Haem oxygenase-1 genotype and cardiovascular adverse events in patients with peripheral artery disease

BACKGROUND

A functional GT dinucleotide length polymorphism in the haem oxygenase-1 (HO-1) gene promoter is thought to be involved in the pathogenesis of cardiovascular disease. Short (< 25) (GT)n repeats are suggested to facilitate enhanced HO-1 up-regulation in response to injury and confer potent anti-inflammatory and antioxidative effects.

MATERIALS AND METHODS

We investigated the association between the HO-1 GT-polymorphism and cardiovascular outcome in 472 patients with advanced peripheral artery disease. Cardiovascular risk profile and DNA samples for determination of the HO-1 genotype (carrier vs. noncarrier of a short (GT)n repeat allele) were obtained at baseline, and patients were followed for median 21 months for the occurrence of coronary events (myocardial infarction, percutaneous coronary interventions and coronary artery bypass graft), cerebrovascular events (stroke or carotid revascularization) and all-cause mortality.

RESULTS

Coronary events occurred in 48 patients (9%), cerebrovascular events in 40 patients (9%) and 59 patients (13%) died. In total, 173 major adverse cardiovascular events (MACE) occurred in 133 patients (28%). Carriers of the short (GT)n repeat allele had a 0.46-fold reduced adjusted hazard ratio for coronary events (P = 0.016) as compared to noncarriers. No significant difference was found for cerebrovascular events, mortality and overall MACE.

CONCLUSION

Apparently, the HO-1 genotype exerts potentially protective effects against coronary adverse events in patients with peripheral artery disease. Homozygous and heterozygous carriers of < 25 (GT)n repeats had lower rates of myocardial infarction, percutaneous coronary interventions and coronary bypass operations compared to patients with longer (GT)n repeats.

Dermal and bronchial symptoms in children: are they caused by PAH containing parquet glue or by passive smoking?

OBJECTIVE

In 1997 a new source of potential polycyclic aromatic hydrocarbon (PAH) exposure was discovered: very high levels of (PAHs) and benzo-a-pyrene (BaP) were detected in household dust from former American Forces housing in Frankfurt am Main, Germany, built in 1955/1956. This contamination was caused by a parquet glue containing coal tar, the use of which was formerly a standard building practice in Germany. Children were considered to be at special risk for exposure to PAHs when playing on the floor via mouthing. Therefore, the children's symptoms and complaints were analysed for association with PAH contamination in parquet glue and household dust as well as with internal exposure to PAHs via determination of 1-hydroxypyrene in urine samples.

PARTICIPANTS AND METHODS

Two hundred and eighty seven children <6 years of age living more than 12 months in the former US-housing estates are enrolled in this analysis, representing 22.3% of the children <6 years of age living there. Their spot urine samples were analysed for 1-hydroxypyrene. The level of BaP in parquet glue and in household dust was available in the homes of 215 and 212 children, respectively. There were no hints for differences in PAH contamination in parquet glue or in household dust of the participants' flats compared to the flats of the non responders. In 246 cases data on environmental tobacco smoke exposure at home was known as well. Data on symptoms and complaints observed by their parents during the preceding 12 months (1-year prevalence) were obtained using the ISAAC questionnaire (modified).

RESULTS

The following 1-year prevalences were reported: 15% itching eczema in elbows, 10% itching and urticaria, 6% itching in the palate and throat, 20% sneezing and running nose or stuffed nose, 15% nosebleed; 25% wheezing, 42% dry cough, and 60% frequent infectious disease. No consistent associations between symptoms and BaP in parquet glue or in household dust or urinary levels of 1-hydroxypyrene in the children could be found. However, associations between symptoms and exposure to environmental tobacco smoke at home were to be seen, significant for dermal and bronchial symptoms.

CONCLUSION

Informed about PAHs in parquet glue and household dust many parents demanded for total redevelopment of their flats. According to statistical evaluation of the children's symptoms, observed by their parents, no hints for an association with exposure via BaP in parquet glue or household dust were found. However, significant associations between symptoms and the exposure to environmental tobacco smoke were observed, especially bronchial and dermal symptoms. Therefore instead of redevelopment of flats with parquet glue containing coal tar, intensified information on the harmful effects of passive smoking in childhood seems to be mandatory.

