Clinical course, treatment and visual outcome of an outbreak of Burkholderia contaminans endophthalmitis following cataract surgery.

BACKGROUND: Postoperative endophthalmitis is a rare but dreaded complication of intraocular surgery and often results in severe visual impairment or blindness. The present study describes the clinical course, treatment and visual outcome of an outbreak of Burkholderia contaminans endophthalmitis following cataract surgery. METHODS: Among 290 patients who underwent uneventful phacoemulsification cataract surgery at one outpatient clinic between January 4th and 28th 2019, 6 cases developed Burkholderia contaminans endophthalmitis. Clinical data were collected by retrospective review of patient records. Microbiological samples from vitreous aspirates, intraocular lenses (IOL) and lens capsules were cultured, and recA and draft whole genome sequences analysed. RESULTS: The recA sequences of all Burkholderia contaminans isolates and the allelic profile of the isolates were identical. All cases had a similar clinical presentation with rapid development of endophthalmitis symptoms with variable time to onset. The mean time to admission was 34 days (12-112 days). All cases had a seemingly favourable response to intravitreal antibiotics. However, acute recurrences occurred after long time periods (12-71 days). The cases experienced between 0 and 3 recurrences. Due to persistent infection, the cases received between 5 and 15 treatments (mean 7.8) including IOL and lens capsule explantation in 5 of 6 cases. Burkholderia contaminans was detected in all explanted lens capsules. The final corrected distance visual acuity (CDVA, Snellen chart) was between 0.8 and 1.2 and all cases had final CDVA ≥0.8. CONCLUSIONS: A persistent and intensive treatment approach including total lens capsule and IOL explantation is recommended for Burkholderia contaminans endophthalmitis following cataract surgery and may lead to a favourable visual result.

Do Voluntary Lab-Based Active Learning Sessions Impact Medical Student Knowledge Retention?

BACKGROUND: Despite recent evidence demonstrating the benefits of case-based and active learning strategies in medical education, many medical schools have reduced or entirely eliminated teaching laboratories in medical microbiology courses. The objective of our investigation was to analyze the impact of a voluntary hands-on microbiology laboratory session on students' knowledge retention and ability to apply the underlying principles to exam questions in our Introduction to Infectious Diseases (IID) course. METHODS: We compared the performance of students participating in the wet labs with those who did not, analyzing scores on exam questions directly related to the concepts presented in the laboratory session and their overall scores on the IID module exam. The voluntary nature of our microbiology lab session provided a unique opportunity to assess its impact on knowledge retention independent of other factors, such as lecture and exam content, etc. Data were collected for 7 academic years and analyzed in aggregate. RESULTS: Students who attended voluntary lab sessions scored higher on exam questions related to lab exercises than students who did not attend (Mann-Whitney, p = 0.0074). These results support the benefit of reexamining material originally presented during classroom sessions in an active, collaborative learning environment. Course evaluation responses indicted that students valued the opportunity to visually reinforce concepts they had previously read in a textbook or heard in lectures. CONCLUSIONS: At a time when many medical schools are reducing or eliminating hands-on lab sessions in microbiology and other basic sciences, our results highlight the benefits of this teaching strategy. The laboratory session provided an opportunity for students to revisit concepts initially presented in the traditional classroom setting and to actively engage in applying these concepts to case-based scenarios. The improved educational outcomes will benefit students in future standardized exams as well as in their professional practice.

Impact of Venous Thromboembolism on the Formation and Progression of Carotid Atherosclerosis: The Tromsø Study.

Venous thromboembolism (VTE) is associated with increased risk of arterial cardiovascular diseases (CVD), and development of atherosclerosis secondary to VTE may be an intermediate between VTE and CVD. Therefore, we aimed to investigate whether incident VTE was associated with subsequent carotid atherosclerosis formation and progression in a population-based observational study. Subjects attending two or more ultrasound examinations of the right carotid artery, with measurement of total plaque area (TPA), in the Tromsø Study in 1994-1995, 2001-2002, and/or 2007-2008 were eligible. We identified 150 subjects diagnosed with first-lifetime VTE between the initial and follow-up visit, and randomly selected 600 age- and sex-matched subjects without VTE between the visits. Subjects with VTE and carotid plaque(s) at the first visit had 4.1 mm 2 (ß: 4.13, 95% CI: -1.72 to 9.98) larger change in TPA between the first and second visit compared with subjects without VTE after adjustment for change in high-sensitivity C-reactive protein (hs-CRP) and traditional atherosclerotic risk factors. The association remained after restricting the analyses to VTE events diagnosed in the first half of the time interval between the carotid ultrasounds (ß: 4.02, 95% CI: -3.66 to 11.70), supporting that the change in TPA occurred subsequent to the VTE. No association was found between VTE and novel carotid plaque formation. In conclusion, we found a possible association between VTE and atherosclerosis progression in those with already established carotid plaques, but not between VTE and novel plaque formation. The association between VTE and carotid plaque progression was not mediated by low-grade inflammation assessed by hs-CRP.

