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.

Source attribution of human Salmonella cases in Sweden.

The aim of this study was to identify the sources of sporadic domestic Salmonella cases in Sweden and to evaluate the usefulness of a source-attribution model in a country in which food animals are virtually free from Salmonella. The model allocates human sporadic domestic Salmonella cases to different sources according to distribution of Salmonella subtypes in the different sources. Sporadic domestic human Salmonella cases (n=1086) reported between July 2004 and June 2006 were attributed to nine food-animal and wildlife sources. Of all Salmonella cases, 82% were acquired abroad and 2·9% were associated with outbreaks. We estimated that 6·4% were associated with imported food, 0·5% with food-producing animals, and 0·6% with wildlife. Overall, 7·7% could not be attributed to any source. We concluded that domestic food-producing animals are not an important source for Salmonella in humans in Sweden, and that the adapted model is useful also in low-prevalence countries.

First detection of Echinococcus multilocularis in Sweden, February to March 2011.

Surveillance for the fox tapeworm, Echinococcus multilocularis, has been carried out in Sweden since 2000, with about 300 red foxes analysed annually. We report the first finding of E. multilocularis in Sweden, in a fox shot in December 2010 in the south-west of the country. A second infected fox shot in the same location was detected in March 2011. This paper describes the national monitoring programme and the ongoing work to estimate the prevalence and spread of the infection.

Potential infection of grazing cattle via contaminated water: a theoretical modelling approach.

Wastewater discharge and agricultural activities may pose microbial risks to natural water sources. The impact of different sources can be assessed by water quality modelling. The aim of this study was to use hydrological and hydrodynamic models to illustrate the risk of exposing grazing animals to faecal pollutants in natural water sources, using three zoonotic faecal pathogens as model microbes and fictitious pastures in Sweden as examples. Microbial contamination by manure from fertilisation and grazing was modelled by use of a hydrological model (HYPE) and a hydrodynamic model (MIKE 3 FM), and microbial contamination from human wastewater was modelled by application of both models in a backwards process. The faecal pathogens Salmonella spp., verotoxin-producing Escherichia coli O157:H7 (VTEC) and Cryptosporidium parvum were chosen as model organisms. The pathogen loads on arable land and pastures were estimated based on pathogen concentration in cattle faeces, herd prevalence and within-herd prevalence. Contamination from human wastewater discharge was simulated by estimating the number of pathogens required from a fictitious wastewater discharge to reach a concentration high enough to cause infection in cattle using the points on the fictitious pastures as their primary source of drinking water. In the scenarios for pathogens from animal sources, none of the simulated concentrations of salmonella exceeded the concentrations needed to infect adult cattle. For VTEC, most of the simulated concentrations exceeded the concentration needed to infect calves. For C. parvum, all the simulated concentrations exceeded the concentration needed to infect calves. The pathogen loads needed at the release points for human wastewater to achieve infectious doses for cattle were mostly above the potential loads of salmonella and VTEC estimated to be present in a 24-h overflow from a medium-size Swedish wastewater treatment plant, while the required pathogen loads of C. parvum at the release points were below the potential loads of C. parvum in a 24-h wastewater overflow. Most estimates in this study assume a worst-case scenario. Controlling zoonotic infections at herd level prevents environmental contamination and subsequent human exposure. The potential for infection of grazing animals with faecal pathogens has implications for keeping animals on pastures with access to natural water sources. As the infectious dose for most pathogens is more easily reached for calves than for adult animals, and young calves are also the main shedders of C. parvum, keeping young calves on pastures adjacent to natural water sources is best avoided.

Inhibition of insulin release by cyclosporine and production of peripheral insulin resistance in the dog.

