Spleen in the thorax: A case report on traumatic diaphragmatic rupture.

INTRODUCTION: Most of the cases of diaphragmatic rupture occur following abdominal trauma and herniation of abdominal organs into the thorax can occur. PRESENTATION OF CASE: Twenty three years old male presented after a blunt abdominal trauma following a road traffic accident. Investigations revealed a left sided diaphragmatic rupture with herniation of spleen and stomach into the left hemithorax. Surgical repair of the defect was done and splenectomy had to be done due to extensive splenic laceration. Two third of the spleen was found in the left hemithorax. DISCUSSION: Diagnosis of diaphragmatic rupture can be missed in cases of polytrauma. High clinical suspicion with aids from imaging modalities help in the diagnosis. In suspicion of herniation of abdominal contents into the thorax, one should be careful in insertion of chest tube in view of damaging the herniated organs. Treatment is surgical repair and reduction of herniated contents. CONCLUSION: Although a rare entity, diaphragmatic rupture can occur in cases of abdominal trauma. High clinical suspicion with imaging helps in the diagnosis.

Prevalence and incidence of surgical site infections in the European Union/European Economic Area: how do these measures relate?

BACKGROUND: In 2011-2012, the European Centre for Disease Prevention and Control (ECDC) initiated the first European point prevalence survey (PPS) of healthcare-associated infections (HCAIs) in addition to targeted surveillance of the incidence of specific types of HCAI such as surgical site infections (SSIs). AIM: To investigate whether national and multi-country SSI incidence can be estimated from ECDC PPS data. METHODS: In all, 159 hospitals were included from 15 countries that participated in both ECDC surveillance modules, aligning surgical procedures in the incidence surveillance to corresponding specialties from the PPS. National daily prevalence of SSIs was simulated from the incidence surveillance data, the Rhame and Sudderth (R&S) formula was used to estimate national and multi-country SSI incidence from the PPS data, and national incidence per specialty was predicted using a linear model including data from the PPS. FINDINGS: The simulation of daily SSI prevalence from incidence surveillance of SSIs showed that prevalence fluctuated randomly depending on the day of measurement. The correlation between the national aggregated incidence estimated with R&S formula and observed SSI incidence was low (correlation coefficient = 0.24), but specialty-specific incidence results were more reliable, especially when the number of included patients was large (correlation coefficients ranging from 0.40 to 1.00). The linear prediction model including PPS data had low proportion of explained variance (0.40). CONCLUSION: Due to a lack of accuracy, use of PPS data to estimate SSI incidence is recommended only in situations where incidence surveillance of SSIs is not performed, and where sufficiently large samples of PPS data are available.

Development of case vignettes for assessment of the inter-rater variability of national validation teams for the point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals.

BACKGROUND: In 2016-17 the European Centre for Disease Prevention and Control (ECDC) organized the second point prevalence survey (PPS) of healthcare-associated infections (HCAIs) and antimicrobial use in European acute care hospitals. This survey included a validation study to maximize the accuracy of case identification and classification. AIM: ECDC developed case vignettes to assess the performance of the national validation teams. METHODS: Case vignettes were developed by two medical doctors with experience in the management of HCAIs and antimicrobial stewardship. The case vignettes were based on actual clinical cases. The distribution of HCAIs among the case vignettes reflected the distribution of HCAIs in the previous PPS. All case vignettes were pilot-tested by three expert raters. Agreement among the expert raters was measured using kappa statistics. FINDINGS: Sixty case vignettes were developed. Twenty-nine of them were HCAI cases and 31 were cases without an HCAI. The inter-rater reliability using kappa statistics was 0.78 for the presence of HCAI and 0.89 for the antimicrobial use, respectively. CONCLUSION: The agreement between the expert raters was very good for antimicrobial use and good for the presence of HCAI. Case vignettes can be a tool to support standardization of surveillance, improving the validity and comparability of the data.

Attributable mortality of carbapenem-resistant Klebsiella pneumoniae infections in a prospective matched cohort study in Italy, 2012-2013.

