Measles virus genotyping an important tool in measles outbreak investigation in Norway, 2011.

This study describes 33 laboratory-confirmed cases of measles that occurred in Norway in 2011, mainly among unvaccinated children between seven months and 10 years of age. Laboratory testing included detection of anti-measles IgM- and IgG antibodies by enzyme-linked immunosorbent assay (ELISA) and molecular detection and characterisation of measles virus by polymerase chain reaction (PCR) and sequencing. Epidemiological data and genotyping revealed that the measles cases originated from eight separate importations, resulting in four outbreaks and four sporadic cases. Except for the first outbreak which affected 18 cases, limited secondary spread occurred in each of the three other outbreaks. The outbreaks were caused by measles virus genotypes B3, D4 and D9, whereas genotypes D8 and B3 were detected in the sporadic cases. This study highlights that genetic characterisation of measles virus is an essential tool in the laboratory surveillance of measles, especially in countries like Norway which are approaching the measles elimination goal. The investigation revealed that importation of measles resulted in subsequent transmission within Norway to non-vaccinated individuals, and twelve cases occurred in healthcare settings, involving both staff and children. The four cases detected among healthcare workers (HCWs) emphasised that the coverage of measles-mumps-rubella (MMR) vaccination among healthcare personnel needs to be improved and both primary and secondary vaccine failure was demonstrated in two fully immunised HCWs.

Ongoing outbreak of measles in Oslo, Norway, January-February 2011.

Between 19 January and 17 February 2011, 10 cases of measles (eight laboratory-confirmed and two probable) were reported in Oslo with the majority of cases in a mainly unvaccinated immigrant community. Of these, two cases were identified outside the immigrant community, in Norwegian children.

Antioxidant effect on urinary excretion of malondialdehyde in non-athletes during aerobic training.

Conditions in the body during aerobic exercise increase the level of lipid peroxidation (LP). LP is associated with elevated concentration of modified low-density lipoproteins that are implicated in development of cardiovascular disease. Supplementation with antioxidant vitamin E to athletes at 267 mg (400 IUs) or greater has been reported to reduce levels of LP associated with exercise. Little is currently known about the effects of modest supplementation of vitamin E on previously sedentary adults who initiate an aerobic fitness program. In the present study, sedentary subjects (n = 14) kept 24-hour diet records to establish antioxidant intake of vitamins E and C and collected 24-hour urine samples that were used to determine baseline urinary malondialdehyde (MDA) concentrations, one measure of in vivo LP. No significant differences were noted in the parameters between groups. Seven subjects were randomly selected and supplemented daily with 133 mg (200 IUs) of vitamin E. All subjects participated in moderate-intensity aerobic training for 8 weeks. Post-training, non-supplemented subjects excreted significantly more MDA (p<0.05) and consumed significantly fewer antioxidants than the supplemented group. Vitamin E supplementation appears to suppress elevated LP associated with beginning an aerobic exercise regimen in previously sedentary subjects.

Does software optimization influence the radiologists' perception in low dose paediatric pelvic examinations?

PURPOSE: To investigate whether software optimisation can improve an observers' perception of image quality in low dose paediatric pelvic examinations. METHODS: Twenty-five consecutive patients (3-7 years old) were referred for a pelvic digital radiography (DR) examination. They were prospectively enrolled in the study over a 3-month period. Images were taken at 80 kV and 2-4 mAs depending on pelvic thickness (9-15 cm). A small focal spot, 130 cm SID: 10 cm air gap and 1 mm Al and 0.2 mm Cu additional filtration were also utilised. Images were acquired on a Canon DR detector and optimised using five different combinations of the multi-frequency processing software (Canon DR system version NE, Version 7.1 with SPECTRA) to comply with the ALARA principle. Image quality was blindly evaluated using the subjective Visual Grading Analysis (VGA) by five experienced musculoskeletal radiologists, including the evaluation of six anatomical image quality criteria (scored from 1 to 5). RESULTS: Consistently, the VGA results indicated that by using software optimised parameters, image quality was suitable for diagnosis in 48-71% of all images. Based on a VGC analysis all software optimised images did have significant better image quality then the one with just the clinical settings. Noise reduction was the software setting which influenced the image quality the most, area under the curve (AUC) of 0.8172 95%CI 0.7953-0.8375. CONCLUSION: Software optimisation improve the radiologists' perception of image quality and should thus be thoroughly considered within clinical practise. Noise reduction is the software parameter which has the greatest influence.

Costs and health consequences of chlamydia management strategies among pregnant women in sub-Saharan Africa.

