Outbreak of hepatitis A infection associated with the consumption of frozen berries, Ireland, 2013--linked to an international outbreak

In May 2013, a European alert was issued regarding a hepatitis A virus (HAV) outbreak in Italy. In June 2013, HAV subgenotype IA with an identical sequence was identified in Ireland in three cases who had not travelled to Italy. The investigation consisted of descriptive epidemiology, a case-control study, microbiological testing of human and food specimens, molecular typing of positive specimens and food traceback. We identified 21 outbreak cases (14 confirmed primary cases) with symptom onset between 31 January and 11 October 2013. For the case-control study, we recruited 11 confirmed primary cases and 42 matched controls. Cases were more likely than controls to have eaten berry cheesecake (matched odds ratio (mOR): 12; 95% confidence interval (CI): 1.3-114), whole frozen berries (mOR: 9.5; 95% CI: 1.0-89), yoghurt containing frozen berries (mOR: 6.6, 95% CI: 1.2-37) or raw celery (mOR: 4; 95% CI: 1.2-16). Among cases, 91% had consumed at least one of four products containing frozen berries (mOR: 12; 95% CI: 1.5-94). Sixteen food samples tested were all negative for HAV. As products containing frozen berries were implicated in the outbreak, the public were advised to heat-treat frozen berries before consumption.

Surveillance of the first 205 confirmed hospitalised cases of pandemic H1N1 influenza in Ireland, 28 April - 3 October 2009

From 28 April 2009 to 3 October 2009, 205 cases of confirmed pandemic H1N1 influenza were hospitalised in Ireland. Detailed case-based epidemiological information was gathered on all hospitalised cases. Age-specific hospitalisation rates were highest in the age group of 15 to 19 year-olds and lowest in those aged 65 years and over. Nineteen hospitalised cases (9%) were admitted to intensive care units (ICU) where the median length of stay was 24 days. Four hospitalised cases (2%) died. Fifty-one percent of hospitalised cases and 42% of ICU cases were not in a recognised risk group. Asthma was the most common risk factor among cases; however, people with haemoglobinopathies and immunosuppression were the most over-represented groups.

Surveillance of the first 205 confirmed hospitalised cases of pandemic H1N1 influenza in Ireland, 28 April – 3 October 2009

From 28 April 2009 to 3 October 2009, 205 cases of confirmed pandemic H1N1 influenza were hospitalised in Ireland. Detailed case-based epidemiological information was gathered on all hospitalised cases. Age-specific hospitalisation rates were highest in the age group of 15 to 19 year-olds and lowest in those aged 65 years and over. Nineteen hospitalised cases (9%) were admitted to intensive care units (ICU) where the median length of stay was 24 days. Four hospitalised cases (2%) died. Fifty-one percent of hospitalised cases and 42% of ICU cases were not in a recognised risk group. Asthma was the most common risk factor among cases; however, people with haemoglobinopathies and immunosuppression were the most over-represented groups.

The utilisation and expenditure of medicines for the prophylaxis and treatment of osteoporosis

The elderly population represent the fastest growing age-group and the incidence of osteoporotic related fractures is likely to increase with continued ageing of the population. This study determined the prescribing patterns on the Health Services Executive's (HSE) Primary Care Reimbursement Services Scheme (HSE-PCRS) of medicines dispensed for the prophylaxis and treatment of osteoporosis in Ireland. The HSE - PCRS prescription databases were analysed for the years 2004/2005. Approximately 65% of patients (total 60,000) were dispensed either Alendronate (Fosamax once weekly) or Risedronate (Actonel once weekly). The majority of the patients (69.3%) were over 70 years. The study identified that the longer a patient was prescribed prednisolone the greater the likelihood of subsequently being prescribed a bisphosphonate. Approximately 50% of patients on long-term steroids did not receive prophylaxis for osteoporosis. There were low levels of co-prescribing (2.5%) with potentially interacting drugs. Levels of co-prescribing with proton pump inhibitors was 22%.

