Newly identified risk factors for MRSA carriage in The Netherlands.

OBJECTIVES: To elucidate new risk factors for MRSA carriers without known risk factors (MRSA of unknown origin; MUO). These MUO carriers are neither pre-emptively screened nor isolated as normally dictated by the Dutch Search & Destroy policy, thus resulting in policy failure. METHODS: We performed a prospective case control study to determine risk factors for MUO acquisition/carriage (Dutch Trial Register: NTR2041). Cases were MUO carriers reported by participating medical microbiological laboratories to the RIVM from September 1st 2011 until September 1st 2013. Controls were randomly selected from the community during this period. RESULTS: Significant risk factors for MUO in logistic multivariate analysis were antibiotic use in the last twelve months, aOR 8.1 (5.6-11.7), screened as contact in a contact tracing but not detected as a MRSA carrier at that time, aOR 4.3 (2.1-8.8), having at least one foreign parent, aOR 2.4 (1.4-3.9) and receiving ambulatory care, aOR 2.3 (1.4-3.7). Our found risk factors explained 83% of the MUO carriage. CONCLUSIONS: Identifying new risk factors for MRSA carriers remains crucial for countries that apply a targeted screening approach as a Search and Destroy policy or as vertical infection prevention measure.

[Carbapenemase producing Enterobacteriaceae in the Netherlands: unnoticed spread to several regions]. / Carbapenemase-producerende enterobacteriën in Nederland.

- Carbapenemase producing Enterobacteriaceae (CPE), including Klebsiella pneumoniae and Escherichia coli, are only sporadically seen in the Netherlands and then mainly in patients who have been transferred from foreign hospitals.- CPE are resistant to virtually all beta-lactam antibiotics, including carbapenems, e.g., meropenem and imipenem. Several genes, e.g., OXA-48, KPC and NDM-1, code for carbapenemase enzymes that deactivate carbapenems.- Control of CPE focuses on timely identification of patients who are infected or are carriers and the application of preventive measures to prevent spread.- Genotypic analysis of CPE isolates submitted to the national CPE surveillance revealed close relationships between 8 NDM-1 positive K. pneumoniae isolates of patients from different parts of the Netherlands and isolates obtained through contact tracing during a known hospital outbreak.- Based on retrospective epidemiological investigation, no shared exposure could be found.- These findings indicate unnoticed spread of CPE in the Netherlands.

Detection and epidemiology of carbapenemase producing Enterobacteriaceae in the Netherlands in 2013-2014.

Laboratory detection of carbapenemase-producing Enterobacteriaceae (CPE) is complicated. Screening with MIC values below clinical breakpoints followed by genotypic confirmation is recommended. We evaluated the application of recommended CPE screening and confirmation methods and provide an overview of CPE epidemiology in E. coli and K. pneumoniae in the Netherlands. Data on E. coli and K. pneumoniae isolates with elevated meropenem (>0.25 mg/L) and/or imipenem (>1 mg/L) MIC values in 2013-2014 were selected from the Infectious Disease Surveillance Information System for Antibiotic Resistance. Laboratories were requested to provide additional results of any confirmatory testing performed. Confirmation of elevated carbapenem MIC values using gradient testing was performed in 59.8 % of eligible isolates. Confirmatory testing showed elevated MIC values in 8 % of E. coli and 32 % of K. pneumoniae isolates. The overall proportion of confirmed non-susceptible E. coli and K. pneumoniae was 0.01 % and 0.16 %, respectively. Genotypic confirmation was performed in 61.0 % of isolates with confirmed elevated carbapenem MIC values. A carbapenemase gene was identified in 47 % of E. coli and 65 % of K. pneumoniae isolates. OXA-48, NDM and KPC were the most frequently found carbapenemase genes. The majority (62 %) of CPE isolates was detected through targeted screening. CPE are a rare finding in the Netherlands. Adherence to the national guideline is suboptimal and differs between laboratories, implying a risk of inadequate CPE detection. Since accurate identification of CPE is the first step in prevention of CPE spread, successful implementation of guidelines for testing and reporting of CPE is essential.

Rabies vaccinations: are abbreviated intradermal schedules the future?