OBJECTIVES: Chlamydia is the most common bacterial sexually transmitted infection worldwide and a major cause of morbidity-particularly among women and neonates. We compared costs and health consequences of using point-of-care (POC) tests with current syndromic management among antenatal care attendees in sub-Saharan Africa. We also compared erythromycin with azithromycin treatment and universal with age-based chlamydia management. METHODS: A decision analytical model was developed to compare diagnostic and treatment strategies, using Botswana as a case. Model input was based upon (1) a study of pregnant women in Botswana, (2) literature reviews and (3) expert opinion. We expressed the study outcome in terms of costs (US$), cases cured, magnitude of overtreatment and successful partner treatment. RESULTS: Azithromycin was less costly and more effective than erythromycin. Compared with syndromic management, testing all attendees on their first visit with a 75% sensitive POC test increased the number of cases cured from 1500 to 3500 in a population of 100,000 women, at a cost of US$38 per additional case cured. This cost was lower in high-prevalence populations or if testing was restricted to teenagers. The specific POC tests provided the advantage of substantial reductions in overtreatment with antibiotics and improved partner management. CONCLUSIONS: Using POC tests to diagnose chlamydia during antenatal care in sub-Saharan Africa entails greater health benefits than syndromic management does-and at acceptable costs-especially when restricted to younger women. Changes in diagnostic strategy and treatment regimens may improve people's health and even reduce healthcare budgets.

Bengal Bay clone ST772-MRSA-V outbreak: conserved clone causes investigation challenges.

BACKGROUND: The Bengal Bay clone, ST772-MRSA-V, associated with multi-drug resistance, Panton-Valentine leukocidin (PVL) and skin and soft tissue infections, is emerging worldwide. In Norway, a country with low prevalence of meticillin-resistant Staphylococcus aureus (MRSA), increased occurrence of ST772-MRSA-V has also caused hospital outbreaks. The conserved nature of this clone challenged the outbreak investigations. AIM: To evaluate the usefulness of S. aureus protein A (spa) typing, multiple-locus variable number tandem repeat fingerprinting/analysis (MLVF/MLVA) and pulsed-field gel electrophoresis (PFGE) when investigating outbreaks with a conserved MRSA clone. METHODS: A panel of 25 MRSA isolates collected in 2004-2014, consisting of six hospital outbreak isolates and 19 sporadic isolates, were analysed using spa typing, polymerase chain reaction detection of genes encoding PVL, MLVF/MLVA and PFGE. FINDINGS: All isolates were ST772-MRSA-V-t657 and resistant to erythromycin, gentamicin and norfloxacin, and 88% were PVL positive. PFGE could not discriminate between the isolates (≥85% similarity). MLVF resolved five types [Simpson's index of diversity (SID)=0.56], MLVA resolved six types (SID=0.66), and both methods separated the hospital isolates into two defined outbreaks. CONCLUSION: MLVF/MLVA could not discriminate all epidemiologically unlinked cases and identical genotypes originated from a timespan of 10 years. MLVA was regarded as most suitable due to its higher discriminatory power and ability to provide unambiguous profiles. However, the Bengal Bay clone may require higher resolution methods for exact demarcation of outbreaks due to low diversity among isolates.

Cohort analysis of asylum seekers in Oslo, Norway, 1987-1995: effectiveness of screening at entry and TB incidence in subsequent years.

SETTING: Municipalities of Baerum and Oslo, Norway. OBJECTIVES: To examine the effectiveness of tuberculosis (TB) screening in asylum seekers 1987-1995, and to describe TB incidence rates after arrival. DESIGN: Register-based, retrospective cohort study of 19912 asylum seekers with a mean follow-up of 6.3 years. RESULTS: Seventy-six persons were diagnosed with TB, of whom 43 (57%) had pulmonary TB. Twenty-two cases (17 pulmonary) were found through screening at entry. Eleven persons had abnormal mass miniature X-rays (MMRs), but had inadequate follow-up and were diagnosed later through passive case finding. MMR itself had a sensitivity of 96% and a specificity of 98% for pulmonary TB, diagnosed within 1 year after arrival. TB prevalence at entry was 110/100000; for Somalis it was 577/100000. Incidence rates were stable in the total cohort after arrival, whereas rates for extra-pulmonary TB in Somalis increased. CONCLUSIONS: Screening on entry should continue, but follow-up of abnormal MMRs must be improved. There should be more emphasis on treatment of latent infection.

Filling of a model left ventricle studied by colour M mode Doppler.

