Testing of methicillin resistance by in vitro susceptibility and the presence of the mecA gene in clinical Staphylococcus aureus isolates in Finland

A total of 140 epidemiologically unrelated Staphylococcus aureus strains collected in Finland between 1983 and 1994 were sent to the reference laboratory with verified or suspected methicillin resistance. These strains and 37 S. aureus strains previously identified as methicillin-susceptible were retested using 5 different susceptibility test methods including agar screening, disc diffusion, growth around methicillin (25 micrograms) test strips and minimal inhibitory concentration (MIC) determinations by an agar dilution method and E-test. The isolates were also analyzed for the presence of the mecA gene by the polymerase chain reaction (PCR). Based on in vitro susceptibility, 69 strains were identified as methicillin-resistant and were positive for the mecA gene in PCR, while 84 strains were methicillin-susceptible and negative for this gene. Susceptibility testing gave conflicting results for 24 (14%) strains. When the tests were repeated in triplicate for each isolate, discrepant results were still achieved with 18 of the 24 strains in at least 2 different tests. Thus, based on in vitro susceptibility, these strains could not be definitely classified as resistant or susceptible to methicillin. Yet 7 of them were positive for the mecA gene as an indication of genetic resistance to methicillin. Corroborating earlier studies, these results illustrate the difficulty of detecting methicillin resistance/susceptibility based only on susceptibility testing and underscore the importance of confirming methicillin resistance in S. aureus in specialized laboratories.

Estimated collective effective dose to the population from X-ray and nuclear medicine examinations in Finland

The collective effective doses to the population from X-ray and nuclear medicine (NM) examinations in Finland in 2008 and 2009, respectively, were estimated. The estimated collective effective dose per inhabitant was 0.45 mSv from X-ray examinations and 0.03 mSv from NM examinations. The collective effective doses per inhabitant have not changed substantially during the last 10 y. However, proportional dose due to CT examinations has increased from 50 % in 2005 to 58 % in 2009 of the total collective effective dose from all X-ray examinations and proportional dose of PET examinations from 7 to 13 % of the total collective effective dose from NM examinations. The collective effective dose from conventional plain radiography was over 20 % higher when estimated using the new (ICRP 103) tissue weighting factors than that obtained using the old (ICRP 60) tissue weighting factors.

A clinical audit programme for diagnostic radiology: the approach adopted by the International Atomic Energy Agency

The International Atomic Energy Agency (IAEA) has a mandate to assist member states in areas of human health and particularly in the use of radiation for diagnosis and treatment. Clinical audit is seen as an essential tool to assist in assuring the quality of radiation medicine, particularly in the instance of multidisciplinary audit of diagnostic radiology. Consequently, an external clinical audit programme has been developed by the IAEA to examine the structure and processes existent at a clinical site, with the basic objectives of: (1) improvement in the quality of patient care; (2) promotion of the effective use of resources; (3) enhancement of the provision and organisation of clinical services; (4) further professional education and training. These objectives apply in four general areas of service delivery, namely quality management and infrastructure, patient procedures, technical procedures and education, training and research. In the IAEA approach, the audit process is initiated by a request from the centre seeking the audit. A three-member team, comprising a radiologist, medical physicist and radiographer, subsequently undertakes a 5-d audit visit to the clinical site to perform the audit and write the formal audit report. Preparation for the audit visit is crucial and involves the local clinical centre completing a form, which provides the audit team with information on the clinical centre. While all main aspects of clinical structure and process are examined, particular attention is paid to radiation-related activities as described in the relevant documents such as the IAEA Basic Safety Standards, the Code of Practice for Dosimetry in Diagnostic Radiology and related equipment and quality assurance documentation. It should be stressed, however, that the clinical audit does not have any regulatory function. The main purpose of the IAEA approach to clinical audit is one of promoting quality improvement and learning. This paper describes the background to the clinical audit programme and the IAEA clinical audit protocol.

Cholesterol metabolism and non-cholesterol sterols in patients with ileal pouch anastomosis

BACKGROUND

Previous studies suggest only minor changes in bile acid metabolism after panproctocolectomy with ileal pouch construction.

AIMS/METHODS

To investigate these changes further, we studied cholesterol absorption and serum, biliary and fecal non-cholesterol sterols and lipids in 12 ileal pouch patients and 10 controls.