Embolisms and refilling in the maize leaf lamina, and the role of the protoxylem lacuna

The proportion of embolized vessels in the veins of maize leaf laminas was measured during 24 h by direct counting in snap-frozen samples in the cryo-scanning electron microscope. All vessels were sap filled at night. Vessels of intermediate and small veins, and the small tracheary elements of lateral veins, were sap filled throughout the 24 h. The large metaxylem vessels of lateral veins were embolized during the day. The percentage of these vessels embolized was maximum (>70%) at 1400, and declined during the afternoon to 20% at dusk. Leaf water potential reached a minimum (-1.2 MPa) at dusk. The protoxylem lacuna of the lateral veins was much less embolized than the large vessels, although it was of comparable diameter. The observations are interpreted in terms of the refilling hypothesis that is part of the compensating pressure theory of water transport.

Contributions to the debate on water transport

The useful criticisms of my theory of water transport by Comstock (American Journal of Botany 86: 1077-1081) and by Stiller and Sperry (American Journal of Botany 86: 1082-1086) are acknowledged and reviewed. I make the following responses. (1) Tensile stresses to contain tissue pressure are kept within modest limits by the organization of vascular tissues into cylindrical bundles with small ratios of radius/boundary thickness. (2) The balance of pressures within tissues of a nontranspiring leaf is best understood by treating it as a single compartment containing several pressure-generating engines whose resultant is the pressure throughout the compartment. An error in the published notional balances for a transpiring leaf is corrected. (3) The argument against a valve in the transpiring leaf, which allows water out but not in, is not convincing. (4) The "robust and extremely consistent" cohesion theory gains this status by neglecting large bodies of experimental fact, once well known to plant physiologists. (5) The demonstration that living cells are not involved in the refilling of embolisms in birch stems is welcomed as an important advance. However, the major questions remain unresolved. (6) Proof is still needed that embolisms in vessels are not refilled by the collapse of gas bubbles under small positive pressures during conductance measurement. (7) The survival of unbroken water threads in vessels under centrifugal stress has still not been demonstrated. (8) Both questions 6 and 7 can be easily answered by direct observation of gas/liquid volumes in frozen stems in the cryo-scanning electron microscope.

Applications of the compensating pressure theory of water transport

Some predictions of the recently proposed theory of long-distance water transport in plants (the Compensating Pressure Theory) have been verified experimentally in sunflower leaves. The xylem sap cavitates early in the day under quite small water stress, and the compensating pressure P (applied as the tissue pressure of turgid cells) pushes water into embolized vessels, refilling them during active transpiration. The water potential, as measured by the pressure chamber or psychrometer, is not a measure of the pressure in the xylem, but (as predicted by the theory) a measure of the compensating pressure P. As transpiration increases, P is increased to provide more rapid embolism repair. In many leaf petioles this increase in P is achieved by the hydrolysis of starch in the starch sheath to soluble sugars. At night P falls as starch is reformed. A hypothesis is proposed to explain these observations by pressure-driven reverse osmosis of water from the ground parenchyma of the petiole. Similar processes occur in roots and are manifested as root pressure. The theory requires a pump to transfer water from the soil into the root xylem. A mechanism is proposed by which this pump may function, in which the endodermis acts as a one-way valve and a pressure-confining barrier. Rays and xylem parenchyma of wood act like the xylem parenchyma of petioles and roots to repair embolisms in trees. The postulated root pump permits a re-appraisal of the work done by evaporation during transpiration, leading to the proposal that in tall trees there is no hydrostatic gradient to be overcome in lifting water. Some published observations are re-interpreted in terms of the theory: doubt is cast on the validity of measurements of hydraulic conductance of wood; vulnerability curves are found not to measure the cavitation threshold of water in the xylem, but the osmotic pressure of the xylem parenchyma; if measures of xylem pressure and of hydraulic conductance are both suspect, the accepted view of the hydraulic architecture of trees needs drastic revision; observations that xylem feeding insects feed faster as the water potential becomes more negative are in accord with the theory; tyloses, which have been shown to form in vessels especially vulnerable to cavitation, are seen as necessary for the maintenance of P, and to conserve the supplementary refilling water. Far from being a metastable system on the edge of disaster, the water transport system of the xylem is ultrastable: robust and self-sustaining in response to many kinds of stress.