BACKGROUND: In Italy, infections with carbapenem-resistant Klebsiella pneumoniae (CRKP) have increased markedly since 2009, creating unprecedented problems in healthcare settings and limiting treatment options for infected patients. AIM: To assess the attributable mortality due to CRKP in ten Italian hospitals and to describe the clinical characteristics of patients with an invasive CRKP and carbapenem-susceptible K. pneumoniae (CSKP) infection. METHODS: We conducted a matched cohort study, and calculated crude and attributable mortality for CRKP. The attributable mortality was calculated by subtracting the crude mortality rate of the patients with CSKP from the crude mortality rate of the patients with CRKP. We also described the clinical characteristics of CRKP and CSKP patients and analysed the determinants of mortality by using conditional Poisson regression. FINDINGS: The study included 98 patients, 49 with CRKP and 49 with CSKP. CRKP patients had undergone more invasive procedures and also tended to have more serious conditions, measured by higher Simplified Acute Physiology Score II. The attributable mortality of CRKP at 30 days was 41%. CRKP patients were three times more likely to die within 30 days [matched incidence rate ratio (mIRR): 3.0; 95% confidence interval (CI): 1.5-6.1]. Adjusting for potential confounders, the risk remained the same (adjusted mIRR: 3.0; 95% CI: 1.3-7.1). CONCLUSION: CRKP infection had a marked effect on patient mortality, even after adjusting for other patient characteristics. To control the spread of CRKP we recommend prioritization of control measures in hospitals where CRKP is found.

Measles outbreak on a cruise ship in the western Mediterranean, February 2014, preliminary report.

A measles outbreak occurred in February 2014 on a ship cruising the western Mediterranean Sea. Overall 27 cases were reported: 21 crew members, four passengers.For two cases the status crew or passenger was unknown. Genotype B3 was identified. Because of different nationalities of cases and persons on board,the event qualified as a cross-border health threat. The Italian Ministry of Health coordinated rapid response.Alerts were posted through the Early Warning and Response System.

Correlation between knowledge, attitude and practices on HIV and AIDS: cases from the Kathmandu Valley.

BACKGROUND: This study investigated the correlation between knowledge, attitude and practices on HIV and AIDS in the context of Nepal.The study was conducted among the 404 respondents; selected from the transport workers, garment factory workers, brick factory workers and health workers. METHODS: It was non-experimental cross sectional study based on descriptive as well as correlational research design. Simple random technique was used to select the respondents. Survey was conducted to collect the primary data and r value was used to analyze the correlation between variables. RESULTS: Finding shows that 391 (96.8%) respondents have heard about HIV and AIDS; among them 388 (95.8%) respondents were mentioned that they had knowledge of way of HIV transmission also. Total 50 out of 171 unmarried (29.2%) respondents had pre-marital sexual experience. It was found that only 71 (25.6%) respondents had used the condom during their first time sexual intercourse.There was significant association (p=.000) found between the knowledge on way of HIV transmission and occupation of respondents, similarly relationship found (r = .815, p = .000 (2-tailed) between marriage age and age of first time sexual intercourseof respondents. But there was no relationship (r = .097 and p =.106 (2-tailed) found between Knowledge on way of HIV transmission and sex with non-regular sex partners. CONCLUSIONS: Data showed that safer sex practices was low than the level of knowledge. The educational status of respondents shows the positive association with attitude towards the necessary to have knowledge of HIV and AIDS.

Antimicrobial prescribing in nursing homes in Finland: results of three point prevalence surveys.

PURPOSE: The purpose of this study was to analyse the Finnish European Surveillance of Antimicrobial Consumption (ESAC) nursing home (NH) point prevalence surveys' (PPSs) data in detail, i.e. to evaluate the variability in the prevalence of antimicrobial prescription between NHs and its relationship to resident characteristics. METHODS: All residents present in NHs for ≥ 24 h and receiving systemic antimicrobials on the day of the survey were included. Data on antimicrobials and their indications (prophylaxis or treatment, type of infection) were collected. RESULTS: Three PPSs were performed: eight NHs participated in April and November 2009 and nine in May-September 2010. In total, there were 5,691 eligible residents (range by survey, 1,706-2,320; range by NH, 60-688), 716 (12.6 %; range by NH, 3.2-33.3 %) of which received at least one antimicrobial and 40 residents received two. The most common indication was prophylaxis (487/5,691, 8.6 %), mainly for urinary tract infection (UTI) (460/487, 94.5 %). Of the residents, 269/5,691 (4.7 %, range by NH, 1.5-6.0 %) were on antimicrobial treatment. UTI (119/269; 44.2 %) was the most common indication for treatment. Methenamine (306/756, 40.5 %) was the most commonly used antimicrobial, followed by trimethoprim (13.6 %) and pivmecillinam (11.0 %). In the eight NHs participating in all three surveys, the prevalence of residents receiving antimicrobials decreased from 16.6 to 9.7 %. CONCLUSIONS: Antimicrobial use was common in NHs in Finland and most were used for UTI prophylaxis and treatment. The usage, however, varied among NHs and tended to decrease during the surveys. NHs may benefit from antimicrobial stewardship interventions focused on UTI.