Prospective surveillance for healthcare-associated infections in German nursing home residents

We undertook a prospective surveillance study in order to determine the incidence of healthcare-associated infections (HCAIs) in German nursing home residents. All people residing for more than one day in a 103-bed nursing home for the elderly in Bonn, Germany between December 1998 and November 1999 were included. Active surveillance was based on previously published consensus definitions. Rates for HCAIs and urinary tract infections (UTIs) were calculated based on resident-days and device-utilization days, respectively. The overall incidence of HCAIs was 6.0 per 1000 resident-days, with respiratory tract infections, gastroenteritis, skin/soft tissue infections and UTIs representing 94% of all HCAIs (2.2, 1.2, 1.2 and 1.0 infections per 1000 resident-days, respectively). Residents with pneumonia were more likely to die than residents with other HCAIs (RR=5.09; 95%CI 1.87-13.89; P=0.011). We conclude that HCAIs are a serious health problem in German nursing home residents. Standardized surveillance in nursing homes is important to assess the effectiveness of infection control standards, and should be based on consensus definitions in order to allow for meaningful interfacility comparisons. In Germany, the implementation of a hospital reimbursement system based on diagnosis-related groups is likely further to increase the proportion of vulnerable populations in long-term-care facilities.

Prevention and control of health care-associated waterborne infections in health care facilities

The current article is a review of the public health risks attributable to waterborne pathogens in health care. The consequences of health care-associated infections (HAIs) are discussed. Not only are Legionella spp involved in HAIs, but also Pseudomonas aeruginosa, other gram-negative microorganisms, fungi, and amoeba-associated bacteria. This is particularly noteworthy among immunocompromised patients. New prevention strategies and control measures brought about through advanced planning, facility remodelling and reconstruction, disinfection, and filtration have resulted in a significant reduction of the incidence of waterborne HAIs. The positive consequences of a comprehensive multibarrier approach including prevention and control programs in health care facilities are discussed. Environmental cultures are now integrated within the infection control program of some European countries. In high-risk areas, the application of disposable sterile point-of-use filters for faucets and shower heads appears to be the practice of choice to efficiently control waterborne pathogens and to prevent infections.

[1974-2004: the Commission for Hospital Hygiene has been working for 30 years. From the "old" to the "new" guideline]

After 2 years of preparation, the Commission for Hospital Hygiene, founded in 1974 by the former German Public Health Service, published the "Guideline for Assessment,Prevention, and Controlling of Nosocomial Infections," which represented an exemplarily complete standard for hospital hygiene. In 1997 within the framework of planning the amendment to the Federal Epidemic Law, a new Commission for Hygiene and Infectious Disease Prevention started work and adapted the guideline to meet today's standards of systematic risk analysis and risk management. The amended Infection Protection Act (Infektionsschutzgesetz, IfSG), which came into force in January 2001, installed the Commission for Hospital Hygiene and Infectious Disease Prevention legally and required it to formulate a guideline to decrease the rate of nosocomial infections, the number of outbreaks, and the dissemination of antibiotic-resistant pathogens in healthcare facilities by establishing standards of modern prevention. This article describes the political importance of nosocomial infections for public health as well as the working basis, the methods, and the latest guidelines of the Commission.

[Hygiene in endoscopy in the clinic and practice, 2003: Results of infection hygiene survey on endoscopy services in Frankfurt am Main by the public health service]

Guidelines for reprocessing flexible endoscopes have been published in many countries. Compliance to the German guidelines, published in 2002 by the Commission on Hospital Hygiene and Infection Prevention on the Robert Koch Institute is mandatory in all endoscopic units, in hospitals as well as in private practices. Here, a survey of current reprocessing practices in an urban region in Germany is published, covering all hospitals and private practices in this region.

MATERIAL AND METHODS

In summer 2003, all endoscopic units in Frankfurt/Main, Germany--15 hospitals and 23 private practices -- were visited by members of the public health service, using a checklist based on the recommendations of the German guideline.

