Health status and health care utilization after discharge from geriatric in-hospital stay - description of a register-based study.

BACKGROUND: This study is the first part of a register-based research program with the overall aim to increase the knowledge of the health status among geriatric patients and to identify risk factors for readmission in this population. The aim of this study was two-fold: 1) to evaluate the validity of the study cohorts in terms of health care utilization in relation to regional cohorts; 2) to describe the study cohorts in terms of health status and health care utilization after discharge. METHODS: The project consist of two cohorts with data from patient records of geriatric in-hospital stays, health care utilization data from Stockholm Regional Healthcare Data Warehouse 6 months after discharge, socioeconomic data from Statistics Sweden. The 2012 cohort include 6710 patients and the 2016 cohort, 8091 patients; 64% are women, mean age is 84 (SD 8). RESULTS: Mean days to first visit in primary care was 12 (23) and 10 (19) in the 2012 and 2016 cohort, respectively. Readmissions to hospital was 38% in 2012 and 39% in 2016. The validity of the study cohorts was evaluated by comparing them with regional cohorts. The study cohorts were comparable in most cases but there were some significant differences between the study cohorts and the regional cohorts, especially regarding amount and type of primary care. CONCLUSION: The study cohorts seem valid in terms of health care utilization compared to the regional cohorts regarding hospital care, but less so regarding primary care. This will be considered in the analyses and when interpreting data in future studies based on these study cohorts. Future studies will explore factors associated with health status and re-admissions in a population with multi-morbidity and disability.

A common approach for ranking of microbiological and chemical hazards in foods based on risk assessment - useful but is it possible?

This article compares and contrasts microbial and chemical risk assessment methodologies in order to evaluate the potential for a common framework for ranking of risk of chemical and microbiological hazards, and developments needed for such a framework. An overview of microbial (MRA) and chemical (CRA) risk assessment is presented and important differences are highlighted. Two microbiological and two chemical hazard-food combinations were ranked based on both a margin of exposure and a risk assessment approach. The comparisons illustrated that it is possible to rank chemical and microbiological hazard-food combinations with traditional approaches from each domain and indicated that the rank order but not the absolute measures is similar using either approach. Including severity in the assessment using DALY reduced differences between hazards and affected the outcome more than which approach was used. Ranking frameworks should include assessment of uncertainty as an integral part of the ranking, and be based on assessment of risk, not safety, and expressed in a common health metric such as disease burden. Necessary simplifications to address data gaps can involve the use of default scenarios. Challenges include comparisons of case-based vs. non-case-based health-endpoints, e.g. biomarker concentration, and integration of the severity of health effects into ranking.

Predicting the concentration of verotoxin-producing Escherichia coli bacteria during processing and storage of fermented raw-meat sausages.

A model to predict the population density of verotoxigenic Escherichia coli (VTEC) throughout the elaboration and storage of fermented raw-meat sausages (FRMS) was developed. Probabilistic and kinetic measurement data sets collected from publicly available resources were completed with new measurements when required and used to quantify the dependence of VTEC growth and inactivation on the temperature, pH, water activity (aw), and concentration of lactic acid. Predictions were compared with observations in VTEC-contaminated FRMS manufactured in a pilot plant. Slight differences in the reduction of VTEC were predicted according to the fermentation temperature, 24 or 34°C, with greater inactivation at the highest temperature. The greatest reduction was observed during storage at high temperatures. A population decrease greater than 6 decimal logarithmic units was observed after 66 days of storage at 25°C, while a reduction of only ca. 1 logarithmic unit was detected at 12°C. The performance of our model and other modeling approaches was evaluated throughout the processing of dry and semidry FRMS. The greatest inactivation of VTEC was predicted in dry FRMS with long drying periods, while the smallest reduction was predicted in semidry FMRS with short drying periods. The model is implemented in a computing tool, E. coli SafeFerment (EcSF), freely available from http://www.ifr.ac.uk/safety/EcoliSafeFerment. EcSF integrates growth, probability of growth, and thermal and nonthermal inactivation models to predict the VTEC concentration throughout FRMS manufacturing and storage under constant or fluctuating environmental conditions.

Investigations and actions taken during 2011 due to the first finding of Echinococcus multilocularis in Sweden.