Xylem feeding by spittlebug nymphs: some observations by optical and cryo-scanning electron microscopy

The feeding of spittlebug nymphs (Philaenus spumarius) from mature xylem vessels was studied by optical and cryo-analytical scanning electron microscopy. Feeding did not produce xylem embolisms and vessels remained liquid-filled during the day. Saliva secreted by the insect forms a hardened lining (salivary sheath) between the stylet bundle and the plant tissues. This sheath is continuous through the hole made by the stylets as they enter a vessel, and it extends into the vessel and along its periphery beyond the breach. The sheath is heterogeneous, with a thin outer layer adjoining the plant tissues and a thicker layer that contacts the stylet bundle. Both layers give positive histochemical reactions for proteins and, in fresh tissues, contain a red, strongly autofluorescent pigment, possibly condensed tannin derived from the plant (which is lost during tissue preparation), and other phenyl propanoid compounds, which are retained and which may produce the intense reaction of the periodic-acid-Schiff's-positive inner layer. It is concluded that the salivary sheath allows the insects to feed from functioning vessels without embolizing them or losing xylem fluid to the surrounding tissues. These findings and others in the entomological literature indicate low daytime tensions in the xylem conduits of the host plants.

Vessel contents of leaves after excision - a test of Scholander's assumption

A test was attempted of the assumption that, when a leaf is cut, the xylem still contains water under tension beyond the first vessel cross walls. This assumption enabled Scholander to argue that the balance pressure in his pressure chamber measured the tension in water columns in the vessels before cutting. The numbers of embolized vessels were counted, after rapid freezing of petiole and midrib samples of sunflower leaves, in the cryo-scanning electron microscope. Counts were made on leaves still attached to the plant and at intervals after cutting from the plant (up to 16 min) during a short spring day's transpiration. The lengths of vessels in the leaves, measured by latex particle perfusion, showed that 8% of vessels in the mid-petioles and 0% in the midribs should be opened by cutting. The changing percentages of embolized vessels (E) with time showed that: (1) in intact plants E was close to zero until midday when it rose to ~40%, and then fell progressively to near zero by 1600; (2) in excised leaves there was no detectable change in E immediately after cutting, and, in all but two time courses, no change as large as the 8% of opened vessels within 16 min; (3) but briefly, when E was high (midday), it rose further after cutting to a plateau (_E = 30-40%) in 4 min. From this rate of emptying, the estimated maximum pressure difference between vessels and parenchyma was of the order of 0.05-0.2 MPa (0.5 to 2 bar) at this time. (4) All these changes occurred in the petioles 1 h before they were found in the midribs. The test failed because the expected large pressure difference between vessels and parenchyma was not present. Further, the embolized vessels were refilled at the time of peak transpiration, which would be impossible with any substantial tension in the vessels. Because these results contradict the whole basis of the Cohesion Theory, a second experiment was carried out to test them, and is reported in a companion paper.

Vessel contents during transpiration - embolisms and refilling

A test was made of the previous unexpected observation that embolized vessels were refilled during active transpiration. The contents of individual vessels in petioles of sunflower plants were examined, after snap-freezing at 2-h intervals during a day's transpiration, in the cryo-scanning electron microscope, and assessed for the presence of liquid or gas (embolism) contents. Concurrent measurements were made of irradiance, leaf temperature, transpiration rate, and leaf water potential (by pressure chamber). Up to 40% of the vessels were already embolized by 0900 (transpiration rate ~5 _g_cm-2_s-1, water potential about -300 J/kg), and the proportion declined to a minimum (as low as 4%) at 1500. This was the time of highest transpiration rate (~25 _g_cm-2_s-1) and most negative water potential (-600 to -700 J/kg). Images of vessels with mixed gas and liquid contents showed water being extruded through pits in the walls of the vessels to refill them. The data indicate that: (1) the water columns are weak and break under quite small tensions; (2) embolisms are repaired by refilling the vessels with water on a short time scale (minutes) throughout the day; (3) the vigor of this refilling process is adjusted by the plant on a longer time scale (hours) to the intensity of the water stress; (4) the pressure chamber balance pressure (P) does not measure tension in the vessels; (5) P is also not a measure of water stress (as measured by vessel embolization); and (6) P is a measure of the plant's response to water stress, i.e., a measure of the vigor of the refilling process. The test confirms the previous observations and negates all the assumptions and evidences of the Cohesion Theory. The data are fully consistent with the Compensating Pressure Theory, which predicted the relations demonstrated in this experiment. Using the assumptions of that theory it is easy to outline a simple mechanism by which the refilling of vessels might be achieved by reverse osmosis, and the adjustment in (3) might be achieved by osmoregulation in the starch sheath.