RESULTS

In these institutions, more than 70 000 endoscopic examinations per year are performed. 87 % (13 /15) of the hospitals and 43 % (10/23) of the practices, reported to conduct more than 1000 procedures per year. Great differences were found in hygienic quality comparing endoscopic units in hospitals and in private practices. In hospitals compliance with the guidelines was satisfactory. Main problems in the practices were: missing facilities for ultrasonic cleaning (74%) and sterilizing (43%), faults in reprocessing the bottle and tube for air/water-channel flushing (26%) which was filled in with water not sterilised (48%), storage of the endoscope with risk of recontamination (48%), missing routine-tests of the endoscopes after reprocessing (44%). Generally, hygienic conditions and procedures were worse in smaller units than in bigger ones.

DISCUSSION

The data from Frankfurt hospitals are satisfactory. In private practices, however, especially in smaller ones, improvements are mandatory. Improvements should cover the quality of structure and process, i.e. specific education of the nurses, availability of ultrasonic cleaners and sterilizators and -- preferably -- automatic dishwashers, as well as implementation of a written protocol for hygiene in endoscopy, based on the German Guidelines.

[Parasitic zoonoses transmitted by drinking water. Giardiasis and cryptosporidiosis]

Nowadays, the parasitic zoonose organisms Giardia lamblia und Cryptosporidium spp. are among the most relevant pathogens of drinking water-associated disease outbreaks. These pathogens are transmitted via a fecal-oral route; in both cases the dose of infection is low. Apart from person-to-person or animal-to-person transmissions, the consumption of contaminated food and water are further modes of transmission. The disease is mainly characterized by gastrointestinal symptoms. In industrialized countries, the prevalence rate of giardiasis is 2-5 % and of cryptosporidiosis 1-3%. Throughout the world, a large number of giardiasis and cryptosporidiosis outbreaks associated with drinking water were published; in 2001 the first case in Germany was identified. Giardia and Cryptosporidium are detected in surface water and sporadically in unprotected groundwater. Use of these waters for drinking water abstraction makes high demands on the technology of the treatment process: because of the disinfectant resistance of the parasites, safe elimination methods are needed, which even at high contamination levels of source water guarantee safe drinking water. Further measures for prevention and control are implementation of the HACCP concept, which includes the whole chain of procedures of drinking water supply from catchment via treatment to tap and a quality management system.

Household cleaning and surface disinfection: new insights and strategies

Recently, new insights into the persistence of pathogens, their transfer from inanimate surfaces to humans and the risk of contamination and dissemination of pathogens by detergents have been gained. Furthermore, new experimental data on the interruption of chains of infection by disinfectants as well as results of outbreak-control studies are now available. Hence it has become necessary to reassess the potential benefits using disinfectants to prevent and control nosocomial infections. Based on the new findings and in view of the increasing incidence of nosocomial infections and antibiotic resistances, the German Robert-Koch-Institut has issued completely revised recommendations on Household Cleaning and Surface Disinfection. With respect to these recommendations we developed a new test method, which allows comparison of the efficacy of disinfection in reducing the microbial loads and their dissemination with that of cleaning procedures under practical conditions. In a multi-factor approach, mechanical properties (wet mop technique), utensils (different mop materials) and active agents (disinfectant, detergent) were taken into consideration. We found that under the given conditions, dissemination of the test organism Staphylococcus aureus did not take place when using aldehydes and peroxides, it did take place, however, when water, surfactants, and the disinfectants glycol derivatives, quaternary ammonium compounds and alkylamines were used.

The size of a microsatellite polymorphism of the haem oxygenase 1 gene is associated with idiopathic recurrent miscarriage

