Hospital-wide outbreak of Burkholderia contaminans caused by prefabricated moist washcloths.

We experienced a hospital outbreak of Burkholderia contaminans (Burkholderia cepacia Group K) in a German university hospital with two campuses. Cases were defined as the microbiological detection of B. cepacia complex (BCC) in any clinical specimen sent to the laboratory during 30 June to 21 October 2008. Species identification of BCC was performed by recA gene sequencing, followed by pulsed-field gel electrophoresis (PFGE; SpeI digest) for clonal identity. In total, 61 BCC-positive cases were diagnosed at the two campuses. At least nine patients contracted a ventilator-associated pneumonia with BCC. One patient suffered an infection of a pacing wire insertion site and four patients had septicaemia. Sixteen patients died in hospital, none thought to be due to the outbreak strain. BCC was eventually found in packages of moist prefabricated washcloths used for intensive care patients. German healthcare authorities were informed and a Europe-wide alarm (RAPEX) was initiated through the systems to prevent infections in other hospitals. PFGE proved clonal identity between isolates from clinical specimens and washcloths of both campuses. After elimination of the contaminated washcloths no further cases occurred. This example of a relatively newly introduced product raises the question of whether current regulations are adequate to protect consumers. For critically ill patients, care products should be carefully evaluated. In case of infections due to contaminated products, immediate communication to healthcare authorities is required, including RAPEX warning if products are sold across Europe.

Tissue donation and virus safety: more nucleic acid amplification testing is needed.

In tissue and organ transplantation, it is of great importance to avoid the transmission of blood-borne viruses to the recipient. While serologic testing for anti-human immunodeficiency virus (HIV)-1 and -2, anti-hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), anti-hepatitis B core antigen (HBc), and Treponema pallidum infection is mandatory, there is until now in most countries no explicit demand for nucleic acid amplification testing (NAT) to detect HIV, hepatitis B virus (HBV), and HCV infection. After a review of reports in the literature on viral transmission events, tissue-specific issues, and manufacturing and inactivation procedures, we evaluated the significance of HIV, HCV, and HBV detection using NAT in donors of various types of tissues and compared our results with the experiences of blood banking organizations. There is a significant risk of HIV, HCV, and HBV transmission by musculoskeletal tissues because of their high blood content and the high donor-recipient ratio. If no effective virus inactivation procedure for musculoskeletal tissue is applied, donors should be screened using NAT for HIV, HCV, and HBV. Serologically screened cardiovascular tissue carries a very low risk of HIV, HCV, or HBV transmission. Nevertheless, because effective virus inactivation is impossible (retention of tissue morphology) and the donor-recipient ratio may be as high as 1:10, we concluded that NAT should be performed for HIV, HCV, and HBV as an additional safety measure. Although cornea allografts carry the lowest risk of transmitting HIV, HCV, and HBV owing to corneal physiology, morphology, and the epidemiology of corneal diseases, NAT for HCV should still be performed. If the NAT screening of a donor for HIV, HCV, and HBV is negative, quarantine storage of the donor tissue seems dispensable. In view of numerous synergistic effects with transfusion medicine, it would be advantageous for tissue banks to cooperate with blood bank laboratories in performing virological tests.

Flow cytometric testing of immunological effects of a phytomedicinal combination (equimun) and its compounds on bovine leucocytes.

