Comparison of disease severity in glaucoma patients identified by screening in the 1990s and in routine clinical care in the 2010s in Sweden.

BACKGROUND AND PURPOSE: In a previous study comparing the amount of visual field damage at presentation in patients having open-angle glaucoma (OAG) identified through screening and in patients diagnosed in routine clinical practice in the 1990s, the damage was considerably worse in the clinically diagnosed patients. In the present study we compare visual field damage at presentation in the same 402 screened patients with that seen in 281 newly detected previously untreated patients clinically diagnosed in the 2010s. METHODS: The perimetric visual field index mean deviation (MD) was compared in the two groups of patients. RESULTS: In the clinical patients diagnosed with bilateral visual field damage the median MD was -5.1 dB in the better eye and -13.0 dB in the worse eye. In the screened patients the median MD in the better eye was -6.5 dB and -11.5 dB in the worse eye. The differences between the clinical and screened patients were non-significant, p = 0.28 and p = 0.67 respectively. More clinical patients had severe visual field loss, defined as MD less than -20 dB, in the worse eye than in the screened patients, 18.5% versus 12.7% respectively, p = 0.037. CONCLUSION: The visual field damage at presentation in clinically diagnosed OAG patients has improved in the past 20 years, but the proportion of patients with severe visual field loss in at least one eye, almost 20%, is still unacceptably high considering that severe visual field damage at presentation is the most important risk factor for later development of glaucoma blindness.

EUCAST disc diffusion criteria for the detection of mecA-Mediated ß-lactam resistance in Staphylococcus pseudintermedius: oxacillin versus cefoxitin.

OBJECTIVES: Until recently, the European Committee on Antimicrobial Susceptibility Testing (EUCAST) recommended the cefoxitin disc to screen for mecA-mediated ß-lactam resistance in Staphylococcus pseudintermedius. A recent study indicated that cefoxitin was inferior to oxacillin in this respect. We have re-evaluated cefoxitin and oxacillin discs for screening for methicillin resistance in S. pseudintermedius. METHODS: We included 224 animal and human S. pseudintermedius isolates from Europe (n = 108) and North America (n = 116), of which 109 were mecA-positive. Disc diffusion was performed per EUCAST recommendations using 30-µg cefoxitin and 1-µg oxacillin discs from three manufacturers and Mueller-Hinton agar from two manufacturers. RESULTS: Cefoxitin inhibition zones ranged from 6 to 33 mm for mecA-positive S. pseudintermedius (MRSP) and from 29 to 41 mm for mecA-negative S. pseudintermedius (MSSP). The corresponding oxacillin zone intervals were 6-20 mm and 19-30 mm. For cefoxitin 16% (95% CI 14.8-18.0%) of the isolates were in the area where positive and negative results overlapped. For oxacillin the corresponding number was 2% (1.6-2.9%). For oxacillin a breakpoint of susceptible (S) ≥ 20 mm and resistant (R) <20 mm resulted in only 0.4% and 1.1% very major error and major error rates respectively. CONCLUSIONS: This investigation confirms that the 1-µg oxacillin disc predicts mecA-mediated methicillin resistance in S. pseudintermedius better than the 30-µg cefoxitin disc. For a 1-µg oxacillin disc we propose that 20 mm should be used as cut off for resistance, i.e. isolates with a zone diameter <20 mm are resistant to all ß-lactam antibiotics except those with activity against methicillin-resistant staphylococci.

Local facial cutaneous vasoconstriction: an unusual complication of inhaled racemic epinephrine in a neonate.

A term infant treated for post-extubation stridor with nebulized racemic epinephrine developed localized facial blanching due to cutaneous absorption of the aerosolized vasoconstrictor. Local application of heat restored circulation to the afflicted area. This complication of a commonly used medication is not previously reported in the medical literature and has the potential for severe sequelae.

Characterization of plasmid-mediated AmpC-producing E. coli from Swedish broilers and association with human clinical isolates.