Endothelial damage, impaired microvascularization and immune maladaptation have been described as aetiological factors in recurrent miscarriages. We investigated the relationship between idiopathic recurrent miscarriage (IRM) and a (GT)(n) repeat microsatellite polymorphism of the gene encoding haem oxygenase 1 (HO-1), known to modulate immune functions such as T-helper (TH) cell function and to be associated with cardiovascular disease. We investigated 162 women with IRM and 129 healthy, post-menopausal controls. The length of the HO-1 (GT)(n) microsatellite was assessed by PCR and direct sequencing in all women. Results were correlated with clinical data. The distribution of genotypes was in Hardy-Weinberg equilibrium. The HO-1 (GT)(n) microsatellite repeat numbers ranged from 13 to 37, with (GT)(23) and (GT)(30) being the most common alleles in both groups. We compared alleles consisting of < or =27 GT repeats, termed class S (short) alleles and alleles consisting of >28 GT repeats, termed class L (long) alleles. Seventy per cent of women with IRM had an S allele either in heterozygous (L/S) or homozygous (S/S) form, compared to 56% of controls (P = 0.02; OR 0.54; 95% CI 0.32-0.90). With respect to S allele frequencies, we found no significant difference among women with IRM and controls [P = 0.3; odds ratio (OR) 1.23, 95% confidence interval (CI) 0.86-1.76]. Comparing women with primary and secondary IRM, no difference with respect to the length of the HO-1 (GT)(n) microsatellite was ascertained. In summary, this is the first report on a HO-1 (GT)(n) microsatellite polymorphism among women with IRM, demonstrating that the investigated polymorphism is associated with IRM in a relatively large Caucasian population.

Heterotrophic plate count measurement in drinking water safety management

A group of microbiology and public health experts including regulatory and medical expertise was convened in Geneva, Switzerland, 25-26 April 2002 to consider the utility of heterotrophic plate count (HPC) measurements in addressing drinking water quality and safety. The group was convened following the NSF International/World Health Organization Symposium on HPC Bacteria in Drinking Water--Public Health Implications? The Expert Meeting was attended by 31 participants from Australia, Canada, France, Germany, Italy, Japan, the Netherlands, South Africa, Switzerland, UK and USA.

Bedeutung der Verordnung �ber die Qualit�t von Wasser f�r den menschlichen Gebrauch (Trinkwasserverordnung 2001) f�r die Krankenhaushygiene

Since January 2003, the new German Drinking Water Ordinance (DWO) has become operative. This paper briefly reviews some major consequences for hospitals. One of the main topics is the increased responsibility of operators of drinking water installation systems in hospitals concerning both the maintenance and control of good drinking water quality. Besides harmful chemical parameters, proliferation of pathogens can occur such as Pseudomonas aeruginosa, Legionella spec., Acinetobacter, and others which are mainly bound to biofilms and thus less affected by disinfectants. Recent epidemiological investigations point out that the relevance of waterborne pathogens is still considerably underestimated, particularly in hospitals. Local public health authorities play a central role in clinic inspection, supervision of water installations, surveillance, and risk assessment in cases of noncompliance with DWO requirements. For this reason, every irregularity detected must be reported to the local public health authority.

Effects of ion-pairing reagents on the electrospray signal suppression of sulphonated dyes and intermediates

High-performance liquid chromatography/mass spectrometry (HPLC/MS) analysis of anionic species such as sulphonic acid dyes and intermediates requires volatile ion-pairing mobile phase additives. Six di- and trialkylammonium acetates were compared with tetraalkylammonium salts and ammonium acetate in the concentration range 0-20 mmol l(-1) as mobile phase additives for HPLC/MS of polysulphonated compounds. The effects of the structure and concentration of the ion-pairing reagents on the electrospray response of mono-, di- and tetrasulphonic aromatic acids and acid dyes were studied in detail. Further, five different mass analysers and instrument geometries were compared. A higher signal decrease is observed with linear geometry instruments in comparison to orthogonal or even Z-spray geometry mass spectrometers. The concentration of mobile phase additives has a significant influence on the abundance ratios of multiply charged ions in the mass spectra of polysulphonated compounds. The competing ions of sulphonic acids may also cause significant signal suppression.

Adrenocortical Tumors: Prevalence of Impaired Glucose Tolerance and of “Paradoxical Rise” of Cortisol During an Oral Glucose Tolerance Test