Echinococcus multilocularis is a parasite that can cause alveolar echinococcosis disease. After the first positive finding of E. multilocularis in Sweden in 2011, a consulting group with representatives from relevant authorities was summoned. In this group, all relevant information was shared, strategies for information dissemination and any actions to be taken due to the finding of E. multilocularis were discussed and decided. The present paper describes the actions taken during 2011 and the results thereof, including surveillance in animals, risk assessment for humans to become infected and recommendations given to the public. Further discussion about whether the parasite was introduced, and if so, how, as well as possible future development of the infection in animals and humans in Sweden and future actions are included.

Modelling time to growth of Escherichia coli as a function of water activity and undissociated lactic acid.

AIMS: To model the effect of water activity (a(w)) and concentration of undissociated lactic acid (HLac) on the time to growth (TTG) and the growth/no growth boundary of acid-adapted generic Escherichia coli, used as model organisms for Shiga toxin-producing E. coli (STEC). METHODS AND RESULTS: For each of two E. coli strains, the TTG in brain heart infusion broth at 27 degrees C was estimated at 30 combinations of a(w) (range 0.945-0.995) and concentration of HLac (range 0-6.9 mol m(-3)) by using an automated turbidity reader. Survival analysis was used to develop a model predicting the TTG and the growth/no growth boundary. CONCLUSIONS: The present model can be used to predict the TTG and to indicate the growth/no growth boundary of acid-adapted E. coli strains as a function of a(w) and concentration of HLac. SIGNIFICANCE AND IMPACT OF THE STUDY: Fermented food products have been implicated as sources of STEC in several outbreaks. The study results are relevant for modelling of growth of STEC in fermented food and can be used in microbiological risk assessments or in the design and validation of food-production processes.

Risk ranking of chemical and microbiological hazards in food.

Risk ranking is a versatile tool used to prioritise activities performed by public health regulatory bodies. It also allows efficient communication between all stakeholders in the process of risk analysis. However, risk ranking methods are still not optimal. Because of the different approaches employed in the risk assessment of microbiological agents and chemicals, it is difficult to rank them together using the same metrics. In our work, we first discuss differences and commonalities between chemical and microbiological risk assessment to provide a starting point for consideration of a common risk ranking platform. In the second part, we perform risk ranking of contaminants and regulated chemicals using the recently developed Risk Thermometer tool. In this approach, chemicals are not ranked solely on the basis of the margin of exposure between a reference value and the exposure, but also by considering the severity of the critical health effects used. The results show that ranking using both methods provides different results from the use of either method alone. Overall, specific chemical groups (i.e. heavy metals, pesticides, etc.) do not generally rank higher or lower, but individual compounds are scattered in the rankings from low to high. Risk ranking methods demand further development to gain wide acceptability and recognition.

Microbiological baseline study of swine carcasses at Swedish slaughterhouses.

This 13-month survey was conducted to estimate the prevalence and counts of foodborne pathogenic bacteria and indicator bacteria on swine carcasses in Sweden. A total of 541 swine carcasses were sampled by swabbing prechill at the 10 largest slaughterhouses in Sweden. Pathogenic Yersinia enterocolitica was detected by PCR in 16% of the samples. The probability of finding Y. enterocolitica increased with increasing counts of Escherichia coli. No samples were positive for Salmonella. The prevalences of Campylobacter, Listeria monocytogenes, and verocytotoxin-producing E. coli were low (1, 2, and 1%, respectively). None of the verocytotoxin-positive enrichments, as determined by a reverse passive latex agglutination assay, tested positive for the virulence genes eaeA or hlyA by PCR. Coagulase-positive staphylococci, E. coli, and Enterobacteriaceae were recovered from 30, 57, and 87% of the samples, respectively, usually at low levels (95th percentiles, 0.79, 1.09, and 1.30 log CFU/cm2, respectively). The mean log level of Enterobacteriaceae was 0.35 log CFU/cm2 higher than that of E. coli on carcasses positive for both bacteria. The mean log level of aerobic microorganisms was 3.48 log CFU/cm2, and the 95th percentile was 4.51 log CFU/cm2. These data may be useful for risk assessment purposes and can serve as a basis for risk management actions, such as the use of E. coli as an alternative indicator organism for process hygiene control.

Microbiological baseline study of broiler chickens at Swedish slaughterhouses.

