Chlorination for low-cost household water disinfection - A critical review and status in three Latin American countries.

Chlorination has historically provided microbiologically safe drinking water in public water supplies. Likewise, chlorine has also been introduced as a low-cost disinfection method in rural and marginalized communities, both at community and household level, as well as during emergencies. Although this practice is common and well established for use as a household water treatment technology in the Global South, several challenges in effective and efficient implementation still need to be addressed. Here, we explored these issues by a literature review and narrowed them to the status of three Latin American countries (Mexico, Colombia, and Brazil). Overall, it was found that although guidance on household-based chlorination includes information on health risks and hygiene, this may not create enough incentive for the user to adapt the method satisfactorily. Physicochemical quality of the water influences chlorination efficiency and it is found that variations in quality are rarely considered when recommending chlorine doses during implementation. These are far more often based on a few measurements of turbidity, thereby not considering dissolved organic matter, or seasonal and day-to-day variations. Other factors such as user preferences, chlorine product quality and availability also represent potential barriers to the sustainable use of chlorination. For chlorination to become a sustainable household water treatment, more focus should therefore be given to local conditions prior to the intervention, as well as support and maintenance of behavioural changes during and after the intervention.

Similar glycaemic control with less nocturnal hypoglycaemia in a 38-week trial comparing the IDegAsp co-formulation with insulin glargine U100 and insulin aspart in basal insulin-treated subjects with type 2 diabetes mellitus.

AIMS: To confirm non-inferiority of insulin degludec/insulin aspart (IDegAsp) once-daily (OD) versus insulin glargine (IGlar) U100 OD + insulin aspart (IAsp) OD for HbA1c after 26 weeks, and compare efficacy and safety between groups at W26 + W38. METHODS: A 38-week, randomised, open-label, treat-to-target (HbA1c < 7.0%) trial in adults with type 2 diabetes mellitus (on basal insulin ±â€¯oral antidiabetic drugs; HbA1c 7.0-10.0%). Randomisation (1:1): IDegAsp or IGlar U100 + IAsp. Intensification to IDegAsp twice daily (BID) was permitted at W26 + W32, or with additional IAsp injections at W26 (maximum IAsp BID) or W32 (maximum IAsp three-times daily). RESULTS: For W0-W26, mean percentage-change (standard deviation) HbA1c was: IDegAsp, -1.1 (0.9); IGlar U100 + IAsp, -1.1 (0.8); estimated treatment difference: 0.07% (95% confidence interval [CI]: -0.06; 0.21) confirmed non-inferiority. At W26 and W38, target HbA1c achievement, and mean fasting and postprandial glucose were similar across groups. At W38, more subjects achieved target HbA1c without hypoglycaemia with IDegAsp (22.5%) than with IGlar U100 + IAsp (21.1%), with significantly fewer nocturnal episodes (W0-W38, estimated rate ratio: 0.61 [95% CI: 0.40; 0.93]). Safety profiles were similar across treatment groups throughout. CONCLUSIONS: IDegAsp OD/BID are effective treatment intensification options versus multiple injection basal-bolus therapies, achieving similar glycaemic control, with significantly less nocturnal hypoglycaemia.

Inhibition of Small Conductance Calcium-Activated Potassium (SK) Channels Prevents Arrhythmias in Rat Atria During ß-Adrenergic and Muscarinic Receptor Activation.

Sympathetic and vagal activation is linked to atrial arrhythmogenesis. Here we investigated the small conductance Ca2+-activated K+ (SK)-channel pore-blocker N-(pyridin-2-yl)-4-(pyridine-2-yl)thiazol-2-amine (ICA) on action potential (AP) and atrial fibrillation (AF) parameters in isolated rat atria during ß-adrenergic [isoprenaline (ISO)] and muscarinic M2 [carbachol (CCh)] activation. Furthermore, antiarrhythmic efficacy of ICA was benchmarked toward the class-IC antiarrhythmic drug flecainide (Fleca). ISO increased the spontaneous beating frequency but did not affect other AP parameters. As expected, CCh hyperpolarized resting membrane potential (-6.2 ± 0.9 mV), shortened APD90 (24.2 ± 1.6 vs. 17.7 ± 1.1 ms), and effective refractory period (ERP; 20.0 ± 1.3 vs. 15.8 ± 1.3 ms). The duration of burst pacing triggered AF was unchanged in the presence of CCh compared to control atria (12.8 ± 5.3 vs. 11.2 ± 3.6 s), while ß-adrenergic activation resulted in shorter AF durations (3.3 ± 1.7 s) and lower AF-frequency compared to CCh. Treatment with ICA (10 µM) in ISO -stimulated atria prolonged APD90 and ERP, while the AF burden was reduced (7.1 ± 5.5 vs. 0.1 ± 0.1 s). In CCh-stimulated atria, ICA treatment also resulted in APD90 and ERP prolongation and shorter AF durations. Fleca treatment in CCh-stimulated atria prolonged APD90 and ERP and abbreviated the AF duration to a similar extent as with ICA. Muscarinic activated atria constitutes a more arrhythmogenic substrate than ß-adrenoceptor activated atria. Pharmacological inhibition of SK channels by ICA is effective under both conditions and equally efficacious to Fleca.