Use of a Field Portable X-Ray Fluorescence Analyzer for Environmental Exposure Assessment of a Neighborhood in Cairo, Egypt Adjacent to the Site of a Former Secondary Lead Smelter.

The objectives of this study are to demonstrate for the first time the use of a field portable X-Ray Fluorescence Analyzer (XRF) in a multi-media environmental survey and to use the survey results to determine if residual lead from a once-active secondary lead smelter in Cairo, Egypt, still posed a health risk to the residents when comparing results with US EPA standards. Results were analyzed to determine if relationships among the variables indicated that there were residual impacts of the former smelter. Samples collected inside and near a total of 194 dwellings were analyzed. The mean floor dust lead loading was 7.48 µg lead/ft(2). Almost 10% of the dwellings had at least one floor dust wipe sample that exceeded the United States Environmental Protection Agency's (USEPA) interior settled dust lead level of 40 µg lead/ft(2). The median paint lead level was 0.04 mg lead/cm(2). 17% of the dwellings had at least one interior paint sample that exceeded the USEPA standard of 1.0 mg lead/cm(2). Mean soil lead concentration in the study area was 458 ppm and 91 ppm outside the study area. Four of nine composite soil samples exceeded the US EPA limit for bare soil in play areas. Lead concentrations in samples collected in locations outside the study area did not exceed the limit. The highest concentration was in the plot closest to the smelter and may represent residual impact from the former smelter. Statistically significant relationships were not detected between interior floor dust lead loading and either interior paint lead loading or exterior dust lead concentration. Thus, no significant exposure from the former smelter was indicated by these analyses. This may have resulted from the time elapsed since the closing of the smelter and/or the relatively low paint lead levels. Further study is needed in other areas of Egypt near former and active lead smelters. Elevated levels of mercury and arsenic detected in soil samples do not appear to be related to the smelter but warrant further study.

Total lead concentration in new decorative enamel paints in Lebanon, Paraguay and Russia.

Lead concentrations in new enamel decorative paints were determined in three countries in different areas of the world where data were not previously available. The average total lead concentration of the enamel decorative paints purchased in Lebanon, Paraguay and Russia was 24,500ppm (ppm, dry weight), more than 270 times the current limit of 90ppm in Canada and in the United States. Sixty-three percent of these paints contained concentrations greater than 90ppm. Fifty-nine percent contained concentrations greater than 600ppm, the current limit in some countries. The maximum concentrations found were 236,000ppm in Lebanon, 169,000ppm in Paraguay and 52,900ppm in Russia. An average of 29% of the samples contained exceedingly high lead concentrations, >=10,000ppm. Five brands of paint were sampled in each of Lebanon and Paraguay and seven in Russia. Three colors from each brand were analyzed. For five of the six samples of the two brands in Lebanon with affiliations outside the country, the lead concentrations ranged from 1360ppm to 135,000ppm. In Lebanon the maximum concentration in the Egypt-affiliated brand (Sipes) was 135,000ppm and the maximum for the USA-affiliated brand (Dutch Boy) was 32,400ppm. Lead was not detected in any paints from the three of the four brands of paint purchased in Paraguay that had headquarters/affiliations in other countries (Brazil-Coralit), Germany (Suvinil) and USA (Novacor)). Two of the three paints from each of the other Paraguay brands contained high levels of lead with the maximum concentrations of 108,000 and 168,000ppm; one of these brands was manufactured under a license from ICI in the Netherlands. All of the paints purchased in Russia were from Russian brands and were manufactured in Russia. All three paints from one brand contained below detection levels of lead. The maximum levels of lead in the other six brands in Russia ranged from 3230 to 52,900ppm. The two brands with the highest lead concentration, TEKS and LAKRA, were produced by companies in the top three in market share.. Overall, lead concentrations were much higher in the colored paints such as red and yellow than in white paints. In each of the three countries a brand based in that country had a colored paint that either met a 90ppm limit or was close to meeting the limit-demonstrating that practical technology was available in each of these countries to produce low lead bright colored enamel decorative paints. Even though technology for producing paint without added lead existed in each of these countries, twenty-nine (29) percent of the paints analyzed contained exceedingly high concentrations (>=10,000ppm) of lead.