RESULTS

In patients, cholesterol absorption was markedly reduced and was associated with low serum total and LDL cholesterol and LDL triglyceride levels, but surprisingly, cholesterol synthesis, as indicated by sterol-balance data or serum cholesterol precursor levels, was within low normal limits. The high proportions of serum plant sterol to cholesterol, particularly that of campesterol, were not related to cholesterol absorption, but were attributable to a markedly reduced biliary cholesterol secretion. Interestingly, in these patients the fractional absorption of campesterol was normal, whereas that of sitosterol, like cholesterol, was reduced and was positively related to the intestinal influx of cholesterol. The patients' serum cholestanol proportion was normal, but the proportion of the cholestanol formed during intestinal passage was significantly reduced (17.9% vs 65.2% in controls).

CONCLUSIONS

Thus ileal pouch patients are characterized by sterol malabsorption, lowered serum total and LDL-cholesterol levels, but unexpectedly without any increase in cholesterol synthesis. The lack of high serum cholestanol, shown earlier frequently in unoperated patients with ulcerative colitis, may indicate reversible cholestasis, a finding deserving further exploration.

Treatment of respiratory tract infections with erythromycin acistrate and two formulations of erythromycin base

Erythromycin acistrate (EA)--a new ester of erythromycin--was compared with erythromycin base as enterocoated pellets in capsules (EB enterocapsules) and enterocoated tablets of erythromycin base (EB enterotablets) in the treatment of respiratory tract infections. The present double-blind, multicentre study, conducted in eight occupational health centres, included 474 patients; 236 treated with EA, 117 with EB enterocapsules and 121 with EB enterotablets. The diagnoses included tonsillitis, sinusitis, otitis media, bronchitis and pneumonia. The patients were examined on admission and at the end of the treatment. The dosage of EA was 400 mg tid and that of the two erythromycin base preparations 500 mg tid. The treatment was given for seven to 14 days. In the EA-group, 97% of patients were clinically cured by the end of the treatment, while the cure rates for EB enterocapsules and EB enterotablets were 95% and 94%, respectively. Gastrointestinal side effects were reported by 36% of the patients on EA, 54% on EB enterocapsules and 50% on EB enterotablets. Discontinuations due to adverse effects occurred in 8% in the EA, in 21% in the EB enterocapsule and in 12% in the EB enterotablet groups. All three preparations were thus equally effective, but EA caused statistically significantly less gastrointestinal side effects overall (P less than 0.01), especially nausea (P less than 0.01) and abdominal pain (P less than 0.05), than the two formulations containing erythromycin base. Also discontinuations due to side effects occurred statistically significantly less frequently in the EA-group.

[Intravenous cholegraphy in acute cholecystitis (author's transl)]

In this prospective study iv-cholegraphy was performed before surgery on 152 patients by whom acute cholecystitis could not be excluded. The examination was diagnostic in 85% of the cases. Most of the patients (20/23) with nonvisualization of the biliary tract by iv-cholegraphy suffered from acute cholecystitis, the others (3/23) from acute pancreatitis. In three false negative examinations the opacification of the gallbladder was weak and in three false positive cases the cystic duct obstruction was caused by a chronic gallbladder disease. Because the preliminary clinical suspicion of acute cholecystitis even when using rigid criteria proved to be false in 30% of the cases, we consider a radiologic clarification to be indicated. Iv-cholegraphy is found to be an important examination in acute cholecystitis, practicable even at small radiologic departments with conventional equipment, and a reliable indicator of cystic duct obstruction.

AB0 and Lewis blood groups in reactive arthritis

In this study we evaluated secretor status in patients with reactive arthritis. Previous evidence indicates that non-secretion of AB0 and Lewis blood group antigens to saliva and other secretions is associated with susceptibility to certain bacterial infections and certain diseases with suspected autoimmune etiology. Secretor status can be determined based on the Lewis phenotype. We studied AB0, Lewis and Rhesus blood groups of 54 patients with previous reactive arthritis, 26 of whom had uroarthritis and 28 of whom had arthritis after enteric infection. Furthermore, 25 patients with uncomplicated yersiniosis and 57 healthy controls were studied. We did not find any correlation between secretor status and reactive arthritis or gastroenteritis due to Yersinia. AB0 blood group antigen B appeared to be protective against uroarthritis.