Outcome and clinical course of EHEC O104 infection in hospitalized patients: A prospective single center study.

OBJECTIVES: Shiga-toxin producing O157:H7 Entero Haemorrhagic E. coli [STEC/EHEC] are the most common cause of Haemolytic Uraemic Syndrome [HUS] related to infectious haemorrhagic colitis. Nearly all recommendations on long term treatment of EHEC infections refer to this strain. The 2011 outbreak in Northern Europe was the first of this dimension to be caused by the serotype O104:H4. We report on the 3.5 year follow up of 61 patients diagnosed with symptomatic EHEC O104:H4 infection in spring 2011. METHODS: Patients with EHEC O104 infection were followed in a monocentric, prospective observational study at four time points: 4, 12, 24 and 36 months. These data include the patients' histories, clinical findings, and complications. RESULTS: Sixty-one patients suffering from EHEC O104:H4 associated enterocolitis participated in the study at the time of hospital discharge. The mean age of patients was 43 ± 2 years, 37 females and 24 males. 48 patients participated in follow up 1 [FU 1], 34 patients in follow up 2 [FU 2], 23 patients in follow up 3 [FU 3] and 18 patients in follow up 4 [FU 4]. Out of 61 patients discharged from the hospital and included in the study, 54 [84%] were examined at least at one additional follow up. Serum creatinine decreased significantly between discharge and FU 1 from 1.3 ± 0.1 mg/dl to 0.7 ± 0.1 mg/dl [p = 0.0045]. From FU 1 until FU 4, no further change in creatinine levels could be observed. The patients need of antihypertensive medications decreased significantly [p = 0.0005] between discharge and FU 1 after four months. From FU 1 until FU 3, 24 months later, no further significant change in antihypertensive treatment was observed. CONCLUSIONS: Our findings suggest that patients free of pathological findings at time of discharge do not need a specific follow up. Patients with persistent health problems at hospital discharge should be clinically monitored over four months to evaluate chronic organ damage. Progressive or new emerging renal damage could not be observed over time in any patient.

Return of spontaneous circulation and long-term survival according to feedback provided by automated external defibrillators.

BACKGROUND: We aimed to investigate the effect of automated external defibrillator (AED) feedback mechanisms on survival in out-of-hospital cardiac arrest (OHCA) victims. In addition, we investigated converting rates in patients with shockable rhythms according to AED shock waveforms and energy levels. METHODS: We collected data on OHCA occurring between 2011 and 2014 in the Capital Region of Denmark where an AED was applied prior to ambulance arrival. Patient data were obtained from the Danish Cardiac Arrest Registry and medical records. AED data were retrieved from the Emergency Medical Dispatch Centre (EMDC) and information on feedback mechanisms, energy waveform and energy level was downloaded from the applied AEDs. RESULTS: A total of 196 OHCAs had an AED applied prior to ambulance arrival; 62 of these (32%) provided audio visual (AV) feedback while no feedback was provided in 134 (68%). We found no difference in return of spontaneous circulation (ROSC) at hospital arrival according to AV-feedback; 34 (55%, 95% confidence interval (CI) [13-67]) vs. 72 (54%, 95% CI [45-62]), P = 1 (odds ratio (OR) 1.1, 95% CI [0.6-1.9]) or 30-day survival; 24 (39%, 95% CI [28-51]) vs. 53 (40%, 95% CI [32-49]), P = 0.88 (OR 1.1 (95% CI [0.6-2.0])). Moreover, we found no difference in converting rates among patients with initial shockable rhythm receiving one or more shocks according to AED energy waveform and energy level. CONCLUSIONS: No difference in survival after OHCA according to AED feedback mechanisms, nor any difference in converting rates according to AED waveform or energy levels was detected.