OBJECTIVE: It has been proposed that the early diastolic flow pattern inside the left ventricle reflects ventricular diastolic function. The flow pattern often divides into two phases towards the apex. The aim of this study was to examine the hydrodynamic nature of this phenomenon. METHODS: A rubber balloon representing the ventricle was connected to a reservoir representing the atrium, both filled with anticoagulated blood. Rigid "mitral" orifices 20 mm long and 15-40 mm in diameter were used. Surrounding the ventricle was a water filled chamber to which suction could be applied. The colour M mode Doppler sample beam coincided with the ventricular long axis. Colour M mode measures velocity at multiple sites along the beam simultaneously. The timing and magnitude of the velocities were analysed digitally. The filling was also qualitatively studied by ultrasonic two dimensional sector scanning. RESULTS: At the start of the filling, blood moved simultaneously at all levels, behaving as a fluid column. This was denoted "phase I". A flow wave then propagated from the mitral orifice towards the apex, called "phase II". This was found to represent a ring vortex, with blood velocities twice its propagation velocity [ratio 2.1(SEM 0.016)]. The ratio between the velocity time integrals of phase II and phase I decreased progressively from 51(15) to 0.41(0.14) when mitral orifice diameter was increased in 5 mm steps from 15 mm to 40 mm (p < 0.001). The propagation velocity correlated strongly with peak transmitral blood velocity, r = 0.95, p < 0.001. The flow patterns resembled patterns recorded in patients. CONCLUSIONS: The two phases of the filling pattern represented the motion of a blood column and the propagation of a ring vortex, respectively. Mitral orifice size determined which phase dominated the flow pattern.

Murine monoclonal antibodies against pneumococcal capsular polysaccharide types 4, 8, 22F and 19A/19F.

Monoclonal antibodies (MAbs) were produced against pneumococcal capsular polysaccharides after subcutaneous immunization of BALB/c mice with a 23-valent vaccine (Pneumovax N, Merck, Sharp & Dohme). Selected antibodies were tested in ELISA against individual polysaccharides from 23 different pneumococcal types and in a dot blot assay with heat-killed whole bacteria adhered to nitrocellulose paper. Three MAbs (isotype IgM) were found to be specific for types 4, 8 and 22F, respectively, whereas one (isotype IgA) reacted both with 19A and 19F. Very mild acid hydrolysis of the capsular polysaccharides resulted in loss of reaction with the antibodies.

Pulmonary tuberculosis in Kweneng District, Botswana: delays in diagnosis in 212 smear-positive patients.

SETTING: Health facilities in Kweneng District, Botswana. OBJECTIVES: To describe and analyse causes of delays in the diagnosis of smear-positive pulmonary tuberculosis. DESIGN: Cross-sectional descriptive study based on data from patient records and interviews of 212 cases. RESULTS: Median total delay was 12 weeks (mean 17.3), median patient's delay was three weeks (mean 5.1), median health services' delay was five weeks (mean 12.2). An inverse relationship was found between patient's delay and health services' delay. Treatment was started on the basis of positive acid-fast bacilli in 165 patients (78%), and chest X-ray findings in 47 (22%). Delayed sputum examination despite prolonged productive cough was common, and 31 patients (15%) had one or more negative initial investigations. Significant risk factors for delay were: first visit to a health post, and visiting a traditional or faith healer before start of treatment (total delay and health services' delay); treatment of a sexually transmitted disease in the last three years (total delay); staying in a village without a hospital, self-rated health being held as poor or very poor, and being married (health services' delay); and self-rated health being fair or good (patient's delay). CONCLUSIONS: Sputum must be examined in all patients with prolonged productive cough, and negative investigations should be repeated. Patients should be told to return if symptoms persist. Dialogue between modern health workers and traditional healers should be encouraged.

The epidemiology of adult lung disease in Botswana.

SETTING: Republic of Botswana. OBJECTIVES: To describe and analyse the epidemiology of adult lung disease in Botswana and provide information about risk factors. DESIGN: Register-based retrospective study. RESULTS: Poverty and human immunodeficiency virus (HIV) infection are major risk factors for lung disease. In 1997, TB caused 15.7%, pneumonia 8.3%, asthma/COPD 0.7% and lung cancer 0.4% of adult in-patient deaths, while 15.5% of deaths were classified as AIDS. Respiratory conditions accounted for 14.2% of hospital admissions and 18.1% of out-patient consultations. Pneumoconiosis was under-reported. Classification problems exist between AIDS, TB and pneumonia. The case fatality rate for in-patients with pneumonia was 5.6% in 1990 vs. 15.5% in 1997, and for TB patients it was 7.4% in 1990 vs. 11.2% in 1997. Morbidity rates also increased for pneumonia and TB through the 1990s. There was a steeper rise in pneumonia mortality and morbidity rates in females than males. The gender distribution in TB incidence remained unchanged, but the average age of female TB patients decreased by 7.7 years from 1983 to 1998, vs. a decrease of 5.3 years in males. CONCLUSIONS: Pulmonary TB and pneumonia are major causes of adult mortality and morbidity in Botswana. Incidences and case fatality rates are increasing, due to co-existent HIV infection. Non-communicable lung diseases are less common causes of death, and prevalences seem to be stable.