Cyclosporine has been shown to cause glucose intolerance in both humans and animals. This can result from alterations in insulin release, insulin metabolism, the sensitivity of peripheral or hepatic tissues to insulin, or a combination of these factors. The present study was designed to simultaneously evaluate the effect of CsA on these variables. A group of chronically catheterized dogs were administered oral CsA (20 mg/kg/day) for a period of 10 weeks. The glucagon stimulation test (GST) and the euglycemic glucose clamp technique, using a primed continuous infusion of 3H-3-glucose and a continuous insulin infusion (0.8 mU/kg/min), were employed to evaluate pancreatic insulin release, peripheral glucose disposal rate (Rd), hepatic glucose output (HGO), and metabolic clearance rate (MCR) of insulin. The dogs were tested before and after 2, 6, and 10 weeks of CsA administration. Serum CsA levels were 358 +/- 85, 244 +/- 48, and 355 +/- 81 ng/ml at 2, 6, and 10 weeks, respectively (P = NS). Elevated fasting glucose and an abnormal glucose response to an i.v. bolus of glucagon (0.25 U) were noted after 2, 6, and 10 weeks of CsA administration. The areas under the glucose curve (AUCG) for 0-60 min were 9605 +/- 773, 11634 +/- 1226, 12380 +/- 719, and 12626 +/- 1560 mg/min/dl at 0, 2, 6, and 10 weeks, P(F3, 15 = 5.1) = 0.012, demonstrating a CsA-induced disturbance of glucose homeostasis. The areas under the insulin curve (AUCI) for 0-20 min of the insulin response curve were 2033 +/- 203, 1089 +/- 187, 1038 +/- 179, and 972 +/- 161 uU/min/dl at 0, 2, 6, and 10 weeks, P(F3, 15 = 13.1) less than 0.001, indicating a 50% reduction during CsA treatment. CsA did not affect basal Rd, but peripheral insulin resistance was noted in the insulin-stimulated state. Rd during the third hour of the insulin infusion decreased from 6.72 +/- 0.69 to 4.42 +/- 0.44, 5.02 +/- 0.64, 4.47 +/- 0.52 mg/kg/min at 0, 2, 6, and 10 weeks, respectively, P(F3, 15 = 6.94) less than 0.004. HGO suppression by insulin and MCR of insulin were not altered by CsA. Similarly, glucagon secretion did not appear to be influenced by CsA. In conclusion, this study has simultaneously evaluated the effect of CsA on several aspects of glucose and insulin metabolism in the dog. CsA administration produces abnormal glucose homeostasis by reducing pancreatic insulin release, in addition to inducing peripheral insulin resistance.(ABSTRACT TRUNCATED AT 400 WORDS)

Recovery and hypersecretion of insulin and reversal of insulin resistance after withdrawal of short-term cyclosporine treatment.

We have previously demonstrated decreased insulin release and insulin resistance in dogs treated with cyclosporine (20 mg/kg/day). In this study we examine the changes caused by a lower CsA dose and evaluate the reversal of these changes. Six animals were treated for 2 weeks with oral CsA (15 mg/kg/day), after which CsA was discontinued. Glucagon stimulation tests (GST) and euglycemic clamp studies (ECS) were used to evaluate changes in insulin release and insulin resistance. GST were performed before CsA, after 2 weeks of CsA, and 3, 9, and 15 days after discontinuing CsA. ECS were performed before CsA, after 2 weeks of CsA, and 2, 4, 8, and 14 days after discontinuing CsA. The mean serum CsA level after 2 weeks of treatment was 188 +/- 28 ng/ml. GST demonstrated decreased insulin release during CsA with recovery and hypersecretion after CsA withdrawal. ECS showed peripheral insulin resistance during CsA with a rapid recovery and a temporary increase in insulin sensitivity after CsA withdrawal. Comparisons were made with our previous study group given 20 mg/kg/day of CsA. In summary, CsA induces a dose-dependent impairment of glucose homeostasis due to inhibition of insulin release and development of peripheral insulin resistance. Withdrawal of short-term CsA at commonly used therapeutic doses results in reversal of and temporary overcompensation for these changes. CsA withdrawal after long-term treatment results in a slower normalization of the insulin response as compared with after short-term treatment. The hypersecretory reaction of the beta cell may be of help in further investigations of mechanisms of CsA- and FK506-induced inhibition of insulin release.

Nutritional support for liver transplantation: identifying caloric and protein requirements.

OBJECTIVE: To characterize the caloric and protein requirements of patients with end-stage liver disease before and for 28 days after liver transplantation. DESIGN: We prospectively assessed 16 adult patients who were scheduled to undergo liver transplantation between December 1989 and September 1990. MATERIAL AND METHODS: Nitrogen balance, 24-hour urinary creatinine, 3-methylhistidine, and resting energy expenditure were determined before transplantation and on days 1, 3, 5, 14, and 28 after transplantation. The investigators were unaware of the results of these measurements, and patients were fed in accordance with a previously established clinical protocol. RESULTS: Resting energy expenditure did not increase from preoperative values; however, urinary nitrogen and 3-methylhistidine increased significantly after liver transplantation, an indication of protein catabolism from a myofibrillar source. A negative nitrogen balance persisted for 28 days post-operatively. CONCLUSION: We recommend that caloric intake be determined by using the formulation provided by the Harris-Benedict equation at ideal body weight plus 20%. We also recommend that intake of protein be adjusted on the basis of preoperative nutritional assessment, perioperative hepatic and renal function, and results of tests used to measure the adequacy of administered protein. Parenterally or enterally administered protein of more than 1.2 g/kg daily should be well tolerated in most patients who have undergone liver transplantation.