Use of an autologous leucocyte and platelet-rich fibrin patch on hard-to-heal DFUs: a pilot study.

OBJECTIVE: Leucopatch is a leukocyte and platelet-rich fibrin patch that provides concentrated blood cells and signal substances to the surface of an ulcer. It is produced by centrifugation of the patient's own venous blood. The aim of this pilot multicentre cohort study was to evaluate effects of the leucocyte patch in patients with hard-to-heal diabetic foot ulcers (DFUs). METHOD: Non-ischaemic Wagner grade 1 or 2 DFUs with a duration of more than 6 weeks and a maximal area of 10cm² were included. Patients with >40% ulcer area change during a two-week run-in period were excluded. The treatment was applied once a week for up to 19 treatments or until the foot ulcer was completely epithelialised. The primary endpoint was healing within 20 weeks. RESULTS: Of the 60 patients who gave consent 16 were excluded during run-in period, 44 patients initiated study treatment and 39 were included in the per-protocol analysis. Complete epithelisation was achieved in 34% (per-protocol analysis 36%) at 12 weeks and 52% (59%) at 20 weeks. In patients with ulcer duration less than 6 months, 73% of ulcers healed within 20 weeks. Patients with healed ulcers had larger ulcer area reduction during the first two treatment weeks compared to non-healers. Adverse events were mild and rare. CONCLUSION: The leucocyte patch is well-tolerated, easy to use and has potential in the armamentarium of the DFU treatment, provided this outcome is confirmed in an appropriately powered randomised clinical trial.

[Quality of care of patients with chronic heart failure in primary care]. / Calidad de la atención a los pacientes con insuficiencia cardiaca crónica en atención primaria.

INTRODUCTION: The prevalence of Chronic Heart Failure (CHF) in Spain is very high. It is the main cause of many hospital admissions and it is associated with high mortality rates. Its management in Primary Care is not always adequate. Our objective was to evaluate whether an educational intervention in general practitioners would improve the health care of their patients with chronic heart failure. MATERIAL AND METHODS: Prospective, randomised, and controlled study. A structured formative course was given to the intervention group (IG) of practitioners. A year later changes were compared with a control group (CG). The settings were two Primary Care Centres. One of them was in a rural setting, and the other one with a mixture of rural and urban populations. The study included 185 patients diagnosed with CHF, with a mean age of 79.8 years, and they were assigned to 20 practitioners (Total population: 15, 921) We evaluated the quality of medical history, clinical examination, laboratory tests and treatment. RESULTS: At the end of the study there were marked differences between both groups. In the IG, the Medical History improved 1.42 points (95% CI: 0.57 to 2.28), P = .001. The Clinical Examination improved 2.37 points (95% CI: 1.10 to 3.65), P > .001 and the Laboratory Tests, 0.75 points (95% CI: -0.15 to 1.66), P = .10; The Overall Difference was 5.44 points (95% Cl: 3.25 to 7.62), P > .001. There were slight improvements in Treatment. CONCLUSIONS: The intervention promoted from our own work settings achieved a general improvement in the care of patients with heart failure.

Data management in automated external defibrillators: a call for a standardised solution.

BACKGROUND: The ECG data stored in automated external defibrillators (AEDs) may be valuable for establishing a final diagnosis and deciding further diagnostics and treatment. Different data management systems are used and this may create significant problems for data storage and access for physicians treating victims in whom an AED has been used. METHODS: In this descriptive study, we collected information (number, manufacturer and model) on 17 December 2010 from a web page used for the voluntary registration of AEDs in Denmark. The manufacturers were contacted and asked to provide information about data downloading. RESULTS: There were 12 different manufactures and 20 different AED models. Five models were registered in a quantity <5. We report data from the remaining 15 models (3603 AEDs). Several models stored only one case or 15 min of ECG data. All models had a data transfer option, but most had outdated 'hardware': Seven had infrared transfer; one had a cable with a serial port. Four had a removable memory device, but only one was a USB. The software was available as freeware only in a few cases. Otherwise, a CD ROM was needed, some even with a licence. The software for the second most common AED could not be installed. CONCLUSION: The development of data management solutions is not a high priority. We encourage the manufacturers to collaborate with researchers to develop a simple data transfer solution in order to improve patient care and facilitate research.