Analysis of factors correlating with medical radiological examination frequencies

The European Commission (EC) funded project Dose Datamed 2 (DDM2) had two objectives: to collect available data on patient doses from the radiodiagnostic procedures (X-ray and nuclear medicine) in Europe, and to facilitate the implementation of the Radiation Protection 154 Guidelines (RP154). Besides the collection of frequency and dose data, two questionnaires were issued to gather information about medical radiological imaging. This article analyses a possible correlation between the collected frequency data, selected variables from the results of the detailed questionnaire and national economic data. Based on a 35 countries dataset, there is no correlation between the gross domestic product (GDP) and the total number of X-ray examinations in a country. However, there is a significant correlation (p < 0.01) between the GDP and the overall CT examination frequency. High income countries perform more CT examinations per inhabitant. That suggests that planar X-ray examinations are replaced by CT examinations.

Intercomparison of Nordic therapy level exposure secondary standards for 60Co gamma radiation

An intercomparison of therapy level exposure secondary standards from the Nordic countries was made at 60Co gamma radiation at the secondary standard dosimetry laboratory in Helsinki . One standard seemed to be in error by about one per cent and another was found to be unreliable. From the analysis it was concluded that inter-comparisons of secondary standards can be made with an overall uncertainty of about 0.2 per cent. This uncertainty is of the same size as the difference between primary standards, which may therefore play a role in the evaluation of differences between secondary exposure standards.

Endometrial carcinoma in the cancer family syndrome

The study group consisted of 26 women with endometrial adenocarcinoma belonging to 19 cancer families. Age at the onset of cancer, the stage and histologic differentiation of the tumor, initial symptoms, other malignancies, 5-year survival, and transmission of cancer to descendants were studied. The focus was on the importance of endometrial carcinoma in the tumor spectrum. The diagnosis of cancer family was delayed in 14 of the 19 families because endometrial carcinoma was not included in the primary diagnostic carcinoma. This delay may have been harmful to 16 family members who had carcinomas later in life. In ten of the 14 women with multiple malignancies, endometrial adenocarcinoma was the primary malignancy diagnosed, thus enabling the suspicion of a gene carrier and screening for subsequent malignancies. The authors concluded that endometrial carcinoma is a significant component of cancer family syndrome and should be included in the main criteria of Lynch syndrome II.

Comparison of performance standards for radiation beam uniformity characteristics of a linear accelerator

The recent international standards published by the International Electrotechnical Commission (IEC) on the performance of medical electron accelerators describe suggested test procedures for the performance of radiotherapy accelerators. The recommendations of the Nordic Association of Clinical Physics for testing of the radiation beam characteristics include test conditions, methods and suggested tolerances that are different from those of the IEC. In this work the two publications were compared for acceptance testing of a Philips SL25 linear accelerator. It is important to gain experience on the practical use of these standards.

Replication errors in benign and malignant tumors from hereditary nonpolyposis colorectal cancer patients

A replication error (RER) phenotype has been documented both in sporadic colorectal tumors and in tumors from patients with hereditary nonpolyposis colorectal cancer (HNPCC). In the current study 8 of 49 (16%) sporadic colorectal cancers (CRCs) and 25 of 29 (86%) CRCs from HNPCC patients were found to be RER+. All 9 (100%) CRCs from HNPCC patients with germline mutations of the mismatch repair gene MSH2 were found to be RER+, while 16 of 20 CRCs from HNPCC kindreds unlinked or not studied for linkage to MSH2 were RER+. Corresponding analysis in colorectal adenomas revealed that only 1 of 33 (3%) sporadic tumors but 8 of 14 (57%) HNPCC tumors were RER+. Moreover, RER was found in all 6 extracolonic cancers (endometrium, 2; kidney, 1; stomach, 1; duodenum, 1; and ovary, 1) derived from members of HNPCC families. These data suggest the involvement of mismatch repair deficiency in the premalignant stage of tumorigenesis in HNPCC cases, and suggest that mismatch repair genes (MSH2 or others) are defective in the germline of nearly all these patients.