Laparoscopic cholecystectomy: early Mayo Clinic experience.

Prospective data and follow-up information were collected on the initial 200 patients who underwent laparoscopic cholecystectomy at the Mayo Clinic. The operation was completed laparoscopically in all but five patients, who required conversion to laparotomy because of dense scarring or stones in the common bile duct. The median surgical time was 85 minutes. The major postoperative complications were retained stones in the common bile duct (in seven patients), intraperitoneal hemorrhage that necessitated transfusion (in two patients), and intra-abdominal abscess and pulmonary infection (in one patient each). The median hospital stay was 1 day (range, 0 to 8 days), and the median times to full activity and normal employment were 8 days and 12 days, respectively. Laparoscopic cholecystectomy is associated with a low frequency of complications in most patients with symptomatic gallstones and allows a rapid return to normal activity. Currently, laparoscopic cholecystectomy is the treatment of choice for most patients with symptomatic cholelithiasis.

Comparison of loading capacities of various proteins and peptides in culture medium and in pure state.

Chromatographic media suppliers most frequently state the capacities of their gels based on either static capacities or frontal analysis experiments of pure proteins, however, these capacity values are often far from the capacities experienced in the production of such proteins. In this work static and dynamic capacities of various pure industrial proteins or peptides are compared to the capacities of the proteins or peptides under similar conditions in their natural culture medium. The results show a significant decrease in the static and dynamic capacities of the proteins or peptides when present in culture medium due to competitive binding of medium proteins. The proteins and peptides included in this study are: lipolase, glucagon-like peptide-1, truncated prothrombin, insulin precursor, and anti-Factor VII monoclonal antibody.

Experience of a 10-year use of competitive exclusion treatment as part of the Salmonella control programme in Sweden.

In Sweden, competitive exclusion (CE) treatment has been used since 1981 as a part of the national control programme for Salmonella. According to the programme all broiler flocks are tested for Salmonella before slaughter thus providing an evaluation of CE treatment. The CE culture used is mainly for the two consecutive flocks raised in a unit after a Salmonella-infected flock has been identified. During the period 1981-1990 Ce culture has been given to 179 flocks, involving 3.82 million chickens. Only one of the treated flocks was found to be Salmonella-positive. A special study during a period when Salmonella was spread by contaminated feed demonstrated that CE treatment was effective in controlling Salmonella under field conditions. A likely contributory factor is that the hatcheries in Sweden can be claimed to be Salmonella-free. In addition, the control programme and related action, have led to a very low incidence of Salmonella in broiler chickens. A nationwide study carried out in 1990 demonstrated that less than 1% of broiler chickens was contaminated with Salmonella after slaughter.

Control of Salmonella enteritidis in Sweden.

The Swedish control of Salmonella, with special reference to Salmonella enteritidis, in poultry is described. The control is directed at all serotypes of Salmonella and imported grandparent chickens are controlled, which is considered to be the main reason why Sweden so far is not found to be involved in the worldwide spread of different phagetypes of S. enteritidis. However, this spread has initiated a more stringent control of Salmonella in layers as earlier existed in broilers. Since 1990, 90% of the layer flocks are voluntarily tested for Salmonella before slaughter by bacteriological examination of pooled faecal samples. If S. enteritidis is isolated the flock is destroyed. This test, and in addition two similar tests during the production are mandatory as of January 1st, 1994. The voluntary Salmonella control programme has also been extended to all of the layer parents and hatcheries since 1991. Only heat-treated feed is given to all layer chickens during the rearing period and its use is becoming gradually more common also during the production period. Since 1987, four layer flocks have been found to be infected by S. enteritidis phagetype 4 and one flock with phagetype 6. During 1970-1984, 90% of all flocks of broilers were voluntarily tested bacteriologically for Salmonella before slaughter, and since 1984 such a control is mandatory to all flocks. As a result of this and other controls, S. enteritidis has not been isolated from broilers since 1972. Based on a governmental regulation from 1961, introduced as a result of a large Salmonella epidemic in 1953, Sweden runs an active, official control of Salmonella (Wierup et al., 1992).(ABSTRACT TRUNCATED AT 250 WORDS)

A chiral capillary electrophoresis method for ropivacaine hydrochloride in pharmaceutical formulations: validation and comparison with chiral liquid chromatography.

