Intraabdominaalse hüpertensiooni esinemissagedus intensiivravihaigetel ja mõju ravitulemustele

Tartu Ülikooli Kliinikumi üldintensiivraviosakonnas on intraabdominaalset rõhku (IAP) mõõdetud alates 2004. aastast. Käesolev töö keskendub intraabdominaalse hüpertensiooni (IAH) esinemissageduse ja mõju uurimisele kahe perioodi võrdluses: esimesel perioodil (2004–2006) mõõdeti IAP ainult eeldatava riskirühma patsientidel, teisel perioodil (2006–2007) aga kõikidel aparaadihingamisel olevatel haigetel. Uurimuse tulemustest selgus, et IAH riskirühm on raskesti kindlaks tehtav. Jälgides IAPd ainult valitud patsientidel, jääb osa IAH-patsientidest identifi tseerimata. IAH esineb intensiivravipatsientidel sageli ning on seotud nende suurema suremusega. Eesti Arst 2008; 87(3):191−19

Varase sepsise riskiga vastsündinute limaskestade kolonisatsioon ja selle osatähtsus invasiivse infektsiooni prognoosimisel

Väitekirja elektrooniline versioon ei sisalda publikatsioone.Uurimistöö peamiseks eesmärgiks oli selgitada vastsündinute varase sepsise empiiriliseks raviks kasutatavate ravirežiimide (ampitsilliin ja penitsilliin kombinatsioonis gentamütsiiniga) mõju vastsündinute rektaalse ja ninaleelu kolonisatsioonile oportunistlike mikroobidega. Lisaks sellele hinnati perinataalsete, neonataalsete ja keskkonna faktoreite osa limaskestade kolonisatsiooni tekkes; seost kolonisatsiooni ja infektsioone põhjustavate mikroobitüvede vahel; ning kaks korda nädalas kogutud järelevalvekülvide olulisust sepsise prognoosimisel. Meetodid. Prospektivine, kahekeskuseline, klaster-randomiseeritud avatud uuring viidi läbi Tallinna Lastehaigla ja Tartu Ülikooli Kliinikumi laste- ja vastsündinute intensiivravi osakondades 02.08.2006 kuni 30.11.2007. Uuringusse kaasati 278 vastsündinut, kes olid osakonda saabudes nooremad kui 72 tundi, vajasid sepsise kahtluse või riskifaktorite olemasolu tõttu empiirilist antibakteriaalset ravi ning viibisid osakonnas vähemalt 24 tundi. Limaskestade kolonisatsiooni hindamiseks koguti nina-neelu materjal (n=1153) ja rektaalkaabe (n=1250) patsiendi osakonda saabumisel ja edaspidi kaks korda nädalas kuni osakonnas viibimise lõpuni või kuni 60-da ravipäevani. Uuringumaterjalid steriilsetest kehavedelikest (n=554) võeti patsiendi osakonda saabumisel enne antibakteriaalse ravi alustamist ja edaspidi vastavalt kliinilisele vajadusele. Materjal mikrobioloogilisteks uuringuteks külvati veri-, MacConkey ja Sabouraud agarile ning ampitsilliin-resistentsete tüvede selgitamiseks MacConkey agarile, kuhu oli lisatud 16 µg/ml ampitsilliini. Molekulaarseid uuringuid kasutati limaskestade ja invasiivsete tüvede klonaalsuse selgitamiseks. Nii emapoolsete kui ka keskkonnast ja lapsest sõltuvate kolonisatsiooni riskifaktorite (n=22) selgitamiseks kasutati ühest ja mitmest logistilist regressiooni. Järelevalvekülvide väärtuse hindamiseks sepsise prognoosimisel arvutati eraldi sensitiivsus, spetsiifilisus ning positiivne (PPV) ja negatiivne prognostiline väärtus iga võetud külvi kui ka patsiendi kohta. Tulemused ja järeldused. Esmased seedetrakti koloniseerijad olid Gram-positiivsed bakterid, milledest ülekaalukalt domineerisid koagulaas negatiivsed stafülokokid. 