Rabies is a deadly disease, and current preexposure vaccination schedules are lengthy and expensive. We identified nine studies investigating abbreviated schedules. Although initial responses were lower, accelerated adequate immune responses were elicited after booster vaccinations. Lower-dose (and therefore cheaper) vaccination schedules may constitute a valid alternative to current vaccination schedules.

Miltefosine treatment of Leishmania major infection: an observational study involving Dutch military personnel returning from northern Afghanistan.

In a retrospective, observational study involving 34 patients with Leishmania major infection, 31 of whom had experienced unsuccessful treatment with intralesional antimony (ilSb(v)), miltefosine proved effective. Thirty patients experienced cure after receipt of miltefosine, 3 after receipt of additional ilSb(v), and 1 after 28 daily intravenous injections of antimony. Temporary diminution of ejaculate volume was reported by 21 patients.

The effect of weekly iron and vitamin A supplementation on hemoglobin levels and iron status in adolescent schoolgirls in western Kenya.

BACKGROUND/OBJECTIVES: Iron deficiency anemia is a major public health problem in developing countries and may affect school performance and physical work capacity in nonpregnant adolescents, and may increase the risk of anemia during subsequent teenage pregnancies. We assessed the effect of weekly iron (120 mg elemental iron) and vitamin A (25 000 IU) supplementation on hemoglobin, iron status and malaria and nonmalaria morbidity in adolescent schoolgirls. SUBJECTS/METHODS: A total of 279 schoolgirls aged 12-18 years from public primary schools in Kisumu, western Kenya. Double-blind randomized placebo-controlled trial using a factorial design. RESULTS: Five months of iron supplementation was associated with a 0.52 g dl(-1) (0.21, 0.82) greater increase in hemoglobin relative to iron placebo. The effect was only observed in girls with iron deficiency on enrollment (1.34 g dl(-1) (0.79, 1.88)), but not in iron-replete girls (-0.20 g dl(-1) (-0.59, 0.18)). Similar differences in treatment effect were seen between menstruating and nonmenstruating girls. The effect of iron was independent of vitamin A. The baseline prevalence of vitamin A deficiency was low (6.7%) and no sustained increase in hemoglobin was seen with weekly vitamin A (-0.07 g dl(-1) (-0.38, 0.25)). Incidence of malaria parasitemia was higher in the iron than iron-placebo groups (Rate ratio 1.33 (0.94, 1.88)). CONCLUSIONS: Weekly iron supplementation results in substantial increases in hemoglobin concentration in adolescent schoolgirls in western Kenya, which may outweigh possible risks caused by malaria, but only in iron-deficient or menstruating girls and not in iron-replete and nonmenstruating girls.

Prevalence and severity of malnutrition and age at menarche; cross-sectional studies in adolescent schoolgirls in western Kenya.

OBJECTIVE: Nutritional status is an important marker of overall health and linear growth retardation has serious long-term physiological and economic consequences. Approximately 35 and 29% of preschool children in sub-Saharan Africa are stunted and underweight, respectively. There is relatively little information available about the nutritional status in adolescents, the age group with the highest growth velocity after infancy. We conducted a series of cross-sectional surveys to determine the prevalence and main risk groups for malnutrition and to describe the associations between age, sexual maturation and nutritional status in adolescent schoolgirls in western Kenya. DESIGN: Three cross-sectional surveys; one in Mumias, using random sampling in all schools, and two surveys in Asembo, using a multi-stage random sample design. SETTING: Public primary schools in two different rural malaria endemic areas in western Kenya with high levels of malnutrition in preschool children. SUBJECTS: In all, 928 randomly selected adolescent schoolgirls aged 12-18 y. RESULTS: Overall prevalence of stunting and thinness was 12.1 and 15.6%, respectively. Of the total, 2% were severely stunted. Menarche and start of puberty were delayed by approximately 1.5-2 y compared to a US reference population. The prevalence of stunting and thinness decreased with age and mean height for age z-scores converged towards the median of the US reference curve. Girls who had not yet started menstruating were more likely to be stunted than the girls of the same age who were post-menarche. CONCLUSIONS: Stunting and thinness are common in young adolescent schoolgirls in these poor rural settings in western Kenya, but the prevalence decreases with age, providing observational support that children catch up on incomplete growth attained earlier in life due to a maturational delay of 1.5-2 y allowing prolonged growth.