A capillary electrophoresis method for the determination of the enantiomeric purity of the local anaesthetic ropivacaine hydrochloride in injection solutions has been validated. The method showed the required limit of quantitation of 0.1% enantiomeric impurity. Good performances were shown for specificity, linearity, system repeatability, intermediate precision and accuracy. Robustness was tested via a full factorial design at two levels and the method proved to be robust. Comparison of the capillary electrophoresis method with the liquid chromatographic method currently used for several years at our laboratory on real samples of ropivacaine injection solutions showed that the techniques do not give significantly different results.

A simple method of maintaining chronic vascular access in the dog.

Maintaining chronically indwelling catheters and avoiding destruction, dislodgement, or infection of the catheters is often a significant challenge for the investigator using large animals. A method is described that, in the hands of the authors, has provided long-term venous and arterial access with a low rate of malfunction and infection.

A Reed-Frost model of the spread of tuberculosis within seven Swedish extensive farmed fallow deer herds.

The within-herd transmission of tuberculosis, after introduction of infection, was evaluated in seven Swedish herds of farmed fallow deer. The evaluation was based on a subset of data obtained from a previous epidemiological investigation, comprising 13 tuberculosis-infected deer herds, with the purpose of tracing the source of infection. A computer spreadsheet model based on the Reed-Frost method was developed to estimate the number of new infections. For each herd, a k-value (the number of effective contacts made by an individual during a time period) was estimated through fitting the model to the observed incidence in each herd. We concluded that, despite the relatively short observation periods and uncertain tuberculosis incidence estimates for the observed herds, the k's obtained could be used to quantify the estimated spread of tuberculosis in extensive deer herds in Sweden.

Herd-based monitoring for tuberculosis in extensive swedish deer herds by culling and meat inspection rather than by intradermal tuberculin testing.

The effect of random slaughter and meat inspection as a tool to detect or eradicate tuberculosis in large, extensive deer herds in Sweden was evaluated. A computer spreadsheet model based on the Reed-Frost method was developed. Numbers of new infections and of infected deer slaughtered as well as probability of detecting tuberculosis or slaughtering all infected deer in a herd, were simulated. The model predicted that, given a 20% annual slaughter and that disease was introduced with one infected deer, the infection would be detected or eliminated in most herds (90%) after 15 years.

Aureobasidium pneumonia in a post liver transplant recipient: a case report.

This is the first report of Aureobasidium (A.) pullulans as an opportunistic pulmonary infection in a liver transplant recipient. A 46-year-old caucasian man had an orthotopic liver transplant in 1988. His liver disease was primary sclerosing cholangitis. He required 2 subsequent liver re-transplants for primary graft non-function and acute rejection. The patient had been living in the California desert for two months prior to admission and presented with ventilator-dependent acute respiratory failure and hemodialysis-dependent acute renal failure. Imaging studies revealed severe bilateral infiltrates. His initial bronchoalveolar lavage (BAL) and brushings grew A. pullulans. Pancultures, including sputum and throat cultures, were negative for bacterial or other fungal organisms. The patient responded to pulmonary support and aggressive systemic antifungal agents while being maintained on cyclosporine and prednisone for immunosuppression. He was discharged to a skilled nursing facility 37 days after hospitalisation. Delay in discharge was primarily due to severe malnutrition and renal impairment. Opportunistic fungal infections continue to be a major problem in immunosuppressed patients including liver transplant recipients. Here we report a pulmonary infection with Coccidioides (C.) immitis and superinfection with A. pullulans. Opportunistic infections such as A. pullulans can be treated successfully with systemic fluconazole when amphotericin B is not well tolerated.

Bovine tuberculosis in Swedish deer farms: epidemiological investigations and tracing using restriction fragment analysis.