Family history of myocardial infarction and cause-specific risk of myocardial infarction and venous thromboembolism: the Tromsø Study.

BACKGROUND: A family history of myocardial infarction (FHMI) has been shown to increase the risk of venous thromboembolism (VTE). The mechanism underlying the association remains unclear. Therefore, we aimed to determine the risks of MI and VTE by FHMI using a cause-specific model and to explore whether atherosclerotic risk factors could explain the association between FHMI and VTE in a population-based cohort. METHODS AND RESULTS: The study included 21 624 subjects recruited from the Tromsø Study in 1994 to 1995 and 2001 to 2002. Incident MI and VTE events were registered from date of enrollment to end of follow-up, December 31, 2010. There were 1311 MIs and 428 VTEs during a median follow-up of 15.8 years. FHMI was associated with a 52% increased risk of MI (adjusted hazard ratio, 1.52; 95% confidence interval, 1.35-1.70) and a 26% increased risk of VTE (adjusted hazard ratio, 1.26; 95% confidence interval, 1.02-1.55) in the cause-specific Cox model. Similar results were found using the traditional Cox model. The risk estimates by status of FHMI were highest for unprovoked deep vein thrombosis (adjusted hazard ratio, 1.69; 95% confidence interval, 1.12-2.56), and the risk increased with increasing number of affected relatives. Modifiable atherosclerotic risk factors slightly altered the association between FHMI and MI but had a negligible effect on the association between FHMI and VTE. CONCLUSIONS: FHMI was associated with increased risk of both MI and VTE in a cause-specific model. Apparently, the association between FHMI and VTE applied to unprovoked deep vein thrombosis and was not explained by modifiable atherosclerotic risk factors.

Examination of lead concentrations in new decorative enamel paints in four countries with different histories of activity in lead paint regulation.

Paints with high lead concentrations (ppm) continue to be sold around the world in many developing countries and those with economies in transition representing a major preventable environmental health hazard that is being increased as the economies expand and paint consumption is increasing. Prior lead paint testing had been performed in Brazil and India and these countries were selected to examine the impact of a new regulatory limit in Brazil and the impact of efforts of non-governmental organizations and others to stop the use of lead compounds in manufacturing paints. Armenia and Kazakhstan, in Central Asia, were selected because no information on lead concentration in those regions was available, no regulatory activities were evident and non-governmental organizations in the IPEN network were available to participate. Another objective of this research was to evaluate the lead loading (µg/cm(2)) limit determined by X-Ray Fluorescence (XRF) for areas on toys that are too small to obtain a sample of sufficient size for laboratory analysis. The lead concentrations in more than three-fourths of the paints from Armenia and Kazakhstan exceeded 90 ppm, the limit in the United States, and 600 ppm, the limit in Brazil. The percentages were about one-half as high in Brazil and India. The average concentration in paints purchased in Armenia, 25,000 ppm, is among the highest that has been previously reported, that in Kazakhstan, 15,700 ppm, and India, 16,600, about median. The average concentration in Brazil, 5600 ppm, is among the lowest observed. Paints in Brazil that contained an average of 36,000 ppm before the regulatory limit became effective were below detection (< 9 ppm) in samples collected in the current study. The lack of any apparent public monitoring of paint lead content as part of regulatory enforcement makes it difficult to determine whether the regulation was a major factor contributing to the decline in lead use in these paints. Using data from the current study and those available from other studies 24 of 28 paints from major brands in India decreased from high concentrations to 90 ppm or lower. Since lead concentrations in golden yellow paints from these brands were found to decrease to ≤ 90 ppm, it is possible that all 28 of these paints now contain ≤ 90 ppm since yellow paints usually have the highest lead concentrations. Other brands in Brazil and India that have been analyzed only one time had lead concentrations up to 59,000 ppm and 134,000 ppm, respectively. Less than one-third of the paints had notations on their labels with information about lead content and these were sometimes inaccurate. The label from one brand indicating "no added lead" contained paint with 134,000 ppm lead, the highest found in this study. Three percent (3 of 98) of the paints with surface lead loading that did not exceed 2 µg/cm(2), the limit established by the Consumer Product Safety Improvement Act for small areas on toys, contained greater than 90 ppm lead and thus were false negatives. Of the new paint samples that contained ≤ 600 ppm, 88% contained ≤ 90 ppm. Of the samples that contained ≤ 90 ppm, 97% contained ≤ 45 ppm and 92% contained ≤ 15 ppm. Based on these data it appears to be technically feasible to manufacture paints containing ≤ 90 ppm and in many cases to produce paints that have lead concentrations that do not exceed 15 ppm.