Coronary blood flow reserve measured by contrast media injection depends on myocardial viability

Coronary blood flow reserve may be affected by several physiological variables besides hydraulic impediment to flow. A hyperaemic response induced by hyperosmolar radiopaque contrast medium was recorded in the left anterior descending and left circumflex arteries with a steerable pulsed Doppler system in four patients with Q wave anterior myocardial infarction chronic scar and non-stenotic coronary arteries. Resting flow velocities were similar in both arteries. The magnitude of the hyperaemic response induced by contrast media in the circumflex artery (mean flow velocity increase from 5.9 +/- 2.5 baseline to 12.2 +/- 0.6 cm s-1 at peak flow, P less than 0.05) was almost twice that induced in the left anterior descending artery (mean flow velocity increase from 6.1 +/- 2.2 baseline to 7.4 +/- 2.6 cm s-1 at peak flow, P = N.S.). The peak flow to baseline flow velocities ratios were 1.22 +/- 0.15 in the left anterior descending artery vs 2.23 +/- 0.75 in the circumflex artery. Thus when a post-myocardial infarction chronic scar is supplied by a non-stenotic coronary artery, the coronary blood flow hyperaemic response to contrast media-induced transient ischaemia is decreased, suggesting that coronary blood flow reserve depends on a myocardial metabolic stimulus which is impaired by ischaemic cell death.

[Evolution of the primary successes of percutaneous aortic valvuloplasty]

Between November 1985 and August 1988, we performed 89 percutaneous aortic valvuloplasties. Sixty-two of these were considered a primary success on the basis of two main criteria: stage I or II on discharge and greater than 50 p. 100 increase in aortic valve area. The mean age of these patients was 78.4 +/- 6.1 years. On actuarial analysis, after 5 months 98 p. 100 of the patients with primary success were alive and 89 p. 100 were in stage I or II and had not been operated upon or redilated. At 15 months 79 p. 100 of the patients with primary success were alive, but only 48 p. 100 were in stage I or II and neither operated upon or redilated. Ultrasonic data obtained one and twelve months after dilatation were compared in 8 patients who had kept the full functional benefit of angioplasty for 14.6 +/- 4.3 months (group 1) and 9 patients who had lost this initial benefit (group 2). In group 1 patients the aortic valve area had moderately and non significantly diminished from 0.92 to 0.72 cm2. In group 2 patients the aortic valve area had gone down from 0.89 to 0.63 cm2 (p less than 0.01), indicating restenosis. We conclude that after the 4th post-valvuloplasty month the medium-term success of the procedure undergoes some degradation, and in these patients the echocardiographic signs of stenosis are clear-cut.

Results of percutaneous valvuloplasty for calcific aortic stenosis with different balloon catheters

Percutaneous aortic valvuloplasty is a palliative treatment for patients with calcific aortic stenosis who would be poor candidates for surgical treatment. The results and associated complications of this procedure were analysed in a series of 47 patients in which different types of dilating catheters were used. In 25 patients a single balloon (19 mm) was used (group A), in 13 patients a bifoil balloon (2 x 15mm) (group B), and in the remaining nine patients (group C) a trefoil balloon (3 x 10mm) was used. An increase in aortic valve area was achieved in all patients. The results obtained with the bifoil balloon were better than with the other types of balloon catheter, with an increase in aortic area of + 118% vs. + 74% (monofoil) and + 76% (trefoil) (P less than 0.05). The tolerance of the inflation procedure was also better with this type of balloon, as it allowed for shorter inflation and deflation times. These results show that balloon aortic valvuloplasty, when indicated, is best performed with a bifoil balloon dilating catheter, and undue complications usually do not occur.