New Danish reference values for height, weight and body mass index of children aged 0-5 years.

AIM: To derive new reference values for height, weight and body mass index (BMI) of children aged 0-5 years in Denmark and to compare them with the national reference from the 1970s and the 2006 WHO standard. METHODS: The height and weight of 4105 healthy singleton children born in 1995 were obtained from a cohort study. Children were measured at birth and at seven regular health examinations by a general practitioner up to 5 years of age. Generalized additive models for location, scale and shape were used to construct percentile curves. RESULTS: Mean length, weight and BMI at birth and during the first months of life increased significantly, but the differences diminished thereafter, and at 1 year BMI had decreased. In boys, weight and BMI had decreased by 2 years of age but had increased, together with height, at 5 years. Children were taller, heavier and had a higher BMI than that referred to in the WHO standard. CONCLUSION: New references for length or height, weight and BMI by age were constructed for children in Denmark. Since the 1970s, weight, length and BMI at birth increased, and growth during the first year of life appears to be healthier.

Photobacterium damselae subsp. damselae, an emerging pathogen in Danish rainbow trout, Oncorhynchus mykiss (Walbaum), mariculture.

A selection of 16 field isolates of Photobacterium damselae from marine rainbow trout farms in Denmark was subjected to phenotypic and genotypic characterization and pathogenicity to fish. All isolates belonged to the subspecies damselae, being positive for haemolysis, motility and urease. There were considerable differences in haemolytic properties, some isolates presenting a broad zone of haemolysis and others only a narrow zone. Pulsed-field gel electrophoresis revealed a high diversity indicating that P. damselae subsp. damselae is an opportunistic, not clonal pathogen in Danish marine rainbow trout. Virulence of the strains to rainbow trout was highly variable with LD(50) values ranging from 3.9 x 10(3) to 1.5 x 10(8) cfu at 20 degrees C. The virulence was significantly higher at 20 degrees C than at 13 degrees C. The strains with the strongest haemolytic properties were the most virulent suggesting a strong involvement of haemolysin in the pathogenesis. The pathological changes were consistent with a bacterial septicaemia and the haemorrhages were more pronounced than for most other bacterial infections.

Environmental properties of long-chain alcohols. Part 2: Structure-activity relationship for chronic aquatic toxicity of long-chain alcohols.

Daphnia magna reproduction tests were performed with C(10), C(12), C(14) and C(15) alcohols to establish a structure-activity relationship of chronic effects of long-chain alcohols. The data generation involved substantial methodological efforts due to the exceptionally rapid biodegradability of the test substances and the need to test as close as possible to their water solubility limits. Test concentrations were determined by GC-MS before and after test solution renewal. Whereas apparent toxicity based on survival and reproduction increased with increasing C-chain lengths up to C(14), observations of toxicity to C(15) alcohol were not in line with lower chain lengths due to the lack of toxicity below the level of water solubility. When omitting C(15), the slope of most (Q)SARs approach -1, being consistent with the expectation of a non-polar narcotic mode of action. Further testing at higher chain lengths is not sensible due to progressively lower solubility, at remaining biodegradability. Effects on mortality and reproduction are not expected below the level of water solubility.

Serovars of Salmonella from captive reptiles.

The distribution on serovars of 60 Salmonella isolates from reptiles kept in captivity in Denmark during the period 1995-2006 was investigated. The isolates were all recovered from clinical specimens submitted to the National Veterinary Institute. A majority of the samples were from reptiles in zoological gardens or similar, while a minor number was from reptiles kept in private homes. A total of 43 serovars were detected, most of them being what is usually called exotic serotypes, and many not having a trivial name, while a few isolates belonged to well-known human pathogenic serovars, such as S. Enteritidis, S. Typhimurium, S. Bovismorbificans. One isolate was rough and two were non-typeable. Isolates from turtles belonged to the subspecies enterica, while many isolates from both sauria and snakes belonged to other subspecies. The findings underline the potential zoonotic risk by handling reptiles in zoological garden or other public settings, or keeping pet reptiles in private homes.