Impact of incident venous thromboembolism on risk of arterial thrombotic diseases.

BACKGROUND: Growing evidence supports an association between venous thromboembolism (VTE) and arterial thrombotic diseases (ie, myocardial infarction and ischemic stroke). We aimed to study the association between VTE and future arterial events and to determine the population attributable risk of arterial events by VTE in a large prospective cohort recruited from the general population. METHODS AND RESULTS: In 1994 to 1995 and 1993 to 1997, 81 687 subjects were included in the Tromsø Study and in the Diet, Cancer and Health Study and followed up to the date of incident venous and arterial events (myocardial infarction or ischemic stroke), death or migration, or to the end of the study period (2010 and 2008, respectively). There were 1208 cases of VTE and 90 subsequent arterial events during a median follow-up of 12.2 years. An association between VTE and future arterial events was found in all women and men aged <65 years but not in men aged >65 years. Women <65 years old with VTE had 3.3-fold higher risk of arterial disease (adjusted hazard ratio, 3.28; 95% confidence interval, 1.69-6.35) compared with women of the same age without VTE. The corresponding hazard ratio in men aged <65 years was 2.06 (95% confidence interval, 1.32-3.20). Only 0.9% of the arterial events were attributed to VTE, and the VTE explained 63.8% of the risk of arterial events among VTE patients. CONCLUSIONS: Our findings imply that women and young men with VTE have higher risk of arterial thrombotic disease than those without VTE. However, only 1% of the arterial thrombotic events in the population are attributed to VTE.

Lead levels in new residential enamel paints in Taipei, Taiwan and comparison with those in mainland China.

Five brands of new enamel household paints from Taiwan were analyzed: two multi-nationals and three local. The median lead concentration of 2574 parts per million (ppm) dry weight was more than 30 times the current US standard of 90ppm for new paints and was more than 4 times the former standard of 600ppm. Lead levels ranged from below detection (4.5ppm) to 158,000ppm. Lead concentrations varied significantly by color of paint and paint brand but not by price per liter. Fifty-six percent of Taiwan paints had lead levels above the 90ppm US limit. One of the multi-national brands and two of the local brands had high levels of lead with the averages ranging from 12,890 to 53,640ppm. Concentrations were less than 90ppm in each of the samples from the other two brands. One of the two multi-national paint brands was imported as the house brand for its big box store in Taipei and had lead levels above 600ppm in four of five samples. Comparison of the lead concentrations of paints from Taiwan with those that we previously analyzed from mainland China revealed higher levels in Taiwan where the median level was 2574ppm compared to 46ppm in mainland China.

Manganese accumulation in the mouse ear following systemic exposure.

There is evidence in human populations that exposure to manganese (Mn), or Mn in combination with excessive noise exposure, results in hearing loss. Quantitative reverse-transcriptase polymerase chain reaction revealed expression of the metal transporters DMT1, ZIP8, and ZIP14 in control mouse ears. ZIP8 is known to have a high affinity (K(m) = 2.2 microM) for Mn transport, and ZIP8 protein was localized to the blood vessels of the ear by immunohistochemistry. We treated mice (strains C57BL/6J and DBA/2J) with Mn (100 mg/kg MnCl(2), by subcutaneous injection, on three alternating days), and Mn was significantly elevated in the ears of the treated mice. Mn concentrations remained elevated over controls for at least 2 weeks after treatment. These studies demonstrate that metal transporters are present in the mouse ear and that Mn can accumulate in the ear following systemic exposure. Future studies should focus on whether Mn exposure is associated with hearing deficits.