A selection of plasmid-mediated AmpC-producing Escherichia coli isolates carrying blaCMY-2 from Swedish broilers were characterized to establish their relatedness to and a possible overlap with human clinical E. coli isolates. The results showed diversity among the E. coli isolated from broilers, indicating that the spread in the population was not due to one strain. However, only one type of plasmid belonging to replicon type incK was identified. Furthermore, there were no indications of spread of blaCMY-2 E. coli isolates from broilers to human clinical settings, although Swedish broilers may be a source of blaCMY-2 and/or the plasmid carrying blaCMY-2 .

Improved understanding of key elements governing the toxicity of energy ash eluates.

Ash from incinerated waste consists mainly of a complex mixture of metals and other inorganic elements and should be classified based on its inherent hazardous effects according to EUs Waste Framework Directive. In a previous study, we classified eight eluates from ash materials from Swedish incineration plants, both chemically and ecotoxicologically (using bacteria, algae, crustacean and fish). Based on measured concentrations in the eluates together with literature acute toxicity data on the crustacean Nitocra spinipes we identified six elements (i.e. Zn, Cu, Pb, Al, K and Ca) potentially responsible for the observed ecotoxicity. However, comparing the used test methods with N. spinipes, the acute test was relatively insensitive to the eluates, whereas the (sub)chronic test (i.e. a partial life cycle test, investigating larval development ratio) was very sensitive. The overall aim of this follow-up study was to verify if the pinpointed elements could be responsible for the observed (sub)chronic toxicity of the eluates. Individual effect levels (i.e. NOEC values) for these six elements were therefore generated using the (sub)chronic test. Our results show that for six of the eight eluates, the observed ecotoxicity can be explained by individual elements not classified as ecotoxic (Al, K and Ca) according to chemical legislation. These elements will not be considered using summation models on elements classified as ecotoxic in solid material for the classification of H-14, but will have significant implications using ecotoxicological test methods for this purpose.

Tumour recurrence and enlargement in patients with craniopharyngioma with and without GH replacement therapy during more than 10 years of follow-up.

OBJECTIVE: Most patients who have been treated for craniopharyngioma (CP) are GH deficient (GHD). GH replacement therapy (GHRT) may stimulate tumour regrowth; and one of the concerns with long-term GHRT is the risk of tumour progression. Therefore, the objective was to study tumour progression in CP patients on long-term GHRT. DESIGN: Case-control study. PATIENTS AND METHODS: The criteria for inclusion of cases were: i) GHD caused by CP; ii) GHRT >3 years; and iii) regular imaging. This resulted in 56 patients (mean age at diagnosis 25±16 years) with a mean duration of GHRT of 13.6±5.0 years. As controls, 70 CP patients who had not received GHRT were sampled with regard to follow-up, gender, age at diagnosis and initial radiation therapy (RT). RESULTS: The 10-year tumour progression-free survival rate (PFSR) for the entire population was 72%. There was an association (hazard ratio, P value) between PFSR and initial RT (0.13, 0.001) and residual tumour (3.2, 0.001). The 10-year PFSR was 88% for the GHRT group and 57% for the control group. Substitution with GHRT resulted in the following associations to PFSR: GHRT (0.57, 0.17), initial RT (0.16, <0.001), residual tumour (2.6, <0.01) and gender (0.57, 0.10). Adjusted for these factors, the 10-year PFSR was 85% for the GHRT group and 65% for the control group. CONCLUSIONS: In patients with CP, the most important prognostic factors for the PFSR were initial RT and residual tumour after initial treatment. Long-term GHRT did not affect the PFSR in patients with CP.

Genetic diversity among VRE isolates from Swedish broilers with the coincidental finding of transferrable decreased susceptibility to narasin.