Reduction in Clostridium difficile infections in Finland, 2008-2010.

BACKGROUND: In January 2008, laboratory-based surveillance of Clostridium difficile was initiated as a part of the Finnish National Infectious Disease Register (NIDR) and enhanced surveillance of hospitalized patients with C. difficile-associated infections (CDI) by the Finnish Hospital Infection Programme (SIRO). AIM: To present data from the first three years. METHODS: All laboratories reported C. difficile findings positive for toxin production from stools to NIDR. Surveillance of hospitalized patients with CDI was conducted using the interim case definitions of the European Centre for Disease Prevention and Control for CDI, origin and severe case of CDI. In all, 16 acute care hospitals from 10 of the 21 healthcare districts (HDs) participated in SIRO during 2008-2010. Clinical microbiology laboratories were asked to send isolates from severe cases and persistent outbreaks to the national reference laboratory for genotyping. FINDINGS: The annual incidence rate of CDIs decreased by 24%, from 119 per 100,000 population in 2008 to 90 per 100,000 in 2010. The decrease occurred in 13/21 (62%) HDs (range of decrease by HD: 2-51%). The nosocomial rate decreased 26%, from 0.31 to 0.23 per 1000 patient-days, and occurred in about half of the hospitals that participated in SIRO. During 2008-2010, 17 HDs sent C. difficile specimens for typing. Ribotype 027 was found in eight HDs, all showing values above the mean or increasing population-based incidence rates of CDIs. CONCLUSIONS: Population-based surveillance of CDIs and enhanced surveillance of nosocomial cases showed reduction in CDIs, but success in controlling the disease varied between regions.

Dynamic estimation of cardiac repolarization characteristics during hypoglycemia in healthy and diabetic subjects.

Hypoglycemia is known to affect the repolarization characteristics of the heart, but the mechanisms behind these changes are not completely understood. We analyzed repolarization characteristics continuously from 22 subjects during normoglycemic period, transition period (blood glucose concentration decreasing) and hypoglycemic period from nine healthy controls (Healthy), six otherwise healthy type 1 diabetics (T1DM) and seven type 1 diabetics with disease complications (T1DMc). An advanced principal component regression (PCR)-based method was used for estimating ECG parameters beat-by-beat, and thus, continuous comparison between the repolarization characteristics and blood glucose values was made. We observed that hypoglycemia related ECG changes in the T1DMc group were smaller than changes in the Healthy and T1DM groups. We also noticed that when glucose concentration remained at a low level, the heart rate corrected QT interval prolonged progressively. Finally, a few minutes time lag was observed between the start of hypoglycemia and cardiac repolarization changes. One explanation for these observations could be that hypoglycemia related hormonal changes have a significant role behind the repolarization changes. This could explain at least the observed time lag (hormonal changes are slow) and the lower repolarization changes in the T1DMc group (hormonal secretion lowered in long duration diabetics).

Hypoglycemia detection based on cardiac repolarization features.

Hypoglycemia is known to affect repolarization characteristics of the heart. These changes are shown from ECG by prolonged QT-time and T-wave flattening. In this study we constructed a classifier based on these ECG parameters. By using the classifier we tried to detect hypoglycemic events from measurements of 22 test subjects. Hypoglycemic state was achieved using glucose clamp technique. Used test protocol consisted of three stages: normoglycemic period, transition period (blood glucose concentration decreasing) and hypoglycemic period. Subjects were divided into three groups: 9 healthy controls (Healthy), 6 otherwise healthy type 1 diabetics (T1DM) and 7 type 1 diabetics with disease complications (T1DMc). Detection of hypoglycemic event could be made passably from 15/22 measurements. In addition, we found that detection process is easier for healthy and T1DM groups than T1DMc group diabetics because in T1DMc group subjects' have lower autonomic response to hypoglycemic events. Also we noticed that changes in ECG occurs few minutes after blood glucose is decreased below 3.5 mmol/1.

