Community-Associated Methicillin-Resistant Staphylococcus aureus Isolated in Finland in 2004 to 2006

A nationwide population-based study on community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in Finland during 2004 to 2006 showed that both incidence (1.9/100,000 population) and strain variation increased in comparison to years 1997 to 1999. There were 7 community-associated epidemic and 25 sporadic MRSA strain types. Half of these had Panton-Valentine leukocidin genes.Few population-based estimates of the burden of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) have previously been published (1-3, 12, 14). In Finland, the incidence of MRSA has been low. During 1997 to 1999, one-fifth of the 526 Finnish MRSA isolations were from persons without any connection to a hospital, and three strain types were associated with community acquisition (14). However, the total number of MRSA findings reported to the National Infectious Disease Register in Finland in 2004 to 2006 increased eightfold since 1997 to 1999. This increase has mostly been due to outbreaks and active screening in hospitals and hospital-associated strains (6, 15).In this study, we estimated the proportion of CA-MRSA strains among the MRSA isolates obtained either by screening or from a clinical specimen and determined the incidence and type of clinical CA-MRSA infections during 2004 to 2006. The MRSA strain types obtained from persons with and without hospitalization were compared.In Finland (population, 5.3 million), all clinical microbiology laboratories notify MRSA findings, including only the first isolate from a person, to the National Infectious Disease Register and send the corresponding isolates to the reference laboratory. During 2004 to 2006, a total of 4,054 (97%) isolates from 4,166 newly detected MRSA-positive persons were received.For each MRSA isolate, pulsed-field gel electrophoresis (PFGE) and antimicrobial drug susceptibility testing were performed (6, 10, 15). Multilocus sequence type (MLST), spa type, and SCCmec determinations were performed for isolates with a PFGE type shared by five or more persons (15). Panton-Valentine leukocidin (PVL) genes (lukS-PV, lukF-PV) were tested for by PCR in all CA-MRSA isolates. Identical or closely related PFGE types, MLSTs, and spa types (4) defined a strain type designated by a FIN number. A sporadic strain was shared by five or fewer persons.For all 4,030 persons with an MRSA isolate from 2004 to 2006, excluding 24 persons with an erroneous national identity code, data on previous hospitalizations were retrieved from the National Hospital Discharge Register. Background information was obtained for each person with MRSA isolated outside a hospital setting or within 2 days of hospital admission and who had not been hospitalized within 2 years of a positive MRSA culture by sending a questionnaire to infection control nurses at the relevant health care facilities. These data included risk factors for MRSA acquisition, the reason for obtaining the culture (screening or infection), and the type and treatment of a possible infection as recorded in medical charts by the patient''s primary health care provider. The Ministry of Social Affairs and Health, the Finnish data protection authority, and the National Research and Development Center for Welfare and Health approved the use of data from the National Hospital Discharge Register.Community association was calculated for each MRSA strain type carried by at least 10 persons. The chi-square test with Yates correction or Fisher''s exact test, as appropriate, was used for categorical variables. The means and medians of the continuous variables were compared by Student''s t test or the Mann-Whitney U test, depending on the sample distribution.A total of 570 persons without previous hospitalization in the last 2 years were identified. Based on the survey, 94 health care workers, 158 long-term care facility residents, and 20 newborns less than 28 days old were excluded. Thus, 298 (7.4%) of the 4,030 MRSA-positive persons and isolates were community associated (range by year, 5.8 to 8.9%); 185 (62%) and 113 (38%) were obtained as clinical specimens and by screening, respectively. Ultimately, 191 (64%) had a clinical infection. The mean annualized incidences of all CA-MRSA findings and CA-MRSA infections, respectively, were 1.9 and 1.2/100,000 population (ranges of annual incidences, 1.6 to 2.1 and 1.0 to 1.4). Persons with a CA-MRSA isolate were younger (median, 37 versus 75 years, P < 0.001) and more often males (56 versus 49%, P < 0.05) than those with previous hospitalization.Among the 4,030 MRSA isolates, our typing scheme showed a total of 148 strain types, of which 109 (74%) were sporadic and 39 (26%) were shared by at least five persons. Twenty-five strain types, each of which was isolated from ≥10 persons, represented 3,971 (99%) of the 4,030 isolates. Seven of these strain types, including two of the three old CA-MRSA strain types and 25 sporadic strain types, were associated with community acquisition (Table ​(Table11).