Prevalence and severity of anemia and iron deficiency: cross-sectional studies in adolescent schoolgirls in western Kenya.

OBJECTIVE: Anemia is a major public health concern in preschool children and pregnant women in the developing world. While many studies have examined these two at-risk groups, there is a paucity of data on anemia in adolescents living in developing countries in the complex ecologic context of poverty, parasitism, and malnutrition. We evaluated the prevalence, severity, and risk factors of anemia in adolescent schoolgirls in an area with intense malaria transmission in western Kenya. DESIGN: Two cross-sectional surveys were conducted, using a multistage random sample design. SETTING: Public primary schools in an area with intense malaria transmission in western Kenya. SUBJECTS: A total of 648 randomly selected adolescent schoolgirls aged 12-18 y. RESULTS: The prevalence of anemia (Hb <120 g/l) was 21.1%; only one girl had an Hb less than 70 g/l. Ferritin levels were available from a subsample of 206 girls. The prevalence of iron deficiency (ferritin <12 microg/l) was 19.8, and 30.4% of anemic girls were iron deficient. Malaria and schistosomiasis were the main risk factors for anemia in younger girls (12-13 y), while menstruation was the principal risk factor in older girls (14-18 y). CONCLUSIONS: Iron deficiency and anemia in school-attending girls in western Kenya were more prevalent than in developed countries, but considerably less prevalent than in preschool children and pregnant women from the same study area. Our findings are consistent with other recent school-based surveys from western Kenya, but not with recent community- and school-based cross-sectional surveys from other parts of sub-Saharan Africa. It deserves further study to determine if adolescent girls not attending school are at higher risk of anemia.

The healing process of palatal tissues after operations with and without denudation of bone: an experimental study in dogs.

The aim of this study was to evaluate wound healing clinically and histologically in beagle dogs after palatal repair during growth by the partially split flap technique and the von Langenbeck technique. A standardised soft tissue defect was created in the medial region of the palate. The partially split flap technique was performed in 14 dogs (age 12 weeks). Von Langenbeck repair was simulated in 12 dogs (age 12 weeks). Four dogs (age 12 weeks) served as controls. Standardised slides of the palate were taken on eight occasions and the wound surface areas were measured. Histological sections were prepared at three different ages. The animals were studied until the age of 25 weeks. Re-epithelialisation was complete in roughly two weeks in dogs after palatal repair by the partially split flap technique. The histological features of this group were close to normal limits. After the von Langenbeck's procedure re-epithelialisation took about three weeks and scar tissue was firmly attached to bundle bone by Sharpey's fibres. We conclude that the histological appearance of the palatal tissues in dogs after palatal repair during growth by the partially split flap technique was close to normal. We assume that this is reason for more favourable dentoalveolar development after the partially split flap technique compared with von Langenbeck's repair.

The healing process of palatal tissues after palatal surgery with and without implantation of membranes: an experimental study in dogs.

The aim of this study was to evaluate the wound-healing process clinically and histologically in growing beagle dogs after palatal repair according to von Langenbeck, with and without implantation of membranes of a copolymer of polyhydroxybutyrate 80%-hydroxyvalerate 20% (=PHB-co-HV 80/20). Von Langenbeck's repair was performed in 12 dogs (age 12 wk), while von Langenbeck's repair followed by implantation of PHV-co-HV membranes was carried out in 11 dogs (age 12 wk). Four dogs (age 12 wk) served as unoperated controls. Standardized intra-oral slides of the palate were taken and measurements of the wound surface areas were carried out. Histological sections were prepared at three different ages. The animals were studied until the age of 25 wk. It was found that wound closure after the von Langenbeck's procedure took about 3 wk, while the use of PHB-co-HV membranes after von Langenbeck's repair resulted in complete wound closure after approximately 7 wk after the membranes had sequestered. At the age of 25 wk, the histologic results after the von Langenbeck procedure showed that the entire scar tissue covering the former denuded bony areas was attached to the bone by means of Sharpey's fibres, while after implantation of the membranes only local scar tissue attachment by means of Sharpey's fibres was found. Further research is necessary to develop a membrane which allows wound closure without sequestration of it.

