Outbreak of hospital-acquired gastroenteritis and invasive infection caused by Listeria monocytogenes, Finland, 2012.

During one week in July 2012, two patients from the same ward at the municipal hospital in Vaasa, Finland, were diagnosed with septicaemia caused by Listeria monocytogenes. An outbreak investigation revealed eight concomitant cases of febrile gastroenteritis caused by L. monocytogenes on the same ward. Median age of the cases was 82 years and median incubation time for listerial gastroenteritis was 21 h (range 9-107). An additional 10 cases of invasive listeriosis caused by the same outbreak strain were identified across the whole country during the summer of 2012. Environmental investigation at the affected municipal hospital ward revealed ready-sliced meat jelly as the suspected source of the infection. During inspection of the meat jelly production plant, one pooled sample taken from a floor drain and a trolley wheel in the food processing environment was positive for the outbreak strain of L. monocytogenes. After the producer stopped the production of meat jelly, no further cases of listeriosis with the outbreak strain were identified via nationwide surveillance.

Raw grated beetroot linked to several outbreaks of sudden-onset gastrointestinal illness, Finland 2010.

In 2010, 7/44 (16%) reported foodborne outbreaks in Finland were linked with raw beetroot consumption. We reviewed data from the national outbreak registry in order to hypothesize the aetiology of illness and to prevent further outbreaks. In the seven outbreaks, 124 cases among 623 respondents were identified. Consumption of raw beetroot was strongly associated with gastrointestinal illness (relative risk 8∙99, 95% confidence interval 6∙06-13∙35). The illness was characterized by sudden onset of gastrointestinal symptoms; the median incubation time was 40 min and duration of illness 5 h. No common foodborne pathogens or toxins were found in either clinical or beetroot samples, but all tested beetroot samples were of poor quality according to total bacterial counts. Beta-haemolytic Pseudomonas fluorescens was detected in several beetroot samples but its effect on human health is unknown. No outbreaks were reported after the Finnish Food Safety Authority Evira advised against serving raw beetroot in institutional canteens.

Influenza-associated hospitalisations in Finland from 1996 to 2010: unexpected age-specific burden during the influenza A(H1N1)pdm09 pandemic from 2009 to 2010.

To assess the burden of influenza on the Finnish healthcare system, we analysed hospitalisations during 1996-2010 using the International Classification of Diseases codes potentially related to influenza and its complications from the national hospital discharge registry. To compare the influenza A(H1N1)pdm09 pandemic with previous influenza seasons in 1996-2009, we calculated hospitalisation rates by age- and diagnostic groups. We built a negative binomial regression model based on times series analysis to assess the impact of the pandemic. Influenza-associated hospitalisation rates were higher during the pandemic compared to pre-pandemic influenza seasons for 5-24 year-olds (incidence rate ratio (IRR): 1.52, 95% confidence interval (CI): 1.44-1.60) and 25-64 year-olds (IRR: 1.33, 95% CI: 1.29-1.36), but did not differ for persons aged ≥ 65 years (IRR: 0.98, 95% CI: 0.97-1.00). Hospitalisation rates exceeded the upper limit of the prediction line by 177% in 5-24 year-olds, 66% in 0-4 year-olds and 57% in 25-64 year-olds. During the influenza season of 2003/04, all age groups had higher-than-expected hospitalisation rates, whereas other seasonal peaks were only notable among persons aged ≥ 65 years. These age-specific differences in the hospital burden underscore the importance of the continuous surveillance of hospitalisations in order to evaluate immunisation priorities for seasonal influenza and pandemic preparedness including use of antiviral medication.

Ophthalmic injuries in British Armed Forces in Iraq and Afghanistan.