Bovine tuberculosis was eradicated from Sweden after a programme lasting many years. By 1991, no tuberculosis in wildlife had been discovered for 50 years and the last case in cattle had occurred 13 years before. In 1991, the disease was identified in a herd of farmed fallow deer (Dama dama) and over the next three years nine other infected herds were identified. Investigation revealed that all the infected deer were either deer that had been imported into Sweden from the United Kingdom in 1987 or had been in contact with them. Restriction fragment analysis of eight isolates of Mycobacterium bovis from five of the herds showed that the isolates had identical patterns of DNA fragments, which indicated a common source of infection. Among more than 800 isolates of M bovis that have been analysed, these patterns were identical to those of only two previous isolates, both of which came from British deer. These results indicate that the eight Swedish strains of M bovis and the two British strains may have a common source of infection.

Survey of Campylobacter species, VTEC O157 and Salmonella species in Swedish wildlife.

Samples collected from 791 wild animals (Canada geese, roe deer, hares, moose, wild boar and gulls) shot during hunting were examined for verocytotoxin-producing Escherichia coli (VTEC) O157, and thermophilic Campylobacter and Salmonella species. With the exception of one positive isolate from a wild boar, VTEC O157 was not isolated from any of the animals. Salmonella species were isolated only from the gulls, of which 4 per cent were estimated to be positive. Thermophilic Campylobacter species were commonly isolated from all the species except deer.

Salmonella isolated from animals and feed production in Sweden between 1993 and 1997.

This paper presents Salmonella data from animals, feedstuffs and feed mills in Sweden between 1993 and 1997. During that period, 555 isolates were recorded from animals, representing 87 serotypes. Ofthose, 30 serotypes were found in animals in Sweden for the first time. The majority of all isolates from animals were S. Typhimurium (n = 91), followed by S. Dublin (n = 82). There were 115 isolates from cattle, 21 from broilers, 56 from layers and 18 from swine. The majority of these isolates were from outbreaks, although some were isolated at the surveillance at slaughterhouses. The number of isolates from the feed industry was similar to that of the previous 5-year period. Most of those findings were from dust and scrapings from feed mills, in accordance with the HACCP programme in the feed control programme. It can be concluded that the occurrence of Salmonella in animals and in the feed production in Sweden remained favourable during 1993-97.

[Policy program to minimize spread of infection. Prolonged cough may be a sign of tuberculosis]. / Policyprogram för minskad smittspridning. Långdragen hosta kan vara tuberkulos.

In a worldwide epidemiological perspective, Sweden is well favoured with an annual tuberculosis incidence of approximately six cases per 100,000 of the population. Neither the impact of the HIV pandemic nor the occurrence of multiresistant strains of Mycobacterium tuberculosis has yet become a major problem in the care of tuberculosis patients in Sweden. Only a few per cent of HIV patients have developed tuberculosis, and during the period, 1991-94, only one per cent of M. tuberculosis isolates in Sweden were resistant to such antimycobacterials as isoniazid and rifampicin. However, the epidemiological situation in the neighbouring Baltic states is a matter for concern. Bovine tuberculosis has been eradicated in Sweden, the last case having been diagnosed in 1978. Although the reported efficacy of BCG (bacillus Calmette-Guérin) tuberculosis vaccine varies according to the population studied, protective rates of 70-85 per cent have been reported for Sweden and other west European countries. Re-vaccination of tuberculin-negative individuals has not been shown to yield added protection. The aim of a national programme for protection against tuberculosis is to preserve our favourable epidemiological situation by early detection of new cases, effective contact tracing, and BCG vaccination of children in population groups at risk. The primary means of achieving this is the education of health care personnel to retain tuberculosis as a differential diagnosis. Moreover, national guidelines for contact tracing must be duly observed, and immigrants from high prevalence areas need to be screened for tuberculosis. Registration of all cases of tuberculosis should be maintained at regional and national levels, and follow-up must be meticulous until a successful outcome of treatment is accomplished. Recommendations for dealing with tuberculosis should be made available and duly implemented at all hospitals caring for tuberculosis patients, in order to avoid nosocomial transmission. Although BCG vaccination at birth was formerly general in Sweden, since 1975 only children considered to be at risk have been vaccinated. Thus, non-vaccinated young adults are now entering the health care sector as students or employees, and should be offered BCG vaccination. Moreover, the epidemiological situation both in Sweden and in neighbouring countries needs to be monitored carefully in order that recommendations concerning BCG vaccination and other preventive measures can be modified if necessary.