Evidence that the MCC-APC gene region in 5q21 is not the site for susceptibility to hereditary nonpolyposis colorectal carcinoma

Hereditary nonpolyposis colorectal carcinoma (HNPCC) is the most common form of hereditary colon cancer. Autosomal dominant inheritance is evident from pedigrees but the genetic basis of the disorder is otherwise unknown. Recently, two genes in 5q21 involved in colon carcinogenesis, APC and MCC, were identified, and APC was shown to be the gene predisposing to familial adenomatous polyposis. To determine if these genes also confer susceptibility to HNPCC we performed linkage analyses in nine affected families. The MCC-APC region could be formally excluded as the locus for HNPCC in seven families. In one family the results were suggestive of exclusion, although they were not conclusive. The remaining family was uninformative. We used two alternative definitions of affected status. Based on haplotypes for MCC and APC the added pairwise logarithm-of-odds score for all nine families was -22.57 at the recombination fraction of 0.00 using more stringent criteria for the HNPCC phenotype and -22.67 for less stringent criteria. In addition to blood DNA samples from living family members, DNA from formaldehyde-fixed archival pathology specimens from decreased individuals contributed to these linkage results.

Antibiotics in acute cholecystitis

In 460 cholecystectomies performed for acute cholecystitis 215 (47%) positive gallbladder bile cultures were obtained. In 73% of emergency operations bacteria were recovered, in 48% of early operations (p less than 0.001) and in 29% of late operations (p less than 0.001). In vitro concentrations of 8-16 mcg/ml of ampicillin or cephalothin inhibited in most cases the growth of E. coli, Klebsiella and Enterococci, which comprised 75% of all strains isolated. One hour after intravenous infusion of 1 g ampicillin the mean serum level was 21 mcg/ml, the mean common duct level 16 mcg/ml and the mean gallbladder bile level 4.4 mcg/ml. In acute cholecystitis 2 g cephalothin gave mean concentrations of 14, 8, and 1.2 mcg/ml. Most of these patients had cystic duct obstruction both on intravenous cholegraphy and during operation. Control patients with patent cystic ducts who received ampicillin had mean gallbladder and common duct bile levels of 47 and 56 mcg/ml, and those receiving cephalothin 23 and 28 mcg/ml. It appears that adequate gallbladder bile concentrations of antibiotics are not attainable in acute cholecystitis because of the obstruction to the bile flow. The favourable results of prophylactic antibiotic treatment in reducing septic complications seem to depend more on adequate serum and tissue concentrations than on the concentration of antibiotics in the bile.

Hepatic dearterialization in the treatment of carcinoid syndrome

Fourteen patients with carcinoid syndrome due to metastatic ileal (10), ileo-coecal (3) or appendiceal (1) carcinoid tumours were treated with hepatic dearterialization procedures: 15 surgical interruptions of arterial connections to the liver and 1 angiographic embolization of hepatic arteries. 11 patients had complained of recurrent attacks of flush, diarrhea and/or dyspnea and 3 patients had already progressed to general debility and cardiac failure caused by tumour products. Hepatic dearterialization abolished the carcinoid syndrome symptoms for 3-60 months (mean 19 months). Urinary 5-HIAA decreased for a mean period of 27 months. After relapsing symptoms 2 patients had redearterialization of the liver with a renewed symptomless period and lowered 5-HIAA excretion. Operative mortality was 19%: the deaths occurred when liver dearterialization was performed for end-stage patients or simultaneously with bowel resection, which should be considered as contraindications. Hepatic dearterialization seems to be temporarily effective in relieving carcinoid syndrome symptoms and in reducing hormonally active tumour mass and serotonin formation.

Exclusion of PTEN and 10q22-24 as the susceptibility locus for juvenile polyposis syndrome