Glucose tolerance and the behaviour of cortisol during an oral glucose tolerance test (OGTT) was investigated in 126 patients with adrenal "incidentalomas" (age: > 45 years) and in 129 age-matched controls. Impaired glucose tolerance (IGT) was found to be more common (p < 0.02) among patients with adrenal incidentalomas. Subdividing these patients by their body weight it was found that 29% (controls: 25%) of those with normal body weight (BMI 20 - 25 kg/m2) had IGT/DM. In overweight (BMI 25 - 30 kg/m2) and obese patients (BMI 30 - 40 kg/m2) the share of IGT/DM was 32% (controls: 19%) and 66% (controls 42%), respectively. The prevalence of a "paradoxical" rise in serum cortisol concentrations during the OGTT was slightly higher (p < 0.05) among patients with adrenal incidentaloma than among controls. Patients as well as controls with this abnormal behaviour of cortisol were characterized by lower basal serum cortisol concentrations (p < 0.01) but no association was seen with either the presence of IGT or with post-dexamethasone concentrations of serum cortisol. Thus both in patients with and without adrenal incidentalomas abnormal glucose tolerance is an age- and weight-dependent phenomenon unrelated to the post-prandial behaviour of serum cortisol concentrations.

Severe Serratia liquefaciens sepsis following vitamin C infusion treatment by a naturopathic practitioner

A 66-year-old female patient developed severe Serratia liquefaciens sepsis following vitamin C infusion treatment by a naturopathic practitioner. The clinical course of the infection was characterized by several complications, and the direct costs of the hospital stay amounted to about 40000 Euro. Genotypically identical S. liquefaciens was isolated from the residue of the infusate given to the patient, as well as from the washbasin overflow and from two other infusion bottles. A careful inspection of the dispensing facilities and review of procedures used to prepare the infusate revealed several indications of poor hygiene. However, the source of contamination could not be fully clarified. This case report raises questions about the local facilities and personal qualifications required for naturopathic practitioners to conduct invasive procedures and demonstrates that lapses in hygiene can lead to severe morbidity and high cost.

Impact of portable air filtration units on exposure of haematology-oncology patients to airborne Aspergillus fumigatus spores under field conditions

We undertook a one-year study to investigate the impact of the NSA model 7100A/B portable air filtration unit on exposure of haematology-oncology patients to airborne Aspergillus fumigatus spores under field conditions. Weekly measurements for airborne A. fumigatus were conducted in indoor and outdoor air, and surveillance for invasive aspergillosis was based on a combination of ward liaison, targeted chart review and consultation with the medical staff. The mean indoor A. fumigatus counts (8.1 cfu/m3; range, <0.8 to 42 cfu/m3) reflected the fungal load of outdoor air (9.4 cfu/m3; range, <0.8 to 50 cfu/m3), and were reduced by only about one third in rooms with portable air filtration units (5.3 cfu/m3; range, <0.8 to 41 cfu/m3). During the study period, a total of five cases (incidence density, 0.8 per 1000 patient-days) of invasive aspergillosis (one proven case, four suspected cases; case fatality rate 40%) were recorded. None of these five patients was allocated to a room with portable air filtration unit, however, the difference between incidence densities in rooms with and without portable air filtration units was non-significant (Fisher's exact test, P=0.33). Due to the noise level and thermal discomfort, patient compliance with the air filtration units was poor. We conclude that under field conditions this air filtration unit cannot be recommended for prevention of invasive aspergillosis in neutropenic haematology-oncology patients.

Use of the oral glucose tolerance test to define remission in acromegaly

An oral glucose tolerance test (OGTT) was used to assess growth hormone (GH) secretion in patients with acromegaly prior to (n = 26) and after (n = 71) transsphenoidal adenomectomy as well as in 196 controls. In controls, suppressed concentrations of GH showed a negative relationship both with body mass index (BMI) and with age. Having calculated the reference intervals for suppressed GH concentrations to be expected for any given age and BMI, we compared these individually predicted ranges to GH concentrations actually observed in patients with acromegaly during OGTT. Preoperatively, concentrations exceeded the normal range in all patients. Postoperatively, glucose-suppressed concentrations of GH were less than 2.0 ng/mL in 56 (79%) patients and less than 1.0 ng/mL in 44 (62%). However, only 37 of 71 (52%) patients had glucose-suppressed GH concentrations within the calculated reference intervals (defined by the 95th percentile of normal). Comparing these data with the patient's concentrations of insulin-like growth factor-1 (IGF-1; normal range first established and corrected for age and sex in 494 healthy individuals), congruency of both parameters was found in 59 (77%) patients with an unexplained discrepancy between GH and IGF-1 in the remaining in 16 (23%) patients. Our results confirm that concentrations of IGF-1 must be corrected for sex and age, whereas glucose-suppressed concentrations of GH depend on age and BMI. "Across-the-board" cut-off-values are clearly inadequate and should not be used. Rather, serum GH measurements obtained during an OGTT must be interpreted individually by comparison to control values taking into account both age and BMI.