AIMS: In this study, the molecular diversity among clones of vancomycin resistant Enterococcus faecium with vanA gene (VRE) is investigated. The aims were to better understand why one clone is predominant in Swedish broiler production and to better assess the potential for zoonotic gene transfer from the different clones. METHODS AND RESULTS: Twenty-six isolates were separated into 11 clones. Vancomycin resistance was transferrable from the predominant and five minority clones. Decreased susceptibility to narasin was co-transferred with vancomycin resistance in four clones, including the predominant. The plasmid addiction system axe-txe was not detected, and the ω-ε-ζ system was detected in one of the minority clones but was not co-transferred with vancomycin resistance. CONCLUSIONS: The results do not explain why one clone is predominant among VRE in Swedish broiler production but confirms the potential for zoonotic spread of vancomycin resistance genes. The near absence of investigated plasmid addiction systems indicates that they do not play an important role in the epidemiology of VRE in Swedish broiler production. The finding that decreased susceptibility to narasin can be co-transferred with the vanA gene indicates that the use of narasin might play a role in the persistence of vancomycin resistance in enterococci colonizing Swedish broilers. SIGNIFICANCE AND IMPACT OF THE STUDY: This is, to our knowledge, the first report of transferrable decreased susceptibility to narasin.

Inter-batch contamination and potential sources of vancomycin-resistant Enterococcus faecium on broiler farms.

1. Vancomycin-resistant Enterococcus faecium (VRE(fm)) has recently spread among Swedish broiler farms. The objectives were to investigate VRE(fm) persistence within barns between flocks, and to determine whether day-old chicks, feed or forklift trucks used for loading crates could be identified as a means of transmission. 2. Faeces were collected for selective culture from 12 farms (9 culture-positive, 3 culture-negative as determined by prior monitoring), and samples were collected from the barn environment before and after cleaning and disinfection, from forklift tyres, hatcheries and feed. 3. VRE(fm) was isolated only from previously known VRE(fm)-positive farms. The proportions of culture-positive environmental samples were 75% (9 out of 9 farms) prior to and 31% (7 out of 9 farms) after cleaning/disinfection. Five out of 6 samples from forklift tyres were culture-positive. No VRE(fm) were isolated from feed or hatcheries. The majority of 27 vanA gene positive isolates showed similar banding patterns by SmaI restriction digestion and pulse-field gel electrophoresis. No consistent differences were observed regarding management between VRE(fm)-positive and negative farms. 4. We conclude that VRE(fm) contaminates barns and remains present between flocks. Forklift trucks are one possible means of transmission between farms.

Optic disc classification by the Heidelberg Retina Tomograph and by physicians with varying experience of glaucoma.

PURPOSE: To compare the diagnostic accuracy of the Heidelberg Retina Tomograph's (HRT) Moorfields regression analysis (MRA) and glaucoma probability score (GPS) with that of subjective grading of optic disc photographs performed by ophthalmologists with varying experience of glaucoma and by ophthalmology residents. METHODS: Digitized disc photographs and HRT images from 97 glaucoma patients with visual field defects and 138 healthy individuals were classified as either within normal limits (WNL), borderline (BL), or outside normal limits (ONL). Sensitivity and specificity were compared for MRA, GPS, and the physicians. Analyses were also made according to disc size and for advanced visual field loss. RESULTS: Forty-five physicians participated. When BL results were regarded as normal, sensitivity was significantly higher (P<5%) for both MRA and GPS compared with the average physician, 87%, 79%, and 62%, respectively. Specificity ranged from 86% for MRA to 97% for general ophthalmologists, but the differences were not significant. In eyes with small discs, sensitivity was 75% for MRA, 60% for the average doctor, and 25% for GPS; in eyes with large discs, sensitivity was 100% for both GPS and MRA, but only 68% for physicians. CONCLUSION: Our results suggest that sensitivity of MRA is superior to that of the average physician, but not that of glaucoma experts. MRA correctly classified all eyes with advanced glaucoma and showed the best sensitivity in eyes with small optic discs.

Founding physicks: the lives and times of the physician signers of the Charters of Freedom.

The Declaration of Independence had 56 signers, four of whom were physicians. The constitutional convention in 1787 had 55 delegates and 39 of them signed the Constitution. Three of these delegates were physicians and two signed the document. The Bill of Rights was a product of the first Federal Congress and three of its members were physicians. This paper presents a biographic outline of these physicians and their contributions to society, within a context of contemporary medicine during the first 25 years of the USA.

An ecotoxicological approach for hazard identification of energy ash.