The influence of atrioventricular conduction and heart rate on the pulmonary venous flow pattern.

The pulmonary venous flow (PVQ) pattern usually has two antegrade flow waves, corresponding to ventricular systole and diastole, respectively, and is used to assess left atrial pressure. To study the effects of atrioventricular conduction (AVD) and heart rate (HR) on the PVQ pattern, transthoracic pulsed Doppler recordings of pulmonary venous, transmitral, and aortic flow were made in five healthy subjects with dual-chamber pacemakers. Recordings were made at HRs of 80, 100, and 120 beats/min, with AVDs of 75, 150, and 220 msec at each HR. When the AVD was increased, the biphasic PVQ changed to a monophasic pattern in which a single flow wave covered the transition between ventricular diastole and systole. There was a shift of flow from ventricular systole to diastole. When HR was increased, the systolic fraction of the PVQ increased as a result of an increase in the relative duration of systole. In conclusion, AVD and HR influenced the PVQ pattern in subjects without signs of ventricular dysfunction. This may be a limitation to the use of the flow pattern to assess left atrial pressure.

Ngaka ya setswana, ngaka ya sekgoa or both? Health seeking behaviour in Batswana with pulmonary tuberculosis.

The health seeking behaviour of tuberculosis (TB) patients, and their beliefs and attitudes with regard to the disease, was studied in 212 Batswana with smear-positive pulmonary TB during 1993/94. There is an apparent resemblance between traditional ideas of disease being caused by pollution (breaking of taboos) and modern theories of spread via germs. TB may be regarded as a 'European disease' or as a 'Tswana disease' and this has implications for health behaviour. Patients who regard TB as a 'Tswana disease' may use modern medicine for symptom relief but traditional medicine to treat what they consider the cause of the disease. All patients were eventually diagnosed and initiated specific antituberculous treatment in a modern health facility. The median number of health facility visits was two, and the median delay period was 12 weeks. 95% of patients visited a modern health facility as their first step of action. Before start of specific treatment one or more alternative treatments was tried by 52% of patients during the delay period. After starting modern treatment, 47% of patients visited, or planned to visit, a traditional healer or a faith healer. Traditional explanations of disease seemed less prevalent in 1993/94 than in a study conducted among TB patients in Botswana ten years earlier, but few patients had a thorough understanding of TB from a biomedical point of view. More knowledge about patients' health seeking behaviour and perceptions would be useful for health workers. The findings of this study could offer suggestions for improvement in the area of health education.

Repeatability of measurements of pulmonary venous flow indices.

We investigated the measurement repeatability of four pulmonary venous flow indices. The indices were measured on 45 anonymised, transthoracic Doppler recordings of adequate technical quality. Measurements were taken by two independent observers, and repeated after 10 days. Plus/minus the repeatability coefficient, which was used to quantify repeatability, gives the 95% probability limits for random variation between repeated measurements. The index D-diff, which is the difference in duration of the pulmonary venous flow reversal during atrial systole and the transmitral A-wave, had repeatability coefficients of 50 and 57 ms intra- and inter-observer. For the fraction of antegrade pulmonary venous flow during ventricular systole, the coefficients were 12 and 13 percentage points, but improved to 6 and 7 among the high-quality recordings. The retrograde pulmonary venous flow during atrial systole as a fraction of the antegrade flow, had coefficients of 5 percentage points both intra- and inter-observer. The coefficient for the peak velocity of retrograde pulmonary venous flow was 0.05 m/s intra- and inter-observer. Thus, the systolic fraction was the only index that showed a satisfactory repeatability. We suggest that if the other indices are used, measurements should be taken by a blinded observer to avoid observer bias.

A new color M-mode index of diastolic filling compared with radionuclide ventriculography.