Repeated prevalence surveys of healthcare-associated infections in Finnish neonatal intensive care units.

More than one-fifth of patients in neonatal intensive care units (NICUs) have been reported to suffer from healthcare-associated infections (HAIs). The aim of this study was to assess prevalence, onset and types of HAI in Finnish NICU patients. We conducted six monthly point-prevalence surveys in all Finnish NICUs (N=24) between November 2008 and May 2009. For all patients present on the day of survey, the underlying conditions and invasive devices or treatments used on the day of survey and during the preceding six days were recorded on standardised forms. All HAIs active or under treatment on the day of survey were included. HAIs were categorised into early-onset (onset within the first 72 h of life) and late-onset (onset after the first 72 h of life) infections. During the six surveys, 1281 forms were obtained. Among them, 164 HAIs in 163 patients were identified (overall prevalence, 13%); 63 (38%) of the HAIs were late-onset infections (prevalence, 6.5%). Main types of HAI were clinical sepsis, laboratory-confirmed bloodstream infection, conjunctivitis, and pneumonia. Of all HAIs, 24% were microbiologically confirmed. Patients with birth weight <1500 g suffered from late-onset HAIs more commonly than those with birth weight > or =1500 g (10% vs 4%, P<0.01). Also hospitalisation of > or =7 days was associated with increased prevalence of HAI (8% vs 3%, P=0.01). The study was useful in terms of increasing awareness of HAI in the participating NICUs. These results can be used to strengthen incidence surveillance of HAIs in the Finnish NICUs in the future.

Kalman smoother based time-varying spectrum estimation of EEG during single agent propofol anesthesia.

A time-varying parametric spectrum estimation method for analyzing EEG dynamics is presented. EEG signals are first modeled as a time-varying auto-regressive stochastic process and the model parameters are estimated recursively with a Kalman smoother algorithm. Time-varying spectrum estimates are then obtained from the estimated parameters. The proposed method was applied to measurements collected during low dose propofol anesthesia. The method was able to detect changes of event related (de)synchronization type elicited by verbal command.

Cluster of imported malaria from Gambia in Finland--travellers do not listen to given advice.

Twelve Finnish tourists contracted falciparum malaria from Gambia in the period between 3 and 27 November 2008. None of them had used adequate malaria chemoprophylaxis.

Antibiotic susceptibility patterns of community- and hospital-acquired Staphylococcus aureus and Escherichia coli in Estonia.

This study compares the susceptibility patterns of Staphylococcus aureus and Escherichia coli isolated from patients with hospital-acquired and outpatient infections. A total of 902 isolates of S. aureus and 1,114 of E. coli were collected in five different Estonian medical centers between January 1997 and November 1997. Strains were grouped into two different categories, depending on whether they had been obtained from inpatients or outpatients. Compared to S. aureus strains isolated from inpatients, the strains from outpatients were significantly more resistant to erythromycin (25.3% vs. 17.9%), tetracycline (33.5% vs. 22.4%) and trimethoprim-sulfamethoxazole (13.9% vs. 7.9%). The overall prevalence of oxacillin-resistant S. aureus was 10.4%, with no significant differences noted between isolates recovered from inpatients and outpatients. In the case of E. coli, significantly more isolates from inpatients (42.8%) than from outpatients (34.4%) were ampicillin-resistant. Inpatient isolates of E. coli were also more resistant to cefotaxime (9.3%) and nitrofurantoin (11.2%) than outpatient strains (0% and 3.1%, respectively). Analysis showed remarkable co-resistance among both inpatient and outpatient strains of S. aureus and E. coli. Multiple resistant S. aureus and E. coli strains represented 15.1% and 17.3%, respectively of the organisms examined in this study. With respect to E. coli, significantly more multiresistant isolates were found in inpatient than outpatient isolates (20.4% vs. 8.9%). Our results indicate that the distinction between community-acquired and hospital infections due to S. aureus and E. coli may not be valid in Estonia.