49-l (17,8%) esines rektaalne kolonisatsioon Candida spp-ga. Isoleeritud rektaalsest ja nina-neelu materjalist esines vastavalt 55,8%-l ja 42,8%-l Gram-negatiivseid mikroobe. Kuigi antud kahe piirkonna mikroobne kooslus oli sarnane, esines siiski ka piirkonna valikulist mõju. Näiteks oli rektaalselt võrreldes nina-neeluga 1,5-2,5 korda suurem šanss kolonisatsiooniks enterobakteritega ja väiksem šanss (OR=0,52; 95% CI 0,30-0,89) Acinetobacter spp-ga. Selgus, et limaskestade kolonisatsiooni E. coli, K. oxytoca ja C. albicans’ga mõjutasid peamiselt emapoolsed ja perinataalsed faktorid, kusjuures kolonisatsioon K. pneumoniae, E. cloaceae, MRSA ja mitte-albicans-Candida’ga oli peamiselt tingitud haigla keskkonnast ja lapse enneaegsusest. Riskifaktorite mõju (näiteks haiglas viibimise aeg, osakond, gestatsiooni vanus, sünniviis) sooletrakti ja nina-neelu kolonisatsioonile nii antibiootikum-tundlike kui ka ravimresistentsete tüvede osas oli sarnane, omavahel tihedalt seotud ja mikroobispetsiifiline ning seetõttu on neid võimalik üldistada mõlemale piirkonnale. Võrreldes ampitsilliini, kui laiema toimespektriga antibiootikumi mõju penitsilliiniga, võib väita, et esmamainitu toimet Gram-negatiivsele mikrofloorale ja ravimresistentsete tüvede tekkele on ilmselt ülehinnatud. Siiski esines valikulist mõju just Gram-positiivsele mikrofloorale. Näiteks koloniseeruti ampitsilliinravi korral võrreldes penitsilliiniga rohkem S. haemolyticus´e (erinevus +0,7; p=0,039) ja S. hominis´ga (+1,9, p=0,003), kuid vähem S. aureus’e (-1,9; p=0,006) ja enterokokkidega (-1,2; p<0,001). Seega peaks ravimrežiimi eelistus baseeruma lokaalsel olukorral; st millised on vastava osakonna sagedasemad infektsioonitekitajad ja nende ravimtundlikkus. Samuti tuleks arvestada enneaegsust ja muid lapsest sõltuvaid faktoreid. Eelnev limaskestade kolonisatsioon Gram-negatiivsete oportunistlike mikroobide ja MRSA-ga võib olla aluseks invasiivse infektsiooni väljakujunemisele. Siiski on järelevalvekülvide sensitiivsus, spetsiifilisus ja PPV invasiivse infektsiooni tekke prognoosimiseks madalad (väärtused vastavalt 27%, 66% ja 4%) ja seega on nad väheefektiivsed. Samuti on nende kogumine küllalt kulukas ja aeganõudev. Siiski on järelevalvekülve mõttekas koguda teatud spetsiifiliste mikroobide (K. pneumoniae, MRSA) poolt põhjustatud haiglainfektsioonide puhangute korral. See aitaks parandada infektsioonikontrolli meetmeid ja oleks abiks empiirilise ravi valikul.The general aim of the study was to compare how antibiotics commonly used for empiric therapy of EOS (ampicillin or penicillin both combined with gentamicin) influence the development of gut and nasopharyngeal (NP) microbiota and to define which of the abovementioned regimens should be preferred in terms of mucosal colonisation. Besides it, the aims were also addressed to identify independent perinatal, neonatal, and environmental factors influencing the colonisation process; to identify the relatedness of microorganisms isolated from NP and rectum to isolates form sterile sites and thus characterize their potential for causing invasive disease; and to define the value of twice a week collected surveillance cultures in predicting Gram-negative late onset sepsis (LOS) in high risk neonates admitted to NICU. Study design and methods. The prospective open label two centre cluster randomised study was conducted between August 2, 2006 and November 30, 2007 in NICUs of Tartu University Hospital and Tallinn Children’s Hospital. Neonates were included in the study (n=278) if they were younger than 72 hours, needed early empiric antibiotic treatment on clinical suspicion and/or due to risk factors of infection and were expected to stay in the unit for >24 hours. Rectal (n=1250) and NP (n=1153) specimens were collected on admission and then twice a week until discharge or Day 60 whichever occurred first. From patients receiving artificial lung ventilation tracheal aspirate (n=60) instead of NP swab was collected. Normally