This 1-year study was conducted to estimate the prevalence and concentrations of pathogenic and indicator bacteria on Swedish broiler chickens. A total of 636 chilled carcasses were collected from 10 slaughterhouses and sent to the National Food Administration for analyses of carcass rinses. No carcasses were positive for Salmonella. Campylobacter, predominantly Campylobacter jejuni, were detected on 15% (by enrichment) or 14% (by direct plating) of the carcasses. With one exception, all samples from late December through April were Campylobacter negative. The 10th and 90th percentiles of Campylobacter numbers per carcasses were 3.0 and 5.0 log CFU, respectively, and the maximum was 7.1 log CFU. Coagulase-positive staphylococci were detected on 68% of the carcasses, with a maximum of 3.5 log CFU/cm2. The 10th and 90th percentiles were 3.4 and 4.4 log CFU/cm2 for total aerobic microorganisms, 1.8 and 3.3 log CFU/cm2 for Enterobacteriaceae, and 2.0 and 3.6 log CFU/cm2 for Escherichia coli. No correlation was found between numbers of any indicator bacteria and numbers of pathogenic bacteria. Subsets of the samples were analyzed for Listeria monocytogenes, Clostridium perfringens, pathogenic Yersinia enterocolitica, and Enterococcus, resulting in prevalence estimates of 29, 18, 9 (as determined by a PCR assay), and 97%, respectively. L. monocytogenes was most common at slaughterhouses with a low prevalence of coagulase-positive staphylococci, and vice versa. These results will improve the ability of researchers to assess the importance of chicken as a source of foodborne pathogens and can serve as a basis for risk management actions.

Postchill campylobacter prevalence on broiler carcasses in relation to slaughter group colonization level and chilling system.

Data from an ongoing national surveillance program of Campylobacter prevalence in broiler slaughter groups were related to results from a 1-year baseline study of broiler carcasses postchill. The goals were to establish the relation between Campylobacter prevalence in slaughter groups and on carcasses and to determine the effect of various chilling systems on Campylobacter prevalence. Pooled cloacal and neck skin samples from the surveillance program were analyzed after enrichment. Carcass rinse samples from the baseline study were analyzed after enrichment and by direct plating. Data from both studies were available for 614 carcasses. Direct-plating analyses indicated that the percentages of carcasses positive for Campylobacter jejuni and other Campylobacter spp. in slaughter groups with negative cloacal samples were 2 and 10%, respectively, whereas enrichment analyses indicated prevalences of 2% in both cases. Campylobacter prevalence in slaughter groups with a high degree of intestinal colonization (more than half of the pooled cloacal samples positive) was significantly higher than in slaughter groups with a low degree of colonization (76 to 85% and 30 to 50%, respectively, depending on Campylobacter spp. and analytical method). The prevalence of Campylobacter-positive carcasses postchill was at the same level as the prevalence of carcasses that originated from slaughter groups with positive neck skin samples at four of the six slaughterhouses. Only at one slaughterhouse, with an air-chilling system, was the postchill prevalence (13%) lower than that expected from slaughter group data (23%). The postchill prevalence (43%) was higher than that expected from slaughter group data (33%) at one slaughterhouse with immersion chilling.

Distribution of Campylobacter genotypes on broilers during slaughter.

The highly discriminatory genotyping methods now available for Campylobacter have enabled investigation of the diversity, origin, and route of transmission of this organism. In this study, we investigated the frequency of several genotypes of Campylobacter on chicken carcasses postchilling and on neck skin and cloacal swabs taken at slaughter. Campylobacter isolates recovered with and without enrichment from carcasses were subtyped by macrorestriction profiling. Subtyping 199 Campylobacter isolates from 36 carcasses revealed an average of 1.5 genotypes per carcass. The genotypes present on carcasses were, in most cases, also found in the cloacal samples taken at the beginning of the slaughter process. However, genotypes present on carcasses were, in some cases, not found in the corresponding cloacal samples but in cloacal samples of the preceding slaughter group and, in one case, from the preceding day. The genotypes present in cloacal samples were, with one exception, also found on the corresponding carcasses, indicating that most genotypes survive processing. In most cases, there was a difference of several bands between genotypes present in the same slaughter group, indicating different origins of the isolates rather than the occurrence of a recombination event. However, in two cases, a recombination event could have generated the difference in band patterns seen for two pairs of isolates with nearly identical band patterns, even after cleavage with a second restriction enzyme. The results indicate that individual Campylobacter-positive Swedish chicken carcasses, as well as whole carcass groups, are, in general, contaminated by one or two different genotypes.