Within the EU, ash should be classified by its inherent hazardous effects under criterion H-14 (ecotoxic) in the Directive on waste (2008/98/EC). Today, however, there are no harmonized quantitative criterions for such a classification, but it is stated that biological test systems can be used. In this study seven ash materials were leached and characterized, both biologically and chemically. The objectives were to evaluate if (a) clear concentration-response relationships could be achieved for the selected toxicity tests (bacteria, algae, crustacean and fish), (b) some test(s) are generally more sensitive and (c) the toxic responses were consistent with the chemical analyzes. Interestingly, our results indicate that high concentrations of non-hazardous components (Ca, K) influenced the toxicity of almost all ash eluates, whereas hazardous components (e.g. Zn, Pb) only influenced the toxicity of the eluates ranked as most hazardous. If considering both hazardous and non-hazardous substances, the observed toxic responses were relatively consistent with the chemical analyzes. Our results further showed that the (sub)chronic tests were much more sensitive than the acute tests. However, the use of extrapolation factors to compensate for using the less sensitive acute tests will likely lead to either over- or underestimations of toxicity. Our recommendation is therefore that classification of waste according to H-14 should be based on (sub)chronic test data. Finally, given that treatment of the eluates prior to toxicity testing has a major significance on the concentration and speciation of released substances, further studies are needed in order to propose a relevant testing scheme.

Focusing on glaucoma progression and the clinical importance of progression rate measurement: a review.

PURPOSE: This review aims to provide guidance in managing glaucoma patients more effectively. It focuses on the importance of detecting progression and measuring its rate within the management of primary open-angle glaucoma today. Recent findings strongly indicate that continued monitoring of visual fields (VFs) and reassessment of target intraocular pressures (IOPs) depending on VF progression rates are mandatory in the management of glaucoma. METHODS: Data on glaucoma progression from older as well as most recent literature findings are summarized in this article. In addition, the article elaborates on the scientific content from a series of lectures given by experts in the field during several international symposia on 'rate of progression' in 2008. RESULTS: This review summarizes key findings on the natural history of glaucoma and known factors for disease progression. It highlights the visual function changes observed as glaucoma progresses and discusses disease impact on patients' quality of life. Findings support the need to obtain information on rate of progression and its importance for clinical management. Practical ways to measure rate of progression are given by new software options to help measure major parameters. Finally, on the basis of a patient's individual rate of progression therapeutic options are assessed, such as maximum medical therapy with fixed combinations. CONCLUSIONS: Estimating a patient's individual rate of VF progression by using newly developed analyses will be helpful to forecast the potential future development of the glaucoma. An individualized treatment approach then requires that in patients in whom the risk of becoming visually impaired or blind during their lifetime is higher, a more intensive medical IOP-lowering therapy such as fixed combinations can be considered as treatment option.

Comparing progression of non-functioning pituitary adenomas in hypopituitarism patients with and without long-term GH replacement therapy.

OBJECTIVE: An important safety issue with GH replacement therapy (GHRT) in hypopituitary patients with a history of a pituitary adenoma is the risk for tumour recurrence or enlargement. Design Case-control study. SUBJECTS AND METHODS: We studied tumour progression rate in 121 patients with hypopituitarism on the basis of non-functioning pituitary adenomas (NFPA) receiving long-term GHRT. A group of 114 NFPA patients not receiving GHRT who were matched in terms of duration of follow-up, gender, age, age at diagnosis and radiotherapy status were used as a control population. The average duration of GHRT was 10+/-4 years (range 2-17). RESULTS: In patients with a known residual adenoma, 63% had no detectable enlargement of tumour during the study. In patients who had no visible residual tumour prior to GHRT, 90% did not suffer from recurrence. In total, the 10-year tumour progression-free survival rate in patients with NFPA receiving GHRT was 74%. In the control population not receiving GHRT, the 10-year progression-free survival rate was 70%. Radiotherapy as part of the initial tumour treatment reduced the rate of tumour progression in both GHRT and non-GHRT patients to a similar extent. CONCLUSIONS: The rate of tumour progression was similar in this large group of GHRT patients and the control population not receiving GHRT. Our results provide further support that long-term use of GH replacement in hypopituitarism may be considered safe in patients with residual pituitary adenomas.