AIM: British military ophthalmologists have not been deployed in support of operations since 2003. Eye injuries in British forces receive definitive treatment on return to the United Kingdom. We report the injury patterns, management strategies, and outcomes for eye injuries in British Armed Forces in Iraq and Afghanistan. METHODS: Retrospective consecutive case series of eye injuries in British Armed Forces in Iraq or Afghanistan from July 2004 to May 2008. Outcomes assessed by final best-corrected visual acuity (VA; few patients lost to follow-up), rates of endophthalmitis, and proliferative vitreoretinopathy (PVR). RESULTS: There were 630 cases of major trauma, 63 sustained eye injuries (10%), and 48 sustained significant eye injuries. There were 21 open-globe injuries: 9 ruptures and perforating injuries, of which 7 were enucleated/eviscerated; 11 intraocular foreign body (IOFB) injuries, of which 1 was eviscerated. Primary repair was combined with posterior segment reconstruction in 9/11 cases with IOFB. Mean time to primary repair was 1.9 days (range 0-5). Intravitreal antibiotics were given at primary repair in five cases. All cases received early broad-spectrum systemic antibiotics. Median final VA was logMAR 0.25 excluding evisceration/enucleations. There were two cases of PVR and none of endophthalmitis. CONCLUSIONS: The number of eye injuries as a proportion of all casualties is lower than recently reported. The injuries are more severe than in civilian practise. The outcomes were comparable with previous reports, this demonstrates that, in certain cases, primary repair can be safely delayed beyond 24 h in the patient's best interests, in order to optimise the conditions for treatment.

Idiopathic intracranial hypertension associated with iron deficiency anaemia: a lesson for management.

AIM: To document the causal association of iron deficiency anaemia (IDA) and intracranial hypertension (IH). METHODS: A consecutive case note review of patients with a clinical diagnosis of idiopathic intracranial hypertension (IIH) and anaemia presenting to a tertiary referral unit over a 2.5-year period. Demographics, aetiology and clinical details were recorded and analysed. RESULTS: Eight cases were identified from 77 new cases presenting with IIH. All 8 had documented microcytic anaemia with clinical evidence of raised intracranial pressure. There was no evidence of venous sinus thrombosis on MRI and MR venography in 7 subjects and on repeated CT venography in 1. On correction of anaemia alone, 7 cases resolved. One patient with severe progressive visual loss underwent ventriculoperitoneal shunt in addition to treatment of anaemia, with good outcome. The incidence of this association is 10.3%. CONCLUSION: These cases present an association between IDA and IH, in the absence of cerebral sinus thrombosis. As a clinically significant proportion of cases presenting with signs of IIH have IDA, we recommend all patients presenting with IIH have full blood counts and if they are found to be anaemic, they should be treated appropriately.

Spontaneous retinal venous pulsation: aetiology and significance.

Spontaneous retinal venous pulsation is seen as a subtle variation in the calibre of the retinal vein(s) as they cross the optic disc. The physical principles behind the venous pulsations has been the point of much debate. Initial theories suggested that the pulsation occurred because of the rise in intraocular pressure in the eye with the pulse pressure. This article presents an argument that this is not the case. The pulsations are in fact caused by variation in the pressure gradient along the retinal vein as it traverses the lamina cribrosa. The pressure gradient varies because of the difference in the pulse pressure between the intraocular space and the cerebrospinal fluid. The importance of this is that as the intracranial pressure rises the intracranial pulse pressure rises to equal the intraocular pulse pressure and the spontaneous venous pulsations cease. Thus it is shown that cessation of the spontaneous venous pulsation is a sensitive marker of raised intracranial pressure. The article discusses the specificity of the absence of spontaneous venous pulsation and describes how the patient should be examined to best elicit this important sign.

Using the second instrument peripheral corneal incision in phacoemulsification as a blow-off valve.