sterile body fluids (n=554) were cultured preferably before administration of antibiotics on admission and then if clinical condition deteriorated and symptoms suggestive of neonatal sepsis. Rectal swabs were plated onto blood agar, MacConkey agar for isolation of Gram-negative bacteria, and Sabouraud agar for isolation of yeasts. NP specimens were plated onto McConkey agar. All samples were also plated onto MacConkey agar with 16 μg/ml of ampicillin for the detection of Gram-negative ampicillin-resistant (AR) strains. The molecular analysis was performed for detection relatedness of mucosal and invasive strains. The sensitivity, specificity, negative and positive predictive values of surveillance cultures of 2108 mucosal and corresponding invasive culture pairs were calculated in predicting Gram-negative late-onset sepsis. The association between colonization by different microbes and a total of 22 maternal or neonatal predefined risk factors was assessed by using univariate and multiple logistic regression analyses. Results and conclusions. The first colonizers in neonates admitted to NICU with risk factors of EOS were Gram-positive bacteria, among which coagulase negative staphylococci clearly predominated. Colonization by Gram-negatives in NP and rectal area were similar. The frequent opportunistic colonizers were also frequent causative agents of LOS. The mucosal colonisation by E. coli, K. oxytoca and C. albicans is mainly influenced by maternal and early perinatal factors, while K. pneumoniae, E. cloacae, MRSA and non-albicans Candida spp. are predominantly affected by the hospital environment and prematurity. Risk factors (e.g. duration of NICU stay, unit, gestation age, route of delivery) influencing NP and rectal colonisation including AR strains are similar and species-specific and are closely inter-related making extrapolations from one site to the other feasible. In patients with risk factors for EOS the impact of ampicillin (a broader spectrum antibacterial agent compared with penicillin) on mucosal colonisation with Gram-negative microorganisms including AR strains may have been over-estimated. The main differences between these two agents are as follows: patients receiving ampicillin containing regimen are less frequently colonised with S. aureus and Enterococcus spp. but more often colonised with S. haemolyticus and S. hominis than those treated with penicillin. Thus, the avoidance of unwanted initial gut colonisation should not be a limiting factor in choosing between ampicillin and penicillin for the empiric treatment of EOS. We suggest that the selection should be made mainly according to the local distribution of EOS causing microorganisms and their antibiotic susceptibility. Host-related factors like the degree of prematurity should also be considered. Prior mucosal colonization with Gram-negative opportunistic micro-organisms and MRSA may lead to invasive disease. However, the sensitivity, specificity and PPVs of mucosal surveillance samples in predicting invasive disease is moderate for Enterobacteriaceae and suboptimal for non-fermentative micro-organisms. So, routine and non-targeted surveillance cultures are not efficient in predicting LOS in NICU as they are of low diagnostic accuracy, expensive and time consuming. Targeted for specific organisms, surveillance cultures may prove to be useful especially during outbreaks of nosocomial infections. They may offer an opportunity to improve infection control measures, to cohort patients and to select the most appropriate empiric antibiotic regimen