Oral endotoxin in healthy adults.

This article presents a study that measured oral endotoxin levels in healthy persons with the Limulus amoebocyte lysate microassay. Only young nonsmoking adults with a healthy dentition measured with the plaque index and a good level of oral hygiene based on a twice-daily (morning and evening) tooth-brushing regimen were admitted to this open study. Each person was required to provide two oral washings of 10 ml sterile saline solution 1 week apart. Only those volunteers without oral carriage of aerobic gram-negative bacilli were enrolled in the baseline study. A total of 15 healthy adults with a median age of 29 years (range, 25 to 43 years) were included in the trial. The mean plaque score of the group was 1.2 +/- 0.1. They all maintained a twice-daily tooth-brushing regimen unaltered throughout the sampling period. A total of 30 mouth rinses were studied. None of the samples yielded potential pathogens including aerobic gram-negative bacilli, Staphylococcus aureus and yeasts; a culturing technique based on preenrichment in nutrient medium was used. Data showed mean oral endotoxin levels of 20 ng per ml of mouth rinse; the aerobic E. coli endotoxin was used as the classical standard. This is equivalent to 1 mg of anaerobic endotoxin per ml of undiluted saliva after correcting for the 10 to 10(2) dilution factor of the mouth rinse itself and for the 10(3) times less sensitivity of anaerobic endotoxin in the Limulus amoebocyte lysate-assay. The discussion includes the physiologic and clinical benefit of the low endotoxicity of anaerobic gram-negative flora apart from the technical aspects of both culture and endotoxin assays used in the study.

Supraperiosteal flap technique versus mucoperiosteal flap technique in cleft palate surgery.

Recent animal experiments have shown that palatal repair without denudation of bone leads to a superior dento-alveolar development. The aim of this clinical study was to evaluate the peri- and postoperative course and the dento-alveolar development of the deciduous dentition in Japanese ULCP, and CP patients up to 5 years after two different types of palatal repair. One of the methods, the Kohama (1991) supraperiosteal flap technique, is performed without denudation of the bony palate, while the other, the Wardill (1937) push-back technique, results in areas of denuded bone. It was concluded that the supraperiosteal technique can be performed successfully in approximately the same amount of time as the push-back technique. Re-epithelialization of the wound areas after supraperiosteal repair takes about 1 week, which is one third of the time associated with healing after the push-back technique. Arch depth of the deciduous dentition after the supraperiosteal technique is superior compared to the push-back technique. The question of whether or not the supraperiosteal technique produces more favorable dento-alveolar development than the mucoperiosteal technique in the permanent dentition in humans has to be elucidated in future research.

Palatal surgery without denudation of bone favours dentoalveolar development in dogs.

The present study compared the dentoalveolar development in beagle dogs after palatal repair according to the partially split flap technique and the von Langenbeck method. It was concluded that palatal surgery according to the partially split flap technique resulted in significantly wider transverse distances of the maxillary dental arch than after the von Langenbeck procedure and that its final outcome closely resembled that of the control group.

Wound healing in beagle dogs after palatal repair without denudation of bone.

The connection of scar tissue to palatal bone by Sharpey's fibers, after cleft palate surgery, might lead to maxillary growth inhibition. The aim of this study, in beagle dogs, was to investigate the possibility of preventing the development of Sharpey's fibers by means of a modified surgical technique. In group 1, palatal repair according to von Langenbeck, was simulated. In group 2, palatal surgery was performed using a new partially split flap technique. The palates were histologically evaluated 12 weeks after surgery and compared with a control group. In group 1, the scar tissue was firmly attached to bundle bone by means of Sharpey's fibers. In group 2 and in the control group, this kind of attachment was not found; the bone was of the lamellar type. The partially split flap technique had led to the development of vaguely demarcated scar tissue and it had prevented, to a large extent, development of Sharpey's fibers.

[Oral aspects of radiotherapy and/or chemotherapy in the head and neck area]. / Radio- en/of chemotherapie in het hoofd-halsgebied.

Patients who are treated with irradiation and/or chemotherapy for head and neck cancer are at risk for several oral complications. The most frequent occurring complications, the prevention of these complications, and the responsibilities of the general practitioner are described.