PURPOSE: To assess the rise in intraocular pressure following phacoemulsification and whether it can be modified by the architecture of the peripheral corneal incision for the second instrument. SETTING: Frimley Park Hospital, Frimley, United Kingdom. METHOD: Forty-two patients had intraocular pressures measured from both eyes preoperatively, then underwent routine scleral section phacoemulsification. They were randomly assigned to perpendicular (blow-off valve) and oblique (water-tight) peripheral corneal incision groups. Postoperative intraocular pressures were measured at 3, 6, 12 and 18 hours. Pressures from the unoperated eyes were used as controls. Aqueous release from the second instrument peripheral corneal incisions and frown scleral incision were assessed using the Seidel's test. RESULTS: There was a rise in intraocular pressure in both groups compared to the control eyes (mean 10.95+/-2.19 mmHg, P<0.00005) at 6 hours. The difference between the groups was significant at 12 hours (mean difference 3.35 mmHg, P<0.05); 63.6% of the perpendicular incisions and 15% of the oblique incisions were Seidel's positive. The frown incision did not leak. CONCLUSION: This study documents the natural history of the rise in intraocular pressure following phacoemulsification peaking at 6 hours. Pharmacological agents should be administered to cover this period. The perpendicular peripheral corneal incision had a tendency to act as a blow-off valve allowing release of aqueous when intraocular pressures were elevated in the first 18 hours following phacoemulsification. This phenomenon is likely to result in a reduction in rise of intraocular pressure compared to the oblique peripheral corneal incision group which tended to be water-tight.

Paediatric cycloplegia: a new approach.

BACKGROUND: Cycloplegia is a traumatic experience for most children, as guttae cyclopentolate stings on instillation into the conjunctival sac. This may result in inadequate cycloplegia, difficulty in further examination and a child who is scared of both the doctor and the ophthalmology department. Guttae proxymetacaine hydrochloride 0.5% (Ophthaine, Proparacaine) is a topical local anaesthetic that does not sting on instillation. METHODS: Eighty-eight consecutive children in the paediatric clinic were assessed. The response of the patient to previous use of cyclopentolate alone was assessed by the parents of the child using a grading scheme. The use of proxymetacaine prior to instillation of cyclopentolate was then assessed using the same grading system. RESULTS: Seventy per cent of the children who received cyclopentolate alone were assessed to have cried and been unhappy. Ninety-one per cent of the children who received cyclopentolate after proxymetacaine were assessed to have shown no adverse reaction to the cycloplegia and remained happy. CONCLUSION: This study shows that use of proxymetacaine prior to cyclopentolate results in atraumatic cycloplegia in children. This can confer multiple benefits on the doctor-patient relationship.

Solution structure of the granular starch binding domain of glucoamylase from Aspergillus niger by nuclear magnetic resonance spectroscopy.

The solution structure of the granular starch binding domain (SBD) of glucoamylase 1 from Aspergillus niger has been determined by heteronuclear multidimensional nuclear magnetic resonance spectroscopy and simulated annealing. A total of 1092 nuclear Overhauser enhancement-derived 1H-1H distance constraints, 137 dihedral constraints and 86 hydrogen bond constraints were incorporated into an X-PLOR simulated annealing and refinement protocol. The family of calculated structures shows a well defined beta-sheet structure consisting of one parallel and six antiparallel pairs of beta-strands which forms an open-sided beta-barrel. The root-mean-square deviation (rmsd) of 53 individual structures to the calculated average structure for the backbone atoms of residues excluding the N terminus and two mobile loops is 0.57(+/-0.10) A while the rmsd for backbone atoms in beta-strands is 0.45(+/-0.08) A. Structural features of the SBD in solution are compared to the X-ray crystal structure of a homologous domain of cyclodextrin glycosyltransferase (CGTase) in the free and bound forms. Titration studies with two ligands, maltoheptaose and beta-cyclodextrin, show the existence of two binding sites. Examination of the tertiary structures shows these two sites to be at one end of the molecule on opposite faces. The majority of residues showing the largest 1H and 15N chemical shift changes are located in loop regions. Many residues implicated in binding, based on these changes, are similar in location to previously identified binding site residues in the crystal structures of CGTase. Overall, the shift changes are small indicating that the SBD does not undergo large conformational changes upon ligand binding.