Preparation of PCR samples from food by a rapid and simple centrifugation technique evaluated by detection of Escherichia coli O157:H7.

A sample treatment method based on buoyant density centrifugation which separates bacteria from food, concentrates bacteria and removes PCR inhibitors is described. The method involves a one minute centrifugation of food homogenate layered over a gradient medium (Percoll or BacXtractorTM) in Eppendorf tubes, followed by a single wash step. The small scale of this treatment makes it possible to process many samples in a short time. To evaluate the method beef and minced beef samples, spiked with strains of Escherichia coli O157:H7, were treated and then analysed by PCR aimed at verocytotoxin- (VT1 and VT2) and eae-genes. The detection limits in 1:10 (w/v) beef and minced beef homogenates were 125-250 cfu ml-1 (1250-2500 cfu g-1) and 1000 cfu ml-1 (1 x 10(4) cfu g-1), respectively. The enrichment of spiked samples in buffered peptone water at 37 degrees C for 6 hours before buoyant density centrifugation and PCR, allowed 0.5 cfu g-1 beef and 5 cfu g-1 minced beef to be detected. This combination of enrichment and buoyant density centrifugation was also used for analysis of 43 beef samples from a consignment in which E. coli O157:H7 had been detected, and detected VT-genes in all 43 samples. E. coli O157:H7 was also separated and detected in spiked samples of milk, lettuce, shrimps, and blue cheese at arbitrary concentrations of 3000 cfu ml-1. The present sample preparation method has the potential to be applicable to many other combinations of bacteria and food, and in connection with other detection methods than PCR as well.

Quantitative risk assessment for Listeria monocytogenes in smoked or gravad salmon and rainbow trout in Sweden.

The objective of the present work was to develop a quantitative risk assessment model in which the exposure and risk of acquiring listeriosis from consumption of packaged smoked or gravad salmon and rainbow trout were estimated. An Excel spreadsheet model was constructed in which variables were represented by distributions based on surveys of L. monocytogenes in these food products, and on demographic and consumption data. Growth or inactivation was not included in the model. The model was run through Monte Carlo simulations using the @Risk software (Palisade Corporation). The probability of illness per serving was calculated using two dose-response models from the literature. The first was an exponential model in which the species specific constant R, that helps define the dose-response curve, previously has been estimated to be 1.18 x 10(-10) based on German data (GR). In this study, R was estimated to 5.6 x 10(-10) based on Swedish data. The second model was a flexible Weibull-Gamma model (WG), with different coefficients for high- and low-risk groups. The exponential model (GR), although conservative and generally overestimating the risk, still predicted a lower probability of illness than the WG-model. The estimated mean risk per serving was 2.8 x 10(-5) (GR, high-risk group), 2.0 x 10(-3) (WG, low-risk group) and 0.016 (WG, high-risk group), respectively. The average number of reported listeriosis cases in Sweden is 37 per year. In comparison, the mean number of annual cases predicted by the risk assessment model was 168 (range 47 to 2800, GR, high-risk group), and 95 000 (range 34 000 to 1.6 x 10(6), WG high-risk group), respectively. If 1 to 10% (uniform distribution) of strains, instead of all, were considered virulent, the mean number of predicted cases would decrease to nine (GR) and 5200 (WG), respectively. The mean annual cumulative individual risk in the high-risk group based on a monthly exposure was estimated to be 4.0 x 10(-4) (range 8.0 x 10(-8) to 5.4 x 10(-3), GR). This risk increased to 1.5 x 10(-3) (range 1.7 x 10(-5) to 9.2 x 10(-3), GR) based on a weekly exposure. The risk assessment model was most sensitive to the input distribution describing the level of contamination and to a lesser degree on the prevalence of L. monocytogenes, the proportion of virulent strains, and serving sizes. A lack of data on the prevalence and concentration of L. monocytogenes in these products, dose-response data and quantitative information on the proportion of virulent strains were identified.

