were identical in 78% of the tests and the statistical error of the method was 0.46. In a group of 32 subjects, the cytotoxic test was repeated on 3 consecutive days. Deviations in the results occurred in 18--20% of the tests, the statistical errors varying between 0.38 and 0.43. In a series of serum samples (75 subjects) with positive leukocyte reactions to food antigens, various in vitro procedures were carried out in connection with the cytotoxic test. The following observations were made: In 42 of 58 tests, a positive leukocyte reaction was transferred with the reactive serum to cells from non-reactive subjects. After heating of the reactive serum (56 degrees C, 2 h) and washing of the cells, reactivity was no longer observable in 44 out of 52 tests. Treatment with EDTA consistently blocked expected cytotoxic reactions in 36 tests. DSCG inhibited expected reactions in 45%, antihistamine in 93%, and cortisone in 20% of the tests.

Volatiles from apple (Malus domestica) eliciting antennal responses in female codling moth Cydia pomonella (L.) (Lepidoptera: Tortricidae): effect of plant injury and sampling technique.

The antennal responses of codling moth females, Cydia pomonella, to volatiles from apple branches with green fruits were recorded by electroantennography coupled to gas chromatography. The antennae strongly responded to 4,8-dimethyl-1,3(E),7-nonatriene, linalool, beta-caryophyllene, (E)-beta-farnesene, germacrene D, (Z,E)-alpha-farnesene, (E,E)-alpha-farnesene and methyl salicylate. These compounds were all present in volatile collections on Porapak Q from both living and cut branches. Analysis by the solid phase microextraction technique (SPME) showed that the emission of some electrophysiologically active compounds increased after branches had been cut, especially 4,8-dimethyl-1,3(E),7-nonatriene, linalool and (E,E)-alpha-farnesene. The identification of apple volatiles eliciting antennal responses is the first step towards the identification of compounds mediating host-finding and oviposition in codling moth females.

Marketers don't wear plaid: marketing and health care administration in the Canadian context.

Marketing has a bad reputation among Canadian health managers, even though marketing solutions may address many of their problems. This article provides an overview of current understandings of marketing and how they may be applied to health care situations. Marketing should be considered an ongoing process. This is particularly helpful if we understand the root task of health managers as creating and promoting exchanges--with governments, physicians, nurses, other health workers and client groups. Exchanges that are desirable to the health care community will more likely occur if the true costs and benefits of health services are analyzed, understood and imaginatively communicated. The public constantly evaluates the health system. Constant evaluation implies a need for marketing directed internally at staff and those within the health system, and externally at constituents outside the system. Properly understood and practiced, marketing can be part of the innovative solutions health care managers develop and apply as they deal with the difficult challenges facing them in Canada's current health care environment.