Reconstruction of the early invasion history of the quagga mussel (Dreissena rostriformis bugensis) in Western Europe

The recent introduction of the quagga mussel into Western European freshwaters marked the beginning of one of the most successful biological invasions during the past years in this region. However, the spatial and temporal origin of the first invasive population(s) in Western Europe as well as subsequent spreading routes still remain under discussion. In this study, we therefore aim at reconstructing the early invasion history of the quagga mussel in Western Europe based on an age-corrected temporally and spatially explicit spread model. Data were derived from time-series studies at selected sites as well as from a broad spatial survey in Western Europe. According to our spread model, the first successful introduction into Western Europe occurred in the Main-Danube Canal in early 2004, probably via inland navigation. Once populations were established, subsequent spread of the quagga mussel was characterized by a combination of jump dispersal and diffusive spread. This study gives insights into the very early invasion history of the quagga mussel and stresses the importance of the Main-Danube Canal for the introduction of non-native freshwater species into Western Europe

Ampitsilliini-gentamütsiini ja penitsilliini-gentamütsiini kombinatsioonide võrdlus vastsündinu varase sepsise ravis

Töö eesmärgiks oli võrrelda ampitsilliini-gentamütsiini vs penitsilliinigentamütsiini kombinatsioonide kliinilist efektiivsust vastsündinute varase sepsise (VVS) ravis. Kahekeskuseline prospektiivne klastriga juhuslikustatud uuring hõlmas kõik VVS-kahtlusega alla 72 tunni vanused vastsündinud. Esimesel uuringuperioodil kasutati ühes keskuses ampitsilliini ja teises penitsilliini kombinatsioonis gentamütsiiniga. Beetalaktaamantibiootikumid vahetati, kui pooled haiged olid uuringusse lülitatud. Primaarne tulem oli ravi ebaõnnestumine (vajadus antibakteriaalse ravi muutmiseks 72 tunni jooksul) ja/või surm 7 päeva jooksul. Soole kolonisatsiooni hinnati perineumi kaape alusel. Tõestatud VVSi sagedus oli 4,9%. Ampitsilliini ja penitsilliini skeemide vahel ei olnud erinevust 72 tunni jooksul antibakteriaalse ravi vahetuse, 7 päeva suremuse ega ravi ebaõnnestumise osas. Ampitsilliin ja penitsilliin kombinatsioonis gentamütsiiniga on võrdselt tõhusad vastsündinu varase sepsise empiirilises ravis. Eesti Arst 2009; 88(Lisa4):21−2

Do Foreign Representatives Need to Satisfy the Recognition Requirement?

(Excerpt) A foreign representative must obtain recognition of a foreign proceeding pursuant to section 1517 of title 11 of the United States Code (the “Bankruptcy Code”) prior to applying directly to a court in the United States for any relief such as operating the debtor’s business operations in the U.S. or seeking assets and discovery from U.S. entities. However, under section 1509(f), a foreign representative may sue in a United States court to collect or recover a claim which is the property of the debtor without first obtaining recognition. The scope of this exception, though, remains unclear. This memorandum explores whether recognition under chapter 15 of the Bankruptcy Code is a prerequisite for a foreign liquidator or debtor to bring litigation in the U.S. Part I discusses the general requirement of recognition under section 1509 before a foreign representative can bring a suit in U.S. courts. Part II provides a brief overview of the cases where the courts have allowed foreign representatives to circumvent the recognition requirement. Part III concludes by highlighting the scope and desirability of the section 1509(f) exception after exploring its possible interpretations