One of the major goals of this study was to establish fast, reliable and sensitive assays for the quality control of immunomodulating phytopreparations and to determine whether pharmacological compounds or phytopreparations have effects on bovine immune cells. Flow cytometric methods were chosen because they are very sensitive in the detection of even subtle effects on cells. In this study, we addressed the question of whether these methods are useful in monitoring the effects of EquiMun and its compounds on bovine leucocytes in vitro. EquiMun is a fixed combination of Echinacea purpurea (Ec), Thuja occidentalis (Th) and elemental phosphorus (Ph) in different starting concentrations. Separated blood mononuclear cells (MNC) and polymorphonuclear cells (PMN, mainly neutrophils) were cultured for up to 44 h in vitro in the presence or absence of the tested substances. Whereas MNC were not affected by any of the compounds, EquiMun, Ec, Th and Ph significantly reduced the forward scatter (size) of cultured PMN without affecting their side scatter (granularity). The size effects were paralleled by a significantly enhanced viability of PMN after 20 h in culture. The observed effects were constant over wide concentration ranges and indicate a very similar reaction of leucocytes from individual cows. Whereas spontaneous generation of reactive oxygen species (ROS) by neutrophils was up-regulated by Ph and EquiMun, EquiMun down-regulated the phorbol ester-stimulated ROS production. However, ROS generation by neutrophils displayed a large inter-individual variation with less apparent, down-regulatory effects of EquiMun. The ability of PMN to kill target cells via antibody-independent cellular cytotoxicity showed small inter-individual variations and was enhanced by Ec and Th but not by Ph and EquiMun, probably due to dose-dependent effects. In summary, the flow cytometric characterization of cellular viability and shape changes of neutrophils seem to be a suitable and reliable approach for the quality test of immunomodulating phytomedicines based on bioassays.

Uptake of colostral leukocytes in the intestinal tract of newborn calves.

The role of colostral immunoglobulins for the protection of newborn calves has been studied extensively, but little is known about the importance of colostral leukocytes. To study the uptake of colostral leukocytes in the intestine of calves and to determine preferential sites for this uptake, FITC-labelled colostral cells derived from the respective dams were injected into intestinal loops with/without Peyer's patches of three male Holstein Frisian calves about 5h post natum. In adjacent loops, PBS was injected as control. Loops were excised after an exposure of 1.5-2h. FITC-labelled material and cells were detected by the direct immunoperoxidase method in paraplast sections. Twenty-five consecutive sections were evaluated from each localization. Uptake of labelled material and cells was observed in all three calves in the jejunal Peyer's patch and in two calves in the ileal Peyer's patch as well. In the jejunal Peyer's patch, labelled material and cells were present in epithelium, domes and sinuses around lymphoid follicles, whereas in the ileal Peyer's patch, they were found in the sinuses only. These findings confirm that uptake of colostral leukocytes through the intestinal barrier is possible and that the preferential route of uptake is through follicle-associated epithelium of Peyer's patches.

Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment.

OBJECTIVES: The goal of this study was to define the association between low QRS voltage and cardiac tamponade or pericardial effusion and to assess the reversibility of low QRS voltage after therapeutic procedures. BACKGROUND: It is unclear whether low QRS voltage is a sign of cardiac tamponade or whether it is a sign of pericardial effusion per se. METHODS: In a prospective study design, we recorded consecutive 12-lead electrocardiograms and echocardiograms in 43 patients who were referred to our institution for evaluation and therapy of a significant pericardial effusion. Cardiac tamponade was present in 23 patients (53%). Low QRS voltage (defined as maximum QRS amplitude <0.5 mV in the limb leads) was found in 14 of these 23 subjects (61%). Nine of these 14 patients were treated by pericardiocentesis (group A). Five patients received anti-inflammatory medication (group B). Group C consisted of nine patients with pericarditis and significant pericardial effusion who had no clinical evidence of tamponade. RESULTS: In group A, low QRS voltage remained largely unchanged immediately after successful pericardiocentesis (0.36 +/- 0.17 mV before vs. 0.42 +/- 0.21 mV after, p = NS), but QRS amplitude recovered within a week (0.78 +/- 0.33 mV, p < 0.001). In group B, the maximum QRS amplitude increased from 0.40 +/- 0.20 mV to 0.80 +/- 0.36 mV (p < 0.001) within six days. In group C, all patients had a normal QRS amplitude initially (1.09 +/- 0.55 mV) and during a seven-day follow-up (1.10 +/- 0.56 mV, p = NS). CONCLUSIONS: Low QRS voltage is a feature of cardiac tamponade but not of pericardial effusion per se. Our findings indicate that the presence and severity of cardiac tamponade, in addition to inflammatory mechanisms, may contribute to the development of low QRS voltage in patients with large pericardial effusions.

Echocardiographic detection of coronary artery fistula into the pulmonary artery.

A rare case of left coronary artery--pulmonary artery fistula is reported. Transoesophageal echocardiography was capable of precisely demonstrating the origin, the course and the drainage site of the fistula. In contrast, transthoracic echocardiography could visualise a drainage flow in the pulmonary artery only. In conclusion, transoesophageal echocardiography may be helpful in the diagnosis or exclusion of the form of coronary artery fistula.