Diagnosis of coronary aneurysms in siblings: treatment with a new surgical procedure

We report the cases of two brothers who simultaneously developed myocardial infarction, and in whom we found coronary artery aneurysms at echocardiography. In one case a new surgical procedure was performed. The aneurysm was bypassed by an aorto-coronary vein graft and the coronary ostium of the related coronary artery was closed. Thus, perfusion of the dependent vessels of the aneurysm was maintained, and the risk of distal embolism was prevented. The aetiologies of coronary artery aneurysms are discussed. In our patients the aneurysms were probably congenital, but we cannot exclude the possibility of previously undiagnosed Kawasaki's disease.

[Reproducibility of myocardial ischemia induced by atrial stimulation]

Reproducibility of myocardial ischemia induced by atrial pacing (P) was investigated in 25 patients (pts) without previous anterior myocardial infarction and showing a positive exercise stress test. The second period of atrial pacing (P2) was exerted 20 minutes after the first (P1). During P2, a reduction in the parameters reflecting myocardial oxygen requirements (maximal left ventricular pressure, dp/dt max, TTI*HR values) was noted, while the signs of ischemia were less pronounced (ST depression decreasing from 2.3 +/- 1 mm to 1.6 +/- 1.0 mm; % of lactate extraction (%L) decreasing from - 6.4 +/- 25.5 to + 8.5 +/- 19.2; p less than 0.5). The 25 pts were divided into 2 groups according to the ejection fraction (EF greater than .55 16 pts Gr.F+; EF less than .55 9 pts Gr.F-). The distribution of coronary lesions was the same for the 2 groups. During P1 GR.F+ registered a negative % L as opposed to Gr.F-. During P2, the difference in the % L between the 2 groups was also significant (2.6 +/- 19.9% F+ vs 18.9 +/- 14.3% F-; p less than .05). Collateral circulation had no effect upon the results, neither for P1 or P2. This study shows that a second period of atrial pacing, 20 minutes after the first, induced lesser ischemia than the first period of atrial pacing. This phenomenon could explain the paradoxical improvement observed in certain patients after a first episode of angina. These results have implications as regards the necessity of double blind studies compared to placebo when using this technique in the evaluation of the effects of anti-ischemic drugs.

[Phase variations in the left coronary transstenotic pressure gradient before and after dilatation by percutaneous coronary angioplasty]

The concept of significant coronary stenosis may be approached by studying the effects of the narrowing not in absolute values of pressure and flow but by studying the mode of blood flow across the stenosis. Ten patients with isolated stenosis of the LAD were studied for phasic variations of the transstenotic pressure gradient before and after dilatation. The material used was a ST 3.7 catheter with a 0.12 inch guide. Instantaneous pressure recording throughout the cardiac cycle were obtained using a computer. After dilatation, the area of the stenosis minus the area of transverse section of the dilating catheter increased from 0.5 +/- 0.3 to 2.2 +/- 0.3 mm2, the average gradient between the aorta and the post stenotic LAD decreased from 75 +/- 10 to 12 +/- 8 mmHg, and the ratio between the mean diastolic gradient and mean gradient increased from 75 +/- 7 to 245 +/- 30% (p less than 0.01 for the 3 parameters, paired t test). These results show that the LAD transstenotic pressure gradient is not phasic in severe stenosis. It becomes phasic, only in diastole, after dilatation of the stenosis (slight residual stenosis due to the catheter). This difference may be due to the type of flow, continuous and dependent on the stenosis before dilatation, or phasic dependent on the distal coronary circulation after dilatation. Analysis of the phasic changes of coronary flow may be useful for the evaluation of the severity of left coronary stenosis in the absence of pressure measurements.