A summary of reported foodborne disease incidents in Sweden, 1992 to 1997.

Reports of foodborne disease incidents in Sweden from 1992 to 1997 are summarized. The results are based on reports from the municipal environmental and public health authorities to the National Food Administration and from medical authorities to the Swedish Institute for Infectious Diseases Control. A total of 555 incidents, of which 84% were outbreaks, were reported, involving 11,076 ill people. In 66% of the incidents, no disease agent was determined. Bacterial agents were implicated in 25% and viruses in 8% of the incidents. Calicivirus was the most reported agent both in terms of incidents and cases. Mixed dishes was the food category most often implicated in outbreaks, and smorgasbord and casserole or stews were the subcategories that caused the most cases. The place of consumption was unknown in 8% of the incidents. In about 60% of the incidents, the implicated food was consumed in commercial food establishments; in approximately 20% of incidents, it was consumed at home. The average annual incidence of reported foodborne disease in Sweden was estimated to be 21 cases per 100,000. The average annual incidence of reported foodborne salmonellosis and campylobacteriosis was estimated to be 2.0 and 0.6 cases per 100,000, respectively. The awareness and motivation to report foodborne diseases need to be improved, but additional sources of information are needed to counteract some of the limitations of reporting discussed in this work.

Home storage temperatures and consumer handling of refrigerated foods in Sweden.

The lack of data on consumer refrigeration temperatures and storage times limits our ability to assess and manage risks associated with microbial hazards. This study addressed these limitations by collecting data on temperatures and storage handling practices of chilled foods. Consumers from 102 households in Uppsala, Sweden, were instructed to purchase seven food items (minced meat, fresh herring fillets, soft cheese, milk, sliced cooked ham, vacuum-packed smoked salmon, and ready-to-eat salad) and to store them using their normal practices. They were interviewed the next day, and food temperatures were measured. In general, there were no significant relations between temperature and characteristics of the respondents (e.g., sex, age, education, age of the refrigerator). Mean storage temperatures ranged from 6.2 degrees C for minced meat to 7.4 degrees C for ready-to-eat salad. Maximum temperatures ranged from 11.3 to 18.2 degrees C. Data were not significantly different from a normal distribution, except for ready-to-eat salad, although distributions other than the normal fitted data better in most cases. Five percent to 20% of the food items were stored at temperatures above 10 degrees C. Most respondents knew the recommended maximum temperature, but less than one fourth claimed to know the temperature in their own refrigerator. Practical considerations usually determined where food was stored. For products with a long shelf life, stated storage times were different for opened and unopened packages. The current situation might be improved if consumers could be persuaded to use a thermometer to keep track of refrigerator temperature.

Early mental and neurological sequelae after Japanese B encephalitis.

Japanese B encephalitis is a disease with high mortality and many of those surviving suffer from serious sequelae. During the 1992 epidemic in northern Vietnam 50 patients treated at the Institute for Protection of Children's Health in Hanoi were studied concerning the type of sequelae and the development of the symptoms during the first two months of the disease. The age span was 1 to 15 years. 29 of the patients (58%) did not recover fully during the observation period. Fifteen (30%) showed signs of both neurological and mental disturbances. Nine (18%) only had mental symptoms while 5 (20%) suffered from isolated neurological sequelae. EEG was pathological in 9 out of 30 tested cases (30%); 9 of 23 patients (39%) performed subnormal IQ tests. Deep coma, bronchopneumonia with cyanosis, apnea attacks, prolonged fever and coma were all correlated (without statistical significance) to a higher risk for subsequent sequelae.

The current status of nursing informatics in undergraduate nursing programs: comparative case studies between Sweden and Australia.

During the last ten years, the inclusion of education in health information systems has assumed an important role in graduate programs for health professionals. More recently, attention has focused on undergraduate programs. Throughout the world schools of nursing, organisations and associations are addressing the issue of educational offerings in nursing informatics. This paper reports on the status of nursing informatics at undergraduate level. Nurse academics from Gävle and Lund in Sweden, and from Melbourne and Sydney in Australia, took part in a survey of the respective nursing courses. The purpose of the study was to identify and describe examples of types of nursing informatics courses in Australia and Sweden. A convenient sample of academics were approached and interviewed. The results of the survey illustrate, in the schools surveyed, the slow emergence of nursing informatics into nursing curricula.