Juvenile polyposis syndrome (JPS; MIM 174900) is an autosomal dominant condition with incomplete penetrance characterized by hamartomatous polyps of the gastrointestinal tract and a risk of gastrointestinal cancer. Gastrointestinal hamartomatous polyps are also present in Cowden syndrome (CS; MIM 158350) and Bannayan-Zonana syndrome (BZS; also called Ruvalcaba-Myhre-Smith syndrome; MIM 153480). The susceptibility locus for both CS and BZS has recently been identified as the novel tumor suppressor gene PTEN, encoding a dual specificity phosphatase, located at 10q23.3. A putative JPS locus, JP1, which most likely functions as a tumor suppressor, had previously been mapped to 10q22-24 in both familial and sporadic juvenile polyps. Given the shared clinical features of gastrointestinal hamartomatous polyps among the three syndromes and the coincident mapping of JP1 to the region of PTEN, we sought to determine whether JPS was allelic to CS and BZS by mutation analysis of PTEN and linkage approaches. Microsatellite markers spanning the CS/BZS locus (D10S219, D10S551, D10S579, and D10S541) were used to compute multipoint lod scores in eight informative families with JPS. Lod scores of < -2.0 were generated for the entire region, thus excluding PTEN and any genes within the flanking 20-cM interval as candidate loci for familial JPS under our statistical models. In addition, analysis of PTEN using a combination of denaturing gradient gel electrophoresis and direct sequencing was unable to identify a germline mutation in 14 families with JPS and 11 sporadic cases. Therefore, at least a proportion of JPS cases are not caused by germline PTEN alteration or by an alternative locus at 10q22-24.

Predictive genetic testing for hereditary non-polyposis colorectal cancer: uptake and long-term satisfaction

The aim of this prospective study was to assess the uptake of predictive genetic testing for hereditary non-polyposis colorectal cancer (HNPCC) and its associations with sociodemographic and other factors, and long-term satisfaction with taking the test. The test was offered to all high-risk members (n = 446) of 36 Finnish HNPCC families in which the mutation was known. The procedure comprised an educational counselling session, a period for reflection, and a test disclosure session. Data were collected by questionnaires sent before the educational counselling and 1 month and 1 year after the test disclosure. Of those eligible, 85% (n = 381) completed the first questionnaire study. Non-participation was more common among men living alone who had not participated in the clinical cancer surveillance programme. Of the 347 subjects who attended counselling, 334 (75% of all subjects) were actually tested. After logistic-regression analysis, the only significant factor predicting test acceptance proved to be employment status: those employed were more likely than others to accept the test (odds ratio = 2.25; 95% confidence intervals, 1.09 to 4.6 1). At follow-up, over 90% of the subjects were fully satisfied with the decision to take the test. In conclusion, acceptance of the test was considerably higher than in previously reported studies. We attribute this to our careful face-to-face individualized counselling, our health care system, and to attitudes of the Finnish population, which are generally favourable towards health care and disease prevention.

Cholescintigraphy in the diagnosis of acute cholecystitis

Technetium-99-m-diethyl-IDA (Solco HIDA) cholescintigraphy was performed on 50 patients with suspected acute cholecysitis. The final diagnosis was acute cholecytitis in 34 cases, other biliary tract disease in 5 cases and nonbiliary disease in 11 cases. A nonfilling gallbladder was regarded as indicative of acute cholecystitis. The sensitivity in detecting acute cholecystitis was about 90%, the specificity about 80%; the predictive value of a positive test was about 90% and that of a negative test about 80%. The false positives consisted of two cases of acute pancreatitis with normal gallbladders and one case of coincidental chronic gallbladder disease and duodenal ulcer. The false negatives were examined after one week's treatment. A severe common bile duct obstruction could be detected in cholescintigraphy, but a slight obstruction was not always distinguishable from conditions in which the bile flow was normal.

Microsatellite marker analysis in screening for hereditary nonpolyposis colorectal cancer (HNPCC)

Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant cancer predisposition syndrome caused by germ-line mutations in DNA mismatch repair genes. It is relevant to identify HNPCC patients because colonoscopic screening of individuals with HNPCC mutations reduces cancer morbidity and mortality. Microsatellite instability (MSI) is characteristic of HNPCC tumors. A panel of five markers (BAT25, BAT26, D2S123, D5S346, and D17S250, the so-called Bethesda markers) has been proposed for screening for MSI. To test a hypothesis that the use of BAT26 alone is feasible in screening for MLH1/MSH2 mutation-positive HNPCC patients, we compared the MSI results of 494 colorectal cancer patients obtained using BAT26 with results obtained using the Bethesda markers. BAT26 was able to identify all 27 mutation-positive individuals in this series. The marker failed to identify 2 high MSI tumors and 20 low MSI tumors, all of which expressed MLH1, MSH2, and MSH6 when scrutinized by immunohistochemistry.