Percutaneous coronary angioplasty of a left anterior descending artery implanted on a Dacron coronary prosthesis on an aortic conduit

Certain surgical techniques may make it difficult to catheterize the coronary ostia and perform percutaneous coronary angioplasty. We report the case of a 48 year old patient who developed unstable angina four years after a Bentall's procedure with reimplantation of the coronary arteries on a Dacron coronary prosthesis. The anginal pain was related to very severe stenosis of the proximal segment of the left anterior descending artery. The difficulties encountered during the dilatation procedure were due to: (a) the ectopic position of the ostium of the prosthesis on the anterior aortic wall; (b) the forces exerted on the aortic prosthesis wall and on the valvular prosthesis during positioning of the guiding catheter which were poorly tolerated and induced a vagal reaction; (c) the direction taken by the distal tip of the guiding catheter, perpendicular to the wall of the aortic prosthesis; (d) the sinuosity of the arterial trajectory: the left coronary segment of the coronary prosthesis was directed towards the left circumflex artery rather than towards the left anterior descending artery. Coronary angioplasty succeeded after relatively complex technical procedures: special guiding catheter, unusual intra-aortic manoeuvres for positioning the guiding catheter, dilatation catheter change on a 3-metre long guide wire in order to cross the stenotic segment; this was performed with a super low-profiled dilatation catheter. There were no complications and anginal pain disappeared.

[Differential diagnosis between constrictive pericarditis and cardiac amyloidosis by computerized M-mode echocardiography]

A diastole is a non specific haemodynamic syndrome which may result from constrictive pericarditis or from a restrictive cardiomyopathy. The aim of this study was to differentiate these two types of condition by analysis of computerised M mode recordings of the left ventricle. Three groups of patients were studied: 5 cases of confirmed cardiac amyloidosis (Am); 5 cases of constrictive pericarditis confirmed surgically (CP) and 10 normal subjects (NL). The study was based on analysis of parameters of ventricular filling and of diastolic thinning of the LV free wall. A significant difference was observed between AM and CP but not between PC and NL. Amyloidosis was characterised by a reduction in the maximum velocity of endocavitary diameter lengthening (AM 0,84 +/- 0,56 cir/sec; PC 3,95 +/- 0,77, p less than 0,01), prolongation of the rapid filling phase (AM 0,42 +/- 0,17 sec; PC 0,16 +/- 0,06 sec, p less than 0,02) and a decrease in maximum velocity of free wall thinning (AM 0,45 +/- 0,23 th/syst/sec; PC 4,79 +/- 2,1, p less than 0,01). The diastolic thickness of the free wall was greater in the amyloidosis group (AM 1,73 +/- 0,61 cm; PC 1,05 +/- 0,21, p less than 0,05) and correlated with the reduction of maximum velocity of free wall thinning. Parameters of global diastolic filling did not distinguish the two conditions. The M mode recordings were therefore digitalised to provide graphs of chamber filling and wall thinning and their derivatives.(ABSTRACT TRUNCATED AT 250 WORDS)

[Interatrial septal aneurysm. Echocardiographic diagnosis]

Interatrial septal aneurysm is a rare abnormality and can now be diagnosed by echocardiography. We report the case of a 52 year old woman in whom this condition was diagnosed after an embolic cerebrovascular accident. M mode recordings showed a linear echo in the left atrial cavity in early and mid systole. The aneurysm was directly visualised by 2D echo as a hemispherical bulge in the mid portion of the interatrial septum, which was mobile and had a to-and-fro motion between the two atria in relation to the different phases of the cardiac cycle. The diagnosis was confirmed by angiography, and at surgery. A feature of this case was the close correlation between echocardiographic, angiographic and operative findings. The pathogenesis of this type of aneurysm remains conjectural as does its role in the production of cerebral embolism, the evidence for which was circumstantial in the absence of other demonstrable causes and in the light of previously reported cases.

[Are post-infarction left ventricular aneurysms distensible? Volumetric study using angiography]

During left ventriculography, post-infarction left ventricular aneurysms present as diastolic deformations of the ventricular contour which, when accentuated during systole, give rise to paradoxical systolic expansion. The volumic consequences of thie parietal dyskinesia were studied in 10 cases of chronic anterior wall aneurysm. The borders of the aneurysm were determined by Watson's technique: diastolic and systolic volumes and endocardial surface areas were measured using a computer. In 9 out of 10 cases, neither volume nor endocardial surface area of the aneurysm varied from diastole to systole. Systolic distension of the aneurysm was observed in only one case. In the remainder, paradoxical systolic expansion was related to a charge in the shape of the aneurysm and to overall movement of the heart. The angiographic observations are important for the understanding of the physiopathology of post-infarction aneurysm and for choice of techniques for surgical treatment.