Profound accidental hypothermia in the deep South: clinical experience.

Accidental hypothermia resulting from exposure is generally associated with frigid regions and not with the more temperate areas of the South. However, we present clinical experience from two cases in which the victims of motor vehicle accidents were exposed to the elements for prolonged periods and became profoundly hypothermic. The first patient was a 21-year-old male who was ejected from, and pinned under, his vehicle for approximately four hours in -15 degrees C ambient temperature. Upon admission to the Emergency Room, the patient was unresponsive with fixed and dilated pupils and his core temperature was 25 degrees C. After a prolonged period of cardiopulmonary resuscitation, percutaneous femoral to femoral cardiopulmonary bypass (CPB) was instituted for core rewarming. After reaching 37 degrees C, the patient was removed from bypass. The patient was discharged from the hospital on the fourth postoperative day. The second patient was a 40-year-old male who was ejected from his vehicle into a stream, where he was partially submerged for several hours. Although the ambient temperature was approximately 22 degrees C, his core temperature at admission was 27 degrees C. After a positive peritoneal lavage, the patient was taken to the Operating Room and placed on percutaneous femoral to femoral CPB for core rewarming. During rewarming, an exploratory laparotomy and a splenectomy were performed. The patient was discharged from the hospital on the seventh postoperative day. These cases are unique in that both were trauma patients with suspected internal injuries which required the avoidance of anticoagulation. Therefore, both cases utilized a Carmeda-bonded circuit without systemic anticoagulation.

Expression in Aspergillus niger of the starch-binding domain of glucoamylase. Comparison with the proteolytically produced starch-binding domain.

Glucoamylase 1 from Aspergillus niger is an economically important enzyme in many industrial processes. It hydrolyses granular starch and comprises two distinct domains, a catalytic and a starch-binding domain (SBD). We have transformed A. niger with an expression vector for the secretion of SBD for physico-chemical studies. This was achieved by introducing into the glucoamylase gene a short sequence encoding an endoproteolytic cleavage recognition site such that free SBD was secreted at yields up to 200 mg/l. Free SBD was also obtained by proteolytic digestion of full-length glucoamylase 1. Electrospray mass spectroscopy was used to determine the carbohydrate content of both SBDs. It revealed that the engineered one is more glycosylated: an average of three mannose residues compared to one for the proteolytically derived SBD. Sequencing results also suggest partial glycosylation for the three Thr residues involved (510, 511, 513). It is probable that the engineered SBD represents the true glycosylation level of the SBD in native glucoamylase. Binding of beta-cyclodextrin to the SBD was investigated. It was found that the stoichiometry and the spectral perturbation of Trp residues were identical for both SBDs, but the engineered SBD bound less strongly to the ligand. At high concentrations of beta-cyclodextrin relative to the estimated Kd values, the maximum absorbance changes were identical. The observed difference at low beta-cyclodextrin levels was probably due to the higher level of glycosylation of the expressed SBD. We conclude that the proteolytically derived and expressed starch binding domains both bind 2 mol beta-cyclodextrin/mol protein, but that the pattern of glycosylation and strength of binding are different.

1H and 15N assignments and secondary structure of the starch-binding domain of glucoamylase from Aspergillus niger.

1H and 15N NMR resonance assignments of the granular starch-binding domain (SBD) of glucoamylase from Aspergillus niger have been made by multi-dimensional homonuclear and heteronuclear NMR techniques. Secondary structure analysis based on chemical shifts, 1H-1H NOEs, coupling constants and backbone amide exchange data indicates the presence of a well-defined beta-sheet structure. This consists of one parallel and five antiparallel pairs of beta-strands forming two beta-sheets. Cis-trans isomerisation of proline residues and O-glycosylation of threonine residues are observed and compared between the proteolytically derived SBD fragment and the recombinant protein. Structural features of the SBD in solution were compared to the X-ray crystal structure of a homologous domain of cyclodextrin glycosyltransferase from Bacillus circulans. There are some differences in the locations of the start and end of beta-strands but overall the two structures are very similar. This study will form the basis for the structure determination of the granular SBD and of its complexes.