Puukborrelioos Saaremaal

Taust. Puukborrelioosi riskirühmaks on sageli metsas viibivad isikud. Diagnostika põhineb antikehade sisalduse suurenemisel, kuid pole teada nende foontase ja ELISA-testi tulemuste kinnitamise vajadus immunoblotuuringuga. Eesmärk. Selgitada puukborrelioosivastaste antikehade esinemine tervete jahimeeste vereseerumis ning hinnata ELISA-testi ja immunoblotuuringu omavahelist korrelatsiooni. Meetodid. Saaremaal küsitleti jahimehi (n = 184) varasema borrelioosi võimaliku esinemise suhtes ning määrati IgM- ja IgG-tüüpi antikehad ELISA-meetodil. Perearstide poole pöördunud 181 ELISA-testi järgi positiivse tulemusega (109 testi näitas IgM-tüüpi ja 123 IgG-tüüp antikehi) patsienti anketeeriti ja nende veri testiti üle immunoblotuuringuga. Tulemused. Jahimeestest olid IgG- ja IgM-tüüpi antikehad olemas vastavalt 47%-l ja 5%-l. Metsas käimise sagedus ja puugirünnete osakaal antikehade olemasolu ei mõjutanud, küll aga oli IgG-tüüpi antikehade olemasolu sagedasem vanematel ja pikema jahimehestaažiga isikutel. ELISA-testi immunoblotiga kinnitamisel ilmnes, et IgM- ja IgG-tüüpi antikehade valepositiivseid tulemusi oli vastavalt 24%-l ja 19%-l. ELISA-testi positiivne prognoosiv väärtus IgM-tüüpi antikehade korral oli 76% (95% uv 67–84) ja IgG-tüüpi antikehade korral 81% (73–88). Erythema migrans’i esinemissagedus oli väike ega olnud seotud antikehade positiivsete tulemustega. Järeldused. Seropositiivsus jahimeeste hulgas on suur, mistõttu ei saa pelgalt antikehade ja ebaspetsiifiliste kliiniliste sümptomite alusel puukborrelioosi diagnoosida. ELISA-testi spetsiifilisus on vähene antikehade piiripealsete või nõrgalt positiivsete väärtuste korral ja seega on vajalik tulemused kinnitada immunoblotuuringuga.Eesti Arst 2015; 94(4):203–21

New Universality Class of Quantum Criticality in Ce- and Yb-based Heavy Fermions

A new universality class of quantum criticality emerging in itinerant electron systems with strong local electron correlations is discussed. The quantum criticality of a Ce- or Yb-valence transition gives us a unified explanation for unconventional criticality commonly observed in heavy fermion metals such as YbRh2Si2 and \beta-YbAlB4, YbCu5-xAlx, and CeIrIn5. The key origin is due to the locality of the critical valence fluctuation mode emerging near the quantum critical end point of the first-order valence transition, which is caused by strong electron correlations for f electrons. Wider relevance of this new criticality and important future measurements to uncover its origin are also discussed.Comment: 20 pages, 4 figure

The Relationship between Gram-Negative Colonisation and Bloodstream Infections in Neonates: A Systematic Review and Meta-Analysis.

OBJECTIVES: Neonates admitted to Neonatal Intensive Care Units (NICU) are at significant risk of developing bloodstream infections (BSIs). Gram-negative bacteria (GNB) both colonise and infect, but the association between these entities is unclear. By conducting a systematic literature review, we aimed to explore the impact of factors on the association between GN colonisation and GN-BSI at both baby level and unit level. METHODS: We searched Medline, Embase, and Cochrane Library. Observational cohort studies published after 2000 up to June 2016 reporting data on the total number of neonates (0-28 days) colonised with GNB assessed by rectal/skin swab culture and the total number of neonates with GN-BSI (same bacteria) were included. Studies were excluded if data on skin/rectal colonisation, neonates, and GNB could not been identified separately. The meta-analyses along with multivariate meta-regression with random-effect model were performed to investigate factors associated with the GN colonisation and GN-BSI at baby-level and unit-level. RESULTS: 27 studies fulfilled our inclusion criteria, 15 for the baby-level and 12 for the unit-level analysis. Study heterogeneity was high, with suboptimal overall quality of reporting assessed by the STROBE-NI statement (44.8% of items adequately reported). In 1,984 colonised neonates, 157 (7.9%) developed GN-BSI compared with 85 of 3,583 (2.4%) non-colonised neonates. Considerable heterogeneity across studies was observed. Four factors were included in the meta-regression model: Gross domestic product (GDP), pathogen, outbreak, and frequency of screening. There was no statistically significant impact of these factors on GN colonisation and GN-BSI in baby level. We were unable to perform the multivariate meta-regression due to the insufficient reported data for unit level. CONCLUSIONS: Study limitations include the small number and the high heterogeneity of the included studies. While this report shows a correlation between colonisation and BSI risk, this data currently doesn't support routinely screening for GNB. The analysis of large cohorts of colonised neonates with clinical outcomes is still needed to define the major determinants leading from colonisation to infection