We correlated the new diastolic index 'delay of apical peak velocity', as measured by colour M-mode Doppler, with radionuclide ventriculographic indices of ventricular function. Thirty-seven patients with coronary artery disease participated in the prospective and blinded study, which included repeated acquisitions to determine the effect of realigning the Doppler sample beam. In multiple regression, neither peak filling rate, left ventricular phase histogram width nor ejection fraction were statistically significantly related to delay of apical peak velocity. The standard deviation of the differences between duplicate colour M-mode acquisitions corresponded to half the reference range of the index. We conclude that in this blinded investigation, the new Doppler index did not provide information about ventricular function equivalent to radionuclide ventriculography. The index may be significantly influenced by sample beam position.

Repeatability of colour M-mode Doppler measurements of left ventricular filling.

We investigated the repeatability of two recently reported colour M-mode Doppler measures of left ventricular diastolic function. 'Delay of peak velocity' is the time interval from peak velocity of early filling at the mitral tip level to peak velocity in the apical region. The 'velocity of flow propagation' is the speed of the mitral to apical spread of the early diastolic filling. Two examiners independently and blindly made measurements by both methods on 32 digital recordings twice, using custom software. Inter- and intra-observer repeatability were given in terms of limits of agreement, where 1 denotes perfect agreement. Limits of intra-observer agreement were 0.72-1.43 for measurements of 'delay of peak velocity', and 0.39-2.28 for 'velocity of flow propagation'. Limits of inter-observer agreement were 0.68-1.42 and 0.19-2.04 respectively. The correlation between the methods was weak (r = 0.45), suggesting that they may detect different properties of early diastole. We suggest that the reliability of the methods may be improved by replicate measurements performed blindly. There are reasons to express the velocity of flow propagation on a logarithmic scale.

High-dose diclofenac for postoperative analgesia after elective caesarean section in regional anaesthesia.

Although the use of non-steroidal anti-inflammatory drugs (NSAIDs) is well established in the postoperative setting, their use after caesarean sections is still controversial. In a randomised, double-blinded, placebo controlled study we have estimated the opioid-sparing effect of diclofenac suppositories after elective caesarean sections in spinal anaesthesia. Eighty-two women ASA class I or II scheduled for caesarean section were randomised to receive either diclofenac suppositories 100 mg or placebo every 12 h after the operation. The diclofenac group (n = 40) consumed significantly less morphine in the postoperative period (14.0 +/- 1.5 mg in 32 h) compared with the placebo group (21.5 +/- 1.6 mg in 32 h, P < 0.05). The average level of postoperative pain as estimated by a visual analogue scale (VAS) and a verbal scale tended to be lower in the diclofenac group, but this was not significant. There were no differences in demographic data, perioperative bleeding, side-effects or discharge time between the groups. Diclofenac suppositories 100 mg given twice daily after caesarean section are opioid sparing.

Former migrant mineworkers with respiratory disease: the South African compensation system, and implications for neighbouring countries.

In the region of Southern Africa, substantial numbers of people, primarily males, have been employed in the South African mining industry. Migrant workers from neighbouring countries have constituted a large part of the work force. Until recently, there has been little or no attention directed toward the state of health of these individuals, despite the fact that their work involves a high health risk, especially in regard to mine-related lung diseases. In addition, the South African workers' compensation programme has seldom been utilised by the migrant worker who is a victim of occupational disease. However, recent experiences from Botswana show that compensation claims can be successfully made from the neighbouring countries where the migrant workers originate. Efforts are being made to address the problem systematically, and the government of Botswana is actively involved. The major occupational lung disorders are described briefly, and differential diagnostic problems with pulmonary TB are discussed. Furthermore, a survey of the compensation system in South Africa is presented, and practical steps for medical examinations involving compensation claims are described.

Cognitive engineering in interface design.

Today, many medical information systems are not satisfactory to their users. To ensure ultimate acceptance of health care information systems asks for systems that map on health care workers' tasks and on their cognitive processes in performing these tasks. The development of human-oriented computer interfaces requires insight in users' information needs and information processing in view of the tasks that will be computer-supported. Cognitive engineering aims at understanding the fundamental principles behind human activities that are relevant in designing a system that supports these activities. The application of cognitive engineering methods may therefore contribute to computer systems that fit better in health care working practices. We used cognitive engineering methods in designing a user interface for a physicians' workstation to support them in preparing their patient screening. The information needs and information search strategies of 4 physicians were revealed by systematic analyses of verbal protocols and video's while they successively worked through 10 paper-based patient records in preparing their patient visits. The results of these analyses were used as input for the design of a conceptual higher-order model that represents both the information needs and information search strategy of these physicians. Based on this higher-order conceptual model, we developed paper-mock ups and a first prototype of the user interface. The physicians will evaluate this prototype in the next phase of the project.