Perceived consequences of being a renal failure patient.

This study describes the perceived consequences of illness and treatment among end stage renal disease (ESRD) patients. A qualitative, explorative-descriptive design was used, which included continuous ambulatory peritoneal dialysis (CAPD) (n = 26), hemodialysis (HD) (n = 30), and transplantation (n = 30) patients. Data collection was performed using unstructured interviews, mostly in the patients' homes. All interviews were tape-recorded with permission from the informants, transcribed verbatim, and analyzed by content analysis. An overall theme was identified, "Wishes for independence and normality." Four main categories emerged: "Wish for normality," "Wish to manage one's own life," "Deprivation of one's normal life," and "Concerns." Interview statements were classified in 11 subcategories: live as usual, keep up appearances, social comparison, hope/fulfilled dreams, freedom/lack of freedom, control/lack of control, losses, dependence on others, physical problems, disgusted with oneself, and broodings. The perceived consequences of being an ESRD patient are multidimensional and involve several aspects of everyday life. It is important for nurses to appreciate the patient's view of illness as well as the patient's perceived stressors and expectations. It may help to direct the focus of nursing assessment in planning and implementing nursing care.

Hospital organizational factors influence work-family conflict in registered nurses: Multilevel modeling of a nation-wide cross-sectional survey in Sweden.

BACKGROUND: The present shortage of registered nurses (RNs) in many European countries is expected to continue and worsen, which poses a substantial threat to the maintenance of healthcare in this region. Work-family conflict is a known risk factor for turnover and sickness absence. OBJECTIVE: This paper empirically examines whether the nurse practice environment is associated with experienced work-family conflict. DESIGN: A multilevel model was fit with the individual RN at the 1st, and the hospital department at the 2nd level using cross-sectional RN survey data from the Swedish part of RN4CAST, an EU 7th framework project. The data analyzed here is based on a national sample of 8356 female and 592 male RNs from 369 hospital departments. RESULTS: We found that 6% of the variability in work-family conflict experienced by RNs was at the department level. Organizational level factors significantly accounted for most of the variability at this level with two of the work practice environment factors examined, staffing adequacy and nurse involvement in hospital affairs, significantly related to work-family conflict. Due to the design of the study, factors on ward and work group levels could not be analyzed, but are likely to account for additional variance which in the present analysis appears to be on the individual level, with private life factors likely explaining another major part. CONCLUSION: These results suggest that higher level organizational factors in health care have a significant impact on the risk of work-family conflict among RNs through their impact on the nurse practice environment. Lower level organizational factors should be investigated in future studies using hierarchical multilevel sampling.

Subtyping of Listeria monocytogenes isolates recovered from retail ready-to-eat foods, processing plants and listeriosis patients in Sweden 2010.

Identification and prioritisation of food safety interventions requires an understanding of the relationship between food, pathogens and cases. Such understanding can be gained through different approaches, e.g. microbial subtyping to attribute cases of foodborne disease to food vehicles or other sources of illness. In this study, Listeria monocytogenes isolates (n=166) from (i) three categories of ready-to-eat (RTE) foods, (ii) food processing plant environments, and (iii) human listeriosis cases, all sampled during 2010 in Sweden, were subtyped. In addition, 121 isolates from human listeriosis cases, collected 2005-2009, were subtyped. Subtyping consisted of both serotyping (conventional method and PCR) and genotyping using pulsed-field gel electrophoresis (PFGE). Serotype 1/2a dominated in all three groups of isolates (range 73-96%). Eighteen percent of the human isolates (2010) belonged to serotype 4b, but only 1.4% of the food isolates. The food isolates differentiated into 19 pulsotypes (ID=0.843), the human isolates collected 2010 into 31 pulsotypes (ID=0.950) and the processing plant isolates into 22 pulsotypes (ID=0.991). Six of the pulsotypes were shared between the food and human isolates. These pulsotypes comprised 42% of the human isolates and 59% of the food isolates. For some processing plants, there was suggested persistence of one or more specific L. monocytogenes strains, as indicated by repetitive isolation of the same pulsotype from food. This study indicated the presence of L. monocytogenes in the processing plant environment as a likely source of contamination of gravad and cold-smoked fish, and this food category as an important source of human exposure to the pathogen.