Assessment of the environmental risk of long-chain aliphatic alcohols.

An environmental assessment of long-chain alcohols (LCOH) has recently been conducted under the OECD SIDS High Production Volume (HPV) Program via the Global International Council of Chemical Associations (ICCA) Aliphatic Alcohols Consortium. LCOH are used primarily as intermediates, as a precursor to alcohol-based surfactants and as alcohol per se in a wide variety of consumer product applications. Global production volume is approximately 1.58 million metric tonnes. The OECD HPV assessment covers linear to slightly branched LCOH ranging from 6 to 22 alkyl carbons (C). LCOH biodegrade exceptionally rapidly in the environment (half-lives on the order of minutes); however, due to continuous use and distribution to wastewater treatment systems, partitioning properties, biodegradation of alcohol-based surfactants, and natural alcohol sources, LCOH are universally detected in wastewater effluents. An environmental risk assessment of LCOH is presented here by focusing on the most prevalent and toxic members of the linear alcohols, specifically, from C(12-15). The assessment includes environmental monitoring data for these chain lengths in final effluents of representative wastewater treatment plants and covers all uses of alcohol (i.e., the use of alcohol as a substance and as an intermediate for the manufacturing of alcohol-based surfactants). The 90th percentile effluent discharge concentration of 1.979microg/L (C(12)-C(15)) was determined for wastewater treatment plants in 7 countries. Chronic aquatic toxicity studies with Daphnia magna demonstrated that between C(13) and C(15) LCOH solubility became a factor and that the structure-activity relationship was characterized by a toxicity maximum between C(13) and C(14). Above C(14) the LCOH was less toxic and become un-testable due to insolubility. Risk quotients based on a toxic units (TU) approach were determined for various scenarios of exposure and effects extrapolation. The global average TU ranged from 0.048 to 0.467 depending on the scenario employed suggesting a low risk to the environment. The fact that environmental exposure calculations include large fractions of naturally derived alcohol from animal, plant, and microbially mediated biotransformations further supports a conclusion of low risk.

Surveillance of health status on eight marine rainbow trout, Oncorhynchus mykiss (Walbaum), farms in Denmark in 2006.

The health status of eight marine rainbow trout farms was followed from mid-June to mid-September 2006 by sampling both dead and healthy fish approximately every 2 weeks for bacteriological and virological investigation. No fish pathogenic viruses were detected, but all farms experienced disease and mortality as a result of various bacterial infections. Yersinia ruckeri was found on four and Renibacterium salmoninarum on five of the farms, but only during the first part of the surveillance period. This indicates that the fish carried the infection from fresh water, and cleared the infection in salt water. Aeromonas salmonicida subsp. salmonicida caused mortality on five farms, but persisted throughout the sampling period. Although A. salmonicida was probably carried from fresh water, the fish were not able to clear the infection in the sea. Vibrio anguillarum caused mortality on six of the farms throughout the sampling period, O1 being the dominant serovar, and Photobacterium damselae subsp. damselae was found on seven farms as a cause of disease. During the period of highest water temperatures Vibrio parahaemolyticus and Vibrio vulnificus were detected in dead fish in five and two farms, respectively, although their significance as causative pathogens is questionable. Vibrio vulnificus has not previously been found in rainbow trout in Denmark. Both mortality and number of antimicrobial treatments during the period were considerably higher in unvaccinated compared with vaccinated fish. Resistance to commonly used antimicrobials was low or absent.

Calculating pH in pig manure taking into account ionic strength.

Models such as the Anaerobic Digestion Model No. 1 (ADM1) assume that pH can be calculated directly from the concentration of hydrogen ions. However because pH is, by definition, the negative logarithm of the hydrogen ion activity, and thus pH measurements represent hydrogen ion activities, this approach may lead to a bias between measured and predicted pH values. Implementing ionic strength effects into the charge balance equation and the calculation of pH is a theoretical improvement to this. In this study a model, implementing a procedure for calculating pH, was developed to analyse the effect of ionic strength on pH in a pig manure. By adding KCl to samples of pig manure, experimental results could be analysed with help from the model. A modified form of the Davies equation was found to give the most accurate prediction of pH in the pig manure studied in this paper with changing ionic strength.