TABLE 1.

MRSA strain types significantly more often isolated in persons without previous hospitalization, i.e., CA-MRSA strain types, in Finland in 2004 to 2006

The moderating effect of employee hostility on the association of long-term elderly care unit's negative resident characteristics to employee stress and well-being

This study examined the moderating effect of employee hostility on the association of unit-level resident characteristics (depression and behavioral problems) to individual-level employee's resident-related stress and psychological well-being during 1-year follow-up study among 501 employees in elderly care. Our results showed that employee hostility was associated with decreased psychological well-being. In addition, hostility moderated the association between unit-level proportion of depressive residents and resident-related stress experienced by the individual employees. Hostile employees reported increased resident-related stress irrespective of the proportion of depressed residents in the unit. Instead, nonhostile employees were sensitive to the depression in the unit. They reported low levels of stress when depression levels in the unit were low and increased stress when depression levels were high.     

Gastrointestinal stromal tumors (GIST)--a paradigm of successful targeted therapy of solid tumors

Gastrointestinal stromal tumors (GIST) have attracted basic scientists as well as clinicians in the last 10 years. The reason for this is explanation of the pathogenetic mechanism of tumor growth by activation of c-Kit protein, followed by a rationally designed suppressor, a drug named imatinib. It is the first successful therapy for solid tumors to date, although there are other ongoing studies of agents with targeted action on different molecules in different tumors. In 80% of patients there is a clinical benefit from imatinib trreatment. GIST shows great diversity in clinical presentation and some questions still remain, such as malignant potential and prognostic criteria in these tumors. Imatinib therapy demonstrates many favorable effects such as acceptable toxicity and relative mild side effects, excellent quality of life, good patient compliance, etc. There are ongoing trials of new agents designated for target molecules, which would hopefully show benefit after developing resistance to imatinib.     

Predictors of sustained organizational commitment among nurses with temporary job contracts

OBJECTIVE: To examine sociodemographic, work-related factors and psychological health as predictors of sustained organizational commitment among temporary hospital employees. BACKGROUND: The participants were 412 nurses who had a temporary job contract and reported being committed to their organization at baseline. METHODS: Organizational commitment was measured again 2 years later. RESULTS: The results of logistic regression analysis showed that age over 35 years, high job control, high participative safety, high perceived justice in decision making, and low psychological distress predicted sustained organizational commitment at follow-up. The change from temporary employment to a permanent job and high job control predicted sustained organizational commitment even after the effect of all the other predictors was taken into account. CONCLUSION: Organizations that employ temporary workers should pay attention to the job control and career prospects of temporary staff.     

Inguinal or inguino-iliac/obturator lymph node dissection after positive inguinal sentinel lymph node in patients with cutaneous melanoma

Background

The aim of the study was to determine whether the presence of inguinal sentinel lymph node (SLN) metastases smaller than 2 mm (micrometastases) subdivided according to the number of micrometastases predicts additional, non-sentinel inguinal, iliac or obturator lymph node involvement in completion lymph node dissection (CLND).

Patients and methods.

Positive inguinal SLN was detected in 58 patients (32 female, 26 male, median age 55 years) from 743 consecutive and prospectively enrolled patients with primary cutaneous melanoma stage I and II who were treated with SLN biopsy between 2001 and 2007.

Results

Micrometastases in inguinal SLN were detected in 32 patients, 14 were single, 2 were double, and 16 were multiple. Twenty-six patients had macrometastases.

Conclusions

No patient with any micrometastases or a single SLN macrometastasis in the inguinal region had any iliac/obturator non-sentinel metastases after CLND in our series. Furthermore, no patient with single SLN micrometastasis in the inguinal region had any non-sentinel metastases at all after CLND in our series. In these cases respective CLND might be omitted.     