Homocysteine promotes the LDL oxidase activity of ceruloplasmin

Ceruloplasmin (CP) oxidises low density lipoprotein (LDL). The oxidising potential depends on the formation of Cu(+)-CP which is redox-cycled during oxidation. Homocysteine (HCY) reduces free Cu(2+), potentiating its cell-damaging property. We show that HCY enhanced LDL oxidation by CP, but did not activate the LDL oxidising potential of Cu(2+)-diamine oxidase. Selective removal of the redox-active Cu(2+) abolished the LDL oxidase activity of CP. However, HCY partially restored the LDL oxidase activity of redox-copper depleted CP, indicating that the remaining six copper atoms in CP may also be involved in the process. Spectroscopic and oxidation inhibition studies using the Cu(+)-reagent bathocuproine revealed that HCY induced Cu(+)-CP formation, thus promoting its LDL oxidase activity.

Pseudomonas aeruginosa outbreak in a haematology-oncology unit associated with contaminated surface cleaning equipment

An outbreak of six cases of hospital-acquired Pseudomonas aeruginosa infections (two pneumonia two septicaemia, two skin/wound infection) occurred between August and September 2000 in an adult haematology-oncology unit at a tertiary-care centre. During the outbreak, hospital-acquired infection (HAI) incidence density rates rose from 29.4 to 62.3 (P < 0.05) infections per 1000 days at risk (i.e., neutropenic days). A systematic outbreak management system was actioned in accordance with a German draft guideline. Multiple samples from the patients' environment were tested for the presence of P. aeruginosa. A total of 4.5% of samples from sanitary equipment and 20.0% of samples from surface cleaning equipment were found to be contaminated with P. aeruginosa. Genotypic analysis by pulsed-field gel electrophoresis showed different patterns for all (N = 6) of the patient isolates, however, two of the patient isolates were identical in comparison with environmental isolates from cleaning equipment (four samples) and sanitary equipment (one sample). Our investigation revealed that the cleaning staff had used cleaning solution instead of disinfectants for decontamination of the patients' environment. The outbreak was terminated after re-adoption of surface disinfection, application of sterile filters on taps and shower heads, chemical disinfection of the washbasin drains, and appointment of a hospital hygiene nurse to a previously unfilled position. After institution of the control measures, HAI incidence densities decreased to pre-outbreak level. This investigation emphasizes the need to carefully evaluate cleaning and disinfection practices for patient care, particularly in neutropenic patients.

House dust mite allergen levels in German day-care centers

We investigated the levels of the major house dust mite allergens, Der p 1 and Der f 1, in dust collected from various locations in 41 day-care centers from two German cities (Düsseldorf and Bonn). One hundred and thirty-seven (96%) of 143 samples yielded detectable amounts of house dust mite allergen (range, < 15-85,000 ng/g; interquartile range, 210-1,480 ng group I allergen [sum of Der p 1 and Der f 1]/g dust), and 24 (17%) of the samples (8/34 mattresses; 11/46 cushions/soft toys; 5/43 carpeted floors, 0/20 smooth floors) exceeded the proposed "threshold" level of 2,000 ng/g dust in 18 (44%) of 41 day-care centers. Der p 1 and Der f 1 could be detected in nearly an equal number of samples. The highest concentrations of house dust mite allergens were found in dust from mattresses (geometric mean, 1,103 ng/g dust) and cushions/soft toys (geometric mean, 1,004 ng/g dust). The allergen load per unit area from carpeted floors exceeded that from smooth floors by more than two orders of magnitude. In comparison with dust samples from private homes within the same geographical area, the mite allergen levels in mattress dust (RR, 0.34; CI95, 0.18-0.64) and floor dust (RR, 0.21; CI95, 0.09-0.49) from day-care centers were significantly lower (p < 0.001). We conclude that day-care centers should be included as potential places of additional exposure to house dust mite allergens if avoidance measures are taken.