Community spread of Legionella pneumophila serogroup 1 in temporal relation to a nosocomial outbreak.

To clarify whether a nosocomial outbreak of legionnaires' disease in the Värnamo hospital in Sweden was part of a wider outbreak in the Värnamo community a number of investigations were performed. First, the proportion of cases of legionnaires' disease in a group with nosocomially acquired pneumonia (11%) was compared to the proportion within a group with community-acquired pneumonia (14%) and the difference was found not to be significant (p > 0.05). Second, the proportion of the nursing staff at the Värnamo hospital with an elevated antibody titre (> or = 16) to Legionella pneumophila serogroup (sg) 1 (33%, 84/258) was compared to the proportion in a group of local residents of Värnamo community (26%, 25/96) and found not to be significant; in contrast, comparison with the proportion in a group from the assistant nursing staff at another hospital 60 km away (5%, 4/80) was highly significant (p < 0.001). Furthermore, Legionella species were cultured from samples drawn from the hospital water supply as well from the water supply from municipal buildings. In 1996 a follow-up study was conducted, which showed that < 1% of the assistant nurses and local residents had an elevated titre to L. pneumophila sg 1. These results indicate that there was a temporary spread of L. pneumophila sg 1 in the Värnamo community at the beginning of 1991, both in the local hospital and the surrounding community. This implies that physicians should be aware of community-acquired cases of legionnaires' disease when a nosocomial outbreak is detected.

Aminoglycosides do not improve the efficacy of cephalosporins for treatment of acute pyelonephritis in women.

A prospective, coordinated, randomized multicentre trial was conducted to determine whether tobramycin 160 mg intravenously (i.v.) once daily for 2 days would improve the efficacy of cefotaxime 1 g i.v. twice daily for 2 days followed by a 10-day course of oral cefadroxil 1 g twice daily, in the treatment of community-acquired acute pyelonephritis in women. Of 73 patients enrolled in the study, 51 could be evaluated according to the protocol. There were no significant differences in bacteriological cure rates between the combined treatment with tobramycin/cefotaxime and cefotaxime alone, either at short-term follow-up (63.0% vs 59.1%; 95% confidence interval (CI) for difference in proportions -23.4% to 31.2%), or up to 7 weeks after cessation of treatment (42.9% vs 52.2%; 95% CI, -18.0% to 36.6%). A modified intention-to-treat analysis showed no difference in clinical efficacy between the two regimens (68.6% vs 69.2%; 95% CI, -22.9% to 24.1%). Tobramycin seemed to enhance the resolution of inflammation by a more rapid decline in C-reactive protein levels. The high recurrence rates after treatment with beta-lactam antibiotics in this and previous studies of acute pyelonephritis may be explained by adverse ecological effects rather than failure to eradicate the infection.

Atypical mycobacteria in extrapulmonary disease among children. Incidence in Sweden from 1969 to 1990, related to changing BCG-vaccination coverage.

SETTING: In April 1975, the general BCG vaccination of newborns in Sweden was replaced by selective vaccination of groups at increased risk of tuberculosis. OBJECTIVE: To relate the incidence of atypical mycobacterial disease in children to BCG vaccination. DESIGN: A nationwide survey in Sweden during the period 1969-90 disclosed 390 children under 15 years of age with bacteriologically confirmed atypical mycobacteria from extrapulmonary lesions. RESULTS: The average, annual incidence of atypical mycobacterial disease per 100,000 children under 5 years of age increased from 0.06 during the period 1969-74 to a maximum level of 5.7 during 1981-85. Among the cohorts born in Sweden in the period 1975-85, the cumulative incidence rate before 5 years of age was estimated at 26.8 per 100,000 non-BCG-vaccinated children and at 4.6 among those BCG-vaccinated, ratio 5.9 (95% confidence limits 1.6, 48.5). Mycobacterium avium-intracellulare was found in 83%. Disseminated, fatal disease developed in 3 children. The remaining ones suffered from local infections, most often lymph-node or soft-tissue lesions. The observed incidence of bacteriologically confirmed diagnosis was estimated to represent approximately 40% of the 'true' number, if patients with diagnosis based on histological, clinical and epidemiological findings only were included. CONCLUSION: The present study indicates that BCG vaccination plays a role in protection against localized disease caused by atypical mycobacteria in children.