Full performance of modern echocardiography within the heart: in-vivo feasibility study with a new intracardiac, phased-array ultrasound-tipped catheter.

BACKGROUND: Intracardiac echocardiography with full performance of high-resolution two-dimensional-, M-mode-, colour, pulsed and continuous wave Doppler and Doppler tissue imaging has not been previously demonstrated. AIMS: This first European in-vivo study was designed to determine the utility and feasibility of a new ultrasound-tipped catheter for intravascular and intracardiac echocardiography. METHODS: The miniaturized, multi-modal, multiple-frequency (5-10MHz) transducer tipped 10Fr (3.3mm) catheter was tested in five anaesthetized mongrel dogs linked to a standard echocardiographic platform. The catheter was introduced through an 11 Fr femoral venous sheath into the inferior vena cava and right heart chambers and the pulmonary artery under limited fluoroscopic and catheter ultrasound guidance. RESULTS: Abdominal and thoracic aorta as well as their branches, both ventricles and atrias with their appendices, all valves, pulmonary arteries and all veins could be visualized with excellent quality. All Doppler signals and the determined haemodynamics, global and regional wall motion and Doppler tissue imaging were of high diagnostic quality. Coronary flow reserve could also be determined. CONCLUSIONS: Intracardiac echocardiography is feasible and potentially useful for assessing functional and morphological disorders, and probably for the guidance of interventional procedures as well as monitoring of cardiac function. A new window to the heart has been opened.

X-ray densitometry for the measurement of regional myocardial perfusion.

The evaluation of regional myocardial blood flow (RMBF) during cardiac catheterization is of particular diagnostic interest. The purpose of this investigation was to validate x-ray densitometric parameters for the evaluation of RMBF. In five anesthetized dogs, arterial flow in the circumflex coronary artery was measured continuously with an electromagnetic flowmeter, and RMBF was determined by colored microspheres. Five different perfusion levels were created by mechanical obstruction of the coronary artery or by intravenous infusion of adenosine. At each steady-state perfusion level, digital subtraction coronary angiograms were obtained for densitometric analysis. Results documented a close correlation between the related time parameters 1/Mean Transit Time (1/MTT, r2 = 0.969), and 1/Rise Time (1/RT, r2 = 0.965) and RMBF over a wide range between 0.36 ml/(min x g) and 11.16 ml/(min x g). Maximum myocardial contrast density (Imax) also showed a good, but inverse correlation (r2 = 0.889) with RMBF and, therefore, did not reflect vascular volume. Contrast medium Appearance Time (AT) showed no correlation to RMBF (r2 = 0.017). Repeat densitometric measurements for different perfusion levels revealed a good reproducibility for MTT (accuracy: 0.001 s; precision: 0.447 s or 6.7 %) and RT (accuracy: 0.014 s; precision: 0.202 s or 10.4 %), while AT (accuracy: 0.072 s; precision: 0.420 s or 68.5%) and Imax (accuracy: 0.022 GL; precision: 1.197 GL or 44.5%) showed substantial variation. Myocardial perfusion reserve (MPR) calculated from RT (r2 = 0.90) or MTT (r2 = 0.94) showed better correlations to RMBF reserve than MPR calculated from AT (r2 = 0.04). In conclusion, only 1/MTT and 1/RT showed a good reproducibility and a close correlation to RMBF. Therefore, only these parameters can be recommended for calculations of RMBF and its reserve under clinical conditions.

Hepatitis C virus transmission by a blood donation negative in nucleic acid amplification tests for viral RNA.

Hepatitis C virus (HCV) was transmitted by transfusion of a platelet concentrate made from an anti-HCV and HCV-PCR-negative blood donation. Even a negative nucleic acid amplification test cannot completely prevent transmission of HCV.

[Contrast medium echocardiography-assisted pericardial drainage]. / Kontrastmittelechokardiographisch gesteuerte Perikarddrainage.