Spread without known selective pressure of a vancomycin-resistant clone of Enterococcus faecium among broilers.

OBJECTIVES: The aim of this paper was to describe an increased occurrence of vancomycin-resistant enterococci (VRE) in Swedish broilers since 2000 and to investigate the genetic relatedness of isolates. METHODS: Caecal content from slaughtered broilers was cultured for VRE on medium supplemented with vancomycin (16 mg/L). Species identification, antibiotic susceptibility determination, vancomycin resistance genotyping, multilocus sequence typing (MLST) and characterization of Tn1546 were performed. RESULTS: The proportion of VRE-positive samples increased gradually from <1% in 2000 to slightly over 40% in 2005. Between 2005 and 2006, the proportion of VRE-positive samples decreased and between 2006 and 2007, it was stable at just below 30%. All isolates tested were Enterococcus faecium and carried the vanA gene. A majority of the isolates had similar antibiograms, the same MLST sequence type and Tn1546 transposon. CONCLUSIONS: The proportion of VRE-positive samples from broilers has increased since 2000, and this is due to the spread of one major clone. Moreover, this has taken place in an environment without any obvious selective pressure.

Microbial aetiology of acute clinical mastitis and agent-specific risk factors.

A nation wide study on the microbial aetiology of cases of acute clinical mastitis in Swedish dairy cows was conducted with the aim to investigate changes in the microbial panorama compared to a previous study performed 1994-1995. Another aim was to investigate some agent-specific environmental and individual risk factors. Milk samples were collected from 987 udder quarter cases from 829 cows during six 2-month periods from May 2002 to April 2003, and data on risk factors and demography were collected at sampling by means of a questionnaire. In total, 1056 bacteriological diagnoses were made. The most frequently isolated bacterial species was Staphylococcus aureus constituting 21.3% of the diagnoses, followed by Escherichia coli (15.9%), Streptococcus dysgalactiae (15.6%), Streptococcus uberis (11.1%), coagulase-negative staphylococci (6.2%), Arcanobacterium pyogenes (6.1%) and Klebsiella spp. (4.2%). Samples with no growth or contamination constituted 10.6% and 4.5% of the diagnoses, respectively. A major shift in the panorama of udder pathogens was not observed compared to the survey in 1994-1995. Isolation of Klebsiella spp. was strongly associated with the use of sawdust as bedding material. On the other hand, using sawdust as bedding reduced the risk of isolating S. uberis relative to using straw or peat. The risk of isolating E. coli increased with increasing milk yield and was higher in loose housing systems than in tie stalls. Isolation of S. aureus was associated with tie stalls, and A. pyogenes with low yielding cows and teat lesions. S. dysgalactiae infections were also associated with teat lesions.

Comparison of a commercialized phenotyping system, antimicrobial susceptibility testing, and tuf gene sequence-based genotyping for species-level identification of coagulase-negative staphylococci isolated from cases of bovine mastitis.

In order to evaluate the usefulness of some phenotypic and genotypic methods for species identification of coagulase-negative staphylococci (CNS), isolates were obtained from bovine cases of clinical and sub-clinical mastitis from different geographical areas in Sweden. By using the Staph-Zym test, antimicrobial susceptibility testing, and sequencing of part of the CNS tuf gene and, when needed, part of the 16S rRNA gene we characterized 82 clinical isolates and 24 reference strains of 18 different species of staphylococci. The genotypic methods identified nine different species of CNS among the 82 milk isolates. A comparison with results obtained by tuf gene sequencing showed that Staph-Zym correctly identified CNS reference strains to species level more often than bovine milk CNS isolates (83% and 61%, respectively). In addition, tests supplementary to the Staph-Zym were frequently needed in both groups of isolates (50% of reference strains and 33% of milk isolates) to obtain an identification of the strain. It is notable that Staph-Zym judged two isolates as CNS, although they belonged to other species, could not give a species name in 11% of the bovine CNS isolates, and gave 28% of the isolates an incorrect species name. The present study indicates that the studied phenotypic methods are unreliable for identification of CNS from bovine intra-mammary infections.