Antibacterial susceptibility of intestinal lactobacilli of healthy children.

We investigated the antibacterial susceptibility of intestinal lactobacilli of Estonian and Swedish children aged 1-2 y. Sixty isolates (10 species) of lactobacilli (29 Estonian and 31 Swedish strains) were tested against ampicillin, cefuroxime, cefoxitin, gentamicin, ciprofloxacin, tetracycline, vancomycin, metronidazole and erythromycin. We observed that intestinal lactobacilli do not display uniform susceptibility to antibiotics. None of the tested lactobacilli was resistant to ampicillin, gentamicin and erythromycin. Single strains were resistant to cefuroxime and tetracycline, about half of the strains to cefoxitin and ciprofloxacin and 73% of the strains to vancomycin. All studied strains were resistant to metronidazole. Most of the strains investigated were resistant to two or three antibiotics out of nine. Some differences in susceptibility were noted between strains belonging to different fermentation types. No differences in susceptibility were found between Estonian and Swedish isolates. Metronidazole, cefoxitin, vancomycin and ciprofloxacin seem to be safer for gastrointestinal lactoflora than other tested antibiotics in both countries.

Automatic detection of frequency changes depends on auditory stimulus intensity.

OBJECTIVE: A cortical cognitive auditory evoked potential, mismatch negativity (MMN), reflects automatic discrimination and echoic memory functions of the auditory system. For this study, we examined whether this potential is dependent on the stimulus intensity. DESIGN: The MMN potentials were recorded from 10 subjects with normal hearing using a sine tone of 1000 Hz as the standard stimulus and a sine tone of 1141 Hz as the deviant stimulus, with probabilities of 90% and 10%, respectively. The intensities were 40, 50, 60, 70, and 80 dB HL for both standard and deviant stimuli in separate blocks. RESULTS: Stimulus intensity had a statistically significant effect on the mean amplitude, rise time parameter, and onset latency of the MMN. CONCLUSION: Automatic auditory discrimination seems to be dependent on the sound pressure level of the stimuli.

[The quantitative composition of lactoflora and a method for its determination]. / Kolichestvennyi sostav laktoflory i metodika ego opredeleniia.

A newly developed method for the determination of the quantitative composition of lactoflora is described. According to this method, the material under study is subcultured, after its primary inoculation into solid selective medium M P C - 4, placed into fructose- and sorbitol-containing media by the replica method. The characterization of fecal lactoflora of young healthy persons, made with the use of the above-mentioned new method, is presented.

A limited survey of fumonisins in corn and corn-based products in Asian countries.

Natural occurrence of fumonisins B1 (FB1) and B2 (FB2), a promoter for hepato-carcinogenesis, was investigated in corn and corn - based products sampled in Japan, Nepal, and China by high - performance liquid chromatographic method. From the 9 imported corn kernel and 6 gluten feed samples, FB1 was detected in 8 corn (0.6 ∼ 4.1µg/g) and all gluten feed (0.3 ∼ 2.4µg/g) samples, while FB2 was found in the same corn (0.3 ∼ 10µg/g) and 3 gluten feed (0.8 ∼ 8.5µg/g) samples. ELISA analysis also revealed the contamination of aflatoxin B1 in 2 corn and all gluten feed samples along with fumonisins. Of 17 corn grit samples, 14 and 5 samples were contaminated with fumonisin B1 and B2, with maximum levels of 2.6 and 2.8µg/g, respectively. As for corn-based foodstuffs marketed in Japan, no significant contamination of fumonisins was observed. Among 24 corn kernel samples in Nepal, 12 and 7 samples were positive for FB1 and FB2, and averaged to 0.6 and 1.6µg/g, respectively. One sample showed the highest fumonisin contents as 4.6 and 5.5µg/g, respectively. In corn samples harvested at Shanghai and Beijing, China, FB1 and FB2 were detected in various concentrations. Mycological survey has also revealed the presence of a fumonisin - producing fungus in a crop field of Japan. These findings have for the first time demonstrated high levels of contamination of fumonisins in corn and corn - based products in Asian countries. Natural co - occurrence of fumonisins and aflatoxin B1 was also detected in raw materials for mixed feed.