The most effective treatment for pericardial effusion and cardiac tamponade is removal of the pericardial fluid. Surgical pericardiotomy is associated with high mortality and morbidity. Similarly, subcostal percutaneous blind pericardiocentesis was reported to have unacceptably high mortality and complication rates. Major complications associated with blind needle punctures are right heart penetration, hemopericardium, puncture of the coronary arteries, liver and lung bleeding. Even under fluoroscopic guidance and electrocardiographic needle monitoring high complication rates persist. Pericardial drainage has been often inadequate, with frequent recurrences of significant pericardial effusions. Two-dimensional echocardiographically guided pericardiocentesis is reported to improve efficacy and safety of percutaneous puncture. Moreover, it allows immediate verification of the procedural success. We evaluated the efficacy and safety of an echocardiographically guided contrast agent controlled pericardiocentesis. This is a retrospective, descriptive study on 126 consecutive patients who underwent percutaneous pericardiocentesis at the University Hospital Essen, Germany, from 1995 to June 2000. There were 51 women (41%) and 75 men (55%) with a mean age of 52 +/- 14 years. Standard techniques for quantification of pericardial effusion were used. Depending on the localization of the pericardial effusion an apical or subxiphoidal approach was chosen. The puncture was performed under echocardiographic guidance and the position of the needle was controlled by injection of contrast agent. Over a long guidewire a pigtail catheter was inserted through a sheath for further drainage of pericardial fluid. The catheter was removed after a maximum of 48 hours to avoid infection of the pericardial cavity. An apical approach was chosen in 98 patients (78%), a subcostal in 28 patients (22%). The procedure was successful in 99% of the attempts. No death or clinical complication occurred. The maximal pericardial diameter measured by two-dimensional echocardiography was 32 +/- 16 mm before and 5.3 +/- 2 mm after drainage. The calculated pericardial effusion was 657 +/- 342 ml. A fluid volume of 605 +/- 342 ml could be drained. In all patients a pericardial catheter was placed for 1.4 +/- 0.8 days. Recurrence of pericardial effusion occurred in 18 patients (14%). Of these, 15 patients underwent repeated successful pericardiocentesis (2.5 +/- 0.8), and 3 patients were referred to surgical pericardiotomy. Pericardiocentesis under echocardiographic contrast agent guidance is a safe, successful and cost effective procedure for diagnostic and therapeutic drainage of pericardial effusion. Two-dimensional echocardiography allows localization of the optimal puncture site as well as the quantification of the effusion depth. The injection of contrast agents into the pericardial cavity improves the safety and accuracy of the procedure. Even recurrent pericardial effusions can be treated successfully.

[Anti-ischemic effect of verapamil within the scope of interventional recanalization]. / Antiischämische Wirkung von Verapamil im Rahmen einer interventionellen Rekanalisation.

We report on a 46-year-old male with unstable angina pectoris due to a total proximal occlusion of the left circumflex artery. At the side of a plaque rupture there was a thrombotic occlusion. With PTCA recanalization was possible, but a dissection occurred, therefore coronary stents were implanted. Besides an optimal morphological result and recurrent applications of nitroglycerin, the baseline blood flow velocity declined from initial 16 cm/s to 11 cm/s after PTCA down to 8.4 cm/s after stent implantation. Because peak flow velocity remained almost unchanged, the low baseline velocity ("slow flow phenomenon") did not lead to an impaired coronary flow velocity reserve (CFVR). Only after application of 1 mg verapamil, a sustained flow velocity on a higher baseline level was reached (17 cm/s), at the same time typical signs of ischemia in the ECG (ST-segment depressions) improved. Additionally, in the non-treated LAD there was an increase in coronary blood flow velocity from 10 cm/s up to 25 cm/s. The reduction in coronary blood flow velocity with increasing manipulations might be due to an impairment of the coronary microcirculations with increasing alpha-adrenergic vasoconstriction, a distribution of vasoactive agents and peripheral microembolizations. Only after administration of verapamil, a calcium channel blocker with non-specific anti-adrenergic effects, the slow flow was removed and ECG signs of ischemia improved. The blood flow velocity in the non-treated LAD was low at baseline and improved after verapamil. This phenomenon leads to the conclusion that mechanisms with vasoconstrictive effect are present in the whole coronary system, but these mechanisms are less pronounced in non-treated vessels.