Cerebral cardiovascular and respiratory variables after an experimental brain missile wound.

Brain missile wounding (BMW) affects brainstem and medullary cadiorespiratory functions leading to immediate systemic hypertension, bradycardia, and apnea. Secondary complications may also occur because of subsequent changes in systemic and intracranial physiological variables. To delineate the immediate and secondary effects of BMW, we monitored changes in several cerebral and cardiorespiratory parameters in pentobarbital-anesthetized spontaneously breathing cats before wounding and up to 90 min afterward. Total and regional cerebral blood flow (rCBF) and cardiac output (CO) were measured (microsphere technique) and arterial blood was sampled for pH, PO2 and PCO2 once before BMW and one to four times afterward. Mean arterial blood pressure (MABP), intracranial pressure (ICP), cerebral perfusion pressure (CPP = MABP - ICP), electrocardiogram (ECG), heart rate (HR), and electroencephalogram (EEG) were continuously recorded. Respiratory frequency (f), tidal volume (Vt), and ventilation (V) were recorded during each flow measurement and periodically throughout the experiment. Four unwounded cats served as controls and 15 cats were wounded at 1.4 J fronto-occipitally through an intact cranium. Unwounded cats showed no significant changes in any physiological variable measured during a 100 min experimentation period. Four wounded cats survived a 90 min post-BMW period and had only a transient brainstem effect including a 50% increase in MABP concurrently with 50% reductions in the f and HR. Nonsurvivors (11 of 15) lived from 1 to 41 min after wounding. These cats initially demonstrated similar changes in MABP, f, and HR to survivors, but these variables remained unstable, possibly indicating a persisting brainstem damage. Apnea accounted for death in 10 of 11 nonsurvivors. Although the primary brainstem effect might have existed in all nonsurvivors, it appears that only one cat died from reduced respiration alone. Others had one or several postwounding secondary complications: abruptly increased ICP producing a negative CPP, extreme reductions in CO or CBF and ventilation. Cardiac arrest occurred once. Thus, post-BMW mortality cannot be consistently ascribed to the impairment of a single physiological variable.

2',3'-cyclic nucleotide phosphohydrolase activity determined using an image analyzer detection system.

The activity of 2',3'-cyclic nucleotide phosphohydrolase (CNPase) was assayed using high-performance thin-layer chromatography (HPTLC) and an image analyzer detection system. The assay system was used to study a possible inhibitory effect by aminoguanidine on CNPase specific activity. One advantage of using a fixed-time HPTLC system over a real-time spectrophotometric system for an enzyme activity study was that apparent inhibition of the enzyme due to interference of the assay system (chromophore inhibition, etc.) was avoided. In addition, due to the increased accuracy of the image analyzer over conventional methods of TLC plate analysis, a rapid and more accurate measurement of HPTLC plates was possible which required only nanomole amounts of substrate. Also, a digital image of each plate analyzed was stored indefinitely in the computer's memory for future reference. The measurements of CNPase specific activity made using this system compared favorably to those found in recent literature.

A biochemical study of optic nerve myelin isolated by a micromethod from different aged rats.

A micromethod was used to study myelin from individual rat optic nerves as a function of age. Protein and galactolipid content as well as 2',3'-cyclic nucleotide phosphohydrolase (CNPase) activity at ages 2, 4, 22, and 28 months were determined. Protein content increased significantly at 22 months and decreased at advanced age. Galactolipid content increased significantly at 28 months while CNPase activity decreased. The ratios of protein to galactolipid and CNPase to galactolipid changed with changing age. These data suggest that, unlike the central nervous system, specific biochemical parameters of the optic nerve change with age.