Oral budesonide for maintenance of remission of Crohn's disease: a pooled safety analysis.

BACKGROUND: Budesonide exhibits similar efficacy to systemic glucocorticosteroids (GCSs) in Crohn's disease (CD), but with fewer adverse events (AEs). Aim To evaluate budesonide's safety profile in CD patients, in particular, incidences of clinically important AEs known to be associated with systemic GCSs. METHODS: Five 1-year, double-blind, placebo-controlled trials evaluating budesonide for mild-to-moderate CD were pooled for analysis. RESULTS: The highest incidence rates of AEs were gastrointestinal- and endocrine systems-related in both groups (budesonide 6 mg/day, n = 208; placebo, n = 209). Incidence rates were similar, except for higher incidence of endocrine disorders in budesonide versus placebo patients (P = 0.0042) caused by a higher overall occurrence of cutaneous GCS symptoms (P = 0.0036) in the budesonide group; differences in individual symptoms were nonsignificant. Percentage of patients with normal adrenal function was significantly lower at 13 weeks (three of five studies), but not at 52 weeks (two studies) in the budesonide versus placebo groups. Occurrence of clinically important or serious AEs associated with systemic GCSs, including sepsis, cataracts, adrenal insufficiency was rare and similar between groups. CONCLUSIONS: Budesonide treatment for up to 1 year is well-tolerated in CD patients, with an AE profile similar to placebo and only rare occurrences of clinically important AEs associated with systemic GCSs.

Practical recommendations for measuring rates of visual field change in glaucoma.

To date, there has been a lack of evidence-based guidance on the frequency of visual field examinations required to identify clinically meaningful rates of change in glaucoma. The objective of this perspective is to provide practical recommendations for this purpose. The primary emphasis is on the period of time and number of examinations required to measure various rates of change in mean deviation (MD) with adequate statistical power. Empirical data were used to obtain variability estimates of MD while statistical modelling techniques derived the required time periods to detect change with various degrees of visual field variability. We provide the frequency of examinations per year required to detect different amounts of change in 2, 3 and 5 years. For instance, three examinations per year are required to identify an overall change in MD of 4 dB over 2 years in a patient with average visual field variability. Recommendations on other issues such as examination type, strategy and quality are also made.

The spread of apomixis and its effect on resident genetic variation.

In a simulation model we investigated how much of the initial genetic variation that is retained in a population after a dominant mutation has brought apomixis to fixation in it. A marker allele associated with the apomixis mutation is generally retained after the fixation of apomixis, particularly if the two alleles are closely linked. The spread of asexuality, however, normally leads to almost no loss of genetic variation, neither with respect to cytotypes nor with respect to genotypes. This holds for large populations and apomixis mutants with strong pollen production. In smaller populations, and with apomicts with reduced pollen production, the outcome is more variable, ranging from no genetic variation retained to only weakly reduced variability compared with the initial state. These results help explain the high genetic variability in many apomicts. They also imply that natural selection will have many genotypes to act on even after the spread of apomixis.

Detection of growth hormone abuse in sport.

OBJECTIVE: To develop a test for GH abuse in sport. DESIGN: A double blind placebo controlled study of one month's GH administration to 102 healthy non-competing but trained subjects. Blood levels of nine markers of GH action were measured throughout the study and for 56 days after cessation of GH administration. Blood samples were also taken from 813 elite athletes both in and out of competition. RESULTS: GH caused a significant change in the nine measured blood markers. Men were more sensitive to the effects of GH than women. IGF-I and N-terminal extension peptide of procollagen type III were selected to construct formulae which gave optimal discrimination between the GH and placebo groups. Adjustments were made to account for the fall in IGF-I and P-III-P with age and the altered distribution seen in elite athletes. Using a cut-off specificity of 1:10,000 these formulae would allow the detection of up to 86% of men and 60% of women abusing GH at the doses used in this study. CONCLUSIONS: We report a methodology that will allow the detection of GH abuse. This will provide the basis of a robust and enforceable test identifying those who are already cheating and provide a deterrent to those who may be tempted to do so.