Type and location of tumor-infiltrating macrophages and lymphatic vessels predict survival of colorectal cancer patients

The type of tumor-infiltrating macrophages may be decisive in tumor immunity, lymphangiogenesis and in the clinical outcome of cancer. Here, we elucidated the prognostic significance of lymphatic vessels, different types of macrophages and the balance between different macrophage types in colorectal cancer. We analyzed the impact of density, type and location of macrophages on the clinical behavior of 159 primary colorectal carcinomas using CD68 as a pan-macrophage marker and CLEVER-1/Stabilin-1 as a marker for regulatory/suppressive macrophages. Podoplanin was used as a pan-lymphatic vessel marker. A high number of CLEVER-1/Stabilin-1(+) peritumoral macrophages positively correlated with survival (p = 0.04). However, in more advanced disease (Stage IV), the patients with a high number of peritumoral or intratumoral CLEVER-1/Stabilin-1(+) macrophages had a shorter disease-specific survival (p = 0.05, and p = 0.008, respectively). Moreover, a low number of suppressive intratumoral CLEVER-1/Stabilin-1(+) macrophages among high numbers of CD68(+) macrophages correlated with a low number of distant recurrences (p = 0.01) and to fewer disease relapses exclusively in the liver as well (p = 0.006). A high number of intratumoral lymphatics correlated with poor survival (p = 0.03). The results of this work suggest that the type of macrophages, number of lymphatic vessels and their location contribute to the clinical behavior of colorectal cancer in a disease stage-specific manner.     

Scleredema treated with broad-band ultraviolet A phototherapy plus colchicine

Scleredema is an uncommon condition characterized by induration of skin. The pathogenesis is not known, although the increased expression of collagen-producing fibroblasts in the skin has been demonstrated. Scleredema has been difficult to treat with scattered reports of success with bath psoralen plus ultraviolet A (PUVA), cream PUVA, UVA1 and others. The use of low-dose broad-band UVA phototherapy was found to be effective in the treatment of morphea. Colchicine has been shown to interfere with collagen synthesis and is used successfully in scleroderma. We report the first case of scleredema that improved markedly with low-dose broad-band UVA plus colchicine treatment.     

Dramatic response of chronic ulcerating necrobiosis lipoidica to ultraviolet A1 phototherapy

We report on a 52-year-old female patient with chronic, ulcerating necrobiosis lipoidica (NL) who dramatically responded to ultraviolet A1 (UVA1) phototherapy. The patient had NL on her right shin for more than 30 years without evidence of diabetes mellitus. Treatment with a variety of local and systemic agents failed to prevent progression into ulceration, which necessitated repeated surgical interventions in the past. When the patient presented again with torpid ulcers at the periphery of previously grafted skin, high-dose UVA1 phototherapy was initiated. Improvement occurred rapidly and after 22 irradiations and a total exposure dose of 1480 J/cm2, the ulcers had healed completely. During a follow-up period of 6 years,two minor recurrences were successfully retreated with UVA1 phototherapy.     

Management of complication from temporal bone fractures

The objective of the study is to review clinical findings and outcomes in patients with temporal bone fractures, and to show an incidence and management of complications. It is the retrospective clinical study and the study took place at tertiary referral center. Fifty-two patients with temporal bone fractures. Data were collected from patients’ charts and clinical review. Patients were classified into five groups according to the CT scan. The primary endpoint of study was to show management of possible complication from temporal bone fractures and to analyze association with intracranial injuries. The second endpoint was to show incompleteness of traditionally classification of fracture type. Of the 52 patients with 54 fractures, 27 (50%) had longitudinal fractures, 4 (7.4%) had transverse fractures, 17 (31.5%) had temporal squama-mastoid fractures, 4 (7.4%) had mixed fractures and 2 (3.7%) had isolated meatal fracture. Fifty-eight percent of patients had at least one intracranial pathologic finding, of which 11% had two or more. Persistent conductive hearing loss was noted in 8 of 16 affected patients. The facial paralysis occurred in seven patients. One patient had benign paroxysmal positional vertigo developed 3 weeks after injury. In conclusion, rarely temporal bone fractures are isolated injures. The squama-mastoid fracture in most cases associated with intracranial injuries. Coordination between the neurosurgeon and otologist is essential in the care of such patients. Further large studies will be done to give a more complete classification of temporal bone fractures which will include all fracture patterns and predict clinical outcome.